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In 1948, ophthalmologists started implanting plastic spheres partially covered with tantalum mesh (eg, the Valley Forge Implant) in anophthalmic sockets. Numerous patients have developed complications ten to 15 years after surgery: pain ("pinching" or "deep"), headache, heavy mucopurulent discharge and diffuse conjunctival inflammation, migration of the implant, thinning or erosion of tissues covering the implant (extrusion), and inability to wear an artificial eye. Management includes refabrication of the artificial eye and replacement of the implant with a dermis-fat graft or a silicone ball plus scleral graft. Tantalum-mesh--covered orbital implants should probably not be used.

Anophthalmic orbits that reject conventional implants may accept the dermis-fat graft. The subsequent fitting of such a socket differs in many important ways from the fitting of sockets containing conventional implants. Before surgery, the ocularist should construct a custom-made scleral ring to be inserted after the operation. This replaces the standard conformer that can erode the underlying dermis. The socket must be observed carefully for any evidence of damage to the conjunctiva-dermis suture line by the ring, and the latter modified or replaced as necessary. Granulation tissue forming around the sutures uniting conjunctiva and dermis may have to be resected and cauterized. Impression molding of an artificial eye is performed five weeks after surgery. The artificial eye always requires modifications over the first six months as the graft recedes due to partial atrophy of the fat of the graft, thus deepening the socket.

Two patients with epibulbar juxtalimbal primary conjunctival melanomas experienced local intralymphatic metastases to the inferior cul-de-sac, and a hematogenous metastasis to the conjunctiva developed in five other patients with cutaneous melanomas. Whether reflective of a local or distant metastasis, all of the lesions histopathologically were located in the substantia propria, and were separated from the overlying epithelium by a thin mantle of collagen. There was no evidence of atypical intraepithelial melanocytic proliferation, as would be expected in association with a primary conjunctival melanoma. Two of the cutaneous metastases exhibited a binodular or multinodular appearance that correlated histopathologically with variably confluent micronodules suggestive of the origin of the clinical lesion from a shower of tumor cell emboli. Patients with local intralymphatic spread from a primary conjunctival melanoma may experience additional lesions in the conjunctival sac or eyelid skin and are at risk for regional or distant metastases. They should be examined closely several times a year. The patients with the distant metastases all had their previously diagnosed primary cutaneous tumors on the truncal skin (a similar tendency emerges from a review of previous ocular cases), typically had myriad other cutaneous lesions, and two of them had a neoplastic iridocyclitis and vitreitis. These patients tended to die of the disseminated tumors within 1 year after conjunctival metastases developed.

An unusual eyelid tumor with sebaceous differentiation developed in two 70-year-old men and each had an earlier history of one or more colonic carcinomas--the so-called Muir-Torre syndrome. These eyelid tumors were both behaviorally and histopathologically different from previously documented cutaneous neoplasms in this syndrome. In the first case, a sebaceous adenoma took multifocal origin from the epidermis and exhibited an interanastomosing retiform growth pattern in the underlying dermis; the lesion rapidly recurred as a keratoacanthoma after subtotal excision. In the second case, a conjunctival tumor with features of a poorly differentiated squamous cell carcinoma manifested focal evidence of sebaceous differentiation. Again, after an incisional biopsy, the latter tumor rapidly regrew and transformed into a well-differentiated squamous cell carcinoma with massive central necrosis. Although sebaceous carcinoma of the eyelids does not appear to presage the Muir-Torre syndrome, any benign sebaceous or transitional squamo-sebaceous neoplasm should be considered a possible manifestation of this syndrome. Both clear-cut benign and transitional sebaceous neoplasms should also be recognized as having the potential to undergo an ominous clinical regrowth upon subtotal excision and a complete squamous transformation.