RU2435554C1 - Method of syrgical treatment of involutional entropium of lower eyelid - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, in particular to ophthalmology, and can be applied in treatment of involutional entropium of lower eyelid. Essence of method includes performance of horizontal cut of skin along eyelash edge of eyelid, blunt separation of cutaneous-muscular layer from tarso-orbital fascia and adipose sacs with the following application on suture on skin wound. Horizontal cut of skin is made from lacrimal point to lateral edge of orbit into lateral cantus. 2.0-2.5 mm wide and 2.5-3.0 mm long strap of tarso-orbital fascia is ablated on the top of adipose sacs. Lower pedicle of lateral ligament is cut off with scissors at 1.0-2.0 mm distance from the point of its fixation to orbit edge. Part of ligament is excised depending on degree of entropium expression. On ligament edges mattress absorbable suture is applied. Excess of skin and triangular flap of skin of wound lower edge outwards from lateral palpebral commissure is excised. Strap of orbicular muscle is ablated. After that, edge of streatched or torn off lower eyelid retractor is found and fixed to lower edge of tarsal plate with three mattress absorbable sutures.

EFFECT: application of claimed invention makes it possible to increase efficiency of surgical treatment by impact on main causes of involutional entropium, as well as prevent disease recurrence.

3 cl, 2 ex

Description

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

In the structure of diseases of the adnexal apparatus, senile diseases of the eyelids still occupy an important place, the number of which does not decrease, but, on the contrary, increases due to the deterioration of the general environmental situation, the absence of reliable means of prevention and the increase in overall life expectancy. Of the changes in the position of the eyelids, their involutional inversion is most often found. Senile entropion (inversion) is a fairly numerous and difficult to correct pathology. The constant contact of the eyelashes with the anterior segment of the eye is a powerful irritant for the sensitive cornea, causes mechanical damage to its epithelium and contributes to the development of secondary infection, which can ultimately lead to corneal ulcer with the threat of perforation, a sharp decrease in vision and loss of eye. In addition, without restoration of the normal function of the lower eyelid, it is impossible to perform a number of operations on the eyeball in patients of gerontological age, for example, cataracts.

The mechanism for the development of involutional inversion is quite complicated, but the main reasons are the following: a) stretching of the tendons of the inner and outer corners of the eye and an increase in the horizontal eyelid length; 2) excessive gaping (separation from the tarsal plate) of the lower eyelid retractor; 3) spasm of the orbicular muscle with its hypertrophy and overhang of the skin over the border of the curled eyelid.

In the literature, there are more than 80 methods of surgical treatment of involutional inversion. All of them are usually aimed at correcting one, at most two main causes of inversion. The variety of methods indicates that the problem of treating this disease has not yet been resolved, the effect of interventions is often insufficient, variable, relapses are frequent. Therefore, the development of a method for the treatment of this pathology, aimed at eliminating all three leading causes of involutional inversion, remains an urgent task.

A known method of lower eyelid plasty in spastic inversion by excision of skin grafts (Zaykova MV Plastic ophthalmic surgery. M: Medicine, 1980, p.90). The essence of the method is that, departing 3-4 mm from the edge of the eyelid, a skin flap (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 edge 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 disadvantages of the method are the low cosmetic effect of the operation and the possibility of postoperative complications.

There is a method of treating lower eyelid inversion, including dissection of the eyelid along intermarginal space and forming in its lateral, middle and medial third of the tunnels to a depth twice as high as the cartilaginous plate, introducing the corresponding size of the plate from canned cartilage into them and suturing the intermarginal space (USSR AS No. 1560195, CL A61F 9/00, publ. 30.04.90).

The disadvantages of the method are its complexity and the possibility of recurrence of inversion of the lower eyelid and rejection of cartilage grafts.

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 (A.S. USSR 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 homo-cartilaginous plates of a certain width, the danger of rejection of the implant, insufficient cosmetic effect of the operation.

A known method of surgical treatment of lower eyelid inversion, including a horizontal incision of the skin along the lower ciliary edge, separating the skin to the lower edge of the orbit, excising excess skin and applying a suture from non-absorbable material to the skin wound, the horizontal incision starting from the middle of the nasal third of the century to the outer corner eyes and then at an obtuse angle down, along one of the natural wrinkles, in the area of the lateral third of the palpebral part of the circular muscle of the eye, form a duplicate by overlaying on the mouse tsu of nodular sutures from non-absorbable material, between the seams along the duplicate line, 2-6 coagulates are applied to the muscle, and then the separated skin flap is pulled in the lateral direction and the excess skin is excised (RF Patent No. 224106, class A61F 9/007, publ. 20.06. 2005).

The disadvantage of this method is the complexity of the operation.

The closest to the claimed method - the prototype, is a method of surgical treatment of lower eyelid inversion, including an inclined skin incision with the capture of the muscle layer, starting at the outer corner of the eye in the direction of one of the wrinkles, blunt separation of the musculoskeletal layer to the lower edge of the orbit through the received access, horizontal skin incision along the ciliary edge of the eyelid towards the inner corner of the eye, delamination of the fibers of the circular muscle of the eye to the level of the tarso-orbital fascia, the formation of folds from excess after her, its excision on the basis of the entire length, with subsequent comparison of the edges of the incision and adapting them with a twisted suture from absorbable material with subsequent suturing of the muscular skin incision from non-absorbable material (RF Patent No. 2224489, class A61F 9/007, publ. 02/27/2004).

The disadvantages of this method are the lack of stability of the effect of the operation and the possibility of recurrence of inversion or inversion of the lower eyelid, since other causes of inversion are not eliminated, namely hypertrophy of the spasmodic orbicular muscle and tendon stretching of the outer corner of the eye.

An object of the invention is to increase the efficiency of the operation by affecting the main causes of involutional inversion and the prevention of relapse of the disease.

The technical task is achieved by the claimed method, which consists in the following.

After processing the surgical field, marking the lines of the skin subcutaneous incision and local transconjunctival anesthesia, a horizontal skin incision is made along the intended line with the capture of muscle tissue from the inner to the outer corner of the eye with an extension of 5-7 mm beyond the outer corner of the eye. Through the obtained access, the skin-muscle layer is stupidly separated from the tarso-orbital fascia and fat bags, a strip of tarso-orbital fascia is removed along the top of the fat bags 2.0-2.5 mm wide and 2.5-3.0 cm long. Lower leg The lateral ligament of the eyelid is cut with scissors 1.0-2.0 mm from the place of its attachment to the edge of the orbit, a part of the ligament is excised depending on the degree of its stretching, and a mattress absorbable suture is applied to the edges of the ligament (biosorb 6.0). Next, excess skin of the lower edge of the wound is excised outward from the lateral adhesion of the eyelid in the form of a skin triangle. The edge of the skin is removed along with the strip of orbital muscle along the entire lower edge of the wound. After taking the fat bags up, find the edge of the stretched (or torn) retractor, which looks like a strip of white dense connective tissue, and attach it to the lower edge of the tarsal plate using three mattress absorbable sutures from biosorb 6.0 passing through the lower edge of the tarsal plate and edge of the lower eyelid retractor.

The defining differences of the proposed method from the prototype are the following:

- remove a strip of tarsoorbital fascia along the apex of fat bags 2.0–2.5 mm wide and 2.5–3.0 cm long, which eliminates excess fascia and increases the compressive effect of the tarsal (cartilaginous) plate of the eyelid;

- horizontal eyelid weakness is corrected by shortening the tendon of the outer corner of the eye: for this, the lower leg of the lateral ligament of the eyelid is cut with scissors 1.0-2.0 mm from the point of attachment to the orbit, a part of the ligament is excised depending on the degree of stretching, and the edges of the ligament impose a mattress absorbable suture, which reduces the horizontal length of the lower eyelid;

- excise excess skin of the outer corner of the eye in the form of a triangular flap, which allows you to stretch the edge of the eyelid in the horizontal direction, strengthen the pressing effect of the skin on the tarsal plate and increase the stability of the effect of the operation;

- remove a strip of orbicular muscle depending on its hypertrophy along with a strip of excess skin, which helps prevent muscle protrusion beyond the edge of the eyelid after applying a suture and remove excess stretched skin of the lower eyelid;

- attach the edge of the stretched (torn) retractor of the lower eyelid with three mattress sutures from biosorb 6.0 to the lower edge of the tarsal plate after the eyelid is properly stretched, which allows you to restore its mobility.

Search and analysis of sources of known scientific, technical and patent information showed that the claimed technical solution meets the criteria of the invention of "novelty and inventive step", since a similar method that matches the distinguishing features of the proposed method was not found.

The invention is illustrated by the following examples of specific performance.

Example 1

Patient Markova L., 73 years old, was admitted to the hospital with a diagnosis of involutional inversion of the lower eyelid of the left eye.

The patient performed the operation of the claimed method. After preparation of the surgical field and marking with a marker of a future skin incision, anesthesia was performed with 2% lidocaine solution (3.0 ml) with epinephrine 1: 100 000 (0.2 ml), introduced through the lower conjunctival vault, which had previously been anesthetized using local application of a local anesthetic . Using a special micro-blade, 2 mm down from the lower lacrimal opening, a horizontal cut of the musculoskeletal layer of the eyelid was made 2.0 mm from the ciliary edge, along the entire eyelid from the inner to the outer corner of the eye, extending beyond the outer corner of the eye by 5 mm . Through the obtained access, the skin-muscle layer was stupidly separated from the tarso-orbital fascia and fat bags, the strip of tarso-orbital fascia along the top of the fat bags 2.0 mm wide and 2.5 cm long was removed. In the next stage of the operation, the lower leg of the external ligament of the eyelid is cut off scissors 1.0 mm from the point of attachment to the orbit, its lateral part is separated from the mucosa and musculoskeletal plate in the form of a strip 4 mm long and 2 mm wide to provide access to the tendon of the outer corner of the eye. Then a section (part) of a ligament 4 mm wide freed from mucous and skin is excised. The edges of the ligament are sewn with a mattress absorbable suture from biosorb 6.0. The excess skin formed on the outer corner of the eye and eyelid in the form of a triangle 3.0 × 3.0 × 3.0 mm in size was dissected. Then, together with a strip of muscle 2 mm wide, the excess skin of the lower edge of the skin wound 2 mm wide is excised. After the fat sacks were lifted upward by the eyelid lifter, the torn edge of the lower eyelid retractor was found upward and attached to the lower edge of the tarsal plate using three mattress sutures from biosorb 6.0.

The edges of the horizontal skin incision are adapted with a 10-0 nylon seaming seam. At the end of the operation, the wound was treated with brilliant green. Under the skin of the outer edge of the orbit, an injection of 0.3 ml of gentamicin solution and 0.3 ml of dexamethasone solution was made. An aseptic dressing is applied.

When examining the patient on the fourth day after the operation: a slight swelling of the lower eyelid persisted, the inner edge of the lower eyelid was located correctly, the inversion was eliminated, the eyelashes were turned away from the eyeball. Throughout the century, there has been a complete adaptation of the edge of the eyelid to the eyeball. On the same day, stitches were removed from the skin wound.

When examining the patient after 3 months: the position of the lower eyelid of the left eye is normal, the edge of the eyelid is pressed against the eyeball, a barely noticeable scar hidden in the skin fold was detected parallel to the ciliary edge, there was no tendency to inversion of the ciliary edge.

Example 2

Patient Yunakova P., 78 years old, was admitted to the hospital with a diagnosis of involutional inversion of the lower eyelid of the left eye.

The patient performed the operation of the claimed method. After preparing the surgical field and marking with a marker for a future skin incision, anesthesia of 3.0 ml of 2% lidocaine with 0.2 ml of epinephrine 1: 100 000, injected through the lower arch of the mucous membrane of the eye, which was previously anesthetized using local application of a local anesthetic, was performed. Using a special blade, retreating 1.5 mm from the ciliary edge, a deep skin incision was made along the entire lower eyelid towards the outer corner of the eye, approaching the lateral angle by 7 mm. Through the obtained access, the musculoskeletal layer is bluntly separated from the tarso-orbital fascia and fat bags. A strip of tarso-orbital fascia 2.5 mm wide and 3.0 cm long was removed along the top of the fat bags. The lower leg of the lateral ligament of the eyelid was vertically cut with scissors 2.0 mm from its attachment to the orbit, its lateral part was separated from the mucosa and skin -muscular plate in the form of strips 3.5 mm long and 2 mm wide. Then a section (part) of a ligament 3 mm wide freed from mucous and skin is excised. The edges of the ligament are sewn with a mattress absorbable suture from biosorb 6.0. Then the triangular skin flap of the lower-outer edge of the wound with dimensions of 3.5 × 3.5 × 3.5 mm was removed. Excess skin was excised with a width of 3 mm of the lower edge of the wound of the eyelid along with a strip of orbicular muscle 4 mm wide. Further, fat bags were allotted upward by the eyelid, the stretched edge of the lower eyelid retractor was found and attached to the lower edge of the tarsal plate using three mattress sutures from biosorb 6.0.

The edges of the horizontal skin incision are adapted with a 10-0 nylon seaming seam. At the end of the operation, the wound was treated with brilliant green, 0.3 ml of gentamicin solution and 0.3 ml of dexamethasone solution were injected under the skin of the outer edge of the orbit. An aseptic dressing is applied.

When examining the patient on the fourth day after the operation: moderate swelling of the lower eyelid persisted, the inner edge of the lower eyelid was positioned correctly, the inversion was corrected, eyelashes were turned away from the eyeball, adaptation of the inner edge of the eyelid to the eyeball was available throughout the century. On the same day, sutures were removed from the skin wound.

When examining the patient after 4 months: the position of the lower eyelid of the left eye is normal, the inner edge of the lower eyelid of the left eye is pressed against the eyeball, eyelash growth is correct from the eyeball.

In parallel with the ciliary edge, a barely visible scar was detected, hiding in the skin fold, there is no tendency to inversion of the ciliary edge.

Using the proposed method will allow, in comparison with the known method, to increase the effect of the operation by eliminating three causes of inversion at once, namely by eliminating hypertrophy of the spasmodic orbicular muscle, excessive gaping (separation from the tarsal plate) of the lower eyelid retractor and stretching of the tendon of the outer corner of the eye. This will enhance the compressive effect of the muscle layer of the eyelid, limit the mobility of the cartilage plate, facilitate the management of the postoperative period, and increase the cosmetic effect of the operation.

The method is simple to implement, practically has no contraindications for use, does not require equipping with additional tools and can be performed on an outpatient basis.

Claims (3)

1. A method for surgical treatment of involutional lower eyelid inversion, including a horizontal skin incision along the ciliary edge of the eyelid, blunt separation of the musculoskeletal layer from the tarso-orbital fascia and fat bags, followed by the application of a nylon suture to the skin wound, characterized in that a horizontal skin incision is made from the lacrimal opening to the lateral edge of the orbit with the approach beyond the lateral cantus, a strip of tarso-orbital fascia is removed along the top of the fat sacs 2.0–2.5 mm wide and 2.5–3.0 cm long, the lower leg is lateral the ligaments are cut with scissors 1.0-2.0 mm from the place of its attachment to the edge of the orbit, a part of the ligament is excised depending on the degree of inversion, and a mattress is absorbed on the ligament, absorbable suture, excess skin and a triangular skin flap of the lower edge of the wound are excised outwards from the lateral adhesion of the eyelid, remove the strip of the orbicular muscle, find the edge of the stretched or torn retractor of the lower eyelid and attach it to the lower edge of the tarsal plate with three mattress absorbable sutures. 2. The method according to claim 1, characterized in that the horizontal skin incision is made by stepping 1.5-2.0 mm from the ciliary edge, along the entire lower eyelid towards the outer corner of the eye, approaching lateral canthus by 5.0-7 , 0 mm. 3. The method according to claim 1, characterized in that biosorb 6.0 is used to adapt the lower edge of the tarsal plate and the edge of the lower eyelid retractor.