Summary of doctor of medicine thesis researching the effectiveness of lengthening levator muscle surgery to treat moderate and severe eyelid retraction

1 INTRODUCTION Upper eyelid retraction (UER) is defined as an elevation beyond the normal position of the upper eyelid margin in the primary position (normally, in a straight forward position, the eyelid margin covers the upper edge of the cornea, mm from the 12-hour-angle edge of the cornea) UER can be caused by abnormalities in the morphology and function of the eyelids, leading to changes in the surface of the ocular surface to varying degrees, possibly even threatening the visual function In 2002, Lai CS et al reported a clinical case on a new technique for treating UER by using an orbital septum flap as a spacer to lengthen the levator muscle In 2013, author Watanabe A et al conducted a multi-center study applying the technique of Lai CS on 12 patients experiencing upper eyelid retraction The results showed that 70% of patients achieved good results In Vietnam, there has not been any research mentioning the surgery method to lengthen levator muscle using orbital septum flap Previous author's reports did not mention the factors related to the long-term outcome and effectiveness 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 Evaluate the results of lengthenning upper levator muscle surgery to treat moderate and severe eyelid retraction 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 lengthen the levator muscle to treat cases of moderate and severe UER in a study with a large-enough number of patients The follow-up time is long enough to comprehensively 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), chapters: Chapter 1: Overview (27 pages), Chapter 2: Subjects and research methods (15 pages), Chapter 3: Research results (40 pages), Chapter 4: Discussion (47 pages), Conclusion (2 page), novel contribution (1 page), Proposal (1 page) There are also: references, appendices, tables, charts, illustrations of the results 2 CHAPTER 1: OVERVIEW 1.1 Anatomy of eyelid physiology Eyelid is a complex structure that plays an important role in maintaining visual function Eyelids are limited to orbital organizations in the orbital septum 1.1.1 Appearance of eyelids In young people, the height of the skin crease is from 10-11 mm vertically, but over time, the upper eyelid tends to droop, so the height of the eyelid cleft is only 8-10 mm In the primary position, the marginal of the upper eyelid is usually located at the edge of the cornea for children, and less than 1.5-2 mm below the edge of the cornea in adults 1.1.2 Eyelid anatomy * Orbicularis ocular muscle The eyelid part of the orbicularis ocular muscle contributes to the skin crease of the eyelids what dominates by nerves VII * Orbital septum From the eyelid septum membrane, the orbital septum moves towards the front, through the orbicularis ocular muscle of the anterior fat pad of the muscle This position is usually - mm from the margin of the tarsal * Fat pads Upper eyelids usually have two fat pads: Medial fat pads and Temporal fat pads, also called sub-fascial fat pad * Levator muscle The levator muscle is about 36 mm long and span almost the width of the tarsal The upper layer continues into the levator muscle, but the lower layer enters the Muller's muscle * Muller's muscle The smooth muscles governed by the sympathetic nervous system exist in both the upper and lower eyelids Muller's muscles are to 12 mm long, 0.5 – 1.0 mm thick * Eyelid tarsal The upper eyelid tarsal is about 25 mm long, – 12 mm high and has a slight curl that fits into the surface of the eyeball * Conjunctival The conjunctival is the transparent mucosa at the back of the eyelid Conjunctival is connected to the skin behind gray line * Vascular and nerve - Artery: eyelid artery system is separated from two main sources: eyelid artery and facial artery - Vein: there are two veins in the eyelids: shallow vein network and deep vein network - 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 the normal position of the upper eyelid margin in the primary visual position (normally, in a straight forward position, the eyelid margin covers the upper edge of the cornea, 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 different pathogenetic mechanisms and in many cases the exact cause cannot be identified Barley divides the causes of UER into groups: 1.2.2.1 Muscular causes The Muller's muscle inflammation and fibrosis process ranges from a sparse to a dense level that causes changes from muscle atrophy, fat infiltration or fibrosis to increase muscle size Similarly, the levator muscle also has changes including striated muscle atrophy, fat infiltration, collagen proliferation and mast cell infiltration 1.2.2.2 Neurological causes Common in congenital UER or common in the posterior brainstem syndrome, neuropathic regeneration III, myasthenia gravis that causes UER in the opposite side (Herring Law), orbicularis ocular muscle weakness due to paralysis VII 1.2.2.3 Mechanical causes Injury caused after a chemical burn, or by surgery in the eye area that causes changes in the location of the eyelid margin 1.2.3 Symptoms Eyelid retraction is one of the common pathologies of eyelids The illness can occur on one or both sides, symmetrical or asymmetrical between the eyes The symptoms of UER can manifest in a variety of ways, including: 1.2.3.1 Functional symptoms - Functional symptoms may include irritation, redness, watery eyes, blurred vision, photophobia, feeling like something stuck in the eyes, aches, etc - Eyelid retraction may cause double vision and mobility pain 1.2.3.2 Physical signs - Withdrawal of upper eyelid, palpebral fissure height wider than normal The upper sclera is visible when looking straight (Dalrymple sign) - Signs of lig lag: is defined as the condition when the eyes look downward, the upper eyelid is at a higher position than normal 4 - Von Graefe sign: This is an abnormally related change in the eyelid movement - Lagophthalmos: is a condition where the eyes are not closed properly when the patient closes the eyes or when sleeping - Incomplete blinking (Stellwag sign) - Regular or irregular eyelid retraction: Eyelid retraction occurs in the center 1/3 or in the lateral 1/3 - Over-reaction of the levator muscle - superior rectus due to reaction with inferior rectus - Proptosis due to increased orbital septum volume, the eyeball is pushed forward, 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 of TSH (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 > mm + PFH > 10 mm + Lid lag > -1 mm + Upper sclera show on varying degrees + May lose the physiological contour of the eyelids margin (C 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 the corneal reflex to the eyelid margin in the primary position (MRD1 index) - Mild UER: MRD1< mm - Moderate UER: MRD1 = – mm - Severe UER: MRD1 > mm 5 1.2.5 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 for UER patients with very positive results * Steroid injection method Steroid injections around the eyeball or under the conjunctiva may be considered 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 has limitations 1.2.5.2 Surgical treatments * The method of cutting or reversing the levator muscle with Muller's muscle cutting For severe eyelid retraction this surgery is not enough to adjust the position of the upper eyelid to normal level * Methods of using spacers The spacers is relatively hard, and there is no feeding circuit, so the results are quite limited in improving the aesthetics and there are risks of removal or rejection of the spacer * Methods of using flaps Rotating the flap with different lengths, depending on the degree of extending 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 orbital septum 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 used orbital 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 Basedow eyelid retraction have been stabilized for at least months 6 1.3.4 Results According to Watanabe A., more than 90 % of patients happy with the surgery results The successful rate of surgery is 90% 1.3.5 Complications Excessive correction, premature correction, recurrence, granulomas, other complications 1.3.6 Surgery-related factors Factors that may affect treatment results include: age, gender, causes of eyelid retraction, history of treatment of eyes, history of systemic disease, duration of illness, duration of eyelid retraction, degree and position of eyelid retraction, amplitude of levator muscle movement, sclera show, proptosis, lid lag In Vietnam, there are many authors who perform surgery to extend the upper levator muscle with many different materials at major ophthalmic centers such as Hospital 108, Hospital 103, National Hospital of Ophthalmology, Ho Chi Minh Hospital of Ophthalmology The materials used in this surgery are relatively diverse, including lip mucosa membrain, ear cartilage, palate cartilage However, there have been no studies using the flap of the orbital septum to extend the upper levator muscle CHAPTER SUBJECTS AND METHODS OF THE STUDY 2.1 Researched subject group The subjects of the study were patients with moderate and severe Eyelid retraction who were examined, diagnosed and treated at Vietnam National Eye Hospital from October 2016 to October 2019 2.1.1 Selection criteria Patients diagnosed with moderate to severe UER in one or both eyes due to various causes according to Elner's criteria: Moderate condition: MRD1 = – mm, severe condition: MRD1 > mm Stable Eyelid retraction for at least months There is a minimum of 12-month postoperative follow-up 2.1.2 Exclusion criteria Patients with a history of surgery in the previous eyelid area or UER due to trauma Patients under 16 years old Severe proptosis (degree > 22 mm) There is a progressive systemic pathology There is an infection in the eyelid / eyeball that cannot be operated The patient did not agree to perform the surgery, did not agree to participate in the study 2.2 Method of research 2.2.1 Research design Non-controlled clinical trial study 2.2.2 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 after another * 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, Volk ophthalmoscopes, cameras, medical records * Surgical equipment: Eyelid surgery kits, bipole electric burners, surgical microscopes, shock-proof kits 2.2.5 Research process 2.2.5.1 Medical inquiry - Acquiring general information: Name, age, gender, address, phone number, occupation - Acquiring functional symptoms information: blurred vision, aches and pains, red eyes, watery eyes, dizziness, double vision Asking about medical history (trauma, Basedow, congenital, idiopathic ), history of treatment, stable duration of disease Preoperative photography 2.2.5.2 Physical examination - Measure eyesight and vision correction using Snellen vision board (classified by the World Health Organization) - Visual acuity classification (20/20 - 20/70, 20 / 80–20 / 200, 20/400 – CF m) - Assessing the condition of the eyeball: conjunctiva, cornea, eye fundus, mobility - Assess eyelid condition and compare sides based on the following indicators: + 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 the midpoint 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 looks downwards + 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 the eyelid 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 a straight 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 straight looking positions + Proptosis assessment: The Hertel ruler is placed parallel to the plane across the 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 when maximally looking down and maximally looking up as the forehead muscle has been blocked at the reflection in the pupil at 12 o'clock when the eye is fully 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, thyroid ultrasound - General tests prepared for surgery 9 2.2.5.4 Surgery * Surgical steps The steps are as follows: - Posture of the patient: Lying on the back, disinfected, lying on surgical towels which allows to sit up, local anesthesia with Dicain solution - Mark the skin incision on the expected skin crease or under the crease of the opposite eye For cases where the eyes not have creases, the height of the crease is expected based on the standard Asian creases (5-7 mm) If the patient has retraction in both eyes and needs surgery for both eyes, the incision of the skin crease can be used according to the old skin creases - Local anesthetic under the eyelids with a 2% Lidocaine solution mixed with 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 from the orbicularis ocular muscle and the tarsal Continue to separate the levator muscle from the conjunctiva and remove the Muller's muscle - From the position of the skin incision, surgery up to mm to reach the orbital septum From here, we need to dissect the orbital septum and turn over the flap by 180 degree so that the edge the flap goes down and connected to the levator muscle The width of the orbital septum flap is fixed based on the length of the upper eyelid tarsal with a size of about 20 mm However, the height of the flap of the orbital septum can be adjusted according to the degree of eyelid retraction - Exposure the lateral horn of the levator muscle and cutting off the lateral horn - Suture fix the edge of the orbital septum flap to the edge of tarsal with Vicryl 6.0 stitches - Sit the patient up, evaluate the height and curvature of the upper eyelid Adjust until eyelids are mm lower than normal - 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 the stitches after days, maintain fixed stitches pulling down the cheek for week with adhesive tape * Follow-up - Visit again after week, month, months, months and 12 months 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 months if indicated 2.2.6 Research variables and indicators The research results were collected through research records and evaluated and categorized according to Mourits and Sasim's research Results are evaluated at month, months, months and 12 months before and after surgery Research variables and indicators are categorized as follows: Table 2.1: Methods to evaluate variables and research indicators Methods Variable and tools for Variable name type data collection MRD1 Quantitative Millimeter Ruler Goal Research Quantitative PFH medical C Quantitative records SC Quantitative Quantitative SC Satisfaction Qualitative Age Quantitative Medical Inquiry Gender Qualitative Illness duration Quantitative Research Duration of disease stability Quantitative medical records History of eye treatment Qualitative Subclinical History of systemic disease Qualitative Goal examination Cause Qualitative Medical examination Position of UER Qualitative Sterile Damage to the ocular surface Qualitative Compass Lagophthalmos condition Quantitative Scleral show Quantitative Lid lag Quantitative LF Quantitative Proptosis difference Quantitative Size of orbital septum flap Quantitative 11 2.2.7 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 crease height difference and the patient satisfaction level are the criteria that affect the overall outcome of surgery, In which MRD1 and eyelid contour C are the other main criteria, the remainders are sub-criteria [95] The criteria related to the general outcome of surgery are categorized and evaluated according to the following score level: Table 2.2: Evaluate research criteria Critera points points points 2,5–4,5 > 4,5–5,5 mm or 1,5– >5,5 mm or MRD1 mm 2,0 mm mm  PFH < mm Curvature (C) < mm  mm < mm or > Skin crease – mm – 10 mm 10mm < mm - mm > mm  Skin crease Table 2.3: Assess the level of patient satisfaction Criteria points points points Satisfaction level Very satisfied Satisfied Not satisfied Evaluate general results according to the above criteria with levels: Good, medium and poor based on the results of the overall scores of each research indicator according to Mourit and Sasim's classification as follows: Table 2.4: Evaluate the results according to the levels Class: Good Average Poor Total 15 12-14 < 12 and at least main indicator score is poor Evaluation after surgery, results are good and average is considered successful, poor results are considered failure 2.3 Data processing and analysis Data collected from research records will be processed using medical statistical methods using SPSS 16.0 software 12 CHAPTER RESEARCH RESULTS Our study was conducted on 43 patients with 46 moderate-to-severe UER eyes who were examined and treated with extending levator muscle surgery Orbital septum flap at Vietnam National Eye Hospital since October 2016 to October 2019 Through data analysis we have obtained the 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, accounting for 86.04% 3.1.2 Eye characteristics 7/46 eyes studied were caused by thyroid related to orbitopathy (15.22%), congenital UER eyes (15.22%), 69.56% temporarily idiopathic 11 patients with a history of pathology (diabetes, hypertension ) accounted for 25.58% 74.42% of study patients had no previous medical history 13.04% of eyes had a history of previous eye surgery Visual acuity of the group under 20/70 accounts for the highest proportion with 86.96% The subjective symptoms for patients who visit and receive treatment include blurred vision (6.50%), red eyes (4.30%), teary eyes (8.70%) and limited mobility (10.90%) 69.57% of patients come for aesthetics treatment 28.30%, eyes had slight damage to the surface of the eyeball (superficial keratitis, fibrous keratitis, dry eye) The average duration of illness was 68 months The median duration of stable treatment was 61 months The study was conducted on 10 severe UER eye (21.74%) and 36 medium 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 mm and 12,65  1,41 mm, respectively The group of severe UER had the largest sclera show of 2.30 ± 0.95 mm, which is higher than the level of moderate 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 The average lid lag of the groups was 2.26 ± 1.07 The levator function and skin crease are and 5.38 ± 0.89 mm 14,24  2,12 mm, respectively 13 The average proptosis for the severe UER group was 15.00 ± 1.33 mm The average lagophthalmos degree of the study group was 0.15 ± 0.42 mm 3.2 Surgical results 3.2.1 During surgery The average surgery time is 37.5 ± 5.48 minutes The shortest surgery time is 28 minutes, the longest is 45 minutes The average height of the orbital septum flap used in surgery is 5.28 ± 0.77 mm The height of the orbital septum and MRD1 are linearly related by the equation: The height of the flap = 0.02 x MRD1 + 5.24 (p > 0.05) The average follow-up time after surgery is 22.06 ± 12.03 months The longest follow-up patients were up to 37 months; the shortest follow-up patients were 12 months (p > 0.05) 3.2.2 After surgery Visual acuity of the group under 20/70 accounts for the highest proportion with 86.96% There was no difference in visual acuity of patients before and after treatment (p = 0.026) After surgery, all subjective symptoms have improved with p < 0.05 month, months, months and 12 months after surgery, 95.7% of the eyes had no damage to the ocular surface, p = 0.001 For UER in the center 1/3, after months and 12 months, there was 2.17% of the UER recurrence at this location For the UER lateral 1/3 there were 6.52% of eyes with UER 1/3 lateral recurrent at and 12 months (p < 0.05) 3.2.2.1 Physical features and functions of eyelid and eyeball * MRD1: MRD1 of UER eye decreased from 5.96 mm to 3.42 mm 12 months after surgery The MRD1 difference between the two eyes decreases from 2.62 mm to 0.03 mm after surgery (p > 0.05) * PFH: Before surgery, the average PFH was 12.65 mm After surgery the PFH index of the UER eye returned to approximately the same as the normal eye index (9.90 mm) p > 0.05 * SC: The skin crease in UER eyes before surgery is 5.38 mm, lower than in the normal eyes is 6.21 mm The skin crease increased 1-month postoperative time and then gradually decreased to the level equivalent to the skin crease of normal eye after 12 months, p> 0.05 * Sclera show degree: Before surgery the largest indext is in the group of severe eyelid retraction with 2.30 ± 0.95 mm while this value in the group of general eyelid retraction is 1.70 ± 0.72 mm,p 0.05 * Lid lag: Before surgery, the lid lag was 2.26 ± 1.07 mm and decreased after surgery as -0.73 ± 0.66 mm (p = 0.001) * LF: LF before the surgery was 14.24 ± 2.12 mm and after surgery 12 months is 14.41 ± 2.05 mm, p= 0,042 * Lagophthalmos degree: The gap of the eyelid before surgery is 0.15 ± 0.42 mm After surgery, no lagophthalmos, p< 0.05 * Ocular surface exposure and difference proptosis: The proptosis before surgery 14.35 ± 1.49 mm and after surgery 14.07 ± 1.40 mm The difference in proptosis between the eyes before and after surgery is 0.80 ± 0.92 mm with p 0.05 * Three months after surgery At the time of months after surgery, there were 44 eyes with successful surgery accounted for 95.65% The group of severe EUR having the rate of good surgical results was 80,00%, higher than the moderate group which was 75% with p > 0.05 * Six months after surgery The surgery results at the time of months showed that the success rate was 91.30% The rate of good results of moderate and severe group had little difference with values of 70.00% and 66.67% with p > 0.05, respectively 15 * Twelve months after surgery and general results After 12 months, 91.30% of eyes achieved successful results with 78.26% good results and 13.04% average level, 8.70% failed after surgery The moderate and severe group had the same good rate 3.3 Factors related to surgical results 3.3.1 Position of eyelid retraction and surgical results Successful surgical results and position of UER were statistically significant (p 0.05 3.3.5 Etiology and surgical outcome The thyroid-related cause group had a successful rate of 71,40% The successful rate of group with idiopathic is 93,80% However, the correlation is not statistically significant with p> 0.05 3.3.6 Systemic medical history and surgical results The group without a history of systemic illness had a success rate of 93.75% The group with a history of systemic illness had a success rate of 81,82%, but the correlation was not statistically significant (p> 0.05) 3.3.7 Duration of diseases and surgical outcome There is a difference in the rate of successful surgical results, but the difference is not statistically significant (p> 0.05) 3.3.8 Degree of eyelid retraction and surgical outcome The successful rate is equivalent to the the severe group which is 90.00% and the moderate group which is 91.67% (p> 0.05) 3.3.9 Ocular surface damage and surgical outcome There is a difference in the rate of successful surgery after 12 months and damage to the ocular surface damage The difference was not statistically insignificant (p > 0.05) 16 3.3.10 Sclera show and surgical results There are differences in the rates of successful surgical outcomes after 12 months and the degree of sclera show However, this difference is not statistically significant (p > 0.05) 3.3.11 Lid lag index and surgical results There is a difference in the successful rate of surgical results after 12 months and lid lag However, this difference is not statistically significant (p> 0.05) 3.3.12 Relationship between LF index and surgical results The successful rate of surgical outcomes and an LF has a looselyrestricted linear relationship (p > 0.05) 3.3.13 Lagophthalmos condition and surgical results There was a difference in the rate of successful surgical results of the group with lagophthalmos and the healthy group However, this difference is not statistically significant (p> 0.05) 3.3.14 Difference of the proptosis and the surgical outcome We have not found the closely relationship between the difference in the proptosis and the surgery result (p> 0,0,5) 3.3.15 Orbital septum flap size and surgical results There was a relationship between size of flap and surgical results after 12 months, but not statistically significant (p > 0.05) CHAPTER DISCUSSION 4.1 Characteristics of researched subjects before surgery 4.1.1 Patient characteristics Age average is 33,35  32,25, from 17 to 50 accounts for the highest rate up to 86.04% This result can be explained by that the age group of 17 - 50, is the working age and these patients have higher social need, so the aesthetic demand is also higher than other ages Women to men ratio % in the research is 1.4:1, that is suitable for author Watanabe A's (female: male = 1.5:1) It is possible to explain the above results because this study performed a group of patients with upper eyelid retraction due to many different causes so there is no difference between men and women Patients with a history of hypertension that need to be noted before taking medication for blood pressure before and during surgery Patients with a history of diabetes are not only should pay attention to the issue of using medication during the preparation of surgery but also be monitored the incision status and general condition after surgery 17 4.1.2 Characteristics of the researched eye 4.1.2.1 Cause This study found eyes with Basedow stable for at least months During time of researching, we have found over 1/3 patients have UER with TRO but have uncondition for operation or requiring depression surgery to protect vision function 4.1.2.2 Duration of disease and duration of stable disease The average duration of disease was 68 months The average duration of stable disease was 61 months Shaefer and his colleagues performed surgery on patients with Basedow disease for at least months This is considered a stable period of time to allow surgery 4.1.2.3 History of ophthalmic treatment The results showed that 13.04% of the eyes had a history of previous eye surgery (4 eyes have a history of trabeculectomy on a patient diagnosed with TRO Some hypotheses that hypertrophic scars cause pseudo-upper eyelid retraction because a hypertrophic scar prevents the eyelids from returning to normal 4.1.2.4 Visual acuity Visual acuity with corrective lenses before treatment is mainly at 20/20 - 20/70 Vision of patients studied did not change after treatment Thereby it can be found that for the study group of patients with relatively good corrected vision, upper eyelid retraction can cause vision changes but not much Surgery to treat eyelid retraction does not affect the patient's vision after surgery 4.1.2.5 Functional symptoms before and after surgery The rate of patients coming for surgery due to functional and physical symptoms is very small (3 eyes blurred, eyes red eyes, eyes watery eyes and eyes have limited eye mobility) After surgery most of the functional symptoms are improved because surgery reduces the ocular surface and corrects symptoms of lagophthalmos 4.1.2.6 Physical signs before and after surgery * Condition of the ocular surface In the study, 13 eyes had slight damage to the surface of the eyeball (dry eyes, superficial keratitis, etc.) Most of the symptoms of damage to the surface of the eyeball have recovered after surgery, suggesting this is an effective method for treating UER * Level of UER 18 The study showed that in the researched eye group, 21.74% of eyes had severe UER and 78.26% of eyes had moderate UER This result is similar to the study results of the author Đ.V.Nghĩa (2013) After surgery, there were mild recurrent UER associated with recurrent thyroid condition It can be seen that the method of using the orbital septum flap is effective for moderate to mild UER * Position of UER In the study, center 1/3 eyelid retraction eyes accounting for 78.26% and lateral 1/3 UER accounted for 21.74% This result is lower than that of the author Đ.V.Nghĩa Thereby, it can be seen that adjusting the retraction of the eyelid in the lateral 1/3 is a difficulty for the surgeon, and is also a factor that needs to be explained and prognosed for patients before surgery 4.1.2.7 The condition of the eyelids and eyeball before and after surgery Factors assessed on eyelid morphology and function of eyelid retraction include: * MRD1: The average MRD1 before surgery was 5.97 ± 0.85 mm After surgery, the MRD1 index decreases to 3.42 ± 0.26 mm and a twoeye difference after 12 months of 0.03 ± 0.22 mm (p> 0.05) It can be seen that after 12 months of follow-up, the difference in MRD1 between the two eyes returned to nearly normal values, proving the effectiveness of surgery in improving the eyelid function and aesthetics * PFH: The average height of the eyelid gap before surgery was 12.65 ± 1.41 mm, in which in the severe UER group was 13.20 ± 1.36 mm, larger than the moderate UER group of 12, 50 ± 1.40 mm After 12 months of surgery, the height of the eyelid gap was reduced to 10,10 ± 0,29 mm Thus, this method effectively helps to improve eyelid gap height at different levels * SC: The average skin crease before surgery were 5.38 ± 0.89 mm The difference in the skin crease between the two eyes at 12 months after surgery was 0.01 ± 0.22 mm Thereby, besides the improvement of the function of the eyelids and the ocular surface, surgery to treat UER by the orbital septum flap also contributes to cosmetic remedy * Sclera show: The average sclera show before surgery was 1.70 ± 0.73 mm By the time of months and 12 months after surgery, the sclera show had negligible changes, an average of 0.01 ± 0.07 mm However, recurrence of UER occurs at months and 12 months after surgery, so monitoring of patients should be done for a minimum of months 19 * C: At 12 months after surgery, eyes had mild recurrence of 1/3 lateral retraction, in which eye also has Basedow recurrence Therefore, it is necessary to have a note for the patient, a thorough explanation of the prognosis and the possibility of recurrence of the illness after surgery * Lid lag: The author Leili GJ has shown the close relationship between LF and lid lag that if the LF index decreases by mm, the lid lag will increase by 0.29 mm with p < 0.001 However, in the study we found a difference If the amplitude of levator muscle mobility decreased by mm, the lid lag increased by 1.6 mm It is possible that the study subjects in this study were moderate and severe UER patients, and the average lid lag value in our study was larger than some other studies, so the variation of these indexes is also different * The amplitude of levator muscle mobility: 42/46 eyes with good amplitude of levator muscle mobility and eyes with average amplitude of levator muscle mobility 0.05 * months after surgery At months after surgery, the success rate increased to 95.6%, which was equivalent to the results of the author Đ.V.Nghĩa which is 95,24% This can be explained by the fact that compared with the time before treatment, the clinical manifestations of eyelid retraction are more pronounced and cause more effects on function and aesthetics for patients, so the symptoms improved after surgery with marked differences * months after surgery Evaluation of results after months of treatment we found that the success rate of surgery was 91.30%, which is lower than the success rate at months of the author Đ.V Nghĩa (97.61%) Thus, it can be seen that the time of recurrence can occur at any time after surgery, but it is most evident at months after surgery * 12 months after surgery and the overall surgical results With 12-month surgical results, we found that the success rate of the surgery remained at 91.30%, which were lower than that of the author Đ.V.Nghĩa 95,24% We have found that the success rate of the moderate and severe UER group is stable at months after surgery, but to evaluate the stability and long-term effectiveness of the surgery, a minimum follow-up time of 12 months is needed 4.2.2.9 Satisfaction level In our study, 90,9% of patients were very satisfied with the surgical results This result is similar to the result of author Watanabe A with (90% satisfaction) and author Đ.V.Nghĩa (95.24) but higher than the research of Mourit and Sasim (50% satisfied and 32% acceptable) 21 4.2.2.10 Complications during and after surgery To minimize the risk of surgical instruments causing damage to the surface of the eyeball or the thermal effects of a bipolar, a corneal protective barrier should be placed during surgery However, thanks to the bipolar electric machine and Epinephrine injection combined with anesthetic during surgery, patients are under control of bleeding during and after surgery 4.3 Factors related to surgical results After analyzing data we found factor that have closely relative to surgical outcome 4.3.1 UER position For cases of outward one-third retraction, when performing surgery one of the important factors is to find the lateral horn of the upper levator muscle However, we found that the removal of the lateral horn was sufficient to adjust for most degree of lateral 1/3 UER It can be seen that the indices had a close relationship with p = 0.008 4.3.2 History of eye treatment The analysis results showed a uncorrelation between the good surgical rate and the history of eye surgery have correlation was statistically significant with p > 0.05 This result can be explained the number of patients with history of treatment is not large enough to represent the results of the study 4.3.3 Age We did not found an association between age and surgical results with p> 0.05 This result can be explained by the majority of patients in the age group of 17 to 50 accounting for 78.26% Therefore, the proportion of age group below 16 years old and over 50 years old does not make a large enough sample size to represent the entire age group in the study patient group 4.3.4 Gender In our study the ratio female: male is 2:1 Among the female group, 96.00% of patients achieved successful results, the success rate of male group was 83.33% Our research conducted on many different causes, of which more than half of the causes are idiopathic so the gender ratio is evenly distributed Therefore, it is possible to explain why gender is loosely related to surgical results 4.3.5 Causes of UER In our study, 69,56% of UER patients identified as idiopathic with success rate of 93,80% 15,22% of patients in the study group were 22 identified as having UER due to TRO, in this group, 71,40% of patients achieved successful results In this study we did not find a correlation between the cause of UER and the treatment outcome 4.3.6 History of systemic diseases We have not found any association with a history of systemic illness with surgical results in this study Perhaps the illness history of the patient group is relatively simple and the sample size is not large enough to represent the results of the study 4.3.7 Duration of diseases For patients with UER determined by Basedow, the time for surgical treatment of lowering eyelid is usually determined when Basedow has been stable for at least months However, the research results not show the relationship between the time of infection and the surgical results, which can be explained by that the sample size in our study is not large enough 4.3.8 Level of UER Research conducted on moderate and severe UER group showed that the success of these two groups at 12 months after surgery was equivalent with 91.67% success in the moderate and 90.00% success in the severe group However, the difference is not statistically significant with p > 0.05 4.3.9 Damage to the ocular surface Surgical results achieved success in the group with damage to the eyeball surface is 93.90% and the group without damage to the eyeball surface has a success rate of 84.60% We have not found a relationship between the change in the surface of the eyeballs associated with the surgical outcome (p> 0.05) 4.3.10 Sclera show degree In the group with sclera show of  mm, 91.70% of the eyes achieved successful surgical results, this rate reached 90.00% in the group with sclera show > mm However, we have not found a relationship between sclera show and surgical results with p = 0.389 4.3.11 Lid lag In the group of patients with average lid lag>1 mm, 89.70% of surgical patients achieved successful results For patients with lid lag ≤ mm, 100% of patients have successful surgical results However, through data analysis we have not found a correlation between lid lag indicator and surgical results with p = 0.38 23 4.3.12 LF Our research results showed that the group of patients with LF ≥ 12 mm had 92.90% achieved successful results after surgery The group of 12 mm levator muscle function has patients accounting for 8.7% with 75% of patients achieving successful results after surgery However, the sample size was not large enough so we could not find a correlation between the levator muscle function index and surgical results with p = 0.231 4.3.13 Lagophthalmos We found that lagophthalmos caused patients to come for examination and treatment accounted for only 10.87% (5 eyes) and 89.13% of patients did not have lagophthalmos Successful surgical results reached 90,00% in the group without lagophthalmos and reached 100% in the group with lagophthalmos However, we did not find an association between the symptom of lagophthalmos and the surgical outcome with p = 0,327 4.3.14 Difference in proptosis The rate of surgery that achieved 12-month postoperative success in the group with proptosis difference < mm was 90.70 %%, this rate in the group with proptosis difference ≥ mm was 100% We found that these two values are not closely related to p > 0.05 4.3.15 The height of the orbital septum flap We have not found a relationship between the height of the septum and the surgical results This can be explained by the fact that besides the size of the flap, the status of the levator muscle and local scarring are also important factors that determine the outcome of surgery CONCLUSION The study involved 43 patients with 46 moderate and severe eyelid retraction Surgical results - The research group has an average age of 33.35 with 58.14% of women 69,56% of eye retraction is idiopathic, 15,22% is related to thyroid illness Average follow-up time: 22.06 months - MRD1 decreased from 5.960.85 mm preoperation to 3.420.26 mm after 12 months - The difference of PFH dropped to 0,09  0,08 mm from 2,67  1,57 mm before surgery - The difference of SC between eyes redused from 2,67  1,57 mm 24 preoperation to 0,35  1,21 mm post-operation - Eyelid curvature pre and postoperation are 1,09  2,14 mm and 0,35  1,21 mm - The average height of the orbital septum flap is 5.28  0.77 mm and is estimated by the formula: Height of flap = 5,24 + 0,02 x MRD1 - 90.90% of patients are very satisfied and satisfied with the surgery results - The successful rate of surgery is 91.30%, of which the group with severe eyelid retraction has the success rate of 90% - Complications: During surgery: 6.52% conjunctival tear, 9.69% hemorrhage After surgery: 2.17% of conjunctival hemorrhage, 8.68% recurrent Factors related to surgical results - The UER position are factors related to surgical result (p 0.05 FUTURE RESEARCH DIRECTIONS OF THE THESIS The following issues need to be studied and researched in the near future: Determine the formula for calculating the orbital septum flap according to the degree of eyelid retraction Evaluation of research results on subjects with eyelid retraction after surgery to treat eyelid drooping Study the histopathological changes of Muller's muscle and levator muscle in eye illness related to the thyroid gland  ... ocular muscle and the tarsal Continue to separate the levator muscle from the conjunctiva and remove the Muller's muscle - From the position of the skin incision, surgery up to mm to reach the orbital... Surgical treatments * The method of cutting or reversing the levator muscle with Muller's muscle cutting For severe eyelid retraction this surgery is not enough to adjust the position of the upper eyelid. .. and Temporal fat pads, also called sub-fascial fat pad * Levator muscle The levator muscle is about 36 mm long and span almost the width of the tarsal The upper layer continues into the levator