Prevention of Socket Complications in Anophthalmic Patients

Workflow and treatment results for computer-aided design and 3D-printed conformer therapy of congenital anophthalmia and microphthalmia

BACKGROUND/AIMS

To evaluate treatment with custom, three-dimensional (3D) printed conformers for socket expansion in congenital microphthalmia and anophthalmia (MICA).

METHODS

Retrospective analysis of prospective cohort from 2016 to 2020. All children received custom-made 3D-printed conformers increasing in size. We measured height, width, thickness, surface and volume of first and consecutive conformers, as well as horizontal palpebral fissure length (HPF) at start and follow-up visits. We analysed these parameters for severely (<45%) and moderately (>45%-75%) affected children, based on affected axial length on ultrasonography.

RESULTS

We included 18 cases (9 severe, 9 moderate) with a total of 174 conformers (88 severe, 86 moderate) and a mean follow-up of 2.8 years (range 1.3-4.8). The mean relative HPF increased from 77% to 93% with 16/17 cases reaching >80%, and 12/17 cases >90% symmetry. Horizontal and vertical conformer dimensions increased up to 10 months of treatment, with a steeper slope for the severe group (10.5% vs 5.5% for height and 9.0% vs 6.1% for width gain per treatment month, for severe and moderate MICA, respectively). After 10 months of treatment conformer height and width increased only slightly. No serious complications were observed.

CONCLUSION

3D-design and printing of solid conformers results in highly acceptable horizontal eyelid symmetry in the treatment of congenital MICA. The mean increase in conformer height and width in the first 10 months should be about 170% for moderate and about 200% for severe MICA. The presented conformer size formulas can aid ophthalmologists and ocularists to plan conformer treatment.

Novel point-of-care biomarkers of the dry anophthalmic socket syndrome: tear film osmolarity and matrix metalloproteinase 9 immunoassay

PURPOSE

To compare tear film osmolarity (TFO) values and matrix metalloproteinase 9 (MMP-9) levels between anophthalmic sockets and healthy fellow eyes and to assess the use of the MMP-9 and TFO as objective biomarkers for the dry anophthalmic socket syndrome (DASS).

METHODS

In this prospective single-center study, the anophthalmic sockets and healthy fellow eyes of 98 unilateral anophthalmic patients were assessed using the ocular surface disease index (OSDI) questionnaire, InflammaDry® MMP-9 point-of-care immunoassay, TFO with TearLab™ Osmolarity System, and clinical conjunctival inflammation. MMP-9 concentration and conjunctival inflammation were graded semi-quantitatively. Differences between anophthalmic sockets and the healthy fellow eyes for OSDI scores, MMP-9, TFO values, clinical conjunctival inflammation, and eyelid abnormalities as well as the correlation between these factors and demographic data were evaluated.

RESULTS

Patients had significantly higher OSDI, MMP-9, and TFO values, as well as higher conjunctival inflammation on the anophthalmic side, compared to the healthy side (p ≤ 0.002, respectively). For anophthalmic sockets, there was a significant positive correlation between OSDI scores and TFO values (p = 0.007), between the grade of posterior blepharitis and TFO values (p = 0.026), and between the conjunctival inflammation and MMP-9 values (p < 0.001), as well as between MMP-9 levels and time since eye loss (p = 0.004).

CONCLUSIONS

Measuring MMP-9 and TFO may be helpful tools as efficient, quantifiable biomarkers, disease course parameters, or predictors for treatment response in the clinical management of patients with DASS or future therapy studies. Ophthalmologists should consider the updated diagnosis criteria including TFO and the definition for DASS proposed in this study.

[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.

[Complications of anophthalmic orbits-Treatment and aftercare]

The possible complications of anophthalmic eye sockets can occur due to many different pathomechanisms. A differentiation is made between allergic, infectious, inflammatory or mechanical causes. This article gives an overview on the different etiologies of socket complications with their pathophysiology and treatment options.

Health Literacy in Patients Wearing Prosthetic Eyes: A Prospective Cross-Sectional Study

PURPOSE

To investigate general and electronic health literacy (HL) levels in prosthetic eye wearing patients, to define factors associated with reduced HL, and to identify a potential healthcare gap.

METHODS

In this prospective cross-sectional study 148 prosthetic eye wearers were screened using the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16) and the 8-item electronic Health Literacy Scale (eHEALS). HLS-EU-16 and eHEALS scores were correlated to health levels, vision functioning, and sociodemographic factors.

RESULTS

A total of 85 patients (57%) had adequate, 38 (26%) problematic, and 9 (6%) inadequate general HL, while 16 (11%) had no valid HLS-EU-Q16 score. General HL was positively correlated with physical health (p = 0.009) and negatively with a migration background (p = 0.023). There was a positive correlation between electronic HL and educational level (p < 0.001), social status (p = 0.048), and mental health (p = 0.013). Higher age was associated with lower electronic HL (p < 0.001).

CONCLUSIONS

More than 30% of the prosthetic eye wearers had problematic or even inadequate general HL, suggesting a significant health care gap. To identify patients with reduced HL, a standardized screening tool should be implemented as part of routine clinical care. Within integrated care, patients with insufficient HL should be offered barrier-free advisory services and information brochures in various languages.

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.