**7. Postoperative complications**

**5.2. Autologous tissue**

50 Advances in Eye Surgery

risk of donor site morbidity.

used as implant cover materials.

**6. Considerations in children**

**5.3. Synthetic tissue**

This type of tissue includes temporalis fascia, dermis, human donor pericardium, fascia lata, or posterior auricular muscle complex [43]. Their autologous origin prevents an immune host versus graft reaction. Nevertheless, they require an extra surgical procedure to harvest them and prepare them to cover the implant, which increases surgical time, and there is always the

Polyglactin 910 mesh (Vicryl mesh, Ethicon, Sommerville, NJ, USA) is used to wrap hydrox‐ yapatite and bioceramic orbital implants. It offers a series of advantages: there is no risk of disease transmission, there is no need of a second surgical site, and it is easy to use. It has a porous structure that allows fibrovascular ingrowth [33]. Polytetrafluoroethylene and polyglicolic acid (Dexon mesh style no8, Davis & Geck, Manati, Puerto Rico) have also been

Hydroxyapatite polyglactin mesh-wrapped implants [44] have been used in secondary

The anophthalmic or microphthalmic socket in children has special features that we will discuss. One of the most important issues is that the orbit of the child should continue growing after the eye is removed. The surgeon must have that in mind in order to achieve good cosmetic

The most frequent cause of enucleation in pediatric age is retinoblastoma. There has been a special concern whether to place an implant in these orbits due to the difficulties in the followup and the detection of tumor recurrence with an orbital implant in place. However, once it was observed that orbits in children with no orbital implants did not develop appropriately, the decision to implant was taken. Normal face and bony orbit growth depends on the orbital soft tissue contents. When the child is five and a half years old, his face is about 90% of the size of an adult's face [45]. Generally talking, the management of an anophthalmic socket in a child younger than 5 years old requires an implant that can increase in size, such as a dermis-fat graft or orbital tissue expander. A large fixed-sized orbital implant can be placed in children older than 5 years [46]. Orbital growth is completed by the time the child is 12-14 years old [47]. Dermis-fat grafts harvested from the thigh have shown to stimulate orbital growth in children [48], but their motility is poor. Thus, this is an ideal implant for children younger than 5 years old. The dermis-fat graft is also used to cover hydroxyapatite exposures and to reconstruct sockets. A low incidence of complications has been reported with hydroxyapatite implants in a large series of pediatric patients who had undergone enucleation surgery for different reasons after 60 months of follow-up and excellent cosmetic results. We should not forget that when treating an anophthalmic cavity in a child, we need to increase the conjunctival fornices,

implants with good results both in prosthesis motility and low exposition rate.

and anatomical results. This will condition the implant selection.

#### **7.1. Anophthalmic socket complications**

We can divide them depending on the surgery performed in the socket.

Patients underwent enucleation or evisceration.

#### *7.1.1. Dryness, discharge, or irritation*

Tear secretion may decrease with time [50]. Patients may be advised to use artificial tears or gel. Saline solution can be used to clean the ocular surface. Most anophthalmic sockets have some degree of discharge. Foreign body reaction, loss of prosthetic surface polishing, and therefore smooth surface, abrasion of conjunctival surface, and accumulation of debris between the prosthesis and the conjunctiva are factors that are believed to increase the production of debris and discharge [51]. It is advisable to minimize the handling of the prosthesis. If discharge is present, both the socket and the prosthesis should be evaluated. Scratches and loss of luster are relatively frequent, especially if the prosthesis is old. The ocularist usually helps with keeping the surface polished by smoothing the surface and removing proteins and debris every 6 or 12 months. Once surface problems or inadequate fit in the socket have been discarded, steroid or antibiotic steroid drops can be used once or twice daily. If the discharge is mucopurulent, especially if the eyelids are swollen and conjunctival hyperemia and chemosis is present, an infectious conjunctivitis should be considered. Treatment should include cultures and antibiotic (quinolone) drops.

Some patients may have a giant papillary conjunctivitis, which may require steroid and antihistamine drops. The artificial eye should be removed in the night and washed in soft contact lens daily cleaner and denture cleaning products.

### *7.1.2. Pain*

Pain after eye removal is difficult to handle. If the prosthesis is correctly fit in the orbit, the conjunctiva should be checked for any signs of inflammation or infection. If the implant migrates anteriorly, it can compress the tissue and hurt. Pain may have its origin in the trochlea. This can be examined by pressing on this zone. If the pain resembles that experienced by the patient, triamcinolone injection in the trochlea can be effective [52]. Other causes or pain may be amputation neuroma, sinus inflammation, tumor, depression, or secondary gain [53].

#### *7.1.3. Orbital cysts*

They manifest as pain or pressure sensation or even only increased difficulty to fit the artificial eye. Cysts may grow if conjunctival epithelium is incarcerated after wound closure or when there is epithelial ingrowth in wound dehiscence [54]. Management options are complete surgical excision, marsupialization, absolute alcohol injection, or trichloroacetic acid (TCA) injection [55].

#### *7.1.4. Lower eyelid malposition*

When the eye is enucleated, the disruption of the fibrous framework of the orbit may result in the rotation of the orbital contents inferiorly and anteriorly. This will shallow the inferior fornix and tilt the prosthesis. The inferior portion of the prosthesis pushes on the inferior eyelid, while the superior portion moves posteriorly inside the orbit, deepening the superior sulcus. Both of these two features are part of the anophthalmic socket syndrome, which includes an upper eyelid ptosis, a deep superior sulcus, an enophthalmos, a lower eyelid malposition, and a fornix retraction. With time, the lower eyelid becomes more lax, especially when heavier prosthesis is fitted. This enhances the inferior migration of orbital tissues. The final result is a poorly fitting artificial eye, lower eyelid malposition, shortening of the inferior fornix, and deepening of the superior sulcus. In older patients, the laxity of the inferior eyelid increases, especially when wearing a prosthesis even if it is not heavy.

#### **7.2. Eyelash misdirection and entropion**

Several situations are responsible for eyelash misdirection. Fornix contracture is one of the most common due to the trauma of surgery of the eye removal or contracture as a result of chemical burn. Sometimes the contracture of the fornix is result of the contracture of the conjunctiva as a result of chronic inflammation. Lower eyelid laxity can also produce eyelash misdirection. In order to correct eyelash misdirection, there are a series of options depending on the underlying cause. When laxity of the eyelid is present, lateral canthoplasty can be a good option. A transverse tarsal incision with marginal rotation is a simple way to change the direction of the eyelashes. If there is a shallow fornix, a silicone band to reform the fornix is a suitable option, but if there is a moderate to severe contraction of the fornix, fornix deepening will require grafts that may be harvested from the hard palate, ear cartilage, or contralateral upper lid tarsus.

#### *7.2.1. Ectropion*

*7.1.2. Pain*

52 Advances in Eye Surgery

*7.1.3. Orbital cysts*

injection [55].

upper lid tarsus.

*7.1.4. Lower eyelid malposition*

when wearing a prosthesis even if it is not heavy.

**7.2. Eyelash misdirection and entropion**

Pain after eye removal is difficult to handle. If the prosthesis is correctly fit in the orbit, the conjunctiva should be checked for any signs of inflammation or infection. If the implant migrates anteriorly, it can compress the tissue and hurt. Pain may have its origin in the trochlea. This can be examined by pressing on this zone. If the pain resembles that experienced by the patient, triamcinolone injection in the trochlea can be effective [52]. Other causes or pain may be amputation neuroma, sinus inflammation, tumor, depression, or secondary gain [53].

They manifest as pain or pressure sensation or even only increased difficulty to fit the artificial eye. Cysts may grow if conjunctival epithelium is incarcerated after wound closure or when there is epithelial ingrowth in wound dehiscence [54]. Management options are complete surgical excision, marsupialization, absolute alcohol injection, or trichloroacetic acid (TCA)

When the eye is enucleated, the disruption of the fibrous framework of the orbit may result in the rotation of the orbital contents inferiorly and anteriorly. This will shallow the inferior fornix and tilt the prosthesis. The inferior portion of the prosthesis pushes on the inferior eyelid, while the superior portion moves posteriorly inside the orbit, deepening the superior sulcus. Both of these two features are part of the anophthalmic socket syndrome, which includes an upper eyelid ptosis, a deep superior sulcus, an enophthalmos, a lower eyelid malposition, and a fornix retraction. With time, the lower eyelid becomes more lax, especially when heavier prosthesis is fitted. This enhances the inferior migration of orbital tissues. The final result is a poorly fitting artificial eye, lower eyelid malposition, shortening of the inferior fornix, and deepening of the superior sulcus. In older patients, the laxity of the inferior eyelid increases, especially

Several situations are responsible for eyelash misdirection. Fornix contracture is one of the most common due to the trauma of surgery of the eye removal or contracture as a result of chemical burn. Sometimes the contracture of the fornix is result of the contracture of the conjunctiva as a result of chronic inflammation. Lower eyelid laxity can also produce eyelash misdirection. In order to correct eyelash misdirection, there are a series of options depending on the underlying cause. When laxity of the eyelid is present, lateral canthoplasty can be a good option. A transverse tarsal incision with marginal rotation is a simple way to change the direction of the eyelashes. If there is a shallow fornix, a silicone band to reform the fornix is a suitable option, but if there is a moderate to severe contraction of the fornix, fornix deepening will require grafts that may be harvested from the hard palate, ear cartilage, or contralateral

It is normally associated to lower eyelid laxity with aging in normal anophthalmic sockets. Heavy prosthesis or frequent removal of the artificial eye will result in premature ectropion, sometimes in very young patients. If the enucleation was due to orbital and eye trauma, skin scars can precipitate the apparition of ectropion. When ectropion is due to eyelid laxity, lateral tarsal strip is a good and a simple surgical option that offers good results. Heavy prosthesis should be changed for lighter ones. Anterior lamella contraction should be treated with skin or skin and muscle grafts and may benefit from lateral canthopexy procedures to tighten the eyelid.

#### *7.2.2. Ptosis*

Ptosis in an anophthalmic socket is sometimes difficult to manage. Too small or too big implants, migration of the implant, levator traumatic damage, trauma from a poorly fitted prosthesis, trauma from the original injury, or levator aponeurosis dehiscence from the tarsal plate can end in upper eyelid ptosis. If the implant is too small, it can be replaced for a bigger one or volume can be increased with a dermis-fat graft. When the implant migrates inferior and anteriorly, it can be repositioned superior and posteriorly with a subperiosteal implant. Once the other factors have been considered and corrected if possible, a levator aponeurosis advancement can be achieved through an anterior approach. The anterior approach will preserve the conjunctiva from potentially contract and helps to create a symmetric eyelid crease.

#### *7.2.3. Deep superior sulcus and enophthalmos*

Soft tissue and volume changes in the socket after enucleation or evisceration are responsible of upper lid ptosis and lower lid laxity but also deepening of the superior sulcus. Even when the initial surgical result may be satisfactory, with time, the implant may migrate inferior and anteriorly, deepening the superior sulcus and making the eye socket look sunken or enoph‐ thalmic. Conservative management may include alterations in the prosthesis or wearing glasses to camouflage the superior sulcus. Best results should be expected with surgery. Volume augmentation with orbital floor implant placement is the first step, followed by superior sulcus fat grafting and lower lid tightening. The last surgical procedure will be ptosis repair.

Orbital floor implants placed subperiosteally are indicated if the implant is of adequate size and in position. Different materials such as acrylic (polymethylmethacrylate), bone grafts, hydroxyapatite, autogenous fat, injectable hydroxyapatite, dermis-fat grafts, and others have been used. Polymethylmethacrylate is a well-tolerated material placed subperiosteally using a swinging eyelid technique. This implant displaces the orbital implant and surrounding connective tissue and fat anterior and superiorly, thus reducing the sunken superior sulcus. If there is a residual defect after this surgery or when the defect of the superior sulcus is mild or when the patients rejects the placement of a subperiosteal implant, the superior sulcus can be filled with a dermis-fat graft or with an autologous fat graft or a dermal filler such as hyaluronic acid [56]

#### *7.2.4. Implant exposure or extrusion*

They are the most frequent complications reported in the literature. They can happen with any kind of implant and at any time. There are many factors involved, including incorrect closure of the wound, infections, implant too large for the socket, bad prosthesis adaptation, or delayed fibrovascular ingrowth.

Exposures in the first 3 months after the surgery are probably due to poor wound healing or surgical closure or incorrect position of the orbital implant. Once again, we would like to highlight the importance of a correct tension-free closure of Tenon's layer. Exposures occurring 3 months to 1 year after surgery can be due to the factors previously reported and others like infection or inflammatory response. When exposures occur beyond the first 2 years, they are usually due to mechanical factors such as friction or pressure from the prosthesis [57].

If a nonporous implant exposition is acute and not too big, it can be solved with prompt medical or surgical treatment, but when the exposition is big (more than 3 mm) or long lasting (4 months or more), it usually leads to implant extrusion and, therefore, to its removal. On the other hand, exposed porous implants generally do not extrude because of their fibrovascular anchorage in the socket [58]. Although some porous implants can expose 10 years after surgery, most of the exposures take place within the first year after the surgery. As mentioned above, the use of materials that cover porous implants is an attempt to reduce implant exposition when the surface of the implant is rough enough to rub and tear the conjunctiva. However, Suter et al. [59] have suggested that this kind of material could produce the contrary effect as it would act as a barrier to fibrovascular ingrowth. Kamai et al. [60] used 20% autologous serum when there was conjunctival postoperative dehiscence and necrosis with good results. They recommend to put a drop at least 10 times a day. They observed that the healing occurred after 2 weeks of autologous serum use, preventing the exposure of the implant. Quaranta-Leoni et al. [61] found the presence of Gram-positive cocci infection in 59% of the patients in a group of 25 people when the porous orbital implants were exposed requiring explantation. A histopathological examination showed the presence of a chronic inflammatory infiltrate in 22 implants (88%) and significantly reduced fibrovascular ingrowth of the implant in all patients. They consid‐ ered a good surgical option the implantation of a dermis-fat graft in the socket once explanted the implant in order to address the volume deficit following implant removal.

There are many surgical options to treat exposed implants: scleral patch grafts [62], mucous membrane grafts [63], temporalis fascia grafts [64], conjunctival pedicle grafts [65], and dermisfat grafts [66]. Chu et al. [67] proposed a triple layer to treat exposed implants: donor sclera, muscle flaps, and oral mucosa.

#### *7.2.5. Socket contracture*

The patient will complain that the prosthesis keeps falling out of the socket. Acquired socket contraction is the consequence of shrinkage and shortening of some or all of the tissues of the anophthalmic orbit; thus, the fornices are not able to retain the prosthesis. In order to prevent it, it is mandatory to carry out a straightforward enucleation or evisceration surgery that is, taking care to keep trauma to the conjunctiva, connective tissue, and orbital at minimum levels. Fornices should not be undermined, and cauterization should be minimized by using gauzes soaked in freezing water and using the bipolar cautery with low energy levels. The conformer should be fit in the socket once the surgery is finished and kept in place until a nondefinite artificial eye is fitted [68]. The more surgeries a socket undergoes, the bigger the risk of developing a socket contracture. In order to simplify its management, we can classify it into the following:

*Mild socket contracture*. When the posterior lamella shortens, the lashes rotate inward and entropion develops. There is a decrease of the inferior fornix causing a prolapse of the inferior pole of the prosthesis. A transverse tarsal incision with marginal rotation is the initial treatment of choice [69]. There is usually a lower eyelid horizontal laxity too. When there is enough conjunctiva, a lateral canthal tendon procedure associated to a fornix reformation procedure should be performed. The fornix is reformed using 3-0 or 4-0 polyglactin sutures anchored to the periorbita and skin tied over a bolster [70]. However, if there is a lower lid contraction, a posterior lamella lengthening procedure is the best option. Several autogenous spacer grafts have been used: fascia lata, oral mucosa [71], nasal cartilage, hard palate, upper eyelid tarsus, or auricular cartilage [72]. Auricular cartilage is easy to harvest, provides support for the artificial eye, lengthens the posterior lamella, and prevents forward tilt of the prosthesis [73]. Oral mucosa is an excellent option to increase the mucous surface but lacks supportive properties.

*Moderate socket contracture*. One or both of the fornices are contracted. Typically, the first to contract is the inferior fornix. When the superior fornix contracts, the artificial eye may be retained but the eyelid excursion may be very limited. The gold standard for the treatment of moderate socket contracture is mucous membrane grafting, usually obtained from oral (lip) or buccal (cheek) mucosa [74,75]. Grafts undergo shrinkage with time, so a graft harvested 40% bigger than the defect is recommended. The conjunctiva is undermined, and the graft is sutured with absorbable 7-0 interrupted sutures. A retinal band can be used to reform the inferior and upper fornices, anchoring it to the periorbita and the skin with bolsters. Then a conformer is placed. Amniotic membrane has also been used as a graft with good results.

If the patient has a socket volume deficiency associated to the socket contracture, the patient will improve with a dermis-fat graft [76], increasing the orbital volume and the conjunctival surface area.

*Severe socket contracture*. The conjunctival fornices are nearly or completely obliterated, and the prosthesis may fall constantly or give the patient a "staring" appearance. It is frequent to have discharge and irritation or even an active inflammation. The goal of the surgery is to make the patient comfortable and have a good cosmesis. The patient may need to undergo several surgeries with buccal mucosa grafts and flaps from temporalis muscle or radial forearm. When results are very poor, some patients may benefit from an exenteration procedure, which may improve the aesthetics and the comfort of the socket.

Patients underwent exenteration.

*7.2.4. Implant exposure or extrusion*

fibrovascular ingrowth.

54 Advances in Eye Surgery

muscle flaps, and oral mucosa.

*7.2.5. Socket contracture*

They are the most frequent complications reported in the literature. They can happen with any kind of implant and at any time. There are many factors involved, including incorrect closure of the wound, infections, implant too large for the socket, bad prosthesis adaptation, or delayed

Exposures in the first 3 months after the surgery are probably due to poor wound healing or surgical closure or incorrect position of the orbital implant. Once again, we would like to highlight the importance of a correct tension-free closure of Tenon's layer. Exposures occurring 3 months to 1 year after surgery can be due to the factors previously reported and others like infection or inflammatory response. When exposures occur beyond the first 2 years, they are usually due to mechanical factors such as friction or pressure from the prosthesis [57].

If a nonporous implant exposition is acute and not too big, it can be solved with prompt medical or surgical treatment, but when the exposition is big (more than 3 mm) or long lasting (4 months or more), it usually leads to implant extrusion and, therefore, to its removal. On the other hand, exposed porous implants generally do not extrude because of their fibrovascular anchorage in the socket [58]. Although some porous implants can expose 10 years after surgery, most of the exposures take place within the first year after the surgery. As mentioned above, the use of materials that cover porous implants is an attempt to reduce implant exposition when the surface of the implant is rough enough to rub and tear the conjunctiva. However, Suter et al. [59] have suggested that this kind of material could produce the contrary effect as it would act as a barrier to fibrovascular ingrowth. Kamai et al. [60] used 20% autologous serum when there was conjunctival postoperative dehiscence and necrosis with good results. They recommend to put a drop at least 10 times a day. They observed that the healing occurred after 2 weeks of autologous serum use, preventing the exposure of the implant. Quaranta-Leoni et al. [61] found the presence of Gram-positive cocci infection in 59% of the patients in a group of 25 people when the porous orbital implants were exposed requiring explantation. A histopathological examination showed the presence of a chronic inflammatory infiltrate in 22 implants (88%) and significantly reduced fibrovascular ingrowth of the implant in all patients. They consid‐ ered a good surgical option the implantation of a dermis-fat graft in the socket once explanted

the implant in order to address the volume deficit following implant removal.

There are many surgical options to treat exposed implants: scleral patch grafts [62], mucous membrane grafts [63], temporalis fascia grafts [64], conjunctival pedicle grafts [65], and dermisfat grafts [66]. Chu et al. [67] proposed a triple layer to treat exposed implants: donor sclera,

The patient will complain that the prosthesis keeps falling out of the socket. Acquired socket contraction is the consequence of shrinkage and shortening of some or all of the tissues of the anophthalmic orbit; thus, the fornices are not able to retain the prosthesis. In order to prevent it, it is mandatory to carry out a straightforward enucleation or evisceration surgery that is, taking care to keep trauma to the conjunctiva, connective tissue, and orbital at minimum levels.

#### **7.3. Exenterated orbit**

#### *7.3.1. Sino-orbital fistula*

Its frequency has been reported to be as high as 68% [77] and as low as 28% [78]. It is more common when the orbit is left to granulate rather than when a skin graft is used.The majority affect the ethmoid sinus. Risk factors are surgical trauma to the ethmoid or lacrimal bones, sinus disease, radiotherapy, and immunocompromised. They can lead to ethmoidal sinusitis. Management ranges from conservative socket hygiene to surgical repair with flaps or grafts, but it is not unusual for the fistula to recur [79].

#### *7.3.2. Chronic discharge*

Once healed, if the socket has a sino-orbital fistula, pus from the ethmoid sinus can drain to the orbit when sinusitis is present. In these cases, systemic antibiotics like third-generation cephalosporin twice daily for 14 days may be enough. If medical treatment is not curative, the patient may be referred to the head and neck surgeon in order to program the patient for endoscopic sinus drainage surgery.

The skin coating the orbit will need to be cleaned with soap and water, just as any other part of the body. Sometimes patients are reticent to let anyone do this for them and it is relatively frequent to find dirty skin in the orbit.

#### *7.3.3. Cerebrospinal fluid leak*

A cerebrospinal fluid (CSF) leak may lead to meningitis, delayed cerebral abscess, seizures, CSF hypotension with position-dependent headache syndrome, occult hemorrhage, and even death [80]. The incidence reported by an Australian team was 0.6% [81]. However, it can be as high as 29% [82]. Interestingly, the intraoperative use of monopolar cautery in areas of thin orbital bone may contribute to the incidence of CSF leaks [83]. Once you detect clear liquid leaking from the bone in areas of high risk of encountering dura, prompt treatment usually ends in good results. It is very advisable to consult the neurosurgery team. A dural laceration can be sutured with 5-0 or 6-0 polyglactin or nylon to create a watertight seal. If the defect is large, an autologous graft (fat, temporalis muscle or fascia, and pericranium) and a tissue adhesive such as human fibrinogen and bovine thrombine or cyanoacrylate [84] can be used. In smaller defects, tissue adhesives may be enough to seal the leak. Additional materials used in the repair of CSF leaks at other sites include the use of gelfoam® in epidural blood patches. At the end, packing material can be placed in the socket to hold the plug of muscle or fascia against the defect and therefore protect from further leakage. After surgery, the patient must avoid blowing his or her nose and coughing as well as physical activity. Acetazolamide is used to reduce the production of CSF in order to treat CSF leaks. Some authors use systemic antibiotics when there is an intraoperative leak of CSF, but many believe they are unnecessary to prevent meningitis [85].

#### *7.3.4. Delayed healing*

**7.3. Exenterated orbit**

56 Advances in Eye Surgery

*7.3.1. Sino-orbital fistula*

*7.3.2. Chronic discharge*

endoscopic sinus drainage surgery.

frequent to find dirty skin in the orbit.

*7.3.3. Cerebrospinal fluid leak*

to prevent meningitis [85].

but it is not unusual for the fistula to recur [79].

Its frequency has been reported to be as high as 68% [77] and as low as 28% [78]. It is more common when the orbit is left to granulate rather than when a skin graft is used.The majority affect the ethmoid sinus. Risk factors are surgical trauma to the ethmoid or lacrimal bones, sinus disease, radiotherapy, and immunocompromised. They can lead to ethmoidal sinusitis. Management ranges from conservative socket hygiene to surgical repair with flaps or grafts,

Once healed, if the socket has a sino-orbital fistula, pus from the ethmoid sinus can drain to the orbit when sinusitis is present. In these cases, systemic antibiotics like third-generation cephalosporin twice daily for 14 days may be enough. If medical treatment is not curative, the patient may be referred to the head and neck surgeon in order to program the patient for

The skin coating the orbit will need to be cleaned with soap and water, just as any other part of the body. Sometimes patients are reticent to let anyone do this for them and it is relatively

A cerebrospinal fluid (CSF) leak may lead to meningitis, delayed cerebral abscess, seizures, CSF hypotension with position-dependent headache syndrome, occult hemorrhage, and even death [80]. The incidence reported by an Australian team was 0.6% [81]. However, it can be as high as 29% [82]. Interestingly, the intraoperative use of monopolar cautery in areas of thin orbital bone may contribute to the incidence of CSF leaks [83]. Once you detect clear liquid leaking from the bone in areas of high risk of encountering dura, prompt treatment usually ends in good results. It is very advisable to consult the neurosurgery team. A dural laceration can be sutured with 5-0 or 6-0 polyglactin or nylon to create a watertight seal. If the defect is large, an autologous graft (fat, temporalis muscle or fascia, and pericranium) and a tissue adhesive such as human fibrinogen and bovine thrombine or cyanoacrylate [84] can be used. In smaller defects, tissue adhesives may be enough to seal the leak. Additional materials used in the repair of CSF leaks at other sites include the use of gelfoam® in epidural blood patches. At the end, packing material can be placed in the socket to hold the plug of muscle or fascia against the defect and therefore protect from further leakage. After surgery, the patient must avoid blowing his or her nose and coughing as well as physical activity. Acetazolamide is used to reduce the production of CSF in order to treat CSF leaks. Some authors use systemic antibiotics when there is an intraoperative leak of CSF, but many believe they are unnecessary

The orbital defect left to heal spontaneously once exenterated will granulate slowly if allowed only to grow from the orbital rim, and it will heal faster when it heals from spared eyelids. Nevertheless, this will take at least 2-3 months more than when the defect is covered by a temporalis muscle transposition [86], dermis-fat graft (in subtotal exenteration), or split skin graft [87]. Healing by granulation has shorter operating room time and allows for better clinical monitoring of recurrence. However, it requires frequent visits to change the dressings [88], every week and sometimes every 2 or 3 days, and may delay other therapeutic procedures such as radiotherapy. Depending on how the granulation process is developing, dressings may need to be associated to hydrogel mesh or silver mesh. Orbital obliteration with temporalis muscle or a graft may induce less pain, improve personal hygiene, and reduce the risk of sinoorbital fistula, but it requires image techniques such as MRI, CT, or PET to detect local recurrences.

#### *7.3.5. Tumor recurrence*

Tumor recurrence following orbital exenteration can occur in 24-45% of cases [82,89]. Early detection of tumor recurrence in patients who have undergone orbital exenteration is very important. This task is relatively easy when the orbit was left to granulate, but it is difficult when the normal anatomical landmarks have been lost (like when exenteration is associated to ethmoidectomy), and there are flaps covering large cavities. Recurrent tumors may appear as soft tissue similar to the primary tumor, especially in the first 2 years of the surgery (65% of the cases) and in the margin of the flap [90]. Lee et al. recommend to follow this patients with frequent MRI, at least every 4 months after surgery for the 2 first years and every 6 months for 3 more years. On MRI, recurrences appear on the margin of the flap and are often T2 isointense, as opposed to the hyperintense appearance described in normal flaps. PET has also been used to help to differentiate recurrence from scarring or radiation-associated tissue changes.
