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关注儿童先天性上睑下垂手术时机和手术方式的选择

Selection of surgical timing and techniques for congenital blepharoptosis

来源期刊: 眼科学报 | 2021年11月 第36卷 第11期 847-851 发布时间: 收稿时间:2023/8/4 17:13:36 阅读量:4727
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先天性上睑下垂手术时机弱视儿童
congenital blepharoptosis surgical timing amblyopia children
DOI:
10.3978/j.issn.1000-4432.2021.11.06
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上睑下垂是眼整形科最常见的疾病之一,由于儿童处于生长发育阶段的特殊性,不规范的诊疗不仅会影响外观,同时可能会导致视功能发育迟缓。目前关于儿童先天性上睑下垂的手术时机和手术方式的选择尚无统一的标准和共识,本文通过对儿童先天性上睑下垂分类细化,阐明合并不同原因导致弱视的患者手术时机的选择;对比不同手术方式,分析其原理及优缺点,进一步明确矫正重度儿童先天性上睑下垂的手术方式,以期规范儿童先天性上睑下垂手术时机和手术方式的选择,提高手术的成功率,减少弱视的发生。
Blepharoptosis is one of the most common diseases in oculoplastics. Due to the particularity of children in the stage of growth and development, non-standard diagnosis and treatment not only affect the appearance,but also lead to the retardation of visual function development. Currently, there are no uniform standards and consensus on the choice of surgical timing and methods for pediatric congenital blepharoptosis. Here through refined classification of congenital blepharoptosis, we try to elucidate the choice of surgical timing for congenital blepharoptosis patients combined with amblyopia caused by a variety of reasons. By comparing different surgical methods, we analyze their mechanisms and advantages, and illustrate the surgical indication for severe congenital blepharoptosis, so as to standardize the choice of surgical timing and methods for pediatric congenital ptosis,improve the surgical success rate, and reduce the occurrence of amblyopia.
先天性上睑下垂是儿童常见眼病,发病率为0.18%~1.41%[1-3],其中单眼发病占65%,可单独发病或合并全身及眼部其他疾病。在正常情况下,睁眼平视时上睑缘遮盖角膜缘1~2 mm,在排除额肌作用下,遮盖角膜缘>2 mm即可诊断为上睑下垂。
由于儿童处于生长发育阶段,尤其视功能仍在发育,手术治疗不及时可能会导致形觉剥夺性弱视或影响弱视的治疗[4]。近年来,有关儿童先天性上睑下垂的手术时机有了新的认识,并且出现了以新材料膨体聚四氟乙烯(expanded polytetrafluoroethylene,e-PTFE)[5-6]为代表的额肌悬吊术及联合筋膜鞘(combined fascia sheath,CFS)[7-8]悬吊术等新术式,但针对手术方式的选择目前仍有较大争议。现就儿童先天性上睑下垂的手术时机、手术方式的选择进行评述。

1 儿童先天性上睑下垂的手术时机选择

上睑下垂可根据下垂量进行分类,一般分成轻度上睑下垂(下垂量1~2 mm)、中度上睑下垂(下垂量3 mm)和重度上睑下垂(下垂量≥4 mm)。对于儿童轻、中度上睑下垂,一般不对视力产生明显影响,较少发生弱视,可暂时观察,定期随诊,待3周岁以后择期手术治疗;对于儿童重度上睑下垂,需结合患者视功能发育情况选择手术时机。

1.1 合并形觉剥夺性弱视的患者应尽早手术

儿童处于视功能发育的关键时期,目前已达成共识,影响视力发育的先天性上睑下垂应尽早手术治疗[4],因此需客观、准确地评估上睑下垂对视功能发育的影响。弱视是先天性上睑下垂患儿视力下降最常见的原因,在一般人群中弱视的患病率为3.0%,约22.7%先天性上睑下垂患者合并弱视[1],对于这类患者如果下垂眼睑遮挡视轴需尽早手术治疗,去除形觉剥夺因素对视功能发育的影响,如果麻醉及手术条件允许,可在 约1岁时进行手术治疗,术后密切随访双眼视功能发育情况。

1.2 合并屈光不正性弱视的患者手术时机选择

弱视的产生原因不仅与形觉剥夺有关,与屈光不正、屈光参差及斜视亦有很大关系,部分学者指出先天性上睑下垂患者的弱视约1/3由屈光参差引起,约1/3由斜视引起,剩余仅1/3由混合因素导致或者形觉剥夺引起[9]。对于视轴未完全遮挡的患儿,目前没有充分的证据证实屈光参差或者散光导致的弱视是绝对的手术指征。研究[10]发现相对于正常眼,虽然下垂眼角膜地形图异常,理论上矫正上睑下垂后可减少机械性压迫,进而可以减轻散光,但结果发现上睑下垂术后患眼散光不降反而增长。Chisholm等[11]提出对于未遮挡视轴的上睑下垂患者,若合并屈光不正导致的弱视,可适当推迟手术时间至约4岁,患儿可以更好地配合检查、术后更容易护理以及可减少麻醉相关的并发症。对于合并弱视的上睑下垂患者,需要明确导致弱视的原因,如果上睑下垂未遮挡视轴,弱视为屈光不正等其他原因导致,上睑下垂手术可以适当推迟至3岁以后,随着患者的生长发育,年龄越大,手术效果越确切,患儿配合程度越高,术后护理较为配合,同时可减少角膜暴露等手术并发症[12]

1.3 合并斜视性弱视患者手术时机选择

10%~30% 的先天性上睑下垂患者合并斜视[13]。上睑下垂和斜视均需要手术的患者,目前广泛采取分阶段手术方式,先矫正斜视,稳定一段时间后行眼睑手术,否则可能会影响手术效果[14-16]。近年有学者[17]提出可同期完成斜视和上睑下垂矫正,术中先行斜视矫正术,再行上睑下垂矫正术。Revere等[18]随访观察38例同期手术患者,发现对比于传统分阶段手术,同期手术效果无明显差异,但后者可减少手术和麻醉次数,同时缩短恢复时间、降低手术费用,为合并斜视的先天性上睑下垂患者的治疗提供了新的思路。由于上睑提肌毗邻上直肌,中间有筋膜等软组织连接,针对上睑下垂合并垂直斜视患者,术中如果需要同时处理提上睑肌及上直肌,调整上直肌可能会影响睑裂高度,调整提上睑肌也可能会改变眼位[18],这类患者是否可以行同期手术仍需进一步的临床研究。

2 儿童先天性上睑下垂手术方式选择

矫正上睑下垂的手术从原理分析主要归纳为:1 )依靠加强提上睑肌肌力的手术,通过缩短、前徙、缩短联合前徙、超常量缩短等方法;2 )借助额肌力量上抬眼睑,包括额肌瓣悬吊术和借助各种内植入材料如丝线、阔筋膜、硅胶管等连接体间接借助额肌力量上抬眼睑的额肌悬吊术[19];3)利用其他腱膜性组织悬吊,包括Whitnall韧带和CFS悬吊术等。儿童先天性上睑下垂手术方式的选择主要依据提上睑肌肌力,参考下垂量决定,如肌力≥4 mm,应选择提上睑肌缩短术或提上睑肌折叠术;如肌力<4 mm,应采用借助额肌力量、增强提上睑肌肌力或者其他组织悬吊的手术,本文重点评述该类重度儿童先天性上睑下垂手术方式的选择。

2.1 额肌瓣悬吊术

额肌瓣悬吊术是目前矫正先天性上睑下垂效果最佳的经典术式[20-21],手术通过从额肌上分离部分组织制作上宽下窄梯形额肌瓣,前缘宽13~18 mm并将其缝合固定在眼睑睑板。目前国内部分学者主张可在3岁左右行额肌瓣悬吊术,Medel等[22]提出在约2岁时可行额肌瓣矫正术,随访观察3 0例患者,其中2 7例(90%)眼睑高度、形态均良好,3例(10%)需二次手术治疗。额肌在2岁左右发育成 熟[23],对于合并弱视的患者,可在2岁左右行额肌瓣悬吊术。额肌瓣悬吊手术效果佳,一般无需二次手术,手术切口少,同时可避免植入物排斥、感染、肉芽肿形成等植入物相关反应,是目前临床认可度最高的手术方式。

2.2 额肌悬吊术

额肌悬吊术目前应用的悬吊材料为阔筋膜、硅胶管、ePTFE等。自体阔筋膜在3~4岁发育成熟,由于不能满足先天性上睑下垂患者需尽早手术的需要[23],并且存在供区取材创伤,术后长期可能吸收等风险,目前在国内应用较少。硅胶管由于弹性和柔韧性较好,基本可以实现“动态悬吊”,术中可通过调整松紧度确定睑裂高度,术后眼睑外观较为理想,并且除了重睑切口,手术在额部切口较小,无需分离额肌,创伤更小。但硅胶条悬吊术并非永久性手术,可能需要二次手术取出,且存在排斥、感染、断裂等风险[24-25]。ePTFE材料稳定性及生物相容性更好,表面富含疏松的孔样结构,便于血管化,虽然同样存在术后排斥、感染及复发等问题,但是由于生物相容性好,排斥概率相对较低,对比各种悬吊材料,文献报道应用ePTFE进行额肌悬吊的复发率是除自体阔筋膜之外最低的[5,26]。由于硅胶条及ePTFE等材料延展性较好,患儿术后早期眼睑闭合更佳,对于年龄较小术后不易护理的患者或者术后角膜暴露风险较大,如合并眼外肌麻痹、Bell’s征阴性的患者可优先考虑使用[27]

2.3 超常量提上睑肌缩短术

超常量提上睑肌缩短术指术中分离提上睑肌至Whitnall韧带以上并进行缩短、将其固定于睑板提升眼睑[28]。Cruz等[29]对35例重度上睑下垂患者进行多中心回顾性研究,术后半年患者眼睑高度良好,其中9例(29%)存在眼睑弧度轻度异常,33例(93%)存在自主眨眼功能障碍,28例(79%)存在上睑迟滞。重度先天性上睑下垂患者大部分由提上睑肌发育不完全引起,提上睑肌由脂肪、纤维组织等替代[30],提上睑肌缩短术无法增强肌肉力量,仅通过类似韧带的作用悬吊,因此手术悬吊位置较高,术后早期常出现眼睑闭合不良、眼睑迟滞,导致角膜暴露引起的暴露性角膜炎可能性增加,因此对于Bell’s征阴性的患者不推荐使用;对于一些提上睑肌肌力较好的患者可考虑使用该术式,如果肌力较差,术后上睑下垂复发的可能性较大。

2.4 CFS悬吊术

CFS 又名 Check 韧带,是由提上睑肌与上直肌筋膜融合延续增厚而组成,是附着于结膜上穹隆部的一条具有弹性的致密纤维结缔组织[31]。Holmstr?m等[7]于2002年首先报道了上睑下垂患者CFS悬吊术,国内Xing等[8]报道了CFS悬吊联合提上睑肌缩短在上睑下垂患者中的应用。从解剖学角度来分析,CFS的主要动力均来自于上直肌[31],采用CFS悬吊可保持眼睑开启时眼睑运动方向与原有的提上睑肌一致,使上睑开启符合生理状态,术后眼睑弧度和外观更自然,同时手术创伤小,术后恢复时间短。但该术式的临床应用有一定的限制,首先目前关于CFS发育成熟的时间未知,目前无解剖学证据表明在儿童时期已经发育良好,对于儿童先天性上睑下垂不建议使用。其次CFS是一层菲薄的组织,厚度大约(1.1±0.1) mm[7],并且个体之间存在解剖变异,悬吊效果不确切,术后存在上睑下垂复发的风险。CFS悬吊矫正儿童先天性上睑下垂的有效性和安全性仍待临床大样本、多中心的研究验证。
综上所述,针对儿童先天性上睑下垂,术前需详细地评估,明确是否合并弱视及导致弱视的原因并进行分类,根据不同患者的情况选择个性化的手术时间;针对患者不同的提上睑肌肌力状态、Bell’s征情况选择合适的手术方法,努力为儿童先天性上睑下垂患者提供科学、规范、合理的治疗,提高手术的成功率,减少弱视的发生,并最终提高患者的生活质量。

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1、邓希童. 基于人脸关键点检测的上睑下垂辅助诊断系统的设计与实现[D].华东师范大学,2023.Deng XT. Design and implementation of an auxiliary diagnosis system for ptosis based on facial key point detection[D]. Shanghai: East China Normal University, 2023.
2、叶娟,楼丽霞.矫正儿童上睑下垂的手术时机[J].中华眼科杂志,2023,59(7):514-517.Ye J, Lou LX. Surgical timing for childhood blepharoptosis[J]. Chin J Ophthalmol, 2023, 59(7): 514-517.
1、中山大学中山眼科中心“五个五”临床专科建设项目 (3030901010071)。
This work was supported by the Five-year Plan Project of Zhongshan Ophthalmic Center, China (3030901010071).()
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