Objectives of this lecture are:
• Considerations regarding enucleation vs. evisceration
• Review tips and tricks in preventing implant exposure and extrusion
• Discuss management of anophthalmic socket syndrome
• Review options in managing the contracted socket

Lecture Location: on-board the Orbis Flying Eye Hospital, Kingston, Jamaica
Lecturer: Dr. Bradford Lee, Bascom Palmer Eye Institute, USA


DR LEE: All right. Good. So here are just a couple examples of anophthalmic sockets. Okay. So question number one: What is an ideal sized orbital implant? 16, 18, 20, or 22 millimeters? A 20-millimeter sphere. Okay. All right. Number two: What is a potential risk of evisceration, compared to enucleation? Poor prosthesis motility, superior sulcus deformity, spread of ocular tumor, or implant extrusion? Spread of ocular tumor. All right. Which is not a treatment option for superior sulcus deformity? Placement of a thicker or larger prosthesis, injection of filler or fat into the orbit, removal of ocular implant and placement of a dermis fat graft, or placement of a subperiosteal wedge implant? Placement of a thicker or larger prosthesis. Okay. All right. So our objectives are to discuss enuc versus evisc, talk about some tips and tricks in preventing implant exposure, discuss the management of the anophthalmic socket syndrome, and then review options in managing the contracted socket. So first let’s think about the indications. Because depending on why the patient is having their eye taken out, it can determine which one you really should or should not be doing, as an option. So endophthalmitis and panophthalmitis is an infected eye that has to come out so that it doesn’t spread into the orbit. Typically they’ve failed the intravitreal antibiotics. Scleritis — this could be an autoimmune-type scleritis, with intractable pain, or it could be like a fungal or other type of bacterial scleritis as well. So you’re trying to get the sclera out, to prevent the persistent infection. A blind, painful eye, typically from late neovascular glaucoma or severe glaucoma. Intraocular tumors like retinoblastoma, choroidal melanoma, and then irreparably ruptured globes. Which I always say… Don’t do it immediately. Give them some time to process it mentally. At least a few days. So considerations. Let’s say… Well, let’s ask a few questions. So which is easier and less invasive? So I think all of us would agree that evisceration is easier. You don’t have to detach the muscles. It’s a quicker surgery. Et cetera. How about risk of sympathetic ophthalmia? I would say, assuming it’s intact… So theoretically, evisceration has a slight risk of sympathetic, even though it’s extremely rare. How about in the setting of prior incisional intraocular surgery? So some of my colleagues feel that if they’ve had prior vitrectomy or PKP or basically the antigens of the eye have come out once, they think… Oh, maybe we don’t want to open the eye and expose it again. I’m not sure there’s a huge evidence for that. But it’s a consideration. How about in the setting of a ruptured globe? Sometimes I think… Either one is a possibility. But sometimes if the globe is really ruptured, it might be a little… The tissues may be a little bit compromised, when you’re trying to put implants in, if you’re trying to do an evisc. It’s still possible. There’s also the thought of the sympathetic ophthalmia too. Spread of infection. Sometimes people think about evisceration as not spreading the contents into the orbit. That said, for a treated infection, I will sometimes take it out, irrigate the orbit with antibiotics, or Betadine, and then still put in an implant. Or if you’re worried, you can also wait, give it a month to cool down, and then go in and put in a secondary implant. Spread of intraocular cancer. This is one of the reasons why I don’t like doing eviscerations. I’ve heard of people having cases of a diffuse infiltrative melanoma that’s very easy to miss, even on a clear view to the fundus. Certainly if you have media opacities and you don’t have a clear view, you definitely have to do a B scan. But even some of these infiltrating ones are very easy to miss, and so since I’ve heard people having that happen, I’m always thinking about that. So enucleation, again, doesn’t open up the eye to potentially spread those cancer cells. Scleritis and panophthalmitis. So if you have infected or inflamed sclera, that has to come out. You can’t leave it and do an evisc. Because a nidus of infection and inflammation… And then phthisis bulbi — that in itself is not an indication for enucleation. They can always wear a scleral shell over the phthisical eye. But if they have phthisis bulbi and other issues like blind, painful eye with phthisis or prephthisis, then typically the sclera is so small that to put an adequately-sized implant in is very difficult. So I typically prefer enucleation. So I’m just keeping track of time here. So let’s talk a little bit about orbital implants. So it’s very important to place a large enough implant, if possible, and I typically like to place a 22 millimeter implant. Some people will go even bigger than that. But if there are issues, like a lot of conjunctival scarring, you can sometimes have a higher chance of extrusion, if you put too big of an implant. So bigger is not always better. Porous versus non-porous implants — this is always a controversial thing. I typically use porous. I know people who always use non-porous. And I think the truth is that you can generally have good outcomes with either one. There’s some studies showing that there’s higher extrusion and exposure rates with the non-porous ones, which have a rough surface. But there’s also people who have published their results with almost zero incidents of exposure with porous implants. So I think it really depends on your surgical technique. But probably non-porous is slightly better in terms of exposures and extrusions. Porous would be calcium hydroxyapatite or porous polyethylene. Non-porous would be things like silicone, acrylic, or if you’re in a setting where you don’t have implants available, I heard that people sometimes will use marbles, even. And it still fills the space. Not necessarily approved as an implant, but it seems to work. Risk of exposure, extrusion, infection — we kind of talked about it. When you have a porous implant, if it gets seeded with infection, it gets embedded in the implant. Very difficult to clear the infection. And typically it has to be taken out. And scleral wrapping — some people will wrap their implants with sclera. I typically don’t. But some people think of it as being a little bit of a barrier. I don’t think it’s really necessary. Attachment of the extraocular muscles — so if you have an acrylic implant or a marble, it’s very difficult. You can’t really attach the muscles to the implant itself. Whereas the porous ones, you can sew it through the porous implant, or some of them come with prefabricated tunnels, where you can pass a suture through it, and tie it off in the implant. Pegging I would say — almost nobody does pegging these days, because of the risk of infections and complications. If you have the right patient, who is like: I don’t care. I just want to have the most natural movement possible, and I’m willing to have complications and possible need for further surgery… You can try pegging. But you have to read them the riot act and warn them. And then cost. The non-porous tend to be much cheaper than the porous implants. So how about some tips for preventing exposure and extrusions? First of all, I would say beware of the infected and inflamed orbit. These patients not only have orbital inflammation. They typically have a lot of conj inflammation. The tissue can sometimes be a little bit ratty and necrotic, and these are patients who, when you have inflamed tissue, trying to hold the implant in place, it’s not gonna hold and heal as strongly, initially. So these are sometimes patients who I like to give them time to cool down, for about a month, let the infection and inflammation settle down, and then go back about a month later and put in a secondary implant. Other risk factors for exposure: Any smokers. Obviously they have poorer wound healing, greater risk of infection. Radiation. For types of cancers, the blood supply and the tissue will be more friable. Multioperated patients for glaucoma, cornea, retinal surgery. There’s scarring. Again, the tissue has been compromised. Elderly patients don’t heal as well as younger patients. And then immunosuppressed patients also. The immune system is necessary for healing as well. And so they tend to have poor wound healing. I also say it’s very important to consider the individual patient. And that’s a theme for all of everything we do in oculoplastic. So if it’s a young, 30-year-old patient who’s lost her eye, she’s clearly aesthetically inclined, you really don’t want to give her a superior sulcus deformity, enophthalmos, and everything. If it’s one of my 90-year-old patients with endophthalmitis, and his brow is so droopy that it’s blocking his lid, he’s like… I don’t care. I don’t even want an ocular prosthetic. I don’t want another surgery. I don’t want anything. Then, you know, why take the chance of pushing the limits of a large implant? If they could get away with a small implant. Then they don’t even care about it. They just want to wear a patch. So it’s always a trade-off. The larger implant gives better aesthetics, but it sometimes can cause a higher chance of extrusion. We talked about the sizing and the types of implants, attachment of the extraocular muscle. I think this is an underappreciated thing that’s not taught that often, but if you really advance the extraocular muscles to the anterior pole of the implant, you have a really robust vascularized layer that’s serving as an extra barrier to extrusion. Some people attach the muscles kind of to the equator, the pseudoequator of the implant. But I like to form what I call the anterior annulus of Zinn. Think of it like putting all your four rectus muscles right up against each other, and that forms a really nice vascularized barrier for implant extrusion. The Tenon’s closure is really extremely critical. Way more so than the conjunctival closure. This is what is gonna hold the implant in place. So you need to get good bites of Tenon’s, close it, sometimes in double layers, so there’s no implant exposed at all. And then finally, manage your bleeding. Your risk of retrobulbar hemorrhage. If you have a retrobulbar hemorrhage, that’s more likely to put a lot of pressure in the orbit and pop the implant and burst it through. So if they’re on blood thinners, or they have liver failure and their clotting factors are poor, just be very mindful of that risk, and talk to your patients about it. Okay. So let’s talk a little bit about anophthalmic socket syndrome. We’re running close to noon. But this is a triad of superior sulcus deformity, enophthalmos, and oftentimes lid malposition. Typically like the ectropion, but sometimes also a ptosis as well. And the most common cause is an inadequately sized orbital implant. Again, we’ve said we ideally would like a 22 millimeter. This gentleman had an infected one, and he has no orbital implant in there. So you can see everything is magnified. The physiology has to do with this posterior rotation of the tissues and suspensory ligaments. There can be soft tissue atrophy from trauma, surgery, from the eye removal, and then sometimes the forces of the prosthetic weighing on the lower lid. It just accelerates the process of the involutional aging changes. A weight weighing down on the eyelid, and it can cause ectropion and laxity. And then the treatment typically is — you can actually place a larger prosthetic. A thicker prosthetic. It has a trade-off. So you can have a larger volume prosthetic that will volumize the superior sulcus, but it’s gonna weigh more heavily on the lower lid, so over time, it may be more likely to have ectropion. But you can do that. Secondary implant, if they didn’t have one, or an implant exchange if it got infected. It needs to come out. Make sure you put an adequately sized implant. A subperiosteal wedge is something that — you kind of wedge it posteriorly under, along the orbital floor, and that really helps to fix the enophthalmos and the superior sulcus deformity. And then you can also do filler or fat transfer to the orbit, to volumize the eye socket. This is a patient of mine who had a very contracted socket. She had multiple contracted socket surgeries of hard palate, mucous membrane grafts, and she was unhappy with her cosmetic appearance here, and I was like: We are not going in and cutting through your conj and risking contracting your socket again. So I actually did 8CCs of fat grafting from her abdomen to the orbit. I injected fat into the superior sulcus, into the lateral canthal region. And she still has her old prosthetic, which is very tiny and vaulted, but you can see how the superior sulcus is improved. Her enophthalmos is slightly better. And once she gets fit with the proper prosthetic, it’s even better. This is another patient of mine who had, like, 12 prior socket and eyelid and facial surgeries, prior to coming to see me. And the problem with him was that he had an inadequately repaired orbital fracture. First of all, he didn’t have an orbital implant, as you can see on the axial, but even if you put in your 22 millimeter implant, you can see his orbital volume has been so grossly expanded that 22 millimeter, even a 24 millimeter — it’s not gonna fix things. He has to have the socket — the fracture repaired, to recreate a properly sized orbit, and then he can get the implant placed. So finally, our last topic: Contracted sockets. So our goal with contracted sockets is for the patient to be able to wear a prosthesis that’s not gonna be falling out all the time. If the patient says: I don’t care. I don’t want a prosthetic. I just want to wear a patch — don’t put them through any more surgery. Because the whole goal is for them to wear a prosthetic. It’s typically due to conjunctival contracture and loss of the fornices. Like you can see here, there’s no pocket for the implant to fit in. You need a pocket below and you need a pocket above, to fit the prosthetic. It’s really a partnership between the ocularist and the oculoplastic surgeon. So I typically have them see the ocularist first, see what they can do. If they say: No, we can’t do any more, they just need surgery, then we go ahead and do surgery. But sometimes they can do what’s called pressure conformers. Kind of like stretching the fornix and recreating a pocket. And you can get some improvement there. Otherwise, we’re talking about mucous membrane grafts, hard palate grafts, sometimes a dermis fat graft is a nice option if you need volume, plus contracted socket repair, and then sometimes they just have a little bit of a symblepharon that’s just popping it out. And you just need to lyse the symblepharon, and with that, you can just do a little amniotic membrane graft for the repair of the symblepharon. Typically after all of these contracted socket repairs, which are challenging surgeries, fraught with the same scarring problems we just talked about, over the first three months — everything contracts again. The grafts shrink. Everything we talked about. But all of them typically get symblepharon rings or some type of bolster. I put in a tarsorrhaphy, to try to maintain that pressure on the fornices, and they all get 5FU, sometimes even mitomycin, in my clinic. Sometimes at the time of surgery. And repeating every one to two weeks, or as needed. It’s a very challenging surgery. Today is when we’re gonna do a mucous membrane graft. This is our patient, who’s coming in later today. So she had — I’m sorry. Tomorrow. You’re right. Tomorrow. This patient had a laceration through the eyelid, but you can also see there’s all this scarring in the inferior fornix, and it’s very shallow, especially medially. So she’s unable to retain a prosthesis. So we’re gonna do a mucous membrane graft to deepen the fornix for her. So in conclusion, enuc and evisc — they each have their pros and cons, but there are certain cases where one is better than the other. Porous and non-porous implants are both reasonable and good options in the right patient. A lot of it, extrusions have to do with surgical technique, but you also want to consider size of the implant, the type, the risk factors for the individual patient. Anophthalmic socket syndrome, usually due to an inadequately sized implant. And we have various surgical or non-surgical filler or fat transfer-type options to improve that. And then contracted sockets are challenging cases. They often require grafts and 5FU. But it is a marriage and a partnership with your ocularist. So let’s do quick voting. So what is an ideal sized orbital implant? 16, 18, 20, or 22 millimeters? And let’s see what people said. 22. Very good. 100%. What is a potential risk of evisceration, compared to enucleation? Yep. Spread of ocular tumor. You can get all of the other things with enuc or evisc, but really, once you open the eye and let all the contents out, that’s how you can spread intraocular tumors. Which is not a treatment option for superior sulcus deformity? So actually, as we talked about, placement of a thicker and larger prosthesis is an option. You can do a larger volume prosthetic. It just has a little bit of trade-offs. It might cause more ectropion and laxity over time. But it will volumize the superior sulcus deformity. Removal of the ocular implant and the dermis fat graft — I would say that’s an option if the ocular implant is extruding. But the problem with dermis fat graft is it’s very unpredictable. You can’t very predictably size the dermis fat graft, and you can’t predictably determine how much of it is gonna atrophy over time. So I don’t necessarily guarantee myself that I’m gonna have an overall improvement in the volume. Whereas with all of these other ones, you’re only augmenting volume. There’s no chance of you having a decrease in volume or staying volume-neutral. Okay. That’s it.

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April 06, 2019

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