Ocular rehabilitation following socket reconstruction with amniotic ...

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There are several clinical situations that require enucleation in children, with retinoblastoma being the most common. Intra-orbital implants are routinely placed ...
Contact Lens & Anterior Eye 38 (2015) 64–69

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Case report

Ocular rehabilitation following socket reconstruction with amniotic membrane transplantation with failed primary hydroxyapatite implant post enucleation Himanshi Aggarwal ∗ , Pradeep Kumar, Raghuwar Dayal Singh, Pooran Chand, Habib A. Alvi Department of Prosthodontics, Faculty of Dental Sciences, King George’s Medical University UP, Lucknow, Uttar Pradesh, India

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Article history: Received 8 May 2014 Received in revised form 28 August 2014 Accepted 11 September 2014 Keywords: Anophthalmic socket reconstruction Enucleation Intra-orbital implant Ocular prosthesis

a b s t r a c t There are several clinical situations that require enucleation in children, with retinoblastoma being the most common. Intra-orbital implants are routinely placed in children at the time of initial surgery to provide motility and cosmesis in addition to adequate orbital volume. Current practice employs intraorbital implants made of nonporous silicone, hydroxyapatite, or porous polyethylene. Complications are usually minimal with these implants but they do occur. The purpose of this clinical report is to describe the rehabilitation of a pediatric patient with failed primary intra-orbital coralline hydroxyapatite implant post enucleation, who was successfully fitted with custom ocular prosthesis following secondary socket reconstruction with amniotic membrane transplantation after removal of infected implant. © 2014 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

1. Introduction Removal of an eye for treatment of ocular disease was first described by Bartisch in 1583 [1]. The modern form of this operation was introduced in 1841 by Farrell and Bonnet, and in 1885, Mules placed the first intra-orbital implant after evisceration. A year later, Frost described the utility of intra-orbital implant placement after enucleation surgery. Enucleation in a child may result in retarded orbital growth [2]. So following enucleation, primary reconstruction of the socket is usually done with intra-orbital implants so that the potential for contracture and volume deficit is reduced and the best cosmetic results are achieved in addition to stimulation of orbital growth [3,4]. Various intra-orbital implant configurations are available. Different materials may be used to create intra-orbital implants, including cartilage, bone, fat, cork, rubber, gold, silver, silk, wool, aluminum, ivory, petroleum jelly, acrylics, silicone, quartz, glass, titanium, and porous materials such as polyethylene and hydroxyapatite (HA) [1]. Current practice employs intra-orbital implants made of nonporous silicone, hydroxyapatite, or porous polyethylene. The intact extraocular muscles are attached either to the implant or to the wrapping material placed around the implant.

∗ Corresponding author at: Room No. 404, E Block, Gautam Buddha Hostel, KGMU, Lucknow, India. Tel.: +91 9369610205. E-mail address: [email protected] (H. Aggarwal).

The normal innervations of the muscles move the artificial eye in coordination with the healthy eye so that some degree of normal motility is preserved [3]. Hydroxyapatite, a porous material derived from reef-building coral of genus Porites, was introduced as a buried intra-orbital implant by Dr. Arthur Perry in 1985 [5–7]. The major advantage of this implant is its superior biocompatibility and proclivity to become fibrovascularly integrated with the residual muscles and orbital tissues [6,8,9]. One major disadvantage of hydroxyapatite is that the implant must be covered with wrapping material such as donor sclera or donor or autogenous fascia lata because direct suturing to the hydroxyapatite is not possible [10]. Theoretically, the integration of the implant into host orbital tissues reduces the risk of migration, extrusion, and infection in the post-surgical period [11]. However, hydroxyapatite being an alloplastic intraorbital implant may be associated with potential complications, including exposure, infection and extrusion [1,12,13]. Spontaneous healing of exposed porous implants is relatively uncommon. So, many exposed porous implants are salvaged with secondary repair with patch grafts. However, cases unamenable to conservative management require may implant removal [14]. Following implant removal, a stable socket with adequate forniceal depth must be established by increasing the surface area with the use of grafts [15]. The purpose of this clinical report is to describe the rehabilitation of a pediatric patient with failed primary intraorbital coralline hydroxyapatite implant post enucleation, who was

http://dx.doi.org/10.1016/j.clae.2014.09.003 1367-0484/© 2014 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.

H. Aggarwal et al. / Contact Lens & Anterior Eye 38 (2015) 64–69

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Fig. 1. Pre-operative view showing exposed and medially displaced hydroxyapatite implant in left eye socket.

successfully fitted with custom ocular prosthesis following socket reconstruction with amniotic membrane transplantation (AMT) [16–20] after removal of infected implant. 2. Clinical report A 3 year-old child with an acquired left ocular defect was referred for the fabrication of an ocular prosthesis. The history revealed that she had been diagnosed with intraocular retinoblastoma of the left eye 6 months back. Enucleation of the left eye with primary intraorbital hydroxyapatite implant placement was performed 2 months back. Post-enucleation adjunctive chemotherapy with six cycles of vincristine, etoposide and carboplatin was also administered. As the optic nerve was not invaded by the malignancy, so radiotherapy was not given. 3. Clinical examination Examination of the defect area revealed enucleated socket with exposed and medially displaced hydroxyapatite implant along with mucus discharge collection in the inferior fornix (Fig. 1). The patient also reported mild discomfort and pain associated with left ocular socket. The computed tomographic scan findings correlated with the clinical findings (Fig. 2). The patient’s condition precluded

Fig. 2. Computed tomographic scan showing intra-orbital implant in left eye socket.

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the fabrication of an acceptable ocular prosthesis. So, the patient was referred to ophthalmology for management of infected and exposed intra-orbital implant. Initially, the patient was treated conservatively with topical antibiotics and steroid for 6 weeks. But, there was no improvement. So, it was established that the condition was not amenable to conservative therapy, thereby mandating surgical intervention. 4. Pre-prosthetic surgical procedure The procedure including the limitations was explained in detail to the patient/parents and an informed consent was also taken for the surgery and also for making photographic records. It was planned to perform patch grafting with donor sclera to cover the exposed implant area. But unfortunately, this minimally invasive surgical procedure also failed, thereby, leaving no options other than either secondary implant exchange surgery or removal of

implant followed by socket reconstruction with amniotic membrane transplantation (AMT). The patient’s parents refused for secondary implant exchange surgery, probably due to the past experience of implant failure. So, it was planned to reconstruct the socket with amniotic membrane transplantation following removal of exposed and infected hydroxyapatite implant. Amniotic membrane was obtained under sterile conditions after an elective cesarean from a seronegative (for HBV, HCV, HIV, syphilis) donor by the procedure described by Kumar et al. [16]. The amniotic membrane was manually separated from underlying placental tissue and rinsed in 0.9% normal saline to wash away blood and then in 0.25% sodium hypochlorite. It was then cut into pieces measuring 5 × 5 cm and stored in normal saline containing 50,000 U of penicillin and 1 g of streptomycin per 400 mL of saline at a temperature of +4 ◦ C not exceeding a period of one week. At the time of surgery, the amnion was dissected bluntly from the chorion and washed in normal saline. This prepared

Fig. 3. Stock conformer in surgically reconstructed socket.

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Fig. 4. Socket reconstructed with amniotic membrane transplantation.

amniotic membrane was spread on the surface of the socket with its epithelial side up and sutured to the underlying tissue with 8-0 vicryl after removal of hydroxyapatite implant. Following surgery, an appropriate size stock conformer with multiple perforations was placed in the socket to prevent the contracture, preserve the fornices and to allow drainage (Fig. 3). It was left in the socket until 6 weeks postoperative period for healing to take place. The socket was cleaned gently after taking out the conformer at postoperative week 1 and 3. This was done by irrigating the socket with normal saline with the help of 10 mL syringe. The conformer was replaced in the socket after instillation of topical ciprofloxacin drops. After 6 weeks (Fig. 4), the patient was fitted with a new, custom-made ocular prosthesis (Fig. 5). 5. Prosthetic procedure The procedure was initiated by using the patient’s stock conformer as an impression tray to which a needle-less syringe was attached to serve as a handle. Then an intermediate mixture of

ophthalmic grade alginate (Opthalmicmoldite, Milton Roy Co.) was loaded into the syringe and injected into the socket to make its impression. The wax pattern (Metrodent, Metro International Corp., Delhi, India) was made on the cast obtained after pouring the impression and it was adjusted in the patient’s eye socket. Finally the iris, matching in size and color of the contralateral eye [21,22], was obtained from a stock eye and positioned carefully on the wax pattern. A trial was done and required corrections made. This was invested, dewaxed and processed in heat-cured PMMA resin (Trevalon). The finished and polished prosthesis was disinfected and lubricated to maintain a tear film over the prosthesis. Minor adjustments were made at the time of delivery, as per the patient’s comfort and esthetics. Instructions regarding the proper care, handling of the prosthesis and use of ancillary products such as lubricants and cleansers were given. The patient was put on a regular 3-month follow up regime. At 1 year postoperatively, the patient was able to wear an acceptable ocular prosthesis without any complications. Patient’s parents also reported improvement in quality of life as a result of

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Fig. 5. Post-prosthetic rehabilitation view after 6 months.

this esthetic remedy [23,24]. Thus, the patient was successfully rehabilitated by combining socket reconstruction surgery with amniotic membrane transplantation following removal of failed intra-orbital coralline hydroxyapatite implant post enucleation and custom ocular prosthesis. 6. Discussion Intra-orbital implants have been used for more than a century. An ideal intra-orbital implant should yield excellent motility and cosmesis with few complications. Many authors have suggested that an implant that is completely buried will minimize migration and extrusion [1]. Attachment of the extraocular rectus muscles to the implant results in improved motility and cosmesis. The microporous HA implant fulfills these criteria and, therefore, has come into popular use. Complications are minimal with these implants with the reported exposure rates ranging from 0% to 22% [1]. Kim and colleagues demonstrated that, with HA implants, small areas of

exposure (