Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 850 - файл
.pdf
Eye Protection
https://t.me/medicina_free
Fig.13.1 Moist chamber
eye protection
13
13.1 Overview (Fig. 13.1)
•
Occlusive dressings
•
Manual blink
•
Tarsal Traction Suture
•
Non-tarsal traction
•
Temporary Suture tarsorrhaphy
•
Permanent lateral tarsorrhaphy
•
Permanent medial canthoplasty.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_13
161
162 13 Eye Protection
https://t.me/medicina_free
The purpose of the eyelids is to both protect the eye and to regularly replenish
the optical surface of the pre-corneal tear film through blinking. If eyelid function
is impaired, whether by paralysis or by a tissue defect, alternative eye protection
becomes a priority.
13.2 Occlusive Dressing
The simplest protective measure is the application of an antibiotic or lubricant
ointment under an occlusive, non-stick dressing. This is the treatment of choice
for acute lid defects, such as result from lid tumour excision, while awaiting a
histology report. Similarly, use it after trauma if you are unable to repair the
lid immediately. Occlusive dressings can safely be left undisturbed for a week
if necessary.
13.3 Manual Blink (Fig. 13.2)
When eyelid closure is impaired, by paralysis or lid retraction, and there is no
significant corneal epithelial defect, teach the patient to perform a ‘manual blink’.
This reduces eye drying and discomfort during waking hours. The patient performs
this by momentarily pushing the lower lid up across the cornea to spread the
marginal tear strip across the eye to replenish the pre-corneal tear film. It needs to
be repeated frequently (as often as possible) and requires strong patient motivation
and commitment.
a b
Fig.13.2 Manual blink. a Place a finger on the lower lid. b Push the lower lid up momentarily to
spread the pre-corneal tear film
13.5 Closing the Eye 163
https://t.me/medicina_free
13.4 ‘Cling Film’ Occlusion
When a patient is asleep, they cannot perform a ‘manual blink’. Therefore, manage
symptomatic lagophthalmos (incomplete eyelid closure) with an occlusive dressing overnight. This can be made from a square of transparent plastic food wrap
film hermetically fixed around the eye with adhesive tape to create a moist chamber. This is more effective than using lubricant eye ointment alone. Proprietary
transparent occlusive dressings are available as an alternative.
13.5 Closing the Eye
13.5.1 Not the ‘Grey Line’!
When the above conservative measures are insufficient or inappropriate, surgical
protection may be required. The simplest way of reliably and reversibly closing a
lid is to insert a lid margin traction suture and tape this to the skin to pull the lid
closed. Traditionally, and in my view wrongly, such sutures are inserted into the
grey line of the lid margin.
Anatomically the grey line marks the junction between the anterior lamella
of the lid (skin and orbicularis muscle) and the posterior lamella (tarsal plate
and conjunctiva). The grey colour is imparted by the muscle of Riolan (modified orbicularis of the lid margin) as viewed through extremely thin, translucent
skin (Fig. 13.3).
Muscle of
Riolan
Fig.13.3 Grey line and meibomian orifice line. The meibomian orifices mark the mid tarsal plate
thickness. The grey line marks the anterior and posterior lamellar junction
Meibomian orifice line
Grey line
164 13 Eye Protection
https://t.me/medicina_free
The grey line is a poor landmark as with age it becomes increasingly difficult to
discern. Far better landmarks exist on either side of the grey line: the meibomian
orifice line posteriorly, marking the mid tarsal plate thickness, and the lash line
anteriorly.
As a site for traction suture placement the grey line is woefully inadequate as
neither thin skin nor muscle have any suture holding strength. Sutures placed in
the grey line alone will cut out in a matter of hours when put on traction. For this
reason, it is customary to externalize a grey line suture through the skin, pass it
over a bolster or through tarsorrhaphy tubing and then re-enter the skin and exit
through the grey line. In this way the traction force is spread over an area of skin
making the suture less likely to cut through. Unfortunately, the pressure of the
tubing on the skin can be uncomfortable or frankly painful. It can even cause lid
margin pressure necrosis by impairing perfusion. This results in traction failure, lid
margin distortion with possible trichiasis and sometimes lash line necrosis and permanent lash loss. Fortunately, there exists a simple, safe, and effective alternative:
the tarsal traction suture.
13.5.2 Avoid Toxin Ptosis
Botulinum toxin injection of the upper lid levator muscle has been advocated as
a means of inducing temporary upper lid closure. Unfortunately, this is invariably associated with superior rectus paresis knocking out the protective Bell’s
reflex. Furthermore, and perhaps surprisingly, on rare occasions permanent vertical
diplopia results. There are better ways to protect an eye.
13.5.3 The ‘Tarsal Traction Suture’ (see Chap. 5)
13.5.3.1 Principle and Considerations
It is generally accepted that the tarsal plate is the strongest structure in the eyelid
and thus best suited for anchoring a traction suture. Furthermore, the edge of the
tarsal plate is easily identifiable on the lid margin by the meibomian orifice line
which marks the mid tarsal plane. Gently squeezing the lid margin with forceps
causes meibomian secretion egress making the orifice line easy to see. A suture
inserted perpendicularly into this ‘meibomian orifice line’ will provide strong purchase for many weeks or months. Once in place it is completely painless and does
not distort or damage the lid margin. Eventually, like all sutures placed in living
tissue, the suture will migrate out through the lid margin. Slow migration is quite
different from rapid ‘cheese-wiring’ or ‘cutting out’ in so far as it leaves no scarring or anatomical alteration. The cells simply part in front and re-unite behind the
migrating suture until all tension is dissipated.
13.5 Closing the Eye 165
https://t.me/medicina_free
13.5.3.2 Case Selection
Any eye requiring temporary lid closure for protection.
13.5.3.3 Steps (Fig. 13.4)
1. Grasp the full thickness of the lid margin with large forceps (such as Adson’s
or Thaller Tarsal Forceps (Altomed UK A6360)) and evert it to view the lid
margin edge on.
2. Insert a 4/0 monofilament non-absorbable suture on an atraumatic round bodied,
taper point half circle needle (e.g., 4/0 Prolene W8557 Prolene™ Ethicon, or 4/
0 Premilene® B Braun) into the meibomian orifice line perpendicularly to the
margin (Fig. 13.4a).
3. Advance the suture needle within the tarsal plate, allowing it to follow its own
curve, to exit the lid margin form the meibomian orifice line about 10–12 mm
from its insertion point (Fig. 13.4b).
4. If the needle tip exits posteriorly (trans-conjunctively) or anteriorly (transcu-
taneously), simply withdraw it slightly, adjust the tilt of the lid margin with
the grasping forceps and re-advance the needle tip. A non-cutting taper-point
needle causes minimal damage during such repeated passage. Had a cutting
needle been used, each pass would cut the tarsal plate eventually shredding and
weakening it.
a b
0
90
c
Fig.13.4 Tarsal Traction Suture Placement. a Enter the meibomian orifice line perpendicularly
with a non-cutting needle. b Advance the needle within the tarsal plate to exit in the meibomian
line. c Tape the traction suture to the forehead securely
166 13 Eye Protection
https://t.me/medicina_free
5. Pull the suture tight and stick it to the forehead or cheek with three layers
of adhesive tape, bending the suture 180° between layers to prevent it from
slipping through the tape (Fig. 13.4c).
13.5.4 Non-tarsal Traction (Fig. 13.5)
13.5.4.1 Principle and Considerations
Sometimes it is still possible to protect an eye with traction sutures when the tarsal
plate is missing. In this situation the traction suture force must be spread to stop
it cutting through the skin. A silicone band can provide the necessary purchase
on the remaining tissues. This temporizing technique buys time while awaiting
a histology report or planning a definitive repair. During the wait, the stretched
tissues will expand.
a b
Fig.13.5 Non-tarsal traction. a Insert a 4/0 monofilament suture through the conjunctival wound
edge and retractor and bring out through the skin and into a silicone band. Re-enter the band 5 mm
to one side in the reverse direction picking up the tissue layers. b Place additional sutures in the
same manner as the need dictates (usually 3–4). c Tape the sutures to the skin on the opposite side
of the wound under strong traction
c
13.5 Closing the Eye 167
https://t.me/medicina_free
13.5.4.2 Case Selection
Temporary eye protection following any full thickness eyelid defect pending
reconstruction.
13.5.4.3 Steps
1. Insert a 4/0 monofilament suture through the conjunctival wound edge.
2. With the same suture pick up any retractor tissue and bring this suture out
through the skin.
3. Now push it through the centre of a silicone band (240 retinal detachment
encircling explant) and re-enter the band 5 mm to one side in the reverse
direction.
4. Pass the needle through all the tissue layers picked up with the first bite in the
reverse direction (Fig. 13.5a) and clip both ends of this suture together.
5. Place additional sutures in the same manner as the need dictates (usually 3–4
(Fig. 13.5b).
6. Tape the sutures to the skin on the opposite side of the wound under strong
traction. Prepare the skin with a coating of tincture of benzoin and apply
three layers of tape for each pair of suture ends. Remember to alternate the
suture direction between layers to prevent the suture slipping through the tape
(Fig. 13.5c).
7. Apply antibiotic ointment to the wound and an occlusive pressure dressing.
Note: Avoid getting ointment on the adhesive tape or it will lose its adhesion.
8. Leave the dressing undisturbed until formal reconstruction.
13.5.5 Temporary Central Suture Tarsorrhaphy (Fig. 13.6)
The tarsal traction suture technique described above can be extended by passing
the same suture through the opposing eyelid margin in the same way (Fig. 13.6c).
The suture ends are then tied firmly together creating a simple, yet very effective,
temporary tarsorrhaphy (Fig. 13.6d). This can work over many weeks before suture
migration eventually causes it to fail. The suture knot should be tied medially or
laterally as far from the cornea as possible to minimise the risk of corneal irritation.
Furthermore, the suture ends should be left long (2–3 cm) to make it impossible
for the sharp cut ends to enter the palpebral aperture and irritate the eye. Because
monofilament sutures are smooth, the knot seldom irritates the cornea even when
contact occurs.
13.5.6 Temporary Lateral Suture Tarsorrhaphy (Fig. 13.6e)
The principle above may be used to create a lateral tarsorrhaphy (Fig. 13.6e). For
this I recommend you place two tarsal sutures. The more central suture takes most
168 13 Eye Protection
https://t.me/medicina_free
a b
0
90
c d
e
Fig.13.6 Temporary suture tarsorrhaphy. a Enter the meibomian orifice line perpendicular with
a taper point needle. b Bring the suture out through the meibomian line about 10 mm away. c Tak e
a strong bite of the upper lid margin in the same way. d Tie the suture ends together laterally, away
from the cornea. e Use two such sutures to create a temporary lateral tarsorrhaphy
of the strain and will loosen first through migration. Remove it when it is no longer
effective, leaving the lateral suture in place until that also fails.
In my view there is no longer a place for using tubing or bolsters when performing a suture tarsorrhaphy (provided the meibomian orifice line is used for
suture placement).
13.6 Permanent Surgical Tarsorrhaphy 169
https://t.me/medicina_free
13.5.7 Notes
•
Occasionally, following the removal of a tarsorrhaphy suture a mucosal bridge
will be found between the lids. This can be left to break on its own or simply
be cut without anaesthetic.
•
No Temporary Surgical Tarsorrhaphy.
Because meibomian line suture tarsorrhaphy is so simple to perform, effective
and easy to repeat, I contend that there is no-longer any reason for carrying out
a temporary surgical tarsorrhaphy. The latter takes longer to perform and risks
leaving an irregular lid margin and trichiasis after it is re-opened.
13.6 Permanent Surgical Tarsorrhaphy
If a patient requires long-lasting eyelid union, as for example when managing nonrecovering seventh nerve palsy, then you must encourage the lids to heal together
firmly and permanently. The simplest way is to make the opposing lid margin
surfaces raw before suturing them together in close contact until they heal together.
This can work well but often the union is too weak to last and the lids either
separate spontaneously or else the join stretches into an unsightly and ineffective
web. The larger the area of tarsal plate contact that you create the stronger your
tarsorrhaphy.
13.6.1 Permanent (Overlap) Lateral Tarsorrhaphy (Fig. 13.7)
13.6.1.1 Principle
Create a bare area between the overlapping upper and lower tarsal plates and hold
them together with sutures until a strong permanent scar has formed. The greater
the bare area of contact the stronger the union obtained. Overlapping the tarsal
plates creates a larger area of contact than an edge-to-edge tarsorrhaphy.
It is often combined with a medial canthoplasty.
13.6.1.2 Case Selection
•
Incomplete eye closure e.g., non-recovering facial palsy
•
Atonic lower lid ectropion
•
Lower lid retraction e.g., Thyroid eye disease (only when combined with
retractor recession).
170 13 Eye Protection
https://t.me/medicina_free
a
b
c d
e f
Fig.13.7 Permanent (overlap) lateral tarsorrhaphy. a Make a 4–5 mm long incision in the lower
lid grey line up to the lateral canthus. b Excise a semicircle of anterior lamella below it, including skin, orbicularis, and lash follicles, to expose the underlying tarsal plate. c Evert the upper lid
margin and diathermy a corresponding semicircle on the sub-tarsal conjunctiva to destroy the conjunctiva. d Insert a 6/0 absorbable suture through the middle of the exposed lower lid tarsal plate
margin and then a bite of the upper edge of the adjacent diathermied area and tie this suture, cutting
its ends short. e Insert a 4/0 monofilament suture on a round bodied needle through the upper lid
skin, so that it exits the denuded tarsal plate close to the lateral canthus. Then take a strong, partial
thickness bite of the exposed lower lid tarsal plate. Complete this suture by taking it through the
upper lid tarsal plate, skin and through a silicone sleeve. f Place one or two 6/0 absorbable sutures
into the upper lid meibomian orifice line, bringing them down to engage the cut edge of the lower
lid orbicularis and skin. Then tie the preplaced 4/0 monofilament suture to hold the raw tarsal plate
surfaces in firm apposition, so that they unite
Соседние файлы в папке @xirurgi_2025