Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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BIBLIOGRAPHY
1.Singh D. Orbicularis Plication for Ptosis. Ann Ophthalmol 2006;28;3: 185-93.
2.Singh D, Kaur A, Singh K, Singh SK, Singh RSJ. Sutureless Levator Plication by Conjunctival Route. Ann Ophthalmol 2006;38,4:285-95.
Ptosis management is a real problem. There are various techniques for treating it. A new surgical technique for acquired and congenital ptosis with poor levator function in which Seiff silicone suspension set is used in frontalis sling procedure is described. Here the entire length of the silicone set is guided in the muscle plane through a single stab incision of 2 mm. The advantage of the procedure includes less surgical time, no multiple incisions, no postoperative scars or edema and early recovery. Six eyes of 5 patients underwent the technique for congenital ptosis with poor levator function. The postoperative outcome was comparable with conventional frontalis sling surgery. Thus it provides good cosmesis while retaining the usual advantages of standard sling procedures.
INTRODUCTION
Frontalis muscle suspension procedure1-3 is the gold standard for the treatment of congenital ptosis with poor levator function. It creates a linkage between the frontalis muscle and the tarsus of the upper eyelid, which allows for a better eyelid position in primary gaze. There have been various modifications4-6 of performing the sling procedures in the recent past. Different sling materials7-9 namely from
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autologous facia lata to several suture materials have been tried. Our technique differs from the conventional procedures by use of a single stab incision in making the pentagon or triangle and guiding the silicone sling in the muscle plane with one external incision while suspending the frontalis muscle.
SURGICAL TECHNIQUE
The upper eyelid is infiltrated with lidocaine 2% with 1:100,000 epinephrine. In children and adolescent patients, surgery is performed with general anesthesia. Under aseptic precaution, the eye is cleaned and draped. The pentagon shape is marked over the skin with a marker (Figure 1A). Amount of upper lid elevation needed is again decided on table. Single supra eyebrow stab incision of about 2 mm is put on the superior mark of the pentagon about 5 mm from the eyebrow (Figure 1B). Sterile Seiff silicone frontalis suspension set dipped in antibiotic solution is then taken. It has a long silicone tube with stainless hollow rods on both ends with moderately sharp ends. The silicone sling of the set measures about 23.5 mm on each side and the rod measures about 6.3 cm. The overall diameter of the tube is 0.9 mm. One end of the tube is advanced through the stab incision in the muscle plane (Figure 1C) and guided along the incision sites marked. When the corner of the pentagon is reached, it is then turned downwards along the marks made on the overlying skin. Care is taken so that the surgeon maintains the muscle plane all throughout the procedure. If crumbling of tissue is observed while advancing the rod, it indicates that the plane of the tissue in which the rod is positioned is not uniform. Surgeon’s left hand index finger (Figure 1D) can be used to palpate while the rod is advanced underneath. When the lid margin is
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Figures 1A to H: Single pentagon (A) is marked on the skin. Seiff suspension set is passed through the supra brow incision (B) and advanced through the stab incision in the muscle plane (C, D). Then turned laterally (E, F), brought to the other end of the pentagon and finally through the same superior stab incision (G, H). Skin of the supra brow incision closed with a nonabsorbable suture
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reached, the needle end is palpated and again turned laterally (Figures 1E and F) and brought to the other end of the pentagon. Finally it is brought back through the same superior stab incision (Figures 1G and H) and exteriorized. Lid margin is adjusted according to the amount of correction. When the two ends of the silicone rods are tied, automatically the upper lid margin is positioned. Minimum 4 knots are placed and the knots are buried below the subcutaneous layer. A stay suture is placed with 6-0 vicryl or any non absorbable suture to secure the silicone knot in position. If needed, one can also hitch the silicone tube knot to the underlying periosteum. The single supra brow stab incision is closed with silk suture.
DISCUSSION
The advantage of the technique is that with minimal skin incisions and less surgical time, the clinical outcome of conventional frontalis sling procedure is obtained. Postoperative lid edema, pain and suture related complications due to multiple sutures can be avoided. The technique can be performed in all eyes with ptosis and poor levator function which necessitates frontalis sling. The stab incision used is only about a 2 mm. The surgeon if faces difficulty while changing the direction of the rod; the rod is curved to pass it smoothly along the lid curvature. It is advantageous over the conventional procedure that involves five stab incisions which creates more bleeding and edema in the postoperative period. Though mild immediate postoperative edema was encountered in our technique, it was observed to resolve spontaneously within 24 hours. There have been reports in the past on minimum incision10 and incision less sling procedures.11 Our technique differs from their procedure10 by being permanent and use of silicone rod
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instead of non absorbable suture9. Though silicone material12-14 for frontalis sling suspension has been tried successfully, our method of guided sling procedure with silicone sling has not been reported. Skin of infant is prone to early scar formation and moreover forehead scars caused by frontalis suspension procedures can be a cosmetic problem in future as the child grows. We believe our technique will provide better aesthetic and functional results in such patients with poor levator function and requiring better cosmetic results. In our 6 months postoperative follow up, the results are comparable with conventional technique. However long duration follow up and comparative study with conventional technique in large study population might be required to evaluate the long-term prognosis. Simple learning curve, good cosmesis, less number of sutures with better functional results while retaining the usual advantages of standard sling procedures are the unique features of our technique.
REFERENCES
1.Wagner RS, Mauriello JA, Nelson LB, et al. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials.Ophthalmology 1984 Mar;91(3):245.
2.Unilateral Frontalis Sling for the Surgical Correction of Unilateral Poor-Function Ptosis Ophthalmic Plastic and Reconstructive Surgery 21(6):412-6.
3.Clauser L, Tieghi R, Galie M. Palpebral ptosis: clinical classification, differential diagnosis, and surgical guidelines: an overview. J Craniofac Surg 2006 Mar;17(2):246-54.
4.Goldberger S, Conn H, Lemor M. Double rhomboid silicone rod frontalis suspension. Ophthal Plast Reconstr Surg 1991;7:48-53.
5.Dailey R, Wilson DJ, Wobig JL. Transconjunctival frontalis suspension (TCFS). Ophthal Plast Reconstr Surg 1991;7: 289-97.
6.Advances in the diagnosis and treatment of ptosis. Curr Opinion Ophthal 2005 Dec;16(6):351-5.
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7.Wasserman B, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol 2001;119:687-91.
8.Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol 2005 Nov;140 (5):877-85.
9.Yagci A, Egrilmez S. Comparison of cosmetic results in frontalis sling operations: the eyelid crease incision versus the supralash stab incision. JAAPOS 2003 Jul-Aug;40(4):213-6.
10.Betharia M. Frontalis sling: a modified simple technique. Br J Ophthalmol 1985 Jun;69(6):443-5.
11.Yip CC, Goldberg RA, Cook TL, McCann JD. Incision-less frontalis suspension. Br J Ophthalmol 2004;88:585-6.
12.Carter S, Meecham WJ, Steiff SR. Silicone frontalis slingsfor the correction of blepharoptosis: indications and efficacy. Ophthalmology 1996;103:623-30.
13.Brun D, Hatt M. Ptosis operations with silicone suspension at the eyebrow 1991 Dec;199 (6):457-60.
14.Bernardini F, de Conciliis C, Devoto MP. Frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis. Orbit 2002; 21:195-8.
INTRODUCTION
I started my private practice at Nandurbar, which is located in backward area of Maharashtra. Actually it is small tribal area. I was the first ophthalmologist surrounding 50 km area. Therefore from the first day, I started getting patients. I started my practice with two cataract set, one DCR set, one enucleation set and a refraction set. That time I was doing intracapsular cataract surgery. Then, I purchased second hand microscope and started doing extracapsular cataract surgery. It was my first IOL after 1 year of my practice. That time I used to do dacryocystectomy (DCT) and dacryocystorhinostomy (DCR). But one day I heard one comment from my one of my colleague that “To do DCT is a crime”. Because of that thought I became alert and from that time I stopped doing DCT and all my surgeries were DCR.
Usually ophthalmologist who is performing cataract and IOL are always habitual in working blood less field. I was getting handsome money from IOL. With that practice many of them were reluctant of doing DCR. In spite of my good practice for cataract and IOL I was regularly doing DCR regularly.
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DCR SURGERY
Performing DCR required a big courage and disturbing night sleep. DCR is most unpredictable surgery with success rate varied from patient to patient. DCR surgery is performed in chronically inflamed and vascularizes area. So there is always uncontrolled bleeding which cannot be stopped by any means other than repeated packing and pressure. In spite of doing all these measures when the pack is removed the bleeding again starts. Bleeding also occurs with each removal of lacrimal bone by nibbler and bleeding also suddenly increases when nasal mucosa is incised. I have seen many surgeon and even my self, taking lot of struggle for getting one suture to the the nasal mucosa and lacrimal sac. The surgery is performed in a very narrow and deep area which required lot of surgical skill. The patient’s nasal packing is done which is not easily accepted by patient. I have seen many patient canceling their surgery when nasal packing is tried.
In spite of all these difficulties and struggle I was performing DCR surgery successfully for more than one decade. But two patients made me stop doing this surgery. One patient had profuse nasal bleeding and he was about to die but with the help of my ENT surgeon, physician and anesthetist we could save his life. For six months I stopped doing this surgery. But after six month I again started surgery and second patient had profuse bilateral nasal bleeding due to sudden rise in blood pressure after 24 hours. After that event I thought seriously and stopped doing DCR that was my last DCR surgery. For next 2 years many patient came to me but some how I gave many reasons and cancelled their surgery. But my underlying conscious was not allowing me to keep quite.
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Intracystic Implant
That time I came across with one article for intracystic implant by Dr Pawar and I was immediately attracted to the technique. I have gone through the details and then I tried these implant to many of my patients.
Nowaday the surgery has changed. The time required for surgery is reduced. On table bleeding was less and controlled. Implantation of tube was easy. On table petancy was obtained. The surgery was safe and simplified. No nasal packing was required. No intraoperative and postoperatively bleeding. I became very much happy and then I started doing surgery regularly.
For more than 2 years I performed many surgeries and I was telling my friend about these surgeries. But during postoperatively I came across with problems. Few patients had extrusion of implant through nasal cavity, few patients had block implant. But few patients had funny problem. Postoperatively patient had sac patent but still the patient had repeated complaints of watering. Even after 6 months patient had sac petency on table but their complaint persist. So the failure rate was more than what I thought.
Now again I got disturbed. What to do now?
Endonasal Surgery
By that time the popularity of endonasal surgery increased and then I have decided to refer all these patients to ENT surgeon. A surgery which was primarily bread and butter of the ophthalmologist was becoming right of ENT surgeon. But what can we do?
Laser DCR
During that period laser DCR came. I attended one workshop. The surgery was simple and I decided to go for it. I was little