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镜下改良眼轮匝肌手术治疗先天性下睑内翻的临床疗效

Clinical efficacy of modified orbicularis oculi surgery under microscope in the treatment of congenital lower eyelid entropion of children

来源期刊: 眼科学报 | 2022年10月 第37卷 第10期 780-785 发布时间: 收稿时间:2022/11/18 16:05:05 阅读量:3614
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镜下改良眼轮匝肌手术先天性下睑内翻
under the microscope modified orbicularis oculi muscle operation congenital entropion of lower eyelid
DOI:
10.3978/j.issn.1000-4432.2022.10.05
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目的:分析临床应用镜下改良眼轮匝肌手术治疗儿童先天性下睑内翻的效果。方法:回顾性分析安康市中医医院2年期间,应用镜下改良眼轮匝肌手术治疗61例(112眼)儿童先天性下睑内翻,根据睑内翻程度决定缝线跨度、松紧度及去除肌皮瓣量,0/6缝线将睑缘下眼轮匝肌与下睑缩肌缝合,0/8缝线连续缝合皮肤伤口,并做好术后护理。结果:所有患儿随访6~24个月,刺激症状缓解,106眼治愈,2眼好转,4眼复发,总有效率达96.43%。结论:镜下改良眼轮匝肌手术治疗儿童先天性下睑内翻美观、易操作、复发率低。
Objective: To analyze the clinical efficacy of modified orbicularis oculi surgery under microscope in the treatment of congenital lower eyelid entropion of children. Methods: Sixty-one cases (112 eyes) of children with congenital lower eyelid entropion treated by modified orbicularis oculi surgery in Ankang Hospital of Traditional Chinese Medicine from Aug 2020 to Sep 2022 were retrospectively analyzed. The suture span, tightness and the amount of myocutaneous flap removed were determined according to the degree of entropion. The orbicularis oculi muscle of lower eyelid margin was suturedwith 0/6 suture, and the skin wound was sutured continuously with 0/8 suture, and postoperative nursing was done well. Results: All children were followed up for 6–24 months, and the irritation symptoms were relieved, 106 eyes were cured, 2 eyes turned well, and 4 eyes relapsed. The total effective ratereached 96.43%. Conclusion: The modified orbicularis oculi surgery for treatment of children with congenital lower eyelid entropion conforms to visual aesthetics. In addition, it is easy to operate and have a low recurrence rate.
      先天性下睑内翻是儿童常见眼病,多见于下睑内眦部,与内眦赘皮牵拉、下睑皮肤过多、睑缘及睑板前轮匝肌肥厚造成的睑缘内翻[1-2], 轻者随着年龄的增长会自然消失,重者由于睫毛长期摩擦角结膜导致反复眼红、异物感、羞明、流 泪,出现角结膜炎、角膜血管翳影响视功能[3-5], 需要手术,而手术方式有多种,各有优缺点[6-7]。 2019年11月至2021年5月在安康市中医医院采取镜下改良眼轮匝肌手术治疗儿童先天性下睑内翻,取得好的效果,现报告如下。

1 对象与方法

1.1 对象

      诊断标准:参照《临床诊疗指南:眼科学分册》中的相关诊断标准[8]。回顾性分析2019年 1 1月至2021年5月在安康市中医医院住院的儿童 先天性下睑内翻患者6 1例(112眼)。其中男3 1例 (60眼),女30例 (52眼);年龄3~25(6.5±1.3)岁; 单眼下睑5例(5眼),双眼上下睑合并内眦赘皮4例 (10眼),下睑合并内眦赘皮12例(24眼), 睑裂狭小综合征2例(4眼),双行睫1例(2眼),8例(9眼)合并角膜血管翳,双眼下睑29例(58眼)。

1.2 方法

      所有患者全程手术在显微镜下实施,95%患者采取全身麻醉+局部浸润麻醉手术,仅7个大龄患儿选择局部浸润麻醉。麻醉满意后手术操作:1 ) 常规消毒、铺巾,暴露双眼。2 )用亚甲蓝在下睑缘下2 mm处画线标记,根据下睑内翻倒睫程度,画线超出倒睫部位外5mm,严重达外眦者需在外眦处向外45°角斜向外下延长3~5 mm。3)2%利多卡因含1:1000000肾上腺素局部轮匝肌间浸润麻醉0.2 mL,使局部稍肿胀。4)固定好画线处皮肤, 11号尖刀切开皮肤。5 )用高频电刀切开,制作肌皮瓣至下眶缘处,内侧超过下泪小点内2mm,彻底止血。6 )在下睑缘切口轮匝肌处,将睑缘下眼轮匝肌与下睑缩肌用可吸收0/6缝线做4~6对“8” 字缝合固定,松紧度以睫毛外翘无睑球分离为 度。7 )整理平铺肌皮瓣。8 )用亚加蓝将多余肌皮瓣切口侧标记。9)去除多余肌皮瓣。10)外眦部肌皮瓣的轮匝肌面间断美容缝合1针,线结埋于肌肉面。11)用0/8缝线连续缝合皮肤,镜下严密对 位。12)合并上睑内翻、内眦赘皮、双行睫儿童术前家长同意手术者,同时联合上睑内翻矫正、内眦赘皮矫正术、双行睫高频电极针电解术。13)术毕伤口涂妥布霉素地塞米松眼膏。14)不包扎(避免儿童包眼恐惧哭闹加重出血、肿胀)。15)术后加替沙星滴眼液外用擦拭伤口至拆线,保持伤口清洁。16)术后1周在头戴式放大镜下拆线(不配合的儿童按公斤体重,采取10%水合氯醛灌肠后拆线)。手术步骤见图1~6。

图1 亚甲蓝标记画线
Figure 1 Methylene blue marker line drawing

20230206112617_5551.png

图2 切开皮肤
Figure 2 Cut open the skin

20230206112702_7328.png

图3 制作肌皮瓣
Figure 3 Making myocutaneous flaps

20230206113930_4171.png

图4 轮匝肌与下睑缩肌缝合
Figure 4 Suture of orbicularis muscle and lower eyelid
constrictor

20230206114037_4043.png

图5 去除多余肌皮瓣
Figure 5 Removal of redundant myocutaneous flap excess skin

20230206114109_2659.png

图6 连续缝合皮肤
Figure 6 Suture of skin

20230206114147_2727.png

1.3 观察指标

      1 )眼睑位置:正常、内翻、外翻。2 )睫毛位 置:正常、倒睫、外翘。3 )眼部刺激症状:有、 无。4)角膜荧光染色:(-)、(+)。5)球结膜充血: 无、减轻、充血。

1.4 疗效评价标准

      治愈:眼睑及睫毛位置正常,眼部刺激症状消失,角膜荧光染色阴性,结膜无充血;好转: 眼睑内翻、倒睫毛程度,眼部刺激症状、角膜荧光染色及结膜充血明显减轻;复发:眼睑及睫毛位置、眼部刺激症状、结膜充血情况同前,角膜荧光染色阳性。手术有效率= (治愈例数+好转例 数)/总例数×100%。

1.5 统计学处理

      采用SPSS19.0统计软件分析数据。计数资料以率表示,比较行χ2检验。P<0.05为差异有统计学意义。

2 结果

      随访10~24个月,所有患儿术后1~2d稍肿胀,3d后肿胀、结膜充血逐渐消退,角膜荧光染色 2~7d转阴,术后1个月眼部不适症状完全消失。 61例 112眼中108 眼有效,总有效率达 96.43%( P<0.05),其中5 6例(106眼)治愈,2例 ( 2眼)好转,3例( 4眼)复发。4例内眦赘皮矫正术后内眦处皮肤伤口稍突起,应用抗瘢痕药物后消失,其余患儿伤口平整、切口痕迹不明显,无巩膜外露及下睑折皱(双眼皮)形成。

3 讨论

      亚洲人群由于下睑眶隔附着点过高,下睑缩肌腱膜止于下睑板下方,因此亚洲人群的下睑内翻发病率较高[9-10]。先天性下睑内翻多见于婴幼儿及儿 童,多为双侧,大多由内眦赘皮、睑缘部轮匝肌过 度发育或者睑板发育不全所致。已有研究[11]报道 睑内翻会影响儿童患眼的屈光发育,与角膜散光 的形成相关。有些婴幼儿比较胖,加之鼻根发育欠饱满,也能造成下睑内翻,由于婴幼儿睫毛细软,刺激症状一般不明显,随年龄增长,鼻梁发育,先天性睑内翻可自行消失,不必急于手术,因严重内翻倒睫导致并发症者可提前手术。如果患儿已长至5~6岁,睫毛内倒仍未消失,严重刺激角膜,流泪又多,导致严重并发症的情况下,需手术治疗[12-14]。传统手术方式下睑缝线法虽操作简单,但远期效果欠佳,复发率高[15]。应用于成人 睑内翻如“Hotz”氏、倒V形松解术等睑板切断、 灰线切开、电解睫毛等方法均不适合在婴幼儿及儿童患者中使用,针对儿童先天性下睑内翻矫正还有多种术式[16-20]
      针对先天性下睑内翻患眼眼轮匝肌过度发育、内眦部皮肤较多因素,本研究采用镜下改良眼轮匝肌手术,随诊10~24个月,取得较好效果, 总有效率达到96.43%。该手术是在传统下睑内翻 (切开法或缝线法)手术基础上的改良,改良点如下:1)制作轮匝肌肌皮瓣;2)睑缘轮匝肌与下睑缩肌缝合;3 )轮匝肌缝线跨度、力度、深度改良; 4)多重方式联合(去除肌皮瓣、轮匝肌与下睑缩肌缝合);5)此操作不需要切开眶隔,缝合时在睑板下缘的睑结膜面可见缝合针即达下睑缩肌层。总结该术式改良优点如下:1 )显微镜下全程操作, 精准、微创。2 )全身麻醉加局部浸润麻醉联合术后水合氯醛灌肠拆线,术中便于层间分离,减少出血,减轻患儿术后及拆线疼痛感及恐惧感,利 于儿童身心健康发育。3 )术中应用高频电刀,彻底止血,减少术中、术后出血,不但止血充分并且快捷,减少术后肿胀,有利于术后恢复,术后无需加压包扎,避免因加压包扎使患儿恐惧哭闹不安,加重肿胀与出血发生率。4 )术中发现先天性下睑内翻患者眼轮匝肌均较正常人肥厚,其肥厚程度与内翻程度成正比,术中采取肌皮肤瓣切开并去除多余肌皮瓣,包括睑板前及部分眶隔前轮匝肌,解除导致内翻因素,皮肤及眼轮匝肌的最大切除量在内眦部,向外侧逐渐减少,去除肌皮瓣的量,以平镊轻轻夹起睑缘皮肤以睑缘复位平整为度。5 )下睑内翻内侧切口要超过下泪小点,达内眦部,减少术后内眦部倒睫复发率,特别注意勿损伤下泪道。6 )大部分患者内翻部位睫毛粗硬垂直睑缘,向角膜方向生长,术中采取切口下睑缘轮匝肌与下睑缩肌肉缝合,睑缘位置以不出现睑球分离,轻度过矫为度。7 )改良轮匝肌与下睑缩肌固定缝合,术后患者在睁眼时,下睑缩肌收缩可进一步对抗眼轮匝肌收缩时内翻作用,对远期减少复发率有事半功倍之效。8 )术后早期双重睑外观不明显,伤口对合整齐微创、无瘢痕。
      对于4眼复发病例原因分析如下:1)4例患儿均为早期开展手术患儿,有2例为睑裂狭小综合征患者,1例合并有内眦赘皮,1例合并过敏性结膜炎,早期经验不足,未行内眦赘皮矫正。2 )下睑内侧皮肤、轮匝肌去除不足。3 )内侧倒睫术中发现过矫时下泪小点有外翻,导致角度欠矫。4 )术中应用可吸收缝线,过敏性结膜炎患儿因眼痒揉眼多,可吸收缝线吸收后粘连创面松脱,不应过度揉眼。
      综上所述,镜下改良眼轮匝肌手术治疗儿童先天性下睑内翻术后微创、美观、复发率低,值得临床推广应用。

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1、安康市科技局 (AK2019-SFZC-03)。This work was supported by the Ankang Science and Technology Bureau (No. ak2019-sfzc-03), China()
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