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Memphis Society of Ophthalmology and Otolaryngology
1156
SOCIETY PROCEEDINGS
P L A S T I C REPAIR OF LATERAL MARGINS OF UPPER
A N D LOWER LIDS A N D RECON
STRUCTION OF OUTER C A N T H U S
Sgt. P. W., aged 24 years, suffered a severe lye burn to his left eye and lids when he was three years old. The eye was enucleated at that time and the socket was lined with split-skin graft. The upper and lower lid defects were not repaired and because of this he was unable to re tain a prosthesis. On February 23, 1943, a pedicle skin graft from above the eye brow was brought down and anchored to the upper-lid defect. On March 15, 1943, the pedicle skin graft was split toward the base and reversed to be approximated to the lower-lid defect. Later the pedicle will be severed and the skin will be split along the margin of the outer canthus and skin edges will be approximated. Pvt. R. W. S., aged 30 years, had his left eyeball enucleated on August 10, 1942, when the globe was ruptured and other injuries were sustained when a land mine exploded near him. The globe was removed and the orbit was packed with vaseline gauze and sulfanilamide. Con siderable scarring of the orbital tissue remained along with a loss of substance and contraction of the nasal portion of the upper eyelid. The conjunctival sacs were almost obliterated by adhesions and scarring. On January 8, 1943, under pentothal sodium anesthesia, the scars and adhesions were dissected loose and the medial portion of the upper lid freed from its scar bed and inserted into its normal anatomic position. The orbit was packed with gauze. The patency of the conjunctival sacs did not persist and on February 10, 1943, under similar anes thesia, dissection was carried out well into the upper outer part of the orbit and the lower sac dissected free. A stent of dental molding wax was made to fit into the orbit and around this was wrapped a split-skin graft taken from the right thigh.
The graft had taken well and the patient was soon fitted with a larger prosthesis than was required for the purpose of pre venting any further contraction deformity in healing. Walter A. Ohmart, Secretary.
M E M P H I S SOCIETY OF OPH THALMOLOGY AND OTOLARYNGOLOGY April 12, 1943 DR.
C.
HAYS GLOVER,
presiding
C O N G E N I T A L BLEPHAROPTOSIS A N D S I M U LATING CONDITIONS DR. P H I L I P M. LEWIS reported three cases of congenital blepharoptosis, each patient operated upon by the method that seemed best suited to the individual. Kodachrome slides were shown of each case before and after operation. ■ Case 1. J. D. H., aged five years, had had a drooping of the right upper eyelid all her life and the eye was also crossed. The eyelid covered the upper two thirds of the cornea; there were 30 prism diopters of esotropia and a definite limi tation of motion of the right eye up and out. There was no tendency to raise the lid by elevation of the brow. Resection of the levator was performed and also reces sion of the internus and resection of the externus. A slight undercorrection of the ptosis at the outer extremity remained, but the improvement was definite.
Case 2. R. C , aged six years, had had a drooping left upper eyelid all his life. The lid covered slightly more than the upper half of the cornea. There was no action of the levator muscle, and the lid could be lifted only very slightly by means of raising the brow. As the superiorrectus action was good, a Motais opera-
SOCIETY PROCEEDINGS
tion was performed. A marked overcorrection resulted, and the eyeball was turned down badly. One week later a "reversed Motais" operation was per formed. The tongue of muscle was freed from the lid and divided antero-posteriorly. The posterior portion was reattached to the stump whence it came, and the anterior half attached to the surface of the tarsus. The result was excellent. Case 3. E. S., aged five years, had had a drooping of both upper eyelids all his life. Two thirds of the corneas were covered except when he made a strong effort to raise the lids by elevating the brows. It was noticed that he did this most of the time, which along with a tilting of the head backward enabled him to see to get about. A bilateral Reese ptosis operation was performed, which utilized dissected strips of orbicularis muscle to connect with the frontalis muscles of the brows. Both the cosmetic and functional results were highly satisfactory. Dr. Lewis reported a case of the Marcus Gunn, or jaw-winking phe nomenon, and also a case of blepharochalasis, both of which simulated ordi nary ptosis. Kodachrome slides were shown, with a discussion of the treatment of these interesting conditions. A slide of a patient with Homer's syndrome was shown because of the moderate ptosis present. CATARACT EXTRACTIONS, HEMORRHAGE, PROLAPSE, AND GLAUCOMA DR. E. C. ELLETT reported a case of cataract complicated by postoperative hemorrhage, iris prolapse, and secondary glaucoma. Mr. C. was first examined in 1912 at the age of 50 years. His eyes were normal. The vision, R.E., was 20/20 with +1.75D. sph. O +1.50D. cyl. .ax. 180°; L.E., 20/20, with + 1.25D. sph. =C= + 1.00D. cyl. ax. 180°. With a suitable
1157
addition he read J l . He was examined again 10 years later, and there was very little change in the refraction. The vision was still 20/20 and J l , but he had a be ginning cataract in the right eye, in the shape of a spicule up and out. In 1928 the vision in the right eye was 20/100, improved to 20/30 with -0.50D. sph. O +2.25D. cyl. ax. 180°. The vi sion in the left eye was still 20/20. The lens opacity had increased, and there was a slight opacity in the left eye. The pupils, tension, and fundi were normal. In 1929 the best vision in the right eye was 20/80 with - 2 . 0 0 D . sph. O -1.50D. cyl. ax. 90°. The vision in the left eye was still normal. In 1932 the vision in the right eye was 3/200 and in the left eye 20/20. In 1934 the vision in the right eye was light perception. The vision in the left eye was 20/20 and J3, but the refraction was -0.S0D. sph. =C= -2.25D. cyl. ax. 90°. The cataract in the right eye was mature. On November 24, 1934, the lens was extracted from the right eye—a simple intracapsular operation, a peripheral iridectomy having been done. The patient was then 72 years old. The day after the operation the patient got out of bed and pulled off his mask. The iris prolapsed, and was cleanly excised the same day, and the pillars dressed back. On the fourth day the stitch was removed. On the next day, he coughed and had a hemorrhage in the anterior chamber, but the wound was firm. He developed an atropine dermatitis which disappeared when duboisin was substituted for the atropine. On December 28th, the vision was 6/7.5 with +11.00D. sph. O +4.50D. cyl. ax. 15°, and with a suitable addition he read J l . In June, 1938, he returned for a check up. Vision in the right eye was 6/7.5 and J2 with glasses. The optic nerve showed
1158
SOCIETY PROCEEDINGS
a large cup, not definitely pathologic, cut off and much blood was found in the with steep, nasal sides, but shelving to anterior chamber. The nasal half of the the temporal side. The tension was 43 mm. wound was slightly separated, but the Hg (Schiotz). The pupil was large, stitch was removed on the 14th day and feebly active, and there was a dot of pig the patient left the hospital on the follow ment in the wound over the root of the ing day. Clearing of the eye was slow, as temporal pillar of the coloboma. Eserine there was blood in the anterior and reduced the tension, and the patient con vitreous chambers, and a high degree of tinued to use it until his recent death. astigmatism resulted. It was nearly a Tension rose occasionally, and the nerve year before the best vision was obtained. became more cupped, but in February, This was 6/12 with +7.00D. sph. =C= 1943, the tension was 26 mm., vision 6/12 + 10.00D. cyl. ax. 10°. A cystoid condi and J3. The visual fields were never very tion of the scar in the left eye was treated satisfactorily recorded, because of the with trichloracetic acid in June, 1941, for cataract lenses, but there seemed to be a several weeks, with a resultant flattening nasal contraction to 20 degrees. of the wound. The tension never rose in The left eye developed a cataract and the left eye, and the fundus was well seen was operated on on February 19, 1941. a few months after the operation. The last This was after glaucoma had developed examination, made a month before the pa in the right eye, but the tension was never tient's death, was as follows: R.E. vision elevated in the left eye. A combined intra- 6/12 with +11.00D. sph. O +5.00D. capsular extraction was done. Vitreous cyl. ax. 15°; L.E., vision 6/12 with came into the anterior chamber, but none + 8.00D. sph. =C= +10.00D. cyl. ax. 10°. was present in the wound. The next With both eyes the vision was 6/9—. morning, although there had been no pain He read J3, R.E., and J4, L.E., with at all, the dressing was found saturated glasses. The tension was R.E. 26 mm. with blood, and a mass of clot and pre and L.E. 22 mm. The patient died in sumably ocular contents protruded be March, 1943, aged 81 years. tween the lids. Choroidal hemorrhage was The interesting features are the preser more than suspected, but on close inspec vation of useful vision in the right eye tion, the hemorrhage was found to be with miotics, and the happy error in re superficial, and the mass was only a gard to the nature of the postoperative clot attached to.the wound. The clot was trouble in the left eye.
SOCIETY PROCEEDINGS
P L A S T I C REPAIR OF LATERAL MARGINS OF UPPER
A N D LOWER LIDS A N D RECON
STRUCTION OF OUTER C A N T H U S
Sgt. P. W., aged 24 years, suffered a severe lye burn to his left eye and lids when he was three years old. The eye was enucleated at that time and the socket was lined with split-skin graft. The upper and lower lid defects were not repaired and because of this he was unable to re tain a prosthesis. On February 23, 1943, a pedicle skin graft from above the eye brow was brought down and anchored to the upper-lid defect. On March 15, 1943, the pedicle skin graft was split toward the base and reversed to be approximated to the lower-lid defect. Later the pedicle will be severed and the skin will be split along the margin of the outer canthus and skin edges will be approximated. Pvt. R. W. S., aged 30 years, had his left eyeball enucleated on August 10, 1942, when the globe was ruptured and other injuries were sustained when a land mine exploded near him. The globe was removed and the orbit was packed with vaseline gauze and sulfanilamide. Con siderable scarring of the orbital tissue remained along with a loss of substance and contraction of the nasal portion of the upper eyelid. The conjunctival sacs were almost obliterated by adhesions and scarring. On January 8, 1943, under pentothal sodium anesthesia, the scars and adhesions were dissected loose and the medial portion of the upper lid freed from its scar bed and inserted into its normal anatomic position. The orbit was packed with gauze. The patency of the conjunctival sacs did not persist and on February 10, 1943, under similar anes thesia, dissection was carried out well into the upper outer part of the orbit and the lower sac dissected free. A stent of dental molding wax was made to fit into the orbit and around this was wrapped a split-skin graft taken from the right thigh.
The graft had taken well and the patient was soon fitted with a larger prosthesis than was required for the purpose of pre venting any further contraction deformity in healing. Walter A. Ohmart, Secretary.
M E M P H I S SOCIETY OF OPH THALMOLOGY AND OTOLARYNGOLOGY April 12, 1943 DR.
C.
HAYS GLOVER,
presiding
C O N G E N I T A L BLEPHAROPTOSIS A N D S I M U LATING CONDITIONS DR. P H I L I P M. LEWIS reported three cases of congenital blepharoptosis, each patient operated upon by the method that seemed best suited to the individual. Kodachrome slides were shown of each case before and after operation. ■ Case 1. J. D. H., aged five years, had had a drooping of the right upper eyelid all her life and the eye was also crossed. The eyelid covered the upper two thirds of the cornea; there were 30 prism diopters of esotropia and a definite limi tation of motion of the right eye up and out. There was no tendency to raise the lid by elevation of the brow. Resection of the levator was performed and also reces sion of the internus and resection of the externus. A slight undercorrection of the ptosis at the outer extremity remained, but the improvement was definite.
Case 2. R. C , aged six years, had had a drooping left upper eyelid all his life. The lid covered slightly more than the upper half of the cornea. There was no action of the levator muscle, and the lid could be lifted only very slightly by means of raising the brow. As the superiorrectus action was good, a Motais opera-
SOCIETY PROCEEDINGS
tion was performed. A marked overcorrection resulted, and the eyeball was turned down badly. One week later a "reversed Motais" operation was per formed. The tongue of muscle was freed from the lid and divided antero-posteriorly. The posterior portion was reattached to the stump whence it came, and the anterior half attached to the surface of the tarsus. The result was excellent. Case 3. E. S., aged five years, had had a drooping of both upper eyelids all his life. Two thirds of the corneas were covered except when he made a strong effort to raise the lids by elevating the brows. It was noticed that he did this most of the time, which along with a tilting of the head backward enabled him to see to get about. A bilateral Reese ptosis operation was performed, which utilized dissected strips of orbicularis muscle to connect with the frontalis muscles of the brows. Both the cosmetic and functional results were highly satisfactory. Dr. Lewis reported a case of the Marcus Gunn, or jaw-winking phe nomenon, and also a case of blepharochalasis, both of which simulated ordi nary ptosis. Kodachrome slides were shown, with a discussion of the treatment of these interesting conditions. A slide of a patient with Homer's syndrome was shown because of the moderate ptosis present. CATARACT EXTRACTIONS, HEMORRHAGE, PROLAPSE, AND GLAUCOMA DR. E. C. ELLETT reported a case of cataract complicated by postoperative hemorrhage, iris prolapse, and secondary glaucoma. Mr. C. was first examined in 1912 at the age of 50 years. His eyes were normal. The vision, R.E., was 20/20 with +1.75D. sph. O +1.50D. cyl. .ax. 180°; L.E., 20/20, with + 1.25D. sph. =C= + 1.00D. cyl. ax. 180°. With a suitable
1157
addition he read J l . He was examined again 10 years later, and there was very little change in the refraction. The vision was still 20/20 and J l , but he had a be ginning cataract in the right eye, in the shape of a spicule up and out. In 1928 the vision in the right eye was 20/100, improved to 20/30 with -0.50D. sph. O +2.25D. cyl. ax. 180°. The vi sion in the left eye was still 20/20. The lens opacity had increased, and there was a slight opacity in the left eye. The pupils, tension, and fundi were normal. In 1929 the best vision in the right eye was 20/80 with - 2 . 0 0 D . sph. O -1.50D. cyl. ax. 90°. The vision in the left eye was still normal. In 1932 the vision in the right eye was 3/200 and in the left eye 20/20. In 1934 the vision in the right eye was light perception. The vision in the left eye was 20/20 and J3, but the refraction was -0.S0D. sph. =C= -2.25D. cyl. ax. 90°. The cataract in the right eye was mature. On November 24, 1934, the lens was extracted from the right eye—a simple intracapsular operation, a peripheral iridectomy having been done. The patient was then 72 years old. The day after the operation the patient got out of bed and pulled off his mask. The iris prolapsed, and was cleanly excised the same day, and the pillars dressed back. On the fourth day the stitch was removed. On the next day, he coughed and had a hemorrhage in the anterior chamber, but the wound was firm. He developed an atropine dermatitis which disappeared when duboisin was substituted for the atropine. On December 28th, the vision was 6/7.5 with +11.00D. sph. O +4.50D. cyl. ax. 15°, and with a suitable addition he read J l . In June, 1938, he returned for a check up. Vision in the right eye was 6/7.5 and J2 with glasses. The optic nerve showed
1158
SOCIETY PROCEEDINGS
a large cup, not definitely pathologic, cut off and much blood was found in the with steep, nasal sides, but shelving to anterior chamber. The nasal half of the the temporal side. The tension was 43 mm. wound was slightly separated, but the Hg (Schiotz). The pupil was large, stitch was removed on the 14th day and feebly active, and there was a dot of pig the patient left the hospital on the follow ment in the wound over the root of the ing day. Clearing of the eye was slow, as temporal pillar of the coloboma. Eserine there was blood in the anterior and reduced the tension, and the patient con vitreous chambers, and a high degree of tinued to use it until his recent death. astigmatism resulted. It was nearly a Tension rose occasionally, and the nerve year before the best vision was obtained. became more cupped, but in February, This was 6/12 with +7.00D. sph. =C= 1943, the tension was 26 mm., vision 6/12 + 10.00D. cyl. ax. 10°. A cystoid condi and J3. The visual fields were never very tion of the scar in the left eye was treated satisfactorily recorded, because of the with trichloracetic acid in June, 1941, for cataract lenses, but there seemed to be a several weeks, with a resultant flattening nasal contraction to 20 degrees. of the wound. The tension never rose in The left eye developed a cataract and the left eye, and the fundus was well seen was operated on on February 19, 1941. a few months after the operation. The last This was after glaucoma had developed examination, made a month before the pa in the right eye, but the tension was never tient's death, was as follows: R.E. vision elevated in the left eye. A combined intra- 6/12 with +11.00D. sph. O +5.00D. capsular extraction was done. Vitreous cyl. ax. 15°; L.E., vision 6/12 with came into the anterior chamber, but none + 8.00D. sph. =C= +10.00D. cyl. ax. 10°. was present in the wound. The next With both eyes the vision was 6/9—. morning, although there had been no pain He read J3, R.E., and J4, L.E., with at all, the dressing was found saturated glasses. The tension was R.E. 26 mm. with blood, and a mass of clot and pre and L.E. 22 mm. The patient died in sumably ocular contents protruded be March, 1943, aged 81 years. tween the lids. Choroidal hemorrhage was The interesting features are the preser more than suspected, but on close inspec vation of useful vision in the right eye tion, the hemorrhage was found to be with miotics, and the happy error in re superficial, and the mass was only a gard to the nature of the postoperative clot attached to.the wound. The clot was trouble in the left eye.