THE TREATMENT OF TRACHOMA BY

EXCISION OF THE TARSUS ANJJ>

TARSAL CONJUNCTIVA OF

THE UPPER LTD.

By W. R. SCOTT MO NO III EF, m.d., f.u.c.s (Edin lieitt.-col., i.M.S. (Retired.)

Residency Surgeon, Western Rajpulana Stales.

Considering the amount of disability caused by trachoma in this country it is somewhat remarkable that so little appears in the Indian Medical Gazette regarding its pathology, clinical aspects, and in particular its treatment. It is probably the most frequent cause for the

rejection of otherwise desirable recruits for the Indian Army. It very often complicates other eye diseases we have to treat, and in itself it causes an enormous amount of partial and total blindness. Most of us have not the time to

devote to such thorough study of eye diseases as will enable us to write authoritatively about them, and to those who have the time and energy required the fascinating subject of cataract seems to come first, to the exclusion of the equally or

perhaps more important disease trachoma. While on tour recently in Marwar (Jodhpur

State) I made the following note of cases of eye diseases seen at three district dispensaries. In addition to those noted many others were seen in villages, at my camp, at railway stations, at wayside vaccination inspections, in fact wherever I went. Eye disease is extremely common in Marwar but the population is scattered, distances

Aug., 1916.1 THE PREVALENCE OF TRACHOMA. 295

between villages are great, and communication is chiefly by camel. Other conditions too were not favourable for a large collection of patients so that this lamentable procession of blinded

men, women, and children 110 doubt represented but a moderate proportion of the total affected in the districts visited.

Fifty-seven various ophthalmic operations were done and a few cases were taken to headquarters for treatment. The following inoperable cases, mostly blind, were seen.

Glaucoma absolute ... 34 eyes in 24 persons. Shrunken eyes ... 18 ? 15 ,, Corneal conditions ... 4(3 ? 27 ,, Cataract complicated...

"

,, o ?

Uveal disease ??? 1 ,, 3 ? Couched ... 4 ? 4 ?

lliere were also some cases of immature

cataract, congenital defects, fundus disease, and many of different kinds and degrees of ophthal- mia. In the stress of work no doubt a number went unrecorded.

These cases were rapidly recorded while select- lng cases fit for operation ; there was 110 time to note details in the inoperable but those familiar with eye disease in India will see at once what an important factor trachoma is in this record. The condition of phthisis bulbi and the corneal conditions 04 blind eyes in 42 persons were of course mainly due to trachoma with 1ts complications?pannus, ulcer, perforation, entropion, xerosis, etc. A few were probably (lue to smallpox. From this record then we obtain striking

evidence of the ravages caused by trachoma and We must admit that we have 110 satisfactory treatment that appeals to the villager. In trachoma the patient is warned in plenty of time that his sight is going; these patients all live within reasonable distance of a dispensary; most of them had probably been treated from tune to time; in some the conjunctiva was stained by silver nitrate. To publish this numerical collection of cases

111 the I. M. G. may seem superfluous as most C1vil surgeons meet with such as part of the day's work, but the publication may prove stimulating to the younger men in India and interesting to those in other countries. The opinions I have formed regarding trachoma

are the result of experience gained in many other States in Rajputana besides Jodhpur, of several years in the Kurram valley, N.-W. Frontier Province, where the disease is prevalent and where 1 used to follow up a good many cases, visiting them in the villages und lastly of two years' experience of trachoma in East Indian and Chinese immigrants in British Columbia. It was when dealing with trachomatous Chinese immigrants at the request of a colleague in the immigration department that I was for the first

time "up against'"' the prognosis in trachoma. Can these men be cured or should they be deported ? True, I had seen many cases among recruits before enlistment and in the Indian Army But one rejects a recruit with trachoma straightway without expressing or even forming a definite opinion as to his future progress and in the case of the enlisted soldier we know that

leading a healthy life under constant 116 IS ifciuiu^ j observation and we treat his symptoms as they arise. Trachoma is not prevalent in the Indian Army owing no doubt to the strict medical examination* before and healthy existence after enlistment, but the reliable figures available ought to furnish useful information regarding treatment by different methods. The jail populations should furnish even more valuable results. The question asked by the medical inspector of immigrants remains unanswered. The sub-assistant surgeons in charge of these

three dispensaries referred to are all well up to average of their class and have been for some years in their appointments. Their treatment of trachoma consists in the use of silver nitrate solutions, copper sulphate, etc. They know about expression and grattage and have occasionally used these methods. One of them has been for eleven years in his present appointment, is a capable physician and surgeon and very popular. In his district in the westernmost desert part of Fodhpur trachoma is extremely prevalent. Here then we have conditions tor success if success is obtainable in a rural population from local medicinal treatment and the following are several questions I put to him with his answers. q trachoma very common in your district ? ^ Yes, it is common in this district. q Have you treated any cases by expression

or grattage or any other surgical treatment ? 2 I have no chance of treating any case by

these methods.

q What is your usual method of treatment.'' j .?Caustic and copper. q guppose an inhabitant of town is being

treated by you with caustic or copper, how many times does lie attend on an average? A.?About three months.

q About three months in the case of a villager from a distance ? ? They had to remain here for about three

months. ])0 y0U think you can get a pucca cure

by any treatment. 4certain cure, except in few cases of

mild nature. . However one interprets the answers, this is

rather damning evidence as regards treatment with caustic and copper. I have asked for further details regarding average duration of attendance. \ow these conditions exist at practically all

district dispensaries and I believe at most

296 I'HE INDJAtf MKD1CAL UAZttTTK. [Aug., iU16.

headquarters hospitals. We all know the out- door ticket?" Disease (jr. Lids treatment Rx. Caust. lot." and before the patient has ceased to attend or lost his ticket several dates will be added showing subsequent attendances. What- ever the merits of treatment by caustics (including copper) astringents and

" resorbents "

when carried out thoroughly, I hold that as applied to the vast majority of trachoma patients in India it is hopelessly inadequate.

Carbon dioxide snow I have tried in a number

of cases and have found to be no more efficacious than caustics. It is expensive and out of the question in district dispensaries.

Then we come to expression and grattage with or without subsequent local medicinal applications.

Few cases are suitable for expression which in my experience hastens the improvement obtained by caustic treatment but does not do much more.

(Irattage I have found to bring about an

apparent cure very quickly in some cases but it often lias to be repeated and supplemented by caustics. In some cases it seems to be no better than the caustic treatment.

Sub-conjunctival injections I have found to be disappointing in trachoma as in other ej^e diseases in which great things were hoped for from their use.

Excision of the conjunctiva of the fornix I have done a few times only.

Since being recalled to India and stationed at Jodhpur I have been aiming at better treatment for the large number of victims of trachoma. At the Hewson Hospital, Jodhpur city, I see all trachoma cases myself. Carbon dioxide snow and grattage have been given a good trial, a special "

Grattage register" being kept. The results from snow treatment are poor as I expected from

my former experience of it. The (irattage register

" shows that the treatment has often to

be repeated and that many cases cease to attend. Tt i= painful enough to frighten children and not quick enough in its results. Up to the middle of last year in doing

entropion operations I bad occasionally removed most of the tarsus as a modification of the Snellen operation. I had read of excision of the tarsus or tarsal cartilage but had never seen it described in detail. (I use the expression tarsus in preference to tarsal cartilage for brevity and because this structure is composed of dense connective tissue and does not contain any cartilage cells.)

Excision of the tarsus done from the skin

aspect of the lid is a difficult performance and I never liked the idea of removing conjunctiva. It seemed fraught with possibilities of cicatrisation, contraction, and entropion. In Ophthalmology for July 1915 Webster Fox of

Philadelphia at the end of an article on trachoma and its treatment gives a brief description of "

extirpation of the whole of the cartilage together with its conjunctival covering for chronic trachoma associated with great infiltration and thickening of the tarsus." He has been doing the. operation

" for two or three

years with splendid results." In the same number of Ophthalmology there

is a review of an article by W. K. Thompson, Fort Worth, Texas, on the surgical treatment of trachoma. He considers resection of the tarsus

to be the operation par excellence for all cases of trachoma with involvement of the tarsus.

In the October 1915 number of Ophthal- mology there is a long article by 1). \V. White and P. C. White of Tulsa Oklahoma, V. S. A., on the same subject. This article is difficult to follow in places but it is well worth study by anyone practising in India. From it I got the idea of mobilising and suturing the conjunctiva to the ciliary border.

Then in the Ophthalmoscope there recently appeared a review of an article on this subject by E. Temple Smith in the A ustralian Medical Journal. I have written to Dr. Temple Smith and hope shortly to receive a reprint of this article.

As a result of personal experience and after reading these articles I have come to believe that excision of the tarsus is the only adequate treatment for trachoma involving the tarsus and tarsal conjunctiva.

I shall describe the operation as I do it and shall do so at some length as I know of no book giving a description of the operation in detail and in my early cases I felt the want of this. The excision is not a complete one as of course the free ciliary border of the tarsus which forms the lid margin remains.

It is done from the conjunctival aspect and the tarsal conjunctiva and tarsus are removed in one piece.

There are two methods of operating, one a

simple excision leaving a raw surface; the other an excision followed by undermining and

suturing of the conjunctiva over the raw surface.

Simple excision of the tarsus of the

UPPER LID.

The eyelashes should be left uncut to facilitate eversion of the lid afterwards.

Anaesthesia.?A general anaesthetic is advisable for the following reasons : (a) infiltration with a local anaesthetic disturbs the anatomical relations

of the part ; (/>) it possibly lowers the vitality of the delicate tissues ; (c) even if local anaesthesia is preceded by an injection of morphine or morphine and hycin the cutting and manipulation of the tarsus is still very painful and though the tarsus can be excised very rapidly the patien

Aug., 1916.J TREATMENT OF TRACHOMA. 297

will not improbably refuse operation on the second eye.

Position of Operator and Assistants.?For both eyes I stand behind the patient's head with 1st assistant on my left side and 2nd assistant at my right front. The anesthetist is on the patient's left front. A sterilised cloth with a bole in it is fixed to the cheek and brow with fine forceps. The anesthetist works under this cloth which I fix with two hare-lip foreeps, but I think this is not enough for, during the later stages of the operation, the blood-soaked cloth gets displaced which is very annoying especially Jn the more complicated operation when the sutures are being inserted. Suppuration seldom occurs in lid operations probably because of the good vascular supply of the tissues. Recently, however, [ saw a case (not my own) where suppuration and some sloughing occurred. Strict asepsis should therefore be aimed at. It might be advisable to wash out the conjunctival sac. Fixing the aseptic cloth to the face with antiseptic varnish might be better than the use of forceps. With a very contracted palpebral aperture I sometimes begin the operation with a

canthoplasty. I now run a suture of horse-hair or silk through

the centre of the lid just above the ciliary border, remove the needle, and knot the two ends. (See A, ^ ig- 1.) This gives good control of the lid. I

now evert the lid over a metal shield placed against the skin surface and hand over the fixing suture and shield to the 1st assistant. By manipulation of these the assistant can bring each part of the everted lid in turn into the best

position for the incisions to be made and he can

by making pressure upwards with the shield so control the haemorrhage that the oj^erator can niake his incisions accurately without the

interruption of sponging becoming necessary. The use of a clamp of suitable shape might be an improvement on the above device. Snellen's entropion forceps reversed I found unsatisfactory for when eversion was produced by raising the handle the blades slipped. A shield with a curved stem would I think be better than the

straight one I use as it would not impinge on the orbital margin which the straight one does

slightly. Eversion of the lid plus the tension of the fixing suture makes the lid margin curved

with the convexity towards me and the

prominence of the upper border of the tarsus, normally curved, now appears straight or nearly so. (The normal curve of the upper border is often of course altered as a result of pathological deformity of the tarsus.) The curve of this line is also affected by the position of the shield. I make a straight incision along

the upper border of the

through conjunctiva and sub-conjunctival tissue and "inclining the knife edge slightly towards the lid margin. I do this to avoid the

possibility of the knife slipping over the border of

the tarsus towards the cornea. (See B, Fig. 1). I make a second incision from the nasal to the

temporal end of the first close to and following

the curve of ciliary border (nasal and temporal here apply to the right eye). ^

This incision goes deeply into the tarsus and

is deepened till it reaches the orbicularis muscle.

(See C, Fig. 1.) , fl . f I now with suitable forceps get a nrm grip of

the whole thickness of tarsus and conjunctiva towards its temporal end, raise it and passing the knife below the tarsus from the second to the first

incision cut out beyond or through the temporal end of the tarsus. I then raise the free temporal end of the tarsus with its adherent conjunctiva and with knife or scissors detach

it from the

orbicularis muscle cutting against the tarsus and

working along towards the inner canthus. When

operating under local anaesthesia it is perhaps

better to get through the tarsus quickly towards

the temporal end (at the first cut if possible) and

then complete the nasal part of the tarsal incision

when separating it from the orbicularis. Rat-

toothed forceps, preferably with a catch, should be used to grip the tarsus

which is hard and slippery. Haemorrhage is seldom troublesome but I

sometimes apply a Dieffenbach's forceps to a

spoutino- artery, usually the inner one, and twist

before removing. In one of my cases I found an

artery spouting 24 hours after operation. I

apply a pad and bandage for 12 or 24 hours.

Little after teatment is required. After opera-

tion on a dirty eye I instil 10 per cent, argyrol

morning and evening. Within a week the raw

surface is covered by what is indistinguishable from normal palpebral conjunctiva. In three of

my cases small lumps of granulation tissue were

snipped off; in one case mild suppuration

occurred; in a recent case (the one in which

haemorrhage continued) pain, photophobia, and

lncrimation are present a month after operation. I have not seen this

case since a few days after

operation and have not the record of the case

with me. recent ^ge in which the disease was

fairly active I operated and there was swelling of the lids, pain, photophobia, and lacrimation for a week following. At the same time the

cornea was getting clearer,

Fig. 1. Fig. 1.

298 THE LJNDIAN MISL)l(JAI< GAZETTE. [Aug., 1916.

These are the only cases in which there was not early uninterrupted improvement though 1 should add that a few cases were not seen by me personally ofter operation.

Cases are commonly treated as out-patients.

Excision of tarsus of upper lid with

UNDERMINING AND SUTURE OF THE CONJUNCTIVA

TO THE CILIARY BORDER OF THE LID.

Passing a suture (suture No. I, in Fig. 2) through the lid and everting the lid as before I pass two doubly armed silk sutures (sutures Nos. II and III) through the conjunctiva just above the upper border of the tarsus at the junction of the middle third with the nasal and temporal thirds respectively. I put a Dieffenbacli's forceps on each of these and have them held out of the way by the 2nd

assistant. These sutures act as fixation sutures

during the undermining of the conjunctiva and may afterwards be used to fix the edge of the conjunctiva to the ciliary border. For this reason if of silk they are left doubly armed. If horse- hair is used the needle can be removed and

rethreaded before the final suturing. I now excise the tarsus and when doing a double operation if haemorrhage is troublesome I now put a swab ou the first eye and go as far as this stage with the second eye.

Returning to the first eye I now put the con-

junctiva on the stretch with the two silk sutures and undermine it almost to the limbus, snipping away redundant and apparently diseased sub- conjunctival tissue. The undermining is easily done with a blunt-pointed instrument. At this stage of the operation I proceed warily. Owing to manipulation of the lid anatomical relations are disturbed. The sub-conjunctival region of the fornix is a part with which I for one am not familiar and it is not easy to distinguish the normal from the pathological. A dissection on the cadaver from this aspect would be instructive. During this mobilising of the conjunctiva the 1st assistant with fixation suture and shield mani-

pulates the lid as required. By removing the shield and manipulating the three fixation sutures (sutures Nos. I, II, and III) a good view

of the sub-conjunctival region is obtained and the conjunctiva can be drawn down and accurately coapted to the raw deep surface of the orbicularis and held there while the final suture or sutures are inserted. As already mentioned the two conjunctival fixation sutures may be used to fix the conjunctiva to the ciliary border, but it is perhaps better to use fresh sutures. Sometimes I use only one suture placed centrally, one end being brought through the remaining strip of tarsus, the other just above it, the two ends there being knotted over a bit of rubber tubing. In two cases I have used a continuous suture

passing it through lid and conjunctiva alternately along the whole length of the lid just above the strip of tarsus. This suture begins and ends on the skin surface where the ends are loosely knotted. It is easily removed. D. W. and P. C. White, in the article already referred to, give minute instructions as to the insertion of the sutures. I found this part of their article difficult to understand. It will be evident to those familiar with lid operations that in regard to this operation the question of entropion comes very much to the fore. I think that the simple excision corrects a certain amount of entropion. I have not yet made up my mind as to the effects on the position of the ciliary border that it is possible to produce by varying the position of the sutures. Then, apart from incurving of the ciliary border, it is evident that deformity may be caused by inserting sutures incorrectly in a lateral direction. In one case I used one central suture and got an excellent result except lor a slight puckering of the skin at the site of the suture. It was slightly but curiously disfiguring. In ten cases where entropion also existed I did a simple excision followed by removal of a strip of skin and suture of the skin, wound. The results were good. In this operation the strip of skin has to be removed with care to avoid buttonholing the lid. When the ciliary border does not evert readily I remove a vertical wedge from the remaining strip of tarsus going close to the lid margin but bearing in mind that what was originally the free border has become incurved and will again become the free border after the operation. In one case I brought my vertical incision too far down towards the cilia and the result was an unsightly notch in the new free border.

In entropion difficult to correct D. W. and P. C. White in addition to special placing of sutures recommend incision of the remaining strip of tarsus from end to end. I have excised the tarsus of the lower lid in three cases ; it

is, as a rule, unnecessary to do so. Excision of the tarsus is not an ideal operation

for it is a mutilating operation but in advanced trachoma the parts re moved have become

incurably diseased and deformed. The healthy

Fig. 2. Fig. 2.

Aug., 1911).| TREATMENT OF TRACHOMA. ?39

tarsus gives shape and support to the lid, addi- tional protection to the eye-ball, attachment to the aponeurosis of the levator muscle and a sup- porting bed for the Meibomian glands.

As a result of the operation the lid does not lose its shape ; on the contrary in advanced cases its shape is improved and the levator muscle can still exercise its function.

Does the eye suffer from the removal of the

Meibomian glands of the upper lid ? These are of necessity removed with tarsus and conjunc- tiva. I). W. and P. C. White write as follows on this point: "The Meibomian glands should not he destroyed, though I have removed all tissue Jn this region (they are apparently referring to the canthal ends of the tarsus) and years after- wards I have seen the patient, and no xerosis of cornea developed. Trachoma in many cases ls seemingly destructive to the glands, but in my experience I have met with only a small

percentage of xerosis of the cornea." In examining eyes affected with advanced

trachoma I have not as far as I remember noticed the oily Meibomian secretion as beads along the lid margin or trickling down over the cornea as one sometimes sees it when using focal illumination or the ophthalmoscope, but then I have not specially looked for this. I have not investigated the condition of these glands in trachomas, this is a Point that has newly occurred to me.

I have however noticed that when the tarsus is incised thick cheesy matter exudes, which I take to be alteied Meibomian gland secretion. It would be strange indeed if the glands, placed ~s they are, retained their function in view of the morbid anatomy of the diseased lid. It may be then that the secretion of these glands is so altered that nothing is lost by their removal.

Moreover, the glands of the lower lid remain. I have no books here to refer to but believe

Jt is usually stated that pannus trachomatosus ls due to invasion of the corneal conjunctiva by the trachoma bodies and not to mechanical action of the thickened tissues of the lid. When the freshly excised tarsus with its conjunctiva Ls examined, I for one cannot but believe that Mechanical action is a very important factor in the causation of corneal changes. In one case the freshly excised tarsus and tarsal conjunctiva together measured over 3 m.m. in thickness and in all my cases this thickening has been Marked. Now in the normal eye the tarsal conjunctiva is held in contact with the eye-ball by the tension of the tarsal ligament externally and ?f the tendo oculi internally acting through the rigid tarsus. Thickening of the tarsal conjunctiva must therefore cause continuous j)ressure on the eye-ball and principally on the cornea. The rapid clearing of the cornea that follows the operation even when the trachomatous tissue of the fornix is left untouched is another

argument in favour of mechanical action being the main factor in the production of corneal changes. Results?At the Hewson Hospital, Jodhpur

the operation has been done on 47 eyes mostly

by me, in a few cases by my assistants. In the

district I have done a few cases and Major F. E. Wilson and I are now doing the operation at the Adams Memorial Hospital, Mount Abu

I have records of 54 of my own cases made up as

follows: 26 simple excision, 15 excision with

suture of conjunctiva, 13 simple excision with removal of skin for entropion.

In three of the cases of excision with suture

of conjunctiva a Jaesche-Arlt entropion operation was done a few days later (on 5th, 5th and

9th days respectively) under local aiiEestliesia. In some cases grattage was done in one eye

and excision of tarsus in the other; in others

simple excision in one and excision with suture

of conjunctiva in the other. In none of these

cases, except those already mentioned, has there

been anything but a good immediate result. The immediate results are very good indeed

and I can see no reason why the improvement should not be maintained, though T have not been able to follow up my cases long enough to

be dogmatic on this point. A few illustrative

cases are given below. With the class of patients

I treat it is a waste of time to use any but coarse

tests for acnity of vision. I tested and recorded

the cases myself and Major Wilson corroborated

the results in some of them

Indications for operation.?Involvement of

the tarsus causing thickening and deformity or.

short of this, commencing cicatrisation in the

tarsal conjunctiva with or without corneal com-

plications ; these I consider absolute indications

for excision. Whether it is advisable to operate

during an exacerbation of the disease I have

not made up my mind. I have hitherto avoided

doing so.

Should one operate on cases in earlier stages

than those above noted ? One's opinion as to the

effect of the medical and lesser surgical measures

will influence one here. Also the social standing

of the patient must be considered. In the case

of a trachomatous villager or a child with ignorant

parents, to apply any form of treatment which is

painful and devoid of quick results is to court

failure. Some of these patients will no doubt

continue to attend but many will cease to do so

before a satisfactory result is attained, and before

commencing treatment we do not know as a rule

to which of these classes our patient belongs.

Take the case of a girl from a distant village with early trachoma. Local

medicinal treatment or

minor surgical measure, given once may remove

all symptoms?possibly cure the disease; but further treatment may

be required and for various

reasons not be given. Her next appearance

300 THE INDIAN MEDICAL GAZETTE. [Aug., 1916.

will probably be as a middle-aged woman with entropion and corneal changes beyond all hope of recovery of fall vision. Or, she may even miss this chance of partial cure and only appear to us again as one of a collection of the hopelessly blinded to be told that this time nothing can be done for her. I have sketched an imaginary case but such cases are common. They are to be seen every day in all of the above

stages. This being so, we must consider whether even

in the early stages of true trachoma we should not excise the tarsus and thus obviate the

deformity and dangerous complications which follow in so many cases. I would emphasize that I am here considering the rural population. One can of course be more conservative if sure that the patient will remain under observation and treatment.

Illustrative cases copied verbatim from my own notes:?

No. 62 of 1016.?Hindu female, age 45, admitted 10th May, 1916.

R. Eye Trachoma + pannus tenuis, pupil small, inactive, apparently occluded, doubtful irregular dilatation to atropine, vision = P. L. + T. N.

I\th May, 1916. Operation under chloroform, excision of tarsus upper lid, slight undermining of conjunctiva which was then fixed to centre of margin of lid by one suture.

16th May, 1916.?Suture removed; patient says vision is much better, that formerly she had only P. L. but now she sees large objects. Atropine instilled.

29th May, 1916. ?Cornea much clearer. Iris and pupil now well seen.

20i/i May, 1916.?Y = Fingers at 6 to 9 feet. Cornea clear except for some old vessels which reach the pupillary area. Iris and pupil well seen, there is opaque matter in the pupil which is irregular. Atropine. T. N.

L. Eye. Small central corneal opacity, pupil small and dilated slightly and irregularly to atropine, vision large objects.

11th May. 1916.?Excision of tarsus upper lid, free undermining of conjunctiva almost to limbus. Conjunc- tiva then sutured to lid border by one continuous suture and one extra suture in centre. (With the exception of these notes the record is the same for L. Eye as for R. eye.) Patient was discharged on 20tli May, 1916, to return for further treatment if desired. There was no apparent limitation of move- ment in either eye. No 66 of 1916.?Hindu male, age 58, disease began

22 years ago. 25th May, 1916.?R. Eye Old trachoma, conjunctiva

hot very rough and thick, tarsus slightly deformed, commencing entropion, bulbar conjunctiva senile and thick. Cornea not clear vessels pterygium.

2Qth May, 1916.?Excision of tarsus + suture. Con- tinuous suture used.

27th May. 1916.?Dressed by assistant. 2nd June, 1916 V = fingers at 21 feet and perhaps

more. Absolutely no entropion. L. Eye. V = less than fingers, tarsus deformed,

entropion, trichiasis, slight kerosis.

?26 th May, 1916.?Simple excision + strip of skin removed.

2nd June, 1916.?V = fingers at 6 feet easily. (Record otherwise the same for L. eye as for R. eye.) Discharged on 2nd June, 1916. No imitation of movement.

No. 69 of 1916.?Hindu male, age 50.

27th May. 1916.?It. eye. Trachoma old but active, trichiasis towards inner canthus ; cornea opaque, vascular, and much-facetted. V = fingers at about 5 feet, improved a little under argyrol treatment.

1st June, 1916.?Simple excision of tarsus upper lid by Major F. E. Wilson, i.m.s.

L. eye.? No trichiasis, otherwise same as R. eye. 1*? June. 1916.-Excision + suture, one central

suture and one continuous suture, the conjunctiva came down very easily without any undermining. The suture was difficult owing to poor light and very fine red silk. On completion there was some vertical

folding of conjunctiva towards each canthus. 6th June, 1916.?In both eyes there has been con-

siderable pain and lacrimation, lids red and swollen. To-day condition is better and the cornese are already clearer.

In a few days a strip of skin will be removed to correct the trichiasis in the R. eye.

No. 43.?Hindu female?a purdahnashin lady?-age 16 years. Double chronic trachoma, very marked opacity of cornea with vessels especially marked in R. eye; father says that disease began 6 or 7 months ago, there is some lacrimation and photophobia.

8th March, 1916.?R. eye. Excision of tarsus with insertion of one suture which brought down freed con- junctiva very nicely. Much trachomatous sub-conjunc- tival tissue removed. L eye. Simple excision.

5th Aprii. 1916.?Has received after treatment from assistant seen by me to-day. Says she has now no discomfort and vision is improved; still some opacity of cornea ; movements of eyeballs unimpaired. No entropion, lids soft, stitch mark just shows in R. eye. There was a little suppuration in L. eye, palpebral surface now smooth in both eyes.

2nd May, 1916.?Her father wrote to say that there is no discomfort in either eye. The opacity is less and vision improved in L. eye, but in R. eye there is not much improvement.

Just as I had finished this article I heard from

Dr. E. Temple Smith of Sydney and I am writing to ask him to give me permission to publish his letter in the I. M. 0. or to write an article on

the subject himself. In his article referred to he

speaks very highly of the operation but does not

go into details. References.

" Trachoma and its Treatment" by L. Webster Fox, M.D., LL.D., Philadelphia. Ophthalmology, July 1915. " Surgical Treatment, of Trachoma

"

by W. R. Thompson Fort Worth. Texas. Texas State Jour, of Med. April 1915, reviewed in Ophthalmology, July 1915. " The Surgical removal of the tarsal cartilage and palpebral

conjunctiva in 402 eases fcr the prophylaxis, present arid future elim nation, and eradication of trachoma

"

by D. W. White, M l)., and P, C. White, M.D., Tulsa Oklahoma, Ophthalmology, October 1915.

"Some modern developments in Ophthalmology and the relationship of the Specialty to general Clinical Medicine

"

by E. Temple Smith, M.B., I'.R.C S. (Edin.), Ophthalmic Surgeon, St. Vincents Hospital, Sydney. Med. Jour, of Australia, Dec. 5, 1914.