On the Operations for Traumatic 
DUTolobomaia of the Eyelids. 
BY 
II. K^APP. 
Reprinted from Archives of Ophthalmology and Otology. 
Volume V. No. I. 1876. 
NEW YOKE: 
WILLIAM WOOD & CO., 27 Great Jones Street. 
1876. ON THE OPERATIONS FOR TRAUMATIC COLOBO- 
MATA OF THE EYELIDS. 
TRAUMATIC colobomata of the lids are not very rare. The 
operative procedures for their cure differ according to the seat, 
the extent (degree), and the complications of the colobomata. 
Without entering into a discussion on the various conditions this 
affection may present, I will here mention only one principle 
which guided me in all these operations, namely, in the first place 
carefully to remove all cicatricial tissue. If this is omitted, the 
patient is exposed to the danger of an almost certain relapse. In 
removing the cicatrix, we must have regard to two complications 
mostly met with in colobomata of the lids, i.e., i, a certain de- 
gree of a partial or total ectropium ; and 2, the hypertrophic 
swelling of the conjunctiva resulting from the prolonged eversion 
of the lids. Not infrequently a more or less pronounced lateral 
displacement of the lid is present in these cases as a third compli- 
cation, which, however, commonly disappears as soon as the 
cicatrix is completely excised. 
The operative procedure best calculated to remedy the diffi- 
culty under consideration mainly depends on the location and ex- 
tent of the loss of substance caused by the removal of the cicatrix 
and the hypertrophic portion of the conjunctiva. If the defect 
be small and triangular, and the surrounding tissue extensible, it 
will suffice, in most cases, to unite the wound by simple or twisted 
sutures. If the defect be larger, undermining of the adjacent skin 
will materially relieve the tension and secure the union. If the 
defect be extensive, a plastic operation can hardly be avoided, 
and I would, above others, recommend, in such cases, the 
method of forming lateral flaps, which I described, about ten 
yearsago, in Graefe's Archives, and have since repeatedly practised 
with good results. This method, the principle of which has long 2 
H. Knapp: 
been well known, seems to have been cultivated particularly by 
French surgeons, for in a French book I found it designated as 
" Methode par glissement des lambeaux, ou methode fran^aise." 
In moderately large defects a method did me excellent service 
which stands midway between the simple union and the blepliaro- 
plasty by lateral flaps. This method may be briefly described as 
follows : Besides the careful union of the coloboma, the outer 
commissure is divided, and the adjacent skin, towards the temple, 
either above or below the outer canthus, according to the seat of 
the coloboma, is detached from its base to the extent of half an 
inch or more. Though no regular quadrangular flap, as in the 
sliding method, be formed, the outer portion of the lid is drawn 
toward the nose, and thus the shortening of the palpebral fissure 
is obviated. A part of the surface of the wound in the outer 
corner may be covered by stitching the conjunctiva and skin to- 
gether, as is done in canthoplasty. Stitching the whole wound 
in the commissure would lead to lengthening of the palpebral fis- 
sure. For the details of the operation I refer the reader to the 
following case, to which the method was particularly adapted. 
Jos. F., ofWerschau, Nassau, Prussia, was hurt on Nov. 16th, 1874, 
by a full bottle thrown on the right half of his face and breaking into a 
multitude of fine pieces, which, like grains of salt, partly remained on his 
face, partly fell to the ground. The skin of the forehead and cheek was 
cut down to the bone; on the upper lip the wound penetrated through 
the skin and the gums, and several teeth had become loose. A gaping 
corneal wound was in the eyeball, and the lower lid was split from the 
centre of its free edge down and inward. Fie was confined to his bed, 
and made cold applications for five weeks, but there were no cerebral 
symptoms. The wound in the eyelid was closed with sutures by Dr. 
Ulrich of Dauborn. The patient consulted me in July, 1875. He 
looked well, strong, and plethoric. Concerning his character, his friends 
testified unanimously that he liked spirituous liquors of every description, 
and since the time he received the injury had been addicted to idleness 
and drinking. His hostess informed me that he was accustomed to take 
about twenty glasses of beer a day, and a glass of whiskey every now and 
then between the beer. He told me that he had a hollow molar tooth 
which bled once or twice every day. A large cicatrix was on his forehead, 
another on his cheek, which went through the whole thickness of his 
upper lip. The shape and motion of the upper eyelid were normal. Operations for Coloboma of Eyelids. 
3 
The globe had the usual size and consistence. The lower two-thirds of 
the cornea were diffusely opaque, and an irregular vertical adherent 
cicatrix passed through the whole cornea. In the upper-inner part a 
remnant of clear cornea and anterior chamber was preserved, through 
which the iris was visible. Perception of light being present, an artificial 
pupil at this point was not without a tolerably good chance of restoring 
a moderate degree of useful vision. The centre of the lower lid (four 
lines in length) was everted and drawn down by a dense cutaneous scar 
passing in a curved line down and inward. Opposite the cutaneous 
scar there was a roundish, ungainly intumescence of hypertrophied con- 
junctiva (Fig. i, w). The lids could not be closed on account of this scar 
and conjunctival intumescence, and the patient suffered from epiphora 
and catarrhal conjunctival discharge. 
With the kind assistance of Dr. Hess I operated on the patient in the 
following way : With a strong pair of strabismus scissors I excised the 
whole scar and hypertrophied portion of conjunctiva. This occasioned a 
considerable loss of substance (Fig. 2), leaving hardly four lines of eyelid 
on each side. The skin on both sides (a and b, Fig. 2) was undermined 
Fig. 1. 
Fig. 2. 
with a pair of scissors; but when I tried to unite the flaps there still was 
marked tension. I therefore slit the outer commissure and undermined 
the outer part of the lower lid and the skin under the wound in the outer 
commissure (r, d, Fig. 2) to the extent of half to three-quarters of an inch. 
The division of tough ligamentous bands, which gave a perceptible re- 
sistance to the scissors, rendered the outer flap so movable that now 
the union of the preserved lateral parts of the lids could be easily ac- 
complished, and there was no longer any tension. I used five simple 
sutures, the highest of which was close to the edge of the lid (see Fig. 
3). In addition to this, I united the conjunctiva with the skin at the 
inner-lower part of the wound in the commissure by two sutures (see Fig. 
3). There was no notch in the edge of the lid ; the whole lower lid was 4 
H. Knapp : 
properly applied to the globe, and the lids could be easily closed and 
opened. The whole lower lid had preserved its natural color, even the 
edges of the previous coloboma showed no blue discoloration. Both eyes 
were closed with the usual charpie-flannel bandage, the charpie of the 
eye operated on having previously been greased by a thin layer of cold 
cream. 
There had been very little loss of blood during the operation. The 
Fig- 3- 
sutures having been applied after the bleeding had carefully been arrested, 
caused no new hemorrhage. 
Patient had a good night. On changing the dressing I found the 
whole wound beautifully united, no secretion of the conjunctiva, and no 
oedema of the lids. Both eyes were kept closed as before ; fluid or soft 
food, excluding liquors, ordered, and he was forbidden to leave his bed. 
The third day after the operation he was in a satisfactory condition. 
On the fourth day I removed the two sutures at the outer canthus, and 
three sutures from the wound in the lid, leaving the upper and the middle 
one. The wound was perfectly closed, and there was no notch at its 
upper end. Both eyes were kept bandaged, and the patient particularly 
cautioned to stay quietly in bed, since, after the removal of the sutures, 
the least stretching of the lid might break the fresh and weak union of the 
wound. But on visiting him unexpectedly in the afternoon, I was surprised 
to find him sitting in the most comfortable neglige behind an open window, 
the bandage of the healthy eye shifted up over his brow, a pipe in his mouth, 
a novel in his hand, and an empty beer pitcher at his side. He looked 
an enviable picture of contentedness with his own self and surroundings. 
That this happy situation was rudely brought to an untimely end by my 
unexpected interference, I hardly need mention. On removing the 
bandage I found a slight separation in the lower part of the wound. 
When he held his eyes open he would wink obstinately, briskly, and 
almost incessantly, by which, of course, he pulled persistently and effi- 
ciently at the young scar. I therefore bandaged both eyes again, and Operations for Coloboma of Eyelids. 
5 
gave him strict injunctions not to touch the bandage any more, and lie 
Quietly in bed on his back. 
In the morning of the fifth day the lower part of the wound had re- 
united, and the lid showed no irritation. I removed the last two sutures, 
which was done without bleeding or rupture of the wound. No sup- 
puration had taken place in the stitch canals. Both eyes were bandaged 
again, and the patient was warned to abstain from all movements of his 
eyelids, since after the removal of all the sutures the wound had no pro- 
tection left against tearing of any kind. In the afternoon I was called : 
" the eye bled." I found the bandage and lint saturated with fresh 
blood, which, however, had ceased running. The whole wound was still 
united, yet the interposed new cicatricial tissue was distended. I there- 
fore supposed that on the conjunctival surface a portion of the scar had 
given way, causing the hemorrhage. 
On the sixth day the eyelid looked excellently well. The wound ap- 
peared firmly united in its whole extent. For the sake of precaution, 
both eyes were again bandaged, and the patient was requested to remain 
in bed another day. At three o'clock at night I was called : "the eye 
was profusely bleeding." I at once hastened to the patient, and saw 
bright red blood freely running down the cheek. After removal of the 
dressing I found the whole wound still united, and blood welling up be- 
tween the lid and the eyeball, consequently from the inner surface of the 
wound. I applied cold wet compresses to the eye for about a quarter of 
an hour, but to no effect. Not being allowed to turn the eyelid and put 
styptic remedies on the bleeding surface itself, I applied a pressure-ban- 
dage consisting of several thicker wet compresses, which were pressed 
against the closed eyelids by a threefold turn of an elastic flannel ban- 
dage. Some blood still oozing out, I placed another thick wet compress 
upon the first dressing, and increased the pressure by a second rather 
tight flannel bandage. This completely arrested the bleeding without 
causing any pain. This dressing remained untouched until the evening, 
when I carefully removed it. The bleeding had not returned, the lid was 
not swollen, but at its edge the wound was separated about a tenth of an 
inch. I padded the eye with picked lint, placed a compress on the lint, 
and fastened it with a flannel roller. 
In the morning of the eighth day a slight bleeding had again taken 
place, which, however, soon stopped. The wound was as the day 
before. Dressing the same. The ninth day all irritation had disap- 
peared. On the tenth day, no further bleeding having occurred, the pa- 
tient was discharged, with the understanding to have the small notch in 
the lid removed by a second operation, if it should prove worth the H. Knapp: 
6 
trouble. He presented himself again a week afterward ; the notch was 
almost closed, there was no swelling of the lid, no lachrymation, and the 
position and movements of the lid were normal. 
Since colobomata are very often left after injuries of the eye- 
lids, especially the lower, the treatment of those injuries should 
be particularly directed toward their prevention. The main 
cause of these colobomata lies in the action of the m. orbicularis 
palpebrarum, as is well known, and could be beautifully demon- 
strated in the case just reported. The mechanism, briefly stated, 
is the following : When the orbicular muscle of the eyelids, the 
fixed points of which are the ligamenta canthi internum et ex- 
ternum, contracts, the shortening of the muscular arcs raises the 
the lower lid and depresses the upper until the free edges of the 
lids form a part of a greatest circle track, which is the shortest 
cut between their end-points. When these muscular arcs are 
divided, the parts contract in such a way as to move the edges 
of the wound toward the ligaments. To counterbalance this mus- 
cular action is the problem and secret of the successful treatment 
of the injuries of the eyelids. Adapting the methods of operation 
to the condition and degree of the affection, we have, to obtain 
our aim, the following means at our disposal : 
i. Careful ttnion of the wound by simple or Twisted sutures, or 
both combined. I use in these and similar (plastic) operations al- 
most exclusively simple sutures of fine Chinese bead-silk. They 
are applied with delicate curved needles by means of a Sands' or 
similar needleholder at no greater distance from one another 
than one or two-tenths of an inch. In this manner the coapta- 
tion of the edges of the wound is as close as it can be made, the 
contusion of tissue from the piercing needles is very slight, the 
calibre of the stitch-canals and the foreign bodies lying in them is 
minimal, and the traction from muscles and other elastic tissue is 
more uniformly distributed over the whole wound, that is, divided 
among a greater number of fixed points than when coarser material 
is used for sewing, which, it is true, necessitates fewer sutures, 
but they must be drawn tighter. Many fine sutures, if I am 
not mistaken, produce suppuration not so readily than few larger 
sutures. A very. exact union of the wound, such as can be 
effected only by delicate sutures, which are close together, is of Operations for Coloboma of Eyelids. 
7 
particular importance on the free edge of the lid. A fine suture 
has to be applied, under all conditions, to the intermarginal part, 
or to its nearest vicinity. In addition to simple sutures, one or 
more twisted sutures might be employed. As a rule, I avoid, in 
operations on the lids, twisted sutures, as well as coarser buttoned 
sutures, for both, bypassing through a larger extent of tissue, and 
being drawn more tightly, favor the eversion of the free palpebral 
edge by which just that part is stretched, the union of which is 
not only most important, but most difficult. On account of its 
manageableness, I prefer silk thread to silver wire, which is so 
celebrated by my gynaecological friends, and appreciate its ad- 
vantages for the peculiar and easy way by which the tying is 
done in cavities difficult of access. 
2. Closure of both eyes. I prefer for this purpose the usual 
charpie-flannel bandage, because it secures better than others the 
immobility of the lids, provided the corners of the eye be well 
padded. The closure of both lids has to be continued uninter- 
ruptedly until a rupture of the wound is no longer to be feared, 
that is, in some cases, five or six days. Closure of one eye (the 
diseased) does not protect it from the incessant motions which its 
lids perform under the bandage in association with the motions of 
the lids of the other (healthy) eye left open. 
In the great majority of the cases of traumatic coloboma these 
two means, careful union of the wound by sutures, and closure of 
both eyes, will be found sufficient to effect a cure. If, however, 
the wound be large, and the patient so uncontrollable as in the 
case above described, further expedients have to be sought. 
These are : 
3. Supporting sutures. Chinese bead-silk, I think, is the most 
appropriate material also for these sutures. In the lower lid the 
needle pierces the tarsal cartilage from the skin toward the con- 
junctiva at a distance of 2"'-f" from the wound ; the thread then 
passes along the conjunctiva to a point 2'"-f' on the other side 
of the wound, then again pierces the lid, this time from the conjunc- 
tiva toward the skin, and is tied on the outer side of the lid. The 
cornea always being raised when the eye is closed, the highest 
suture may be applied near the free edge of the lid without irri- 
tating the cornea. On the upper lid I would apply the support- 
sutures in the following way: The needle, about 2"'-f" distant H. Knapp: 
8 
from the wound, and I y" above the free palpebral border, pene- 
trates through skin and muscle into the substance of the fibro- 
cartilage, passes straight down through the cartilage, and emerges 
on the skin near the insertion of the cilia. The thread then is car- 
ried over the skin, just above the eyelashes, to a point situated 
about as far from the other wound as the point of insertion was on 
this side ; there the needle penetrates again through skin and mus- 
cle into the cartilage, passes straight upward in its substance, and 
emerges about Iabove the free edge of the lid. The ends of 
the thread are then united on the skin. The thread nowhere 
comes in contact with the eyeball. One supporting suture for 
each lid will, I think, be sufficient in the majority of cases that re- 
quire supporting sutures at all. When placed in the vicinity of 
the free edge of the lid, it counterbalances most efficiently the ac- 
tion of the orbicular muscle tending to separate the wound. If the 
wound in the lid be long, and considerable tension of the skin be 
present after its union, another supporting suture may be applied 
at a greater distance from the free palpebral edge. Care, however, 
has to be taken that the sutures, in particular the lower one of 
the lower lid, are not too tightly drawn, lest ectropium ensue, with 
its unpleasant consequences. 
Supporting strips of adhesive plaster, drawing the skin from 
both sides toward the wound, may well be applied ; but on ac- 
count of the uneven surface of the vicinity of the eyes, their effi- 
ciency is less in this locality than in most others. On the whole 
we must not expect a great deal from their efficacy. 
4. Relaxing incisions. There is no obstacle in the way of divid- 
ing, on one or both sides of the wound, the skin and muscle by 
vertical incisions down to the cartilage, respectively the orbito- 
palpebral fascia. Such incisions gape considerably at first, and 
therefore must relax the tension most effectively; but later they 
very kindly heal, leaving a scar hardly visible, and occasion no 
change in the position and movements of the lids. 
In the above case I obtained, in a different way, the relaxation of 
the skin and the temporary suspension of the action of the orbic- 
ular muscle on one side-the temporal-of the wound, namely, by 
slitting the outer commissure and detaching the skin below it 
from the temporo-buccal fascia. The nasal side of the wound had 
been left untouched. The consequence of this condition was that Operations for Coloboma of Eychds 
9 
every motion of the lids drew the lower lid toward the nose, thus 
exerting a constant, though one-sided pull at the wound. These 
motions were extraordinarily extensive in our patient, who was in 
the habit of constantly and forcibly winking. In his case a ver- 
tical incision, near the lachrymal point and on the temporal side 
of it, would have been indicated. 
Another method of temporarily and almost completely paralyz- 
ing the tension of the skin, and the traction of the muscle toward 
the nose, a method which I would recommend in high degrees 
of palpebral coloboma, and certain plastic operations on the lids, 
is the following : That portion of the lid which lies below the inner 
commissure is detached with a pair of strabismus scissors from its 
base, in such a way that, from the conjunctival sac toward the 
cheek and nose, all the muscular fibres, except the highest bundle 
around the canaliculus, are severed without implicating the 
lachrymal sac and the canaliculus, nor dividing the inner commis- 
sure. Neither the cartilage, which in this locality is only 
in breadth, nor the skin need be injured, though an accidental 
perforation-fenestration-of the skin does no harm. The fixation 
and nutrition of the lid are effected by the skin and the tissue 
surrounding the canaliculus. The mode of loosening just described 
renders the inner part of the lid very extensible, without endanger- 
ing its integrity of substance and position. The injury is less ex- 
tensive than with the method of blepharoplasty by lateral flaps, 
which, on its part, when restricted to its proper limits, i.e., to 
defects not exceeding two-thirds of the lids, reckoned from the 
lachrymal point to the outer commissure, does not expose the 
flaps to the danger of sloughing. 
The different operative procedures which I have here described 
seem calculated, either one alone, or some in combination, ac- 
cording to the condition of the case, to supply all palpebral defects 
that do not exceed one-third, or even two-fifths, of the edge of the 
lid. A maximum effect is obtained if the outer commissure is 
divided ; further, the lid and adjacent skin near both commissures 
are, with a pair of strabismus scissors, undermined and detached 
from their base, the wound is united by simple sutures placed 
close together, one or two supporting sutures are added, and 
both eyes kept shut by a charpie-flannel bandage as long as there 
is danger of separation of the wound. 10 
H. Knapp ; Operations for Coloboma of Eyelids. 
These methods, as well as the formation of lateral flaps, have 
the advantage over others of obviating ectropium, ungainly swell- 
ing or extensive sloughing of the flaps. The worst accident I 
have met with in these operations is the separation of the upper 
end of the vertical line of union. This is of less importance than 
it seems at first to be, for the partially open wound, provided 
no old cicatrix be present, unites later in an unexpected manner, 
similar to the ultimate reunion of divided commissures. If a 
notch is left, it can readily be closed by a simple secondary 
operation.