Surgical reconstruction or prosthetic rehabilitation following orbital exenteration: The clinician's dilemma

Sir,

I commend the authors of the article entitled “Total upper and lower eyelid reconstruction using deltopectoral flap,”[1] for their courageous attempt of utilizing deltopectoral flap for eyelid reconstruction following orbital exenteration. The aesthetic outcome achieved in this case by painstaking reconstructive surgery is fairly good. However, being a prosthodontist, actively involved in the prosthetic rehabilitation of patients with ocular and orbital defects, I would like to discuss another treatment modality that is prosthetic rehabilitation.

The basic objectives of treatment are to address functional, psychological, aesthetic and social issues associated with the disease. Unfortunately, whenever orbital exenteration is planned for any patient, the functional aspect of preservation of vision becomes impossible and target shifts mainly to aesthetic, psychological and social issues. All these issues can be effectively addressed by an orbital prosthesis.[2] In my opinion, subjecting the patient to multiple surgical procedures is a complicated, time consuming and highly demanding procedure in terms of surgical expertise in addition to its inherent disadvantages, i.e., donor site morbidity, psychological trauma, risk of graft rejection etc. Moreover, it eliminates the possibility of keeping vigilance over disease reoccurrence in early stages and anyway, even after the complex reconstruction surgery, patient will have to use ocular prosthesis if not orbital prosthesis.

Gujjalanavar and Girish[1] have mentioned that the use of spectacle mounted prosthesis is obvious and will have an unsightly appearance. But, sir, the outcome of prosthetic rehabilitation is more aesthetic and predictable when compared with surgical reconstruction as shown in Figures 1 and 2. Gone is the time when, orbital prosthesis lacked the liveliness. Hitherto, acrylic was used for fabrication of orbital prosthesis. However, now-a-days, a more lifelike prosthesis can be made with silicone.[3] To add to its liveliness, a photodynamic iris that utilizes liquid crystal display technology instead of a static iris, may be incorporated in the ocular component of the orbital prosthesis.[4] To more closely simulate the natural eye, the concept of blinking orbital prosthesis has also been introduced.[5,6] Previously, medical adhesives or spectacle were commonly used for retention of orbital prosthesis. Now, surgeons prefer to place implants in the superior and lateral orbital bony rim to provide a stable and more retentive means of securing the prosthesis. The use of optical camouflage methods such as progressive tinted lens or negative sphere spectacle lens to provide an illusion of depth can further disguise or improve the appearance of an orbital prosthesis. Today's anophthalmic patient doesn’t need to bother about his appearance nor has to be conscious about their prosthesis falling off.

Figure 1.

Orbital exenteration defect of the left side

Figure 2.

Patient with orbital prosthesis

Sir, in my opinion, the creation of palpebral aperture of 15 mm with 32 mm cavity inside, as mentioned by Gujjalanavar and Girish,[1] will result in inadequate hygiene maintenance of the pouch. Furthermore, the absence of eyelashes, lack of fornix formation and colour mismatch of reconstructed area are other problems with the described surgical procedure that require critical appraisal. Although, the prosthetic rehabilitation lacks the sensation of a normal or reconstructed periocular region, but it has the obvious advantage that it does not require the multiple procedures of surgical reconstruction and the accompanying loss of time for healing and rehabilitation. Such a life-like prosthesis may fulfil the aesthetic and psychological needs of patients to look like everybody else, with two eyes and a beautiful face to face the public without embarrassment.