High-density porous polyethylene wedge implant in correction of enophthalmos and hypoglobus in seeing eyes

Patient Specific Implants for Orbital Reconstruction in the Treatment of Silent Sinus Syndrome: Two Case Reports

Silent sinus syndrome is a rare disorder characterized by ipsilateral enophthalmos and hypoglobus following a collapse of the orbital floor, in the presence of asymptomatic long-term maxillary sinusitis. It results in enophthalmos, hypoglobus and deepening of the superior palpebral sulcus. A standardized treatment protocol for this infrequent syndrome has not yet been established. The management includes restoration of maxillary sinus ventilation with functional endoscopic sinus surgery and orbital reconstruction, either concurrently or separately. In this paper, the authors presented two patients successfully treated with patient-specific implants, and intraoperative navigation. These cases highlight the benefit of computer-assisted planning and titanium patient-specific implants in the management of silent sinus syndrome. To the best of our knowledge, this is the first report that described the use of PSI with titanium spacers performed with the aid of intraoperative navigation for SSS treatment. Advantages, drawbacks of this technique and treatment alternatives currently available in the literature were also discussed.

Comparison of Postoperative Enophthalmos Between Fresh and Delayed Unilateral Orbital Fractures After Orbital Reconstruction With Titanium Mesh Using Computer-Assisted Navigation

This study compares postoperative enophthalmos between fresh and delayed unilateral orbital fractures after orbital reconstruction with titanium mesh using computer-assisted navigation. The sample was composed of 45 patients with post-traumatic unilateral enophthalmos who were divided into the fresh fracture group and the delayed fracture group. They underwent orbital reconstruction with standard preformed orbital implants and computer-assisted navigation system. The following parameters were measured with computed tomography images: the degree of enophthalmos, orbital volume, and fracture defect area. Patients were reviewed preoperatively (T0), 1 week postoperatively (T1), and 6 months postoperatively (T2). Computed tomography measurements showed that in both groups, the degree of enophthalmos decreased after surgery but increased significantly from T1 to T2 ( P <0.05). ΔE (difference in the degree of enophthalmos between T1 and T2) was similar in patients with fresh and delayed fractures. There was a significant difference in the degree of ΔE between patients with single-wall orbital fractures and those with two-wall orbital fractures. The findings indicate that postoperative enophthalmos is common in both the groups and is closely related to the degree of preoperative enophthalmos. Furthermore, the recurrence of enophthalmos is similar between the 2 groups, but it is higher in patients with orbital fractures involving 2 walls.

Patient specific implants in orbital reconstruction: A pilot study

Purpose

Successful repair of the orbital skeleton restores function and cosmesis by normalizing globe position and allowing full motility of the extraocular muscles. Routine repairs are successful with standard implants. However, defects that are irregular or cause volume deficiency can be challenging to repair. The development of patient specific implants (PSI) offers an additional tool in complex cases. Herein, we report our experience using PSI for orbital reconstruction.

Methods

An IRB-approved review was conducted of consecutive patients who received PSI from 8/2016–9/2018. Demographic and examination findings were recorded. PSI was designed using high-density porous polyethylene or polyetheretherketone (PEEK) and implanted for repair. The postoperative course was reviewed for outcomes and complications.

Results

Eight patients were identified. Two had silent sinus syndrome, 3 were complex facial fracture revisions, and 3 were post-oncologic reconstruction. Seven received porous polyethylene implants, and 1 had a PEEK implant. Mean follow up time was 10.2 months (3.3–28.3). All had an improved functional and aesthetic result. Diplopia and enophthalmos completely resolved in 60% of fracture and silent sinus patients. All fracture and silent sinus patients were orthotropic without diplopia in primary gaze at last follow up. Tumor patients had improvement in symmetry and functionality. There were no complications.

Conclusion and importance

Complex orbital skeleton derangements can be difficult to repair and standard implants may incompletely resolve the anatomic problem. In challenging cases, PSI may better achieve an aesthetically and anatomically successful outcome and improve functionality.

Incidence and management of retrobulbar hemorrhage after blowout fracture repair

BACKGROUND

Retrobulbar hemorrhage (RBH) is a rare complication after orbital surgery but associated with ocular complications including blindness. The aim of this study was to identify clinical characteristics of patients with RBH requiring emergent orbital decompression after blowout fracture repair.

METHOD

A retrospective review of 426 blowout fracture patients at a tertiary oculoplastic clinic provided data regarding demographics, physical examination findings, and computed tomography (CT) images. Extraocular motility had been recorded in patient charts on a scale from 0 to - 4. Patients requiring emergent orbital decompression due to RBH after surgery (RBH group) were compared with those who did not (Control group), using the Mann-Whitney U-test. Incidences of RBH according to primary or secondary surgery were also investigated, using Fisher's exact test.

RESULT

Five (1.2%) of the 426 patients who underwent blowout fracture repair developed RBH requiring emergent intervention. All RBH patients fully recovered after the decompression procedure or conservative treatment. Number of days to surgery was significantly longer in the RBH group (97.0 ± 80.1) than in the Control group (29.0 ± 253.0) (p = 0.05). Preoperative enophthalmos was also significantly greater in the RBH group (RBH vs. Control group, 3.6 ± 1.7 mm versus 1.2 ± 1.3 mm (p = 0.003)). The incidence of RBH was significantly higher in patients that underwent secondary surgery (odds ratio = 92.9 [95% confidence interval, 11.16-773.23], p = 0.001).

CONCLUSIONS

Surgeons should pay more attention to hemostasis and postoperative care in patients with a large preoperative enophthalmic eye, when time from injury to surgery is long and in revision cases. When RBH occurs, time to intervention and surgical decompression is critical for visual recovery and preventing blindness.

TRIAL REGISTRATION

The institutional review board of the Yeungnam University Medical Center approved this study ( YUMC 2018-11-010 ), which was conducted in accord with the Declaration of Helsinki.

Resorbable Material for Pediatric Orbital Floor Reconstruction

INTRODUCTION

The use of resorbable materials is becoming more popular for pediatric orbital floor reconstruction. The purpose of this systematic review is to evaluate the effectiveness and safety of the various materials used in pediatric orbital floor reconstruction.

METHODS

A systematic literature search was performed to identify all relevant articles reporting complications following pediatric orbital floor reconstruction. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and PubMed starting from database establishment to July 2017. Primary endpoints were enophthalmos, diplopia, and infection. Resorbable material was compared to autologous grafts and nonresorbable material.

RESULTS

A total of 14 studies containing 248 patients were included in this review. Fifty-four (21.8%) patients had reconstruction performed with autologous grafts, 72 (29.0%) patients with resorbable material, and 122 (49.2%) patients with nonresorbable material. Resorbable materials had the lowest rate of postoperative enophthalmos (3/52; 5.8%) and the highest rate of postoperative diplopia (19/72; 26.4%). In contrast, nonresorbable materials had the lowest rate of postoperative diplopia (5/122; 4.1%), the highest rate of postoperative enophthalmos (14/102; 13.7%). Autologous reconstruction was associated with an 11.1% (4/36) rate of postoperative enophthalmos and a 22.2% (12/54) rate of postoperative diplopia. Nine cases (8.8%) of postoperative infection were documented with nonresorbable materials. No cases of infection were reported with autologous grafts or resorbable materials.

CONCLUSION

Newer resorbable implants are safe and have a similar complication profile as traditional autologous grafts in pediatric orbital floor reconstruction.

Combined orbital floor wedge implant and fornix reconstruction for postenucleation sunken socket syndrome

BACKGROUND

The purpose of this study was to evaluate the efficacy of simultaneous correction of a postenucleation sunken socket syndrome and deficient inferior fornix with a porous polyethylene wedge and oral mucosa graft.

METHODS

In this study, the authors retrospectively reviewed 24 patients who underwent simultaneous correction of postenucleation sunken socket syndrome by wedge implants and deficient inferior fornix by oral mucosa graft from January of 2009 until December of 2011. Upper and lower fornix depths were measured and exophthalmometry was performed before and 6 months after surgery. A paired t-test analysis was used to compare preoperative and postoperative results of fornix depth and exophthalmos.

RESULTS

Of the 24 patients, 15 were women and nine were men. The mean age of the patients was 44.1 years and the mean follow-up period was 11.2 months. Enophthalmos significantly decreased in all cases, with a mean change of 3.3 ± 1.26 mm (p < 0.001). Inferior fornix depth increased significantly, with a mean difference of 5.0 ± 0.86 mm (p < 0.001). There were no significant complications after surgery.

CONCLUSION

A simultaneous correction of postenucleation sunken socket syndrome and deficient inferior fornix using porous polyethylene wedge implants and oral mucosa graft can be effective for cosmetic improvements in anophthalmic patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Computer-aided orbital wall defects treatment by individual design ultrahigh molecular weight polyethylene implants

Despite of well-known advantages of high molecular weight polyethylene (Medpor, Synpore) in orbital reconstructions, the thickness of those implants significantly exceeds 0.5 mm and precise modification of thickness is limited. The aim of this study was to present the application of a self-developed method of treatment orbital wall fracture by custom implant made of ultrahigh molecular weight polyethylene (UHMW-PE).

MATERIAL AND METHOD

First, the test of influence of sterilization process upon implant deformation was performed (autoclaving, ethylene oxide, gas plasma, irradiation). Next, ten cases for delayed surgical treatment of orbital fracture were included into this study (7 males, 3 females). Based on CT scan and mirrored technique, a CAD model of virtual implant for repairing orbital wall was made. Then, an implant was manufactured with a computer numerical controlled milling machine from UHMW-PE block, sterilized and used during a surgical procedure. Clinically used implants had thickness from 0.2 to 4.0 mm.

RESULTS

The best method of sterilization is ethylene oxide process, and the worst is autoclaving. In this series of delayed surgical cases, functional results of orbital surgery are worse than in simpler, early treated cases, but long-term subsidence of diplopia is noticeable [10% poor results]. The results of the treatment depend on the initial level of diplopia where severe initial diplopia to be corrected requires thicker implants (p < 0.01). It also leads to longer surgical procedures (p < 0.01), but prolongation of the surgery had no negative influence upon results of any investigated follow-up examinations. Obviously, the orbital destruction intensity is related to injury-evoked initial diplopia but it also influences whole results of treatment up to 12 months post-op. Interesting result is presented by the relation of maximal implant thickness to 12-month diplopia evaluation. Thicker implants used result in lower residual diplopia (p < 0.05). This is important because of the correlation between the higher orbital destruction intensity with a thicker UHMW-PE implant (p < 0.05) applied in this series.

CONCLUSION

Patient-specific ultrahigh molecular weight polyethylene implants enable precise reconstructions of orbital wall. One should not be afraid of a significant eye globe reposition caused by these thickness modulated implants, as such repositioning is essential for an efficient correction of enophthalmos.