RU2140240C1 - Method of treatment of ptosis of upper eyelid of serious grade with weak witnall ligament - Google Patents

Abstract

FIELD: ophtalmosurgery. SUBSTANCE: method includes mobilization and resection of levator by standard procedure; prior to resection, weakened ligament is reinforced by making its duplicate; transferring levator over reinforced ligament and fixation of levator shortened by 20-30 mm to front surface of cartilage. Method provides for support for levator in form of strong lateral connection, even if it was weakened and functionally inferior. EFFECT: higher per cent of positive outcomes in cases of serious ptosis. 2 dwg

Description

 The invention relates to medicine, in particular to ophthalmology, and for the surgical treatment of severe ptosis of the upper eyelid in the presence of a weakened transverse ligament.

 The treatment of severe congenital ptosis of the upper eyelid is a difficult task. For a long time, surgery to suspend the upper eyelid to the eyebrow was used for surgical correction of this pathology [Crowel Beard Ptosis. // Saint Louis 1976. - P. 164-181.]. For this purpose, a wide variety of materials were used: strips of the dura mater or broad fascia of the thigh, silk, supramid or tendon sutures, silicone tapes, etc. This operation creates a rigid connection between the tarsal plate of the upper eyelid and the eyebrow, and the raising of the upper eyelid is carried out by reduction of the frontooccipital aponeurosis. However, after the operation, the eyelid and its movements look unnatural, because the direction of the rise of the eyelid changes, and the eyelid loses its natural fold. There is a method of surgical treatment of ptosis of the upper eyelid of moderate severity by means of a 15–25 mm levator resection, which was modified by G. Epstein b A. Putterman to correct severe ptosis in the form of complete mobilization with the intersection of the entire ligamentous apparatus and the maximum levator resection in ZO-ZZ mm (Epstein G., Putterman A. Super-maximum levator resection for severe unilateral congenital blepharoptosis. Ophthalmic Surgery. 1984, v.l5, N 12, p. 971-979). However, despite the possibility of achieving a good result directly on the operating table, a hypoeffect is often observed in the long term due to severe dystrophy of the muscle that raises the upper eyelid.

 The closest to the technical implementation is a method of eliminating ptosis of the upper eyelid of a severe degree, including resection of the levator with the preservation of its ligamentous apparatus and movement of the levator through the transverse ligament of Whitnall before hemming it to the tarsal plate (Kataev M.G., Filatova I.A. moving through the Whitnall ligament. // Vestn. Ophthalmol. M 1996. S. 18-22). This method of surgical treatment allows you to make a smaller amount of resection of the levator due to the stabilization of the levator complex using the transverse ligament and as a result to achieve increased efficiency of the result and increase the amplitude of movements of the upper eyelid.

 This method is adopted as a prototype.

 The disadvantages of the prototype are the insufficient effect of surgical treatment with a sharp dystrophic change in the Whitnall transverse ligament, the inability in some cases to isolate a sufficiently strong ligament that can withstand the severity of the levator moved through it and, as a result, raise the upper eyelid to the required height.

 The technical result of the proposed solution is to increase the efficiency of the method of surgical treatment in cases of severe ptosis of the upper eyelid with weakness and functional inferiority of the Whitnall transverse ligament.

 The technical result is achieved by strengthening the weakened Whitnall ligament by creating its duplicate.

 The method is as follows. The skin incision is made along the folds of the skin of the upper eyelid, bluntly spread the fibers of the circular muscle, open the tarso-orbital fascia, expose the anterior surface of the levator aponeurosis, dissect the aponeurosis at the level of the upper border of the tarsal plate, free the lower surface of the levator from adhesions with the conjunctiva and tenon capsule, fix cut off the end of the levator with a Berke clamp, cut the lateral horns of the levator aponeurosis by 10 mm, pull the levator down and examine the zone of transition of the muscle body into the aponeurosis, find m Uitnalla hundred bundles of locations. A bunch is evaluated visually and sampled with forceps for strength. In the presence of a weak stretched ligament (Fig. 1.), it is separated from the levator, the intersection of the lateral horns of the aponeurosis above the ligament is continued until the levator is completely mobilized. Then the ligament is strengthened by creating its duplicate, fixing its stretched weakened part with seams in the fold (Fig. 2.). The levator is carried out over the reinforced ligament, pulled down and sutured with three sutures to the front surface of the tarsal plate, shortening it by 20-30 mm, trying to raise the edge of the upper eyelid to the level of the upper limb of the cornea, stitch the skin.

 An example of clinical use of the proposed method.

 Patient K. in 8 years. Diagnosis: severe congenital ptosis of the upper eyelid of the right eye. Condition before surgery: ptosis 4 mm, the mobility of the upper eyelid of the left eye 13 mm, the right eye - 3 mm, the fold of the upper eyelid is weakened, the mobility of the eyeball is not limited, there is no synkinesis.

 Technique of the operation: a skin incision along the fold of the upper eyelid, circular muscle fibers are bluntly divided, the tarso-orbital fascia is opened, the orbital tissue is pushed up, the levator aponeurosis is crossed at the level of the upper border of the tarsal plate, the lower surface of the levator is mobilized from adhesions with the conjunctiva and tenon capsule, the proximal part of the levator was taken on the Berke clamp, the lateral horns of the aponeurosis were notched by 10 mm, the levator was pulled down, when examining the high part of the aponeurosis, a Whitnall ligament was found, positioning extending in II mm from the tarsal plate. The ligament is thinned and weakened, when it is separated from the aponeurosis, it was stretched. To strengthen the ligament, it is fixed in the form of a fold with two seams and its duplicate is created. After that, the intersection of the lateral horns of the aponeurosis under the ligament to an additional height of up to 20 mm was continued, the clamp was removed, the levator was held over the Whitnall sphincted reinforced ligament, pulled down and hemmed to the front surface of the tarsal plate with a shortening of 27 mm, while the edge of the upper eyelid was at a level the upper limb of the cornea, the wound of the skin is sutured with a continuous nylon seam.

 When viewed after a month: there is no ptosis, the edge of the eyelid is 1 mm below the upper limb, the mobility of the eyelid is 3 mm, the fold is of the correct shape.

 When viewed 6 months after surgery: there is no ptosis, the edge of the eyelid is 1.5 mm below the upper limb, the mobility of the eyelid is 4 mm, the fold of the upper eyelid is flat, the surface of the eyelid has a regular contour symmetrical to the right side.

 The proposed method allows you to create support for the levator in the form of a strong transverse ligament, even if it was weakened and functionally inferior, which ultimately will increase the percentage of positive outcomes in severe ptosis.

Claims (1)

 A method of surgical treatment of severe upper eyelid ptosis in case of weakness of the Whitnall ligament, including mobilization and resection of the upper eyelid levator with its movement through the Whitnall ligament, characterized in that before the resection of the levator, the ligament is strengthened by creating its duplicature and the levator is carried out over the strengthened ligament and hemmed , shortening by 20 - 30 mm.

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