|Year : 2014 | Volume
| Issue : 2 | Page : 193-195
Autologous serum for anterior tissue necrosis after porous orbital implant
Saurabh Kamal, Sushil Kumar, Ruchi Goel
Ophthalmic Plastic Surgery Services, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||1-Apr-2014|
MS, 2180, Sector 28, Faridabad, Haryana - 121 008
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Orbital implants are now routinely used after enucleation and evisceration. However exposure of the implant can lead to infection and extrusion. Hence, early repair of larger exposure with graft material is required. We describe three cases where early postoperative mucosal dehiscence was successfully managed with autologous serum.
Keywords: Conjunctiva, Enucleation, Evisceration, Ocular Prosthesis, Orbital Implant Exposure
|How to cite this article:|
Kamal S, Kumar S, Goel R. Autologous serum for anterior tissue necrosis after porous orbital implant. Middle East Afr J Ophthalmol 2014;21:193-5
|How to cite this URL:|
Kamal S, Kumar S, Goel R. Autologous serum for anterior tissue necrosis after porous orbital implant. Middle East Afr J Ophthalmol [serial online] 2014 [cited 2019 Aug 25];21:193-5. Available from: http://www.meajo.org/text.asp?2014/21/2/193/129776
| Introduction|| |
Orbital implants have been successfully used for replacing volume loss during eye removal. Various modifications in surgical technique for preventing implant exposure, migration and extrusion have been reported but the incidence may be as high as 4.9-8.1% requiring repair using different graft materials. 
We describe three cases with postoperative conjunctival dehiscence and necrosis over the anterior surface of an implant and the novel use of autologous serum (AS) drops which resulted in complete healing, preventing exposure of the implant.
| Case Reports|| |
A 28-year-male with history of right post-traumatic phthisis bulbi presented with complaints of progressive difficulty in placing the prosthesis in the socket and enophthalmos. On examination, all the conjunctival fornices were shallow along with deep supratarsal sulcus deformity. As globe size was very small with foreshortened conjunctival fornices, enucleation with placement of donor sclera wrapped hydroxyapatite (HA) implant (20 mm) and surface area augmentation with buccal mucosa was performed. Postoperative treatment included local hygiene, topical (tobramycin 0.3% eye drop q.i.d.) and systemic antibiotics (oral ciprofloxacin 500 mg b.i.d.). At 1 week postoperatively, pallor and necrosis of the buccal mucosa in the central area was noted, which progressed over 24 hours [Figure 1]a. A swab sample revealed no infection. After informed consent, the patient was administered 20% AS in balanced salt solution (BSS) under standard aseptic condition. The solution was instilled over the graft at least 10 times a day. After five days of AS use, there was significant decrease in the area of central necrosis [Figure 1]b. Complete healing occurred after 2 weeks of AS use [Figure 1]c, which was continued for an additional week. At 3 months postoperatively, scarring in area of previous necrosis was present but the fornices were well formed and the implant well encapsulated [Figure 1]d.
|Figure 1: (Case 1) (a) Buccal mucosa necrosis at the 6th postoperative day; (b) Response after 5 days of treatment with 20% autologous serum; (c) Complete healing after 2 weeks; (d) Well encapsulated implant at 3 months (note the scar medially)|
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A 56-year-male underwent evisceration of the right eye for a bleeding anterior staphyloma. After adequate anterior and posterior sclerotomies, an 18 mm HA implant was placed in the scleral cavity and covered with double layer of sclera anteriorly. Meticulous closure of Tenon's fascia and conjunctiva was performed, along with placement of an adequately sized conformer. Five days postoperatively, rapidly progressing central conjunctival dehiscence with necrosis of the conjunctiva was observed [Figure 2]a. Ocular pain, discharge or swelling was absent, and conjunctival swab culture was sterile. AS 20% was prepared in BSS and instilled 10 times a day. After 24 h of AS use, there was noticeable decrease in the area of conjunctival defect and necrosis [Figure 2]b, and complete conjunctival healing occurred after one week of treatment but there was atrophic Tenon's fascia anteriorly [Figure 2]c. At 4 months post-treatment, conjunctiva and Tenon's fascia were healthy with a well encapsulated implant [Figure 2]d.
|Figure 2: (Case 2) (a) Conjunctival dehiscence/necrosis at 5th day postoperative; (b) Decrease in necrosis after 24 hours with use of 20% autologous serum; (c) Conjunctival healing with atrophic Tenon's after one week; (d) Healthy conjunctiva-Tenon's at 4 months|
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A 32-year-male presented with a bleeding anterior staphyloma in the left eye. Evisceration with 20 mm HA implant was performed after anterior and posterior sclerotomies. At one week postoperatively, conjunctival dehiscence and necrosis was observed [Figure 3]a. AS (20%) in BSS was instilled 10 times a day over the conjunctival dehiscence. After 2 days of AS use there was significant decrease in the area of necrosis with complete healing occurring after one week [Figure 3]b and c. Therapy with AS was continued further for one week. At 4 months of follow up, the implant was well encapsulated [Figure 3]d.
|Figure 3: (Case 3) (a) Central conjunctival necrosis at 1 week postoperative; (b) Response after 2 days of 20% autologous serum treatment; (c) Healing after 1 week treatment; (d) Healthy socket at 4 months postoperatively|
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In all 3 cases, the patients underwent an informed consent procedure and principles of Declaration of Helsinki were followed.
| Discussion|| |
Conventional treatment of implant exposure includes repair using different materials such as scleral patch, hard palate mucosa, dermis fat graft (DFG), buccal mucosa, temporalis fascia or amniotic membrane.  AS drops have been recommended for the treatment of severe dry eye, superior limbal kerato-conjunctivitis, recurrent corneal erosion syndrome, persistent epithelial defects, supportive measure in ocular surface reconstruction, leaking blebs and refractive surgery.  It contains various growth factors, which accelerates migration of epithelial cell, and has anti-apoptotic and bactericidal effects.
In our series we observed necrosis and dehiscence of buccal mucosa (Case 1) and conjunctiva (Case 2, 3) with exposure of underlying sclera in the early postoperative period. Generally, the conjunctiva grows over exposed implant without intervention. But in the cases presented here, there was a progressive increase in the area of dehiscence. Tenon's capsule and conjunctiva are relatively avascular but the orbital tissues and extraocular muscles are well vascularized.  A more vascularized posterior socket was unable to provide sufficient vascular supply to the anterior layers due to placement of the implant. Conjunctival dehiscence is prone to infection and further progression may have resulted in exposure of the HA implant. As the sclera was intact beneath Tenon's, the rough surface of HA was not the cause of conjunctival dehiscence.
Using AS drops in our patient resulted in rapid healing and can be attributed to the presence of various growth factors such as epithelial growth factor, vascular endothelial growth factor, nerve growth factor, transformer growth fibroblast β-factor, fibronectin and vitamin A.  These growth factors accelerate migration of epithelial cells, repair of epithelial and stromal processes. Proteins such as albumin have anti-apoptotic activity, while α2 macroglobulin has anti-collagenase activity. AS also contains various immunoglobulins e.g. IgG, IgA and lysozyme that provide bacteriostatic and bactericidal effects. Quality control issues with AS includes proper storage (at 4° C) and the risk of microbial contamination. Transmission of infection can occur if serum from the donor is utilized and therefore serology for blood-borne diseases should be performed prior to use. AS, for the current cases, was prepared using the patients own blood which was allowed to clot for 2 hours. This was followed by centrifugation at 3000 g for 20 min. The serum was diluted with BSS to make a 20% concentration of AS.
AS have been used for the treatment of ulcerated DFG with complete resolution in 3 weeks.  Kim and associates studied the effect of AS on the conjunctivalization of exposed porous polyethylene implants in a rabbit model.  Although there was no statistical difference between the AS group and the control group, but there was a more rapid conjunctival growth rate with higher complete healing rate in cases treated with AS. In a real clinical situation, the actual non-healing defect in humans may be different from that left during primary closure along with different healing patterns between humans and rabbits.
The primary shortcoming of our case series is the lack of a comparison. All three cases were on topical antibiotic (tobramycin 0.03% q.i.d.) and routine systemic antibiotic (oral ciprofloxacin 500 mg b.i.d.) postoperatively for one week. Although conjunctival swab culture was negative in all cases, use of antibiotic could have a confounding effect on healing. However the arrest of progression and the prompt response that was observed with AS suggests a causal relationship. The use of AS in our cases promoted the healing of conjunctival dehiscence and necrosis observed during the early postoperative period and prevented the exposure of the HA implant. Other probable uses could include prevention of exposure in cases with previous ocular surgery, trauma, or secondary implantation, where insufficient vascularization is anticipated. The use of AS in such situations may obviate the need for surgical intervention. However, the role of AS in late exposure of implant, which occurs due to constant abrasion of conjunctiva by irregular surface, would require further reports.
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[Figure 1], [Figure 2], [Figure 3]