Operation. First step. The base of the socket is freely divided in a horizontal direction opposite the palpebral aperture so as to produce a gaping wound.

Second step. This gaping wound is put on the stretch in the following way: A thick piece of style wire is bent round to fit into the fornices of the socket, the ends being brought out over the lid at the inner canthus. The circle of wire is opened out as far as possible so as to put the wound at the bottom of the socket on the stretch to its fullest extent.

Third step. Skin grafts are then cut from the inner surface of the arm (see Vol. I, p. 670), applied by means of probes, and pressed down on to the raw surface. No dressings should be applied directly to the grafts, but a watch-glass may be placed over the palpebral aperture and dressings applied over it. The style wire should be removed on the fourth day.

INCLUSION OF FLAPS. MAXWELL’S OPERATION

Indications. It is especially useful for the enlargement of the socket by the formation of new fornices. As a rule it is performed for the reproduction of the lower fornix, as it is frequently due to the obliteration of this cul-de-sac that the artificial eye cannot be retained. The operation, however, may be modified and applied to the formation of both the upper and outer culs-de-sac.

Instruments. Scalpel, forceps, scissors, and sutures.

Operation. A general anæsthetic is required.

First step. An incision is made in the lower fornix throughout its whole length and carried downwards for a distance of about half an inch (Fig. 137, A).

Fig. 137. Maxwell’s Operation for Contracted Socket. First step. A is the incision through the conjunctiva. The flap of skin from the outer surface of the lower lid is entirely raised from the subcutaneous tissue, except for the pedicle B which holds the new fornix in position.    Fig. 138. Maxwell’s Operation. Final step. Showing the flap of skin from the outer surface of the lower lid turned in to form the new lower fornix. The surface wound has been closed by sutures.

Second step. A crescentic piece of skin is marked out on the lower lid by two incisions which have their concavity directed upwards. The upper one is parallel with the margin of the lower lid and about 5 millimetres below it. This crescentic flap is then dissected up from the deeper tissues all round, except for a small pedicle at its centre (Fig. 137, B).