Extrusion and infection incidence in scleral buckling surgery with the use of silicone sponge: to soak or not to soak? An 11-year retrospective analysis

PURPOSE: To assess the incidence of extrusion and infections of encircling silicone sponges in scleral buckling surgery for retinal detachment with and without the use of an intraoperative antibiotic soaking procedure. METHODS: The authors performed a retrospective analysis reviewing the charts of 1127 patients who underwent episcleral buckling surgery operated by the same surgeon in three different institutions during a period of 11 years. The authors reviewed the charts of patients treated with a single episcleral silicone sponge (Labtician) indentation in three different models. The infection prophylaxis on the operating field was the same in all cases and only since February 1997 was the silicone sponge preoperatively treated with an antibiotic soaking procedure. RESULTS: No immediate postoperative infections were reported in the operated eyes. Three eyes had an implant extrusion and in all these cases silicone sponge removal was performed. All three extrusion cases developed when sponge soaking was not adopted. CONCLUSIONS: The data indicate that the soaking procedure does not decrease extrusion and infection incidence in scleral buckling surgery when both accurate surgical technique and disinfection prophylaxis are performed.     

预塑形钛网植入对眼眶骨折手术治疗预后的影响

目的：探讨与常规钛网手术植入相较,3D打印的预塑形钛网在眼眶骨折修复中的有效性和安全性。

方法：选择2015-06/2016-03来我院眼科就诊的眼眶骨折患者72例72眼进行回顾性分析。全部病例分为两组,其中预塑形钛网植入组(观察组)40例40眼,常规钛网植入组(对照组)32例32眼。对照组由医师根据经验手工弯制和塑形衬垫钛网植入患侧眼眶; 观察组由医师直接在患侧眼眶植入3D打印的预塑形钛网。在术后1、3、6mo复查眼球内陷、复视、眼球运动恢复情况,比较两种方法各观察指标在手术前后不同时间点的组内差异,及同一时间点两种材料间各指标的组间差异。

结果：观察组和对照组眼球内陷治愈率分别为84%、59%,两组相比,差异有统计学意义(P<0.05 ); 观察组和对照组复视治愈率分别为80%和70%,两组相比差异无统计学意义(P>0.05 ); 观察组眼球运动受限治愈率为73%,对照组治愈率为66%,两组相比,无显著统计学意义(P>0.05)。术后随访期间两组均无感染,无钛网移位、脱出、变形及排斥等并发症。

结论：预塑形钛网植入眼眶骨折患者手术术中无需塑形,可缩短手术时间,重建眶壁确切,减少手术并发症,提高疗效。     

Late infection of hydroxyapatite orbital implants

BACKGROUND: Exposure and minor complications of hydroxyapatite orbital implants are common. Infection appears to be rare and fibrovascular ingrowth into hydroxyapatite implants may make infection and extrusion less likely than with other types of orbital implant. METHODS: We describe three cases of chronic low-grade infection of hydroxyapatite implants, occurring late after apparently uncomplicated surgery, with tiny or inapparent areas of conjunctival loss or exposure. RESULTS: Two of the three cases grew Staphylococcus oureus on culture. All three implants ultimately needed to be removed. A characteristic histological pattern was seen, with abrupt transition between vascularized and abscessed implant. CONCLUSIONS: Chronic infection of hydroxyapatite implants can occur late, in the absence of large conjunctival defects, or other obvious risk factors.While exposure of the implant to pathogens through a breach in the conjunctiva may have been a factor, it appeared that the infection may have arisen in an avascular portion of the implant prior to the conjunctival breakdown in one or more of these cases.     

A review of the outcome of upper lid lowering for eyelid retraction and complications of spacers at a single unit over five years

AIM To review the outcome of upper lid lowering for eyelid retraction at a single unit over five years and to report the high complication rate with mersilene mesh as a spacer material. METHODS We retrospectively reviewed the case records of 48 patients who underwent upper lid lowering for lid retraction between January 1995 and January 2000. RESULTS The indication for surgery was eyelid retraction secondary to dysthyroid disease in 41 patients, seventh nerve palsy in 3 cases, overcorrection of ptosis elsewhere in 3 cases and previously treated orbital lymphoma in one patient. A good result was achieved in 80% with a single procedure. Undercorrection occurred in 10% and overcorrection occurred in 8%. Spacer material, either mersilene mesh or more recently vicryl, was used in 42% of lids. Late extrusion of mersilene mesh occurred in 20% of lids that had a spacer inserted an average of 18 months postoperatively. CONCLUSIONS The high extrusion rate with mersilene was unacceptable and the alternative spacer material vicryl is now used.The possibility of revisional surgery because of under- or overcorrection should be explained to patients.     

Biofilm on scleral explants with and without clinical infection.

PURPOSE: Biofilm is a glycocalyx matrix secreted by microorganisms that confers protection against host defenses and antimicrobial treatment. Biofilms have been implicated in the persistence of scleral buckle infections. This study aimed to evaluate the incidence of biofilm growth on scleral explants and the relationship to explant infection. METHODS: Scleral explants were obtained following removal for infection or extrusion or during repeat surgery. Explants were fixed with rhuthenium red and examined by scanning electron microscopy to visualize the glycocalyx. RESULTS: A total of 28 explants were analyzed. Ten were removed because of either infection or extrusion and 18 were removed during repeat surgery. The mean time to removal of explants was 36 months in the infection/extrusion group and 12 months in the others. Biofilm was identified on five explants-two removed because of infection/extrusion and three for surgical indications. Bacterial elements were identified in all biofilms. CONCLUSIONS: Biofilm was identified on explants removed because of infection or exposure and on explants removed for technical reasons at repeat surgery. This implies that bacterial contamination and biofilm formation occur without exposure of the explant, probably due to inoculation at the time of initial surgery. Biofilms may contribute to the persistence of scleral explant infections but a causative role in buckle extrusion is unproved.     

Corneal-scleral melt in association with cataract surgery and intraocular lenses: a report of four cases

Four patients with rheumatoid arthritis had cataract extraction with implantation of an intraocular lens (IOL). Postoperatively three patients developed progressive scleromalacia perforans. All three cases required patch grafting of the sclera and two of them developed progressive melting of the sclera and graft. The fourth case involved progressive corneal melting with extrusion of the IOL despite treatment with penetrating keratoplasties. All four cases developed retinal detachments with loss of vision and three of the eyes were subsequently enucleated. We describe each case and discuss the clinicopathologic correlations of this condition. The need for careful evaluation of rheumatoid arthritis patients with cataract surgery and IOL implantation is emphasized.     

慢性中耳炎术后听力改善的临床分析

目的 观察慢性中耳炎(chronic otitis media, COM)患者术后听力改善情况,并探讨可能的影响因素.方法 回顾分析经手术治疗的COM患者148例.术后随访1年.98例患者术中行听骨链重建,术中置入部分听骨赝复物(partial ossicular replacement prothesis, PORP)84例,置入全听骨赝复物(total ossicular replacement prothesis, TORP)3例,置入自体软骨11例.结果 术后置入PORP、TORP及自体软骨患者气骨导差小于20 dB者分别占55.95%、54.5%和66.7%.假体听骨脱出率为1.1%.术前双侧中耳炎患者术后听力改善不及单侧中耳炎患者(P=0.048).结论 COM手术治疗对于改善听力及预防中耳炎复发效果明显.置入假体听骨链时,推荐在鼓膜与假体听骨链间放置软骨.双侧COM患者术后应加强随访.     

Bovine hydroxyapatite orbital implant: a preliminary report

PURPOSE: To determine the safety and efficacy of bovine hydroxyapatite as an orbital implant material. METHODS: Prospective, consecutive case series of patients undergoing enucleation, evisceration, or secondary orbital implantation. A motility peg was placed in all consenting candidates. Patients were followed 1 week, 1 month, and several months after surgery for signs of inflammation, infection, extrusion, or other complication. RESULTS: Twenty-seven patients received a bovine hydroxyapatite orbital implant. Magnetic resonance imaging was obtained in 3 patients (3 orbits) approximately 4 weeks after surgery and showed signs of peripheral fibrovascular ingrowth in all three cases. Magnetic resonance imaging was obtained in 9 patients (9 orbits) 4 to 12 months after surgery and showed signs of incomplete fibrovascular ingrowth in 1 of 9 (11%) cases, subtotal fibrovascular ingrowth in 2 of 9 (22%) cases, and complete fibrovascular ingrowth in 6 of 9 (67%) of cases. Complications included postoperative chemosis in 3 cases (11%) and exposure requiring reoperation in 2 cases (7%). Motility peg placement was performed successfully in 5 patients (5 orbits). CONCLUSIONS: Bovine hydroxyapatite appears to be a safe and effective orbital implant material. The material appears to be biocompatible and nonallergenic. Bovine hydroxyapatite allows for fibrovascular integration and motility peg placement.     

Lacrimal canalicular bypass surgery with the Lester Jones tube

PURPOSE: To analyze outcomes of lacrimal bypass surgery with the Lester Jones tube and to determine the level of patient satisfaction. DESIGN: Interventional case series. METHODS: We retrospectively analyzed the outcomes of 49 patients (42 patients) who underwent conjunctivodacryocystorhinostomy between 1984 and 2002. Data were obtained from medical records, semistructured phone interviews, and written questionnaires. RESULTS: The causes of lacrimal obstruction were idiopathic and trauma, congenital agenesis, infection, inflammation, herpes, basal cell carcinoma, radiation therapy, penicillin-induced Steven-Johnsons syndrome, systemic chemotherapy, and facial nerve palsy. Patients had undergone previous failed lacrimal surgery in 21% of cases. Complete or significant improvement of epiphora was achieved in 94% of cases. Best results were obtained for trauma and herpetic obstruction. Complications were frequent and included extrusion, recurrent extrusion, malposition, obstruction, discomfort, infection, and diplopia. Of the 32 patients who were interviewed, 70% were satisfied with the result, 35% reported tube maintenance to be troublesome, and all patients were pleased with the esthetics of the Jones tube. CONCLUSIONS: Conjunctivodacryocystorhinostomy with the insertion of a Jones tube can be expected to improve epiphora significantly in most cases and remains the standard treatment for canalicular obstruction. Complications occur in most cases, requiring replacement, repositioning, and cleaning of the tube by the ophthalmologist over an indefinite period of time. Despite frequent complications, patients will usually be satisfied if they obtain a comfortable, dry eye. If, however, a completely dry eye is not achieved, frequent complications may contribute to patient dissatisfaction.     

Diagnosis and treatment of cytomegalovirus iridocyclitis without retinal necrosis

AIM: To describe the diagnostic and therapeutic management of cytomegalovirus (CMV) anterior uveitis unassociated with retinal necrosis in immunocompetent patients. METHODS: Patients referred between 2001 and 2003 for management of unilateral, chronic, recurrent uveitis associated with secondary glaucoma underwent extensive investigation including laboratory tests for herpes virus infections. Specific antiviral treatment was initiated in all cases and the level of ocular inflammation was evaluated during the follow up. RESULTS: Five patients, three men and two women, were included. Median age was 50 years old (range 30-80 years). Anterior unilateral uveitis without iris atrophy was observed in all cases. Uveitis was chronic in three cases and recurrent in two cases. Glaucoma was observed in all patients with a median intraocular pressure of 30 mm Hg (range 22-43 mm Hg). Five patients responded initially to specific anti-CMV therapy. Even though glaucoma surgery was necessary in two cases, both ocular inflammation and glaucoma were controlled in all cases. Relapses occurred in three cases after cessation of therapy, requiring prolonged maintenance therapy with valganciclovir. CONCLUSIONS: CMV infection and specific antiviral therapy should be considered in all cases of relapsing or chronic iridocyclitis and secondary glaucoma. Maintenance regimens of valganciclovir may be necessary to prevent further relapses.     

内眼手术后真菌性眼内炎的临床及预后分析

目的分析内眼手术后真菌性眼内炎患者的临床表现、病理改变、治疗及预后,探讨影响患者预后的相关因素。方法回顾性分析9例内眼手术后真菌性眼内炎患者的临床表现、病理改变、治疗过程及预后。结果 9例患者中,涂片或病理活检及培养均真菌阳性者4例,单纯真菌培养阳性者2例,单纯病理活检阳性者3例。培养阳性的6例中烟曲霉菌感染者3例,腹孢镰刀菌感染者1例,毛霉菌感染者1例,木贼镰刀菌感染者1例。6例行眼球摘除术;1例拒绝行眼球摘除术出院;1例眼内炎症缓解后出院;1例病情稳定后行硅油填充及取出术,术后视力光感。结论内眼手术后由真菌引起的眼内感染治疗棘手,由曲霉菌属引起者预后不良。     

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.     

Evisceration and secondary enucleation with implantation following endophthalmitis

PURPOSE: Primary evisceration followed by secondary enucleation and implant placement makes it possible to use the sclera of a patient with endophthalmitis. This sclera will be used for secondary implantation. PATIENTS AND METHODS: Four patients with endophthalmitis and corneal perforation (bacterial infection in three cases and fungal infection in one case) underwent evisceration and, 4-6 weeks later, enucleation. During the secondary enucleation, the sclera was recovered and used as wrapping material for the alumina implant (Al2O3) (20 and 22 mm in diameter). Between the two operations, the patients were treated with systemic and topical antibiotics or antifungal agents. RESULTS: No complications were observed for both the first and the second operation. Enucleated sclera was crumpled and bent in all four cases. The sclera was spread out and used as wrapping material. Prosthetic fitting was performed 4-5 weeks after the second operation. No complications have been observed to date (10 to 32 months follow-up). CONCLUSION: Primary implantation following endophthalmitis is debatable because an infectious complication cannot be excluded. The use of sclera for implant wrapping decreases the risk of implant extrusion, especially when the conjunctiva and Tenon's facia have been weakened by previous surgery or infection. Primary evisceration with a conformer placement followed by enucleation and implantation is an ideal solution in endophthalmitis because this technique allows the use of patient's own sclera.     

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.     

Congenital ptosis: results of surgical management

Purpose: To determine the visual and cosmetic outcome following the surgical correction of isolated congenital ptosis. Methods: A retrospective review of the outcome of isolated congenital ptosis corrected under the supervision of one surgeon at The Children's Hospital, Camperdown, between January 1983 and January 1993 was examined. Some 65 patients with 80 involved eyes were identified; 30 eyes underwent a levator resection procedure, 40 eyes underwent a brow suspension using donor stored fascia lata, and in 10 eyes a brow suspension was performed using mersilene mesh. Results: In 78 eyes of 63 patients, a good cosmetic result was achieved. In two patients (two eyes) a poor cosmetic result was achieved. These two patients refused further surgery following an undercorrection of their initial ptosis. The recurrence rates for the primary procedures were 16.7% for levator resection procedures, 35% for brow suspension procedures using donor fascia lata, and 30% for brow suspension surgery using mersilene mesh. Some 35.3% of eyes following mersilene slings required further surgery for granulomas and exposed mersilene mesh compared with 6% having similar complications with stored fascia lata. Nine patients (11.25%) had reduced visual acuity (one line or more on the Snellen chart or its equivalent with the other tests used) on the operated side. Only one patient was found to have significant astigmatism. Conclusions: An acceptable cosmetic result was achieved with one operation in 75.3% of cases. In 20.8% of cases a second operation was required and in 3.9% of cases three or more operations were required. This series supports the view that where possible, levator resection is the preferred form of surgery to correct congenital ptosis. When the levator function is inadequate, brow suspension is performed. The use of donor fascia lata resulted in a good cosmetic appearance with a low occurrence of surgical side effects. Amblyopia, when strictly defined, occurred in 11.25% of eyes despite early surgery for severe cases and intensive amblyopia therapy. Management requires repeated follow up for early detection and introduction of occlusion therapy or surgical ptosis correction.     

Congenital ptosis: results of surgical management

PURPOSE: To determine the visual and cosmetic outcome following the surgical correction of isolated congenital ptosis. METHODS: A retrospective review of the outcome of isolated congenital ptosis corrected under the supervision of one surgeon at The Children's Hospital, Camperdown, between January 1983 and January 1993 was examined. Some 65 patients with 80 involved eyes were identified; 30 eyes underwent a levator resection procedure, 40 eyes underwent a brow suspension using donor stored fascia lata, and in 10 eyes a brow suspension was performed using mersilene mesh. RESULTS: In 78 eyes of 63 patients, a good cosmetic result was achieved. In two patients (two eyes) a poor cosmetic result was achieved. These two patients refused further surgery following an undercorrection of their initial ptosis. The recurrence rates for the primary procedures were 16.7% for levator resection procedures, 35% for brow suspension procedures using donor fascia lata, and 30% for brow suspension surgery using mersilene mesh. Some 35.3% of eyes following mersilene slings required further surgery for granulomas and exposed mersilene mesh compared with 6% having similar complications with stored fascia lata. Nine patients (11.25%) had reduced visual acuity (one line or more on the Snellen chart or its equivalent with the other tests used) on the operated side. Only one patient was found to have significant astigmatism. CONCLUSIONS: An acceptable cosmetic result was achieved with one operation in 75.3% of cases. In 20.8% of cases a second operation was required and in 3.9% of cases three or more operations were required. This series supports the view that where possible, levator resection is the preferred form of surgery to correct congenital ptosis. When the levator function is inadequate, brow suspension is performed. The use of donor fascia lata resulted in a good cosmetic appearance with a low occurrence of surgical side effects. Amblyopia, when strictly defined, occurred in 11.25% of eyes despite early surgery for severe cases and intensive amblyopia therapy. Management requires repeated follow up for early detection and introduction of occlusion therapy or surgical ptosis correction.     

改良式肌锥内义眼台植入术

目的观察改良式肌锥内羟基磷灰石（HA）义眼台植入的临床效果。方法96例眼球摘除和眼内容摘除术后采取HA义眼台植入肌锥内,义眼台前部采用巩膜或阔筋膜完全包埋。结果术后随访3～24个月,无发生义眼台感染、暴露及脱出者,活动度达到预期目的。外观饱满,双眼对称性好。结论采取HA义眼台植入肌锥内,前部采用巩膜或阔筋膜包埋固定的方法,并发症少、疗效良好。     

The quasi-integrated porous polyethylene orbital implant

PURPOSE: To describe a new quasi-integrated porous polyethylene orbital implant that combines the advantages of host tissue incorporation and improved motility with a single-stage surgery. METHODS: Twenty-four consecutive patients undergoing primary or secondary orbital implantation received the quasi-integrated porous polyethylene implant. Approximately 6 weeks after implantation, a custom-fitted prosthesis was made by an impression technique to provide a "lock-and-key" fit with the orbital implant. Postoperative complications and motility of the prosthetic shell were evaluated. RESULTS: During the 27-month period between December 1998 and March 2001, 24 patients received the quasi-integrated porous polyethylene implant as a buried orbital implant. Thirteen patients received the implant as a primary orbital implant after either evisceration or enucleation and 11 patients received the implant as a secondary orbital implant. Follow-up ranged from 3 months to 30 months, with an average of 16.9 months. All patients were considered to have good motility of their prosthetic shell at their final follow-up visit. No cases of implant extrusion or migration were noted. Two patients required deepening of their inferior fornix to accommodate the increased motility of their prosthesis. CONCLUSIONS: The new quasi-integrated porous polyethylene orbital implant provides improved motility without the need for secondary placement of pegs or screws. It has the advantage of biocompatibility, allowing host tissue incorporation to resist implant migration and extrusion. The implant is available in three sizes: small, medium, and large, approximating the volume of a 16-, 18-, and 20-millimeter sphere, respectively.     

Functional results and complications of Mersilene mesh use for frontalis suspension ptosis surgery

AIMS: To assess the functional results and complications of Mersilene (polyester) mesh frontalis sling suspension to correct poor levator function ptosis. METHODS: Retrospective case series. 32 eyelids of 20 patients (12 children and eight adults). RESULTS: Follow up 1-69 months (mean 32). CHILDREN: eight patients had bilateral and four unilateral surgery (20 eyelids). Good long term functional results were achieved in 73% (8/11 children) and 77% (14/18) eyelids. Two children had early postoperative wound infection requiring removal of mesh in one; the other was lost to follow up following medical treatment. ADULTS: four patients had bilateral and four unilateral surgery (12 eyelids). Good long term functional results were achieved in 75% (6/8 patients, 9/12 eyelids). One postoperative wound infection and one mesh exposure were treated definitively by surgical excision of mesh. CONCLUSION: Mersilene mesh provides good functional results but up to 20% of patients have early soft tissue complications. Other materials such as monofilament suture or autogenous fascia lata should be considered.     

Lund-Mackay评分预测慢性泪囊炎合并慢性鼻窦炎同期手术疗效的作用

目的：分析Lund-Mackay评分预测慢性泪囊炎合并慢性鼻窦炎同期手术疗效的作用。

方法：将我院2016-05/2019-03就诊的慢性泪囊炎合并慢性鼻窦炎的患者共92例92眼纳入前瞻性单盲研究,根据Lund-Mackay评分将患者病情分为轻(22例)、中(34例)、重(36例)三组,每组随机分为同期手术组和分期手术组。比较同期手术与分期手术的手术疗效和并发症情况。

结果：轻度和中度慢性泪囊炎合并慢性鼻窦炎患者,同期和分期手术手术有效率、并发症均无差异(P>0.05); 重度慢性泪囊炎合并慢性鼻窦炎患者,分期手术有效率高于同期手术(94% vs 61%,P<0.05),并发症发生率低于同期手术(P<0.05)。

结论：根据Lund-Mackay评分,轻度和中度慢性泪囊炎合并慢性鼻窦炎患者建议同期手术,重度患者建议分期手术。