RU2440073C1 - Method of surgical management of severe blepharoptosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely ophthalmology and ophthalmoplasty, and can find application in surgical management of severe blepharoptosis. Substance of the method involves shortening of a levator and connection of an upper tarsal plate and a frontal muscle though a skin approach. The shortening of the levator is conducted by its resection by 1/2-1/3 of its length. The upper tarsal plate and the frontal muscle are connected with a mercilene mesh by a lower one-third of the tarsal plate.

EFFECT: use of the given invention enhances the correction of upper lid shape and position in severe ptosis combined with forming a physiological upper lid shape with ensuring a more stable result.

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Description

The invention relates to medicine, namely to ophthalmology, and plastic ophthalmic surgery and is intended for surgical correction of the position of the upper eyelid when it is omitted due to congenital or post-traumatic pathology.

Normally, the edge of the upper eyelid is located above the upper limb or covers 1-2 mm of the upper limb, but the pupil is always open. The omission of the upper eyelid to the upper edge of the pupil is regarded as ptosis of the upper eyelid of a weak degree and is only a cosmetic flaw. Severe ptosis is characterized by complete closure of the pupil, and accordingly, the field of view and the absence or significantly reduced levator function. With severe unilateral ptosis, amblyopia develops, with bilateral ptosis, the forced position of the head, which in turn leads to changes in the cervical spine (Beard C. Ptosis. // St. Louis - C.V. Mosby Co - 1976 - 288P.).

There are a significant number of different methods for the surgical treatment of prolapse (ptosis) of the upper eyelid. The treatment method should be selected in accordance with the basic requirements that serve as indications for the operation in case of one form or another of ptosis, and the operation itself was performed without technical errors. There is a method of eliminating severe ptosis of the upper eyelid by maximal and supermaximal resection of the levator up to 28-30 mm (Epstein GA, Putterman AM Super-maximal levator resection for severe unilateral congenital blepharoptosis. // Ophthalm. Surg. - 1984. - vol. 15. - P.971-979.) And a combination of the maximum resection of the levator with displacement through the Whitnall ligament (Kataev MG, Filatova I.A. Resection of the levator with displacement through the Whitnall ligament // Vestnik Oftaltmol. - 1996 - N 2 - С. 18-22.). However, the maximum shortening of the muscle that raises the upper eyelid leads to lagophthalmus and pronounced retraction of the upper eyelid when looking down. In addition, in the complete absence of the levator function, this method is futile.

The most common methods for eliminating severe ptosis, i.e. in the absence or extremely low levator function, are operations of the suspending type, as a result of which the tarsal plate of the upper eyelid is connected with the frontal muscle (A. Callahan. Surgery of eye diseases // translated from English. - M.: State. Publishing house of medical literature - 1963 - P.20-46; Fox SA Surgery of ptosis // Baltimore / London - Williams & Wilkins - 1980 - 165P.).

Suspension of the upper eyelid was carried out using various materials: cotton, kapron or silk thread, tantalum wire, rubber thread, allotendinous sutures, wide fascia of the thigh, silicone tape, strips of mersilene mesh.

The methodology of the operation was gradually improved from “blind” conducting the “suspension” through punctures with a long needle to open access surgery and thoroughly fixing the “suspension” to the front surface of the tarsal plate and holding the ends of the “suspensions” into the tunnels above the eyebrow.

This method allows you to create a strong connection between the upper eyelid and the eyebrow, which helps to raise the upper eyelid with tension of the frontal muscle, for example, in patients with levator paralysis. However, with such a lifting mechanism, the upper eyelid rises in a straight line vertically, and not arched towards the top of the orbit, as it happens when the eyelid is raised due to the levator. In addition, with this method of operation, the depth of the fold of the upper eyelid is absent or significantly reduced. Due to a change in the mechanism of raising the upper eyelid, an incomplete fit of the upper eyelid to the surface of the eyeball, a change in the contour of the upper eyelid, and the eyelid itself look somewhat unnatural (Kataev M.G., Orudzhev N.Z. A new combined method for the surgical treatment of severe blepharoptosis: the method of hanging from the eyebrow and Whitnall ligament // Russian Pediatric Ophthalmology - 2009 - N 2 - S.22-25).

To achieve a more stable effect in the elimination of ptosis of the upper eyelid, some authors supplement the suspension of the upper eyelid to the eyebrow with elements of other operations. For example, suspension of the upper eyelid was combined with additional suspension to the Whitnall ligament. The method was performed as follows. The skin incision was made along the upper eyelid along the fold, the fibers of the circular muscle were separated in a blunt way, the tarsoorbital fascia was opened and the tarsal plate was isolated. On the skin above the eyebrow, 2 incisions were made 5-6 mm long, from which tunnels in soft tissues were formed bluntly towards the tarsal plate and between the incisions above the eyebrow. A strip of mercilene mesh was drawn through the tunnels so that both ends of the strip remained on the front surface of the tarsal plate. First, one end of the strip was sewn with interrupted sutures on the upper part of the tarsal plate, the mercilene mesh was pulled up and the position of the upper eyelid was adjusted to the desired level. After the upper eyelid was established, the second end of the strip was hemmed to the desired height with interrupted sutures. Further between the ligament of Whitnall and the tarsal plate, interrupted sutures were applied. At the same time, aponeurosis was not resected and the lateral horns did not cross. The skin over the eyebrow was sutured with interrupted sutures, on the upper eyelid - with a continuous suture. (Kataev MG, Orudzhev N.Z. A new combined method for the surgical treatment of severe blepharoptosis: the method of suspension from the eyebrow and Whitnall ligament // Russian Pediatric Ophthalmology - 2009 - N 2 - P.22-25.) The disadvantage of this method, in our opinion, is the fixation of a strip of mercilene mesh to the upper edge of the tarsal plate, which when tensioned "suspension" can lead to inversion of the eyelashes of the upper eyelid. In addition, the authors believe that this method allows the upper eyelid to be raised along the fronto-sagittal axis, but the anatomically Whitnall ligament is located horizontally from the medial to the lateral edge of the orbit and can only further raise the upper eyelid vertically.

Closest to the claimed one, is a method of surgical treatment of ptosis of the upper eyelid, including excision of a lunate flap from the skin of the upper eyelid, the formation of a levator duplicate directed inward using U-shaped closed sutures and the connection of the edge of the cartilage of the upper eyelid with the frontal muscle by applying internal allotendin sutures with subsequent application of a microsurgical suture to the skin incision (Method for the surgical treatment of ptosis of the upper eyelid // Patent Application N 2006141988 of 11/27/2006).

In our opinion, the main advantage of this method is the ability to give the upper eyelid a more physiological form due to the levator duplication, however, the method has the following disadvantages: an attempt to shorten the levator by the duplicate method leads to its thickening in the distal part, which, firstly, makes the upper eyelid heavier and it is difficult to lift it with eyebrow tension, and secondly, the levator duplication is an additional layer of tissue just at the location of the “suspensions”, which also shifts them from the shortest passage waiting from the tarsal plate to the eyebrow. In addition, the authors indicate that the “pendants” of the allograft tendon were fixed to the upper edge of the cartilage of the upper eyelid, but our experience shows that such fixation can lead to lower eyelashes and even inversion of the upper eyelid, which undoubtedly reduces the effect of the operation. In our opinion, the localization for the optimal fixation of the "suspension" is the lower third of the tarsal plate. The material of the “pendant” in the form of allo-tendon sutures is gradually absorbed and replaced by scar tissue, which, in turn, leads to a decrease in tension and, accordingly, to the hypoeffect of the operation.

The task of the invention is to develop an improved method for eliminating ptosis of the upper eyelid of a severe degree.

The technical result of the invention is the expansion of the correction of the shape and position of the upper eyelid with ptosis of the upper eyelid of a severe degree in combination with the formation of a physiological form of the upper eyelid.

The technical result is achieved by combining previously mutually exclusive steps of the operation: hanging the upper eyelid to the eyebrow by creating a connection between the tarsal plate of the upper eyelid and the frontal muscle with a strip of mercilene mesh for the lower third of the tarsal plate, and also the resection of the levator within only up to ½-1 / 3 of its length.

A distinctive feature of the method is that in order to ensure stable fixation of the upper eyelid to the frontal muscle and give the upper eyelid a physiological shape, the levator duplicate is replaced by a levator resection, and the tarsal plate of the upper eyelid is connected with the frontal muscle with strips of mercilene mesh.

In the present invention, a skin incision is made symmetrically to the fold of the upper eyelid of the paired eye and two additional incisions above the eyebrow are 3-4 mm long. In a dull way, they divide the circular muscle of the eye, open the tarsoorbital fascia, orbital fatty tissue is displaced upward from the levator. Allocate a levator, take it to Berke’s clip and mobilize. Cross the lateral horns of the levator aponeurosis. A strip of mercilene mesh with a width of 5 mm, a length of 15 cm and is hemmed to the front surface of the tarsal plate in its lower part 2-3 mm from the line of eyelashes. The levator is pulled down and hemmed to the front surface of the tarsal plate in front of a strip of mercilene mesh previously fixed in this zone. The levator is shortened by ½-1/3 of its length, that is, two times less than with maximum resection. From the incisions above the brow in the tissues, tunnels are formed with access to the wound to the tarsal plate and between the incisions along the brow. The ends of the mercilene mesh are drawn into the tunnels and tied above the eyebrow until the upper eyelid rises above the pupil. Next, a fold of the upper eyelid is formed by applying U-shaped sutures to the skin wound with an additional taking in the suture of the fibers of the front surface of the levator. The skin wound is sutured with a continuous suture.

The essence of the method is illustrated by the following drawings (Fig.1-5).

The method is as follows. After treating the skin of the face with an antiseptic solution, the patient in the supine position is drawn a cut line on the upper eyelid along the natural fold. The skin incision is made symmetrically to the fold of the upper eyelid of the paired eye (Fig. 1 (1)) and two additional cuts above the eyebrow 3-4 mm long (Fig. 1 (2)). Then, in a blunt way, the circular muscle of the eye is divided, the front surface of the tarsal plate is released. With the help of eye scissors, the tarsoorbital fascia is opened, orbital fatty tissue is displaced upward from the levator. Allocate the levator (Fig.2. (3)), mobilize its front and rear surfaces. Cross the lateral horns of the levator aponeurosis ((Fig. 2 (4)) and pull it out of the orbit, taking the distal part of the muscle to Berke's clamp (Fig. 2 (5)). A strip of mercilene mesh 5 mm wide, 15 cm long (Fig. .3. (6)) is hemmed to the front surface of the tarsal plate (Fig. 3 (7)) 3 mm from the line of eyelashes, i.e. in its lower part (Fig. 3 (8)). with the eyebrow in the tissues, tunnels are formed with access to the wound to the tarsal plate and between them.The levator (Fig. 4 (9)) is pulled down and hemmed to the front surface of the tarsal plate in front of the mercilene mesh with ½-1/3 of its length (Fig. 4. (10)). The ends of the mercilene mesh are placed on the sides of the levator, held in the tunnels formed and tied above the eyebrow until the upper eyelid rises above the pupil (Fig. 4 (11)) Next, a fold of the upper eyelid is formed by applying U-shaped sutures to the skin wound with additional taking of the fibers of the anterior surface of the levator into the suture (Fig. 5 (12)). The skin wound along the upper eyelid is sutured with a continuous suture (Fig. 5 (13)), wounds above the eyebrow - separate interrupted sutures (Fig. 5. (fourteen). Skin sutures on the eyelid and over the eyebrow are removed on the 7th day.

The invention is illustrated by the following clinical example.

1. Patient R., born in 2004, was undergoing surgical treatment at the Institute of Eye Diseases named after Helmholtz with a diagnosis of OS - congenital ptosis of the upper severe degree.

Preoperative examination: From birth, the upper eyelid is left on the left. The edge of the upper eyelid completely covers the pupil. Width of palpebral fissures OD = 8 mm, OS = 4 mm, mobility of the upper eyelid OD = 14 mm, OS = 2 mm. The fold of the upper eyelid on the left is weakened, the mobility of the eyes in full. Vision OD = 1.0, OS = 0.6 s + 1.0D = 0.6. OU - calm, transparent environments, fundus without pathology.

Patient R. performed the removal of ptosis of the upper eyelid of a severe degree on the left of the claimed method. The skin incision was made symmetrically to the fold of the upper eyelid OD at 7 mm from the eyelash line and two additional incisions above the eyebrow 3-4 mm long. In a dull way, they divided the circular muscle of the eye. Using eye scissors, the tarso-orbital fascia was opened, orbital fatty tissue was displaced upward from the levator. We allocated a levator, took it to Berke’s clip, mobilized its front and back surfaces. Crossed the lateral horns of the levator aponeurosis. A 5 mm wide, 15 cm long mercilene mesh strip was prepared and its central part was hemmed to the front surface of the tarsal plate 3 mm from the eyelash line. The levator was pulled down and hemmed to the front surface of the tarsal plate in front of the mercilene mesh with a 21 mm shortening. From the incisions above the eyebrow, tunnels were formed in the tissues with access to the wound to the tarsal plate and between them along the eyebrow. The ends of the mercilene net were held on the sides of the levator, led into the formed tunnels and tied above the eyebrow until the upper eyelid was raised above the pupil. Then a fold of the upper eyelid was formed by applying U-shaped sutures to the skin wound with additional taking of the anterior surface of the levator into the suture. A continuous cutaneous suture was applied along the upper eyelid and nodular on the wounds above the eyebrow.

Examination after 1 month, and then 6 months after the operation showed that the shape of the left palpebral fissure was symmetrical to the right. With the tension of the eyebrow (frontal muscle), the pupil was open. The fold of the upper eyelid was well defined, symmetrical to the right. Lagophthalmus was unstable within 1-2 mm, the mobility of the eyes was in full. The functional and cosmetic effect of surgical treatment is stable, no signs of hypoeffect are noted.

Thus, the proposed method provides

- a strong anatomical connection of the tarsal lamina of the upper eyelid with the frontal muscle due to fixation to the eyebrow with a mercilene mesh, which is not susceptible to resorption, and due to the germination of the patient’s tissues creates a stable "suspension" design;

- additional raising of the upper eyelid due to shortening (resection) of the levator, which helps to move the upper eyelid even in the absence of levator function;

- physiological shape of the upper eyelid due to the formation of the folds of the upper eyelid, fixed to the levator;

- raising the upper eyelid in an arc towards the top of the orbit along the levator;

- increasing the effectiveness of surgical treatment by reducing the likelihood of hypoeffect, because lifting of the upper eyelid is ensured by two mechanisms: shortening of the levator and hanging of the upper eyelid to the eyebrow.

Claims (1)

A method for surgical treatment of severe upper eyelid ptosis, including shortening the levator and connecting the tarsal plate of the upper eyelid with the frontal muscle through the dermal access, characterized in that the levator is shortened by resection by 1 / 2-1 / 3 of its length, and connecting the tarsal plate carried out using mercilene mesh for the lower third of the tarsal plate.

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