Pathology and Treatment of Non-cicatricial Entropion by the Method Proposed by Wies.

ACCORDING to Kettesy (1948), non-cicatricial or senile entropion is the direct result of a migration and accumulation of orbicularis fibres at the lid margin. The contraction of the orbicularis which follows causes excessive pressure on the upper margin of the eyelid, the mechanics of the lid musculature are altered, and entropion results. As stated by Kettesy (1948): "The normal distribution of orbicularis is maintained by connective tissue branching off between bundles"; in senility there is a slackening of this palpebral connective tissue, allowing the migration of muscle fibres, whereas in the young adult the pretarsal muscle fibres are firmly attached to the tarsal plate (Jones, 1960). Most authors agree on the importance of senile degenerative processes in the eyelid in the aetiology of entropion. These processes include senile atrophy of orbital fat with relative enophthalmos, loss of elasticity of skin, degenerative flaccidity of the tarsus (Kirby, 1952), relaxation of inferior ligaments (Butler, 1948), and slackening of the whole palpebral connective tissue (Kettesy, 1948; McFarlane, 1956). But, as Kettesy (1948) states, these are preliminary conditions. It is the accumulation of orbicularis fibres along the lid margin that causes entropion and surgical procedures must be designed to prevent it. Non-cicatricial entropion of the upper eyelid is rare, because the insertions of the levator palpebrae into the skin form a more permanent anchor for the orbicularis. This effect is weakest at the outer margin, and one case of noncicatricial entropion of the outer third of the upper lid is included in this series. The operation proposed by Wies (1954) is designed to place a barrier in front of the tarsal plate and thus to prevent the free movement of the orbicularis over it; if this movement is accepted as the primary cause of senile entropion, the excision of skin and orbicularis, or of wedges of tarsal plate, is unnecessary. Wies's operation, as originally described, produces over-correction in a proportion of cases (Wies, 1954; McFarlane, 1956; Hill and Witzell, 1956); Wies incises the whole length of the tarsal plate, but, as the purpose of the operation is only to create a vertical barrier to the horizontally-acting muscle fibres, a more local incision should be sufficient. With the present technique, which is only slightly modified from Wies's original procedure, immediate cure results and over-correction does not occur.