|Year : 1969 | Volume
| Issue : 4 | Page : 163-165
BM Varma, BK Garg
Department of Ophthalmology and Paediatrics, G.S.V.M. Medical College, Kanpur, (U.P.), India
|Date of Web Publication||10-Jan-2008|
B M Varma
Department of Ophthalmology and Paediatrics, G.S.V.M. Medical College, Kanpur, (U.P.)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Varma B M, Garg B K. Congenital epitarsus. Indian J Ophthalmol 1969;17:163-5
Epitarsus is 'an apron-like fold of conjunctiva' attached to the inner tarsal surface of the lid, the edge being free so that a probe can be passed underneath it for some distance. Both surfaces of this fold are covered with mucosa. It may occur in one or both lids of one or both eyes. The historical aspects have been discussed by Duke-Elder (1964). The deformity was fully described and named by Schapringer (1899, 1906).
As congenital epitarsus is an extremely rare condition the present case is being reported.
| Case Report|| |
G.D., 3-year-old Hindu male child was brought with the complaint that the appearance of the left eye was different from that of the right since birth. There was no history of drug intake by the mother or of infection, trauma or exposure to radiation during pregnancy. He was the product of a normal full term pregnancy. The neonatal period and infancy had been uneventful. There was no history of sore-eyes, trauma to the eyes or of exanthematous fevers except uncomplicated measles which he had at the age of 2 years. He had been successfully vaccinated for small pox. None of the family member had any congenital abnormality or disease of the eyes.
Physical examination revealed a well nourished child. Apart from the malformation in the left eye no other abnormality was detected on physical examination.
There was no abnormality in the right eye. A thin, translucent, pinkish membrane was found to be covering the anterior part of the left eyeball except in the central area, about 5 mm in diameter, through which the cornea could be seen. As the child was uncooperative detailed examination was done under general anxsthesia. This membrane was found to extend from the medial canthus, continuous with the plica semilunaris, towards the upper and lower fornices where it was attached. On the lateral side this membrane was attached to the conjunctiva of the lateral canthus. Thus it formed a complete diaphragm with a central aperture, about 5 mm. in diameter, with a free margin through which a probe was passed and no attachment of this membrane with either cornea or bulbar conjunctiva, right upto the fornices, was found [Figure - 1]. The cornea, anterior chamber, iris and pupil were normal. Funduscopy did not reveal any abnormality. There was no evidence of trachoma or any other infective disease of the conjunctiva.
The conjunctival smear, apart from some epithelial cells, did not show any organism or pus cells. The routine examination of the urine and blood did not reveal any abnormality.
The operation was done under general anesthesia. The lids were retracted by Desmare's lid retractors and the membrane, which was loose, became taut and was incised with scissors through the central opening upto the lateral and medial canthi. Some of the redundant portion was excised and the remaining part was reposited into the fornices. The patient made an uneventful recovery and was discharged from the hospital on the sixth postoperative day. He has been followed up for six months and has been found to be doing well [Figure - 2].
| Comments|| |
The only reference to this condition in the English Ophthalmic literature which we could find is by Treacher Collins (1921) who cites Lindsay Johnson as seeing a boy who had an obvious nictitating membrane which reached almost upto the cornea and was capable of slight movement.
The plica semilunaris in man may be looked upon as atavistic (Mann, 1957) as this represents the third eyelid or the nictitating membrane of the lower animals. Generally speaking, one finds this membrane less developed as the hand is more able to wipe the eyes (Ovio, 1927). This is well developed in the solipeds, but less in the cat. In man and in many monkeys it is absent, but chimpanzees have one (Wolff).
Wibaut (1925-26) suggested that congenital epitarsus is a primary congenital malformation and is due to the persistence of hypertrophic fold of the plica semilunaris. Its occurrence in monozygotic twins (Wibaut, 1925-26; Bersiere, 1948) also supports this view. Schapringer (1899) suggested that these folds were the result of adhesions of the amniotic bands to the epithelial covering of the globe while Nitsch (1927) and Taborisky (1928) thought these to be a sequel of intra-uterine conjunctivitis. We feel that epitarsus in the present case was congenital in origin because it had been present since birth, it was continuous with the plica semilunaris and there were no signs of inflammation or a previous history of such an episode.
Duke-Elder (1964) writes "that a similar deformity may be produced in postnatal life through a neglected conjunctival inflammation is seen by the fact that it is frequently found in these circumstances among Hindus (Herbert, 1901) and Palestine Jews (Taborisky, 1928)". From the Institute of Ophthalmology, Aligarh (India), Singh anti Grover (1960) and Nema Nath, Ahuja and Shukla (1965) have reported cases of so-called epitarsus following mucopurulent or pseudomembranous conjunctivitis, untreated trachoma, misuse of caustics, xerophthalmia and scraping operation in the florid stage of trachoma. These are really varieties of symblepharon and not of epitarsus and in fact Shukla (cited by Singh and Grover, 1960) had suggested the term 'epitarsoblepharon' for these cases. So their plea that the term epitarsus is vague and misleading and should be discarded is not valid as is examplified by the present case.
| Summary|| |
Congenital epitarsus in the left eye, reaching upto and covering the peripheral part of the cornea, in a 3-yearold Hindu boy is described. It has been suggested that this condition was due to the persistence of the nictitating membrane. The literature concening its pathogenesis is reviewed.
| References|| |
BESSIERE, (1948) Bull. Soc. franc. OphthaI.. 61, 149.
DUKE-ELDER, S.. (1964) System of Oph
thalmology, Vol. III, Normal and Abnormal Development, Part 2, Congenital Deformities, p. 908-909, Henry Kimpton. London.
HERBERT. H. (1901) Trans. ophthal. Soc. U.K.. 21, 16.
MANN, I.. (1949) The Development of the Human Eye. ed. II p. 266, The British Journal of Ophthalmology Ltd., London.
NEMA, H. V.. MATH, K., AHUJA, O. P. and SHUKLA. B. R. (1965) Accessory Conjunctival Folds : So-called Epitarsus. Brit. J. Ophthal.. 49, 148.
NFTSCH, M., (1927) Zeits. Augenheilk.. 62, 63. cited by Duke-Elder in 2.
OVIO. (1927) Anatomie et Physiologic de I' Oe it, translated by C. Dejean, Paris.
SCHAPRINGER, A. (1893) Zeits. Augenheilk., 2, 41.
- (1906) Zhl. prakt. Augenheilk.. 30, 146.
S1NGH, S., and GROVER, A. D., (1960) Epitarsus. and Post-inflammatory conjunctival Adhesions. A.M.A. Arch. Ophthal., (Chicago). 63,
TABORISKY, (1928) Klin. Mbl. Augenheilk.. 81, 488.
TREACHER COLLINS (1921) Changes in the Visual Organs with the adoption of arboreal life and with the assumption of erect posture. Trans. ophthal. Soc. U.K., 41, 10-90.
WIBAUT, F. (1925) Ned. T. Geneesk.. 69 (2). 460, cited by Duke-Elder.
(1926) Zeits. Augenheilk., 59, 50. Cited by Duke-Elder.
WOLFF, E.: (1958) The Anatomy of the Eye and Orbit ed. 4. p. 457. H. K. Lewis Co. Ltd. London.
[Figure - 1], [Figure - 2]