文獻學習:《眼瞼成形術後結膜水腫的處理》

《眼瞼成形術後結膜水腫的處理》，原文發表於2013年。

譯者：胡健。著作權/版權歸原作者/出版社所有。原作者工作於「Aesthetic Plastic Surgery」美容整形外科，因此有些觀點可能與眼科醫生不同。

 

Abstract

摘要

Clinically significant chemosis occasionally complicates lowereyelid blepharoplasty. In this report, the etiologic components of postblepharoplastychemosis are discussed. The time course and duration of chemosis vary accordingto the underlying cause. Early, late, and prolonged chemosis are managed withdifferent strategies. Diagnostic and therapeutic algorithms for chemosisassessment and management are presented.

臨床意義顯著的結膜水腫是偶見於下瞼成形術的併發症。本文討論眼瞼成形術後結膜水腫的病因學因素。根據其潛在原因不同，結膜水腫的時間進程和持續時間有所不同。早期、晚期和長期結膜水腫有不同的處理策略。本文介紹了對結膜水腫進行評估和處理的診斷和治療性步驟。

 

（正文）

Conjunctival chemosis, a billowing or blister-like swelling of theconjunctiva, is a condition seen following blepharoplasty, particularly of thelower lid. There are predisposing factors for chemosis, including inflammation,venous congestion, and disrupted lymphatic drainage. Presentation ofpostblepharoplasty chemosis can vary between patients. Frequently, the mostsevere cases are seen immediately following surgery; however, severity mayincrease during the postoperative course in some patients. Chemosis can beclassified by the severity of conjunctival inflammation, but in general, it ismost useful to classify the condition by degree of conjunctival prolapsebetween the eyelid margins, as follows (Figure 1):

1.  Mild chemosis: presence ofonly a slight, 「billowing」 sheen in the conjunctiva, with slight conjunctivalprotrusion

2.  Moderate chemosis:presence of a more pronounced conjunctival prolapse, but the eyelids can stillbe closed over the protruding conjunctiva

3.  Severe chemosis: presenceof conjunctival prolapse to the degree that it impairs eyelid closure or theability of the eyelids to cover the cornea, even during manual attempts atclosure

結膜水腫是結膜鼓起或泡樣水腫，可見於眼瞼成形術後，尤其是下瞼成形術後。有一些結膜水腫的易感因素，包括炎症、靜脈淤血和淋巴引流中斷。眼瞼成形術後結膜水腫的表現因人而異。最嚴重的病例常在術後即刻表現出結膜水腫，然而一些患者術後期間病情可能加重。結膜水腫可以根據結膜炎症程度進行分類，但一般而言，最有用的分類方法是根據結膜相對於上下瞼緣的膨出程度，如下所示（圖1）：

1. 輕度結膜水腫：結膜輕度「鼓起」，結膜輕度向前突出。

2. 中度結膜水腫：結膜脫出更加顯著，但是眼瞼仍可閉合、覆蓋突出的結膜。

3. 重度結膜水腫：結膜脫出程度已經妨礙眼瞼閉合或妨礙眼瞼覆蓋角膜，即使在人工試圖閉合眼瞼的情況下。

圖1. （A）女性，70歲，下瞼成形（有眥成形術式）術後出現急性、輕度結膜水腫1周。結膜脫出程度沒有超過瞼緣。（B）女性，48歲，下瞼成形術後出現急性、中度結膜水腫。結膜隆起1周，在下瞼顳側遮蓋了瞼板腺開口處。眼瞼閉合沒有受到影響。（C）女性，70歲，下瞼成形（有眥成形術式）術後出現急性、中度【譯者註：應為重度】結膜水腫1周。結膜水腫、突出，眼瞼不能完全閉合。

Chemosis, in any category, is generally accompanied by inflammationat the outset. Late chemosis may or may not involve a persistent inflammatoryprocess since, commonly, secondary mechanical factors in the cornea and eyelidsmay contribute to its persistance.

無論是哪類結膜水腫，在開始時一般伴有炎症。晚期結膜水腫可有或無持續性炎症過程，角膜和眼瞼的繼發機械性因素通常促進了炎症的持續。

CAUSES AND PREDISPOSITIONS

病因和易感性

Chemosis occurs as a result of conjunctival response to a variety ofinflammatory conditions of the eye or eyelid, including allergy, infection, andtrauma (surgical or otherwise). Chemosis may also occur as the result oforbital inflammation due to trauma, infection, or inflammation, includingidiopathic orbital inflammation and Graves disease. It is not restricted tohumans and occurs in a variety of animals under similar conditions. Sincechemosis occurs in a myriad of nonsurgical situations, it is reasonable tomaintain that inflammation (as a response to the trauma of surgery) is likelythe initial cause of postblepharoplasty chemosis. Other factors have beenimplicated as well, such as impairment of the eyelid and orbital lymphaticdrainage. Lymphatic drainage has been documented in the orbit and eyelids, butthe pathways remain inconsistent in present studies. It has also been suggestedthat chemosis can be stimulated as a result of canthal surgery (canthopexy orcanthoplasty). Some series have shown that chemosis can occur as frequently as11.5% or 12.1% of the time when canthoplasty or canthopexy has been performedand as infrequently as 1% of the time in a series in which there was no canthalanchoring. This occurrence has not been documented in controlled studies, butthere remains a causal possibility. A definite predisposition forpostblepharoplasty chemosis exists in certain patients who have preexistinglaxity and folding of the conjunctiva (conjunctivochalasis; Figure 2), pooreyelid closure mechanics, lower lid laxity, or preexisting ocular surfacedisease.

結膜水腫是結膜對眼球或眼瞼各種炎性狀況反應的結果，包括過敏、感染和外傷（手術或其他）。結膜水腫也可以是外傷、感染或炎症（包括特發性眶炎和Graves病）所致的眶炎的結果。它並不局限於人類，很多動物在相似情況下也會發生。既然結膜水腫發生於眾多非手術情況下，那麼有理由推測炎症（手術創傷的反應）有可能是眼瞼成形術結膜水腫的最初原因。其他因素也可能累及，例如眼瞼和眶淋巴引流受損。據報導眶和眼瞼存在淋巴引流，但現有研究對其路徑尚無一致意見。有研究認為眥手術（眥固定或眥成形）可能刺激發生結膜水腫。據報導眥成形或眥固定手術的結膜水腫發生率高達11.5%或12.1%，而無眥錨定步驟的手術的結膜水腫發生率低至1%。這種情況並沒有在對照研究中有記錄，但仍可能存在因果關係。一些患者有明確的眼瞼整形術後結膜水腫的易感性，即術前存在結膜鬆弛（圖2）、眼瞼閉合功能差、下瞼鬆弛、術前有眼表疾病。

圖2. 女性，68歲，結膜鬆弛。請注意結膜平滑隆起呈嵴狀，騎跨於下方角膜緣。沒有明顯水腫。

 

PATHOGENESIS

發病機制

Prolongation of Chemosis

長期結膜水腫

Following the onset of conjunctival chemosis caused by the traumaticinflammation from blepharoplasty, the anatomic distortion of the lid-cornealinterface may establish a mechanical cycle that prolongs the condition. Theswollen conjunctiva becomes dessicated and more inflamed, causing the eyelid tobecome further separated from the cornea, most notably at the limbus of theeye. This further interrupts the normal tear film dynamics of the ocularsurface. The cornea, to maintain its transparency, has a dehydrating mechanismthat acts based on tear flow over the limbal area. If the cornea is deniednormal tear flow in this area due to separation of the lid from the globe, andpossibly due to capillary attraction along the swollen conjunctival interface,the dehydrating mechanism will overcompensate and cause thinning of the corneaand loss of surface epithelium. This process is known as dellen formation. Dellenformation further stimulates a local inflammatory response that, in turn, feedsback into the process and worsens the chemosis. It is important to break thisfeedback cycle using lubrication or patching to achieve resolution of chemosis(Figures 3-5).

在眼瞼成形術的創傷性炎症導致出現結膜水腫後，眼瞼-角膜界面的解剖性變形可能進而形成機械性循環，延長病程。腫脹的結膜變得更加乾燥、炎症更重，因而眼瞼與角膜進一步分離，最明顯的位置是角膜緣。這進一步破壞了眼表的正常淚膜動力學。角膜為了維持透明度有一個脫水機制，作用基礎是淚液流過角膜緣區域。如果角膜緣區沒有正常淚液流動（原因是瞼球分離，另有原因可能是結膜界面的毛細管吸引作用），脫水機制將會過度代償，引起角膜變薄、上皮細胞丟失。該過程被稱為角膜小凹（dellen）形成。小凹的形成進一步刺激局部炎症反應，進而反饋至病變過程中，加重結膜水腫。重要的是打破這個反饋循環，方法是使用潤滑藥物或戴眼罩，使結膜水腫緩解（圖3-5）。【譯者註：角膜脫水、保持透明是角膜內皮的作用。】

 

圖3. 角膜小凹形成的解剖元素。結膜水腫引起相鄰角膜緣的角膜局灶性乾燥，涉及多種因素，包括滲透壓使該區缺乏淚膜【譯者註：水腫結膜滲透壓增高，從相鄰角膜表面吸水，使得該部位乾燥】。

 

圖4. 患者女性，40歲，裂隙燈圖像顯示與結膜水腫處相鄰的角膜小凹形成。窄裂隙光顯示角膜表面局灶性不規則。

圖5. 結膜水腫和形成角膜小凹的正「反饋」循環的事件序列。Conjunctival inflammation，結膜炎症；ConjunctivalSwelling/Chemosis，結膜水腫；Poor Lid/Corneal Apposition 眼瞼/角膜相對位置不良；CornealDrying/Dellen Formation，角膜乾燥/小凹形成；More Dellen，更多角膜小凹。

 

TREATMENT

治療

A comprehensive algorithm for chemosis management is presented inFigure 6. 結膜水腫的綜合性治療措施見圖6。

圖6. 處理結膜水腫的綜合方案。

 

Preoperative

術前

Recognition and correction of preexisting ocular surface disorders,conjunctivochalasis, poor eyelid closure mechanics, and lower lid laxity mustbe taken into consideration as part of the surgical plan to avoid or minimizepostoperative chemosis. Prophylactic treatment with anti-inflammatories such astopical steroid eye drops, systemic steroids, or COX-2 inflammatory inhibitors(Celebrex; Pfizer, New York, New York) may reduce inflammation and possiblyreduce or avoid chemosis in the postoperative patient.

為了避免或減少術後結膜水腫可能，必須將發現並治療已經存在的眼表疾病、結膜鬆弛、眼瞼閉合功能障礙和下瞼鬆弛當做手術計劃的一部分。預防性抗炎治療如局部類固醇滴眼液、全身使用類固醇或COX-2炎症抑制劑（Celebrex; Pfizer, New York, New York）【譯者註：COX-2推測是環氧合酶-2】可減輕炎症，可能減少或避免術後結膜水腫。

Intraoperative

術中

Sometimes, chemosis can be observed forming intraoperatively,particularly in patients with preexisting conjunctivochalasis, and should beaddressed at that time. Intraoperative intermarginal suture placement may beuseful in some cases of mild swelling; a tarsorrhaphy suture may suffice(Figure 7). In other, more severe cases, simple surgical procedures to halt thechemosis may be performed intraoperatively. Plication of redundant conjunctivacan be performed with 6-0 plain sutures, placed in the fornix to add tension tothe loose conjunctiva (Figure 8), thereby preventing conjunctival ballooning. A1-snip procedure can release accumulating fluid in the conjunctival balloon(Figures 9 and 10). The snip should be made through the bulbar conjunctiva andpenetrate the underlying Tenon’s capsule (fascia bulbi), which is mildlyadherent to the undersurface of the conjunctiva, to allow release of fluidbuildup. More extensive opening of the conjunctiva to relieve chemosis has beenreported, but in the authors』 experience, a 1-snip procedure adequately allowsthe needed release of fluid. A video of the authors』 intraoperative single-sniptreatment technique is available at www.aestheticsurgeryjournal.com. You mayalso use any smartphone to scan the code on the first page of this article tobe taken directly to this video on www.YouTube.com.

有時術中可見到結膜水腫形成，尤其是那些術前存在結膜鬆弛的患者，術者應在當時予以處理。對一些輕度水腫，術中進行瞼緣縫合可能有用；臨時式瞼緣縫合可能足以解決問題（圖7）。【譯者註：根據圖7實際內容增加了「臨時式」。】對程度較重的病例，術中可採取簡單手術阻止結膜水腫。使用6-0線對多餘結膜進行摺疊，置於穹窿，增加對疏鬆結膜的張力（圖8），防止結膜球形隆起。一剪法可釋放結膜球形隆起中積聚的液體（圖9和圖10）。剪開球結膜，穿過相應的Tenon’s囊（球筋膜囊），後者貼附於結膜下表面；剪開這些組織使得液體釋放。據報導更廣泛的切開/剪開球結膜能夠緩解結膜水腫，但根據作者經驗，一剪法足以釋放所需液體。作者的一剪法視頻可以從www.aestheticsurgeryjournal.com獲取【譯者曾嘗試但未成功獲取視頻】。您也可以用智慧型手機掃描本文首頁的二維碼，直接在www.YouTube.com觀看視頻。【此處放置首頁的二維碼】

圖7. 術中瞼緣縫合，防止術後結膜水腫。通常使用6-0尼龍線。縫線穿入和穿出眼瞼是半厚【不是穿透眼瞼全層的縫合】，避免與眼表接觸。【譯者註：瞼緣穿出、穿入的位置是灰線，這是臨時式瞼緣縫合，與永久式瞼緣縫合不同。】

 

圖8. 術中將近下穹窿位置的球結膜摺疊，防止術後結膜水腫。使用快速吸收縫線，縫線位置遠離角膜。

圖9. 一剪法結膜切開術，釋放結膜水腫的液體。（A）相應Tenon’s囊也被剪開，允許液體流出。（B）顯示結膜、Tenon’s囊和水腫液體之間的關係。為了最大量釋放液體，需要打開Tenon’s囊。

圖10. （A）女性，63歲，下瞼成形術後結膜水腫10天。（B）同一患者，一剪法結膜切開術後即刻的照片，在醫生辦公室操作即可，結膜隆起幾乎完全消失。

Instillation of anti-inflammatory and vasoconstrictive eye drops,phenylephrine 2.5%, and topical cortisone drops (1% Pred Forte; Allergan,Irvine, California) is also beneficial in reducing inflammatory response in theconjunctiva (Figure 11). Treatment with these can be combined with the otherintraoperative maneuvers described in this section.

使用抗炎和收縮血管滴眼液，如2.5%苯腎上腺素和局部可的松滴眼液（1% Pred Forte; Allergan, Irvine, California）也有助於減輕結膜炎性反應（圖11）。這些治療可聯合應用本文描述的其他術中措施。

圖11. 2.5%苯腎上腺素和1%地塞米松的眼用製劑。

 

Postoperative

術後

Early Chemosis (FirstWeek)

早期結膜水腫（術後第1周）

Mild chemosis. Mild chemosis, which is seen in the early postoperative period,may be treated successfully with 2 drops of 2.5% ophthalmic phenylephrine anddexamethasone eye drops and standard ocular lubricants. These are only to beadministered in the physician’s office. They have a very beneficial effect onchemosis, purportedly because they restabilize the conjunctival vasculature andreduce inflammation (e-mail communication with Dr. Zane Pollard, pediatricophthalmologist). In some mild cases, chemosis can resolve by the next officevisit. Patients are also instructed to use lubricants at home. In addition,initiating a temporary low-carbohydrate diet that restricts carbohydrates toless than 20% of caloric intake can often facilitate reduction of swelling.

輕度結膜水腫。輕度結膜水腫見於術後早期，治療可使用2滴2.5%苯腎上腺素滴眼液、地塞米松滴眼液和標準眼部潤滑眼藥，一般能夠治癒。只能在醫生辦公室用藥。對結膜水腫有很好的效果，原理是能夠穩定結膜血管和減輕炎症（與兒童眼科醫生Dr. Zane Pollard進行了電子郵件交流）。一些輕度病例下次複診時結膜水腫已經消失。也要指導患者在家使用潤滑眼藥。此外，開始進行暫時性低碳水化合物的飲食（將碳水化合物限制在熱量攝入的20%以下）常可有利於減輕水腫。

Moderate chemosis.  When chemosis is moresevere, occlusion of the eyelids with firm patching for 24 hours shouldsupplement the office administration of phenylephrine and dexamethasone dropsand use of lubricants, ointment, and eye drops in mild cases. Depending on theseverity of chemosis, the patch can be left in place for 1 to 2 days, at whichtime the eye can be rechecked. It is imperative that eye patching be performedproperly (Figure 12) so that it accomplishes complete closure of the eyelidswith corneal coverage and creates firm pressure on the eye, both of which willreduce the chemosis. If they experience severe pain, patients are instructed toremove the patch early and begin topical antibiotic drops for treatment ofpresumptive corneal abrasion due to incomplete closure under the patch.Additional systemic anti-inflammatories (Medrol dose pack; Pfizer) may becombined with pressure eye patching.

中度結膜水腫。如前所述，輕度病例在醫生辦公室使用苯腎上腺素和地塞米松滴眼液、潤滑眼藥、眼膏和滴眼液，若病情較重，需要增加措施，使用結實的眼罩遮蓋眼瞼24小時。眼罩戴1-2天，取決於結膜水腫的嚴重程度，在此期間複查。需要強調眼罩配戴合適（圖12），這樣才能完全閉合眼瞼，起到遮蓋角膜、對眼部施加壓力的作用，這兩點都能減輕結膜水腫。如果患者疼痛明顯，可早期去掉眼罩，使用抗菌眼藥治療可能存在的角膜摩擦（戴眼罩的情況下眼瞼未能閉合完全）。另外在使用眼罩提供壓力的同時，可以全身使用抗炎藥物（美卓樂; Pfizer）。【譯者註：Medrol dose pac，美卓樂，甲潑尼龍片劑】

圖12. 患者女性，28歲，圖示作者用於治療結膜水腫的眼罩方法。三層圓形眼墊，加上一英寸紙膠帶多層固定。（A）第一個眼墊摺疊，用鹽水溼潤，置於閉合的眼瞼表面。（B）第二個眼墊置於第一個眼墊上，用紙膠帶固定。（C）多條膠帶固定於額部和頰部，進一步壓迫眼墊。

Severe chemosis. In cases of impaired eyelid closure or failure of eye pressurepatching, conjunctivotomy with release of fluid should be administered. Thiscan be performed easily with only topical anesthetic (tetracaine) and 2.5%phenylephrine for vasoconstriction. Afterward, pressure patching of theaffected eye should be applied for at least 2 days and systemicanti-inflammatories should be used. Following this regimen, additionaltreatment can be employed depending on how well the patient responds.

重度結膜水腫。對那些眼瞼閉合功能受損或壓力性眼罩失敗的患者，進行結膜切開、釋放液體。操作容易，局麻下（丁卡因）即可進行，2.5%苯腎上腺素用於收縮血管。然後患眼使用壓力性眼罩至少2天，全身使用抗炎藥物。此後，根據治療效果可選用其他治療措施。

Later Chemosis (2-3 Weeks)

晚期結膜水腫（術後2-3周）

On occasion, despite the use of steroid drops and lubricants,recurring chemosis may persist. If chemosis is allowed to become more chronicand inflammation has subsided, additional changes in the cornea may prolong thecondition. As described above, the cornea may become dehydrated adjacent to thechemotic conjunctiva. Loss of corneal epithelial integrity causes furtherirritation and inflammation in the conjunctiva, thereby perpetuating chemosis.This 「feedback」 cycle must be broken with firm patching of the affected eye. Atthis point, the conjunctiva may appear to have little inflammation, appear morewhite in color, and take the appearance of a noninflamed blister.Anti-inflammatories will no longer be effective at this stage. The mostefficient course of resolution is to release fluid within the chemotic blisterwith a 1-snip conjunctival opening, as described above. It is advisable toapply a mild-pressure eyelid bandage afterward to compress the conjunctiva.

有時儘管使用了類固醇滴眼液和潤滑眼藥，結膜水腫仍可能復發並持續。如果結膜水腫成為慢性病變並且炎症已消退，角膜其他改變可能會延長結膜水腫時間。如前所述，在結膜水腫的相鄰位置角膜脫水。角膜上皮完整性喪失，導致結膜進一步受刺激和發生炎症，因而使結膜水腫持續存在。必須要打破這個「反饋」循環，對患眼使用結實的眼罩。此時的結膜可能表現為炎症很輕微，顏色更白，出現無炎症性水泡。在這個階段抗炎不再有效。最有效的措施是如前所述的一剪法剪開結膜、釋放水泡內的液體。然後建議使用繃帶輕壓眼瞼，從而壓迫結膜。

Prolonged Chemosis (1 orMore Months)

持續性結膜水腫（1個月或更長時間）

Uncommonly, chemosis persists even after all of the above measureshave been taken. One author (C.D.M.) has consulted on cases of chemosis thathave persisted for several months to a year despite all conventional efforts atresolution. In these cases, it is common to see dysfunction in eyelid closuremechanics as the underlying etiology. In some cases, there may be no lower lidmalposition or stiffness in the upper lid, but only a 「fish-mouthing」 type ofpoor lid closure due to canthal laxity. A video demonstrating this phenomenonis available at www.aestheticsurgeryjournal.com. You may also use anysmartphone to scan the code on the first page of this article to be takendirectly to this video on www.YouTube.com. With these prolonged cases, it isimportant to diagnose and correct any lagophthalmos, closure problems, or lowerlid laxity that may exist. In every case seen by the authors thus far,correction of dysfunctional eyelid problems has allowed remission oflongstanding chemosis (Figure 13).

有一種少見的情況，即使採取了以上所有措施，結膜水腫仍持續存在。本文的一位作者（C.D.M.）會診了一位患者，結膜水腫已持續數月至1年，已經採取了所有傳統措施。在這些病例，一般眼瞼閉合功能異常是潛在病因。一些病例可能沒有下瞼位置異常或上瞼僵硬，但因眥鬆弛而僅有「魚嘴」樣眼瞼閉合不良。www.aestheticsurgeryjournal.com有一個視頻展示這一現象。您也可以用智慧型手機掃描本文首頁的二維碼，直接在www.YouTube.com觀看視頻。在持續性結膜水腫病例，重要的是診斷和矯正可能存在的兔眼、眼瞼閉合問題或下瞼鬆弛。迄今作者遇到的每個病例，通過矯正眼瞼功能異常都已經緩解了長期結膜水腫（圖13）。

 

圖13. （A、C）患者女性，43歲，眼瞼成形術後慢性結膜水腫持續1年。眼瞼閉合差，外眥呈「魚嘴」樣移動。作者（C.D.M）遇到的另一位患者的視頻可通過www.aestheticsurgeryjournal.com獲取。您也可以用智慧型手機掃描本文首頁的二維碼，直接在www.YouTube.com觀看視頻。（B、D）對該患者施行了鑽孔眥錨定術，調整眼瞼位置，術後4周如圖所示。解除了結膜水腫，恢復了正常眼瞼閉合。

 

CONCLUSIONS

結論

Postblepharoplasty chemosis can generally be considered apostoperative (or intraoperative) inflammatory response in the conjunctiva thatmay or may not persist regardless of our proposed algorithm for management.Intraoperative detection and utilization of intermarginal sutures or forniceal1-snip procedures can help prevent severe postoperative chemosis. Initialpostoperative management is aimed at controlling the inflammatory component ofthe pathophysiology. However, as the chemosis becomes more chronic, it isimportant to diagnose and treat any associated mechanical problems, includingconjunctivochalasis, fixed and noninflamed blistering, and eyelid mechanical abnormalities.

眼瞼成形術結膜水腫一般被認為是術後（或術中）的結膜炎性反應，無論我們採取各種治療措施，結膜水腫有可能持續或不持續。術中發現並進行瞼緣縫合或一剪法穹窿結膜切開術能夠有助於防止術後嚴重的結膜水腫發生。術後早期處理的目的是控制炎症（病理生理機制）。但是如果結膜水腫變成慢性病變，那麼重點是診斷和治療任何相關的機械性問題，包括結膜鬆弛、固定的和非炎性的結膜水泡以及眼瞼機械性異常。

（正文結束）