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Ptosis with Elephantiasis and Ectropion*
NOTES, CASES, INSTRUMENTS
1144
ing rather than cutting effect on the vessels that completely controls all bleeding from the posterior ciliary arteries, central retinal artery, and vein. This step is easily mastered because the operator quickly develops a sense of feel denoting the point when the optic nerve is well crushed. Another point in favor of the snare tech nique is that it is not necessary to use a tight pressure bandage to prevent postoperative hemorrhage into Tenon's capsule with pos sible expulsion of implant. The patient may be out of bed after he has recovered from the anesthesia. SUMMARY
The snare technique in enucleation has the following points of advantage over scissors: 1. Less traumatism to posterior one third of Tenon's capsule and no lacerations occur. 2. No bleeding when eye is enucleated saving 5 to 15 minutes on operating time. 3. Control of postoperative hemorrhage, making negligible the possibility of extrusion of the implant. 4. Tight uncomfortable pressure dressing not necessary. 5. Patient may be out of bed as soon as he has recovered from anesthesia. Any operator who uses this technique a few times will be well pleased with it and will use it to replace the scissors in most of his enucleation pro cedures. 1720 Exchange Building (3).
PTOSIS W I T H E L E P H A N T I A S I S AND ECTROPION* SIDNEY A. Fox,
M.D.
New York Beard1 tells us that "advancement, or shortening the levator, by making a fold therein, was first suggested by Bowman . . . and first practised by Everbusch of Munich (in 1883)." He also credits Snellen of * Ophthalmology Service, New York UniversityBellevue Medical Center.
Utrecht with the first resection of the levator tendon. Since then there have been in numerable modifications of the original tech niques, including the now classical Everbusch procedure. Of these modifications probably the most popular is that of Blaskovics2 who, in 1923, first suggested tarso-levator resec tion by the conjunctival route. Since then, many variations of this latter procedure have in turn found their way into the litera ture. The rare case of ptosis reported here in which a Blaskovics approach was used is presented because of the bizarre history, the unusual combination of deformities it pre sented, and the unexpectedly fortunate re sults obtained. CASE REPORT
History. E. C , a 12-year-old Negro boy, was first seen in March, 1948. At the age of 18 months he was struck in the right eye with a baseball. A few weeks later, the right upper lid began to swell and the eye to close. This condition progressed until the eye was com pletely closed and has remained so since. On March 31, 1939, he was admitted to the Manhattan Eye, Ear, and Throat Hos pital where a biopsy of the lid swelling was made. The pathologic diagnosis was plexiform neuroma. The vision at that time was 20/40 in the right eye and 20/30 in the left eye. He was discharged April 4, 1939. On January 22, 1947, he was admitted to Metropolitan Hospital for a "lump on his right eyelid" after having been treated at Memorial Hospital for fibromatosis involving the right orbit and temple (date not speci fied). Because of right-sided convulsive seizures, right hemiparesis, and possible left cortical atrophy (X ray) a craniotomy was done through a left temporoparietal flap. A subarachnoid cyst was found and drained. A local -pachymeningitis was also found. The patient was discharged on April 23, 1947. He was readmitted to Metropolitan Hospital on July 15, 1947, with a diagnosis of ptosis
NOTES, CASES, INSTRUMENTS
and elephantiasis of the right upper lid. At operation on July 29, 1947, "scar tissue was excised from the right upper lid." The patho logic diagnosis was nonspecific fibrous tissue. He was discharged on August 1, 1947. Physical examination. When seen in March, 1948, the boy appeared underde veloped. He was mentally retarded and had been a behavior problem in school. The right arm was atrophic and held in flexion across the chest. There was a soft, irregular, nontender mass anterior to the right ear. Eye examination. The right upper lid was twice the normal size and covered the eye completely (fig. 1). The lid was twice the normal thickness and the palpebral fissure measured 45 mm. in length. There was an ectropion with thickening and excoriation of the exposed conjunctiva as is usually seen in cases of long standing. There was a hori zontal scar, 5.0 cm. in length, running along the lower border of the right eyebrow. De spite all this there was slight movement of the lid on looking upward, though not enough to uncover any part of the cornea. The best obtainable vision was: R.E., 20/100, with the lid held up; L.E., 20/25. There was limitation of rotation of the right
Fig. 1 (Fox). Appearance of patient before operation.
eye in all directions. The fundus was nega tive. X-ray studies of the orbits showed normal optic foramina but there were "sclerotic changes adjacent to the right orbit external ly." X-ray studies of the skull showed "a sella larger than normal with the posterior
1145
portion widened." No destructive pathologic process was noted. Operative procedure. On March 4, 1948, a modified Blaskovics operation was per formed under general anesthesia. On eversion of the lid the conjunctiva was found to be so thickened, discolored, redundant, and fibrotic that it was impossible to identify the upper edge of the tarsus clearly. A hori-
Fig. 2 (Fox). Appearance after first repair. Note good lid fold.
zontal incision, 10 mm. from the lid edge, was made in the thickened conjunctiva and tarsus along the whole length of the lid with considerable difficulty and undermined up ward for 15 mm. This tissue was so thick that it was everted and portions of it shaved off to thin it out. Much bleeding was en countered. In place of the normally thin levator mus cle a thick, fibrotic tissue was discovered which did not look as if it had any contrac tile elements at all. However, this was dis sected up from the subjacent thickened orbicularis (more by guess than by anatomic appearance) as far back as it was possible to go, and a strip about 15 mm. in width was resected. Three double-armed, 4-0 plain cat gut sutures were passed through the upper edge of the presumed levator which was then pulled down and sutured between, the lower edge of cut tarso-conjunctiva and the skinmuscle layer. The conjunctiva was revised, a good deal of the redundancy resected and the cut edges sutured together with 4-0 black silk interrupted sutures. Because of the difficulty encountered in
NOTES, CASES, INSTRUMENTS
1146
identifying tissues and because of the exten sive dissection, the prognosis for success was not particularly good. It was gratifying, therefore, to note two weeks after operation that there was elevation of the right upper lid almost equal to that of the left upper lid. Not" only that, but there was a good lid fold (fig. 2 ) . However, there was still a protru sion of redundant, thickened conjunctiva although the ectropion had disappeared. Six weeks later the excess conjunctiva was
Fig. 3 (Fox). Appearance after excision of re dundant conjunctiva. Canthoplasty required. resected with the result seen in Figure 3. T h e patient was now able to open and close his eyes normally. T h e palpebral fissure was still too long and the boy was told to return in four weeks for a final canthoplasty. H e did not return. Five years from now he will
probably drift into another hospital and the final repair will be made. COMMENT
T h e obvious comment here, of course, is that no case however seemingly hopeless is necessarily so. Certainly the result here ex ceeded all reasonable expectations. Another unusually interesting feature—at least to me—is the latent power residual in a levator which had been inactive for 10 years and had undergone tremendous fibrosis in addition. One can only postulate sufficient concomitant hypertropy of levator muscle fibers along with hypertrophy of the rest of the lid to retain a modicum of elevating func tion when given the chance. It is also worth mentioning, I think, that however abnormal the conditions encoun tered, it is always wise to stick to basic tech niques which have been found trustworthy. It is true that the techniques may have to be simplified. In this case the bare essentials of the Blaskovics procedure were employed. N o attempt was made to use any of the surgical elaborations abounding in the literature— levator resection at its simplest was done. A n d Fortune smiled. 11 East 90th Street (28).
REFERENCES
1. Beard, C. H.: Ophthalmic Surgery. Philadelphia, Blakiston, 1914, p. 238. 2. De Blaskovics, L.: A new operation for ptosis with shortening of the levator and tarsus. Arch. Ophth., 52-.563-573,1923.
A N E W METHOD FOR EXPOSURE OF THE GLOBE IN CATARACT SURGERY B E N N E T T W . M U I R , M.D.
AND A. J. K A F K A ,
M.D. Denver, Colorado It is a well-known fact, and one which m a y be easily demonstrated by even casual observation at the operating table, that the ordinary speculum used in cataract surgery frequently presses on the globe and causes
an increase in intraocular pressure. Some times undesirable effects, such as the loss of vitreous, can be traced directly to this in creased pressure. A speculum is essentially rigid in its make up and cumbersome to adjust, particularly during the course of an operation after the eye has been opened. At the end of opera tion even the removal of a speculum is not entirely free from danger, since the spring mechanism is often quite strong, and the ma nipulation of one blade moves the other. O n e
1144
ing rather than cutting effect on the vessels that completely controls all bleeding from the posterior ciliary arteries, central retinal artery, and vein. This step is easily mastered because the operator quickly develops a sense of feel denoting the point when the optic nerve is well crushed. Another point in favor of the snare tech nique is that it is not necessary to use a tight pressure bandage to prevent postoperative hemorrhage into Tenon's capsule with pos sible expulsion of implant. The patient may be out of bed after he has recovered from the anesthesia. SUMMARY
The snare technique in enucleation has the following points of advantage over scissors: 1. Less traumatism to posterior one third of Tenon's capsule and no lacerations occur. 2. No bleeding when eye is enucleated saving 5 to 15 minutes on operating time. 3. Control of postoperative hemorrhage, making negligible the possibility of extrusion of the implant. 4. Tight uncomfortable pressure dressing not necessary. 5. Patient may be out of bed as soon as he has recovered from anesthesia. Any operator who uses this technique a few times will be well pleased with it and will use it to replace the scissors in most of his enucleation pro cedures. 1720 Exchange Building (3).
PTOSIS W I T H E L E P H A N T I A S I S AND ECTROPION* SIDNEY A. Fox,
M.D.
New York Beard1 tells us that "advancement, or shortening the levator, by making a fold therein, was first suggested by Bowman . . . and first practised by Everbusch of Munich (in 1883)." He also credits Snellen of * Ophthalmology Service, New York UniversityBellevue Medical Center.
Utrecht with the first resection of the levator tendon. Since then there have been in numerable modifications of the original tech niques, including the now classical Everbusch procedure. Of these modifications probably the most popular is that of Blaskovics2 who, in 1923, first suggested tarso-levator resec tion by the conjunctival route. Since then, many variations of this latter procedure have in turn found their way into the litera ture. The rare case of ptosis reported here in which a Blaskovics approach was used is presented because of the bizarre history, the unusual combination of deformities it pre sented, and the unexpectedly fortunate re sults obtained. CASE REPORT
History. E. C , a 12-year-old Negro boy, was first seen in March, 1948. At the age of 18 months he was struck in the right eye with a baseball. A few weeks later, the right upper lid began to swell and the eye to close. This condition progressed until the eye was com pletely closed and has remained so since. On March 31, 1939, he was admitted to the Manhattan Eye, Ear, and Throat Hos pital where a biopsy of the lid swelling was made. The pathologic diagnosis was plexiform neuroma. The vision at that time was 20/40 in the right eye and 20/30 in the left eye. He was discharged April 4, 1939. On January 22, 1947, he was admitted to Metropolitan Hospital for a "lump on his right eyelid" after having been treated at Memorial Hospital for fibromatosis involving the right orbit and temple (date not speci fied). Because of right-sided convulsive seizures, right hemiparesis, and possible left cortical atrophy (X ray) a craniotomy was done through a left temporoparietal flap. A subarachnoid cyst was found and drained. A local -pachymeningitis was also found. The patient was discharged on April 23, 1947. He was readmitted to Metropolitan Hospital on July 15, 1947, with a diagnosis of ptosis
NOTES, CASES, INSTRUMENTS
and elephantiasis of the right upper lid. At operation on July 29, 1947, "scar tissue was excised from the right upper lid." The patho logic diagnosis was nonspecific fibrous tissue. He was discharged on August 1, 1947. Physical examination. When seen in March, 1948, the boy appeared underde veloped. He was mentally retarded and had been a behavior problem in school. The right arm was atrophic and held in flexion across the chest. There was a soft, irregular, nontender mass anterior to the right ear. Eye examination. The right upper lid was twice the normal size and covered the eye completely (fig. 1). The lid was twice the normal thickness and the palpebral fissure measured 45 mm. in length. There was an ectropion with thickening and excoriation of the exposed conjunctiva as is usually seen in cases of long standing. There was a hori zontal scar, 5.0 cm. in length, running along the lower border of the right eyebrow. De spite all this there was slight movement of the lid on looking upward, though not enough to uncover any part of the cornea. The best obtainable vision was: R.E., 20/100, with the lid held up; L.E., 20/25. There was limitation of rotation of the right
Fig. 1 (Fox). Appearance of patient before operation.
eye in all directions. The fundus was nega tive. X-ray studies of the orbits showed normal optic foramina but there were "sclerotic changes adjacent to the right orbit external ly." X-ray studies of the skull showed "a sella larger than normal with the posterior
1145
portion widened." No destructive pathologic process was noted. Operative procedure. On March 4, 1948, a modified Blaskovics operation was per formed under general anesthesia. On eversion of the lid the conjunctiva was found to be so thickened, discolored, redundant, and fibrotic that it was impossible to identify the upper edge of the tarsus clearly. A hori-
Fig. 2 (Fox). Appearance after first repair. Note good lid fold.
zontal incision, 10 mm. from the lid edge, was made in the thickened conjunctiva and tarsus along the whole length of the lid with considerable difficulty and undermined up ward for 15 mm. This tissue was so thick that it was everted and portions of it shaved off to thin it out. Much bleeding was en countered. In place of the normally thin levator mus cle a thick, fibrotic tissue was discovered which did not look as if it had any contrac tile elements at all. However, this was dis sected up from the subjacent thickened orbicularis (more by guess than by anatomic appearance) as far back as it was possible to go, and a strip about 15 mm. in width was resected. Three double-armed, 4-0 plain cat gut sutures were passed through the upper edge of the presumed levator which was then pulled down and sutured between, the lower edge of cut tarso-conjunctiva and the skinmuscle layer. The conjunctiva was revised, a good deal of the redundancy resected and the cut edges sutured together with 4-0 black silk interrupted sutures. Because of the difficulty encountered in
NOTES, CASES, INSTRUMENTS
1146
identifying tissues and because of the exten sive dissection, the prognosis for success was not particularly good. It was gratifying, therefore, to note two weeks after operation that there was elevation of the right upper lid almost equal to that of the left upper lid. Not" only that, but there was a good lid fold (fig. 2 ) . However, there was still a protru sion of redundant, thickened conjunctiva although the ectropion had disappeared. Six weeks later the excess conjunctiva was
Fig. 3 (Fox). Appearance after excision of re dundant conjunctiva. Canthoplasty required. resected with the result seen in Figure 3. T h e patient was now able to open and close his eyes normally. T h e palpebral fissure was still too long and the boy was told to return in four weeks for a final canthoplasty. H e did not return. Five years from now he will
probably drift into another hospital and the final repair will be made. COMMENT
T h e obvious comment here, of course, is that no case however seemingly hopeless is necessarily so. Certainly the result here ex ceeded all reasonable expectations. Another unusually interesting feature—at least to me—is the latent power residual in a levator which had been inactive for 10 years and had undergone tremendous fibrosis in addition. One can only postulate sufficient concomitant hypertropy of levator muscle fibers along with hypertrophy of the rest of the lid to retain a modicum of elevating func tion when given the chance. It is also worth mentioning, I think, that however abnormal the conditions encoun tered, it is always wise to stick to basic tech niques which have been found trustworthy. It is true that the techniques may have to be simplified. In this case the bare essentials of the Blaskovics procedure were employed. N o attempt was made to use any of the surgical elaborations abounding in the literature— levator resection at its simplest was done. A n d Fortune smiled. 11 East 90th Street (28).
REFERENCES
1. Beard, C. H.: Ophthalmic Surgery. Philadelphia, Blakiston, 1914, p. 238. 2. De Blaskovics, L.: A new operation for ptosis with shortening of the levator and tarsus. Arch. Ophth., 52-.563-573,1923.
A N E W METHOD FOR EXPOSURE OF THE GLOBE IN CATARACT SURGERY B E N N E T T W . M U I R , M.D.
AND A. J. K A F K A ,
M.D. Denver, Colorado It is a well-known fact, and one which m a y be easily demonstrated by even casual observation at the operating table, that the ordinary speculum used in cataract surgery frequently presses on the globe and causes
an increase in intraocular pressure. Some times undesirable effects, such as the loss of vitreous, can be traced directly to this in creased pressure. A speculum is essentially rigid in its make up and cumbersome to adjust, particularly during the course of an operation after the eye has been opened. At the end of opera tion even the removal of a speculum is not entirely free from danger, since the spring mechanism is often quite strong, and the ma nipulation of one blade moves the other. O n e