Reprinted from the North American Practitioner. 
SPASTIC SENILE ENTROPION GYRED BY CANT IIOTOMY.* 
By Boernc Henman, JI.D. 
OF 
GentlemenThe patient I present you today has recovered from 
a lid trouble which lasted about half a year. During that time a num- 
ber of measures were employed for his alleviation, without avail, until 
I determined as a dernier ressort to make a canthoplasty, the good results 
of which were immediate and permanent. 
This gentleman had a spastic entropion of both lower eye-lids. If 
you will examine him closely, you will observe a linear and several 
punctiform scars on these parts due to the various operations made to 
give the lids a normal position. You will also observe that the cilia 
arc turned outward and that when he winks or closes his eyes the lid 
margins remain in the frontal plane. 
A few words as to entropion in general, before we repeat his clinical 
history. The term, as you know, indicates an inversion of the lids. 
This condition is cither partial or complete—and may be due to a 
variety of causes. 
For the sake of brevity and clearness three forms of entropion are 
recognized, due to various anatomical or rather pathological factors: 
Muscular entropion, cicatricial entropion; entropion bulbale. The 
second variety is well illustrated in those cases resulting from trachoma 
where the chronic inflammatory process induces cicatrization of the 
palpebral conjunctiva resulting in a curved condition of the lids 
and an inversion of their edges. 
When the lid support is lacking, associated with slight changes in 
the conjunctiva, as in enucleation of a sensitive eye, the third form of 
entropion often occurs. 
The variety to which 1 wish to call particular attention is due to 
spasmodic action of the ciliary margin of the obicular muscle. Ordin- 
arily there is associated with it a relaxed condition of the cutaneous 
surface, and an irritability of the conjunctiva, as for instance a conjunc- 
tivitis, giving rise to senile entropion and spastic entropion. 
It may be only temporary and instantly relieved when the exciting 
cause is removed, as unbandaging an eye which has been kept covered. 
Again, it may be more permanent and only relieved by operative 
measures. 
* A Clinical Lecture delivered at the Post-Graduate Medical School, Chicago. 2 
The case in question is one of this nature, and if you will follow’ 
the clinical history as I relate it, you will become acquainted with the 
usual treatment adopted, and also with the difficulties often encoun- 
tered in arriving at a successful termination. 
The mucous lining of this patient’s lids is slightly discolored, having 
a brownish appearance, known as argyrosis, due to long continued 
applications of nitrate of silver. 
Our patient, who is sixty-five years old, was admitted into the 
Illinois Charitable Eye and Ear Infirmary April 2, 1892, suffering from 
a spastic entropion of both lower lids. He informed us that during 
the past four years he had repeated attacks of conjunctivitis which 
had been cured by application of silver nitrate. The ciliary margins 
were so completely everted that the cilia2 were barely visible. On 
everting the lids with the finger they retained their normal position 
until he winked, when they again forcibly turned inward. 
The palpebral conjunctiva of both eyes was swollen, reddened, and 
partially covered by a muco-purulent discharge. The cutaneous sur- 
face was wrinkled. The conjunctivitis had lasted about a week and 
was either the result or cause of the entropion. I therefore determined 
to overcome both symptoms as neither could be abrogated unless both 
subsided. 
The conjunctivitis was treated with a one per cent, solution of 
nitrate of silver and the lids everted and fastened to the cheeks by 
strips of adhesive plaster. These, however, would not hold the parts 
in place, the tears and secretion constantly flowing over the face, wet- 
ting and washing them- off. Pads were next applied under the lids 
held firmly in position by bandages—with no better results. I then 
passed two sutures through each lid at the edges underneath the skin 
and brought the end out an inch below and fastened them over two 
pieces of rolled paper. As long as they remained in situ, the cilia 
retained their normal position and the conjunctivitis ceased. No 
sooner had the threads cut through than the entropion returned. 
This operation was repeated on the lower lid June 16, but a week 
later both lids had gradually resumed their abnormal position and the 
conjunctivitis returned. 
Aug. 22 my assistant, Dr. Woodruff, made a double Hotz’s opera- 
tion combined with the removal of an oval piece of skin. In other 
w'ords, the ciliary margin was fastened to the lower margin of the 
tarsus. The result of this maneuver was temporarily good; at the end 
of three weeks the old state of affairs had returned. The eye-lashes 
sw'ept over the conjunctiva and cornea, causing an irritation which 
resulted in conjunctivitis. 
Having exhausted all the methods ordinarily employed for the 
correction of this condition and having been balked at every step, 1 3 
for the first time gave the matter my serious attention and considered 
its pathological features—which, as you know, are spasmodic action of 
the ciliary margin of the obicular muscle and secondary conjunctival 
irritating. 
It occurred to me that if the contraction of the muscular fibres 
could be overcome and their power lessened; the spasmodic action 
would cease. I therefore decided to divide the muscles to make, in 
other words, a canthotomy. This I did in the following manner: I 
introduced the blade of a straight pair of scissors under the outer can- 
thus, the other blade passed over its outer surface and the intervening 
parts were cut at one stroke. Thus I severed the inner edge of the 
orbicularis palpebralis muscles in both eyes. 
The result was not only immediate, but permanent, the patient 
being discharged three weeks later, Dec. 20, perfectly cured. Today, 
March 15, his lids appear absolutely normal excepting the scars 
already referred to. This operation has, so far as I can learn, never 
been performed for spastic senile entropion, although it has been 
adopted for entropion due to blepharospasm associated, however, with 
the excision of a fold of skin from the lid. 
The indication of this operation in these cases appears quite logical. 
An orbicular muscle is in a state of clonic spasm. The end in view is 
to induce its relaxation. Ifl again meet a similar case, I shall at first 
try hot or cold applications, then hypodermic injections of morphine, 
and if the spasm doesn’t yield, cut the tense contracted muscular 
fibres which in this case abolished the spastic condition. 
Treatment of Strabismus. 
As long as the minds of medical men are subject to the same 
influences which affect the brain of other mortals, so long will results 
of investigations take upon themselves the color of various stages of 
scientific periods. No branch of ophthalmology illustrates this more 
fully than the chapter devoted to strabismus. After the conception 
of orthopedic surgery had been fully formed by Stroymeyer and 
special attention had been directed by him to strabismus, the keen 
surgeon Dieffenbach, practically carried his suggestions into effect. 
The novelty and simplicity of his new procedure created great enthu- 
siasm, the effects of which are still felt to this day. The indications 
for operative interference not being fully established, the usual error 
of general, universal application of a remedy was committed. It was 
not until Graefc and Donders appeared on the scene and demonstrated 
the relationship between squint and errors of refraction, that the 
demand for more conservative treatment was heard. The rules laid 4 
down then did not find general application. Kven to this day many 
surgeons, although recognizing the importance of spectacle treatment, 
still feel the influence of former teachers and regard tenotomy of 
primary importance. But it is difficult to stem the tide. A reaction 
is beginning to set in; soon it will reach its height, and with the ebb 
the wave of public sentiment will flow the other way. 
Physiological anatomical researches have taught us that hyperme- 
tropia is responsible for 75 per cent, of all cases of convergent stra- 
bismus. Further inquiry has proven that accommodation and'con- 
vergence, which stand in intimate relationship one with the other, are 
the important underlying factors. What is more rational than to 
overcome the cause, by fitting appropriate glasses and thus correct 
the evil. The general practitioner, the family adviser, is frequently 
the obstacle to more enlightened methods. The youth of the child is 
regarded as an objection to curative measures, or the possibilities of 
“outgrowing the squint” is held out to the parents and willingly 
grasped by them. 
The statement has been advanced that fully 50 per cent, of cases 
of periodic strabismus will yield, to the correction of the ametropia, 
by glasses and the use of atropine. If the age of the infant precludes 
such mode of treatment, the vitality, the function of the visual organ, 
should be preserved until a later age. Disuse of any organ must 
necessarily be followed by disturbed function. A fore-arm bandaged to 
the upper arm for a number of years will cause atony of the contractors 
and extensors. Long standing convergence will be associated with 
altered conditions in the dynamic power of the external and internal 
recti-muscles. Amblyopia from disuse will follow in the wake. A 
satisfactory solution of the problem lies in orthopedic training. The 
muscles of paralytics are kept in a normal state by exercising them. 
The acuity of vision and contractile force of the recti can be equally 
preserved by bandaging the normal eye and bringing into action the 
deviating one. An alternating squint may thus be produced which 
will render more facile the subsequent effects of glasses or tenotomy. 
The non-operative measures require a long time for fruition, but they 
are attended with more lasting and beneficial results to the patient and 
with more credit and gain to the physiciah.