1. The document describes a case of a 73-year-old man who presented with spontaneous bleeding from his right eye along with pain and redness. He had a history of blindness in the right eye for 10 years along with glaucoma in both eyes. 2. The patient underwent an evisceration of the right eye with placement of a silicon implant under local anesthesia. Post-operatively, the conformer was well-placed with mild discharge and congestion. Tissue samples were sent for histopathology and microbiology. 3. Evisceration involves removing the intraocular contents while leaving the external shell of the eye intact. It has advantages over enucleation such as being simpler

1. EVISCERATION, ENUCLEATION
AND ORBITAL IMPLANTS
DR DEBARUN SHARMA
JUNIOR RESIDENT, 5TH SEMESTER
UNIT VI

2. HISTORY OF PRESENT ILLNESS
 73 year old man, farmer by occupation, presented to RPC casualty on
1/11/2020 with history of spontaneous bleeding in right eye from 1 day
 Associated with pain and redness in the right eye. Severe pain for last 3 days
with significant decrease in pain with episode of bleeding.
 No history of any ocular trauma
 No history of any ocular surgery

3.  Patient gave a history of no vision in the right eye since the last 10 years
 Painful, blind eye for the last 10 years for which he was on conservative
management
 History of glaucoma in both eyes for the last 12 years (no documents available)
 Medical treatment of glaucoma from outside
 Currently not on any anti-glaucoma medication for the other eye

4. SYSTEMIC HISTORY
 History of squamous cell carcinoma of the floor of the mouth on
21/05/2019 for which Left Commando operation+ marginal mandibular
reconstruction+ skin grafting+ advancement flap done in Park Hospital,
Gurgaon
 HPE of lesion- S/O moderately differentiated squamous cell carcinoma
Grade 2
 Lymphatic invasion seen
 No angiomatous invasion seen
 Underwent Radiotherapy for 30 times
 H/O one cycle of chemotherapy- Inj Paclitaxel 260 mg IV on D1 on 28/10/20
Inj Carboplatin 450 mg IV on D2 on
29/10/2020

5. PET SCAN
 Done on 20/10/2020
 Metabolically active soft tissue density lesion in the right
submandibular region
 Post operative changes noted along median left paramedian
aspect of mandible
 No definite evidence of metabolic active disease in rest of the body

6. PAST OCULAR HISTORY
 History of PI done in both eyes 12 years back (no documents
available)
 History of left eye cataract surgery in 2019 in Gurgaon- Uneventful
post op course

8. OCULAR EXAMINATION
Right Eye Left Eye
Visual acuity No perception of light, PR inaccurate
in all the quadrants
6/6
Near Vision Could not be assesed N6
IOP(mm hg) Could not be assesed 14 mm Hg
Ocular movements
No restriction of any ocular motility
Eyelids Upper and lower eyelids edema
present
No ptosis, ectropion on entropion
Normal palpebral aperture
No ptosis, ectropion on entropion
Conjunctiva Diffuse congestion of conjunctiva
present
Mild conjunctival chemosis present
No evidence of any scarring or foreign
body
No discharge
No congestion
Normal bulbar and palpebral
conjunctiva
No foreign body
No restriction of any ocular
motility

9. Right Eye Left Eye
Cornea Distortion of size and shape of
cornea
9x8 mm of corneal perforation
with irregular margins with
surrounding area of infiltrate
Active bleeding present from the
perforated site
Extruded ocular contents present
Normal size and shape
Cornea clear
No ulcer
No Vascularisation
No opacity, or dystrophy
Arcus Senilis present
Sclera Intact scleral shell, no evidence of
any perforation, nodules or
No nodules or ectasia
Anterior chamber Flat, no details available VH III
Iris Details not visible Superonasal PI patent, Patchy iris
atrophy, No NVI
Lens Details not visible PCIOL in bag, stable
Vitreous Details not visible Optically clear
No opacities

10. Right Eye Left Eye
Distant Direct Ophthalmoscopy
Indirect Ophthalmoscopy No glow Glow present
Media clear
Vertically oval disc
Average size
Margins distinct
NRR pink
CDR- 0.4:1
AVR- 2:3
FR sharp
No peripheral treatable lesion

11. DIAGNOSIS
 BE PACG with RE Absolute eye with perforated corneal ulcer with
Autoeviscerated eye with LE Pseudophakia

12. PRE OP CONSIDERATIONS
 Patching of the right eye was done
 Patient was started on the following medications-
1. Tab Ciprobid 750 mg BD
2. Tab Zinase D 1 tab BD
3. Tab Pantop 40 mg OD BBF
 RE USG for PSE- No evidence of any intraocular malignancy
 Surgery Planned- RE Evisceration with Silicon Implant under LA

13. Take consent regarding the following-
1. Patient explained regarding loss of
vision in same eye and spread of
disease to other parts of the body if
eye is not removed
2. Risk of Sympathetic Ophthalmia in
the other eye
3. Need for an artificial prosthesis
4. Requirement of further surgery
5. Consent for anesthesia
Signature of Witness
Signature of Senior
Resident
Signature of
Consultant/Operating
Surgeon
Signature of Junior
Resident

14. POST OP COURSE
 Post op examination-
1. Visual acuity- No PL
2. Conformer was well in place, Mild watery
discharge, Mild lid congestion and
mechanical ptosis, Conjunctiva well apposed
3. Documentation of distance and near vision
of other eye, Ac reaction (cells/flare) and
fundus examination done- To rule out
sympathetic ophthalmia
4. Patient counselled regarding immediate
consultation in case of redness, pain,
decreased vision and photophobia in other
eye

15. • The eviscerated sample and the host cornea were sent
for both histopathological and microbiological
evaluation.
• Histopathology report- Awaited
• Microbiology report- Culture of host cornea
revealed sterile results. There was no growth of any
bacterial or fungal organisms.

16. HISTOPATHOLOGY
Mention about
fixing media-
Usually 10%
formalin is used
1.Mention about the eye
eviscerated/enucleated.
2. In case of enucleation
mention about length of
optic nerve stump
1. Brief clinical history
2. Findings of Ct Scan,
MRI or any other
imaging modality
3. Ultrasound of eye
findings
4. Any intraoperatively
noted scleral thinning,
calcification,
staphyloma, anterior
chamber seeding(in
case of RB),
involvement of
emissary vein area( in
case of choroidal
melanoma)
5. No of
chemotherapy/radiothe
rapy/EBRT received
6. Previous EUA findings
and any focal therapy
used
7. Diagram of lesion with
dimensions if any

17. WHY EVISCERATION IN THIS CASE ?
1. Painful blind eye with bleeding anterior staphyloma
2. History of Squamous cell carcinoma of floor of mouth- Chances of
microscopic spread of tumour to orbital tissues
3. Decreased chances of intraorbital spread of infection as optic
nerve intact
4. Better implant mobility and cosmesis
5. Lower risk of implant extrusion

18. DISCUSSION

19. EVISCERATION
 Removal of contents of eyeball leaving behind the sclera, extraocular
muscles and surrounding adnexa is termed as evisceration
 1817- Bear introduced evisceration for expulsive hemorrhage.
 1884- Mules described placing a hollow glass sphere into the eviscerated
cavity.
 1887- First report of sympathetic ophthalmia occurring in association with
evisceration.
Meltzer MA, Schaefer DP, Della Rocca RC. Evisceration. In: Della Rocca RC, Nesi FA, Lishman RD, editors. Smith’s ophthalmic
plastic and reconstructive surgery. Vol. 2. St. Louis: CV Mosby; 1987. p. 1300-7

20. INDICATIONS
 Blind, painful eye.
 Panophtahlmitis
 Bleeding anterior staphyloma
 Penetrating ocular trauma with intact
scleral shell
 Expulsive choroidal hemmorhage
Shah RD, Singa RM, Aakalu VK, Setabutr P. Evisceration and enucleation: A national survey of
practice patterns in the United States. Ophthalmic Surg Lasers Imaging 2012;43:425-30

21. CONTRAINDICATIONS
• Suspected intraocular malignancy
• Microphthalmia
• Pthysis bulbi with marked shrinkage of globe
• Integrity of globe disrupted
• Chronically inflamed eye
• Patient with nystagmus

22. STEPS OF SURGERY
Peritomy
Keratectomy
Removal of Intraocular contents
Sclerotomy
Placement of implant and closure

23. • Conjunctiva ballooned with local
anaesthetic ideally to permit easy
dissection and hemostasis
• Undermine the conjunctiva and
Tenon capsule for approximately 5
mm for 360°
• Care is taken to preserve as much
conjunctiva as possible
PERITOMY

24. KERATECTOMY
• Stab incision is made at limbus at 12’o
clock position with no.11 Bard Parker
Knife
• Gentle reduction of IOP to prevent
profuse choroidal bleeding.
• 360 degree keratectomy performed
with Westcott Scissors

25. REMOVAL OF INTRAOCULAR CONTENTS
• Intraocular contents removed with an
evisceration spoon.
• Attempt should be made to remove the
intraocular contents en bloc (although they
usually come out piecemeal)
• Maintain hemostasis with suction and bipolar
cautery
• Wipe the entire internal scleral surface with
cotton- tipped applicators soaked with 95%
absolute alcohol
• Denature any residual uveal pigment that may
contribute to the development of sympathetic
ophthalmia.

26. SCLERAL ENVELOPE- FOUR PETALS TECHNIQUE
• Described by Sales-Sanz in
2007.
• Four sclerotomies are
performed from the limbus,
between the rectus muscle
insertions, to the optic nerve
• The four sclerotomies reach
one another to form four
separate scleral petals, each
containing one rectus muscle
insertion. Sales-Sanz M, Sanz-Lopez A. Four-petal evisceration: a new technique. Ophthalmic Plast
Reconstr Surg. 2007 Sep-Oct;23(5):389-92. doi: 10.1097/IOP.0b013e318142cc4c.

27. ADVANTAGES OF FOUR PETALS TECHNIQUE
1.The sclera can cover any size of implant without
tension, even in phthisical or microphthalmic globes.
2.Covering the implant with a double scleral layer gives
the implant an additional layer of protection against
erosion and exposure.
3.Preserves the positions of all the muscles, giving the
socket more natural motility.

28. OTHER METHODS OF SCLEROTOMIES
• 1987- Stephenson reported performing
multiple radial expansion sclerotomies as well as
a posterior spiral sclerotomy- To accommodate
a larger implant
• 1995- Lee et al. Scleral windows posterior to
insertion of rectus muscles- reduce tissue
breakdown and exposure after
hydroxyapatite implantations
• 2001- Massry and Hold- Scleral modification
with optic nerve release for coverage of any
sized orbital implant.
• 2011- Georgescu et al. Evisceration with
equatorial sclerotomy for phthisis bulbi and
microphthalmos
• Stephenson CM. Evisceration of the eye with expansion sclerotomies. Ophthal Plast Reconstr Surg 1987;3:249-51
• Georgescu D, Vagefi MR, Yang CC, McCann J, Anderson RL. Evisceration with equatorial sclerotomy for phthisis bulbi and microphthalmos. Ophthal Plast
Reconstr Surg 2010;3:165-7

29. PLACING THE IMPLANT AND CLOSURE
• Implant soaked in antibiotic solution inserted
in scleral envelope
• Pressure is applied to the implant with a
cotton- tipped applicator and implant pushed
posteriorly until the anterior scleral edges can
be closed without tension.
• Vertical petals are sutured first followed by
horizontal petals using 6-0 Vicryl
• Tenon’s and conjunctiva are closed in layers
using 8-0 Vicryl
• Placement of conformer and patching of eye

30. SURGICAL VIDEO

31. COMPLICATIONS
EARLY
• Infection
• Hemorrhage
LATE
• Implant extrusion
• Lower eyelid laxity and
ectropion
• Socket contraction
• Conjunctival cyst formation
• Implant migration

32. INFECTION AND HEMORRHAGE
• Hemorrhage is usually self-limited
• Severe cases can be controlled with a firmly placed pressure patch
• Placing a temporary tarsorrhaphy at the close of the case prevents
conjunctival prolapse should post-operative bleeding be encountered
• Sterile technique with peri and postoperative systemic antibiotics limits the
risk of infection.
• Signs of implant infection include persistent mucopurulent discharge despite
antibiotic coverage, recurrent pyogenic granuloma and socket discomfort.
• Implant infection typically requires implant explantation with the risk of rectus
or levator muscle damage or oculomotor nerve injury.

33. IMPLANT EXPOSURE
• Causes-
1. Placement of an oversized implant
2. Inadequate sclerotomy
3. Poor wound closure
4. Poorly fitting conformer or prosthesis.
Management-
• Small exposed areas- Heal spontaneously and are observed
• Larger exposed areas- Closed with a variety of flaps (Tenon’s flaps, bipedicled
conjunctival flaps, tarsoconjunctival flaps), grafts (temporalis fascia, fascia lata,
dermis fat graft)and even donor or synthetic materials
• Implant exchange or repositioning may be required

34. SOCKET CONTRACTION
Types of socket
contracture
Treatment
Mild- shortening of the
posterior lamella resulting
in vertical lash orientation
and marginal eyelid
entropion
Transverse tarsal incision (tarsotomy)
with marginal rotation +/- horizontal lid
shortening
Moderate- loss of tissue
in the inferior and/or
superior
conjunctival fornix
Amniotic membrane Graft(AMG)- mild
tissue loss
Mucous membrane transplantation
Severe- conjunctival
fornices are nearly absent
or may be obliterated
making it difficult to hold
even a small prosthetic
• Split-thickness mucous membrane
graft
• Poorly vascularized, contracted, and
volume-deficient(enophthalmic)
sockets--temporalis muscle flaps

35. ADVANTAGES OF EVISCERATION OVER ENUCLEATION
• Simpler and faster than enucleation.
• More cost efficient
• Less risk for significant bleeding- as it leaves the optic nerve and EOM
intact
• Allows for better preservation of orbital anatomy
• Improved mobility
• Enhanced cosmesis
• Less risk of superior sulcus deformity
• Lower rates of migration and extrusion of implant
Migliori ME. Enucleation versus evisceration. Curr Opin Ophthalmol. 2002 Oct;13(5):298-302. doi: 10.1097/00055735-
200210000-00002. PMID: 12218460.

36. DISADVANTAGES
 Risk of sympathetic ophthalmia
 Dissemination of suspected intraocular malignancy
 Provides disrupted pathological specimen

37. SYMPATHETIC OPHTHALMIA
Earliest symptom- Loss of
accommodation
Earliest sign- Retrolental cells
and flare
Dalen Fuch’s
nodules Multiple
exudative RD

39. Absolute contra-
indication of evisceration

42. Conclusion
Evisceration with primary
implant placement is
preferred in patients with
endophthalmitis due to the
following reasons-
1. Ease of procedure
2. Convenience of a single
procedure
3. Rapid resolution of
infection
4. Successful retention of
implant

43. ENUCLEATION

44. Indications-
1. Retinoblastoma
2. Uveal melanoma and
other malignant
intraorbital tumours
3. Primary enucleation after
trauma
4. Secondary enucleation
after sympathetic
ophthalmia
5. Chronic painful blind eye
6. Atrophic bulbi/ pthysis for
cosmesis
Contraindications
1. Intraocular malignancy with
evidence of orbital spread
2. Relatively contraindicated
in patients who will
experience increased
psychological trauma due
to the loss of the eye

45. TECHNIQUES OF ENUCLEATION
Imbrication Technique Integrated Implant
Technique
Myoconjunctival
Technique
Type of Implant Non-integrated Integrated (porous) Non-integrated
Need for mesh around
the implant
No Yes No
Repositioning the rectus
muscles
Superior rectus
imbricated with inferior
rectus, and medial rectus
imbricated with lateral
rectus
Muscles directly sutured
to the scleral cap or the
mesh around the implant
in a location
corresponding to muscle
insertion
Recti muscles sutured
just short of the
respective fornices with
sutures passing through
the anterior Tenon’s-
conjunctival complex
Repositioning the
oblique muscles
No Yes No
Main complications Implant displacement
and extrusion
Persistent infection, and
implant exposure
Implant extrusion

46. MYOCONJUNCTIVAL TECHNIQUE
 After implant placement each of the recti
muscle sutures is passed though
respective conjunctival fornices
 Superior and inferior recti are placed 12
mm from horizontal edge of conjunctival
wound
 Medial and lateral recti are passed
through medial and lateral fornices 25
mm apart.
 Nunery and Chen's modification of
MCT: Attaching the superior oblique to
the superior rectus and inferior oblique
to inferior border of the lateral rectus
 Increase implant stability and prosthetic
motility.
Yadava U, Sachdeva P, Arora V. Myoconjunctival enucleation for enhanced implant
motility. result of a randomised prospective study. Indian J Ophthalmol. 2004
Sep;52(3):221-6.

47. a)360 degree peritomy done and tenon’s tissue is dissected away from globe.(b) All four recti
hooked and a double-armed 6-0 Vicryl suture is passed, locked on either side of the muscle.
Muscle belly transected using bipolar cautery (c) The inferior oblique tendon is cut. (d) The
superior oblique tendon is cut. (e) The tips of the enucleation scissors are positioned on either
side of the optic nerve( At least 10 mm of optic nerve stump is cut)(f) Once the optic nerve has
been transected, the entire globe moves forward. Hemostasis applied by rolled cotton wraps and
pressure applied for at least 5 minutes.

48. (g) Placing the implant in the socket. (h) Applying posterior pressure to the implant to “seat” the
implant within Tenon’s tissue space. (i) Tenon’s tissue retracted with a toothed forceps while pressure
is being applied posterior to seat the implant (j) The rectus muscles are sutured just short of the
respective fornices with sutures passing through the anterior Tenon’s-conjunctival complex(Myo-
conjunctival technique) (k) Tenon’s is closed under no tension in two layers (l) The conjunctiva is
closed with a running or interrupted 8-0 Vicryl suture.

49. SURGICAL VIDEO

50. ORBITAL IMPLANTS

51. CHARACTERISTICS OF AN IDEAL IMPLANT
 Mimics normal globe as close as possible
 Replaces sufficient volume but allows for a prosthesis of adequate anterior
chamber depth.
 Has minimal rate of exposure, extrusion, infection, inflammation
 Is non antigenic, biologically inert
 Provides socket motility transmitted to prosthesis
 Is completely buried, simple in construction without projection/ angulations
which erode conjunctiva

52. CLASSIFICATION
Type Definition Example
Nonintegrated No direct or indirect integration of the
synthetic implant (PMMA or Silicone) with
the orbital structures or with the
prosthesis
PMMA or Silicone spheres
Semi-integrated Indirect (mechanical) integration of the
synthetic implant with the orbital
structures but not with the prosthesis
Allen implant
Integrated Indirect (mechanical) integration of the
synthetic implant with the orbital
structures and with the prosthesis
Cutler’s implant
Biointegrated Direct (biological) integration of a natural
or a synthetic implant with the orbital
structures with or without integration with
the prosthesis
Hydroxyapatite,
Porus polyethylene
Aluminium oxide
Biogenic An autograft or allograft of a natural
tissue with direct (biological) integration
with orbital structures but not with the
prosthesis
Dermis-fat graft
Cancellous bone

53. NON POROUS IMPLANTS
 1. Silicon Implant
 Made of medical grade silicone
 Come in sizes from 14 mm to 20 mm
 Provides comfort to patient and inexpensive
 Lower rates of extrusion
 Silicon implant ensures motility by surface tension at
conjunctival prosthetic interface
 Other non porous implants
1. Acrylic implant
2. PMMA implant

54. NON INTEGRATED ORBITAL IMPLANTS
Advantages:
 Cheap, easily available
 Smooth surface
 Least complication rates
 Can attach muscles if wrapped with sclera
Disadvantages
 Poor motility if not wrapped
 High chances of migration

55. POROUS IMPLANTS
 1. Hydroxyapatite Implants
 The HA implants (FDA approved in 1989)- New
generation of buried, biointegrated spheres
 Bio-Eye™
 Regular system of interconnecting pores(500 micron
pore size) that allowed host fibrovascular ingrowth.
 Fibrovascularization potentially reduced the risk of
migration, extrusion, and infection of the implant
 Allows secure attachment of the extraocular
muscles- Leads to improved implant motility
 Needs a wrapping material because of rough surface

56. Synthetic Porous Polyethylene
Implants
• MEDPOR®
• Well tolerated by orbital soft tissue
• Smoother surface than HA implants- May be
placed without wrapping
• Easier implantation and potentially less
irritation of the overlying conjunctiva following
placement.
• High tensile strength yet are malleable which
allows sculpting of the anterior surface of the
implant.
• Slower rate of vascularization
• Incites less inflammation as compared to HA
Blaydon SM, Shepler TR, Neuhaus RW, White WL, Shore JW. The porous polyethylene (Medpor) spherical orbital implant: a retrospective study of 136 cases.
Ophthalmic Plast Reconstr Surg. 2003 Sep;19(5).

57. BIOCERAMIC IMPLANTS
Aluminum oxide (Al2O3)
 Aluminum oxide is a porous, inert substance
 These implants permit host fibrovascular
ingrowth similar to the HA
 Human fibroblasts and osteoblasts proliferate
more rapidly on aluminum oxide than HA
 More biocompatible substance than HA
 Microcrystalline structure is smoother than the
rough- surfaced Bio-Eye™
Jordan DR, Mawn LA, Brownstein S, et al. The bioceramic orbital implant: a new generation of porous implants. Ophthalmic Plastic and
Reconstructive Surgery. 2000 Sep;16(5):347-355

58. INTEGRATED IMPLANTS
ADVANTAGES OF POROUS IMPLANTS
 Increase success rate of the implant
 Reduce implant migration and extrusion
 Permit better movement of the overlying prosthesis
 Motility peg fixation allows the weight of the prosthesis to be borne by the
implant reducing stress on the lower eyelid
DISADVANTAGES
 Cost of implant is high
 Motility peg placement often necessitates 2nd stage surgery
 Additional expenses due to MR scans to confirm vascularisation

59. SEMI INTEGRATED IMPLANTS
 Allow attachment of extra ocular muscles in the tunnels on their anterior surface
for better motility.
 The anterior location of the mounds provides projections into Tenon’s capsule and
conjunctiva that allow indirect coupling of the implant with impression fitting of
the ocular prosthesis without placement of a peg or screw.
Allen's implant Iowa, Universal Castroviejo

60. SEMI INTEGRATED IMPLANTS
 Medpor Quad-Motility Implant
 Rounded orbital implant with four mounds located
anteriorly
 Advantages of the semi integrated implants
 Provide projections in the Tenon capsule and
conjunctiva that allow coupling of the implant with
the ocular prosthesis without penetrating the
conjunctiva.
 Requires no wrapping material
 Obviates the need for secondary placement of a
peg or screw.
 Four anterior mounds provide a “lock-and-key” fit
with the ocular prosthesis for improved motility

61. SEMI INTEGRATED IMPLANTS
Disadvantages of Semi-Integrated Implants
 Irregular anterior surface
 Discomfort and rates of erosion and extrusion are high
 Special customised prosthesis are needed to fit its shape

62. ORBITAL WRAPPING
 Advantages
1. Diminishes tissue drag
2. Facilitates precise
anatomic fixation of the
rectus muscles to the
implant surface
3. Provide a barrier function
over the spiculated porous
implant surface
 Disadvantages
1. Theoretical barrier to
vascularisation
2. Increased cost of the
procedure
3. Theoretical risk of
transmission of prion-like
diseases
4. No evidence of increased
motility

63. METHODS OF ORBITAL WRAPPING
1. Allograft wraps
 Human Donor Sclera
 Historically the first choice of implant
wrapping material for most orbital surgeons
 Carries the risk of transmission of viruses (e.g.,
HIV, hepatitis B or C) and other pathogens
(prions)
Other allograft materials-
1. Processed human donor pericardium
2. Fascia lata
3. Processed bovine pericardium (Peri-Guard®)
4. Autologous temporalis fascia Bovine pericardium (Peri-
Guard®)

64. • Synthetic wraps
1. Microporous expanded
polytetrafluoroethylene (e-PTFE) (Gore-Tex)
2. Undyed polyglactin 910 mesh (Vicryl mesh,
Ethicon, Somerville, NJ, USA)
• Eliminates the risk of infectious disease
transmission
• Does not require a second surgical site
• Permits fibrovascular ingrowth over the entire
implant surface unlike implants completely
wrapped in sclera
• Addition of a small scleral cap (13–15 mm) over
the anterior surface of the Vicryl mesh wrapped
reduces implant exposure
Jordan DR, Allen LH, Ells A, Gilberg S, Brownstein S, Munro S, Grahovac S, Raymond F. The use of Vicryl mesh (polyglactin 910) for implantation of hydroxyapatite
orbital implants. Ophthalmic Plast Reconstr Surg. 1995 Jun;11(2)

65. COMPARISON OF POROUS AND NON POROUS IMPLANTS
Anterior migration
• Overall rate of implant migration
may be higher with porous
implants as compared to non
porous
Implant exposure
• Nonporous implants become
exposed– typically extrude from
the socket
• Porous orbital implants
become exposed--the
fibrovascular ingrowth helps
retain them within the orbit, often
preventing complete extrusion.
• Wladis et al. reported that rates
of exposure (and extrusion) are
generally comparable between
porous and nonporous
implants(1)
Infection Rate
• Nonporous implants (e.g.,
PMMA/silicone) have been shown
to have a low infection rate (0–
1%) [2]
Motility Rate
• Without a peg in place, there is
no proven motility advantage of
porous over nonporous implants.
• Peg placement improves
horizontal gaze movements in
the artificial eye
1.Wladis EI, Aakalu VK, Sobel RK, et al. Orbital implants in enucleation surgery; a report by the American Academy of Ophthalmology. Ophthalmol 2017; 2017. pii: S0161–
6420(17)32438–7.
2. Hornblass A, Biesman BS, Eviator JA. Current techniques of enucleation: a survey of 5,439 intraorbital implants and a review of the literature. Ophthalmic Plast Reconstr Surg.
1995;11:77–88.

66. PEGGING OF IMPLANTS
 Motility peg placement improves horizontal gaze
movements in the artificial eye
 Peg placement is delayed until approximately 6 months
or more after implant is placed
 Gadolinium-enhanced MRI of the orbit is done to assess
fibrovascular ingrowth into the implant.
 Vascularization of the implant is described as being –
1. Partial (incomplete vascularization, less than 75% of
diameter of implant at the equator)
2. Complete (greater than 75% of the equatorial implant
diameter)
A, Nonsleeved peg system, showing peg
that will be placed directly within the
hydroxyapatite implant. B, Sleeved peg
system, showing threaded unidirectional
sleeve (left) and central slender peg (right)

67. TECHNIQUE OF PEGGING
 The geometric center of the implant is marked
 A 10-mm horizontal incision is made along the prior
conjunctival wound.
 Limited dissection is then performed through Tenon's
fascia and scleral wrap until the surface of the implant
is reached
 The implant is then stabilized with forceps or a
Thornton fixation ring
 A 3-mm wide drill bit for nonsleeved pegs and a 3.2-
mm wide bit for sleeved pegs on an air-driven hand
drill is used
 Drilled perpendicular to the anterior plane of the orbit
 Minimum drilling of 10 mm into the implant at the
premarked geometric center
 Sleeved or non sleeved peg used
 Four weeks -The temporary peg of both systems is
replaced with a permanent peg

68. COMPLICATIONS OF PEGGING
 Discharge
 Recurrent pyogenic granulomas
 Implant exposure around the peg
 Implant infection
 Tissue overgrowth
 Peg dislocation
 Audible clicking

69. IMPLANT SELECTION
In infants and pre school children
 Wrapped non porous sphere implant (PMMA, Silicon) centered on muscle
cone
 Replace with porous orbital implant at age>15 years
Adults(>65 years)
 Quasi integrated implant preferred
 Porous implants are not preffered due to difficulty in pegging

70. IMPLANT SIZING
 Proper implant sizing is crucial. Implant that provides about 65-70% of volume
replacement is ideal, the remaining 35-30% being contributed by the
prosthesis.
 A smaller implant has a higher tendency to displace or migrate and develop
superior sulcus deformity.
 A larger implant is known to improve both cosmesis and motility. However, an
inappropriately large implant may produce tension on the conjunctival wound
and result in wound gape and implant exposure.

71.  Generally, a 16-18 mm implant is used in infants, 18-20 mm in older children,
and 20-22 mm in adults.
 There are implant sizers that may help gauge the appropriate size.
 Axial length of the fellow eye (axial length in mm - 2 = implant diameter in
mm)
 One should remember to deduct an additional 2-mm from the axial length if
the implant is traditionally wrapped but not when the scleral cap technique is
used.
Kaltreider SA1. The ideal ocular prosthesis: analysis of prosthetic volume. Ophthalmic Plast
Reconstr Surg. 2000 Sep;16(5):388-92.

72. CONFORMERS
• Dumbbell shaped
• Champagne glass
Hydrogel hemisphere conformer
Conformer with pegs
Cosmetic shells

73. ROLE OF THE OCULARIST
 Close collaboration between the orbital surgeon
and the ocularist is essential in order to obtain the
best functional and cosmetic results.
 Prosthesis is generally fit after approximately 6
weeks after anophthalmic surgery
 Modified impression technique is currently the
best means of prosthetic fitting
 Chronic socket discharge caused by a poorly fitted
prosthesis
 Refitting the socket with a new prosthesis
(generally every 5 years)
Silicon Putty

74. Artificial Cosmetic Eye