Risk factors for orbital implant exposure after evisceration: A case control study of 93 patients

Surgical management of orbital implant exposures after evisceration or enucleation: Retrospective study - Limoges University Hospital

INTRODUCTION

Implant exposure is the most frequent complication after evisceration or enucleation, and multiple surgical techniques for the management of orbital implant exposure. The goal of our study is to investigate the success rate and risk factors for failure of various surgical procedures.

METHODS

This was a retrospective study performed at the University Hospital of Limoges. We collected data from the files of every patient operated on for implant exposure between January 2005 and December 2020. The main criterion was the percentage of success for each procedure. Secondary objectives were to identify risk factors for failure of Müller's muscle flaps and to determine the incidence of post-enucleation socket syndrome depending on whether the orbital implant was maintained.

RESULTS

Fifty-one patients were included: 26 patients who underwent Müller's muscle flap, 16 dermis-fat graft, 3 conjunctival flap, 2 amniotic membrane graft, 1 temporalis fascia graft, 1 buccal mucosa graft, 1 implant rotation, and 1 implant exchange. The dermis-fat grafts were more successful (87.5%) than the Müller's muscle flaps (52.2%) (P=0.0213). The study highlighted the importance of good vascularization of the implant (OR=32.00, P-value=0.0245) for the success of Müller's muscle flaps, and we found no statistically significant difference between the patients who maintained their implants and those who did not (P=0.3865) with regard to the incidence of post-enucleation socket syndrome.

CONCLUSION

Müller's muscle flap may remain a reasonable option in the management of medium-sized implant exposures of well-vascularized implants confirmed on MRI in patients with no systemic healing disorders. Dermis-fat graft remains the option of choice in other cases, especially in large exposures or complicated orbits.

[Epidemiological and clinical profile of ocular eviscerations in northern Algeria, about 136 cases]

Introduction

Despite the existence of well codified indications, the performance of mutilating surgery in ophthalmology is not an easy decision to take due to the aesthetic and moral damages that patients may suffer. This surgery should be considered as a last resort in the case of a non-functional, painful and unsightly eye or in the presence of an oncological involvement and after all conservative alternatives have been exhausted. This study aims to define the factors making it possible to favor ocular evisceration, which is the least mutilating of the above-mentioned surgeries, by determining the epidemiological and clinical aspects of the patients. In addition, the results of the study will serve as a starting point for epidemiological surveillance and will guide preventive activities and the fight against blindness.

Material & method

We conducted an exhaustive retrospective study of medical records from the archives of the ophthalmology departments of the Dr. Tidjani Damardji University Hospital Center in Tlemcen, the Specialized Hospital Establishment in ophthalmology of Oran Hamou Boutlelis, the Specialized Hospital Establishment in ophthalmology of Oran Front de mer and the University Hospital Center of Bejaia (unit Franz Fanon), in order to specify the epidemiological-clinical profile of patients who have undergone an ocular evisceration in the north of Algeria from January 1, 2008 to December 31, 2014.

Results & discussion

We have identified 136 patients, representing an admission rate of 0,13% in all these services. We noted a slight male predominance with an estimated sex-ratio of 1.4. Evisceration was carried out mainly following an ocular trauma in 39% of cases. The surgical technique performed in all patients is a classic non-conservative evisceration of "four quadrants" or "four squares" under general anesthesia in 55.9% of cases. Post-operative complications were found in 19.8% of patients in our series, the main one being exteriorization of the intra-scleral implant in 9.5% of cases. This rate corresponds to the data in the literature, with figures between 0 and 67%. This complication may be in relation with the experience or even the competence of the surgeon. Accessibility to ocularists and the quality of prosthetic equipment were also studied. All the data collected were compared with data from the international medical literature. Our study carried out in the north of Algeria on ocular eviscerations, allowed us to deduce that this surgery is rarely carried out in ophthalmology. Its main indications are post-traumatic and post-infectious.

Conclusion

The prevention of mutilating surgeries requires early diagnosis and appropriate treatment of ophthalmological pathologies and trauma. Losing an eye is always experienced as a tragedy and can be devastating at any age, affecting self-image and self-esteem. Psychological support is therefore essential.

Outcome of eviscerations and enucleations at a Swedish tertiary referral centre between 2008 and 2019: improved surgical management leading to reduced complication rate

PURPOSE

The aim of this study was to investigate the results of all eviscerations and enucleations performed at the Department of Ophthalmology, Sahlgrenska University Hospital, during 2008-2019 and to compare them with previously collected data from 1999 to 2007.

METHODS

This was a retrospective investigation using the medical records for all patients having had an evisceration or an enucleation at the Department of Ophthalmology, Sahlgrenska University Hospital, during the two defined periods of time. Main outcome measure was postoperative complications.

RESULTS

During 1999-2007, 181 surgeries were performed, 100 with implants, and 28/100 exposed implants and 9/100 removed implants were recorded during follow-up. During 2008-2019, 250 operations were performed with 158 implants, and there were 3/158 exposed implants and 2/158 extruded implants. Two ruptures of the surgical wound without implant exposure were noted, and one implant was exchanged. The reduction of exposed implants between the two periods was statistically significant (p < .001, Chi-square test). In enucleations, the use of one kind of porous polyethylene implant in the recent study period replaced a multitude of implants in the earlier study period. In eviscerations, the major change between the two study periods was the introduction of the split sclera technique and smaller implant size.

CONCLUSION

The change in surgical technique between the two periods led to a significant reduction in implant-related complications.

Infection rate following elective oculoplastic surgery in a minor procedure setting: a single-centre retrospective study

OBJECTIVE

A surgical site infection after oculoplastic surgery is a serious complication that can lead to endophthalmitis and vision loss. Although performing these procedures in a minor-surgery setting is common, there is a lack of evidence in the literature regarding the incidence of postoperative infections. The objective of this study was to determine the infection rate associated with elective outpatient oculoplastic procedures performed in a minor-surgery setting.

METHODS

A retrospective review was completed for all patients who underwent elective oculoplastic surgery in the minor-procedure room at the Misericordia Health Centre in Winnipeg between April and December 2018. Operations were performed by 2 senior oculoplastic surgeons. Data collected included the type of procedure, number of surgical incisions, type and number of sutures, use of prophylactic antibiotics, time to follow-up, complications, and presence of surgical site infection.

RESULTS

Review of 539 patients showed an infection rate of 0.37% (2 of 539). Infection cases were an exposed orbital implant using a temporalis fascia graft and ptosis repair using a frontalis sling. Thirteen complications were identified, corresponding to a complication rate of 2.41% (13 of 539).

CONCLUSION

Study results show an infection rate of 0.37% for elective oculoplastic surgery in a minor-procedure setting.

Allogenic dehydrated human pericardium patch graft (Tutoplast): A novel use for reconstruction in orbital implant exposure

PURPOSE

Exposure of orbital implant post enucleation or evisceration remains one of the common complications irrespective of the type of implant used. Dermis fat graft and temporalis fascia have been used to repair the implant exposure in anophthalmic sockets. Tutoplast^® pericardium, gamma sterilised dehydrated human pericardium, has been used as a scleral patch graft for glaucoma drainage device exposure and scleral thinning post squint surgery. We report the novel use of Tutoplast^® patch graft to repair orbital implant exposure in this case series.

METHODS

The case notes of three patients who received Tutoplast^® pericardium patch graft to repair implant exposure were reviewed. Data regarding presenting symptoms, implant type, time to exposure from primary surgery, post-operative complications and length of follow up post Tutoplast^® pericardium patch graft were collected.

RESULTS

Three patients presented with implant exposure following evisceration. The presenting symptoms were recurrent infection, discharging socket and discomfort in all three patients. One patient had a Medpore implant, two had silicone implants. Total follow-up ranged from 9 to 22 months. In all three cases, there was relief from symptoms and the graft had incorporated fully into the surrounding orbital tissue with no recurrent exposure noted during the follow-up period.

CONCLUSION

Tutoplast^® pericardium has demonstrated a good safety profile and is a suitable material to use as a patch graft for orbital implant exposure.

To implant or not to implant: emergency orbital eviscerations with primary orbital implants

BACKGROUND/OBJECTIVES

To evaluate the outcomes of orbital evisceration with primary implant placement in acutely infected/inflamed eyes, using implant exposure/extrusion as a surrogate of success. To contextualise this with previously published literature.

SUBJECTS/METHODS

A retrospective case series of all patients with acutely infected/inflamed eyes undergoing urgent orbital evisceration with primary implants, at a British tertiary centre between January 2006 and August 2018. A systematic literature review of orbital eviscerations with primary implant placement in acute endophthalmitis/infection and recent trauma.

RESULTS

Twenty-six eyes were eviscerated in the context of acute infection/inflammation. Twenty-four eyes had primary orbital implants. Indications for evisceration included endophthalmitis (18/26, 69%), microbial keratitis with corneal perforation (4/26, 15%), non-infectious corneal perforation (3/26, 12%), and recent trauma (1/26, 4.8%). The implants used were acrylic (15/24, 63%), MEDPOR (5/24, 21%), and silicone (4/24, 17%). The follow-up period was 15 months to 14 years. Implant exposure occurred in two (8.3%), managed with implant exchange and scleral reformation in one, and implant removal with dermis fat grafting in the other. One patient (4.2%) had conjunctival wound dehiscence with spontaneous healing. Six (25%) required further surgery for minor complications as follows: conjunctival prolapse, upper lid ptosis with slight sulcus loss, lower lid entropion with shortened fornix, and lower lid ectropion. The systematic literature review showed that the mean rate of orbital implant exposure/extrusion in this subset of patients was 7.8% (95% CI: 2.7%, 12.9%, SD 8.0%), range 0-27%.

CONCLUSIONS

In acutely infected/inflamed eyes, the implant exposure/extrusion rate following orbital evisceration with primary implant placement is acceptable.