Orbital Implant Surgery

Reconstructive surgery for patients undergoing the removal of an eye or for patients who already have an artificial eye (ocular prosthesis) Patients can now benefit from modern reconstructive surgery techniques to gain the best possible cosmetic results.

There are a variety of orbital implants which can now be used to achieve the best possible socket reconstruction for a patient who needs to undergo an enucleation or evisceration (removal of the eye) or who has already lost an eye and needs socket reconstructive surgery e.g. the hydroxyapatite orbital implant, the Medpor orbital implant and the bioceramic orbital implants. The most appropriate implant suited to your individual needs will be selected.

Might other surgical procedures be required?
This is always a possibility. Sometimes the size of implant used is insufficient to overcome a sunken appearance or hollow appearance in the upper eyelid. If this is unsatisfactory a second type of implant can be used. This is referred to as a subperiosteal implant and is placed beneath the lining of the bone at the outer aspect of the orbit through a small skin incision in the laughter lines at the outer corner of the eye under general anaesthesia or under local anaesthesia with sedation (“twilight anaesthesia”). Approximately 5% of patients require this. The implant most commonly used for this is Medpor (porous polyethylene).

Alternatively fat can be taken from the outer aspect of the thigh via a tiny stab incision and injected into the back of the socket to improve the appearance of the upper lid hollow. This is referred to as structural fat grafting or Coleman fat injections. The same technique is used to improve facial hollows and lines.

Another alternative is the injection of small expandable pellet implants. These expand to 4 times their injected size and provide additional socket volume.

Eyelid surgery to deal with a droop to the upper eyelid (ptosis) or sagging of the lower eyelid is occasionally required under local anaesthesia with sedation at a later date.

Are there any risks associated with this surgery?
No operation is free from risk. There are risks common to all operations performed under general anaesthesia. The risks are kept to an absolute minimum e.g. the risk of postoperative infection is minimised by a strict aseptic surgical technique and by the use of intraoperative and postoperative antibiotics.

How long will I be in hospital?
Usually you will be admitted on the day of surgery and discharged home the following day.

Occasionally a further night in hospital is required in the event of excessive sickness from general anaesthesia. It is wise to plan for a 2 night stay if you have far to travel home. Medicines are available which can reduce feelings of nausea.

How soon will I be able to return to work?
This very much depends on your individual circumstances and the type of work you do. Most people take at least the first week after surgery off. It is wise to take off more time if your work is not in a clean environment. You will be discharged home with a pressure dressing in place and a bandage around your head to keep bruising and swelling to a minimum. This should be kept in place for 2 days. When it is removed the eyelids may be quite bruised. Your eyelids will have been sewn together temporarily (a temporary suture tarsorrhaphy) with a blue nylon suture (stitch) which is tied over small clear silicone or red rubber bolsters. This is to prevent any prolapse of swollen tissue between the eyelids. The suture is removed at the first postoperative visit 2 weeks after the surgery.

The appearance of the socket can be camouflaged with dark glasses or with tape stuck over the lens of a pair of ordinary glasses. A temporary eye pad may be applied to go home with but this should not be worn continuously. Initially the upper lid will be droopy due to swelling but this will begin to rise within a few days.

How long will it be before I get my new artificial eye?
The socket has to heal fully before a new artificial eye is fitted. This usually takes a minimum of 8 weeks. If all is well after surgery your ocularist may proceed with fitting arrangements. Please take note that the time this process takes may be longer depending on your own postoperative progress and the demands made on the service.

At 2-3 weeks after surgery a visit may be required for a surgical conformer to be fitted by your ocularist. This is like an artificial eye but it is made of clear plastic with 2 drainage holes. This is inserted into the socket to prevent shrinkage. A conformer may have been fitted in the operating theatre but the ocularist may exchange this for another as the shape of the socket can change with postoperative swelling.

Your artificial eye
This will be made by your Ocularist. Each artificial eye (ocular prosthesis) is specially made for you, to fit your individually shaped socket and to conform to the shape of your irnplant. It will be hand painted in your presence to match your natural eye colouring. There will be no pain during the procedures and anaesthetics will not be necessary. You will be required to return for three separate appointments:

First appointment
An impression is obtained of your socket by introducing cream which will set to a very soft, rubbery consistency and will record the shape of your socket. A painting to match your remaining eye is usually made at this stage. This is competed in your presence to obtain the best possible colour match. This appointment usually lasts one hour.

Second appointment
A wax pattern will by now have been produced to fit the plaster model resulting from the impression of your socket obtained during your first appointment. This wax pattern will be tried in the socket and modified by careful sculpturing until an ideal compromise between fit, comfort, mobility, lid-line and contour is achieved. Lastly, the iris/cornea unit is positioned to match the remaining natural eye. This appointment will take about one hour.

Third appointment
This is usually a simple matter of collecting your artificial eye prosthesis. There may be some minor adjustments necessary.

Cleaning
Your artificial eye need only be cleaned occasionally. You may sleep with your artificial eye in. In fact it is advisable to do so. However, when it is removed, it should be cleaned by using hard contact lens cleaner, as the most common problem is irritation and watering caused by a protein build up.

If not cleaned correctly this protein will collect upon the surface of the artificial eye as a crystalline coating which will eventually make the artificial eye feel gritty. The socket lining and the inner surface of the eyelids may become inflamed and sore with discharge in extreme cases.

It is also important to use artificial tear supplements 3-4 times a day and at bedtime. The best drops to use are SYSTANE eye drops.

Annual check ups and replacements
You are advised to return annually for a check up when any small fitting changes will be assessed and your artificial eye will be re-polished to remove deposits and any scratches. You will be advised when your prosthesis needs to be replaced. This can be required every two to five years as your body is constantly changing but this time-scale varies considerably from patient to patient.

Before Surgery

1. Discontinue the use of aspirin and products containing aspirin e.g. Anadin, and any anti-inflammatory medicines e.g. Indomethacin, Ibuprofen, Diclofenac, Nurofen, for three weeks before your scheduled surgery unless instructed otherwise.
2. As your operation is planned to be done under a general anaesthetic (when you will be asleep), you may have some blood tests done and an ECG (heart tracing) prior to surgery. Please bring all your tablets/medications in their original, labelled bottles. Also provide information on any known allergies.
3. It is important that you follow instructions about food and drink prior to surgery (you should have nothing to eat or drink for 6 hours prior to the time of your surgery).

After Surgery

1. You will awaken in the recovery room in the theatre.
2. You will be returned to the ward usually after a period of up to 30 minutes in the recovery room.
3. You may go to the bathroom with assistance.
4. Your usual medications may be continued. Resume aspirin, blood thinners, and arthritis medications 72 hours after surgery unless otherwise instructed.
5. You may experience difficulty wearing your glasses because of the dressings.
6. If a graft was taken from your lower lip use Difflam mouthwash 4-5 times a day and eat a soft diet. Avoid hot drinks for at least 2 weeks.
7. You will be given antibiotics to take postoperatively, usually Cephalexin 500mg twice a day (or Erythromycin if you are allergic to Penicillin) for 7 days. Please ensure that you complete the course and do not omit a dose.
8. You will also be given a 2 week course of anti-inflammatory tablets, Diclofenac 50mg 3 times a day. You should not take these if you have a history of ulcer problems or if you experience heartburn. These should be taken with food. They also act as a painkiller. You may also be prescribed Kapeke tablets to take home. These are quite strong painkillers. If simple analgesics are sufficient use these instead.
9. Apply antibiotic ointment three times a day to the edges of the eyelids and the bolsters for 2 weeks after the dressings have been removed. Use sterile cotton wool balls and saline to keep the eyelids clean of any discharge 2-3 times a day. This will be changed to antibiotic eye drops as soon as the temporary stitch has been removed.
10. The stitches used to close the wound in the socket are absorbable and will drop out in 3-4 weeks.
11. It may be necessary to remove and clean your conformer. You will be shown how to do this.

Consultants who undertake this procedure:

Saj Ataullah
Anne Cook
Brian Leatherbarrow
Ahmed Sadiq