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, 2 wk, 1, 3, 6, and 12 mo after surgery.RESULTS: Altogether 32 cases finished the followup 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 6 mo after placement of the orbital implant. The case of exposure of donor sclerawrapped implant was noted at the 12 mo 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.     

Bovine pericardium versus homologous sclera as a wrapping for hydroxyapatite orbital implants

PURPOSE: To report our experience with bovine pericardium as a wrapping material for hydroxyapatite orbital implants after enucleation and to compare the exposure rates of the implants wrapped with bovine pericardium versus donor sclera. METHODS: We retrospectively reviewed the records of all patients who received bovine pericardium-wrapped or donor sclera-wrapped hydroxyapatite implant after primary enucleation between March 1995 and December 2001. RESULTS: Of the 26 patients who received donor sclera-wrapped implants after enucleation, 1 (3.8%) had implant exposure. Of the 26 patients who received bovine pericardium-wrapped implants after enucleation, 6 (23%) had implant exposure. The incidence of implant exposure with the use bovine pericardium wrapping material was found to be significantly higher than with sclera (P = 0.05). Six of the 7 implant exposures were noted in the first 6 months after placement of the orbital implant. Five of the 6 exposed bovine pericardium-wrapped hydroxyapatite implants were associated with socket infection. The case of exposure of the sclera-wrapped implant was treated conservatively by observation. Six patients who had exposure of bovine pericardium-wrapped implants required multiple repairs because of recurrent exposures. Four of these patients eventually required removal of the implant. CONCLUSIONS: Despite the advantages of using bovine pericardium as a wrapping material for hydroxyapatite orbital implants, we observed a significantly higher incidence of exposure with bovine pericardium compared with donor sclera in the early postoperative period. Use of bovine pericardium as a wrapping material for orbital implants should be avoided unless some future modifications of the technique can be developed to prevent such complications.     

Bovine pericardium versus homologous sclera as wrapping materials for hydroxyapatite ocular implants: an animal study.

PURPOSE: We compared bovine pericardium and homologous sclera as wrapping materials for hydroxyapatite (HA) ocular implants in enucleated New Zealand white rabbits. METHODS: Eighteen rabbits were unilaterally enucleated and the sockets implanted with 10-mm HA spherical implants. Six implants were wrapped with homologous sclera, 6 with bovine pericardium, and 6 were not wrapped. The rabbits were killed 7 weeks later and the sockets were examined clinically for inflammation and implant exposure. Exenterated specimens were assessed histopathologically for inflammation and vascularization. RESULTS: No clinical evidence of implant exposure or extrusion was detected in rabbits receiving sclera or bovine pericardium wrapped implants. Histopathologically, the bovine pericardium displayed more inflammation in its outer portion, as well as more disruption of its lamellar arrangement than did the sclera. Fibrovascular in-growth was complete in all wrapped implants. CONCLUSION: Bovine pericardium behaves similar clinically to homologous sclera as a wrapping material for spherical HA ocular implants in a rabbit model, and may represent a reasonable alternative to sclera in such procedures in humans.     

巩膜花瓣状成形羟基磷灰石义眼台植入32例分析

目的 探讨巩膜花瓣状成形羟基磷灰石义眼台植入术的手术体会.方法 对32例行巩膜花瓣状成形羟基磷灰石义眼台植入术,随访3～18月,观察术后效果.结果 32例中1例结膜囊狭窄.均未发现义眼台暴露、脱出及感染等并发症.结论 巩膜花瓣状成形羟基磷灰石义眼台植入术术后并发症少,义眼台活动好,手术方便易行、疗效较可靠.     

Use of bovine pericardium as a wrapping material for hydroxyapatite orbital implants

AIM: To present the results of 27 patients who had enucleation for malignant melanoma of the choroid with hydroxyapatite implant wrapped in bovine pericardium. METHOD: A retrospective study was performed on 27 patients, 12 males and 15 females, who had enucleation as a primary treatment for their choroidal melanomas. The patients were followed up at 1 week, 1 month, 3 months, and then every 6 months. A conformer was fitted at 1 week and an artificial eye at 1 month. The average follow up was 1.7 years. RESULTS: No patient had extrusion of the implant. One patient needed repair of the wound, two patients required a lateral tarsal strip, and one patient developed a conjunctival granuloma, which did not need excision. In one patient there was shallowing of the inferior fornix. The cosmetic results and ocular movement were satisfactory in all but one patient. CONCLUSION: Use of bovine pericardium as wrapping material for the hydroxyapatite implants has shown promising results with minimal extrusion rates providing an effective alternative for sclera, eliminating the potential risks of CJD.     

自体巩膜覆盖预防羟基磷灰石义眼座暴露的临床观察

目的：观察自体巩膜覆盖羟基磷灰石(HA)义眼座对预防术后义眼座暴露的临床效果。

方法：对69例69眼采用双层巩膜覆盖43例、带直肌的板层巩膜瓣覆盖26例为加固物,行一期HA义眼座植入术。

结果：术后随访4～24mo,均无义眼座暴露发生。

结论：在行HA义眼座植入时,双层巩膜、带直肌的板层巩膜瓣为加固物覆盖HA,能有效地预防义眼座暴露。     

Bovine pericardium as a wrapping for orbital implants

PURPOSE: We report the use of bovine pericardium as an alternative wrapping for porous orbital implants after enucleation. METHODS: We retrospectively reviewed the records of all patients who received a bovine pericardium-wrapped orbital implant after enucleation by the authors between August 1, 1996, and December 1, 1999. RESULTS: Eighty patients underwent placement of bovine pericardium-wrapped orbital implants. The average age at the time of implantation was 49.3 years (range, 5 years to 83 years). The mean follow-up interval was 11.8 months (range, 2 to 41 months). There were no intraoperative complications. No patient had secondary systemic infection or showed evidence of rejection. There was no clinical evidence to suggest that vascularization of the porous implant was unusually delayed, and there were no complications after secondary drilling and placement of a coupling post. Four (5%) of 80 patients had complications requiring removal of the spherical implant. All 4 patients had hydroxyapatite implants. Two patients had significant exposure requiring removal of the implant at 2 months after surgery; 1 patient had a chronic fistulous tract with secondary infection 3 years after surgery: and 1 patient had chronic orbital pain requiring removal of the implant at 1 year after surgery. CONCLUSIONS: The incidence of implant exposure was less than 4%. This compares favorably to the incidence of exposure of 9% to 21% reported in recent literature. Other complications were few and of minimal clinical significance. The authors conclude that bovine pericardium is a viable option to sclera as a wrapping for porous orbital implants.     

Comparison of orbital volumes in enucleated patients with unilateral retinoblastoma: hydroxyapatite implants versus silicone implants

PURPOSE: To compare the difference in volume between enucleated and contralateral, uninvolved orbits in patients with unilateral retinoblastoma treated with primary enucleation who received either hydroxyapatite or solid silicone implants. METHODS: In this retrospective, comparative interventional case series, data were reviewed for all patients (N = 33) with retinoblastoma at St. Jude Children's Research Hospital who underwent unilateral enucleation and received either hydroxyapatite or solid silicone implant from 1969 to 1999. Patients who received external beam radiation or systemic chemotherapy were excluded. CT and/or MRI were used to compare the difference in orbital volumes between the enucleated orbit and the contralateral orbit in 13 patients who underwent enucleation with hydroxyapatite implants vs. 20 patients who underwent enucleation with silicone implants. The main outcome measure was the difference in volume between enucleated and contralateral, uninvolved orbits correlated to implant material, which we determined using the Wilcoxon rank sum test. RESULTS: The median difference in orbital volumes between enucleated and contralateral, uninvolved orbits was 0.9 cm (range, -3.78 to 3.09 cm; quartiles, -0.37, 2.72 cm; mean +/- standard error [SE], 0.76 +/- 0.64 cm; 95% confidence interval [CI], -0.49 to 2.01 cm) for patients treated with hydroxyapatite implants vs. 0.63 cm (range, -4.43 to 3.91 cm; quartiles, 0, 2.13 cm; mean +/- SE, 0.8 +/- 0.41 cm; 95% CI, -0.004 to 1.6 cm) in patients treated with silicone sphere implants. The median differences did not differ between the 2 types of implant (p = .74). The median follow-up time was 137 months (range, 10-244 months; quartiles, 37, 179 months; mean +/- SE = 118.31 +/- 22.83 months; 95% CI, 73.56-163.06 months) and 144 months (range, 57-251 months; quartiles, 98, 154 months; mean +/- SE, 136.1 +/- 10.78 months; 95% CI, 114.97-157.23 months), respectively. CONCLUSIONS: In unilateral retinoblastoma patients treated with primary enucleation, hydroxyapatite-integrated orbital implants provide no better symmetry of orbital volume than do more traditional silicone implants.     

珊瑚羟基磷灰石Ⅱ期眶内植入

目的：观察眼球摘除后羟基磷灰石眼座二期眶内植入的修复疗效。方法：用珊瑚多孔羟基磷灰石作为二期眶内植入物共253例。结果：随访6个月-15个月均获得良好的效果。并发症少,未发现眶内感染,植入物排出移位现象,结论：珊瑚羟基磷灰石并发症少,是目前眼球摘除后的良好眶内充填材料。     

羟基磷灰石义眼台植入的手术体会

目的比较巩膜包裹羟基磷灰石(hydmxypatite，HA)义眼台植入法与带线HA义眼台直接植入法的疗效。方法眶内植入HA义眼台共58眼，用自体或异体巩膜包裹义眼台后眶内植入40眼，用带线义眼台直接植入眼眶18眼，随访3月-4年。结果义眼台暴露7眼12％(7／58)，Ⅰ期1眼，Ⅱ期6眼；6眼采用巩膜包裹植入法15％(6／40)，1眼采用带线义眼台直接植入法5．6％(1／18)。结膜囊狭窄1眼。结论HA义眼台植入术后主要并发症是义眼台暴露，用带线义眼台直接植入发生这种并发症的机率变小。     

Late infection of hydroxyapatite orbital implants

BACKGROUND: Exposure and minor complications of hydroxyapatite orbital implants are common. Infection appears to be rare and fibrovascular ingrowth into hydroxyapatite implants may make infection and extrusion less likely than with other types of orbital implant. METHODS: We describe three cases of chronic low-grade infection of hydroxyapatite implants, occurring late after apparently uncomplicated surgery, with tiny or inapparent areas of conjunctival loss or exposure. RESULTS: Two of the three cases grew Staphylococcus oureus on culture. All three implants ultimately needed to be removed. A characteristic histological pattern was seen, with abrupt transition between vascularized and abscessed implant. CONCLUSIONS: Chronic infection of hydroxyapatite implants can occur late, in the absence of large conjunctival defects, or other obvious risk factors.While exposure of the implant to pathogens through a breach in the conjunctiva may have been a factor, it appeared that the infection may have arisen in an avascular portion of the implant prior to the conjunctival breakdown in one or more of these cases.     

Mobility of hydroxyapatite orbital implant covered with autologous sclera

PURPOSE: To evaluate the mobility of a hydroxyapatite implant covered with autologous sclera from the enucleated globes of patients with severe atrophy of the eyeball or eyelid retraction. METHODS: This implant was used in seven patients with phthisis bulbi. We measured the movement of the implant by photographic analysis of the anterior orbit and by using a strain gauge. RESULTS: At 1-3 years after surgery, neither infection nor prolapse of the implant had occurred in any of the patients. The implant remained stable in the orbit; the extraocular muscles sutured to the sclera of the implant were functioning satisfactorily, and the implants showed great conjugate mobility to the ocular movement of the healthy eye. On photographic analysis of the anterior orbit, the adducting efficiency of the implant was 92.6 +/- 3.3%; the abducting efficiency was 85.9 +/- 5.4%; the supraducting efficiency was 84.9 +/- 5.6%, and the infraducting efficiency was 90.9 +/- 3.9%. The mean tugging weight, as determined using a strain gauge, was 344.2 +/- 29.2 g for adduction, and 327.6 +/- 33.4 g for abduction. These values corresponded to 90.4 +/- 4.4% and 89.5 +/- 5.3% of the respective movements of the healthy eye. CONCLUSIONS: Fitting an artificial eye to the peg of this implant did not greatly impair the movement of the implant, and its mobility was greater than that of the artificial eye of the controls in which a semi-integrated magnetic implant, previously available, had been used. This new technique makes it possible to wear an artificial eye earlier than with other prosthetic procedures.     

眼球明显萎缩的近原位HA植入术

目的：探讨眼球明显萎缩的羟基磷灰石义眼座植入方法。方法：常规眼内容摘除，于直肌间将巩膜放射状剪至视神经处，呈4瓣，沿视乳头环形切开巩膜，形成4个带直肌的游离巩膜瓣，将眼座置入眼肌锥内，分组对合巩膜瓣，分层缝合筋膜与结膜。共植入25例。结果：追踪观察3－10月，患者外形矫正满意，义眼活动自如，改善了眼部外观，未见严重并发症与后遗症。结论：此手术方法操作简单，术后效果良好。     

Exposure of tantalum mesh orbital implants

This retrospective study of 195 enucleations with tantalum mesh implants reviews the role of demographic, preoperative, and operative factors in subsequent implant exposure or extrusion. Fourteen implants (7.2%) became exposed, two of which subsequently extruded. Significant associations were found between implant exposure and history of prior orbital infection, and suturing of the inferior oblique to the lateral rectus muscle. The average age at enucleation was 20.4 years for those whose implant became exposed, which was significantly less than the average age of 38.7 years for those without exposure of the implant. No association was found between implant exposure and gender, preoperative diagnosis, proptosis, chemosis, sharp trauma to the orbit, orbital fracture, previous orbital surgery, implant size, closing of posterior Tenon's capsule, or muscles sutured to the implant. Because of the high exposure rate, it is recommended that the use of tantalum mesh implants be discontinued.     

Polytetrafluoroethylene as a wrapping material for a hydroxyapatite orbital implant

PURPOSE: Porous coralline hydroxyapatite orbital implants have been used with great success in anophthalmic sockets. We used a substitute for donor sclera as a wrapping tissue. METHODS: Orbital implants were wrapped with polytetrafluoroethylene (PTFE) instead of homologous donor tissue in five patients after enucleation. RESULTS: The postoperative course was uneventful in three cases. Complications occurred in two cases: one with implant exposure, and one with severe implant infection leading to its eventual removal. CONCLUSIONS: PTFE is inferior to other wrapping tissue.     

自体小巩膜壳帽状扣盖术在羟基磷灰石义眼台植入术中的应用

目的 观察改良巩膜壳帽状扣盖术对自体巩膜较小的患者行羟基磷灰石义眼台植入术的临床效果.方法 16例(16眼)有自体巩膜但仅能包裹义眼台1/4～1/2的患者接受了这种手术.先将自体巩膜呈帽状包盖并固定于义眼台前极后再植入深层肌锥内,缝合眼外肌至较正常解剖位置靠前的巩膜预置切口处,最后无张力分层缝合筋膜和结膜.结果 本组16眼患者中14眼结膜创口一期愈合,2眼结膜切口裂开经保守治疗2周后自愈.术后随访6个月～3 a,无一例发生感染、义眼台暴露及交感性眼炎等并发症,所有患者义眼活动良好.结论 改良巩膜壳帽状扣盖术应用于自体巩膜较小的患者行羟基磷灰石义眼台植入安全可靠,值得雅广应用.