重度眼球萎缩患者巩膜腔内HA植入术的临床研究

目的:探讨重度眼球萎缩患者巩膜腔近原位羟基磷灰石(HA)义眼座植入的可能性。方法:眼轴直径在18mm以下的重度眼球萎缩患者76例(76眼),采用眼内容物剐除后切下直径14mm后巩膜,然后在巩膜腔内植入18～20mmHA义眼座并在眼座前覆盖切下的后巩膜,再分层缝合角巩膜瓣筋膜结膜。结果:本组76例患者74例结膜创口一期愈合,2例结膜切口裂开经保守治疗愈合,术后随访6～22mo,所有患者无感染、交感性眼炎及义眼座暴露,眼窝饱满,所配带义眼活动度好,效果满意。结论:巩膜腔近原位HA义眼座植入术仍然适合于重度眼球萎缩患者的容貌矫正。     

巩膜瓣下肌锥内羟基磷灰石义眼座一期植入

目的观察巩膜瓣下肌锥内羟基磷灰石义眼座一期植入的临床效果。方法眼内容摘除50例,剪断视神经,剪开巩膜壳,制作巩膜瓣,植入羟基磷灰石义眼座于肌锥内,缝合巩膜瓣及结膜筋膜组织。结果追踪观察1年,观察眼外形,眼球运动,结膜愈合及义眼座位置。所有义眼矫正的外形美观,活动度良好,无结膜愈合不良或巩膜瓣暴露者。义眼座无移位、固定或感染。结论巩膜瓣下肌锥内羟基磷灰石义眼座一期植入术并发症少,眼球运动、眼部外观与健眼基本相同,可达到美容效果。     

改良巩膜壳内羟基磷灰石义眼台植入术的临床观察

目的：评价改良巩膜壳内羟基磷灰石义眼台植入术的临床效果。
　　方法：对34例患者施行眼内容物剜除后,自体巩膜壳前后均瓣状成形并后巩膜开窗,一期植入羟基磷灰石义眼台,术后观察结膜伤口愈合情况、义眼台活动度及并发症的出现情况。
　　结果：随访观察6~12mo,未发现义眼台暴露、巩膜溶解、结膜伤口裂开、结膜囊缩窄病例。安装义眼片后,活动度良好,眼球内外侧转动可达10o~15o,睑裂双侧等大,外观双眼基本对称,眼窝饱满。
　　结论：改良巩膜壳内羟基磷灰石义眼台植入术基本保持了眶内组织的正常解剖关系,术后眼窝饱满度、义眼台活动度良好,手术操作简单易行。通过观察随访,并发症少,临床效果满意。     

巩膜花瓣状成形羟基磷灰石义眼座植入术疗效观察

目的 探讨巩膜花瓣状盛开有羟基磷灰石义眼座植入术的手术效果.方法 22例行有包裹无预置缝线的巩膜花瓣状成形HA植入术,随访3～17月,观察术后效果.结果 22例中术后1例结果菲薄,巩膜缝线外露,1月后重新缝合盘腊结腊治疗后愈合.1例结膜囊狭窄.未发生义眼座暴露、脱出及感染等并发症.结论 巩膜花瓣状成形羟基磷灰石义眼座植入术术后并发症少,义眼座活动好,手术方便易行、疗效较可靠.     

自体巩膜瓣在眼球摘除联合羟基磷灰石义眼座植入术中的应用

目的探讨自体巩膜瓣覆盖羟基磷灰石(HA)义眼座前部对预防术后眼座暴露的临床效果。方法眼球摘除后,取自体巩膜瓣覆盖缝合固定于I期植入的HA义眼座前部。结果所有病例随访6～18个月,均无义眼座暴露发生。结论在行HA义眼座植入术时,使用自体单层巩膜瓣覆盖义眼座前部,能阻止义眼座的粗糙表面对前部眼球筋膜囊和球结膜持续的机械刺激,避免眼球筋膜囊和球结膜裂开,有效地预防义眼座暴露。     

自体巩膜转位双层巩膜帽部分肌锥内羟基磷灰石义眼台植入术的临床观察

目的探讨一种操作简便、术后反应轻、不易暴露的羟基磷灰石(hydroxyapatite,HA)义眼台植入新术式.方法将在我科就诊的65例(65眼)患者随机分为2组,观察组:共35例,行自体观膜转位双层巩膜帽部分肌锥内HA义眼台植入术;对照组:共30例,行自体双层巩膜肌锥内HA义眼台植入术.术后随访1～3 a.对其术后并发症进行分析比较.结果观察组术后早期疼痛、胃肠道反应、结膜水肿、结膜出血均明显比对照组轻(疼痛:6 h:u=3.80,1d:u=3.50,3 d:u=3.45.5 d:u=2.50,P均<0.05;胃肠道反应:l d:u=7.44,3 d:u=5.11,5 d:u=2.45,P均<0.05;结膜水肿:3 d:u=6.02,5 d:u=5.70.7 d:u=4.31.P均<0.01;结膜出血:3 d:u=5.18,7 d:u=6.91,14 d:u=3.89;P均<0.01);观察组义眼台活动度优32例,良3例,差0例,均未发生义眼台暴露;对照组义眼台活动度优15例,良11例,差4例,义眼台轻度暴露4例,中度暴露l例,经比较2组间义眼台活动度和暴露情况差异均有统计学意义(u=3.76,2.94;P均<0.05).结论自体巩膜转位双层巩膜帽部分肌锥内HA义眼台植入术操作简便,并发症少,义眼活动度满意,美容效果好,可在基层医院推广应用.     

带眼外肌的自体巩膜壳覆盖羟基磷灰石义眼台植入术

目的观察带眼外肌的自体巩膜壳覆盖羟基磷灰石（HA）义眼台植入术的临床效果。方法54例（54只眼）无视功能者行眼内容物剜除后,采用带眼外肌的自体巩膜后肌锥内HA义眼台一期植入,术后观察术眼结膜的愈合、结膜囊深浅、HA义眼台位置及活动度等。结果术后随访4个月至2年,术后效果优50只眼（92．59％）,良4只眼（7．41％）,所有术眼结膜愈合好,未出现HA义眼台或巩膜暴露、感染,无义眼台移位,安置薄型义眼片后外观逼真,转动功能良好,眼窝饱满,双眼外形基本对称。结论肌锥内带眼外肌的自体巩膜壳覆盖HA义眼台植入术保留了完整的巩膜层、眼外肌和邻近的结缔组织,可以避免或最大限度的减少HA义眼台暴露的发生,术后义眼台运动度良好。     

双层巩膜覆盖的Ⅰ期羟基磷灰石义眼座植入

目的探讨双层巩膜覆盖的羟基磷灰石义眼座植入手术方法和疗效。方法38例(38眼)眼内容摘除术后,从鼻上方内直肌与上直肌之间将义眼座植入肌锥腔,巩膜壳平铺于义眼座上,分层缝合巩膜、筋膜、结膜。结果随访12～24月,36例眼窝饱满,无塌陷,装上义眼片后活动度良好,2例义眼座暴露,其中1例取出,1例手术修复。结论该手术方法简单、易行,义眼座植入并发症少,义眼片活动度好。     

双层巩膜覆盖的I期羟基磷灰石义眼座植入

目的探讨双层巩膜覆盖的羟基磷灰石义眼座植入手术方法和疗效。方法38例（38眼）眼内容摘除术后，从鼻上方内直肌与上直肌之间将义眼座植入肌锥腔，巩膜壳平铺于义眼座上，分层缝合巩膜、筋膜、结膜。结果随访12—24月，36例眼窝饱满，无塌陷，装上义眼片后活动度良好，2例义眼座暴露，其中1例取出，1例手术修复。结论该手术方法简单、易行，义眼座植入并发症少，义眼片活动度好。     

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。     

个性化义眼片活动度相关因素分析

目的:探讨义眼片的材料、厚度及配戴眼的结膜囊剩余面积、深度等因素对其活动度的影响。方法:对100例(100眼)羟基磷灰石义眼座植入术后患者行义眼片配制,记录义眼片的厚度、结膜囊剩余面积、深度等参数,分析配戴6mo后义眼片的活动度、材料、厚度及结膜囊剩余面积、深度之间的关系。结果:聚对苯二甲酸乙二酯(polyethylene terephthalate,PET)组义眼片活动度为4.8±1.0mm(范围3～7mm),聚甲基丙稀酸甲酯(polymethyl methacrylate,PMMA)组义眼片活动度为6.4±1.3mm(范围4～8mm),两组差异有显著性意义(P<0.05)。义眼片活动度与其本身厚度(r=-0.92,P<0.05)、结膜囊深度(r=-0.90,P<0.05)存在密切的负相关,而与结膜囊剩余面积(r=0.90,P<0.05)存在密切的正相关性。结论:配戴成品义眼片的活动度受多种因素影响,其中选用PMMA材质,适当减低义眼片边缘厚度,提高光滑度减少磨擦所造成的阻力,增加结膜囊剩余面积可以增加义眼片的活动度,提高其仿真程度。     

Four-petal evisceration: a new technique

PURPOSE: To describe a new evisceration technique that allows the use of large orbital implants and closure without tension on the wound. METHODS: Interventional prospective study. The technique involves quadrisectioning the sclera and placement of a large orbital implant. The sclera is sutured in 2 layers covering the implant. RESULTS: A total of 73 eyes underwent surgery. The implants were 22 mm in 11 eyes (15%), 20 mm in 60 eyes (82.2%), and 18 mm in 2 eyes (2.8%). Thirty-one eyes (42%) were phthisical with small scleral cavities. There was 1 case of postoperative mild superior sulcus deficiency and no cases of extrusion of the implant. CONCLUSIONS: The 4-petal evisceration is technically easy to perform and provides excellent results with few complications. It allows the use of orbital implants of any desired size.     

121例多孔聚乙烯义眼座眶内植入的临床分析

目的 评价高密度多孔聚乙烯义眼座(Medpor)HN内植入的疗效及其并发症.方法 回顾分析2003年3月至2006年3月期间眶内植入多孔聚乙烯义眼座121例,男性91例,女性30例,平均年龄29岁(6～53岁).其中眼球摘除术后Ⅰ期植入20例,眼球内容剜除术后Ⅰ期植入54例,Ⅱ期植入47例.结果 随诊时间6～36个月,平均随访时间18个月.121例均取得满意效果,结膜创口愈合好,义眼座无脱出,无暴露及感染.义眼座植入眼眶后活动度较好,所配带的义眼外观满意.结论 Medpor义眼座眶内植入可明显地矫正眼窝凹陷,可采用自体巩膜包裹或者直接眶内植入,术后义眼座活动度好,并发症少.是一种理想的眶内植入物材料.     

羟基磷灰石义眼台Ⅱ期植入矫正重度眼窝内陷

目的探讨羟基磷灰石义眼台Ⅱ期植入术矫正眼窝重度内陷效果。方法对26例（26眼）眼球摘除或眼内容摘除术后半年至38年采用羟基磷灰石义眼台Ⅱ期眶内植入。结果眼窝重度内陷矫正术后外观良好。义眼活动度好,双眼相似,真假难辨。术后随访3～5年无排斥反应发生,未发现义眼台移位、脱出或眶内感染者。结论Ⅱ期眶内植入义眼台矫正眼窝重度内陷要根据眶内容积大小和结膜囊腔大小选择术式和合适的义眼台,并需要用异体巩膜固定在4条直肌附着处覆盖于义眼台表面,可以增加义眼活动度,并可防止义眼台排出。     

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.     

眼内容摘除羟基磷灰石义眼座植入术96例疗效观察

目的 探讨Ⅰ期或Ⅱ期眼内容摘除羟基磷灰石义跟座植入术的手术效果.方法 对96例(96眼)Ⅰ期或Ⅱ期行眼内容摘除、经眼球内视神经断离、自体巩膜成形、羟基磷灰石义眼座植入术,跟踪观察10-24月.结果 术后眼睑轻度肿胀,球结膜水肿,眼眶区胀痛,仅2例球结膜切口裂开,经保守治疗愈合.无义眼座暴露、脱出及感染,交感性眼炎等并发症.结论 此术式符合眼球及眼肌生理解剖,手术方便易行,并发症少,术后义眼座球体稳定,眼眶饱满,活动度好,外观逼真.     

A Histopathologic Study of Orbital Implant Vascularization

Purpose: To histopathologically assess the extent and pattern of vascularization of explanted porous polyethylene (PP) and hyrdoxyapatite (HA) orbital implants. To compare the vascularization in PP implants harvested after enucleation versus after evisceration. Methods: This is a comparative case series of six orbital implants explanted between 11 months and 5 years and 4 months post implantation. The implants were subjected to histopathological examination with various stains, after complete decalcification. Results: There were 2 post evisceration, 3 post enucleation and 1 secondary implant. The size of the implants varied from 18 to 23 mm diameter. The reason for explantation was exposure in all the 6 cases with additional infection in 2 cases. Histopathology revealed complete vascularization up to the core of the implant in all the cases. There was evidence of chronic inflammation within all the explanted specimens. Acute inflammation was present at the site of exposure in four of the implants. Three of these implants had additional evidence of necrosis. Two cases with clinically evident infection had Gram positive cocci within the implant. Foreign-body type giant-cells, melanophages and haemosiderin laden macrophages were also observed. Eviscerated specimens showed scleral remodelling and thickening. Conclusion: All the implants were vascularized up to the core. There was histologic evidence of chronic inflammation in all the explanted implants possibly indicating the foreign nature of the implant material. The sclera did not impede vascularization of the implants in eviscerated specimens. We found no difference in the degree of vascularization of the implant in enucleated versus eviscerated implants.     

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.     

Late porous polyethylene implant exposure after motility coupling post placement

PURPOSE: To report the probable association of motility coupling post placement and late porous polyethylene implant exposure. DESIGN: Retrospective, observational case series. METHODS: This was a retrospective analysis of 27 patients who had primary porous polyethylene orbital implantation from February 1999 to November 2000. Data on demographics, previous surgery, ocular diagnosis, type of surgery, size of the implant, and motility coupling post placement were collected. Complications of porous polyethylene implants and implant exposure were documented. RESULTS: Among the 27 patients, 18 eyes (66.7%) received motility coupling post insertion after primary porous polyethylene implantation. Implant exposure occurred in six (33.3%) of the 18 eyes with motility coupling post insertion. None of the eyes without insertion had implant exposure. The mean interval between porous polyethylene implantation and motility coupling post placement for the implant exposure group (6 of 18) was 6.5 +/- 0.4 months, which was not statistically significant compared with 7.2 +/- 0.6 months in the nonexposure group (12 of 18). For these 6 cases of implant exposure, the mean interval between implantation and implant exposure was 24.2 +/- 11.8 months, and the mean interval between pegging and exposure was 17.6 +/- 11.7 months. Among these 6 patients, 4 underwent removal of exposed porous polyethylene implants and reimplantation of hydroxyapatite implant or dermis fat reconstruction. CONCLUSIONS: We found a trend (P =.07) of increasing risk of porous polyethylene implant exposure with motility coupling post placement. Although the pegging group did not show a statistically significant higher rate of exposure compared with the nonpegging group, we believe that more care was needed when performing motility coupling post placement. In addition, longer postoperative follow-up is needed after insertion of a motility coupling post.     

Autogenous temporalis fascia patch graft for porous polyethylene (Medpor) sphere orbital implant exposure

BACKGROUND: Temporalis fascia has been recommended for hydroxyapatite sphere exposure. The aim of this study was to identify potential risk factors for exposure of porous polyethylene (Medpor) sphere implants and evaluate the use of autogenous temporalis fascia as a patch graft for exposure. METHODS: A retrospective review of consecutive cases of porous polyethylene sphere orbital implant exposure. RESULTS: Five cases presented between May 2000 and October 2001 (three males, two females; mean age 44.5 years). Three had enucleation (two with primary implants) and two had evisceration (one with primary implant). Exposure occurred in one primary, two secondary, and two replacement implants. Orbital implant diameter was 20 mm in four cases and 16 mm in one case (contracted socket). The mean time from implantation to exposure was 23 months (range 0.7-42.6). Three patients had secondary motility peg placement before exposure. The average time from last procedure (sphere implant or peg insertion) to exposure was 3 months (range 0.7-12.6). Four patients required surgical intervention, of which three needed more than one procedure. Autogenous temporalis fascia grafting successfully closed the defect without re-exposure in three of these four patients. The grafts were left bare in three patients, with a mean time to conjunctivalise of 2.4 months (range 1.6-3.2). CONCLUSIONS: Exposed porous polyethylene sphere implants were treated successfully with autogenous temporalis fascia graft in three of four patients. This technique is useful, the graft easy to harvest, and did not lead to prolonged socket inflammation, infection, or extrusion.