Case Reports Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene Peter J. Timoney, M.D.*, Jeremy D. Clark, M.D.†, Paul A. Frederick, M.D.*, Mark Krakauer, M.D.†, Christopher Compton, M.D.†, Craig Horbinski, M.D., Ph.D.‡, Jason Sokol, M.D.§, and William R. Nunery, M.D., F.A.C.S.† Abstract: Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue. Foreign body reaction to porous polyethylene has been reported in facial tissue, but to our knowledge, not in the orbit. We report 2 cases of foreign body inflammatory giant cell reaction in patients who underwent orbital fracture repairs with porous polyethylene implants.

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orous polyethylene (MEDPOR) implants are commonly used in the orbit for reconstruction of the anopthalmic socket or orbit fracture.1 Porous polyethylene is a high-density material containing an array of interconnecting micropores that facilitate fibrovascular ingrowth.1,2 Biocompatibility is a perceived advantage of porous polyethylene orbital implants.3,4 Reported complications of this material include exposure, infection, and distortion of the existing anatomy.5,6 Foreign body reaction to porous polyethylene has been reported in facial contour implants, although to our knowledge, it has not been reported to have occurred in the orbit.7 We report 2 cases of foreign body granuloma formation in the setting of prior orbital reconstruction with porous polyethylene. The research adhered to the tenets of the Declaration of Helsinki, and the Health Insurance Portability and Accountability Act.

CASE 1 A 55-year-old man sustained left globe trauma 30 years prior to presentation and underwent left enucleation with placement of a silicone orbital implant. In 1997, he suffered a left orbital floor fracture and underwent repair with placement of a porous polyethylene-coated titanium implant (MEDPOR TITAN). In early 2013, he presented to the emergency department with left retro-orbital pain, a subjective fever and chills, and nasal congestion with associated discharge. A facial computed tomography (CT) scan revealed a well-circumscribed dome-shaped lesion encompassing his entire inferior and medial orbital area, extending to the orbital apex. This left orbital lesion was thought to represent a subperiosteal orbital abscess, especially given his associated ethmoidal and maxillary sinusitis as demonstrated on the imaging study. Endoscopic ethmoidectomy and maxillary antrostomy with attempted drainage of the presumed orbital abscess were performed, but no drainage was noted from the orbit. The patient *Department of Ophthalmology and Visual Sciences, University of Kentucky, Lexington; †Department of Ophthalmology and Visual Sciences, University of Louisville, Louisville; ‡Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, Kentucky; and §Department of Ophthalmology, University of Kansas, Lawrence, Kansas, U.S.A. Accepted for publication August 16, 2014. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Jeremy Clark, m.d., Kentucky Lions Eye Center, 301 East Muhammad Ali Boulevard, Louisville, KY 40202. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000328

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returned 6 days later with worsening left orbital pain and pressure, discharge from his orbit, and spontaneous expulsion of his silicone sphere implant. He was then referred to the oculofacial plastics and orbital surgery service for management. Orbital exploration revealed no purulence or necrotic tissue. A hard, bone-like mass lesion involving large portions of his orbital floor and medial orbital wall was identified and biopsied for histological and microbial analysis. Along with this mass, a titanium plate with porous polyethylene covering was noted, extending from the inferior orbital rim toward the orbital apex with the posterior portion of the titanium plate angled at 90° superiorly and enmeshed in the orbital mass. Histological analysis revealed areas of pseudocysts filled with polarizable foreign material. Fibrosis and foreign body giant cell reaction with granulation tissue was apparent. There was no identifiable orbital infectious component and his white blood cell count was normal (Fig. 1).

CASE 2 A 37-year-old man presented with diffuse right orbital pain 2 years after right zygomaticomaxillary and orbital floor fracture repair with titanium plates on the orbital rim and infraorbital porous polyethylene implant. Visual acuity was 20/80 OD with a right afferent pupillary defect. CT imaging demonstrated a mass lesion in the right inferior orbit with invasion of the maxillary sinus and pterygopalatine fossa (Fig. 2). Serum angiotensin-converting enzyme and lysozyme, as well as C-ANCA and P-ANCA were negative. The patient underwent a frontal orbitotomy to biopsy the mass. Histologic examination revealed acute and chronic inflammation with foreign-body type multinucleated giant cells and fibrosis. His vision declined to hand motion OD. The orbital inflammatory reaction and pain was so severe that this could not be adequately controlled with systemic corticosteroids, chemotherapy and radiation therapy. The orbit was subsequently exenterated for pain control. Histological examination of the periorbital soft tissue demonstrated caseating granulomatous inflammation with associated extensive fibrosis and foreign body giant cells (Fig. 3) with a refractile, polarizable foreign material consistent with porous polyethylene.

DISCUSSION Foreign body reactions are a common inflammatory response, and can be seen throughout the body. Histologically, foreign body granulomas are characterized by granulomatous inflammation surrounding an offending agent, combined with the presence of multinucleated giant cells and epithelioid macrophages. These reactions normally occur as acute or subacute responses, but can occasionally be seen chronically. Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue.8 Complications associated with the use of porous polyethylene orbital implants include implant exposure, conjunctival thinning, discharge, pyogenic granuloma formation, implant infection, and persistent pain or discomfort.5,6,9 To our knowledge, foreign body reaction to porous polyethylene has yet to be reported in the orbit, although it has been seen in facial tissue.7 In the first case presented, the patient had a foreign body reaction in an orbit with a silicone sphere and a MEDPOR TITAN implant. This implant had remained stable for approximately 30 years. In this case, implant extrusion was due to increasing inflammation and enlargement of the granulomatous tissue mass. Case 2 had reconstruction of the orbital floor with porous polyethylene with histologic evidence of inflammatory

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P. J. Timoney et al.

FIG. 1.  Histologic features of periglobe resection material from Case 1. Sections showed areas of pseudocysts (A) filled with polarizable foreign material (B), eliciting brisk fibrosis and foreign body giant cell reaction (C). Granulation tissue was nearby (D). (A) and (B) are ×100, (C) and (D) are ×400.

FIG. 3.  Histologic features of periglobe resection material from Case 2: Slide demonstrating caseating granulomatous inflammation with extensive fibrosis. (×100).

FIG. 2.  Coronal CT scan showing right orbital mass.

foreign body granuloma. The inflammatory mass continued to enlarge and the patient ultimately required exenteration for mass removal and pain control. In both cases, orbital inflammation from foreign body reaction occurred in the distant postoperative period. Patients with porous polyethylene implants require long-term follow-up to monitor for such complications.

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4. Han DH, Chi M. Comparison of the outcomes of blowout fracture repair according to the orbital implant. J Craniofac Surg 2011;22:1422–1425. 5. Christmas N, Gordon C, Murray T, et al. Intraorbital implants after enucleation and their complications. Arch Ophthalmol 1998; 116:1199–1203. 6. Remulla HD, Rubin PA, Shore JW, et al. Complications of porous spherical orbital implants. Ophthalmology 1995;102:586–593. 7. Gosau M, Draenert FG, Ihrler S. Facial augmentation with porous polyethylene (Medpor)–histological evidence of intense foreign body reaction. J Biomed Mater Res B Appl Biomater 2008;87:83–87. 8. Bratton EM, Durairaj VD. Orbital implants for fracture repair. Curr Opin Ophthalmol 2011;22:400–406. 9. Iordanidou V, De Potter P. Porous polyethylene orbital implant in the pediatric population. Am J Ophthalmol 2004;138:425–429.

© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.

Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene.

Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and int...
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