[Effects of basic fibroblast growth factor composite sponge treated collagen on vascularization of orbital implants: a histopathologic analysis]

OBJECTIVE

To evaluate the effect of basic fibroblast growth factor (bFGF) treated collagen composite sponge on vascularization of HA orbital implants.

METHODS

New Zealand rabbits received three different orbital implants:naked implants, implants wrapped with collagen composite sponge and implants wrapped with bFGF treated collagen composite sponge.Implants were harvested 2, 4, 6, 8 and 12 weeks after surgery. The vascularization of implants was then assessed by light and electron microscopy.

RESULTS

At post-surgery weeks of 2, 4 and 6, bFGF treated collagen composite sponge induced the highest degree of vascularization of orbital implants. Collagen composite sponge alone resulted in higher extent of vascularization than naked implants. Complete vascularization of implants was observed at post-surgery 6 weeks by bFGF treated collagen composite sponge, which was not observed in the other two groups until post-surgery 8 weeks. There were significant differences in the average length of fibrovasculature and in the degree of vascularization among each group at post-surgery 2, 4 and 6 weeks (P<0.05), while no statistical difference was observed at post-surgery 8 and 12 weeks (P>0.05).

CONCLUSIONS

bFGF treated collagen composite sponge facilitates fibrovascularization of orbital implants, and shortens the time required for complete vascularization. Collagen composite sponge alone promotes early-stage fibrovascularization, but fails to facilitate complete vascularization of orbital implants.

Biomaterials for orbital implants and ocular prostheses: overview and future prospects

The removal of an eye is one of the most difficult and dramatic decisions that a surgeon must consider in case of severe trauma or life-threatening diseases to the patient. The philosophy behind the design of orbital implants has evolved significantly over the last 60 years, and the use of ever more appropriate biomaterials has successfully reduced the complication rate and improved the patient's clinical outcomes and satisfaction. This review provides a comprehensive picture of the main advances that have been made in the development of innovative biomaterials for orbital implants and ocular prostheses. Specifically, the advantages, limitations and performance of the existing devices are examined and critically compared, and the potential of new, smart and suitable biomaterials are described and discussed in detail to outline a forecast for future research directions.

Orbital implants: potential new directions

This article reviews orbital implants used to replace an eye after enucleation or evisceration. Advantages of implant placement are described, with discussion of implant and wrap material, and design features that affect clinical outcomes. Implants may be porous or nonporous, pegged for linkage with a cosmetic shell or unpegged, and may be wrapped with a covering material or tissue or unwrapped. Device shape, volume and material qualities affect tissue tolerance and the risk of exposure or extrusion. Limitations of currently available devices are discussed, with factors affecting surgeon and patient choice. Ideally, a device should be easy to insert, avoid the need for wrapping or adjunctive tissues, be light, biointegratable, comfortable after implantation and provide satisfactory orbital volume replacement, movement and cosmesis without requiring further surgery or pegging. This review briefly discusses developments in implant design and aspects of design that affect function, but is not a detailed clinical review; rather, it aims to stimulate thought on optimal design and discusses recent developments. Novel technology in the form of a prototype device with a soft, biointegratable anterior surface is described as an example of newer approaches.

Use of extraocular muscle flaps in the correction of orbital implant exposure

Purposes

The study is to describe a new surgical technique for correcting large orbital implant exposure with extraocular muscle flaps and to propose a treatment algorithm for orbital implant exposure.

Methods

In a retrospective study, seven patients with orbital implant exposure were treated with extraocular muscle flaps. All data were collected from patients in Chang Gung Memorial Hospital, Taiwan during 2007–2012. All surgeries were performed by one surgeon (Y.J.T). Patient demographics, the original etiology, details of surgical procedures, implant types, and follow-up interval were recorded. Small exposure, defined as exposure area smaller than 3 mm in diameter, was treated conservatively first with topical lubricant and prophylactic antibiotics. Larger defects were managed surgically.

Results

Seven patients consisting of two males and five females were successfully treated for orbital implant exposure with extraocular muscle flaps. The average age was 36.4 (range, 3–55) years old. Five patients were referred from other hospitals. One eye was enucleated for retinoblastoma. The other six eyes were eviscerated, including one for endophthalmitis and five for trauma. Mean follow-up time of all seven patients was 19.5 (range, 2–60) months. No patient developed recurrence of exposure during follow-up. All patients were fitted with an acceptable prosthesis and had satisfactory cosmetic and functional results.

Conclusions

The most common complication of orbital implant is exposure, caused by breakdown of the covering layers, leading to extrusion. Several methods were reported to manage the exposed implants. We report our experience of treating implant exposure with extraocular muscle flaps to establish a well-vascularized environment that supplies both the wrapping material and the overlying ocular surface tissue. We believe it can work as a good strategy to manage or to prevent orbital implant exposure.

Alphasphere as a successful ocular implant in primary enucleation and secondary orbital implant exchange

PURPOSE

To describe the surgical technique for a novel poly-HEMA (2-hydroxyethyl methacralate)[PHEMA] implant (Alphasphere, Addition Technology, Des Plaines, IL) in primary enucleation and placement of secondary orbital implant.

METHODS

Retrospective chart review of all patients receiving an Alphasphere implant for primary enucleation or secondary implant exchange from October 2009 to 2011. Interval follow-up was performed again on January 2013. Patient demographics, indications for surgery, and post-operative complications were reviewed.

RESULTS

Twelve patients received an Alphasphere implant for primary enucleation (n = 10) or secondary exchange (n = 2), with follow-up that ranged from 2 weeks to 14 months. The study included 9 adult and 3 pediatric patients with a mean age of 40 years, range 8-82 years. The indication for enucleation included: painful blind eye (n = 9), enophthalmos with difficult prosthesis fit in cases of secondary implant exchange (n = 2), and prophylaxis for sympathetic ophthalmia (n = 1). Only one patient required removal of the implant, due to a sinus infection with subsequent extrusion of the implant. Otherwise, the only other complication experienced was slight implant migration (n = 1).

CONCLUSION

This initial report indicates that Alphasphere can be successfully used in the management of an anophthalmic socket. The advantages of the Alphasphere implant include: it does not require tissue wrapping, extraocular muscles can be directly sutured to the implant, it maintains a smooth surface to limit risk of exposure due to conjunctival breakdown, and undergoes anterior orbital fibrovascular ingrowth which optimizes prosthesis location and socket motility.

Intracranial arachnoid cyst; an unusual cause of epiphora

PURPOSE

To describe a case of unilateral intracranial arachnoid cyst in association with enophthalmos and epiphora on the same side.

METHODS

Case report.

RESULTS

A young man with symptoms of unilateral epiphora is described. He had a large intracranial arachnoid cyst with an unusually large orbit leading to enophthalmos and symptomatic epiphora on that side. Radiological features of the orbit and associated pneumosinus dilatants are described. We also offer hypotheses to describe the paradoxical occurrence of an expanding intracranial mass and inward growth of the orbit and paranasal sinuses.

CONCLUSION

A new cause for enophthalmos is described.

Desmoplastic fibroma: report of rare lesion in unusual craniofacial location

Desmoplastic fibroma (DF) is a benign but aggressive intraosseous tumor. These lesions are categorized as central tumors of bone. They are composed of small fibroblasts in a setting of abundant extracellular material, which is rich in collagen. DF represents fewer than 0.1% of all bony tumors. They can be found in any part of the skeleton. Based upon on our literature review, we believe this is the second reported case of desmoplastic fibroma occurring in the zygoma area.

[Implants in ophthalmology and potential of visual control]

Results of complex ultrasonic examination in different time after socket reconstruction using biomaterial "Alloplant" are presented. Modified technique of primary socket reconstruction showed good cosmetic result.

[Surgical rehabilitation in patients with zygomatic orbital fractures and orbital floor fractures]

The study presents the results of surgical management of 65 patients with zygomatico-orbital complex and orbital floor fractures according to a self-designed technique using polymer implants Reperen. Being a method of choice the technique reduces treatment time, promotes good esthetic results, reduces complication rate, and contributes to a patient's quality life improvement.

Measurement of orbital volume after enucleation and orbital implantation

Introduction

This article reports experience relating to the measurement of orbital volume by means of cone beam computed tomography (CBCT) and Cranioviewer program software in patients who have undergone enucleation and orbital implantation.

Patients and Methods

CBCT scans were made in 30 cases, 10 of which were later excluded because of various technical problems. The study group therefore consisted of 20 patients (8 men and 12 women). The longest follow-up time was 7 years, and the shortest was 1 year. In all 20 cases, the orbital volume was measured with Cranioviewer orbital program software. Slices were made in the ventrodorsal direction at 4.8 mm intervals in the frontal plane, in both bony orbits (both that containing the orbital implant and the healthy one). Similar measurements were made in 20 patients with various dental problems. CBCT scans were recorded for the facial region of the skull, containing the orbital region. The Cranioviewer program can colour the area of the slices red, and it automatically measures the area in mm.

Results

In 5 of the 20 cases, the first 4 or all 5 slices revealed that the volume of the operated orbit was significantly smaller than that of the healthy orbit, in 12 cases only from 1 to 3 of the slices indicated such a significant difference, and in 3 cases no differences were observed between the orbits. In the control group of patients with various dental problems, there was no significant difference between the two healthy orbits. The accuracy of the volume measurements was assessed statistically by means of the paired samples t-test.

Summary

To date, no appropriate method is avaliable for exact measurement of the bony orbital volume, which would be of particular importance in orbital injury reconstruction. However, the use of CBCT scans and Cranioviewer orbital program software appears to offer a reliable method for the measurement of changes in orbital volume.

Clinical application of artificial orbital implantation with a turning implantation method in 46 cases

PURPOSE

To analyze and summarize the application of a turning implantation method in artificial orbital implantation.

METHODS

Artificial orbital implants were implanted into 46 patients who were willing to accept artificial orbital implantation with a turning implantation method.

RESULTS

After the implantation, 46 cases (46 eyes) with HA orbital implants were healed with plump orbits. No ptosis appearance, deformity, or rejection was observed. The implants were qualified in appearance and flexibility. Two cases presented with chemosis and eye grinding pain during the early postoperative period, but these patients recovered after effective treatment. After 6-24 months of follow-up, no patient had artificial implant exposure or abnormal orbital stimulation.

CONCLUSION

The turning implantation method provides a good artificial orbital implantation.

Extraoral implants in the rehabilitation of craniofacial defects: implant and prosthesis survival rates and peri-implant soft tissue evaluation

PURPOSE

Few reports have evaluated cumulative survival rates of extraoral rehabilitation and peri-implant soft tissue reaction at long-term follow-up. The objective of this study was to evaluate implant and prosthesis survival rates and the soft tissue reactions around the extraoral implants used to support craniofacial prostheses.

MATERIALS AND METHODS

A retrospective study was performed of patients who received implants for craniofacial rehabilitation from 2003 to 2010. Two outcome variables were considered: implant and prosthetic success. The following predictor variables were recorded: gender, age, implant placement location, number and size of implants, irradiation status in the treated field, date of prosthesis delivery, soft tissue response, and date of last follow-up. A statistical model was used to estimate survival rates and associated confidence intervals. We randomly selected 1 implant per patient for analysis. Data were analyzed using the Kaplan-Meier method and log-rank test to compare survival curves.

RESULTS

A total of 150 titanium implants were placed in 56 patients. The 2-year overall implant survival rates were 94.1% for auricular implants, 90.9% for nasal implants, 100% for orbital implants, and 100% for complex midfacial implants (P = .585). The implant survival rates were 100% for implants placed in irradiated patients and 94.4% for those placed in nonirradiated patients (P = .324). The 2-year overall prosthesis survival rates were 100% for auricular implants, 90.0% for nasal implants, 92.3% for orbital implants, and 100% for complex midfacial implants (P = .363). The evaluation of the peri-implant soft tissue response showed that 15 patients (26.7%) had a grade 0 soft tissue reaction, 30 (53.5%) had grade 1, 6 (10.7%) had grade 2, and 5 (8.9%) had grade 3.

CONCLUSIONS

From this study, it was concluded that craniofacial rehabilitation with extraoral implants is a safe, reliable, and predictable method to restore the patient's normal appearance.

Two-piece impression procedure for implant-retained orbital prostheses

Obtaining an accurate impression of facial tissues with undercuts and extraoral implants has always been a challenge for both clinicians and patients. This report describes a three-step, two-piece technique that enables an accurate and comfortable impression of undercut tissues and extraoral implants in an orbital defect. An impression of the basal tissue surface of the defect area was made using a medium-body polyether impression material followed by an impression of the entire face of the patient made with a polyvinyl siloxane (PVS) impression material. First, the PVS impression material was removed; second, the impression posts were removed from the magnets; and third, the polyether impression was removed from the defect. The impression posts were attached to the implant analogs and placed in the negative spaces in the polyether impression. The polyether impression, which carries the implant analogs and impression posts, was placed in the PVS impression through the negative spaces. This technique minimizes trauma to the soft tissues and implants during impression making and also does not require additional materials.

Enucleation and evisceration: 20 years of experience

OBJECTIVE

To determine the indications, relative frequencies, surgical times, and complications for enucleation and evisceration performed at a single academic center.

METHODS

Medical records of all patients who underwent an enucleation or evisceration between January 1st, 1990 and December 31st, 2009 at a single academic center were reviewed. Patient demographics and surgical indications, times, and complications were recorded.

RESULTS

A total of 85 eyes in 85 patients underwent enucleation (n = 31; 36%) or evisceration (n = 54; 64%) during the study period. Almost all patients were of African descent (96%). The most common underlying cause leading to eye removal was trauma. On average, eviscerations (47.3 ± 10.3 minutes) took significantly less time to perform than enucleations (89.6 ± 10.1 minutes; p < 0.01). Complications included implant exposure, infection, lower lid laxity, fornix insufficiency, and need for subsequent surgery; the occurrence of these complications was found to be similar between the two groups (p = 0.77). No case of sympathetic ophthalmia or inadvertent evisceration of an eye with an occult intraocular malignancy was noted. From the first decade for which data were available (1990- 1999) to the second decade (2000- 2009), the average number of enucleations decreased (p = 0.02) and the average number of eviscerations (p = 0.04) increased.

CONCLUSION

Evisceration was found to be a safe and quicker alternative to enucleation in our study. A change in surgical preference from enucleation to evisceration was seen during the 20-year study period.

Quality of life of eye amputated patients

PURPOSE

To evaluate eye-amputated patients' health-related quality of life, perceived stress, self-rated health, job separation because of illness or disability and socioeconomic position.

METHODS

Patients were recruited from a tertiary referral centre situated in Copenhagen. Inclusion criteria were eye amputation, i.e. evisceration, enucleation, orbital exenteration or secondary implantation of an orbital implant during the period 1996-2003, and participation in a previous investigation (2005). In total, 159 eye-amputated patients were included, and completed a self-administered questionnaire containing health-related quality of life (SF-36), the perceived stress scale and answered questions about self-rated health, job changes because of illness or disability and socioeconomic status. These results were compared with findings from the Danish Health Interview Survey 2005.

RESULTS

The eye-amputated patients had significantly (p < 0.05) lower scores (poorer health) on all SF-36 subscales and more perceived stress compared to the general population. In all, 43.3% of the patients rated their health as excellent or very good compared to 52.1% of the general population. In total, 25% of the study population has retired or changed to a part-time job because of eye disease. The percentage of eye amputated patients, who were divorced or separated, was twice as high as in the general population.

CONCLUSION

The impact of an eye amputation is considerable. The quality of life, perceived stress and self-rated health of many eye-amputated patients are drastically changed. Eye amputation has a marked negative influence on job separation because of illness or disability and on socioeconomic position.

The use of mersilene mesh for wrapping of hydroxyapatite orbital implants: mid-term result

PURPOSE

To report the results of Mersilene mesh wrapped hydroxyapatite orbital implantation.

MATERIALS AND METHODS

Records of 63 patients operated between April 2002 and March 2006 were retrospectively reviewed. Parameters studied included sex, cause of enucleation, length of follow-up after operation, implant exposure, secondary implantation, and surgeon experience. Student's t-test and χ(2) were used for comparison group having implant exposure and those without implant exposure.

RESULTS

The rate of exposure with use of Mersilene mesh was found to be 4.7%. Gender and cause of enucleation did not influence incidence of implant exposure in this study. The surgeon related factor, reported in terms of oculoplasty surgeon and non-oculoplasty surgeon, was a statistically significant factors that affected implant exposure.

CONCLUSION

Mersilene showed favorable results in wrapping of hydroxyapatite orbital implants.

One-stage explant-implant procedure of exposed porous orbital implants

PURPOSE

To investigate the risks of implant exposure after a combined explant-implant procedure in patients with an exposed porous orbital implant.

METHODS

Twenty-four consecutive patients who had a combined explant-implant procedure of an exposed hydroxyapatite (21) or porous polyethylene (3) orbital implant from January 2000 to February 2009 were included. The patient records were reviewed; patients were interviewed by telephone and invited for a clinical examination. Histopathological examination was carried out on the removed implants. Main outcome measures were: presence of exposure of the new implant or not, patient graded satisfaction with the cosmetic result, and presence of poor motility.

RESULTS

None of the new implants became exposed or infected in the follow-up period of 25 [3-94] months (median [range]). The patients scored their satisfaction with the cosmetic result to a median score of 9 (range 5-10). Poor motility was present in six of 17 patients. Micro-organisms were identified in three removed implants and signs of inflammation were present in 20 removed implants.

CONCLUSIONS

If a decision of implant removal has been made, it is safe to replace the implant at the same procedure in sockets without profound signs of infection. The procedure carries a possible risk of poor motility.

[Comparative experimental study of current implant materials used in orbital surgery]

Reconstructive orbital procedures are often associated with the use of different implant materials, that may sometimes cause complications resulting in surgery efficacy impairing and need of reoperation. At the present time in Russia and abroad various orbital implants are used though there are no experimental or clinical studies comparing implant materials used In this study comparative experimental morphological investigation of biointegrative characteristics of 6 current orbital implant materials was performed, tissue reactions in response to implantation is described in details in laboratory animals, recommendations for implant use in clinic are given.

Stability measurements of craniofacial implants by means of resonance frequency analysis: 1-year clinical pilot study

PURPOSE

The purpose of this pilot study was to apply resonance frequency analysis (RFA) to measure the clinical stability of craniofacial implants and compare the RFA measurements over a 12-month period.

MATERIALS AND METHODS

Patients with auricular or orbital defects were treated with prostheses retained by two or three implants. After healing periods of 3 months for auricular implants and 6 months for orbital implants, prostheses were fabricated. RFA measurements were performed immediately after implant placement, at abutment connection, and at 6 and 12 months. All stability measurements were repeated three times for each implant, and the mean value was used for analyses. For measurements performed after prosthesis delivery, connecting bars and abutments were removed prior to RFA. The stability of both types of implants was compared at different time intervals.

RESULTS

Fifty-four implants were placed in 10 patients with auricular defects (26 implants) and 10 patients with orbital defects (28 implants). All auricular implants survived, and four orbital implants in four different patients failed. For auricular implants, statistically significant differences in stability values were noted between implant placement, abutment connection, and 6 months; there was no significant difference between 6 and 12 months. For orbital implants, no significant differences were found between implant placement and abutment connection, a significant increase was observed at 6 months, and no significant difference was seen between 6 and 12 months. No significant differences were found for auricular versus orbital implants between placement and abutment connection, but auricular implants showed significantly higher stability values than orbital implants at 6 and 12 months.

CONCLUSIONS

The stability of surviving auricular and orbital implants increased with time according to RFA. Prior to failure, the failed implants showed RFA values that were below the mean.

Evisceration with four anterior relaxing incisions and circumferential posterior sclerotomies with porous polyethylene orbital implants: an 8-year study

PURPOSE

To present long-term follow-up data on eviscerations carried out with scleral modification and placement of spherical porous polyethylene implants.

METHODS

We conducted a retrospective, interventional study on eviscerations performed with four anterior relaxing incisions and posterior sclerotomies made circumferentially behind the equator at approximately 330° and placement of porous polyethylene spherical implant, performed between March 2000 and August 2007 by a single surgeon. Patient age, sex, causative diagnosis, axial length, implant size, follow-up duration, complications and treatment were recorded.

RESULTS

In total, 92 patients were identified. The mean implant size was 19.46 mm. During the follow-up period (mean: 60 months, range: 19-107 months), there were no cases of implant exposure. In some patients, mild discharge, ptosis and conjunctival cysts developed.

CONCLUSIONS

Primary evisceration with four anterior relaxing incisions and posterior sclerotomies made circumferentially behind the equator at approximately 330°, combined with porous polyethylene orbital implant placement, is a useful technique for treating a variety of end-stage eye diseases.