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

Purpose: 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. Methods: 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. Results: 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. Conclusion: 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.

Intraoperative Computed Tomography Image Fusion for Orbital Blowout Fracture Reconstruction

Intraoperative computed tomography (CT) has been previously described and acknowledged for its use in orbital blowout fracture reconstructions. We described a clinical case series managed by this technique combined with intraoperative image fusion for accuracy in orbital implant position. In total, eight patients who sustained a total number of 19 orbital wall fractures were described. From the total number of 19 blowout orbital fracture reconstructions comprised of medial and inferior (floor) orbital fractures, malposition was identified in a total of four orbital implants by using image fusion. All cases of implant malposition were immediately revised intraoperatively. Subsequent fusion was carried out to confirm whether the revision was satisfactorily achieved. We found that the intraoperative image fusion technique utilised to determine orbital implant position, especially at the posterior ledge, further augmented the role of intraoperative CT scanning. Image fusion conceptually provides an immediate, real-time, and objective solution for intraoperative image analysis and potentially eliminates problems with misaligned CT images. It also reduces the need for the surgeon to ‘eye-ball’ the CT images acquired or the need for additional intraoperative time, since the patient’s head orientation is always axially at random during the acquisition of the CT. Conventional methods for CT image assessment are subjected to one’s own interpretation and may introduce inconsistent or longer intraoperative decision-making. The technique facilitates intraoperative decision-making and reduces the risk of orbital implant malposition in orbital blowout fracture reconstructions. Hence, surgical complication in relation to orbital implant malposition in orbital blowout fracture management could be minimised. In addition, no further postoperative imaging is required.

Case series of shrinking hydroxyapatite orbital implants

BackgroundAn orbital implant is used after enucleation or evisceration surgery to replace the volume lost and to aid in prosthesis fitting and movement. Different materials have been used through the years. The authors noted that with bone-derived hydroxyapatite orbital implants, some patients lose their orbital volume.MethodsThe operating theatre record was searched to find patients who had their hydroxyapatite orbital implant removed at Dunedin Hospital, New Zealand, between 2011 and 2015. The original implant size and size at removal were noted. Histological results were noted. Medical notes were reviewed.ResultsA total of six patients had hydroxyapatite orbital implants removed during this time. Four patients had implants that were smaller than their original sizes. All specimens had fibrovascular infiltration noted, three had chronic inflammatory cells and one had osteoclastic activity.ConclusionsBone-derived hydroxyapatite orbital implants can reduce in size, and this may occur due to osteoclastic activity. The surgeon must consider this scenario when choosing the type of implant to be used after enucleation or evisceration.

Conjunctival Epithelial Inclusion Cyst following Evisceration with Primary Orbital Implantation

A 29-years-old Turkish man who had undergone evisceration with primary orbital implantation 20 months prior complained of difficulty wearing his artificial eye. Slit-lamp examination revealed a conjunctival cyst in the center of the anophthalmic socket, with no evidence of scleral or orbital implant exposure. The cyst was completely excised under general anesthesia and did not require use of any sclerosing substance or dye. At 6 months postoperatively, there was no recurrence of the cyst or exposure of the sclera or orbital implant. As the upper and lower fornices were sufficiently deep, the patient could wear his artificial eye.

Orbital abscess due to infection of a non-absorbable porous orbital implant after orbital wall fracture repair : An uncommon and delayed occurred case

We report a rare case of a patient who developed an orbital abscess several years after successful orbital medial wall fracture repair. A 37-year-old female patient who underwent orbital fracture repair with a titanium Medpor® orbital implant two years prior visited the clinic for pain, conjunctival injection, discharge, and lid swelling of the right eye. Orbital CT revealed severe orbital cellulitis and sinusitis. After administering antibiotics, the sinusitis was successfully resolved. However, the orbital inflammation around the implant did not improve, forming an orbital abscess. Abscess drainage and implant removal were performed. The removed implant was infected at the center, exhibiting a yellowish abscess-like discoloration. The patient improved rapidly and recovered without complications. In rare cases, orbital cellulitis and orbital abscesses develop even after a considerable period of time after orbital fracture repair using a non-absorbable porous orbital implant. In such cases, delayed orbital implant infection should be suspected as the cause, and an imaging study should be performed. If the patient does not respond to antibiotic treatment, it may be necessary to remove the infected implant with immediate drainage.

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.

Auricular cartilage versus donor sclera as a wrapping of hydroxyapatite orbital implants

AIM: To retrospectively compare postoperative outcomes after primary enucleation and placement of a hydroxyapatite (HA) implant without wrapping, wrapped with auricular cartilage or donor sclera. METHODS: Medical records of patients presented as intraocular tumor or severe ocular injury were identified from the electronic medical record system. Cases underwent enucleation and HA orbital implantation were enrolled in this study and were divided into 3 groups according to the wrapping material of HA implant. Cases with autogenous cartilage caps were enrolled in group A (n=11), with donor sclera caps in group B (n=12), and without any wrapping material in group C (n=9). Follow-ups were set at 1, 2wk, 1, 3, 6, and 12mo after surgery. RESULTS: Altogether 32 cases finished the follow-up and were enrolled in this study. Three cases (27.27%) in group A, 4 cases (33.33%) in group B, and 4 cases (44.44%) in group C developed one complication each after surgery. In group A, no HA exposure occurred, but conjunctival inclusion cyst occurred in one and severe conjunctive chemosis in two cases. In group B, one HA exposure occurred, conjunctive inclusion cysts occurred in one, severe conjunctive chemosis occurred in one, and conjunctival granuloma occurred in one case. In group C, one HA exposure occurred, severe conjunctive chemosis occurred in two cases, and conjunctival granuloma occurred in one case. The case of exposure of none-wrapped implant was noted in the first 6mo after placement of the orbital implant. The case of exposure of donor sclera-wrapped implant was noted at the 12mo after placement of the orbital implant. Both exposure cases were treated successfully with conservative treatment. CONCLUSION: With low incidence of implant exposure and mild complications, auricular cartilage can be a good choice of alternative wrapping material of orbit implant with satisfied outcome.