Clinical effect of a mixed solution of sodium hyaluronate and sodium carboxymethylcellulose during the transconjunctival approach for orbital wall reconstruction.

Original Article-Surgery www.cmj.ac.kr Clinical Effect of a Mixed Solution of Sodium Hyaluronate and Sodium Carboxymethylcellulose During the Transconjunctival Approach for Orbital Wall Reconstruction Byung Wan Kang, Hyo Seok Lee, Han Jin Oh and Kyung Chul Yoon* Department of Ophthalmology, Research Institute of Medical Sciences, Chonnam National University Medical School and Hospital, Gwangju, Korea This study aimed to evaluate the anti-adhesive effect of a mixed solution of sodium hyaⓇ luronate and sodium carboxymethylcellulose (HACMC, Guardix-sol ) during the transconjunctival approach to orbital wall reconstruction. Eighty-seven patients who underwent orbital wall reconstruction by the transconjunctival approach were enrolled in this prospective study. We applied HACMC between the orbicularis oculi muscle and the orbital septum after surgery in 47 patients and did not use it in 40 patients. Lower lid retraction and marginal reflex distance 2 (MRD2) were measured to analyze the degree of postoperative adhesion at 1 week and 1, 3, and 6 months. The degree of MRD2 showed clinically significant differences at postoperative 1 week and 1 month between the HACMC and control groups (p＜0.05). Lower lid ectropion developed in two patients (5.0%) in the control group but did not occur in the HACMC group. In orbital wall reconstruction by the transconjunctival approach, the HACMC mixture solution is effective for preventing adhesion and lower lid ectropion during the early postoperative period. Key Words: Eyelid retraction; Eyelids; Orbital fractures This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Corresponding Author: Kyung Chul Yoon Department of Ophthalmology, Medical School & Research Institute of Medical Sciences, Chonnam National University, 8 Hak-dong, Dong-gu, Gwangju 501-757, Korea TEL: +82-62-220-6741 FAX: +82-62-227-1642 E-mail: to prevent adhesion and are absorbed by the surrounding tissue after the wound healing process. In addition, such agents do not require an additional removal process after application because the absorption of the adhesive material into the body is harmless. In ophthalmologic surgery, anti-adhesives have been used in strabismus surgery to prevent adhesion between the extraocular muscles and sclera as well as in dacryocystorhinostomy to prevent adhesion at the rhinostomy site.6-9 In addition, a mixture of sodium hyaluronate (HA) and carboxymethylcellulose (CMC), also known as SeprafilmⓇ (Genzyme Corp., Cambridge, MA, USA), has been used in orbital wall reconstruction.10 In the present study, we evaluated the clinical anti-adhesive effects of HACMC, a mixture of HA and CMC, by applying it between the orbicularis oculi muscle and orbital septum during a transconjunctival surgical procedure for orbital wall fracture. INTRODUCTION Orbital wall reconstruction by the transconjunctival approach involves reduction of the protruded tissue from the fracture site and insertion of a prosthesis to recover both the functional and anatomical roles of the orbital wall.1 Diplopia, enophthalmos, ocular deviation, lower lid retraction, infra-orbital nerve damage, occlusion of the lacrimal passage, dacryocystitis, pupil dilation, and lymph edema are well-known complications that can occur after orbital wall reconstruction. Among these, lower lid retraction can result in severe problems associated with cosmesis and tear film function and is known to be caused by contracture between the orbicularis oculi muscle and orbital septum.2 Recently, many studies have been performed on the use of various anti-adhesive agents after orbital wall reconstruction by the transconjunctival approach.3-5 Anti-adhesive agents form a physical barrier around the surgical area http://dx.doi.org/10.4068/cmj.2012.48.2.123 Ⓒ Chonnam Medical Journal, 2012 Article History: received 13 July, 2012 revised 24 July, 2012 accepted 24 July, 2012 123 Chonnam Med J 2012;48:123-127 Anti-adhesive Effect of HACMC MATERIALS AND METHODS A prospective study was performed on 87 eyes of 87 patients who visited our hospital, underwent orbital wall reconstruction by the transconjunctival approach, and were followed up for at least 6 months from July 2009 to August 2010. No patients had a history of surgery, damages, or abnormality of the lower lid. Anti-adhesive solution was applied between the orbicularis oculi muscle and orbital septum in 47 eyes of 47 patients (the HACMC group), whereas no anti-adhesive solution was administered to the other 40 eyes of 40 patients (the control group) during the operation. The anti-adhesive solution, Guardix-solⓇ (Hanmi Pharm Co., Seoul, Korea), is a colorless clear liquid that uses a 1:1 mixture ratio of HA and CMC. External ocular muscle movement, forced duction, diplopia, and Hertel exophthalmometer test were evaluated along with routine ophthalmologic examinations. In addition, computed tomography scanning was performed to determine the size and location of the orbital wall fracture and the involvement of orbital soft tissues. Surgery was performed through the transconjunctival approach under general anesthesia by a single surgeon (K.C.Y.). The lower lid was retracted downward and an incision was made on the conjunctiva along the border of the tarsal plate by unipolar electrocautery. The orbicularis oculi muscle was removed from the orbital septum, and a DesMarres retractor was used to retract the lower lid and orbicularis muscle downward. A malleable retractor was inserted behind the orbital septum to expose the periosteum of the inferior orbital border. A #15 Bard-Parker knife was used to make an incision on the periosteum, and a rugine was used to expose the fracture site. Then, the malleable retractor, suction tip, and rugine were used to repair the muscles and soft tissues. The damage site was measured, and MedporⓇ (Stryker, Newnan, GA, USA) was inserted on the fracture site after applying anti-bacterial solution. The periosteum was sutured with 5-0 Vicryl sutures, and Guardix-solⓇ was applied between the orbicu- laris oculi muscle and the orbital septum. Finally, the conjunctiva was sutured with 6-0 Vicryl sutures. To prevent lower lid retraction, a traction suture was applied to the lower lid to pull it upward. The suture was removed 3 days after the surgery, and dexamethasone was injected intravenously after the surgery to reduce edema, which was tapered over 3 days. Ofloxacin (Ocuflox, Samil, Seoul, Korea) and 0.1% fluorometholone (Ocumetholone, Samil, Seoul, Korea) eyedrops were applied three times a day. Follow-up examination was performed at 1 week and 1, 3, and 6 months after surgery. Ocular movement was classified into five grades as follows: grade 0, no ocular movement impairment; grade (...truncated)