结膜旷置法治疗Ⅱ期义眼台植入时结膜囊缩窄的疗效观察

A new method to solve anophthalmic contracted socket in embedding orbital implant in 114 cases

摘要:

目的：观察新的结膜旷置法行Ⅱ期义眼台植入，同时处理结膜囊缩窄的治疗效果。

方法：2008-01/2014-07期间，我院收治的114例114眼眼球摘除术后眼窝内陷、结膜囊缩窄患者，在行Ⅱ期义眼台植入后同时处理结膜囊，从筋膜表面充分分离结膜至穹隆处，将预先制作的透明薄壳眼模置入结膜囊，使结膜瓣后退形成上、下穹窿，同时眼睑闭合时无明显张力。取出透明眼膜，并评估结膜缺损面积(即筋膜暴露面积)，根据缺损区垂直径长度分为4组，Ⅰ组：缺损长0～5mm； Ⅱ组：缺损长6～10mm； Ⅲ组：缺损长11～15mm； Ⅳ组：缺损长≥16mm。对所有病例采用旷置球结膜中央缺损区的方法，在上下结膜瓣后退的位置将结膜间断缝合于筋膜上，在义眼台的前部出现筋膜暴露区。如下穹窿浅，联合行下穹窿成形术； 如眼睑闭合张力较大或结膜瘢痕较重，考虑术后结膜挛缩严重的患者联合行睑缘缝合术。结膜囊内涂抗生素眼膏后置入合适的眼模。

结果：所有患者暴露的筋膜区域于术后逐渐缩小并被结膜覆盖。平均于术后1mo内旷置的结膜区被新生的结膜覆盖完全。结膜缺损区垂直径<5mm均能在2wk内完全移行覆盖，结膜囊形成良好，无需再次手术处理。结膜缺损区垂直径6～10mm能在3wk之内填补覆盖完全，少数患者结膜囊会有少量的收缩，但不影响配戴义眼片。结膜缺损区垂直径11～15mm能在4wk内移行生长覆盖完全，但结膜囊会轻度收缩，可配戴磨小的义眼片，部分术前结膜瘢痕较严重的患者需再次行结膜囊成形术。结膜缺损区垂直径≥16mm也能在6wk以内完全覆盖整个筋膜暴露区域，结膜囊会有较明显收缩，需再次行结膜囊成形联合睑缘缝合术，3mo后拆除睑缘缝线后能够配戴义眼片。有2例出现义眼台暴露，行义眼台暴露修补联合结膜囊成形术，术后结膜囊成形好。

结论：新的结膜旷置法能够很好地处理Ⅱ期义眼台植入时轻到中度结膜囊缩窄，无需任何移植物，患者损伤轻，减少多次手术。对于处理重度结膜囊狭窄，再手术风险较大，尚需进一步临床观察。

Abstract:

AIM: To perform a new method for orbital implant and contracted socket through one time and its results.

METHODS: Totally 114 patients 114 eyes, from January 2008 to June 2014, with contracted socket participated in this study. We incised the bulbar conjunctiva horizontally and excised scar tissue, then implanted the hydroxyapatite in the four extraocular muscles and tightly sutured the Tenon' capsule. After that, we put the superior and inferior conjunctival petals backwards and sutured them to the Tenon's capsule. All the patients were divided into four groups according to the vertical diameter length of the conjunctival defect area: Group Ⅰ: ≤5mm; Group Ⅱ: 6-10mm; Group Ⅲ: 11-15mm; and Group Ⅳ: ≥16mm. These patients were followed up for 6mo to 3y to observe the conjunctival sac shaping and growth of conjunctiva.

RESULTS: There were 64 cases in Group Ⅰ, 31 cases in Group Ⅱ, 16 cases in Group Ⅲ and 3 cases in Group Ⅳ. All patients' conjunctival defect was covered by new conjunctiva and scar tissue 4 to 6wk after surgeries. Ten cases had contracted socket; 2 cases had orbital implant exposure, requiring reoperation. Of the 114 cases, 8 had contracted socket and could use a smaller conformer, 106 could use a normal size conformer.

CONCLUSION: When the conjunctival defect was ≤15mm, this new method can address the orbital implant and contracted socket at the same time. While it was ≥16mm, flap transplantation is necessary.