Advances in ophthalmic plastic and reconstructive surgery最新文献

There are a number of etiologies underlying the development of socket deformity with associated lower eyelid malposition, lateral canthal tendon laxity, and/or contraction of the inferior fornix. In addition to cosmetic considerations, each of these anatomic problems can interfere with comfortable wear and retention of a prosthesis. This chapter gives an overview of these problems and details our preferred surgical approaches to repair of these anatomic deformities. Specifically discussed are techniques for: mucous membrane and ear cartilage grafting to repair lower lid inner lamellar tissue shortage, reconstruction of the inferior fornix/cul-de-sac, direct lower eyelid lateral canthal resuspension, and resuspension using a periosteal flap or autogenous fascia lata from the iliotibial tract.

Anophthalmic patients can develop a deep recess or sulcus in the upper lid, usually associated with enophthalmos. If due to an absence or loss of a socket implant, a secondary one can be implanted. In those cases with a socket implant, one method of treatment is directed at adding a silicone block to the inferior orbit to cause a forward movement of fat to fill out the upper eyelid as well as reducing the enophthalmos. Another approach, particularly if enophthalmos is minimal, is to directly implant a dermis-fat graft into the upper eyelid. The graft is taken from above the iliac crest and the amount implanted should create a slight overcorrection, allowing for some fat absorption.

Surgical psycho-ophthalmology is the integration of ophthalmic surgery and medicine with basics in psychiatry and psychology, lest the psyche be forgotten amid the spectacular leaps in techniques and technology, or our judgment be veiled by our related psychodynamics [1]. Its scope encompasses a much broader spectrum than the conventional psychosomatic eye diseases. Besides due consideration of the psychological and physical conditions of patients, it increases the awareness of the surgeons' psychodynamics that reflect on our continuing judgment before, during, and after surgery. Further, surgical psycho-ophthalmology impacts on the indications, timing, planning, and performance of each individual operation and/or reoperation. It equally emphasizes both the psychologic priming of patients and attuning of the surgical team. In establishing and maintaining rapport with the patient, surgical psycho-ophthalmology helps to curb the growing problems of malpractice, iatrogenicity, and noncompliance. It also stresses careful weighing of the risk/benefit ratio in adherence to the surgical axiom: "primum non nocere". Despite all advances and ingenuity in contracted socket surgery, the challenge still remains. However, with the proper evaluation and management in the perspective of psycho-ophthalmology we may achieve success, not only in esthetics, but also in sight preservation, and even in life salvage.

Standard enucleation techniques provide excellent results. Modifications can render the operative field bloodless and permit the performance of all manipulations under direct visualization. Standard enucleation has been postulated to disseminate choroidal malignant melanoma cells as a result of fluctuations in intraocular pressure incident to surgical manipulations. It is possible that the stabilization of intraocular pressure preceding induction of tumor freezing may decrease such dissemination and thereby increase survival.

An ocular prosthesis fitted over phthisis bulbi or a discolored blind eye of near normal size is a positive approach to improve the cosmetic appearance and psychological well-being of the patient. Unless surgical intervention is essential, fitting a prosthesis over the residual eye is a successful alternative to enucleation or evisceration. In general, for these individuals there is minimal disruption of the periocular tissues, thus, reducing fitting problems associated with enucleation and evisceration. A prosthesis properly fitted over phthisis bulbi or a discolored blind eye will maintain the integrity of the orbital anatomy, enhance cosmesis, and accelerate the rehabilitation of the patient.

It is important that an ocularist be knowledgeable of the five types of anophthalmic ptosis, their causes and most effective treatment method. In earlier days ocularists had only one method of correcting this problem. With the advent of plastic material several more were invented, but none were totally effective or comfortable for the patient. This chapter describes the five types of ptoses, some simpler methods for correction with prostheses, but emphasizes a complex method initiated in the early 1950s by Lee Allen. It has been used by many other ocularists since. A description of the method and its effectiveness is discussed.

This seldom discussed subject is brought into focus with examples of the complex emotional ramifications of eye loss. The professional who is best equipped to counsel these patients is the ocularist. Patients psychological needs are successfully met with accurate information. Our objective is to alter the patient's attitude concerning losing an eye. A step-by-step method of achieving that goal is presented.

The GORE-TEX soft tissue patch is composed of large open spaces surrounded by polytetrafluoroethylene (PTFE) fibers connected to nodules of solid PTFE. It was used in 12 oculoplastic surgery patients. Primary and secondary spherical silicone implants were wrapped with a GORE-TEX patch and implanted into Tenon's capsule. This study reports our first results using this versatile material.