Evaluation of an integrated orbital tissue expander in congenital anophthalmos: report of preliminary clinical experience

Craniofacial Growth and Development: A Primer for the Facial Trauma Surgeon

Understanding craniofacial growth and development is important in the management of facial trauma in the growing pediatric patient. This manuscript is a review of craniofacial growth and development and clinical implications of pediatric facial fractures.

Workflow and treatment results for computer-aided design and 3D-printed conformer therapy of congenital anophthalmia and microphthalmia

BACKGROUND/AIMS

To evaluate treatment with custom, three-dimensional (3D) printed conformers for socket expansion in congenital microphthalmia and anophthalmia (MICA).

METHODS

Retrospective analysis of prospective cohort from 2016 to 2020. All children received custom-made 3D-printed conformers increasing in size. We measured height, width, thickness, surface and volume of first and consecutive conformers, as well as horizontal palpebral fissure length (HPF) at start and follow-up visits. We analysed these parameters for severely (<45%) and moderately (>45%-75%) affected children, based on affected axial length on ultrasonography.

RESULTS

We included 18 cases (9 severe, 9 moderate) with a total of 174 conformers (88 severe, 86 moderate) and a mean follow-up of 2.8 years (range 1.3-4.8). The mean relative HPF increased from 77% to 93% with 16/17 cases reaching >80%, and 12/17 cases >90% symmetry. Horizontal and vertical conformer dimensions increased up to 10 months of treatment, with a steeper slope for the severe group (10.5% vs 5.5% for height and 9.0% vs 6.1% for width gain per treatment month, for severe and moderate MICA, respectively). After 10 months of treatment conformer height and width increased only slightly. No serious complications were observed.

CONCLUSION

3D-design and printing of solid conformers results in highly acceptable horizontal eyelid symmetry in the treatment of congenital MICA. The mean increase in conformer height and width in the first 10 months should be about 170% for moderate and about 200% for severe MICA. The presented conformer size formulas can aid ophthalmologists and ocularists to plan conformer treatment.

Socket expansion with conformers in congenital anophthalmia and microphthalmia

PURPOSE

To report the outcomes of acrylic conformer-assisted socket expansion in congenital anophthalmia and microphthalmia.

METHODS

In this noncomparative, interventional case series, the medical records of 24 eyes of 18 consecutive patients with congenital anophthalmia (n = 3), clinical anophthalmia (n = 8), and microphthalmia (n = 13) were reviewed retrospectively. Twelve cases were unilateral; 6 were cases bilateral (3 clinical anophthalmia and 3 microphthalmia). Serial socket expansion with progressively larger acrylic conformers was managed in clinic. Horizontal palpebral fissure (HPF) width was graded as good (final HPF ≥20 mm, or interocular difference ≤2 mm for unilateral cases), fair (17-19 mm, or 3 mm interocular difference), or poor (<17 mm, or ≥4 mm difference).

RESULTS

The mean initial lid lengths in anophthalmia, clinical anophthalmia, and microphthalmia were 11.0, 12.4, and 16.9, increasing to 21.0, 19.9, and 22.2, respectively, over a mean period of 51 months. Mean age at the initiation of treatment was 19 months (range, 1-78). Percentage increases in lid length were 90.9%, 61.2%, and 31.3% in anophthalmia, clinical anophthalmia, and microphthalmia, respectively, with an average 7 conformer exchanges. For unilateral cases, the mean final lid length of involved eyes was 22.3 mm, comparable to 23.5 mm in normal contralateral eyes. Good outcomes were achieved in 18 orbits (75%); fair outcomes, in 6 (25%) cases. None of the sockets had poor expansion at final follow-up. All cases had good cosmesis with acceptable prosthesis wear at last visit.

CONCLUSIONS

In our patient cohort, good socket expansion was achieved with acrylic conformers alone in congenital anophthalmia and microphthalmia, with acceptable prosthesis wear.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

Deep Orbital Hyaluronic Acid Gel Filler for Volume Augmentation in Orbital Dysplasia

PURPOSE

Orbital dysplasia is caused by congenital microphthalmos, anophthalmos, or eye atrophy. Orbital volume growth is known to parallel ocular growth and the absence of an eye results in noticeable hemifacial deformity that affects patients' lives. The aim of this study was to observe the effects of injections of hyaluronic acid gel into the orbit combined with ocular prosthesis to treat orbital dysplasia.

METHODS

Three patients with orbital dysplasia who were 3 to 7 years old treated in our department. Each year, the hyaluronic acid gel was injected into each patient intraconal and extraconal posterior orbit and each wore an ocular prosthesis. The length of the palpebral fissure and orbital volume were measured before and after the injections.

RESULTS

A total of 9 injections were performed on 3 patients ages 7, 5, and 4 years old, respectively. The follow-up periods were 5, 5, and 2 years. The authors observed significant improvements in patient appearance. The length of the palpebral fissure and the volume of the orbit increased linearly with the increasing age, and there were no complications, such as intraorbital hemorrhage or local hyperplastic stimulation.

CONCLUSIONS

Orbital hyaluronic acid gel injection and combined with an ocular prosthesis is a safe, convenient, and effective treatment for orbital dysplasia.

Implantable device actuated by manual button clicks for noninvasive self-drug administration

Self-injectable therapy has several advantages in the treatment of metabolic disorders. However, frequent injections with needles impair patient compliance and medication adherence. Therefore, we develop a fully implantable device capable of on-demand administration of self-injection drugs via noninvasive manual button clicks on the outer skin. The device is designed to infuse the drug only at the moment of click actuation, which allows for an accurate and reproducible drug infusion, and also prevents unwanted drug leakage. Using a mechanical means of drug infusion, this implantable device does not contain any electronic compartments or batteries, making it compact, and semi-permanent. When tested in animals, the device can achieve subcutaneous injection-like pharmacokinetic and pharmacodynamic effects for self-injection drugs such as exenatide, insulin, and glucagon.

Outcomes of the use of orbital hydrogel expanders in the management of congenital anophthalmia: CT-based orbital parameter analysis

PURPOSE

To evaluate the outcomes of orbital hydrogel expanders in the management of congenital anophthalmia.

METHODS

In this retrospective one-armed cohort study, a chart review was performed of eight children with congenital anophthalmia who underwent orbital expansion using orbital hydrogel tissue expander from January 2006 to July 2018. Computed tomography (CT) of orbital parameters was evaluated before and after surgery. Changes in the orbital parameters were correlated with clinical factors.

RESULTS

The study sample comprised 11 anophthalmic orbits of eight children (seven males, one female; median age = 12 months), with a median postoperative follow-up of 3.8 years. The anophthalmic orbital parameters after hydrogel expander implantation improved significantly compared to preoperative assessment as follows: mean orbital height improved from 21.7 mm to 25.4 mm (P < .001); width from 19.2 mm to 23.8 mm (P < .001); depth from 27.5 mm to 32.6 mm (P = .008); and volume from 3.7 cm³ to 5.3 cm³ (P = .001). Despite enlargement in all dimensions, the anophthalmic orbits with hydrogel expander had a significantly lower development than the normal orbits, mainly in height and volume. At the last postoperative visit, four (36.4%) cases had fornices deep enough to maintain the conformer. Migration and extrusion occurred in two (18.2%) cases.

CONCLUSIONS

Orbital hydrogel expander can improve the orbital development in congenital anophthalmia. However, the enlargement is not as extensive as that observed in the normal orbit. Orbital expanders associated with external conformers were not sufficient to induce normal growth of lids and fornix.

Three-dimensional periorbital asymmetry assessment of congenital microphthalmia children with a structured light 3D scanning system

Congenital microphthalmia is a rare phenotype characterized by eye growth retardation. Due to the lack of eyeball stimulation, children suffering from congenital microphthalmia always have bony orbital maldevelopment, which leads to facial asymmetry. In the present study, a structured light 3D scanning system was used as a novel method to measure the three-dimensional periorbital asymmetry in children with congenital microphthalmia. Children with unilateral congenital microphthalmia of 0-6 years old were enrolled in the present study. All participants underwent an ultrasound scan to measure the axial length, and accepted the structured light 3D scanning system for their periorbital appearance. The degree of periorbital asymmetry was evaluated using 17 facial landmarks within a three-dimensional cartesian coordinate system (the X-axis represented the horizontal direction, the Y-axis represented the vertical direction, and the Z-axis represented the sagittal direction). Paired student t-test and ANOVA were used in the present study. A three-dimensional periorbital topography was also established to further illustrate the periorbital asymmetry. A total of 67 children were recruited, which included 31 boys and 34 girls. The axial length on the affected side (12.28 ± 3.35 mm) was generally smaller than that on the unaffected side (20.54 ± 1.65 mm, P < 0.001). When grouped by age, the periorbital asymmetry mainly manifested in the Y-axis and Z-axis directions. The unaffected side had a higher orbitale superior (5.09 ± 0.35 vs. 3.02 ± 0.30, P < 0.001) and a lower orbitale inferior (-19.52 ± 0.51 vs. -16.90 ± 0.53, P < 0.001) in 0-1 year old group. Same performances were also found in the 1-3 and 3-6 age groups. When grouped according to the proportion of axial length on the bilateral sides, seven of the 12 Y-values and all 12 Z-values had statistical differences. The structured Light 3D scanning system may serve as a beneficial complementary tool for computed tomography, in order to better understand the periorbital deformities caused by congenital microphthalmia.

Successful conjunctival socket expansion in anophthalmic patients until the age of 2 years: an outpatient procedure

Purpose

To report the results of a simple outpatient method for soft tissue socket expansion in young children with congenital anophthalmos.

Methods

Seventeen congenital anophthalmic sockets of 15 infants of a mean age of 4.2±4.4 months were fitted with specially designed serial solid acrylic shapes or hydrogel expanders using cyanoacrylate for eyelids closure when using the latter.

Results

At the age of 2 years, the mean horizontal eyelid length increased from a mean of 11.6±4.5 to 19.4±4.6 mm and the volume of the last expander from a mean of 0.6±0.2 to 2.0±0.3 cm². The specially designed acrylic shapes could be a substitute to the custom-made molds, which require general anesthesia.

Conclusion

Successful increase in the horizontal eyelid length as well as the conjunctival socket volume could be achieved by a simple outpatient procedure without the need for repeated hospitalization and general anesthesia in these infants.

Digital Evaluation of Orbital Cyst Associated with Microphthalmos: Characteristics and Their Relationship with Orbital Volume

Purpose

To study the characteristics of orbital cyst associated with microphthalmos in a group of Chinese patients, and to analyze the relationship between orbital cyst and orbital volume.

Design

Cross-sectional comparative study.

Participants

120 patients who were diagnosed as unilateral clinical blind microphthalmos, in which 20 patients had orbital cyst in the affected eye.

Method

Participants had computed tomography (CT) scan. CT images were analyzed with a computer-aided software.

Main Outcome Measures

Volume and position of orbital cyst, microphthalmic to contralateral ratio (MCR) of orbital volume, height and depth and orbital rim displacement.

Results

38.1% of the cysts located anterior to or at the equator of the globe, 75% of which located infratemporally and all of which were outside the muscle cone. Most (84.6%) of the posterior cysts were inside the muscle cone. The anterior cysts were larger than the posterior cysts (p = 0.005). MCR of orbital volume (p<0.001), height (p = 0.004) and width (p = 0.043) were significantly higher in patients with orbital cyst than controls. For patients with orbital cyst, larger cyst-plus-globe volume of the affected eye was associated with higher MCR of orbital volume (r = 0.630, p = 0.003). Patients with large cyst-plus-globe volume had higher MCR of orbital volume (p = 0.002), height (p = 0.014), width (p = 0.005) and depth (p = 0.002) and less displacement in inferior (p = 0.004) orbital rim, compared with patients with small cyst-plus-globe volume, but the differences between patients with small cyst-plus-globe volume and patients without cyst were not significant.

Conclusions

Microphthalmic eyes with large cyst-plus-globe volume showed better similarity with the contralateral eyes, comparing with microphthalmic eyes without orbital cyst or with small cyst-plus-globe volume. It suggested that the existence of orbital cysts (especially large cysts) in microphthalmic eyes might play a positive role in the orbital development.

Management of neonatal proptosis: a systematic review

Gross proptosis presenting at birth is an uncommon manifestation of a variety of lesions that can compromise vision and result in disfigurement or even loss of life. Notably, many disease entities have different presentations and prognoses in neonates compared to older children. A structured mental framework is essential to an efficient and coordinated response. We present three challenging cases of neonatal proptosis and discuss the clinical presentation and biological behavior of the lesions that are most often implicated.

Tissue regeneration during tissue expansion and choosing an expander

This paper reviews the various aspects of tissue regeneration during the process of tissue expansion. “Creep” and mechanical and biological “stretch” are responsible for expansion. During expansion, the epidermis thickens, the dermis thins out, vascularity improves, significant angiogenesis occurs, hair telogen phase becomes shorter and the peripheral nerves, vessels and muscle fibres lengthen. Expansion is associated with molecular changes in the tissue. Almost all these biological changes are reversible after the removal of the expander.This study is also aimed at reviewing the difficulty in deciding the volume and dimension of the expander for a defect. Basic mathematical formulae and the computer programmes for calculating the dimension of tissue expanders, although available in the literature, are not popular. A user-friendly computer programme based on the easily available Microsoft Excel spread sheet has been introduced. When we feed the area of defect and base dimension of the donor area or tissue expander, this programme calculates the volume and height of the expander. The shape of the expander is decided clinically based on the availability of the donor area and the designing of the future tissue movement. Today, tissue expansion is better understood biologically and mechanically. Clinical judgement remains indispensable in choosing the size and shape of the tissue expander.

Surgical and prosthetic treatment for microphthalmia syndromes

Our aim was to evaluate the long-term outcomes of prosthetic treatment and orbital expansion in the management of microphthalmia syndromes. We did a retrospective single-centre study of all cases of microphthalmia treated between 1989 and 2010. The patients were divided into three groups: isolated microphthalmia, microphthalmia associated with micro-orbitism, and complex microphthalmia syndrome. To evaluate the results a score was computed for each patient by assessing the length of the palpebral fissure, the depth of the conjunctival fornix, and local complications together with an evaluation of the satisfaction of patients and their families. Forty-four children were included (27 boys and 17 girls). Twenty-seven had unilateral microphthalmia (61%) and 17 bilateral microphthalmia (39%). Twelve patients were lost to follow up. The mean duration of follow-up was 12 years (range 4-21). Management involved an ocular conformer in only 31 patients (71%). The treatment was deemed satisfactory in all except 10 children. Surgical treatment with orbital expansion permitted good symmetry of the orbital cavities with a final mean difference of 9% (range 3-17) compared with the initial 16.8% (range 13.6-20.3). The prosthetic treatment gives satisfactory results. Despite limited indications and difficult follow-up, our experience emphasises the value of surgical treatment for severe micro-orbitism.

Congenital anophthalmia: current concepts in management

PURPOSE OF REVIEW

The introduction of hydrogel socket and orbital expanders has modified the approach towards the rehabilitation of congenital anophthalmia. This study highlights the most recent advances for the treatment of congenital anophthalmia based on personal experience and the review of recent literature.

RECENT FINDINGS

Hydrogel socket expanders may be positioned as an out-patient procedure with topical anaesthesia, using cyanoacrylate glue as opposed to temporary tarsorraphy. Increased orbital volume has been confirmed by computed tomography (CT) scan or magnetic resonance imaging (MRI) following early dermis-fat graft in children with congenital anophthalmia. An orbital tissue expander made of an inflatable silicone globe sliding on a titanium T-plate and secured to the lateral orbital rim appears to be effective to stimulate orbital bone growth and development.

SUMMARY

Congenital anophthalmia has a complex cause with both genetic and environmental factors involved. The ideal treatment is simultaneous expansion of the eyelids, socket and orbital bones, and it should begin after birth as soon as possible. Socket expansion with self-inflating expanders is a useful technique, although custom-made conformers may produce similar results. Dermis-fat grafts are another reasonable option as an orbital implant, following adequate lid and socket expansion.