Changes in Intraocular Lens Explantation Indications and Comparison of Various Explantation Techniques

PURPOSE

To examine the current causes of intraocular lens (IOL) explantation, compare various IOL explantation techniques, and assess the visual outcomes and complications.

DESIGN

Retrospective comparative case series.

PARTICIPANTS

A total of 175 eyes of 160 patients who underwent IOL exchange for a one-piece foldable acrylic IOL between January 2010 and March 2022 were covered by the research. Group 1 included 74 eyes from 69 patients in which the IOL was removed after being grasped, pulled, and refolded inside the main incision. Group 2 consisted of 66 eyes from 60 patients in which the IOL was removed by bisecting it, whereas group 3 included 35 eyes from 31 patients in which the IOL was removed by enlarging the main incision.

MAIN OUTCOMES

Surgical indications, interventions, visual outcomes and refraction, and complications.

RESULTS

The mean patient age was 66.1 ± 10.5 years. The mean time between primary surgery and IOL explantation was 57.0 ± 38.9 months. IOL dislocation (in 85 eyes, 49.5%) was the most common reason for IOL explantation. When the patients were examined in terms of both surgical indication groups and IOL removal techniques, corrected-distance visual acuity increased significantly in all subgroups (P < .001). The increase in astigmatism after surgery was 0.08 ± 0.13 diopters (D) in group 1, 0.09 ± 0.17 D in group 2, and 0.83 ± 0.29 D in group 3 (P < .001).

CONCLUSIONS

The grasp, pull, and refold technique for IOL explantation provides a simpler surgery, less complication, and good visual outcomes.

Differential Diagnosis of Changes in Intraocular Lenses

Differentiating between various intraocular lens (IOL) changes can be a challenge. In particular, certain IOL models carry the risk of late postoperative calcification. A major cause of IOL exchange surgery could be avoided if appropriate modifications were made during the IOL manufacturing process. The use of a hydrophilic acrylate carries the risk of IOL calcification, especially when a secondary procedure, such as a pars plana vitrectomy or other procedures using gas or air, is performed. In secondary IOL calcification, there is a wide range of opacification patterns, which are usually located in the centre on the anterior surface of the IOL or sometimes elsewhere. Often, granular deposits accumulate just below or on the surface of the IOL, leading to significant deterioration in visual quality and eventually requiring IOL exchange surgery. Therefore, in the case of eyes requiring secondary surgical intraocular intervention in the future, the use of hydrophilic IOLs should be critically evaluated. With regard to hydrophobic IOL materials, there are clear differences in the susceptibility to the formation of glistenings. Over time, there has been a significant decrease in glistening formation over the past 30 years due to optimisation of the material. With hydrophobic IOLs, special care should also be taken to avoid mechanical damage. In general, the only treatment option for functionally-impairing IOL opacification is surgical lens exchange, which carries potential risks of complications. In cases with a low degree of functional impairment, and especially in eyes with additional ocular diseases, it may be difficult to weigh the risk of additional surgery against the potential benefit. In some cases, it may be more appropriate not to perform an IOL exchange despite the IOL opacification. Recent visualisation methods that allow high-resolution analysis of the opacities in vivo and in vitro may be used in the future to estimate the functional effects of various IOL material changes on the optical quality.

Biosocial profile of New Zealand prosthetic eye wearers

AIM

To describe the biosocial profile of New Zealand (NZ) artificial eye wearers and establish a basis for future research and international comparison.

METHODS

This retrospective study surveyed 431 NZ artificial eye wearers to investigate their ethnicity, gender, age, causes of eye loss, age of current prosthesis, ocular prosthetic maintenance regimes and the extent and severity of discharge associated with prosthesis wear.

RESULTS

Approximately 3000 people wear artificial eyes in NZ. Accidents were the main cause of eye loss prior to 1990 and medical conditions have been the main cause since. In the 1960s, the ratio of men to women losing an eye from accidents was 5:1, but during the past decade the ratio was 1.4:1. Socket discharge occurred at least twice daily for one-third of the study group.

CONCLUSIONS

Approximately 1 in 1440 people wear artificial eyes in NZ. Decline of eye loss due to accidents is consistent with decreasing workplace and traffic accidents and may be due to improved medical management, workplace safety standards and safer roads. Mucoid discharge is prevalent in the anophthalmic population of NZ and an evidence based treatment protocol for discharge associated with prosthesis wear is needed. Research into this distressing condition is planned.

[The embedded mobile orbital implant from methylmethacrylate "Hydron"--clinical and histopathological findings 25 years after implantation]

The embedded mobile hydrogel methylmethacrylate ("HYDRON" Spofa) orbital implants introduced in the beginning of 70th years of 20th century was a new method to get good cosmetic effects after enucleation. At the Dept. of Ophthalmology of the Comenius University, Bratislava, the rejection rate of this type of orbital implants in the first years after enucleation (1971-1974) was only 16.8%. This technique was applied in patients after enucleation due to traumatic phtisis of the eye globe. Authors submit a case report of a female patient from the group of implanted mobile orbital implant HYDRON implanted in 1984. They analyze clinical features and histopathological findings after surgical removement 25 years after implantation.

Complications and management of cosmetic anterior chamber iris implants

PURPOSE

To report the management of complications due to cosmetic iris implantation.

DESIGN

Interventional case report.

METHODS

A 27-year-old female underwent bilateral anterior chamber NewColorIris implants in Panama to cosmetically change her eye colour. Two weeks later she presented as an eye emergency in London with corneal decompensation, raised intraocular pressure and significantly reduced vision. Bilateral explantation was performed with good postoperative recovery.

RESULTS

Three months following explantation, visual acuity had normalized and intraocular pressure was within the normal range without medication.

CONCLUSIONS

Cosmetic iris implantation can lead to potentially sight threatening complications. This is the first case to be reported in the United Kingdom. There is a lack of published safety data and their cosmetic application should be cautioned against.

[Complications from eye prosthesis]

In Denmark, 3,000-4,000 people have lost an eye, they are eye amputated. The most frequent complications associated with the use of an artificial eye, eye-prosthesis, are secretion, lagophthalmos, enophthalmos, rotating prosthesis, prosthesis falling out, and exophthalmos. The wearing of an eye prosthesis and the related complications are important issues that the medical doctor should discuss with the patient.

Surgical outcome and ocular complications of evisceration and intraocular prosthesis implantation in dogs with end stage glaucoma: a review of 20 cases

Surgical outcome and complications following evisceration and implantation of intraocular silicone prosthesis (ISP) in 20 canine eyes with end-stage glaucoma were analyzed, including clinical signs, complications, cosmetic appearance, and owners' responses. The mean postoperative follow-up time was 312 days. Major short-term surgical complications were central corneal ulceration (6/20) and infections (3/20), while long-term complication was keratoconjunctivitis sicca (KCS) (2/20). All patient owners (100%) showed satisfied with the surgical outcome and postoperative cosmetic effect including 85% of the owners gave an excellent or good rating of satisfaction. No more medication needed for long term control except the KCS cases. With careful case selection and post-operative care, evisceration with ISP implantation proves a good and safe surgical procedure with minimal complications for end stage glaucoma.

Immunohistochemical findings in prosthesis-associated giant papillary conjunctivitis

PURPOSE

To identify functional subsets of inflammatory cells and expression of cytokines in the conjunctiva of patients with ocular prosthesis-associated giant papillary conjunctivitis (P-GPC).

METHODS

Specific immunohistochemical staining using monoclonal antibodies was performed on biopsy specimens obtained from superior tarsal conjunctiva of 18 patients with P-GPC. The prosthetic eyes were taken as the study group, whereas their fellow eyes were used as matched controls.

RESULTS

In normal conjunctiva, mast cells (MCs) were located only in the substantia propria (SP), whereas in P-GPC eyes MCs were also notable in the epithelium in five specimens. Tryptase-chymase-positive MCs (MC(TC)) were predominant both in P-GPC (79%) and in fellow (72%) eyes. MC(TC), CD4(+) lymphocyte, CD8(+) lymphocyte and eosinophil numbers were higher in P-GPC specimens compared with the fellow eyes (P = 0.005, 0.074, 0.012 and 0.025, respectively). Eosinophils were detected in 58.8% of P-GPC specimens and 16.7% of control specimens (P = 0.053). The number of inflammatory cells expressing eotaxin and interleukin (IL)-4 was higher in P-GPC group (P = 0.050 and 0.048, respectively). Nine out of 17 giant papillary conjunctivitis specimens (52.9%) showed eotaxin and IL-4 immunoreactivity, which was considerably higher than the fellow eyes (16.7%) (P = 0.064).

CONCLUSION

These findings suggest that P-GPC is an allergic disease of the eye associated with increased numbers of MC, eosinophils and lymphocytes in the conjunctiva and a remarkable expression of IL-4 and eotaxin both by the conjunctival epithelium and by the inflammatory cells in the SP.

[Lacrimal adenocarcinoma and anophtalmos]

INTRODUCTION

The classical symptoms of orbital tumors are modified in the event of an anophthalmic socket.

CASE REPORT

We report a case of primary malignant neoplasm of the lacrimal gland in an enucleated 70-year-old women.

DISCUSSION

Patients with an anophthalmic orbit often present postenucleation socket syndrome: problems of tolerance and rocking of the ocular prothesis, enophthalmos, ptosis, lower eyelid ectropion. Development of a malignant tumor of the lacrimal gland is however exceptional. An oversized lacrimal gland is suggestive of tumor development. Rigorous clinical and radiological follow-up (CT, MRI) is essential. We discuss diagnostic and therapeutic aspects including the type of exenteration, radiotherapy, and reconstruction technique.

Conjunctival cytology features of giant papillary conjunctivitis associated with ocular prostheses

PURPOSE

In this study, the conjunctival cytology features of giant papillary conjunctivitis (GPC) associated with ocular prosthesis wear was examined.

METHODS

In a prospective study, 12 consecutive patients diagnosed with GPC associated with ocular prosthesis wear were examined. Impression cytology specimens were taken from the upper eyelid tarsal conjunctiva, the bulbar conjunctiva, and the lower eyelid tarsal conjunctiva of each socket, with the contralateral eye serving as a matched control.

RESULTS

The randomized impression cytology specimens showed no significant change in goblet cell density or epithelial cell morphology when comparing the GPC and control specimens. The GPC specimens did have a statistically significant increase in conjunctival inflammation and mucous strands on all three sample areas. In addition, the GPC specimens from the upper and lower tarsal conjunctiva had a honeycomb pattern consistent with giant papillae.

CONCLUSIONS

This is the first report to describe the honeycomb pattern created by giant papillae on impression cytology and the changes of GPC on the lower tarsal conjunctiva.

[Long-term results of implantation of hydroxylapatite as artificial eye]

BACKGROUND

Since its first implantation as an eyeball replacement in the United States in 1985, hydroxyapatite has been rarely used as an orbital implant in Germany. The aim of the study was to collect data on long-term tolerance, postoperative complications and the cosmetic end results.

PATIENTS AND METHODS

In the spring of 1997, 52 patients underwent a follow-up examination at our hospital. The average post-operative follow-up period was 23 (12-41) months.

RESULTS

The subjective tolerance was considered good by 3/4 of the patients. In the comparison of position and prominence of the artificial eye, 8 patients achieved complete equalization. As regards defective lid position, 8 patients had a ptosis, 6 an ectropium, and there was one case of entropium. Changes in conjunctiva stretched from muciferous secretion to follicular squamous hyperplasia. There was no case of implant extrusion in the series examined. With reference to the method of implantation, far superior motility was observed in primary implantations. Statistically significant motility differences could not be shown regarding muscle attachment because of the small number of the cases.

CONCLUSIONS

In the series examined, hydroxyapatite proved to be a generally well-tolerated orbital implant with few postoperative complications and good motility. Primary implantation with attachment of all six eye muscles gave the best results.

Volumetric determination of enucleation implant size

PURPOSE

To determine whether volumetric calculation of enucleation implant size improves the results of the enucleation procedure.

METHODS

The volume of the enucleated globe was measured in 33 eyes of 33 patients, allowing intraoperative calculation of implant size. The degree of postoperative anophthalmic volume deficit was evaluated by determining the relative enophthalmic position of the implant using Hertel exophthalmometry. These results were compared with those obtained from two groups of historical control patients who had previously undergone enucleation with the insertion of standard size 18-mm or 20-mm implants.

RESULTS

There was significant variability in the volume of "normal" size globes (range, 7.0 to 9.0 ml; mean, 7.9 ml; standard deviation [SD], 0.7), resulting in the placement of implants between 18 to 22 mm in diameter. Study patients undergoing volumetric determination of implant size demonstrated less implant enophthalmos (mean, 5.9 mm) than historical control patients who received 18-mm (mean, 8.5 mm; P =.0001) or 20-mm (mean, 6.8 mm, P = .0332) implants.

CONCLUSIONS

Volumetric determination and individualization of enucleation implant size appears to reduce postoperative anophthalmic volume deficit.

Effect of lodoxamide on tear leukotriene levels in giant papillary conjunctivitis associated with ocular prosthesis

Leukotrienes have been shown to play a role in the pathogenesis of ocular inflammatory and allergic reactions like vernal keratoconjunctivitis and contact lens-associated giant papillary conjunctivitis. This study was designed to determine leukotriene B4 (LTB4) and leukotriene C4 (LTC4) levels in the tears of patients with ocular prosthesis-associated giant papillary conjunctivitis (OP-GPC) and to evaluate the effects of lodoxamide 0.1% on tear LTB4 and LTC4 levels of OP-GPC patients. Tear LTB4 and LTC4 levels were determined by an ELISA technique in the tears of ten OP-GPC patients before and after treatment with lodoxamide 0.1% for one month. The results were compared with that of ten healthy control subjects. The mean tear LTB4 and LTC4 levels of the OP-GPC patients were significantly higher than those of the control group. After treatment with lodoxamide 0.1%, tear LTB4 and LTC4 levels of the OP-GPC patients decreased significantly. This is the first report of elevated LTB4 and LTC4 levels in tears of OP-GPC patients and it points to the possible role of leukotrienes in the immunopathogenesis of OP-GPC. The results also indicate that lodoxamide 0.1%, a mast cell membrane stabilizer, is effective in significantly reducing tear LTB4 and LTC4 levels in OP-GPC patients.

Squamous cell tumors and ocular prostheses

Conjunctival squamous cell carcinoma is an infrequent tumor. It has been reported to occur in association with actinic damage and chronic irritation. To the authors' knowledge, however, this tumor has not been reported secondary to poorly fitting ocular prostheses. Two patients were studied in whom conjunctival squamous cell carcinoma had developed. In both instances, the patient had been enucleated and fitted with an ocular prosthesis more than 40 years before tumor development. Histopathologic evaluation of each tumor revealed its squamous cell origin. In one of the patients, the tumor was found to be metastatic to the ipsilateral parotid gland, an uncommon finding. The authors attempted to identify risk factors that may have contributed to the development of these tumors. Aside from the poor fit of the prostheses, neither patient had significant risk factors for the development of conjunctival squamous cell carcinoma. It is concluded that a new, sanguineous conjunctival discharge or focal eyelid swelling after years of prosthetic wear may not be due to mechanical irritation alone. The onset of these symptoms, especially years after the initial fitting of an ocular prosthesis, should prompt a thorough investigation of its cause.

Orbital development in long-term survivors of retinoblastoma

PURPOSE

To determine the effects of enucleation, irradiation, and age at diagnosis on bony orbital growth in long-term survivors of retinoblastoma using measurements based on computed tomographic (CT) imaging.

PATIENTS AND METHODS

We used CT obtained at a median age of 13 years to measure orbital volume and configuration in 54 patients who had been treated for retinoblastoma a minimum of 5 years previously.

RESULTS

Enucleation and high-dose orbital irradiation (> 35 Gy) both independently adversely affected orbital development (P = .014 and P = .022, respectively). Orbital volume differences for children treated when < or = 1 year old were no greater than those for children treated when older than 1 year of age. In children treated for bilateral retinoblastoma, the impact of enucleation on orbital development was not statistically different from that of irradiation (P = .13). Small implants (12 to 14 mm in diameter) were more commonly associated with smaller orbital volumes. Migration of orbital implants was associated with the smaller orbital sphere size in children < or = 1 year of age (P < .035).

CONCLUSION

Treatment for retinoblastoma compromises orbital development. Resulting orbital asymmetry seems to be at least partially related to the size of the implant. Detailed imaging-based measurements of orbital volume and configuration may aid the planning for cosmetic and reconstructive surgery in those who develop orbital asymmetry.

Implant-retained prosthetic rehabilitation of orbital defects

OBJECTIVE

To evaluate the use of endosseous transcutaneous implants to retain removable facial prostheses for the rehabilitation of orbital defects.

SETTING

Tertiary referral center.

PATIENTS

Six patients with a history of facial defects secondary to orbital exenteration for cancer ablation.

OUTCOME MEASURES

Clinically noted functional and cosmetic results, patient reports of satisfaction, and complications encountered.

RESULTS

Twenty-three of 25 implants were integrated (postoperative period, 13 to 65 months; mean, 44.2 months), representing an integration success rate of 92%. All patients were successfully wearing implant-retained prostheses after 48.3 months (post-prosthesis delivery period, 1 to 48.3 months; mean, 24.5 months). Overall patient satisfaction was very high.

CONCLUSIONS

Implant-retained prosthetics represent a safe and effective treatment option. It is anticipated that this treatment will become the standard of rehabilitative care for patients with orbital defects.

Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases

The coral derived hydroxyapatite sphere is a popular, integrated orbital implant designed to provide improved motility of the ocular prosthesis following enucleation. Although the implant has rapidly become widely used by ophthalmologists, little information is available regarding the problems of this technique in a large series of cases. Experience with 250 consecutive cases of hydroxyapatite orbital implant use was reviewed and the problems of the implants and their management investigated specifically. The reasons for enucleation included uveal melanoma (157 cases), retinoblastoma (70 cases), blind painful eye (22 cases), and intraocular medulloepithelioma (one case). Earlier treatment to the eye was performed before enucleation in 47 cases and included repair of ruptured globe (17 cases), plaque radiotherapy (18 cases), external beam radiotherapy (six cases), and others (six cases). During a mean of 23 months' follow up (range 6-40 months), there have been no recognisable cases of orbital haemorrhage related to the implant, and no cases of implant extrusion or implant migration. There was one case of presumed orbital infection (culture negative) that resolved with intravenous antibiotics and the implant was retained within the orbit. Other problems included conjunctival thinning in eight cases managed by observation and prosthesis adjustment, and conjunctival erosion in four cases managed by combinations of scleral patch graft, conjunctival flap, and prosthesis adjustment. The conjunctival erosion was caused by a poorly fitting prosthesis in three cases and wound dehiscence in one case. The problem rate in eyes receiving prior radiotherapy or surgery was not increased. The hydroxyapatite integrated orbital implant is a well tolerated motility implant without the high rate of extrusion and infection seen with other motility implants. The prosthesis fit may contribute to the tolerance of the implant.

Ophthalmic implants and explants

There are a variety of relatively common implants and explants used in ophthalmology. The ED physician should be familiar with and recognize them when they present primarily or secondarily to the ED. The lids and lacrimal system harbor devices that improve physiologic function. The globe is home to the most common implant, the contact lens, and now increasingly, the intraocular lens after cataract surgery. Orbit fractures are often repaired with light metals or other alloplastic materials. The anophthalmic socket, depending on its age, has been filled with many types of implants, some of which may present years later with complications of migration or extrusion. All implants and explants used in ophthalmology can have complications and potentially appear in the ED. Complications that include ocular or orbital infections, especially sight-threatening intraocular infections, require immediate referral. The less-emergent problems mentioned can usually be seen in a few days. The need and timing of ophthalmic referral can be determined with a telephone consultation from the ED.

Enucleation, evisceration, and exenteration

This review outlines many of the recent advancements in the understanding and management of the anophthalmic patient. A population-based study demonstrated that the annual incidence of enucleations for all causes was about 3 to 5 per 100,000. Application of expandable orbital implants appears to be promising in the management of microphthalmia or anophthalmia in infants to maximize orbital growth. Some reports on the use of hydroxyapatite enucleation implants are encouraging, with no major complications observed in one large series. Yet other reports of hydroxyapatite implant exposures, at a very concerning frequency, are also beginning to emerge. Few of the exposures heal spontaneously; however, infections or extrusions are very rare, and they are attributable to the porous composition of the implant. Conjunctival flaps alone are suboptimal in the management of exposures. Adjunctive autologous fascial grafts seem preferable to heterologous sclera in the management of these exposures. Magnetic resonance imaging of the hydroxyapatite implant appears to be superior to bone scan in the noninvasive assessment of vascularization of these implants. Further advancements are necessary to achieve a more optimal enucleation implant.

Postoperative endophthalmitis resulting from prosthesis contamination in a monocular patient

Monocular patients who wear an ocular prosthesis may harbor pathogenic conjunctival flora both in the socket and in the contralateral eye. They may therefore be at increased risk of developing endophthalmitis after intraocular procedures. We studied a monocular, prosthesis-wearing, 86-year-old man who underwent cataract extraction, subtotal transpupillary vitrectomy, and intraocular lens insertion. Fulminant endophthalmitis ensued postoperatively, and despite complete vitrectomy and administration of intraocular antibiotics, the eye lost light perception. Intravitreal as well as conjunctival cultures bilaterally grew Proteus mirabilis. The patient disclosed that he cleaned the prosthesis frequently because of discharge. We considered an association between this bacterial colonization and the risk of developing postoperative endophthalmitis and suggest prophylactic measures for treatment of monocular patients undergoing intraocular procedures.

[Keratoprosthesis from a personal collection 15-year old material]

The study presents the analysis of a 15-years material concerning the keratoprosthesis in severe corneal leukoma of various aetiology. The material comprises 82 cases of corneal leukoma of the 5th category (hopeless leukoma) caused in the majority of cases by chemical burns as well as post-inflammatory leukoma, on the background of pemphigus, after opacified corneal grafting. The authors discuss the characteristic complications of keratoprosthesis and present their personal results.

Ocular prostheses and contact lenses. I--Cosmetic devices

Images

Enucleation combined with orbital implants for malignant melanoma of the uvea

Advanced malignant melanomas of the uvea unsuited for an eye salvaging approach require enucleation of the tumor containing eye. A series of 68 patients is reported who underwent enucleation combined with insertion of a spherical dura-encased implant after 30 Gray pre-irradiation therapy of the orbit. Postoperative results with special attention to cosmetic outcome and motility of the prosthesis suggest that the insertion of an orbital implant should be preferred to the enucleation with no implant.

Correction of enophthalmos and superior sulcus depression in the anophthalmic orbit: a long-term follow-up

The purpose of this study was to review the long-term results in anophthalmic patients treated for enophthalmos. The patients in our series had augmentation of the volume of their orbital contents by subperiosteal placement of room-temperature vulcanized silicone. From 1972 to 1985, sixty-three patients received subperiosteal placement of room-temperature vulcanized silicone for their enophthalmos. Twenty-four of these patients were seen in long-term follow-up 1 to 13 years postoperatively. Indepth follow-up evaluation showed that room-temperature vulcanized silicone subperiosteal implantation for the treatment of enophthalmos and superior sulcus depression in the anophthalmic orbit is a reliable, safe procedure that is without serious complications and has excellent long-term results.

Correction of depressed supratarsal sulcus by an arterial subcutaneous composite flap

A depressed supratarsal sulcus can be filled by means of a soft-tissue arterial flap including subcutaneous tissue, galea, and periosteum. The donor site is the temporal region, and the flap is passed subcutaneously into the upper eyelid. The same type of flap can also be used as filling material in other situations, such as Treacher-Collins malar bone defects. The correction of a depressed supratarsal sulcus by anophthalmic orbits is to be done only after complete and careful adjustment of the eye prosthesis by the ocularist, or after adjustment of the socket itself.

Improved prosthetic motility following enucleation

Enucleation is the beginning of a long-term relationship between the ophthalmologist and the patient to provide a comfortable, cosmetically acceptable, anophthalmic socket. The ideal socket should have a low risk of implant extrusion, normal volume, and normal motility of the prosthesis. Aspheric motility implants provide good motility, but pressure points between implant and prosthesis may lead to discomfort or extrusion. Spherical volume implants minimize pressure between implant and prosthesis, but have been criticized for inability to transmit motility to the prosthesis. The authors describe a modification of the traditional sphere implant technique that provides improved motility, ease in prosthetic fitting, and a comfortable socket.

Magnetic orbital implants

Sixty-six consecutive cases undergoing enucleation with the insertion of the Roper-Hall magnetic implant at the Birmingham and Midland Eye Hospital (BMEH) were followed up to re-establish the rate of extrusion. It was possible to study the records of all 66 patients. An extrusion rate of 1.5% was found.

Management of the contracted eye socket

The approach to the surgical management of the contracted eye socket requires a good patient history and preliminary evaluation. Upon assessing the extent of socket contraction, the surgeon has at his disposal several procedures. For moderate socket contraction, a mucous membrane graft may be employed. For severe contraction, split thickness skin graft and a socket mold wired to the orbital rim is advocated. For the extruding or exposed implant, a dermal-far graft is recommended.

Complications associated with use of tantalum-mesh--covered implants

In 1948, ophthalmologists started implanting plastic spheres partially covered with tantalum mesh (eg, the Valley Forge Implant) in anophthalmic sockets. Numerous patients have developed complications ten to 15 years after surgery: pain ("pinching" or "deep"), headache, heavy mucopurulent discharge and diffuse conjunctival inflammation, migration of the implant, thinning or erosion of tissues covering the implant (extrusion), and inability to wear an artificial eye. Management includes refabrication of the artificial eye and replacement of the implant with a dermis-fat graft or a silicone ball plus scleral graft. Tantalum-mesh--covered orbital implants should probably not be used.

An immunopathologic study of giant papillary conjunctivitis associated with an ocular prosthesis

A 21-year-old woman, whose left eye had been enucleated when she was 2 years old, developed giant papillary conjunctivitis and experienced ocular discomfort and increased tearing when she wore her prosthesis. Cultures grew normal flora, and topical antibiotics failed to relieve her symptoms. Immunopathologic studies of a conjunctival biopsy specimen disclosed plasma cells of all five classes of immunoglobulins in the substantia propria and many IgE-containing cells. Russell bodies found in some of the plasma cells were of the IgM and IgG types. The patient was treated with a 2% solution of cromolyn sodium, applied four times a day. Within one month, her symptoms had resolved, there was less conjunctival congestion, and the papillae were much less prominent. Our findings suggested that there may be a heterogenous humoral response in giant papillary conjunctivitis along with a strong immediate (Type I) hypersensitivity component.

The use and fate of fascia lata and sclera in ophthalmic plastic and reconstructive surgery

The introduction and use of newer surgical materials, better surgical instruments, finer suture materials, and improved optical equipment have allowed us to advance certain techniques in ophthalmic surgery and ophthalmic plastic surgery. In oculoplastic surgery, fascia lata and sclera are but a few of these materials used with greater frequency. In this paper, a number of techniques are described depicting the use of fascia lata and sclera. A histologic study of these materials after variable periods of implantation is presented.

Artificial eyes and tear measurements

Ninety-four consecutive persons with unilateral enucleations or eviscerations were tested by the Schirmer I and Schirmer II tests for tear production. The findings on the artificial eye were compared with those on the companion, living (control) eye. The collected data were subjected to statistical analysis. The control eyes were shown to respond in the normal manner, more tears without topical anesthetic than with it. The sockets of artificial eyes produced no more tears without anesthetic than with it. The control eyes produced a normal amount of reflex tears, whereas the sockets of many artificial eyes produced practically no reflex tears. Tear production in persons with no complaints was compared to those with noteworthy problems. Persons with problems had only half as much basic tear secretion as those without problems. Elimination of the stimulus to reflex tear production by removal of the cornea and by the presence of the prosthesis is suggested as the cause of dryness of the eye socket. The potential value of aqueous or oily artificial lubricants is mentioned.

Giant papillary conjunctivitis with ocular prostheses

In seven patients who each had either a methyl methacrylate corneal shell, a postenucleation ocular prosthesis, or a keratoprosthesis, giant papillary conjunctivitis of the tarsus of the upper lids developed after prolonged wear. These cases expand the spectrum of disease that was initally described in wearers of hard and soft contact lenses. The papillary changes in prostheses wearers did not always produce symptoms and were not readily reversible. Basophils and mast cells characterized the inflammatory infiltrate, suggestng an antigen-antibody mechanism underlying the response. Increased production of epithelial mucin, in contrast to goblet cell mucin, may play a role in producing symptoms in this syndrome.