RU2140239C1 - Method of surgical treatment of lagophthalmos in anophthalmus - Google Patents

Abstract

FIELD: ophthalmology; applicable in plastic operations for elimination of lagophthalmos in anophthalmus syndrome. SUBSTANCE: method includes separation of straight eye-moving muscles from cicatricial stump; thorough mobilization of levator from upper straight muscle and orbital implant is placed into formed muscle funnel; fixing to implant of separated muscle; suturing of tissues in adopted sequence. EFFECT: higher efficiency of treatment and cosmetic rehabilitation.

Description

 The invention relates to the field of ophthalmology and is intended for plastic surgery to eliminate lagophthalmus with anophthalmic syndrome.

 Currently, various methods are used to eliminate lagophthalmos: partial blepharography, transplantation of free flaps of the skin and mucous lip onto the eyelids, levator recession, implantation of magnets in the thickness of the upper and lower eyelids, implantation of an elastic spring in the upper eyelid, fixation of a gold plate to the cartilage of the upper eyelid, recession of the levator with its lengthening due to the stitching of the gold plate to the edges of the wound, recession of the levator with simultaneous resection or excision of the Mueller muscle, lengthening of the levator using scaveral cadaver on the flap. (McCord CD, Tanenbaum M. Oculoplastic Surgery, Raven Press, New York, 1987. - P. 186-191; Fox SA Ophthalmic Plastic Surgery. Chapter 20. Acquired anomalies. Fifth edition. New York, 1976. - P. 503 - 507 .; McCord CD Eyelid surgery.// Lippincom-Raven-press. - Philadelphia - New York. -P. 225-227, 237-245, 347-353 .; Lieb WE, Pfennigsdorf S., Munnich S., Lindeman V. Muellerectomy in patients with thyroid ophthalmopathy // Abstract book of the 13th meeting of ESOPRS. - Rostok, 1995. - P. 43-44.; Hedin A. Long-term experience of the eyelid spring for lagophthalmos. // The same, P.32 .; Sasim 1.V., Mourits M.Ph. Free levator recession in patients with Graves' orbitipathy.// Abstract book of the 14th meeting of ESOPRS. - Utrecht, 1996. - P. 78-79 .).

 Known methods can lengthen the upper and lower eyelids, to achieve their closure. However, in the treatment by such methods, a number of complications are known: hypo- and hypercorrection, the reaction of surrounding tissues to foreign bodies (magnets, weighting plates, spring), cosmetic defects. In addition, most of the described methods are not used for anophthalmos.

 There is a way to eliminate lagophthalmus with anophthalmus, which consists in conducting conjunctival incisions on the eyelids, separating subconjunctival and deep scars and mobilizing the eyelids, after which the mobilized eyelids are pulled with traction sutures, and the formed defect is performed with a free flap of the mucous lip. (Kataev MG, Filatova IA On the issue of eliminating lagophthalmus in patients with anophthalmus. // Eye burns and their consequences. Materials of a scientific and practical conference. Moscow, 1997. - P. 65-66.).

 This method is adopted as a prototype.

 The disadvantage of the prototype is that despite the good effect after surgery in the long term in patients with anophthalmic syndrome, contracted oculomotor muscles, including the levator, cause additional retraction of the upper eyelid and can lead to relapse of lagophthalmus.

 The technical result of the invention is the functional and cosmetic rehabilitation of patients with lagophthalmus with anophthalmic syndrome.

 The technical result is achieved by the fact that in order to eliminate lagophthalmus in patients with anophthalmos, additional fibers of the rectus muscles are additionally mobilized from the cicatricial stump, and an implant is placed in the resulting muscle funnel, to which the mobilized muscles are fixed.

 The method is as follows: under anesthesia, a horizontal incision of the conjunctiva is made and subconjunctival scars are dissected. Then the oculomotor rectus muscles, which are in a state of scar conglomerate, are mobilized, and the muscle that raises the upper eyelid is soldered to the upper rectus muscle. We select all the rectus muscles, free up the space between them and separate the muscle that raises the upper eyelid from tight fibrous adhesions with the superior rectus muscle. In the depth of the resulting muscle funnel, we will interfere with the orbital implant, to which the selected rectus muscles are sutured. Over the implant, we suture the Tenon capsule with a purse-string catgut suture and the conjunctiva - continuous catgut suture. The operation ends with an injection of an antibiotic and for 4 days we leave a bandage bandage. The proposed method operated on 17 patients. Analysis of their pre- and postoperative state, as well as the results of long-term follow-up showed an increase in the functional and cosmetic effect of the operation.

 The technical result of the presented method lies in the fact that all the tissues of the orbit, which after enucleation without plastic support stump under the influence of gravity mix down and form a single scar conglomerate, return to their normal position. Implantation into orbit is accompanied by the separation of the formed scars and the movement of the oculomotor muscles in their physiological position, which leads to the release of the upper eyelid, its retraction is eliminated, due to which lagophthalmos is reduced.

Examples of clinical use:
Patient K-va. Diagnosis: anophthalmic syndrome on the right, postradiation atrophy of orbit tissue, lagophthalmos. The right eye was removed in childhood for retinoblastoma. Anophthalmus for 10 years. The prosthesis retraction is 19mm, the upper eyelid retraction is 23mm. Lagophthalmus 13mm. The conjunctival arches of medium depth, the stump is empty, motionless, the mobility of the upper eyelid is also absent.

 The operation was performed - delayed plastic stump with a carbon implant. Under general anesthesia, a horizontal incision was made in the conjunctiva, subconjunctival and deep scars were dissected. The fibers of the rectus oculomotor muscles were isolated from scars. The muscle that lifts the upper eyelid is mobilized from the superior rectus muscle. An implant of 4 carbon felt disks is immersed in the depths of the muscular funnel. The rectus muscles are fixed at the edges of the implant. Tenon's capsule is sutured over the implant with a purse-string catgut suture. The conjunctiva is sutured with a continuous catgut suture. A standard plastic prosthesis is placed in the cavity and the eyelids are sewn over the implant with temporary sutures. Antibiotic injection. They left a bandage for 4 days. In the postoperative period, when washing the cavity, a small amount of sacred discharge was observed. Rafic seams were removed after a week. When viewed after 2 weeks, the stump is voluminous, slightly mobile, the prosthesis has decreased by 12 mm, the prosthesis is in the correct position, the contour of the eyelids is correct, there is no lagophthalmos, and slight blinking movements appeared. When examined after 6 months and 1 year, almost no changes were found in the patient's condition: the correct position of the prosthesis remains, the asymmetry of the orbits and palpebral fissures remains, but significantly less pronounced than before the operation, the prosthesis retraction compared to a healthy eye is 7 mm. The contour of the eyelids is smooth, there is no retraction, the stump is of medium volume, soft-elastic consistency, slight mobility, there are no signs of implant displacement or rejection, there is no lagophthalmos, there is mobility of the upper eyelid with an amplitude of 3 mm.

 Sick F-owls. Diagnosis: left anophthalmic syndrome, lagophthalmos. The left eye was removed 2 years ago due to the consequences of a penetrating wound to the eye with the introduction of a splinter, subatrophy and sluggish post-traumatic uveitis. During enucleation, the stump was formed by cartilage. After 3 months, purulent inflammation of the stump developed and the cartilage was rejected, the wound healed by secondary intention, the cavity was partially reduced. The prosthesis sinks by 6 mm, the lowering of the upper eyelid by 8 mm. Lagophthalmus 9 mm. The mobility of the upper eyelid is reduced by 8 mm. Conjunctival arches of medium depth, in the center of the stellate scar of the conjunctiva, the stump is empty, motionless, the mobility of the upper eyelid is reduced.

 The operation was performed - delayed plastic stump with a carbon implant. Under general anesthesia, a horizontal incision was made in the conjunctiva, subconjunctival and deep scars were dissected. The fibers of the rectus oculomotor muscles were isolated from scars. The muscle that lifts the upper eyelid is mobilized from the superior rectus muscle. An implant of 3.5 carbon felt disks is immersed in the depths of the muscular funnel. The rectus muscles are fixed at the edges of the implant. Tenon's capsule is sutured over the implant with a purse-string catgut suture. The conjunctiva is sutured with a continuous catgut suture. A standard plastic prosthesis is placed in the cavity and the eyelids are sewn over the implant with temporary sutures. Antibiotic injection. They left a bandage for 3 days. In the postoperative period, when washing the cavity, an insignificant amount of blood flow was observed. Rafic seams were removed after a week. When examined after 2 weeks, the stump is voluminous, slightly mobile, the prosthesis is not retracted, the prosthesis is symmetrical to the right eye, the prosthesis is in the correct position, the eyelid contour is correct, lagophthalmus decreased to 4 mm, the mobility of the upper eyelid improved by 5 mm. When viewed after 6 months and 1 year, almost no changes were found in the patient's condition: the correct position of the prosthesis remains, there is no asymmetry of the orbits and palpebral fissures, and there is no retraction of the prosthesis and upper eyelid. The contour of the eyelids is even, there is no retraction, the stump is of medium volume, soft elastic consistency, slight mobility, there are no signs of implant displacement or rejection, residual lagophthalmus is 3 mm, mobility of the upper eyelid is 10 mm.

 Thus, the use of the above method significantly increases the effectiveness of the treatment and cosmetic rehabilitation of patients with lagophthalmus with anophthalmic syndrome. The correct position of the prosthesis and the smooth contour of the eyelids are maintained, and the retraction of the prosthesis and upper eyelid is significantly reduced. Lagophthalmus is completely corrected or reduced. There is some mobility of the stump and prosthesis. Based on our clinical observations, we consider it reasonable to introduce the above method into practice.

Claims (1)

 A method of surgical treatment of lagophthalmus with anophthalmus, including mobilization of the muscle that raises the upper eyelid, characterized in that the fibers of the rectus muscles are additionally extracted from the cicatricial stump, and an implant is placed in the funnel formed, to which the selected muscles are fixed.