International Journal of Advanced and Integrated Medical Sciences

Show Contents

An Innovative Modified Orbital Implant in EnucleatedEyes for Postoperative Functionality and Cosmesis
An Innovative Modified Orbital Implant in EnucleatedEyes for Postoperative Functionality and Cosmesis
1Surabhi Sinha, 2Y Rizvi, 3A Dokania
1Resident (2nd Year), 2Professor and Head, 3Associate Professor
1-3Department of Ophthalmology, Rohilkhand MedicalCollege & Hospital, Bareilly, Uttar Pradesh, India
Corresponding Author:
Surabhi Sinha, Resident (2nd Year)Department of Ophthalmology, Rohilkhand Medical College &Hospital, Bareilly, Uttar Pradesh, India,
Phone: +919897410173
Orbital implants replace the volume lost by enucleated eye,impart motility to the prosthesis, and maintain cosmetic symmetrywith the fellow eye. They include nonintegrated, syntheticsemi-integrated, integrated, bio-integrated, and biogenicvarieties. The much favored hydroxyapatite (bio-integrated)implant, due to its rough surface, needs to be wrapped in donorsclera or other wrapping materials (like polyglactin-910 mesh,polytetrafluoroethylene sheet, etc.) to which the muscles couldbe directly sutured. Cost factor of such wrappings is often prohibitivethat add to the expense of such implants.
Purpose: To highlight monofilament polypropylene surgicalmesh commonly used for herniorrhaphy as an alternativeimplant wrapping for achieving augmented implant volume andenabling easier extraocular muscle attachment in postenucleationreconstruction of artificial eye.
Materials and methods: Following enucleation of a nonfunctionaleye in a patient who met with a road traffic accident, a14 mm hydroxyapatite ball was used to replace the globe. Theball was wrapped with a monofilament polypropylene surgicalmesh used in herniorrhaphy and sutured. The patient achieveda satisfactory cosmesis and movements of the implant for differentgazes. No ocular discomfort or implant extrusion wasreported following 6 months of follow-up.
Conclusion: Monofilament polypropylene mesh can be usedsafely as an orbital implant wrapping, economizing the implantcost.
Keywords: Hydroxyapatite, Implant wrappings, Orbitalimplants.
How to cite this article: Sinha S, Rizvi Y, Dokania A. AnInnovative Modified Orbital Implant in Enucleated Eyes forPostoperative Functionality and Cosmesis. Int J Adv Integ MedSci 2017;2(1):47-50.
Source of Support: Nil
Conflicts of Interest: None


Following enucleation or evisceration, there is a reductionin the volume of the orbital contents, which needs to bereplaced by an orbital implant. A prosthetic eye withoutan implant causes stretching of the lower lid under itsweight and has poor motility. Thus, an orbital implantis inserted for achieving satisfactory prosthetic motilityand better cosmetic results. The implant can be insertedat the time of surgery (enucleation or evisceration) or later.


A 30-year-old male presented to our hospital with complaintsof protrusion of right eye, loss of vision, and severepain in the same eye following a road traffic accident3 days before the time of presentation. Loss of vision wassudden in onset associated with severe pain along withtwo episodes of vomiting. There was no history of loss ofconsciousness or bleeding from the ear. The patient wasreferred to us from a local hospital following first aid thatincluded repair of a right temporal laceration.

On local examination, sutures were present over theright temporal and zygomatic region. Globe was proptosedwith absent extraocular movements. Periorbitaledema and ecchymosis were present in both the lids ofthe right eye with marked subconjunctival hemorrhage,the posterior margins of which could not be assessed.Cornea was dry and lusterless following exposure keratopathy.Anterior chamber was shallow. Pupil was dilatedand fixed (Figs 1A and B). Visual acuity: Oculus dexter -PL negative; oculus sinister - 6/6.

On general and systemic examination, abrasions werepresent over the right knee with mild pain. No othersignificant abnormality was detected. Routine bloodinvestigations were carried out and polymorphs (83%),total leukocyte count (16,400/mm3), and erythrocytesedimentation rate (18 mm in first hour) were slightlyraised. Noncontrast computed tomography (NCCT) headshowed fracture of lateral wall of right orbit, right zygomaticarch, and right lamina papyracea with abnormalattenuation in retroconal region. The NCCT orbit (Fig. 1C)showed findings of:
  • Soft tissue swelling involving preseptal and retrobulbarregion on right side with proptosis.
  • Multiple fractures involving right zygomatic arch,right nasal bone and septum, right maxillary sinuswall with air fluid level in right maxillary sinus, andsuggestion of avulsion of the globe.

Conservative option being ruled out, enucleation wasperformed under general anesthesia due to the painful,nonfunctional status of the eye with nil visual prognosis.A 14 mm hydroxyapatite ball was used to replace theglobe (Fig. 2A). The ball was wrapped with a monofilamentpolypropylene surgical mesh used in herniorrhaphyand sutured with 5-0 Vicryl (Fig. 2B). The wrappedimplant was placed in normal saline for 5 minutes toloosen the stiffened fibers of the mesh. Implant wasplaced in the socket thereafter under the cover of tenons(Fig. 3A). The free ends of tendons of the recti and obliquemuscles were sutured on the wrap at preordained markings(Fig. 3B). The tenons and conjunctival layers weresutured subsequently in vertical and horizontal fashionusing 5-0 Vicryl and silk sutures respectively (Fig. 3C).

International Journal of Advanced & Integrated Medical Sciences, January-March, Vol 2, 201747

Surabhi Sinha et al

An Innovative Modified Orbital Implant in EnucleatedEyes for Postoperative Functionality and Cosmesis
Figs 1A to C: (A and B) Presentation of the patient; and (C) NCCT orbit showing multiple fractures

An Innovative Modified Orbital Implant in EnucleatedEyes for Postoperative Functionality and Cosmesis
Figs 2A and B: Wrapping of the implant with prolene mesh

An Innovative Modified Orbital Implant in EnucleatedEyes for Postoperative Functionality and Cosmesis
Figs 3A to C: (A) Placing the implant in the socket; (B) suturing the extraocular muscles to the mesh; and (C) closing the socket

Postoperative recovery was uneventful with subsidenceof edema within 48 hours. Satisfactory movementsof the implant were achieved for different gazes (Figs 4Aand B). No ocular discomfort or implant extrusion wasreported, following 6 months of follow-up (Fig. 4C).


There are various types of orbital implants available:Nonintegrated or solid implants [polymethyl methacrylate(PMMA), silicone], semi-integrated implants(Allen implant), integrated or porous implants (Cutler'simplant), bio-integrated implants (hydroxyapatite, porouspolyethylene), and biogenic implants (cancellous bone).


An Innovative Modified Orbital Implant in Enucleated Eyes for Postoperative Functionality and Cosmesis

An Innovative Modified Orbital Implant in EnucleatedEyes for Postoperative Functionality and Cosmesis
Figs 4A to C: (A) Postoperative day 1; (B) postoperative day 7; and (C) after 6 months

Nonintegrated implants do not allow integrationwith orbital structures or prosthesis; PMMA and siliconespheres are the commonest nonintegrated implants usedtoday.1 There is a recent trend of wrapping a PMMA orsilicone implant in donor sclera and attaching the extraocularmuscles to the sclera to provide better implantcentering and prosthesis motility.2

Hydroxyapatite, a complex calcium-phosphate salt,is a component of human bone. The porous hydroxyapatiteimplant allows fibrovascular ingrowth into itand gets incorporated into the orbital tissue, minimizingthe chance of displacement and extrusion as well asproviding better motility. Because of its rough surface,the implant needs to be wrapped in donor sclera or othermaterials.

Motility peg insertion provides an indirect attachmentof the orbital implant to the prosthesis, enhancingprosthesis motility.3 Pegging of hydroxyapatite implantcan sometimes be performed as early as 6 months afterinitial surgery in patients desirous of having a betterprosthesis motility, pending confirmation of vascularization.4 Pegging may, however, increase the risk of implantexposure and infection.5

Implant exposure seems to be a major complicationwith hydroxyapatite implant (1-15%).6 The results varyvastly due to variations in surgical procedure. Properimplant size and meticulous wound closure minimizethe risk of implant exposure.

Proper implant size is important. An implant thatprovides about 65 to 70% of volume replacement is ideal,the remaining 30 to 35% being contributed by the prosthesis.A recent trend is to use the axial length of the felloweye (axial length in mm2 = implant diameter in mm) tochoose the implant size.7

The advantages of implant wrapping include:Providing an additional barrier with reduced risk ofimplant exposure, enabling easy attachment of extraocularmuscles providing better prosthesis motility, entailinga smooth external surface making the process of implantinsertion easier, and helping in volume enhancement byadding 1 to 1.5 mm in the implant diameter.8

Most popular wrapping material is the donor sclera.Others include donor-processed pericardium and fascialata. Popular synthetic wrapping materials are polyglactin-910 mesh, poly-tetrafluoroethylene sheet,9 etc. Theuse of these synthetic wrapping materials significantlyraises the cost of surgery.

Present work had tried a monofilament polypropylenesurgical mesh as an alternative implant wrappingmaterial, which is used in herniorrhaphy procedures,with satisfactory postoperative results. Key advantageswere easy availability of the mesh and minimizing thecost of the implant.


In surgeries involving orbital implants, a monofilamentpolypropylene mesh can be used safely as an alternativeto other synthetic orbital implant wrapping material.In addition to the advantage of using a biointegratedimplant, the newly tried wrapping material economizesthe implant procedure.

  1. Van Acker E, De Potter P. Porous polyethylene (Medpor)orbital implant. Prospective study of 75 primary implantations.J Fr Ophtalmol 2001 Dec;24(10):1067-1073.
  2. Trichopoulos N, Augsburger JJ. Enucleation with unwrappedporous and nonporous orbital implants: a 15-year experience.Ophthal Plast Reconstr Surg 2005 Sep;21(5):331-336.
  3. Ashworth J, Brammar R, Inkster C, Leatherbarrow B. A studyof the hydroxyapatite orbital implant drilling procedure. Eye(Lond) 1998;12(Pt 1):37-42.
  4. Klapper SR, Jordan DR, Ells A, Grahovac S. Hydroxyapatiteorbital implant vascularization assessed by magneticresonance imaging. Ophthal Plast Reconstr Surg 2003Jan;19(1):46-52.
  5. Jordan DR, Chan S, Mawn L, Gilberg S, Dean T, Brownstein S,Hill VE. Complications associated with pegging hydroxyapatiteorbital implants. Ophthalmology 1999 Mar;106(3):505-512.

International Journal of Advanced & Integrated Medical Sciences, January-March, Vol 2, 201749

Surabhi Sinha et al

  1. Lin CJ, Liao SL, Jou JR, Kao SC, Hou PK, Chen MS.Complications of motility peg placement for porous hydroxyapatiteorbital implants. Br J Ophthalmol 2002 Apr;86(4):394-396.
  2. Kaltreider SA. The ideal ocular prosthesis: analysis of prostheticvolume. Ophthal Plast Reconstr Surg 2000 Sep;16(5):388-392.

  1. Arat YO, Shetlar DJ, Boniuk M. Bovine pericardium versushomologous sclera as a wrapping for hydroxyapatite orbitalimplants. Ophthal Plast Reconstr Surg 2003 May;19(3):189-193.
  2. Jordan DR, Klapper SR, Gilberg SM. The use of Vicryl mesh in200 porous orbital implants: a technique with few exposures.Ophthal Plast Reconstr Surg 2003 Jan;19(1):53-61.