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.
