Mycobacterium Abscessus Infection in a Case of Recurrent Orbital Implant Exposure

Exposure is one of the most frequent complications of porous orbital implants, while infection is rarely observed. Atypical mycobacteria are ubiquitous germs of mostly variable pathogenicity. A patient with recurrent orbital implant exposure is described, in whom a final diagnosis of Mycobacterium abscessus infection was made on culture of the orbital implant remnant at its removal.

In orbital implant exposure, infection with unexpected organisms should be considered and in these cases only the complete removal of the implant may allow the socket to settle.     

Enduragen Patch Grafts for Exposed Orbital Implants

Purpose: To present a new technique using the recently introduced Enduragen^® material (Tissue Science Laboratories) as a patch graft for exposed ocular implants.

Methods: A retrospective, interventional, non-comparative case series of 3 patients who had Enduragen patch grafts for the closure of Tenon’s capsule and conjunctiva over exposed ocular implants. Medical records were reviewed and the following parameters were collected: age, gender, indication for surgery, type of surgery, laterality, type of orbital implant, complications after repair and length of follow-up.

Results: Three patients were identified, 2 males and 1 female. One patient had a secondary quad-motility implant with supertemporal exposure. The second patient had a secondary implant with a fistula at the lateral aspect of the socket. The third patient had a centrally exposed primary hydroxyapatite implant. All patients received Enduragen patch grafts to cover the implant. Follow up ranged from 40 to 43 months (mean, 41.3 months; SD, ± 1.5). None of the 3 patients had any signs of implant re-exposure at the time of the last post-operative visit. There were no intra-operative or early complications observed.

Conclusions: This consecutive case series suggests that Enduragen could be used as a safe and effective patch graft for exposed ocular implants. However, a larger prospective study with longer follow-up would be useful in further defining the indications and limitations of the Enduragen patch graft for the treatment of exposed orbital implants.     

Autogenous temporalis fascia patch graft for porous polyethylene (Medpor) sphere orbital implant exposure

BACKGROUND: Temporalis fascia has been recommended for hydroxyapatite sphere exposure. The aim of this study was to identify potential risk factors for exposure of porous polyethylene (Medpor) sphere implants and evaluate the use of autogenous temporalis fascia as a patch graft for exposure. METHODS: A retrospective review of consecutive cases of porous polyethylene sphere orbital implant exposure. RESULTS: Five cases presented between May 2000 and October 2001 (three males, two females; mean age 44.5 years). Three had enucleation (two with primary implants) and two had evisceration (one with primary implant). Exposure occurred in one primary, two secondary, and two replacement implants. Orbital implant diameter was 20 mm in four cases and 16 mm in one case (contracted socket). The mean time from implantation to exposure was 23 months (range 0.7-42.6). Three patients had secondary motility peg placement before exposure. The average time from last procedure (sphere implant or peg insertion) to exposure was 3 months (range 0.7-12.6). Four patients required surgical intervention, of which three needed more than one procedure. Autogenous temporalis fascia grafting successfully closed the defect without re-exposure in three of these four patients. The grafts were left bare in three patients, with a mean time to conjunctivalise of 2.4 months (range 1.6-3.2). CONCLUSIONS: Exposed porous polyethylene sphere implants were treated successfully with autogenous temporalis fascia graft in three of four patients. This technique is useful, the graft easy to harvest, and did not lead to prolonged socket inflammation, infection, or extrusion.     

Evisceration with Primary Orbital Implant in Fulminant Endophthalmitis/Panophthalmitis

Purpose: To compare the outcome of evisceration with primary orbital implant in blind eyes with and without fulminant infection (endophthalmitis/panophthalmitis).

Methods: Retrospective nonrandomized comparative interventional case series. Patients with a minimum postoperative follow-up of 6 months were considered for inclusion. Thirty-four eyes of 34 patients were included. Sixteen eyes were infective and 18 noninfective. Nonporous silicone implants were used for all cases and the main outcome measure was successful retention of the primary implant. Major and minor complications and successful prosthesis fitting were also noted.

Results: All except 3 cases were able to retain the primary implant successfully and all but 2 patients underwent successful prosthesis fitting. Major complications included implant extrusion in 3 cases (2 infective, 1 noninfective) and implant exposure in 1 case (noninfective). The difference in major complications between the groups was not statistically significant (p?=?0.66, Fisher exact test).

Conclusion: Our data suggest that evisceration with primary orbital implant is a feasible option in fulminant endophthalmitis/panophthalmitis and provides a good postoperative cosmetic outcome to the anophthalmic socket at an economical cost.     

新鲜羊膜联合唇黏膜移植治疗义眼座暴露的疗效观察

目的：探讨新鲜羊膜联合唇黏膜移植治疗义眼座暴露的手术方法及临床效果。

方法：对24例义眼座植入术后义眼座暴露的患者行新鲜羊膜联合唇黏膜移植,观察术后义眼座有无外露、感染。

结果：移植唇黏膜全部成活,眼座无外露,结膜囊无缩窄,患者基本满意。

结论：新鲜羊膜联合唇黏膜移植是治疗义眼座暴露的理想方法。     

后巩膜瓣旋转覆盖义眼座巩膜腔内植入术临床分析

目的:为了达到最佳的运动和仿真效果及长期的稳定,设计后巩膜瓣旋转覆盖巩膜腔内Medpor义眼座植入术,并评价此术式的手术适应证和疗效。方法:2008-01/2011-07在深圳市眼科医院接受眼内容剜除后巩膜瓣旋转覆盖巩膜腔内Medpor义眼座植入术120例患者:眼内容摘除后制作后巩膜瓣,将义眼座植入后方开放的巩膜腔内,旋转后巩膜瓣覆盖在义眼座表面,缝线固定义眼座。随访1～3a,记录最后一次就诊时的义眼座活动度,义眼片活动度,结膜囊剩余面积,结膜囊深度,并发症发生情况。结果:义眼座活动度:115例为优,5例为良;义眼片活动度89例为优,26例为良,5例为差;平均结膜囊剩余面积为178.1±7.5mm2;平均结膜囊深度为2.7±1.1mm;2例出现义眼座暴露感染,3例出现结膜下植入性囊肿,2例出现义眼座固定缝线外露,未出现义眼座内陷、上眶区凹陷、结膜囊狭窄、下睑外翻、眼眶蜂窝织炎。结论:后巩膜瓣旋转覆盖Medpor义眼座巩膜腔内植入术对于轻中度眼球萎缩、角巩膜葡萄肿、绝对期青光眼患者具有良好的治疗效果。     

Current trends in managing the anophthalmic socket after primary enucleation and evisceration

PURPOSE: To evaluate current trends in the management of the anophthalmic socket after primary enucleation and evisceration. METHODS: The active membership of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) was surveyed regarding primary enucleations and eviscerations performed between January and December 2002. Survey questions included practice demographics, orbital implant use, wrapping materials, placement of a motility peg, reasons for implant choice, and complications encountered. RESULTS: A total of 2,779 primary orbital implants were reported, comprising 1,919 (69.1%) enucleations and 860 (30.9%) eviscerations. The high-density porous polyethylene implant was used most frequently for enucleations (42.7%), followed by coralline hydroxyapatite (27.3%) and nonporous alloplastic implants (19.9%). For eviscerations, the high-density porous polyethylene implant was the most commonly used implant (42.3%), followed by hydroxyapatite (25.9%) and nonporous alloplastic implants (25.7%). The top 3 reasons for implant choice were outcome (69.3%), cost (43.6%), and experience (39.5%). Most implants were either not wrapped (59.8%) or were wrapped in donor sclera (25.2%) or polyglactin mesh (7.2%). Pegs were used in 8.1% of all implants reported. The most frequent complications encountered for unpegged implants were exposure (3.2%) and infection (0.4%). For pegged implants, the most common complications reported were pyogenic granuloma (13.7%), exposure (5.7%), and discharge (5.7%). CONCLUSIONS: In managing the anophthalmic socket, ASOPRS survey respondents preferred to use the porous polyethylene implant after primary enucleation and evisceration. Most orbital implants were not wrapped, and most surgeons preferred not to place a motility post or peg in the implant.     

One‐stage explant–implant procedure of exposed porous orbital implants

Purpose: To investigate the risks of implant exposure after a combined explant–implant procedure in patients with an exposed porous orbital implant. Methods: Twenty‐four consecutive patients who had a combined explant–implant procedure of an exposed hydroxyapatite (21) or porous polyethylene (3) orbital implant from January 2000 to February 2009 were included. The patient records were reviewed; patients were interviewed by telephone and invited for a clinical examination. Histopathological examination was carried out on the removed implants. Main outcome measures were: presence of exposure of the new implant or not, patient graded satisfaction with the cosmetic result, and presence of poor motility. Results: None of the new implants became exposed or infected in the follow‐up period of 25 [3–94] months (median [range]). The patients scored their satisfaction with the cosmetic result to a median score of 9 (range 5–10). Poor motility was present in six of 17 patients. Micro‐organisms were identified in three removed implants and signs of inflammation were present in 20 removed implants. Conclusions: If a decision of implant removal has been made, it is safe to replace the implant at the same procedure in sockets without profound signs of infection. The procedure carries a possible risk of poor motility.     

The Quasi-Integrated Porous Polyethylene Implant in Pediatric Patients Enucleated for Retinoblastoma

Purpose: To describe the clinical outcomes of patients receiving a quasi-integrated porous polyethylene orbital implant following enucleation for retinoblastoma. Methods: A retrospective review of all retinoblastoma patients who received the quasi-integrated porous polyethylene implant following enucleation during the 56-month period between October 2000 and May 2005 was conducted. Results: Ten patients were identified who received the quasi-integrated porous polyethylene implant as a buried, primary orbital implant. Approximately 6 weeks following implantation, a custom-fitted prosthesis was made by an impression technique to provide a “lock-and-key” fit with the orbital implant in the majority of patients. Follow-up ranged from 2 months to 78.5 months following surgery, with an average of 36 months. One case of implant exposure was noted, with no other significant complications. Good motility of the prosthesis was noted in all cases. Conclusions: The quasi-integrated porous polyethylene orbital implant is safe to implant and provides good prosthetic motility without the need for pegs or screws. It was associated with an exposure rate similar to other commonly used implants following enucleation in retinoblastoma cases.     

Orbital Adherence with Titanium Mesh Floor Implants: A Review of 10 Cases

Abstract

Background: Multiple materials have been used in the repair of orbital floor fractures. We report 10 cases of complications relating to the use of titanium mesh orbital floor implants.

Method: A retrospective review of 10 cases in 2 centres in New Zealand. Patients presented with diplopia or eyelid retraction following repair of an orbital floor fracture with titanium mesh implants.

Results: Ten patients (7 male, 3 female) aged between 15–78 years old (mean 39 years) presented with significant restriction of eye movement and/or eyelid retraction following repair of an orbital floor fracture with a titanium mesh implant. Seven patients presented with restriction of eye movement alone. Three patients had lower lid retraction in addition to restriction of eye movement. One patient presented with epiphora following erosion of the implant through the nasolacrimal duct. Seven patients underwent surgical removal of the implant with all patients showing improvement of extraocular movement post-operatively. Three cases did not undergo implant removal with one case showing mild improvement over 9 months, and 2 cases showing no improvement. The mean interval between the initial surgery and removal of the implant was 7.1 months.

Discussion: In our series, 7 cases required explantation of the original titanium implant. In these cases a vigorous fibrotic reaction had taken place between the orbital contents and the titanium mesh implant. We postulate that the fibrous reaction between the implant and the orbital contents caused the eye movement restriction and the lid retraction. Implant materials used in orbital floor fracture surgery should be inert with a flat profile rather than a mesh to prevent adhesions through the mesh that may cause cicatricial eye movement restriction and eyelid retraction.     

Porous and nonporous orbital implants for treating the anophthalmic socket: A meta-analysis of case series studies

Purpose: To assess the efficacy and safety of porous and nonporous implants for management of the anophthalmic socket.

Methods: Case series meta-analysis was conducted with no language restriction, including studies from: PUBMED, EMBASE and LILACS. Study eligibility criteria were case series design with more than 20 cases reported, use of porous and/or nonporous orbital implants, anophthalmic socket and, treatment success defined as no implant exposure or extrusion. Complications rates from each included study were quantified. Proportional meta-analysis was performed on both outcomes with a random-effects model and the 95% confidential intervals were calculated. Results: A total of 35 case series studies with a total of 3,805 patients were included in the meta-analysis. There are no studies comparing porous and nonporous implants in the anophthalmic socket treatment. There was no statistically significant difference between porous polyethylene (PP) and hydroxyapatite (HA) on implant exposure: 0.026 (0.012–0.045) vs 0.054 (0.041–0.070), respectively and, neither on implant extrusion: 0.0042 (0.0008–0.010) vs. 0.018 (0.004–0.042), respectively. However, there was a significant difference supporting the use of PP when compared to bioceramic implant: 0.026 (0.012 –0.045) vs. 0.12 (0.06–0.20), respectively, on implant exposure. Conclusion: PP implants showed lower chance of exposure than bioceramic implant for anophthalmic socket reconstruction, although we cannot rule out the possibility of heterogeneity bias due to the nature and level of evidence of the included studies. Clinical trials are necessary to expand the knowledge of porous and nonporous orbital implants in the anophthalmic socket management.     

Six cases of bacterial infection in porous orbital implants

BACKGROUND: We present 6 cases of bacterial infection that developed after porous orbital implant surgery. CASES: Five patients with hydroxyapatite implants showed lid swelling, discharge, and suppurative granuloma 14 days to 3 years after surgery. The hydroxyapatite implants were removed 14 days to 41 months postoperatively, and synthetic porous polyethylene orbital implants were inserted. Thick discharge and conjunctival melting was noted 14 months after primary Medpor implant surgery in the sixth patient, and the infection was controlled by medical therapy. OBSERVATIONS: The culture of specimens removed with swabs from the conjunctiva of patients and from the hydroxyapatite implants showed growth of Staphylococcus aureus, Staphylococcus epidermidis, alpha-hemolytic streptococcus and peptostreptococcus in 4 patients, whereas Streptococcus pyogenes were cultured from the conjunctiva in the Medpor implant patient. Culture for the remaining patient was negative .CONCLUSIONS: If there is continuous pain, injection, and discharge after porous implant insertion, bacterial infection in the implant should be considered immediately. Systemic antibiotics and topical eye drops should be administered without delay. If no improvement is observed, the implant should be removed and a different approach must be considered.     

A Histopathologic Study of Orbital Implant Vascularization

Purpose: To histopathologically assess the extent and pattern of vascularization of explanted porous polyethylene (PP) and hyrdoxyapatite (HA) orbital implants. To compare the vascularization in PP implants harvested after enucleation versus after evisceration. Methods: This is a comparative case series of six orbital implants explanted between 11 months and 5 years and 4 months post implantation. The implants were subjected to histopathological examination with various stains, after complete decalcification. Results: There were 2 post evisceration, 3 post enucleation and 1 secondary implant. The size of the implants varied from 18 to 23 mm diameter. The reason for explantation was exposure in all the 6 cases with additional infection in 2 cases. Histopathology revealed complete vascularization up to the core of the implant in all the cases. There was evidence of chronic inflammation within all the explanted specimens. Acute inflammation was present at the site of exposure in four of the implants. Three of these implants had additional evidence of necrosis. Two cases with clinically evident infection had Gram positive cocci within the implant. Foreign-body type giant-cells, melanophages and haemosiderin laden macrophages were also observed. Eviscerated specimens showed scleral remodelling and thickening. Conclusion: All the implants were vascularized up to the core. There was histologic evidence of chronic inflammation in all the explanted implants possibly indicating the foreign nature of the implant material. The sclera did not impede vascularization of the implants in eviscerated specimens. We found no difference in the degree of vascularization of the implant in enucleated versus eviscerated implants.     

Late reexposure after upper eyelid tarsoconjunctival flap for exposed porous orbital implant.

The records of four patients with exposed porous orbital implant treated with the upper eyelid tarsoconjunctival Hughes flap were reviewed. The tarsoconjunctival Hughes flap was fashioned for two patients with recurrent orbital porous implant exposure and two patients with primary orbital porous implant exposure (5 to 6 mm at largest dimension; mean, 5.6 mm). There were two hydroxyapatite and two high-density polyethylene implants. In all patients, reexposure (2 to 3 mm at largest dimension; mean, 2.5 mm) occurred 6 to 24 weeks (mean, 13 weeks) after the tarsoconjunctival Hughes flap procedure at the junction of the flap and the socket surface conjunctiva. Mean follow-up duration was 18.7 months (range, 7 to 27 months). Linear late reexposure is the main drawback of the upper eyelid tarsoconjunctival Hughes flap to cover an exposed orbital porous implant.     

Comparative analysis of use of porous orbital implant with mucus membrane graft and dermis fat graft as a primary procedure in reconstruction of severely contracted socket

Purpose:

The purpose of our study is to present a surgical technique of primary porous orbital ball implantation with overlying mucus membrane graft (MMG) for reconstruction of severely contracted socket and to evaluate prosthesis retention and motility in comparison to dermis fat graft (DFG).

Study Design:

Prospective comparative study.

Materials and Methods:

A total of 24 patients of severe socket contracture (Grade 2-4 Krishna''s classification) were subdivided into two groups, 12 patients in each group. In Group I, DFG have been used for reconstruction. In Group II, porous polyethylene implant with MMG has been used as a primary procedure for socket reconstruction. In Group I DFG was carried out in usual procedure. In case of Group II, vascularized scar tissues were separated 360° and were fashioned into four strips. A scleral capped porous polyethylene implant was placed in the intraconal space and four strips of scar tissue were secured to the scleral cap and extended part overlapped the implant to make a twofold barrier between the implant and MMG. Patients were followed-up as per prefixed proforma. Prosthesis motility and retention between the two groups were measured.

Results:

In Group I, four patients had recurrence of contracture with fall out of prosthesis. In Group II stable reconstruction was achieved in all the patients. In terms of prosthesis motility, maximum in Group I was 39.2% and Group II, was 59.3%. The difference in prosthesis retention (P = 0.001) and motility (P = 0.004) between the two groups was significant.

Conclusion:

Primary socket reconstruction with porous orbital implant and MMG for severe socket contracture is an effective method in terms of prosthesis motility and prosthesis retention.     

Mycobacterium abscessus infection in a case of recurrent orbital implant exposure

Exposure is one of the most frequent complications of porous orbital implants, while infection is rarely observed. Atypical mycobacteria are ubiquitous germs of mostly variable pathogenicity. A patient with recurrent orbital implant exposure is described, in whom a final diagnosis of Mycobacterium abscessus infection was made on culture of the orbital implant remnant at its removal. In orbital implant exposure, infection with unexpected organisms should be considered and in these cases only the complete removal of the implant may allow the socket to settle.     

Primary placement of a titanium motility post in a porous polyethylene orbital implant: animal model with quantitative assessment of fibrovascular ingrowth and vascular density

PURPOSE: To determine whether a Medpor porous polyethylene orbital implant, at the time of initial orbital implant surgery, will tolerate the insertion of a titanium screw on the anterior surface of the implant. METHODS: Twelve New Zealand white rabbits were enucleated and implanted with a porous polyethylene orbital implant. At the time of enucleation, the porous polyethylene orbital implants were drilled, and titanium motility coupling posts were inserted. The motility coupling posts were inserted at two projection heights (2 or 4 mm) and either covered within Tenon capsule/conjunctiva (eight implants) or left exposed (four implants). Rabbits were killed at 6 or 12 weeks. Clinical tissue tolerance, histologic response to the motility coupling post, and vascular density of the porous polyethylene orbital implant were evaluated. RESULTS: The motility coupling posts were well tolerated, and extrusion or migration of the motility coupling post did not occur. The average percentage cross-sectional area of the implant occupied by fibrovascular tissue at 6 and 12 weeks was 76.3% and 97.5%, respectively. In comparing the vascular density (number of vessels per square millimeter) in the porous polyethylene orbital implant within a 1-mm zone immediately surrounding the motility coupling post, no significant difference between this zone and the vascular density found within its entire corresponding annulus was found at either 6 or 12 weeks. CONCLUSIONS: During the 6- and 12-week observation periods, all implanted motility coupling posts demonstrated favorable tissue tolerance and stable interfaces with surrounding tissues. The extent of fibrovascular tissue ingrowth and vascular density verify that initial screw insertion does not adversely affect the healing process after porous polyethylene orbital implant implantation. Thus, primary placement of the motility coupling post may obviate the need for a secondary surgical procedure.     

Medpor板修复眼眶骨折合并眼球内陷的临床观察

目的：观察高密度多孔聚乙烯( Medpor )板在眼眶骨折合并眼球内陷修复术中的应用效果。
　　方法：对因眼眶骨折致眼球内陷患者17例17眼,采用Medpor板进行眶壁骨折修复手术。术后随访6mo,观察眼球突出度、眼球运动及复视等变化。
　　结果：术前患眼较对侧平均内陷(3.4±1.5) mm,术后6mo有2例残存眼球内陷1mm,其余15例眼球突出度与健眼差值小于1 mm。术前17例均存在眼球运动受限并伴有不同程度复视,术后6mo,16例患者眼球运动受限治愈,复视消失,1例患眼轻度外展受限并残存外侧水平复视。术后随访期间未见Medpor板的脱出、排斥、感染或其他不良反应。
　　结论：Medpor板可有效补充眼眶容积,修复眼球内陷等眼眶骨折并发症。     

Exposure rates of wrapped and unwrapped orbital implants following enucleation.

PURPOSE: To compare the complication rate of porous polyethylene orbital motility implants with solid acrylic implants following enucleation and identify possible risk factors. METHODS: The authors retrospectively reviewed the charts of a total of 117 consecutive enucleations performed at the University of Illinois at Chicago between March 28, 1994, and May 28, 1999. Data obtained included patient demographics, surgical indication, implant type, attending surgeon, surgical technique, and any reported complications. The primary outcome was presence or absence of implant exposure at the final recorded visit. RESULTS: Of the 117 identified cases, 29 were eliminated due to insufficient follow-up data. Of the 88 remaining cases, 48 patients received porous implants and 40 received solid acrylic implants. Implant exposure developed in four cases. All exposures occurred in unwrapped porous polyethylene implants (n=2) or porous polyethylene implants wrapped in absorbable material (n=2). All exposures occurred in patients younger than 18 years of age, and 75% occurred early after trauma-associated enucleation surgery. CONCLUSIONS: The exposure rate of porous polyethylene implants in this study (9%) was found to be comparable to published rates for hydroxyapatite implants. There were no exposures of unwrapped solid acrylic spheres. Unwrapped porous implants in pediatric patients or following trauma-related enucleation may represent an increased risk for postoperative implant exposure. Absorbable wrapping of porous implants may carry the same risk for exposure as no wrapping. Porous implants wrapped in durable material appear to be as safe as solid acrylic spheres.     

前巩膜片技术预防多孔材料义眼座植入的暴露

目的探讨在眼球摘除后多孔材料义眼座前部增加一巩膜片植入眼眶后预防暴露的有效性。方法美国Ore-gon州OHSU医学院Casey Eye Institute眼科研究所眼面部整形外科从2000年1月至2009年1月,John D Ng医生的162例（170眼）眼球摘除合并眼眶内植入有孔材料,使用前巩膜片技术（在多孔义眼座的前部缝合一7.5 mm×7.5 mm的巩膜片,并将四条直肌缝在巩膜片上）。根据病例资料,眼疾诊断,手术操作技术,先前眼科手术史,植入物的大小,随访时间,植入后并发症等,观察统计义眼暴露率及并发症。结果植入暴露发生7例,7眼（4.12%,7/170）。其中一例发生在早期（〈6个月）,6例发生在晚期（〉6个月）。这7例中1例给于抗生素及结膜切除手术,暴露得到修复;另外6例结膜撕裂较大未能得到修复,遂取出义眼座植入一新的前部缝有巩膜片的义眼座。这7例经过1a以上的随访,未出现再次暴露。结论巩膜片在移植物的前表面可以作为一种屏障,在预防暴露方面具有一定的有效性。