enucleation, evisceration, exenteration Prosthesis, types, complication, management

2. Ophthalmic horizon
Published on September 2016
OCULAR PROSTHESIS:
AN ESSENTIAL
COSMETIC
MANAGEMENT
Prof. Munirujzaman Osmani

3. BACKGROUND
• The ocular prosthetic device is very important to
provide the best possible functional & cosmetic
results.
• It is important to have a firm understanding of
management of the anophthalmic socket, and when
to make appropriate referrals to the ophthalmic
surgeon.

4. SURGICAL PROCEDURES
To understand & manage the complications associated
with prosthetic eye wear, eye care professionals first must
understand anophthalmic procedures.
There are three main surgical techniques used in the
partial or complete removal of the eye:
• Enucleation,
• Evisceration, &
• Exenteration.

5. ENUCLEATION
It is the complete removal of the globe, along with a
portion of the optic nerve, while maintaining the surrounding
orbital tissue.
INDICATION:
 Intraocular malignancy include –
• Retinoblastomas &
• Uveal melanomas
 Phthisical eyes of unknown etiology.
 Severely ruptured globe.

6. EVISCERATION
It involves the surgical removal of the contents of globe,
while preserving the sclera, extraocular muscles & optic nerve.
INDICATION:
 Painful blind eyes found in end stage of –
• Chronic uveitis or
• Neovascular glaucoma, and
• Corneal perforation.
 Endophthalmitis

7. EXENTERATION
It is a procedure involving removal all of the tissues
within the entire orbit, typically including the conjunctiva,
globe, orbital fat, part or all of the lids & sometimes a portion
of the bony orbit.
INDICATION:
• Large, highly invasive orbital tumors
• Malignant tumors involving the orbit from –
 Eyelids,
 Conjunctiva,
 Intraocular structures

8. GOALS
The short term goals after
both enucleation &
evisceration are
• deep fornices
• healthy conjucntiva,
• a normal appearance of the
lid.

9. THE CONFORMER
• Made of either acrylic or
silicone
• It is left in the conjunctival
fornices for 4-6 weeks
• Helps to fit the prosthesis
• Helps to stabilize the implant
during the healing process
• Reduces the risk of tissue
contracture of an
anophthalmic socket.

10. ORBITAL IMPLANTS
Orbital implants are typically made of either non- porous or
porous materials.

11. NONPOROUS ALLOPLASTIC IMPLANTS
 Silicone & polymethyl methacrylate (PMMA) .
 Solid, spherical implant that are well tolerated,
POROUS MATERIAL
 More commonly used
 Material: porous polyethylene, hydroxyapatite & aluminum
oxide.
 Due to the porous nature of these materials, fibrovascular
ingrowth occurs, allowing for improved implant stability &
decreases rejection risk.

12. TYPES OF OCULAR PROSTHESIS
• BASED ON THICKNESS:
• BASED ON FABRICATION:
Prosthetic eye Prosthetic shell
Thickness more than 1.5 mm Thickness less than 1.5mm
Ready made Custom made
Advantage:
 Inexpensive
 Time limitation exists
Disadvantage:
 Ill fitting
 Improper shade matching
• Increases the adapting with
movement of the eyeball as well as
fitting
• Exactly matches the iris position as
that of the adjacent natural eye

13. FABRICATION OF OCULAR PROSTHESIS
• Six to eight weeks after surgery, an ocular prosthesis can be
fitted.
• A prosthetic device can be fabricated in two forms,
• A scleral shell -- fit over a phthisical eye
• A full thickness prosthesis -- fit over the anophthalmic
socket.

14. • Prosthetic devices can be fit either from a stock set of pre-
fabricated eyes or can be custom made.
• Custom made prosthetic eye is preferred to increase stability
& aid in movement.
• The fitting method chosen is upon the ocularist.
• One of the most common fitting techniques is the
impression fitting.

15. IMPRESSION FITTING
• Injecting alginate material directly into the patient’s orbit
using an impression tray.
• The substance hardens & removed from the orbit,
• Adjusted to form the front surface of the device using wax.

16. • The mold is filled with methyl- methacrylate resin that is liquid acrylic.
• The mold is heat treated to harden the liquid.
• After this stage, the device is hand painted to reflect the unaffected eye.
• The iris & pupil positioned taking into account the appearance of the
fellow eye.
• It is recommended that the patient should see the ocularist every six
months for polishing & adjustments to the device at least annually.
• Removal of prosthetic device is similar in fashion to the removal of a
hard contact lens.
polishing contouring

17. Ocular prosthesis in CEITC, Bangladesh

18. In 45 study patients, commonly performed
surgical procedures listed in a table (n = 45)

19. COMPLICATION
The common complications include
• discharge,
• dry eye,
• discomfort,
• implant exposure,
• pain,
• ptosis,
• lid laxity,
• expulsion,
• Adhesions , &
• problem associated with the peg.

20. According to the study held in 2015, CEITC; The major
complications of prosthetic eye wearer who followed
up in the hospital are given below in a bar diagram

21. CONCLUSION
To provide the patient with the most
comprehensive eye care, the most important procedure –
• Is removal of the device for inspection of the tissue
& prosthesis,
• Treat the underlying tissue disorders
• Refer to the appropriate specialist.

22. LITERATURE REVIEW

23. ANOPHTHALMIA
• Anophthalmia is absence of globe
• It may be congenital or acquired.

24. CONGENITAL ANOPHTHALMIA
• Very rare condition
• Optic vesicle fails to develop
• Causes:
• Idiopathic/ sporadic
• Inherited as dominant, recessive
or sex- linked
• Maternal exposure or
teratogenic infection

25. OCULAR FINDING
• Orbital findings:
Small orbital rim & entrance
Reduced size of bony orbital cavity
Extra ocular muscles usually absent
Lacrimal gland may be absent
Small & maldeveloped optic foramen
• Eyelid findings:
Foreshortening of the lids in all directions
Absent or decreased levator function with decreased lid folds
Contraction of orbicularis oculi muscle
Shallow conjunctival fornix, especially inferiorly

26. ACQUIRED ANOPHTHALMIA
 After enucleation, evisceration or exenteration.

27. IDEAL ANOPHTHALMIC SOCKET
1. Centrally placed, well- covered, buried implant of adequate
volume.
2. Fabricated from a bio- inert material.
3. Socket lined with healthy conjunctiva.
4. Fornices deep enough to retain a prosthesis
5. Eyelids with normal position & appearance, & adequate
tone to support a prosthesis
6. Normal position of the eyelashes & eyelid margin
7. A comfortable ocular prosthesis that looks similar to the
sighted, contralateral globe & in the same horizontal plane.

28. ADVANTAGES OF EVISCERATION OVER
ENUCLEATION:
• Less disruption of orbital anatomy
• Good motility of prosthesis
• Lower rate of migration, extrusion & reoperation.

29. Changes associated with anophthalmia

30. POST ENUCLEATION SOCKET SYNDROME
• Introduced by Tyler's & Collin
• Sequelae of an enucleation are orbital volume deficiency &
changes in the orbital soft tissue architecture leading to the
clinical picture of “POST- ENUCLEATION SOCKET SYNDROME
(PESS)”.
• CLINICAL FEATURES:
 Enophthalmos
 An upper eyelid sulcus deformity
 Ptosis or eyelid retraction
 Laxity of the lower eyelid
 A backward tilt of the ocular prosthesis.

33. MANAGEMENT
1. Orbital volume replacement
a) Secondary implant (intraconal) if no implant was placed at
the time of primary surgery
b) Orbital floor implant
c) Dermis fat graft to upper sulcus (option in patients with
associated surface contracture)
2. Lower lid tightening
a) Lateral canthal sling
b) Medial canthal reconstruction
c) Fascial sling
3. Correction of shallow lower fornix
Fornix deepening sutures
4. Ptosis correction

34. IDEAL ORBITAL IMPLANT
• Maintain natural Lid shape
• Light weight
• Porosity
• Natural biocompatibility
• Non toxic & non allergic.
COMPLICATION OF IMPLANT:
Exposure & Extrusion of implant:
• Implant exposure may occur with any type of implant or at
any time may lead to implant extrusion or explantation.
• Porous orbital implants have a lower incidence of implant
exposure than traditional non porous implants.

35. PREDISPOSING FACTORS OF EXPOSURE OF
IMPLANT
1. Closing the wound under tension
2. Poor wound closure techniques
3. Infection
4. Mechanical or inflammatory irritation from the speculated
surface of the porous implant
5. Delayed ingrowth of fibrovascular tissue with subsequent
tissue breakdown

36. PREVENTIVE MEASURE FOR IMPLANT
EXPOSURE
• Proper placement of the implant within the orbit followed by a
two- layered closure of anterior Tenon’s capsule & conjunctiva
• The rectus muscles are then attached to the wrapped implant.
TREATMENT:
if few weeks,
• No infection, simple reclosure or with a patch graft (e.g.
sclera, temporalis fascia) is required.
• If infection is suspected & treated vigorously with topical &
systemic antibiotics, an extrusion & removal of the implant
may be avoided.

37. Beyond 4-6 months,
• If non porous implant, the defect should not be closed, &
secondary orbital implant surgery should be arranged.
• If porous,
exposure
< 3 mm >3 mm
Treat conservatively
Wait 8 weeks for spontaneous closure
no
Closure with scleral patch graft
• Surgical repair is
indicated
• Using scleral patch
graft or temporalis
fascia patch graft

38. THANK YOU
Next case presentation by DR. BURHAN UDDIN
Topic: THYROID ORBITOPATHY