Efficacy of tocilizumab in patients with moderate-to-severe corticosteroid-resistant thyroid eye disease: a prospective study.

PURPOSE: To evaluate the clinical outcomes of intravenous tocilizumab (TCZ) injection in patients with moderate-to-severe active thyroid eye disease (TED). METHODS: Patients with active and moderate-to-severe TED who did not respond to conventional therapies were treated with TCZ from June 2019 to January 2021. The medical records of the patients were evaluated before the treatment. We analyzed patient demographics, including the duration of Graves' disease and TED, and assessed subjective symptoms, such as diplopia and ocular movement, clinical activity score (CAS), modified NOSPECS score, and exophthalmos before treatment and at 4, 8, 12, and 16 weeks after the first drug injection. Blood tests, including TSH Rc Ab and TS Ab, were performed before treatment and 24 weeks after the first injection. And orbital computed tomography (CT) was performed and Barrett's Index was calculated at baseline and after completion of all injections. RESULTS: Nineteen completed the scheduled treatment. There were no significant side effects, other than herpes zoster in one case and headache and dermatitis in another. Clinical symptoms before and 16 weeks after the treatment showed mean CAS decreased by 2.4 points, mean modified NOSPECS score decreased by 3.7 points, and mean exophthalmos decreased by 0.4 mm. Diplopia and extraocular muscle limitation improved in ten and remained stationary in five of the 15 patients, who presented with extraocular motility abnormalities. Six of 11 patients who underwent orbit CT showed improvement in muscle size. The mean TSH Rc Ab decreased by 7.5 IU/L and TS-Ab decreased by 162.9%. CONCLUSION: TCZ can treat active moderate-to-severe TED, showing high drug compliance and reasonable response to inflammation and extraocular motility abnormality.

Correlation Between Radiologic and Histopathologic Features of Orbital Epidermoid and Dermoid Cysts.

PURPOSE: Epidermoid cysts (EC) and dermoid cysts (DC) typically appear as well-circumscribed lesions on CT. This study aimed to clarify the radiologic and histopathologic characteristics of orbital EC and DC and to determine the correlations between them. METHODS: The medical records of 69 patients who underwent surgery for orbital DC or EC at Samsung Medical Center between January 2001 and August 2016 were retrospectively reviewed. The size and location of the cysts, rim enhancement, homogeneity of contents, presence of hemorrhagic or calcific components, radiodensity of contents, and extent of bony remodeling were evaluated using CT. Additionally, the cyst lining and contents were examined histopathologically. RESULTS: Among patients with orbital cysts, EC and DC were diagnosed in 10 (14.5%) and 59 (85.5%) patients, respectively. Further, 50.0% of EC and 79.7% of DC were located in the superotemporal quadrant of the orbit. On orbital CT, the average radiodensity of EC and DC was 18.9 ± 56.2 and -67.9 ± 63.3 HU, respectively. The cystic contents were more frequently homogeneous than heterogeneous in both EC and DC; however, the radiodensity of cysts differed significantly, which may be attributed to sebaceous gland activity. Focal bony notching, bone remodeling under pressure, and bony changes from dumbbell-shaped cysts were observed more frequently in DC than in EC. CONCLUSIONS: Radiological and histopathological features are correlated in orbital EC and DC. Therefore, orbital EC and DC can be preoperatively differentiated using CT, based on the average radiodensity and bony remodeling.

Early response to intravenous methylprednisolone therapy for restrictive myopathy in patients with thyroid eye disease.

PURPOSE: To report the therapeutic efficacy of intravenous methylprednisolone (IVMP) in patients with restrictive myopathy caused by thyroid eye disease (TED). METHODS: The present prospective uncontrolled study comprised 28 patients with TED and restrictive myopathy who presented with diplopia that had developed within 6 months before their visit. All patients were treated with IVMP for 12 weeks. Deviation angle, limitation of extraocular muscle (EOM) movement, binocular single vision score, Hess score, clinical activity score (CAS), modified NOSPECS score, exophthalmometric value, and the size of EOMs on computed tomography were evaluated. The patients were divided into two groups: those whose deviation angle had decreased or remained unchanged 6 months after treatment (group 1; n = 17) and those whose deviation angle had increased in that time (group 2; n = 11). RESULTS: The mean CAS of the whole cohort significantly decreased from baseline to 1 month and 3 months after treatment (P = 0.03 and P = 0.02, respectively). The mean deviation angle significantly increased from baseline to 1, 3, and 6 months (P = 0.01, P < 0.01, and P < 0.01, respectively). The deviation angle decreased in 10 (36%), remained constant in seven (25%), and increased in 11 (39%) of the 28 patients. When groups 1 and 2 were compared, no single variable was identified as a cause of deviation angle deterioration (P > 0.05). CONCLUSIONS: When treating patients with TED who have restrictive myopathy, physicians should be aware that some patients show worsening of the strabismus angle despite inflammation control with IVMP therapy. Uncontrolled fibrosis can result in motility deterioration.

Hyaluronic acid gel injection for dysthyroid upper eyelid retraction in Asian patients.

PURPOSE: To evaluate the role of hyaluronic acid (HA) filler injection in the management of upper eyelid retraction (UER) in thyroid eye disease (TED). METHODS: Retrospective interventional series of all patients with TED who had undergone HA injection, from February 2011 to April 2013 by a single surgeon (Y-DK) in a tertiary medical institution. Outcome measures: Mean margin reflex distance 1 (MRD1) pre- and post-filler. RESULTS: There was a total of 13 patients and 17 eyes included in the study. The injection dosage for 15 eyes was 0.5 ml, one patient had 0.35cc on the right eye and 0.65cc on the left eye. Mean MRD1 at presentation was 6.21 mm. There was a mean decrease in MRD1 of 2.01 mm (p < .001) at 1 month post filler, 2.06 mm (p < .001) at 6 months post filler and 2.61 mm (p < .001) at 1 year post filler. There was no correlation between pre-filler MRD1 and change in MRD1 at various time points post-filler, nor any correlation between pre-filler upper scleral show (USS) and change in USS post-filler. There was also no correlation found between clinical activity score (CAS) and change in MRD1, as well as duration of thyroid eye disease (TED) and change in MRD1. Complications included mild upper lid lumpiness on downgaze (n = 4, 23.5%) which improved but persisted with time. There were no untoward intravascular or vision-threatening complications. CONCLUSION: Transconjunctival HA injection is an effective treatment option for TED-related UER in both active and inactive TED patients in an East Asian population, with a potentially long-lasting effect.

Clinical Outcomes of IgG4-Related Ophthalmic Disease and Idiopathic Sclerosing Orbital Inflammation.

PURPOSE: To compare the clinical features, treatment outcomes, and prognoses of immunoglobulin G4-related ophthalmic disease (IgG4-ROD) and idiopathic sclerosing orbital inflammation (ISOI). METHODS: This retrospective case series included 40 and 22 biopsy-proven cases of IgG4-ROD and ISOI, respectively. The authors reviewed medical charts and images to determine the clinical presentation, involvement pattern, and treatment outcomes. The main outcome measures were differences in disease manifestation, treatment modalities and efficacy, medication-free remission rate, and predictive factors for remission. RESULTS: The median ages were 51 (range 31-72) and 39 (range 9-73) years in the IgG4-ROD and ISOI groups, respectively. The most frequently involved sites were the lacrimal gland (39 cases, 98%) in IgG4-ROD patients and the extraconal region (15 cases, 68%) in ISOI patients. No significant difference was observed in the initial treatment response between the groups. Medication-free remission was achieved in 22 (55%) IgG4-ROD patients and 10 (45%) ISOI patients; none of the IgG4-ROD patients showed permanent ocular dysfunction, while half of the ISOI patients had permanent visual loss or limited ocular motilities. Multivariate analysis indicated that extraocular muscle enlargement (odds ratio, 0.11; 95% confidence interval, 0.01-0.98) and IgG4:IgG ratio on histopathology (odds ratio, 0.08; 95% confidence interval, 0.01-0.86) were negatively associated with medication-free remission in IgG4-ROD patients. CONCLUSIONS: Although IgG4-ROD and ISOI share common histological findings of mass-forming sclerosis, IgG4-ROD frequently has a more indolent clinical course, whereas ISOI often demonstrates a more aggressive clinical course, resulting in ocular dysfunction even after remission. Different pathogeneses may account for the different disease characteristics.

Prognostic factors of restrictive myopathy in thyroid eye disease.

To investigate the prognostic factors of extraocular muscle restriction in patients with thyroid eye disease (TED), 65 patients with TED and restrictive myopathy were evaluated. Demographics, clinical activity score (CAS), smoking status, thyroid disease status, thyroid hormone status, thyroid autoantibody status, orbital computed tomography (CT) scan at initial presentation, and treatment regimens were assessed. The movements of the most severely affected extraocular muscles were categorized into five grades. The patients were divided into the improved and the not-improved group based on the improvement in the limitation of the extraocular muscle excursion (LOM) throughout the follow-up, and the groups were compared using clinical factors. The mean LOM significantly improved from 2.3 ± 1.1 to 1.7 ± 1.2 after 1 year of follow-up. The excursion of the most restricted muscle improved in 32 patients but not in 33 patients during the follow-up. The initial concentration of the thyroid-stimulating antibody (TSAb) was significantly lower in the improved (229.3 ± 114.1) than in the not-improved group (345.0 ± 178.6) (P = 0.02) Age, sex, smoking status, CAS, thyroid status, and muscle thickness on the CT scan did not significantly differ in the groups. This study showed that the initial concentration of TSAb is a factor affecting the recovery of restrictive myopathy.

Clinical characteristics and treatment outcomes of diffuse large B-cell lymphoma involving the eye and ocular adnexa in East Asia.

PURPOSE: To investigate the clinical features and outcomes of diffuse large B-cell lymphoma (DLBCL) involving the eye and ocular adnexa in an East Asian population and emphasize the importance of prompt biopsy and treatment in unusually progressive ocular adnexal DLBCL for better visual outcomes. METHODS: Retrospective case series of 38 patients diagnosed with DLBCL involving the eye and ocular adnexa between 1995 and 2018 at a single tertiary institution. RESULTS: There were 38 patients (22 men, 16 women), 22 (57.9%) of which had ocular adnexal lymphoma (OAL) and 16 (42.1%), vitreoretinal lymphoma (VRL). The OAL group showed higher rates of unilateral involvement (p = 0.01) and localized disease presentation (p = 0.01). Thirteen (59.1%) of 22 OAL patients were primary diseases and 9 (40.9%) were secondary. Between primary and secondary OAL groups, there was no statistical difference in clinical characteristics such as age, gender and laterality (p = 0.47, p = 0.19 and p = 0.66, respectively). All secondary OAL cases were either disseminated or relapsed by definition and only two cases (15%) of primary OAL showed disseminated presentation (p < 0.01). Six (37.3%) of 22 OAL patients showed a rapid decrease in visual acuity within 15 days and the visual recovery was irreversible in 3 of them. CONCLUSION: OA-DLBCL has a grave prognosis and its visual outcomes largely depend on the timing of diagnosis and treatment. When a high-grade lymphoma is suspected, prompt biopsy and treatment should be performed to ensure optimal visual, clinical and survival outcomes.

Lagophthalmos after congenital ptosis surgery: comparison between maximal levator resection and frontalis sling operation.

BACKGROUND/OBJECTIVES: To compare postoperative lagophthalmos after maximal levator resection (MLR) and frontalis suspension (FS) in congenital ptosis patients with poor levator function (LF). METHODS: A cross-sectional study was performed to compare postoperative outcomes in patients with preoperative LF ≤ 4 mm who had undergone MLR or FS at a single tertiary institution, and who had visited the outpatient clinic between February 2017 and August 2018. Main outcome measures were as follows: (1) Preoperative LF and margin reflex distance 1 (MRD1), (2) Postoperative MRD1, lagophthalmos and grade of superficial punctate keratopathy (SPK). RESULTS: Our study comprised 152 eyelids of 122 patients. There were 71 eyelids in the MLR group and 81 eyelids in the FS group. The MLR group had comparable mean postoperative MRD1 (2.8 ± 0.8 mm) to the FS with autogenous fascia lata (AFL) group (3.0 ± 0.7 mm), while the FS with preserved fascia lata (PFL) group had the lowest mean postoperative MRD1 (2.2 ± 1.0 mm). The PFL group had significantly less lagophthalmos (0.6 ± 1.0 mm) than the AFL (1.9 ± 1.4 mm) and maximal levator resection (1.9 ± 1.7 mm) groups. In the MLR group, there was no significant difference in postoperative surgical measurements between the LF 0-2 mm group and LF 2.5-4 mm group in terms of exposure keratopathy, degree of lagophthalmos and MRD1. CONCLUSION: MLR is an effective alternative to FS in congenital ptosis patients with poor levator function, with the risk of postoperative lagophthalmos related to postoperative MRD1 rather than preoperative LF.

Occurrence of ocular injury and orbital fracture in orbital blunt trauma patients at tertiary care center emergency room.

PURPOSE: To analyze the prevalence and association of ocular injury and orbital fracture in orbital trauma patients METHODS: Patients with periocular trauma who visited the emergency room at the referral center from 2014 to 2016 were screened. Patients examined by ophthalmologists and evaluated by CT scan were included. Patients' age, gender, cause of trauma, and injury patterns were retrieved. The location of the fracture and morphologic parameters were reviewed. The patients were divided into groups based on the presence of orbital fracture and/or the presence of ocular injury and clinical data were compared. RESULTS: Two hundred patients were included and 158 presented with fracture. Ocular injuries occurred in 129 of 158 (81.6%) in the fracture group, and in 40 of 42 (95.2%) in the no fracture group; ocular injuries were found more often in the no fracture group (p = 0.031). Open globe injuries occurred in 5 of 158 (3.2%) in the fracture group and in 6 of 42 (14.3%) in the no fracture group; open globe injuries were found more often in the no fracture group (p = 0.012). Patients with ocular injuries showed shorter depth of the orbit (41.9 vs. 44.1 mm; p = 0.003) compared to the patients without ocular injuries. Logistic regression revealed that short orbit was associated with the presence of ocular injury (p = 0.004). CONCLUSION: The incidence of ocular injuries was significantly higher in patients without orbital fracture than in those with fractures of the orbit. The orbital fracture may play a protective role against ocular injury by providing a decompressive effect on the orbital tissue.

Orbital decompressive effect of endoscopic transorbital surgery for sphenoorbital meningioma.

PURPOSE: This study was aimed at evaluating the orbital decompressive effect of endoscopic transorbital approach (TOA) in the management of sphenoorbital meningioma involving the orbit. METHODS: Patients treated with TOA for this tumor from December 2016 to December 2019 were included, and the data were reviewed. Pre- and postoperative clinical and imaging findings were compared with a volumetric study. RESULTS: Eighteen patients (two men and 16 women) were included. Lateral wall hyperostosis (13 patients), extraconal tumor infiltration (18 patients), intraconal tumor infiltration (seven patients), and superior and lateral rectus encasement (nine patients) were found. Intraconal tumor infiltration in the posterior orbit affected compressive optic neuropathy (CON) more often than other tumor manifestations. The orbital soft tissue volume decreased to 91.18% ± 8.19% compared to that in the contralateral side preoperatively. The postoperative volume increased to 113.73% ± 12.92% compared to the preoperative volume. The average values of LogMAR visual acuity and visual field index score of ten patients with CON improved from 0.80 to 0.42 and 48.9 to 65.9%, respectively. All 17 patients with proptosis showed improvement after surgery. There were no significant complications associated with the surgery. Additional treatment, including gamma knife surgery, was applied to 12 cases for the remaining tumor. CONCLUSION: This minimally invasive surgical debulking procedure was successful in treating sphenoorbital meningioma without significant adverse events. Lateral orbital wall decompression and limited intraorbital tumor resection were effective for compressive orbitopathy from the tumor.

Stereotactic radiosurgery for orbital cavernous venous malformation: a single center's experience for 15 years.

BACKGROUND: Stereotactic radiosurgery such as Gamma Knife radiosurgery (GKRS) has been shown to have a good treatment effect for orbital cavernous venous malformation (CVM). However, radiation-induced retinopathy or optic neuropathy is a vision-threatening complication of orbital irradiation. Predicting the post-treatment visual outcome is critical. METHODS: Clinical and radiological outcomes were investigated in 30 patients who underwent GKRS for orbital CVM between July 2005 and February 2020. Measurement of peripapillary retinal nerve fiber layer (pRNFL) thickness using optical coherence tomography (OCT) was obtained in 14 patients. RESULTS: The median clinical and radiological follow-up periods were 46.6 months (range, 15.9-105.8) and 27.5 months (range, 15.4-105.8), respectively. Twenty-eight patients underwent multisession (4 fractions) GKRS. The median cumulative marginal dose was 20 Gy (range, 16-24). Two patients underwent single-session GKRS. Marginal doses were 15 Gy and 10.5 Gy in each patient. The volume of CVM decreased in 29 (97%) patients. Visual acuity was improved in 6 (20%) patients and was stable in 22 (73%) patients. Visual field defect and exophthalmos were improved in all patients. Serial investigation of OCT showed no statistically significant difference in pRNFL thickness after GKRS. Patients with normal average pRNFL thickness showed better visual recovery than patients with thin average pRNFL thickness. CONCLUSIONS: GKRS is an effective and safe treatment option for orbital CVM. The pRNFL thickness before GKRS can be a prognostic indicator for visual recovery in orbital CVM after GKRS.

Complications of Asian Double Eyelid Surgery: Prevention and Management.

Double eyelid surgery remains one of the most popular aesthetic surgeries, especially among East Asian populations. Complications related to double eyelid surgery can be divided into various categories: (1) patient dissatisfaction, (2) problems with the eyelid crease, (3) problems with the eyelid height, (4) suture-related complications, and (5) complications related to eyelid surgery in general. As with all eyelid surgeries, it is important to understand and appreciate the normal and abnormal function and anatomy of the Asian eyelid to reduce the risk of complications. It is also important to recognize the various complications and their underlying causes so that the surgeon can confidently revise the surgery to achieve optimal outcomes.

Enhanced orbital adipogenesis in a mouse model of T-cell-mediated autoimmunity, zymosan A-treated SKG mice: Implications for Graves' ophthalmopathy.

Inflammation and remodelling of orbital tissue associated with enhanced adipogenesis commonly occur in Graves' ophthalmopathy (GO), however, the underlying mechanisms that link immune cells and adipocytes in orbital inflammation are not well-known. The primary aim of this study was to elucidate how a genetically determined shift in the T-cell repertoire toward self-reactive T-cells could drive orbital adipogenesis. To induce the T-cell-mediated autoimmune response, SKG mice were intraperitoneally injected with zymosan A once at 8 weeks of age. After three months, orbital magnetic resonance imaging (MRI), histopathologic studies, and in vitro analyses were performed to evaluate inflammation and adipogenesis. The eyes of the zymosan A-treated SKG mice displayed proptosis and blepharitis. A detailed analysis of orbital adipose tissue showed enhanced orbital adipogenesis and cellular infiltration compared to controls. In addition, increased secretion of adipokines and other cytokines in the periorbital tissue was observed, together with elevated serum concentration of inflammatory cytokines. Orbital adipogenesis was enhanced in zymosan A-treated SKG mice, a novel mouse model for GO-like inflammatory adipose phenotypes most likely induced by T-cell mediated autoimmune responses. This mouse model gives us the opportunity to examine the underlying molecular mechanisms of enhanced adipogenesis in GO, ultimately providing a potential therapeutic target alternative to conventional GO treatment.

Pilosebaceous Malignant Transformation of Dermoid Cyst in the Orbit.

Dermoid cysts may occur in the orbit, most commonly in the superolateral area. Malignant transformation of such lesions has been previously reported; however, most turn out to be squamous cell carcinoma. The authors' patient initially presented with mild proptosis and limitation in extraocular movements. Preliminary biopsy showed whitish amorphous material and abundant hairs filling the thin-walled cyst, consistent with dermoid cyst. The patient underwent tumor resection via lateral orbitotomy with bone window and transorbital endoscopic approach for the dural involvement. Final biopsy showed dermoid cyst with pilosebaceous malignant transformation showing p53 expression and 30% of Ki-67 index. Adjuvant radiotherapy was performed. To the best of the authors' knowledge, this is the first reported case of this type. Despite its rarity, there should always be a high index of suspicion and complete work-up for an accurate diagnosis.

Perioperative Prophylactic Antibiotics in 1,250 Orbital Surgeries.

PURPOSE: Intravenous antibiotic prophylaxis is used for many clean-contaminated surgeries or clean surgeries with an implant, but its value for clean orbital surgery has not been determined. This study investigated infection risks and adverse effects related to antibiotics in patients undergoing orbital surgery. METHODS: A prospective, nonrandomized comparative case series of all patients undergoing orbital surgery with participating surgeons between October 1, 2013, and March 1, 2015. Types of surgery, antibiotic regimens, corticosteroid use, antibiotic side effects, and surgical site infections (SSIs) were entered into an electronic database and subsequently analyzed. Cases in which patients received postoperative oral antibiotics were analyzed separately. RESULTS: Of 1,250 consecutive orbital surgeries, 1,225 met inclusion criteria. A total of 1208 patients were included in the primary analysis: 603 received no antibiotic prophylaxis (group A), and 605 received a single dose of intravenous antibiotic (group B). Five patients (0.42%) developed an SSI, 3 in group A and 2 in group B. The difference in SSI rates was not statistically significant between the 2 groups (p = 0.66). Antibiotic prophylaxis, alloplastic implants, paranasal sinus entry, and corticosteroid use were not associated with differences in SSI rates. All SSIs resolved on a single course of oral antibiotics; an implant was removed in 1 case. There were no complications associated with a single dose of intravenous prophylaxis. However, 12% of 17 patients (group C) who received 1 week of oral postoperative prophylactic antibiotics developed antibiotic-related complications (diarrhea, renal injury), yielding a number needed to harm of 8.5. CONCLUSIONS: In this large series, antibiotic prophylaxis does not appear to have reduced the already low incidence of SSI following orbital surgery. Given the detriments of systemic antibiotics, the rarity of infections related to orbital surgery, and the efficacy of treating such infections should they occur, patients undergoing orbital surgery should be educated to the early symptoms of postoperative infection and followed closely, but do not routinely require perioperative antibiotics.

Course of upper eyelid retraction in thyroid eye disease.

AIMS: To evaluate the natural course of upper eyelid retraction (UER) in patients with thyroid eye disease (TED) and factors affecting its course. METHODS: Retrospective non-interventional cohort study in a single tertiary institution from March 2006 to March 2015 on patients with TED with (1) unilateral or bilateral UER within 6 months from initial presentation, and (2) no prior interventions nor surgical treatment for their UER. Main outcomes and measures were mean margin reflex distance 1 (MRD1) and factors associated with UER improvement. RESULTS: There were a total of 61 patients and 81 eyes (41 unilateral and 20 bilateral UER). Mean age was 42.3±15.1 years. Mean MRD1 decreased from 6.1 mm at presentation to 4.8 mm at 12 months, and 4.4 mm at 24 months. The proportion of eyes with normalisation of lid height increased from 0% at presentation to 22.2% at 6 months, 37.0% at 12 months and 49.4% at 24 months. Mean time to normalisation of MRD1 was 18.0±12.4 months. A positive family history of TED was found to be associated with a 6.2 times lower likelihood of normalisation. Change in exophthalmometry, clinical activity score and thyroid-stimulating immunoglobulin were significantly correlated to change in MRD1 (p<0.05). There was no correlation between change in MRD1 and thyroid-stimulating hormone receptor antibodies. CONCLUSION: An improved knowledge of the natural history of UER in TED will allow us to better decide and evaluate the optimal management for such patients.

Use of Meshed Acellular Dermal Allograft as a Lining Material After Orbital Exenteration.

PURPOSE: To evaluate the surgical outcome and safety of acellular human dermal allograft as a new lining material to the exposed orbit after exenteration. METHODS: Retrospective case series of patients who underwent orbital exenteration followed by reconstruction with meshed-type acellular dermal allograft from 2009 to 2018 in a single tertiary institution. RESULTS: There were 14 eyes (2 right, 12 left) of 14 patients (6 men, 8 women). Mean age at operation was 69.1 ± 16.5 years. Indication for surgery was malignancy in all patients. One patient underwent subtotal exenteration, while the rest underwent total exenteration. SureDerm Meshed was used in 12 patients, AlloDerm Meshed in 1, and CGDerm Meshed in 1. Mean follow-up period was 12.1 months. Full or nearly full epithelialization occurred in 10 of 14 patients (71.4%) at 1 month and 9 of 12 patients (75.0%) at 3 months. There was delayed epithelialization in 3 patients due to poor wound care (n = 1), adjuvant radiotherapy (n = 1), and adjuvant radiotherapy followed by cerebrospinal fluid leak (n = 1). CONCLUSIONS: Meshed acellular human dermal allograft showed good success in reconstruction after orbital exenteration and may be considered as an alternative lining material to split-thickness skin graft after orbital exenteration.