Orbital Expansion for Congenital Anophthalmia May Be Achievable in Infancy But Not in Childhood

Determining Asymmetry Thresholds in Anophthalmia/Microphthalmia Using a Three-dimensional Animated Model

PURPOSE

Congenital microphthalmia and anophthalmia are rare development disorders with underdevelopment of the orbital region, resulting in asymmetry of the face. No clear guidelines exist to determine when these deviations are acceptable.

METHODS

The face of a healthy 6-year-old child was three-dimensionally scanned. On this scan, we modeled various incremental degrees of facial asymmetries using three-dimensional modeling software. We modeled for smaller palpebral fissures, sunken eyes, and downward displacement of the eye. We also tested whether adjusting the vertical palpebral fissure height in relation to the horizontal palpebral fissure width affected perception. A total of 22 videos were created in which the model turned the head horizontally and vertically. We created a questionnaire asking raters how acceptable the face is, on a linear scale from 0 to 10.

RESULTS

Results showed a correlation between the degree of asymmetry and the acceptability score of the raters. Enophthalmos of ≥6 mm, palpebral fissure width ≤79% compared with the other eye, and 2 mm or more downward displacement of the eye resulted in a significant different acceptability score. The desire for correction was strongly increased when these thresholds were exceeded. Adjusting the vertical palpebral fissure height to the horizontal palpebral fissure width resulted in a worse acceptability score.

CONCLUSION

A unilateral sunken eye (enophthalmos) of 6 mm or more, asymmetric horizontal palpebral fissure length of ≤79%, and a lower position of one eye of more than 2 mm resulted in unacceptable judgment. These data can be used to evaluate treatment outcome in children treated for congenital microphthalmia and anophthalmia.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

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.

Eye Conformers as Socket Expanders in Children: Experience at a Tertiary Eye Hospital in Central Saudi Arabia

Purpose To share our experience with pediatric orbital expansion using eye conformers for anophthalmia and microphthalmia and parental feedback on outcomes. Methods Cases of congenital anophthalmia and severe microphthalmia were managed with eye conformers for orbital expansion and formation of lid fornices at the anaplastology clinic of King Khaled Eye Specialist Hospital, Saudi Arabia. Data were collected on the globe adaptation process and the perceived achievements by the parents at different follow-up visits. Parental feedback was collected on their acceptance of eye conformer use to address anophthalmia and microphthalmia. Results The anophthalmia/microphthalmia annual prevalence was 1.7 per 10,000 live births in Saudi Arabia. Of the 45 sockets treated for orbital expansion since 2014, 15 children were managed by using eye conformers. Six children had a bilateral birth defect. Severe microphthalmia was in seven children while eight children had anophthalmos. At the first visit, small eye conformers (nine), stem eye conformer (four), symblepharon ring (one), and hydrogel eye conformer (one) were fitted. After multiple visits and follow-ups, at the two-year follow-up, seven (46.7%) children were fitted while three (20%) were under the process of prosthesis fitting, as volume expansion was satisfactory. Parents of these children replied that they prefer this method over others and would recommend others to follow the same. Conclusions Orbital expansion and lid fornices formation by using an eye conformer is effective, easy, and acceptable to parents. It can be initiated in the early months of a child's life.

Computer-Assisted Volumetric Analysis and Quantitatively Anophthalmic Orbit Reconstruction With Dorsalis Pedis Flap and Bone Graft

Current approaches to orbit reconstruction are based on the assumption of facial symmetry and surgeons' experiences, and the reconstructed orbits are not precise. Through computer-assisted volumetric quantitative analysis, the volume of the bony orbit, and the volume of the soft tissues in both the anophthalmic orbit and the contralateral orbit are calculated in 39 anophthalmic patients. The rib graft is used for orbit reconstruction; the dosalis pedis flap and lipo-injection were used for soft tissue reconstruction and skin socket reconstruction. The size and the shape of the rib graft and soft tissues were designed according to the volumetric analysis. The size and the shape of the skin socket were designed according to measurement during surgery. Asymmetry eye sockets with adequate size were created in the 37 patients. Two patients presented with a poor asymmetry with the contralateral orbit, and got gradual extrusion of the eye prosthesis 4 months after operation, which was because of necrosis of the flaps. The flaps were remedied by frontal island flap and skin grafting. Further surgeries, such as lipoinjection, lid surgery, and canthoplasty, were applied to improve the surgical results. The eye prostheses fitted well in all of the reconstructed sockets using this technique. Our studies suggest that the computer-assisted volumetric analysis technique combined with quantitative bone graft and dorsalis pedis flap transfer, ± lipoinjection proved to be an accurate method and a quality assurance for optimization of bony orbit, soft tissue and skin socket reconstruction, and promised a successful postoperative outcome for patients' functional and esthetic appearance.

Biphasic growth of orbital volume in Chinese children

Objective

The aim of this study was to map out the developmental curve of the orbital volume of Chinese children aged 1–15 years.

Methods

CT scanning was performed on 109 children and the orbital volume, interlateral orbital rim distance (IORD), and extent of exophthalmos were measured on the CT images and plotted against age.

Results

The development of the orbit structure followed a biphasic pattern. The first growth phase was before 3 years and the second growth phase was between 7 years and 12 years of age. The growth speed in the first phase was about 3 times that of the second one (first vs second phase: 2.28 cm³/year vs 0.67 cm³/year for orbital volume, 5.01 mm/year vs 1.57 mm/year for IORD, 1.29 mm/year vs 0.42 mm/year for the exophthalmos). During development, there was no significant difference between the left and right orbits. There was no significant difference between boys and girls before 12 years of age. However, after 12 years of age, boys had significantly larger orbital volumes (22.16±2.28 cm³/year vs 18.57±1.16 cm³/year, p<0.001) and a greater IORD (96.29±3.18 mm/year vs 91.00±4.54 mm/year, p<0.001) than girls.

Conclusions

In Chinese children, the development of orbital volume follows a biphasic pattern and a sex difference becomes significant after the age of 12 years.