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While there are many effective entropion repair techniques, the pre-tarsal orbicularis muscle transposition is one of the simplest to perform. It gives excellent result by addressing the pathophysiology and minimally disturbing normal anatomy. It may be used in the correction of involutional and severe form of spastic entropion. Recurrence is very rare, and when it occurs, the same technique may be repeated without difficulty.

Es ist das grose Verdienst von A. B. Scott (San Francisco), die muskellahmende Wirkung des Botulinustoxin A in die Ophthalmologie zur Erzeugung kunstlicher Paresen eingefuhrt zu haben. Beim essentiellen Blepharospasmus und beim Hemispasmus facialis stellt die Injektion des Toxins in den M. orbicularis eine echte Alternative zur medikamentosen und operativen Therapie dar. Der Effekt der Injektionen dauert einige Wochen bis mehrere Monate an, wobei die besonders bei wiederholten Injektionen auftretende Denervationsatrophie des Orbicularis erwunscht ist.

Insertion of full-thickness absorbable eyelid sutures was carried out during a four-year period on 34 unselected patients with spastic or senile entropion. Four 5/0 Dexon sutures proved to be the most effective method. The over-all success rate was 50% and thus the operation cannot be recommended as the standard procedure for cases of entropion. Even so, it is useful in cases of spastic entropion due to surgery or corneal ulceration, when 100% success can be expected, and also when minimal surgical trauma or inconvenience is desired for often very elderly patients.

The treatment of spastic entropion has in my experience not been entirely satisfactory, and in talking with other ophthalmologists I find that they have had similar disappointments. This applies to the treatment of entropion which has not responded to injections of alcohol, the use of sutures or other therapeutic measures. Some of the numerous procedures for the relief of entropion follow, with a description of the principles involved in a number of them : Temporary mechanical correction by means of collodion, adhesive plaster, sutures or cautery puncture. Correction by plastic procedures, such as the Celsus operation, Graefe's operation, Vogt's canthoplasty and the Panas-Chronis procedure. These procedures evert the lid by shortening the skin from above down, as in the Celsus operation, or by making the skin taut from side to side, pushing backward on the orbicularis oculi muscle and the lower border of the tarsus, thereby correcting the faulty position of

IT IS the purpose of this report to review the mechanism of so-called spastic entropion of the lower lid and to call attention to a simple and effective operation for this condition. This procedure is directed toward correction of the abnormal anatomic relations which predispose to malfunction of the orbicularis oculi muscle. Many operations have been described for the correction of spastic entropion, but none is directed at correction of what seems to be the fundamental cause, namely, an abnormal relation of the tarsal plate to the globe, with resultant improper function of the orbicularis oculi. In some previously described procedures attempts have been made to modify the action of the orbicularis on the tarsus or to buckle the tarsal plate outward either by establishing an everting cicatrix or removing a wedge from the outer surface of the plate parallel to the lid. Other procedures have been directed toward tacking

WHEELER,1,2in 1938, described an operation for the correction of spastic entropion, the basic feature of which is the dissection of a band of orbicularis muscle from the anterior surface of the tarsal plate, overlapping it, and reattaching it to the tarsoorbital fascia just below the tarsus Hotz,3in 1879, had described a technique of suturing the upper border of a horizontal skin incision to the lower border of the tarsal plate, in order to pull the margin of the lid downwards and prevent it from inverting. Hill4devised an operation which combines the principles of these procedures, modified by the creation of tissue barriers to prevent preseptal orbicularis from moving upwards over the tarsus to the lid edge. These barriers consist of the following: (1) vigorous curettage of the anterior surface of the tarsal plate and of the undersurface of the skin overlying the tarsus in order

Introduction For approximately 15 years the author has used a simple cautery procedure for the relief of spastic entropion. During this time it has not been necessary to resort to any of the more complicated and varied plastic operations described by various ophthalmic surgeons. Most of these require varying periods of disability, pressure bandages, and, frequently, hospitalization. The method outlined below entails none of these. It would seem that the classic Ziegler punctures 1 are not effective enough in the hands of many ophthalmologists. Otherwise these multiple plastic procedures would not continue to be published, and, in addition, described at ophthalmological meetings. This operation is indicated only for persistent entropion. It has not been needed for the temporary turning in of a lower lid occasionally seen after cataract extractions and other types of ophthalmic surgery. Technique After procaine infiltration, the lower lid is grasped near its center with a Graefe

Spastic entropion of the lower lid is frequently stubbornly resistant to surgical correction. The inadequacy of methods of treatment is emphasized by the multiplicity of procedures advocated for its correction, which range from the use of adhesive tape to mutilating surgical procedures on the lid. This presentation will be confined to a description of a simple surgical procedure for correcting this condition. The term spastic entropion is used here to mean the intermittent spastic intorsion of the free border of the lower lid. This definition excludes true cicatricial entropion. The anatomic considerations pertinent to this discussion are the location and the attachment of the lower palpebral free border portion of the orbicularis palpebrarum muscle and the location of the tarsal ligament. The temporal third of the lower lid is composed of two layers ; the anterior, or cutaneous, and the posterior, or conjunctival. The anterior part is composed of skin, cilia

Through the needle used for preliminary novocain anesthetization, ninety-five percent alcohol is injected into the outer fibers of the orbicularis muscle near the margin of the lower lid. The method is simple, painless, and usually permanent in its effect.

To the Editor: The article by Dr. P. H. Ballen regarding his treatment of a patient with cicatricial entropion of the upper lid (Archives of Ophthalmology72: 239-240, 1964) was most interesting. A little over a year ago I was faced with a similar problem in an elderly lady with cicatricial entropion of the upper lid secondary to old trachoma. Because of her poor general condition I was reluctant to perform any surgery and therefore confined my treatment to the frequent removal of large numbers of offending cilia. When this treatment seemed to be getting nowhere, I decided to perform the simplest operation that might have any chance of success. After reviewing the many procedures described in the various surgical reference books, I chose the Wies operation which I had used successfully many times in the treatment of spastic entropion of the lower lid. The result of this operation on

SENILE entropion is a common and troublesome clinical entity. It is as troublesome to the ophthalmologist as to the patient, because minor measures are usually ineffective and yet the clinical manifestations frequently do not seem severe enough to the patient to warrant major surgical intervention. Unfortunately, only operation can effect a permanent cure, though even this is not always certain. Most textbooks define senile entropion as a form of spastic entropion of the lower lid, or, conversely, the commonest form of spastic entropion is described as occurring in the lower lid of older people. It is usually attributed to a spasm of the orbicularis brought on by ocular irritation, either inflammatory or traumatic. Over the years, many procedures have been suggested for the correction of this condition. However, the armamentarium of remedies offered is larger than it is effective. The commonest of these methods may be summarized as follows: 1.

Ectropion and entropion, of mild degree, whether from interstitial shrinkage or from moderate cicatricial contracture, are so inefficiently remedied by our present operative measures that I have thought it desirable to present to the profession a simple procedure I have used for many years and from which I have never yet failed to secure the desired results. There are many conditions which we can relieve by this procedure: A. Spastic entropion or ectropion. B. Senile or relaxed ectropion or entropion. C. Paralytic ectropion. D. Contraction from lachrymal irritation. E. Moderate cicatricial contraction. F. Small cicatricial distortions or dimplings. G. Cases of distichiasis. Many varieties of suture operations have been employed to relieve these conditions, but, while successful in some instances, they are quite inefficient in the larger proportion of cases.