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An Age-Related Algorithm For Management Of Micro-orbitism From Anophthalmia: A Systematic Review
Brandon J. De Ruiter, BS1, Robert P. Lesko, BA1, Anne Barmettler, MD2, Anand R. Kumar, MD, FACS, FAAP3, Edward H. Davidson, MD3.
1Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY, USA, 2Montefiore Medical Center, New York, NY, USA, 3Case Western Reserve University, Cleveland, OH, USA.

Purpose:
Management of pediatric anophthalmia is challenging and must address skeletal growth to avoid micro-orbitism. A number of treatment options have been described, however the efficacy and safety of each varies with skeletal age. Bony changes become recalcitrant to traditional implant based therapy in those at skeletal maturity. Osteotomies achieve orbital expansion, however are invasive and grow technically challenging following frontal sinus aeration. To date, there are no criteria for guiding treatment selection. The aim of this study was to review methods for managing micro-orbitism and develop an age-based treatment approach.
Methods:
A systematic literature review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, and Web-of-Science databases were queried using MESH and non-MESH search terms to identify studies pertaining to management of micro-orbitism. A reference search of included articles was completed to identify additional sources. All data was screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample size, number of orbits, intervention, age, complications, and retention of ocular prostheses was obtained. Representative case reports are presented.
Results:566 studies were obtained on initial search, 198 subjected to full-text review, and 35 included for analysis. 399 patients with 437 anophthalmic orbits were included for analysis. Interventions included osteotomies (22.9%), inflatable-expanders (22.9%), osmotic-expanders (14.3%), distraction osteogenesis (8.6%), dermis-fat grafts (5.7%), bone-grafts (5.7%), custom devices (2.9%), and multiple interventions (8.6%). Dermis fat-grafts were successful until the age of 4 after which graft atrophy (21%) limited therapeutic effect. Implant based therapy was described in patients as old as 10, though a majority of those effectively managed were younger: ages of those treated with inflatable, osmotic, and solid implants were 2.6 years, 2.3 years, and 1 year respectively. Osteotomies corrected micro-orbitism in those refractory to implants with limitations including persistent soft-tissue deformity and need for invasive open procedure. Overall, good outcomes with minimal complications and successful ocular prosthetic retention were achieved in those 0-4 years managed with dermis-fat grafts, 5-7 years managed with implants, and 8+ years managed with osteotomies. For those 8+ years with aerated frontal sinuses or insufficient bone stock, we propose use of onlay camouflage prosthetics which are depicted in the presented case and which improve projection, orbital volume, and avoid risk of frontal sinus injury.
Conclusions:
Many techniques for managing micro-orbitism exist. Selection of therapy should be tailored to skeletal-age to optimize outcomes.


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