Advances in ophthalmic plastic and reconstructive surgery最新文献

A method for the clinical evaluation of patients with orbital and midfacial fractures is presented. Pertinent anatomic relations, classification of fractures, and significant associated injuries are reviewed. Principles of treatment are offered.

Disturbances of ocular motility following trauma are manifested by diplopia and faulty ocular rotations which frequently require an abnormal head position for fusion. Motility imbalance may occur following injury to the eye alone, to the eye and associated extraocular muscles, and to the orbital walls, and also following closed head trauma. The clinical findings early following injury may be very different from the clinical picture several months following injury. The diagnosis of abnormal motility includes the use of forced ductions, saccadic velocity recording, active force generation, measurements of deviations of the eyes in the cardinal positions of gaze as well as the use of computed tomography (CT scan) and ultrasonic techniques. The presence of slipped or lost muscles must be diagnosed, and evaluation of restricted rotations and paretic muscles is essential. The treatment of motility disturbance includes relief of restricted rotations by lysis of adhesions and lengthening or recessing appropriate muscles as well as strengthening underacting muscles by resection and/or advancement. In cases of severe trauma one must not overlook injury to the eye itself in addition to the motility disturbance.

Sympathetic ophthalmia is a bilateral diffuse granulomatous panuveitis occurring after accidental or surgical penetrating injury to one eye. Onset of sympathetic ophthalmia may occur as early as 5 days or as late as 42 years following the injury.

Intravascular occlusion of traumatic carotid cavernous fistulas, originally performed under direct visualization with fascia and/or muscle, has evolved into the use of catheters with pressure-sensitive detachable balloons that can be deflated and repositioned prior to final inflation and separation from the catheter. The balloon is filled with contrast material and can be identified with follow-up x-rays. Proptosis is often relieved immediately after this treatment. Detailed pre- and posttreatment ophthalmic evaluations of three consecutive patients with carotid-cavernous fistulas successfully treated with detachable balloon occlusion with a minimum 1-year follow-up are presented. Indications and timing of treatment are discussed. Following blunt head trauma, these patients presented with proptosis, decreased vision, orbital bruit, conjunctival chemosis, diplopia, orbital pain, ocular pulsations and diplopia; they often complained of "a ringing" in the ear on the involved side.

Periorbital burns require special care as compared with burns of other parts of the body. Not only is one interested in the healing and repair of the burned structures, but also in safeguarding and maintaining the function of the underlying eye.

Blunt trauma can cause a wide range of ocular injuries. An immediate evaluation of the potential damage may be impossible because of vitreous hemorrhage or may be ill-advised because of hyphema or damage to other ocular or orbital structures. One must remember that potentially severe injuries can be harbored in the recesses of the angle or far periphery of the retina. In any case of blunt trauma, although one eye may have more obvious signs of injury, an extensive examination of the fellow eye must always be included because less severe trauma may have resulted in serious injuries that can go undetected. The types of injuries from blunt trauma that threaten vision--damage to the angle, lens, macula, and peripheral retina--must be noted and recorded because all have potential long-term visual consequences. Early treatment of these lesions, especially retinal tears and elevated intraocular pressure, can help prevent potentially severe loss of vision.

High-velocity trauma to the orbit is characterized by complete disruption of the orbital rim and comminution of the walls of the orbital cavity. The incidence of associated injury to the intraorbital contents, and to contiguous facial skeletal structures, is significant. Failure to recognize and repair the skeletal injuries results in progressive contracture of the overlying soft tissues, collapse of the bony framework of the orbit, and atrophy of incarcerated intraorbital contents. Immediate orbital reconstruction aims to restore and maintain the normal anatomy of the craniofacial skeleton. The introduction of computed tomography (CT) and craniofacial surgical techniques facilitates comprehensive evaluation of orbital fractures. Further adaptation of the principles and techniques of rigid internal skeletal fixation and primary bone grafting permits a stable, three-dimensional, anatomic reconstruction of virtually any traumatic orbital deformity.

Volkmann's ischemic contractures have long been recognized by orthopedic surgeons as a sequela of increased pressure within osseofascial muscle compartments. We present evidence that the same mechanism is a cause of fibrosis and contracture of extraocular muscles following orbital blowout fractures. Surgical treatment of a specific, recognizable type of blowout fracture is proposed.