Year : 1984 | Volume
: 32 | Issue : 5 | Page : 368--370
An evaluation of Gillies' procedure for lagophthalmos in leprosy
Nitin Verma1, SP Garg1, VK Kalra1, G Fromberg2,
1 Dr. Rajendra Prasad Centre for Ophthalmic Sciences; AIIMS, Ansari Nagar, New Delhi, India
2 D 6690 ST Wendel BruhlstraBe 2, Germany
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi
|How to cite this article:|
Verma N, Garg S P, Kalra V K, Fromberg G. An evaluation of Gillies' procedure for lagophthalmos in leprosy.Indian J Ophthalmol 1984;32:368-370
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Verma N, Garg S P, Kalra V K, Fromberg G. An evaluation of Gillies' procedure for lagophthalmos in leprosy. Indian J Ophthalmol [serial online] 1984 [cited 2022 Jul 1 ];32:368-370
Available from: https://www.ijo.in/text.asp?1984/32/5/368/27513
Lagophthalmos with its attendant exposure keratitis is a serious and preventable cause of blindness in leprosy. It frequently coexists with neuroparalytic keratitis.
Apparently, lagophthalmos maybe treated easily; the large variety of procedures available attest against it.,,,
Tarsorraphy is the most widely practised operation for this condition, it however, frequently opens out, does not correct medial ectropion and epiphora, i s cosmetically unacceptable and requires frequent revision due to the progressive laxity of the tissues. Moreover, it has to be opened up to perform intraocular surgery at a later date.,
Involvement of the motor division of the trigeminal nerve is rare in leprosy, and thus the use of the temproalis muscle as a source of power to move the eyelid is possible. Using a modification of the original operation described by Gillies, it has been our experience that this is the most efficient, logical physiological and cosmetically acceptable solution to the problem of lagophthalmos. Our experience of the temporalis transfer procedure (modified Gillies method) in twenty cases of lagophthalmos is presented.
MATERIAL AND METHODS
Twenty cases of unilateral and bilateral lagophthalmos with varying degree of exposure keratitis were chosen from among 1016 inmates of the Leprosy Home at Shahdara, Delhi. They were on regular DDStherapy and had Lepromatous (11), borderline (2) and tuberculoid (7) leprosy. Their ages varied from 21 to 52 years. Fifteen were males. The duration of lagophthalmos varied from 1 to 4 years. All patients had one or more lateral tarsorraphies done that had failed.
All patients were evaluated with regards to their orbicularis oculus tone, ectropion, conjunctival hyperemia, degree of epiphora, extent of exposure keratitis and subjective symptoms. Schirmer's test, Rose Bengal staining, and break-up time were also evaluated. All procedures were carried out under local infiltration anaesthesia (2% lignocaine with 1:150 TRU hyaluronidase and 1:10,000 adrenaline).
The head was shaved prior to the procedure. The skin preparation was done with Betadine. A hook-shaped skin incision was made [Figure 1], bleeders isolated and tied off and the glistening temporalis fascia exposed from its origin to its insertion. Using the knife, a 1 cm wide strip of fascia was isolated and stripped off from the muscle. The central muscle strip of the temporalis with the overlying fascia was disinserted from its origin and the underlying temporal bone and reflected towards the mandible [Figure 2].
Tunnelling, using fine haemostats and scissors was done along the lid margin till the medial palpebral ligament [Figure 1]. The muscle-fascia joint was reinforced with 5-0 Mersiline suture and the fascia split into 2 limbs. The fascial limbs were then pulled through the tunnels till the medial palpable ligament, resulting in an inversion of the central temporalis strip. The fascial strips were tightened and sutured under tension to the medial palpable ligament with 5-0 mersiline. At this stage the lids should be shut tight by the musculo fascial system. The skin incision was closed with 4-0 silk (interrupted sutures) and a pressure dressing applied over the temple. All dressings were opened after 24 hours.
Post-operatively, the patients were kept on analgesic, anti-inflammatory tablets (phenylbutazone) and topical antibiotic ointment. Suture removal was done after eight days.
Physiotherapy and diet
1st and 2nd week: liquid to semi-solid diet No clenching of the jaw was permitted.
3rd week : Solid diet
4th week onwards: chewing a rubber pipe or chewing gum in front of a mirror 300-400 times daily to re-educate the temporalis muscle to close the eyelids. This then becomes a habit.
Surgery in leprosy has its own problems. However, despite the length and extent of surgery the only complications observed were:
i) formation of a cold abscess at the musclefascia junction (in a case with pul. monary tuberculosis).
ii) delayed post-operative haemorrhage (two patients).
The results are depicted in [Table 1]. Intraocular procedures (Sector indectomy-2 and lens extractions-4) were performed after 6 months. The post-operative course was uneventful.
Gillies' procedure is preferable to Johnson's procedure (which essentially differs in, that fascia lata i s used) because a single site is operated upon. The fascial slings get slowly integrated with the tissue. The bump formed by the turned over temporalis muscle gets incorporated within the hair line and is not a cosmetic blemish. Since there are no lid fissure anomalies, complete correction of ectropion and cessation of epiphora, many patients (including women) now prefer this procedure to the conventional tarsorraphy. The muscle is constantly reinforced while eating and so is lid closure. The tension of the sling gives enough coverage to the globe so that the cornea is covered even in those individuals who sleep with their mouth open.
We recommend this procedure for all patients physically fit to withstand it, those with exposure keratitis and lower lid paralytic ectropion.
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