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THE INDIAN MEDICAL GAZEITE.

[Fes, 1904. 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