摘要背景 眼眶爆裂性骨折引起明显的眼球形态和功能的异常.眼眶解剖结构复杂,故眼眶骨折修复手术中植入物的设计和制作具有一定的难度,而计算机辅助设计与制作(CADM)技术有望提供一种新的方法,但其临床应用价值有待评估.目的 研究CADM技术在眼眶爆裂性骨折治疗中的应用方法,评价其临床效果.方法 对河南省眼科研究所河南省立眼科医院2006年7月至2012年7月收治的眼眶爆裂性骨折患者74例74眼的手术过程和疗效进行回顾性分析,其中CADM手术者58例58眼,非CADM手术者16例16眼,2个组间患者基线特征,如年龄、性别和眼别均匹配.CADM手术组术眼采用CADM技术进行个体化三维立体植入物的设计和制作并进行眶骨骨折缺损处的填充,非CADM手术组术眼采用常规羟基磷灰石人工骨或多孔聚乙烯高分子合成材料(Medpor)填充法.所有术眼术前均行常规眼部检查以及CT检查,术后随访22～69个月,在随访期间内定期进行眼部临床观察和CT检查.观察指标包括最佳矫正视力、眼球突出度、眼球位置、眼球运动和复视改善情况以及并发症情况.结果 CADM手术组和非CADM手术组术眼术前最佳矫正视力分别为0.71±0.37和0.69±0.41,术后最佳矫正视力分别为0.74±0.38和0.72±0.41,组间差异无统计学意义(F分组=0.043,P=0.837),术眼手术前后视力的总体比较差异有统计学意义(F时间=13.576,P＜0.01),其中2个组术眼术后视力均好于术前,差异均有统计学意义(均P＜0.05).2个组间复视和眼球运动障碍治愈和好转的眼数分布差异均无统计学意义(Z=-0.298,P=0.766;Z=-0.548,P=0.584).CADM手术组和非CADM手术组术眼术前眼球眼球内陷度值分别为(3.93±0.99) mm和(3.88±0.97)mm,术后分别为(0.91±0.67)mm和(1.84±0.80)mm,组间总体比较差异无统计学意义(F分组=3.558,P=0.063),各组术眼术后眼球眼球内陷度值均明显低于术前,差异均有统计学意义(均P＜0.05).CT影像显示,CADM手术组术眼植入物在位,与眶骨骨折缺损处贴合良好,患者眼球位置及外观均恢复正常.非CADM手术组术眼发生植入物翘起并损伤内直肌.随访期内CADM手术组未发现组织感染、排斥反应等不良反应.结论 CADM技术用于眼眶爆裂性骨折的治疗可重建三维立体骨性眼眶,并有效改善患眼位置、眼球运动功能和视觉功能,其疗效优于传统植入物填充术.

abstractsBackground Orbital blow-out fracture often results in the abnormalities of appearance and function of eye.Because of the special and complex anatomical structure of orbital cavity,it is difficult to design and manufacture the corresponding orbital implants.The computer-aided designing and manufacturing (CADM) technology provides a new approach to orbital implants.However,the clinical value of this method is still under evaluation.Objective This study was to investigate the application and the therapeutic effect of CADM for orbital blow-out fracture.Methods The clinical data of 74 eyes of 74 patients who received surgery for orbital blow-out fracture from July 2006 to July 2012 in Henan Eye Institute,Henan Eye Hospital were retrospectively analyzed.Fiftyeight patients underwent CADM implanted surgery and 16 patients received non-CADM surgery in the same period with matched age,gender and lateral eyes in both groups.The individualized 3D orbital implants were designed and manufactured by the technology of CADM and then were implanted in the bone defects in the CADM group,while the traditional hydroxyapatite artificial bone or high density porous polyethylene material (Medpor) was utilized in the non-CADM group with a fellow-up duration for 22 to 69 months.The best corrected visual acuity (BCVA),eyeball exophthalmos,ocular position,eye movement,diplopia and postoperative complications were evaluated.Results The preoperative BCVA were 0.71±0.37 and 0.69±0.41,and the postoperative BCVA were 0.74±0.38 and 0.72±0.41 in the CADM group and the non-CADM group,respectively,showing an insignificant intergroup difference (Fgroup =0.043,P=0.837),but a significant variation was found over time (Ftime =13.576,P ＜ 0.01).The BCVA was significantly improved after surgery compared with before surgery in both groups (both at P＜0.05).No significantdifferences were found in the number of eyes with curative and improved diplopia and eye movement disorders between the two groups during the fellow-up duration (Z =-0.298,P =0.766;Z =-0.548,P =0.584).The preoperative eyeball exophthalmos values were (3.93±0.99)mm and (3.88±0.97)mm and the postoperative ones were (0.91 ±0.67)mmand (1.84±0.80) mm in the CADM group and the non-CADM group,respectively,without significant differencebetween the two groups (Fgroup =3.558,P =0.063).However,the eyeball exophthalmos values after operation wereremarkably lower than those before operation in both groups (both at P＜0.05).CT imaging displayed implants fitting well with fracture defect and attached to bone tissue accurately in all of the eyes in the CADM group,but in the nonCADM group,the bulge of implants damaging extraocular muscles or optical nerve was found in 2 eyes.No postoperative complication was seen throughout the fellow-up duration in the CADM group.Conclusions CADM technology for orbital blow-out fracture can reconstruct a 3D bony orbit and effectively repair ocular position and appearance,and furthermore restore eye movement and visual functions.The therapeutic outcome of CADM technology for orbital blow-out fracture is superior to conventional implants.