[Illustration: FIG. 151. MODIFIED KUHNT’S OPERATION. _Fourth step._ Showing the sutures in position. The outer part of the lid has been undermined and dissected up. The V-shaped gap in the tissues is sutured first.] _Fourth step._ The lid is sutured into position. The V-shaped wound in the conjunctiva and tarsus is sutured, the knots being placed on the conjunctival surface with the exception of the suture at the lid border, which is turned the other way, the ends being brought out through the skin of the outside flap, after the latter has been sutured in position, and the two ends tied over a bead. The outside flap of skin is brought up into position by a suture at its upper angle. As the result of this a few eyelashes project beyond the outer canthus; these should be excised. Additional sutures to hold the flap in position are then inserted. Both eyes should be bandaged after the operation, otherwise the knots in the conjunctiva may rub on the cornea. =Argyll Robertson’s operation.= The operation aims at shortening the border of the lower lid and at the same time pulling it upwards into position by means of a strap of skin and subcutaneous tissue cut from the outer side, the attached end of the strap being formed by the outer portion of the skin of the lower lid. =Indications.= It is especially useful for paralytic cases, and as a subsequent measure to the VY operation described below for cicatricial ectropion. The operation is likely to be successful if a marked reduction in the deformity is effected by pulling the skin at the side of the outer canthus upwards. =Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, sutures. [Illustration: FIG. 152. ARGYLL ROBERTSON’S OPERATION FOR ECTROPION. _Second step._ Showing the method of shortening the lid and the strap of skin reflected. The upper convex line shows the piece of skin to be removed so that the lid may be pulled upwards into position.] [Illustration: FIG. 153. ARGYLL ROBERTSON’S OPERATION FOR ECTROPION. _Final step._ The strap of skin has been sutured in position after pulling it upwards sufficiently to reduce the deformity and enlarging the raw area upwards to allow this to be done.] =Operation.= _First step._ An incision, 2 millimetres below the lid margin and opposite its outer third, is carried through the skin parallel to the border of the lower lid outwards to the canthus; having reached this point the direction of the incision is changed and it is carried more upwards and outwards till the upper end is on a level with the upper orbital margin. The incision is then carried outwards for about 6 millimetres and again downwards, slightly diverging from the former incision, until it is opposite the lower orbital margin. This flap of skin and subcutaneous tissue is dissected up from above downwards (Fig. 152).