羟基磷灰石义眼座眶内植入139例分析

目的探讨带预置缝线的羟基磷灰石(hydroxyapatite，HA)义眼座直接植入眶内的手术效果。方法自1997年9月～2002年6月进行带预置缝线的HA义眼座直接植入眶内手术139例(139眼)，其中Ⅰ期眶内义眼座植入117眼，Ⅱ期眶内义眼座植入22眼。随访6～24月，平均11．8月。结果139眼术后出现轻微眼睑及球结膜水肿，4眼结膜切口裂开，经保守治疗自愈。2眼HA义眼座暴露，经修复后愈合。随访观察139眼义眼活动良好，眼窝饱满；Ⅰ期较Ⅱ期植入的义眼活动度大，外观更逼真。未发生义眼座脱出及感染等并发症。结论眼球摘除术后植入HA义眼座，提高了眼球运动效果和面部美观程度，效果较好。     

Hydroxyapatite orbital implant exposure in children.

PURPOSE: Hydroxyapatite orbital implants are buried implants that may be integrated into the overlying prosthesis after enucleation. We report problems encountered using these implants during a 14-year period in a pediatric population. METHODS: Retrospective analysis of a pediatric population from 1987 through 2001. RESULTS: Indications for enucleation (N = 19) included retinoblastoma (n =17), persistent hyperplastic primary vitreous (n =1), and painful blind eye (n =1). Conjunctival erosion (36.84%) and consequent implant exposure (15.70%) were the main problems identified in this study. There were no cases of orbital infection. Management included resuturing and scleral patching. CONCLUSION: Conjunctival erosion of hydroxyapatite implants contributed to significant morbidity in 19 children who underwent enucleation and hydroxyapatite orbital implant.     

眶内植入带线羟基磷灰石义眼座的临床分析

目的 探讨眶内植入带线羟基磷灰石（HA）义眼座的临床效果。方法 对85例（85眼）眼球摘除者眶内植入带线HA义眼座。结果 术后随访12-36个月,平均18个月。义眼座活动度良好。82例结膜创口Ⅰ期愈合,2例结膜变薄,1例结膜创口裂开,义眼座暴露。无眶内血肿或感染等并发症。结论 眶内植入带线HA义眼座手术操作简单,术后并发症少,美容效果佳,临床效果好。     

Complications of hydroxyapatite orbital implants in children: a series of 105 cases

PURPOSE: To describe the complications encountered using hydroxyapatite as an orbital implant in the pediatric population after enucleation, and try to define the risk factors for their occurrence. MATERIAL: and methods: Retrospective review of charts of children who underwent enucleation with placement of an hydroxyapatite implant between January 1991 and 1998. Complications and their type (conjunctival, extrusion, eyelids complications) have been specifically looked for. A statistical analysis trying to isolate the risks factors was performed. RESULTS: 105 implants have been used during this period with 26.7% of complications appearing during a median followup of 22 months. Extrusion of the implant was observed in 1.9% of the cases, a chronic conjunctival erosion in 15%, a conjunctival lesion without erosion in 4.75% and no eyelid lesion could be seen. Treatment (medical or surgical) achieved 75% good results. No risk factor could be found. CONCLUSION: Hydroxyapatite orbital implants were initially thought to have no or few complications. More recently, chronic erosions in particular were described. Little data exists on the pediatric population. Our series confirms that complications occur and that they are comparable to the adult population. Nevertheless the hydroxyapatite orbital implant seems better tolerated than other porous or non porous implants and warrants its use.     

Synthetic hydroxyapatite-based integrated orbital implants: a human pilot trial

PURPOSE: Orbital implants are used as fillers following enucleation or evisceration surgeries to replace the lost volume for better cosmesis and motility of the artificial eye. Over the last decade porous hydroxyapatite (HAp) implants derived from the naturally occurring corals, are increasingly used. Recently synthetic HAp-based implants have been introduced. After fibrovasculrisation they have the added advantage of being directly integrated with the artificial shell, thereby increasing the motility to a great extent. The current study, evaluated the efficacy of two different models of synthetic HAp with 75% porosity and pore sizes ranging from 100 to 300 mm. METHODS: Synthetic HAp powders were prepared with a novel wet chemical route. Two models of porous orbital implants with the characteristic designs for both evisceration and enucleation surgery were developed, characterised and implanted to consecutive 25 human subjects, 17 following evisceration, and 8 following enucleation. The postoperative performances of these implants were evaluated in respect to the degree of volume replacement (implant + prosthesis), presence/absence of lagophthalmos and lower eye-lid laxity, status of socket and fornices. Magnetic resonance imaging assessed the stability of the implants within the socket and progressive fibro-vascularisation within the porous scaffold as a function of time. Finally, motility of the implants as well as the prostheses (horizontal movements by Lister Perimeter) and subjective cosmetic results (qualitative) were also evaluated. RESULTS: During the 2.5 years of follow-up study, no significant postoperative complications were noticed. One case, showed an anterior implant exposure of 3-4 mm, and was managed with donor scleral patch graft and one case of conjunctival thinning was corrected by re-suturing the conjunctival dehiscence. Fourteen of the 25 patients had a very good movement of the prostheses (> 20 degrees horizontal movement) and the other 11 patients had a fair motility (10 - 20 degrees). The degree of volume replacement (with prosthesis) was found to be very good in 21 patients and fair in other 4 patients. All patients reported cosmetic satisfaction. CONCLUSION: Synthetic HAp-based integrated orbital implants with this modified design were found clinically safe and cosmetically acceptable.     

Enucleation with primary implant insertion for treatment of recalcitrant endophthalmitis and panophthalmitis

PURPOSE: A prevalent conception exists that a two-stage operation (i.e., primary enucleation or evisceration with delayed secondary orbital implant insertion) is necessary when enucleation is required for recalcitrant endophthalmitis or panophthalmitis. The purpose of this study was to assess the utility of single-stage enucleation and primary reconstruction in this setting. METHODS: In a retrospective interventional case series, 22 consecutive patients with advanced endophthalmitis or panophthalmitis refractory to prior medical treatment underwent enucleation and primary implant placement by a single surgeon between 1991 and 2001. Eleven patients received hydroxyapatite implants; 11 patients received silicone implants. All patients were treated during surgery with intravenous antibiotics. All patients were evaluated for persistent local or systemic infection, implant exposure, extrusion, and successful fitting of their prostheses. RESULTS: No cases of persistent orbital cellulitis or meningitis occurred in any of the patients. Two patients with silicone orbital implants had extrusions; one was successfully managed with a secondary dermis-fat graft, and another patient who refused additional treatment was allowed to heal by secondary intention after the implant was removed. None of the patients with hydroxyapatite orbital implants had complications. All patients (20/20) who elected to undergo prosthetic fitting were successfully fit with prostheses. One patient elected not to pursue prosthetic fitting. One patient died of unrelated causes before a prosthesis could be fit. There were no objective findings to preclude successful fitting in either case. CONCLUSIONS: This study suggests that enucleation with primary orbital reconstruction and implant insertion for recalcitrant, fulminant ocular infection is an acceptable and advantageous treatment strategy. The risks and expenses associated with two separate surgeries are decreased, hospitalization time is potentially reduced, and subsequent rehabilitation can be initiated in a more timely fashion.     

二期羟基磷灰石植入眼窝成形术

目的 总结对已摘除眼球后造成眼窝塌陷的病例,施行二次结膜囊切开,羟基磷灰石植入眼眶的临床效果。方法 切开结膜囊,寻找四直肌,打开肌圆锥,植入同种异体巩膜包囊的羟基磷灰石,总计31例。结果 随访3～27月（平均17月）,患者都不同程度地获得眼窝塌陷和义眼运动的改善,没有眼眶感染和植入物逐出或义眼脱落等现象。结论 羟基磷灰石也适用于眼球摘除术后造成塌陷,病程长短不限。     

眼球摘除188例原因分析及义眼台植入的效果

目的对188例眼球摘除的原因进行分析，评价义眼台植入的效果。方法采用回顾性研究的方法，分析了眼球摘除的原因，并对眼球摘除的适应证及其并发症进行了讨论。结果眼球摘除的188例中，眼外伤93例，占49．47％；恶性肿瘤41例，占22．81％；失明伴眼痛、眼球萎缩及眼内炎等其他原因54例，占28．72％。其中义眼台植入76例，出现并发症者5例，包括2例结膜息肉，3例义眼台暴露。结论眼外伤是眼球摘除占首位的原因。眼球摘除后义眼台的及时植入，能改善外观，手术并发症少。     

Wrapping hydroxyapatite orbital implants with posterior auricular muscle complex grafts

PURPOSE: To report the use of posterior auricular muscle complex grafts as a wrapping material for hydroxyapatite orbital implants in enucleation surgery. METHOD: In a retrospective multicenter study, autogenous posterior auricular muscle complex grafts were used to cover hydroxyapatite orbital implants in 83 patients with a mean age of 38.6 years (range, 1 to 85 years), of whom 63 had primary unilateral enucleation and 20 had secondary orbital implants following enucleation. The mean follow-up period after posterior auricular muscle complex grafts was 36 months (range, 14 to 60 months). RESULTS: Of the 83 patients, two (2.4%) developed limited orbital implant exposure, which was treated with a second posterior auricular muscle complex "patch graft." No patient developed postoperative orbital infection or implant extrusion. All patients were fitted with an acceptable prosthesis and had satisfactory cosmetic and functional results. No patient developed vascular compromise or a wound defect associated with the posterior auricular donor site. CONCLUSION: Autogenous posterior auricular muscle complex grafts should be considered as an appropriate wrapping material for hydroxyapatite orbital implants for primary enucleation and for secondary orbital implants after enucleation.     

A morphological study of drill holes applied with mitomycin-C in hydroxyapatite orbital implants.

For maximum motility of the prosthesis, the hydroxyapatite orbital implant should be drilled and coupled to the prosthesis via a motility peg. However, problems of peg extrusion have been reported to occur in 25-30% of cases. In this animal study, serial histopathological changes within the drill hole after hydroxyapatite implantation were observed and the effect of mitomycin-C (MMC) was evaluated as a new method of hole maintenance. A hole was drilled into each hydroxyapatite implant 20 weeks after enucleation and different concentrations of MMC solution were applied. The morphological changes of the holes were evaluated with proliferating cell nuclear antigen. In the control group (non-MMC-treated), all the motility pegs were extruded showing occluded holes. In the groups treated with 0.5 and 1.0 mg/ ml MMC, all the motility pegs were maintained in position with the holes at ample depth and width. However, toxicity, such as conjunctival ulcer and implant exposure around the hole, was observed in the 1.0 mg/ml MMC group. A 0.5 mg/ml MMC application for 5 min to the drill hole effectively reduced the risk of peg extrusion in this albino rabbit model.     

Tolerance of orbital implants. Retrospective study on 14 years

The authors report the results of enucleations performed from 1985 to 1998 and the different orbital implants used. MATERIAL AND METHODS: All patients undergoing enucleation from 1985 to 1998 were studied. RESULTS: 68 men and 32 women had an enucleation. The main indication was tumoral diseases, principally choroidal melanomas and ciliary melanomas (respectively, 26 and 8). More rarely the indication was orbital metastasis or eyelid carcinoma. The follow indications were traumatisms and neovascular glaucomas. The orbital implants used were mainly Allen implants, silicone implants and hydroxyapatite implants. The main complication was the expulsion of the implant, which occurred in about 20% of the cases, for the most part in the group of silicone and tunnel implants patient. These expulsions were found less with hydroyxapatite implants. For the hydroxyapatite implants we also noticed the some conjunctival erosion. The expulsion of the implant occurred most often before 2 years. CONCLUSION: The authors report on the survey of orbital implants used for 14 years. They noticed the high frequency of expulsions when they used tunnel or silicone implants and better results with hydroxyapatite implant.     

UK national survey of enucleation, evisceration and orbital implant trends

AIM: To evaluate current clinical practice in the UK in the management of the anophthalmic socket; choice of enucleation, evisceration, type of orbital implant, wrap, motility pegging and complications. METHODS: All consultant ophthalmologists in the UK were surveyed by postal questionnaire. Questions included their practice subspecialty and number of enucleations and eviscerations performed in 2003. Specific questions addressed choice of implant, wrap, motility pegging and complications. RESULTS: 456/896 (51%) consultants responded, of which 162 (35%) had a specific interest in oculoplastics, lacrimal, orbits or oncology. Only 243/456 (53%) did enucleations or eviscerations. 92% inserted an orbital implant after primary enucleation, 69% after non-endophthalmitis evisceration, whereas only 43% did so after evisceration for endophthalmitis (50% as a delayed procedure). 55% used porous orbital implants (porous polyethylene, hydroxyapatite or alumina) as their first choice and 42% used acrylic. Most implants inserted were spherical, sized 18-20 mm in diameter. 57% wrapped the implant after enucleation, using salvaged autogenous sclera (20%), donor sclera (28%) and synthetic Vicryl or Mersilene mesh (42%). A minority (7%) placed motility pegs in selected cases, usually as a secondary procedure. 14% of respondents reported implant exposure for each type of procedure and extrusion was reported by 4% after enucleation and 3% after evisceration. CONCLUSIONS: This survey highlights contemporary anophthalmic socket practice in the UK. Most surgeons use porous orbital implants with a synthetic wrap after enucleation and only few perform motility pegging.     

儿童羟基磷灰石植入眼窝成形术

目的:总结18例18眼3～12岁儿童,因眼外伤等不同原因,行眼球摘除,羟基磷灰石植入眼眶的临床效果。方法:切开结膜囊,暴露四直肌,预置6-0双针尼龙线,剪断四直肌和视神经,眼球摘除后去除角膜,彻底清除眼内容后利用自体巩膜包囊羟基磷灰石并植入眼窝,总计18眼。结果:随访3～36(平均24)mo,患者都不同程度地获得眼窝塌陷和义眼转动的改善,没有眼眶感染和植入物逐出或义眼片脱落等现象。结论:羟基磷灰石也适用于儿童眼球摘除术后减轻眼窝塌陷,改善义眼转动,改善义眼外观的效果。     

Enucleation with on-the-table evisceration. Is it a good technique?

PURPOSE: To evaluate the surgical technique of enucleation followed by an "on-the-table evisceration" and placement of a hydroxyapatite orbital implant wrapped by the patient's own sclera for the treatment of blind phthisis painful eyes. PATIENTS AND METHODS: In this single-center retrospective study, 50 consecutive patients undergoing an operation using the same surgical technique, between April 1993 and November 1999, were studied. Patients underwent enucleation, then the eyeball was eviscerated "on the table". The patient's own cleaned sclera was used to wrap a hydroxyapatite orbital implant, the posterior pole of the sclera was placed at the anterior pole of the implant. Conjunctival breakdown, sphere size, conjunctival discharge, the first signs of sympathetic ophthalmia motility, and cosmetic results were analysed. RESULTS: After an average follow-up of 13.3 months few complications were encountered: 4 cases (8%) of inclusion cyst and 3 cases (6%) of discharge. The implant placed had a diameter of 18 mm, 20 mm, 22 mm in, respectively, 48%, 48%, and 4% of the eyes. The prosthesis motility was good, medium, and poor in, respectively, 33 (78.6%) cases, 8 (19%) cases, and 1 (2.4%) case. The prosthesis tolerance was good, medium, and poor in respectively 86%, 10%, and 4% of the cases. CONCLUSION: The surgical technique of enucleation followed by an "on-the-table" evisceration and autologous sclera wrapping a hydroxyapatite implant is an easy procedure. It allows, on phthisis eyeballs, the placement of a large orbital implant for good cosmesis results, without major complications.     

Improved prosthetic motility with placement of a second coupling PEG

PURPOSE: Integrated coupled orbital implants have been shown to improve prosthetic motility over noncoupled orbital implants. Some patients are limited in prosthetic motility despite this coupling for various mechanical and physiological reasons. A common limitation of motility in anophthalmic rehabilitation is forniceal constriction or scarring. Anophthalmic patients with coupled integrated implants who were noted to have limited prosthetic motility because of conjunctival scarring, improperly placed coupling pegs, rotation of the prosthesis, or contracture in the fornices underwent placement of a second coupling peg with the aim of improving prosthetic motility. METHODS: Six patients were selected who fit the criteria of poor prosthetic motility despite excellent implant motility. All patients had previously placed hydroxyapatite implants followed by motility peg placement several months later. Titanium motility peg placement was only placed after gadolinium-enhanced magnetic resonance imaging neuroimaging studies were performed to assess proper vascularization of the integrated implant. After determining the direction of motility limitation caused by conjunctival dysfunction, a second titanium motility peg was placed in the standard fashion to improve prosthetic motility. RESULTS: All six patients had improvement of prosthesis motility, as noted by both the patient and surgeon, after second motility coupling peg placement. No complications were encountered. CONCLUSIONS: In select patients with poor translation of implant motility to prosthesis motility, placement of a second motility coupling peg may improve prosthetic motility.     

Exposed hydroxyapatite orbital implants. Report of six cases.

Six patients with complications of primary or secondary hydroxyapatite implants were studied. Complications included socket infection and/or conjunctival dehiscence. Complications were detected during regular follow-up examinations, and various treatment approaches were used. The hydroxyapatite implant exposure occurred 4 to 6 weeks (mean, 4.5 weeks) after implantation. Three of the six implants were wrapped in preserved donor sclera before implantation. One of the implants showed wide exposure and chronic infection and was removed. In two cases, scleral patch grafts with a conjunctival pedicle graft were performed, resulting in successful coverage of the implant without further conjunctival dehiscence. In one of the patients, a Tenon's conjunctival flap was advanced to cover the defect, and was unsuccessful with the spicules of the hydroxyapatite eroding through the vascular flap after 1 month. Three of the patients demonstrate a persistent conjunctival epithelial defect. These three patients with chronically exposed hydroxyapatite have remained stable with follow-up intervals ranging from 8 to 12 months. Early exposure of hydroxyapatite orbital implants is a potential problem despite meticulous technique. Implant coverage is difficult, although chronic exposure seems to be tolerated often in the hydroxyapatite orbital implant without migration or extrusion.     

Culture-proven Aspergillus fumigatus infection in a primary hydroxyapatite orbital implant

Hydroxyapatite orbital implants are widely used in enucleation surgery. Infection in this setting is an uncommon but severe complication. Herein a patient with a 3-year history of chronic socket discharge, orbital discomfort, conjunctival breakdown and implant exposure after enucleation and implantation of a hydroxyapatite sphere 7 years previously is reported. Repeated attempts at covering the exposed implant failed. Eventually the implant was removed, and Aspergillus fumigatus was cultured from the explanted material. This is the second reported case of Aspergillus infection of a hydroxyapatite orbital implant, and the first case where fungal cultures were positive.     

Coralline hydroxyapatite as an ocular implant.

Fifty patients received a coralline hydroxyapatite sphere as a buried integrated ocular implant after enucleation or evisceration surgery. The surgical technique is described and the results discussed. All patients obtained final prosthetic motility superior to that possible with simple spherical methylmethacrylate implants. After a follow-up of 2 to 27 months (mean, 10.4 months) there have been no cases of migration or extrusion. Complications have been minimal and easily managed. The hydroxyapatite implant appears to offer excellent cosmetic reconstruction without the unacceptable infection and extrusion rates seen with other integrated implants.     

羟基磷灰石义眼座植入Ⅰ期钻孔的初步效果

目的 评价羟基磷灰石义眼座植入Ⅰ期钻孔放置钛钉的疗效。方法 对31例眼球摘除患者行Ⅰ期或Ⅱ期羟基磷灰石义眼座植入同时行钻孔,钻入钛钉的螺纹套子,中间放置平头钉,3～7个月后剪开,更换为球头钉,定制义眼片。结果 随访3．0～11．0个月(平均6．9个月),所有患者对义眼外观及活动度满意,无义眼座暴露、继发感染、栓钉脱出、栓钉偏斜等并发症。结论 羟基磷灰石义眼座植入Ⅰ期钻孔手术效果好,无明显增加并发症的发生机会,是一种可供选择的手术方法。     

Primary banked scleral patch graft in the prevention of exposure of hydroxyapatite orbital implants

PURPOSE: The most frequently reported complication of hydroxyapatite orbital implantation is exposure of the implant, which may result in infection or extrusion of the implant. This study describes the use of banked sclera patch grafts to prevent implant exposure. DESIGN: A retrospective noncomparative interventional case series. PARTICIPANTS: The procedure was performed on 110 patients over a 2-year period. Hydroxyapatite implantation was performed either at the time of enucleation or as a secondary procedure to correct postenucleation socket syndrome. INTERVENTION: A banked scleral patch graft from the second eye of the same donor was placed over a scleral-wrapped hydroxyapatite implant at the time of operation. The case records were reviewed retrospectively. OUTCOME MEASURES: The primary outcome measure was the number of patients who developed exposure of their hydroxyapatite implant. The number of patients who had a postoperative conjunctival wound dehiscence was also recorded. RESULTS: No patients developed exposure of the implant. A significant percentage of patients developed conjunctival wound dehiscence (33%). Further surgery was not required in any of these cases, because the dehiscence spontaneously reconjunctivalized over the surface of the scleral patch graft. CONCLUSIONS: Insertion of a banked scleral patch graft at the time of hydroxyapatite orbital implantation is an effective means of preventing implant exposure, even in more complex cases. It thereby reduces the morbidity resulting from the procedure and obviates the need for further surgery when there is breakdown of the conjunctival wound postoperatively.