Expansion of the human microphthalmic orbit

Orbital Development in Children with Retinoblastoma: An Imaging-Based Study

PURPOSE

To examine whether children treated for Retinoblastoma (Rb) have impaired orbital development.

METHODS

A retrospective case series was performed among children with Rb treated at a single medical center from 2004 to 2020. Orbital volumes and measurements were assessed by 3-dimensional image processing software. The main outcome measures were differences in orbital growth between Rb and non-Rb eyes assessed at last follow-up.

RESULTS

Among 44 patients included (mean age 16.09 ± 18.01 months), a positive correlation between age and orbital volume was observed only in the uninvolved, healthy eyes (p = .03). In unilateral cases, orbital growth in the horizontal, vertical, and depth planes was smaller on the affected side compared to the healthy eyes (p < .05). Orbits that underwent enucleation showed decreased growth over time compared to those treated conservatively (p = .017).

CONCLUSIONS

Orbital growth rate is slower in the orbits of children treated for Rb compared to healthy orbits. Enucleation negatively affects orbital growth.

Stepwise self-inflating hydrogel expansion for congenital anophthalmia and blind microphthalmia: Over 15 years' experience in China

BACKGROUND

Self-inflating hydrogel expanders have been used to treat anophthalmia and blind microphthalmia. This study aimed to investigate the long-term outcomes of treatment with self-inflating hydrogel expanders for congenital anophthalmia and blind microphthalmia.

METHODS

In this retrospective study, the medical records of 161 patients with anophthalmia and blind microphthalmia who underwent hydrogel expansion were reviewed. We measured the palpebral fissure height (PFH), palpebral fissure length (PFL), and distance between the inner canthal and mid-nasal line (ICMN) before and after surgery. Cox regression analysis was conducted to determine which variables were related to the implantation of spherical expanders following hemispherical expander implantation.

RESULTS

After treatment, the PFH and PFL increased significantly (p < 0.001). Complications including expander migration and extrusion occurred in 15 cases. Five patients needed enucleation or further dermis fat graft implantation because of insufficient expansion. The necessity for further spherical expansion was substantially related to a relative axial length (rAL) <0.5 (p = 0.007).

CONCLUSION

Self-inflating hydrogel expansion can significantly increase the lid fissure. The occurrence of complications is rare, and surgical intervention can effectively address them. Abnormal eyes with a rAL of less than 0.5 demonstrate a higher possibility of needing additional orbital expansion.

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.

Intraorbital self-inflating hydrogel expander implantation with a modified technique in congenital microphthalmia

PURPOSE

To investigate the long-term outcomes of intraorbital self-inflating hydrogel expander implantation with optic nerve transection in children with congenital microphthalmia.

METHODS

The medical records of unilaterally blind microphthalmic pediatric patients undergoing intraconal hydrogel expander implantation with optic nerve transection were reviewed retrospectively. For each patient, the microphthalmic eye was preserved. The orbital volume and globe volume were measured and analyzed based on computed tomography scans taken preoperatively and 36 months postoperatively. The palpebral length was measured between the medial and lateral canthus at every follow-up. Surgical complications were also recorded.

RESULTS

Twelve patients were included (median age, 44.25 ± 17.5 months). At 36 months postoperatively, the microphthalmic and contralateral orbital volumes increased by 3.07 ± 0.77 ml and 2.03 ± 0.67 ml, respectively. The mean microphthalmic/contralateral ratio (MCR) of the orbital volume increased significantly from 76.60% ± 5.46% to 83.81% ± 5.41% (P < 0.001). The microphthalmic palpebral length increased by 6.17 ± 1.85 mm, whereas the contralateral palpebral length increased by 2.67 ± 1.44 mm. Significant changes were observed in the palpebral length MCR (68.00% ± 4.83% vs 85.07% ± 3.87%; P < 0.001). There was no significant change in the microphthalmic globe volume at 36 months postoperatively (P = 0.215). For the fellow eye, the globe volume increased significantly by 0.53 ± 0.34 ml (P < 0.001). During the follow-up period, 2 patients developed a sunken prosthesis. One patient had difficulty opening the eye after wearing the conformer. There were no cases of expander rejection or extrusion.

CONCLUSIONS

In this small cohort of patients with congenital microphthalmia, intraorbital self-expanding hydrogel expander implantation with optic nerve transection led to excellent osseous and eyelid growth throughout the 36-month follow-up period.

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.

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.

Management of congenital microphthalmos and anophthalmos with orbital cyst

PURPOSE

To study the effects of an individualized treatment approach to children with congenital microphthalmos and anophthalmos.

METHODS

Patients with congenital microphthalmos or anopthalmos with orbital cysts who were referred to Beijing Tongren Hospital between July 2009 and July 2017 were included in this retrospective case series study. For patients ≤6 years of age, the cyst was retained to promote orbital development unless a prosthesis could not be fitted at all or disproportionate orbital growth was detected. Hydrogel orbit expanders were implanted initially if orbital volume was poor. For patients >6 years of age, the cyst was removed if it caused cosmetic problems or unsatisfactory prosthesis fitting. Eyelid procedures were performed after puberty to improve appearance.

RESULTS

The study included 26 orbits of 24 patients. Of the 14 patients ≤6 years, 3 underwent cyst excision, 8 were treated with conformers only, and 3 had hydrogel orbit expander implantation initially. Of the 10 patients >6 years, 1 had the cyst removed, 5 had eyelid surgeries without removing the cyst, 3 wore an artificial eye without any surgery, and 1 used no prosthesis. During the follow-up period (range, 6 months to 8 years), 23 patients had a good cosmetic outcome and were eventually able to retain an ocular prosthesis; 1 patient could not wear prostheses but refused further treatment. No procedure-related complications were noted.

CONCLUSIONS

The individualized treatment of congenital microphthalmos and anophthalmos with orbital cysts depends on the patient's age at presentation, the growth pattern of the cyst, and the volume of the affected orbit.

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.

Digital evaluation of orbital development in chinese children with congenital microphthalmia

PURPOSE

To evaluate the asymmetry of bilateral orbital development in Chinese children with congenital microphthalmia and to provide a criterion for tailoring treatment timing and therapy.

DESIGN

Retrospective cohort study.

METHODS

By combining multisection helical computerized tomography imaging with a computer-aided design system, we measured 38 children between 0 and 6 years of age with congenital microphthalmia and 70 normal children of the same age group. Variables were measured, including orbital volume, depth, width, and height and eyeball volume. Displacement of the orbital rims was calculated by mirroring the unaffected orbit across the midsagittal plane of body.

RESULTS

Significant differences were observed between the orbital volume, eyeball volume, orbital width, and orbital height of the affected and unaffected sides of children with congenital microphthalmia (P < .001). The difference between the orbital depth of the affected and unaffected sides was not significant (P = .055). Growth of the inferior and lateral rims retarded by an average of 3 mm, whereas that of the medial and superior rims retarded by less than 1 mm.

CONCLUSIONS

The amount of decrease in orbital volume of children with congenital microphthalmia is related to the severity of the disease (decrease in size of the eye), rather than to age. Retarded orbital development is evident primarily in the inferior and lateral rims, correlating mostly with zygomatic and then maxilla and frontal bone. The growth of the affected orbit slows down or even stagnates by 3 years of age. Intervention therapy before 3 years of age was critical.

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.

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

PURPOSE

To evaluate the effectiveness of an orbital tissue expander designed to stimulate orbital bone growth in an anophthalmic socket.

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

SETTINGS

Institutional.

STUDY POPULATION

Nine consecutive patients with unilateral congenital anophthalmos.

INTERVENTION

The orbital tissue expander is made of an inflatable silicone globe sliding on a titanium T-plate secured to the lateral orbital rim with screws. The globe is inflated by a transconjunctival injection of normal saline through a 30-gauge needle to a final volume of approximately 5 cm(3). Computed tomography scans were used to determine the orbital volume. The data studied were: demographics, prior orbital expansion procedures, secondary interventions, orbital symmetry, and implant-related complications.

MAIN OUTCOME MEASURES

The primary outcome measure was the orbital volume change, and the secondary outcome measures were changes in forehead, brow, and zygomatic eminence contour and adverse events.

RESULTS

The average patient age at implantation was 41.89 ± 39.42 months (range, 9 to 108 months). The initial average volume of inflation was 3.00 ± 0.87 cm(3) (range, 2.0 to 4.0 cm(3)), and the average final volume of 4.33 ± 0.50 cm(3) (range, 4.0 to 5.0 cm(3)) was achieved. The duration of expansion was 18.89 ± 8.80 months (range, 4 to 26 months). All patients demonstrated an average increase in the orbital tissue expander implanted orbital volume of 5.112 ± 2.173 cm(3) (range, 2.81 to 10.38 cm(3)). The average difference between the volume of the implanted and the initial contralateral orbit was 5.68 ± 2.34 cm(3), which decreased to 2.53 ± 1.80 cm(3) at the final measurement (P < .001, paired t test). All implants remained inflated except for 2 iatrogenic punctures at the second inflation and 1 that was the result of implant failure. All were replaced.

CONCLUSIONS

The integrated orbital tissue expander is safe and effective in stimulating anophthalmic socket bone growth.

The use of soft tissue expanders in periocular reconstruction: a case series

PURPOSE

To describe the use of soft tissue expanders for periocular reconstruction in the presence of limited local tissue availability.

METHODS

A retrospective case series of 5 patients who attended the Manchester Royal Eye Hospital. They presented a reconstructive challenge due either to the presence of periocular scarring or to a marked loss or limitation of normal local skin for reconstruction. The soft tissue expander (SOE-3624 device) was inserted under the skin and subcutaneous tissue at a site selected to provide the desired additional tissue. Over periods of time varying from 6 to 16 weeks, the soft tissue expander was gradually inflated with injections of sterile saline in the outpatient clinic. As soon as the desired amount of additional skin and subcutaneous tissue had been obtained, reconstructive surgery was undertaken. Functional and cosmetic results were the main outcomes of the intervention.

RESULTS

Four of the patients had the device inserted in the lower eyelid or cheek area and one patient had the device inserted above the eyebrow. No episode of tissue necrosis occurred in our patients. All the devices were tolerated by the patients and were removed without any complications. The implant migrated in one patient, limiting the reconstructive surgery, and one patient had a lateral canthal dehiscence following reconstruction. All patients thought that the surgery had improved their cosmesis. No patient required any additional surgical procedures.

CONCLUSIONS

The authors conclude that the SOE-3624 tissue expander represents a good option in providing additional tissue for periocular reconstruction, particularly in younger patients. It was well tolerated and effective in this series.

Evaluation of an integrated orbital tissue expander in an anophthalmic feline model

PURPOSE

To evaluate the anatomical effects and tissue biocompatibility in a feline model of an integrated orbital tissue expander (OTE) designed to stimulate bone growth in an anophthalmic socket.

DESIGN

An animal study was performed in cats to assess orbital bone growth with and without an OTE.

METHODS

The OTE is an inflatable (0.5 to >6.0 cm(3)) polymeric globe sliding on a titanium T plate secured to the lateral orbital rim with screws. Eight cats had left eye enucleation at age two weeks, with five orbits receiving an OTE and the remaining three serving as nonimplanted controls. Serial transconjunctival implant inflation was performed by injecting normal saline solution into the OTE to a final volume of 3.5 ml. Serial computed tomographic scans were obtained to assess socket growth. All eight cats were euthanized at 18 weeks and dry skulls prepared. The effective orbital volume was measured by inflating an OTE in the orbit of a dry skull until it filled the cavity completely.

RESULTS

Three cats periodically scratched open the tarsorrhaphy and conjunctiva to rupture the OTE, which resulted in implant exchanges. At 18 weeks, the OTE expanded orbital volume was approximately 18% smaller than the normal contralateral side. In the control animals, the anophthalmic orbital volume was approximately 66% smaller than the contralateral orbit. Histopathology of orbital tissues showed no evidence of foreign body reaction.

CONCLUSIONS

This proof-of-concept pilot study demonstrated implant efficacy in cats, and no implant-related adverse effects were observed. OTE has the potential to stimulate bone growth in human anophthalmic orbits.

Expansion of the Socket and Orbit for Congenital Clinical Anophthalmia

BACKGROUND

Congenital clinical anophthalmia requires fitting an artificial eye, achieving a pleasing aspect of the palpebral apparatus, and stimulating growth of the orbit, as well as of the entire midface.

METHODS

Out of 25 patients with clinical anophthalmia, 22 were treated according to a new protocol (first described by Wiese et al. in 1999) and followed for up to 6 years. In 10 patients, anophthalmia was bilateral, in nine patients, it was on the right side only and in three it was on the left side only. Treatment consisted of implantation of an osmotic expander to first stimulate growth of the conjunctival sac and eyelids followed by serial implantation of osmotic expanders to stimulate growth of the orbit (and thus of the midface). The material used was a copolymer of methylmethacrylate and N-vinylpyrrolidone.

RESULTS

Fitting of an artificial eye was without any problem within the first year of life for the most part. Growth of the orbit was stimulated by more than 65 percent of a healthy one. Aesthetically, the results were very largely pleasing. Complications were encountered, especially when the wrong expander sizes had been implanted.

CONCLUSION

Using osmotic expanders of this type, through a staged therapy of minor operations, promises to achieve all goals before the child enters school.

Management of the anophthalmic socket in pediatric patients

PURPOSE OF REVIEW

The management of the pediatric anophthalmic socket is distinguished from adult anophthalmia, because normal socket and facial development is dependent on orbital growth. Recent literature on managing anophthalmic sockets is discussed with a focus on the pediatric patient.

RECENT FINDINGS

There are many studies discussing the management of the anophthalmic socket, but few are randomized clinical studies. Although the management of anophthalmia in the child is fraught with challenges and nuances, the principal aim is to encourage socket growth.

SUMMARY

Both congenital and acquired pediatric anophthalmia are discussed. Surgical decisions, choice of orbital implants, various methods of socket expansion, and socket reconstructions are examined.

Orbital development in Hong Kong Chinese subjects

The purpose of this study was to examine the development of the orbit in Hong Kong Chinese subjects. Orbit volume was determined from magnetic resonance images of 81 subjects aged from 1 to 42 years old. Results show that orbit volume ranged from 11.56 to 25.50 cm3. In the first year of life, the mean orbit volume was 12.36 cm3. The orbit showed rapid growth in the first 3 years of life. From about 1-3 years old, the mean volume was 15.31 cm3. The orbit grew steadily to the age of 10 years. From age 11 to 15 years old, the mean volume was 20.24 cm3. Orbit growth levelled off at about 16 years of age with the mean volume at 21.00 cm3.

Abnormalities of orbital volume

New information on the physiopathology and treatment of orbital volumes pathologies is described: 1) In post-enucleation or evisceration socket syndrome placing of synthetic material (HA-TCP) directly in the intraconal orbital fat can correct most of the symptoms. However the best approach is to prevent orbital volume deficiencies during first surgery using an implant large enough to allow a future prosthesis of a volume less than 2 mL. New procedures for placing the implant after enucleation or evisceration are described. 2) In proptosis related to Graves' orbitopathy relative indications are given for orbital decompression by removal of fat or bone.