ENTROPION AND TRICHIASIS’ 
OP THE 
UPPEE LID; 
THEIR RADICAL TREATMENT, 
AN OPERATION, 
WITHOUT DIVISION OF THE SKIN. 
BY JOSEPH S. HILDRETH, M.D., 
LATE BREVET LT.-COL. AND SURGEON U.S. VOLS., IN CHARGE OF DESMARRES 
(U.S.) ARMY EYE AND EAR HOSPITAL; OPHTHALMIC AND AURAL 
SURGEON TO COOK COUNTY HOSPITAL, CHICAGO, ILL. 
[Reprinted from the Chicago Medical Examiner.] 
f' ..... n 
CHICAGO: 
GEORGE H. FERGUS, BOOK AND JOB PRINTER, 
12 & 14 CLARK STREET. 
1866. ENTROPION AND TRICHIASIS 
OF THE 
U P P E E L [ D. 
That abnormal condition of the lid which makes its free bor- 
der turn inward is called Entropion. Its causes are various; 
but the operation here proposed is intended to apply, mainly, 
to that form of the affection resulting from atrophy, or loss of 
the mucous membrane, and alterations of the tarsus. 
Trichiasis is that condition of the eyelashes which brings 
them into contact with the globe. Certain modifications are 
designated as districhiasis and tristrichiasis, according to the 
subdivision of the deviated lashes into two or three rows. 
These distressing conditions of the lid, so frequently fatal to 
the eye involved, can be relieved, permanently, by surgical or 
mechanical means only. 
When confined to the lower lid the procedure is compara- 
tively simple; but the upper lid from its peculiar mechanism, 
is much more difficult of treatment. 
To relieve that form of entropion referred to above and tri- 
chiasis, I resort to either destruction of the cilia or change their 
position on the tarsus. The former operation is admissible 
when but few of them are affected, and on account of extreme 
age of the patient or other conditions the latter becomes inex- 
pedient. With these exceptions, the operation of “transplanta- 
tion” is always to be preferred. This consists in dissecting up 
that portion of the lid which contains the deviated cilia from 
the tarsus, and then causing it to become so attached to the 4 
ENTROPION AND TRICHIASIS OF THE UPPER LID. 
cartilage that the lashes assume and remain in their proper 
position. 
Before describing the manner in which this may be accom- 
plished, a few words upon the mechanism of some of the parts 
involved will not be inappropriate. 
1st. The position and functions of the orbicularis are such 
that, when contracting, it tends to draw the ciliary margin of 
the external integument of the lid over the free edge of its car- 
tilage. 
2d. The levator, when contracting, tends to draw the free 
edge of the cartilage away from the ciliary margin of the skin 
covering it. 
Hence two antagonistic forces, both tending to produce a 
projection of the ciliary border of the skin covering the lid over 
the corresponding edge of the tarsus, and thereby deviating the 
cilia inward. 
This constitutes the principle obstacle to be overcome, and 
the one which not unfrequently militates against success in the 
operation of transplantation. 
To counteract this difficulty, and at the same time avoid 
dividing the external integument, the following method of oper- 
ating suggested itself:— 
1st. An incision is made in the free edge of the lid, anterior 
to the orifices of the meibomian glands, and posterior to the 
deviated lashes. 
It may extend from within one millimetre of the lachrymal 
punctum to the outer commissure, or further, if required. 
2d. The tarsus is to be dissected in its whole breadth, and, 
as far as practicable, to the length of the incision just made, 
from the parts external to it, including the skin, orbicularis, etc. 
The former is now under the influence of the levator only, the 
latter, that of the orbicularis. 
3d. The lid must next be reversed outward, and the tendon 
of the levator made to descend, so that a separate, coarse silk 
thread can be passed through it, close and parallel to the supe- 
rior edge of the tarsus, and near both extremities of its separa- 
tion from the external integuments. Both strands of each liga- 
ture must come through the mucous surface, and each loop ENTROPION AND TRICHIASIS OF THE UPPER LID. 
5 
should embrace horizontally about five millimetres of the ten- 
don, taking care not to include any of the parts external to it. 
The four strands of the two cords thus left projecting from the 
aperture of the lids should be left four or six inches long, in 
order to insure fastening to the cheek. 
4th. Traction on these cords must next be made sufficient to 
bring the ciliary edge of the tarsus in contact with—in some 
cases below—the corresponding border of the opposite lid, and 
then firmly secured to the cheek by strips of adhesive plaster. 
The skin and fibres of the orbicularis are now to be drawn 
upward and fixed to the tarsus in proper position by two broad 
stitches, inserted near the junction of the outer thirds with the 
inner third of the dissection of these parts from the tarsus. 
The following cut, sketched immediately after an operation, 
shows the proper position of the parts:— 
1, Represents method of securing cords which control the 
levator. 
2, 2, The cords holding the levator. 
3, 3, Stitches securing proper position of external integu- 
ment. 
4, Ciliary border. 6 
ENTROPION AND TRICHIASIS OF THE UPPER. LID. 
5, Lachrymal punctum. 
6, Border of tarsus, projecting, in this case, about two milli- 
metres below the ciliary margin of the skin. 
The strips of adhesive plaster should be numerous enough 
and the cords sufficiently long to guard against slipping. 
The lower border is made to project a short distance below 
the ciliary margin of the external integuments, to allow for sub* 
sequent contraction. The extent to which it should project 
must depend upon the condition of its inner and lower edge. 
If this is well defined, it requires less than when rounded and 
irregular. In some cases, after adhesion has taken place, it 
may be well to remove a small portion of the lower border of 
the cartilage and thereby restore its normal shape. 
The cords holding the levator should always be so arranged 
as not to rest on the cornea. They can be passed through the 
upper margin of the cartilage as well as the tendon, if the oper- 
ator is fearful of their becoming detached too soon, and may 
remain in position a week, if desired; but three days, ordi- 
narily, will be sufficient. 
The outer stitches can be removed after the third day. But 
the removal of these, as well as the long cords, must of course 
depend upon the rapidity and firmness with which adhesion 
takes place. 
Both eyes should be kept closed until the cords are removed. 
Great care should be taken to so operate as to include all the 
deviated lashes. Should a few escape, they can be destroyed 
subsequently. 
The advantages offered by this mode of operating are:— 
1st. No wound of the external integument of the lid is 
required, which always produces more or less deformity. 
2d. The tendency of the transplanted parts to suppurate, 
to fail to unite well, or of the cilia to subsequently fall out on 
account of imperfect nutrition, is avoided. 
The circulation of the parts being but little interfered with, 
reunion is rapid and the result permanent. 
The presence of the cords within the lids controlling the 
levator, like stitches required within the lids in other opera- 
tions, does not prove to be a practical objection.