Surgical repair of orbital fractures: how soon after trauma?

PURPOSE: To determine the results of surgical exploration soon after orbital trauma in comparison with surgery half a year or longer after trauma. METHODS: A retrospective study was done on 41 patients with motility disorders after trauma. Full ophthalmologic and orthoptic investigation was done in all patients. CT-scans and/or X-ray photographs were also made. The 41 patients were divided into two groups. One group of 13 patients did not need surgical repair. One group of 28 patients needed an operation. RESULTS: In 13 patients there was an orbital fracture but no surgical repair was needed. In 28 patients surgical repair was done. In 8 patients the operation was performed half a year or longer after trauma, 15 patients underwent surgery within two weeks after trauma, and 5 patients within two months. CONCLUSION: The best final results were obtained when the operation was done soon after trauma; however, the results in the patients who were operated late were fairly good too.     

Complications of supramid orbital implants

PURPOSE: To determine the incidence and risk factors of complications associated with Supramid orbital implants. METHODS: A retrospective chart review was performed to document complications in a series of 41 patients receiving Supramid implants during orbital reconstruction or fracture repair. Implant size, duration of time between trauma and implant insertion, and history of prior orbital surgery were examined as possible risk factors for the development of complications. RESULTS: Four patients had hemorrhage within the implant capsule. An orbital abscess developed in a single patient. All but one complication appeared 7.8 to 10 years after implant insertion. Patients who had complications had a longer duration of time between trauma and implant insertion than those in whom complications did not occur (P =0.0019). Complications were more frequent among patients with larger (>600 mm2) implants and a history of orbital surgery. CONCLUSIONS: Spontaneous infection or hemorrhage may occur within the capsules of Supramid orbital implants, even many years after surgery. The insertion of larger implants in the late repair of extensive bony orbital defects may predispose patients to these complications. Implant removal and marsupialization of the implant capsule to the maxillary sinus appears to be curative without causing significant postoperative enophthalmos.     

眼眶骨折不同位点的修复对眼球内陷治疗的影响

目的：通过对眼眶内壁联合下壁骨折患者手术后眼球内陷治疗情况的临床观察,探讨不同手术位点的修复对手术预后的意义。

方法：回顾性分析眼眶内壁与下壁骨折伴眼球内陷23例23眼患者的临床资料。术后观察3mo,眼球内陷均小于2mm。通过术后CT检查,分析后隅角、内壁上缘、下壁外缘三个手术位点的修复情况。

结果：术后患者预后良好,三个手术位点的修复情况是不同的,其中后隅角的修复率最高(100%),内壁上缘的修复率次之(83%),下壁外缘修复率最低(43%)。

结论：不同手术位点的修复对于手术效果的影响是不同的,其中后隅角的修复对手术效果作用最大; 手术中对重要位点的关注可以指导手术操作,减小手术风险。     

眼部弓箭射伤诊治的体会

目的探讨眼部弓箭射伤的手术治疗方法。方法7例（7眼）眼部弓箭伤进行分析。7例眼部巨大异物（箭）分别采用分离软组织后拔出和眼球摘除同时拔出异物（箭）。结果7例均完整取出弓箭异物，不伤及眼球者视力完好，眼球破裂者视力丧失，伴颅脑损伤者有神经并发症。结论眼部弓箭射伤是罕见的眼部巨大异物，需及时手术取出，术前行CT检查，手术的方式根据箭伤及的部位和是否伴有眼球贯通和颅脑伤。     

羟基磷灰石复合材料修复爆裂性眼眶骨折的临床观察

目的:探讨羟基磷灰石(hydroxyapatite,HA)复合材料修复眼眶爆裂性骨折的手术治疗效果。方法:回顾性总结2005/2008年经下睑睫毛下皮肤入路开眶术治疗26例眼眶爆裂性骨折患者的手术疗效。结果:术前眼球内陷(与健眼差值-3～-6mm)22例、复视18例、眼肌运动受限26例;术后眼球内陷改善(与健眼突出度差值≤±1.5mm)22例、4例眼球内陷残留(与健眼差值-3～-4mm),14例复视完全消失、4例复视有所改善,眼球运动无受限18例、受限减轻8例。手术未影响视力,术后随访期间无HA复合材料感染、排出及移位等并发症。结论:临床表现明显的眼眶爆裂性骨折及早修复效果好,HA复合材料作植入物眶内骨折充填安全有效,是重建眶壁理想的生物材料。     

Flap tear of rectus muscles: an underlying cause of strabismus after orbital trauma

PURPOSE: To present an avulsion injury of the rectus muscle after orbital trauma, usually the inferior rectus, and detail its diagnosis and operative repair. METHODS: Forty-three patients underwent repair of flap tears of 62 rectus muscles. During surgery, we found the muscle abnormality was often subtle, with narrowing or thinning of the remaining attached global layer of muscle. The detached flap of external (orbital) muscle was found embedded in surrounding orbital fat and connective tissue. Retrieval and repair were performed in each case. RESULTS: The causes of orbital trauma were as follows: orbital fractures (15 patients), blunt trauma with no fracture (11 patients), suspected trauma but did not undergo computerized tomographic scan (12 patients), and status after retinal detachment repair (5 patients). Of note, 15 of the 43 patients (35%) underwent repair of the flap tear alone, without any additional orbital or strabismus surgery. Diagnostically, the predominant motility defect in 45 muscles was limitation toward the field of action of the muscle, presumably as a result of a tether created by the torn flap; these tethers simulated muscle palsy. Seventeen muscles were restricted away from their field of action, simulating entrapment. The direction taken by the flap during healing determined the resultant strabismus pattern. All patients with gaze limitation toward an orbital fracture had flap tears. The worst results after flap tear repair were seen in patients (1) who had undergone orbital fracture repair before presentation, (2) who had undergone previous attempts at strabismus repair, and (3) who had the longest intervals between the precipitating event and the repair. The best results were obtained in patients who underwent simultaneous fracture and strabismus repair or early strabismus repair alone. CONCLUSIONS: Avulsion-type flap tears of the extraocular muscles are a common cause of posttraumatic strabismus. Early repair produces the best results, but improvement is possible despite long delay.     

可吸收眶底板在眼眶骨折手术中的应用

目的:评价可吸收眶底板在眼眶骨折修复手术中的临床应用效果。方法:回顾性分析眼眶骨折患者48例48眼的临床资料,所有患者均采用可吸收眶底板进行眼眶骨折修复,术中充分暴露骨折缺损范围后还纳疝出的眶内组织,根据缺损范围塑形可吸收眶底板,植入眶内并以可吸收螺钉固定。手术前后通过眼部检查和眼眶CT扫描评价可吸收眶底板在眼眶骨折修复手术中应用的可行性和精确性。结果:本组患者均顺利完成手术,均未出现严重的并发症,CT扫描可见眼眶骨折均得到良好的解剖复位。术后1a复查,术前18眼眼球运动障碍患者中1眼好转(6%),17眼治愈(94%);术前30例复视患者中12例好转(40%),18例治愈(60%);术前32眼眼球凹陷患者中10眼好转(31%),22眼治愈(69%);术前40眼眶下神经分布区麻木患者中33眼好转(82%),7眼治愈(18%)。本组患者中1眼术前出现下睑内翻、倒睫,术后得以恢复。结论:可吸收眶底板在眶壁骨折修复术中应用效果良好,是一种较好的眼眶修复材料。     

Timing of fornix reconstruction for postoperative conjunctival prolapse

Background and objective: To describe fornix reconstruction for conjunctival prolapse occurring after ocular surgery. Materials and methods: Two patients with persistent conjunctival prolapse of variable duration following ocular surgery underwent fornix reconstruction using the method described by Barrett. The two patients underwent different surgical methods. In the second patient, no attempt was made to include the malar periosteum.Results: Case 1 with longer duration of prolapse needed further surgery to excise residual prolapsing conjunctiva that had hyperplastic squamous epithelium. Case 2 in which fornix reconstruction was done 2 months after prolapse showed a good result after only one surgical operation.Conclusion: Forniceal reconstruction is recommended for persistent postoperative conjunctival prolapse. Early surgery appears to have better results.     

Frontal periosteum as an exposed orbital implant cover

PURPOSE: To describe the surgical technique of harvesting frontal bone periosteum, through an eyelid-crease incision, for coverage of orbital implants. METHODS: A retrospective review of the medical records of 15 patients who underwent the procedure. RESULTS: Eleven patients had surgery to cover exposed orbital implants, whereas in 4 patients the periosteal graft was used as an implant cover during enucleation. Periosteal grafts as large as 25 mm in diameter can be harvested. Recurrent exposure developed in 2 patients who had complicated histories of local trauma. One of these patients required a secondary dermis-fat graft, and the other experienced spontaneous granulation. The remaining 13 patients had excellent results without complications. CONCLUSION: Harvesting frontal bone periosteum, through an eyelid-crease incision, for orbital implant coverage is a relatively straightforward surgical technique. The procedure can be performed in the office under local anesthesia and yields excellent results. Recurrent exposure occurred only in 2 patients with histories of significant local trauma.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

Nylon foil "wraparound" repair of combined orbital floor and medial wall fractures

PURPOSE: To evaluate a technique of implanting a single 0.4-mm-thick nylon foil (Supramid) continuously across combined medial wall and floor fractures within weeks of orbital trauma. METHODS: This retrospective, interventional case series includes patients with combined medial wall and floor fractures with or without external orbital and facial fractures, without prior surgery, and who were in the early posttrauma phase. One hundred two orbits in 98 consecutive patients were treated with a "wraparound" technique. The surgical technique is provided in detail. Comatose patients, those with cranial nerve palsies, severe globe injury, anophthalmia, or previous repair of the same fractures were excluded. Patients underwent surgery from 5 to 21 days after trauma. Postoperatively (average, 6.2 months), patients were evaluated for enophthalmos, extraocular motility, and diplopia. RESULTS: In 101 of 102 orbits, normal globe position, and full extraocular motility without diplopia was accomplished. One orbit had persistent enophthalmos, requiring a second procedure. This same patient had ipsilateral restriction in extreme upgaze, but no diplopia symptoms. This orbit had complete loss of inferomedial strut support. Overall, strut loss was not a risk factor for subsequent enophthalmos. No other patient had globe malposition, restrictive myopathy, or diplopia. Implant migration, hemorrhage, fistula, or infection was not observed. The transconjunctival and canthal wounds were hidden and tolerated by all patients with no eyelid cicatrization, webbing, or malposition. CONCLUSIONS: The "wraparound" technique for 0.4-mm nylon foil implantation continuously across orbital floor and medial wall fractures was associated with almost no enophthalmos and diplopia in this series.     

Clinical features and management of intraorbital foreign bodies

PURPOSE: To review the clinical features and management of patients with intraorbital foreign bodies. DESIGN: Noncomparative interventional case series. PATIENTS AND METHOD: Forty patients seen at two regional orbital surgery departments with intraorbital foreign bodies were reviewed. MAIN OUTCOME MEASURES: Visual acuity, surgical interventions, and complications. RESULTS: Seventy-three percent of patients were younger than 30 years old. There were 22 metallic, inorganic; 5 nonmetallic, inorganic; and 13 organic intraorbital foreign bodies (IOrbFb) in this series. Thirty patients were seen at the time of injury, and 10 patients were seen in a delayed setting with orbital complications. Thirty-four patients had surgical removal of their IOrbFb either because of complications or easy surgical access. Six patients had no surgery because of posteriorly located inorganic foreign bodies. Thirteen patients had resultant blind eyes; 12 of these were blind from the initial trauma. CONCLUSIONS: Loss of vision in conjunction with IOrbFbs is usually a result of the initial trauma. All patients should have antibiotic therapy because of the high incidence of secondary orbital infections. Computed tomography is the best initial mode of imaging. Surgical removal is indicated for all organic IOrbFbs. Inorganic IOrbFbs should be removed if causing complications or if located anteriorly after discussion of potential surgical complications with the patient. Posteriorly located inorganic IOrbFbs should be left alone, unless they are causing significant orbital complications.     

保留眼球的眶周侵袭性恶性肿瘤切除及修复

目的　总结保留眼球及个体化皮瓣修复用于治疗眶周侵袭性恶性肿瘤的手术治疗效果及预后。方法　回顾性分析2007年3月至2016年3月我院收治的14例（14眼）眼睑及眼眶侵袭性恶性肿瘤,手术完整切除肿瘤,残留结膜或皮瓣覆盖眼球,个体化皮瓣修复缺损,对该手术治疗方法的效果进行分析。结果　14眼中眼睑基底细胞癌3眼,鳞状细胞癌4眼,皮脂腺癌6眼,横纹肌肉瘤1眼。14例恶性肿瘤均完整摘除,1例治疗20个月后死亡,1例复发性横纹肌肉瘤放弃继续治疗,1例术后放疗后无光感,皮肤溃疡角膜暴露,其余患者随访2~5 a均无复发,创面愈合良好,皮瓣下眼球运动良好,光感存在。结论　眶周侵袭性恶性肿瘤较为罕见,肿瘤扩大性切除后可以采取保留眼球的手术方式,并根据缺损范围选择合适的皮瓣修复,可以减少创伤,简化手术操作,保留一定外观。血管吻合皮瓣修复应慎重应用于该类侵袭性肿瘤患者中。     

眶下壁骨折后下直肌麻痹的手术治疗

目的 探讨眶壁骨折后,或眶壁骨折修复手术后发生单独的下直肌麻痹斜视患者的诊断和最佳手术治疗方案.方法 回颐分析诊治的8例下直肌麻痹斜视患者,均有眶壁骨折或眶壁骨折修复手术病史,6例患者正前方垂直斜度小于20△,下方斜度显著,行下直肌缩短加强手术,缩短量从3.5mm到6mm;2例患者正前方垂直斜度大于20△,上转、外转、下转时垂直斜度均较显著,行下直肌缩短联合同侧上直肌后徙手术.手术采用术中调整缝线的方法.结果 5例患者术后正前方正位,复视和代偿头位消失,远期随访眼位维持稳定,2例患者正前方过矫2△,远期随访正前方正位,复视和代偿头位消失.1例患者正前方欠矫4△,复视消失,头位改善.所有8例患者正前方和下方阅读距离视野复视消失.结论 下直肌缩短加强手术对于眶壁骨折后下直肌麻痹斜视患者消除复视,代偿头位是有效的,如果正前方斜度大,并且斜视累及上方视野,可行下直肌缩短联合同侧上直肌后徙手术,可有效增大双眼单视野.

Abstract：

Objective To study the diagnosis and surgical management of isolated inferior rectus paralysis following orbital trauma or caused by contusion at the time of surgical repair of a blow out orbital fracture.Methods In 8 patients with isolated inferior rectus paralysis,all of which had orbital fracture and 7 of them had history of surgical repair for orbital fracture,3.5mm～6mm resection of the paralyzed inferior rectus was done in 6 patients whose vertical deviation was less than 20△ in primary position;resection of inferior rectus combined with ipsilateral recession of superior rectus was done in other 2 patients whose vertical deviation was over 20△.Adjustable suture technique was used during surgery.The patients were followed up for more than 6 months.Results Postoperatively,5 patients were orthophoria without diplopia or abnormal head position,2 patients were 2△ over correction in primary position which became orthophoria during follow up,I patient was 4△ less correction with no diplopia and improved head position.Diplopia in primary and downward gaze position was disappeared in all the patients.Conclusions Resection of paralyzed inferior rectus is effective to correct vertical deviation both in primary and in downward gaze position for isolated inferior rectus paralysis.When the deviation is most pronounced in both downward and upward gaze position and the deviation in primary position is over 20△ resection and recession is effective to increase single binocular vision.     

眼眶爆裂性骨折应用Medpor外科种植体联合医用耳脑胶治疗的研究

目的探讨Medpor外科种植体联合医用耳脑胶治疗眼眶爆裂性骨折的临床应用意义。方法手术治疗眼眶骨折26例（26眼）。术前常规CT检查,并检查眼球内陷、复视及眼球运动情况,评价术后治疗效果。结果术后25例眼球内陷得到明显改善,术后6个月,21例复视完全治愈,3例复视症状好转,所有病例无Medpor植入术后不良反应。结论眼眶爆裂性骨折应早期即做出准确诊断,如伴明显复视与眼球内陷,应该早期手术治疗,术中应用Medpor联合医用耳脑胶植入骨折缺损处,术后早期行眼球运动训练,可取得良好疗效。     

Inferior rectus rupture following blowout fracture

Background: Extra-ocular muscle rupture is uncommon, usually seen after penetrating trauma or surgery. It is a very rare cause of diplopia following blunt orbital trauma.
Methods: A patient who presented with no inferior rectus function after blunt orbital trauma is described.
Results: Computed tomography (CT) scans demonstrated a large orbital floor fracture and suggested that the inferior rectus muscle was ruptured. This was confirmed at operation. Despite anatomical repair, there was no postoperative improvement in ocular motility.
Conclusions: Traumatic rupture of the inferior rectus is rare. Forced duction and force generation testing and CT are important in diagnosing ocular motility defects following orbital trauma.     

Our results of orbital fracture treatment

PURPOSE: To present our results of orbital fracture treatment. MATERIAL AND METHODS: There were 28 patients with orbital fracture hospitalized at Ophthalmology Department of Medical University in Gdańsk during last 5 years. Most of them had a blow-out fracture type. We reconstructed it using artificial materials (cranioplast). It was shaped according to the defect of the bone. Fracture of zygomatico-frontalis and zygomatico-maxillaris suture was fixed by bone sutures. The same method was used to treat gaps in medial and superior wall of the orbit. RESULTS AND CONCLUSIONS: We took into consideration the period of time between the trauma and surgical procedure. Full recovery (lack of diplopia) was achieved in 10 cases which underwent operation in less then 14 days after trauma and only in 2 cases in the group where patients were operated later than 14 days after accident.     

眶壁骨折修复术后斜视和复视的手术治疗

目的 观察眶壁修复术后斜视和复视眼外肌手术矫正效果.方法 对14例眼眶爆裂性骨折修复手术6月后仍有斜视和复视的患者,采取二期眼外肌手术治疗.结果 4例为限制性斜视,二期手术探查,松解肌肉、解除限制因素,后徙受累肌或/和缩短拮抗肌后,前方及前下方视野内复视消除;10例为非限制性眼肌功能不足所致斜视,二期手术缩短受累肌/和后徙拮抗肌后,9例复视明显好转,前方及前下方视野内垂直及水平斜视度分别小于10△和15△.1例仍有眼位偏斜,需佩戴三棱镜矫正复视.结论 正确分析爆裂性眼眶骨折修复术后斜视和复视的原因,采取相应的术式,可获得较好的治疗效果.     

上颌骨骨折合并泪道损伤的诊治体会

目的 探讨上颌骨骨折合并泪道损伤的手术方法，提高治疗效果。方法 对上颌骨骨折合并泪道损伤的病例，及时行上颌骨骨折的复位固定，对泪道充血、积血、炎症者早期应用抗生素滴眼、冲洗泪道、泪道置管等；对泪小管断裂者在显微镜下行泪小管吻合术，鼻泪管断裂者行鼻腔泪囊吻合术。结果 24例随访半年治愈21例，好转1例，共占91．67％。结论 复合性泪道损伤及时进行骨折复位及泪道修复手术，可获比较满意的效果。