Chronic orbital epithelial defect is a rare complication that occurs
after exenteration. Skin grafts, rotation flaps, or free flaps are the traditional
surgical means to correct such abnormalities. We describe a case of a chronic
orbital epithelial defect after exenteration refractory to conventional treatment
that resolved after being treated with 0.01% topical becaplermin gel (recombinant
human platelet–derived growth factor BB [rh-PDGF-BB] or Regranex [Ortho-McNeil
Pharmaceuticals Inc, Raritan, NJ]).
A 57-year-old African American patient with a history of hypertension,
seizures, and diabetes underwent a subtotal exenteration with placement of
a full-thickness skin graft for primary orbital melanoma. The orbital defect
healed slowly for several weeks. A year later the patient underwent placement
of craniofacial orbital implants for retention of an orbital prosthesis. Following
this procedure, she developed an ulcer at the apex of the socket that measured
15 × 4 mm with elevated edges and what appeared to be granulation tissue
at the base of the ulcer (Figure 1).
A biopsy specimen of the area demonstrated chronic inflammatory changes. The
ulcer was treated with hydrogen peroxide soaks, wet-to-dry dressings twice
a day, and discontinued use of the prosthesis (as allowed). The prosthesis
was refitted to minimize the pressure at the orbital apex. A course of topical
antibiotic cream was also applied. The ulcer, however, did not resolve for
15 months. Discharge was not present and cultures were not obtained. Treatment
was then initiated with 0.01% topical becaplermin gel daily, which was the
only modification in the treatment regimen. The ulcer gradually decreased
in size and was completely healed after 3 weeks (Figure 2). Use of the gel was discontinued a week later without
a tapering dose. No recurrence had occurred with a follow-up period of 12
The socket of the left eye before
treatment with becaplermin. A 15 × 4-mm ulcer is present at the apex
of the orbit. The 2 metal/ implants that hold the orbital prosthesis are seen
at the roof of the orbit.
The same area 3 weeks after treatment
Chronic epithelial defects after exenteration have been described after
radiation to the orbit,1 after socket infection,
and with diabetes (as occurred in our patient). Skin grafts in these conditions
have a high chance of failure because of compromised blood supply. A temporalis
rotation muscle flap offers a good chance of cure but requires additional
surgery and may deform the temporalis fossa region. Free flaps result in scarring
and deformity of the donor site and neck area, where the microvascular anastomosis
is performed. Local treatment with agents that promote wound healing is therefore
the most simple and cost-effective treatment when taking into account the
cost of surgery.
Recombinant human platelet–derived growth factor BB is involved
in regulation of all phases of normal wound healing. It is either synthesized
or released from all cell types involved in the healing process.2,3
Both rh-PDGF-BB and other growth factor levels have been found to be reduced
in chronic, nonhealing wounds.2 Exogenous
administration of rh-PDGF-BB in the form of 0.01% becaplermin gel promotes
wound healing and was found to be effective for the treatment of diabetic
foot ulcer and pressure ulcers in multicenter, double-blind, placebo-controlled
trials.4 It is currently the only growth
factor approved by the Food and Drug Administration for the treatment of chronic
diabetic foot ulcers.
This is the first reported case, to our knowledge, of clinical use of
0.01% becaplermin gel (Regranex) in the ophthalmic literature and suggests
that this may be a powerful tool in the treatment of chronic epithelial defects
in oculoplastic surgery. The Food and Drug Administration, however, has not
yet approved becaplermin for treatment of conditions other than diabetic foot
ulcers. Appropriate caution must be exercised by physicians who choose to
use this medication.
The authors have no commercial, proprietary, or financial interest in
the product mentioned in the article.
Corresponding author: James W. Karesh, MD, Department of Ophthalmology,
Krieger Eye Institute, Sinai Hospital of Baltimore, 2411 W Belvedere Ave,
Baltimore, MD 21215 (e-mail: firstname.lastname@example.org).
Yassur I, Hirschbein MJ, Karesh JW. 0.01% Becaplermin Gel for the Treatment of a Chronic Orbital Ulcer After Exenteration. Arch Ophthalmol. 2001;119(12):1858-1859. doi: