Anophthalmic Socket Research Articles

The Evolution of Orbital Implants and Current Breakthroughs in Material Design, Selection, Characterization, and Clinical Use.

It is occasionally essential to surgically remove the damaged eye of the patient in the case of serious oculoorbital injuries, intraocular cancers, and other life-threatening diseases. An orbital implant is placed into the anophthalmic socket after the eye is removed to provide adequate volume reinstatement and revamp the cosmetic look of a normal eye. In the previous few decades, implant design and material selection criteria have progressed from basic nonporous polymeric spheres to devices with more complicated shapes and functions to ensure improved long-term clinical results. Because of their highly interconnected porous design, ceramic and polymeric porous implants have found popularity as a passive framework for fibrovascular ingrowth, with lower obstacle rates and the option of setting to improve prosthetic eye mobility. These materials, however, are not without flaws. The danger of migration and extrusion, infections after surgery, and poor motility transferred to the cosmetic ocular prosthesis are important elements of orbital implants of today. As a result, the development of novel biomaterials with improved functionalities (i.e., antibacterial effect, angiogenesis, and in situ moldability) that allow better eye replacement is more desirable than ever, highlighting one of the most challenging aspects of research topics in the field of ocular implants. This study highlights the history of orbital implants. It gives an outline of current advancements in the area, over and above some essential observations for materials design, selection, characterization, and transformation to clinical applications.

Fornix Deepening by Using Amniotic Membrane Transplant

Objective: To assess the cosmetic outcomes of fornix deepening by using Amniotic membrane transplant in anophthalmic sockets in terms of good retention of ocular prosthesis. Abstract: Methods: This interventional case series was carried out at Khalid eye clinic, Karachi during the period of March 2019 to August 2019. Twenty-five patients belonging to either gender between the ages of 20 to 50 years were included, having anophthalmic sockets with fornix deformities incapable of retaining ocular prosthesis due to variable causes such as cicatrization, symblepharon, cyst, or poor conjunctival suturing technique following evisceration or enucleation. Amniotic membrane was transplanted following the division of bands, excision of cyst and release of adhesions. Pre and post fornix measurements were done and each patient was followed for a duration of six months after the operation to observe the cosmetic appearance and retention of ocular prosthesis. Results: Good cosmetic outcome with retention of ocular prosthesis was achieved in twenty-three (92%) cases, whereas two (8%) cases ended up in failure despite multiple surgeries. The mean pre-operative lower fornix depth was 3.8 ± 1.23 mm, which improved to 8.9 ± 1.10 mm (p- value < 0.001). None of the patients developed any infection or graft rejection. Conclusion: Fornix reconstruction in an anophthalmic socket is a challenging task, but a good cosmetic outcome can be achieved using amniotic membrane transplantation together with good oculoplastic surgical expertise.

Lateral tarsal strip through osteotomies for recurrent ectropion and eyelid laxity correction

to present a surgical technique for treating patients with recurrent ectropion and severe lower eyelid laxity. Lateral tarsal strip and canthal fixation by osteotomy was performed in 6 patients with recurrent ectropion and 1 patient with extreme lower eyelid laxity secondary to an anophthalmic socket. Preoperative and postoperative photographs were evaluated in order to assess the outcomes of the procedure. Patients were followed up 4 weeks, 6 months, 12 months and 24 months of the postoperative period. The initial symptoms of the patients were eye redness, epiphora, foreign body sensation, aesthetic complaints, and facial asymmetry. Symptoms and aesthetic results were assessed by questioning, photographs, and fluorescein and lissamine green stains taken in each visit. No postoperative complications were observed. No recurrence episodes were reported during the follow-up period and physical appearance improvement and symptom severity reduction were maintained during the observation. Lateral tarsal strip through osteotomies is an effective surgical procedure for treating severe recurrent ectropion cases or lower eyelid laxity and could be considered as an alternative treatment option or even a primary surgical technique in selected difficult cases.

The Effect of The Mitomycin C on Anophthalmic Contracted Socket (Literature Review)

This study aims to provide information about the effect of the Mitomycin C on contracted sockets surgery so that Mitomycin C can inhibit migration of fibroblast and synthesis of collagen thus causing reduce fibrosis in vitro and in vivo and a significant reduction of scarring. The literature study used is the literature of the last 10 years in 2021. Literature searches were used from the Science Direct, PubMed, and Google Scholar electronic databases. The initial stage obtained 43 national and international articles that are considered relevant. The search for articles using the keywords “anophthalmic socket and mitomycin c”, and “contracted socket and mitomycin c” then continued at the screening stage, which in the end obtained 5 articles that matched the object to be discussed.. The results of this study explain that the Mitomycin C has an effect in a decrease fibroblast in contracted socket surgery and has been successful in reducing recurrence by inhibiting fibrosis.

Use of volumetric analysis in the management of recurrent dermis fat graft hypertrophy

Autologous dermis fat graft is an option commonly used for volume replacement in congenital anophthalmic sockets. Hypertrophy of the graft is a very rare complication that can be managed by debulking the graft. Volumetric analysis by computed tomography or magnetic resonance imaging helps in calculating the amount of fat to be excised while debulking. We report a case of recurrent dermis fat graft hypertrophy managed by debulking with the aid of volumetric analysis. The patient underwent dermis fat grafting at the age of 1, followed by graft hypertrophy at the age of 2 years and recurrent hypertrophy at the age of 6 years. Debulking was done with the aid of volumetric analysis when hypertrophy recurred. The patient is doing well with a stable cosmesis at the last follow-up after 1 year.

Blepharoptosis in the Setting of an Ocular Prosthesis: A Literature Review and Description of the Novel Use of a Template Prosthesis

Blepharoptosis in acquired anophthalmia is common, yet the best treatment methods remain uncertain. We review the literature for descriptions of pathophysiology or management of blepharoptosis in acquired anophthalmic sockets and describe a technique and results of using a template prosthesis to facilitate intraoperative adjustment during external levator resection ptosis repair. The PubMed database was searched in October 2021 to identify all studies in English describing the pathophysiology or treatment of anophthalmic blepharoptosis. Seventy-one articles were identified; 13 met inclusion criteria and were reviewed. We also reviewed the charts of 12 adult patients with acquired anophthalmia undergoing external levator resection using a limbal templated, non-detailed, customshaped prosthesis. We assessed results (margin to reflex distance 1 [MRD1] and symmetry), as well as the number of eye prosthesis modifications. According to the literature, levator pathophysiology and orbital volume loss are important variables in anophthalmic ptosis. Prosthesis augmentation may be useful to treat ptosis in many instances, but may be limited by decreased motility and a poorer overall prosthesis fit. A variety of blepharoptosis repair surgical techniques have been described with reported success rates of 88–100%. The use of a template prosthesis to facilitate intraoperative lid positioning in ptosis repair was effective in 12 patients. All patients had MRD1 within 1 mm of target and with good facial symmetry. There were no complications or need for revision ptosis repair or redundancy in prosthesis fabrication at 3 years (mean; minimum 6-month) follow-up.

The consequences of dermis fat graft in the reconstruction of anophthalmic socket with large orbital implant exposure

The consequences of dermis fat graft in the reconstruction of anophthalmic socket with large orbital implant exposure

Evaluation of Topical Mitomycin-C Eye Drops After Reconstructive Surgery for Anophthalmic Contracted Socket.

PurposeTo report the outcomes of using topical mitomycin-C (MMC) after reconstructive surgery for contracted socket and to compare the results with those of the conventional postoperative treatment.Patients and MethodsThe medical records of patients who underwent reconstructive surgery for contracted anophthalmic socket were retrospectively reviewed. Based on the postoperative treatment protocol, two groups of patients were identified; group I (15 patients) who received topical MMC drops (0.02%) 4 times daily for 6 weeks and group II (15 patients) who received the conventional treatment (topical antibiotic-steroid combination). Preoperative data were extracted for age, gender, cause and timing of anophthalmia, history of previous surgeries, preoperative forniceal depth and socket volume (SV). The main postoperative outcome measures were superior fornix depth (SFD), inferior fornix depth (IFD) and SV at the end of 6th postoperative month. Prosthesis fitting and complications were also considered for analysis.ResultsThe mean preoperative IFD was 1.67±0.04 mm in group I and 1.58±0.37 mm in group II, by the end of the 6th postoperative month it increased to 6.1 ±0.27 mm and 5.12 ±0.25mm, respectively. The mean preoperative SFD in group I was 8.3±0.9 mm and 8.9±1.1 mm in group II, by the end of the 6th postoperative month SFD became 13.4±1.2 mm and 10.2±1.4 mm in groups I and II, respectively. The mean SV measured six months postoperatively was 1.9±0.2 mL and 1.3±0.09 mL in groups I and II, respectively. These differences in the postoperative SFD, IFD and SV between both groups were statistically significant. More cases reported successful fitting in group I than in group II but this difference was not statistically significant.ConclusionPostoperative use of topical MMC is associated with higher forniceal depth and greater SV when compared to the conventional treatment in socket reconstructive surgeries with amniotic membrane graft (AMG).

Amplitude of movements with conical or spherical implants in anophthalmic socket

ABSTRACT Purpose: To evaluate the amplitude of movement in anophthalmic sockets reconstructed with conical or spherical orbital implants with and without an external ocular prosthesis (EOP), and whether the fornix depth could play a role. Methods: Prospective observational study involving unilateral anophthalmic sockets evaluated the amplitude of movement with conical (20 subjects) or spherical (16) non-porous orbital implants, with and without an EOP, having the contralateral eye as the control group. Standardized photographs were obtained in the four gaze directions and measurements were performed using the Image J software. The upper and lower fornix depths were measured using rulers. Results: Compared to the contralateral eye, the median movement amplitude without EOP was smaller with conical implants in supraduction (−0.88 mm, p=0.008), abduction (−2.26 mm, p<0.001) and adduction (−0.91 mm, p=0.008). Spherical implants had reduced movement only in abduction (−2.63 mm, p<0.001). Conical and spherical implants had similar amplitudes of movement in all versions, and were always smaller compared to the control. The median movement amplitude with the EOP was −3.05 mm (p=0.001) than without the EOP in abduction and −2.07 mm (p=0.020) in adduction, regardless of implant format. The fornix depth did not affect the orbital implants or EOP movement amplitude’s median. Conclusion: Conical and spherical implants provide similar amplitude of movement and fornix depth did not have an influence on it. The amplitude of movement was significantly limited compared to the contralateral eye and was even more reduced if the EOP was in place with conical or spherical implant formats.

Should we care about the ocular surface in the anophthalmic patient?

To assess clinical and biomolecular changes of the conjunctival epithelium in anophthalmic patients wearing an ocular prosthesis. Thirty-five unilateral anophthalmic patients were enrolled. Patients with blepharitis, lid abnormalities, and topical/systemic medication affecting the ocular surface were excluded. Symptom Assessment in Dry Eye (SANDE) questionnaire and tear function test (Schirmer Test Type I) were recorded. Conjunctival inflammation and meibomian gland dysfunction (MGD) were graded in the anophthalmic side and fellow eye. Impression cytology sampling of the upper, lower tarsal, and posterior/bulbar conjunctiva from the anophthalmic socket were collected and compared to healthy controls. Patients had significantly higher SANDE (p < 0.001), Schirmer I test (p = 0.004), conjunctival inflammation (p < 0.001), and MGD scores (p < 0.001) on the anophthalmic side compared to the fellow eye. Mucin 5AC, inflammatory markers (MMP-9, ICAM-1) expression (p < 0.001), and response to oxidative stress (NRF2-KEAP1 signaling pathway) (p < 0.05) were significantly upregulated in the posterior conjunctival surface in the anophthalmic socket. Anophthalmic patients complained of more pronounced dry eye symptoms and presented more significant signs of inflammation and MGD on the anophthalmic side. The bulbar conjunctiva, behind the prosthesis, showed more significant hyperexpression of mucins, markers of inflammation, and increased response to oxidative stress compared to the tarsal conjunctiva. Patients wearing ocular prosthesis had signs of inflammation resembling dry eye disease.

Minimally invasive harvesting fascia lata (FL) in ophthalmic plastic surgery.

To describe a minimally invasive technique of harvesting fascia lata, and also to analyze the clinical uses and the outcome of fascia lata in Ophthalmic Plastic and Reconstructive surgery. This interventional study was done in three tertiary care eye hospitals in Bangladesh from July 2014 to June 2020. We obtained autologous fascia lata for the correction of congenital ptosis with poor levator function (⩽4 mm), covering the ciliary staphyloma, repair of the extruded implant following anophthalmic socket surgery, and was also used to wrap the orbital implant after enucleation. Preserved FL was used only for children before 6 years of age for the treatment of congenital ptosis. Out of 60 subjects, 38 (63.3%) were male and 22 (36.7%) were female. Autogenous fascia lata was used for frontalis brow suspension (FBS) in 25 (41.67%) patients of congenital ptosis with poor levator function, as patch graft in ciliary staphyloma (11 cases, 18.3%), to wrap orbital implant following enucleation in intraocular malignancies (nine cases, 15%), to repair of implant extrusion following evisceration (five cases, 8.3%), and as fascial sling to correct recurrent paralytic ectropion (one case, 1.67%). Allogeneic or preserved fascia lata was used to correct congenital ptosis in patients less than 6 years of age (nine cases, 15%). Mean follow-up time was 5.32 months. Fascia lata (autogenous and allogeneic preserved) has varied uses in ophthalmic plastic surgery. Harvesting fascia lata (FL) using with minimally invasive method was successful with the least scar on the thigh to correct congenital ptosis, ciliary staphyloma, repair of extruded implant, and in wrapping implant after enucleation to get better cosmesis and motility.

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.

Medical comorbidities and orbital implant exposure.

To investigate medical conditions and systemic therapies associated with orbital implant exposure in patients with anophthalmic sockets. 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. 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). 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.

Morphological Changes in the Lacrimal Gland of Anophthalmic Socket in Relation to the Contralateral Normal Eye in Male Wistar Albino Rats: A Histopathology Study

ABSTRACT Purpose: The purpose of the study is to analyze the structural and functional alterations of the lacrimal gland and its tear secretion post-enucleation in Wistar rats. Method: Adult male Wistar rats (n = 15) of 8-week-old were randomly assigned into three groups viz. control, sham, and experimental group (n = 5). Rats of the experimental group were subjected to enucleation of the right eye. Under aseptic surgical conditions, with sterilized forceps, right eyeball of the rats of experimental group was exposed completely out of the socket by applying pressure on the lateral canthus of the eye. Enucleation was then achieved after holding the optic nerve tightly. The surgical procedure was similar in sham group without enucleation. Quantity of tears (Basal and reflex) secreted in both eyes in rats of all groups were measured by using Schirmer’s strip, pre- and post-three weeks of enucleation. The lacrimal gland was harvested to analyze histopathological (structural) alterations. Results: Pr- and post-enucleation there was no significant difference observed in the tear volume across the groups. Histopathology of the lacrimal glands from all groups showed preserved lobular architecture with serous acini arranged in lobules, intralobular and interlobular ducts, interstitial fibro collagenous tissue. There was no glandular distortion and atrophy in experimental group. Conclusion: Enucleation do not co-relate or affect the tear volume and lacrimal gland acinar microstructural changes in an anophthalmic socket co-relating to the contralateral normal functional eye.

LATERAL TARSAL STRIP (LTS) - A SIMPLE SOLUTION TO VARIED EYELID MALPOSITIONS.

PURPOSE: To study the functional and cosmetic outcome of lateral tarsal strip (LTS) procedure in correcting various eyelid disorders. METHODS: A retrospective analysis of 30 patients who underwent the procedure in a 2 year period from January 2018 - January 2020 was done. RESULTS: The average age was 50.15 years (range-19-80 years). Nineteen males and 11 females were followed up for 32 weeks (mean-9.58 weeks). The procedure was done for facial nerve palsy (14 patients), involutional entropion (6 patients), anophthalmic socket with lax lower lids (7 patients) and cicatricial ectropion (3 patients). Common clinical indications for treatment were lagophthalmos (14 patients), epiphora (9 patients) and unacceptable cosmetic appearance (7 patients). Common ancillary procedures were fornix forming sutures (6 patients), lid everting sutures (8 patients) and medial canthoplasty (4 patients). Functional and cosmetic success was achieved in 29 patients (96%) with total success in 27 patients and partial in 2 patients. CONCLUSION LTS is a very simple basic technique which can be used in correcting various eyelid disorders and renders excellent cosmetic and functional satisfaction to the patients.

Facial cosmetic enhancement by secondary implant and ocular prosthesis to avoid camouflaging hair style

Aim: Aim of this study is to access the improvement in psychosocial awareness and self-image of surgical anophthalmic patient after cosmetic rehabilitation with secondary implant followed by ocular prosthesis. Materials and Methods: It was conducted with 15 surgical anophthalmic patients who maintained a special and unnatural hair style to hide the facial deformity from others. These hair styles included growing long hair on a particular side of the head, covering part of the forehead and eyes. This makes other people curious and it does not look normal. Result: After reconstruction of the a anophthalmic socket by secondary ball implant along with scleral graft and followed by fitting of a well matching custom designed ocular prosthesis, the psychological condition, self-confidence of the patients were improved significantly. The follow up photographs of the same patient revealed that they no longer maintained the earlier special type of hair style. They looked confident in normal hair pattern. Conclusion: The study suggest that the psychological well being of those living with facial deformity due to eye loss is related to having a pessimistic outlook and the beliefs a patients has about their appearance and how accepted they feel by the society. Keywords: Contracted socket, Orbital implant, Socket reconstruction, Scleral graft.

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

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

The cover photo shows different neovascularization types from the paper by Smid et al.

The cover photo shows different neovascularization types from the paper by Smid et al.

Dry anophthalmic socket syndrome \u2013 morphological alterations in meibomian glands

PurposeTo evaluate morphological alterations of meibomian glands (MGs) in the dry anophthalmic socket syndrome (DASS).MethodsFifteen unilateral anophthalmic patients wearing cryolite glass prosthetic eyes were enrolled. All patients with clinical blepharitis or other significant eyelid abnormalities were excluded. In vivo laser scanning confocal microscopy (LSCM) of the MGs in the lower eyelids both on the anophthalmic side and the healthy fellow eye was performed to quantify acinar unit density, acinar unit diameter, acinar unit area, meibum secretion reflectivity, the inhomogeneous appearance of the glandular interstice, and inhomogeneous appearance of the acinar walls.ResultsThe lower eyelids of the anophthalmic sockets revealed a significant reduction of the acinar unit density (p = 0.003) as well as a significantly more inhomogeneous appearance of the periglandular interstices (p = 0.018) and the acinar unit walls (p = 0.015) than the healthy fellow eyelid. However, there were no significant differences regarding the acinar unit diameter, acinar unit area, and meibum secretion reflectivity of the MGs on the anophthalmic side compared to the healthy fellow eyelid (p ≥ 0.05, respectively).ConclusionsThe eyelids of anophthalmic sockets without clinical blepharitis demonstrate a reduced density of MG acinar units and a more inhomogeneous appearance of the periglandular interstices and the acinar unit walls. This can cause meibomian gland dysfunction contributing to DASS and suggests early treatment of these symptomatic patients, even in the clinical absence of any blepharitis signs.

Outcomes of secondary autologus dermo-fat orbital implants in anophthalmic sockets.

Objectives:To evaluate the outcomes of secondary autologous dermis-fat graft as an orbital implant in anophthalmic sockets.Methods:In this prospective study, which was conducted at Jinnah Post Graduate Medical Centre, Karachi, between January 2015 and January 2020, we evaluated 12 patients between the ages of four and 60 years. Most of the adults were victims of trauma, whereas children were known cases of retinoblastoma or trauma and all underwent enucleation. All of them were primarily treated elsewhere and not offered primary orbital implants. We performed autologous dermis-fat graft as an orbital implant in these patients harvesting graft from gluteal region and followed them up to look for complications.Results:Out of 12 patients two went into failure, while rest of the patients showed successful outcome. All patients underwent successful surgery. Initially, a silicon conformer was placed, which was later on replaced with artificial prosthetic eye.Conclusion:Regardless of the small sample size, this procedure proved to be a safe and effective method for augmenting orbital volume in anophthalmic sockets in children and adults.