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孙×,男,33岁,农民.病历号64777.于1993年8月16日扛木材时向前摔倒伤及右眼,当时剧痛难忍而急诊入院.体检:除头颅枕部可见2×2cm皮下血肿外,全身其它部位及化验室检查未见异常.眼部检查:左眼视力1.5,未发现异常.右眼:眼睑皮下瘀血,上睑下垂,下睑轻度内翻,睑裂变小,睑裂内有泥土异物,眶下缘完整.清洗异物后可见上穹窿部有2cm的横形裂口,可见部分上直肌外露,无眼球.即在局麻下探查,发现眼眶底部眶下裂后内侧骨折,眼球嵌入上颌窦内.上直肌
Sun ×, male, 33 years old, farmer. Medical record number 64777. In August 16, 1993 fall forward when carrying timber injury and right eye, was unbearable pain and emergency admission. Physical examination: in addition to the head occipital visible 2 × 2cm subcutaneous hematoma, the other parts of the body and laboratory tests showed no abnormalities. Eye examination: left eye vision 1.5, no abnormalities found. Right eye: eyelid subcutaneous bleeding, ptosis, lower eyelid mild varus, eyelid Fissile small, palpebral fissure within the soil foreign body, complete orbital margin.After cleaning the foreign body can be seen on the fornix 2cm cross-shaped tear, visible part of the upper rectus muscle exposed, no eyeballs .In local anesthesia to explore and found the bottom of the orbital infraorbital Fracture medial fracture, the eye embedded in the maxillary sinus. Upper rectus muscle