无眼球重度结膜囊缩窄和闭锁术式应用分析

目的 探讨一种手术方式治疗重度结膜囊缩窄和闭锁,改善眼眶的丰满度及义眼安置后的外观.方法 收集2005 ～2010年收治的无眼球重度结膜囊缩窄和闭锁患者23例,采取游离皮片移植、硬腭黏膜移植等方式完成结膜囊成形,同期完成羟基磷灰石义眼台植入.术后测量结膜囊上、下、内、外四个方位结膜囊深度.术后测量方法:患者结膜囊取模,制作义眼.安置义眼后,在上、下、内、外四个方位标记睑缘与义眼接触的部位,然后取出义眼,测量四个方位义眼边缘与睑缘标记点之间的距离.取眼睑中份测量值做为结果记录.结果 术前结膜囊缩窄,患者无法安置义眼.术后结膜囊上穹窿平均深度7.1 mm,下穹窿平均深度5.7 mm,内侧穹窿平均深度3 mm,外侧穹窿平均深度1.9 mm.术前术后患者外观有明显改善,义眼安置满意.远期观察义眼台未出现暴露、排异等并发症.结论此术式可以治疗重度结膜囊缩窄和闭锁,并具有良好的远期疗效.     

Ⅱ期眼窝凹陷及结膜囊狭窄的联合整复手术

目的 探讨眼球摘除或眼内容物剜出术后眼窝内陷伴结膜囊狭窄的同期整复手术方法及临床疗效。方法 对2007年8月至2010年5月收治35例患者施行Ⅱ期义眼座植入联合结膜囊成形术,其中7例结膜囊轻度缺损采用下、上穹窿结膜划开;23例结膜囊中度缺损采用异体巩膜;5例结膜囊重度缺损采用自体唇粘膜移植。所有病例结膜囊内眼模支撑,轻、中度组行睑缘临时缝合,术后1月拆线,自体唇黏膜移植组行部分睑缘粘连术,术后3个月分开眼睑,试装义眼。观察术后眼窝内陷矫正、结膜囊成形情况。随访3～6月。结果 术后所有患者眼窝内陷明显改善,结膜囊成形良好,穹窿深浅可,均可配戴适合的义眼,活动度可。结论 Ⅱ期义眼座植入联合结膜囊成形术是治疗眼球摘除或眼内容物剜出术后眼窝内陷伴结膜囊狭窄的理想手术。     

结膜囊成形术的研究进展

正常结膜囊是由附着在睑板后面的睑结膜、穹隆部结膜以及覆盖在眼球表面的球结膜所组成的囊状腔隙。由于各种原因引起的结膜囊变浅、变小而使义眼不能置入的称之为结膜囊狭窄,严重者结膜囊完全或近乎完全消失,则称结膜囊闭锁。黄发明等[1]将结膜囊狭窄分为四类:结膜囊缩小约1/3上下穹隆部变浅,上下睑轻度塌陷,结膜囊腔仅能装入小号义眼为Ⅰ°;结膜囊缩小1/2,上下穹隆部明显变浅,上下睑明显塌陷,结膜囊腔小号义眼也不能装入,需要将上下部加工磨小方能装戴为Ⅱ°;结膜囊腔重度缩小,仅有正常大小的1/3,上下穹隆完全消失,结膜囊底部垂直径<10mm,…     

带结膜muuller肌瓣转移修补术治疗顽固性义眼座暴露

目的 探讨顽固性羟基磷灰石义眼座暴露的处理方法。方法沿暴露的上半结膜缺损边缘在义眼座表面向上分离，两侧剪开形成结膜瓣，宽度与暴露区的直径相同，越过穹隆部后，继续在muuller肌与提上睑肌腱膜之间分离至睑板上缘，形成一含结膜、筋膜与muuller肌的带蒂组织瓣膜，覆盖于缺损区。结果随访6～12个月，5例顽固性义眼座外露均愈合良好，未再复发。结论带结膜的muuller肌瓣转移修补术是修补顽固性义眼座暴露的有效方法。     

带结膜müller肌瓣转移修补术治疗顽固性义眼座暴露

目的探讨顽固性羟基磷灰石义眼座暴露的处理方法。方法沿暴露的上半结膜缺损边缘在义眼座表面向上分离，两侧剪开形成结膜瓣，宽度与暴露区的直径相同，越过穹隆部后，继续在ｍüｌｌｅｒ肌与提上睑肌腱膜之间分离至睑板上缘，形成一含结膜、筋膜与ｍüｌｌｅｒ肌的带蒂组织瓣膜，覆盖于缺损区。结果随访６～１２个月，５例顽固性义眼座外露均愈合良好，未再复发。结论带结膜的ｍüｌｌｅｒ肌瓣转移修补术是修补顽固性义眼座暴露的有效方法。     

异种(牛)脱细胞真皮在结膜囊成形术中的临床应用

目的探讨采用异种(牛)脱细胞真皮作为移植材料行结膜囊成形术的安全性及效果。方法 9例(9眼)眼内容摘出术后结膜囊狭窄患者,行义眼座植入联合结膜囊成形术,术中应用Medpor义眼座作为眼窝填充材料、异种(牛)脱细胞真皮作为结膜生长支架移植材料。义眼座植入后行结膜囊成形术,将异种脱细胞真皮修剪后移植于结膜缺损处,放入眼模,缝合睑缘,术后抗炎治疗3个月拆除睑缘缝线。随访观察6～18个月,平均8个月。结果 9例患者术后均无明显排斥反应,无义眼座暴露;植片色泽逐渐红润,无坏死、脱落及明显收缩,结膜上皮爬行并覆盖植片表面。术后3个月植片近似正常结膜外观,结膜囊成形好,配戴义眼片后患眼外观良好,不滑脱。9例患者中8例效果良好,1例一般。结论采用异种(牛)脱细胞真皮作为结膜囊成形移植材料,手术操作方便,异种脱细胞真皮组织相容性好,结膜囊成形效果满意。     

义眼台联合皮片包裹眼模植入的结膜囊成形术

目的　观察联合中厚皮片包裹眼模倒向植入的义眼台植入结膜囊成形术的疗效。方法　对 41例 (4 1眼 )因外伤或炎症而摘除眼球致结膜囊完全闭锁或大部分消失的患者 ,行联合中厚皮片包裹眼模倒向植入的义眼台植入结膜囊成形术。结果　 41例 (4 1眼 )术后 3月切开睑裂及眼模表面的皮片 ,取出眼模。 40例新形成的结膜囊均能充分容纳义眼片 ,且可上、下、左、右转动 ,1例眼台顶部暴露。结论　联合中厚皮片包裹眼模倒向植入的义眼台植入结膜囊成形术是治疗结膜囊严重狭窄的有效方法。     

多层新鲜羊膜移植联合结膜囊成形术治疗结膜囊狭窄

目的:探讨多层新鲜羊膜移植术治疗结膜囊狭窄的临床疗效。方法:对52例(52眼)结膜囊狭窄、无法安装义眼的患者行结膜囊成形术,根据结膜囊狭窄的不同程度分为3组。将2~3层新鲜羊膜上皮面朝上移植于结膜缺损区,上下睑缘褥式缝合。每周打开眼睑并用荧光素试纸染色,观察结膜上皮生长情况。术后3mo拆除上下眼睑缝线,定制合适的义眼。结果:术后随访12mo。术后4wk51眼羊膜表面全部被结膜上皮覆盖,有1眼发生羊膜上皮融解,结膜上皮未愈。术后3moⅠ度结膜囊狭窄(A组)15眼全部治愈;Ⅱ度结膜囊狭窄(B组)17眼中15眼治愈,2眼好转;Ⅲ度结膜囊狭窄(C组)20眼中16眼治愈,3眼好转,1眼无效。Ⅲ度结膜囊狭窄患者手术成功率与Ⅰ度、Ⅱ度结膜囊狭窄患者比较,其差异无显著性意义(P>0.05)。结论:多层新鲜羊膜移植联合结膜囊成形术是治疗结膜囊狭窄的有效方法,同样适用于重度结膜囊狭窄。     

羊膜联合自体阔筋膜移植术修补羟基磷灰石义眼台暴露

目的:探讨羊膜联合自体阔筋膜移植术修补义眼台暴露的临床效果.方法:对13例羟基磷灰石义眼台植入术后发生义眼台暴露的患者进行HA义眼台修整削平,取自体阔筋膜植片覆盖于暴露的义眼台表面,以保存异体羊膜植片覆盖于阔筋膜表面,修补缺损区,术后5～8wk安装义眼片,术后随访观察6～18mo.结果:术后未再出现结膜裂开及义眼台暴露,义眼活动度良好.结论:羊膜联合自体阔筋膜移植术是修补义眼台暴露的有效方法.     

新鲜羊膜移植治疗义眼台暴露

目的评价新鲜羊膜移植冶疗羟基磷灰石义眼座暴露的临床疗效。方法彻底分离眼球筋膜囊缝合深埋或用异体巩膜覆盖暴露的义眼座,新鲜羊膜移植修补结膜囊缺损区。结果12例（12眼）羊膜植片生长良好,无感染,无融解。2月后结膜上皮覆盖羊膜表面,结膜囊愈合,全部安装义眼片。结论羊膜作为一种生物膜可以减轻炎症反应,阻止巩膜融解,有利于促进结膜上皮的爬行修复,用新鲜羊膜移植治疗义眼座暴露效果良好。     

The use of vicryl mesh in 200 porous orbital implants: a technique with few exposures

PURPOSE: To report the results of a wrapping technique for porous orbital implants by using polyglactin 910 (Vicryl) mesh (Ethicon Inc., Somerville, NJ, U.S.A.). METHODS: We retrospectively reviewed the records of 200 consecutive patients from one author's practice who received a polyglactin 910 mesh-wrapped porous orbital implant after enucleation or as a secondary implant between October 1, 1996, and April 15, 2001. We recorded potential problems that might be attributed to polyglactin 910 mesh both before pegging (excessive inflammatory response to the material, conjunctival thinning, and implant exposure) and after pegging (exposure of the implant around the sleeve, conjunctival thinning, and implant exposure other than adjacent to the peg). RESULTS: One hundred twenty-two men and 78 women underwent placement of a polyglactin 910 mesh-wrapped porous orbital implant. The average age at the time of implantation was 48.9 years (range, 11 to 85 years). The average follow-up interval in the 200 patients was 19.4 months (range, 2 to 80 months). Thirteen of the 200 patients had less than 6 months of follow-up, leaving 187 patients with an average follow-up of 20.5 months (range, 6 to 80 months). There were 76 primary enucleations and 124 secondary orbital implants. Thirty-seven patients received a Bio-Eye hydroxyapatite implant (HA) (Integrated Orbital Implants, San Diego, Calif), 97 received a synthetic FCI hydroxyapatite implant (FCI, Issy-Les-Moulineaux, France), and 66 received a Bioceramic implant (aluminum oxide-Al2O3) (FCI, Issy-Les-Moulineaux, France). One hundred fourteen patients (57%) underwent peg placement. The average time to pegging was 9.9 months (range, 6 to 16 months). Before pegging, 4 of 187 patients (2.1%) had implant exposure. Three of these exposures followed secondary orbital implant placement (2 Bio-Eye HA, 1 synthetic FCI3 HA) and one followed an enucleation (synthetic FCI3 HA). Two patients required a temporalis fascia graft and one required a scleral patch; the remaining defect closed spontaneously. One patient had conjunctival thinning 6 months after orbital implantation, which remained stable with no frank exposure for 36 months. No patient had excess socket inflammation. After peg placement, 3 additional patients had exposure of the implant around the peg site. There were no cases of conjunctival thinning or exposure of the implant other than adjacent to the peg site. CONCLUSIONS: Polyglactin 910 mesh is an excellent option as a wrapping material for porous orbital implants. It is simple to use, readily available, eliminates the need for donor tissue, does not require a second operative site, and it is less expensive than other currently available wrapping materials. We attribute our high success rate to our technique, which emphasizes proper placement of the implant within the Tenon space, suturing the extraocular muscles anterior to their normal anatomic sites, and meticulous closure of the Tenon capsule and conjunctiva in separate layers.     

Pericranium grafts for exposed orbital implants

PURPOSE: To report the use of autologous pericranium grafts to cover exposed orbital implants. METHODS: A two-center consecutive case series of exposed orbital implants covered with autologous pericranium grafts. A patch of pericranium was harvested from the parieto-occipital region and was placed over the implant within a pocket between the implant and the Tenon capsule, followed by layered closure of Tenon and conjunctiva. RESULTS: Four patients (2 women, 2 men) with a mean age of 37 years (range, 26 to 45 years) were included in the study. The mean follow-up period was 9.5 months (range, 7 to 12 months). In all cases, there was no recurrence of exposure and no donor site morbidity. A small pyogenic granuloma, arising from the conjunctival suture line, developed in one case. CONCLUSIONS: Autologous pericranium is a useful covering material for exposed orbital implants and may be used as an alternative to frontal periosteum.     

羟基磷灰石义眼台植入术临床应用

目的探讨眼球摘除或眼内容剜除羟基磷灰石义眼台植入术临床应用。方法眼内容剜除,后巩膜开窗,羟基磷灰石义眼台植入巩膜腔或肌锥内,分层紧密缝合巩膜、筋膜及结膜。结果2例2眼义眼台轻度外露,观察随访半年无发展,后行羊膜移植后愈合,其余21例21眼均无结膜裂开及义眼台外露,取得了满意的效果。结论眼内容剜除后一期植入义眼台于巩膜腔或肌锥内,术中充分降低巩膜、筋膜及结膜的张力,并紧密分层缝合是降低和预防结膜裂开,义眼台外露、脱出的关键。     

Our Experience With Dermofat Graft in Reconstruction of Anophthalmic Socket

Purpose: To present our experience with dermofat graft in reconstruction of anophthalmic socket.

Material and methods: In period from September 2005 until June 2009, eight patients have undergone orbital surgery of transplantation of dermofat graft. In six patients the dermofat graft was used as the secondary orbital implant after extrusion of hydroxyapatite orbital implant with major defect of bulbar conjunctiva. The other indication for the dermofat graft was correction of deep superior sulcus of the upper lid in anophthalmic socket in two patients. The graft was harvested from the left side of the belly. The size of the graft purposely exceeded the size of the defect to account for the expected tissue resorption.

Results: We experienced no major complication. Approximately 20–40% of dermofat graft reduction was noticed in 3-months period postoperatively. It took 6–8 weeks for the graft to fully epithelize from the conjunctival edge. Silicone conformer was introduced for that period of time. Subsequently, in two out of six patients with dermofat graft as the secondary implant, fornix had to be reconstructed later on with oral mucosa graft.

Conclusion: Dermofat graft is a valuable material in orbital reconstruction especially in anophthalmic socket.     

Dermis-fat graft as a movable implant within the muscle cone.

A 31-year-old woman had an extruding ocular implant in her right orbit. After surgically removing the implant, we transferred an autogenous dermis-fat graft from the hip region to the freshly prepared socket. The graft was sutured to the conjunctiva, and a conformer was placed in the socket. Eight weeks postoperatively, the dermis-fat graft was covered with conjunctival epithelium and a prosthesis was fitted successfully. No evidence of infection has occurred. This technique of using composite dermis-fat grafts in enophthalmos avoids recurrent extrusions and corrects the cosmetic problems produced by migrating or extruding implants.     

羊膜移植治疗义眼座植入术后结膜裂开伴结膜囊狭窄

目的:探讨羊膜移植治疗羟基磷灰石义眼座植入术后结膜裂开伴结膜囊狭窄的临床效果。方法:羟基磷灰石义眼座植入术后结膜裂开伴结膜囊狭窄患者16例16眼,手术松解结膜张力后,行保存羊膜移植于巩膜暴露区。结果:所有患者中,15例术后结膜愈合完全遮盖巩膜,结膜囊恢复理想深度;1例失败。结论:保存羊膜移植是治疗义眼座植入术后结膜裂开、保持理想结膜囊深度的有效方法。     

Consideration for eliminating conjunctival closure in the enucleation procedure

To compare post-operative results and complications in patients who undergo enucleation with or without suture closure of the conjunctiva. This was a retrospective chart review study. Review of 50 cases of enucleation surgery at the University of Arkansas for Medical Sciences and Arkansas Children’s Hospital between July 2011 and December 2014. Criteria for inclusion in the study were all cases of enucleation that had extraocular muscles attached to a spherical orbital implant with or without conjunctival closure, and at least 2 months of postoperative follow up. Post-operative complications were evaluated. A total of 36 cases fulfilled the criteria for inclusion in the study; 12 cases with direct sutured layered direct closure of Tenon's and then conjunctiva and 24 cases with Tenon's capsule sutured closure but without direct conjunctival sutured closure. No implant complications were identified in either group (p = 1.0). Mean follow-up for all groups was 16.71 months (range 2 to 43 mo., SD 11.94). Mean follow up for the non-closure group was 14.42 months (range 2.25 to 36 mo., SD 10.35). Two cases in the conjunctival closure group developed a conjunctival cyst, affecting prosthesis fit, approximately 3 months postoperatively: no such cysts were identified in the non-conjunctival closure group. Fisher exact test for cyst formation between the two groups was not statistically significant (p = 0.1048). Direct conjunctival closure following enucleation surgery does not appear to increase the risk of extrusion, exposure, or infection. Foregoing direct closure decreases surgical time and reduces cost. It is unclear if this decreases conjunctival cyst formation.     

Primary placement of a motility coupling post in porous polyethylene orbital implants

The placement of a motility coupling post (MCP) to integrate the prosthesis with a porous orbital implant may enhance prosthetic motility following enucleation. Previously, MCP placement has required a second operation usually at least 6 months following enucleation. We developed a technique to place an MCP reliably and safely into a porous orbital implant at the time of enucleation. Eligibility criteria included high motivation to achieve maximal prosthetic motility, adequate conjunctiva to ensure desirable wound closure, and isolation of the 4 rectus muscles. Enucleation was performed in standard fashion with implantation of a conical porous polyethylene orbital implant. Implanted MCPs protruded anteriorly 2 to 4 mm. The Tenon capsule and conjunctiva were closed in separate layers over the protruding MCP. Thirty-two patients underwent primary placement. Follow-up ranged from 1 to 33 months (mean, 15 months). Nine MCPs spontaneously exposed within the first 4 months. One additional post autoexposed at 12 months. Three patients underwent a secondary procedure to expose the MCP. There were no cases of infection, explantation, or gross MCP malposition. Minor complications included pyogenic granuloma (n=2) and conjunctival overgrowth (n=1). All patients were successfully fit with prostheses. Prosthetic motility was acceptable in all patients. Motility coupling post placement at the time of enucleation surgery in selected patients is an effective, efficient surgical option. Arch Ophthalmol. 2000;118:826-832     

Minimally invasive pterygium surgery: a new approach for prevention of recurrence

PURPOSE: To introduce a novel approach for pterygium excision, to report recurrence rates, and to compare with conjunctival autografting. DESIGN: A comparative, prospective clinical case series design was used. METHODS: The study population consisted of 155 patients with unilateral primary or recurrent pterygia. All patients underwent pterygium excision, either by conventional conjunctival autografting (Group A) or by the minimally invasive pterygium excision (MIPE) technique (Group B). The new technique involves making a limbal incision of the conjunctiva through the body of pterygium, removing the head of the pterygium by blunt dissection, keeping the adjacent Tenon capsule intact, and performing a small conjunctival autograft to cover the epithelial defect. The recurrence rate of each technique was compared statistically. RESULTS: There were 84 patients in Group A and 71 patients in Group B. The recurrence rates were 18% at 1 year after surgery in the conjunctival autografting technique and 4.2% in the MIPE technique. The MIPE technique had significantly lower recurrence rates compared with conjunctival autografting technique (p<0.0001). CONCLUSIONS: The MIPE technique had lower recurrence rate and fewer postoperative complications than the conjunctival autografting technique. Preserving the Tenon capsule and minimizing conjunctival excision in pterygium surgery does not appear to increase the recurrence rate in the 1- year period. However, the effectiveness of this technique in preventing recurrences needs to be proven with more than 1-year results, which we plan to report in the future.     

Complications of primary placement of motility post in porous polyethylene implants during enucleation

PURPOSE: To evaluate the complications associated with the primary placement of a motility coupling post (MCP) in spherical porous polyethylene (PP) implants at the time of enucleation. DESIGN: Retrospective, interventional case series. METHODS: The records of all patients who had undergone primary enucleation and spherical PP implant with MCP insertion, and who were followed for at least six months were reviewed. The MCP was screwed to a wrapped implant to protrude 3 mm to 4 mm anteriorly. After placing the implant into the orbit, the extraocular muscles were sutured to the implant, and the Tenon capsule and conjunctiva were closed onto the MCP. When the MCP was not exposed spontaneously within two months after surgery, it was externalized with a conjunctival cut-down procedure. RESULTS: The study included 52 patients (29 male, 23 female; age range, three to 76 years). The MCP became exposed spontaneously in 10 patients (19%). In the early postoperative period, we recorded nine complications in seven patients (13%), which might be related to primary MCP placement. These included prominent MCP decentration associated with implant motility restriction (6%), preseptal cellulitis (4%), and conjunctival prolapsus (8%). An ocular prosthesis was fit successfully onto the MCP in 51 patients. During the late period, 22 complications occurred in 15 patients (29%), including excessive discharge (15%), MCP decentration (4%), implant exposure (6%), implant infection (2%), pyogenic granuloma (8%), conjunctival overgrowth over the MCP (2%), conjunctival discoloration (4%), and lax eyelid syndrome (2%). Mean follow-up time was 34 months (range, six to 68 months). CONCLUSIONS: Although MCP placement in the spherical PP implant during enucleation is a useful technique, it may be associated with complications such as MCP decentration, excessive discharge, exposure, and infection of the implant.