同种异体巩膜修补鼓膜的疗效观察

1984～1993年，我们用同种异体巩膜作为移植物修补鼓膜穿孔51例（耳），用自体组织（领肌筋膜、耳屏软骨膜）修补15例（耳）。经对其疗效进行比较观察，发现两者成功率无显著差异。报告如下。1临床资料66例均为鼓膜紧张部大穿孔，有少许残边。移植物使用同种异体巩膜者sl例（耳）；用自体额肌筋膜、耳屏软骨膜者15例（耳）。同种异体巩膜取自本院因外伤行眼球摘除术，无全身急、慢性传染病患者的眼球。将巩膜内、外表层刮除后仅留基质层，保存于95％酒精中备用。2手术方法和结果全部病例均在手术显微镜下使用内植法行鼓膜修补术。术后10d抽…     

顶端巩膜覆盖在羟基磷灰石义眼座植入术中的应用

目的 探讨羟基磷灰石义眼座植入术中结合顶端巩膜覆盖的方法及疗效。方法 对37例行回顾性分析,均行羟基磷灰石义眼座植入术中采用顶端巩膜覆盖,术后随访6～24个月,观察术后效果。结果 均未发生义眼座暴露、感染、脱出、移位;无眶内感染及上睑下垂现象。结论 羟基磷灰石义眼座植入术中使用顶端巩膜覆盖是安全有效的,可以避免义眼座暴露等并发症。     

眼球贯通伤并眶内金属异物1例

患者,男,44岁,因被砂轮碎片崩伤左眼,肿痛出血,视物不清2h,于2014年6月19日入住天津市眼科医院。患者否认既往全身疾病史和手术史。入院全身检查未见明显异常。眼部检查：右眼视力1．0,左眼视力0．2。右眼前节和眼底检查未见明显异常。左眼眼睑肿胀,皮下出血,下睑鼻侧见不规则形状伤口,8mm×5mm。左眼结膜弥漫充血,结膜下出血。鼻下方巩膜可见不规则形伤口,4mm×3mm,未见眼内容物脱出,可见伤口内色素膜。左眼角膜透明,上皮光滑完整。前房深浅可,房水闪光（＋）。虹膜无脱出,无嵌夹,瞳孔圆,直径约3mm,直、间接光反应迟钝。晶状体轻度混浊。玻璃体混浊,眼底窥不清。眼球运动尚自如。眼眶CT检查显示：①左眼眶肌锥内邻近内直肌处有一长条形高密度异物;②左侧玻璃体和肌锥内小气泡,考虑眼球后壁损伤（图1）。入院诊断：①左眼球贯通伤;②左眼巩膜穿通伤;③左眼玻璃体积血;④左眼眶内异物;⑤左眼睑裂伤。入院当日急诊行左眼巩膜伤口修复＋眼睑裂伤修复术。术眼球后阻滞麻醉。术中见一长约5mm的巩膜伤口,位于8点子午线方向,距离角膜缘后约4mm。伤口未横跨直肌,8-0线间断缝合。8-0可吸收缝线连续缝合结膜伤口,间断缝合下睑皮下组织。5-0缝线间断缝合下睑皮肤伤口。术后左眼视力0．2,眼睑肿胀,皮下淤血,下睑伤口对合良好,缝线在位,结膜弥漫充血,结膜下出血,角膜轻度水肿,前房深度正常,房水闪光（＋）,虹膜无脱出,无嵌夹,瞳孔圆,直径约3mm,对光反应迟钝,晶状体轻度混浊,眼底窥不清,眼球运动自如。给予抗炎、抗感染对症治疗。并预防应用破伤风抗毒素。考虑患者左眼贯通伤病史明确,CT检查提示眶内异物,急诊行左眼巩膜伤口修复术后10d,眼球情况基本稳定,考虑行左眼眶内异物取出术。于2014年7月3日全麻下行左眼眶内异物取出术,做牵引线固定眼球于外下转位,暴露鼻上方穹窿部结膜,剪开鼻上方球结膜,沿眶缘分离并打开眶隔,于鼻上方眼球后发现金属异物,未嵌顿于眼球内,远端位于眶脂肪内,镊子夹出20mm×2mm金属异物,压迫止血后,连续缝合鼻上方球结膜,手术顺利结束。术毕给予绷带加压包扎。术后第1天,左眼视力0．3,下睑可见皮肤瘢痕,结膜充血水肿,巩膜伤口、结膜术口对合良好,缝线在位,角膜透明,前房闪光（＋）,晶状体轻度混浊,玻璃体混浊,眼底窥不清,眼压Tn,眼球上转及内转受限,眶压正常。术后7d行眼部B超示左眼玻璃体积血,建议患者考虑行玻璃体切除手术。后转入玻璃体视网膜科进一步治疗。     

球结膜、筋膜瓣错层缝合对青光眼小梁切除术后滤泡弥散程度的影响

目的探讨不同球结膜筋膜瓣缝合方式对青光眼小梁切除术后滤泡弥散程度的影响。方法治疗组:女59眼,男41眼,平均57岁。其中急性闭角型青光眼缓解期58眼,慢性闭角型青光眼8眼,原发开角型青光眼34眼。对照组:女58眼,男42眼,平均59岁。其中急性闭角型青光眼缓解期56眼,慢性闭角型青光眼9眼,原发开角型青光眼35眼。采用日产TOPCON裂隙灯观察不同球结膜筋膜瓣缝合方式青光眼小梁切除手术患者术后1个月、6个月、12个月、18个月、24个月时的滤泡弥散程度,探讨缝合方式与滤泡弥散程度的关系。手术方法（术前准备和小梁切除部分省略）：做切口时用2％利多卡因紧贴结膜下浸润麻醉,角膜缘上7.5?mm剪开球结膜,向角膜缘方向钝性分离约2?mm,剪开筋膜,勿损伤上直肌鞘膜,缝合时先行将筋膜瓣用8／0可吸收缝线对位连续缝合,后将结膜瓣用8／0可吸收缝线连续缝合,达到筋膜瓣和结膜瓣错层缝合。结果两组术后1～6个月均有良好滤过泡,两组间差异无统计学意义（P>0.05）。术后12个月、18个月、24个月在滤泡弥散程度两组间差异有统计学意义,并且随时间延长显著性增大（P<0.05）。结论治疗组（球结膜筋膜瓣错层缝合）能有效防止滤泡的局限,可明显增加患者的舒适度,有利于眼压的远期控制。     

自体巩膜双层覆盖羟基磷灰石生物陶瓷义眼台植入术的回顾性分析

目的本文旨在通过回顾性分析观察自体巩膜双层覆盖羟基磷灰石生物陶瓷义眼台植入术患者的疗效。方法回顾性分析2017年9月至2020年9月30例眼内容物剜除术后选择自体巩膜双层覆盖义眼台一期植入的临床数据。连续随访6~12个月,观察了该项手术的疗效及术后相关并发症。结果所有病例均伤口痊愈良好,义眼台无任何暴露或外力移位,眼眶饱满,眼球运动程度适中,患者美容满意,并发症少。结论自体巩膜双层覆盖羟基磷灰石生物陶瓷义眼台植入术对比其他手术方法更简便,术后义眼台不易暴露,眼球运动程度好,这是一种比较成熟的手术治疗方式。     

后巩膜加固术的术前准备和术后观察

2000年3月至2001年12月我院共实施后巩膜加固术56例、102眼,男32例、59眼,女24例、43眼,8～48岁,平均21.8岁.术前视力(裸眼)指数/眼前～0.4,平均术前视力0.12,术前眼轴24.48～33.50mm,平均28.56mm.术后眼轴24.46～33.42mm,平均28.48mm.手术方法:采用异体巩膜材料,根据眼轴长度将异体巩膜做成长50～65mm,宽7～8mm的条带,以外眦为底沿角膜缘切开,穿越下直肌、下斜肌、外直肌、上直肌,展平后移至球后部,将异体巩膜上下端缝合固定于上、下直肌止后2mm,偏鼻侧的巩膜浅层.松紧适度,术毕结膜下注射妥布霉素2万U,氟美松2mg,包扎术眼.治疗结果:手术前后视力＜0.1分别为42眼、30眼,0.1～0.2为50眼、60眼,0.25～0.40为10眼、12眼.术后2周内70%以上的患者视力提高.手术前后眼轴对比:眼轴≤27,手术前后分别为26眼、25眼,27.01～28为18眼、21眼;28.01～29手术前后均为26眼,29.01～30均为9眼;＞30术前30眼,术后21眼.     

额肌筋膜瓣悬吊治疗重度睑下垂

2001年2月至2003年5月,我们采用额肌止点下移缝合于睑板治疗上睑提肌肌力小于3mm的睑下垂55例、65眼,效果满意.65眼中先天性58眼,外伤性7眼,双眼10例,单眼45例,男25例,女30例,8～60岁,平均19岁.术前常规检查测量睑裂高度,睑提肌、额肌及上直肌功能,检测Bell现象是否正常.术前睑下垂2～3mm 25眼,4～6mm 30眼,大于6mm 10眼.睑提肌肌力均在3mm以下,额肌活动幅度均在8mm以上,Bell现象正常.手术设计皮肤切口,上睑切口高度,双眼者按重睑手术设计,重睑高度在中间5mm,两侧为4mm,内侧略低.单睑者参照健眼上睑重睑皱褶高度,均用局部浸润麻醉.先沿画线切开上睑皮肤,并切除切口下唇的1条眼轮匝肌,在眼轮匝肌下方与眶膈之间向上分离,在眶上切迹颞侧,向上分离皮下组织与额肌间的联系,分离高于眉上10～15mm,宽15～20mm,在额肌与眶部眼轮匝肌接合部横形切开额肌达骨膜表面,向上分离额肌与骨膜间的联系,分离高度15～20mm,在额肌筋膜内侧向上剪10～15mm,外侧向上剪开10mm,形成蒂在上方,上宽下窄的舌形额肌筋膜瓣.在睑板中1/3与上1/3交界处,将额肌筋膜瓣与睑板做3对褥式缝线固定,使上睑缘位于角膜上缘处,切除多余额肌,上睑皮肤切口缝合时,按重睑缝合,结膜囊涂红霉素眼膏,闭合眼裂,加压包扎.术后静滴抗生素3～5d,术后2d去除绷带,局部用新洁尔灭棉球清洁,遮盖眼帘,每日滴抗生素眼水6～10次,睡前涂红霉素眼膏至睑裂闭合不全完全消失.睑下垂手术理想的标准是(1)双眼平视时瞳孔完全暴露,睑裂高度、双重睑和睫毛倾斜角度,两眼对称;(2)睑缘弧度自然流畅,无内外翻;(3)眼脸开闭功能正常,瞬目反射及眼球运动协调;(4)眼肌保持平衡,无复视或斜视[1].本组患者术后随访1～3年,上睑缘位于角膜上缘之下1mm 19眼,2mm 36眼,3mm 10眼,双眼平视时瞳孔完全暴露于睑裂.术后早期均有不同程度的睑裂闭合不完,其中49眼于2～4周消失,最长3个月消失,无1例出现暴露性角膜炎、复视、斜视或秃睫等并发症.4例重睑沟变浅,估计系缝合皮肤切口未挂住额肌残端所致,未再次手术.     

巩膜表面解剖学标志定位法眼内金属异物摘出术

目的研究眼球后段金属异物外路摘除术中巩膜表面径线定位新方法,以提高眼后段异物摘除手术效果.方法遵循离体及在体眼球巩膜表面的解剖学标志定论,将95例眼球后段异物患者,依据术前X线摄片所示眼内不同位置,术中选用眼外肌、涡静脉、睫状后长动脉径线定位切口摘除异物.结果此法与20例角膜缘缝线标志法术后效果进行比较,前者一次性切口异物摘出成功率,脱盲脱残率,并发症发生率等均优于后者(P＜0.05).结论解剖学标志定位,方法简单,创伤小,准确性高,可避免术中牵拉眼球旋转所造成的径线位误差,是外路异物摘出术中一种较为可靠的径线位新方法.     

鼻窦内窥镜手术致死性和严重并发症

鼻窦内窥镜手术(SES)引起全盲、颅内出血或死亡尚未见报道,作者介绍5例并作讨论。例1.SES术后右眼巩膜出血、睑球结膜水肿、突眼和右眼球内收运动障碍,CT显示右侧纸板和内直肌损伤。经治疗仍留有永久性复视。例2.术后发现双眼失明,虽经治疗视力不能恢复。CT呈双纸板及视神经损伤,左视神经断离。例3.术后有脑脊液性鼻漏。病变标本中发现有神经胶质组织和神经轴索。CT显示双筛板骨缺损,MRI发现额叶脑内小血肿。开     

眼损伤120例临床分析

目的报告120例眼损伤的部位、原因、临床诊断及治疗结果.方法回顾分析120例眼损伤的临床资料,其中男97例,女23例,右眼61例,左眼47例,双眼12例.眼睑裂伤合并泪小管断裂11眼;结角膜化学伤11眼;结角膜热灼伤3眼;下直肌断离1眼;角巩膜穿通伤、外伤性白内障、球内异物、球后异物等55眼;撞伤性前房积血、虹膜根部离断、房角后退、晶体脱位等41眼;眼球挫伤并发孔源性视网膜脱离3眼;眶骨暴裂性骨折3眼;视神经挫伤4眼.结果复诊3个月, 泪小管断裂10眼泪道通畅.1眼拔管后阻塞.下直肌断裂复位后复视消失.其它各类眼外伤矫正视力1.0以上49眼,0.6～0.8者26眼,0.3～0.5者23眼,0.05～0.20者12眼,指数/30cm 1眼,光感3眼,光感消失3眼,眼球摘除植入义眼座3眼.结论眼损伤致盲率高,应引起高度重视,要以预防为主,发生眼损伤后及时就诊,努力保护和修复眼内组织,为复明创造条件,降低致盲率.     

Repair of orbital floor fractures with marlex® mesh

The best method for reconstructing the acutely fractured orbital floor is controversial. In this review, the outcome of 81 patients with an operatively confirmed pure orbital blow-out fracture is evaluated with respect to postoperative enophthalmos, diplopia, infection, and extrusion. A Marlex^® mesh implant was used to repair 58 of the fractures, with minimal resultant complications. We believe that Marlex^® mesh is an ideal implant for use in repairing the early blow-out fracture.     

Lactic acid polymer implants in the repair of traumatic defects of the orbital floor]

BACKGROUND: The criteria determining the choice of the technique used to repair traumatic orbital floor defects include the quality of the expected result, morbidity, ease of use and plasticity of the method, and its cost and availability. Among the different methods proposed, lactic acid polymer implants are particularly interesting. MATERIAL AND METHODS: Eighteen patients with an isolated blow-out fracture of the orbital floor were treated with a lactic acid polymer implant between 1995 and 1996. Ten of these patients were reviewed at 24 to 43 months follow-up. RESULTS: The mean age of the patients was 35 years (20-52 years). No residual diplopia was observed. None of the patients had an anomalous orbital volume or ocular dystopia. None of the implants migrated. One patient experienced episodes of palpebral inflammation that resolved spontaneously. The ten patients reviewed were satisfied with the outcome. DISCUSSION: The properties of lactic acid polymer implants facilitate their use, avoid morbidity and provide a quality result. This is the procedure of choice for repairing tissue loss of the orbital floor. It has several advantages over alternative methods (the implants are rigid, thin, resorbable and well tolerated) without having their defects (thickness, fragility, roughness, predetermined form, rapid alteration, specific instrumentation, iatrogenic disorders). In addition, lactic acid polymer plates can be remodeled when heated, allowing a precise adaptation of the implant to the orbital structures. Finally, the cost, compared with the advantages, is not a barrier for routine use.     

Post-traumatic orbital floor reconstruction with nasoseptal cartilage in children

OBJECTIVE: Repair of orbital floor fractures may require the placement of a graft or implant. Both autogenous and alloplastic materials have been used for this purpose. This article reports the use of nasal septal cartilage for the repair of orbital floor defect secondary to blunt facial trauma in children. METHODS: Three children with disruption of the orbital floor after facial trauma were included in this prospective review. All children underwent open reduction with rigid fixation of the facial fractures and reconstruction of the orbital floor with nasoseptal cartilage. RESULTS: All of the cases were successfully treated by restoration of the orbital floor continuity. On follow-up clinical examination, one patient had persistent mild enophthalmus. CONCLUSIONS: Nasal septal cartilage is a readily accessible autogenous material with minimal donor site morbidity, and should be considered when an autogenous orbital implant is needed for the repair of a traumatic orbital floor defect.     

经鼻填充鼻中隔软骨修复眶内侧壁骨折

目的：探讨应用鼻内镜填充鼻中隔软骨,修复眶内侧壁骨折,经鼻做眼部手术的可能性。方法：选取眶内侧壁骨折患者11例（11眼）,术前检查均有不同程度的眼球内陷、复视、视力减退症状,行眼眶CT诊有眶内容物疝入筛窦并伴积液,其中6例内直肌肿胀。手术开始在内镜直视指引下,经鼻腔开放筛窦,摘除筛房,暴露骨折的纸板,将疝入物回纳眶内,鼻中隔软骨覆盖骨折区。结果：患者手术后全部治愈。双眼突出度相差≤1mm,平均0.11mm。视力较术前不改变或者略有改善。鼻内镜检查见筛窦术腔上皮化,填充的鼻中隔软骨无移动,无感染及排斥现象。结论：经鼻填充鼻中隔软骨修复眶内侧壁骨折方法简便,成功率高。自体鼻中隔软骨无排斥反应。     

Wraparound nylon foil implant for isolated orbital floor fractures

PurposeThere are a variety of implant materials available for orbital floor fracture repair. Implant selection is guided by surgeon experience, availability, and patient specific needs. The purpose of this study is to describe a “wraparound” technique for nylon foil implant placement for large, isolated floor fractures that provides excellent results with low incidence of enophthalmos or other complications.Materials and methodsA retrospective chart review from 2012 to 2020 was conducted in patients who underwent isolated orbital floor fracture repair with the use of the “wraparound” nylon foil implant. The surgical technique is described. Preoperative CT scans were assessed, and the patients were divided into groups based on the size of the floor fracture. Postoperative data was collected including Hertel measurements and complications related to the implant.ResultsThere were eighty patients who underwent orbital floor fracture repair with the described technique and had adequate follow-up. There were 18 (22.5%) small-sized fractures, 32 (40%) medium-sized fractures, and 30 (37.5%) large-sized fractures in the study group. One patient (3.33%) in the large fracture group had clinically significant enophthalmos of 2 mm postoperatively. There were no other patients with clinically significant enophthalmos. There were no instances of any complications related to the implant, and no patients required implant removal.ConclusionsThe “wraparound” technique for a nylon foil implant provides excellent results for isolated orbital floor fractures. It provides more support and stability than traditional nylon implants for larger fractures and has minimal complication rates.     

Fractures of the orbital floor

The charts of 324 patients treated for 363 orbital floor fractures between 1965 and 1973 were reviewed retrospectively. Of these, 38 (11 percent) were isolated floor fractures, 27 (8 percent) were rim and floor fractures, 168 (46 percent) were trimalar fractures and 130 (35 percent) were associated with complex facial fractures. On initial examination, 31 percent of the patients were found to have diplopia and 4 percent enophthalmos. Orbital prolapse was suspected in 31 percent of the patients. Thirty-seven percent of the patients had demonstrable ocular injury at the time of initial examination. Treatment was surgical in 336 of the fractures and non-surgical in 29. Of the surgical patients 140 had no support placed, 120 had antral support only, 51 had both antral support and orbital implant, and 20 had an orbital implant only. Postpperatively the incidence of diplopia was 8 percent in all patients, and 7 percent had enophthalmos. A smaller group followed for more than five months were found to have diplopia in 17 percent and enophthalmos in 11 percent. Of the 29 patients treated non-surgically, none had persistent diplopia.     

Endoscopic orbital fracture repair

Orbital fractures involving the middle or posterior third of the orbital floor are difficult to visualize with traditional surgical approaches. The authors describe their method of combining a transconjunctival incision with an endonasal endoscopic approach in the repair of orbital fractures. In their experience, this technique is especially useful in the treatment of posterior fractures or secondary repairs for residual enophthalmos. Besides better visualization, advantages include increased illumination; video projection for the rest of the surgical team and for documentation and recording; confirmation of correct implant placement; and, most importantly, precise and complete reduction of herniated orbital soft tissues.     

Silent sinus syndrome: combined sinus surgery and orbital reconstruction – report of 15 cases

Background: Silent sinus syndrome (SSS) is defined as spontaneous, painless enophthalmos, hypoglobus with orbital floor resorption and maxillary sinus collapse on the ipsilateral side. Different methods of orbital floor reconstruction have been proposed.

Aims/objectives: The purpose was to analyse the results of combined endoscopic sinus surgery (ESS) and reconstruction using orbital floor implant of 15 patients with SSS and to present recent histological findings.

Materials and methods: Retrospective case review of 15 patients with SSS treated in clinic between 2007 and 2017.

Results: Eleven women and four men presented with unilateral, spontaneous enophthalmos. Averaged duration of enophthalmos was 10.7 months. On affected side, mean enophthalmos was 2.6?mm and hypoglobus 2.7?mm. Computed tomography imaging (CT) imaging showed maxillary sinus opacification on the affected side in every case, and the orbital floor was displaced downwards in all cases. In total, 13 patients underwent simultaneous ESS and rebuilding of orbital floor with a titanium implant. Statistical analysis confirmed significant differences for pre- and postoperative measure of enophthalmos and hypoglobus.

Conclusion and significance: Implementation of titanium implants is the reliable method of reconstruction that allows good aesthetic result, shorter time of procedure with an excellent long-term outcome and satisfactory patient’s tolerance.     

脑脊液鼻漏修补术修补材料的选择

目的：探讨脑脊液鼻漏各种修补材料的特点，选取最佳修补材料。方法：回顾分析1999年3月至2005年3月间收治的36例持续性脑脊液鼻漏的临床资料。结果：36例均经内窥镜手术治愈，其中1次修补成功31例，术中采用大腿阔筋膜修补19例，均获成功；鼻中隔黏骨膜修补9例，成功7例，失败2例；下鼻甲黏膜修补3例，成功1例，失败2例；颞筋膜修补5例，成功4例，失败1例；2次修补均获成功。随访2个月～3年, 未见复发。取材部位愈合良好,无感染及鼻中隔穿孔。结论：阔筋膜成功率最高，术中可根据具体情况选择合适的修补材料。     

Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach

OBJECTIVE: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess. DESIGN: Case series. SETTING: Tertiary pediatric hospital. PATIENTS: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy. INTERVENTION: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidectomy was also performed. MAIN OUTCOME MEASURES: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications. RESULTS: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid malposition. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone transnasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach. CONCLUSIONS: The combined endoscopic and transcaruncular surgical approach to medial orbital subperiosteal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transcaruncular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage.