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.

Medical comorbidities and orbital implant exposure.

PURPOSE: To investigate medical conditions and systemic therapies associated with orbital implant exposure in patients with anophthalmic sockets. METHODS: Retrospective review of patients who underwent enucleation or evisceration at a single centre between January 1, 2008 and March 1, 2018. Medical comorbidities, including peripheral or coronary artery disease, rheumatologic conditions, diabetes, malignancy and history of smoking were recorded. Use of immunomodulatory and anticoagulation therapy at the time of eye removal was noted. Patients were divided into two groups-those with implant exposure and those without. Univariate and multivariate analysis was used to compare groups. RESULTS: Two hundred and twenty-nine patients underwent eye removal surgery over a ten-year period. Implant exposure was seen in 20 (8.7%) patients. Univariate analysis revealed a statistically significant difference between groups in rates of smoking, malignancy, and immunomodulatory therapy at the time of surgery. A history of smoking (HR = 11.72; 95% CI: 2.95, 46.53; p = 0.0001) and immunomodulatory therapy (HR = 8.02; 95% CI: 1.96, 32.87; p = 0.004) were independent predictors of exposure. The probability of exposure was 81.2% when all three risk factors were present versus 4.4% when none were present (c-index = 0.737, 95% CI: 0.608, 0.865; p < 0.001). The model was a good fit to the data (Hosmer-Lemeshow goodness-of-fit test p = 0.475). CONCLUSIONS: Smoking and immunomodulatory therapy were associated with orbital implant exposure in patients with anophthalmic sockets. This is the first report examining medical comorbidities in patients with orbital implant exposure. Understanding the pathophysiology of implant exposure is crucial to preoperative planning and postoperative care.

Autologous pericranium grafts for large orbital implants.

INTRODUCTION: Insufficient orbital volume in an anophthalmic socket is a major problem for the placement of an ocular prosthesis. This study reports the outcomes of the use of autologous pericranium graft in association with a large primary or secondary orbital implant in patients with a contracted socket and large orbital volume deficit. METHODS: This was a retrospective single-institution study. Participants were 13 patients with contracted socket, volume deficit, and insufficient conjunctiva to cover the new implant divided into two groups, A (n = 3) and B (n = 10), according to the baseline condition of the socket. Surgery was primary evisceration (group A only) and placement of a large orbital implant followed by an autologous pericranium graft over the implant (groups A and B). RESULTS: Mean follow-up duration for the patient series was 9.5 months (range 9-24). Complete epithelialization of the pericranium graft was recorded at 47.3 days of follow-up (range 33-67). No cases of implant exposure or shrinkage were noted during follow-up. Main postoperative complications were conjunctival granuloma (five patients, 38.5%), conjunctival seroma (one patient, 7.7%). All patients were satisfied with the aesthetic outcome. CONCLUSION: Autologous pericranial graft was effective in reconstructing the contracted socket so that the anophthalmic socket could accommodate a larger or secondary orbital implant. The efficacy of this procedure needs to be confirmed in a larger patient series.

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.

Treatment of Exposed Hydroxyapatite Orbital Implants Wrapped with a Synthetic Dura Substitute.

PURPOSE: To describe cases of exposed hydroxyapatite (HA) implants wrapped with the synthetic dura substitute Neuro-Patch treated via simple Neuro-Patch removal. METHODS: The medical records of seven patients who experienced exposure of their HA implant were reviewed. All patients had been enucleated and implanted with HA wrapped with Neuro-Patch. For treatment, Neuro-Patch was removed to the greatest extent possible. After applying local anesthesia with lidocaine, blunt dissection was performed to separate the conjunctiva and Neuro-Patch via the site of exposure. Pressure was applied to the remaining Neuro-Patch with forceps and removed with scissors. RESULTS: Neuro-Patch was visible at the area of exposure in all patients. No surgery beyond initial Neuro-Patch removal was necessary in six of the seven patients. In five cases, the exposed area began to heal rapidly after Neuro-patch removal without primary closure of the defect. In one case, the Neuro-Patch material and all necrotic tissue was removed aggressively due to inflammation around the orbital implant. Lastly, an infection was noted in one case, prompting complete removal of the Neuro-Patch-wrapped HA implant. CONCLUSIONS: Wrapping material may hinder implant vascularization. Exposure of HA in wrapped implants can be successfully treated by a simple removal procedure if detected and managed early.

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

Purpose: The study aims to analyze risk factors for exposure of orbital implants after evisceration by comparison of patients with and without exposure of implants. Methods: This is a case control study in retrospective interventional case series; Group A- implant exposures after evisceration, Group B - Patients on follow up after evisceration with implant, without exposure, with matched duration of follow up. The sample size is calculated for a power of 80. Results: Group A comprised 32 sockets with implant exposure, presenting at median 18 months after surgery; Group B included 61 eviscerated sockets, without implant exposure, with follow up median 36 months. Odds Ratio (OR) was calculated; infected eyes -OR 1.3, P = 0.6; phthisical eye - OR 1.4, P = 0.43; multiple prior surgeries- OR 1.55, P = 0.33. Group A had 59.3% porous implants, Group B 55.7%, - OR 1.3, P = 0.5. Mean implant size in Group A 19.06 mm, Group B 18.78 mm- showed no statistical difference. Multiple logistic regression analysis showed no significant risk factor for exposure. Surgeon factor was not analyzed since there were multiple surgeons. Conclusion: This is the first study with calculated sample size, comparing implant exposure patients to a control group. Porous implant material, presence of infection, phthisical scleral shell, and prior surgery showed higher trend of exposure (Odds ratio >1), but none was conclusive. Larger size of implant was not a risk factor for exposure. Eliminating the role of several factors in implant exposure allows the surgeon to make better surgical choices: such as place an implant of appropriate size, of a material of surgeon's choice, and do primary placement of implant in a patient with evisceration post-corneal ulcer or endophthalmitis. A hypothesis and a recommendation is that meticulous attention be paid to surgical technique.

Primary replacement for the management of exposed orbital implant.

Purpose: We present a series of primary orbital implant replacement for cases of implant exposure to describe our experience of this one-staged surgical approach. Methods: This study reports on a one-stage technique which involved the removal of the exposed implant or dermis fat graft (DFG) and insertion of a secondary (replacement) in the same procedure, with a variety of materials, including autologous tissue. Re-exposure in a socket where a DFG was placed was defined as a new defect in the newly epithelialized conjunctiva or dehiscence of the dermis-conjunctiva junction. All cases of primary replacement for the management of exposed orbital implant, porous and non-porous, were included, even when there were clinical signs suggestive of infection. The primary outcome was the rate of re-exposure, requiring additional surgical procedures. Infection following primary replacement was a secondary outcome. Results: Seventy-eight patients had primary replacement for the management of an exposed orbital implant. 6.4% had re-exposure at a mean follow-up of 49.7 months (9.1% for ball implants and 4.5% for DFG). The rate of exposure was higher in those with prior signs of infection than those without (8% vs. 3.6%). Re-exposure occurred in 4.5% of cases with DFG implantation, 4.3% of cases with non-porous implants and in 20% of cases with porous implants. Conclusion: Primary replacement for management of exposed orbital implant, porous and non-porous, has a high rate of successful outcome even in cases with presumed or confirmed infection.

Treatment of Exposed Hydroxyapatite Orbital Implants Wrapped with a Synthetic Dura Substitute

PURPOSE: To describe cases of exposed hydroxyapatite (HA) implants wrapped with the synthetic dura substitute Neuro-Patch treated via simple Neuro-Patch removal. METHODS: The medical records of seven patients who experienced exposure of their HA implant were reviewed. All patients had been enucleated and implanted with HA wrapped with Neuro-Patch. For treatment, Neuro-Patch was removed to the greatest extent possible. After applying local anesthesia with lidocaine, blunt dissection was performed to separate the conjunctiva and Neuro-Patch via the site of exposure. Pressure was applied to the remaining Neuro-Patch with forceps and removed with scissors. RESULTS: Neuro-Patch was visible at the area of exposure in all patients. No surgery beyond initial Neuro-Patch removal was necessary in six of the seven patients. In five cases, the exposed area began to heal rapidly after Neuro-patch removal without primary closure of the defect. In one case, the Neuro-Patch material and all necrotic tissue was removed aggressively due to inflammation around the orbital implant. Lastly, an infection was noted in one case, prompting complete removal of the Neuro-Patch–wrapped HA implant. CONCLUSIONS: Wrapping material may hinder implant vascularization. Exposure of HA in wrapped implants can be successfully treated by a simple removal procedure if detected and managed early.

Orbital implant exposure after Acanthamoeba panophthalmitis.

PURPOSE: Acanthamoeba is a protozoa that can lead to severe ocular disease and sequelae. Although intraocular Acanthamoeba infection is rare, the following case demonstrates an unusual presentation of recurrent Acanthamoeba infection in a 30 year old contact lens wearing male. OBSERVATIONS: After presenting with recurrent Acanthamoeba keratitis and undergoing various treatments, the patient developed nodular scleritis, which evolved into panophthalmitis, and ultimately, required enucleation. Eight months post-operatively, the patient developed orbital implant exposure secondary to persistent Acanthamoeba infection and underwent removal of the implant and aggressive, systemic treatment involving a multispecialty care team. He then underwent placement of a dermis fat graft and had no signs of persistent infection at the time of last follow-up, which was 24 months after placement of the dermis fat graft. CONCLUSIONS: and Importance: To the authors' knowledge, this is the first known case of Acanthamoeba infection causing orbital implant exposure. Persistent infection should be considered in Acanthamoeba patients who have undergone enucleation and have orbital implant exposure. Better knowledge regarding the pathogenesis and extracorneal complications of this challenging disease may improve patient care and outcomes.

Orbital implant exposure following enucleation or evisceration.

PURPOSE: To study the exposure rate of orbital implant postenucleation or evisceration procedures in two tertiary hospitals in Oman. DESIGN: A retrospective, descriptive, cross-section study. MATERIALS AND METHODS: Patients' records were reviewed for patients' demographics, surgical indications, implant types, follow-up and any reported complications after surgeries. Patients with a minimum of 1 year follow-up period were selected. All patients who underwent enucleation or evisceration with primary orbital implant were included in the study. Patients who underwent secondary orbital implant were excluded from the study. RESULTS: A total of 37 patients (age between 4 and 88-year-old, median age is 54-year-old) underwent enucleation or evisceration during 2008-2014. The most common indications for the surgical intervention were painful blind eye (35%), followed by trauma (16%), and perforated corneal ulcer (16%). Out of 37 patients, hydroxyapatite implant was implanted in 17 patients (46%), a glass or acrylic implant was implanted in 17 patients (46%), bioceramic implant was implanted in two patients (5%), and Molteno prosthesis was implanted in one patient (3%). There was no case of orbital implant exposure in any patients in this study. CONCLUSIONS: No orbital implant exposure was recorded in this study. The surgical technique, end to end rectus muscles suturing, used for enucleation/evisceration was the main reason for reduced implant exposure. In addition, the preexisting ocular pathology did not affect the outcome of the study.

Helium-neon laser therapy in the treatment of hydroxyapatite orbital implant exposure: A superior option.

The aim of the present study was to evaluate the efficacy of helium-neon laser therapy in the treatment of hydroxyapatite orbital implant exposure and compare the results with those of a combined drugs and surgery regimen. A total of 70 patients with hydroxyapatite orbital implant exposure in 70 eyes were randomly divided into two groups: Helium-neon laser therapy (group A) and drugs plus surgery (group B). Each group contained 35 patients. The healing rates and times of the conjunctival wound were recorded and compared following helium-neon laser treatment or the drugs plus surgery regimen. Changes in the hydroxyapatite orbital implant prior to and following helium-neon laser irradiation were analyzed. A similar animal study was conducted using 24 New Zealand white rabbits, which received orbital implants and were then received drug treatment or helium-neon therapy. In the human experiment, the rates for conjunctival wound healing were 97.14% in group A and 74.29% in group B, with a significant difference between the groups (χ2=5.71, P<0.05). Patients with mild exposure were healed after 7.22±2.11 days of helium-neon laser therapy and 14.33±3.20 days of drugs plus surgery. A statistically significant difference was found between the groups (t=8.97, P<0.05). Patients with moderate to severe exposure were healed after 18.19±2.12 days of helium-neon laser therapy and 31.25±4.21 days of drugs plus surgery. The difference between the groups was statistically significant (t=7.91, P<0.05). Enhanced magnetic resonance imaging showed that the helium-neon laser therapy significantly promoted vascularization of the hydroxyapatite orbital implant. These results, combined with pathological findings in animals, which showed that a helium-neon laser promoted vascularization and had anti-inflammatory effects, suggest that helium-neon laser irradiation is an effective method for treating hydroxyapatite orbital implant exposure, thereby avoiding secondary surgery.

Pericranium grafts for exposed orbital implants: An observational case-series study.

OBJECTIVE: The aim of this article is to highlight our experience with autologous pericranium graft in wide exposures (≥3 mm). The pericranium graft was taken from the parietal region of the scalp in six consecutive clinical cases of orbital implant exposure in anophthalmic sockets. MATERIAL AND METHODS: This is a prospective, descriptive case series study of patients who had orbital implant exposures and were treated with autologous pericranium graft. RESULTS: The average postoperative follow-up period was 10 months, and the mean time for conjunctivalization of the graft was 3 months. In all cases, complete conjunctivalization was achieved, and no re-exposure of the implant was observed. CONCLUSIONS: The pericranium graft from the parietal region is an effective technique to treat both small and large orbital implant exposures with no comorbidity. Time to complete conjunctivalization is similar to that of other autologous grafts. It is a simple and convenient method for the oculoplastic surgeon that constitutes a good alternative for covering anophthalmic cavities. Further studies with more cases and longer follow-up are required to confirm the effectiveness of this technique.

The versatility of the temporoparietal fascial graft (TPFG) in orbital implant exposure.

BACKGROUND: The use of TPFGs for hydroxyapatite, porous polyethylene and silicone implant exposure has been described previously. To the authors' knowledge, this is the first description of this technique for acrylic implant exposure and paediatric patients. PURPOSE: To demonstrate the versatility of the TPFG in orbital implant exposures of varying duration, implant types and patient age as well as for recurrent exposure. METHODS: Retrospective, interventional, non-comparative case series. RESULTS: Twelve patients (13 grafts) are presented with a mean follow-up of 9.5 months. The duration of exposure prior to grafting ranged from 1-11 months occurring in bioceramic, hydroxyapatite, porous polyethylene and acrylic implant types. There were 2 graft failures (success rate 84.6%), one of which was treated with a 2nd TPFG. Two of the cases were from the paediatric age group. CONCLUSION: This study provides further supporting evidence for the safety and efficacy of the TPFG and demonstrates the use of this graft in a variety of different clinical situations.

Autologous serum for anterior tissue necrosis after porous orbital implant.

Orbital implants are now routinely used after enucleation and evisceration. However exposure of the implant can lead to infection and extrusion. Hence, early repair of larger exposure with graft material is required. We describe three cases where early postoperative mucosal dehiscence was successfully managed with autologous serum.

The effect and applications of acellular dermal allograft (AlloDerm) in ophthalmic plastic surgery.

PURPOSE: To describe the use and efficacy of AlloDerm in ophthalmic plastic and reconstructive surgery. METHODS: A retrospective review was conducted of 31 eyes of 25 patients who underwent an AlloDerm graft procedure for correction of lower lid retraction, anophthalmic socket contraction, superior sulcus deformity, implant exposure, or skin defect. Clinical outcomes were measured by the degree of improvement and incidence of complications. Operation success and reoperation rates were also evaluated. RESULTS: There were 15 cases of lower lid retraction, 10 anophthalmic socket contractions, 2 superior sulcus deformities, 2 orbital implant exposures, and 2 periorbital skin defects. The mean age of the patients was 44.7 (±2.8) years. The mean follow-up period was 16.7 (±2.5) months. Twenty-seven eyes (87.1%) had successful outcomes and 4 eyes of 4 patients required further surgery. Three of those were due to undercorrection, and the other was due to severe adhesion. Applications of AlloDerm skin substitute were satisfactory at the 6-month follow-up examination. There were no statistically significant factors, such as underlying causes or degrees and locations of defects that impacted on outcome. CONCLUSIONS: AlloDerm is an excellent material for correction of lid retraction, contracted socket, superior sulcus deformity, and implant exposure. In patients for whom periorbital skin grafts or flaps are inappropriate or difficult to perform, the use of AlloDerm to cover skin defects may be a good option.

Treatment of intractable orbital implant exposure with a large conjunctival defect by secondary insertion of the implant after preceding dermis fat graft.

AIM: To report a procedure and results of a two-stage operation to manage intractable extensive orbital implant exposure with a large conjunctival defect which was difficult to treat with dermis fat grafts due to repeated graft necrosis. METHODS: A retrospective chart review of four patients who had extensive orbital implant exposures with large conjunctival defects and had past histories of repeated autologous or preserved dermis graft failures was done. As a first-stage operation, the problematic pre-existing orbital implants were removed and autologous dermis fat grafts alone were performed on the defect area. Four months later, new orbital implants were secondarily inserted after confirmation of graft survival. The size of the conjunctival defects and state of the extraocular muscles were checked preoperatively. Success of the operations and complications were investigated. RESULTS: The mean size of the conjuctival defects was 17.3mm×16.0mm, and the mean time from the initial diagnosis of orbital implant exposure to implant removal and autologous dermis fat graft was 20.8 months. After implant removal and autologous dermis fat graft, no graft necrosis was observed in any patients. Also, implant exposure or fornix shortening was not observed in any patients after new orbital implant insertion. CONCLUSION: The secondary insertion of a new orbital implant after pre-existing implant removal and preceding dermis fat graft is thought to be an another selective management of intractable orbital implant exposure in which dermis fat grafts persistently fail.

The Effect of 4 Rectus Muscle Anterior Displacement in Porous Polyethylene Orbital Implant Exposure

PURPOSE: To investigate the effects of anterior displacement of four rectus muscles in exposure of porous polyethylene orbital implant (Medpor(R)). CASE SUMMARY: This retrospective study reviewed 4 eyes with exposed orbital implant who underwent evisceration with porous polyethylene orbital implant (Medpor(R)). The technique involves dissection of conjunctiva and tenon's capsule and isolation of four rectus muscles from sclera. Unsure if each muscle was sutured to each other or if a group of muscles were sutured to another group (i.e. superior and inferior to medial and lateral). Posterior tenon's capsule was closed interruptedly and conjunctiva was closed continuously. Orbital implant exposure was occurred at 2~36 months later after evisceration and implant insertion. One eye was noted wound dehiscence 1 week after operation, then re-suture was done. Re-exposure was notified in 1 eye at postoperative 3 months, but it was small, then we just observed. In other 3 cases, exposure was not identified till last follow up. CONCLUSIONS: Four rectus muscle anterior displacement procedure may be simple and useful method in exposure of orbital implant.