INTRACONAL IMPLANTS ARE WELL

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1 LINIL SINS Mechanisms and Treatment of xtruding Intraconal Implants Socket ging and Tissue Restitution (the actus Syndrome ) Mandeep S. Sagoo, M, Ph, MROphth, FRS(din); Geoffrey. Rose, MS, Sc, FRS, FROphth Objective: To investigate the initial features and treatment of 26 consecutive patients referred with extruding orbital implants between January 1991 and ecember Methods: Retrospective medical record review recording the reason for enucleation, primary implant type, infection when initially seen, time to implant exposure, location of conjunctival defect, and time to surgical revision. Results: Of the 26 eyes, 16 (62%) were removed after trauma, 3 (12%) because of tumor, 3 (12%) because of infection, and 4 (15%) because of painful blind eyes (percentages do not total 100 because of rounding). Of the 26 eyes, 8 (31%) were right eyes and 15 (58%) were hemispheric implants; 8 implants (31%) were acrylic or glass spheres, and 1 (4%) each was a hydroxyapatite, porous polythene, or bone sphere. Hemisphere extrusion occurred at a mean of 16 years after implantation, significantly later than with spheres (mean, 10 years after implantation; P =.05). The conjunctiva was breached medially in only 1 (sphere) (4%), centrally in 13 (50%), and laterally in 12 (46%). Lateral erosion occurred solely with hemispheres, in contrast to central erosions, in which 10 of 13 (77%) were spheres (P.001). Twelve patients (46%) underwent surgical revision within a year of extrusion, 7 (27%) within 2 years, and the remaining 7 (27%) at 2 to 21 years. onclusions: xposure of hemispheres occurred later, from pressure erosion at their prominent lateral edge. In contrast, central erosion (in spheres) occurred earlier, because of gradual tissue restitution after forced-ball implantation ( cactus syndrome ). This may be avoided by implantation through a polythene glide. rch Ophthalmol. 2007;125(12): uthor ffiliations: Orbital linic, Moorfields ye Hospital, London, ngland. INTRONL IMPLNTS R WLL established in the treatment of anophthalmic sockets, 1-3 and complications include tissue breakdown over the implant. nterior migration of the implant because of tissue restitution during healing termed the cactus syndrome by one of us (G..R.) leads to a thinning of surface tissues (Figure 1), with delayed exposure (Figure 1) and, later, a frank extrusion (Figure 1G and H) of the implant. Small areas of implant exposure are more common than full extrusion, 1,4-6 although many techniques have been devised to prevent or treat implant exposure We describe a series of patients referred with exposed orbital implants and treated by one of us (G..R.). The characteristics of this series suggest a possible mechanism for the late exposure of hemispheric orbital implants. MTHOS retrospective case review was performed for a series of patients referred with extruding orbital implants between January 1991 and ecember Information was gathered on the reason for enucleation, type of primary implant, period before symptoms of implant exposure, location of the main conjunctival defect (classified as medial, lateral, or central), and time before surgical revision. The surgical technique of implant revision is shown in Figure 2. fter antiseptic douching of the socket, the conjunctiva is opened at the edge of the defect and the opening is extended medially and laterally across the width of the midline raphe; the upper and lower conjunctival edges are carefully undermined for 3 mm, and the conjunctival flaps are gently slung on 5-0 traction sutures. The exposed implant is removed from its fibrous capsule; in the case of astroviejo-style implants, this involves tissue incision around the edge ring on the anterior face with cruciform division of the union of the recti. The fibrous capsule is inspected, any areas suggestive of epithelial invasion are either excised or ablated with diathermy, and the capsule is divided posteriorly to allow placement of the new spherical implant into the posterior part of the orbit. For primary replacement, the capsular halves and neighboring tissues are slung on 3-0 silk traction sutures and the replacement sphere is implanted deeply in the orbit by passing it through (RPRINT) RH OPHTHLMOL / VOL 125 (NO. 12), ownloaded From: on 05/09/2018

2 G H F I Figure 1. linical examples of central and lateral erosion of implants: a patient with a spherical implant eroding centrally because of tissue restitution ( cactus syndrome ) () and the same patient 2 years later (), wearing a bridging prosthesis (); lateral extrusion, as found in hemispheric implants, is probably because of the predominance of the adductive forces of the medial rectus (-F); and central extrusion (G and H) of a spherical implant, with the patient attempting to use an artificial eye (I). a glide, fashioned from the thumb of a sterile polythene glove. eep tissues are closed with 5-0 absorbable sutures, conjunctiva is closed with 7-0 sutures, and a large socket conformer is placed after fornical instillation of an antibiotic ointment. The socket is padded firmly for 1 week, and the patient is prescribed a postoperative course of systemic antibiotics. RSULTS linical case notes were retrieved for 26 patients (20 males [77%]) who were initially seen between the ages of 6 and 62 years (mean age, 41 years; median age, 42 years), this being between less than 1 year and 37 years (mean, 13.5 years; median, 8 years) after the initial surgery undertaken at between the ages of 2 and 58 years (mean age, 27 years; median age, 28 years). Sixteen patients (62%) underwent removal of blind eyes after trauma, 4(15%) for rubeotic glaucoma, and 3 (12%) each for intraocular tumor or endophthalmitis (percentages do not total 100 because of rounding); 18 (69%) were left eyes (Table). Of the 26 implants, 15 (58%) were hemispheric, 8 (31%) were acrylic or glass spheres (2 with polyester mesh covering), and 1 (4%) each was a hydroxyapatite, porous polyethylene, or bone sphere (percentages do not total 100 because of rounding). One of the hemispheric implants had a gold motility peg. Figure 2. Surgical technique for implant revision (case shown in Figure 1): conjunctival edges are reflected clear of the fibrous capsule left after removal of the extruding implant (); horizontal division of deeper tissues provides access to the posterior part of the socket (); a polyester-covered acrylic sphere is inserted through a polythene glide, to prevent cactus syndrome (); and the lack of any restitutive forces allows the implant to stay deep in the socket, even before suturing of the superficial tissues (). The patients were initially seen between 1 and 37 years (mean, 16 years) after placement of hemispheric implants, this being significantly different from that of (RPRINT) RH OPHTHLMOL / VOL 125 (NO. 12), ownloaded From: on 05/09/2018

3 Table. linical haracteristics of xtruding Intraconal Implants Patient ge, y/reason for Implant/Year Primary Implant Side Time to xposure Symptoms, y Main rea of xposure Time of xposure, y Replacement Spherical Implant 43/tumor/1995 overed acrylic sphere Right 1 entral 1 Secondary covered acrylic 27/old trauma/1990 overed acrylic sphere Left 1 Medial 1 Primary covered acrylic 21/infection/1995 Hemisphere Left 1 Lateral 1 Primary covered acrylic 55/rubeosis/1993 Hemisphere Left 1 entral 7 Primary covered acrylic 21/acute trauma/1995 Hemisphere Left 1 Inferolateral 1 Primary covered acrylic 25/old trauma/2000 Porous polythene sphere Left 1 entral 1 Secondary covered acrylic 36/old trauma/1996 crylic sphere Left 2 entral 1 Secondary covered acrylic 36/old trauma/1996 crylic sphere Left 3 entral 1 Secondary covered acrylic 2/acute trauma/1988 crylic sphere Left 4 entral 1 Secondary covered acrylic 58/rubeosis/1998 crylic sphere Left 4 entral 1 Secondary covered acrylic 35/rubeosis/1999 overed hydroxyapatite sphere Left 5 entral 1 Primary covered acrylic 28/rubeosis/1985 crylic sphere Left 7 entral 2 Primary covered acrylic 51/tumor/1985 Hemisphere Left 8 Lateral 3 None 20/trauma/1988 Hemisphere Left 8 Lateral 1 Primary covered acrylic 3/tumor/1961 Hemisphere Left 10 Lateral 21 Primary covered acrylic 40/trauma/1991 Hemisphere Right 10 Lateral 1 Primary covered acrylic 28/trauma/1980 Hemisphere Left 16 entral 1 Secondary covered acrylic 29/trauma/1974 Hemisphere Right 18 Lateral 1 Primary covered acrylic 30/old trauma/1981 Hemisphere Right 19 Lateral 1 Primary covered acrylic 33/infection/1968 Hemisphere Right 28 Lateral 1 Primary covered acrylic 10/infection/1962 one sphere Right 30 entral 1 Primary covered acrylic 22/acute trauma/1960 Glass sphere Right 32 entral 3 Primary covered acrylic 17/trauma/1963 Hemisphere Left 34 Lateral 1 Primary covered acrylic 6/trauma/1957 Hemisphere Left 35 Lateral 1 Primary covered acrylic 26/old trauma/1959 Pegged hemisphere Right 35 Lateral 5 Primary covered acrylic 5/trauma/1955 Hemisphere Left 37 entral 10 Primary porous polythene spheres (range, 1-32 years; mean, 10 years) (Mann- Whitney test, P=.05). Overall, the mean age at extrusion was 40.9 years (range, years). nteromedial implant exposure occurred in only one case a polyester-covered acrylic sphere that had been malpositioned within the superomedial quadrant of the orbit. entral exposure (13 cases) (Figure 1,, G, and H) occurred mainly with ball implants (10 of 13 cases), whereas lateral erosion (12 cases) (Figure 1-F) occurred solely with hemispheric implants ( 2 =12.8, P.001). The extruding implant was removed with simultaneous replacement in 18 patients (69%) and secondary replacement in 7 (27%); 1 patient (4%) elected not to undergo further implantation. Two patients with significant purulent conjunctivitis and markedly inflamed sockets, pretreated with topical and systemic antibiotics, underwent successful primary reimplantation. The surgery was undertaken within a year of developing new symptoms in 12 of 26 patients (46%) and within 2 years of symptoms in 7 patients (27%); the remainder underwent surgery between 2 and 21 years after symptoms occurred. OMMNT Postenucleation socket syndrome occurs when there is inadequate volume replacement in the anophthalmic socket, requiring the use of a heavy prosthetic eye that causes lower eyelid stretch, secondary upper eyelid ptosis, enophthalmos, and a deep superior sulcus. 12 To avoid postenucleation socket syndrome or complications of a large artificial eye, intraconal implantation is essential for aesthetic rehabilitation after removal of an eye. The ideal volume replacement after removing the eye is a sphere of 21- to 22-mm diameter that, if implanted deep within the orbit, provides a gently convex surface to the socket with about 3-mm central depth, adequate for prosthetic fitting. Several mechanisms have been suggested to explain implant exposure, including infection, edema, hemorrhage, too large an implant, a faulty surgical technique, a poor fitting prosthesis with pressure points, and placement of a motility peg There is also a report 16 of an orbital recurrence of retinoblastoma causing implant extrusion. lthough these may contribute to exposure, the mechanisms of tissue restitution or long-term adductive rotation of the implant may also play a part in anterior tissue breakdown. The fact that all laterally eroding implants (Figure 1-F) were flat fronted, whereas most of the central erosions (Figure 1,, G, and H) occurred with spheres, suggests different mechanisms for the 2 types of implant erosion. One of us (G..R.) has noted that aged sockets with hemispheric implants tend to have superomedially directed implant faces the backward tilt having also been shown with imaging studies ackward tilt is due to tissue gravitation within the anophthalmic socket, 17,18 whereas medial rotation is (conjecturally) due to a power dominance of the medial rectus over the lateral rectus. Whereas the temporal edge (RPRINT) RH OPHTHLMOL / VOL 125 (NO. 12), ownloaded From: on 05/09/2018

4 Glide Figure 3. Schematic representation, and avoidance, of cactus syndrome : status before implantation of a rough-surfaced sphere, with surface tissues labeled (-) (); forced implantation, dragging superficial tissues into the deeper orbit (); tissue restitution during the healing phase carries the implant anteriorly, with an apparent thinning of tissues overlying the ball (). Use of a smooth glide prevents dragging of superficial tissues by the implant (), allowing placement of the ball deep in the socket and closure of the overlying layers without any tension (). of a hemispheric implant will become more prominent with time, leading to surface pressure erosion over this lateral edge, a sphere will not have a similar timerelated change in surface configuration. Logically, flatfronted intraconal implants should probably be avoided because of this long-term risk of rotation within the aging socket. all implants that are too prominent within a socket sometimes termed oversized (Figure 3) are actually positioned too superficially, this probably resulting from cactus syndrome. actus syndrome arises when an orbital implant is forced into the tissues during implantation and the implant surface (particularly where rough, as with hydroxyapatite or porous polythene) drags the superficial tissues into the depths of the socket (Figure 3). The tissues may be closed successfully over the implant but, as with any forced surgical closure, the tension sutures reabsorb and the tissues gradually return to their original relaxed position a natural restitution of tissues. This restitution is manifest as a progressive migration of the ball toward the surface, with a progressive thinning and eventual breakdown of the attenuated tissues over the implant (Figure 1,, and G). The fact that late tissue restitution occurs when a rough-surfaced implant drags fat into the socket depths is analogous to the spring back (restitution) that would occur if a cactus was forced into the flocking within a pillow hence, the term cactus syndrome. lthough many techniques have been described to avoid, or deal with, implant exposure (such as primary revision, 20 dermis fat grafting, 3 use of a cap of sclera or other material, 25 or patch grafting of exposed implants with temporalis fascia or sclera 7,8,10,11 ), most of these techniques fail to address one of the major causes of implant failure namely, the superficial positioning of the ball due to late tissue restitution. Indeed, we would suggest that these myriad techniques would become largely redundant if tissue drag is avoided by implantation of all spherical implants, into the intraconal space, using a suitable technique. Retraction of superficial tissues and their careful repositioning may achieve this goal, but we believe deep orbital implantation is easily achieved using the polythene glide. Submitted for Publication: June 12, 2007; final revision received July 30, 2007; accepted ugust 2, orrespondence: Geoffrey. Rose, MS, Sc, FRS, FROphth, Orbital linic, Moorfields ye Hospital, ity (RPRINT) RH OPHTHLMOL / VOL 125 (NO. 12), ownloaded From: on 05/09/2018

5 Road, London 1V 2P, ngland Financial isclosure: None reported. RFRNS 1. Shields L, Shields J, e Potter P, Singh. Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases. r J Ophthalmol. 1994; 78(9): Karesh JW, resner S. High-density porous polyethylene (Medpor) as a successful anophthalmic socket implant. Ophthalmology. 1994;101(10): Fan JT, Robertson M. Long-term follow-up of the llen implant: 1967 to Ophthalmology. 1995;102(3): uettner H, artley G. Tissue breakdown and exposure associated with orbital hydroxyapatite implants. m J Ophthalmol. 1992;113(6): Oestreicher JH, Liu, erkowitz M. omplications of hydroxyapatite orbital implants: a review of 100 consecutive cases and a comparison of exon mesh (polyglycolic acid) with scleral wrapping. Ophthalmology. 1997;104(2): hristmas NJ, Gordon, Murray TG, et al. Intraorbital implants after enucleation and their complications: a 10-year review. rch Ophthalmol. 1998;116 (9): Fountain J, Helveston M. long-term follow-up study of scleral grafting for exposed or extruded orbital implants. m J Ophthalmol. 1982;93(1): Goldberg MF. simplified scleral graft technique for covering an exposed orbital implant. Ophthalmic Surg. 1988;19(3): Wiggs O, ecker. xtrusion of enucleation implants: treatment with secondary implants and autogenous temporalis fascia or fascia lata patch grafts. Ophthalmic Surg. 1992;23(7): Pelletier R, Jordan R, Gilberg SM. Use of temporalis fascia for exposed hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg. 1998;14(3): Sagoo MS, Olver JM. utogenous temporalis fascia patch graft for porous polyethylene (Medpor) sphere orbital implant exposure. r J Ophthalmol. 2004; 88(7): Tyers G, ollin JR. Orbital implants and post enucleation socket syndrome. Trans Ophthalmol Soc U K. 1982;102(pt 1): Levine MR. xtruding orbital implant: prevention and treatment. nn Ophthalmol. 1980;12(12): Oberfeld S, Levine MR. iagnosis and treatment of complications of enucleation and orbital implant surgery. dv Ophthalmic Plast Reconstr Surg. 1990; 8: delstein, Shields L, e Potter P, Shields J. omplications of motility peg placement for the hydroxyapatite orbital implant. Ophthalmology. 1997;104 (10): Karcioglu Z, Mullaney P, Millar L. xtrusion of porous polyethylene orbital implant in recurrent retinoblastoma. Ophthal Plast Reconstr Surg. 1998;14 (1): Smit TJ, Koornneef L, Zonneveld FW, Groet, Otto J. omputed tomography in the assessment of the postenucleation socket syndrome. Ophthalmology. 1990; 97(10): Smit TJ, Koornneef L, Zonneveld FW, Groet, Otto J. Primary and secondary implants in the anophthalmic orbit: preoperative and postoperative computed tomographic appearance. Ophthalmology. 1991;98(1): etorakis T, ngstrom R, Straatsma R, emer JL. Functional anatomy of the anophthalmic socket: insights from magnetic resonance imaging. Invest Ophthalmol Vis Sci. 2003;44(10): Remulla H, Rubin P, Shore JW, et al. omplications of porous spherical orbital implants. Ophthalmology. 1995;102(4): McNab. Hydroxyapatite orbital implants: experience with 100 cases. ust N Z J Ophthalmol. 1995;23(2): eaver H, Patrinely JR, Holds J, Soper MP. Periocular autografts in socket reconstruction. Ophthalmology. 1996;103(9): Oestreicher JH. Treatment of exposed coral implant after failed scleral patch graft. Ophthal Plast Reconstr Surg. 1994;10(2): Inkster F, Ng SG, Leatherbarrow. Primary banked scleral patch graft in the prevention of exposure of hydroxyapatite orbital implants. Ophthalmology. 2002; 109(2): Jordan R, llen LH, lls, et al. The use of Vicryl mesh (polyglactin 910) for implantation of hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg. 1995; 11(2): From the rchives of the rchives Thirty-two years ago, Mooren described the form of corneal ulcer which he called rodent, and since then about 35 cases have been more or less accurately described. It begins at the margin of the cornea with a narrow grayishwhite infiltration, which in a short time becomes an ulcer. It spreads at intervals with intermittent and often severe signs of irritation (ciliary neurosis), which are out of relation to the corneal process....theulcer spreads about the margin of the cornea and towards the center with a chronic course of months duration, and in the majority of cases eventually destroys the entire surface of the cornea. It is usually shallow, and perforation is unusual. Reference: Hillemanns. Ulcus rodens corneæ. rch Ophthalmol. 1902;31:148. (RPRINT) RH OPHTHLMOL / VOL 125 (NO. 12), ownloaded From: on 05/09/2018