At present, the anophthalmic socket reconstruction methods commonly used in the clinic include the Russian doll technique, four petals technique and on-the-table technique, all of which are modified eye evisceration procedures.[7, 8] C.Kaeilani et al. compared the effectiveness and safety of the three surgical techniques and found that the four petals technique had the best postoperative cosmetic effect, the fewest complications, and the lowest reoperation rate. The surgery technique adopted in this clinical study was also modified eye evisceration, which was different from other classic surgeries in the following aspects: 1) Tenon’s capsule in only one quadrant (superior nasal) needed to be separated after the conjunctival peritomy; 2) Only a lateral incision to the optic papilla on the sclera was made, 3) There was no extraocular muscle separation; 4) Implants with larger diameters were available, both of which were 22 mm; and 5) There were fewer surgery steps, shorter surgery times, less blood loss, and shorter hospitalization times. Because of the modifications of the above aspects, the surgical method had many advantages, such as less damage, faster recovery, and weaker inflammatory reaction after the surgery. In addition, no obvious complications occurred during the long follow-up period, and implant mobility and the cosmetic effect were satisfactory.
Implant extrusion or exposure was the most serious complication after evisceration. Although the surgical method has received many improvements, and the incidence of these complications has been significantly reduced, they still exist. Liu reported that the incidence of implant exposure after evisceration varied from 0–20%. If the implant is placed too shallow, the implant is too large, or there is bleeding in the retrobulbar area, the tension of Tenon’s capsule will be high, which will lead to rupture of the incision, extrusion, or exposure of the implant. In this study, no patient had implant exposure or extrusion. The possible reasons are as follows: 1) The orbital implant was in the intramuscular cone, and two layers of sclera were present anteriorly, preventing migration, erosion, and extrusion (Fig. 2); 2) The implant was exposed to soft tissue directly, which is beneficial for vascularization; 3) There was a large elastic space in the posterior bulbar muscle cone, and therefore an implant with a diameter of 22 mm or more will not cause high tension of Tenon’s capsule; 4) This modified technique produced less damage to the ocular surface, a reduced postoperative inflammatory response, and faster recovery; and 5) Porous HA was used in this study. It is one of the ideal materials for filling the orbital volume after enucleation or evisceration. It is well tolerated by surrounding tissues, and its porous structure can be rapidly infiltrated by host tissue.
Enophthalmos, which is caused by a small implant or absorption of orbital fat, is another serious complication after surgery. It causes difficulties when revision surgeries are needed. C.Keilani et al. compaired average implant diameters in a retrospective review, and they found that the Russian dolls technique group’s average was 16 mm, the on-the-table technique group’s average was 19.9 mm, and the four petals technique group diameter was 20 mm. The incidence of enophthalmos was higher in the Russian dolls technique group. No enophthalmos occurred in this study. This was likely due to the large elastic space in the posterior bulbar muscle cone, which allowed an implant with a diameter of 22 mm or more to be implanted, which could correct the orbital volume loss better, and ensure the full appearance of the socket.
Conjunctival sac stenosis after evisceration is often seen in cases with multiple operations or trauma history. The conjunctival scar and adhesion are difficult to separate, and it is easily damaged. The complicated cases need minimal damage surgery. No complication of conjunctival sac stenosis was documented in this study. The modified technique allowed the conjunctiva, Tenon’s capsule, sclera, and extraocular muscles to remain intact, which protected the ocular surface to the greatest extent. In other surgical methods, especially the on-the-table method, separating the Tenon’s capsule in four quadrants, cutting off the extraocular muscles, and removing the sclera shell, will cause great damage to the ocular surface. Therefore, the on-the-table method is not suitable for particularly complicated cases.
Although the patients had a satisfactory cosmetic effect after placement of the ocular prosthesis in this study, the motility of the prosthesis was not ideal, because the prosthesis and the socket were not fixed, and the movement of the socket could not drive the prosthesis to produce a synchronous and equal amount of movement. In the past, some doctors fixed the prosthesis on the socket with nails, which improved the mobility of the prosthesis, but at the same time, there were serious complications; e.g., exposure of the socket, infection, and conjunctival granuloma.[10–13] Therefore, this flaw still needs to be improved.