The Indian Medical Gazette/Volume 39/January 1904/Symblepharon and its Treatment
SYMBLEPHARON AND ITS TREATMENT : TWO CASES TREATED SUCCESSFULLY BY TRANSPLANTATION OF FLAPS OF MUCOUS MEMBRANE FROM THE MOUTH.
By HARRY GIDNEY, F.R.C.S, (EDIN.). D.P.H. (CAMB.), CAPTAIN, I.M.S.
SYMBLEPHARON, ag is well known, is a disease which consists of a pathological adherence of one or both eyelids either partial ov complete to the eye-ball, The cornea may or may not participate in this adhesion but it usually is somewhat implicated, and this adhesion, between the eyelid and cornea, is called by some “Traumatic Pterygiam.” When, besides this eondition of affairs, the two eyelids adhere to each other it is called anklyoblepharon.
This disease is usnally the result of some very ‘strong irritant, or caustic, gaining access to the eye, and is generally accidentally produced, such ag by molten lead, caustic alkalis, strong »ijneral acids, lime, boiling water, ete. It may also result from a severe burn of the eye, ar the cayeless and injudicious use of very strong astringent applications as nitrate of silver, &e. Diffuse uloeration and consequent sloughiug of the internal aspect of the eyelid may be the exciting cause, or a trauma to the eye which produces a complete denudation of the conjunc- tiva of the part.
The amount of destruction of the conjunctiva, in this disease depends on three factors chiefly, viz. (a) the strength of the irritant or trauma for the stronger the irritant the more fatal and complete the destruction; and (0) the length of time the irritant has had to act on the parts. Even very powerful irritants and caustics if removed at once from the eye produce very little destruction, and that only of a superficial nature. And (c) the extent or area of the conjunctiva that has been acted on by the irritant.
Before adhesion can take place between the _ eyelid and eyeball at any part, there must be total and complete destruction and disappear- ance of the conjunctiva of the part. The pro- cess is generally as fullows:—The oeular and palpebral conjunctives being destroyed or burnt (where the action is slight and superficial the epithelium is thrown off, and regeneration takes place), a slough forms which in time separates and granulations spring up from the opposing raw surfaces, These unite and in the course of time develop into fibro-cicatrical tissue which produces a firm attachment of the lid to the eyeball. The train of events is similar to that which occurs in healing by second in- tention of any other wound of the body.
Should the adhesions be confined ta only a | small area it results in the development ofa band
or bands, narrow or broad, stretching from the lid to the eyeball.
When the cornea is included in the adhesions, the dangers are increased and the prognosis less favourable, being dependent piety on the depth and extent of the corneal lesion and its situation, Should the lower quadrant be the part affected, as it usually is, and the resulting opacity be outside the area of the pupil, then the visual acuity need not necessarily be lessened or in any way affected.. But should a iarge area of the cornea be affected, then vision ia seriously lessened, requiring a subsequent irideectomy to ba performed.
Symblepharon should not be mistaken for 4 shortening of the conjunctival sac, which is found in Xerophthalmos, in which disease there ia an extensive cicatricial degeneration of the conjunc- tiva, which assumes a dry lustreless condition associated with shrinking of the membrane and ig tnost commonly the result of an attack of pemphigus or granular ophthalmia.
This condition of affuirs is often wrongly named ayinblepharon.
I have seen a good number of cases of sym- blepharon and think the following classification accordingly to the severity of the case answera all purposes, wiz. (1) mild; (2) medium, and (3) aevere,
(1) Miid.——In this class [ inelade all those eases where a band or bands stretch from the eyelid to the eyeball, and there is a fairly free movemerit of the eyelid,
(2) Medium—-In this diviaion are included ali those cases in which there is a firm adhesion between only a part of the eyelid and the eyeball
(3) Severe—When the whole of one eyelid or both eyelids are firmly adherent to the eye- bali, and there is absolutely no movement in the lid. This E call a complete symblepharon.
The visual results obtained after relieving the auhesions in any of the above three classes de- pend entirely on the extent and localization of the corneal lesion. In very mild cases a band of adhesicns may extend from the inner surface of the eyelid to the centre of the cornea, and here vision would be seriouely impaired; again, the ‘ease may belong to class (3) (severe) and yet vision be perfectly normal, for I have aeen a case where the whole of the lower lid was firmly adherent to the eyeball beneath the level of the cornea } the eyelid seemed to have sunk down and become attached to the eyeball, the cornea being quite clear and normal. In those severe cases in olass (3) where both the lids are adherent, and more especially when anklyoblepharon exists and the exciting cause must have been a very severe one, the cornea is usually entirely destroyed and vision is absolutely nil. The inability to move the eyeball caused by these firm adhesions is a conatunt source of trouble and irritation to the patient, and frequent attacks of conjunctivitisareset up, which aggravate the trou- ble, often producing a considerable amount of corneal haziness, When a burn is the cause of the symblepharon there is generally a certain amount of ectropion and displacement of the punctum lachymalis, or a closure of the orifice causing epiphora.
Treatment—If the symblephgron seriously affecta the normal movements of the eye-ball, or ifit is the meana of producing serious distur- bance of vision by overlapping the cornea, or if itis the cause of frequent recurring attacks of conjunctivitis, it is desirable to relieve it by means of an operation. Operative précedures should not be undertaken till there is a total subsidence of all inflammation and the cicatrices have consolidated thoroughly. All attempts to prevent union of the eyelid to the eye-ball by means of loosening the adhesions, cutting through them or the interposition of metal shields are useless and only a sheer waate of valuable time. The operative measures resorted to differ according to the nature and severity of the case,
In Class 1 (Mild).—Where simply a band or banda stretch across from eyelid to eye-ball, it may be severed by means of aligature; if the band be a broad one, two ligatures may be used, one for either half of the band. When there are several bands, each must be attacked iu this way.
In Class 2 (Medium).—Where a part of the eyelid is adherent to the eye-bail, the procedure ia quite different. Ina few words the object of the operation is to separate the eyelid from the eye-ball by cutting through the adhesions and covering both the exposed surfaces, viz., palpebral and ocular with ai lear of conjunctiva taken from the healthy conjunctiva on either side of the cornea, as advocated by Teale, or with a layer of mucous membrane taken from the lips, mouth, or vagina as recommended by Riverdin and Stellwag, or a transplantation of a portion of a rabbit's conjunctiva as advised by Wolfe, Teale has also suggested the use of a bridge-like flap of conjunctiva, which he obtains from above the cornea, bringing it over the cornea and using this to cover the raw exposed surface, the base of the flap being cut after the flap is sutured into its new position. It really does not matter much from where you obtain your epithelial flaps so long as you get a suffi- cient amount. Ihave tried Teale’s operation in one or two cases, but the results were not very satisfactory, in fact I could not obtain sufficiently large enough conjunctival fiaps without produc- . ing an undue amount of tension and consequent shrinking. and, moveover, the eye could not spare much of its conjunctiva, :
In my two last cases which I allude to in this paper, I did a modified Stellwag's operation, obtaining my mucous flaps from the mouth, a3 follows :—
Case I.—The whole of the inner two-thirds of the lower eyelid was adherent to the eye-ball ; there was also a amall corneal adhesion. The patient waa a Staffordshire policeman, and the cause was an accidental introduction—of some strong caustic alkali which;be. merely, washed out and did not trouble about till the disease had far advanced, I saw him 5½ months after the accident with the affected part of the eyelid firmly adherent to the eye-ball. He was placed under chloroform, and by means of a blue pencil the hidden and adherent part of the corneal circle was mapped out on the skin of the eyelid
Fig. 1.
A.—This was part adherent to the cornea. The dotted lines were the guide for my incision, indicating the contour of the corneal circle.
as a guide for my incision, vide Fig. 1, A. I then cut down right through the whole thickness of the lid, leaving this small triangular piece of eyelid adherent to the cornea. The lid was then dissected off the eye-ball (i.e., the adherent part of it) right down to the inferior conjunctival fornix, taking great care to get this sulcus on a level with the healthy part of the fornix of the outer third of the eyelid. This was a very bloody procedure at first, but the free use of adrenalin solution (chloride, 1 in 1000) rendered the rest of the operation almost bloodless.
I roughly measured the size of the surfaces requiring epithelial coverings and then proceeded to cut out the mucous membrane required from the mouth and lips. I obtained three
Fig. 2.
A.—Triangular piece of symblepharon adherent to cornea.
B.—Exposed ocular surface covered over by mucous flap B.
C.—Everted (previously) adherent part of eyelid covered with mucus flap C.
D.—Conjuntctive fornix (inferior) covered over by long narrow mucous flap D.
E.—Fine interrupted sutures.
pieces of mucous membrane, two of these for the ocular and palpebral exposed surfaces and a third a somewhat narrower and longer piece for the fornix. All these pieces were somewhat larger than the raw surfaces as I wanted to have more than enough so as to compensate against the subsequent shrinking which usually occurs.
These three flaps were then placed in their respective positions and kept fixed there by means of a liberal application of very fine sutures. A glance at Fig. 2, B, C and D, will show the position of these flaps; here I have purposely everted the previously adherent part of the lower lid so as to explain myself diagramatically; B being the flap over the exposed raw (previously adherent) ocular surface; C the previously adherent but now free lower lid (everted); and D the conjunctinal fornix where I have placed my long narrow flap of mucous membrane. The light triangular piece in the lower corneal quadrant is the part of the adherent eyelid, or symblepharon, which has been left attached to the cornea. This in the course of a short time soon atrophied and disappeared, leaving a slight corneal opacity behind, which did not interfere with vision. These flaps healed very rapidly and firmly, and the result was all that could be expected. The third day after the operation, and on subsequent days, when I dressed the eye, I gently passed a fine probe between the eyelid and eye-ball so as to tear down any slight adhesions which might have developed. I consider this as a very important point in the after-treatment of these cases, as it prevents the formation of any subsequent adhesions which are likely to develop from small uncovered areas. I saw this man regularly every month for almost six months after the operation, and up to that time there were no signs of any tendency to a reunion of the surfaces, his lower eyelid being freely moveable.
The second case was almost similar to the first, but slightly more advanced, encroaching somewhat on the pupiliary area of the cornea and producing a fair amount of visual disturbance.
I treated this case (which was that of a Hindu signboard painter) in precisely the same way as Case I, with the same result. Except, as I said before, the corneal opacity interfered with his vision. I intended doing an iridectomy afterwards, but he left the place.
In the performance of this delicate operation there are some important points which the surgeon has to pay great attention to, as on them depends success or failure, viz.:—
(a) All bleeding must be arrested entirely at the surfaces where the transplantation is to take place, and I again assert that the application of adrenalin chloride solution (1 in 1,000) is invaluable during this part of the operation, for it renders an otherwise rather bloody operation comparatively bloodless; this helps the surgeon tremendously, for he can see plainly what he is ding the whole time, and moreover obviates the constant application of swabs to the bleeding surface, which undoubtedly cause some irritation to the cornea and adjacent conjunctiva. (b) Knowing that mucous flaps usually shrink to almost two-thirds of their original size, one should be very careful that the original flaps are large enough. It is safer and wiser to err on the safe side and have your flaps too large, rather than an exact size of the exposed surfaces or smaller, for should your flaps be not large enough and shrinking occurs, small areas are left unprotected with epithelial covering, and a reunion is the inevitable result.
(c) The flaps should consist of mucous membrane only, and no submucous tissue at all.
(d) The operation should be performed as speedily as possible, so as to have mucous flaps with full vitality in them, and so as not to keep them immersed for too long a time when their vitality is bound to suffer. A good deal of the surgeon's time is here taken up in arresting, by means of a swab or sponge, the capillary oozing from the exposed surfaces, and again I strongly advocate the use of adrenalin chloride as a rapid and most powerful local styptic.
(e) There should be no tension of the flaps as they occupy their new positions, and this is obtained by having large enough flaps.
(f) There should be a liberal application of fine delicate sutures to help and keep the flaps in their correct positions.
{g) Great attention should be paid to the fornix. One is apt to neglect this sulcus, but I believe it in a measure decides the result of the operation, for if it be not properly and adequately covered, adhesions are bound to take place, resulting in a certain amount of fixity of the root of the eyelid and constant discomfort to the patient and most probably a subsequent entropion with its attendant disasters.
(h) The flaps during the interval between their detachment and adjustment (which should be as short as possible) should be kept moist and warm. The application of the long narrow piece of mucous membrane for the fornix is rather difficult and tedious, requiring a deal of patience, but the after-results amply compensate the surgeon for this little extra trouble.
I am of opinion that three flaps of mucous membrane properly applied and ligatured into position, véz., one for the ocular surface, one for the palpebral surface, and the third one to fill up the sulcus of the fornix answers all purposes and gives better results. It is this little toilette of the operation that I attribute the success of my cases with absolutely free movement of the lid.
In cases where there is a very small surface to cover with conjunctiva one can easily do as Teale advocates, viz., obtain it from the conjunctiva of the eye from either side of the cornea, or as a bridge-like flap from above the cornea; but even here we often meet with cases in which the non-adherent or non-diseased parts of the ocular conjunctiva are inflamed, hypervascular, discolored or somewhat contracted, and these eyes can ill spare any conjunctiva. One can more readily and easily obtain liberal flaps from such a large mucous surface as the mouth than from an already partly diseased eye, which cannot afford to spare any of its mucous covering.
In this article I do not mean to put this operation as a new one before the profession, but, as a modification of that of Stellwag and of Riverdin, the latter consists in covering the exposed surfaces with small pieces of mucous membrane obtained from the mouth.
In Class (3) Severe—When the whole of the lower eyelid is adherent to the eyeball, the same procedure as I recommend in class 2, viz. division of the adhesions and transplantation of mucous flaps from the mouth should be tried. Harlan, Kuhut and Snellen, however, advocate a covering of ordinary skin and not mucous membrane for the exposed surface of the lower lid, and this they obtain by making a skin flap from the skin below the lower margin of the orbit, and turning it up as on a hinge and slipping it through another long incision made above this flap on a level with the lower orbital margin, and which incision, being made right through the entire lid, acts as a button-hole for the skin flap to be passed through. This skin flap is next sutured to the inner surface of the lower eyelid. This skin, after some time, becomes modified and somewhat resembles mucous tissue, but does not act in the same way, as the hairs which develop are bound to irritate the conjunctiva and cornea and set up irritation.
When both lids are adherent they may each in turn be separated and covered over with flaps of mucous membrane either from the mouth or from a rabbit. When anklyoblepharon is present, and this, being generally the result of a burn, is almost always accompanied by symblepharon, it can be remedied by a division of the adhesions between the two eyelids, but in these severe cases the cornea is usually so destroyed by the original cause of the disease that operative measures are more or less useless unless there is a chance of obtaining some visual results.