Anophthalmic Orbit Research Articles

Reconstruction of Anophthalmic Sockets With Pedicled Nasoseptal Flap.

Patients who undergo eye removal often present with orbital soft-tissue insufficiency and contraction of the eye sockets. The most commonly used reconstruction strategy is grafting the orbit with free grafts, which is associated with the drawback of harvesting tissue from an unconnected site. This study describes the use of the vascularized nasoseptal flap in the reconstruction and enlargement of the contracted anophthalmic cavity in patients with severe or recurrent contracted eye sockets and evaluates its efficacy. A sphenopalatine-pedicled flap from the nasal septum was harvested and mobilized into the anophthalmic orbit for the reconstruction, coverage, and enlargement of the socket in 17 patients with anophthalmic socket syndrome. Data regarding the demographics, preoperative status, postoperative findings, follow-up, outcomes, dates of mutilant and reconstructive surgery, and relevant clinical or imaging were collected. Krishna´s classification was used to assess the postoperative outcomes. The final rating improved in all patients at a median follow-up duration of 35 months. A greater impact was observed in patients who underwent reconstructive surgery before nasoseptal flap creation. Two minor complications occurred; however, major surgical intervention was not required. Implant extrusion was observed in 2 patients. The novel strategy of applying nasoseptal flaps in the reconstruction of anophthalmic sockets results in improved socket grading and a low rate of recurrence (socket contracture or implant extrusion), and complications. The vascular nature of the flap makes it suitable for use in complex cases.

Facial Lipostructure: an Overview

Aim: Facial lipostructure (FLS) is not a new procedure. In the past, many surgeons steered clear of it because the results were poor and unpredictable . In the 80’s however FLS emerged with precise indications, improved techniques, foreseeable and stable results. Its use has become widespread because it produces natural, long-lasting outcomes with minimal donor site morbidity . FLS usually represents the last procedure or retouch in many reconstructive procedures and protocols. Moreover adipose-derived stems cells (ADSCs) represent a promising source of autologous cells for tissue repair and regeneration. Methods: In the maxillofacial area, FLS is indicated primarily to restore and rejuvenate the zygomas, periorbital region, cheeks, nose, lips, chin, mandible and jawline. Recently, it has been applied to correct localized tissue atrophy, burns, hemifacial atrophy (Parry-Romberg syndrome, scleroderma, anophthalmic orbit), and loss of substance resulting from trauma, tumor excision, and congenital craniofacial deformity sequelae. Orthognathic surgery and fat grafting represent a new application and an appropriate indication. It is well known that this surgery moves the skeletal bases (maxilla, mandible, chin) but often this leads to a lack of soft tissue coverage. Some patients, particularly women, complain about this lack of soft tissue volume after bony surgery. Conclusion: FLS was launched as a means to improve volumes and facial aesthetics. Recently, it has been applied in more complex reconstructive and regenerative procedures. It can especially be used on any facial area lacking soft tissue due to posttraumatic outcomes, post tumor deformities, and as a refinement in for many acquired and congenital maxillofacial deformities. The proposed uses for ADSCs in tissue repair and regeneration are quite impressive. Recent works on ADSCs would suggest that adult cells may prove to be an equally powerful regenerative tool in treating congenital and acquired maxillofacial disorders. More importantly, physicians, researchers and international associations need to work to inform clinicians about what practices are evidence based and to encourage support of additional research. Today tissue engineering and regenerative medicine are a multidisciplinary science that is evolving along with biotechnologic advances.

Issues of rehabilitation of the patients with symblepharon using oral mucosal autografts.

To systematize clinical variants of symblepharon and to analyze rehabilitation availability boundaries in patients with different forms of symblepharons. Retrospective analysis of clinical cases included 26 patients with local, subtotal, and total symblepharon (ankyloblepharon) with a normal or anophthalmic orbit. In all patients, symblepharon was operated using split- or full-thickness oral mucosal autografts and their fixation with U-shaped stitches and compression plates. Preoperatively and postoperatively, best-corrected visual acuity, IOP, extraocular motility, results of Schirmer I test, and tear break-up time with slit-lamp biomicroscopy were analyzed, as well as additional ultrasound and electrophysiological studies were performed in some cases. Follow-up period lasted from 1.5 to 6 years. The proposed surgical technique using mucosal autografts in all patients allowed complete anatomical restoration of conjunctival fornices and cavity. It resulted in improvement of visual function in patients with local symblepharon, full restoration of ocular motility in patients with a presence of the eye and provided an opportunity to wear artificial eye in patients with anophthalmia. Nonetheless, loss of conjunctival Krause's and Wolfring lacrimal glands, goblet cells, meibomian glands, and limbal stem cells prevents from further optic keratoplasty in patients with total or subtotal symblepharon on potentially sighted eye. The most difficult patients for visual rehabilitation were the ones with subtotal or total symblepharon (ankyloblepharon) on potentially sighted eye due to the loss of conjunctival goblet cells, meibomian glands, and limbal stem cells.

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.

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

ObjectiveThe aim of this study was to examine the role of autologous dermis-fat grafts in the reconstruction of orbital soft-tissue defects. PatientsThirty-six patients (3–84 years) were enrolled in this retrospective study from 2002 to 2014. The dermis-fat graft was primarily transplanted in seven cases, and secondarily in 29 patients. All the patients were evaluated for complications, adequate prosthetic cavity, possibility of artificial eye supply and movement, as well as cosmetic results. Follow-up periods ranged from 25 to 144 months. ResultsAll the patients could be supplied with an artificial eye in the long term after dermis-fat transplantation. The clinical evaluation revealed 17 complications allocated to 11 patients. A major complication occurred in three patients (8.3%) so that a surgical correction was necessary. Thirty-three patients (91.7%) showed an aesthetically stable long-term outcome. ConclusionDermis-fat grafts for reconstruction of anophthalmic orbit represent a reliable method with a low complication rate and good cosmetic and functional results. The graft can be used as primary and secondary transplants. The stable long-term results and high aesthetic satisfaction lead us to recommend this method as a routine operation.

Surgical rehabilitation for anophthalmic sockets devoid of orbital implant

PurposeTo determine the necessity of rehabilitative surgical procedures for no implant anophthalmic sockets, and predictive factors of corrective operations after secondary orbital implantation. Material and methodsNineteen unilateral anophthalmic patients without orbital implant were included. The distance of eyebrow, upper eyelid margin, and lower eyelid margin from the horizontal medial canthal line (BM, UM, and LM, respectively) was measured using photographs. The anophthalmic orbit anatomy was compared with that of the healthy side using CT scans. ResultsFive (26.3%) patients showed satisfactory results with the secondary implantation alone. Fourteen (74%) patients needed additional surgeries for ptosis, shallow inferior fornix, enophthalmos, or lower eyelid malposition. Separated superior muscle complex and prominent intermuscular septum connecting the levator and the lateral rectus muscles were noticeable in CT scans. Predictive factors for ptosis surgery included longer BM (p = 0.04), shorter distance from the superior orbital wall to the upper margin of the prosthesis (p < 0.01), and a longer height of the prosthesis (p = 0.04). ConclusionMost patients needed multiple operations after secondary implantation for rehabilitation. Additional ptosis operation may be required for patients with a high brow on the anophthalmic side, a vertically long prosthesis, and an impinged prosthesis against the superior orbital wall.

Compliance With Protective Lens Wear in Anophthalmic Patients.

To evaluate the frequency of protective lens wear by anophthalmic patients and identify factors that influence compliance. An IRB approved descriptive retrospective chart review of patients undergoing surgery with the senior author (PLC) with an anophthalmic orbit and one remaining sighted eye. Results were tabulated and analyzed using age, indication for procedure, duration of visual symptoms, safety glasses wear, number of postoperative visits, and evidence of new trauma to the remaining eye. All patients underwent counseling on the importance of protective lens wear preoperatively and each subsequent visit. Etiologies for loss of the eye in the 132 study patients included trauma (33.3%), blind painful eye (33.3%), congenital disorders (14.4%), adult-onset malignancy (14.4%), and retinoblastoma (4.5%). At the final visit, protective lenses were worn in the following patterns: full-time (55.3%), frequently (11.4%), occasional (6%), and never (28.8%). The regular use of protective eyewear at last visit was more common in patients wearing glasses at presentation (79.7%), than in those who did not (32.9%; p ≤ 0.001). Increased number of office encounters correlated with more frequent use of protective eyewear (p ≤ 0.01). Patient age (p = 0.95), indication for surgery (p = 0.97), and duration of visual loss (p = 0.85) were not predictive of safety glasses wear. Three patients had evidence of subsequent ocular trauma to the remaining eye, with 2 having resultant decrease in acuity; none of these 3 patients wore safety glasses full-time. A significant number of anopthalmic patients were not wearing protective lenses at presentation. Overall compliance was poor; but repeated education on the importance of safety glasses appears to improve compliance. Educating referring providers and primary care physicians about the importance of early and repeated counseling is vital to increasing compliance.

Treatment of a Penetrating Intraorbital Injury by Rubber Projectile

Penetrating injuries caused by rubber projectiles are classified as low-velocity injuries. When the midface is affected, these can cause fractures, eye injuries, and even blindness. Unlike conventional projectiles, the removal of rubber projectiles involving the orbit and correction of associated fractures are mandatory for preventing infection and anophthalmic orbit syndrome, which is characterized by enophthalmos of the prosthesis, superior sulcus depression, and lower eyelid ptosis. This article aims to describe a case of penetrating injury by rubber projectile, associated with the removal and late reconstruction of the orbital walls, and to show the results obtained.

Manufacturing of an ocular prosthesis based on the 3D printed anophthalmic socket

PurposeIn anophthalmos, the ideal ocular prosthesis restores the facial appearance and eye motility, and is comfortable to wear. This can best be achieved with a bespoke prosthesis. The initial step usually involves injection of dental impression material to obtain a mould of the anophthalmic socket. However, the socket impression method distorts the soft tissues, so that additional alterations to the prosthesis are required via the trial and error method. Developing an impression‐free method of the anophthalmic socket.MethodsA cone‐beam CT of the anophthalmic orbit is taken, and with computer‐aided design and computer‐aided manufacturing (CAD/CAM) the anophthalmic socket is printed three dimensionally (3D). The 3D‐printed socket is subsequently used as a trial working prosthesis in the conventional way.ResultsWith this novel technique, a prosthesis was successfully fitted in a 68‐year‐old male who had undergone a recent evisceration.ConclusionsComputer‐aided design and 3D printing can accurately outline the anophthalmic cavity. Validating the impression‐free moulding technique is subjected to further studies.

Use of the anterolateral thigh flap for reconstruction of the pediatric anophthalmic orbit

Children with acquired anophthalmia pose unique reconstructive challenges. With implant-based reconstruction, the current standard of care, there is a tendency toward intraorbital and adnexal tissue contraction and an increasing volume discrepancy with orbital growth, resulting in enophthalmos and eyelid retraction, and also difficulty in retaining an ocular prosthesis. We describe a novel technique for secondary reconstruction of the pediatric anophthalmic orbit using a small free anterolateral thigh (ALT) flap. The technique involves release of retracted eyelids and restoration of orbital volume with an ALT flap based on the superficial temporal vessels. The purpose of this study is to detail the results of treatment of a series of four consecutive patients with unilateral acquired anophthalmia managed with ALT flaps. Improved symmetry, successful retention of an ocular prosthesis, and patient satisfaction were achieved in all cases.

Copper-containing mesoporous bioactive glass coatings on orbital implants for improving drug delivery capacity and antibacterial activity

Anophthalmic orbit restoration with artificial implants is usually accompanied with the risks of bacterial penetration and implant exposure. Here, we develop a facile evaporation-inducing self-assembly approach to modify the porous hydroxyapatite (pHA) orbital implants by using sol-gel derived CuO-containing mesoporous bioactive glass (Cu-MBG). The Cu-MBG coatings with 0-5 mol% CuO were prepared in the pore wall of pHA by immersion-evaporation-ageing route in the sol precursor of Cu-MBG. Brunauer-Emmett-Teller and Barrette-Joyner-Halenda analyses showed that the specific surface area and pore volume were slightly decreased with increasing CuO content, while the Cu-MBG-modified pHA maintained a sustained release of ofloxacin and significantly inhibited the bacterial viability (Staphylococcus aureus and Escherichia coli). These studies demonstrate that the Cu-MBG modification provides an effective and facile strategy to endow combined biological performances of pHA orbital implants and potentially reduce implant-related side effects.

Congenital Zygomatico-Mandibular Fusion (Pseudo-Syngnathia?) in Conjunction with Unilateral Anophthalmia: Review of Terminology and Classification

Syngnathia per se is a rare congenital disorder. A literature survey reveals a total of 26 cases of syngnathia in the English literature since 1936, of which only seven cases involved fusion of the ascending ramus of the mandible to the posterior portion of the maxilla and zygomatic complex. The remaining 19 involved fusion of the alveolar ridges of the maxilla and mandible. This is a unique case of fusion of the mandible to the zygomatic complex presenting with a unilateral anophthalmic orbit in an 18-day-old neonate. The use of the term syngnathia has been reviewed and a modification in classification has been suggested.

Total Upper and Lower Eyelid Reconstruction Using an Expanded Forehead Flap

Surgical modalities have been described with varying success for the correction of eyelid defects. The reconstructive surgeon must choose the procedure on a case-by-case basis taking into consideration the following criteria: mechanism of injury, comorbidities, and goals of surgery. In this study, we describe a unique case of total upper and lower eyelid reconstruction using an expanded forehead flap technique in an adult patient who underwent left eye enucleation and radiation to the orbit for rhabdomyosarcoma in infancy. After this patient reached adulthood, examination revealed a contracted, anophthalmic left orbit with paper-thin upper and lower eyelids adhering to the concave walls of the orbit. There was absence of significant periorbital soft tissue. The expanded forehead flap procedure achieved our aims of providing not only an aesthetic result, but also adequate soft tissue support for placement of an ocular prosthesis.

The Importance of Accurate, Early Bony Reconstruction in Orbital Injuries with Globe Loss

Patients who sustain facial fractures frequently suffer from visual disturbance. Additionally, orbital fractures often involve ocular injury, which, not infrequently, may require enucleation. Yet an anophthalmic orbit does not obviate the need for aggressive orbital fracture treatment. In fact, treatment of the sequelae of the anophthalmic orbit can be difficult and require multiple surgeries. Intraoperative use of a conformer after accurate bony reduction and orbital reconstruction with bone grafts or orbital implants are essential steps to allow for prosthetic rehabilitation of the anophthalmic orbit.

Orbital Augmentation With Injectable Calcium Hydroxylapatite for Correction of Postenucleation/Evisceration Socket Syndrome

To demonstrate the utility of injectable calcium hydroxylapatite (Radiesse) for orbital volume augmentation to correct postenucleation/evisceration socket syndrome (PESS). A retrospective chart review of all consecutive patients in our practice who received injectable calcium hydroxylapatite placed in the extraconal space to augment orbital volume was conducted. Patients with at least 6 months follow-up were included in the study. Among 26 patients with PESS who received injectable calcium hydroxylapatite for orbital volume augmentation, 15 individuals were identified with adequate follow-up. The mean amount of preoperative relative enophthalmos measured by Hertel exophthalmometry was 4 mm (range 0.5-7 mm). An average reduction of 2.4 mm of enophthalmos per syringe of filler was achieved. The mean follow-up obtained was 46 weeks (range 24-78 weeks). Most patients demonstrated clinical and aesthetic improvement that was observed to continue up to 1.5 years. Complications observed included anterior migration of filler, a peribulbar hemorrhage, and orbital discomfort. Two patients demonstrated little response to filler. Injectable calcium hydroxylapatite provides a novel, safe, simple, cost-effective technique to treat volume deficiency in the anophthalmic orbit. Augmentation achieved with this semipermanent filler has demonstrated a lasting effect in the orbit with little volume loss. Volume replacement can be titrated to the socket requirements. Correction of PESS using this technique may be limited in orbits that demonstrate significant fibrosis as a result of multiple surgeries, severe trauma, or radiation treatment.

Free Flap Transfer for Secondary Deformity of Post-traumatic Anophthalmic Orbit without Eyelid / orbital Bone Defect

Free Flap Transfer for Secondary Deformity of Post-traumatic Anophthalmic Orbit without Eyelid / orbital Bone Defect

Anophthalmic Orbit Syndrome: A New Free Tissue Transfer

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Evaluation of the Role of ProKera in the Management of Ocular Surface and Orbital Disorders

To report the efficacy and safety profile of sutureless and adhesiveless amniotic membrane device (ProKera, Bio-Tissue, Inc., Miami, FL) in the management of various ocular surface and orbital disorders. Twenty eyes of 20 patients underwent placement of 21 ProKera implants between March 2006 and July 2007 at the University of Texas Southwestern Medical Center. Patient demographics, indications for placement, and duration of ProKera retention were recorded. Outcomes measured included corneal epithelial healing, visual acuity, patient tolerance, and adverse events. ProKera was most commonly used in patients with corneal neovascularization with or without limbal stem-cell deficiency (10 eyes). Other indications included recurrent pterygium or pseudopterygium (three eyes), anophthalmic orbit contraction (two eyes), persistent epithelial defects (two eyes), severe thinning in a corneal ulcer (one eye), benign hereditary intraepithelial dyskeratosis (one eye), and band keratopathy (one eye). The mean duration of ProKera retention was 25.3 days (range, 0-125) visual acuity improved in 12 eyes (60%). Immediate adverse events included residual epithelial defects after removal (five eyes) and spontaneous extrusion of the implant (four eyes). Six patients (30%) reported eye pain or headache and four eyes (20%) had recurrence of the primary pathology. Sutureless and adhesiveless amniotic membrane transplantation is a safe and effective method to promote healing and reconstruction of the ocular surface and orbit with minimal side effects. Recurrence of the underlying primary pathology remains a concern. The advent of a newer, softer conformer ring may improve patient tolerability and limit discomfort.

Martin Kelly, F.R.C.S., 1965 to 2008

Martin Kelly, F.R.C.S., 1965 to 2008

Decrease in Levator Function in the Anophthalmic Orbit

Background/Aims: It has been argued that levator function in anophthalmic patients is reduced, but no detailed report on this topic has been issued. This study was undertaken to investigate measured levator function in anophthalmic patients, and to determine how measured values are related to prosthesis size. Methods: Unilateral anophthalmic patients with no significant ptosis, and no history of trauma or surgery to orbit or eyelid were recruited. Levator function was measured with patients wearing their prosthesis, test prosthesis of different heights, and no prosthesis. Results: Thirty-two patients were recruited. Levator function was found to be lower in anophthalmic orbits (10.43 ± 1.48 mm) than in contralateral normal orbits (12.74 ± 1.81 mm). Levator function was lower in anophthalmic orbits with any height or type of prosthesis than in contralateral normal orbits (paired t-test, p < 0.05). In the anophthalmic orbits, the levator functions were highest when patients wore a prosthesis of the proper height, and these functions reduced as the prostheses height reduced (linear regression, p < 0.05). Conclusion: Diminished levator function in an anophthalmic orbit doesn’t necessarily mean that levator muscle function is abnormal. When levator function is measured in an anophthalmic orbit, the fact that it is often underestimated should be taken into account.