A rare late complication of silicone orbital implant

Cover Page

Abstract


This study describes clinical and radiological implications as well as early surgical treatment results of a rare and late complication of a nonporous silicone orbital implant, in particular its encapsulation with the formation of an inclusion cyst.


BACKGROUND

The formation of an inclusion cyst around implants made of nonporous polymers (silicone [7, 22, 35, 37, 38], and less often Teflon [17, 27] and supramid [34]) is a rare late complication following orbital floor reconstruction. We present a description of such a case encountered in our clinical practice.

Patient B, 31 years old, sought medical assistance due to visual impairment, double vision, orbital congestion feeling, and moderate pain radiating to the frontal, temporal, and parietal regions for 2 months. The disease history showed that in 2004, the patient underwent a surgical procedure in one of the hospitals of the Russian Ministry of Defense due to a blow-out fracture of the right orbital floor.

Upon physical examination, chemosis of the inferior palpebral sulcus, hypertrophy, proptosis, restricted eyeball repositioning into the orbit, and obvious oculomotor disorders were detected (fig. 1, a-c).

 

Fig. 1. Preoperative patient examination: a) Elevation of the globe (horizontal line), b) exophthalmos (horizontal line), c) restriction of the ipsilateral eye elevation, d–f) implant (big arrow) on the inferior orbital wall enclosed in pseudocapsule (small arrows). Mass lesion at the orbital roof (d) results in the elevation of the globe and increased intraocular pressure. Distance between the sclera and orbital roof (asterisk) significantly differs between the sides

 

A CT scan showed a mass lesion with relatively sharp borders and a soft tissue mass around the implant. It was located near the inferior orbital wall, and displaced the eyeball upward [10, 13] (fig. 1, d-f).

The investigation included differential diagnosis with inflammatory (infection of the implant and subsequent cellulitis) and vascular (varicose veins and carotid cavernous fistula) orbit disorders as well as mucocele and sino-orbital fistula [36].

Hemorrhagic fluid, typical for this condition, was obtained by diagnostic puncture [10, 11, 21, 25, 26]. No microorganisms were detected at bacteriological examination.

A thick pseudocapsule was found around the monolithic silicone implant at orbitotomy (fig. 2). The implant was removed after puncture of the subcapsular space and aspiration of hemorrhagic fluid (1 ml) and after partial excision of the pseudocapsule (without opening the cavity of paranasal sinuses [8, 26]). Explantation of the monolithic implant did not cause any technical difficulties. Orbital floor defect being already replaced by a new tissue and covered by a thick pseudocapsule, as expected, removal of the implant caused neither functional disorders nor cosmetic defects, [4, 17].

 

Fig. 2. Surgical technique: a) Chemosis of the inferior palpebral sulcus; b) blood clot in the subcapsular space; c) hole in the anterior capsule; d, e) explantation (d) of the silicon plate (e); f) removal of the pseudocapsule; g, h) final stages  

 

 

No complications were observed during the procedure and postoperative period (fig. 2; 3, a, b). After a course of antibacterial and anti-inflammatory therapy, the patient was discharged and followed-up by maxillofacial surgeons and ophthalmologists at the Saint-Petersburg Multifield Hospital No. 2. By the end of the first month after surgery, expected mild enophthalmos and hypophthalmos (fig. 3, c, d), considered as reasons for a 6-month delay of additional implantation of porous polytetrafluoroethylene into the orbit, became less obvious, partially due to the mild retraction of the inferior eyelid of the right eye (Fig. 4).

 

Fig. 3. Postoperative examination: a, b) Postoperative swelling of the lower eyelid (a, arrows) and mild restriction of the right eye elevation (b, horizontal line) next day after surgery, c, d) increased inferior palpebral sulcus (arrows) indicates enophthalmos after the swelling of the orbital fat has resolved (days 10 and 12), e) coronal CT demonstrates thickening of the lower muscle complex (arrow), f) sagittal CT shows the fracture line adjacent to the thick pseudocapsule of the implant

 

Fig. 4. Clinical photograph 1 month after surgery: a) Minimal enophthalmos (1 mm horizontal line through the center of the pupil of the contralateral eye), b) absence of the axial globe displacement (eno- and exophthalmos) (horizontal line), c) restored eye elevation

  

A histological examination of the excised tissue showed an epithelial lining at the silicone-facing surface of the pseudocapsule.

DISCUSSION

Until recently, monolithic silicone was the primary non-biological material for orbital floor reconstruction because of its biocompatibility, chemical stability, and availability [2, 3, 7, 14, 32, 33, 39].

However, this class of implants is unable to generate new connective tissue formation, and this may cause several complications such as migration under the skin of the inferior eyelid, into the nasal cavity, or into the maxillary sinus; rejection [5, 16, 24, 27, 29]; and infection of the material [20]. The use of monolithic implants in the presence of traumatic fistula with maxillary sinus is particularly dangerous because of suppurative complications [19].

The chronic character of perifocal inflammatory reaction, which prevents osteogenesis in the bone defect area, is another serious disadvantage of silicone [12, 30]. Silicone causes bone resorption when placed for a long period at the orbital floor. As a result, 70% of patients have the maxillary sinus involved in the pathological process.

The complication described above is quite rare, because it requires the formation of a pseudocapsule (cyst) around the implant, which is lined with one of the following types of epithelium: non-keratinized stratified squamous epithelium (introduced into the orbit through transconjunctival access), keratinized stratified squamous epithelium (introduced through transcutaneous access), or ciliated respiratory epithelium (introduced during the elevation of soft tissues, prolapsed into the maxillary sinus) [18, 23, 28, 37, 38].

Implant encapsulation results in recurrent hemorrhage into the subcapsular space, persistent diplopia, and vertical and axial dystopia and formation of a cutaneous or sino-orbital fistula and cellulitis [35].

Twenty-year follow-up showed that the removal of silicone implants due to complications was required in 13 %-14 % of cases [31]. On average, explantation was performed 4.3 years after osteoplasty, although complications may develop 10, 15, and even 25 years later [5, 9, 40]. The high frequency of late complications has encouraged many clinicians to avoid silicon use of in favor of other synthetic porous materials [1, 6, 15]. A high level of biocompatibility, no risk for infection transmission, well-established manufacturing process, and acceptable costs have made porous polymers the primary material for orbital floor reconstruction.

Genrikh A Khatskevitch

Saint Petersburg City Hospital No 2

Author for correspondence.
Email: genrih15@gmail.com

Russian Federation

MD, PhD, professor. Head of Department of Pediatric Dentistry

Mikhail M Soloviev

Saint Petersburg City Hospital No 2

Email: mmsolovyov@mail.ru

Russian Federation

MD, PhD, assistant professor of Department of Pediatric Dentistry

Tatiana L Onokhova

Saint Petersburg City Hospital No 2

Email: tanyaonokhova@gmail.com

Russian Federation

maxillo-facial surgeon

Vadim P Nikolaenko

Saint Petersburg City Hospital No 2

Email: dr.nikolaenko@mail.ru

Russian Federation

MD, PhD

Tatiana Yu Panova

Saint Petersburg City Hospital No 2

Email: dr.panovatu@gmail.com

Russian Federation

ophthalmic surgeon of Ophthalmology department

  1. Астахов Ю.С., Николаенко В.П., Дьяков В.Е. Использование политетрафторэтиленовых имплантатов в офтальмохирургии. — СПб.: Фолиант, 2007. — 256 с. [Astakhov YS, Nikolaenko VP, D’yakov VE. Ispol’zovanie politetraftoretilenovykh implantatov v oftal’mokhirurgii. Saint Petersburg: Foliant; 2007. 256 p. (in Russ.)]
  2. Брусова Л.А. Восстановительные операции на лице с применением силоксановых композиций (Клинико-эксперим. исслед.): Автореф. дис. … д-ра мед. наук. — М., 1996. — 58 с. [Brusova LA. Vosstanovitel’nye operatsii na litse s primeneniem siloksanovykh kompozitsiy (Kliniko-eksperim. issled.) [dissertation]. Moscow; 1996. 58 p. (in Russ.)]
  3. Волков В.В., Лимберг А.А., Сомов Е.Е., и др. Лечебная тактика при свежих сочетанных повреждениях глазницы и средней зоны лица // Тр. Воен. — мед. акад. — Л., 1984. — Т. 214: Повреждения органа зрения. — С. 62–67. [Volkov VV, Limberg AA, Somov EE, et al. Lechebnaya taktika pri svezhikh sochetannykh povrezhdeniyakh glaznitsy i sredney zony litsa. Tr. Voen. — med. akad. Leningrad; 1984;214:62–67. (in Russ.)]
  4. Aronowitz JA, Freeman BS, Spira M. Long-term stability of teflon orbital implants. Plast Reconstr Surg. 1986;78(2):166-173. doi: 10.1097/00006534–198608000–00003.
  5. Brown AE, Banks P. Late extrusion of alloplastic orbital floor implants. Br J Oral Maxillofac Surg. 1993;31(3):154-157. doi: 10.1016/0266-4356(93)90114-c.
  6. Cho YR, Gosain AK. Biomaterials in craniofacial reconstruction. Clin Plast Surg. 2004;31(3):377-385. doi: 10.1016/j.cps.2004.03.001.
  7. Courtney DJ, Thomas S, Whitfield PH. Isolated orbital blowout fractures: survey and review. Br J Oral Maxillofac Surg. 2000;38(5):496-504. doi: 10.1054/bjom.2000.0500.
  8. Coyle JT. Hemorrhage into an intraorbital pseudocyst. Arch Ophthalmol. 1997;114(9):1156-1157.
  9. Dancey AL, Perry MJ. Late presentation of alloplastic implant extrusion. Plast Reconstr Surg. 2004;113(3):1081-1082. doi: 10.1097/01.prs.0000107655.00920.fa.
  10. DeBacker CM, Dutton JJ, Lipham W. Hemorrhagic cyst following remote alloplastic implantation for orbital floor fracture repair.
  11. J Craniomaxillofac Trauma. 1998;4(4):16-18.
  12. Gilhotra JS, McNab AA, McKelvie P, O’Donnell BA. Late orbital haemorrhage around alloplastic orbital floor implants: a case series and review. Clin Experiment Ophthalmol. 2002;30:(5):352-355. doi: 10.1046/j.1442-9071.2002.t01-1-00555.x.
  13. Gilliland GD, Gilliland G, Fincher T, et al. Timing of return to normal activities after orbital floor fracture repair. Plast Reconstr Surg. 2007;120(1):245-251. doi: 10.1097/01.prs.0000264391.45642.08.
  14. Glavas I, Lissauer B, Hornblass A. Chronic subperiosteal hematic cyst formation twelve years after orbital fracture repair with alloplastic orbital floor implant. Orbit. 2005;24(1). doi: 1080/01676830590892907.
  15. Goldman RJ, Hessburg PC. Appraisal of surgical correction in 130 cases of orbital floor fracture. Am J Ophthalmol. 1973;76(1):152-155. doi: 10.1016/0002-9394(73)90022-6.
  16. Gosain AK, Persing JA. Biomaterials in the face: benefits and risks. J Craniofac Surg. 1999;10(5):404-414. doi: 10.1097/00001665-199909000-00006.
  17. Groombridge C, McGuinness J. Interesting case: foreign body in the nose: an orbital Silastic sheet had migrated into the nasal cavity. Br J Oral Maxillofac Surg. 2006;44(1):33. doi: 10.1016/j.bjoms.2005.01.008.
  18. Hardin JC. Blowout fractures of the orbit. Plast Reconstr Surg. 1996;97(6):1302. doi: 10.1097/00006534-199605000-00034.
  19. Hillier RJ, Osborne SF, Leatherbarrow B. Epithelial inclusion cyst associated with a porous polyethylene orbital floor implant.Ophthal Plast Reconstr Surg. 2009;25(3):238-239. doi: 10.1097/iop.0b013e3181a394e7.
  20. Hollier LH, Rogers N, Berzin E, Stal S. Resorbable mesh in the treatment of orbital floor fractures. J Craniofac Surg. 2001;12(3):242-246. doi: 10.1097/00001665-200105000-00009.
  21. Jacono AA, Moskowitz B. Alloplastic implants for orbital wall reconstruction. Facial Plast Surg. 2000;16(1):63-68. doi: 10.1055/s-2000-7327.
  22. Jones DF, Wilson MW. Respiratory epithelial ingrowth and hemorrhage as late complications of orbital floor fracture repair with silicone sheet implant. Ophthal Plast Reconstr Surg. 2008;24(6):
  23. -499.
  24. Kang SJ, Kwak IH. Hematic cyst formation after repair of blow-out fracture. Korean J Ophthalmol. 1996;10(1):60-62. doi: 10.3341/kjo.1996.10.1.60.
  25. Klisovic DD, Katz SE, Lubow M. The wayward implant: orbital silicone plate extrusion associated with squamous epithelial downgrowth and infection. Orbit. 2002;21(2):149-154. doi: 10.1076/orbi.21.2.149.7190.
  26. Liu D, Al-Sadhan Y. Orbital floor implant migration across the ethmoidal sinuses and nasal septum. Am J Ophthalmol. 1999;128(1):122-123.
  27. McCannel CA, Weinberg DA, Glasgow BJ, Goldberg RA. Intracapsular hemorrhage as a late complication of an orbital floor implant. Arch Ophthalmol. 1996;114(9):1156-1157. doi: 10.1001/archopht.1996.01100140358027.
  28. Marks MW, Yeatts RP. Hemorrhagic cyst of the orbit as a long-term complication of prosthetic orbital floor implant. Plast Reconstr Surg. 1994;93(4):856-859. doi: 10.1097/00006534-199404000-00032.
  29. Massaro-Giordano M, Kirschner RA, Wulc AE. Orbital floor implant migration across the ethmoidal sinuses and nasal septum. Am J Ophthalmol. 1998;126(6):848-850. doi: 10.1016/S0002-9394(98)00239-6.
  30. Mauriello JA, Flanagan JC, Peyster RG. An unusual late complication of orbital floor fracture repair. Ophthalmology. 1984;91(1): 102-107. doi: 10.1016/S0161-6420(84)34335-4.
  31. Mauriello JA, Fiore PM, Kotch M. Dacryocystitis. Late complication of orbital floor fracture repair with implant. Ophthalmology. 1987;94(3):248-250. doi: 10.1016/S0161-6420(87)33465-7.
  32. Morain WD, Colby ED, Stauffer ME, et al. Reconstruction of orbital wall fenestrations with polyglactin 910 film. Plast Reconstr Surg. 1987;80(6):769-774. doi: 10.1097/00006534-198712000-00001.
  33. Morrison AD, Sanderson RC, Moos KF. The use of silastic as an orbital implant for reconstruction of orbital wall defects: review of 311 cases treated over 20 years. J Oral Maxillofac Surg. 1995; 53(4):412-417. doi: 10.1016/0278-2391(95)90714-9.
  34. Newell FW. Ophthalmology. Principles and concepts. 5th ed. St. Louis etc.: Mosby; 1982. 559 p.
  35. Putterman AM, Millman AL. Custom orbital implant in the repair of late posttraumatic enophthalmos. Am J Ophthalmol. 1989; 108(2):153-159. doi: 10.1016/0002-9394(89)90010-X.
  36. Rosen CE. Late migration of an orbital implant causing orbital hemorrhage with sudden proptosis and diplopia. Ophthal Plast Reconstr Surg. 1996;12(4):260-262. doi: 10.1097/00002341-199612000-00007.
  37. Schmidt BL, Lee C, Young DM, O’Brien J. Intraorbital squamous epithelial cyst: an unusual complication of Silastic implantation. J Craniofac Surg. 1998;9(5):452-455. doi: 10.1097/00001665-199809000-00012.
  38. Stewart MG, Patrinely JR, Appling WD, Jordan DR. Late proptosis following orbital floor fracture repair. Arch Otolaryngol Head Neck Surg. 1995;121(6):649-652. doi: 10.1001/archotol.1995.01890060047009.
  39. Tahhan M, Alkhardaji F, Durrani OM, Price NJ. Intraorbital epithelial cyst formation: a rare complication of silastic implantation. Arch Ophthalmol. 2002;120(12):1768-1769. doi: 10.1001/archopht.120.12.1768.
  40. Tan CS, Ang LP, Choo CT, et al. Orbital cysts lined with both stratified squamous and columnar epithelia: a late complication of silicone implants. Ophthal Plast Reconstr Surg. 2006;22(5):398-400. doi: 10.1097/01.iop.0000231551.10932.f7.
  41. Tercan M. Thin Silastic sheet for orbital floor repair. Plast Reconstr Surg. 1995;96(5):1238-1239. doi: 10.1097/00006534-199510000-00053.
  42. Warrier S, Prabhakaran VC, Davis G, Selva D. Delayed complications of silicone implants used in orbital fracture repairs. Orbit. 2008;27(3):147–151. doi: 10.1080/01676830802077611.

Supplementary files

There are no supplementary files to display.

Views

Abstract - 1473

PDF (Russian) - 388

PDF (English) - 64

Cited-By


PlumX


Copyright (c) 2016 Khatskevitch G.A., Soloviev M.M., Onokhova T.L., Nikolaenko V.P., Panova T.Y.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies