Monocanalicular lesions: to reconstruct or not.

OBJECTIVE: To evaluate the success rate of a simple surgical method for the treatment of a monocanalicular lacrimal lesion. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirteen consecutive patients with monocanalicular trauma who were seen from August 1995 to March 1998. In six patients, the canaliculus was lacerated as a result of an external injury and in seven patients as a result of tumor removal (iatrogenic injury). INTERVENTION: Reapproximation of the orbicularis muscle and skin overlying the torn canaliculus without reanastomosis of the lacerated canaliculus. In those patients in whom the canaliculus was sacrificed as part of the removal of an eyelid tumor, no attempt was made to reconstruct the canaliculus. MAIN OUTCOME MEASURES: Symptomatology, patency of the lacrimal passage, fluorescein dye disappearance test, and patient satisfaction. RESULTS: In all patients the injured canaliculus was totally blocked, but despite this none of the patients complained of inconvenient tearing either indoors or outdoors. The ipsilateral unharmed canaliculus was functioning normally in such a way that the fluorescein dye instillation test showed residual dye in six patients after 2 minutes and in none of the patients after 5 minutes. All patients were satisfied with the functional and cosmetic result. CONCLUSION: Nonrepair of a monocanalicular lesion is a valid approach that results in little or no morbidity.

Prosthesis motility with and without intraorbital implants in the anophthalmic socket.

Ocular prosthesis motility was measured and compared in 15 patients with a primary baseball implant after enucleation of an eye, in 11 patients with a secondary baseball implant, in 12 patients with an Allen implant, and in 11 patients without any intraorbital implant. In all patients a noticeable lag of movement of the prosthetic eye was measured: in the extreme directions of gaze the excursions of the prosthesis were far less in comparison with the contralateral normal eye. For normal eye movement round the primary position of gaze, however, the prosthesis motility in the primary baseball and Allen implant group appeared to be sufficient to give a lifelike appearance. The average motility of the prostheses in these two groups did not differ. The motility in the secondary baseball group and in the group without an implant was evidently worse. In the last group the prosthesis motility was most impaired. We conclude that the insertion of an implant, even when inserted some time after the enucleation (a secondary implant), improves the motility of the prosthesis markedly. We recommend the primary baseball implant as the correction of choice after enucleation.

Conjunctival cysts in anophthalmic orbits.

Five out of 149 patients (3%) who received an intraorbital implant to prevent or treat the disfiguring symptoms associated with the postenucleation socket syndrome developed intraorbital conjunctival cysts. All five patients had received a secondary implant two 14 months previously. After excision of the cysts four patients required additional surgery for lack of conjunctiva and/or recurrent cyst formation. The clinical findings, mechanism of development, and management of this rare but serious complication of socket surgery are described.

Primary and secondary implants in the anophthalmic orbit. Preoperative and postoperative computed tomographic appearance.

Sagittal computed tomographic (CT) scans of 10 anophthalmic orbits with a primary implant, an acrylic ball covered with donor sclera, and 10 anophthalmic orbits before and after insertion of a secondary implant were studied. For each patient, the scans of the anophthalmic and contralateral normal orbit were compared. In the anophthalmic orbits, the anatomy was optimally restored in those with a primary implant, and suboptimal results were achieved in the orbits with a secondary implant. The greatest differences were noticed in the orbits without an implant. Differences were noticed for the position and length of the superior muscle complex and the inferior rectus muscle, the position of the upper eyelid, the depth of the superior sulcus, and the backward tilt of the prosthesis. The authors conclude that the rotatory displacement of the orbital contents after enucleation, which explains the sequelae of the anophthalmic orbit, is grossly circumvented by the insertion of an implant. In achieving this effect, primary implants are better than secondary ones.

Computed tomography in the assessment of the postenucleation socket syndrome.

To gain a deeper insight into the cause of the postenucleation socket syndrome, high-resolution computed tomography (CT) was performed in 22 anophthalmic patients before insertion of an intraorbital implant. The anatomy of the normal and the anophthalmic orbits was compared. Computed tomographic scans were made either in the sagittal and the coronal plane or in the sagittal and transverse plane. The authors discovered a sagging and retraction of the superior muscle complex and a downward and forward redistribution of orbital fat. Finally, an upward displacement of the distal end together with a retraction of the inferior rectus muscle was found. These phenomena were measured and appear to cause a rotatory displacement of orbital contents from superior to posterior and from posterior to inferior which is best demonstrated in the sagittal plane. This redistribution of orbital contents can explain the sequelae of the anophthalmic orbit. No signs of orbital fat atrophy could be demonstrated. With this knowledge, the proper treatment of patients with a postenucleation socket syndrome is ascertained.

Primary versus secondary intraorbital implants.

To compare the results of primary and secondary intraorbital implants after enucleation, we retrospectively studied the surgical outcomes of 114 patients. In 44 patients the implant was inserted immediately after enucleation and in the remaining 70 patients the implant was inserted at a later date. To achieve a satisfactory cosmetic result, additional procedures were needed in 11% of the patients with a primary implant and in 49% of those with a secondary implant. The insertion of an implant at the time of enucleation has distinct advantages over the insertion of the implant at a later date.