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Purpose To investigate whether impaired lacrimal pump function is a possible cause of discharge in patients wearing an artificial eye compared with the remaining healthy eye. Methods Consecutive patients wearing unilateral ocular prosthesis for ≥6 months were included in this retrospective study. Excluded were any deformities of eyelids or nasal passage, socket complications such as entropion, ectropion, ptosis, infection, pyogenic granuloma, contracted socket, obstruction of nasolacrimal duct diagnosed with lacrimal irrigation and a difference greater than 2 mm in terms of protrusion between two eyes detected by Hertel exophthalmometry. Patients were asked to score the levels of tearing and mucopurulent discharge between 0 and 5 to assess lacrimal drainage function subjectively. Furthermore, dacryoscintigraphy was performed to assess the functional status of the lacrimal system objectively. Results Included were 32 subjects (12 females, 20 males; aged 32.94 ± 17.62, range 13-78). Mean duration of prosthetic wearing 26.41 ± 21.30 (6-72) months. The mean subjective scores of tearing and mucopurulent discharge were 1.56 ± 1.67 and 1.94 ± 1.63, respectively. The rate of functional stenosis was significantly higher in the anophthalmic socket side as compared to the healthy side (P = 0.002). The rates of a presac, preduct, and intraduct obstruction was notes as n = 9, n = 10, n = 1 and n = 0, n = 6, n = 2 in the anophthalmic side and the companion eye, respectively (P = 0.021). Conclusion Compared to paired healthy eyes, the ocular prosthesis exhibited significantly higher rates of functional lacrimal duct obstruction, especially at the presac level. The alterations in orbital volume and tear film composition in addition to reduced corneal reflex blinking may lead to the failure of lacrimal pump function in artificial eyes.

AIM To determine whether evisceration with optic nerve disinsertion and nonporous implant placement increases the risk of implant migration. METHODS This was a single-center, retrospective consecutive comparative interventional case series including patients undergoing evisceration with nonporous implant between January and December 2014. Patients were grouped into 2 groups: group I where the optic nerve was not disinserted (n = 37) and group II with optic nerve disinsertion (n = 50). Implant migration was assessed clinically and on patient photographs. Migration was subclassified as decentration that did not affect the prosthetic outcome and displacement that affected the prosthetic outcome. The secondary outcome measures were the mean implant diameter, volume of the custom ocular prosthesis, and implant-related complications like exposure and extrusion between the 2 groups. RESULTS At a mean follow up of 12.5 months, none of the sockets in group I and 3 (6%) sockets in group II (p = 0.35) had evidence of implant decentration. There were no cases of implant displacement in both groups. The mean implant diameter in group I was 16.97 mm ± 0.65 mm and in group II 19.2 mm ± 0.83 mm (p = 0.0001). Implant extrusion was not different between the 2 groups. The mean custom ocular prosthesis volume in group I was 3.86 ml ± 0.52 ml and in group II 2.50 ml ± 0.68 ml (p < 0.0001). CONCLUSIONS The rate of nonporous implant migration due to optic nerve disinsertion is not statistically or clinically significant in evisceration with optic nerve disinsertion, allowing placement of a larger implant and fabrication of a custom ocular prosthesis with an ideal weight.

Buphthalmos can create treatment challenges for socket rehabilitation following enucleation due to compression atrophy and mechanical stretching of adnexal tissues. The authors report a case demonstrating a surgical technique for simultaneous volume augmentation of the anophthalmic socket, expansion of the conjunctival fornix, and repair of lower eyelid retraction in a patient with history of buphthalmos and a previously placed 22 mm orbital implant at the time of enucleation. The authors utilized a single-stage, bipedicle dermis fat graft. Postoperatively, the patient demonstrated improvement in lower eyelid position, lower eyelid volume, improved prosthesis fit, improved three-dimensional projection of the ocular prosthesis, and an improvement in the superior sulcus deformity. Bipedicle dermis fat grafts are an option for surgical rehabilitation of the anophthalmic socket when orbital volume deficiency, conjunctival fornix contracture, and eyelid retraction are present and an adequately sized orbital implant has previously been placed.

Aim Ocular prostheses are integral for anophthalmic patients. Part 1 of this study reported that patients' aetiology, opinions, and attitudes significantly affected their prosthetic eyes experience. Part 2 investigates the patient satisfaction and acceptance in light of some of the aetiological demographics reported in Part 1. Methodology One hundred sixty questionnaires were delivered to anophthalmic patients attending oculoplastic clinic. Etiological aspects presented in the questionnaire were disseminated in part 1. Patient satisfaction was assessed through 8 closed-end statements reflecting aspects concerning patient's views on prosthesis comfort and appearance; patient's expectations, self-esteem, and perception; and cooperation with ocularist. Each statement had 3 categories as agree, moderately agree, and disagree. A total of 126 questionnaires were returned (response rate was 78.8%). Data was analyzed using SPSS software. Association coefficients and correlations between variables were also analyzed. Results Total number of responses for the 8 statements was 888, averaging of 111 (expected 126) respondent per statement. Overall, 95.4% of our patients agreed with all satisfaction statements presented echoing very high satisfaction rate with their ocular prosthetics. Having an eye replacement that covers the defect is associated with high satisfaction among patients regardless of ocular prosthetic type. Patient acceptance of prosthesis in relation to employment status was high but not the same among the different categories (P > 0.05). High satisfaction with ocular prosthetics was prevalent among both genders, but there were no statistically significant differences in percentages of agreement in all statements (P > 0.05). Satisfaction and acceptance with ocular prosthetics was the same among all age groups of 12 to 85 years old (P > 0.05). Conclusions The patient satisfaction is associated with the interplay of different variables that is related to ocular prosthesis design and its ability to disguise disfigurement (ie, prosthesis shape, resemblance to existing contra-lateral eye, etc.); patients themselves (ie, gender, age, occupation, marital status, etc); and psychological well-being and social support provided. Anophthalmic patients of the north west of England are significantly happy with their ocular prosthetic rehabilitation and support they receive from their regional hospital. Ocular prosthetics enhances their psychological well-being and social interaction and factors like patients' sex, age, employment status, and type of ocular prosthesis have no effect on their acceptance and satisfaction.

Eye defects can lead to emotional, psychological, and social changes, impacting negatively the quality of life of the patient. When these structures cannot be satisfactorily repaired by reconstructive surgery, the prosthetic rehabilitation is the better treatment option to restore lost ocular anatomy and promote the social integration of the individual. The aim of this clinical report is to report and discuss a case of ocular prosthesis confection eviscerated patient with opening limitation eyelid and shortening of the distance between palpebral commissure, to obtain a more natural and comfortable to the patient ocular rehabilitation.

Microphthalmia is defined by a globe axial length greater than or equal to 2 standard deviations below the age-adjusted mean and can occur as part of a broader syndrome. The presence of a colobomatous cyst with microphthalmia signifies failure of the embryonic neuroectodermal fissure to close appropriately during development of the globe, creating a protuberant globular appendage that inhibits normal growth and development of the eye itself. Cystic reaccumulation of fluid is common after aspiration or surgical removal. Here, the authors describe a case of a young boy with a colobomatous cyst who underwent eyelid-sparing orbital exenteration followed by reconstruction with absorbable gelatin sponge (Gelfoam, Pfizer, Inc.) and the chemotherapeutic agent bleomycin to promote scarring, achieving the equivalent of a biointegrated implant and facilitating satisfactory placement of an ocular prosthesis. A 2-year follow-up MRI revealed adequate volume in the posterior orbit.

The ocular prosthesis is a modality of facial prosthesis that acts on the repair of loss or deformity of the ocular globe. Prosthetic rehabilitations destined to anophthalmic cavities that suffered cicatricial retraction represent a challenge during fabrication since they often need to be reduced due to atrophic of the cavity and simultaneously need to have a good esthetic appearance regarding the contour and artificial iris. This clinical report describes the ocular prosthetic rehabilitation of a 77-year-old man with anophthalmic atrophic cavity due to herpes zoster-induced loss. The treatment focused on comfort and adaptation during use, on satisfactory retention and esthetic appearance, and on care to achieve total eye closure while wearing the ocular prosthesis. This article shows an unusual prosthetic rehabilitation of atrophic anophthalmic cavity with 6 months of follow-up.

Sino-orbital fistulas can occur after orbital exenteration. Chronic nonhealing fistulas lead to bothersome symptoms including malodorous discharge, hypernasal speech, crusting, wound breakdown, or inability to wear an ocular prosthesis. Reconstruction can be difficult due to the complexity of the defects and the multitude of treatments patients often undergo for the management of the primary disease. Prior radiation, lack of available local tissue, or compromised blood supply are some of the issues that make successful fistula closure problematic. This report describes a method for autologous vascularized tissue coverage using a contralateral nasoseptal flap to successfully close a sino-orbital fistula.

PURPOSE To develop a standardized and universally reproducible grading scale for artistic outcome of a custom ocular prosthesis. METHODS A retrospective review of photographs of patients with custom ocular prosthesis. From the ocularistry database of a tertiary eye care hospital, photographs of patients with custom ocular prosthesis (30 random photos with additional 18 repetitions, total n = 50) were selected. Two independent oculoplastic surgeons, on the basis of characteristics of limbus, vascularity, and pigmentation, graded these photos. The photos were adjusted for confounders like magnification and illumination, and both graders used the same display system. The surgeons were blinded to each other. The characteristics were graded on a scale of 0 to 2 and total score was calculated for each photo. Inter-observer and intra-observer agreement was calculated using the kappa statistic. RESULTS The inter-observer kappa coefficient for the three characteristics (95% confidence interval) were as follows: limbus 0.7 (0.55-0.85), vascularity 0.76 (0.58-0.94), and pigmentation 0.6 (0.34-0.85). The intra-observer kappa coefficient for the first surgeon was as follows: limbus 0.88 (0.7-0.95), vascularity 0.88 (0.73-0.95), and pigmentation 0.82 (0.54-0.93). The intra-observer kappa coefficient for the second surgeon was as follows: limbus 0.8 (0.44-0.93), vascularity 0.55 (0.13-0.8), and pigmentation 0.76 (0.6-0.84). CONCLUSIONS A good intra- and inter-observer agreement was demonstrated. In view of no existing grading for prosthesis, this is a unique system to objectively grade the outcome of custom ocular prosthesis and can be incorporated in ocularistry teaching modules for standardization of outcomes.

Purpose To determine the effect of ptosis on compensatory frontalis contraction in patients without visual input and to identify if a sensory stimulus contributes to brow elevation. Methods A prospective study. Clinical photographs were measured by 2 masked oculoplastic surgeons to determine brow height in 8 patients with unilateral ocular prosthesis in 3 conditions: at baseline, after a gold weight was applied to the upper eyelid inducing acute ptosis, and with the gold weight plus topical anesthetic. The measured brow height was then compared between the 3 scenarios. Results Mean brow height increased after application of the gold weight when compared with baseline, and this difference reached significance (p = 0.012). After topical anesthetic was applied, the mean brow height decreased but not back to baseline. When mean brow height during the gold weight with topical anesthesia was compared with baseline and with the gold weight only scenarios, the difference was not significant (p > 0.05). Conclusions Frontalis contraction is observed when acute ptosis is simulated in anophthalmic patients, confirming that a contracted visual field cannot be the only stimulus for compensatory brow elevation. A sensory or proprioceptive mechanism is suggested but not confirmed by the trend of reduction in brow elevation with topical anesthesia.

We present a case of an unexpected focally increased radiotracer uptake in an artificial eye in an FDG-PET/CT scan that was performed on a woman with a history of choroidal melanoma. It is crucial to know the type of prosthesis used and the timing of replacement for a correct interpretation of the findings. Recently, an FDG PET/CT was proposed to monitor the vascularity of the prosthesis instead of gadolinium MRI or of Tc bone scintigraphy.

A 55-year-old man presented with progressive "enophthalmos" of his ocular prosthesis, 12 years after secondary orbital implant placement following evisceration of a severe traumatic globe rupture. The medial orbital wall was found to be displaced inwards, associated with ethmoid sinus opacification, and consistent with post traumatic silent sinus syndrome affecting the ethmoid paranasal sinuses. The authors present the clinical and radiological findings, review the literature on silent sinus syndrome of nonmaxillary sinuses, and discuss the possible mechanisms for his presentation.

PURPOSE In daily practice, it is often encountered that family and friends prefer the true image of the patient with an ocular prosthesis to the image in the mirror. Hence, when the patient looks at himself in the mirror, he may have the worst image of self. The authors studied the subjective difference between the mirror and true image of patients with an ocular prosthesis. METHODS Controlled, prospective case series, including 16 patients with an ocular prosthesis and 16 healthy volunteers. The authors designed a double-mirror device that allowed the participant to see both his mirror and unreversed true image and asked the participants which image they preferred. In a slide show with pairs of the original and mirror-reversed photographs of the participants, they were asked which of the 2 photographs of each pair they preferred, of themselves and of the other participants. RESULTS Of the patients, 100% preferred their mirror image and 79% their mirror-reversed photograph. Of the volunteers, these preferences were 81% and 60%, respectively. The volunteers significantly preferred the photograph of the patients with the ocular prosthesis on their left side. CONCLUSIONS The patient with an ocular prosthesis prefers his mirror image. While judging unfamiliar faces, the right eye is considered to be more important in the case of abnormality.

PURPOSE To describe the clinical features and management of extensive ocular surface squamous neoplasia (OSSN) (squamous cell carcinoma) of the socket. METHODS Retrospective interventional case series. Interferon α 2b (IFNa2b) eye drops (1 million units/cc) 4 times daily and IFNa2b sublesional injection (5 million units/0.5cc to 8 million units/0.8 cc) were delivered for tumor control. Participants were 3 patients with ocular prosthesis who developed extensive socket OSSN. Tumor control was graded as complete regression, partial regression, or no regression. RESULTS OSSN was detected in the socket at age 60, 43, and 20 years in patients who had worn ophthalmic prostheses for 54, 26, and 13 years, respectively. The patients had chronic discharge and irritation (n = 3) managed with intermittent topical corticosteroids (n = 2). There were no predisposing factors of cigarette exposure, radiation exposure, eczema, systemic immune suppression, or organ transplantation. The prosthesis fit well with nonirritative edges. At presentation, OSSN was subtle (n = 3), vascular (n = 3), and multifocal (n = 3), with largest lesions or confluence of lesions measuring 20, 25, and 20 mm, respectively. The tumors involved the tarsal (n = 3), bulbar (n = 2), and forniceal (n = 2) surfaces. All patients were treated with topical and injection IFNa2b, with complete regression achieved in 2 cases (at 1 months and 20 months) and partial regression in one case (at 9 months). All patients continue on chronic maintenance IFNa2b topically. There were no recurrences, and IFNa2b injection side effects of nausea and chills were minor, lasting 1 day. No patient required surgical removal of tumors from the socket and no patient required exenteration. CONCLUSIONS Patients wearing ophthalmic prosthesis over a socket should be monitored for the development of OSSN. Combined topical and injection IFNa2b could represent a potentially effective therapy for this condition.

Anophtalmic socket reconstruction is a challenging problem in plastic surgery. We had described a prefabricated superficial temporal fascia island flap and used this technique in 50 enucleation patients with severe socket contraction ending in excellent or good results for 28 years (Altin- das-1 procedure). However, the flap was not suitable for the exenteration patients with complete eyelid loss. The technique was modified and used in exenteration patients (Altindas-2 procedure). In this 2-staged procedure, the temporoparietal fascia is prefabricated with a full-thickness skin graft from the retroauricular area, and a strip of scalp is preserved at the middle of the flap. The flap is transferred to the orbit through a subcutaneous tunnel at the second stage. The prefabricated flap is used for the reconstruction of eyelids and periorbital skin; scalp island is used for the reconstruction of lid margins and eyelashes; and the neighboring bare temporoparietal fascia is used for the augmentation of the periorbital soft tissues. The orbital lining is elevated as a centrally based skin flap and used for the reconstruction of the eye socket, fornicles, and posterior lining of the eyelids. The technique was used successfully in 5 total exenteration patients with complete eyelid loss. In 1 patient, the ipsilateral temporal island flap was used previously, and the flap was prepared from the contralateral site and transferred to the anophtalmic orbit as a free flap 5 weeks later. By this procedure, it is possible to reconstruct a stable eye socket that is suitable for ocular prosthesis, upper and lower fornicles, periorbital skin with good color matching, naturally looking eyelids with eyelashes and lid margins, and medial and lateral canthal areas. It is also possible to improve periorbital soft tissue atrophy, which is an important problem in patients who had radiotherapy previously. Free transfer of the flap provides a new solution for the reconstruction of cases that were operated previously.

The aim of this study was to evaluate the opacity of the polymethylmethacrylate for ocular prosthesis using an ocular button, a colorless resin for the ocular prostheses, and 4 brands of acrylic colorless resin in the function of weathering (0, 504, or 1008 h) and thickness (1 and 3.5 mm). One hundred twenty specimens were confectioned (made) and allocated into 12 groups (n = 10). Opacity analysis was carried out with a spectrophotometer of visible ultraviolet reflection before and after weathering by 504 and 1008 hours. Data for the opacity were expressed in DeltaE. Data were then analyzed statistically by analysis of variance and the Tukey test (P < 0.01). The data demonstrated statistically significant differences; manufactured ocular button (DeltaE = 47.4) and the resin Vipi Cril (DeltaE = 38.11) presented greater and minor values of opacity, respectively. The weathering showed statistical difference among times (0 h, DeltaE = 36.32; 504 h, DeltaE = 39.98; and 1008 h, DeltaE = 43.9). Ocular button and evaluated resins presented greater values of opacity when presented in 3.5 mm in thickness. The values of opacity increased with the progression of the time of weathering, independent of the evaluated material and the thickness.

Purpose: To describe 2 patients in whom squamous cell carcinoma of the conjunctiva developed in the anophthalmic socket more than 44 years after enucleation and chronic use of an ocular prosthesis. Methods: Retrospective case reports. Results: These 2 patients did not have known risk factors for squamous cell carcinoma, including solar ultraviolet radiation or exposure (since they wore their prosthesis full-time), HIV infection, chronic orbital inflammatory disease, or immune-compromising systemic disease. Both patients had an orbital exenteration and underwent a full work-up including evaluation of the regional lymph nodes and systemic work-up to rule out distant metastasis. Conclusions: Squamous cell carcinoma of the anophthalmic socket can develop many years after enucleation. Regular inspection of the anophthalmic socket containing a prosthesis to rule out conjunctival squamous cell carcinoma is prudent.

Invasive sinonasal mucormycosis is a rare fungal infection that usually occurs in immunocompromised or diabetic patients, and it is often fatal. The authors present a case of a woman patient suffering from systemic lupus erythematosus and diabetes mellitus treated with prednisone, presenting with a rapidly progressive rhino-orbital-cerebral mucormycosis. She was successfully treated with combined intravenous antifungal therapy and radical debridement followed by complex defect reconstruction with a free vertical rectus abdominis myocutaneous flap, tissue expander, and ophthalmic prosthesis.

Introduction: Loss of an eye caused by cancer, trauma, or congenitaldefect creates a deep psychological impact on an individual’s life es-pecially social and professional life. Custom-made prosthesis, com-pared to stock prosthesis, provides a better fit to the eye socket, bettercosmeticresults,andlessdiscomforttothepatientinthelongterm.Themain objective of this article was to describe 3 different alternative andpractical techniques of fabricating custom-made ocular prosthesis.Case Report: An impression of anophthalmic socket was madewith the addition of cured silicone-based precision impression ma-terial in all techniques. A master cast was prepared and duplicatedwith condensation silicone. A self-cure acrylic resin was polymerizedin the silicone model and was fitted into the patient’s eye socket. Adigitalphotographofthepatient’siriswasmadeusingadigitalcameraandprintedongood-qualityphotopaperinvariousshadesandsizesinthe first and the second techniques. Then the photo paper was coatedwith PVC so as not to allow any color flowing. The proper iris wasthen inserted to the acrylic base. The prosthesis was final processedusing orthodontic heat polymerizing clear acrylic resin.In the other technique, after the trying-in process with waxpattern, an acrylic base was fabricated using heat polymerizingscleral acrylic resin. The prosthetic iris was fabricated from a trans-parent contact lens by painting the lens with watercolor paints andattaching it to an acrylic resin with tissue conditioner. The final pro-cess was made with heat polymerizing transparent acrylic resin.Conclusions: Custom-made prosthesis allows better esthetic andfunctional results to the patient in comparison to stock prosthesis.Further follow-up is necessary to check the condition and fit of theocular prosthesis in such patients.Key Words: Custom-made ocular prosthesis, artificial,maxillofacial defect(J Craniofac Surg 2012;23: 1779Y1781)

Ablative surgery for tumors of the globe and its adnexal structures is frequently the cause of major orbitofacial deformity. Radiotherapy compounds the problem because it suppresses skeletal growth in the growing patient and induces a contraction of the remaining soft tissues in the orbit. Goals for reconstruction in these patients include the restoration of orbital structures to allow the fitting of an ocular prosthesis and the correction of distorted orbitofacial relationships. The authors present a series of 53 patients (mean age, 29 years; 28 male) who were treated over the past 18 years by composite reconstruction of the post-tumoral anophthalmic orbit. The follow-up ranged from 5 months to 18 years (mean, 7.75 years). Four patients were treated primarily (immediate reconstruction after tumor ablation), and 49 were treated secondarily (mean oncological follow-up since ablative surgery, 14.8 years). Twenty-eight patients underwent orbital enucleation (including three bilateral cases), 23 underwent orbital exenteration, and two underwent evisceration. Forty-two patients received radiotherapy, including 20 enucleation patients, 15 exenteration patients, and seven others in whom details of primary therapy were incomplete. A staged reconstruction was undertaken in each case; it considered, in turn, the bony orbital volume (orbital remodeling and cranial bone grafts), orbital contents (implant, temporalis muscle transposition, cranial bone grafts, and dermafat grafts), conjunctival sac (mucosal and skin grafts), ocular prosthesis, eyelids (local flaps and skin grafts), and additional procedures to restore orbitofacial symmetry. The authors conclude that the long-term results of post-tumoral orbital reconstruction are favorable, and they particularly recommend the use of autogenous tissues in irradiated orbits.

After trauma or excision of malignant tumor, it is difficult to achieve satisfactory results when reconstructing deformed eyelids and the socket for an ocular prosthesis. The authors demonstrate examples of successful reconstruction for a prosthetic eye that provided adequate and aesthetic soft-tissue support achieved by applying a three-step surgical procedure of reconstruction of the eye socket, the eyelids, and the tarsus and eyelid margin. Because it is highly vascularized and its distal end can be divided into two or three portions for easy three-dimensional reconstruction, the expanded forehead flap alone, with a galea flap, or with a free rectus abdominis muscle perforator flap was used. The expanded forehead flap also provides excellent thin upper lid contour and good color-matching with a recipient site. For the eye socket, sufficient volume of tissue was provided from the expanded forehead flap with or without a galea or a free rectus abdominis muscle perforator flap, and a deep and convex fornix was formed. This resulted in a good fit and in stability of the ocular prosthesis. The surface and the inner lining of the eyelids were reconstructed using portions of the expanded forehead flap. For the tarsus and eyelid margin, conventional reconstruction techniques use cartilage of the concha, which has limitations of length and which does not fit the shape of the tarsal margin. The authors used the scapha composite graft, and a natural shape and good elasticity resulted.

PURPOSE An ocular prosthesis should complement the volume of the intraconal implant to achieve complete replacement of the volume that is removed by enucleation. This study investigates the limitations on the prosthetic volume in achieving this goal. METHODS Prosthetic volume and thickness were measured in 70 patients who underwent enucleation. Patients in group 1 (n = 17) were adults enucleated in childhood, and patients in group 2 (n = 53) were enucleated as adults. Clinical problems after enucleation were documented to determine problems potentially related to prosthetic volume. RESULTS None of the ocular prostheses in this patient series was greater in volume than 4.2 ml (range, 0.75-4.2 ml). The average prosthetic volume for patients with implant diameters of 14 mm to 22 mm was 2.2 ml. A prosthetic volume > or =1.8 ml provided an anterior to posterior dimension of 7 mm. Anterior malposition of the implant and the presence of severe socket contraction were noted in patients with the smallest and the thinnest prostheses. In group 2, larger prostheses were associated with ptosis and lower eyelid laxity (p < 0.05; p < 0.01). CONCLUSIONS One should not depend on the ocular prosthesis to supply more than 4.2 ml of volume in the anterior compartment of the socket. Adult patients with normal bony development, noncontracted sockets, and an average axial length should not receive implant sizes

Conjunctival squamous cell carcinoma developed in a 51-year-old man 40 years after he had enucleation of his left eye because of an explosion injury. He had worn several ocular prostheses for more than 40 years. Recently he had noticed an increasing sanguineous conjunctival discharge, a foreign body sensation, and swelling of his left lower eyelid. Incisional biopsies of an underlying conjunctival mass revealed squamous cell carcinoma. His work history did not involve exposure to radiation, chemicals, or the sun. The authors concluded that squamous cell carcinoma in this case was caused by chronic irritation as the result of long-standing use of a poorly fitting ocular prosthesis.

Children who receive radiation for malignant tumors in the orbital area frequently develop widespread craniofacial deformities. These affect the skull, orbit, maxilla, and mandible. When these patients seek treatment at a later age, they require careful assessment using cephalometrics and three-dimensional imaging. It is recommended that the four levels of skeletal deformity be corrected in a single procedure, that is frontotemporal expansion with repositioning of the skull base area, orbital expansion and repositioning together with maxillary and mandibular surgery. Bone grafts should be inlay rather than onlay and soft tissue should be supplied by free-tissue transfer. This counteracts any residual ischemia related to the previous radiation therapy. The second surgical stage is designed to reconstruct the socket and the eyelids to allow more satisfactory rehabilitation with an ocular prosthesis. In patients who have a globe present, the usual enophthalmos can be corrected by repositioning of the eye as part of the first procedure by reducing the anteroposterior dimensions of the socket. In bilateral cases, the deformity is hourglass in nature and requires correction in the frontal and temporal area with lateral displacement of the orbits. A bimaxillary procedure is also indicated. It is emphasized that to formulate a satisfactory operative plan an in-depth three-dimensional analysis of the deformity is mandatory.

Purpose: To report 3 instances of 2 children who swallowed their ocular prostheses. Methods: A 30-month-old boy whose eye had been enucleated for retinoblastoma swallowed his ocular prosthesis on 2 different occasions, and a 32-month-old boy whose eye had also been enucleated for retinoblastoma swallowed his ocular prosthesis once. Results: In the second child, an abdominal radiograph was obtained, but the swallowed prosthesis was not apparent, and radiographic imaging of the recovered prosthesis failed to demonstrate an identifiable object. In each case, the prosthesis was recovered in the child's stool without incident several weeks later. Neither child had physical complications as a result of the swallowing events. Conclusions: We report 3 instances in which a child fitted for an ocular prosthesis after enucleation swallowed his prosthesis and had no untoward effects. The failure of imaging to detect the prostheses in the second child is attributed to the radiolucent nature of materials used in the manufacture of the prosthesis. Each of the children was having life stresses in addition to his medical treatment that may have accounted for his behavior.

Dermis-fat grafts have been widely used in the reconstruction of the anophthalmic socket, both primarily after enucleation and secondarily after extrusion or migration of an existing implant. The dermis-fat graft is an effective means of replacing orbital volume and affording motility of the ocular prosthesis with both low morbidity and a satisfactory cosmetic result. We present a modification to the dermis-fat graft technique. Our modification creates a domed shape to the anterior surface of the graft that simulates the curvature of the eye. The dome-shaped graft creates deeper fornices than a standard flat-surfaced dermis-fat graft. It also allows better contact between the prosthesis and the dermis as the graft moves. The prosthesis can be thinner centrally and lighter than a prosthesis fabricated for a socket with a standard dermis-fat graft or spherical implant. This results in better motility of the prosthesis while also replacing orbital volume. There is no additional morbidity associated with this technique. We have used this procedure successfully in 18 patients; 10 were primary grafts and eight secondary grafts. Motility of the prosthesis was satisfactory in all cases. There was no abnormal graft shrinkage. All grafts maintained their domed shape. Follow-up ranged from 6 to 21 months.

Corneal discomfort often prevents the successful wearing of a cosmetic scleral shell. Such sensitive corneas are traditionally covered with a Gunderson conjunctival flap. I describe two patients in whom preexisting severe conjunctival scarring precluded the possibility of developing a Gunderson flap. An alternative procedure in which autogenous split-thickness dermal grafts were sutured over the sensitive cornea was utilized in each patient. The dermal grafts reepithelialized with mucosa within 4 weeks, and both patients were then able to retain an ocular prosthesis without discomfort. I conclude that satisfactory corneal coverage may be obtained with a dermal graft when conjunctival scarring precludes the use of a Gunderson flap.

Background: High-density porous polyethylene (Medpor) has been used successfully as an implant in orbital fracture repair and in the management of both cosmetic and post-traumatic facial deformities. The material is well tolerated, resists infection, is nonantigenic, and promotes tissue ingrowth. Additionally, sutures can be passed through it. These characteristics led to its use as an implant in anophthalmic socket surgery. Methods: Twenty-one patients with anophthalmia underwent implantation of spherically shaped high-density porous polyethylene implants. The implant was used in six primary enucleations with direct extraocular muscle attachment, ten secondary implant insertions, one repeat secondary implant insertion, and five eviscerations. Results: Postoperative follow-up averaged 19 months. During this period, there were no extrusions, infections, significant inflammatory responses, or implant exposures. One implant was removed 4 months after insertion due to inadequate initial placement secondary to a severe post-traumatic orbital deformity. Successful re-implantation was performed without complication. Postoperatively, all sockets showed good to excellent motility. Results of histologic examination of the removed implant demonstrated minimal inflammatory response and extensive fibrovascular ingrowth involving 60% of the implant substance. Conclusions: This initial report indicates that high-density porous polyethylene can be used successfully as an implant in anophthalmic socket surgery. Its advantages over other similar implants include a significantly lower material cost and the ability to suture the extraocular muscles directly to it without the need for a covering material such as fascia or sclera. Experimental studies are in progress to determine if this implant can be integrated with an ocular prosthesis to promote improved motility and cosmesis.

We evaluated the need for additional lubrication in 200 consecutive patients using an ocular prosthesis. Of these patients, 154 (77%) required no additional lubrication, while 46 patients (23%) required supplemental lubrication. Enuclene, the only product manufactured specifically for the patient with an ocular prosthesis, has been reported by the majority of our patients to be inadequate for comfort and wearability. Other solutions for contact lens use were compared with Enuclene and found to be far superior by patients using an ocular prosthesis.