RU2840208C1 - Method of surgical treatment of congenital and acquired ptosis of the upper eyelid with a transconjunctival approach - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to plastic surgery, and may be used for surgical management of blepharoptosis from a transconjunctival approach. Conjunctiva of upper eyelid is marked, conjunctiva is sutured. Marking is used to deliver the induced biodegradable suture material in three stitches with two air loops; the conjunctiva and the superior tarsal muscle are lifted by pulling the air loops. Then formed fold is applied with direct clamp, leading biodegradable suture material is removed. Then mattress horizontal seams are applied with biodegradable braided suture from lateral edge of eyelid to medial, tissues are resected along the lower line of the applied clamp; the tissues are closed with using the applied biodegradable braided suture from the medial to lateral edge of the eyelid with covering conjunctiva and 1 mm of the tarsal plate.

EFFECT: method enables restoring the upper lid contour, reducing a risk of postoperative corneal injuries and reducing an intraoperative period ensured by a combination of surgical techniques.

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Description

The proposed method relates to the field of medicine, namely to ophthalmoplastic surgery, and can be used to reduce the trauma of surgical treatment of blepharoptosis with average and normal levator function, maintaining effective results in the long postoperative period.

The use of this surgical intervention technique for upper eyelid ptosis allows performing the surgical technique transconjunctivally, without skin access, which leads to the absence of cicatricial changes on the skin of the eyelid, reducing trauma. When applying markings to the conjunctiva of the upper eyelid, the individual anatomical and physiological characteristics of the patient's eyelids are taken into account to create symmetry of the eyelid contour with the contralateral side.

All known methods of surgical intervention for ptosis are divided into three main groups: suspension to the frontal muscle, levator resection and tarsomullerectomy. The choice of surgical tactics is based on anamnesis data and preoperative examination.

The first surgical method for treating tarsomullerectomy was proposed by R. M. Fasanella and J. Servat in 1961 (Fasanella, R. M. and Javier Servat. "Levator resection for minimal ptosis: another simplified operation." Archives of Ophthalmology 65.4 (1961): 493-496), the technique consisted of eversion of the upper eyelid with the introduction of local anesthetic over the tarsal plate, after which a curved clamp was placed at a distance of 3 mm from the upper border of the tarsal plate, under which horizontal mattress sutures were applied with chromic catgut 5:0. The tarsal plate was resected together with the conjunctiva and the superior tarsal muscle (the anatomical term Müller's muscle is used) and two sutures were applied to the wound in order to prevent mechanical damage to the cornea.

Subsequent modifications of this surgical method of treating upper eyelid ptosis included: changing the suture material (Bodian M. A revised Fasanella-Servat ptosis operation // M. Bodian - Text: immediate // Ann. Ophthalmol. - 1975. - Vol. 7, №4. - P. 603-605), using fibrin glue to seal the wound (Czyz C.N. 2011 Czyz C.N. Comparison of postoperative eyelid position using fibrin sealant versus suture for wound closure in Muller's muscle-conjunctiva resection ptosis repair / C.N. Czyz, N. E. Rich, J. A. Foster, M.C. Kavanagh, J.D. Perry, D. E. Holck. - Text: immediate / Plastic and Reconstructive Surgery. - 2011. - Vol. 128, №2. - P. 423-430), the use of a special clamp invented by Putterman (1972 Putterman AM. A clamp for strengthening Müller's muscle in the treatment of ptosis. Modification, theory, and clamp for the Fasanella-Servat ptosis operation. Arch Ophthalmol. 1972 Jun; 87 (6): 665-7. doi: 10.1001/archopht.1972.01000020667010. PMID: 5032737), which involves resection of the superior tarsal muscle and conjunctiva, leaving the tarsal plate intact.

A method for treating ptosis of the upper eyelid is known, using a set of instruments (patent RU 2257875, application 2004107411, published 10.08.2005, bulletin No. 22, IPC class A61F9/007).

The essence of the proposed method consists of resection of the TMV after passing a retaining suture through the anterior third of the tarsal plate, instillation of 2.5% phenylephrine hydrochloride, which causes contraction of the TMV and retraction of the upper eyelid.

The disadvantage of the known method is the need to use a special set of instruments for resection of the TM, the difficulty of dosing the muscle resection after its contraction, and trauma to surrounding tissues during resection of the TM.

The prototype for the claimed method of surgical treatment of upper eyelid ptosis is the method proposed by the founders R. M. Fasanella and J. Servat.

The objective of the proposed invention is to improve the method by dosed resection of the TM, tarsal plate and conjunctiva, increasing the predictability of treatment results and patient satisfaction due to the lack of skin access and long-term postoperative rehabilitation.

The technical result of the proposed invention is the restoration of the contour of the upper eyelid, the absence of the risk of postoperative damage to the cornea by suture material, a reduction in intraoperative time, and precise dosing of ptosis elimination.

To achieve a technical result in a modified method of eliminating ptosis of the upper eyelid with average and normal levator function, stages of surgical treatment with a preliminary preoperative examination are proposed.

A method for surgical treatment of upper eyelid ptosis using a transconjunctival approach is proposed, which consists of preliminary marking of the upper eyelid conjunctiva of the required volume for resection, insertion of a guiding biodegradable suture material for precise allocation of the tissue volume, followed by application of a direct clamp. Application of horizontal mattress sutures under the clamp allows avoiding tissue displacement. Using one thread when applying a suture from the lateral side of the conjunctiva to the medial side, and subsequently, after removing the clamp and resecting the tissues with a single cut, ensures the accuracy of combining the conjunctiva and underlying tissues, thereby achieving the predicted result in the postoperative period. The proposed method allows avoiding hypo- or hypercorrection in the postoperative period due to the accuracy of marking the upper eyelid conjunctiva, a stable result is achieved due to resection of the tarsal plate and the superior tarsal muscle.

The essence of the invention is shown in Fig. 1, Fig. 2, Fig. 3, Fig. 4, where Fig. 1 shows a preoperative examination of a patient, Fig. 2 shows a preoperative examination of a patient looking upward, Fig. 3 shows an examination of a patient on the 3rd day after surgery looking upward, Fig. 4 shows an examination of a patient on the 3rd day after surgery, Fig. 5, 6, 7 show the imposition of marking of the conjunctiva of the upper eyelid, Fig. 8 shows the lifting of tissues captured with tweezers.

Fig. 1, 2, 3, 4 show clinical example No. 1. Fig. 9, 10, 11, 12 show clinical example No. 2, where Fig. 9.10 shows the examination of the patient before the operation, Fig. 11, 12 shows the examination of the patient after the operation. Fig. 13, 14, 15, 16 show clinical example No. 3, where Fig. 13, 14 shows the examination of the patient before the operation, Fig. 15, 16 shows the examination of the patient after the operation.

Preoperative examination includes the following parameters: MRD 1, palpebral fissure width at the medial edge of the limbus, at the lateral edge of the limbus and at the center of the pupil, angle of inclination of the direction of eyelash growth, uniformity of ptosis distribution within the eyelid, levator function (in mm), use of accessory muscles, palpebral fissure width when the accessory muscles are turned off, presence of ptosis when looking up and down, difference with the contralateral side (with unilateral ptosis), eyebrow mobility.

Anesthetic care in children (up to 18 years) and adults is carried out by inhalation induction with sevoflurane.

After preoperative preparation and treatment of the surgical field, the surgical technique itself is carried out.

The technique of the operation consists of several stages:

1 - creating markings on the conjunctiva of the upper eyelid using a surgical marker with a diameter of 0.3 mm: three points along the edge of the tarsal plate: along the projection of the center of the pupil, along the projection of the medial and lateral limbus. The distance planned for tissue resection is measured using a compass from the marked points in the direction of the upper fornix and identical 3 points are applied to the conjunctiva.

2 - introduction of biodegradable braided suture material 6:0 continuously by stitch-loop method, through marked points at measured distance from the edge of the tarsal plate, in three stitches with two air loops along the points at measured distance. Air loops are lifted, direct clamp is applied along the entire length of the tissues lifted by air loops, including conjunctiva, upper tarsal muscle. Removal of thread for the next stage, by pulling from the tissues located on the clamp.

3 - application of a continuous horizontal suture with a 6:0 biodegradable braided thread under a clamp, from the lateral part of the eyelid to the medial.

4 - lifting the tissues captured by the clamp with tweezers, cutting them off with a single cut along the lower line of the applied clamp.

5 - suturing with the same biodegradable braided thread 6:0 with a mattress suture in the opposite direction, from the medial edge of the eyelid to the lateral one, capturing the conjunctiva and 1 mm of the tarsal plate.

Unlike the initially proposed method of surgical treatment, a suture is applied with a single braided biodegradable thread, using one knot along the projection of the lateral limbus, which allows avoiding postoperative trauma to the cornea. The absence of the use of local anesthetic over the tarsal plate allows avoiding hypocorrection in the postoperative period, due to the application of markings to non-hydrodissected tissues.

The proposed method was used to operate on 42 patients, all of whom had a diagnosis of congenital unilateral ptosis of the upper eyelid. The age of the patients varied from 3 to 17 years (average age 9.2 years). All children underwent an extended preoperative examination to determine the volume of tissue to be resected.

As a result of the proposed surgical treatment method, no cases of iatrogenic complications were observed. Wound infection and suture granuloma were not observed, due to the use of disposable suture material and microsurgical ophthalmological instruments, under the control of optical magnification, as a result of which the tissue was exposed to a minimal traumatic factor. Hypoeffect was observed in two patients (4.76%), however, repeated surgical intervention was not performed due to aesthetic satisfaction with the result.

Clinical example 1: patient N., 9 years old, was admitted to the pediatric surgery department of the S.V. Belyaev Kuzbass Regional Clinical Hospital with complaints of drooping of the upper eyelid on the right. From the anamnesis, according to the parents, it became known that this pathology was detected at birth, a levator resection operation was previously performed, but the aesthetic result in the late postoperative period (more than a year) was not satisfactory. During the examination, a standard ophthalmological examination was performed: refractometry, keratometry, visometry, biomicroscopy, ophthalmoscopy of the fundus against the background of drug-induced mydriasis. The degree of ptosis, distribution of ptosis within the eyelid, width of the palpebral fissure, measurement of levator function were also determined, Marginal reflex distance 1 (MRD1) was assessed, involvement of accessory muscles was determined, and the angle of inclination of eyelash growth was determined: OD width of the palpebral fissure at the center of the pupil is 8 mm, at the lateral limbus 8 mm, at the medial limbus 6 mm. With the accessory (frontal) muscles turned off, the width of the palpebral fissure is 7 mm. The angle of inclination of eyelash growth is directed downwards. Assessment according to the MRD1 scale is +1, levator function is average. Ptosis persisted when looking upward. There is a postoperative scar 1 mm wide formed on the skin of the upper eyelid. OS width of the palpebral fissure at the center of the pupil is 12 mm, at the lateral limbus 10 mm, at the medial limbus 9 mm. With the accessory (frontal) muscles turned off, the width of the palpebral fissure is 10 mm. The ciliary margin is directed straight. MRD1 scale score +4, levator function is good.

Based on the examination data, a diagnosis was made: operated congenital unilateral partial ptosis on the right MRD1 +1 and the surgical tactic chosen was to perform a tarsomullerectomy operation.

The postoperative period was uneventful, during examination on the 1st day, minor swelling of the upper eyelid was noted, lagophthalmos was absent, on the 3rd day a control examination was performed: OD width of the palpebral fissure in the center of the pupil is 12 mm, along the lateral limbus 10 mm, along the medial limbus 9 mm. When turning off the accessory (frontal) muscles, the width of the palpebral fissure is 10 mm. There is no ptosis when looking up. The angle of inclination of eyelash growth is directed straight. Assessment on the MRD1 scale is +4, the levator function is good.

Fig. 1. Examination of the patient before surgery. Fig. 2. 2 Examination of the patient before surgery: ptosis when looking up. Fig. 3. Examination of the patient on the 3rd day after surgery. There is no ptosis when looking up. Fig. 4. Examination of the patient after surgery on the 3rd day.

Clinical example 2: patient G., 9 years old, was admitted to the pediatric surgery department of the S.V. Belyaev Kuzbass Regional Clinical Hospital with complaints of drooping of the upper eyelid on the left. From the anamnesis, according to the parents, it became known that this pathology was detected from birth, there were no previous surgical interventions. During the examination, a standard ophthalmological examination was performed: refractometry, keratometry, visometry, biomicroscopy, ophthalmoscopy of the fundus against the background of drug-induced mydriasis. The degree of ptosis, distribution of ptosis within the eyelid, width of the palpebral fissure, measurement of levator function were also determined, Marginal reflex distance 1 (MRD1) was assessed, involvement of accessory muscles was determined, and the angle of inclination of eyelash growth was determined: OD width of the palpebral fissure at the center of the pupil is 11 mm, at the lateral limbus 10 mm, at the medial limbus 9 mm. With the accessory (frontal) muscles turned off, the width of the palpebral fissure is 11 mm. The angle of inclination of eyelash growth is directed upward. Assessment according to the MRD1 scale is +3, levator function is average. OS width of the palpebral fissure at the center of the pupil is 9 mm, at the lateral limbus 6 mm, at the medial limbus 7 mm. With the accessory (frontal) muscles turned off, the width of the palpebral fissure is 6 mm. The ciliary margin is directed straight. Assessment according to the MRD1 scale is +2, levator function is average.

Based on the examination data, a diagnosis was made: congenital unilateral partial ptosis on the left MRD1 +2 and a surgical tactic was chosen: performing a tarsomullerectomy operation.

The postoperative period was uneventful, during examination on the 1st day, minor swelling of the upper eyelid was noted, lagophthalmos was absent, on the 5th day a control examination was performed: OS width of the palpebral fissure at the center of the pupil is 11 mm, at the lateral limbus 10 mm, at the medial limbus 9 mm. When switching off the accessory (frontal) muscles, the width of the palpebral fissure is 10 mm. There is no ptosis when looking up. The angle of inclination of eyelash growth is directed straight. Assessment on the MRD1 scale is +3, the levator function is average (Figs. 9, 10, 11, 12).

Clinical example 3: patient T., 7 years old, was admitted to the pediatric surgery department of the S.V. Belyaev Kuzbass Regional Clinical Hospital with complaints of drooping of the upper eyelid on the left. From the anamnesis, according to the parents, it became known that this pathology was detected at birth, no surgical interventions had been performed previously. During the examination, a standard ophthalmological examination was performed: refractometry, keratometry, visometry, biomicroscopy, ophthalmoscopy of the fundus against the background of drug-induced mydriasis. The degree of ptosis, distribution of ptosis within the eyelid, width of the palpebral fissure, measurement of levator function were also determined, Marginal reflex distance 1 (MRD1) was assessed, involvement of accessory muscles was determined, and the angle of inclination of eyelash growth was determined: OD width of the palpebral fissure at the center of the pupil is 9 mm, at the lateral limbus 8 mm, at the medial limbus 6 mm. With the accessory (frontal) muscles turned off, the width of the palpebral fissure is 9 mm. The angle of inclination of eyelash growth is directed upward. Assessment according to the MRD1 scale is +2, levator function is average. The palpebral fold is formed. OS width of the palpebral fissure at the center of the pupil is 7 mm, at the lateral limbus 5 mm, at the medial limbus 5 mm. With the accessory (frontal) muscles turned off, the width of the palpebral fissure is 5 mm. The ciliary margin is directed straight. Assessment according to the MRD1 scale is 0, levator function is weak. The palpebral fold is formed.

Based on the examination data, a diagnosis was made: congenital unilateral partial ptosis on the left MRD1 0 and a surgical tactic was chosen: performing a tarsomullerectomy operation.

The postoperative period was uneventful, during examination on the 1st day, minor swelling of the upper eyelid was noted, lagophthalmos was absent, on the 7th day a control examination was performed: OS width of the palpebral fissure in the center of the pupil is 10 mm, along the lateral limbus 8 mm, along the medial limbus 9 mm. When switching off the accessory (frontal) muscles, the width of the palpebral fissure is 10 mm. There is no ptosis when looking up. The angle of inclination of eyelash growth is directed straight. Assessment on the MRD1 scale is +2, the levator function is average (Figs. 13, 14, 15, 16).

Claims (1)

A method for surgical treatment of upper eyelid ptosis using a transconjunctival approach, including preliminary marking of the upper eyelid conjunctiva, suturing the conjunctiva and resection of tissues, characterized in that, according to the marking, a guiding biodegradable suture material is inserted in three stitches with two air loops, the conjunctiva and upper tarsal muscle are lifted by tensioning the air loops, then a straight clamp is applied to the formed fold, the guiding biodegradable suture material is removed, after which horizontal mattress sutures are applied with a biodegradable braided thread from the lateral edge of the eyelid to the medial edge, tissue resection is performed along the lower line of the applied clamp, the tissues are sutured using the applied biodegradable braided thread from the medial edge of the eyelid to the lateral edge with capture of the conjunctiva and 1 mm of the tarsal plate.