[Coexistence of unilateral retinoblastoma and Leber-Coats's disease in contralateral eye-case report]

PURPOSE

A case report of retinoblastoma and Leber-Coats' disease coexistence--two diseases which are very dangerous to the organ of vision.

MATERIAL AND METHODS

The paper presents a young patient who was sent to our Clinic at the age of 6 with very advanced unilateral retinoblastoma. He underwent enucleation of the eyeball as the initial treatment. Histopathological examination confirmed clinical diagnosis without infiltration of optic nerve or sclera. After 9 years of oncological observation there were characteristic changes for Leber's angiomatosis (temporo-inferior part of the retina) in another eye. Laserocoagulation of changes was performed twice.

RESULTS

During 14 years of observation there was no retinoblastoma recurrence. In the peripheral part of the retina in the only eye there is constant progression of vessel changes which are the sources of periodical preretinal bleeding. In the macular region there were extensive exudative changes which lifted the retina and caused the total secondary retinal detachment. Laser photocoagulation, cryopexy and steroid therapy were ineffective. Ultimately the patient's visual acuity at distance deteriorated to light perception.

[Attempts of orbit irradiation after enucleation of the eye with malignant choroidal melanoma. Part I]

PURPOSE

The problem of orbit irradiation after enucleation of the eye with choroidal melanoma is controversial. We have decided to analyse our own material in order to estimate the effectiveness of this method.

MATERIAL AND METHODS

The clinical material comprised 202 patients, 97 women and 105 men, in the age of 15-84 years, whose eyeballs were enucleated because of choroidal melanoma. In 72 patients the orbit was irradiated after enucleation with 60Co applicator (CKA4). The dose was about 50 Gy, 5 mm deep. The height of tumour, its location, histological type, infiltration of the sclera or beyond the eyeball and the treatment of tumour before enucleation were analysed. The follow-up time was 5-20 years.

RESULTS AND CONCLUSIONS

The survival time of patients in the age below 30 years (p < 0.05) and of patients with choroidal melanoma of the height above 3 mm (p < 0.01) was significantly longer when the orbit was irradiated. Also the survival time of patients with scleral infiltration and with spindle-cell type of tumour was longer (but statistically not significantly) in those, whose orbits were irradiated after enucleation. Exenteration of the orbit was necessary in 4 cases not irradiated after enucleation, only in 1 case after irradiation. The probability of survival after irradiation of the orbit was significantly higher than in cases not irradiated (0.6971 vs. 0.6219). The estimated mean survival time (in months) was longer, but not significantly, in patients after irradiation of the orbit (197.017 vs. 181.409). We conclude that irradiation of the orbit after enucleation of the eye with choroidal melanoma should be recommended. Further investigations will be continued with collaboration of Institute of Oncology in Cracow.

[Ocular and palpebral surgery: indications and limits]

Oculo-plastic surgery includes all the problems bound to the eyelids. In this presentation, we expose the most frequent oculo-palpebral pathologies, their treatment and some of the commonest complications. In all facial surgery, there is a plastic component, so it seems impossible to talk about this surgery without taking into account the cosmetical aspects.

Deviated hydroxyapatite orbital implant syndrome

PURPOSE

To describe a patient with a deviated orbital implant after enucleation.

METHOD

Case report.

RESULT

We examined a postenucleation patient with a medially deviated ("esotropic") implant after peg drilling. Modification of the posterior surface of the prosthesis improved cosmesis in the primary position.

CONCLUSIONS

During enucleation surgery, surgeons may use a spherical implant rather than modify the anterior face in patients with preexisting strabismus, with severe trauma to the extraocular muscles, or with risk of implant deviation. Additionally, secondary procedures may alter implant position. Occasionally, patients without obvious preoperative risk factors may have deviation of the modified face of the implant. Flattening the implant creates an asymmetric surface that may lead to a deviated orbital implant.

[Dermal fatty tissue transplant as primary and secondary orbital implant. Complications and results]

In this retrospective study we report the indications, complications and functional and cosmetic results after dermofat grafting into anophthalmic orbits. The method consists of implantation of autogenous dermis with attached subcutaneous fat from the gluteal region into the orbit. Twenty-four primary and 4 secondary grafts were implanted in 28 patients aged 12 to 49 years. In the explantation site one patient showed delayed healing. All implants became integrated, none were lost because of infection or extrusion. Eleven patients developed minor complications like central ulceration in the dermis, hair growth on the dermis or suture granuloma. In the primary implant group the functional and cosmetic outcome was evaluated by measurements of the lid structures, exophthalmometry (Hertel) and measuring the prosthesis motility (Kestenbaum). Three patients showed fair results; all the others had good or very good results. In one case of a secondary implant marked graft atrophy was observed. Despite the more extensive surgery and some minor complications the safety of this method with good functional and cosmetic results makes dermofat grafting an excellent alternative to heterogeneous orbital implants.

Hydroxyapatite eye implant

Hydroxyapatite, a coral, provides an effective foundation for a prosthetic eye. With the implant, the prosthetic eye has a normal appearance, including movement. The infusion of blood into the implant prevents it from behaving as a foreign object in the patient's body.

[Dermal fat transplant as autologous orbital implant]

BACKGROUND

The use of orbital implants after an enucleation is the pre-condition for an adequate fitting of the prosthesis and gives the best functional and cosmetic results. The autogenous dermofat graft is an alternative to the widely used alloplastic orbital implants. It can be used as a primary implant or as a secondary implant for the correction of a contracted socket or a post enucleation socket syndrome.

METHOD

Deepithelialized skin with subcutaneous fat is implanted into the socket. The rectus muscles, Tenon's capsule and conjunctive are fixed to the transplant separately. Surgical technique, possible complications and their therapy are presented.

CONCLUSIONS

Disadvantages of the method are the more extensive surgery, some minor complications and the possible shrinkage of the transplant. Advantageous is the fact, that typical complications of all alloplastic implants, like migration and extrusion, can be avoided, heterologous materials like donor sclera are unnecessary and the functional and cosmetic results are very good.

Positive donor rim culture in penetrating keratoplasty

A 3-year retrospective study on the risk factors of positive donor rim cultures in penetrating keratoplasty was performed. One thousand and ninety-seven consecutive donor rim cultures were reviewed from the period between June 1990 and October 1993 to determine the rate of culture positivity. The sex, age, diabetes status, use of respirator at time of death, cause of death, harvesting technique, storage time, and corneal storage medium utilized for the donors with positive donor rim culture were compared to those for 100 randomly selected culture negative donor controls. Logistic analysis was performed to eliminate confounding effects. Forty-six of the 1,097 (4.19%) donor rim cultures were positive. We found an association between the in situ technique for donor harvesting and culture negativity (p = 0.03). None of the other donor characteristics was associated with culture positivity. None of the 46 recipients who received the positive culture corneas developed endophthalmitis. In situ cornea harvesting promotes less contamination than enucleation and enriched gentamicin and streptomycin storage medium may further decrease donor rim culture positivity.

Current techniques of enucleation: a survey of 5,439 intraorbital implants and a review of the literature

Enucleation is a commonly performed procedure. A multitude of intraorbital implants are available for use following enucleation. Each has advantages and disadvantages. This survey report represents the most comprehensive evaluation yet of the current trends in the rehabilitation of the anophthalmic socket. The membership of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) was surveyed. Information was requested regarding preferred intraorbital implants, complications associated with each implant, and some details of current surgical techniques. Hydroxyapatite (HA) was used in 56% of primary enucleations by this group as compared to 1% in 1989. In comparison to other leading implants, HA was found to have equally low or lower complication rates when poor motility, infection, extrusion, migration, superior sulcus deformity, enophthalmos, lower lid malposition, and contracted fornices were assessed. A detailed discussion of these various complications is presented. The majority (59%) of ophthalmic plastic surgeons use donor sclera when placing an intraorbital implant. HA was clearly the implant material most used by ophthalmic plastic surgeons in 1992, and may be the material of choice for enucleation. To date it has achieved better postoperative results and a favorable side effect profile. Because it has been available for only 5 years, more time is necessary to determine its long-term success rate. Despite theoretical concerns of the transmission of infectious agents with the use of donor sclera, the majority of surgeons use this material when placing an intraorbital implant.

Hydroxyapatite motility implants in ocular prosthetics

For the past 5 years, an increasing number of ophthalmologists have been using hydroxyapatite (HA) motility implants after uncomplicated enucleation or evisceration of the eye. Unlike previous implant materials, HA promotes fibrovascular ingrowth and seemingly true integration of the motility implant to the residual ocular structures. As a result, a more stable defect and greater movement of the overlying prosthesis is produced. In addition, the problems of long-term orbital implant migration and the vexing postenucleation socket syndrome are thought to be minimized. This article briefly reviews the history and development of orbital implants and HA implant surgical and prosthetic procedures. It is concluded that HA implant rehabilitation is indicated after most uncomplicated enucleations or eviscerations where there is small likelihood of complication.

Whole globe enucleation versus in situ corneal excision: a study of tissue trauma and contamination

Twenty-four pair of eyes donated to the Minnesota Lions Eye Bank were studied to determine the effect of corneal procurement methods on tissue quality. Eyes studied were ineligible for transplantation because of a preexisting medical condition other than sepsis or age of > 75 years. The procurement technique was randomized for each donor. One cornea was procured in situ (IS), whereas the fellow eye was enucleated and processed in the laboratory (EN). Procurement protocols were standard Eye Bank Association of America methods. Tissue characteristics were scored according to standard eye bank protocols. Cultures were performed at the time of tissue procurement and following storage for 7 days in Dexol media. With the exception of endothelial striae, no statistical difference was found between groups for any tissue characteristics. The average score for endothelial striae in the IS group was greater than twice that of the EN group. Initial cultures were positive in 10 of 24 in the IS group and four of 24 in the EN group. Each group had three positive end-storage cultures. These results demonstrate superior tissue decontamination after initial processing and less endothelial cell trauma with standard enucleation when compared to in situ corneal excisions.

Clinical management of retinoblastoma

There have been many recent advances in the diagnosis and management of children with retinoblastoma. Regarding diagnosis, the judicial use of ancillary studies, particularly B-scan ultrasonography, has been instrumental in supplementing the diagnosis when opaque media preclude a clear view of the underlying neoplasm. Computed tomography and magnetic resonance imaging are important in the early detection of associated pinealoblastoma, which occurs as part of the recently described syndrome of "trilateral retinoblastoma." With regard to management, the technique of enucleation continues to improve and the scleralized hydroxyapatite implant is now available to provide a better cosmetic appearance and better motility of the artificial eye. Methods have been described for harvesting fresh tumor tissue immediately after enucleation for special DNA studies. Recent reports have documented a decreasing frequency of enucleation and an increasing tendency to use eye-preserving methods of management. Plaque radiotherapy, which provides more localized irradiation to the specific tumor, is gradually supplanting external beam irradiation for localized retinoblastoma that does not exhibit extensive vitreous seeding. The indications and contraindications for cryotherapy and photocoagulation have been more clearly delineated. The role of chemotherapy is being evaluated in the treatment of primary retinoblastoma and for metastatic disease. New breakthroughs in genetic research are being applied to clinical genetic counseling. The prognosis for life and for preservation of vision has improved greatly in recent years.

[The formation of a bulk mobile locomotor stump with carbon implants]

Carbonic composite materials, syntactical carbonic foam, and carbonic felt (carbotextim), were used to form a solid mobile locomotor stump after experimental and clinical enucleation and during delayed stump plasty. Experiments with 96 rabbits demonstrated good results of using carbonic composites for lamellar ophthalmic surgery. Clinical follow-up of 86 patients demonstrated the advantages of carbonic implants vs. the traditional ones. Carbonic implants meet all the requirements to materials used in plastic ophthalmo-surgery: they are porous, easily intergrown with adjacent tissues, do not migrate, retain their shape and volume, are not denuded or rejected, easily sterilized. These properties recommend carbonic implants in intricate cases with marked inflammations of the adjacent tissues and in combination with transplantation of free mucosal grafts. The material structure permits modelling individual transplants during surgery.

Exenteration for benign orbital disease

Exenteration, or removal of the globe with part or all of the surrounding orbital contents, is generally reserved for malignancy. The procedure may, however, be of value in the management of some benign orbital diseases. The indications for exenteration in management of benign orbital disease are threefold. Firstly, patients in whom diffuse disease, such as idiopathic inflammation, has resulted in an irretrievable situation of visual loss and clinically uncontrollable pain or disfigurement; in many such cases we consider exenteration to be preferable to the (often severe) side effects of prolonged and inadequate medical therapy. The second group are those patients with grossly disfiguring orbital abnormalities, such as teratomas, extensive varices, or massive optic nerve tumours. The last group comprises patients with tumours that, while histologically benign, may have malignant potential or show a tendency to diffuse or persistent infiltration of orbital soft tissues. Sixteen illustrative cases of full or partial exenteration for benign disease are described.

Hydroxyapatite orbital implant after enucleation--experience with 200 cases

The recently introduced hydroxyapatite orbital implant was designed to provide improved motility of the prosthesis in patients who have undergone enucleation. To date, little has been written about the use of the hydroxyapatite orbital implant in eyes that harbored malignant neoplasms. We have performed hydroxyapatite orbital implantation in approximately 200 patients, including children as young as 1 month of age, who underwent enucleation primarily for malignant intraocular tumors. During a median follow-up of 24 months, no cases of orbital hemorrhage, orbital infection, implant extrusion, or implant migration have occurred. Three patients have had conjunctival erosion, which was successfully repaired. Motility of the socket and fornices has been excellent, and all patients have cosmetically satisfactory motility of the prosthesis. Use of the hydroxyapatite implant has had no adverse effect on the clinical course of the intraocular neoplasms, and it has not hindered postoperative evaluation for recurrent orbital tumor. Overall, the hydroxyapatite orbital implant seems to be well tolerated, provides improved motility of the prosthesis, and is associated with few complications.

[The gas hypertension technique in enucleation for ocular melanoma]

Using the hypertensive gas technique, before touching the melanoma eye for enucleation intraocular pressure is raised to maximum by an intravitreal gas injection (average 1.2 ml of perfluorocarbon or air), resulting in a rock-hard eye. Changes in intraocular pressure are no longer possible, since the hard eye condition and avascularity persist during enucleation. The vortex veins appear collapsed. Before cutting the optic nerve and vessels, they are compressed by a broad hemostatic clamp for three minutes and then severed by a blade located in the middle of the clamp. With the hypertensive gas technique there is neither bleeding of vortex veins nor of proximal end of stump, which continues to be compressed by the hemostatic clamp. Fifteen patients with choroidal melanomas were enrolled in a prospective study with the hypertensive gas technique from 9/1987 to 6/1989; prior radiotherapy was not performed. Average base diameter of melanoma measured 13.2 mm, height 8.4 mm. Cytology was: 11x spindle, 3x mixed, 1x epitheloid cells. At reexamination in 7/1991 (average follow-up 2.75 years), 2 diabetics had died with no detectable metastases, and 1 of the 15 melanoma patients (6.7%) had died with metastases 2 years after enucleation. The hypertensive gas technique does not postpone enucleation of a melanoma eye while presumed prophylaxis is administered, does not require additional instruments, and takes only a minute when the eye is already draped for surgery. The firm and avascular globe facilities a faster removal of the melanoma eye with practically no bleeding from the bulb.

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.

Enucleation technique for children with retinoblastoma

Based on personal experience with approximately 350 enucleations for retinoblastoma, the authors describe their current surgical technique for removal of the eye, opening the globe to harvest fresh tissue for research including DNA analysis, and placement of the new hydroxyapatite orbital implant. Enucleation should be performed as gently as possible. A hemostat is placed on the stump of the severed medial rectus muscle for traction purposes, and long, minimally curved scissors are used to cut the optic nerve near the orbital apex. Clamps and snares are not advised and cautery of the orbital tissue is avoided. A piece of optic nerve is first submitted separately for histopathologic study and the globe is opened with a specific technique to harvest fresh tumor tissue. A hydroxyapatite implant covered by sterilized sclera is placed in the anophthalmic socket to provide orbital volume and improved motility of the prosthesis.

[Results of animal experiment study of a new enucleation filling of bio-vitroceramics--Bioverit I and II (bioactive and biocompatible)]

The results with two new enucleation prothesis made of Bioverit are presented. After unilateral enucleation 14 rabbits received bioreactive, 14 rabbits biocompatible and 9 rabbits nylon prostheses. Implantation periods: 1-13 months. The tissue surrounding of the prostheses was studied histologically, the ceramic electron microscopically. Of 28 ceramic prostheses, 26 were adapted very well. Bioverit ist excellently suited as orbital prosthetic material, even half-open implants are possible.

Modified enucleation via lateral orbitotomy for choroidal melanoma with orbital extension: a report of two cases

We report two cases of choroidal melanoma with massive orbital extension that were managed by modified enucleation by way of a lateral orbitotomy. In both cases, the orbital component of the tumor was removed intact along with the globe. This approach allows placement of an orbital implant and avoids the long healing process associated with orbital exenteration.

[Orbitoplasty in patients with artificial eyes]

The typical signs of the postenucleation socket syndrome consist of enopthalmos, shallow lower fornix, lower lid laxity and entropion, and ptosis. It causes discomfort and can render the bearing of a prosthesis uncomfortable or impossible. The signs must be corrected in single or combined procedures. The lower fornix and the lids can be corrected with good success, enophthalmos is difficult to correct, however.

Hydroxyapatite implants--a new trend in enucleation and orbital reconstructive surgery

As treatment modalities evolve in ophthalmology one must assess and re-evaluate current methods of therapy in the care and treatment of the patient facing the loss of an eye. With the advent of Hydroxyapatite Orbital Implants, new challenges face the ophthalmic nurse in caring for the patient undergoing enucleation and reconstructive surgery. Integrated orbital implants are used to replace the volume of the orbit when the eye is removed due to enucleation, evisceration, or as secondary orbital implants. Various materials have been used in the past to replace orbital volume, with the most common being silicone or polymethylmethacrylate. Hydroxyapatite is a new orbital implant material which has unique interconnected porous matrix derived from marine corals with a mineral composition similar to bone. This orbital implant undergoes fibrovascular ingrowth by the patient's own tissue, becoming truly integrated and less likely to reject, migrate or extrude. The hydroxyapatite implant may be inserted with a variety of surgical techniques, all of which are more complex than standard enucleation implant techniques and have special considerations for the ophthalmic registered nurse.