Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Special Oculoplasty Surgical Procedures 449
Figure 1: Exposure of the
orbicularis oculi muscle
Figure 2: 80 microns vanadium steel sutures have been passed through the orbicularis oculi muscle at three places
Sometimes, a few bleeding points will need to be cauterized with a bipolar or a radio-cautery.
The reflection of the skin flap is best done with a 6 X head worn magnification. It gives a degree of freedom of movement that is not possible with an operating microscope. One can look under the skin flap and carry out the dissection with confidence. Bright illumination for 5-6 cm. operation area is obtained from the operating microscope. This light transilluminates the skin and helps to identify and separate the orbicularis fibers from the skin. In addition a hand held light is required to sometimes directly illuminate under the skin flap for better visualization (Figure 3).
The making of the skin flap exposes the arches of orbicularis oculi fibers. They are circularly disposed, dark pink in appearance and a number of blood vessels of various sizes are seen coursing over them (Figure 4).
Plication of the Orbicularis Muscle
Vanadium steel 80 micron wire attached to an atraumatic needle is used for plication. The first suture is applied in the middle. The needle is passed under a 2 mm strip of the
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Figure 3: Steel sutures have been tied, bringing the upper and the lower orbicularis oculi fibers together
Figure 4: The skin flap has been closed with superficial 80 microns sutures
orbicularis close to the lid margin. The same needle then lifts a 2 mm strip of the orbicularis muscle towards the orbital margin. The selection of the proximal site varies according to the degree of ptosis. It is closer to the superior orbital margin in cases of severe ptosis. When the central suture is tied the lid margin is seen to rise. The cornea gets exposed. At this stage the cornea is covered with a thick layer of visco-elastic material like methyl cellulose. A reef-knot is used. The ends of the suture are cut close to the knot with a stout scissors. A single suture produces an angulation in the lid margin. To produce a natural looking lift to whole of the lid, one or two sutures are applied on either side of the central suture.
At the end of plication, the following can be noted:
1.The lid margin rises to expose the cornea. If the patient looks straight ahead, the lid margin may appear in the vicinity of the upper limbus.
2.The reflected skin flap looks much bigger than the raw area that needs to be closed.
3.The upper lid margin may in some cases, show a tendency to stand away from the eyeball.
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Managing the Palpebral Skin Flap
The loose skin flap is fixed as follows:
a.The under-surface of the skin is sutured to the plicated orbicularis muscle at three points with single throw 80 micron vanadium steel sutures. This prevents the skin from hanging down.
b.A 2-3 mm strip of the skin is excised.
c.The skin flap is closed with 10-12 single throw superficially applied 80 micron vanadium steel sutures.
Bandaging the Eye
The upper lid is gently pushed down to close the eye. When pressure is released the eyelid moves up, revealing the elasticity of movement. No Frost suture is required. The eyelid is carefully closed, taped and pad and bandage is applied.
The result of orbicularis oculi plication are shown in the following picture.There is lid lag on looking downwards, but there is no lagophthalmos. The eye can be closed easily
(Figure 5).
SUTURELESS CONJUNCTIVAL ROUTE PLICATION OF LEVATOR MUSCLE FOR PTOSIS
Introduction
The ability of the Fugo blade to incise and blunt-dissect in a bloodless manner, encouraged me to explore the possibility of searching the levator muscle, through fornix incisions and to advance it to the anterior surface of the tarsal plate.Thus developed a novel technique for ptosis repair.
The indications for ptosis surgery are a mild moderate or severe degree of ptosis. It can be performed on both infantile and adult ptosis. Most cases are uniocular. When it is bilateral, I prefer to do one eye at a time. It is not indicated for paralytic ptosis.
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Figure 5 : Preoperative and 2 days postoperative appearances in a 9 years old child, who had severe unilateral ptosis with poor levator function
Anesthesia
During surgery, the lid has to be double everted, so that there is considerable pull on the lid. At the time of searching, holding and bringing out the levator there is pull on the muscle. To do all this, I prefer general anesthesia.
Surgical Technique
1.The lid is double everted with Desmarre lid retractor.
2.Thick nylon stay sutures are passed at the upper edge of the tarsal plate, one in the middle and one on either side at a distance of about 6 mm. The weight of the artery forceps holding them keeps the lid everted.
Special Oculoplasty Surgical Procedures 453
3.The conjunctiva over the double everted tarsus is ballooned with lignocaine.
4.Three conjunctival vertical incisions about 10 mm long are made in line with the stay sutures. The incision is made with a 100 microns Fugo blade tip. When this tip crosses a large subconjunctival vessel, there is bleeding. To prevent this, all the visible blood vessels in the proposed line of incision are ablated/closed with a 300 micron tip at low energy. Alternatively, the incision may be started and completed with the 300 micron tip only. This leaves a minor gap in the conjunctiva, which is of no consequence for the surgical result (Figure 6).
5.The fornix ends of the conjunctival incisions are undermined towards the orbit.
6.The structure directly under the incised conjunctiva is Muller muscle. Muller muscle takes its origin from under the levator muscle. If this muscle is pulled anteriorly, we can easily catch the levator muscle in its aponeurosis. While the Muller muscle is red, the levator muscle looks pearly white.
The amount of levator muscle pulled anteriorly depends upon the severity of ptosis. The greater the ptosis, more the anterior pull of levator needed.
Figure 6: The conjunctiva has been ballooned and three incisions have been made with 300 micron Fugo blade tip
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7.Vanadium steel suture, 80 microns size, is passed through the levator muscle caught at the end of each conjunctival incision. The sutures are secured with mini clamps
(Figure 7).
Figure 7: Levator muscle has been brought out and 80 micron vanadium steel suture has been passed through it
8.Now the anterior surface of the tarsal plate is exposed with the help of 300 microns blunt Fugo blade probe. The exposure is done at the three proximal ends of the conjunctival incisions. Exposure of tarsal plate occurs as we ablate Muller muscle and the underlying stretched aponeurosis of levator muscle. The ablation begins close to the nylon stay sutures, which provide us a clue of the depth at which Fugo blade is working. The most important point is not to ablate the tarsal plate, only expose it. Exposure of the tarsal plate with Fugo blade is usually bloodless. If a large vessel is in the way, it shall bleed. The very same Fugo blade tip is touched to the bleeding spot to stop the bleeding. The exposure process is accomplished with Fugo blade without charring of the tissues. This in turn prevents postoperative reaction and edema (Figure 8).
Special Oculoplasty Surgical Procedures 455
Figure 8: Three areas on the anterior surface of the tarsal plate have been exposed with 300 microns tip of Fugo blade, in line with the nylon stay sutures
9.The levator holding steel sutures are then passed through the exposed/prepared anterior surface of the tarsal plate. The needle is entered through partial thickness of tarsal plate about 3 to 3.5 mm from the upper edge of the tarsal plate, and is made to come out about 1.5 mm from the edge (Figure 9).
10.The levator is attached to the tarsal plate with a reef knot to the steel sutures. Excessive force is not used lest the tarsal plate get cheese wired (Figure 10).
11.Stay sutures are removed. The lid is returned to its normal position.
Figure 9: The suture has been passed through half thickness of the tarsal plate
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Figure 10: All the three sutures have been tied and cut. We are looking at the anterior surface of the tarsal plate. When the lid is returned back this surface is away from the cornea
12.The lids are temporarily tied together with a thick nylon suture for 24 hours for adults and 48 hours for the children.
It will be noted that Fugo Blade is needed for the crucial steps of incising the conjunctiva and exposure of the anterior surface of the tarsal plate.
Postoperative Management
Steroid-antibiotic eye ointment three times a day for 15 days. Artificial tear drops 7-8 times a day and making sure that the patient is able to close the lid. A pad and bandage at night time for the first few days.
There is little or no inflammatory reaction after the surgery. A part of the credit goes to the Fugo Blade that ablates without charring and collateral damage and a part goes to the simplicity and atraumatic nature of the surgical technique.
It is important to watch the lid margin, if there is any in turning. In turning can happen if the levator is attached far too anteriorly from the superior edge of the tarsal plate. In a very severe ptosis case, when an excess of levator has to be pulled out, the same situation can happen. The tarsal plate moves up, while the other tissues of the lid tend to hang over
Special Oculoplasty Surgical Procedures 457
Figure 11: Slight ptosis, before and six months after surgery
Figure 12: Ptosis with poor levator function.Pediatric patient, age 7, who was operated at the age of 3.The slight inequality shall be corrected by orbicularis plication later on, if the patient so desires
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Figure 13: Unilateral severe ptosis with good levator function, in a 13 years old patient. The postoperative appearances are one year after the operation
the lid margin. Temporary sutures lifting the skin prevent the cilia from striking the cornea. A bandage lens may be kept for a few days if needed.
We have done over 180 operations during the past 4 years. More than 90% of the cases have a satisfactory outcome. When the correction is short of expectations, I do additional surgery of “plication of orbicularis oculi muscle”, about 6 months or more after the primary operation (Figures 11 to 13).