| Background In the field about severe ptosis correction,improving surgical outcomes and reducing complications are like the two ends of a scale,and it has always been a challenge for clinicians to find the balance between the two in the treatment process.Since the conjoint fascial sheath(CFS)suspension has been used for the correction of severe ptosis,it has gradually gained popularity because of its advantages of natural postoperative appearance and physiological eye movements,which are considered to be a surgical technique that can balance the disease treatment and the aesthetic reconstruction.Since then,scholars have continued to explore the "balance point" of this technique in the hope that it will provide patients with the ideal surgical outcome while reducing complications.Now,clinicians are plagued by the following points: What is the criteria for intraoperative palpebral fissure height correction? What are the postoperative treatment results? How to reduce the occurrence of related complications through clinical practice?Methods1.Patients with congenital severe ptosis undergoing CFS suspension from May 2020 to January 2021 in our department were evaluated.The time points for follow-up were preoperative,1 week,1 month,6 months,and 1 year after surgery.The functional outcome of the eyelid was evaluated by the marginal reflex distance 1(MRD1),palpebral fissure height(PFH)and lagophthalmos(LAG).The aesthetic result of the eyebrow-eye continuum was evaluated by the brow height(BH),symmetry and forehead wrinkles.2.Patients with congenital severe ptosis undergoing CFS suspension in our department from May 2020 to August 2021 were enrolled and divided into 2 groups.In group A,patients’ CFS was dissected via the below-Conjunctiva fornix-Bulbar conjunctiva-Tenon’s capsule(CBT)approach.In group B,patients’ CFS was dissected via the above-CBT approach.The incidence and outcomes of the bulbar conjunctival prolapse(BCP)were collected and analyzed.3.Patients with congenital severe ptosis undergoing CFS suspension in our department from May 2020 to January 2021 were enrolled.The eyeball position,the infraduction and the recovery distance,the eyeball position difference between the two eyes and the cosmetic results were recorded and analyzed.4.A retrospective study of patients with congenital severe ptosis corrected by CFS suspension in our department from January 2021 to March 2022,who did not develop trichiasis after suspension of the upper eyelid onto the CFS during surgery were conducted.Two groups were divided according to whether or not the intraoperative trichiasis prevention technique was used,with non-use being group A and use being group B.The incidence and outcomes of trichiasis in both groups were recorded.5.A retrospective study of patients with congenital severe ptosis corrected by CFS suspension in our department from January 2021 to March 2022 were conducted.Patients were counted for The occurrence and outcomes of postoperative corneal epithelial defects were recorded.Results1.A total of 36 patients(49 eyes)were included.In terms of eyelid functional outcome:the mean MRD1,PFH,and LAG was 6.25±1.26 mm,12.66±1.32 mm,and 4.40±1.45 mm,respectively,at 1 week postoperatively.The mean MRD1,PFH and LAG was4.15±1.03 mm,10.64±1.19 mm and 0.84±0.97 mm,respectively,at 1 year postoperatively.All three decreased with increasing recovery time and gradually stabilized.In terms of the aesthetic results of the eyebrow-eye continuum: Before surgery,the mean medial,center and lateral brow heights(BH)of patients were 31.16 ± 4.62 mm,34.24 ± 4.11 mm and34.00 ± 4.25 mm,respectively.The MRD1,PFH,and pupil-to-brow distance(PTW)symmetry was found in 22.22%,27.78%,and 83.33%,respectively.The degree of forehead wrinkles was 50% for mild,33.33% for moderate and 16.67% for severe.One year after surgery,the mean medial,middle and lateral BH was 28.80±4.30 mm,31.51±3.96 mm,and 32.09±3.59 mm,respectively.The MRD1,PFH,and PTW symmetry was found in 83.33%,83.33% and 91.67%,respectively.The degree of forehead wrinkles was 69.44% for mild,30.56% for moderate and 0 for severe.2.A total of 40 cases were included in group A,with a 25% incidence of postoperative BCP;36 cases were included in group B,with a 2.78% incidence of BCP(P=0.015).Of all the 11 BCP patients,6 patients improved after conservative treatment,while 5 did not.All of them underwent bulbar conjunctiva resection within one year and were cured.No patient complained about the foreign body sensation.3.A total of 36 patients(49 eyes)were included.Before the surgery,the mean eyeball position was 4.66 ± 0.79 mm.Immediately after surgery,the mean eyeball position was3.08 ± 1.16 mm(P < 0.001),the mean infraduction distance was 1.58 ± 1.10 mm.One year after surgery,the mean eyeball position was 4.19 ± 0.80 mm,the mean infraduction distance was 0.47 ± 0.51 mm,and the mean recovery distance was 1.11 ± 0.89 mm.For patients with unilateral ptosis,the eyeball position difference was 0.70 ± 0.42 mm,1.63 ±1.18 mm(P < 0.01),and 0.72 ± 0.62 mm before,immediately after,and 1 year after surgery,respectively.For patients with bilateral ptosis,the mean eyeball position difference was 0.58 ± 0.26 mm,0.83 ± 0.52 mm,and 0.49 ± 0.47 mm before,immediately after,and 1 year after surgery,respectively.The cosmetic results was 1.92 ± 0.95,5.80 ±1.10,8.14 ± 1.11 before,immediately after,and 1 year after surgery,respectively.4.A total of 25 cases(33 eyes)were included in group A.Immediate postoperative eyelash angle was excessive,good,fair,and poor in 0,24.24%,75.76%,and 0,respectively.At the first follow-up,the eyelash angle was excessive,good,fair,and poor in 0,12.12%,51.52%,and 36.36%,respectively.A total of 23 cases(30 eyes)were included in group B.Immediate postoperative eyelash angle was excessive,good,fair,and poor in 73.33%,26.67%,0,and 0,respectively.At the first follow-up,the eyelash angle was excessive,good,fair,and poor in 0,23.33%,66.67%,and 10%,respectively.A total of 15 eyes with poor eyelash angle at the first follow-up in both groups experienced trichiasis.Twelve eyes were cured after first surgery for trichiasis treatment and the other three eyes were cured after second surgery for trichiasis treatment.5.A total of 70 patients(98 eyes)were included in this study.All patients used the ptosis corneal care techniques.During the follow-up period,corneal epithelial defects occurred in 8 eyes,5 of which had trichiasis and were cured with a 1-week all-day eyelid-seal using the modified care technique after the trichiasis treatment technique,and 3 eyes did not have mechanical causes and were cured with a 1-week all-day seal using the modified care technique.Conclusion1.CFS suspension is a reliable and effective correction for severe ptosis,which can not only help patients achieve ideal PFH and eyelid closure function,but gives them a youthful,harmonious appearance by reconstructing the aesthetics the eyebrow-eye continuum.2.The stability of the CBT plays a key role in the prevention of bulbar conjunctival prolapse following severe ptosis correction.The incidence of bulbar conjunctival prolapse decreased significantly by dissecting CFS via the above-CBT approach.For patients with BCP after CFS suspension,bulbar conjunctiva resection could provide satisfactory results.3.The infraduction of the eyeball after CFS suspension can be gradually restored with the prolonged recovery time and does not affect the postoperative appearance of the patient.Intraoperatively,the infraduction distance can be reduced by separating CFS deeper and reducing the adhesions between the CFS and the superior rectus muscle.4.The trichiasis prevention technique should be routinely used in CFS suspension to prevent the occurrence of postoperative trichiasis.Patients who develop trichiasis need to be treated with the trichiasis treatment technique.5.Modified ptosis corneal care techniques have a preventive and therapeutic effect on the postoperative corneal epithelial defects.Patients with mechanical causative factors such as trichiasis should be treated with the trichiasis treatment technique firstly. |
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