Advances in ophthalmic plastic and reconstructive surgery最新文献

Orbital floor fractures can be explored through the eyelid with a subciliary or a smile-crease incision. A two-plane incision is made to expose the orbital rim. Orbital contents are removed from the sinus, and an alloplastic implant is used to cover the fracture. The periosteum is closed over the implant. Fine suture material is used to close the skin. These approaches give good exposure of the orbital floor and excellent postoperative cosmesis.

Thirty-eight patients with computed tomography (CT)-proven orbital fractures and diplopia were studied prospectively to determine the efficacy of steroids in the medical management of orbital fractures. The protocol is based on double-blind assignments to steroid (ST) and non-steroid (NT) treatment groups. Outcome analysis was based on sorting fractures into three CT classes: I-without soft tissue prolapse (n = 15); II-with soft tissue prolapse (n = 14); and III-CT evidence of inferior rectus entrapment (n = 9). Results included resolution of diplopia without surgery in both ST and NT groups in CT classes I and II. Median time course of resolution was compressed to less than 5 days in the ST treatment group, however, versus 13 days in the nontreatment group. All fractures in class III had residual diplopia with five of nine patients having surgical results that were enhanced in the ST treatment group. In addition, enophthalmos was unmasked in the ST treatment group within 1 week of treatment versus 5 months without treatment. A protocol for medical management and surgical decision-making in blowout fracture is presented.

Although periorbital and orbital dog bites are rare, they most frequently occur in young children and commonly involve significant associated adnexal injuries. In most cases, the dog is either the family pet or is otherwise known to the victim. The exact precipitating event is usually unknown. Most victims are treated by a physician soon after injury, and can be reconstructed primarily following meticulous local wound care, including adequate irrigation. Infection is rare, but because of its potentially disastrous consequences, prophylactic treatment with penicillinase-resistant penicillin or cephalosporin seems indicated. Serious, potentially fatal consequences due to underlying intracranial injury in children under aged 2 years, fatal septicemia in splenectomized individuals, tetanus, and rabies must be considered by ophthalmologists who treat such patients.

The fornix or transconjunctival approach to the orbital floor and inferior orbit provides excellent exposure for the surgeon managing orbital fractures. The technique is ideally suited for patients with isolated blowout fractures; however, it can be combined with other surgical incisions to provide wide exposure of the inferior orbit, zygoma, and maxilla for the repair of more complex midfacial fractures. The surgical technique provides excellent access to the inferior orbit for biopsy or excision of orbital tumors and excellent opportunity for surgically augmenting orbits with posttraumatic enophthalmos or enophthalmos associated with anophthalmic sockets. Orbital decompression into the maxillary antrum and ethmoid sinus is easily accomplished through this incision. By avoiding a cutaneous incision in the lower eyelid, one reduces the risk for development of postoperative ectropion. During wound closure, the lower eyelid can be elevated and tightened and the canthal angle can be restored if necessary.

The Iowa implant is a quasi-integrated implant with four mounds on its anterior surface. The rectus muscles are imbricated between the mounds, resulting in a socket with four protrusions that articulate with a custom-fitted prosthesis having four concavities. This imparts excellent motility and support for the prosthesis. This article describes the indications for enucleation, the Iowa implant, surgical technique, and postoperative complications.

If a patient has vision immediately following trauma, with subsequent deterioration of visual acuity and/or field, and the presence of a relative afferent pupillary defect, compression of the optic nerve or its vascular supply is very likely. We currently lack a proven optimal treatment, but in the otherwise healthy patient, we suggest an intravenous (IV) loading dose of methylprednisolone 30 mg/kg, and a second 15-mg/kg dose 2 hours after the initial dose, followed by 15 mg/kg every 6 hours. Optic nerve decompression is indicated in this situation when corticosteroids have only a temporary effect, a diminishing one, or none at all. It may also be indicated when there is evidence of a traumatic optic neuropathy with a fractured or narrowed optic foramen or with dislocated bone fragments that directly impinge on the nerve. Optic nerve sheath decompression is indicated in progressive traumatic optic neuropathy when an enlarged fluid-filled sheath has been demonstrated sonographically.