Surgical management of orbital implant exposures after evisceration or enucleation: Retrospective study - Limoges University Hospital.

INTRODUCTION: Implant exposure is the most frequent complication after evisceration or enucleation, and multiple surgical techniques for the management of orbital implant exposure. The goal of our study is to investigate the success rate and risk factors for failure of various surgical procedures. METHODS: This was a retrospective study performed at the University Hospital of Limoges. We collected data from the files of every patient operated on for implant exposure between January 2005 and December 2020. The main criterion was the percentage of success for each procedure. Secondary objectives were to identify risk factors for failure of Müller's muscle flaps and to determine the incidence of post-enucleation socket syndrome depending on whether the orbital implant was maintained. RESULTS: Fifty-one patients were included: 26 patients who underwent Müller's muscle flap, 16 dermis-fat graft, 3 conjunctival flap, 2 amniotic membrane graft, 1 temporalis fascia graft, 1 buccal mucosa graft, 1 implant rotation, and 1 implant exchange. The dermis-fat grafts were more successful (87.5%) than the Müller's muscle flaps (52.2%) (P=0.0213). The study highlighted the importance of good vascularization of the implant (OR=32.00, P-value=0.0245) for the success of Müller's muscle flaps, and we found no statistically significant difference between the patients who maintained their implants and those who did not (P=0.3865) with regard to the incidence of post-enucleation socket syndrome. CONCLUSION: Müller's muscle flap may remain a reasonable option in the management of medium-sized implant exposures of well-vascularized implants confirmed on MRI in patients with no systemic healing disorders. Dermis-fat graft remains the option of choice in other cases, especially in large exposures or complicated orbits.

Post-enucleation socket syndrome-a novel pathophysiological definition.

BACKGROUND: The last definition of the post-enucleation socket syndrome (PESS) by Tyers and Collin-formulated almost 40 years ago in 1982-is predominantly based on the clinical characteristics and does not include the insights of newer studies into the pathophysiological mechanism of the PESS. METHODS: A systematic PubMed literature review regarding the pathophysiological mechanism of the PESS was performed, and results were comprised to give an overview of the current knowledge of the PESS including the exact pathophysiological mechanism. RESULTS: The primarily postulated pathophysiological mechanism of the PESS was the atrophy of orbital tissues, especially of fat, resulting in variable clinical findings. Newer studies using high-resolution computed tomography and magnetic resonance imaging or performing histopathological analyses found no orbital fat atrophy but rather a rotatory displacement of the orbital tissues from superior to posterior and from posterior to inferior together with the retraction of the extraocular muscles and a possible volume loss of the orbital implant by resorption if it is manufactured from hydroxyapatite. PESS results in a backward tilt of the superior fornix, a deep superior sulcus, a pseudo-ptosis, a lower eyelid elongation and laxity, a shallower inferior fornix, as well as enophthalmos and may lead to an inability of wearing ocular prostheses. CONCLUSIONS: A novel and comprehensive definition of the PESS is proposed: PESS is a multifactorial and variable syndrome caused by a rotatory displacement of orbital contents together with the retraction of the extraocular muscles and possible resorption of the orbital implant if it is manufactured from hydroxyapatite.

Management of post enucleation socket syndrome patients - A retrospective study.

The aim of this retrospective monocentric study was to report the outcomes following the correction of post enucleation socket syndrome (PESS) as well as the factors predicting for a multistep management. Patients were included, if they had received surgery to manage PESS. Demographics and patient history were collected. The symptoms of PESS were clinically rated by the same surgeon and ocularist, preoperatively and after each procedure. The surgery was considered as successful when no PESS clinical symptoms were observed. A prognostic study was performed to investigate the surgical outcomes. RESULTS: Thirty-six patients were included and eight of them had their PESS corrected after the first surgery. In the multivariate analysis (MVA), the deep upper lid sulcus symptom remained the main significant factor associated with an incomplete correction after the first surgery (OR 45.5, IC 95% (3.481-594.6), p = 0.004). For further corrections, the ptosis was the only significant prognostic factor requiring several surgeries (p = 0.005). At the end of the management, 94.4% of the patients had satisfying outcomes. CONCLUSIONS: The management of a PESS involves the correction of both the orbital cavity and the soft tissues. Although its correction is complex and time consuming in the majority of cases, the patients should be informed that the final cosmetic outcomes remain good at the expense of several surgeries.

Custom wave-shaped CAD/CAM orbital wall implants for the management of post-enucleation socket syndrome.

The satisfactory management of post-enucleation socket syndrome is a major challenge. In addition to enophthalmos and hypophthalmos, the appearance of the supratarsal fold is frequently unsatisfactory. Using a combination of orbital volume reduction by means of custom wave-shaped CAD/CAM implants (1), the implantation of a dermis-fat graft (2), and the fitting of an acrylic eye prothesis (3), an algorithm has been developed that has led to considerable long-term improvements. 10 patients have already been treated by this method. The most important step is the reduction of orbital volume by means of custom wave-shaped CAD/CAM implants. These move the intraorbital soft tissue in an anterior and cranial direction. This considerably reduces the required volume of additional dermis-fat grafts, which are always subject to resorption. The use of an acrylic eye prothesis facilitates the aesthetic and functional correction of this condition and exerts less pressure on the lower eyelid due to its low weight. The method presented here leads to stable and aesthetically pleasing results with a minimum risk of complications. One problem is the exact predictability of the necessary orbital volume reduction by the custom wave-shaped CAD/CAM implants. Further studies and a larger number of cases are required to address this problem.

Complications of orbital endoimplantation in the Eye Clinic of the Lithuanian University of Health Sciences.

The aim of the study was to analyse the rate of complications of orbital endoimplantation in patients operated from 2002 to 2014 at the Eye Clinic of the Lithuanian University of Health Sciences and to compare it with the results in the literature. Enucleation must be performed very carefully in order to prevent any additional trauma, infection, deformation, and to create an optimal conjunctival socket. However, complications occur despite efforts and qualified surgeons. The most common complications described in the literature are thinning and cysts of the conjunctiva, a foreign body reaction, secretion, symblepharons, fornix deficiency, ptosis, permanent pain, dislocation, migration and protrusion of the implant, a primary or secondary infection, and implant extrusion. From 2002 to 2014, 128 patients underwent orbital endoimplantation surgery at the Eye Clinic. The most common complications were conjunctival erosion (five patients, or 2.9%), cysts (nine patients, or 7%), and implant extrusion (five patients, or 2.9%). The type and rate of complications were very similar to the data in the literature.

Prosthetic Rehabilitation Following Socket Reconstruction with Blair-Brown Graft and Conformer Therapy for Management of Severe Post-Enucleation Socket Syndrome--A Clinical Report.

One of the most common tumors of the eye diagnosed in childhood is retinoblastoma, which mandates enucleation with adjunctive chemotherapy and radiotherapy to save the patient's life. The most common late enucleation complication is post-enucleation socket syndrome (PESS), which poses a management dilemma for the prosthodontist and surgeon, along with being a major esthetic concern for the patient. The reconstruction of such sockets is complex. The purpose of this clinical report is to describe the rehabilitation of such a pediatric patient with severe PESS. The patient was successfully rehabilitated by presurgical conformer therapy, socket reconstruction surgery with non-meshed intermediate split thickness skin graft (STSG)/Blair-Brown graft, and postsurgical conformer stent. This was followed by fabrication of a custom ocular prosthesis, to achieve favorable functional, physical, and psychological effects.