Primary Orbital Implant Placement with Evisceration in Patients with Endophthalmitis

Primary Orbital Implant Placement with Evisceration in Patients with Endophthalmitis

by Steven C. Dresner, M.D., and James W. Karesh, M.D., September 2000

ABSTRACT

OBJECTIVE: To evaluate the efficacy of primary orbital implant placement with evisceration in patients with endophthalmitis and blind eyes.
DESIGN: Retrospective noncomparative case series.
PARTICIPANTS: Eleven patients with endophthalmitis and blind eyes underwent evisceration by two surgeons between 1994 and 1998.
INTERVENTION: Evisceration and primary orbital implant placement.
MAIN OUTCOME MEASURES: All patients were evaluated for implant exposure and successful fitting of their prostheses.
RESULTS: Ten of 11 patients had uneventful postoperative courses and successful prosthetic fitting. One patient with Pseudomonas aeruginosa endophthalmitis had an implant exposure successfully treated with a fascia lata patch.
CONCLUSIONS: Primary orbital implant placement with evisceration in patients with endophthalmitis is an acceptable treatment, eliminating the need for open evisceration and subsequent delayed orbital implant placement.

INTRODUCTION

Evisceration in patients with endophthalmitis with or without orbital implant placement has been advocated for well over 100 years.1 Because of a relatively high extrusion rate and the potential for sympathetic ophthalmia in the opposite eye, enucleation has been recommended in past years.2 In 1988 Shore et al3 recommended delayed primary closure with evisceration to minimize the risk of an implant extrusion after evisceration. Although delayed primary closure has certain theoretical advantages, primary implantation of orbital implants can avoid prolonged hospitalization and obviate the need for two surgeries. We report the results of 11 patients with endophthalmitis treated with evisceration and primary orbital implants.

PATIENTS AND METHODS

The records of consecutive patients who underwent evisceration for endophthalmitis by two surgeons (SCD and JWK) between 1994 and 1998 were reviewed. The cause of the endophthalmitis was documented, as well as the bacterial agents involved. All the patients were aggressively treated with topical, intracameral, or intravenous antibiotics before evisceration by the referring physicians. All patients underwent eviscerations in which a 360-degree conjunctival peritomy was performed followed by a full keratectomy. The uveal contents were removed with an evisceration spoon until all the pigment was scraped free of the scleral pocket. A 360-degree sclerotomy was performed around the optic nerve, and relaxing incisions were made in the sclera posteriorly between the extraocular muscles to enlarge the scleral pocket (Fig 1). Anterior sclerotomies were made between the 10 and 4 o’clock positions to allow insertion of an orbital implant. After implantation, the sclera was trimmed and closed followed by closure of Tenon’s capsule and conjunctiva. A conformer was placed and the eye was patched. Three patients had autogenous temporalis fascial grafts as an adjunct to the evisceration (Fig 2). One patient had reimplantation of the cornea to cover the anterior portion of the implant, and another patient had a posterior scleral button repositioned over the anterior portion of the implant. The implant type was noted, and any intraoperative or postoperative complications were noted. Possible contributing medical conditions were noted. Final prosthetic fitting in the absence of implant exposure was considered the end point of evaluation and a successful result (Fig 3).


Figure 1. A 360° sclerotomy is performed around the optic nerve and relaxing incisions are made in the sclera posteriorly between the extraocular muscles.


Figure 2. An autogenous fascial graft is sewn onto the anterior surface of a conical porous polyethylene implant.


Figure 3. 
A, pre-operative appearance of a 68 year old diabetic man with endophthalmitis in the right eye.
B, post-operative appearance after evisceration and primary orbital implant placement and successful prosthetic fitting.

RESULTS

A total of 11 patients who underwent evisceration in the presence of endophthalmitis were evaluated. Ten men and one woman were included in the study. There were three right eyes and eight left eyes involved.

The ages ranged between 67 and 84 years old. The mean age was 78 years.

Four patients had endophthalmitis develop after cataract extraction. One patient underwent combined cataract extraction and penetrating keratoplasty. One patient had a corneal ulcer develop after a penetrating keratoplasty and subsequently had endophthalmitis develop. One patient had endophthalmitis develop after a glaucoma filtering procedure. Four patients had corneal ulcers that perforated, leading to endophthalmitis. There were four diabetic patients in the study. Two of the four patients with corneal ulcers had diabetes and two of the postcataract patients had diabetes. None of the patients were immunocompromised. Two patients were infected with Staphylococcus aureus, one patient was infected with Serratia marcescens, one patient was infected with Morganella morganii, one patient had Streptococcus pneumoniae, and one patient was infected with Citrobacter koseri. One patient was infected with Pseudomonas aeruginosa. Four patients were culture negative.

Seven patients received 20-mm volume conical porous polyethylene implants. Two patients received 18-mm porous polyethylene spheres, and two patients received 16- and 18-mm methylmethacrylate spheres.
There was one implant exposure postoperatively in a diabetic patient with P. aeruginosa endophthalmitis. The porous polyethylene spherical implant was then successfully treated with a fascia lata graft and conjunctivoplasty. All the patients were successfully fitted with an ocular prosthesis.


Table 1.   Patient Characteristics

Patient
No.
Age/SexEyeEtiologyOrganism CulturedImplant TypeSurgical AdjunctsComplications
178/FOSCataract extraction and penetrating keratoplastyStaphylococcus aureus18-mm MM sphericalNoneNone
277/MODPenetrating keratoplasty
corneal ulcer
Serratia marcescens16-mm MM sphericalNoneNone
378/MOSCataract extractionStaphylococcus aureus18-mm PPE sphericalNoneNone
471/MOSCorneal ulcer (diabetes)Culture negative20-mm PPE conicalNoneNone
576/MOSCorneal ulcer (diabetes)Pseudomonas auruginosa18-mm PPE sphericalNoneImplant exposure
668/MODCataract extraction (diabetes)Culture negative

20-mm PPE conical

NoneNone
780/MOSCorneal ulcerCulture negative20-mm PPE conicalTemporalis fascia graftNone
878/MOSCataract extractionMorganella morganii20-mm PPE conicalTemporalis fascia graftNone
979/MOSGlaucoma filtering procedureStreptococcus pneumoniae20-mm PPE conicalCorneal transpositionNone
1085/MOSCataract extraction (diabetes)Citrobacter koseri20-mm PPE conicalTemporalis fascia graftNone
1167/MODCorneal ulcerCulture negative20-mm PPE conicalScleral button transpositionNone
MM = methylmethacrylate; OD = right eye; OS = left eye; PPE = porous polyethylene.

DISCUSSION

In medical history there are procedures that, once commonly performed, become less used only to become “rediscovered” when technology or techniques improve. Evisceration is such a procedure that has recently gained more interest and acceptance.4 Evisceration offers many advantages over enucleation, including improved postoperative fornices and implant motility, easier prosthetic fitting, and generally improved cosmesis.1,5

Green et al 6 in 1972 published an article describing four cases of sympathetic ophthalmia after evisceration. This report has given caution to those considering evisceration, leading many to prefer enucleation in blind eyes. In a recent report, Levine et al4 did not document any cases of sympathetic ophthalmia after evisceration in a large series from two centers. These authors emphasize the efficacy and safety of this procedure in the absence of intraocular tumor.

Before the introduction of modern antibiotics, enucleation in the presence of endophthalmitis was thought to increase the risk of postoperative meningitis.5,6 Although the risk of meningitis from enucleation is now deemed remote, there are still distinct surgical advantages to advocate evisceration in patients with endophthalmitis. These orbits and globes are usually markedly inflamed. Many of these patients have had multiple procedures such as cataract extraction followed by anterior chamber paracentesis or vitrectomy. Evisceration in this setting, beyond the previously mentioned advantages, is much more easily performed than enucleation. There is also less dissection, less bleeding, and less operating time.

In 1960, Hughes5 advocated simple evisceration without placing an alloplastic implant in cases of suppurative endophthalmitis. In 1988, Shore et al3 described delayed primary closure of eviscerations for endophthalmitis with secondary alloplastic implantation to prevent implant extrusion. This technique, however, may require prolonged hospitalization and necessitates two surgical procedures in a short interval.

Zolli2 reported a 22% extrusion rate of alloplastic implants after evisceration. This study, however, was before the advent of porous implants such as hydroxyapatite or porous polyethylene. Extrusion of orbital implants is less of an issue with these newer, porous implants, which allow fibrovascular ingrowth.8

Implant exposure, not extrusion, is a more likely complication with porous orbital implants.9 In this study, one of 11 patients had an implant exposure develop. This occurred in a diabetic patient with infection from P. aeruginosa. It is well known that Pseudomonas infections, because of the destructive proteases, can lead to scleral abscess and perforation. The proteases can cause relative antibiotic resistance and a tendency for the infection to recur after apparent remission.
Scleral abscesses may also develop in an area isolated from the original corneal scleral infection.10 The diabetes in this patient may also have contributed to the poor healing and subsequent exposure.

Five patients in the study had anterior scleral reinforcement to prevent exposure. Three patients underwent autogenous temporalis fascial grafts to the anterior surface of a porous polyethylene implant. One patient had reimplantation of the de-epithelialized and de-endothelialized cornea used as a barrier between the anterior scleral incision and the implant. A fifth patient had a posterior scleral button removed and transposed anteriorly over the implant. We believe that these techniques are worthwhile adjuncts to evisceration, ensuring against exposure. Perhaps the patient with Pseudomonas endophthalmitis could have avoided exposure if one of these techniques had been used. Nonautogenous materials such as banked sclera, fascia, or bovine pericardium could also be used. However, autogenous materials are preferable if available.11

Of note in this study, ten of 11 patients were men. In the largest study of endophthalmitis patients, there was no such predilection documented.12 Because of the small number of patients in this study, we cannot draw many conclusions from this unusual data.

Indeed, the incidence of sympathetic ophthalmia after evisceration is low.4 Sympathetic ophthalmia after evisceration for endogenous endophthalmitis has not been reported.3 We believe that unless the endophthalmitis is secondary to recent trauma, there is no need to enucleate. Evisceration is technically easier than enucleation in patients with endophthalmitis and may give better postoperative implant motility and improved cosmesis. Our experience with evisceration in patients with endophthalmitis suggests that primary orbital implant placement at the time of surgery is a viable technique and that delayed primary wound closure with secondary implantation in patients pretreated with antibiotics is unnecessary.7

Presented in part at the annual meeting of the American Academy of Ophthalmology, Orlando, Florida, October 1999.

REFERENCES

1. Burch FE. Evisceration of the globe with scleral implant and preservation of the cornea. Am J Ophthalmol 1940;34:272–82

2. Zolli CL. Implant extrusions in eviscerations. Ann Ophthalmol 1988;20:127–32, 135.

3. Shore J.W., Dieckert J.P., Levine M.R. Delayed primary wound closure. Use to prevent implant extrusion following evisceration for endophthalmitis. Arch Ophthalmol 1988;106:1303-1308.

4. Levine M.R., Pou C.R., Lash R.H. The 1998 Wendell Hughes Lecture. Evisceration. Ophthalmol Plast Reconstr Surg 1999;15:4-8.

5. Hughes W.L. Evisceration. Arch Ophthalmol 1960;63:36-40.

6. Green W.R., Maumenee A.E., Sanders T.E., Smith M.E. Sympathetic uveitis following evisceration. Trans Am Acad Ophthalmol Otolaryngol 1972;76:625-644.

7. Afran SI, Budenz DL, Albert DM. Does enucleation in the presence of endophthalmitis increase the risk of postoperative meningitis? Ophthalmology 1987;94:235–7.

8. Karesh JW, Dresner SC. High-density porous polyethylene (Medpor) as a successful anophthalmic socket implant. Ophthalmology 1994;101:1688–95; discussion 1695–6.

9. Kaltreider S.A., Newman S.A. Prevention and management of complications associated with the hydroxyapatite implant. Ophthalmol Plast Reconstr Surg 1996;12:18-31.

10. Codere F., Brownstein S., Jackson W.B. Pseudomonas aeruginosa scleritis. Am J Ophthalmol 1981;91:706-710.

11. Dresner S.C., Boyer D.S., Feinfield R.E. Autogenous fascial grafts with exposed retinal buckles. Arch Ophthalmol 1991;109:288-289.

12. Johnson M.W., Doft B.H., Kelsey S.F. , et. al. The Endophthalmitis Vitrectomy Study. Relationship between clinical presentation and microbiologic spectrum. Ophthalmology 1997;104:261-272.

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