The document discusses orbital implants and ocular prosthetics used to replace eyes removed due to conditions like trauma, tumors, or infection. It describes different types of orbital implants including porous implants made of materials like hydroxyapatite that allow tissue ingrowth, and non-porous implants made of materials like silicone or acrylic. Complications from implants or prosthetics like exposure, extrusion, or socket contracture are also summarized. Maintaining adequate orbital volume with implants is emphasized, as is regular cleaning and replacement of prosthetics.

1. Sintayehu Ayanaw ( R3 )
JUDO, 2022
Orbital Implants and Ocular Prosthesis
02/02/2024
1

2. Outline
 Introduction
 Anophthalmic socket surgeries
 Orbital implants
 Ocular prosthesis
 Complications of OIs and prosthesis
 Summary
 References
02/02/2024
2

3. Introduction
02/02/2024
3
 Anophthalmia – Without eye
 Anophthalmic socket- an orbit not containing eyeball
 Could be acquired or congenital
 Acquired is more common following:
 Enucleation
 Evisceration
 Exenteration

4. …Cont
 Eye removal can be done:
 To safeguard life
 To preserve vision in the fellow eye
 To enhance comfort and cosmoses
02/02/2024
4

5. …Cont
 There are 3 ways of removing the eye:
 Evisceration
 Enucleation
 Exenteretion
02/02/2024
5

6. Indications
02/02/2024
6
 Enucleation
 Blind painful eye
 Intraocular tumor
 Severe trauma
 severe phthisis bulbi
 severe microphthalmia
 cosmetic deformity
 Evisceration
 As for enucleation except for
intraocular tumor and risk of SO
 Exenteration
 Cutaneous tumors with
orbital invasion
 Lacrimal gland tumors
 Other orbital
malignancy
 Mucormycosis

7. …Cont
 Loss of an eye may cause degraded self image and
depression.
 The transition from binocular to monocular vision is
challenging to the pt.
02/02/2024
7

8. …Cont
 The aim of anophthalmic socket surgery:
 Maximize orbital implant volume
 Optimal eye lid contour, volume and tone
 Establish deep fornixes to retain prosthesis
 Transmit motility from implant to prosthesis
 Achieve comfort and symmetry
02/02/2024
8

9. Orbital Implants
 Ideal properties of orbital implants:
 Mimics globe
 Replaces sufficient volume
 Minimal rate of exposure, extrusion and infection
 Non antigenic, biologically inert
 Provides socket mobility transferred to prosthesis
 Light wt and simple in construction
 Completely buried and affordable
02/02/2024
9

10. …Cont
 Implants may be classified as:
Inert materials(e.g., Glass, silicone, or methylmethacrylate)
Biointegrated materials(e.g., hydroxyapatite, porous
polyethylene, Al2O3
Biogenic-e.g., Dermis-fat graft.
02/02/2024
10

11. …Cont
 Orbital implants can be also be classified as
Porous(hydroxyapatite, porous polyethylene, Al2O3) or
Nonporous(silicone, polymethylmethacrylate)
 In either category, the implants are
Non-integrated, Quasi-integrated, or Integrated
02/02/2024
11

12. …Cont
 Porous implants have rough surface.
 Wrapping is possible with autogenous fascia, cadaver
sclera/fascia, bovin pericardium, polyglactin mesh
 Polyglactin mesh associated with high exposure rate.
 Cadaver tissue: transmission of viral infections & prion
despite screening.
02/02/2024
12

13. Nonintegrated implants
 Do not allow direct/indirect integration with orbital structure
or prosthesis
 Commonly used: PMMA and silicone sphere
02/02/2024
13

14. PMMA
 Ideal material to fabricate IOL, rigid and semirigid contact
lenses.
 To manufacture both ocular prosthesis and implant.
 Its also used to manufacture majority of quasi-integrated
implants
02/02/2024
14

15. Silicone
 A suitable material due to its properties
 Episcleral implants for buckling
 Non porous silicone sphere preferred if pegging not planned
 Non porous silicone sphere also used in infants, preschool
and in age > 65
02/02/2024
15

16. …Cont
Advantages Disadvantages
 Inexpensive
 Technically easy
 Well tolerated
 Few complications
 Smooth surface
 Wrapping in sclera and
attaching EOMs to sclera
 Poor motility if not
wrapped
02/02/2024
16

17. Semi- integrated implants:
 Indirect integration with orbital structures but not with
prosthesis
 Commonly used: Allen, Iowa, Universal, Castroviejo
02/02/2024
17

18. …Cont
Advantages Disadvantages
 Inexpensive
 Good motility
 Irregular anterior surface
 Discomfort
 High rate of erosion and
extrusion
 Customised prosthesis
required to fit its shape
02/02/2024
18

19. Biointegrated:
 Allows fibrovascular ingrowth of orbital tissues for full
integration
 Usually porous: HA, polyethylene, aluminium oxide alpha
sphere
 Advantage : Can be pegged
 Disadvantage : expensive, not easily available
02/02/2024
19

20. Biogenic
 An autograft/ allograft of natural tissue with direct biological
integration with orbital structures but not with prosthesis.
 Commonly used: dermis fat graft and mucous membrane
graft
 Dermis- fat graft:
 Used after both enucleation and evisceration
 Can be used as primary or secondary implants
 Useful particularly in the presence of conjunctiva shortening
02/02/2024
20

21. HA
 Discovered by Perry in 1885.
 Porous structure and chemical nature of human cancellous
bone.
 Produced by marine corral species
 Comprising of calcium phosphate
 Fibrovascular ingrowth: reduces chance of migration and
extrusion
02/02/2024
21

22. …Cont
A B
C
02/02/2024
22

23. …Cont
Advantage Disadvantage
 Good motility
 Good structural
framework for pegging
 Brittle nature
 Different wrapping
material required
02/02/2024
23

24. Polyethylene Implants
 Polymerization of ethylene molecule
 Porous with smooth surface: 150-400 microns
 Biocompatible and allows fibro vascular ingrowth
 Not brittle and muscle can be attached without
wrapping
 Synthetic form: Medpore
02/02/2024
24

25. Aluminium Oxide Implant
 Biocompatible, bio inert, nontoxic, non allergenic, porous
 Easy insertion in to the socket and do not cling to
surrounding tissue
 Easily drilled without crumbling
 Rapid and complete fibrovascularizaton
 Light wt and low exposure rate
02/02/2024
25

26. …Cont
A
B
C
02/02/2024
26

27. Expandable Orbital Implants
 Stimulate orbital growth.
 In congenital anophthalmos/microphthalmos
 Has anterior injection portal, rectus muscle
placement groove and 4 independent expandable
quadrants.
 Promising choice
02/02/2024
27
OTE

28. Orbital Growth
 Removal of an eye in children has a unique problem.
 Orbital growth my retarded after enucleation.
 Implant size in children: 2 mm less than the volume
of enucleated eye.
 Dermis-fat graft grow with growing orbit in
children.
02/02/2024
28

29. Motility
 Attaching the EOM with implant.
 Motility peg which can be placed after 6-12 months of eye
removal.
 Pegging allows direct transmission of movement from
implant to prosthesis.
 Granuloma formation and peg instability may require peg
removal
 Polycarbonate and Titanium types
02/02/2024
29

30. Post Pegging complications:
 Increased discharge
 Recurrent pyogenic granuloma
 Implant exposure, infection
 Tissue overgrowth and clicking
02/02/2024
30

31. Orbital volume
 Adult orbital volume achieved at 12-14 years old.
 At age of 5 years 80% of adult volume achieved.
 Orbital soft tissue volume is critical for orbital bone growth.
 Larger orbital implant should be placed in children following
enucleation.
 OIs volume can be determined preop or interaop
02/02/2024
31

32. …Cont
02/02/2024
32

33. …Cont
 Insufficient volume replacement often results in
 an abnormally deep superior sulcus, upper eyelid ptosis,
&enophthalmos
 may require a larger than desirable prosthesis
 Larger prostheses often result in
 progressive lower eyelid laxity and
 have a higher exposure rate, and
 hinder fitting of an acceptable custom prosthesis
02/02/2024
33

34. …Cont
 Ideally, 70–80% of the volume of normal globe should be
replaced with the orbital implant
 In most adults,
 20–22 mm implants used following enucleation
 18–20 mm implants following evisceration.
 For pediatric age 16–18 mm, depending on the patient's age
and orbital bone development
02/02/2024
34

35. Orbital Implant Selection in Adults
 Implant cost, insurance reimbursement, marketing pressures,
age, healthy status of the pt.
 In healthy, 15-65 years old pts  porous implants
 A quasi integrated such as mounded PMMA/MEDPOR
are alternative
 Non porous, wrapped implants may be another option if
future pegging not planned.
 Non porous implants may be preferred in pts who are 7th
decade or beyond, immunocompromised, prevous hx of
radiotheraphy to periorbital structures
02/02/2024
35

36. Implant selection children
 Children <5 years of ageWrapped non porous implant,
Dermis-fat graft.
 Implant exchange with larger porous OI can be considered in
teenage years.
 Between 5-15 years of ageNon porous implants either
PMMA mounded or wrapped sphere.
 Pegged implants in age < 15 years are not generally
recommended.
02/02/2024
36

37. Orbital Implant wrapping:
 To enhance implant placement with in the soft tissue of the
socket.
 Facilitate precise fixation of rectus muscles to implant
surface.
 Materials for wrapping includes:
 Human donor sclera
 Specially processed human donor pericardium, fascia lata,
 Processed bovine pericardium
 Autologous temporalis fascia, fascia lata, rectus abdominus sheath,
posterior auricular muscle complex
 Microporous Expanded Polytetraflouroethylene
 Undyed polyglactin 910 mesh( vicryl mesh)
02/02/2024
37

38. …Cont
02/02/2024
38

39. Post Surgical Conformers
 It is used till prosthesis placed.
 Important to keep the fornices formed.
 Prevent socket contracture
 Has holes for drainage
 There are also cosmetic conformers
 Different size
02/02/2024
39

40. Ocular Prosthesis
 Its an artificial eye that replaces absent natural eye.
 Indications: anophthalomos, microophthalmia, phthisis bulbi,
disfigured blind eye.
 Can be PMMA, Silicone or acrylic
 Types: ocular or orbital
 It can be also classified as:
 Ready made
 Partially customized
 Fully customized
02/02/2024
40

41. …Cont
02/02/2024
41

42. Cosmetic Contact Lenses
 Are intended to disguise the eye with unacceptable
appearance.
 Classified as: scleral shell, soft corneoscleral CLs, rigid
corneal CLs
 Scleral shell:
 For blind eye which is shrunken or with uneven surface
 Should be worn only while awake
02/02/2024
42

43. …Cont
 Soft corneoscleral lenses:
 Made of d/t types of hydrogels
 To hide corneal scar or iris defect
 Used in normal sized with fairly regular surface
 Can be fully occlusive or can have clear pupil
 Should worn only while awake
02/02/2024
43

44. …Cont
 Rigid lenses
 Made of PMMA
 Their fabrication process and external features
are similar to definitive prosthesis
02/02/2024
44

45. Orbito-facial Prostheses
 Orbital prosthesis restores the tissues that have been
removed, including eyelids and an eye, but it does not blink or
move.
 Various methods of auxiliary retention for facial prostheses
 A prosthesis attached to an eyeglasses frame,
 To the periorbital area (with adhesive),or
 To an osseointegrated implant, which is facilitated with magnetic
posts
02/02/2024
45

46. …Cont
02/02/2024
46

47. Maintenance Of Ocular Prosthesis
 Both ocularist and ophthalmologist should follow the patient.
 Handle and remove the prosthesis as little as possible
 The pt should wash their hands before handling the
prosthesis
 Monthly removal and cleaning
 Polishing yearly and replacement every 5 years
 Ocular lubricants in dry socket
02/02/2024
47

48. Anophthalmic Socket Complications
Deep Superior Sulcus
 Caused by insufficient orbital volume
 Management includes:
 Placement of subperiosteal secondary implant
along orbital floor
 Replacement of original implant with larger one
 Modification of ocular prosthesis
 DFG
02/02/2024
48

49. Giant Fornix Syndrome
 Superior conjunctival fonix may be too deep  build up of
mucous and debris  chronic discharge and infection.
 Management: conjunctival resection
Conjunctival Cyst
 Due to epithelial migration beneath the surface.
 Poor wound closure during enucleation
 Treatment not usually required unless it interferes with
prosthesis wear
02/02/2024
49

50. Giant Papillary Conjunctivitis
 Due to mechanical friction b/n palpebral conjunctiva and the
prosthesis.
 Presented with constant mucous discharge with stringy
consistency.
 Treatment:
 Topical steroids
 Occasionally prosthesis modification
02/02/2024
50

51. Implant Exposure and Extrusion
 Formation of pyogenic granuloma is indicative of implant
exposure.
 Exposure may due to:
Post op infection
Poor wound healing
Poorly fitting prosthesis or conformer
Pressure points b/n implant and prosthesis
Compromised vascularity
02/02/2024
51

52. …Cont
 Exposed implants are subject to infection.
 Management:
 Cover the exposure with scleral patch graft or autoginous dermis- fat
graft
 Deeply seeded implants with infection  removal of the implant
followed by dermis-fat graft
02/02/2024
52

53. Contracture of the Fornices
 Preventing contracted fornices includes:
 Preserve as much conjunctiva as possible
 Limiting dissection in the fornices
 Placing rectus muscles in normal anatomic position
 Wearing conformer in immidiate post op period
02/02/2024
53

54. Contracted Socket
 Sockets are considered contracted when the fornices are too
small to retain the prosthesis.
 Its caused by:
Radiation therapy for malignancy
Extrusion of orbital implants
Severe initial injury ( alkali burns, extensive laceration )
Poor surgical technique
Multiple ocular or socket oprations
Removal of conformer or prosthesis for prolonged period
02/02/2024
54

55. Grading of Socket Contracture
 Grade 1:
 Minimal or no actual contracture
 Inability to retain prosthesis for long time
 Horizontal lid laxity
 Retraction of lower fornix
02/02/2024
55

56. …Cont
 Grade 2:
 Mild contracture of upper and/lower fornices
 Inability to wear the prosthesis
 Pt complain disfigurement
02/02/2024
56

57. …Cont
Grade 3:
 more advanced scarring than grade 2
 cicatrization involves upper and lower fornices
 wearing prosthesis is impossible
Grade 4:
 severe phimosis of palpebral fissure both vertically and
horizontally.
 recurrent cases and irradiated sockets
02/02/2024
57

58. …Cont
Management
 Minimal/mild contracture: Z-plasy/local conjunctival flap,
horizontal lid laxity thightening, graft
 Modrate contracture: split thickness mucosal or full thickness
conjunctival autograft, AMG
 Contracture with volume loss: DFG
 Severe contracture: extermely difficult to repair, space
occupying alloplastic materials ( silicone, polyethylene )
02/02/2024
58

59. Anophthalmic Ectropion
 May result from loosening lower lid support
 Frequent removal or the use of larger prosthesis
 Treatment:
Tightening of lateral or medial canthal tendon
 Ectropion repair + deepening of inferior fornix by
recessing the inferior retractor muscle and mucous
membrane grafting
02/02/2024
59

60. Anophthalmic Ptosis
 Can be caused by:
Suprotemporal migration of sphere implant
Cicatricial tissue in upper fornix
Damage to levator muscle or nerve
02/02/2024
60

61. …Cont
 Management:
 Small ptosis  prosthesis modification, Muller muscle-
conjunctiva resection
 Greater amount  levator aponeurosis advancement
 Frontalis suspension  less/ not useful at all
02/02/2024
61

62. Lash Margin Entropion
 Lash margin entropion, trichiasis and ptosis of lashes are
common.
 Caused by: fornix contracture, cicatricial tissue near the lash
margin
 Treatment:
 Horizontal tarsal incision and rotation
 Splitting of eyelid margin at gray line with mucous
membrane graft in severe cases
02/02/2024
62

63. Summary
 The three ways of eye removal and their indication.
 The classifications of orbital implants.
 The advent of porous OIs has greatly advanced the field of
anophthalmic surgery.
 OIs are available in spherical, mounded, egg, and conical
shape
 Implant selection depends on several factors: age, medical hx,
cost, availability, and surgeons preference.
 Orbital implants Conformer  Ocular prosthesis
02/02/2024
63

64. …Cont
 Pts younger than 5 years of age typically receive non porous
implant and require exchange later in life.
 Older paediatric pts may do well with porous implants.
 Wrapping facilitates implant insertion and rectus muscle
attachment to the implant.
 Polyglactin 910 ( vicryl mesh ) is simple to use, readily
available, permit early fibrovascularization.
 Porous implants can be coupled with overlying prosthesis
with pegging system.
 Anophthalmic surgery complications and management.
 Use plastic protective eye glass for the other eye.
02/02/2024
64

65. References
 Essential in Ophthalmology, Oculoplastic and Orbit, R.F.
Guttaf and J.A Katowitz
 American Academy of Ophthalmology, Oculofacial plastic
and Orbital Surgery, 2020-21
 Kanski Clinical Ophthalmology- Systematic-Aproach-9th ed
 Review Orbital Implants and Prosthesis-Acta Biomater, 2014
 Smith and Nese’s Plastic and Reconstructive Surgery, 4th ed
02/02/2024
65

66. THANK YOU !
02/02/2024
66