James W. Gigantelli, M.D.

Transcription

1 The Path to Anophthalmos James W. Gigantelli, MD Ophthalmic Plastic Surgery and Orbital Disease University of Nebraska Medical Center Objectives Understand conditions that result in anophthalmos/microphthalmos Understand the maintenance of the anophthalmic socket Recognize the common complications of the anophthalmic socket Disclosures I have no proprietary interest in the subject matter or materials discussed in this presentation. 11/3/

2 Predisposing Conditions Congenital Congenital anophthalmos Acquired Tumors Glaucoma Retinal vascular disease Corneal disease Congenital anophthalmos True congenital anophthalmos is rare due to failure to form a primary optic vesicle. most cases are sporadic may be unilateral or bilateral Congenital microphthalmia failed closure of the fetal/choroidal fissure. associated with trisomy 13, Goldenhar syndr. predominantly unilateral. when bilateral, other organ system anomalies are often found. frequently accompanied by an attached cyst 11/3/

3 Early childhood anophthalmos Secondary eyelid and socket development The eye as an inducer of growth Volume augmentation devices Acquired anophthalmos The Nonsighted Orbit Management goals Function Motility Lid position and movement Tearing/Discharge Pain Cosmesis Ocular surface Eyelids/adnexa 11/3/

4 The Nonsighted Orbit Cover before cutting Brackup AB,et al. Ophth Plast Reconstr Surg 1991;7:194. Retrospective series of perforating eye injuries only 18% of injured eyes experienced pain sufficient to require enucleation Cosmetic scleral shell Cosmetic contact lens Scleral shell Anophthalmos & The Ocular Implant History Extirpation Bartisch; 16th Century The Sphere implant Evisceration/ Mules PH (1884) Enucleation/ Frost WA and Lange W (1886) 10 11/3/

5 The Anophthalmic Sphere Implant Preserves intraorbital volume Reduces socket contraction Assists ocular prosthesis motility Reconstructive goals Conventional implant material PMMA Teflon Proplast Dexon Polyethylene Gold Ivory Silicone Sponge Metallic Autologous tissues dermis fat fascia bone Others 11/3/

6 Integrated Ocular Implants Ruedeman AD (1941) partially exposed Cutler NL (1945) buried groove and tunnel peg and socket magnets Dacron strips tantalum mesh Biointegrated Implants Serves as a passive framework or scaffolding for fibrovascular ingrowth stereographic anchoring of implant establishes implant-host contact Biointegrated Implants Hydroxyapatite Bio-eye IOI, Inc. Bioceramic FCI Ophthalmicsl, Inc. Porous polyethylene Medpor Porex Surgical, Inc. 11/3/

7 Porous vs. Plain Hornblass A, Biesman BS, Eviatar JA. Ophthal Plast Reconstr Surg 1995;11: HA implantation at primary enucleation increased from 1% to 56% (1989 to 1992). HA implantation at secondary anophthalmic socket revision: 56%. Ocular Implant Complications Infection Migration Exposure Extrusion Subnormal motility Biointegrated Implants: Complications Deep Superior Sulcus Enophthalmos Implant exposure Implant abscess Ocular prosthesis related Manufacture/fitting Motility Pegging 11/3/

8 Porous vs. Plain Exposure rates Hydroxyapatite 14% Porous Polyethylene 8% AlO 3 /Bioceramic 2% Silicone 1% PMMA 1% 20 Porous vs. Plain: Motility Custer PL, et al. Ophthalmology 1999;106:513-6 Retrospective, nonrandomized trial 76 anophthalmic patients No motility benefit of nonpegged HA over spherical alloplastic implants. Implant movement declines with advancing age. Implant Pegging Frequency of pegging 67% of HA implants in one Canadian practice Lower frequency in most U.S. practices Pegging is associated with both: better prosthetic motility increased side-effects/complications 11/3/

9 Pegging is not innocuous Affect 37.5% of pegged implants Jordan DL, et al. Ophthalmology 1999;106: ocular discharge 37% pyogenic granuloma 31% peg extrusion 29% clicking 11% subtotal motility transfer 11% implant infection <1% Sphere size: Easy as Pi Insert 75/25 on the previous slide. 11/3/

10 Sphere size: Easy as Pi Kaltreider SA. Ophthal Plast Reconstr Surg 2000;16: Ex., for a 23 mm diameter globe V =6.37 ml 70% (6.37) =4.46 ml 80% (6.37) =5.10 ml Anophthalmic Sphere Implants 14 mm sphere ~ 1.44 ml 16 mm sphere ~ 2.14 ml 18 mm sphere ~ 3.05 ml 20 mm sphere ~ 4.19 ml 70% (6.37) =4.46 ml 80% (6.37) =5.10 ml 22 mm sphere ~ 5.58 ml Evisceration: Sphere Implants 11/3/

11 Evisceration: Sphere Implants Posterior scleral barrier inhibits implant size delayed fibrovascular ingrowth Evisceration: Sphere Implants Custom prosthetic fitting I fit the prosthesis at six to eight weeks after surgery take an impression of the eye socket using alginate encase the impression in dental stone (make a mold) 30 11/3/

12 Making the prosthesis Custom prosthetic fitting II molten wax is poured into the mold and allowed to cool/harden (wax pattern) make changes to wax pattern for comfort and eyelid position to match the companion eye. iris button is chosen and built onto the wax pattern Making the prosthesis 11/3/

13 Custom prosthetic fitting III make a final mold of dental stone around the altered wax pattern in a fiberglass flask wax pattern is removed from mold the iris button is placed back in the mold exactly in the same position Custom prosthetic fitting IV white plastic dough is packed into the mold prosthesis is cured by heating in a water bath a thin layer of plastic is ground from the front surface of the prosthesis 11/3/

14 Custom prosthetic fitting V The prosthesis is painted a clear polyethylene sheet is placed between the painted prosthesis and a new layer of clear plastic the prosthesis is returned to the mold and cured 11/3/

15 Daily wear habits Within days, patients are not aware of their prosthesis. Some patients will need lubrication Wear the prosthesis as long as it does not have surface mattering and is comfortable. 40 Daily wear habits: Storage If the prosthesis must be left out of the eye socket overnight or longer, store it in saline/contact lens solution. Allowing the prosthesis to dry out may weaken it along the lines of manufacture. Daily wear habits: Cleaning Never wash or dry the eye with any kind of cloth or paper. slowly wear away the polished surface creates a dull appearance. 11/3/

16 Daily wear habits: Cleaning After making your hands soapy with mild hand soap (Ivory or Palmolive ), rub the prosthesis vigorously with pressure under hot water. Rinse all soap from the prosthesis and hands. Allow to briefly air dry if needed. Annual prosthetic polishing The prosthesis should be polished yearly. Also assess the eye socket and fit. Removal of biofilm The Socket-Prosthetic Fit Socket/implant complications Socket discomfort Eyelid malpositions 11/3/

17 Socket complications Exposure Scarring Discharge Clicking Subnormal motility Prosthesis discomfort Dry eye syndrome Quantitative vs Qualitative Loss of surface polish Microbial infection Giant fornix syndrome Reactive conjunctivitis Giant Papillary Conjunctivitis Implant exposure Prosthesis discomfort Dry eye syndrome Foreign bodies Loss of surface polish Microbial infection Reactive conjunctivitis Giant fornix syndrome 11/3/

18 Prosthesis Lubrication Artificial tears Mineral oil Silicone oil Exposure vs extrusion Pyogenic granuloma Eyelid malpositions Ectropion/retraction surgery (LTS) Upper lid ptosis Ptosis shelf Surgery 11/3/

19 Mandatory care Protective corrective wear ANSI standards Polycarbonate lens May be used to camouflage anatomic deficiencies 50 Thank You! 11/3/