Standardized clinical evaluation of dry anophthalmic socket syndrome in a real-world approach

PURPOSE

To assess which signs and eye prosthesis care habits are related to subjective discomfort in patients with dry anophthalmic socket syndrome (DASS), using standardized tools from daily practice.

METHODS

62 anophthalmic sockets were compared with their healthy fellow eye using the Standard Patient Evaluation of Eye Dryness (SPEED) score. The correlations between SPEED questionnaire and the prosthesis care, discharge characteristics score, conjunctival inflammation score, meibomian gland dysfunction (MGD) scores and Schirmer I test were studied.

RESULT

The anophthalmic sockets group achieved a higher SPEED test score (p < 0.01), discharge score (p < 0.01), conjunctival inflammation score (p < 0.01), MGD scores (p < 0.01) and lower Schirmer I test (p < 0.01) compared with their fellow, healthy eye. Patients with a prosthesis replacement of one year or less, those with a current fit time of one year or less and those with a cleaning frequency above one month reported better SPEED, (p < 0.01), conjunctiva inflammation (p < 0.01) and MGD scores (p < 0.01).

CONCLUSION

Most anophthalmic patients suffer mild to severe DASS, which seems related to discharge, conjunctival inflammation and MGD. Moreover, certain practices related to the care of the prosthesis such as replacing with a frequency lower than yearly, current fitting time inferior to one year and a removing and cleaning regime above one month, were related to a lower discomfort sensation, conjunctival inflammation and MGD. Clinicians should consider the DASS when facing patients with anophthalmic socket and discomfort symptoms.

Burnishing of exposed porous polyethylene orbital implant: is it useful?

OBJECTIVE

To describe and report the surgical outcomes of the burnishing technique for exposed porous polyethylene (PP) orbital implants.

METHODS

A retrospective review of consecutive patients who underwent repair of an exposed PP orbital implant at Hong Kong Eye Hospital and Queen Elizabeth Hospital, Hong Kong, between January 2002 and April 2022 was conducted. Exposed PP orbital implants were burnished with an electric drill. The exposed area was then covered by a donor scleral graft followed by conjunctival wound closure. Patients with a shallow lower eyelid fornix would undergo additional fornix deepening procedures that mobilize the conjunctiva and provide adequate coverage of the implant.

RESULTS

Six patients who had exposed PP orbital implants following enucleation (n = 4) and evisceration (n = 2) underwent repair. Five of the six patients did not experience any recurrence at an average follow-up of 25 months (range, 7-42 months). One patient who suffered from endophthalmitis experienced orbital implant re-exposure 16 months after the revision was managed by reimplantation of an acrylic implant and wrapping with both donor scleral graft and dermis fat graft.

CONCLUSION

In conclusion, we described a burnishing technique for repairing exposed PP orbital implants. Our technique is effective in preventing implant re-exposure and is easy to perform.

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.

Longitudinal Comparison of Orbital Volumes from Enucleated Eyes with Hydroxyapatite Orbital Implant in Unilateral Retinoblastoma Patients

PURPOSE

To compare the orbital volume between enucleated and contralateral, uninvolved orbits over a 5-year period in patients with unilateral retinoblastoma who underwent enucleation with hydroxyapatite (HA) implant placement by a single surgeon.

METHODS

A retrospective review was performed on the clinical records and radiographic images of unilateral retinoblastoma patients who underwent enucleation with primary HA implantation from 2003 to 2020 at a single institution. Bilateral orbital volume measurements were taken from the initial postoperative MRI scan and again at 1- and 5-years postenucleation. The main outcome measure was the longitudinal change in volume difference (∆𝑉). The implant size, age at enucleation, and sex were also evaluated. A linear mixed-effect model was used for analysis.

RESULTS

A total of 124 patients (73 males) with HA implants following enucleation were included. Overall, the unaffected orbit trended toward having a greater volume compared with the enucleated orbit, but this was not statistically significant (β = 0.003; p = 0.122). The mean age at enucleation was 2.4 years. The median time between enucleation and the initial, 1-year, and 5-year postoperative MRIs was 6 months, 17 months, and 55 months, respectively. There was no statistical correlation between age at enucleation, gender, implant size, or orbital volume at any time points ( p > 0.05).

CONCLUSIONS

Patients treated with enucleation and primary HA implant placement for unilateral retinoblastoma did not display significant asymmetry in orbital volume on 5-year postenucleation MRIs, suggesting that HA implants promote orbital growth comparable to a nonenucleated orbit in the pediatric population.

Clinical use of cryopreserved ultra-thick human amniotic membrane for anophthalmic socket contracture

PURPOSE

To study the use of ultra-thick human amniotic membrane for management anophthalmic socket contracture.

METHODS

A prospective study done at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. Thirty-six patients (45 eyelids) were involved. Contracted socket caused by trauma, previous surgery or radiotherapy, delay in use of prosthesis, Congenital Anophthalmia/Microphthalmia, and Anophthalmia secondary to Enucleation/Evisceration were included in the study.

RESULTS

Thirty-three patients (42 eyelids) underwent fornix reconstruction with cryopreserved ultra-thick human amniotic membrane. Mean ± SD age at surgery was (40.90 ± 17.32) years. Mean follow up was 10.5 months. Grade II fornix contracture was the most common type in 23 (54.8%) eyelids. The most common involved primary diagnosis was Anophthalmia secondary to Enucleation/Evisceration (n = 13). The incidence of pyogenic granuloma (PG) after surgery was seen in 8 eyelids (19.0%).

CONCLUSION

Anophthalmic contracted socket secondary to significant history of multiple PG excision (> 5 times) and secondary to enucleation/evisceration were associated with good surgical outcome. Cryopreserved ultra-thick human amniotic membrane is an ideal material for the management of anophthalmic socket contracture.

Factors affecting anophthalmic socket reconstruction outcomes using autologous oral mucosal graft

BACKGROUND

Limited studies have reported surgical outcomes that are defined by strict criteria following grade 2 or 3 socket reconstruction using an oral mucosal graft (OMG). We aimed to determine factors influencing surgical outcomes of anophthalmic socket reconstruction using OMG in patients with grade 2 or 3 socket contractures.

METHODS

Thirty-seven patients who underwent socket reconstruction with autologous OMG between January 2007 and December 2017 were retrospectively analyzed. The successful outcome was defined as an eye prosthesis wearing without experiencing displacement and the absence of any re-operations or additional surgeries following socket reconstruction. Factors affecting surgical outcomes were identified using multivariate analysis.

RESULTS

A total of 15 male and 22 female patients (mean age: 40.2 ± 17.2 years) were included. The median duration of socket contracture was 21.5 years. Grade 2 and 3 socket contractures, based on Tawfik's classification, were reported in 20 and 17 patients, respectively. Twenty-eight and eight patients underwent socket reconstruction using OMG alone and OMG combined with a hard palate graft, respectively. The success rates of grades 2 and 3 socket contracture reconstruction were 80.0% and 52.9%, respectively. Multivariate analysis demonstrated that only grade 3 contractures were predictive of worse outcomes. At the final visit (mean follow-up: 6.3 years), 34 patients (91.9%) could wear their eye prostheses.

CONCLUSIONS

Socket reconstruction using autologous OMG can provide acceptable results in grade 2 and 3 contractures; however, satisfactory results were more significantly reported in grade 2 than in grade 3 contractures.

Chronic anophthalmic socket pain in the setting of deep orbital pseudocysts

An 89-year-old woman presented with chronic pain and foreign body sensation in a healthy-appearing anophthalmic socket. Computed tomography of the orbits showed hyperdense, cystic lesions superior and posterior to the orbital implant. Orbital exploration was performed; the orbital implant and lesions were removed. Histopathology revealed cystic structures composed of fibrocellular tissue lined with histiocytes and multinucleated giant cells, consistent with pseudocysts. Postoperatively, the patient noted the resolution of her symptoms. While the etiology of the pseudocysts remains unclear, we hypothesize that the answer can be traced back to the original surgery. The cysts may have formed after extravasation of fluid or proteinaceous material from the eye, from glycerin on the donor sclera, or after introduction of foreign material during retrobulbar injection of local anesthesia. This is the first report of pseudocysts occurring in the orbit posterior to an implant.

Infection of a Nylon Foil Orbital Implant Due to Fusarium brachygibbosum and Lomentospora prolificans After Intranasal Methamphetamine Use

The authors describe a case of nylon foil implant infection caused by Fusarium brachygibbosum , and Lomentospora prolificans following medial orbital wall fracture repair in the setting of postoperative nasal methamphetamine use. A 61-year-old male presented with OS pain and swelling after a physical assault on his face. A CT of maxillofacial bones without contrast showed a moderately comminuted fracture of the medial wall of the left orbit with depression of fracture fragments into the left ethmoid air cells. Six days after repair of the medial wall fracture, the patient returned with a new onset headache, OS pain, and swelling to the left medial canthal area. He reported snorting methamphetamine approximately 48 hours before his current presentation. CT imaging showed fat stranding and soft tissue density in the extraconal space adjacent to the left medial rectus muscle and chronic fracture deformity of lamina papyracea with approximately 4 mm of medial displacement of the fracture fragments. The patient showed little clinical improvement after 48 hours of intravenous antibiotics, which led to the removal of the nylon foil implant by a left orbitotomy. Intraoperative tissue cultures grew coagulase-negative Staphylococcus , F. brachygibbosum , and Lomentospora (Scedosporium) prolificans . The patient was subsequently transitioned to oral clindamycin 600 mg three times daily and voriconazole 200 mg two times daily. To the authors' knowledge, this is the first case report to document an association between snorted methamphetamine and a fungal infection of an orbital implant.

Socket outcomes following enucleation for uveal melanoma: post enucleation socket syndrome can be challenging

PURPOSE

To evaluate socket outcomes of enucleation for uveal melanoma.

METHODS

This study was a retrospective chart review conducted in December 2022 of all patients who underwent enucleation surgery for uveal melanoma between 2010 and 2015 in the Royal Victoria Eye and Ear Hospital, to evaluate socket outcomes including completion of revision surgery, type of surgery, and completion of multiple revision surgeries, and potential associations.

RESULTS

Between June 2010 and December 2015, 72 patients underwent enucleation for uveal melanoma in the ocular oncology service, including 25 females and 47 males, mean age 65, range 11-91 years old. There were 68 primary enucleations and 4 secondary enucleations. Complete follow-up data was available for mean 4 years, range 1-11 years. Fourteen patients underwent further surgery, including one exenteration for local recurrence. Oculoplastic surgery (n = 6, 8%), implant exposure repair (n = 3, 6%), and orbit volume expanding surgery (n = 4, 6%) were also performed. Eight patients (11%) underwent one further surgery and five patients (7%) underwent a series of procedures. There was a significant association with younger age at enucleation (age <65) with undergoing further surgery (p = 0.03, Fisher's Exact Test (FET)), and also an association of younger age with undergoing multiple further surgeries (p = 0.02, FET). There was no association found with other predictor variables, including primary versus secondary enucleation status. Most patients (75%) with PESS underwent more than one surgery.

CONCLUSION

Post enucleation surgery 82% of patients did not undergo further surgery, but younger patients were more likely to undergo anophthalmic socket revision or oculoplastic surgery. Management of post enucleation socket syndrome was challenging and usually involved a series of procedures.

Novel use of an autologous scleral button graft to close the anterior defect in evisceration surgery

PURPOSE

To present an alternative evisceration technique with long-term follow-up data. This technique involves the insertion of an acrylic implant into a modified scleral shell which is closed using an autologous scleral graft.

METHODS

This was a retrospective analysis of eviscerations performed in a district-general hospital in the UK. All patients underwent conventional ocular evisceration after total keratectomy. A full thickness scleral graft is harvested from the posterior sclera, using an internal approach, with an 8 mm dermatological punch. An 18-20 mm acrylic implant is placed into the shell, and the scleral graft is used to close the anterior defect. Demographic characteristics, implant size and type, and cosmetic results from pictures of all patients were recorded. All patients were invited for a review to measure motility, eyelid height, patient recorded satisfaction and complications.

RESULTS

Of the five patients identified, one had since died. The remaining four attended a review in person. The mean time between surgery and review was 48 months. The mean implant size was 19 mm. There were no cases of implant extrusion or infection. All four had a <1 mm asymmetry in measured eyelid height and ≥5 mm horizontal gaze motility. All patients self-reported "good" cosmesis. An independent assessment identified "mild asymmetry" in two cases and "moderate" in the other two.

CONCLUSION

Evisceration with this novel autologous scleral graft technique restores volume in the anterior orbit with good cosmetic results, and with no cases of implant exposure reported in this small case series. This technique should be compared prospectively to established techniques.

Clinical and histopathological study of a hollow and posteriorly multiperforated polymethylmethacrylate implant in eviscerated rabbit eyes

PURPOSE

The study aimed to evaluate the clinical and tissue response to a hollow polymethylmethacrylate orbital implant with a multiperforated posterior surface in an animal model after evisceration.

METHODS

Sixteen New Zealand rabbits had their right eye eviscerated. All animals received a hollow polymethylmethacrylate implant 12 mm in diameter that is multiperforated in its posterior hemisphere. The animals were divided into four groups, and each one had the eye exenterated at 7, 30, 90, and 180 days post-evisceration. Clinical signs were assessed daily for 14 days post-evisceration and then every 7 days until 180 days. Inflammatory pattern, collagen structure, and degree of neovascularization generated with implant placement were analyzed with hematoxylin-eosin, picrosirius red, and immunohistochemistry staining.

RESULTS

There were no signs of infection, conjunctival or scleral thinning, or implant exposure or extrusion in any animal during the study. On day 7, the new tissue migrated into the implant and formed a fibrovascular network through the posterior channels. Inflammatory response reduced over time, and no multinuclea-ted giant cells were found at any time.

CONCLUSION

Hollow polymethylmethacrylate orbital implants with a multiperforated posterior surface enable rapid integration with orbital tissues by fibrovascular ingrowth. We believe that this orbital implant model can be used in research on humans.

An Ex Vivo Pilot Study to Assess the Feasibility of 3D Printing of Orbital Implants in Horses

Severe ophthalmic conditions such as trauma, uveitis, corneal damage, or neoplasia can lead to eye removal surgery. Poor cosmetic appearance resulting from the sunken orbit ensues. The aim of this study was to demonstrate the feasibility of manufacturing a custom-made 3D-printed orbital implant made of biocompatible material for the enucleated horse and usable in conjunction to a corneoscleral shell. Blender, a 3D-image software, was used for prototype design. Twelve cadaver heads of adult Warmbloods were collected from the slaughterhouse. On each head, one eye was removed via a modified transconjunctival enucleation while the contralateral eye was kept intact as control. Ocular measurements were collected on each enucleated eye with the help of a caliper and used for prototype sizing. Twelve custom-made biocompatible porous prototypes were 3D-printed in BioMed Clear resin using the stereolithography technique. Each implant was fixated into the corresponding orbit, within the Tenon capsule and conjunctiva. Heads were frozen and thin slices were then cut in the transverse plane. A scoring system based on four criteria (space for ocular prosthesis, soft-tissue-coverage, symmetry to the septum, and horizontal symmetry), ranging from A (proper fixation) to C (poor fixation), was developed to evaluate implantation. The prototypes reached our expectations: 75% of the heads received an A score, and 25% a B score. Each implant cost approximately 7.30€ and took 5 hours for 3D-printing. The production of an economically accessible orbital implant made of biocompatible porous material was successful. Further studies will help determine if the present prototype is usable in vivo.

Foldable capsular vitreous body indications, complications, and outcomes: a systematic review

PURPOSE

Foldable capsular vitreous body (FCVB) is an emerging vitreous substitute that has been recently introduced to treat various advanced vitreoretinal conditions including severe ocular trauma, complicated retinal detachment (RD), and proliferative vitreoretinopathy.

METHODS

Review protocol was prospectively registered at PROSPERO (CRD42022342310). A systematic literature search using PubMed, Ovid MEDLINE, and Google Scholar for articles published until May 2022 was performed. The search included the following keywords: foldable capsular vitreous body, FCVB, artificial vitreous substitutes, and artificial vitreous implants. Outcomes included indications of FCVB, anatomical success rates, postoperative intraocular pressure (IOP), best-corrected visual acuity (BCVA), and complications.

RESULTS

A total of 17 studies that utilized FCVB up to May 2022 were included. FCVB was used intraocularly as a tamponade or extraocularly as a macular/scleral buckle for various retinal conditions including severe ocular trauma, simple and complex RD, silicone oil-dependent eyes, and highly myopic eyes with foveoschisis. FCVB was reported to be successfully implanted in the vitreous cavity of all patients. Final retinal reattachment rate ranged from 30 to 100%. Postoperative IOP improved or was maintained in most eyes, with low postoperative complication rates. Improvement in BCVA ranged from 0 to 100% of subjects.

CONCLUSION

Indications of FCVB implantation have recently widened to include multiple advanced ocular conditions such as complex RD, but also include simpler conditions as uncomplicated RD. FCVB implantation showed good visual and anatomical outcomes, few IOP fluctuations, and a good safety profile. Larger comparative studies are required to further evaluate FCVB implantation.

Quality of life and psychological evaluation of patients after anaplastology

A comprehensive questionnaire with 43 questions was designed to evaluate quality of life, based on rehabilitation with a facial prosthesis. Each patient's psychological situation was assessed using the validated questionnaire and associated scales. Different patient groups were compared with each other in terms of questionnaire scores and general data. In total, 76 patients with a prosthesis of the orbit, nose, or ear, or a combination thereof, were included. There was a highly significant difference in overall satisfaction with defect reconstruction via a prosthesis of the ear compared with the orbit and nose (F(3) = 6.511, p = 0.001). Patients with congenital defects showed a significantly higher level of general satisfaction compared with patients with acquired defects (F(2) = 5.795, p = 0.001). Patients who returned to work were significantly more satisfied with their quality of life (T(57) = 2.626, p = 0.011). With regard to improvements to the state-of-the-art prostheses, the majority of patients suggested better retention, more durable colors, make-up possibilities, less noticeable margins, softer materials, and a movable orbital prosthesis. Within the limitations of the study it seems that facial epitheses improved mental wellbeing and increased quality of life among patients with facial defects. Multiple factors, such as type of facial defect, location of residence, and education can have a potential influence on the quality of life of affected patients. However, further studies are needed, since the psychological and social challenges remain.

Surgical outcomes of orbital evisceration with primary orbital implant placement in patients with endophthalmitis

OBJECTIVES

This study reports the surgical outcomes of evisceration with primary orbital implant placement in patients with endophthalmitis and analyses the association with implant exposure and extrusion.

METHODS

A retrospective, multicentre, Chinese cohort study. Review of medical records and orbital images of patients who underwent evisceration with primary orbital implant placement between January 2005 and January 2021.

RESULTS

Out of 79 patients who underwent orbital evisceration with primary orbital implant placement, 26 (26 eyes) of them (male = 13) suffered from endophthalmitis. The duration from endophthalmitis diagnosis (19 = exogenous, 7 = endogenous) to evisceration was 9 standard deviation ± 5 (range: 1-15) days. The follow-up was 70 ± 46 (24-180) months after operation. The orbital implant size was 17 ± 3 (14-20) mm, and silicone was the most used material (69%, 18/26 of patients). The most frequent post-operative complication was orbital implant exposure (42%, 11/26), followed by orbital implant extrusion (12% 3/26) and ptosis (8%, 2/26). Implant exposure or extrusion was more commonly associated with endophthalmitis in comparison to non-endophthalmitis patients that required evisceration and primary orbital implant placement (54% versus 17%, P < 0.05). Univariate analysis showed single scleral closure technique (100% versus 58%, P < 0.05) and endogenous endophthalmitis (50% versus 0%, P < 0.05) were associated with implant exposure or extrusion, and only endogenous endophthalmitis was significant with multivariate analysis (P < 0.05).

CONCLUSIONS

Primary implant placement during evisceration should be avoided in eyes with endophthalmitis especially in those with an endogenous source, and double scleral closure technique may be a better alternative for primary orbital implant placement in infected eyes.

[Evisceration, enucleation and exenteration-Indications, techniques, and postoperative care]

Various surgical techniques are available for the extirpation of an eye, depending on the underlying disease. Typical indications encompass tumors, inflammatory and infectious processes, glaucoma, trauma as well as congenital malformations. Surgical procedures include evisceration (resection of the intraocular space with preservation of the sclera), enucleation (extirpation of the entire eyeball including sclera and cornea) and exenteration (resection of the complete orbital soft tissue). The early detection of postoperatively manifesting complications, such as implant extrusion, conjunctivitis, postenucleation socket syndrome as well as the development of enophthalmus or ptosis, is of particular relevance in the context of postoperative care regarding functional, esthetic and social outcome. Special attention must be paid to ensuring a complication-free rehabilitation process, including the supply of a suitable, precisely fitting prosthesis or epithesis. This ensures the patient's psychosocial reintegration, in which an integrated interdisciplinary cooperation with ocularists and psychologists is essential. The latter play a particularly important role, as the psychological stress resulting from the procedure is often associated with a considerable reduction in the quality of life.

Mechanical behavior of 3D-printed PEEK and its application for personalized orbital implants with various infill patterns and densities

This study proposed a 3D-printed PEEK with a specific design to restore the damaged orbit shape. Such printed personalized implants are greatly affected by the process parameters, wherefore the effects of the nozzle temperatures, printing speed and layer thickness on the tensile properties were investigated based on the Taguchi approach. The optimal mechanical properties, i.e., the tensile strength and Young's modulus, were found to be 54.97 MPa and 2.67 GPa, respectively. These properties were obtained by adjusting the nozzle temperature to its high level (450 °C), while the layer thickness (0.1 mm) and printing speed (20 mm/s) were set to their low levels. Secondly, the mechanical behavior of a personalized orbital implant with these optimized properties was evaluated via finite elements analysis with various infill patterns and densities, at three thicknesses: 0.3, 0.5 and 0.7 mm. It was found that all thicknesses were acceptable for the 100% filling. For the honeycomb pattern, the thicknesses 0.5 and 0.7 mm were satisfactory with a fill rate of 70% and 55% whereas only the thickness of 0.7 mm was suitable for the 40% filling. The honeycomb pattern with 40% filling and a maximum stress (7.186 MPa) and strain (0.00627 mm) should be beneficial for light-weight orbital implants.

Orbital Implants Receiving Food and Drug Administration Premarket Notification

PURPOSE

This perspective explores the Food and Drug Administration (FDA) 510(k) program, occasionally referred to as premarket notification, which facilitates faster marketing of Class II medical devices, such as orbital implants by demonstrating "substantial equivalence" to previously approved devices. This allows for FDA clearance, rather than FDA approval of orbital implants via comparison to currently marketed implants rather than clinically proven safety standards.

METHODS

Utilizing the FDA's publicly available 510(k) Premarket Notification database, we conducted a thorough search of FDA-cleared orbital implants dating back to the inception of the 510(k) process in 1976.

RESULTS

We found that 29 orbital implants received 510(k) FDA clearance between 1987 and 2022. Four of the 29 implants were recalled. Only 9 of 29 implants had available data on their predicate or comparison devices; of these 9, 3 implants received clearance based on devices that were subsequently recalled.

CONCLUSIONS

This investigation into premarket approval of orbital implants identifies a shortcoming in the FDA 510(k) approval process. Long-term implant-associated morbidity is difficult to predict during premarket analysis but is further complicated for 510(k) cleared implants since devices approved based on substantial equivalence to recalled devices may not be automatically recalled. Clinicians should be aware of the approval process for the devices they select, and review of the 510(k) process, especially as it applies to substantial equivalence to devices subsequently recalled is warranted.

Outcomes of evisceration or enucleation by resident trainees in patients with recalcitrant endophthalmitis or panophthalmitis

To evaluate the surgical outcomes and complications of evisceration or enucleation with primary implantation, performed by ophthalmology resident trainees, in regards to patients with recalcitrant endophthalmitis or panophthalmitis. We also compared the surgical outcomes and complications between resident trainees and experienced staff. In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The factors predicting implant exposure or extrusion in regards to patients who underwent eye removal by trainees were identified using multivariate analysis. The percentages of successful prosthesis fittings and complications were also reported. Sixty-six patient records, median age of 46.8 years, who underwent eye removal by resident trainees were reviewed. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = .02, adjusted odd ratio [aOR] = 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = .02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = .03, aOR 38.38). At the last visit, 65 patients had a successful prosthesis fitting. Furthermore, there were similar rates of complications and successful prosthesis fittings between experienced staff and resident trainees. This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications.

Modified procedure of anterior orbital exenteration enables eye socket reconstruction: A retrospective cohort study

The conventional procedure of anterior orbital exenteration is unfavorable for eye socket reconstruction, whereas a modified procedure enables socket reconstruction and prosthesis fitting. Our study aims to compare the cosmetic outcomes between these 2 surgical techniques.We retrospectively recruited patients treated with modified or conventional exenteration during January 2015 to May 2021 in our hospital. The conventional approach was performed along with dermis-fat graft transplantation. The modified approach was conducted followed by eye socket reconstruction and eyelid blepharoplasty. The clinical data were collected and analyzed, including demographics, tumor characteristics, postoperative complications, tumor-related events, and cosmetic outcomes.Forty-nine patients were consecutively recruited in this study, including 22 cases of modified exenteration and 27 cases of conventional exenteration. Forty-four subjects (89.8%) were diagnosed with ocular surface malignancies (conjunctival melanoma and squamous cell carcinoma) and 5 subjects (10.2%) were diagnosed with extraocular stage of uveal melanoma. After follow-up for 31.8 ± 17.1 months, the 1-, 2-, 5-year overall survival rate was calculated as 100%, 79.2%, and 59.2% in the Modified group, and 94.2%, 73.8%, and 51.5% in the Conventional group. Comparison of the survival curves showed no significant differences. In the Modified group, all patients received orbital implant placement and eye socket reconstruction. The implant motility was satisfactory in 12 cases (54.5%) with movements in 3 to 4 directions. The eyelid function was acceptable in 17 cases (77.3%) with no entropion, ectropion or lower lid laxity. Ocular prosthesis was delivered in 17 cases (77.3%) with successful fitting in 11 cases (64.7%). The self-rated cosmetic score was statistically (t test, P < .0001) higher in the Modified group (6.7 ± 0.9) than the Conventional group (2.2 ± 0.4).The modified approach to anterior orbital exenteration enables eye socket reconstruction and cosmetic rehabilitation while still preserves the curable chance for the treatment of advanced periocular/intraocular malignancies.

Reconstruction for diverse fronto-orbital defects with computer-assisted designed and computer-assisted manufactured PEEK implants in one-stage operation: Case reports

RATIONAL

Reconstruction of complex craniofacial defects in fronto-orbital region has been reported to be extremely few. In this study, we report 2 cases with fronto-orbital defects of different etiologies in one-stage surgical reconstruction with polyetheretherketone (PEEK) prosthesis using computer-assisted design and computer-assisted manufactured (CAD-CAM) techniques.

PATIENT CONCERNS

One patient was a 49-year-old man, who admitted with a depressed and comminuted fracture in the left fronto-orbital region as a result of a motor vehicle collision. The other patient was a 45-year-old woman who was hospitalized with an unexpected diagnosis of a fronto-orbital bone tumor during a head CT examination in a minor traumatic brain injury. None of them had a significant past medical history.

DIAGNOSES

The first patient's head computed tomography (CT) showed multiple depressed comminuted fractures in the right fronto-orbital region with localized frontal lobe contusion, and the diagnosis was clear when combined with the mechanism of traumatic head injuries. The second patient's head CT and magnetic resonance image suggested a right lateral orbital neoplastic lesion that distorted peripheral bone, the postoperative pathological examination demonstrated an osteoma with fibromatous hyperplasia, and thus the women's diagnosis was confirmed.

INTERVENTIONS

A three-dimensional image of both patients' skull bone were collected from a high-resolution CT. A virtual surgical planning for lesion excision and defect remodeling based on CAD-CAM techniques was undertaken, and than the reconstruction surgery was performed in a single procedure using PEEK prosthesis. Antibacterial treatment was prescribed routinely.

OUTCOMES

Postoperatively, both patients achieved excellent aesthetic restoration as well as functional recovery of the orbital cavity without neurological or infectious complications during an average 22 months follow-up.

LESSONS

The CAD-CAM PEEK implants could be a preferred option for reconstruction of patients with various complex fronto-orbital defects.

Orbital Bony Reconstruction With Presized and Precontoured Porous Polyethylene-Titanium Implants

PURPOSE

Complex bony orbital defects are reconstructively challenging due to loss of intraoperative anatomical landmarks and adjacent support. Presized and precontoured porous polyethylene-titanium implants (Medpor Titan 3D Orbital Floor Implant) are designed to reestablish normal orbital floor and medial wall anatomy and are modeled after anatomically averaged orbits. This is the first study to report clinical outcomes with this implant.

METHODS

This retrospective case series reviewed clinical data and outcomes for patients undergoing orbital reconstruction with a presized and precontoured porous polyethylene-titanium orbital implant from January 2016 to June 2018.

RESULTS

A total of 34 orbits of 33 patients were identified (mean age: 43 ± 16 years, 70% men). Most bony defects were a result of trauma and included large orbital floor deformities (100%), medial wall defects (74%), disrupted inferomedial struts (68%), and broken posterior ledges (82%). Symptomatic diplopia (73%) and enophthalmos (89%, mean: 3.7 ± 2.1 mm) were common preoperatively. Many cases were revisions (44%). Mean follow up was 7.8 ± 6.7 months. All patients had improved globe positioning, enophthalmos, and hypoglobus. Seven patients had persistent postoperative diplopia: 6 responded to prism therapy and 1 required strabismus surgery. One patient required retrobulbar hematoma drainage and 1 patient required implant explantation due to chronic infection.

CONCLUSIONS

Commercially available presized and precon toured porous polyethylene-titanium implants are useful for complex orbital bony defects and can achieve functional improve ments in diplopia, enophthalmos, and extraocular motility with a low incidence of postoperative complications or revisional surgery.

Spectacle Cord-retained Oculo-Orbital Prosthesis

Retention of an orbital prosthesis plays a key role in treatment success and patient acceptance as does aesthetics. Though numerous retentive aids are available such as implants, adhesives, etc, the cost, surgical aspect, difficulty of use and allergic potential may compromise efficiency. This report describes the case of an 11-year post-enucleation poor retinoblastoma patient, in whom an unfavourable defect leads to a major prosthetic challenge (from point of view of retention and camouflage). This report describes a simple, economical, and user-friendly approach to obtain satisfactory retention and camouflage for such patients with spectacle cords and customised spectacles. Key Words: Oculo-orbital prosthesis, Spectacle, Cord.

Subconjunctival enucleation with orbital implant placement in standing horses: 20 cases (2014-2017)

OBJECTIVE

To develop a protocol for subconjunctival enucleation and orbital implant placement in standing horses and to document short- and long-term complications, cosmesis, and client satisfaction.

ANIMALS

20 horses with nonneoplastic ocular disease requiring enucleation.

PROCEDURES

A standardized protocol of surgical suite cleaning, patient preparation, sedation, local nerve blocks, surgical procedure, and postoperative care was performed. Owners were required to provide follow-up information at 1 year after surgery during a phone questionnaire. Additionally, some owners provided follow-up information at 1.8 to 4 years postoperatively.

RESULTS

11 mares, 6 geldings, and 3 stallions with a mean age of 9 years (range, 0.5 to 25 years) were included in this study. Reasons for enucleation included corneal lacerations (n = 3), perforated ulcers (4), end-stage uveitis (7), fungal keratitis (3), endophthalmitis (1), glaucoma (1), and stromal abscess (1). The mean surgery time was 64 minutes (range, 50 to 83 minutes). The most common implant size used was 45-mm diameter (range, 43- to 47-mm diameter). Complications included mild postoperative colic (n = 4), incisional swelling (1), and drainage from the surgical site (1) that resolved without implant removal. One-year follow-up information was available for 19 of 20 horses. Fourteen owners were very satisfied and 5 owners were satisfied with the cosmetic appearance. One horse was lost to follow-up.

CONCLUSIONS AND CLINICAL RELEVANCE

Subconjunctival enucleation and orbital implant placement in standing horses was a safe and efficient alternative to general anesthesia when a standardized perioperative protocol was used. No horse developed clinically relevant complications, and owner satisfaction and cosmesis were good.

Surgical Outcomes of Orbital Fracture Reconstruction Using Patient-Specific Implants

PURPOSE

Patient-specific implants (PSIs) are known to yield reliable outcomes in orbital wall fracture reconstruction (high precision, smoother operating techniques, and shorter surgical duration). This study analyzed the surgical error and clinical and esthetic outcomes of orbital reconstructions with PSIs.

METHODS

This ambispective cohort study enrolled patients who underwent orbital reconstruction using PSIs between October 2016 and January 2018. The study end points were surgical error, indication and duration of surgery, long-term sequelae, revision surgeries, and surgical complications. Surgical error was analyzed by superimposing the postoperative implant position onto the preoperative virtual plan. Both qualitative (heat map) and quantitative (distance) measurements were obtained.

RESULTS

Three patients were enrolled prospectively, and 23 were enrolled retrospectively. Indications for surgery were defect size (25 patients), diplopia (10 patients), impaired eye motility (4 patients), and significant enophthalmos (6 patients). At the last patient visit, there were 5 cases of diplopia, 1 case of exophthalmos, and 6 cases of slight enophthalmos of incremental degree. In terms of surgical error, a mean distance of 0.6 mm (95% confidence interval, 0.49 to 0.76), with a mean maximal distance of 3.4 mm (95% confidence interval, 2.79 to 4.02), was noted. No revision surgery was necessary. Lid malposition complications were not observed. However, 1 case each of symblepharon and scleral show were observed. No time-saving component was observed.

CONCLUSIONS

PSI use in orbital reconstruction guarantees a preplanned 3-dimensional anatomical shape with a mean surgical error of just 0.6 mm. Our clinical results were similar to those of other protocols; however, warranting a complex 3-dimensional anatomical shape also in large orbital fractures with a low mean surgical error is feasible by using PSIs.

Survival rate of disk and screw-type implants used for the retention of extraoral prostheses

STATEMENT OF PROBLEM

Implant-supported and implant-retained extraoral prostheses are reliable treatment options for patients with craniofacial defects. They provide stable retention and therefore enhance the patient's appearance and quality of life. Despite studies on survival rates of extraoral implants, little attention has been paid to the design of the implants used to support and retain extraoral prostheses.

PURPOSE

The purpose of this longitudinal clinical study was to assess the long-term survival rate (1 to 12 years, mean 6 years) of 2 different designs of implants (disk: single, double, and triple and screw-type) used for extraoral epithesis anchorage.

MATERIAL AND METHODS

Twenty-six participants with orbital and nasal defects, 10 of whom had had radiation treatment, were included in the study. Disk implants and extraoral (EO) screw implants were used and placed in the periorbital (15 participants) and perinasal regions (11 participants). Data were analyzed by using the Chi-square test and the Fisher Exact test for qualitative variables and the Mann-Whitney U test for comparison of quantitative variables. Implant survival rates were calculated by Kaplan-Meier analysis.

RESULTS

The overall 12-year survival rate of all implants was 90.3% (mean=79 months), with 92.9% for nasal (mean=84 months) and 88.2% for orbital (mean=75 months) implants. Related to the implant design, survival rates were as follows: for single-disk implants, 90.2%; for double disks, 94.6%; for triple disks, 88.3%; and for screw implants, 83.3%. In nonradiated participants, the implant survival rate was 97.6%, and for radiated participants, 76.1%.

CONCLUSIONS

Survival rates for implant-retained craniofacial prostheses are limited. The nasal site seems to be a more predictable implant site than the orbital site, with a higher overall survival rate. Also, implants inserted in radiated tissues have lower survival rates for both anatomic sites, with statistically significantly lower results in the orbital region. The most reliable type of implant among the disk implants used was the double disk in the orbital site and the single disk in the nasal site, which may indicate the advantages of some designs in specific areas.

Proposal of a new diffractive corneal inlay to improve near vision in a presbyopic eye

A new class of diffraction-based corneal inlays for treatment of presbyopia is described. The inlay is intended to achieve an improvement of the near focus quality over previous designs. Our proposal is a two-zone hybrid device with separated amplitude and phase areas having a central aperture and no refractive power. An array of micro-holes is distributed on the surface of the inlay conforming a binary photon sieve. In this way, the central hole of the disk contributes to the zero order of diffraction, and the light diffracted by the micro-holes in the peripheral photon sieve produces a real focus for near vision. We employed ray-tracing software to study the performance of the new inlay in the Liou-Brennan model eye. The modulation transfer functions (MTFs) at the distance and near foci, and the area under the MTFs for different object vergences, were the merit functions used in the evaluation. The results were compared with those obtained with previous pure amplitude designs. Additionally, image simulations were performed with the inlays in the model eye to show the good performance of our proposal in improving the quality of the near vision.

Synergistic Effect of Copper-Containing Mesoporous Bioactive Glass Coating on Stimulating Vascularization of Porous Hydroxyapatite Orbital Implants in Rabbits

Rapid and complete vascularization of the porous orbital implants after enucleation is vital for reducing postoperative complications, such as exposure and infection. In this study, the porous hydroxyapatite (pHA) scaffolds modified with the mesoporous bioactive glass with and without adding copper (MBG, Cu-MBG) were prepared by sol-gel technique and followed by evaporation induced self-assembly (EISA) process. The macro-/microstructure analysis of the modified scaffolds (i.e., MBG/pHA, Cu-MBG/pHA) showed highly interconnected macropores, and unique mesoporous structures in the pore wall with higher surface area. A primary angiogenic test in a panniculus carnosus muscle model in rabbit indicated that the Cu-MBG coating was significantly beneficial for the vascularization in the porous architecture of the scaffolds in the early stage. These results suggest that the Cu-MBG modification provides a simple and effective strategy to endow favorable biological performances with pHA implants and greater potential for future application in orbit reconstruction.

Hard palate-dermis fat composite graft for reconstruction of contracted anophthalmic socket

Purpose: To describe a novel technique of using a hard palate-dermis fat composite graft (HPDFG) for reconstruction of a contracted anophthalmic socket. Methods: Retrospective, noncomparative, interventional case series of four patients who underwent HPDFG placement by one surgeon between 2010 and 2017. Results: Six harvested HPDFGs were placed in four patients with contracted anophthalmic sockets. A harvested hard palate graft (HPG) and a dermis fat graft (DFG) were adjoined with sutures to form a composite graft. All adhesions and symblephara between the eyelid and the anterior surface of the anophthalmic socket were lysed. The HPG component was attached to the tarsal margin to vertically lengthen the eyelid. The free edge of the DFG was sutured to the cut edge of the bulbar conjunctiva to simultaneously expand the anterior conjunctival surface area and fornix volume. The line of union between the two grafts formed the apex of the new fornix. Four HPDFG were used to reconstruct both the upper and lower lid fornices in two severely contracted sockets. Three patients received post-operative 5-fluorouracil (5-FU) injections. Three patients underwent additional revisions with buccal mucous membrane graft, amniotic membrane graft, full-thickness skin graft, pedicle flap, and dermal fillers. All four patients achieved excellent cosmesis and comfortable prosthesis fit. Conclusions: Composite HPDFG is an effective method of reconstructing a contracted anophthalmic socket by restoring volume, lengthening the posterior lamella, and expanding the fornix to allow for successful prosthesis retention. Adjunctive use of 5-FU injections can delay post-operative cicatrization.

Posterior auricular muscle patch graft for exposed orbital implant

The purpose of this article is to describe a surgical technique to repair an exposed orbital implant by posterior auricular muscle autograft. A retrospective review was conducted of four patients with an exposed orbital implant that were treated with a posterior auricular muscle graft. Four patients received posterior auricular muscle patch graft to the exposed orbital implant. The donor site healed with minimal scarring and remained well hidden. The graft incorporated fully into surrounding orbital tissue with no recurrent exposure at average of 13 month follow-up. The posterior auricular muscle autograft is a viable technique for repairing an exposed orbital implant.

Evisceration with autogenous scleral graft and bioceramic implantation within the modified scleral shell: 133 cases over 17 years

INTRODUCTION

To present long-term follow-up data on evisceration performed with autogenous scleral grafting and ceramic implantation in a modified scleral shell.

METHODS

This was a retrospective analysis of all consecutive eviscerations performed in the Department of Ophthalmology, Montpellier University Hospital, France, between February 1998 and October 2015. For all patients, the technique used was a conventional anterior evisceration after total keratectomy, disinsertion of the medial rectus muscle, sectioning of the optic nerve and excision of sclera centered on the papilla. The scleral graft was then sutured just behind the sutured keratectomy, and the bioceramic implant was inserted by posterior way in the scleral shell. Demographic characteristics, implant size and type, cosmetic results from pictures of all patients and complications were recorded. This study was performed with Ethics Review Committee Approval, and in compliance with the Declaration of Helsinki.

RESULTS

In total, 133 patients (36.6% women) were identified during the study period. The mean (SD) implant size was 17.32 (1.84) mm. The median follow-up after evisceration was 57.43 (24.7, 68.3) months. Two cases of implant exposure (1.5%) were recorded. For 24 patients (17.9%), additional surgeries were performed for ptosis (2.2%), conjunctival cyst (1.5%), or post-evisceration socket syndrome (6.7%). Cosmetics results were excellent for 50.1% of cases, good for 33.3% and fair for 16.6%; using a grading scale based on the superior sulcus deformity.

CONCLUSION

Evisceration with autogenous scleral grafting and ceramic implantation can result in a high volume of restoration, good cosmetic results, and low risk of exposure of the implant.

Low-cost three-dimensional printed orbital template-assisted patient-specific implants for the correction of spherical orbital implant migration

PURPOSE

To describe the outcomes of a patient-specific implant (PSI), fabricated using a three-dimensional (3D) printed orbital template and placed in the basin of the inferior orbital fissure to correct inferotemporally migrated spherical orbital implant.

METHODS

This is a single-center, prospective, consecutive, interventional, case series of six patients, with non-porous, spherical, orbital implant migration that underwent implant recentration surgically with a novel technique. Migration was subclassified either as decentration that did not affect the prosthetic retention or as displacement that affected the prosthetic retention in the eye socket. Only implant displacements were treated. The primary outcome measure was centration of the implant clinically and radiologically, with ability to retain the prosthesis.

RESULTS

At a mean follow-up of 21 months, all six orbital spherical implants remained centered. There were no cases of extrusion, exposure, or migration of either implants. There were no cases of PSI displacement. Additional procedures to optimize the aesthetic outcome of the customized ocular prosthesis (COP) required were simultaneous fornix formation suture in three patients, subsequent fornix formation with mucus membrane graft in two patients, and levator resection and sulcus hyaluronic acid gel injection in one patient each. The mean PSI implant weight was 2.66 ± 0.53 g. The mean COP weight was 2.2 ± 0.88 g postoperatively. The median patient satisfaction with the procedure was 9 on 10.

CONCLUSION

A 3D printing-assisted PSI placed in the basin of the inferior orbital fissure allows recentration of the migrated implant over a follow-up of 21 months without complications.

Autologous fat graft in irradiated orbit postenucleation for retinoblastoma

Autologous fat grafting has been extensively and successfully adopted in a number of pathologic conditions in regenerative surgery especially on irradiated fields in order to improve pain symptoms and tissue trophism promoting scar release. In the present study, we report our experience with autologous fat grafting for the treatment of postirradiation fibrosis and pain on three consecutive patients undergoing orbital enucleation for locally advanced retinoblastoma (RB) and subsequent radiotherapy. We selected three consecutive patients who underwent orbital enucleation for locally advanced RB and subsequent local radiotherapy showing severe reduction in orbital volume and eyelid length and retraction due to fibrosis, spontaneous local pain exacerbated after digital pressure with no possibility to place an ocular implant. They underwent autologous fat grafting in the orbital cavity and results were evaluated by clinical examination at 5 and 14 days, and 1, 3, 6 months, and 1 year after surgery. A significant release of scar retraction, reduction of fibrosis and orbital rim contraction together with an important improvement of pain symptoms was observed in all patients. The local changes observed enabled an ease placement of an ocular prosthetic implant (implant). No local or systemic complication occurred. Fat grafting is a promising treatment for patients showing radiotherapy related complication in the orbital area and it should be adopted by all oculoplastic surgeon in order to improve pain syndrome creating the ideal local conditions for the placement of an ocular prosthetic implant.

Anophthalmic Sockets in Retinoblastoma: A Single Center Experience

PURPOSE

To evaluate outcomes of anophthalmic sockets in retinoblastoma at a tertiary care center in Singapore.

DESIGN

A retrospective study.

METHODS

Patients who underwent enucleation as sole/part of treatment for retinoblastoma were reviewed at our center from 2005-2017. Details including demographics, grouping and staging, adjuvant therapy, surgery, implant, and complications were collected.

RESULTS

Of 42 patients with retinoblastoma managed over the period, the anophthalmic sockets of 31 patients who underwent enucleation were analyzed. Mean age at enucleation was 2 years. Twenty-three enucleations were performed at our institution and 8 enucleations had been performed elsewhere. Seventeen patients (52%) had porous polypropylene, 9 patients (27%) had polymethylmethacrylate, 1 patient (3%) had glass implant, and 3 (9%) had dermis fat graft. The sizes of implants varied from 10 to 20 mm. Twelve patients had attempts at globe salvation before enucleation. Out of 28 patients with primary orbital implants, 3 had implant exposure. The rates of repeat surgery among patients with and without primary implant were 66.67% (2 out of 3) and 10.7% (3 out of 28), respectively. One patient had postenucleation socket syndrome with stock eye. Five patients referred for enucleation were conservatively managed.

CONCLUSIONS

Anophthalmic sockets in retinoblastoma have long-term implications if the primary procedure is not performed well. While the majority had good outcomes (structural and esthetic), a minority had complications requiring intervention. Ophthalmologists managing retinoblastoma must be aware of these. Primary implant had favorable outcome with minimal complications.

A case series of anophthalmic socket cysts excised utilising fibrin sealant

Anophthalmic socket cysts are challenging to remove and incomplete excision has been shown to increase the risk of recurrence. This case series describes a novel technique utilising the fibrin sealant Tisseel (Baxter AG, Vienna, Austria) to retain the socket cyst integrity during surgical removal to facilitate its complete excision. Five patients were included and followed up for a minimum of 1 year, and there were no signs of recurrence in any of the cases. The surgical technique is described and illustrated. This technique is a safe way of simplifying challenging socket cyst surgery.

Orbital exenteration: Institutional review of evolving trends in indications and rehabilitation techniques

PURPOSE

To determine the changes in indications for orbital exenteration over 20 years and to assess its impact on patient survival. Evolving techniques of rehabilitation of the orbit in our institution were also evaluated.

METHODS

This was a retrospective review of hospital records of patients who underwent orbital exenteration from 1995 to 2015 in a tertiary care center. Data extracted included primary location of the tumor, preoperative treatments, interval between initial diagnosis and exenteration, status of surgical margins, presence of metastatic disease, and postoperative survival. The types of prosthesis utilized over the years were also reviewed. Cox regression analysis was performed for categorical variables. Kaplan-Meier analysis was used to estimate post-exenteration survival.

RESULTS

Over a 20-year period, orbital exenteration was performed on 100 orbits of 100 patients. The mean age was 39.4 years (range: 2 months to 90 years). The most common indications among 98 malignant causes were retinoblastoma, squamous cell carcinoma, basal cell carcinoma, extraocular extension of uveal melanoma, and conjunctival melanoma. Postoperative survival was significantly related to age and tumor location but independent from gender, surgical margin, histopathological diagnosis, previous treatment modality, and preoperative interval. In the whole cohort, 1-year and 5-year survival rates were 97% and 84%, respectively.

CONCLUSIONS

Exenteration appears to be life-saving in children with orbital extension of retinoblastoma. While patients exenterated for malignant eyelid tumors have the best chance of survival, those with orbital extension of uveal melanoma and adenoid cystic carcinoma of the lacrimal gland have the worst prognosis.

Primary Intraocular Malignant Rhabdoid Tumor Without Extrascleral Compromise

Primary intraocular malignant rhabdoid tumor is classified as a malignant extrarenal rhabdoid tumor. It is extremely rare, highly aggressive, and, so far, only one case (in a newborn) has been described in the medical literature. The authors report a second case of primary intraocular malignant rhabdoid tumor, this time without extrascleral involvement and in a teenager, and describe its histological, immunohistochemical, and radiological characteristics along with clinical correlations. [J Pediatr Ophthalmol. 2018;55:e7-e9.].

Complications of Hydroxyapatite Pegging: Comparison between Polycarbonate and Titanium Peg System

PURPOSE

Polycarbonate peg has been customarily used for pegging of hydroxyapatite for years. For better movement, tissue tolerance, and to decrease the complications of pegging, titanium peg system has been used. This study compares the two systems.

METHODS

Complications associated with pegging (polycarbonate: Bio-Eye or titanium: Dr-Perry new P-K) were retrospectively reviewed from the charts of 153 patients admitted to the Labbafinejad Medical Center, Tehran, Iran, for over 5 years from 1997 to 2003.

RESULTS

A total of 153 cases were studied. Ninety-six (62.3%) were male and 57 (37.7%) were female, and the mean age was 27.7 years (6-59 years). In 88 cases pegs were poly-carbonate and sleeve system and in 65 cases pegs were titanium. Forty-one (46%) of cases with polycarbonate and 18 (27%) of cases with titanium had at least one or more complications (p=0.018). The most common complications were granulation tissue, discharge, overgrowth of conjunctiva, and peg falling out in 25%, 23%, 13%, and 8% in polycarbonate peg and 15%, 5%, 1.5%, and 0% in titanium peg group. The prevalence of the last three complications was statistically lower in titanium peg compared with polycarbonate. Twenty-five cases (35%) with polycarbonate peg and 5 cases (7.5%) with titanium peg had two or more complications (p=0.03). Peg removal was done in 11 cases of polycarbonate but only two cases of titanium peg in order to treat the complication.

CONCLUSIONS

Both pegging systems had some complications, although these were less severe and prevalent in titanium peg. More studies on complications due to titanium pegs are recommended.

Self-retaining magnetic implant: A novel design of orbital prosthesis for the exenterated orbit

Orbital exenteration can lead to significant disfigurement causing considerable functional, cosmetic and psychological disturbances to the patient. Orbital prosthesis is important for the patient's cosmetic and psychological rehabilitation. A 49-year-old man received orbital exenteration and postoperative radiotherapy for malignant orbital carcinoma. In view of uncertain suitability and survival of osseointegrated implant in his case, a novel design of ocular implant consisting of a self-retaining magnetic spring retainer and a coupling silicone prosthesis was used. This novel design was shown to provide the patient with ease of use, good cosmetic outcome and better quality of life.

Comparison of primary and secondary enucleation for uveal melanoma

We investigated operative course and post-operative findings of patients undergoing primary enucleation for uveal melanoma versus those requiring secondary enucleation after brachytherapy. A retrospective chart review was performed with IRB approval on patients receiving treatment for uveal melanoma. Patients with enucleation as initial treatment and patients enucleated after plaque brachytherapy were analyzed for demographic data, operative course, and post-enucleation outcome. Further cause analysis for secondary enucleations was investigated. No significant difference was seen in age, laterality, or gender between the primarily enucleated (n = 54) and secondarily enucleated (n = 34) groups. Greater difficulty with surgery was noted in 28/32 (87.5%) of secondary enucleations compared to 1/54 (1.8%) of primary enucleations (p < 0.0001). Operative time was >2 hours in 3/51 (6%) of primary enucleations (vs. 8 of 32, 25%, p = 0.02). Average implant size was similar in the 2 groups (20.6 mm), however 2/34 (6%) of secondary enucleations required dermis fat grafting. Post-enucleation anophthalmic ptosis occurred after 8/49 (16%) of primary cases (vs. 13/30, 43%, p = 0.02) and prosthetic enophthalmos after none (0%) of primary cases (vs. 5/30, 17%, p = 0.006). Class 2 gene expression profile was found in 6/8 (60%) of eyes enucleated for treatment failure. Secondary enucleation performed after plaque brachytherapy was technically more difficult, and had more anophthalmic socket and eyelid complications compared to primary enucleation for uveal melanoma. Primary enucleation may avoid additional surgery and morbidity in a subset of patients with contraindications to plaque brachytherapy.

Patient-specific puzzle implant preformed with 3D-printed rapid prototype model for combined orbital floor and medial wall fracture

BACKGROUND

The management of combined orbital floor and medial wall fractures involving the inferomedial strut is challenging due to absence of stable cornerstone. In this article, we proposed surgical strategies using customized 3D puzzle implant preformed with Rapid Prototype (RP) skull model.

METHODS

Retrospective review was done in 28 patients diagnosed with combined orbital floor and medial wall fracture. Using preoperative CT scans, original and mirror-imaged RP skull models for each patient were prepared and sterilized. In all patients, porous polyethylene-coated titanium mesh was premolded onto RP skull model in two ways; Customized 3D jigsaw puzzle technique was used in 15 patients with comminuted inferomedial strut, whereas individual 3D implant technique was used in each fracture for 13 patients with intact inferomedial strut. Outcomes including enophthalmos, visual acuity, and presence of diplopia were assessed and orbital volume was measured using OsiriX software preoperatively and postoperatively.

RESULTS

Satisfactory results were achieved in both groups in terms of clinical improvements. Of 10 patients with preoperative diplopia, 9 improved in 6 months, except one with persistent symptom who underwent extraocular muscle rupture. 18 patients who had moderate to severe enophthalmos preoperatively improved, and one remained with mild degree. Orbital volume ratio, defined as volumetric ratio between affected and control orbit, decreased from 127.6% to 99.79% (p < 0.05) in comminuted group, and that in intact group decreased from 117.03% to 101.3% (p < 0.05).

CONCLUSION

Our surgical strategies using the jigsaw puzzle and individual reconstruction technique provide accurate restoration of combined orbital floor and medial wall fractures.

[Surgical correction of conjunctival sac narrowing after orbital implantation using polyester fiber heart patches]

OBJECTIVE

To test the feasibility of correcting conjunctival sac narrowing following orbital implantation using polyester fiber heart patches instead of the skin autograft.

METHODS

Twelve patients of conjunctival sac narrowing after orbital implantation (including 3 with orbital implant exposure) admitted in Nanfang Hospital between 2012 and 2016 received surgical correction of the conjunctival sac using polyester fiber heart patches. During the surgery, the central conjunctival sac was opened, the exposed area was covered with suitable polyester fiber heart patches, and the palpebral margin was sutured.

RESULTS

Three months after the operation, 10 patients showed improved appearance after implantation of the prosthetic eye. Two patients received a second operation to remove the patches due to graft rejection and infections and skin autograft was implanted for reconstruction of the conjunctival sac.

CONCLUSION

Polyester fiber heart patches are ideal materials for repairing Conjunctival sac narrowing and orbital implant exposure, but this approach is not suitable in cases of severe narrowing or occlusion of the conjunctival sac.