Psychosocial impact on anophthalmic patients wearing ocular prosthesis

Living with an artificial eye: qualitative insights into patient and family member experiences

PURPOSE

Artificial eye users (AEUs) can experience a negative impact on psychological and emotional wellbeing, including reduced social functioning, which may be a consequence of living with one eye removed, and/or of having a prosthetic eye. This may have wider consequences for their families. We aimed to explore what it means to live with a prosthetic eye, for both AEUs and their families-and how any quality of life (QoL) issues impact on their day-to-day functioning.

METHODS

A subset of AEUs and their family members taking part in a feasibility randomised controlled trial comparing hand-painted to digitally printed artificial eyes were invited for semi-structured interviews. Transcripts were analysed using reflexive thematic analysis. Qualitative results related to trial participation are covered elsewhere. Here, we focus on QoL and day-to-day functioning.

RESULTS

Twelve AEUs (eight males) and five spouses (one male) who had worn artificial eyes for 2-65 years took part, and four themes were identified. (1) Impact on day-to-day life: AEUs and their spouses have to adapt to (partial) sight loss, reduced levels of confidence, and social withdrawal. (2) Impact on psychological and emotional wellbeing: distress among AEUs and their spouses can be severe and prolonged, highlight unmet support needs. (3) Challenges with treatment experiences: AEUs experienced negative impact of fragmentation of care and long waiting times. (4) Worries about the future: AEUs mentioned fragility of remaining sight, and concerns around potential need for further treatment.

CONCLUSION

Patients and their family members experience negative impact of being an AEU on their everyday lives and quality of life. There is a potential role for psychosocial support services in supporting AEUs and their families even long after eye loss.

Reconstruction of Anophthalmic Sockets With Pedicled Nasoseptal Flap

PURPOSE

Patients who undergo eye removal often present with orbital soft-tissue insufficiency and contraction of the eye sockets. The most commonly used reconstruction strategy is grafting the orbit with free grafts, which is associated with the drawback of harvesting tissue from an unconnected site. This study describes the use of the vascularized nasoseptal flap in the reconstruction and enlargement of the contracted anophthalmic cavity in patients with severe or recurrent contracted eye sockets and evaluates its efficacy.

METHODS

A sphenopalatine-pedicled flap from the nasal septum was harvested and mobilized into the anophthalmic orbit for the reconstruction, coverage, and enlargement of the socket in 17 patients with anophthalmic socket syndrome. Data regarding the demographics, preoperative status, postoperative findings, follow-up, outcomes, dates of mutilant and reconstructive surgery, and relevant clinical or imaging were collected.

RESULTS

Krishna´s classification was used to assess the postoperative outcomes. The final rating improved in all patients at a median follow-up duration of 35 months. A greater impact was observed in patients who underwent reconstructive surgery before nasoseptal flap creation. Two minor complications occurred; however, major surgical intervention was not required. Implant extrusion was observed in 2 patients.

CONCLUSIONS

The novel strategy of applying nasoseptal flaps in the reconstruction of anophthalmic sockets results in improved socket grading and a low rate of recurrence (socket contracture or implant extrusion), and complications. The vascular nature of the flap makes it suitable for use in complex cases.

Prevalence of anophthalmia etiological factors in patients treated in a reference center: A retrospective study

Background

Ocular prosthesis rehabilitation has an important social, psychological, esthetic, and functional role. Congenital factors, trauma, and tumors, among others, can cause anophthalmia, and it is essential to identify the etiology to guide its prevention and treatment.

Methods

The aim of this study was to retrospectively investigate the records of patients treated from 2013 to 2020 by the Oral and Maxillofacial Prosthesis Group, aiming to identify the prevalence of patients with anophthalmia and the etiology of their anophthalmia. After approval by the Human Research Ethics Committee, two calibrated researchers evaluated 520 records, identifying those from patients with anophthalmia. The inclusion criteria were records with complete and legible information from patients with anophthalmia and a description of their etiology. Descriptive statistics were performed, and etiological factors were categorized into trauma, congenital cause, end-stage eye disease, and tumor. Spearman's correlation was performed to verify the relation between gender and anophthalmia etiology, with a 5% significance level. Seventy-two records were included in the study.

Results

It was observed that 33.4% of patients were women and 66.6% were men. The etiologies were physical trauma (52.4%), tumor (21.8%), end-stage eye disease (16.6%), and congenital cause (9.2%), and there was no correlation between gender and these etiologies (p = .301).

Conclusion

Most of the cases identified were of traumatic origin, which allows the establishment of preventive and educational measures to avoid new cases of anophthalmia.

Clinical Congenital Anophthalmos and Microphthalmos-Experiences of Patients and Their Parents after More than 10 Years of Treatment

Congenital clinical anophthalmos and blind microphthalmos describe the absence of an eye or the presence of a small eye in the orbit. Between 1999 and 2013, 97 children with anophthalmos or microphthalmos were treated with self-inflating, hydrophilic gel expanders at the Rostock Eye Clinic. More than a decade later, this study investigated the perspective of patients and parents regarding the treatment, the surgical outcome, and the emotional and social well-being of the patients. A total of 22 families with 16 patients sighted in the other eye and six patients blind in both eyes participated. Questionnaires were developed, including items on physical, emotional, social, and medical aspects. The patients felt emotionally stable and integrated into their social environment, with no major limitations reported by the majority. These statements were confirmed by most of the parents. Parents (67%) indicated that the success of the operation was already apparent after the first intervention and that the current situation did not play a role in the patients' social environment. The study provided new insights into the therapy results, the postoperative care, and the social and emotional stability of the prosthesis-wearing patients, indicating the chosen expander methods as promising in terms of positive postoperative care.

Disinfectant effects of Brazilian green propolis alcohol solutions on the Staphylococcus aureus biofilm of maxillofacial prosthesis polymers

STATEMENT OF PROBLEM

Brazilian green propolis may be an alternative product that reduces the development of a microbial biofilm on the polymers used for maxillofacial prostheses. However, its effects as a disinfectant have not been fully established.

PURPOSE

The purpose of this in vitro study was to investigate the effects of Brazilian green propolis alcohol solutions against the Staphylococcus aureus biofilm on polymers used in maxillofacial prostheses, the maxillofacial silicone elastomer (MDX4-4210), and specific acrylic resins for ocular prostheses.

MATERIAL AND METHODS

A total of 324 disk-shaped specimens (3×10 mm) of each material were fabricated. All specimens were contaminated with S. aureus (10⁸ cells/mL) to assess the antibiofilm activity of immersion solutions and protocols. Thus, 162 specimens of each material were randomly distributed and equally divided into 5 groups of disinfectants and 1 control group: 3 separate groups of 2.5%, 5%, and 10% propolis alcohol solutions, 1 group of 5% propolis alcohol gel, a positive control group of 2% chlorhexidine gluconate, and a negative control group of distilled water. Specimens (n=9) were disinfected by immersion for 5, 10, and 15 minutes and immersed in culture medium for 24 hours. Any notable turgescence in the final medium was considered indicative of a biofilm. The effects of disinfectants were analyzed by a turbidity assay and by scanning electron microscopy. Data were analyzed descriptively.

RESULTS

The final medium with specimens disinfected with 10% propolis alcohol solution showed no turbidity, indicating constant efficacy against the S. aureus biofilm. Similarly, these findings were observed in the 2% chlorhexidine gluconate group. Scanning electron microscopy images demonstrated that the surface of the polymers treated with 10% propolis alcohol solution did not show bacterial colonies.

CONCLUSIONS

Disinfection with 10% green propolis alcohol solution was effective in eliminating the S. aureus biofilm from specimens of maxillofacial elastomer and N1 acrylic resin specific to ocular prostheses by immersion for 5 minutes.

Psychosocial distress and psychological adjustment in patients with ocular loss: a framework analysis

BACKGROUND

Patients with ocular loss tend to have physical and psychosocial difficulties. Maxillofacial prosthetic specialists involved in the treatment should be trained with competence to manage psychological complications. However, due to the multifactorial origin of the psychosocial distress, designing such training activities can be challenging. This research aimed to construct a conceptual framework illustrating the effects of ocular loss on patients' physical and psychosocial well-being and their coping strategies, to propose the learning content of training sessions.

METHODS

A semi-structured interview and a topic guide were employed to explore the perceptions from patients who were receiving their first custom ocular prosthesis, fabricated by maxillofacial prosthodontists. The participants were selected using a purposeful sampling up until data saturation. The data were analyzed using framework analysis.

RESULTS

Twelve patients participated in this research. Four main themes emerged from the data analysis: (1) Impact of ocular loss, (2) Factors influencing psychosocial distress, (3) Psychological adjustment, and (4) Expected treatment outcomes. Each theme appeared to have influence on the other, rather than presenting itself independently. Although patients with ocular loss experienced both physical and psychosocial difficulties, psychological distress was greatly influenced by self-perceived disfigurement, etiology, and social status. Therefore, they needed to develop their coping strategies including rehabilitation with ocular prosthesis.

CONCLUSION

Various forms of psychological adjustments were necessary in these patients with ocular loss to resume their daily lives. The specialist involved in the treatment should also partake in patients' psychological adjustment and should be competent in psychological management skills, such as supporting patients to meet their expectations.

The Inflammation Level and a Microbiological Analysis of the Anophthalmic Cavities of Unilateral Ocular Prosthesis Users: A Blind, Randomized Observational Study

Irritation and biofilm adhesion are complaints associated with ocular prosthesis use. This study aimed to evaluate the effects of prosthesis repolishing on several conditions of anophthalmic volunteers. Participants were divided into two groups: intervention (IG, n = 10) and nonintervention (NIG, n = 6) groups. The anophthalmic cavity, contralateral eye, and prosthesis surface were evaluated at initial, day 15, and day 30 after repolishing. Microbiological analysis (colony-forming units), exfoliative cytology (conjunctiva inflammatory cells), sensory analysis (quantitative mechanical sensory test), tear production (Schirmer’s test), and conjunctival inflammation (clinical evaluation) were performed. Nonparametric tests were used to compare groups in the initial period and to analyze periods for the IG (p < 0.05). More microorganisms were formed in the anophthalmic socket and prosthesis than in the contralateral eye in the initial period. For IG, the anophthalmic cavity exhibited more microorganisms and inflammatory clinical signs in the initial period than at 15 and 30 after repolishing. The prosthesis showed greater accumulations of total bacteria and Candida albicans in the initial period than at 15 and 30 days after repolishing. The anophthalmic cavity had more palpebral inflammation than the contralateral eye. In conclusion, repolishing reduced the number of microorganisms and inflammatory signs over time.

Oculofacial Prosthetic Rehabilitation Complemented With Temporary Fillers and Neurotoxin

ABSTRACT

Surgical treatment of head and neck cancer causes severe tissue loss, therefore, deformities and psychosocial consequences. In cases involving orbit exenteration, satisfactory reconstruction can only be achieved with prosthetic replacement, despite successful reconstructive plastic surgery. Extraoral implants, 3D scanning, and prototyping technologies have contributed to increase satisfactory aesthetic results of oculofacial prosthesis. However, to achieve prosthetic rehabilitation refinement, patients' biological tissues have been treated with injectable cosmetic adjuncts methods as complements to results. This study aimed to describe the use of botulinum toxin type A, hyaluronic acid, and calcium hydroxyapatite previously to oculofacial prostheses manufacturing, in 5 oncologic patients of a rehabilitation unit. Outcomes produced by additional cosmetic methods on tissues, prostheses planning, and overall facial rehabilitation were observed and registered by photographs. Botulinum toxin type A, hyaluronic acid, and calcium hydroxyapatite has shown to be useful in improving asymmetries, volumizing surgical depressions and dissembling atrophic scars. Presenting an additional resource to improve overall results, enabling the manufacturing of smaller, thinner, and better-fitting oculofacial prostheses. Limitations as chronic infection and necrosis episodes, related to filler injection into previously irradiated sites, were described. The temporary effect of the materials used generates a need for reapplications but increases the safety of such procedures and enables patients' cancer treatment follow-up.

Treatment strategies and long-term outcomes in patients with congenital microphthalmia-anophthalmia with cyst

BACKGROUND/AIMS

Microphthalmia and anophthalmia are rare conditions, which represent ocular maldevelopment; both may be associated with orbital cysts. Current literature recommends retention to stimulate orbital growth during socket rehabilitation but does not illustrate their potential to deform the periocular tissues. This study aims to illustrate the long-term outcomes when other elements, such as forniceal and lid development, are also considered when formulating bespoke treatment plans for patients.

METHODS

Retrospective case series of 78 patients attending a single prosthetics clinic between 1988 and 2020. Clinical and surgical notes, radiological imaging, clinical photographs and patient/doctor satisfaction questionnaires were used to report patient outcomes and natural history data.

RESULTS

89 sockets of 78 patients (11 bilateral) were included; average age of presentation being 2.8 years (9 days to 29.5 years). Cysts were clinically detected (48%) or were incidental findings (52%). The mean follow-up time was 7.2 years (6 months to 28 years). Cysts in 46% of sockets underwent surgical excision while the remainder were retained. Satisfaction surveys were obtained for 75 patients, with cosmetic outcomes rated as 'excellent' or 'good' in 90% of cases by physicians and 97% of cases by patients or guardians.

CONCLUSION

The favourable long-term outcomes in this study have resulted from bespoke plans which considered periocular tissue development, regional orbital growth and orbital volume replacement. The authors contemplate cyst excision if the prosthetic fitting or retention is impeded by the cyst as this often heralds the increased risk of long-term periocular distortion.

Effect of Rehabilitation with a New Ocular Prosthesis on Electromyography of the Occipitofrontalis, Temporal, Masseter, and Sternocleidomastoid

Objectives  The aim of this study was to verify during facial expressions (“happy,” “sad,” “fearful,” “angry,” “surprised,” and “disgusted”) if: (1) there would be difference in the electromyography (EMG) of the occipitofrontalis, temporal, masseter, and sternocleidomastoid muscles on the normal side (NS) compared with the affected side (AS) (without the use of an ocular prosthesis) in individuals with unilateral absence of the eyeball, and (2) the rehabilitation with a new ocular prosthesis would affect the EMG of the muscles studied on the AS in these individuals.

Materials and Methods  Thirteen individuals, without temporomandibular disorder, with good health, with unilateral absence of the eyeball (the eye must have been removed by evisceration or enucleation), and users or nonusers of an ocular prosthesis were included. EMG of the occipitofrontalis, temporal, masseter, and sternocleidomastoid muscles was performed during rest and facial expressions (“happy,” “sad,” “fearful,” “angry,” “surprised,” and “disgusted”) before (T0) and 90 days after (T1) rehabilitation with a new ocular prosthesis. The analyses were performed in T0 on NS and AS (without the use of an ocular prosthesis), and in T1 on AS with the new ocular prosthesis.

Statistical Analysis  All data were submitted to the Student's t -test with p  < 0.05.

Results  There was no statistically significant difference comparing the AS with the NS in T0 for all muscles studied, during all facial expressions evaluated ( p  > 0.05). There was no statistically significant difference comparing the AS in T0 with itself in T1 for all muscles studied, during all facial expressions evaluated ( p  > 0.05).

Conclusion  Eye loss did not affect the EMG of studied muscles when comparing NS with AS (without the use of an ocular prosthesis). The rehabilitation with ocular prosthesis was not capable of changing the EMG on AS.

The Ruptured Globe, Sympathetic Ophthalmia, and the 14-Day Rule

PURPOSE

Prophylactic enucleation of a ruptured globe with no light perception within 14 days of injury to prevent sympathetic ophthalmia (SO) has been an established dictum in academic teaching for more than 100 years. This treatment strategy was originally based on observation, speculation, and careful thought, but there was never any scientific proof. This review summarizes and updates the current state of our knowledge about globe rupture and SO, examines the origin and validity of the 14-day rule, and emphasizes the importance of trying to save the traumatized eye whenever possible.

METHODS

A comprehensive literature review of SO and globe rupture was performed.

RESULTS

SO is a rare disorder that may potentially occur following traumatic globe rupture as well as following a variety of other intraocular surgeries. Vitreoretinal surgery may be a more common cause than trauma according to some studies. SO may still occur despite having the eye removed within 14 days of the trauma. A variety of new medications including biologic agents are now available to treat SO with improved efficacy in suppressing the associated ocular inflammation and allowing retention of some useful vision. Removing the traumatized, blind eye may have other important psychological consequences associated with it that require consideration before eye removal is carried out. Retaining the blind, phthisical, disfigured eye avoids phantom vision and phantom pain associated with enucleation as well as providing a good platform to support and move an overlying prosthetic eye. Data on the occurrence of SO following evisceration and enucleation with and without predisposing factors confirms the exceedingly low risk.

CONCLUSION

Most civilian open globe injuries can be successfully repaired with modern, advanced microsurgical techniques currently available. Because of the exceedingly low risk of SO, even with the severity of open globe trauma during military conflicts being more devastating as a result of the blast and explosive injuries, today every attempt is made to primarily close the eye rather than primarily enucleate it, providing there is enough viable tissue to repair. The 14-day rule for eye removal after severe globe ruptures is not scientifically supported and does not always protect against SO, but the safe time period for prophylactic eye removal is not definitively known. In the exceptional cases where SO does occur, several new medications are now available that may help treat SO. We advocate saving the ruptured globe whenever possible and avoiding prophylactic enucleation to prevent the rare occurrence of SO. When an eye requires removal, evisceration is an acceptable alternative to enucleation in cases that do not harbor intraocular malignancy.

Assessing the results of anophthalmic prostheses

Purpose

Anophthalmic sockets cause disfigurement that may result in emotional and social distress. The choice of procedure and implant is based upon the surgeon's experience. There remains no standardization of cosmetic result. We sought to identify quantifiable anatomical features and functional properties related to a successful cosmetic result in patients with ocular prosthesis and to determine correlations between self-reported and third-party assessment of cosmetic success.

Methods

This was a prospective observational study, which included 107 adult patients (50.1% female; age 53.08 ± 18.64 years, range 18-89) with acquired anophthalmia following prosthesis fitting. Patients completed a self-assessment questionnaire on self-perception of body image and ocular properties. Three independent examiners assessed cosmetic score. Assessed variables included prosthesis movement, eyelid symmetry, prosthesis stability, and socket fullness.

Results

The general cosmetic result was 8.1 ± 2.19 (on a predetermined scale of 1-10) as perceived by the patients and 7.2 ± 0.19 by the examiners. Interexaminer correlation was high for all variables (P < 0.05). A good cosmetic result was correlated with prosthesis movement (P = 0.02), eyelid symmetry (P = 0.001), and prosthesis stability (P = 0.01). Factors that correlated with a good cosmetic result on multivariate analysis were prosthesis movement (odds ratio [OR] 4.95, P = 0.004), eyelid symmetry (OR 4.51, P = 0.006), and socket fullness (OR 3.56, P = 0.005). No correlation was observed between patients' perceptions of the overall cosmetic result and those of the examiners.

Conclusion

The cosmetic result of prosthesis use among anophthalmic patients is generally good, as perceived by both patients and examiners. Good eyelid position and symmetry, orbital fullness, and prosthesis motility were associated with a better cosmetic result.

Three-dimensional design of a geometric model for an ocular prosthesis in ex vivo anophthalmic socket models

PURPOSE

Fitting a customized ocular prosthesis for anophthalmic patients entails an artisanal labour-exhausting process and is standardly based on impression moulding of the socket, which may be anatomically inaccurate. The objective of the study was to design an impression-free socket mould with three-dimensional (3D) technology.

METHODS

The ex vivo anophthalmic socket models included one silicone, one fresh pig cadaver head and three fresh-frozen human cadaver heads. After intra-socket application with iodine substance, five observers obtained eighteen low-dose cone beam computed tomography (CBCT) scans and one observer one high-dose CBCT scan of each model. The observers designed non-impression 3D moulds of the socket with 3D software. For the human cadaver sockets 3D geometric models of the ocular prosthesis were rendered from the 3D mould of the socket and the mirrored cornea of the contralateral eye.

RESULTS

The posterior surface of the 3D mould was highly accurate, with a mean absolute deviation of 0.28 mm, 0.53 mm, 0.37 mm and mean upper deviation of 0.53 mm, 0.86 mm, 1.17 mm, respectively, for the phantom, pig and human model. The intra- and interobserver repeatability and reproducibility of the 3D moulds and designs was good (<0.35 mm). The largest variation in the 3D geometric model was found at the junction of the 3D mould and mirrored cornea.

CONCLUSION

3D design of an impression-free geometric model for an ocular prosthesis with low-dose CBCT is highly accurate in ex vivo anophthalmic socket models. This novel method is a critical step towards the manufacturing of 3D printed ocular prostheses and requires validation in anophthalmic patients.

Measuring quality of care and life in patients with an ocular prosthesis

PURPOSE

In patients with an anophthalmic condition, the primary determinants of success of ocular prosthetic rehabilitation are satisfaction with care and quality of life (QoL). The aim of this study is to develop a condition-specific questionnaire as a patient-reported outcome measure for patients with an ocular prosthesis.

METHODS

Observational cross-sectional prospective study. We included 100 patients (52 female, 48 male, > 18 years old) with an anophthalmic and ocular prosthetic condition existing for 2 years or more. The patients completed a pre-tested 72-item questionnaire regarding their experience on living with an ocular prosthesis in four domains of QoL: single vision and care, wearing comfort, physical appearance and motility, and psychosocial functioning. Associations with demographic factors and condition- and prosthesis-related variables were investigated with multivariate analysis. The questionnaire was reduced with principal component analysis to obtain the Global Ocular Prosthesis Score (GOPS).

RESULTS

Satisfaction scores for each QoL domain were high with a mean visual analogue score between 7.2 and 7.6. Patients were generally satisfied with the physical appearance of the artificial eye and reported adequate psychosocial functioning. Patients described the reduced peripheral visual field and socket discharge as chief complaints. The test was reduced to a 20-item questionnaire. The mean GOPS was 70.87 (median 75.00).

CONCLUSIONS

Patients with longstanding ocular prosthetic wear are satisfied with their physical appearance and report adequate psychosocial functioning. A concise 20-item questionnaire for the anophthalmic condition is a valuable tool to quantitatively measure patient-reported outcome of ocular prosthetic rehabilitation.

TRIAL REGISTRATION NUMBER

NCT04321382, 03/2020, retrospectively registered.

Postoperative Quality of Life in Oculoplastic Patients

PURPOSE

To conduct a literature review on postoperative quality of life in oculoplastic patients.

METHODS

The authors conducted a database search to evaluate the evidence available for the change in quality of life after oculoplastic surgery.

RESULTS

There was a wide disparity of evidence available for different oculoplastic conditions. Certain conditions, such as nasolacrimal duct obstruction, were well-researched while other conditions, such as epiblepharon, had little to no research supporting improvement in quality of life after surgery. The scales used to measure quality of life displayed heterogeneity.

CONCLUSION

There is a lack of published evidence concerning postoperative quality of life in patients with certain oculoplastic conditions such as brow ptosis, entropion, ectropion, epiblepharon, and orbital wall fracture. There is a need to standardize the quality of life data collection tools and scoring systems to allow better comparison and scrutiny of the current literature.

A Pilot Clinical Study of Ocular Prosthesis Fabricated by Three-dimensional Printing and Sublimation Technique

Purpose

We sought to evaluate the safety and effectiveness of patient-specific ocular prostheses produced by three-dimensional (3D) printing and the sublimation technique. A comparison with prostheses produced using manual manufacturing methods was then performed.

Methods

To confirm the biological and physiochemical safety, cytotoxicity, systemic acute toxicity, intradermal reaction, and skin sensitization tests were conducted according to the International Organization for Standardization guidelines. The compressive strength of the prostheses was also tested. Further, a case series of three patients who wore the 3D printed prostheses for more than eight hours daily for 4 weeks was executed. Self-assessments by these individuals using a questionnaire and safety evaluations focusing on the occurrence of conjunctival inflammation or allergic reactions according to the Cornea and Contact Lens Research Unit criteria by slit-lamp examination and similarity assessment were completed.

Results

The 3D printed ocular prostheses met the necessary qualifications per the biological and physiochemical safety tests, showing the absence of cytotoxicity, acute systemic toxicity, intradermal reactivity, and skin-sensitizing potency. Also, there was no difference in strength test results between previous ocular prostheses and the 3D printed ones. Self-assessment by the patients yielded satisfactory results, with no significant difference in the level of satisfaction reported for the 3D printed and previous handmade ocular prostheses. The 3D printed prosthesis did not trigger any side effects in the conjunctival sac and showed similar objective findings with respect to the color of the iris, sclera, and vessel patterns.

Conclusions

Our study confirms the biologic and physiochemical safety of 3D-printed ocular prostheses created using computer-aided design technology and a sublimation technique. The patients’ questionnaires and the judgment of the ophthalmologists/ocularists showed that the 3D printed ocular prosthesis was acceptable in function and appearance through a case series report.

Visual function and quality of life in children and adolescents with anophthalmia and microphthalmia treated with ocular prosthesis

PURPOSE

To evaluate health-related quality of life (HR-QoL), vision-related (VR-)QoL and perceptual visual dysfunction (PVD) among individuals with anophthalmia (A) and microphthalmia (M) treated with ocular prosthesis.

METHODS

The study comprised 15 individuals (mean age 6.6 years; range 1.7-14.1) with unilateral A or M. Three validated instruments measuring HR-QoL and VR-QoL were used: The Pediatric QoL Inventory (PedsQL), consisting of physical and psychosocial self-report and parent-proxy report (2-18 years); Children's Visual Function Questionnaire (CVFQ); and Effects of Youngsters' Eyesight on Quality of Life (EYE-Q). Perceptual visual dysfunctions (PVDs) were assessed by history taking according to a specific protocol.

RESULTS

A/M children and their parents showed low HR-QoL scores (PedsQL total score: 66.3; 69.6) compared with controls (83.0; 87.61) (p = 0.0035 and <0.0001, respectively, unpaired t-test). No differences were found between A/M children and parents, but parents tended to underestimate their children's emotional state. A/M children with subnormal visual acuity (VA) for age scored lower in physical health compared with A/M children with normal VA (p = 0.03, Mann-Whitney U-test). No significant VR-QoL differences between A/M children and references or between A/M children with subnormal or normal VA for age were found. More A/M children than controls exhibited PVDs in ≥1 area (7/11 versus 4/118; p < 0.0001, Fisher's exact test).

CONCLUSION

A/M individuals show poor HR-QoL and increased PVDs. No difference in QoL was found between children and parents, though the children tended to score lower in emotional well-being. A/M children with subnormal VA showed lower physical health score. These problems indicate the necessity of a thorough multidisciplinary assessment and follow-up of children with A/M.

Antimicrobial effects of photodynamic therapy on Staphylococcus aureus biofilm grown on a specific acrylic resin surface for ocular prostheses

BACKGROUND

Photodynamic therapy (PDT) is a treatment for the specific control of oral biofilms. However, its effects on maxillofacial prostheses have been barely explored. In this study, we evaluated the antimicrobial effect of PDT using methylene blue (MB) and laser against a Staphylococcus aureus biofilm developed on the surface of scleral acrylic resin.

METHODS

Sixty-six specimens of acrylic resin designed for ocular prostheses were fabricated in a disk-shaped format (3 × 10 mm). S. aureus biofilm was grown on the surface of the specimens for 24 h and the disks were then treated with MB at different concentrations (25, 50, 75 or 100 μg/mL), with or without PDT (GaAlAs diode laser; 660 nm; 100 mW; 9 J; 321.4 J.cm^-2; 3.5 W.cm^-2 and 90 s). Control groups were treated with 2% chlorhexidine gluconate (CHX) or phosphate buffered saline. After the treatments, colony forming units (CFU) were counted and the samples were qualitatively evaluated by scanning electron microscopy (SEM). Data were analyzed descriptively and by nested ANOVA and the Tukey test (α = .05).

RESULTS

PDT groups with MB concentrations at 75 and 100 μg/mL formed fewer CFU compared to the other groups (P < 0.001) and the 2% CHX group did not form any CFU. SEM images revealed that the surface of the polymers in these groups did not show bacterial colonies.

CONCLUSIONS

PDT significantly reduced S. aureus biofilm in the scleral acrylic resin when associated with an MB dilution of 75 μg/mL or higher. Thus, PDT can be a promising candidate for disinfecting ocular prostheses.

The prevalence of anophthalmic socket syndrome and its relation to patient quality of life

BACKGROUND

Following removal of the eye, soft tissue changes of the eyelids and orbit may develop into an anophthalmic socket (AS) syndrome, which is often attributed to orbital volume deficiency. While adequate primary orbital volume replacement is nowadays standard of care, patients may still present with facial asymmetry. The aim of this study is to provide insights into these changes and their impact on patient quality of life (QoL).

METHODS

Cross-sectional study of 59 patients with longstanding ocular prosthetic wear after enucleation or evisceration surgery. The alignment, function, and laxity of the eyelids of the anophthalmic side were compared to those of the fellow side. The QoL was assessed with a 4-item questionnaire specific for the prosthetic condition. The different aspects of AS syndrome were analysed in relation to disease-specific and prosthetic data and to the patient QoL scores.

RESULTS

Clinical AS syndrome was prevalent in 53% of patients with acquired anophthalmia. The anophthalmic side was statistically significantly different from the fellow side for the known AS syndrome features such as superior sulcus depression, margin reflex distance 1, and enophthalmia, but also for new features such as levator muscle function and lagophthalmia (P < 0.05). The difference was correlated with duration of prosthetic wear, prior orbital radiotherapy, and size of the prosthesis (P < 0.05). QoL scores were not correlated to the separate features of AS syndrome, except for a positive correlation between wearing comfort of the prosthesis and upper eyelid ptosis (P < 0.05).

CONCLUSION

Patients with an ocular prosthesis show a relatively high prevalence of one or more distinct clinical features of AS syndrome, which do not negatively affect patient QoL. These findings underscore the importance to tailor prosthetic and surgical treatment to the patient's perceived QoL rather than to the objective clinical findings.

Custom ocular prosthesis-related concerns: patient feedback survey-based report vis-à-vis objective clinical grading scales

Purpose: To report the outcomes of a survey on patients' concerns and satisfaction with custom ocular prosthesis (COP) wear and compare with objective clinician grading scales.Methods: The questionnaire was answered by 156 participants. General social concerns and prosthesis-related concerns were plotted on a scale of 0 to 10, indicating least to maximum satisfaction and also not concerned to very concerned. Comparison between subjective patient and objective clinician scores was done.Results: The mean age at presentation was 27.53 ± 15.53 years (range 3-72 years).For patients that underwent a prior surgical procedure, mean satisfaction with the surgery was 9.42 ± 1.27. Mean satisfaction with the COP was 8.98 ± 1.75. The median satisfaction score for the primary surgery as well as for the outcome of the custom ocular prosthesis was 10. Commonest prosthesis-related concerns were reduced motility (mean 3 ± 2, median 3), watering, crusting and discharge (mean 2 ± 2, median 2), and difference in the size of the prosthetic eye relative to the other eye (mean 1 ± 2, median 1). Subjective patient concern responses and the objective clinician grading correlated strongly for movement of the prosthesis (r = -0.84, p < .0001), periocular fullness (r = 0.65, p < .0001), color of the prosthesis (r = -0.8, p < .0001) and size relative to the other eye (r = 0.7, p < .0001).Conclusion: Custom ocular prosthesis usage had a high satisfaction score with minimal concerns. Commonest prosthesis-related concerns correlated strongly with objective clinician grading.

[Does orbital exenteration still has a place in 2019?]

INTRODUCTION

Orbital exenteration is a radical anatomically and psychologically disfiguring procedure. It is mostly performed for management of orbital cancers or cancers with orbital involvement. The lack of benefit in terms of overall survival and the development of new molecular therapies (targeted therapies, immunotherapy) in recent years leads us to question its use. The goal of our review is to answer to the following question: is orbital exenteration a viable procedure in 2019?

MATERIALS AND METHODS

A literature review was performed using the PUBMED and MEDLINE databases. The following terms were used then crossed with each other: "orbital exenteration", "exenterated socket", "overall survival", "life expectancy", "orbital reconstruction", "socket reconstruction". Oncology articles from the past 15 years were included and separated into those in the oculoplastic literature and those in the ENT literature.

RESULTS

Nineteen articles were included in this review. Eyelid tumours represent the main etiology of orbital exenteration. Basal cell carcinoma is the most frequently incriminated tumor, while sebaceous carcinoma and conjunctival squamous cell carcinoma are the most frequently encountered in Asian series. Non-conservative orbital exenteration is the most prevalent surgery performed. Orbital reconstruction depends on the surgeon's speciality: healing by secondary intention and split thickness skin grafts are mostly performed by oculoplastic surgeons, whereas regional or free flaps are mostly performed by ENT surgeons. Cerebrospinal fluid leakage is the most common intraoperative complication, encountered in 0 to 13 % of cases. The most common postoperative complications are ethmoid fistula and infection of the operative site, encountered in 0 to 50 % and 0 to 43 % of cases respectively. Orbital exenteration allows surgical resection of R0 tumors in 42.5 % to 97 % of cases. Overall survival following orbital exenteration is 83 % (50.5-97) and 65 % (37-92) at 1 and 5 years respectively. Identified risk factors for poor overall survival are: age, tumor histology (worse prognosis with choroidal melanoma, better prognosis with basal cell carcinoma), non-R0 surgical resection, locally advanced tumors (size>20mm, BCVA<20/400 and the presence of metastases at diagnosis). Recent studies have demonstrated favorable outcomes when managing locally advanced basal cell carcinoma, lacrimal gland cancer and conjunctival melanoma with targeted therapies or immunotherapies without performing orbital exenteration.

CONCLUSION

Orbital exenteration remains a major part of our therapeutic arsenal. Although orbital exenteration has failed to demonstrate any overall survival benefit, it allows satisfactory local control of the disease with an increasingly less invasive procedure. The development of targeted therapies and immunotherapies may change our therapeutic decisions in the future.

Classification, History, and Future Prospects of Maxillofacial Prosthesis

This review presents a classification system for maxillofacial prostheses, while explaining its types. It also aims to describe their origin and development, currently available materials, and techniques, predicts the future requirements, and subsequently discusses its avenues for improvement as a restorative modality. A literature search of the PubMed/Medline database was performed. Articles that discussed the history, types, materials, fabrication techniques, clinical implications, and future expectations related to maxillofacial prostheses and reconstruction were included. Fifty-nine articles were included in this review. Maxillofacial prostheses were classified as restorative or complementary with subclassifications based on the prostheses finality. The origin of maxillofacial prostheses is unclear; however, fabrication techniques and materials have undergone several changes throughout history. Currently, silicones and acrylic resins are the most commonly used materials to fabricate customized prostheses. Maxillofacial prostheses not only restore several types of orofacial defects but also improve the patients' quality of life. Although the current clinical scenario concerning the field of maxillofacial prostheses is promising, improvements in material quality and techniques for maxillofacial prostheses may be expected in the future, to produce better results in the treatment of patients.

Efficacy of Care for Blind Painful Eyes

PURPOSE

Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions.

METHODS

A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed.

RESULTS

Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure.

CONCLUSIONS

Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

Functional vision and quality of life in children with microphthalmia/anophthalmia/coloboma-a cross-sectional study

PURPOSE

To determine the child's and parental perception of functional visual ability (FVA), vision-related and health-related quality of life (VR-QoL, HR-QoL) in children with microphthalmia/anophthalmia/coloboma (MAC).

METHODS

Between June 25, 2014, and June 3, 2015, we carried out a cross-sectional observational study at Moorfields Eye Hospital, London, UK, enrolling 45 children 2-16 years of age with MAC attending our clinics, and their parents. To assess FVA, VR-QoL, and HR-QoL we asked participants to complete three validated tools, the Cardiff Visual Ability Questionnaire for Children (CVAQC), the Impact of Vision Impairment for Children (IVI-C) instrument, and the PedsQL V 4.0. The main outcome measures were the FVA, VR-QoL, and HR-QoL scores, reported by children and parents.

RESULTS

In children with MAC, FVA is moderately reduced, with a median CVAQC score of -1.4 (IQR, -2.4 to 0.4; range, -3.0 [higher FVA] to +2.8 [lower FVA]). VR-QoL and HR-QoL are greatly reduced, with an IVI-C median score of 63 (IQR, 52-66; normal VR-QoL, 96), a median self-reported PedsQL score of 77 (IQR, 71-90; normal HR-QoL, 100) and parental score of 79 (IQR, 61-93), and a family impact score of 81 (67-93). Psychosocial well-being scores are lower than physical well-being scores. Parents and children have a different perception of the impact of the condition on the child's HR-QoL.

CONCLUSIONS

MAC has a significant impact on a child's FVA and QoL, similar to that described by children with acute lymphoblastic leukaemia and chronic systemic conditions. Children and families may benefit from psychosocial support.

Survey of Ocular Prosthetics Rehabilitation in the United Kingdom, Part 2: Anophthalmic Patients' Satisfaction and Acceptance

AIM

Ocular prostheses are integral for anophthalmic patients. Part 1 of this study reported that patients' aetiology, opinions, and attitudes significantly affected their prosthetic eyes experience. Part 2 investigates the patient satisfaction and acceptance in light of some of the aetiological demographics reported in Part 1.

METHODOLOGY

One hundred sixty questionnaires were delivered to anophthalmic patients attending oculoplastic clinic. Etiological aspects presented in the questionnaire were disseminated in part 1. Patient satisfaction was assessed through 8 closed-end statements reflecting aspects concerning patient's views on prosthesis comfort and appearance; patient's expectations, self-esteem, and perception; and cooperation with ocularist. Each statement had 3 categories as agree, moderately agree, and disagree. A total of 126 questionnaires were returned (response rate was 78.8%). Data was analyzed using SPSS software. Association coefficients and correlations between variables were also analyzed.

RESULTS

Total number of responses for the 8 statements was 888, averaging of 111 (expected 126) respondent per statement. Overall, 95.4% of our patients agreed with all satisfaction statements presented echoing very high satisfaction rate with their ocular prosthetics. Having an eye replacement that covers the defect is associated with high satisfaction among patients regardless of ocular prosthetic type. Patient acceptance of prosthesis in relation to employment status was high but not the same among the different categories (P > 0.05). High satisfaction with ocular prosthetics was prevalent among both genders, but there were no statistically significant differences in percentages of agreement in all statements (P > 0.05). Satisfaction and acceptance with ocular prosthetics was the same among all age groups of 12 to 85 years old (P > 0.05).

CONCLUSIONS

The patient satisfaction is associated with the interplay of different variables that is related to ocular prosthesis design and its ability to disguise disfigurement (ie, prosthesis shape, resemblance to existing contra-lateral eye, etc.); patients themselves (ie, gender, age, occupation, marital status, etc); and psychological well-being and social support provided. Anophthalmic patients of the north west of England are significantly happy with their ocular prosthetic rehabilitation and support they receive from their regional hospital. Ocular prosthetics enhances their psychological well-being and social interaction and factors like patients' sex, age, employment status, and type of ocular prosthesis have no effect on their acceptance and satisfaction.

An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers

We investigate prosthetic eye wearers' initial and current concerns about mucoid discharge, visual perception, and appearance, and the reasons for their concerns. A retrospective, cross-sectional study of private practice patients was designed. Participants were 217 experienced prosthetic eye wearers, aged at least 16 years. An anonymous questionnaire was e-mailed or mailed to participants. Descriptive and inferential statistics were used to investigate differences or correlations between variables. Content analysis was used to analyze participants' open responses. Participants were equally concerned about discharge, visual perception, and appearance during the first three months following eye loss and at least 2 years later, even though their concerns decreased. Older participants were less concerned about appearance, while females were more concerned about current discharge and appearance. The greater the frequency and volume of discharge, the greater was the concern. Participants' initial discharge concern was due to a negative interpretation of what it meant, but later, it was due to discomfort from wiping, and how discharge looked to others. Loss of depth perception and reduced visual range were equally concerning. Initial appearance concerns related to disguisability of the prosthesis, but over time, changes to the socket and eyelids became more important. Loss of self-image is commonly considered to be the major concern of anophthalmic patients, but discharge and visual perception concerns are of equal importance. Reasons given for these concerns provide greater insight into patients' personal experience of eye loss.

Rehabilitation of atrophic anophthalmic cavity with orthostatic ocular prosthesis: A clinical report

The absence of the eyeball can generate psychosocial and facial harmony changes, such as atrophy of the muscles around it. In these cases, the use of an orthostatic prosthesis with expanding function fosters distension of the tissues for subsequent rehabilitation. This technique consists of making individual ocular prostheses with gradual enlargement of size. The aim of this following clinical report was to describe the technique used in the standing prosthetic rehabilitation of a patient, 73 years old, who underwent enucleation of the right eye as a result of glaucoma. Clinical and laboratory procedures were performed such as impression, adjusting curvature of the sclera, centering the pupil area and processing in heat-cured acrylic resin three prostheses made according to the expansion of the anophthalmic cavity. At the end of treatment, there was a considerable increase of the cavity, allowing for volume replacement similar to that existing in the patient's contralateral orbit, thus generating a satisfactory facial harmony.

Vision-Related Quality of Life and Appearance Concerns Are Associated with Anxiety and Depression after Eye Enucleation: A Cross-Sectional Study

Aims

To investigate the association of demographic, clinical and psychosocial variables with levels of anxiety and depression in participants wearing an ocular prosthesis after eye enucleation.

Methods

This cross-sectional study included 195 participants with an enucleated eye who were attending an ophthalmic clinic for prosthetic rehabilitation between July and November 2014. Demographic and clinical data, and self-reported feelings of shame, sadness and anger were collected. Participants also completed the National Eye Institute Visual Function Questionnaire, the Facial Appearance subscale of the Negative Physical Self Scale, and the Hospital Anxiety and Depression Scale. Regression models were used to identify the factors associated with anxiety and depression.

Results

The proportion of participants with clinical anxiety was 11.8% and clinical depression 13.8%. More anxiety and depression were associated with poorer vision-related quality of life and greater levels of appearance concerns. Younger age was related to greater levels of anxiety. Less educated participants and those feeling more angry about losing an eye are more prone to experience depression. Clinical variables were unrelated to anxiety or depression.

Conclusions

Anxiety and depression are more prevalent in eye-enucleated patients than the general population, which brings up the issues of psychiatric support in these patients. Psychosocial rather than clinical characteristics were associated with anxiety and depression. Longitudinal studies need to be conducted to further elucidate the direction of causality before interventions to improve mood states are developed.

Phantom eye syndrome: a review of the literature

The purpose of this literature review was to describe the main features of phantom eye syndrome in relation to their possible causes, symptoms, treatments, and influence of eye amputation on quality of life of anophthalmic patients. For this, a bibliographical research was performed in Pubmed database using the following terms: “eye amputation,” “eye trauma,” “phantom eye syndrome,” “phantom pain,” and “quality of life,” associated or not. Thirteen studies were selected, besides some relevant references contained in the selected manuscripts and other studies hallowed in the literature. Thus, 56 articles were included in this review. The phantom eye syndrome is defined as any sensation reported by the patient with anophthalmia, originated anophthalmic cavity. In phantom eye syndrome, at least one of these three symptoms has to be present: phantom vision, phantom pain, and phantom sensations. This syndrome has a direct influence on the quality of life of the patients, and psychological support is recommended before and after the amputation of the eyeball as well as aid in the treatment of the syndrome. Therefore, it is suggested that, for more effective treatment of phantom eye syndrome, drug therapy should be associated with psychological approach.

Association of cognitive judgment and shyness with frequency and quality of flow experience

OBJECTIVE

To determine the association of cognitive judgment and shyness with frequency and quality of flow experience.

DESIGN AND METHODS

This was a cross-sectional survey of the relationship between psychological tendency and frequency and quality of flow experience in 68 college students, undertaken in Hiroshima, Japan. The predictors were Shyness Scale scores, measure of ambiguity tolerance scores, and Life Orientation Test scores, and the outcome was the frequency and quality of flow experience.

RESULTS

The results of the binary logistic regression analysis indicated that only the measure of ambiguity tolerance (P = 0.02, odds ratio = 1.06, and 95% confidence interval = 1.01-1.11) was a predictor of the quality of flow experience, and only the Shyness Scale (P = 0.007, odds ratio = 0.95, and 95% confidence interval = 0.91-0.98) was a predictor of the frequency of flow experience.

CONCLUSION

The findings suggest that ambiguity tolerance and shyness are associated with the frequency and quality of the flow experience.