Early ocular prosthesis insertion improves quality of life after enucleation

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1 Optometry (2006) 77, Early ocular prosthesis insertion improves quality of life after enucleation Kimberly Chin, O.D., a Charles B. Margolin, M.B.A., a and Paul T. Finger, M.D. a,b,c a The New York Eye Cancer Center, New York, New York; b New York Eye and Ear Infirmary, New York, New York; and c New York University School of Medicine, New York, New York. KEY WORDS: Prosthesis; Enucleation; Aesthetic rehabilitation; Implant; Quality of life BACKGROUND: The aim of this study was to evaluate early insertion of ocular prostheses for aesthetic rehabilitation after enucleation and review current methods of enucleation surgery. METHODS: Twelve patients with large intraocular malignancies were treated by enucleation with implant. At the end of surgery, a medium-size conformer was inserted onto the closed conjunctival wound (just before applying a pressure dressing). The pressure dressing was removed 3 to 5 days after surgery. Immediately after bandage removal, the patients saw themselves in a mirror and were offered placement of a relatively small ocular prosthesis. Patients were asked if they preferred their aesthetic appearance with or without the prosthesis. RESULTS: Eight patients (67%) tolerated introduction of the prosthesis at the time of removal of their pressure dressing (3 to 5 days after enucleation surgery). Because of discomfort, 4 were able to receive their prostheses at their second postoperative visit (day 12 or 13). The manipulation at prosthesis insertion and subsequent wearing was found to have no effect on wound closure, final prosthetic fittings, or movement of the permanent prosthesis. All patients were pleased with the cosmetic benefit afforded by early introduction of the prosthesis and preferred their appearance to that of their eye with the conformer. CONCLUSIONS: Early replacement of the conformer by an ocular prosthesis allows for cosmetic rehabilitation and improved quality of life. Optometry 2006;77:71-75 Corresponding author: Paul T. Finger, M.D., The New York Eye Cancer Center, 115 East 61st Street, New York, New York, pfinger@eyecancer.com Enucleation, defined as removal of the globe from the orbit, may be the oldest operation of ophthalmology. 1 As early as 2600 BC, a Chinese god was devoted to the profession of ocularists. 1 With the advent of general anesthesia, surgeons refined their techniques and opened the door to the development of new orbital implants and prostheses. 2,3 Enucleation continues to be one of the most difficult therapeutic decisions. Current indications for enucleation include otherwise untreatable eyes that are blind and painful, contain a malignant neoplasm, or are at risk for causing sympathetic ophthalmia (e.g., traumatized eyes). The enucleating surgeon must take into account the patient s psychological makeup, the potential for vision in each eye, and the patient s cosmetic concerns. Despite our best efforts, loss of an eye continues to result in psychological trauma for the patients and their families. 1 Patients typically ask, What will I look like after I have my eye removed? To reduce their fear, physicians typically show photographs of patients that have undergone final cosmetic rehabilitation by fitting an ocular prosthesis. We also reassure patients that they will receive their prosthetic eye as soon as possible. In an ongoing effort to decrease the psychological trauma associated with loss of an eye, this /06/$ -see front matter 2006 American Optometric Association. All rights reserved. doi: /j.optm

2 72 Optometry, Vol 77, No 2, February 2006 Table Patients demographics and results of ocular prosthesis insertion Patient Gender Age Diagnosis Eye Prosthetic eye color Initial insertion day Insertion tolerated Final insertion day Cause Cosmetic prosthesis preferred Complications Comment 1 M 67 CM-T3 O.D. Blue 5 Yes Yes None SSD 2 F 37 MM O.D. Hazel 5 No 13 Discomfort Yes None None 3 M 41 CM-T3 O.S. Blue 5 Yes Yes None PCM 4 M 63 CM-T3 O.S. Brown 4 Yes Yes None Proptosis 5 M 53 CM-T3 O.D. Blue 5 Yes Yes None Exotropia 6 F 67 CM-T3 O.D. Blue 3 No 13 Discomfort Yes None PCM 7 M 55 CM-T3 O.S. Brown 5 Yes Yes None None 8 F 48 CM-T3 O.S. Hazel 5 No 12 Discomfort Yes None None 9 F 54 CM-T3 O.D. Hazel 5 No 12 Discomfort Yes None None 10 M 40 CM-T3 O.D. Hazel 5 Yes Yes None None 11 F 69 CM-T3 O.D. Blue 5 Yes Yes None None 12 M 47 CM-T3 O.D. Blue 5 Yes Yes None PCM CM Choroidal melanoma; MM malignant melanocytoma; T3 AJCC-UICC stage for choroidal melanoma 3 ; SSD superior sulcus deformity; PCM poor color match. study examines the feasibility of placement of ocular prostheses immediately after removal of the postoperative pressure dressing. Patients and methods This study was conducted in adherence with the tenets of the Declaration of Helsinki. Eleven patients with COMSlarge/AJCC-T3N0M0 choroidal melanomas and 1 giant malignant melanocytoma were included in this study (see Table). 4,5 Enucleation procedure Details of our methods of enucleation surgery have been described. 1,6 It is important to note in this study that all enucleations were performed under general anesthesia; during surgery a retrobulbar infusion of long-acting local anesthetic with epinephrine was placed to aid hemostasis and for postoperative pain control. A Finger-tip cryoprobe (MIRA, Uxbridge, Massachusetts) was used to create vertical traction on the globe for optic nerve transsection. 6 Postenucleation hemostasis was achieved with digital pressure, and an unwrapped 20-mm polymethylmethacrylate (PMMA) implant was inserted deep to posterior Tenon s fascia. These spherical devices are placed within the orbit, posterior to Tenon s fascia, the rectus muscles, and conjunctiva. These 3 layers typically are closed over the implant and act as a barrier to prevent implant extrusion or migration. After the surgical wound is closed, a clear concave plastic conformer is placed beneath the eyelids, onto the conjunctiva, and over the orbital implant (see Figure 1). The conformer is placed to maintain the shape of the conjunctival fornices and prevent extrusion of soft tissue from between the eyelids. Choice of orbital implant Integrated or nonintegrated implants are currently used widely to replace the lost orbital volume resulting from removal of the eye. Integrated implants (e.g., hydroxyapatite; Medpor, Fairburn, Georgia) are porous and allow for in-growth of blood vessels. Such integration of the implant is thought to decrease the chance of its migration within the orbit. The relatively soft materials used to form integrated implants also allow for placement of metallic pegs (that can be coupled with a prosthesis to improve motility). In contrast, we used nonintegrated implants. Typically made of PMMA, they can be purely spherical or formed to allow integration of the rectus muscles (e.g., the Allen implant). 1 We chose nonintegrated implants because they are less commonly associated with infection or extrusion. They require fewer secondary surgical procedures, and it has been found that the cosmetic motility advantages of integrated implants are time limited (several years). It is also important to note that most of our patients had American Figure 1 A graphic display of an ocular prosthesis seated on an orbital implant. The soft tissues (conjunctiva, Tenon s fascia, rectus muscles) are not included as to illustrate their relative positions.

3 Chin et al Clinical Care 73 Joint Committee on Cancer T3 melanomas and are at great risk for metastatic disease. This subset of patients did not want to be at risk for multiple surgeries (e.g., pegging, covering for exposure, or removal because of infection). 1,4 In our experience, these complications are much less likely with nonintegrated implants. But, clearly prospective randomized comparative study of integrated versus nonintegrated implants has not been performed. Wound closure In either case, wound closure is critical to early placement of an ocular prosthesis. In this series, 10 absorbable interrupted 5-0 Vicryl sutures were placed to close posterior Tenon s fascia over the implant. The rectus muscles were imbricated with the previously placed muscle sutures, and anterior Tenon s fascia was closed with a running 5-0 Vicryl suture. Finally, the conjunctiva was closed with a running 7-0 Vicryl suture. Immediately after surgery, a medium-sized plastic conformer with holes was placed onto the conjunctiva, antibiotic-steroid ointment was introduced through one of the holes, and the eyelid was closed. A pressure bandage was then placed over the eye. Cosmetic rehabilitation by prosthesis insertion Patients were requested to return for bandage removal as early as 3 but preferably 5 days after surgery (see Table 1). They signed consents for prosthesis placement, use of medical photographs for research, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Before insertion of the prosthesis, a drop of proparacaine hydrochloride 0.5% was placed between the eyelids. The conformer was removed and the wound inspected. In all cases, the wound was intact and there appeared to be enough space to accommodate prosthesis insertion. We chose a small temporary prosthesis, not so small that they might fall out or so large that tension was placed on the wound. Much the same size as their conformers, the temporary prostheses were large enough to occupy and maintain the conjunctival fornices. Eight patients were able to accept insertion of the temporary ocular prosthesis at the time of bandage removal, 4 others were able to accept the prosthesis 1 week later. Topical antibiotic steroid drops were placed onto the prostheses until the 30th postoperative day. Patients were instructed to wash their hands if they manipulated the prosthesis. Results All 12 patients were able to accept a temporary prosthesis within 2 weeks of surgery. Eight (67%) were able to have the prosthesis inserted on the day of bandage removal (see Table 1). The prosthesis fell out on day 2 after the insertion in 1 of those 8 patients. Another temporary prosthesis was inserted 2 days later, and the patient tolerated the insertion and was comfortable. Four patients were uncomfortable (eye pain) at the time of initial prosthesis placement but were able to tolerate insertion at their second postoperative visit 7 days later. Marked proptosis was noted in 1 patient, poor color match was noted in 3 cases, and 1 significant exotropia was noted. Within 2 weeks of surgery, all 12 patients were noted to be both comfortable with their prosthesis and happy with their interim cosmetic result (see Figure 2). Other than the temporary discomfort reported during 4 initial attempts at prosthesis insertion, there were no complications related to early cosmetic rehabilitation. There was no dehiscence of the operative wound, infection, or hemorrhage. All patients were pleased with the cosmetic benefit afforded by early introduction of the prosthesis. They all made a stated preference for their appearance with the temporary prosthesis compared with their pink eye with the conformer. In this series, the manipulation at insertion and subsequent wearing of the ocular prostheses was found to have no significant effect on wound closure, final motility, or their subsequent prosthetic fittings (for their permanent prosthesis). Discussion There are several factors that could affect a patient s ability to tolerate early placement of an ocular prostheses after enucleation surgery. 1 These include implant size, implant type, pegging, wrapping materials, postoperative hemorrhage, orbital infection and wound dehiscence. There exist multiple types of implants and multiple methods of implantation. In addition, some surgeons wrap and peg implants. Clearly, wrapping increases implant size. In our experience (within reason), the use of larger implants improves both final cosmesis and prosthetic motility. Conversely, larger implants as well as orbital injections, hemorrhage, and edema will increase postoperative orbital volume and decrease the potential space needed for early prosthetic device insertion. Orbital hemorrhage can complicate the postoperative course of an enucleation patient. Large orbital hematomas are typically rare and painful. In contrast, ecchymosis of the eyelids is typically painless, common, and temporary (see Figure 2). In our experience, patients who experience large orbital hematomas often have pharmacologic or endogenous coagulopathies. The volume created by a postoperative orbital hemorrhage will decrease the potential space required for early prosthetic device insertion. Therefore, orbital hemorrhage is a relative contraindication to early prosthesis insertion. Orbital infection is a rare complication of enucleation that can lead to wound dehiscence. 1 Both topical and systemic antibiotics are given commonly during the acute postoperative period. 1 This is particularly important in pa-

4 74 Optometry, Vol 77, No 2, February 2006 Figure 2 Early ocular prosthesis insertion (both inserted at postoperative day 5). A, swelling and loss of orbital volume leave this eyelid shut. B, the temporary prosthesis lifts the upper eyelid open making the eye visible. C, the clear plastic conformer is visible in this case. D, insertion of the temporary prosthesis allows for early cosmetic rehabilitation. By permission, 2 of 12 patients are displayed. tients with immune deficiency. Although none of the patients in our series had orbital infections, early prosthetic insertion would have decreased our ability to view the wound (as would be possible through the conformer). Therefore, orbital infection and immune deficiency are relative contraindications for early prosthetic insertion. Multiple reports of wound dehiscence, bearing of the prosthesis, and extrusion have been reported. 1 Goldberg et al. 7 and Karcioglu et al. 8 have described cases of conjunctival dehiscence overlying integrated implants. Nunery et al. 9 suggested that exposure could be avoided by deep implantation of the sphere, wrapping of the implant, and drilling access holes to encourage fibrovascular ingrowth. In cases of wound dehiscence, early placement of an ocular prosthesis may cause the stress on the wound and will definitely prevent a direct view (as possible through the conformer). In an effort to reduce the psychological trauma associated with removal of an eye, we have reduced the interval between surgery and cosmetic rehabilitation. Over the last 20 years, this interval has decreased from 6 weeks to less than 4. This study examines insertion of a temporary ocular prosthesis at the time of bandage removal (typically 5 days after surgery). None of our patients suffered from immune deficiency or infection, coagulopathy or hemorrhage, or wound dehiscence or implant exposure. This series of patients with large intraocular tumors managed by enucleation shows that a small standard ocular prosthesis may be placed immediately or soon after enucleation bandage removal. Although a relatively large prospective quality-of-life study may be required for statistical proof of benefit, in this series all 12 patients preferred the early cosmetic rehabilitation associated with placement of an ocular prosthesis. Acknowledgements The authors thank Henry Gougleman D.P.L. and Annette Kirszrot, B.A.D.O., B.C.O. for supplying the temporary prostheses used in this study. This study was supported by The EyeCare Foundation, Inc., New York, New York. The authors have no proprietary interest in the materials used in this study. References 1. Moshfeghi DM, Moshfeghi A, Finger PT. Enucleation. Surv Ophthalmol 2000;44: Musini A. History of ocular prosthesis. Osp Maggiore 1952;40: Bartlett SO, Moore DJ. Ocular prosthesis: a physiologic system. J Prosthet Dent 1973;29: Haik B, Ainbinder DJ, Finger PT, et al. Part X: Opthalmic Sites [Carcinoma of the Eyelid, Carcinoma of the Conjunctiva, Malignant Melanoma of the Conjunctiva, Malignant Melanoma of the Uvea, Retinoblastoma, Carcinoma of the Lacrimal Gland, Sarcoma of the Orbit. In: Greene FL, Page DL, Fleming, ID, et al, eds. AJCC Cancer Staging Manual, Sixth Edition. New York: Springer-Verlag, 2002:

5 Chin et al Clinical Care Kurli M, Finger PT, Manor T, et al. Finding malignant change in a necrotic choroidal melanocytoma: a clinical challenge. Br J Ophthalmol 2005;89: Finger PT. Finger-tip cryoprobe assisted enucleation. Am J Ophthalmol 2005;139: Goldberg RA, Holds JB, Ebrahimpour J: Exposed hydroxyapatite orbital implants. Ophthalmology 1992;99: Karcioglu ZA, Mullaney PB, Millar LC: Extrusion of porous polyethylene orbital implant in recurrent retinoblastoma. Ophthal Plast Reconstr Surg 1998;14: Nunery WR, Heinz GW, Bonnin JM, et al. Exposure rate of hydroxyapetite spheres in the anophthalmic socket: histopathologic correlation with silicone sphere implants. Ophthal Plast Reconstr Surg 1993;9: