Search

Background: Evaluation of the number of enucleations and eviscerations performed in Germany and the orbital implants used., Method: Analysis of the quality reports of German ophthalmological clinics for the years 2012-2021 provided by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G‑BA)., Results: Almost 10 times as many enucleations (8368) as eviscerations (975) are performed in Germany. After enucleation, alloplastic implants are used most frequently (44.6% alloplastic, no further specification, 30.0% alloplastic coated, no further specification; 14.1% microporous implants) and autologous dermis-fat grafts in 6.1% of the cases., Conclusion: In Germany, significantly more enucleations than eviscerations are performed. Alloplastic orbital implants are preferred for primary reconstruction following enucleation., (© 2024. The Author(s).)

Purpose: To describe our experience over 6 years using a new high-density polyethylene-based spherical integrated porous orbital implants (Oculfit)., Methods: This is an observational retrospective case series study analyzing all cases requiring Oculfit implants between February 2015 and September 2021. Clinical information regarding the population included, the characteristics of the implant, and the outcomes and complications during the follow-up were noted. The success of the implant was defined according to anatomical and functional parameters., Results: The study analyzed 90 cases of anophthalmic patients. The main causes for enucleation or evisceration were ocular decompensations (36.7%) and neoplasms (27.8% uveal melanoma and 7.8% retinoblastoma). Anatomical success was identified in 63 (70.0%) cases, functional success in 79 (87.8%) and complete success (anatomical + functional) in 61 (67.7%) cases. Factors associated with the functional success were age and exposure of the primary orbital implant. Complications appeared in 11 (12.2%) cases, which were completely resolved without sequelae in 4 (4.4%). Orbital explant was required in 5 (5.6%) cases., Conclusion: In our experience, Oculfit can be considered a useful alternative among the currently available options for orbital implants and has a good efficacy/safety profile., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Objectives: To retrospectively investigate clinical characterization and the long-term postoperative outcomes of retinoblastoma (RB) patients receiving enucleation with primary orbital implantation in early infancy (0-6 months old)., Methods: The clinical and follow-up data of 42 RB patients receiving enucleation with primary orbital implantation in early infancy at Beijing Tongren Hospital from December 2009 to January 2020 were analysed. The average follow-up time was 83 months. The patient group included 24 males and 18 females, 30 unilateral and 12 bilateral cases. A total of 44 eyes with 10 in stage D and 34 in stage E underwent 40 unilateral and 2 bilateral surgeries. 17 RB eyes received hydrogel and 27 RB eyes received hydroxyapatite implants. This study was performed by following the guideline of STROBE., Results: Enucleation combined with primary orbital implantation promoted survival and was safe with few and minor complications such as increased secretion, upper eyelid ptosis, and sunken eye sockets which were not affected by stages, lateralities, or implant materials. 55-80% RB patients exhibited satisfactory appearance and obvious or moderate motility of orbital implants according to the evaluation by doctors and family members. Family members were likely more optimistic about the appearance and more pessimistic about motility of the orbital implantation than doctors did.The quality of life was high as indicated by PedsQL3.0 or PedsQL4.0 scores ( ≧ 90 for > 75% patients). It was not affected by the stages, laterality, and implant materials, nor affected by the appearance and motility of the implants., Conclusions: The outcomes of the combination of enucleation and primary orbital implantation for pertinent RB patients in early infancy are generally satisfactory with few and minor complications, high safety, appearance, and overall quality of life. Enucleation combined with primary orbital implantation in early infancy benefits pertinent RB patients in appearance, survival, and quality of life., (© 2024. The Author(s).)

Purpose: To evaluate the complications of anophthalmic socket in retinoblastoma patients at a tertiary centre in Malaysia., Design: Retrospective study., Methods: Patients who underwent enucleation for retinoblastoma were reviewed from 2004-2020. Details were recorded, including demographics, diagnosis, surgical techniques, implant types, additional therapies, and complications., Results: Of 250 patients with retinoblastoma managed over the period, the anophthalmic sockets of 160 eyes who underwent enucleation were analysed. The mean age at enucleation was 2.03 years (26 days to 9.18 years). The follow-up periods after enucleation range from 5 days to 16.83 years. Porous polyethylene (Medpor) implants were used in 135 patients (84.4%), as were Bioceramic in 9, glass balls in 7, acrylic in 7, dermis fat grafts in 1, and silicone implants (Aurosphere) in 1. The overall complications in our study were 28.8%. Complications seen in the study included implant exposure (12.5%), shallow inferior fornix (10.6%), granuloma formation (3.1%), discharge (2.5%), implant migration (1.9%), ptosis (0.6%), and orbital dystopia (0.6%). Implant exposure is solely found in Medpor, more common in those with donor sclera caps, and exposure times range from 28 days to 11.42 years. The suturing of the Tenon and conjunctiva in separate layers significantly reduced the rate of implant exposure. Six out of seven radiation patients had shallow inferior fornixes., Conclusions: Long-term post-enucleation complications were not uncommon. Luckily, most had good outcomes, with a few needing surgical intervention. Meticulous suturing technique on the Tenon and conjunctival layer is essential to prevent implant exposure., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This review aims to compare and evaluate the outcomes achieved by integrating technological aids and the influence of different implant designs in the reconstruction of post-traumatic orbital defects., Methods: Electronic searches of the MEDLINE, Embase, Cochrane Library, and Google Scholar databases until March 2023 were conducted. Clinical controlled trials, observational studies, cohort studies, and retrospective studies were identified and included. The predictor variables were the integration of technological aids namely, computer-assisted surgical planning, mirror image overlay, and intraoperative navigation with the utilization of different orbital implant designs (standard orbital meshes, preformed implants, prebent implants, and patient-specific implant [PSI]) during post-traumatic orbital reconstruction. The primary outcome variables were orbital volume, diplopia, and enophthalmos. Weighted or mean difference and risk ratios at 95% confidence intervals were calculated, where P ＜ .05 was considered significant and a random effects model was adopted., Results: This review included 7 studies with 560 participants. The results indicate that the difference in postoperative orbital volume between affected and nonaffected eye showed no statistically significant difference between PSI and prebent group (mean difference, -0.41 P = .28, I 2  = 46%). PSI group resulted in diplopia 0.71-fold less than that of the standard orbital mesh group but was not statistically significant (P = .15). Standard orbital mesh group is 0.30 times at higher risk of developing enophthalmos as compared to PSI group (P = .010). The literature suggests PSIs are preferred for patients with large defects (Jaquiéry's III-IV), whereas prebent implants are equally effective as PSIs in patients with preserved infraorbital buttress and retrobulbar bulge., Conclusion: PSIs are associated with improved outcomes, especially for correcting enophthalmos. The data suggests the potential efficacy of prebent implants and PSIs in orbital volume corrections. There is a lack of randomized studies. This review should serve as a recommendation for further studies to contribute to the existing literature., (Copyright © 2024 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess long-term outcomes and reinterventions for exposed and nonexposed intraconal orbital implants after single-stage socket revisional surgery., Methods: Retrospective case-note review of patients with exposed or nonexposed orbital ball implants, who underwent a single-stage ball exchange (Group I) or ball removal with dermis-fat graft (Group II); Group I was subdivided as having either exposed (A) or nonexposed (B) implants. Outcomes were compared with similar cohorts undergoing multistage surgery., Results: Of 172 patients (54% male), 153 (89%) underwent ball exchange (Group I) and 19 (11%) had dermis-fat graft (Group II). With a mean follow up of 7.8 years, Group I patients without ball exposure (Group IB) had a slightly higher rate of reintervention for persistent volume deficit (21% vs. 9%; p = 0.163) and implant migration (6% vs. 0%; p = 0.091), while Group IA patients-having surgery for exposed implants-had more reexposures (7% vs. 3%; p = 0.270). Single-stage and 2-stage surgery had similar reintervention rates, with the exception of a trend toward fewer volume enhancements for those with nonexposed implants (17% vs. 30%; p = 0.380), and a shorter time to (re)exposure for exposed implants after 2-stage procedures (mean 0.33 vs. 3.5 years; p = 0.571). Group II patients required further volume enhancement in 32% of 1-stage procedures, and one patient needed graft removal., Conclusion: Single-stage volume modification is effective and the results are comparable to staged surgery for either exposed or nonexposed implants. Most patients report a stable prosthesis and satisfactory cosmesis, after a faster rehabilitation., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Objective: To reveal the long-term outcomes of enucleation and secondary orbital implantation surgeries employing nonabsorbable surgical mesh-wrapped acrylic orbital implants for various reasons., Methods: A retrospective interventional study of 48 eyes that underwent primary or late primary enucleation and secondary orbital implantation using polyester mesh-wrapped acrylic orbital implants, between 2012 and 2021. Patient demographics, diagnosis, prior ophthalmic surgery, implant size, follow-up periods, and implant-associated complications were evaluated., Results: The records of 36 patients who underwent primary or late primary enucleation and 12 who underwent secondary orbital implantation due to sphere extrusion were evaluated. Patients' mean age was 38.7 (range: 2-75) and the mean follow-up period was 48.3 months (range: 24-72 mo). Major causes for surgeries were trauma and malignancies (54.1% and 33.3%, respectively). No complications, such as conjunctival dehiscence, implant exposure or extrusion, contracted socket, or fornix insufficiency were observed in any patient during the long-term follow-up period postsurgeries., Conclusion: Using polyester mesh-wrapped acrylic orbital implants in enucleation and secondary orbital implantation surgeries proves to be a successful, safe, and cost-effective option., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Purpose: Various materials have been proposed for reconstructing orbital fractures. The materials used must meet certain criteria to ensure their suitability for restoring the structure and function of the organ. These criteria include biocompatibility, ease of application, non-toxicity, hypo-allergenicity, and non-carcinogenicity. In this study, we systematically reviewed the studies regarding the biomaterials in orbital implants and their clinical application., Methods: A comprehensive search across various databases, including PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science, was conducted until April 10th, 2023. After retrieving the search results and eliminating duplicates, final studies were included after screening through defined criteria. Human and animal studies assessing the clinical application of biomaterials in orbital implants were included. The quality of the case series and controlled intervention studies were evaluated using the NIH tool, and for animal studies, the risk of bias was assessed using SYRCLE's tool., Results: Seventeen studies were included according to defined criteria. These studies aimed to explore the clinical application of biomaterials and examine the associated complications in orbital implants., Conclusion: We found that using biomaterials did not result in elevated intraocular pressure (IOP). However, we did observe certain complications, with infection, residual diplopia, and enophthalmos being the most frequently reported issues., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: Orbital implant exposures, infections, and extrusions can occur many years following enucleation or evisceration. This study analyzes complication rates following porous orbital implant wrapped with a posterior auricular muscle complex graft (PAMCG)., Methods: This is a retrospective study of patients who underwent orbital implantation following enucleation using this technique between 1992 and 2013. Only cases with a minimum of 18 months of follow-up were included. No patients underwent peg implantation. Patient's demographics, follow-up time, type of implant, complications including wound dehiscence, exposure, postoperative infection, and extrusion were recorded., Results: This study included 36 orbits of 36 patients with a mean age of 39.3 ± 23.2 years (range, 3-84 years). Thirty patients had hydroxyapatite implants and six had porous polyethylene. The average follow-up time was 12.6 ± 5.6 years (range, 1.5-31.0 years). There were no implant extrusions, and only one exposure resulting in orbital infection that necessitated implant removal (2.8%)., Conclusion: Wrapping porous orbital implants with PAMCG had favorable long-term outcomes over a thirty-one-year period.

Objective: To describe and report the surgical outcomes of the burnishing technique for exposed porous polyethylene (PP) orbital implants., Methods: A retrospective review of consecutive patients who underwent repair of an exposed PP orbital implant at Hong Kong Eye Hospital and Queen Elizabeth Hospital, Hong Kong, between January 2002 and April 2022 was conducted. Exposed PP orbital implants were burnished with an electric drill. The exposed area was then covered by a donor scleral graft followed by conjunctival wound closure. Patients with a shallow lower eyelid fornix would undergo additional fornix deepening procedures that mobilize the conjunctiva and provide adequate coverage of the implant., Results: Six patients who had exposed PP orbital implants following enucleation (n = 4) and evisceration (n = 2) underwent repair. Five of the six patients did not experience any recurrence at an average follow-up of 25 months (range, 7-42 months). One patient who suffered from endophthalmitis experienced orbital implant re-exposure 16 months after the revision was managed by reimplantation of an acrylic implant and wrapping with both donor scleral graft and dermis fat graft., Conclusion: In conclusion, we described a burnishing technique for repairing exposed PP orbital implants. Our technique is effective in preventing implant re-exposure and is easy to perform., (Copyright © 2023 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the orbital volume between enucleated and contralateral, uninvolved orbits over a 5-year period in patients with unilateral retinoblastoma who underwent enucleation with hydroxyapatite (HA) implant placement by a single surgeon., Methods: A retrospective review was performed on the clinical records and radiographic images of unilateral retinoblastoma patients who underwent enucleation with primary HA implantation from 2003 to 2020 at a single institution. Bilateral orbital volume measurements were taken from the initial postoperative MRI scan and again at 1- and 5-years postenucleation. The main outcome measure was the longitudinal change in volume difference (∆𝑉). The implant size, age at enucleation, and sex were also evaluated. A linear mixed-effect model was used for analysis., Results: A total of 124 patients (73 males) with HA implants following enucleation were included. Overall, the unaffected orbit trended toward having a greater volume compared with the enucleated orbit, but this was not statistically significant (β = 0.003; p = 0.122). The mean age at enucleation was 2.4 years. The median time between enucleation and the initial, 1-year, and 5-year postoperative MRIs was 6 months, 17 months, and 55 months, respectively. There was no statistical correlation between age at enucleation, gender, implant size, or orbital volume at any time points ( p > 0.05)., Conclusions: Patients treated with enucleation and primary HA implant placement for unilateral retinoblastoma did not display significant asymmetry in orbital volume on 5-year postenucleation MRIs, suggesting that HA implants promote orbital growth comparable to a nonenucleated orbit in the pediatric population., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To evaluate long-term outcomes of staged volume rehabilitation for acquired anophthalmos., Methods: Case-note review of patients who had preceding i) eye removal without implant, ii) eye removal with an intraconal implant, but ball-related problems, or iii) removal of exposed implant. Secondary interventions were a) a first-time ball implant, b) dermis-fat graft, c) ball repositioning, d) ball replacement after prior removal, or e) orbital floor implantation., Results: Secondary volume-augmenting surgery was performed in 175 sockets at a mean age of 42.7 years (range 2-91), with 62% secondary ball implants, 3% dermis-fat grafts, 6% ball repositioning, 19% ball replacement after prior removal for exposure, and 10% having orbital floor implantation. After this surgery, further volume enhancement was required in 21% of sockets, this being 40% for spheres ≤18 mm diameter, in contrast to 6% for those ≥20 mm ( p < 0.001). Exposure or malposition of the secondary implant occurred in 8% (12/151) and was unrelated to implant type, size, wrapping, or prior irradiation. Tertiary surgery addressed lining deficiency (18%) or eyelid malposition (25%). Overall, 92/175 (53%) had tertiary surgery to improve cosmesis and comfort, with 49% (36/92) being related to small implants. At a mean follow-up of 9.1 years, 82% of sockets had adequate volume, 79% had excellent lining, and 93% were comfortable. Prosthetic fit was satisfactory in 96% of cases, and 97% reported improved cosmesis., Conclusion: Over half of the sockets having planned 2-stage volume enhancement may need further procedures, especially after small-volume secondary implants, but, with meticulous surgery, reasonable long-term results can be achieved with few complications., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background: Limited studies have reported surgical outcomes that are defined by strict criteria following grade 2 or 3 socket reconstruction using an oral mucosal graft (OMG). We aimed to determine factors influencing surgical outcomes of anophthalmic socket reconstruction using OMG in patients with grade 2 or 3 socket contractures., Methods: Thirty-seven patients who underwent socket reconstruction with autologous OMG between January 2007 and December 2017 were retrospectively analyzed. The successful outcome was defined as an eye prosthesis wearing without experiencing displacement and the absence of any re-operations or additional surgeries following socket reconstruction. Factors affecting surgical outcomes were identified using multivariate analysis., Results: A total of 15 male and 22 female patients (mean age: 40.2 ± 17.2 years) were included. The median duration of socket contracture was 21.5 years. Grade 2 and 3 socket contractures, based on Tawfik's classification, were reported in 20 and 17 patients, respectively. Twenty-eight and eight patients underwent socket reconstruction using OMG alone and OMG combined with a hard palate graft, respectively. The success rates of grades 2 and 3 socket contracture reconstruction were 80.0% and 52.9%, respectively. Multivariate analysis demonstrated that only grade 3 contractures were predictive of worse outcomes. At the final visit (mean follow-up: 6.3 years), 34 patients (91.9%) could wear their eye prostheses., Conclusions: Socket reconstruction using autologous OMG can provide acceptable results in grade 2 and 3 contractures; however, satisfactory results were more significantly reported in grade 2 than in grade 3 contractures., (© 2024. The Author(s).)

An 89-year-old woman presented with chronic pain and foreign body sensation in a healthy-appearing anophthalmic socket. Computed tomography of the orbits showed hyperdense, cystic lesions superior and posterior to the orbital implant. Orbital exploration was performed; the orbital implant and lesions were removed. Histopathology revealed cystic structures composed of fibrocellular tissue lined with histiocytes and multinucleated giant cells, consistent with pseudocysts. Postoperatively, the patient noted the resolution of her symptoms. While the etiology of the pseudocysts remains unclear, we hypothesize that the answer can be traced back to the original surgery. The cysts may have formed after extravasation of fluid or proteinaceous material from the eye, from glycerin on the donor sclera, or after introduction of foreign material during retrobulbar injection of local anesthesia. This is the first report of pseudocysts occurring in the orbit posterior to an implant.

The authors describe a case of nylon foil implant infection caused by Fusarium brachygibbosum , and Lomentospora prolificans following medial orbital wall fracture repair in the setting of postoperative nasal methamphetamine use. A 61-year-old male presented with OS pain and swelling after a physical assault on his face. A CT of maxillofacial bones without contrast showed a moderately comminuted fracture of the medial wall of the left orbit with depression of fracture fragments into the left ethmoid air cells. Six days after repair of the medial wall fracture, the patient returned with a new onset headache, OS pain, and swelling to the left medial canthal area. He reported snorting methamphetamine approximately 48 hours before his current presentation. CT imaging showed fat stranding and soft tissue density in the extraconal space adjacent to the left medial rectus muscle and chronic fracture deformity of lamina papyracea with approximately 4 mm of medial displacement of the fracture fragments. The patient showed little clinical improvement after 48 hours of intravenous antibiotics, which led to the removal of the nylon foil implant by a left orbitotomy. Intraoperative tissue cultures grew coagulase-negative Staphylococcus , F. brachygibbosum , and Lomentospora (Scedosporium) prolificans . The patient was subsequently transitioned to oral clindamycin 600 mg three times daily and voriconazole 200 mg two times daily. To the authors' knowledge, this is the first case report to document an association between snorted methamphetamine and a fungal infection of an orbital implant., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To evaluate socket outcomes of enucleation for uveal melanoma., Methods: This study was a retrospective chart review conducted in December 2022 of all patients who underwent enucleation surgery for uveal melanoma between 2010 and 2015 in the Royal Victoria Eye and Ear Hospital, to evaluate socket outcomes including completion of revision surgery, type of surgery, and completion of multiple revision surgeries, and potential associations., Results: Between June 2010 and December 2015, 72 patients underwent enucleation for uveal melanoma in the ocular oncology service, including 25 females and 47 males, mean age 65, range 11-91 years old. There were 68 primary enucleations and 4 secondary enucleations. Complete follow-up data was available for mean 4 years, range 1-11 years. Fourteen patients underwent further surgery, including one exenteration for local recurrence. Oculoplastic surgery (n = 6, 8%), implant exposure repair (n = 3, 6%), and orbit volume expanding surgery (n = 4, 6%) were also performed. Eight patients (11%) underwent one further surgery and five patients (7%) underwent a series of procedures. There was a significant association with younger age at enucleation (age <65) with undergoing further surgery (p = 0.03, Fisher's Exact Test (FET)), and also an association of younger age with undergoing multiple further surgeries (p = 0.02, FET). There was no association found with other predictor variables, including primary versus secondary enucleation status. Most patients (75%) with PESS underwent more than one surgery., Conclusion: Post enucleation surgery 82% of patients did not undergo further surgery, but younger patients were more likely to undergo anophthalmic socket revision or oculoplastic surgery. Management of post enucleation socket syndrome was challenging and usually involved a series of procedures., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: To present an alternative evisceration technique with long-term follow-up data. This technique involves the insertion of an acrylic implant into a modified scleral shell which is closed using an autologous scleral graft., Methods: This was a retrospective analysis of eviscerations performed in a district-general hospital in the UK. All patients underwent conventional ocular evisceration after total keratectomy. A full thickness scleral graft is harvested from the posterior sclera, using an internal approach, with an 8 mm dermatological punch. An 18-20 mm acrylic implant is placed into the shell, and the scleral graft is used to close the anterior defect. Demographic characteristics, implant size and type, and cosmetic results from pictures of all patients were recorded. All patients were invited for a review to measure motility, eyelid height, patient recorded satisfaction and complications., Results: Of the five patients identified, one had since died. The remaining four attended a review in person. The mean time between surgery and review was 48 months. The mean implant size was 19 mm. There were no cases of implant extrusion or infection. All four had a <1 mm asymmetry in measured eyelid height and ≥5 mm horizontal gaze motility. All patients self-reported "good" cosmesis. An independent assessment identified "mild asymmetry" in two cases and "moderate" in the other two., Conclusion: Evisceration with this novel autologous scleral graft technique restores volume in the anterior orbit with good cosmetic results, and with no cases of implant exposure reported in this small case series. This technique should be compared prospectively to established techniques.

Purpose: The study aimed to evaluate the clinical and tissue response to a hollow polymethylmethacrylate orbital implant with a multiperforated posterior surface in an animal model after evisceration., Methods: Sixteen New Zealand rabbits had their right eye eviscerated. All animals received a hollow polymethylmethacrylate implant 12 mm in diameter that is multiperforated in its posterior hemisphere. The animals were divided into four groups, and each one had the eye exenterated at 7, 30, 90, and 180 days post-evisceration. Clinical signs were assessed daily for 14 days post-evisceration and then every 7 days until 180 days. Inflammatory pattern, collagen structure, and degree of neovascularization generated with implant placement were analyzed with hematoxylin-eosin, picrosirius red, and immunohistochemistry staining., Results: There were no signs of infection, conjunctival or scleral thinning, or implant exposure or extrusion in any animal during the study. On day 7, the new tissue migrated into the implant and formed a fibrovascular network through the posterior channels. Inflammatory response reduced over time, and no multinuclea-ted giant cells were found at any time., Conclusion: Hollow polymethylmethacrylate orbital implants with a multiperforated posterior surface enable rapid integration with orbital tissues by fibrovascular ingrowth. We believe that this orbital implant model can be used in research on humans.

Severe ophthalmic conditions such as trauma, uveitis, corneal damage, or neoplasia can lead to eye removal surgery. Poor cosmetic appearance resulting from the sunken orbit ensues. The aim of this study was to demonstrate the feasibility of manufacturing a custom-made 3D-printed orbital implant made of biocompatible material for the enucleated horse and usable in conjunction to a corneoscleral shell. Blender, a 3D-image software, was used for prototype design. Twelve cadaver heads of adult Warmbloods were collected from the slaughterhouse. On each head, one eye was removed via a modified transconjunctival enucleation while the contralateral eye was kept intact as control. Ocular measurements were collected on each enucleated eye with the help of a caliper and used for prototype sizing. Twelve custom-made biocompatible porous prototypes were 3D-printed in BioMed Clear resin using the stereolithography technique. Each implant was fixated into the corresponding orbit, within the Tenon capsule and conjunctiva. Heads were frozen and thin slices were then cut in the transverse plane. A scoring system based on four criteria (space for ocular prosthesis, soft-tissue-coverage, symmetry to the septum, and horizontal symmetry), ranging from A (proper fixation) to C (poor fixation), was developed to evaluate implantation. The prototypes reached our expectations: 75% of the heads received an A score, and 25% a B score. Each implant cost approximately 7.30€ and took 5 hours for 3D-printing. The production of an economically accessible orbital implant made of biocompatible porous material was successful. Further studies will help determine if the present prototype is usable in vivo., Competing Interests: Declaration of Competing Interest The authors declare they have no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

A comprehensive questionnaire with 43 questions was designed to evaluate quality of life, based on rehabilitation with a facial prosthesis. Each patient's psychological situation was assessed using the validated questionnaire and associated scales. Different patient groups were compared with each other in terms of questionnaire scores and general data. In total, 76 patients with a prosthesis of the orbit, nose, or ear, or a combination thereof, were included. There was a highly significant difference in overall satisfaction with defect reconstruction via a prosthesis of the ear compared with the orbit and nose (F(3) = 6.511, p = 0.001). Patients with congenital defects showed a significantly higher level of general satisfaction compared with patients with acquired defects (F(2) = 5.795, p = 0.001). Patients who returned to work were significantly more satisfied with their quality of life (T(57) = 2.626, p = 0.011). With regard to improvements to the state-of-the-art prostheses, the majority of patients suggested better retention, more durable colors, make-up possibilities, less noticeable margins, softer materials, and a movable orbital prosthesis. Within the limitations of the study it seems that facial epitheses improved mental wellbeing and increased quality of life among patients with facial defects. Multiple factors, such as type of facial defect, location of residence, and education can have a potential influence on the quality of life of affected patients. However, further studies are needed, since the psychological and social challenges remain., Competing Interests: Declaration of competing interest The authors delcare no conflicts of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: We compared the rates of implant exposure and extrusion after evisceration with single and double scleral closure techniques., Methods: This retrospective cohort study included all patients who underwent evisceration with an implant insertion over the past 18 years at Tung Wah Eastern Hospital and Pamela Youde Nethersole Eastern Hospital. Clinical documents and operation records were reviewed., Results: A total of 81 ethnic Chinese patients (44 male) who underwent evisceration with primary implant insertion were reviewed. 39 (48%) patients underwent the double scleral closure technique with an implant placed posterior to the posterior sclera, and 42 (52%) patients underwent the single scleral closure technique with an implant inserted in the intra-scleral cavity. The follow-up interval was 70 months. The surgical indications were endophthalmitis (35%), painful blind eye (23%), traumatic disfigured globe (22%) and phthisis bulbi (20%). Silicone was the most used implant material (69%). The patients who underwent double scleral closure had a larger size of the implant (19.7 vs 17.9 mm, p < 0.05). Both implant exposure (26% vs 3%, p < 0.05) and implant extrusion (26% vs 0%, p < 0.05) were more common in patients who underwent single scleral., Conclusions: Double scleral closure technique allows a larger implant, and it is associated with a lower rate of implant exposure and extrusion. The double scleral closure technique is a superior technique of choice in these patients with primary implant placement., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Objective: To prepare customized porous silicone orbital implants using embedded 3D printing and assess the effect of surface modification on the properties of the implants., Methods: The transparency, fluidity and rheological properties of the supporting media were tested to determine the optimal printing parameters of silicone. The morphological changes of silicone after modification were analyzed by scanning electron microscopy, and the hydrophilicity and hydrophobicity of silicone surface were evaluated by measuring the water contact angle. The compression modulus of porous silicone was measured using compression test. Porcine aortic endothelial cells (PAOECs) were co-cultured with porous silicone scaffolds for 1, 3 and 5 days to test the biocompatibility of silicone. The local inflammatory response to subcutaneous porous silicone implants was evaluated in rats., Results: The optimal printing parameters of silicone orbital implants were determined as the following: supporting medium 4% (mass ratio), printing pressure 1.0 bar and printing speed 6 mm/s. Scanning electron microscopy showed that the silicone surface was successfully modified with polydopamine and collagen, which significantly improved hydrophilicity of the silicone surface ( P < 0.05) without causing significant changes in the compression modulus ( P > 0.05). The modified porous silicone scaffold had no obvious cytotoxicity and obviously promoted adhesion and proliferation of PAOECs ( P < 0.05). In rats bearing the subcutaneous implants, no obvious inflammation was observed in the local tissue., Conclusion: Poprous silicone orbital implants with uniform pores can be prepared using embedded 3D printing technology, and surface modification obviously improves hydrophilicity and biocompatibility of the silicone implants for potential clinical application.

Purpose: To describe the demography, clinical settings and outcomes in 2071 patients undergoing evisceration across a multi-tier ophthalmology hospital network and comparison of results with the global scenario of clinical settings for evisceration., Methods: An analysis of 2071 patients undergoing evisceration and implant between 2013 and 2019., Results: The mean age at surgery was 39 ± 22 years. Children constituted 303(15%) of the cases. The four leading indications for surgery included painful blind eye in 760(37%), phthisis bulbi in 552(27%), staphyloma in 215(10%) and open globe injury in 195(9%) patients. The clinical settings encountered were trauma in 852(41%), ocular infection in 714(34%), glaucoma in 198(10%), post ocular surgery in 146(7%), congenital in 95(5%) and uveitis in 21(1%). Trauma and infection remained the commonest clinical settings in the urban (843,75%), rural (622,77%) and metropolitan (101,71%) areas. Decade wise distribution suggested trauma to be the commonest clinical setting in the first 4 decades and infection in the next 6 decades. The mean follow-up period was 351 ± 386 days (median 194). While trauma remained one of the commonest clinical setting in both the developed and the developing economies, painful blind eye and intractable glaucoma were other common clinical settings in the developed economies and infection was one of the leading clinical setting in the developing economies., Conclusion: Most patients undergoing evisceration are young. The commonest indications for surgery include painful blind eye and phthisis bulbi. Trauma and infection remain the commonest clinical settings for evisceration in developed and developing economies.

Objectives: This study reports the surgical outcomes of evisceration with primary orbital implant placement in patients with endophthalmitis and analyses the association with implant exposure and extrusion., Methods: A retrospective, multicentre, Chinese cohort study. Review of medical records and orbital images of patients who underwent evisceration with primary orbital implant placement between January 2005 and January 2021., Results: Out of 79 patients who underwent orbital evisceration with primary orbital implant placement, 26 (26 eyes) of them (male = 13) suffered from endophthalmitis. The duration from endophthalmitis diagnosis (19 = exogenous, 7 = endogenous) to evisceration was 9 standard deviation ± 5 (range: 1-15) days. The follow-up was 70 ± 46 (24-180) months after operation. The orbital implant size was 17 ± 3 (14-20) mm, and silicone was the most used material (69%, 18/26 of patients). The most frequent post-operative complication was orbital implant exposure (42%, 11/26), followed by orbital implant extrusion (12% 3/26) and ptosis (8%, 2/26). Implant exposure or extrusion was more commonly associated with endophthalmitis in comparison to non-endophthalmitis patients that required evisceration and primary orbital implant placement (54% versus 17%, P < 0.05). Univariate analysis showed single scleral closure technique (100% versus 58%, P < 0.05) and endogenous endophthalmitis (50% versus 0%, P < 0.05) were associated with implant exposure or extrusion, and only endogenous endophthalmitis was significant with multivariate analysis (P < 0.05)., Conclusions: Primary implant placement during evisceration should be avoided in eyes with endophthalmitis especially in those with an endogenous source, and double scleral closure technique may be a better alternative for primary orbital implant placement in infected eyes., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

There are various orbital implant options following enucleation. In cases of severe infection, such as panophthalmitis with extraocular extension, it is reasonable to consider a two-staged approach to decrease the risk of infectious complications. One option, illustrated by this case, is enucleation with insertion of an antimicrobial-eluting cement implant, followed by a secondary procedure to exchange the cement with a permanent orbital implant. We report on a patient with clinical, ultrasound, and radiographical findings consistent with infectious panophthalmitis with extra-scleral extension. Intolerable pain and progressive orbital involvement in a blind eye were the indications for enucleation. To reduce the risk of persistent infection, a gentamycin-eluting cement implant (Palacos® R + G as an intraorbital implant) was utilized in the initial procedure. Two months later, the cement implant was removed, and a scleral-wrapped porous implant was placed into a quiet socket without signs of inflammation or infection. In the setting of severe infection, a two-staged procedure utilizing an antimicrobial-eluting implant can be considered.

Purpose: The aim of this study was to investigate the results of all eviscerations and enucleations performed at the Department of Ophthalmology, Sahlgrenska University Hospital, during 2008-2019 and to compare them with previously collected data from 1999 to 2007., Methods: This was a retrospective investigation using the medical records for all patients having had an evisceration or an enucleation at the Department of Ophthalmology, Sahlgrenska University Hospital, during the two defined periods of time. Main outcome measure was postoperative complications., Results: During 1999-2007, 181 surgeries were performed, 100 with implants, and 28/100 exposed implants and 9/100 removed implants were recorded during follow-up. During 2008-2019, 250 operations were performed with 158 implants, and there were 3/158 exposed implants and 2/158 extruded implants. Two ruptures of the surgical wound without implant exposure were noted, and one implant was exchanged. The reduction of exposed implants between the two periods was statistically significant ( p  < .001, Chi-square test). In enucleations, the use of one kind of porous polyethylene implant in the recent study period replaced a multitude of implants in the earlier study period. In eviscerations, the major change between the two study periods was the introduction of the split sclera technique and smaller implant size., Conclusion: The change in surgical technique between the two periods led to a significant reduction in implant-related complications.

Purpose: To describe the utilization of acellular cadaveric dermal matrix (ACDM) in patients undergoing orbital wall reconstruction after orbital preservation surgery for sinonasal malignancy., Methods: Retrospective case series of seven patients with sinonasal malignancy who had orbital reconstruction with ACDM implants from January 2012 to August 2020. Orbital preservation was performed in all patients with tumor extension up to and including periorbital. The main outcome measures were implant exposure, orbital infection, diplopia in primary gaze, enophthalmos, and eyelid malposition., Results: Patients ranged 37-78 years old (median: 66 years) and included 4 females and 3 males. The median follow-up time was 9 months (range 6-43 months) from the date of surgery. Squamous cell carcinoma comprised the majority of tumors with all patients needing medial wall reconstruction. Three patients received postoperative radiation therapy. No patients had any implant exposure, orbital infection, enophthalmos, or eyelid malposition., Conclusions: ACDM grafts can be used safely in orbital wall reconstruction in patients with sinonasal malignancies.

Various surgical techniques are available for the extirpation of an eye, depending on the underlying disease. Typical indications encompass tumors, inflammatory and infectious processes, glaucoma, trauma as well as congenital malformations. Surgical procedures include evisceration (resection of the intraocular space with preservation of the sclera), enucleation (extirpation of the entire eyeball including sclera and cornea) and exenteration (resection of the complete orbital soft tissue). The early detection of postoperatively manifesting complications, such as implant extrusion, conjunctivitis, postenucleation socket syndrome as well as the development of enophthalmus or ptosis, is of particular relevance in the context of postoperative care regarding functional, esthetic and social outcome. Special attention must be paid to ensuring a complication-free rehabilitation process, including the supply of a suitable, precisely fitting prosthesis or epithesis. This ensures the patient's psychosocial reintegration, in which an integrated interdisciplinary cooperation with ocularists and psychologists is essential. The latter play a particularly important role, as the psychological stress resulting from the procedure is often associated with a considerable reduction in the quality of life., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Techniques used to suture the rectus muscle to the implant can influence the implant-related complications which is still a major problem following retinoblastoma enucleation. The goals of this work were to report the efficacy among patients with retinoblastoma who underwent enucleation followed by porous implant placement with the rectus muscles sutured with 5-0 polyester suture., Methods: This was a retrospective study of consecutive patients with retinoblastoma who underwent primary enucleation and porous implant placement with the rectus muscles tagged and sutured to the implant with polyester 5-0 suture. All the patients were followed up for a minimum of 2 years. The main outcome measure was implant exposure. The secondary efficacy measures were other implant-related complications., Results: Between May 2016 and December 2018, a total of 120 patients (120 eyes) underwent primary enucleation and porous implant placement were included. Postoperatively, 10/120 (8.3%) eyes developed exposure or conjunctival granuloma. Exposure was the most common postoperative complication (7/10, 70.0%). There were no cases of implant extrusion, migration, or infection., Conclusions: Polyester 5-0 sutures are successful in patients with retinoblastoma who underwent enucleation followed by porous implant placement. Complications are minimal. Polyester 5-0 sutures were not associated with unacceptable complications in this pediatric population., (© 2023. The Author(s).)

A 61-year-old man underwent left medial wall and floor fracture repair with a Suprafoil® implant. He had postoperative orbital congestion and lower eyelid swelling that persisted for over seven weeks. Examination demonstrated hyperglobus with supraduction, infraduction, and adduction deficits. Imaging revealed a 3.7 × 3.6 × 2.6 cm isodensity along the implant, thought to be hematoma. The patient elected to pursue exploration and possible drainage. Intraoperatively, there was no hematoma; rather, we found a fibroinflammatory rind along the periorbita surrounding the implant. This was biopsied, and the implant was removed, as the fractures had sufficiently healed. Pathology showed dense fibroconnective tissue with associated inflammation. The patient completed a steroid taper with improvement in all symptoms and resolution of diplopia. To our knowledge, this is the first reported case of such a prominent orbital inflammatory reaction to nylon foil, a departure from the delayed hematic cysts typically associated with these implants.

Purpose: To evaluate the amplitude of movement in anophthalmic sockets reconstructed with conical or spherical orbital implants with and without an external ocular prosthesis (EOP), and whether the fornix depth could play a role., Methods: Prospective observational study involving unilateral anophthalmic sockets evaluated the amplitude of movement with conical (20 subjects) or spherical (16) non-porous orbital implants, with and without an EOP, having the contralateral eye as the control group. Standardized photographs were obtained in the four gaze directions and measurements were performed using the Image J software. The upper and lower fornix depths were measured using rulers., Results: Compared to the contralateral eye, the median movement amplitude without EOP was smaller with conical implants in supraduction (-0.88 mm, p=0.008), abduction (-2.26 mm, p<0.001) and adduction (-0.91 mm, p=0.008). Spherical implants had reduced movement only in abduction (-2.63 mm, p<0.001). Conical and spherical implants had similar amplitudes of movement in all versions, and were always smaller compared to the control. The median movement amplitude with the EOP was -3.05 mm (p=0.001) than without the EOP in abduction and -2.07 mm (p=0.020) in adduction, regardless of implant format. The fornix depth did not affect the orbital implants or EOP movement amplitude's median., Conclusion: Conical and spherical implants provide similar amplitude of movement and fornix depth did not have an influence on it. The amplitude of movement was significantly limited compared to the contralateral eye and was even more reduced if the EOP was in place with conical or spherical implant formats.

Purpose: To describe the surgical outcomes and implant complications in 1,800 patients undergoing evisceration with primary implant., Methods: An Electronic Medical Record-driven analysis of 1,800 patients undergoing evisceration with primary implant between 2013 and 2019. Implant sizing was performed intra-operatively to place the largest implant without tension on the wound closure. Outcome measures included implant complications, prosthesis measurements, and incidence of a good aesthetic outcome. Good outcome was defined as <2 mm enophthalmos and grade 1 or less superior sulcus deformity with a custom ocular prosthesis., Results: Eighteen hundred eyes of 1800 patients were included. The mean age at surgery was 36 ± 21 years (median 32 years). Implants used were poly(methyl methacrylate) (PMMA) in 1737 (97%) and porous polyethylene in 63 (3%) patients. Two-petal sclerotomy was performed in 1512 (88%) and four-petal sclerotomy in 165 (10%) patients. The mean diameter of the implant used was 19.35 ± 1.18 mm (median 20, range 10-22 mm). The implant extrusion rate was 3% (56) and implant displacement was seen in none. The mean prosthesis volume and thickness were 2.22 ± 0.67 ml (median 2, range 1-6.5 ml) and 6 ± 1 mm (median 6, range 2-9 mm). The mean difference in prosthesis projection on Hertel's exophthalmometer was 0.28 ± 1 mm (median 0, range 0-1 mm). Good outcome was observed in 93%. The mean follow-up period was 351 ± 386 days (median 194)., Conclusion: Evisceration with empirically selected primary orbital implant placement is associated with minimal implant complications and gives a good aesthetic outcome in 93% of the patients.

This study proposed a 3D-printed PEEK with a specific design to restore the damaged orbit shape. Such printed personalized implants are greatly affected by the process parameters, wherefore the effects of the nozzle temperatures, printing speed and layer thickness on the tensile properties were investigated based on the Taguchi approach. The optimal mechanical properties, i.e., the tensile strength and Young's modulus, were found to be 54.97 MPa and 2.67 GPa, respectively. These properties were obtained by adjusting the nozzle temperature to its high level (450 °C), while the layer thickness (0.1 mm) and printing speed (20 mm/s) were set to their low levels. Secondly, the mechanical behavior of a personalized orbital implant with these optimized properties was evaluated via finite elements analysis with various infill patterns and densities, at three thicknesses: 0.3, 0.5 and 0.7 mm. It was found that all thicknesses were acceptable for the 100% filling. For the honeycomb pattern, the thicknesses 0.5 and 0.7 mm were satisfactory with a fill rate of 70% and 55% whereas only the thickness of 0.7 mm was suitable for the 40% filling. The honeycomb pattern with 40% filling and a maximum stress (7.186 MPa) and strain (0.00627 mm) should be beneficial for light-weight orbital implants., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objectives: To retrospectively assess the treatment outcomes of endosseous implants placed to retain craniofacial prostheses., Material and Methods: Patients with craniofacial defects resulting from congenital disease, trauma, or oncologic treatment had implant retained prostheses placed in the mastoid, orbital, or nasal region and then assessed over a period of up to 30 years. Implant survival rates were calculated with the Kaplan-Meier method. Clinical assessments consisted of scoring skin reactions under the prosthesis and the peri-implant skin reactions. Possible risk factors for implant loss were identified. Patient satisfaction was evaluated using a 10-point VAS-scale., Results: A total of 525 implants placed in 201 patients were included. The median follow up was 71 months (IQR 28-174 months). Implants placed in the mastoid and nasal region showed the highest overall implant survival rates (10-year implant survival rates of 93.7% and 92.5%, respectively), while the orbital implants had the lowest overall survival rate (84.2%). Radiotherapy was a significant risk factor for implant loss (HR 3.14, p < 0.001). No differences in implant loss were found between pre- and post-operative radiotherapy (p = 0.89). Soft tissue problems were not frequently encountered, and the patients were highly satisfied with their implant-retained prosthesis., Conclusion: Implants used to retain craniofacial prostheses have high survival and patient satisfaction rates and can thus be considered as a predictable treatment option. Radiation is the most important risk factor for implant loss., (© 2022 The Authors. Clinical Implant Dentistry and Related Research Published by Wiley Periodicals LLC.)

Purpose: This perspective explores the Food and Drug Administration (FDA) 510(k) program, occasionally referred to as premarket notification, which facilitates faster marketing of Class II medical devices, such as orbital implants by demonstrating "substantial equivalence" to previously approved devices. This allows for FDA clearance, rather than FDA approval of orbital implants via comparison to currently marketed implants rather than clinically proven safety standards., Methods: Utilizing the FDA's publicly available 510(k) Premarket Notification database, we conducted a thorough search of FDA-cleared orbital implants dating back to the inception of the 510(k) process in 1976., Results: We found that 29 orbital implants received 510(k) FDA clearance between 1987 and 2022. Four of the 29 implants were recalled. Only 9 of 29 implants had available data on their predicate or comparison devices; of these 9, 3 implants received clearance based on devices that were subsequently recalled., Conclusions: This investigation into premarket approval of orbital implants identifies a shortcoming in the FDA 510(k) approval process. Long-term implant-associated morbidity is difficult to predict during premarket analysis but is further complicated for 510(k) cleared implants since devices approved based on substantial equivalence to recalled devices may not be automatically recalled. Clinicians should be aware of the approval process for the devices they select, and review of the 510(k) process, especially as it applies to substantial equivalence to devices subsequently recalled is warranted., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2022 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

To evaluate the surgical outcomes and complications of evisceration or enucleation with primary implantation, performed by ophthalmology resident trainees, in regards to patients with recalcitrant endophthalmitis or panophthalmitis. We also compared the surgical outcomes and complications between resident trainees and experienced staff. In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The factors predicting implant exposure or extrusion in regards to patients who underwent eye removal by trainees were identified using multivariate analysis. The percentages of successful prosthesis fittings and complications were also reported. Sixty-six patient records, median age of 46.8 years, who underwent eye removal by resident trainees were reviewed. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = .02, adjusted odd ratio [aOR] = 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = .02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = .03, aOR 38.38). At the last visit, 65 patients had a successful prosthesis fitting. Furthermore, there were similar rates of complications and successful prosthesis fittings between experienced staff and resident trainees. This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Orbital reconstruction is one of the most complex procedures in maxillofacial surgery. It becomes even more complex when all references to the original anatomy are lost. The purpose of this article is to provide an overview of techniques for complex three- and four-wall orbital reconstructions. Preoperative virtual surgical planning is essential when considering different reconstruction possibilities. The considerations that may lead to different approaches are described, and the advantages and drawbacks of each technique are evaluated. It is recommended to reconstruct solitary three-wall or four-wall orbital defects with multiple patientspecific implants. Optimizations of this treatment protocol are suggested, and their effects on predictability are demonstrated in a case presentation of a four-wall defect reconstruction with multiple patient-specific implants., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

In orbital reconstruction, a patient-specific implant (PSI) may provide accurate reconstruction in complex cases, since the design can be tailored to the anatomy. Several design options may be embedded, for ease of positioning and precision of reconstruction. This study describes a cohort of 22 patients treated for secondary orbital reconstruction with a PSI; one patient received two PSI. The preoperative clinical characteristics and implant design options used are presented. When compared to preoperative characteristics, the postoperative clinical outcomes showed significant improvements in terms of enophthalmos (P < 0.001), diplopia (P < 0.001), and hypoglobus (P = 0.002). The implant position in all previous reconstructions was considered inadequate. Quantitative analysis after PSI reconstruction showed accurate positioning of the implant, with small median and 90th percentile deviations (roll: median 1.3°, 90th percentile 4.6°; pitch: median 1.4°, 90th percentile 3.9°; yaw: median 1.0°, 90th percentile 4.4°; translation: median 1.4 mm, 90th percentile 2.7 mm). Rim support proved to be a significant predictor of roll and rim extension for yaw. No significant relationship between design options or PSI position and clinical outcomes could be established. The results of this study show the benefits of PSI for the clinical outcomes in a large cohort of secondary post-traumatic orbital reconstructions., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Operative repair of orbital fractures utilizes implants constructed of a plethora of materials that vary in cost. Surgeon preference as well as fracture complexity may dictate the implant chosen. In this study, we retrospectively compared the complication rates of the four most common types of implants utilized at our institution. We found no significant difference in complication rates in our sample of 88 patients. Additionally, the least expensive implant was as effective as the most expensive implant in addressing isolated orbital blowout fractures. This situation is not unique to the field of oculoplastics. As evidenced from published literature in other areas of surgery, from orthopaedics to orthodontics, cheaper alternatives often afford similar outcomes as more expensive options. We herein argue that a cost-effective approach should be considered while still allowing for high quality of care, in the face of rising health care costs and health disparities in America., Competing Interests: J.F.T. reports grants, consulting fees, payments from Horizon Therapeutics for Speaker and consultant for Tepezza., (Thieme. All rights reserved.)

Purpose: To investigate medical conditions and systemic therapies associated with orbital implant exposure in patients with anophthalmic sockets., Methods: Retrospective review of patients who underwent enucleation or evisceration at a single centre between January 1, 2008 and March 1, 2018. Medical comorbidities, including peripheral or coronary artery disease, rheumatologic conditions, diabetes, malignancy and history of smoking were recorded. Use of immunomodulatory and anticoagulation therapy at the time of eye removal was noted. Patients were divided into two groups-those with implant exposure and those without. Univariate and multivariate analysis was used to compare groups., Results: Two hundred and twenty-nine patients underwent eye removal surgery over a ten-year period. Implant exposure was seen in 20 (8.7%) patients. Univariate analysis revealed a statistically significant difference between groups in rates of smoking, malignancy, and immunomodulatory therapy at the time of surgery. A history of smoking (HR = 11.72; 95% CI: 2.95, 46.53; p = 0.0001) and immunomodulatory therapy (HR = 8.02; 95% CI: 1.96, 32.87; p = 0.004) were independent predictors of exposure. The probability of exposure was 81.2% when all three risk factors were present versus 4.4% when none were present (c-index = 0.737, 95% CI: 0.608, 0.865; p < 0.001). The model was a good fit to the data (Hosmer-Lemeshow goodness-of-fit test p = 0.475)., Conclusions: Smoking and immunomodulatory therapy were associated with orbital implant exposure in patients with anophthalmic sockets. This is the first report examining medical comorbidities in patients with orbital implant exposure. Understanding the pathophysiology of implant exposure is crucial to preoperative planning and postoperative care., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: Reconstructive surgery after craniofacial trauma aim to restore orbital anatomy for function and aesthetic reasons. The purpose of this study is to improve postoperative orbital symmetry with the use of prebent prefabricated titanium implants., Methods: In this retrospective study, patients with combined unilateral medial wall and floor fractures who underwent orbital reconstruction surgery were selected. The angle of inferomedial orbital strut (AIOS) was measured at 3 standard locations on preoperative facial computed tomography guided scans of the nonfractured orbit in the coronal view and used as a guide to bend the prefabricated titanium implants intraoperatively. The corresponding values were measured on the postoperative computed tomography and compared for symmetry., Results: Out of 83 patients recruited for the study, 54 were in the prebent group while 29 were in the control group. All other demographics were similar among the 2 groups. Anterior AIOS has a difference of 4.9° between 2 orbits in the prebent group whereas a difference of 15.5° was noted in the nonprebent group. For middle AIOS, a difference of 4.7° was noted in the prebent group whereas nonprebent group had a difference of 14.1°. For posterior AIOS, the prebent group had a difference of 3.8° versus 14.1° in the nonprebent group. The difference in AIOS at all 3 points between the prebent and nonprebent group were significant., Conclusions: Anatomical prefabricated titanium plates are versatile implants that facilitate orbital reconstruction. Prebending of these implants according to the fellow orbit can achieve better surgical outcomes in a cost-effective manner., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Purpose: Patient-specific titanium implants are increasingly used in orbital trauma as a means of achieving improved surgical outcomes as well as decreasing postoperative complications; however, the data to support their use remain limited. The purpose of this study is to compare the complication rates and accuracy of orbital reconstruction using preformed titanium mesh implants and patient-specific implants., Methods: The authors conducted a retrospective cohort study consisting of patients with orbital floor and/or medial wall fractures treated by reconstruction with either preformed or patient-specific implants from August 1, 2015 to December 31, 2020. The primary predictor variable was the implant type. Outcome variables were the percent volume difference between the reconstructed and uninjured orbital volume and complications. Statistical analysis was performed using Fisher exact test and Wilcoxon rank-sum test., Results: Of the 85 patients in the study, 73% were male and the average age was 38.7 ± 16.6 years. Sixty-one patients (72%) were treated with preformed implants and 24 (28%) with patient-specific implants. Complications occurred in 8.3% of the patient-specific implant group and 26.2% of the preformed implant group (P = .08). Percent volume difference between the reconstructed and nontraumatized orbit was 4.2% and 6.8% in the patient-specific and preformed implant group, respectively (P = .03)., Conclusions: Patient-specific implants improved orbital volume reconstruction accuracy but did not decrease complications when compared to preformed implants., (Copyright © 2021 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background/aims: To report the long-term outcomes of enucleation and insertion of porous polyethylene (PP) orbital implant according to the evolving surgical techniques and implant in patients with paediatric retinoblastoma ., Methods: Patients with paediatric retinoblastoma who underwent enucleation and PP implant insertion from December 1998 to December 2014 were retrospectively reviewed and divided into four groups: group A, classic enucleation +PP implant; group B, enucleation +PP implant +anterior closure of the posterior Tenon's (ACPT) capsule; group C, enucleation +PP implant +free orbital fat graft +ACPT and group D, enucleation +smooth surface tunnel PP implant +ACPT. Survival analysis of implant exposure and eyelid malpositions was performed., Results: One hundred and ninety-eight eyes of 196 patients were included. The median follow-up period was 13.0 years (range, 5.0-21.1). A 20 mm implant was inserted for 149 eyes (75.3%). The 10-year exposure-free survival probabilities were 44.6% in group A, 96.4% in group B, 97.4% in group C and 97.7% in group D. ACPT was associated with significant reduction in implant exposure (p<0.001). The most common eyelid malposition was upper eyelid ptosis (24.2%). The eyelid malposition-free survival probability did not differ among the four groups. However, the insertion of a 20 mm implant was associated with significant reduction in upper eyelid ptosis and lower eyelid entropion (p=0.004 and 0.038, respectively)., Conclusions: The long-term postenucleation implant exposure was rare after PP implant insertion and ACPT, even with a 20 mm-diameter implant. A larger implant can be beneficial in long-term prevention of eyelid malposition., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The use of patient-specific implants for reconstruction of complex orbital floor defects is increasing and requires communication with an industry partner, which warrants investigation. Therefore, the aim of this study was to evaluate the effects of in-house training of engineers on such communication as well as to identify frequent sources of problems and their solutions for improvement of the implant-planning workflow., Methods: We conducted a retrospective cross-sectional study and enrolled a sample of patients who had undergone orbital reconstruction with patient-specific implants between 2017 and 2020. The predictor variables were in-house training (additional training completed in hospital or not) and implant complexity (complex [multiwalled implants] vs less complex [isolated orbital floor reconstructions]). The outcome variables were duration of communication, message length, and need for synchronous communication or modifications to the original design. Descriptive, univariate, and multivariate statistics were computed, and statistical significance was set at a P value of < 0.05., Results: This study included the data of 66 patients (48 men and 18 women, average age: 42.27 years). The complexity of the implant statistically significantly increased the duration of the communication (8.76 vs 16.03 days; P = .004). In 72.73%, the initial design had to be changed. Engineers trained in house required less communication to plan less-complex implants and generally needed fewer corrections to the original design (P = .020 and P = .036, respectively). Problems during planning were observed in 25.76% of the cases, with an insufficient diagnostic 3-dimensional data set being the most common (15.15%)., Conclusions: In-house training of engineers is time-saving while planning the workflow for patient-specific implants, especially in less-complex cases, given that design changes are not needed often. The high rate of data sets that were insufficient for planning patient-specific implants suggests that diagnostic 3-dimensional data sets should already meet the requirements for such planning., (Copyright © 2021 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)