In 2013, author Watanabe A et al conducted a multi-centerstudy applying the technique of Lai CS on 12 patients experiencing uppereyelid retraction The results showed that 70% of patients
Trang 1In 2002, Lai CS et al reported a clinical case on a new technique fortreating UER by using an orbital septum flap as a spacer to lengthen thelevator muscle In 2013, author Watanabe A et al conducted a multi-centerstudy applying the technique of Lai CS on 12 patients experiencing uppereyelid retraction The results showed that 70% of patients achieved goodresults.
In Vietnam, there has not been any research mentioning the surgerymethod to lengthen levator muscle using orbital septum flap Previous author'sreports did not mention the factors related to the long-term outcome andeffectiveness of surgery In order to contribute to improving the surgical
efficiency of treating UER, we conduct research on the topic "Researching the effectiveness of lengthening levator muscle surgery to treat moderate and severe eyelid retraction" with two sections.
1 Evaluate the results of lengthenning upper levator muscle surgery to treat moderate and severe eyelid retraction.
2 Analysis of factors related to surgical results.
THESIS’S NOVEL CONTRIBUTION
This is the first study on the use of a flap to the orbital septum to lengthenthe levator muscle to treat cases of moderate and severe UER in a study with alarge-enough number of patients The follow-up time is long enough tocomprehensively evaluate the outcome of surgery
Determine the relation to the outcome of the surgery: history of treatment
of eyes, position of eyelid retraction
STRUCTURE OF THE THESIS
The thesis consists 135 pages, including Introduction (2 pages), 4 chapters:Chapter 1: Overview (27 pages), Chapter 2: Subjects and research methods(15 pages), Chapter 3: Research results (40 pages), Chapter 4: Discussion (47pages), Conclusion (2 page), novel contribution (1 page), Proposal (1 page)There are also: references, appendices, tables, charts, illustrations of theresults
Trang 2CHAPTER 1: OVERVIEW 1.1 Anatomy of eyelid physiology
Eyelid is a complex structure that plays an important role in maintainingvisual function Eyelids are limited to orbital organizations in the orbitalseptum
1.1.2 Eyelid anatomy
* Orbicularis ocular muscle
The eyelid part of the orbicularis ocular muscle contributes to the skincrease of the eyelids what dominates by nerves VII
* Orbital septum
From the eyelid septum membrane, the orbital septum moves towards thefront, through the orbicularis ocular muscle of the anterior fat pad of themuscle This position is usually 3 - 5 mm from the margin of the tarsal
* Muller's muscle
The smooth muscles governed by the sympathetic nervous system exist inboth the upper and lower eyelids Muller's muscles are 8 to 12 mm long, 0.5 –1.0 mm thick
* Vascular and nerve
- Artery: eyelid artery system is separated from two main sources: eyelidartery and facial artery
- Vein: there are two veins in the eyelids: shallow vein network and deepvein network
Trang 3- Lymph: includes superficial lymphatic plexus and deep lymphatic plexus
- Nerve: Motor nerves (the branches of the nerve III, VII), sensory nerves
(branch V1, V2), sympathetic nerves
1.2 The pathology of UER
1.2.1 Definition
Upper eyelid retraction (UER) is defined as an elevation beyond thenormal position of the upper eyelid margin in the primary visual position(normally, in a straight forward position, the eyelid margin covers the upperedge of the cornea, 2 mm from the 12-hour-angle edge of the cornea)
1.2.2 Cause
UER is the consequence of many causes with one or more differentpathogenetic mechanisms and in many cases the exact cause cannot beidentified Barley divides the causes of UER into 3 groups:
1.2.2.1 Muscular causes
The Muller's muscle inflammation and fibrosis process ranges from asparse to a dense level that causes changes from muscle atrophy, fatinfiltration or fibrosis to increase muscle size Similarly, the levator musclealso has changes including striated muscle atrophy, fat infiltration, collagenproliferation and mast cell infiltration
1.2.2.2 Neurological causes
Common in congenital UER or common in the posterior brainstemsyndrome, neuropathic regeneration III, myasthenia gravis that causes UER inthe opposite side (Herring Law), orbicularis ocular muscle weakness due toparalysis VII
Trang 4- Von Graefe sign: This is an abnormally related change in the eyelidmovement
- Lagophthalmos: is a condition where the eyes are not closed properlywhen the patient closes the eyes or when sleeping
- Incomplete blinking (Stellwag sign)
- Regular or irregular eyelid retraction: Eyelid retraction occurs in thecenter 1/3 or in the lateral 1/3
- Over-reaction of the levator muscle - superior rectus due to reaction withinferior rectus
- Proptosis due to increased orbital septum volume, the eyeball is pushedforward, the eyelids shrink back on the eyeball
1.2.3.3 Subclinical characteristics
- CT Scan
- The tests of thyroid hormone FT3, increasing FT4 , decreasing TSH.Tests for anti-thyroglobuline antibody, anti-TPO, increasing anti-receptor ofTSH (TrAb) TrAb increases the specificity for Basedow's illness
1.2.4 Diagnosis
1.2.4.1 Definitive diagnosis
UER is definitively diagnosed based on the following factors:
- Functional symptoms: Having symptoms such as blurred vision, redness
of the eyes, dizziness, and watery eyes
- Physical signs:
+ MRD1 > 4 mm
+ PFH > 10 mm
+ Lid lag > -1 mm
+ Upper sclera show on varying degrees
+ May lose the physiological contour of the eyelids margin (C 2 mm),often is a sign of lateral flare
+ Lagophthalmos
1.2.4.2 Differential diagnosis
- UER due to eyelid drooping at the opposite according to Hering’s Law
- Vertical strabismus in upgaze causing sclera show
1.2.4.3 Diagnosis of degree of eyelid retraction
Elner et al classify eyelid retraction according to the distance from thecorneal reflex to the eyelid margin in the primary position (MRD1 index)
- Mild UER: MRD1< 5 mm
- Moderate UER: MRD1 = 5 – 7 mm
- Severe UER: MRD1 > 7 mm
Trang 51.2.5 Treatment of upper Eyelid retraction
1.2.5.1 Medical treatment
Medical eye treatments include:
* Use Guanethidine eye drops
This is a sympatholytic drug that is used to lower eyelids However, the use
of this drug has many limitations due to side effects
* Botulinum toxin A (Botox) injection method
Some authors have used the Botox injection method under conjunctiva forUER patients with very positive results
* Steroid injection method
Steroid injections around the eyeball or under the conjunctiva may beconsidered when total and oral routes are not applicable
* Method of using Hyaluronic Acid (HA) filler
This is an aesthetic improvement method However, this method also haslimitations
* Methods of using spacers
The spacers is relatively hard, and there is no feeding circuit, so the resultsare quite limited in improving the aesthetics and there are risks of removal orrejection of the spacer
* Methods of using flaps
Rotating the flap with different lengths, depending on the degree ofextending the wall needed is determined by the cooperation of the patient
1.3 Surgery to lenghthen the upper levator muscle by using rotation orbital septum flap
1.3.1 Summary of research history
In 2002, Lai CS et al first described the technique of using the orbitalseptum flap to form a natural cartilage to lengthen the upper levator muscle
In 2013, author Watanabe A and his colleagues performed this technique on
10 patients with 12 eyes with upper eyelid retraction due to Basedow and usedorbital septum flap as a material to lenghthen the levator muscle
1.3.2 Indication
Surgery is indicated for cases of moderate and severe eyelid retraction,lateral flare, patients who have not had eyelid surgery, patients with Basedoweyelid retraction have been stabilized for at least 6 months
Trang 6In Vietnam, there are many authors who perform surgery to extend theupper levator muscle with many different materials at major ophthalmiccenters such as Hospital 108, Hospital 103, National Hospital ofOphthalmology, Ho Chi Minh Hospital of Ophthalmology The materialsused in this surgery are relatively diverse, including lip mucosa membrain, earcartilage, palate cartilage However, there have been no studies using the flap
of the orbital septum to extend the upper levator muscle
CHAPTER 2 SUBJECTS AND METHODS OF THE STUDY
2.1 Researched subject group
The subjects of the study were patients with moderate and severe Eyelidretraction who were examined, diagnosed and treated at Vietnam National EyeHospital from October 2016 to October 2019
2.2 Method of research
2.2.1 Research design
Non-controlled clinical trial study
Trang 72.2.2 Sample size
Apply the following formula to calculate the sample size:
Therein:
+ n = minimum number of eyes to be studied
+ z = 1.96 (according to the table corresponding to 95% CI value)
+ p = 90,6 % According to Schaefer's success rate of 90.6 (2007)
+ q= 1-p
+ : error in research (choose = 6.3%.)
According to the above calculation formula, the result is: n = 45 In fact,the study had 46 eyes of 43 patients
Methods of selecting samples: Select the eligible patients one afteranother
* Processing data by statistical algorithms, using SPSS 15.0 software
2.2.4 Research facilities
* Equipment for examination: Snellen vision table, millimeter measure,
Hertel proptosis ruler, eye examination microscopy, ophthalmoscope, Volkophthalmoscopes, cameras, medical records
* Surgical equipment: Eyelid surgery kits, bipole electric burners, surgical
microscopes, shock-proof kits
Trang 8+ MRD1: Measure the distance from the pupil's reflected light to the
eyelid margin at 12 o'clock in a straight looking position
+ MRD1 difference (MRD1) = MRD1 (UER eye) - MRD1 (normal
eye)
Or if the other eye is abnormal: MRD1 = MRD1 (UER eye) – 3,5 mm
+ Palpebral fissure height_ PFH : The height of the skin crease is
measured from the midpoint of the free margin of the upper eyelid to themidpoint of the free margin of the lower eyelid
+ PFH difference (PFH): PFH = PFH (UER eye) – PFH (normal eye).
Or if the other eye is abnormal: PFH = PFH (UER eye) – 10
+ Skin crease height assessment (SC): The height of the crease is
measured from the free margin of the eyelids to the crease when the eye looksdownwards
+ Skin crease difference: ( SC) = SC (normal eye) – SC (UER eye) + Curvature assessment (C): This index is measured by the distance from
the highest point of the upper eyelid margin to the center point between theeyelid and the center of the cornea
+ Sclera show assessment: sclera show index is calculated from the edge
of the cornea to upper eyelid margin at 12 o'clock when the eyes are in astraight looking position
+ Lagophthalmos assessment: Ask the patient to close his eyes to sleep
gently and assess whether the eyelids are completely closed
+ Lid lag (loss of synergy between eyelid and eyeball): Lid lag is
calculated by the difference of the MRD1 in the downward and straightlooking positions
+ Proptosis assessment: The Hertel ruler is placed parallel to the plane
across the 2 cornea vertices allows the measurement of the proptosis
+ Difference proptosis: proptosis = UER eye's proptosis - normal eye's
proptosis
+Levator function assessment (LF): Use a millimeter ruler to measure
the amplitude of the movement of the upper eyelid in the center whenmaximally looking down and maximally looking up as the forehead musclehas been blocked at the reflection in the pupil at 12 o'clock when the eye isfully downward-looking
+ Assess position of retraction: medial 1/3, center 1/3, lateral 1/3
2.2.5.3 Subclinical
- CT scan to determine the mobility condition and the nerve condition
- Tests to evaluate thyroid function: FT3, FT4, TSH, TrAb, thyroidultrasound
- General tests prepared for surgery
Trang 92.2.5.4 Surgery
* Surgical steps
The steps are as follows:
- Posture of the patient: Lying on the back, disinfected, lying on surgicaltowels which allows to sit up, local anesthesia with Dicain solution
- Mark the skin incision on the expected skin crease or under the crease ofthe opposite eye For cases where the 2 eyes do not have creases, the height ofthe crease is expected based on the standard Asian creases (5-7 mm) If thepatient has retraction in both eyes and needs surgery for both eyes, theincision of the skin crease can be used according to the old skin creases
- Local anesthetic under the eyelids with a 2% Lidocaine solution mixedwith Epinephrine 1: 100,000
- Incise the skin with knife number 15 with the length of skin incision from
25 - 30 mm Hemostasis under the skin
- The anatomy reveals and separates the septum of the levator muscle fromthe orbicularis ocular muscle and the tarsal Continue to separate the levatormuscle from the conjunctiva and remove the Muller's muscle
- From the position of the skin incision, surgery up to 5 mm to reach theorbital septum From here, we need to dissect the orbital septum and turn overthe flap by 180 degree so that the edge the flap goes down and connected tothe levator muscle The width of the orbital septum flap is fixed based on thelength of the upper eyelid tarsal with a size of about 20 mm However, theheight of the flap of the orbital septum can be adjusted according to the degree
- Suture the skin, creating eyelids with nylon 7.0
- Fixed two stitches which pull down the cheeks with tape
- Apply antibiotic ointment, and compress-patch the eye
* Care and Post-operative follow-up
- Medicine: Pain relief, antibiotic, anti-edematous, antibiotic ointment
- Apply cold compress for 48 hours, change the dressing daily, cut thestitches after 7 days, maintain 2 fixed stitches pulling down the cheek for 1week with adhesive tape
* Follow-up
- Visit again after 1 week, 1 month, 3 months, 6 months and 12 months
Trang 10* Detect complications and handle complications if any
- Bleeding: mild: Use bandage, hemostatic drug, severe: Open the incision
to remove the hematoma
- Infected: antibiotics combined with immunotherapy
- Injury of the eyeball: Treatment depends on each injury
- Granulomas: Removing granulomas under surgery
- Occur again periodically: Re-surgery after 6 months if indicated
2.2.6 Research variables and indicators
The research results were collected through research records and evaluatedand categorized according to Mourits and Sasim's research Results areevaluated at 1 month, 3 months, 6 months and 12 months before and aftersurgery Research variables and indicators are categorized as follows:
Table 2.1: Methods to evaluate variables and research indicators
Variable name Variable type
Methods and tools for data collection
Goal 1
RulerResearchmedicalrecords
Illness duration Quantitative
Duration of disease stability Quantitative
History of eye treatment Qualitative
History of systemic disease Qualitative
Position of UER Qualitative
Damage to the ocular surface Qualitative
Lagophthalmos condition Quantitative
Proptosis difference Quantitative
Size of orbital septum flap Quantitative
Trang 112.2.7 Methods to evaluate overall results
In the surgical evaluation criteria, the upper eyelid position index(MRD1), the C index, the PFH difference, the crease height, the creaseheight difference and the patient satisfaction level are the criteria thataffect the overall outcome of surgery,
In which MRD1 and eyelid contour C are the other main criteria, theremainders are sub-criteria [95] The criteria related to the generaloutcome of surgery are categorized and evaluated according to thefollowing score level:
Table 2.2: Evaluate research criteria
Table 2.3: Assess the level of patient satisfaction
Satisfaction level Very satisfied Satisfied Not satisfiedEvaluate general results according to the above criteria with 3 levels:Good, medium and poor based on the results of the overall scores of eachresearch indicator according to Mourit and Sasim's classification asfollows:
Table 2.4: Evaluate the results according to the levels
Total
score
15 12-14 < 12 and at least 1 main
indicator is poorEvaluation after surgery, results are good and average is consideredsuccessful, poor results are considered failure
2.3 Data processing and analysis
Data collected from research records will be processed using medicalstatistical methods using SPSS 16.0 software
Trang 12CHAPTER 3 RESEARCH RESULTS
Our study was conducted on 43 patients with 46 moderate-to-severeUER eyes who were examined and treated with extending levator musclesurgery Orbital septum flap at Vietnam National Eye Hospital sinceOctober 2016 to October 2019 Through data analysis we have obtainedthe following results:
3.1 Characteristics off the researched subjects
3.1.1 Patient characteristics
In the study, 43 patients including 41.80% The average age is 33.35 32.5 years old Age group 17 - 50 has the highest proportion, accountingfor 86.04%
3.1.2 Eye characteristics
7/46 eyes studied were caused by thyroid related to orbitopathy(15.22%), 7 congenital UER eyes (15.22%), 69.56% temporarilyidiopathic 11 patients with a history of pathology (diabetes,hypertension ) accounted for 25.58% 74.42% of study patients had noprevious medical history 13.04% of eyes had a history of previous eyesurgery
Visual acuity of the group under 20/70 accounts for the highestproportion with 86.96% The subjective symptoms for patients who visitand receive treatment include 3 blurred vision (6.50%), 2 red eyes(4.30%), 4 teary eyes (8.70%) and 5 limited mobility (10.90%) 69.57% ofpatients come for aesthetics treatment 28.30%, eyes had slight damage tothe surface of the eyeball (superficial keratitis, fibrous keratitis, dry eye).The average duration of illness was 68 months The median duration ofstable treatment was 61 months
The study was conducted on 10 severe UER eye (21.74%) and 36medium UER eye (78.26%) 36 eyes had UER in the central position(center 1/3)
The average MRD1 and PFH of the two groups was 5.97 ± 0.85 mmand 12,65 1,41 mm, respectively The group of severe UER had thelargest sclera show of 2.30 ± 0.95 mm, which is higher than the level ofmoderate UER, of 1.53 ± 0.56 mm The sclera show degree of 1.70 ± 0.73
mm The eyelid curvature of the severe group was 1.20 ± 2.53 mm Theaverage lid lag of the 2 groups was 2.26 ± 1.07 The levator function andskin crease are and 5.38 ± 0.89 mm 14,24 2,12 mm, respectively