RU2342917C1 - Method for surgical treatment of enstrophe of inferior eyelid - Google Patents

Abstract

FIELD: medicine, ophthalmology.

SUBSTANCE: skin is knifed with taking orbicular muscle and making shift for 1.5-2mm from ciliary edge of eyelid and parallel to it. Musculodermic section is made over the external angle of the eye. Musculodermic flap is defined and deepithelised. The deepithelised musculodermic flap is dissected outside and separate for 2/3 of eyelid's length. A lateral part of musculodermic flap is dissected. The flap is fixed to periosteum of lateral edge of orbit in a lower lateral direction from the place of initial fixation. The flap is additionally fixed to the lower edge of cartilage and tarsoorbital fascia. The separated skin of inferior eyelid is strained over the fixed deepithelised musculodermic flap.

EFFECT: restriction of movement of cartilaginous plate of inferior eyelid, risk decrease of herniation.

4 cl, 2 ex, 5 dwg

Description

The invention relates to medicine, namely to ophthalmology, and can be used to treat patients with inversion of the lower eyelid of an atonic nature.

It is known that senile (senile) changes in the tissues of the eyelids, in particular the lower one, lead to significant violations of the topography of the layers of the eyelid, a change in the structures of the eyelid itself and a disruption of the functions of the eyelid.

Among the various causes of age-related lower eyelid dislocations, senile entropion (inversion) is a rather significant and difficult to correct pathology, because the constant contact of the eyelashes with the anterior segment of the eye is a powerful irritant for the sensitive conjunctiva and cornea, causes mechanical damage to the epithelium and contributes to the development of secondary infection, which may ultimately lead to a threat of decreased vision and eye loss. In addition, without restoring the normal function of the lower eyelid, it is impossible to perform a series of operations on the eyeball in patients of gerontological age.

The mechanism of development of atonic inversion is quite complicated, but the dystrophy of the cartilaginous plate and the displacement of the musculoskeletal layer of the eyelid relative to the cartilaginous layer, which leads to the formation of an excess skin fold, weakening the pressing effect of the muscle layer and the displacement of the cartilaginous plate upward with its subsequent inversion. Contributes to the inversion of the lower eyelid senile atrophy of orbital fat and enophthalmos caused by it. The eyeball displaced posteriorly does not provide sufficient support for the edge of the eyelid, which leads to the formation of an inversion.

A known method of lower eyelid plasty in spastic inversion by excision of skin flaps (Zaykova MV Plastic ophthalmic surgery. - Moscow, Medicine, 1980, p.90). The essence of the method is that, having departed 3-4 mm from the edge of the eyelid, a flap of skin (6-8) mm × (20-25) mm is cut out in the middle third, the lower half of the flap is excised with subcutaneous tissue. On the sides of the flap, departing from the edges of the eyelid by 3-4 cm, stripes of the flap 4-5 mm wide are cut out and excised. The vertical flap is separated and the skin wound is sutured.

The disadvantage of this method is the low cosmetic effect of the operation and the possibility of postoperative complications.

There is also a method of treating atonic inversion of the lower eyelid, which consists in implanting curved homo-cartilaginous plates two times the width of the intermarginal space into the intermarginal space of the lower eyelid in the projection of the lateral and medial parts, excising the skin fold between the grafts and applying deep sutures that capture all layers century (AS No. 1706612, class A61F 9/00, publ. 23.01.92).

The disadvantages of this method are the complexity, the complexity of the operation, the need for implantation of homochromatic cartilage of a certain width, insufficient cosmetic effect of the operation.

A known method of treating spastic inversion of the lower eyelid, proposed by Blashkovich in 1958 (A.A. Kolen, Manual on eye diseases, volume No. 4. - Moscow: Medgiz, 1959, p.138). The essence of the method is that, retreating from the edge of the eyelid by 4-5 mm, make a cut and parallel to it continue by 4 cm into the temple area. At the outer end of the incision, an isosceles skin triangle with a side length of 2.5 to 3.5 cm is delineated with a vertex down and out, and it is removed. The skin of the eyelid is separated up to the edge of the eyelid, down to the top of the triangle. Individual fibers of the circular muscle are removed so as to weaken the skin separated flap; the latter is pulled up and its end is sewn into the upper corner of the triangle. The entire wound is sutured with knotted sutures.

The disadvantages of this method are the complexity, the complexity of the operation, the possibility of recurrence of inversion of the lower eyelid, insufficient cosmetic effect.

A known method of surgical treatment of spastic inversion of the eyelids, proposed by A.M. Vodovozov in 1965, comprising two cuts of the skin of the lower eyelid parallel to its free edge from the inner to the outer corner of the palpebral fissure. The first incision is carried out at a distance of 2-3 mm from the free edge of the eyelid. The second section is made 3-4 mm from the first and parallel to it. Under the lower incision with a scalpel, a skin triangle is drawn. Then, a skin roller is formed by stitching into the tube strips of skin between parallel incisions. After that, the fibers of the pretarsal part of the circular muscle intersect at the inner and outer corner of the eyelid, and then a triangular skin flap is excised. At the final stage, stitches are applied and tied to a triangular and horizontal skin incisions with immersion of the formed skin roller (Vodovozov AM // Ophthalmological Journal, 1972, No. 5, p. 390-391; MP Bystrov // Ophthalmic Journal, 1978 city, No. 2, p. 144-146).

The disadvantages of this method are the complexity, the complexity of the operation, insufficient cosmetic effect and the possibility of a relapse inversion or inversion of the lower eyelid.

The closest technical solution to the claimed is a method of surgical treatment of senile inversion of the lower eyelid, including a horizontal skin incision along the ciliary edge, carried out 4 mm below the edge of the eyelid. Next, a strip of circular muscle of the eye with a width of 6 mm is isolated and separated. Inner from the cartilage and slightly more medial than the middle of the century, it is left in connection with the underlying tissues and is separated towards the outer corner. The lateral end of the strip is cut off, the position of the muscle is changed by pulling and suturing it to the periosteum of the orbit below the usual attachment site.

After this, sutures are placed on the edges of the skin wound (Callahan Alston. Eye Disease Surgery, translated from English by MD Dr. M.G. Rabinovich, edited by Prof. V.N. Arkhangelsky, Corresponding Member of the USSR Academy of Medical Sciences, Moscow, 1963 ., p. 50-51) - prototype.

This method allows you to perform operations to eliminate inversion of the lower eyelid, however, it is not effective enough, and the possibility of recurrence of inversion or inversion of the lower eyelid is not excluded.

The objective of the invention is to improve the method of surgical treatment of inversion of the lower eyelid.

The technical result that will be achieved from the use of this technical solution is to increase the efficiency and cosmetic effect of the operation, as well as the prevention of postoperative complications and relapses of the disease.

The technical result is achieved by the fact that in the method of surgical treatment of lower eyelid inversion by changing the direction of tension of the circular muscle of the eyeball, cutting off its lateral end and fixing it to the periosteum of the lateral edge of the orbit, the tension of the circular muscle of the eye is produced by isolating a skin-muscle flap and its epithelialization with subsequent separation of the flap at 2/3 of the eyelid. Fixation of the separated flap is additionally performed to the lower edge of the cartilage and to the tarsoorbital fascia. Separated skin of the lower eyelid is pulled over a fixed de-epithelized musculocutaneous flap.

A muscular-skin incision is continued beyond the outer corner of the eye by 10-15 mm along one of the natural folds.

The de-epithelialized flap is fixed using nodal sutures, and nodal sutures are applied to the edges of the inclined part of the incision, the edges of the horizontal part of the incision are connected with a cosmetic suture.

The essence of the invention lies in the totality of the methods of operation.

The tension of the circular muscle of the eye by isolating the musculocutaneous flap and its depepithelization, followed by separation of the flap by 2/3 of the eyelid length, allows to increase the stability of the operation result due to the clamping action of the de-epithelized musculocutaneous flap.

Fixation of the separated flap in addition to the lower edge of the cartilage and to the tarsoorbital fascia serves to strengthen the tarsoorbital fascia and, as a result, prevents the prolapse of orbital hernias and reduces enophthalmos, as a de-epithelialized musculocutaneous flap exerts pressure on the lower edge of the cartilage, limits the mobility of the cartilaginous plate of the lower eyelid, and acts as a skeleton of the lower eyelid.

The tension of the separated skin of the lower eyelid over the fixed de-epithelized skin-muscle flap allows you to further strengthen the role of the skeleton and increase the cosmetic effect after surgery.

The continuation of the skin-muscle incision beyond the outer corner of the eye by 10-15 mm along one of the natural folds provides the most optimal process of the operation and provides the cosmetic effect of the operation.

Fixation of the de-epithelialized flap with the help of nodal sutures to the periosteum of the orbit contributes to strong scarring in the projection of the lateral angle of the palpebral fissure and prevents the dislocation of the eyelid up.

The application of nodal sutures on the edges of the incline part of the incision, and cosmetic sutures on the edges of the horizontal part of the incision serves to increase the cosmetic effect of the operation; subtle scars that hide in the natural folds of the skin remain on the skin.

From the analysis of scientific, technical and patent literature of the claimed set of methods for surgical treatment of lower eyelid inversion, it is not revealed, which allows us to conclude that the claimed technical solution meets the criteria of "novelty" and "inventive step".

The invention is illustrated by the following drawings, where:

figure 1 shows the first stage - a skin-muscle incision;

figure 2 - the second stage is de-epithelialization of the musculocutaneous flap;

figure 3 - the third stage is the separation of the skin of the eyelid and cutting off the fragment of the flap;

figure 4 - the fourth stage is the fixation of the flap;

figure 5 - the fifth stage is the sealing of the section.

The invention is illustrated by the following method of performing an operation.

For the implementation of the proposed method take patients with the following indications:

- Senile entropion: atonic type 1, 2, 3 stages, with and without destruction of the tarsal plate.

- Relapse of the operated entropion of the lower eyelid.

- Age-related enophthalmos.

- Age-related hypotrophy of the fibers of the circular muscle of the eye.

The surgical field is pre-treated, marking incision lines are applied and local infiltration anesthesia is performed. The skin is cut with the capture of the circular muscle of the eye, retreating 1.5-2 mm from the ciliary edge of the eyelid and 2 mm outward from the lower lacrimal opening along the marker line from the inner corner of the eye parallel to the free edge of the lower eyelid, extending beyond the outer corner of the eye at an obtuse angle by 15 mm along the natural fold with a continuation to the inner corner of the eye at the level of the beginning of the incision (figure 1). The determination of the width of the musculocutaneous flap is determined by the volume that strictly corresponds to the parameters of the inverted part of the skin during a provocative test - multiple eye squeezing. Using scissors carry out de-epithelialization of the resulting skin-muscle flap (figure 2). Then the lower eyelid skin is separated to the lower edge of the orbit. When prolapsed orbital hernias, they are removed and sutured in the tarsoorbital fascia. Next, the de-epithelialized musculocutaneous flap is cut off from the outside (Fig. 3) and separated by 2/3 of the eyelid length towards the nose. Then, the resulting musculocutaneous flap is pulled in the direction of the outer corner of the eye, its lateral part is cut off within 5-6 mm and fixed in the lower lateral direction 5 mm from the place of initial attachment to the periosteum of the lateral edge of the orbit using a non-absorbable suture (proline 7.0) so that the cartilage takes the correct position (figure 4). The upper and lower edges of the separated skin-muscle flap are fixed to the lower edge of the cartilage and to the tarsoorbital fascia with Vicryl suture (7.0) (Fig. 4). Separated skin of the lower eyelid is tightened, imposed on top of a de-epithelized muscle-skin flap. The edges of the skin wound combine and impose a cosmetic inner suture (prolene 6.0) on the edges of the horizontal part of the incision and nodal sutures (propylene 6.0) on the edges of the inclined part of the incision (Fig. 5).

Example 1. Patient S., 77 years old, was admitted to the hospital with a diagnosis of atonic senile inversion of the lower eyelid of the right eye of the II degree. The duration of the inversion is about 3 years, has not previously been treated. The inversion developed gradually, at first without causing concern, later a sensation of a foreign body in the eye appeared, separated by a mucopurulent character. Objectively: inversion of the lower eyelid, the intermarginal margin contacts the conjunctiva, the eyelashes are directed to the lower conjunctival arch. After reposition, the eyelid is again wrapped at the first blinking movement.

The patient performed the operation as described above.

When examining the patient the day after the operation, a mild swelling of the lower eyelid was revealed, the edge of the eyelid was repaired, the eyelashes did not touch the eyeball.

When removing the sutures on the seventh day after the operation: the edema of the lower eyelid is slightly expressed, the position of the lower eyelid of the right eye is correct, the eyelashes are directed away from the eye, the patient did not complain.

When viewed 6 months after the operation, the position of the lower eyelid of the right eye is normal, the edge of the eyelid is pressed against the eyeball, a barely visible scar hiding in the skin fold is determined parallel to the ciliary edge, the tendency to inversion is not determined.

Example 2. Patient K., 70 years old, was admitted to the hospital with a diagnosis of recurrent operated inversion of the lower eyelid of the left eye. The inversion surgery was performed two years ago, but the last four months the patient again began to worry about pain in the eye, a feeling of a foreign body, periodic redness of the eye, clumping of eyelashes.

The patient performed the operation of the claimed method.

When examining the patient the day after the operation, moderate edema of the lower eyelid persisted, the edge of the lower eyelid was located correctly, the inversion was eliminated, the eyelashes were directed away from the eye.

When removing the sutures on the seventh day after the operation, the edema of the lower eyelid is slightly expressed, the position of the lower eyelid is normal, the eyelashes are directed away from the eye, the patient did not complain.

On examination, one year after the operation, the position of the lower eyelid of the left eye is correct, the eyelid edge is pressed against the eyeball, a barely visible scar hidden in the skin fold is determined parallel to the ciliary edge, the tendency to inversion is not determined.

The de-epithelialized musculocutaneous flap plays the role of the lower eyelid skeleton, strengthens the tarsoorbital fascia, prevents the loss of orbital hernias and reduces enophthalmos. The ciliary edge remains intact. Strong scarring in the projection of the lateral angle of the palpebral fissure prevents the dislocation of the eyelid up. The method is simple to execute, has no contraindications, does not require equipping with additional tools, is performed under local anesthesia.

Claims (4)

1. A method of surgical treatment of lower eyelid inversion by changing the direction of tension of the circular muscle of the eyeball, cutting off its lateral end and fixing it to the periosteum of the lateral edge of the orbit, characterized in that the skin is cut with the capture of the circular muscle, departing 1.5-2 mm from the ciliary edge century and parallel to it, continue a skin-muscle incision beyond the outer corner of the eye, allocate a skin-muscle flap, depepithelize it, cut off the de-epithelized skin-muscle flap from the outside and separate it by 2/3 of the eyelid length, cut the lateral part of the musculocutaneous flap, then the flap is fixed to the periosteum of the lateral edge of the orbit in the lower lateral direction from the place of initial attachment, the flap is fixed additionally to the lower edge of the cartilage and to the tarsoorbital fascia, then the separated skin of the lower eyelid is pulled over the fixed de-epithelized musculocutaneous flap . 2. The method according to claim 1, characterized in that the incision beyond the outer corner of the eye is carried out by 10-15 mm along one of the natural folds. 3. The method according to claim 1, characterized in that the fixation of the epithelialized flap is carried out using interrupted sutures. 4. The method according to claim 1, characterized in that nodal seams are applied to the edges of the section of the section, and the edges of the other part of the section are connected by a cosmetic seam.

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