Consider volume augmentation in PESS

Austin, TX-Volume loss is an important aspect of post-enucleation socket syndrome (PESS), resulting from the inability of the prosthetic orbital implant to replace all of the volume lost from an enucleated or eviscerated socket. Fortunately, there are a number of effective techniques for volume augmentation in PESS, said John Shore, MD, FACS, who is in practice with Texas Oculoplastic Consultants, Austin, TX.

PESS is a constellation of physical findings seen in an ophthalmic patient following the loss of an eye and subsequent fitting and wear of an ocular prosthesis. Volume loss is a key part of the syndrome and is due both to the removal of the eye and to the shrinkage of soft tissue from trauma, surgery, or radiation, Dr. Shore explained during a lecture at a combined meeting of the American Academy of Ophthalmology and the American Society of Ocularists.

This volume loss manifests as an apparent enophthalmos, contributing to the appearance of ptosis, sulcus deformity, the narrowing of the palpebral aperture-possibly coupled with poor motility-and relative laxity of the lower eyelid.

Treatment options for volume loss include enlargement of the prosthesis, tightening of the lower eyelid, removal and replacement of the implant, augmentation of the orbital floor, filling out the superior sulcus, or a combination of these approaches.

"Enlargement of the prosthesis has several advantages," Dr. Shore said. "It's easy, nonsurgical, reversible, and you can correct ptosis with it. But of course it may lead to inability to close the eye, aggravation of the dryness, and stretching of the lower eyelid. It's good up to a point, but we can't overdo it. Enlargement of the prosthesis will help in minimal volume disparity, but it may be a temporary fix and we may have to consider more aggressive surgical options.

"Likewise, tightening of the lower eyelid for volume correction is only a temporary fix," Dr. Shore said. "It's ineffective in isolation, and it's best if it's combined with other surgical or nonsurgical procedures such as placement of a larger implant coupled perhaps with an adjustment of the size of the prosthesis or volume augmentation along the orbital floor."

Replacing orbit implants Removal and replacement of the orbital implant has several advantages, a main one being that it addresses the underlying problem in many cases in which an undersized implant was initially placed, he said. With this procedure, the surgeon can substitute a porous implant for a nonporous one and attach muscles late, which can enhance motility. However, it requires a conjunctival incision that can lead to surgical problems and complicate the wear of the prosthesis.

"When the implant needs to be replaced with a larger one, that's a good solution but not the only solution," he added. "And naturally when you have other associated problems such as extrusion, infection, or exposures, it provides the opportunity to replace the implant and correct the volume at the same time."

Dr. Shore added that removal and replacement of an implant should be done only when there is a clear reason, such as an implant that is too small or not centered, the overlying tissue is thin, or there is already evidence of exposure or impending extrusion.

"That's a reason to address the volume correction," he said.

He recommended that a porous implant be used if an exchange is performed. If a nonporous implant is used, the surgeon should consider wrapping it.

Augmentation of orbital floor Augmentation of the orbital floor is an established technique and one of the better methods of addressing volume disparity, according to Dr. Shore. With this technique, the surgeon can make a safe incision that does not result in conjunctival shrinkage if it is made in the correct location; adequately tailor the volume necessary to fill the disparity; lift the implant so that a shift in position can be corrected; and avoid dissection deep in the socket and the potential nerve or muscle damage during implant exchange.