|Year : 1964 | Volume
| Issue : 3 | Page : 107-113
Correction of cicatricial entropion of upper lid by insertion of acrylic plate
Prem Chandra, KL Taneja
Department of Ophthalmology, Govt. Medical College, Paliala, India
|Date of Web Publication||13-Feb-2008|
Department of Ophthalmology, Govt. Medical College, Paliala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandra P, Taneja K L. Correction of cicatricial entropion of upper lid by insertion of acrylic plate. Indian J Ophthalmol 1964;12:107-13
Due to a high incidence of trachoma in Pepsu the number of cases of entropion attending the department of Ophthalmology, Medical College, Patiala is fairly high. In 1959 the number of operations for cicatricial entropion was 282 while in 1959 it was 290 and in 1960 it was 225. Majority of these were operated upon by the Hotz - Anagnostakis technique, some by transposition of cilia and some by mucous membrane graft. The results were not found to be gratifying. Recurrences were common particularly in cases of Hotz' - Anagnostakis operation. Notching of the lid margin, lagophthalmia and abnormal position of the posterior margin of the lid border were some of the complications common to all. In a search for a technique that would give uniformly good results it was decided to evaluate the replacement of distorted tarsus by an acrylic plate.
| Acrylic Plates|| |
These were prepared from methylmethacrylate in three forms in our department. [Figure - 1]
PLATE TYPE A : These were prepared of the following measurements
Length = 15-17 mm.
Breadth = 6 mm. in middle part.
Thickness = 2-2.5 mm. uniformly thick.
The upper border was convex upwards, whereas the lower border was straight. The plate was uniformly convex on the anterior surface and concave on the posterior.
PLATE TYPE B:-These were of the same measurements as in type A, but 4 to 6 holes were drilled in a row parallel to the convex border. [Figure - 2].
PLATE TYPE C:-This differed from type B in that, along the straight border there was a ridge projecting forwards 0.5-1 mm. on the convex surface.
| Animal Experiments|| |
These were done on adult rabbits under open ether anesthesia. The animals were divided into three groups depending upon the plate used. In each group five animals were taken, except in group III where 4 animals were taken and one was used for the second time. In each animal acrylic plate was inserted in one lid. In the opposite lid, cartilage was taken from the pinna of the same animal and placed over the tarsal plate after shaving the latter thin. It was thus possible to compare the reaction of the tissue to the two types of implants. The wound was dressed with achromycine ointment. The animals were examined on the second, fifth, eighth and twenty-first day and finally two months after the operation.
The results are shown in [Table - 1].
Out of the fourteen animals taken, two animals died on the table and one on the 5th day due to pulmonary complications. Out of the eleven animals which survived, the cartilage was placed in the right upper lid in four, the left upper lid in seven, while acrylic was placed in the left upper lid in four, the left lower lid in one and in the right upper lid in seven animals. Thus there were eleven eyelids with implantation of cartilage and twelve with implantation of acrylic. Out of the 12 acrylic implants, 2 got extruded, 9 were fully retained and one partially so, as against the 11 cartilage implants which were retained in all cases. [Figure - 3] a, b, c.
The reaction and thickness of lid was more in acrylic implants than in cartilage implants. The lid margin remained normal in all cases excepting in two where the plate was exposed. In no animal was there any conjunctival reaction or corneal complication. The conclusion from these animal experiments was that the acrylic material, though it causes a reaction in the tissues in which it is implanted, is acceptable and can be retained.
| Clinical|| |
It was therefore decided to insert acrylic plates in the lids of patients suffering from cicatricial entropion who attended the department of Opthalmology. Only adults were selected and the B type plate was used.
Steps of the Operation
The operation was done under local anaesthesia, -instillation of 1 % anethane and infiltration with 2% procain with adrenaline.
i. An incision 5-6 mm. from the lid margin and parallel to it throughout the length of the lid was given.
ii. The orbicularis muscle was incised upto the tarsal plate taking care not to injure the plate. The orbicularis was then separated from the anterior surface of the tarsal plate [Figure - 4].
iii. The tarsal plate was thinned by shaving the anterior three fourths of the thickness along its whole length and breadth. The separation was carried upto as near the margin as possible without injuring the roots of the eyelashes [Figure - 5]. It is important to retain some thickness of the tarsal plate so that the acrylic plate does not lie directly on the conjunctiva.
iv. Acrylic plate was placed in the area so prepared. [Figure - 6]
v. The plate was anchored in position by means of one of the following three types of silk sutures.
a) A suture was passed through the superficial layer of the anterior surface of the tarsal plate near the upper end and then crossing over the acrylic plate, which was placed upon the shaved tarsal plate, again a horizontal bite was taken through the superficial layer of the tarsal plate near the lower border of the acrylic plate. The sutures were then tied over the anterior surface of the acrylic plate. Such 3-4 sutures were taken. [Figure - 6].
b) A suture was passed through the lower flap of skin 1 mm. from the lid border, then over the acrylic plate, then through the deeper tissues above the upper border of the acrylic plate, then through the upper skin flap and again in a reverse way to emerge near the point of entry of the suture. Such 4-5 sutures were passed and tied. [Figure - 7].
c) A double-armed suture was passed through the tarsal plate forming the bed for the implant. The two needles were passed through the holes in the acrylic plate and the suture tied down on the anterior surface of the plate [Figure - 8]. Orbicularis was then sutured and the skin was sutured by interrupted silk sutures.
| Results|| |
Only those patients who were operated upon in 1960 and have been observed for at least 3 years have been reported upon. The implantation of acrylic plate was carried out on 13 cases. In one the lid had been previously operated upon while in another the operation was done on the lower lid. In 11 lids the implant was done in the upper lid. The implant got extruded in two eyes. In both, the extrusion was preceded by infection and break down of stitches. In the remaining 11 cases the plate was well tolerated [Figure - 10]. The oedema of the lid was more than in the Hotz' - Anagnostakis technique but hot fomentations and oral corticosteroids gave relief to the patient.
| Discussion|| |
For cicatricial entropion, particularly the one caused by trachoma, a large number of operative techniques have been described. We could find only one report of implantation of cartilage and mucous membrane for the repair of cicatricial entropion. Cole (1954) obtained the tarsal plate from the other eye. The tarsal implant was anchored to the rudiment of tarsal plate in the upper lid and also to the tarsal plate of the lower lid utilising the principle of reconstruction of the lid developed by Hughes.
Sugar and Forestner (1946) used methylmethacrylate plate for the management of sunken upper lid following enucleation. Excepting for this report we could not find any other mention in literature of the use of methylmethacrylate in upper lid surgery. Further, no report could be found in the literature regarding the use of methylmethacrylate implant for the correction of cicatricial entropion.
The solid polymer of the methylmethacrylate is non-toxic, well tolerated and gets encapsulated by a thin fibrous layer. The liquid monomer is as toxic as acetone but during the process of curing, the monomer is changed to the polymeric form if curing takes place at the temperature of boiling water. That the methylmethacrylate is well tolerated by the tissues is shown by a wide use of this material for the repair of gaps in the skull, deformities of the nose, chin and face, as replacement of femoral head and as an implant in Tenon's capsule. The resin is slowly absorbed by ketones and hence is to be used in diabetics with care.
Sugar and Forestener (1946) implanted the methyl methacrylate in the lids of albino rabbits. For some rabbits the implant was cured at boiling water temperature, for others at lower temperature for longer periods and for the third group they used pigmented resin commonly used for artificial dentures. The lids were sectioned after one month and two months. After one month it was found that the plate was lying loose in the tissues surrounded by a thin capsule which consisted of dense fibrous tissue lined by flattened layer of fibroblasts and endothelial cells. There were few monocytes, lymphocytes and rarely a giant cell. The skin was movable and the lid was pliable. After two months the fibrous capsule had become thinner but the other features were the same as at one month.
In our experiments the holes were drilled in the plates for two purposes; firstly for passing the stitches and secondly for allowing fibrous tissue to pass through and thereby act as buttons for keeping the acrylic plate in position.
It is a well recognised observation that the acrylic plate should be separated from the surface, skin or mucous membrane, by another tissue otherwise the plate is very likely to be extruded. In the cases reported upon here, the acrylic plate in all cases had a thin layer of tarsal plate separating it from the conjunctiva. It was because of the difficulty of ensuring a bed of tarsal plate that this operation was not tried in cases where the tarsal plate was grossly shrunken as a result of disease or previous operation.
To be effective, any operation for the cure of entropion should correct the distortion of the tarsal plate, the contraction of conjunctiva and thirdly the spasm of orbicularis oculi. In the implantation of the acrylic plate only the distortion of the tarsal plate was corrected. The result has been uniformly gratifying indicating that the procedure has simultaneously corrected the faulty action of the oribicularis oculi. With a distorted tarsal plate with its free margin bent towards the eye ball, the pre-tarsal portion of oribicularis is favourably placed to press the lid margin still further backwards. When the distortion of the tarsal plate is corrected, it appears that the backward pressure of oribicularis is exerted uniformly on the tarsal plate over its entire breadth and hence the faulty action of orbicularis is corrected at the same time and does not require to be corrected independently or in addition to the correction of deformity of the tarsal plate.
The operation has been successful even in patients with a gross contraction of the tarsal conjunctiva. It was felt that when the tarsus was thinned and straightened, the acrylic plate was able to overcome the contraction of conjunctiva. This operation has been tried with good result in one case that had been previously operated upon, but it has not been tried in eyes with posterior symblepharon.
One of the disadvantages of the operation has been thickening of the lid. This has however not given an appreciable cosmetic disfigurement. Eversion of the lid can be easily performed. The holes in the plate, besides helping to fix the plate in position can also be used to anchor the levator palpebrae to the plate by stitches. However this was not done in any of the cases as this would have caused a wider dissection of tissues and incision of the fascia orbitalis.
| Conclusion|| |
Acrylic plate can be used effectively for the repair of cicatricial entropion. Though the majority of patients treated did not have a previous operation, in one case the implantation gave good results in a patient who had been previously operated upon. The cosmetic results have been satisfactory.
| References|| |
Cole, J. G. (1954) Amer. J. Ophthal. 38, 544.
Sugar, H. S. and Forestner. H. J. (1946) Amer. J. Ophthal. 29, 993-1000.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]
[Table - 1]