Low-cost three-dimensional printed orbital template-assisted patient-specific implants for the correction of spherical orbital implant migration

PURPOSE

To describe the outcomes of a patient-specific implant (PSI), fabricated using a three-dimensional (3D) printed orbital template and placed in the basin of the inferior orbital fissure to correct inferotemporally migrated spherical orbital implant.

METHODS

This is a single-center, prospective, consecutive, interventional, case series of six patients, with non-porous, spherical, orbital implant migration that underwent implant recentration surgically with a novel technique. Migration was subclassified either as decentration that did not affect the prosthetic retention or as displacement that affected the prosthetic retention in the eye socket. Only implant displacements were treated. The primary outcome measure was centration of the implant clinically and radiologically, with ability to retain the prosthesis.

RESULTS

At a mean follow-up of 21 months, all six orbital spherical implants remained centered. There were no cases of extrusion, exposure, or migration of either implants. There were no cases of PSI displacement. Additional procedures to optimize the aesthetic outcome of the customized ocular prosthesis (COP) required were simultaneous fornix formation suture in three patients, subsequent fornix formation with mucus membrane graft in two patients, and levator resection and sulcus hyaluronic acid gel injection in one patient each. The mean PSI implant weight was 2.66 ± 0.53 g. The mean COP weight was 2.2 ± 0.88 g postoperatively. The median patient satisfaction with the procedure was 9 on 10.

CONCLUSION

A 3D printing-assisted PSI placed in the basin of the inferior orbital fissure allows recentration of the migrated implant over a follow-up of 21 months without complications.

Autologous fat graft in irradiated orbit postenucleation for retinoblastoma

Autologous fat grafting has been extensively and successfully adopted in a number of pathologic conditions in regenerative surgery especially on irradiated fields in order to improve pain symptoms and tissue trophism promoting scar release. In the present study, we report our experience with autologous fat grafting for the treatment of postirradiation fibrosis and pain on three consecutive patients undergoing orbital enucleation for locally advanced retinoblastoma (RB) and subsequent radiotherapy. We selected three consecutive patients who underwent orbital enucleation for locally advanced RB and subsequent local radiotherapy showing severe reduction in orbital volume and eyelid length and retraction due to fibrosis, spontaneous local pain exacerbated after digital pressure with no possibility to place an ocular implant. They underwent autologous fat grafting in the orbital cavity and results were evaluated by clinical examination at 5 and 14 days, and 1, 3, 6 months, and 1 year after surgery. A significant release of scar retraction, reduction of fibrosis and orbital rim contraction together with an important improvement of pain symptoms was observed in all patients. The local changes observed enabled an ease placement of an ocular prosthetic implant (implant). No local or systemic complication occurred. Fat grafting is a promising treatment for patients showing radiotherapy related complication in the orbital area and it should be adopted by all oculoplastic surgeon in order to improve pain syndrome creating the ideal local conditions for the placement of an ocular prosthetic implant.

Anophthalmic Sockets in Retinoblastoma: A Single Center Experience

PURPOSE

To evaluate outcomes of anophthalmic sockets in retinoblastoma at a tertiary care center in Singapore.

DESIGN

A retrospective study.

METHODS

Patients who underwent enucleation as sole/part of treatment for retinoblastoma were reviewed at our center from 2005-2017. Details including demographics, grouping and staging, adjuvant therapy, surgery, implant, and complications were collected.

RESULTS

Of 42 patients with retinoblastoma managed over the period, the anophthalmic sockets of 31 patients who underwent enucleation were analyzed. Mean age at enucleation was 2 years. Twenty-three enucleations were performed at our institution and 8 enucleations had been performed elsewhere. Seventeen patients (52%) had porous polypropylene, 9 patients (27%) had polymethylmethacrylate, 1 patient (3%) had glass implant, and 3 (9%) had dermis fat graft. The sizes of implants varied from 10 to 20 mm. Twelve patients had attempts at globe salvation before enucleation. Out of 28 patients with primary orbital implants, 3 had implant exposure. The rates of repeat surgery among patients with and without primary implant were 66.67% (2 out of 3) and 10.7% (3 out of 28), respectively. One patient had postenucleation socket syndrome with stock eye. Five patients referred for enucleation were conservatively managed.

CONCLUSIONS

Anophthalmic sockets in retinoblastoma have long-term implications if the primary procedure is not performed well. While the majority had good outcomes (structural and esthetic), a minority had complications requiring intervention. Ophthalmologists managing retinoblastoma must be aware of these. Primary implant had favorable outcome with minimal complications.

A case series of anophthalmic socket cysts excised utilising fibrin sealant

Anophthalmic socket cysts are challenging to remove and incomplete excision has been shown to increase the risk of recurrence. This case series describes a novel technique utilising the fibrin sealant Tisseel (Baxter AG, Vienna, Austria) to retain the socket cyst integrity during surgical removal to facilitate its complete excision. Five patients were included and followed up for a minimum of 1 year, and there were no signs of recurrence in any of the cases. The surgical technique is described and illustrated. This technique is a safe way of simplifying challenging socket cyst surgery.

Orbital exenteration: Institutional review of evolving trends in indications and rehabilitation techniques

PURPOSE

To determine the changes in indications for orbital exenteration over 20 years and to assess its impact on patient survival. Evolving techniques of rehabilitation of the orbit in our institution were also evaluated.

METHODS

This was a retrospective review of hospital records of patients who underwent orbital exenteration from 1995 to 2015 in a tertiary care center. Data extracted included primary location of the tumor, preoperative treatments, interval between initial diagnosis and exenteration, status of surgical margins, presence of metastatic disease, and postoperative survival. The types of prosthesis utilized over the years were also reviewed. Cox regression analysis was performed for categorical variables. Kaplan-Meier analysis was used to estimate post-exenteration survival.

RESULTS

Over a 20-year period, orbital exenteration was performed on 100 orbits of 100 patients. The mean age was 39.4 years (range: 2 months to 90 years). The most common indications among 98 malignant causes were retinoblastoma, squamous cell carcinoma, basal cell carcinoma, extraocular extension of uveal melanoma, and conjunctival melanoma. Postoperative survival was significantly related to age and tumor location but independent from gender, surgical margin, histopathological diagnosis, previous treatment modality, and preoperative interval. In the whole cohort, 1-year and 5-year survival rates were 97% and 84%, respectively.

CONCLUSIONS

Exenteration appears to be life-saving in children with orbital extension of retinoblastoma. While patients exenterated for malignant eyelid tumors have the best chance of survival, those with orbital extension of uveal melanoma and adenoid cystic carcinoma of the lacrimal gland have the worst prognosis.

Primary Intraocular Malignant Rhabdoid Tumor Without Extrascleral Compromise

Primary intraocular malignant rhabdoid tumor is classified as a malignant extrarenal rhabdoid tumor. It is extremely rare, highly aggressive, and, so far, only one case (in a newborn) has been described in the medical literature. The authors report a second case of primary intraocular malignant rhabdoid tumor, this time without extrascleral involvement and in a teenager, and describe its histological, immunohistochemical, and radiological characteristics along with clinical correlations. [J Pediatr Ophthalmol. 2018;55:e7-e9.].

Complications of Hydroxyapatite Pegging: Comparison between Polycarbonate and Titanium Peg System

PURPOSE

Polycarbonate peg has been customarily used for pegging of hydroxyapatite for years. For better movement, tissue tolerance, and to decrease the complications of pegging, titanium peg system has been used. This study compares the two systems.

METHODS

Complications associated with pegging (polycarbonate: Bio-Eye or titanium: Dr-Perry new P-K) were retrospectively reviewed from the charts of 153 patients admitted to the Labbafinejad Medical Center, Tehran, Iran, for over 5 years from 1997 to 2003.

RESULTS

A total of 153 cases were studied. Ninety-six (62.3%) were male and 57 (37.7%) were female, and the mean age was 27.7 years (6-59 years). In 88 cases pegs were poly-carbonate and sleeve system and in 65 cases pegs were titanium. Forty-one (46%) of cases with polycarbonate and 18 (27%) of cases with titanium had at least one or more complications (p=0.018). The most common complications were granulation tissue, discharge, overgrowth of conjunctiva, and peg falling out in 25%, 23%, 13%, and 8% in polycarbonate peg and 15%, 5%, 1.5%, and 0% in titanium peg group. The prevalence of the last three complications was statistically lower in titanium peg compared with polycarbonate. Twenty-five cases (35%) with polycarbonate peg and 5 cases (7.5%) with titanium peg had two or more complications (p=0.03). Peg removal was done in 11 cases of polycarbonate but only two cases of titanium peg in order to treat the complication.

CONCLUSIONS

Both pegging systems had some complications, although these were less severe and prevalent in titanium peg. More studies on complications due to titanium pegs are recommended.

Self-retaining magnetic implant: A novel design of orbital prosthesis for the exenterated orbit

Orbital exenteration can lead to significant disfigurement causing considerable functional, cosmetic and psychological disturbances to the patient. Orbital prosthesis is important for the patient's cosmetic and psychological rehabilitation. A 49-year-old man received orbital exenteration and postoperative radiotherapy for malignant orbital carcinoma. In view of uncertain suitability and survival of osseointegrated implant in his case, a novel design of ocular implant consisting of a self-retaining magnetic spring retainer and a coupling silicone prosthesis was used. This novel design was shown to provide the patient with ease of use, good cosmetic outcome and better quality of life.

Comparison of primary and secondary enucleation for uveal melanoma

We investigated operative course and post-operative findings of patients undergoing primary enucleation for uveal melanoma versus those requiring secondary enucleation after brachytherapy. A retrospective chart review was performed with IRB approval on patients receiving treatment for uveal melanoma. Patients with enucleation as initial treatment and patients enucleated after plaque brachytherapy were analyzed for demographic data, operative course, and post-enucleation outcome. Further cause analysis for secondary enucleations was investigated. No significant difference was seen in age, laterality, or gender between the primarily enucleated (n = 54) and secondarily enucleated (n = 34) groups. Greater difficulty with surgery was noted in 28/32 (87.5%) of secondary enucleations compared to 1/54 (1.8%) of primary enucleations (p < 0.0001). Operative time was >2 hours in 3/51 (6%) of primary enucleations (vs. 8 of 32, 25%, p = 0.02). Average implant size was similar in the 2 groups (20.6 mm), however 2/34 (6%) of secondary enucleations required dermis fat grafting. Post-enucleation anophthalmic ptosis occurred after 8/49 (16%) of primary cases (vs. 13/30, 43%, p = 0.02) and prosthetic enophthalmos after none (0%) of primary cases (vs. 5/30, 17%, p = 0.006). Class 2 gene expression profile was found in 6/8 (60%) of eyes enucleated for treatment failure. Secondary enucleation performed after plaque brachytherapy was technically more difficult, and had more anophthalmic socket and eyelid complications compared to primary enucleation for uveal melanoma. Primary enucleation may avoid additional surgery and morbidity in a subset of patients with contraindications to plaque brachytherapy.

Patient-specific puzzle implant preformed with 3D-printed rapid prototype model for combined orbital floor and medial wall fracture

BACKGROUND

The management of combined orbital floor and medial wall fractures involving the inferomedial strut is challenging due to absence of stable cornerstone. In this article, we proposed surgical strategies using customized 3D puzzle implant preformed with Rapid Prototype (RP) skull model.

METHODS

Retrospective review was done in 28 patients diagnosed with combined orbital floor and medial wall fracture. Using preoperative CT scans, original and mirror-imaged RP skull models for each patient were prepared and sterilized. In all patients, porous polyethylene-coated titanium mesh was premolded onto RP skull model in two ways; Customized 3D jigsaw puzzle technique was used in 15 patients with comminuted inferomedial strut, whereas individual 3D implant technique was used in each fracture for 13 patients with intact inferomedial strut. Outcomes including enophthalmos, visual acuity, and presence of diplopia were assessed and orbital volume was measured using OsiriX software preoperatively and postoperatively.

RESULTS

Satisfactory results were achieved in both groups in terms of clinical improvements. Of 10 patients with preoperative diplopia, 9 improved in 6 months, except one with persistent symptom who underwent extraocular muscle rupture. 18 patients who had moderate to severe enophthalmos preoperatively improved, and one remained with mild degree. Orbital volume ratio, defined as volumetric ratio between affected and control orbit, decreased from 127.6% to 99.79% (p < 0.05) in comminuted group, and that in intact group decreased from 117.03% to 101.3% (p < 0.05).

CONCLUSION

Our surgical strategies using the jigsaw puzzle and individual reconstruction technique provide accurate restoration of combined orbital floor and medial wall fractures.

[Surgical correction of conjunctival sac narrowing after orbital implantation using polyester fiber heart patches]

OBJECTIVE

To test the feasibility of correcting conjunctival sac narrowing following orbital implantation using polyester fiber heart patches instead of the skin autograft.

METHODS

Twelve patients of conjunctival sac narrowing after orbital implantation (including 3 with orbital implant exposure) admitted in Nanfang Hospital between 2012 and 2016 received surgical correction of the conjunctival sac using polyester fiber heart patches. During the surgery, the central conjunctival sac was opened, the exposed area was covered with suitable polyester fiber heart patches, and the palpebral margin was sutured.

RESULTS

Three months after the operation, 10 patients showed improved appearance after implantation of the prosthetic eye. Two patients received a second operation to remove the patches due to graft rejection and infections and skin autograft was implanted for reconstruction of the conjunctival sac.

CONCLUSION

Polyester fiber heart patches are ideal materials for repairing Conjunctival sac narrowing and orbital implant exposure, but this approach is not suitable in cases of severe narrowing or occlusion of the conjunctival sac.

[Surgical correction of conjunctival sac narrowing after orbital implantation using polyester fiber heart patches]

OBJECTIVE

To test the feasibility of correcting conjunctival sac narrowing following orbital implantation using polyester fiber heart patches instead of the skin autograft.

METHODS

Twelve patients of conjunctival sac narrowing after orbital implantation (including 3 with orbital implant exposure) admitted in Nanfang Hospital between 2012 and 2016 received surgical correction of the conjunctival sac using polyester fiber heart patches. During the surgery, the central conjunctival sac was opened, the exposed area was covered with suitable polyester fiber heart patches, and the palpebral margin was sutured.

RESULTS

Three months after the operation, 10 patients showed improved appearance after implantation of the prosthetic eye. Two patients received a second operation to remove the patches due to graft rejection and infections and skin autograft was implanted for reconstruction of the conjunctival sac.

CONCLUSION

Polyester fiber heart patches are ideal materials for repairing Conjunctival sac narrowing and orbital implant exposure, but this approach is not suitable in cases of severe narrowing or occlusion of the conjunctival sac.

Consideration for eliminating conjunctival closure in the enucleation procedure

To compare post-operative results and complications in patients who undergo enucleation with or without suture closure of the conjunctiva. This was a retrospective chart review study. Review of 50 cases of enucleation surgery at the University of Arkansas for Medical Sciences and Arkansas Children's Hospital between July 2011 and December 2014. Criteria for inclusion in the study were all cases of enucleation that had extraocular muscles attached to a spherical orbital implant with or without conjunctival closure, and at least 2 months of postoperative follow up. Post-operative complications were evaluated. A total of 36 cases fulfilled the criteria for inclusion in the study; 12 cases with direct sutured layered direct closure of Tenon's and then conjunctiva and 24 cases with Tenon's capsule sutured closure but without direct conjunctival sutured closure. No implant complications were identified in either group (p = 1.0). Mean follow-up for all groups was 16.71 months (range 2 to 43 mo., SD 11.94). Mean follow up for the non-closure group was 14.42 months (range 2.25 to 36 mo., SD 10.35). Two cases in the conjunctival closure group developed a conjunctival cyst, affecting prosthesis fit, approximately 3 months postoperatively: no such cysts were identified in the non-conjunctival closure group. Fisher exact test for cyst formation between the two groups was not statistically significant (p = 0.1048). Direct conjunctival closure following enucleation surgery does not appear to increase the risk of extrusion, exposure, or infection. Foregoing direct closure decreases surgical time and reduces cost. It is unclear if this decreases conjunctival cyst formation.

Self-inflicted enucleations: Clinical features of seven cases

We report the clinical presentation, radiography, and management outcomes of autoenucleations (AE). Charts of 7 patients evaluated at 4 institutions with AE were reviewed. Four males and three females had a mean age of 50 years (range 26-72 years). The etiologies were psychosis secondary to underlying mental illness (6, 88%) and substance use (1, 12%), and the mechanism was largely blunt digital injury (6, 88%). Three (43%) AE patients suffered bilateral enucleations. Common concomitant injuries included eyelid lacerations (5, 71%) and optic nerve avulsion (3, 43%). Radiography was utilized for all of the study patients with computed tomography as the most common (5, 71%), followed by ultrasound (1, 14%), and magnetic resonance imaging with CT angiography (1, 14). Orbital exploration was performed in the management of all patients. Orbital implants were placed in 4 (57%) patients. Patients were followed for a mean of 1.9 months (range 1-4 months). Autoenucleation affects both genders and is commonly associated with eyelid lacerations, optic nerve avulsion, and intracranial hemorrhage. The association with intracranial hemorrhage is consistent with prior reports of internal carotid artery injury following shearing of the optic nerve. Autoenucleation cases were seen secondary to mental or substance induced psychosis, and these patients may be at risk for future injuries such as AE of the contralateral globe. The common causes for psychosis reported our patient group include schizophrenia, depression, schizoaffective disorder, and methamphetamine-induced psychosis, which corroborates with similar cases in the literature. Two of three cases of bilateral AE suffered sequential AE where the contralateral globe was enucleated days apart. All patients suffering AE should have full medical, psychiatric, neurologic, and radiologic evaluation and monitoring while under care. When evaluating patients with obvious ocular injury, accompanying intracranial injuries should be ruled out in a timely fashion before pursuing surgical intervention.

Single-stage socket reconstruction with vascularised temporalis muscle flap following total orbital exenteration: Description of 3 surgical approaches

We describe the techniques and outcome of three different approaches to transfer the posterior 2/3^rd temporalis muscle pedicle flap for orbital socket reconstruction following total orbital exenteration. A retrospective interventional series of 9 patients operated between February of 2000 and 2006. We describe three different techniques, namely supraorbital, transorbital and transorbitectomy approach. All patients were followed for minimum of 3 years and muscle trophism with periorbital contour was clinically studied for outcome. There were 6 males and 3 females with a mean age of 42 years. Three patients each underwent the three mentioned approaches of socket reconstruction following total orbital exenteration performed mainly for oculo-adenexal malignancies with orbital extension (77.78%). Intraoperative, tumor-free histopathological margins were ensured. Postoperatively, bulky lateral orbital rim was noticed in all 3 patients of supraorbital approach, while progressive temporalis flap atrophy was noticed in all with transorbital approach over a period of 6 months. No such complications were observed in transorbitectomy approach and reasonably good periorbital cosmetic appearance with optimum preservation of muscle trophism was obtained. The mean follow-up period was 7 years. Temporalis muscle flap provides adequate orbital volume restoration in an exenterated socket. It also helps in better skin graft uptake, socket health and appearance. The transorbitectomy approach appeared as a reliable one stage surgical technique with reasonably acceptable anatomical and cosmetic outcome over a long-term follow-up. The choice of posterior portion of temporalis muscle as a flap offers satisfactory temporal fossa appearance.

[Long-term results of the compatibility of a coralline hydroxyapatite implant as eye replacement]

BACKGROUND

Coralline hydroxyapatite has been used since 1983 as volume replacement. Through 2001, a total of 200 hydroxyapatite implants were used in our department.

OBJECTIVE

This prospective study was undertaken to measure the subjective and objective long-term tolerance of this implant.

MATERIALS AND METHODS

In 2012, a total of 20 patients were examined, who were enucleated or eviscerated between 1993 and 2001 (average follow-up 16.2 years) and had an hydroxyapatite implant placed with a scleral sheath. We evaluated the subjective tolerance and measured the motility, the prominence of the globe, lid positions, changes of the conjunctiva and postoperative complications.

RESULTS

The subjective long-term tolerance was reported to be good. All patients had a ptosis; an ectropion was found in 50% of patients. In 40% of the patients additional surgery was performed. The motility was better in primary than in secondary placed implants. Volume replacement was successful in 10 patients, 9 patients had a retraction and 1 patient a prominent prosthesis.

DISCUSSION

Hydroxyapatite implants with sclera sheathing were well tolerated and showed good motility on long-term follow-up over more than 16 years. Lid malpositions such as ptosis or ectropion are common but might be due to mechanical stress through the prosthesis and atrophy of the orbital fat.

Indications of enucleations and eviscerations performed at a tertiary eye care unit: A case series

The retrospective study was planned to look at the indications of eye enucleations and eviscerations, and comprised all such procedures done at the Aga Khan University Hospital, Karachi, from January 2006 to December 2015. Data was collected regarding age at the time of procedure, gender, procedure type, indication for enucleation or evisceration, type of implant if used and complications. Of the 66 eyes of 65 individuals, 47 (71.2%) underwent evisceration and 19 (28.8%) enucleation. The mean age at the time of the procedures was 37.86±23.09 years. The indication for enucleation or evisceration were keratitis 14(21.2%), introcular tumours 13(19.7%), trauma 10(15.2%), endophthalmitis 10(15.2%), cosmesis 10(15.2%) and painful blind eye 9(13.6%). Only 5(7.5%) procedures had postoperative complications such as wound dehiscence, infected socket, loose suture, or stich abscess. Most of causes of enucleation and evisceration in this case series could have prevented through the application of evidence-based safety practices.

Recurrent inverted papilloma of paranasal sinus presenting as acute proptosis

Objective. To describe the course of events that followed from the time of the diagnosis to the management of a rare case of recurrent inverted papilloma presenting as an acute proptosis. Methods. A seventy-year-old diabetic female patient presented with a painful left eye proptosis for 15 days. She had a history of resection of inverted papilloma of paranasal sinus followed by radiotherapy for eight years before. The examination revealed a 23 mm proptosis, with restricted ocular movements, corneal oedema, funnel shaped anterior chamber, and total retinal detachment with a complete visual loss. The lobulated fixed hard mass was palpable circumferentially but more in the inferior orbital compartment. The transconjunctival incisional biopsy showed features of highly undifferentiated cytology. The lid sparing exenteration was done under general anesthesia with cosmetic reconstruction. Results. Immunohistochemistry of exenterated mass was doubtfully suggestive of a small cell tumor. However, histopathology confirmed features of rhabdomyosarcoma. Conclusion. The present case study revealed rhabdomyosarcoma cytology presenting as an association-inverted papilloma. Abbreviations : IP = Inverted papilloma, PNS = Paranasal sinus, SCC = Squamous cell carcinoma, IOP = Intraocular pressure, CT = Computed tomography.

Orbital exenteration: The 10-year Massachusetts Eye and Ear Infirmary experience

The authors report their experience with orbital exenteration surgery at one academic institution over a 10-year period and review the literature. This retrospective cohort study monitored outcomes of all patients who underwent orbital exenteration surgery at Massachusetts Eye and Ear Infirmary between January 2003 and January 2013. Patients with no follow-up data or survival data were excluded from the study. The main outcome measures were surgical complications, disease status of surgical margins, need for adjuvant treatment, local recurrence, metastases and survival. 23 patients with malignancy and 2 with mucormycosis met inclusion criteria for the study. Surgical procedures included non-lid sparing total exenteration (44%), lid-sparing total exenteration (32%), non-lid sparing partial exenteration (8%) and lid-sparing partial exenteration (16%). 44% underwent additional extra-orbital procedures. Survival rates were 72% at 1 year, 48% at 3 years, and 37% at 5 years. Of patients with malignancies, 48% had clear margins after exenteration. There was no statistically significant difference in survival between patients with negative surgical margins compared to positive margins (p = 0.12). Mortality was highest in patients with melanoma (85.7%) and lowest in patients with non-squamous cell lid malignancies (0%). Our study suggests that the type of disease has a much greater impact on the survival of patients undergoing exenteration surgery than the type of exenteration surgery or the disease status of surgical margins. Patients with non-squamous cell lid malignancies and localized orbital disease have the best prognosis for tumor eradication from this radical and highly disfiguring surgery.

Perception of patient appearance following various methods of reconstruction after orbital exenteration

This article compares the perception of health and beauty of patients after exenteration reconstruction with free flap, eyelid-sparing, split-thickness skin graft, or with a prosthesis. Cross-sectional evaluation was performed through a survey sent to all students enrolled at the University of Iowa Carver College of Medicine. The survey included inquiries about observer comfort, perceived patient health, difficulty of social interactions, and which patient appearance was least bothersome. Responses were scored from 0 to 4 for each method of reconstruction and an orbital prosthesis. A Friedman test was used to compare responses among each method of repair and the orbital prosthesis for each of the four questions, and if this was significant, then post-hoc pairwise comparison was performed with p values adjusted using Bonferroni's method. One hundred and thirty two students responded to the survey and 125 completed all four questions. Favorable response for all questions was highest for the orbital prosthesis and lowest for the split-thickness skin graft. Patient appearance with an orbital prosthesis had significantly higher scores compared to patient appearance with each of the other methods for all questions (p value < 0.0001). Second highest scores were for the free flap, which were higher than eyelid-sparing and significantly higher compared to split-thickness skin grafting (p value: Question 1: < 0.0001; Question 2: 0.0005; Question 3: 0.006; and Question 4: 0.019). The orbital prosthesis was the preferred post-operative appearance for the exenterated socket for each question. Free flap was the preferred appearance for reconstruction without an orbital prosthesis. Split-thickness skin graft was least preferred for all questions.

Porous and nonporous orbital implants for treating the anophthalmic socket: A meta-analysis of case series studies

PURPOSE

To assess the efficacy and safety of porous and nonporous implants for management of the anophthalmic socket.

METHODS

Case series meta-analysis was conducted with no language restriction, including studies from: PUBMED, EMBASE and LILACS. Study eligibility criteria were case series design with more than 20 cases reported, use of porous and/or nonporous orbital implants, anophthalmic socket and, treatment success defined as no implant exposure or extrusion. Complications rates from each included study were quantified. Proportional meta-analysis was performed on both outcomes with a random-effects model and the 95% confidential intervals were calculated.

RESULTS

A total of 35 case series studies with a total of 3,805 patients were included in the meta-analysis. There are no studies comparing porous and nonporous implants in the anophthalmic socket treatment. There was no statistically significant difference between porous polyethylene (PP) and hydroxyapatite (HA) on implant exposure: 0.026 (0.012-0.045) vs 0.054 (0.041-0.070), respectively and, neither on implant extrusion: 0.0042 (0.0008-0.010) vs. 0.018 (0.004-0.042), respectively. However, there was a significant difference supporting the use of PP when compared to bioceramic implant: 0.026 (0.012 -0.045) vs. 0.12 (0.06-0.20), respectively, on implant exposure.

CONCLUSION

PP implants showed lower chance of exposure than bioceramic implant for anophthalmic socket reconstruction, although we cannot rule out the possibility of heterogeneity bias due to the nature and level of evidence of the included studies. Clinical trials are necessary to expand the knowledge of porous and nonporous orbital implants in the anophthalmic socket management.

Modified technique to improve fabrication and outcome of definitive orbital prosthesis

Facial prostheses are generally fabricated from silicones, which provide life-like appearance and flexibility. The longevity of silicone, however, is limited because of its tendency to support fungal growth, absorb oils and grease, and edge-tearing susceptibility. Polyurethane (PU) liners have been used on the tissue-bearing surface of such prosthesis to improve tear resistance and fungal resistance. Technique sensitivity, discoloration and metamerism are significant limitations of urethane lining. Further, this liner is incorporated during processing of definitive prosthesis, which precludes try-in of tissue surface of prosthesis. This article describes an alternative lining material for fitting surface of definitive orbital prostheses, which could overcome limitations associated with all silicone or PU lined silicone prostheses.