British Journal of Ophthalmology 1995; 79: 830-833

Use of Proplast II as a subperiosteal implant forthe correction of anophthalmic enophthalmos

S Shah, M Rhatigan, R Sampath, C Yeoman, S Sunderland, R Brammer,B Leatherbarrow

AbstractBackground-A variety of autogenousand alloplastic materials have been usedas subperiosteal implants to correctanophthalmic enophthalmos. Proplast IIis a synthetic porous composite of Teflonpolymer and alumina. Proplast II offers anumber of advantages over other com-monly used alloplastic materials such assilicone and polymethyl methacrylate. Itis light, porous, resilient, malleable, andeasy to shape. It can be readily sterilisedafter shaping. It has been found to inte-grate with the surrounding tissues,thereby minimising the risk ofsubsequentimplant migration and extrusion.Methods-Proplast II was used as asubperiosteal implant in a total of 15anophthalmic patients during the periodJune 1990 to March 1994. The indicationfor this procedure in all patients was poororbital volume replacement despite theprior insertion of an adequately sizedspherical socket implant.Results-The results were excelient with agood correction of preoperative uppereyelid sulcus deformity. There were nooperative complications nor any seriouspostoperative complications. The implantswere well tolerated.Conclusion-Proplast II can be highlyrecommended for use as a subperiostealimplant.(BrJ Ophthalmol 1995; 79: 830-833)

Manchester Royal EyeHospital, OxfordRoad, ManchesterS ShahM RhatiganC YeomanS SunderlandR BrammerB Leatherbarrow

Moorfields EyeHospital, City Road,LondonR Sampath

Correspondence to:Mr B Leatherbarrow,Manchester Royal EyeHospital, Oxford Road,Manchester Ml 3 9WH.

Accepted for publication24 May 1995

Anophthalmic patients are often found to bevolume deficient even after placement ofan ade-quately sized orbital implant. This can lead topoor cosmesis owing to the developmentof a deep upper lid sulcus deformity or

upper lid retraction and enophthalmos (thepost-enucleation socket syndrome). Variousmaterials have been used to replace this lostvolume (inserted into different orbital spaces) -

for example, autologous or homologous bone,1cartilage,2 dermal grafts,' glass beads,3 plasticplate,4 and more recently silicone,5-7 andProplast 1.8We describe the use of Proplast II for the

correction of this upper lid sulcus deformityand enophthalmos with a preshaped implantinserted into the inferior subperiosteal spacevia a lateral canthal approach.7 9

Patients and methodsDuring the period June 1990 to March 1994,15 anophthalmic patients underwent surgery

consisting of implantation of Proplast II intothe subperiosteal space of the floor of the orbit.The patients were selected for surgery on thebasis of poor cosmesis owing to the presence ofa deep upper lid sulcus and enophthalmosdespite the presence of an adequately sizedspherical socket implant. All the patients wereseeking an improvement in their cosmeticappearance.Nine patients were male and six female. The

age range was 27 to 66 years with a mean of 46years. Six of the patients had undergone anenucleation with placement of a primaryimplant. The other nine patients had pre-viously undergone a simple enucleation withthe later placement of a secondary implant. Ofthese implants, 10 were baseball implants andfive hydroxyapatite implants. The conditionleading to enucleation was trauma in 11 cases,choroidal melanoma in one case, and con-genital glaucoma with the development of ablind painful eye in three cases. There were nopreoperative complicating factors. None of thepatients had a missed orbital fracture as thecause of the residual volume deficit. Noneof the patients had a contracted socket.The surgery was performed under generalanaesthesia in all cases.

Surgical techniqueThe Proplast implant is fashioned by theocularist, before surgery. A wax mould of anorbital floor is prepared using an adult maleskull with average orbital dimensions. Themould is used as a template for the implantwhich is carved from a Proplast II block, thedimensions of each block being 60X40X10mm. Each block will provide two implants.The block is carved using a scalpel in a cleanfield. As this material is easy to carve, it can beshaped to give maximum thickness posteriorlywhile allowing the edge which lies along theinferior orbital rim to be less than 1 mm inthickness. This obviates the need for removaland debulking of the implant, and because ofthe material's low modulus of elasticity thisedge can be moulded slightly around the rimwithout any springing. When finished theProplast implant weighs about one third of asimilarly sized silicone implant. Steam sterilisa-tion is performed in a standard gravity steriliserfor 30 minutes at 121°C and 1-5 kg/cm2. It isimportant that at no time should unglovedhands come into contact with the implant, as itwill absorb the skin's natural oils rendering theimplant useless.A skin incision is marked beginning at the

lateral canthus and extending laterally and

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Use ofProplast II as a subpeniosteal implantfor the correction of anophthalmic enophthalmos

Figure 1 Proplast II within syringe, impregnated withgentamicin.

slightly downwards for a distance of approxi-mately 2 5 cm (a similar approach to that usedby Rose et a17).A skin incision is made using a number 15

Baird-Parker blade along the line marked....The underlying orbicularis oculi muscle isbluntly dissected in a vertical fashion usingSteven's scissors down to the lateral orbital rimwhich is then exposed using a Freer periostealelevator. The periosteum of the lateral orbitalrim is incised vertically 3 mm beyond thelateral orbital rim and the periosteum iselevated from the underlying bone using the

_IMRMM

Figure 2 Insertion ofProplast II into subperiosteal space.

Freer periosteal elevator. The periosteum iselevated from the inferolateral orbital wall andthe orbital floor. The zygomaticofacial arteryand vein are identified and cauterised. Oncethe space created is large enough to accommo-date the implant, the implant is divided in twolengthways using a number 15 Baird-Parkerblade. The implant is impregnated with agentamicin and saline solution (80 mg in50 ml) by inserting the two pieces into a 50 mlsyringe and alternately depressing and with-drawing the plunger, expelling the air fromimplant (Fig 1). The two pieces are thenplaced into the subperiosteal space to lie sideby side on the orbital floor (Fig 2). A no touchtechnique is observed during manipulation ofthe implant. Once the position of the implant issatisfactory, the periosteum is closed usinginterrupted 5/0 Vicryl sutures on a half circleneedle. If the lower lid has excessive laxity, alateral tarsal strip procedure1o can be per-formed at this stage. The muscle layer is closedusing the same suture. The skin edges arereapproximated using interrupted 7/0 Vicrylsutures. Topical antibiotic ointment is appliedto the wound and the patient receives a 1 weekcourse of systemic antibiotics.

ResultsAll 15 patients tolerated the procedure wellwith no intraoperative complications. Therewere no immediate postoperative complica-tions, in particular, orbital haemorrhage andinfection did not occur. Postoperative pain waseasily controlled with simple analgesics only.During the follow up period (ranging from 3months to 4 years), two minor postoperativecomplications were noted. One patient devel-oped a wound inclusion cyst some monthsafter surgery which was excised without furtherproblem. One patient continues to have mildinfraorbital hypoaesthesia at 3 months' followup. In no case did extrusion or migration ofthe implant occur. Three patients required alateral tarsal strip procedure to correct lowerlid laxity. In six of the other patients this hadbeen performed at the time of implanta-tion. One further patient required a levatoraponeurosis advancement. All patients had amarked increase in orbital volume, as shown bythe improvement in the degree of enophthal-mos, the loss of the upper lid sulcus deformityor upper lid retraction, and by the reduction insize of the required prosthesis (Figs 3A and 3B,4A and 4B). All 15 patients were pleased withthe improvement in their cosmetic appearance.

DiscussionProplast was originally used as a composite ofpolytetrafluoroethylene (PTFE) and vitreouscarbon fibres (Proplast I) by Homsy et al I I in1970. It has been used extensively'2 for 20years in orthopaedic,'3 otolaryngotic,'4 andoral surgery.'5 It was described in ophthalmol-ogy by Lyall'6 in 1976 (as orbital implantsfollowing enucleation) and Lamberts andGrandon'7 in 1978 (as a keratoprosthesis). Itwas used by Bello and Levine'8 in 1980 (direct

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Shah, Rhatigan, Sampath, Yeoman, Sunderland, Brammer, Leatherbarrow

Figure 4A

Figure 3A

t

Figure 4B

Figure 4 Example 2: appearance before (A) and after(B) surgery.

Figure 3B

Figure 3 Example 1: appearance before (A) and after(B) surgery.

insertion of Proplast I into the superior sulcus)and Ma et al 19 in 1987 (subperiosteally via aninfraciliary approach in addition to a Spivey-Allen acrylic floor implant in two out of fourcases) for correction of superior sulcus defor-mities. To our knowledge, this is the firstdescription of Proplast II being used to correctthe superior sulcus deformity of the anoph-thalmic socket via a lateral canthal approach.Proplast II is a white composite (Proplast I wasgrey) of PTFE and alumina. Physically it is

very light with a porosity of 70-90% of thevolume of the material. The pore size variesfrom 50-400 ,um.20 It is malleable, easy tohandle, and it can be shaped with scissors or aknife. It is well tolerated, and integrates withthe surrounding tissues by fibrous ingrowth.Thus it is very stable with a very low risk ofmigration or extrusion. It is inert, non-toxic,and non-biodegradable.

Orbital implants do not replace all of theorbital volume deficiency following enucle-ation. A 14 mm diameter sphere replaces 1-4ml, and 18 mm sphere replaces 3 0 ml, and a20 mm sphere replaces 4-2 ml. The totalvolume loss depends on the volume of theglobe and any associated orbital fat atrophy.This averages approximately 7-0 ml.

Previous materials used for management ofthe superior sulcus deformity of the anoph-thalmic socket have to be harvested if they areautologous or homologous and do not have acompletely predictable effect on orbital volume.Other material such as glass beads and plasticplates are likely to be extruded. The advantages

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Use of Proplast II as a subperiosteal implantfor the correction of anophthalmic enophthalmos

and disadvantages of silicone have beenreported extensively.7 21 22 Silicone does notstabilise because tissue ingrowth cannot occur.The implant moves with even the slightest pres-sure; this movement can result in extrusion ofthe implant. Proplast I had been shown to causesecondary conjunctival melanosis23 and, as it isgrey, may become visible through thinnedtissues. It has been superseded by Proplast 11.24We believe Proplast II offers a number of signifi-cant advantages over other available materialsfor the management of a deep upper lid sulcusdeformity and is extremely well tolerated with-out the risk of extrusion.

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in orientals. BrJ Plast Surg 1980; 4: 79.22 Shirakabe Y, Shirakabe T, Takayanagi S. A new type of

prostheses for augmentation rhinoplasty: our experiencein 1600 cases. BrJ PlastSurg 1981; 34: 353.

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