Anophthalmic socket (evisceration, enucleation, exenteration) including complications and management

1. Anophthalmic socket and
orbital reconstruction
Haitham Al-Mahrouqi
Oculoplasty course
May 2019

2. Outline
• Indications
• Types of anophthalmic socket operations
• Orbital implants
• Complications

3. References
• AAO
• Techniques in Ophthamlic plastic surgery by Jeffery Nerad
• Google images

4. Anophthalmic socket
• Indications:
• Pain
• Cosmesis
• Save the other eye
• Save life

5. Anophthalmic socket
• Psychologically distressing
• However, single eyed patient often live a
normal life (With exceptions to those who
need stereopsis and wide VF)
• Need to safeguard the other eye using
polycarbonate glasses.

6. Before jumping to anophthalmic socket!
• Consider scleral shell for cosmesis for those with:
• Non-painful blind eyes with no malignancy
• Perfect for phthisis bulbi
• If no phthisis, consider colored contact lens

7. Types of anophthalmic surgery
• Evisceartion: Removal of the intraocular contents including cornea.
• Enucleation: Removal of the globe
• Exentration: Removal of the globe as well as some or all the orbital
contents.

8. Evisceration
• Evisceration involves the removal of the contents of the globe, leaving
the sclera, extraocular muscles, and optic nerve intact.
• NOTE: MUST RULE OUT INTROCUOCULAR MALIGNANCY
• This is the procedure of choice in:
• Perforated corneal ulcers
• Endophthalmitis
• Blind painful eye
• Evisceration can be done without keratectomy in case of a healthy
cornea:

9. Evisceration
• Video
http://webeye.ophth.uiowa.edu/eyeforum/VIDEO/plastics/1/E
visceration-placement-of-implant.htm

10. The 4-petal technique of evisceration
• Blind eyes after trauma are often
reduced in size, thereby making it
difficult to accommodate a large-
sized implant.
• 4 petal technique or posterior
sclera relaxing incisions can
accommodate larger inmplants.

11. Evisceration without keratectomy
Evisceration can be done without keratectomy in case of a healthy
cornea. Steps:
• The superior rectus is cut off the eye and an incision through the
sclera is made posterior to the superior rectus insertion.
• After the intraocular contents are removed, an implant is placed into
the eye and the scleral wound is closed.
• The superior rectus is reattached.

12. Evisceration
Advantages Disadvantages
Simple procedure Cannot be performed for ocular
malignancy
Less disruption to the orbital anatomy Higher risk for sympathetic
endophthalmitis as compared to
enucleation
Good motility of the ocular prosthesis Less specimen for histological analysis
Lower rate of implant migration,
extrusion

13. Enucleation
• If the nature of the eye disease is unknown or if suspecting tumor,
enucleation is the treatment of choice (beware of the phthysical eye).
• If performed for tumor, to avoid globe penetration and should take a
long optic nerve segment for histological examination.

14. Enucleation
• Video
https://www.youtube.com/watch?v=XB7jlJfCSJw

15. Enucleation
Advantages Disadvantages
Avoiding sympathetic ophthalmia Technically difficult
Usedful in confined neoplasms to the
globe
Motility less than evisceration
Allows complete histological examination
of the ocular tissue
Significant loss of the orbital volume
which may need expanders in children

16. Case
• 40 year old man with right eye
pain, redness, photophobia and
floaters.

17. Sympathetic ophthalmia
• Enucleation must be done within 10 days of ocular trauma to
eliminate the risk of sympathetic ophthalmia.
• The incidence of sympathetic ophthalmia is estimated to be 0.03 in
100,000 per year.
• The condition has been reported to occur from 9 days to 50 years
after corneoscleral perforation.
• The infrequency of sympathetic ophthalmia, coupled with improved
medical therapy for uveitis, has made early enucleation strictly for
prophylaxis a debatable practice.

18. Extentration
Types of extentration
• Subtotal. The eye and adjacent intraorbital tissues are removed such
that the lesion is locally excised (leaving the periorbita and part or all
of the eyelids). This technique is used for some locally invasive
tumors, for debulking of disseminated tumors, or for partial
treatment in selected patients.
• Total. All intraorbital soft tissues, including periorbita, are removed,
with or without the skin of the eyelids.
• Extended. All intraorbital soft tissues are removed, together with
adjacent structures (usually bony walls and sinuses).

19. Indication
• Destructive tumors extending into the orbit from the sinuses, face,
eyelids, conjunctiva, or intracranial space.
• Intraocular melanomas or retinoblastomas that have extended
outside the globe
• Malignant epithelial tumors of the lacrimal gland.
• Orbital zygomycosis

21. Ideal anophthalmis socket
• Central, buried, bioinert implant replacing the volume of the orbit
• Healthy conjunctiva and tenon with good motility of the implant.
• Comfortable ocular prosthesis which looks similar to the other eye.
• Healthy eyelids with normal position and appearance to the other
eye.

22. Terms
Orbital implant Conformer Ocular
prosthesis/scleral shell

23. Orbital implants
• Used to replace the lost volume of the orbit and for motility
• In children, very important for bony growth of the orbit.
• Size consideration:
• The volume of the orbit is approximately 30 ml. The volume of the eye is 7.5
ml. The volume of the eye must be replaced with volume provided by the
combination of the implant and the prosthesis.
• A 16 mm sphere replaces 2 ml of volume. A 20 mm sphere replaces 4–5 ml of
volume. An average-sized prosthesis can make up for the additional 2.5 ml of
volume lost during enucleation.
• In general, patients receive implants that are 20 mm in diameter. Occasionally,
a 22 mm implant can be placed without undue tension on the closure.

24. Orbital implants
• Types of implants:
• Porous or solid
• Biological vs synthetic
• Buried or exposed
• Muscles attached or unattached

25. Comparison
Porous Non-porous (Solid)
E.g. Hydroxyapetite (HA), bioceramic and Medpor E.g. Silicone, PMMA, Acrylic
Advantages Advantages
• Integration with the blood vessels (vascular
ingrowth; takes about 6 months) therefore
lower rate of migration.
• Allows good motility
• Can be pegged
• Lower rate of exposure
• Cheap
Disadvantages:
• Higher rate of exposure and extrusion
• Higher rate of infection
• Expensive
Disadvantages
• Can migrate within orbit
• Less movement
• Cannot be pegged

26. Complications of anophthalmic socket

27. Discharging anophthalmic socket
• Management:
• According to the cause

28. How to remove ocular prosthesis

29. Superior sulcus syndrome
• Cause: Small or no
implant
• Management:
• Replace the larger orbital
implant. (better outcome)
OR
• Replace with large ocular
prosthesis

30. Exposed implant
• Cause: excessive rubbing of
the conjunctiva over the
porous implants.
• Management:
• Cover with scleral patch
graft
• Removal of the implant

31. Giant papillary conjunctivitis (GPC)
• Cause: Mechanical Rubbing
of the ocular prosthesis
over the tarsal conjunctiva
or immunological reaction
to the prosthesis
• Management:
• Replace the old prosthesis
especially if rought surface
or if too large.
• Steroids, mast cell
stabalizers and lubrications.

32. Contracted socket
• Cause: Short fornices due to not
fitting conformer/prosthesis,
radiotherapy, cicatricial causes such
as chemical injury or poor surgical
technique
• Management:
• Reconstruction using mucous
membrane grafting from buccal
mucosa or lips.

33. Entropion
• Cause: Poor fitting of the prosthesis
leading to shortening of the
posterior lamella.
• Management:
• Custom fit prosthesis
• Grafting of the posterior lamella
• Entropion surgery

34. Ectropion
• Cause: Heavy large prosthesisor
frequent removal of the prosthesis
accelerating the lower eyelid laxity.
• Management:
• Lateral tarsal strip or tightening of the
medial canthal tendon.

35. Ptosis
• Cause: small or non-custom
fitted prosthesis or due to
GPC.
• Management:
• Custom fit prosthesis to
modify the superior lift.
• Treat GPC

36. Thanks