14.7 Which Wrap to Use

14.7 Which Wrap to Use

Human donor sclera has historically been the first choice of implant-wrapping material for most orbital surgeons [27, 100]. The use of human donor material, however, has fallen out of favor with both surgeons and patients due to concerns of infectious disease transmission, including the potential risk of human immunodeficiency virus (HIV), hepatitis B or C, and prion transmission (Creutzfeldt–Jakob disease) [95]. Although we are not aware of any reports of disease transmission from donor sclera, segments of the HIV-1 genome have been identified in preserved human sclera [107]. Creutzfeldt–Jakob disease transmission from dural and corneal transplants has been reported [10, 35, 39, 79]. In addition, seronegative organ and tissue donors may transmit HIV [109]. Many eye banks charge around US $400 to provide whole donor sclera. Another disadvantage of sclera and scleralike substitutes is the potential barrier to fibrovascular ingrowth [85].

Specially processed human donor pericardium, fascia lata, and sclera are marketed as safe alternatives to preserved human donor tissues implant wraps (Biodynamics International, Tampa, FL). These wraps have the conve-

nience of a long (up to 5 years) shelf life; however, they contribute significantly to the cost of the procedure.

Processed bovine pericardium (Peri-Guard® or OcuGuard™ Supple, Bio Vascular, Saint Paul, MN) is FDA approved and available as an implant wrap material [6, 31].Although there have been no reported cases of bovine spongiform encephalopathy (BSE) in American cattle to date, there have been reports of infected cattle in Alberta, Canada, and the potential for prion transmission and BSE remains a concern [95].

Autologous temporalis fascia [99], fascia lata [93], rectus abdominus sheath [69], and posterior auricular muscle complex grafts [94] have been tried as orbital implant-wrapping materials. Use of these tissues requires a second operative site, prolonged operative time, and a potentially increased risk of morbidity.

Microporous expanded polytetrafluoroethylene (e-PTFE) (Gore-Tex, Gore and Associates, Flagsta , AZ) has also been advocated as an implant-wrapping material (Oculo-Plastik, Montreal, Quebec, Canada); however, complications with implant exposure have made its use undesirable [14, 68, 70]. Polyester-urethane like e-PTFE is another permanent synthetic product suggested as an implant-wrapping material. Its use has primarily been

Undyed polyglactin 910 mesh (Vicryl mesh, Ethicon, Somerville, NJ) is a bioabsorbable synthetic material and our preference as a wrapping material for HA and Bioceramic orbital implants [47, 68] (Fig. 14.4a, b). Polyglactin mesh o ers numerous advantages over other currently available materials. Vicryl mesh eliminates the risk of infectious disease transmission, does not require a second surgical site, is readily available, and is technically simple to use. The cost is approximately US $290 per sheet. Polyglactin has a multiporous structure that allows fibrovascular ingrowth over the entire surface of the implant [77]. It provides a minimal barrier to vascularization as opposed to sclera or other donor tissues. In a rabbit model, the degree of vascularization was greater in the first 12 weeks in Vicryl mesh-wrapped implants than sclera-wrapped implants on both histopathologic and MR imaging studies [47, 54]. We have reported a 2.1% incidence of implant exposure in 187 consecutive patients receiving Vicryl mesh-wrapped HA orbital implants [32]. With refinements in implant placement technique, our incidence of exposure is now less than 1% (unpublished data). Importantly, Bioceramic implants wrapped with Vicryl mesh only cost US $50 more than unwrapped implants.

Oestreicher et al. [98] reported a low exposure incidence using a similar bioabsorbable wrapping material composed of polyglycolic acid (Dexon mesh style no. 8, nonstretch, medium-weight closed tricot, Davis and Geck, Manati, Puerto Rico). Despite our success with polyglactin 910 mesh as an implant wrap material, some surgeons continue to believe that it is associated with a higher rate of implant exposure [19, 20, 60]. It remains our view that high exposure rates with Vicryl meshwrapped implants are technique related and can be significantly minimized with correct implant insertion and meticulous tension-free wound closure [58, 60]. In an attempt to limit the risk of implant exposure, a small 1.5 × 1.5 cm sclera patch has been added to the anterior surface of polyglactin-wrapped implants by some surgeons [116, 117]. Wang et al. compared the exposures in Vicryl mesh-wrapped implants to Vicryl mesh-wrapped implants with an additional sclera patch graft. No exposures occurred in the implants capped by the sclera patch compared to 2 (11.7%) in the Vicryl mesh-only implants without a sclera patch [116]. Inkster et al. also reported using a similar technique (i.e., a sclera patch graft to cover a sclera-wrapped HA implant). Although conjunctival

dehiscence occurred in 33% of the patients, it disappeared without further intervention, and no patient developed implant exposure in their series of 110 patients [43].

Summary for the Clinician

■Concern over infectious disease transmission has limited the continued use of sclera and other donor materials as implant-wrapping materials.

■Specially processed human donor tissue may contribute substantially to the cost of the procedure.

■Polyglactin 910 (Vicryl) mesh is an alternative to traditional implant-wrapping materials. Vicryl mesh eliminates the risk of infectious disease transmission, does not require a second surgical site, is readily available, and is technically simple to use. Aluminum oxide implants are supplied prewrapped at minimal additional cost.

14.8 To Peg or Not to Peg Porous Implants

Infrared oculography has demonstrated objective and significant improvement in horizontal gaze after motility peg placement [34]. Despite the improved motility, many surgeons and patients still elect to avoid peg placement due to the satisfactory results without pegging and the possibility of postpegging complications (increased discharge, recurrent pyogenic granulomas, implant exposure around the peg, implant infection, tissue overgrowth, clicking) [12, 28, 29, 45, 53, 80, 84, 119].

Although pegging has declined dramatically over the past few years, a precise and meticulous technique under local anesthesia with intravenous sedation in the appropriately selected patient can be a successful outpatient procedure [59]. It is important to be selective in deciding which patients are candidates for a peg system. Proper care of the artificial eye and regular follow-up visits with the ocularist and ophthalmic plastic surgeon are important to help ensure minimal problems with the peg system. If the patient is unlikely, unable, or unwilling to have adequate postoperative care, then pegging should be avoided. Children under 15 years of age, adults over the age of 65 years or so, or individuals of any age with a chronic illness or vasculopathy (e.g., a collagen vascular disease, sarcoidosis, diabetes mellitus, immunosuppressive therapy, prior orbital radiation therapy, etc.) should not be considered for pegging.

Peg and sleeve implant–prosthesis coupling systems were generally designed for peg or sleeve placement once

fibrovascularization of the implant has been completed. Implant fibrovascularization is believed to diminish the risks of implant infection, exposure, and migration [77, 88]. Drilling into an avascular area of the implant may predispose the implant to infection [1, 76]. Gadoliniumenhanced MR imaging is currently the recommended method of assessing the extent of implant vascularization [76]. Fibrovascular ingrowth may occur at varying rates in di erent patients. Implant drilling and peg placement are generally deferred until 5–6 months after porous implant insertion, which is the time in our experience it takes the implant to vascularize fully [76].

Several titanium peg systems are currently available for use with porous orbital implants. Titanium is more biocompatible and better tolerated by human soft tissue than the original peg systems made of polycarbonate (Fig. 14.5a–c) [59]. Complications associated with peg placement have also been reduced with the introduction of titanium pegs [59]. The FCI peg–sleeve coupling system utilizes an HA-coated titanium sleeve [59]. The HA

coating potentially allows for stronger interface bonding with the orbital fibroblasts than the uncoated P-K system supplied for use with the Bio-Eye. The MEDPOR Motility Coupling Post (MCP) (Porex Surgical) is a titanium screw that can be screwed directly into porous polyethylene implants [13, 41, 106]. Some authors have advocated primary placement of the MCP at the time of implant insertion [41, 62, 82, 83, 106]. This practice remains controversial as early exposure of the preplaced peg (within the first 3 months) may allow microorganisms into the incompletely vascularized implant [27, 29, 50, 61, 75, 83]. In addition, there is no way to be sure the preplaced peg is appropriately centered in the implant. A peg that is o center or on an angle can be di cult to couple properly with the overlying prosthesis [53]. The new magnetic coupling peg system (Porex Surgical) is still evolving [90]. The major advantage of this system is that there is no break in the conjunctiva, as is the case with a protruding titanium peg. A possible disadvantage is the inability of the patient to undergo future MR imaging studies.

14.9Summary

Loss of an eye to malignancy, trauma, or end-stage ocular disease is devastating to persons of any age. Not only is there a loss of binocular vision with reduced peripheral visual field and loss of depth perception with various job restrictions, but also there may be a sense of facial disfigurement. Since eye contact is such an essential part of human interaction, it is extremely important for the patient with an artificial eye to maintain a natural, normalappearing prosthetic eye. Since 1989, there have been numerous developments and refinements in anophthalmic socket surgery with respect to implant material and design, implant wrapping, implant–prosthesis coupling, and socket volume considerations. Anophthalmic surgery is no longer simply about replacing a diseased eye with an orbital implant. Ophthalmic surgeons working closely with qualified ocularists must be focused on restoring a patient’s natural eye appearance with prosthetic motility as near normal as possible. We prefer implantation of a porous Bioceramic implant wrapped in polyglactin mesh. In appropriate clinical circumstances, we consider pegging 6–8 months after implant insertion. The technique requires a certain skill level and may not be appropriate for all implant surgeons or anophthalmic patients.

References

1.Ainbinder DJ, Haik BG, Tellado M (1994) Hydroxyapatite orbital implant abscess: histopathologic correlation of an infected implant following evisceration. Ophthal Plast Reconstr Surg 10:267–270

2.Alwitry A, West S, King J et al (2007) Long-term follow-up of porous polyethylene spherical implants after enucleation and evisceration. Ophthal Plast Reconstr Surg 23: 11–15

3.Anderson RL, Thiese SM, Nerad JA et al (1990) The universal orbital implant: indications and methods. Adv Ophthalmic Plast Reconstr Surg 8:88–99

4.Anderson RL, Yen MT, Lucci LM et al (2002) The quasiintegrated porous polyethylene orbital implant. Ophthal Plast Reconstr Surg 18:50–55

5.Apt L, Isenberg S (1973) Changes in orbital dimensions following enucleation. Arch Ophthalmol 90:393–395

6.Arat YO, Shetlar DJ, Boniuk M (2003) Bovine pericardium versus homologous sclera as a wrapping for hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 19:189–193

7.Arora V, Weeks K, Halperin EC et al (1992) Influence of coralline hydroxyapatite used as an ocular implant on the dose distribution of external beam photon radiation therapy. Ophthalmology 99:380–382

8.Bentley RP, Sgouros S, Natarajan K et al (2002) Normal changes in orbital volume during childhood. J Neurosurg 96:742–746

9.Blaydon SM, Shepler TR, Neuhaus RW et al (2003) The porous polyethylene (Medpor) spherical orbital implant: a retrospective study of 136 cases. Ophthal Plast Reconstr Surg 19:364–371

10.Brooke FJ, Boyd A, Klug GM et al (2004) Lyodura use and the risk of iatrogenic Creutzfeldt–Jakob disease inAustralia. Med J Aust 180:177–181

11.Cepela MA, Nunery WR, Martin RT (1992) Stimulation of orbital growth by the use of expandable implants in the anophthalmic cat orbit. Ophthal Plast Reconstr Surg 8: 157–167

12.Cheng MS, Liao SL, Lin LL (2004) Late porous polyethylene implant exposure after motility coupling post placement. Am J Ophthalmol 138:420–424

13.Choi JC, Iwamoto MA, Bstandig S et al (1999) Medpore motility coupling post: a rabbit model. Ophthal Plast Reconstr Surg 15:190–201

14.Choo PH, Carter SR, Crawford JB et al (1999) Exposure of expanded polytetrafluoroethylene-wrapped hydroxyapatite orbital implant: a report of two patients. Ophthal Plast Reconstr Surg 15:77–78

15.Christel P (1992) Biocompatibility of alumina. Clin Orthop 282:10–18

16.Chuo JY, Dolman PJ, Ng TL et al (2009) Clinical and histopathologic review of 18 explanted porous polyethylene orbital implants. Ophthalmology 116:349–354

17.Colen TP, Paridaens DA, Lemij HG et al (2000) Comparison of artificial eye amplitudes with acrylic and hydroxyapatite spherical enucleation implants. Ophthalmology 107: 1889–1894

18.Cook S, Dalton J (1992) Biocompatibility and biofunctionality of implanted materials. Alpha Omegan 85:41–47

19.Custer PL (2000) Enucleation: past, present, and future. Ophthal Plast Reconstr Surg 16:316–321

20.Custer PL (2001) Reply to Dr. D.R. Jordan’s letter on polyglactin mesh wrapping of hydroxyapatite implants. Ophthal Plast Reconstr Surg. 17:222–223

21.Custer PL,Kennedy RH,Woog JJ et al (2003) Orbital implants in enucleation surgery: a report by the American Academy of Ophthalmology. Ophthalmology 110:2054–2061

22.Custer PL, Trinkaus KM (1999) Volumetric determination of enucleation implant size. Am J Ophthalmol 128: 489–494

23.Custer PL, Trinkaus KM (2007) Porous implant exposure: incidence, management, and morbidity. Ophthal Plast Reconstr Surg 23:1–7

24.Custer PL, Trinkaus KM, Forno J (1999) Comparative motility of hydroxyapatite and alloplastic enucleation implants. Ophthalmology 106:513–516

25.DePotter P, Shields CL, Shields JA et al (1992) Role of magnetic resonance imaging in the evaluation of the hydroxyapatite orbital implant. Ophthalmology 99:824–830

26.DePotter P, Shields CL, Shields JA et al (1994) Use of the hydroxyapatite ocular implant in the pediatric population. Arch Ophthalmol 112:208–212

27.Dutton JJ (1991) Coralline hydroxyapatite as an ocular implant. Ophthalmology 98:370–377

28.Edelstein C, Shields CL, DePotter P et al (1997) Complications of motility peg placement for the hydroxyapatite orbital implant. Ophthalmology 104:1616–1621

29.Fahim DK,Frueh BR,Musch DC et al (2007) Complications of pegged and non-pegged hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 23:206–210

30.Fountain TR, Goldberger S, Murphree AL (1999) Orbital development after enucleation in early childhood. Ophthal Plast Reconstr Surg 15:32–36

31.Gayre GS, DeBacker CM, Lipham W et al (2001) Bovine pericardium as a wrapping for orbital implants. Ophthal Plast Reconstr Surg 17:381–387

32.Gayre GS, Lipham W, Dutton JJ (2002) A comparison of rates of fibrovascular ingrowth in wrapped versus unwrapped hydroxyapatite spheres in a rabbit model. Ophthal Plast Reconstr Surg 18:275–280

33.Goldberg RA, Holds JB, Ebrahimpour J (1992) Exposed hydroxyapatite orbital implants: report of six cases. Ophthalmology 99:831–836

34.Guillinta P, Vasani SN, Granet DB et al (2003) Prosthetic motility in pegged versus unpegged integrated porous orbital implants. Ophthal Plast Reconstr Surg 19:119–122

35.Heckmann JG,Lang CJ,Petruch F et al (1997) Transmission

of Creutzfeldt-Jakob disease via a corneal transplant. J Neurol Neurosurg Psychiatry 63:388–390

36.Heher KL, Katowitz JA, Low JE (1998) Unilateral dermisfat graft implantation in the pediatric orbit. Ophthal Plast Reconstr Surg 14:81–88

37.Heimann H, Bechrakis NE, Zepeda LC et al (2005) Exposure of orbital implants wrapped with polyesterurethane after enucleation for advanced retinoblastoma. Ophthal Plast Reconstr Surg 21:123–128

38.Hintschich C, Zonneveld F, Baldeschi L et al (2001) Bony orbital development after early enucleation in humans. Br J Ophthalmol 85:205–208

39.Hogan RN, Brown P, Heck E et al (1999) Risk of prion disease transmission from ocular donor tissue transplantation. Cornea 18:2–11

40.Howard GM, Kinder RS, Macmillan AS Jr. (1965) Orbital growth after unilateral enucleation in childhood. Arch Ophthalmol 73:80–83

41.Hsu WC, Green JP, Spilker MH et al (2003) Primary placement of a titanium motility post in a porous polyethylene orbital implant. Ophthal Plast Reconstr Surg 16:370–379

42.Imhof SM, Mourits MP, Hofman P et al (1996) Quantification of orbital and mid-facial growth retardation after megavoltage external beam irradiation in children with retinoblastoma. Ophthalmology 103:263–268

43.Inkster CF, Ng SG, Leatherbarrow B (2002) Primary banked scleral patch graft in the prevention of exposure of hydroxyapatite orbital implants. Ophthalmology 109:389–392

44.Iordanidou V, De PP (2004) Porous polyethylene orbital implant in the pediatric population. Am J Ophthalmol 138:425–429

45.Jordan DR (2001) Spontaneous loosening of hydroxyapatite peg sleeves. Ophthalmology 108:2041–2044

46.Jordan DR (2004) Localization of extraocular muscles during secondary orbital implantation surgery: the tunnel technique: experience in 100 patients. Ophthalmology 111:1048–1054

47.Jordan DR, Allen LH, Ells A et al (1995) The use of Vicryl mesh (polyglactin 910) for implantation of hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 11:95–99

48.Jordan DR, Anderson RL, Nerad JA et al (1987) A preliminary report on the universal implant. Arch Ophthalmol 105:1726–1731

49.Jordan DR, Bawazeer A (2001) Experience with 120 syn-

thetic hydroxyapatite implants (FCI3). Ophthal Plast Reconstr Surg 17:184–190

50.Jordan DR,Brownstein S,Faraji H (2004) Clinicopathologic analysis of 15 explanted hydroxyapatite implants. Ophthal Plast Reconstr Surg 20:285–290

51.Jordan DR,Brownstein S,Gilberg S et al (2002) Investigation of a bioresorbable orbital implant. Ophthal Plast Reconstr Surg 18:342–348

52.Jordan DR, Brownstein S, Jolly SS (1996) Abscessed hydroxyapatite orbital implants: a report of two cases. Ophthalmology 103:1784–1787

53.Jordan DR, Chan S, Mawn L et al (1999) Complications associated with pegging hydroxyapatite orbital implants. Ophthalmology 106:505–512

54.Jordan DR, Ells A, Brownstein S et al (1995) Vicryl-mesh wrap for the implantation of hydroxyapatite orbital implants: an animal model. Can J Ophthalmol 30:241–246

55.Jordan DR, Gilberg S, Bawazeer A (2004) Coralline

56.Jordan DR, Gilberg S, Mawn LA (2003) The bioceramic orbital implant: experience with 107 implants. Ophthal Plast Reconstr Surg 19:128–135

57.Jordan DR, Hwang I, McEachren TM et al (2000) Brazilian hydroxyapatite implant. Ophthal Plast Reconstr Surg 16: 363–369

58.Jordan DR, Klapper SR (1999) Wrapping hydroxyapatite implants. Ophthalmic Surg Lasers 30:403–407

59.Jordan DR, Klapper SR (2000) A new titanium peg system for hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 16:380–387

60.Jordan DR, Klapper SR, Gilberg SM (2003) The use of Vicryl mesh in 200 porous orbital implants. Ophthal Plast Reconstr Surg 19:53–61

61.Jordan DR, Klapper SR, Mawn L et al (1998) Abscess formation within a synthetic hydroxyapatite orbital implant. Can J Ophthalmol 33:329–332

62.Jordan DR, Mawn L, Brownstein S et al (2000) The bioceramic orbital implant: a new generation of porous implants. Ophthal Plast Reconstr Surg 16:347–355

63.Jordan DR, Munro SM, Brownstein S et al (1998) A synthetic hydroxyapatite implant: the so-called counterfeit implant. Ophthal Plast Reconstr Surg 14:244–249

64.Jordan DR, Pelletier C, Gilberg S et al (1999) A new variety of hydroxyapatite: the Chinese implant. Ophthal Plast Reconstr Surg 15:420–424

65.Kaltreider SA (2000) The ideal ocular prosthesis: analysis of prosthetic volume. Ophthal Plast Reconstr Surg 16: 388–392

66.Kaltreider SA, Jacobs JL, Hughes MO (1999) Predicting the ideal implant size before enucleation. Ophthal Plast Reconstr Surg 15:37–43

67.Kaltreider SA, Lucarelli MJ (2002) A simple algorithm for selection of implant size for enucleation and evisceration. Ophthal Plast Reconstr Surg 18:336–341

68.Kao L (2000) Polytetrafluoroethylene as a wrapping material for a hydroxyapatite orbital implant. Ophthal Plast Reconstr Surg 16:286–288

69.Kao SCS, Chen S (1999) The use of rectus abdominis sheath for wrapping of the hydroxyapatite orbital implants. Ophthalmic Surg Lasers 30:69–71

70.Karesh JW (1987) Polytetrafluoroethylene as a graft material in ophthalmic plastic and reconstructive surgery: an experimental and clinical study. Ophthal Plast Reconstr Surg 3:179–185

71.Karesh JW, Dresner SC (1994) High-density porous polyethylene (Medpor) as a successful anophthalmic socket implant. Ophthalmology 101:1688–1695

72.Kaste SC, Chen G, Fontanesi J et al (1997) Orbital development in long-term survivors of retinoblastoma. J Clin Oncol 15:1183–1189

73.Kennedy RE (1964) The e ect of early enucleation on the orbit in animals and humans. Trans Am Ophthalmol Soc 62:459–510

74.Kim YD, Goldberg RA, Shorr N et al (1994) Management of exposed hydroxyapatite orbital implants.Ophthalmology 101:1709–1715

75.Klapper SR, Jordan DR, Brownstein S et al (1999) Incomplete fibrovascularization of a hydroxyapatite orbital implant 3 months after implantation. Arch Ophthalmol 106:1640–1641

76.Klapper SR, Jordan DR, Ells A et al (2003) Hydroxyapatite orbital implant vascularization assessed by magnetic resonance imaging. Ophthal Plast Reconstr Surg. 19:46–52

77.Klapper SR,Jordan DR,Punja K et al (2000) Hydroxyapatite implant wrapping materials: analysis of fibrovascular ingrowth in an animal model. Ophthal Plast Reconstr Surg 16:278–285

78.Klett A, Gutho R (2003) Muscle pedunculated scleral flaps. A microsurgical modification to improve prosthesis motility. Ophthalmologe 100:449–452

79.Lang CJ, Heckmann JG, Neundorfer B (1998) Creutzfeldt– Jakob disease via dural and corneal transplants. J Neurol Sci 160:128–139

80.Lee SY, Jang JW, Lew H et al (2002) Complications in motility PEG placement for hydroxyapatite orbital implant in anophthalmic socket. Jpn J Ophthalmol 46:103–107

81.Li T, Shen J, Du y MT (2001) Exposure rates of wrapped and unwrapped orbital implants following enucleation. Ophthal Plast Reconstr Surg 17:431–435

82.Liao SL, Chen MS, Lin LL (2005) Primary placement of a titanium sleeve in hydroxyapatite orbital implants. Eye 19:400–405

83.Liao SL, Shih MJ, Lin LL (2005) Primary placement of a hydroxyapatite-coated sleeve in bioceramic orbital implants. Am J Ophthalmol 139:235–241

84.Lin CJ, Liao SL, Jou JR et al (2002) Complications of motility peg placement for porous hydroxyapatite orbital implants. Br J Ophthalmol 86:394–396

85.Long JA, Tann TM, III, Bearden WH III et al (2003) Enucleation: is wrapping the implant necessary for optimal motility? Ophthal Plast Reconstr Surg 19:194–197

86.Marx DP, Vagefi MR, Bearden WH et al (2008) The quasiintegrated porous polyethylene implant in pediatric patients enucleated for retinoblastoma. Orbit 27:403–406

87.Mawn L, Jordan DR, Gilberg S (1998) Scanning electron microscopic examination of porous orbital implants. Can J Ophthalmol 33:203–209

88.Mawn LA, Jordan DR, Gilberg S (2001) Proliferation of human fibroblasts in vitro after exposure to orbital implants. Can J Ophthalmol 36:245–251

89.Migliori ME, Putterman AM (1991) The domed dermisfat graft orbital implant. Ophthal Plast Reconstr Surg 7:23–30

90.Miller DM, Murray T, Suarez F et al (2007) Motility assessment and clinical outcomes of a magnetically integrated microporous implant. Ophthalmic Surg Lasers Imaging 38:339–341

91.Mitchell KT, Hollsten DA, White WL et al (2001) The autogenous dermis-fat orbital implant in children. J AAPOS 5:367–369

92.Naik MN, Murthy RK, Honavar SG (2007) Comparison of vascularization of Medpor and Medpor-Plus orbital implants: a prospective, randomized study. Ophthal Plast Reconstr Surg 23:463–467

93.Naugle TC Jr, Fry CL, Sabatier RE et al (1997) High leg incision fascia lata harvesting. Ophthalmology 104:1480–1488

94.Naugle TC Jr, Lee AM, Haik BG et al (1999) Wrapping hydroxyapatite orbital implants with posterior auricular muscle complex grafts. Am J Ophthalmol 128:495–501

95.Nunery WR (2003) Risk of prion transmission with the use of xenografts and allografts in surgery. Ophthal Plast Reconstr Surg 17:389–394

96.Nunery WR, Heinz GW, Bonnin JM et al (1993) Exposure rate of hydroxyapatite spheres in the anophthalmic socket: histopathologic correlation and comparison with silicone sphere implants. Ophthal Plast Reconstr Surg 9:96–104

97.Nunery WR, Hetzler KJ (1985) Dermal-fat graft as a primary enucleation technique. Ophthalmology 92:1256–1261

98.Oestreicher JH, Liu E, Berkowitz M (1997) Complications of hydroxyapatite orbital implants: a review of 100 consecutive cases and a comparison of Dexon mesh (polyglycolic acid) with scleral wrapping. Ophthalmology 104: 324–329

99.Pelletier CR, Jordan DR, Gilberg SM (1998) Use of temporalis fascia for exposed hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg 14:198–203

100.Perry AC (1991) Advances in enucleation. Ophthal Plast Reconstr Surg 4:173–182

101.Perry JD (2003) Hydroxyapatite implants [letter]. Ophthalmology 110:1281.

102.Perry JD, Tam RC (2004) Safety of unwrapped spherical orbital implants. Ophthal Plast Reconstr Surg 20:281–284

103.Pfie er RL (1945) The e ect of enucleation on the orbit. Trans Am Acad Ophthalmol 49:236–239

104.Remulla HD, Rubin PAD, Shore JW et al (1995) Complications of porous spherical orbital implants. Ophthalmology 102:586–593

105.Rubin PA, Popham J, Rumelt S et al (1998) Enhancement of the cosmetic and functional outcome of enucleation

with the conical orbital implant. Ophthalmology 105: 919–925

106.Rubin PAD, Fay AM, Remulla HD (1999) Primary placement of motility coupling post in porous polyethylene orbital implants. Arch Ophthalmol 118:826–832

107.Sei SR, Chang JS Jr, Hurt MH et al (1994) Polymerase chain reaction identification of human immunodeficiency virus-1 in preserved human sclera. Am J Ophthalmol 118:528–529

108.Shoamanesh A, Pang N, Oestreicher JH (2007) Complications of orbital implants; a review of 542 patients who have undergone orbital implantation and 275 subsequent peg placements. Orbit 25:173–182

109.Simonds RJ, Holmberg SD, Hurwitz RL et al (1992) Transmission of human immunodeficiency virus type 1 from a seronegative organ and tissue donor. N Engl J Med 326:726–732

110.Su GW, Yen MT (2004) Current trends in managing the anophthalmic socket after primary enucleation and evisceration. Ophthal Plast Reconstr Surg 20:274–280

111.Suter AJ, Molteno AC, Bevin TH et al (2002) Long term follow up of bone derived hydroxyapatite orbital implants. Br J Ophthalmol 86:1287–1292

112.Taylor W (1939) E ect of enucleation of one eye in childhood upon subsequent development of the face. Trans Ophthalmol Soc U K 59:368–373

113.Thaller VT (1997) Enucleation volume measurement. Ophthal Plast Reconstr Surg 13:18–20

114.Trichopoulos N, Augsburger JJ (2005) Enucleation with unwrapped porous and nonporous orbital implants: a 15-year experience. Ophthal Plast Reconstr Surg 21: 331–336

115.Wang JK, Lai PC, Liao SL (2009) Late exposure of the bioceramic orbital implant. Am J Ophthalmol 147:162–170

116.Wang JK, Liao SL, Lai PC et al (2007) Prevention of exposure of porous orbital implants following enucleation. Am J Ophthalmol 143:61–67

117.Wang JK, Liao SL, Lin LL et al (2007) Porous orbital implants, wraps, and PEG placement in the pediatric population after enucleation. Am J Ophthalmol 144:109–116

118.Yago K, Furuta M (2001) Orbital growth after unilateral enucleation in infancy without an orbital implant. Jpn J Ophthalmol 45:648–652

119.Yazici B, Akova B, Sanli O (2007) Complications of primary placement of motility post in porous polyethylene implants during enucleation. Am J Ophthalmol 143: 828–834

120.Yoon JS,Lew H,Kim SJ et al.(2008) Exposure rate of hydroxyapatite orbital implants. Ophthalmology 115:566–572