Autologous dermis - Fat grafts as primary and secondary orbital transplants before rehabilitation with artificial eyes

An Orbital Mystery: A Unique Case of an Obsolete Orbital Implant With a Review of Orbital Implant Materials

Orbital implant materials have evolved greatly over the past century and include but are not limited to metal, ceramic, polymer, silicone, and glass. Knowledge of historically used materials is clinically relevant to patient care as certain materials carry a greater risk of migration, extrusion, infection, and limitations for imaging modalities utilized to visualize adjacent structures. We report an unusual case of an 80-year-old male who presented to our community hospital with seizure-like activity. CT imaging of the brain revealed several white matter and cortex lesions with the largest lesion measuring 2.5 × 2 × 1.9 cm. The patient had a history of enucleation with placement of an orbital implant following a penetrating injury to the left eye at four years of age. Hounsfield scale analysis was read by radiology as being most consistent with a thin metallic shell surrounding the orbital implant. The potential for metallic material was consistent with the implant's age and time of placement. Few reviews on ocular implant materials from this period exist in the current medical literature. A single case report discussing a hollow metal orbital implant with similar-appearing imaging was identified. Due to concern for possible metal implant materials, the patient underwent implant exchange so MRI imaging could safely be performed. Intraoperatively, the implant was identified as a clear, hollow, non-metallic, non-porous polymer sphere. Following surgery, the patient was able to undergo appropriate neuroimaging with subsequent diagnostic biopsy. Current literature reviewing CT or photographic imaging of ocular implant devices prior to the 1940s is limited. This case highlights the importance of detailing materials historically used in orbital implants, their effects on clinical decision-making, and the utility of Hounsfield scale values to identify a material's radiodensity on CT imaging.

Deep Orbital Hyaluronic Acid Gel Filler for Volume Augmentation in Orbital Dysplasia

PURPOSE

Orbital dysplasia is caused by congenital microphthalmos, anophthalmos, or eye atrophy. Orbital volume growth is known to parallel ocular growth and the absence of an eye results in noticeable hemifacial deformity that affects patients' lives. The aim of this study was to observe the effects of injections of hyaluronic acid gel into the orbit combined with ocular prosthesis to treat orbital dysplasia.

METHODS

Three patients with orbital dysplasia who were 3 to 7 years old treated in our department. Each year, the hyaluronic acid gel was injected into each patient intraconal and extraconal posterior orbit and each wore an ocular prosthesis. The length of the palpebral fissure and orbital volume were measured before and after the injections.

RESULTS

A total of 9 injections were performed on 3 patients ages 7, 5, and 4 years old, respectively. The follow-up periods were 5, 5, and 2 years. The authors observed significant improvements in patient appearance. The length of the palpebral fissure and the volume of the orbit increased linearly with the increasing age, and there were no complications, such as intraorbital hemorrhage or local hyperplastic stimulation.

CONCLUSIONS

Orbital hyaluronic acid gel injection and combined with an ocular prosthesis is a safe, convenient, and effective treatment for orbital dysplasia.

A Sandwich-Like Oral Mucosa Graft-Conjunctiva In Situ-Dermis-Fat Graft for Reconstruction of the Anophthalmic Socket with Ocular Infection History

INTRODUCTION

A novel technique of using a sandwich-like structure, namely, an oral mucosa graft (OMG)-conjunctiva in situ-dermis-fat graft (DFG) (OMG-C-DFG), to reconstruct a contracted and low-capacity anophthalmic socket for a patient with ocular infection history was evaluated.

METHODS

This was retrospective case study of four patients (cases) who underwent anophthalmic socket reconstruction surgery in which the OMG-C-DFG technique was applied. The procedures were performed in the Department of Ophthalmology at the Ninth People's Hospital, Shanghai JiaoTong University School of Medicine (Shanghai, China). Postoperative cosmetic appearance, graft outcome, the ability to wear an ocular prosthesis, and postoperative complications were evaluated.

RESULTS

The median (± standard deviation) age of patients was 41.5 ± 22.1 (range 10-60) years. All patients suffered from contracted and low-capacity anophthalmic sockets. Three patients had a history of orbital implant infection and one patient had a history of enucleation due to exogenous endophthalmitis after globe rupture. The DFG and OMG were harvested from the abdominal region and lower lip, respectively. All four patients achieved a good postoperative appearance, with dermal surfaces appearing pink and smooth, the orbital areas showing good fullness, the ocular prosthesis showing good wearability, and no narrowing of the sockets. There was no lipid secretion, fat lysate outflow, or infection in the graft bed. There were only small amounts of scars and no infection of the donor site.

CONCLUSION

The sandwich-like structure can be effectively used to reconstruct the contracted and low-capacity anophthalmic socket with a history of orbital infection in one stage.

Anophthalmic Socket Syndrome: Prevalence, Impact and Management Strategies

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

Reconstruction of the Orbit and Anophthalmic Socket Using the Dermis Fat Graft: A Major Review

PURPOSE

To perform a comprehensive review of dermis fat graft (DFG) in socket reconstruction and illustrate the technical nuances and outcomes using a retrospective case review.

METHODS

A literature search of 143 texts was reviewed. A retrospective case series of 34 patients following primary or secondary DFG after enucleation at a single institution (2009-2019) was performed. Clinical outcomes were statistically analyzed. Variables investigated included age, sex, race, surgical indication, muscle reattachment, complications, motility, eyelid position, prosthesis fit, and need for additional surgery.

RESULTS

The history of DFG, use in socket reconstruction, primary and secondary indications, and surgical techniques are described. Thirty-two adults and 2 pediatric cases of DFG were reviewed; 18.75% indications were primary and 81.25% were secondary. Good eyelid position was observed in 83.3% of patients with primary DFG versus 37.5% with secondary DFG (p = 0.07). Postoperative complications occurred in 58.8% of patients, were typically mild, and resolved with minimal or no intervention. No statistically significant differences were found between occurrence of any particular complication in primary versus secondary DFG placement (p = 0.36) or between primary and secondary DFG placement and the need for additional surgery (p = 1.0). Among the 67.7% patients who had implant exposure or extrusion as an indication for DFG, 39.1% required additional surgery within 2 years. Advanced age was not associated with higher complication rates (p = 0.12).

CONCLUSIONS

DFG is an excellent option for socket reconstruction, particularly in cases involving pediatric patients, complicated orbits, history of multiple previous surgeries, and inflamed, contracted, or scarred sockets.

Computer-Assisted Secondary Orbital Reconstruction

Study Design

This study presents a case-control study of 33 patients who underwent secondary orbital reconstruction, evaluating techniques and outcome.

Objective

Adequate functional and aesthetical appearance are main goals for secondary orbital reconstruction. Insufficient premorbid orbital reconstruction can result in hypoglobus, enophthalmos, and diplopia. Computer-assisted surgery and the use of patient-specific implants (PSIs) is widely described in the literature. The authors evaluate the use of selective laser-melted PSIs and hypothesize that PSIs are an excellent option for secondary orbital reconstruction.

Methods

The sample was composed of 33 patients, previously treated with primary orbital reconstruction, presenting themselves with indications for secondary reconstruction (i.e. enophthalmos, diplopia, or limited eye motility). Computed tomography and/or cone beam data sets were assessed before and after secondary reconstruction comparing intraorbital volumes, infraorbital angles, and clinical symptoms. Clinical outcomes were assessed using a standardized protocol.

Results

Results show a significant change in intraorbital volumes and a reduction of clinical symptoms after secondary reconstruction.

Conclusions

Outcomes of this study suggest that secondary orbital reconstruction can be performed routinely using selective laser-melted PSIs and titanium spacers.

Modified types of orbital exenteration, survival, and reconstruction

PURPOSE

This study aims to analyse the various modifications of orbital exenteration.

METHODS

Patients undergoing orbital exenteration from March 1978 to October 2019 were included in this retrospective study. The patients were evaluated on the basis of the indication, type of exenteration, reconstruction technique, overall survival (OS), and disease-free survival (DFS).

RESULTS

In total, 300 patients were enrolled in this study. As many as 24 patients had lid and conjunctiva sparing anterior exenteration, 16 had lid sparing anterior exenteration, 83 had anterior exenteration, 14 had lid and conjunctiva sparing total exenteration, seven had lid sparing total exenteration, 44 had total exenteration, one had lid and conjunctiva sparing extended exenteration, 23 had lid sparing extended exenteration, and 88 had extended exenteration. As many as 39 patients had a primary wound closure. Six patients underwent reconstruction with a split-thickness skin graft, 177 patients with a local or regional flap, and 40 patients with a microvascular flap. A total of 38 patients did not undergo reconstruction. The mean follow-up was 40 months (range 6-216 months). The OS rate was 82.2% after 1 year, 58.5% after 5 years, and 49% after 10 years for all patients with malignant tumours. The DFS rate was 67.7% after 1 year, 45.6% after 5 years, and 31.7% after 10 years.

CONCLUSION

Individual types of orbital exenteration allow patient-adapted therapies. The preservation of uninvolved orbital tissue facilitates orbital reconstruction. The type of exenteration did not have any influence on overall survival.

Dermis-fat graft as treatment of early implant exposure in a postpenetrating keratoplasty patient with nontraumatic eyeball rupture

Orbital implant exposure may be the most common complication after evisceration surgery with orbital implantation. Management of implant exposure is a vital issue for oculoplastic surgeons. We present the case of a patient with nontraumatic eyeball rupture receiving dermis-fat graft after early implant exposure. The present case with multiple penetrating keratoplasty history underwent emergent evisceration and silicon sphere implantation due to nontraumatic eyeball rupture with severe uvea prolapse. The surrounding corneal tissue of the rupture aperture was almost unidentified before the operation. Deep superior sulcus syndrome and orbital implant exposure developed 2 months after the operation; hence, orbital reconstruction and dermis-fat graft transplantation were performed. Orbital reconstruction and orbital implant exposure management are discussed in the content.