Letters to the Editor Management of Porous Orbital Implants Requiring Explantation: A Clinical and Histopathological Study To the Editor: To our surprise, Quaranta-Leoni et al.,1 evaluating patients with exposed porous orbital implants, do not mention acrylic implants for replacing orbital volume after enucleation or evisceration at all, as if these implants do not exist. Since the introduction of porous implants in 1985, most oculoplastic surgeons appear to have forgotten the acrylic implant, although till now no one has ever demonstrated the superiority of porous implants without pegs. Few surgeons still use pegs, because of the frequent complications associated with these pegs. So is it not time for a reevaluation of the acrylic ball? It has been demonstrated that the motility of acrylic implants is equal to that of porous implants as long as no peg is inserted.2,3 Most patients are satisfied with the cosmetic outcome of the nonpegged implant and do not desire an additional procedure4 with increased risks for complications.5 In our 22 years of personal experience with enucleation for retinoblastoma, not the easiest group of patients receiving implants (think of chemotherapy and/or external beam radiation therapy in growing children), we have found a lower extrusion rate after acrylic ball implantation compared with that of hydroxyapatite implants. Furthermore, if explantation is required, acrylic implants are much easier to be removed. Until there is a proof that expensive porous implants are superior to inexpensive acrylic balls,6 we call for a return to the simple, easy to handle acrylic ball. We are very much interested in your opinion.
Daphne L. Mourits, M.D. Dyonne T. Hartong, M.D., Ph.D. Annette C. Moll, M.D., Ph.D. Maarten P. Mourits, M.D., Ph.D. Correspondence: Daphne L. Mourits, M.D., Department of Ophthalmology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands (D.mourits@ vumc.nl) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Quaranta-Leoni FM, Moretti C, Sposato S, et al. Management of porous orbital implants requiring explantation: a clinical and histopathological study. Ophthal Plast Reconstr Surg 2014;30:132–6. 2. Colen TP, Paridaens DA, Lemij HG, et al. Comparison of artificial eye amplitudes with acrylic and hydroxyapatite spherical enucleation implants. Ophthalmology 2000;107:1889–94. 3. Custer PL, Trinkaus KM, Fornoff J. Comparative motility of hydroxyapatite and alloplastic enucleation implants. Ophthalmology 1999;106:513–6. 4. Shields CL, Shields JA, De Potter P, et al. Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases. Br J Ophthalmol 1994;78:702–6. 5. Jordan DR, Chan S, Mawn L, et al. Complications associated with pegging hydroxyapatite orbital implants. Ophthalmology 1999;106:505–12. 6. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
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Reply re: “Management of Porous Orbital Implants Requiring Explantation: A Clinical and Histopathological Study” To the Editor: We quite agree with Dr. Mourits’s observation: in our experience and in the literature, long-term results may be satisfactory using a great variety of implant materials and surgical techniques.1 No choice of materials or surgical technique can guarantee a successful outcome, and there are reports in the literature suggesting that there are few advantages to the use of porous implants, compared to nonporous implants, when these implants are properly placed in the orbit following evisceration or enucleation.1,2 The cost of mesh-covered porous implants is higher if compared with solid polymethyl methacrylate or silicone spheres, and in most European countries, cost–benefit analysis is becoming an increasingly important consideration in the selection of care options.1,3 However, the choice of the primary implant was not the issue of our paper. The aim of our study was to examine the clinical outcome of patients with exposed porous orbital implants where we selected to perform explant surgery followed by simultaneous replacement with an autologous dermis-fat graft.4 In all the 25 patients described, primary surgery (enucleation or evisceration) had been performed elsewhere by a number of different surgeons. We did not choose the type of the primary implant, and the patients were referred to our orbital clinic for explant surgery and socket reconstruction (see Methods). Microbiology showed the presence of infection in 59% of patients submitted to explantation, and histology showed the presence of a long-term inflammatory infiltrate in 88% of the examined implants. For these reasons, we thought that a dermis-fat graft was a suitable option to address the volume and lining deficit following explantation.4 In any case, tissue ingrowth inside porous orbital implants may offer some advantages, and better blood support may help to reduce the risk of migration of the implant, which is a common problem with implants such as polymethyl methacrylate or silicone.1,2,5 We have recently described a series of patients who underwent secondary ball implantation with porous implants wrapped with a polyglactin mesh after enucleation or evisceration, and we showed that implant stability can be achieved for long term.6 A reliable surgical technique may be the most important factor in predicting implant stability and a low complication rate.6,7 Dermis-fat graft is a suitable option to address the volume deficit following explantation of exposed implants at the same time of implant removal4 or following removal of hydrogel orbital expanders,8 but of course morbidity is higher.9
Francesco M. Quaranta-Leoni, M.D. Correspondence: Francesco M. Quaranta-Leoni, M.D., Oftalmoplastica Roma, Via Archimede 201, 00197 Roma, Italy ([email protected])
REFERENCES 1. Quaranta-Leoni FM. Treatment of the anophthalmic socket. Curr Opin Ophthalmol 2008;19:422–7. 2. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
Daphne L. Mourits, M.D. Dyonne T. Hartong, M.D., Ph.D. Annette C. Moll, M.D., Ph.D. Maarten P. Mourits, M.D., Ph.D. Correspondence: Daphne L. Mourits, M.D., Department of Ophthalmology, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands (D.mourits@ vumc.nl) The authors have no financial or conflicts of interest to disclose.
REFERENCES 1. Quaranta-Leoni FM, Moretti C, Sposato S, et al. Management of porous orbital implants requiring explantation: a clinical and histopathological study. Ophthal Plast Reconstr Surg 2014;30:132–6. 2. Colen TP, Paridaens DA, Lemij HG, et al. Comparison of artificial eye amplitudes with acrylic and hydroxyapatite spherical enucleation implants. Ophthalmology 2000;107:1889–94. 3. Custer PL, Trinkaus KM, Fornoff J. Comparative motility of hydroxyapatite and alloplastic enucleation implants. Ophthalmology 1999;106:513–6. 4. Shields CL, Shields JA, De Potter P, et al. Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases. Br J Ophthalmol 1994;78:702–6. 5. Jordan DR, Chan S, Mawn L, et al. Complications associated with pegging hydroxyapatite orbital implants. Ophthalmology 1999;106:505–12. 6. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
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Reply re: “Management of Porous Orbital Implants Requiring Explantation: A Clinical and Histopathological Study” To the Editor: We quite agree with Dr. Mourits’s observation: in our experience and in the literature, long-term results may be satisfactory using a great variety of implant materials and surgical techniques.1 No choice of materials or surgical technique can guarantee a successful outcome, and there are reports in the literature suggesting that there are few advantages to the use of porous implants, compared to nonporous implants, when these implants are properly placed in the orbit following evisceration or enucleation.1,2 The cost of mesh-covered porous implants is higher if compared with solid polymethyl methacrylate or silicone spheres, and in most European countries, cost–benefit analysis is becoming an increasingly important consideration in the selection of care options.1,3 However, the choice of the primary implant was not the issue of our paper. The aim of our study was to examine the clinical outcome of patients with exposed porous orbital implants where we selected to perform explant surgery followed by simultaneous replacement with an autologous dermis-fat graft.4 In all the 25 patients described, primary surgery (enucleation or evisceration) had been performed elsewhere by a number of different surgeons. We did not choose the type of the primary implant, and the patients were referred to our orbital clinic for explant surgery and socket reconstruction (see Methods). Microbiology showed the presence of infection in 59% of patients submitted to explantation, and histology showed the presence of a long-term inflammatory infiltrate in 88% of the examined implants. For these reasons, we thought that a dermis-fat graft was a suitable option to address the volume and lining deficit following explantation.4 In any case, tissue ingrowth inside porous orbital implants may offer some advantages, and better blood support may help to reduce the risk of migration of the implant, which is a common problem with implants such as polymethyl methacrylate or silicone.1,2,5 We have recently described a series of patients who underwent secondary ball implantation with porous implants wrapped with a polyglactin mesh after enucleation or evisceration, and we showed that implant stability can be achieved for long term.6 A reliable surgical technique may be the most important factor in predicting implant stability and a low complication rate.6,7 Dermis-fat graft is a suitable option to address the volume deficit following explantation of exposed implants at the same time of implant removal4 or following removal of hydrogel orbital expanders,8 but of course morbidity is higher.9
Francesco M. Quaranta-Leoni, M.D. Correspondence: Francesco M. Quaranta-Leoni, M.D., Oftalmoplastica Roma, Via Archimede 201, 00197 Roma, Italy ([email protected])
REFERENCES 1. Quaranta-Leoni FM. Treatment of the anophthalmic socket. Curr Opin Ophthalmol 2008;19:422–7. 2. Custer PL, Kennedy RH, Woog JJ, et al. Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 2003;110:2054–61.
Ophthal Plast Reconstr Surg, Vol. 30, No. 6, 2014
