Anterior surface breakdown and implant extrusion following secondary alloplastic orbital implantation surgery

Long-Term Outcome of Staged Socket Surgery for Acquired Anophthalmos

PURPOSE

To evaluate long-term outcomes of staged volume rehabilitation for acquired anophthalmos.

METHODS

Case-note review of patients who had preceding i) eye removal without implant, ii) eye removal with an intraconal implant, but ball-related problems, or iii) removal of exposed implant. Secondary interventions were a) a first-time ball implant, b) dermis-fat graft, c) ball repositioning, d) ball replacement after prior removal, or e) orbital floor implantation.

RESULTS

Secondary volume-augmenting surgery was performed in 175 sockets at a mean age of 42.7 years (range 2-91), with 62% secondary ball implants, 3% dermis-fat grafts, 6% ball repositioning, 19% ball replacement after prior removal for exposure, and 10% having orbital floor implantation. After this surgery, further volume enhancement was required in 21% of sockets, this being 40% for spheres ≤18 mm diameter, in contrast to 6% for those ≥20 mm ( p < 0.001). Exposure or malposition of the secondary implant occurred in 8% (12/151) and was unrelated to implant type, size, wrapping, or prior irradiation. Tertiary surgery addressed lining deficiency (18%) or eyelid malposition (25%). Overall, 92/175 (53%) had tertiary surgery to improve cosmesis and comfort, with 49% (36/92) being related to small implants. At a mean follow-up of 9.1 years, 82% of sockets had adequate volume, 79% had excellent lining, and 93% were comfortable. Prosthetic fit was satisfactory in 96% of cases, and 97% reported improved cosmesis.

CONCLUSION

Over half of the sockets having planned 2-stage volume enhancement may need further procedures, especially after small-volume secondary implants, but, with meticulous surgery, reasonable long-term results can be achieved with few complications.

One-stage Intraconal Volume Modification for Exposed and Nonexposed Ball Implants

PURPOSE

To assess long-term outcomes and reinterventions for exposed and nonexposed intraconal orbital implants after single-stage socket revisional surgery.

METHODS

Retrospective case-note review of patients with exposed or nonexposed orbital ball implants, who underwent a single-stage ball exchange (Group I) or ball removal with dermis-fat graft (Group II); Group I was subdivided as having either exposed (A) or nonexposed (B) implants. Outcomes were compared with similar cohorts undergoing multistage surgery.

RESULTS

Of 172 patients (54% male), 153 (89%) underwent ball exchange (Group I) and 19 (11%) had dermis-fat graft (Group II). With a mean follow up of 7.8 years, Group I patients without ball exposure (Group IB) had a slightly higher rate of reintervention for persistent volume deficit (21% vs. 9%; p = 0.163) and implant migration (6% vs. 0%; p = 0.091), while Group IA patients-having surgery for exposed implants-had more reexposures (7% vs. 3%; p = 0.270). Single-stage and 2-stage surgery had similar reintervention rates, with the exception of a trend toward fewer volume enhancements for those with nonexposed implants (17% vs. 30%; p = 0.380), and a shorter time to (re)exposure for exposed implants after 2-stage procedures (mean 0.33 vs. 3.5 years; p = 0.571). Group II patients required further volume enhancement in 32% of 1-stage procedures, and one patient needed graft removal.

CONCLUSION

Single-stage volume modification is effective and the results are comparable to staged surgery for either exposed or nonexposed implants. Most patients report a stable prosthesis and satisfactory cosmesis, after a faster rehabilitation.

Anophthalmic Socket Syndrome: Prevalence, Impact and Management Strategies

Anophthalmic socket syndrome determines functional deficits and facial deformities, and may lead to poor psychological outcomes. This review aims to comprehensively evaluate the features of the syndrome, based on literature review and authors’ clinical and surgical experience. An electronic database (PubMed,MEDLINE and Google Scholar) search of all articles written in English and non-English language with abstract translated to English on anophthalmic socket syndrome was performed. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. Different types of orbital implants were evaluated; the management of implant exposure was examined; different orbital volume enhancement procedures such as secondary implantation, subperiosteal implants and the use of fillers in anophthalmic patients were described; the problems related to socket contraction were outlined; the treatment options for chronic anophthalmic socket pain and phantom eye syndrome were assessed; the most recent advances in the management of congenital anophthalmia were described. Current clinical evidence does not support a specific orbital implant; late exposure of porous implants may be due to pegging, which currently is seldom used; filler absorption in the orbit appears to be faster than in the dermis, and repeated treatments could be a potential source of inflammation; socket contraction results in significant functional and psychological disability, and management is challenging. Patients affected by anophthalmic socket pain and phantom eye syndrome need specific counseling. It is auspicable to use a standardized protocol to treat children affected by clinical congenital anophthalmia; dermis fat graft is a suitable option in these patients as it helps continued socket expansion. Dermis fat graft can also address the volume deficit in case of explantation of exposed implants and in contracted sockets in both children and adults. Appropriate clinical care is essential, as adequate prosthesis wearing improves the quality of life of anophthalmic patients.

Novel Histopathologic and Immunohistochemical Observations in Explanted Orbital Peri-implant Capsules

PURPOSE

To describe the histopathologic and immunohistochemical characteristics of peri-orbital implant capsule and correlate the observed changes with delayed implant extrusion.

MATERIALS AND METHODS

Prospective, ex-vivo, histopathologic, immunohistochemical study of peri-implant capsules excised from capsules surrounding a poly-methyl metha acrylate (PMMA) implant. Thirteen capsules were harvested and divided into two groups. Group 1 (implant extrusion group) consisted of capsules harvested from around exposed/extruded implants and Group 2 (implant non-extrusion group) from implants that were surgically exchanged for volume augmentation. Data collected included demography, clinical presentations, etiology of the explantation, age of the capsule in months, inflammatory cells noted/high power field (HPF), CD3, CD20, and CD68, percentage Masson's trichrome staining and mean capsular thickness.

RESULTS

Mean patient age at presentation was 33 ± 13 years. Of the 13 capsules included, 7 belonged to group 1and 6 to group 2. Mean age of the fibro-collagenous membranes were 33 ± 57 months (median 13 months). Median CD3, CD20, and CD68 positivity was 80%, 9%, and 7% denoting a predominant T-lymphocytic response. Mean capsular thickness was 733 ± 422µ (median 678µ). Age of the harvested capsule showed a linear correlation with inflammatory cells/HPF (r = 0.93, p < .0001, 95% C.I. 0.73 to 0.98), with CD3 positivity (r = 0.6, p = .04, 95% C.I. 0.02 to 0.9), with capillary proliferation/HPF (r = 0.85, p = .003, 95% C.I. 0.43 to 0.96) and with percentage of cells showing Masson's trichrome stain positivity (r = 0.71, p = .03, 95% C.I. 0.08 to 0.93). In the extrusion group, the capsules demonstrated high inflammation and low fibrosis.

CONCLUSIONS

PMMA orbital spherical implant incites a predominantly T-cell mediated inflammatory response which clinically presents as a peri-implant capsule. Increasing inflammation in the absence of significant fibrosis may be responsible for delayed PMMA implant exposure and extrusion.

Transcutaneous approach for orbital augmentation with alloplastic implants in acquired anophthalmia

Purpose: To report the outcomes of a transcutaneous surgical technique for orbital volume augmentation with secondary alloplastic implants in acquired anophthalmia.Methods: Retrospective case note review of patients who underwent secondary orbital implant insertion through a subciliary incision between January 2006 and December 2017. Collected data included age, gender, type and cause of primary surgery, time interval before secondary implantation, and details of secondary implantation surgery. The main outcome parameters included postoperative appearance, grade of superior sulcus deformity (SSD), implant centration, and prosthesis function.Results: Thirty-eight patients ranging from 2 to 54 years had undergone secondary alloplastic orbital implant placement through the subciliary approach. The mean follow-up was 5.3 years (range: 1-10 years). All the patients showed satisfactory orbital volume with the average SSD was grade 0.74. There were no cases with implant exposure or extrusion. Implant migration occurred in six cases (15.8%). Fitting a prosthesis was possible in all cases.Conclusion: Subciliary secondary orbital implantation is proved to be effective in correcting volume deficiency in acquired anophthalmia with rapid rehabilitation while avoiding anterior surface breakdown and implant exposure.