Anophthalmic socket-including management

1. ANOPHTHALMIC SOCKET

3. ANOPHTHALMOS
• Absence of the globe and ocular tissues from the
orbit.
ANOPHTHALMIC SOCKET
• orbit not containing an eye ball, but with orbital
soft tissues.
• Most common cause:enucleation
• CAUSES
• acquired
• congenital

4. CONGENITAL ANOPHTHALOMS
• rare (0.2–0.6 /10k births )
• Idiopathic/sporadic /AD,AR,X linked.
• Trisomy /Maternal infections,teratogens/syndromes
• optic vesicle fails to develop .
• ORBITAL FINDINGS –
• Small orbital rim,bony orbital cavity
• Small and mal developed optic foramen
• EOM ,Lacrimal gland –ve

5. EYELID FINDINGS –
• Foreshortening of the lids in all directions
• Absent/decreased levator function & poor lid folds
• Contraction of orbicularis oculi muscle
• Shallow conjunctival fornix, especially inferiorly.
ACQUIRED ANOPHTHALMOS
• After enuceation/evisceration/exenteration

7. IDEAL ANOPHTHALMIC SOCKET
1.A centrally placed,well-covered,buried bio-inert
orbital implant of adequate volume.
2. A socket lined with healthy conjunctiva,fornices
deep enough to retain and move an artificial eye
3. Eyelids with n/l position,appearance and tone to
support a prosthesis,n/l lashes & lid margin.
4. supratarsal eyelid fold symmetric with c/l eyelid
5. Good motility from implantprosthesis
6. A comfortable ocular prosthesis that looks similar
to the sighted with c/l globe in the same horizontal
plane

8. REHABILITATION OF ANOPHTHALMIC
SOCKET
• orbital implant :along with evisceration /enucleation
• conformer :until placement of prosthesis
• ocular prosthesis :6 to 8 wks after.
IMPLANTS
• Nonintegrated – PMMA, Silicone
• Semi-integrated – Allen,Iowa
• Integrated - Cutler
• Biointegrated – Porous implant(HA,porousPMMA,Alo)
• Biogenic – Dermis Fat Graft,
cancellous bone

9. HOW TO PLACE AN IMPLANT
• Remove the eyeHemostasis is achieved .
• select an implant by measuring globe volume or axial
length of the c/l eye.
• cover the implant with wrapping material Insert orbital
implant.
• Attach the muscle to implant after create fenestrations in
wrapping material
• Draw Tenon’s fascia over implant
• Close Tenon’s facia in 1//2 layersconjunctiva
• Insert temporary ocular conformer prosthesis after 4–8
weeks .
• After implant vascularization(Technetium bone/
gadolinium-MRI) an optional secondary procedure can be
done to place a couple peg after 6 months .

10. IMPLANTS

11. IMPLANT SIZE
• Replace 70 – 80 % of globe volume
• Measure AL of eye after enucleation (-2mm)
• Measure Axial length of C/L eye by A scan(-1mm)
• Deduct addnl 2 mm from AL if implant is wrapped.
• Infants 16-18mm
• Older children 18-20mm
• Adults 20-22 mm
• WRAPPING
• a protective barrier against extrusion
• Enable attachment of muscles in non- integrated implants
• Homologous – sclera, fascia lata
• Autogenous – fascia lata, rectus abdominis sheath, p auricular muscle
• Heterologous – bovine pericardium
• Synthetic - vicryl mesh, e-PTFE
IMPLANT SIZE PBLMS
• Smaller – displace, migrate, sup sulcus deformity
• Larger – wound gape, implant exposure

12. DERMIS FAT GRAFT
• Primary –young patients,conjunctival scarring
• Secondary- exposure or extrusion of the implant
• Adv :Volume replacement with additional lining to
the socket
• Disadv - fat atrophy,hair growth
• C/I : Compromised vascularity

13. PROSTHESIS
• STOCK SHELL.
Prefabricated
readily available iwith diff corneal & sclera colours .
Not according to socket size
• SCLERAL SHELL
It is a thin shell with transparent sclera & coloured
cornea
• CUSTOM MADE SHELLS:
fabricated for each patient according to socket size
Its a high quality PMMA material.
Hand painted and fits snugly into the socket .
modifications possible

17. CONGENITAL ANOPHTHALMOS :
• Tissue expansion is required to stimulate growth of
bony orbit to decrease midface asymmetry
• Various surgical options include:
• Insertion of conformers non expanding orbital
implants & have to be changed few times in order
to expand the palpebral fissure and bony orbit until
a suitable prosthesis can be retained.
• Inflatable balloon expanders regularly filled with
saline solution.
• Expandable hemispherical and spherical hydrogel
expanders .
• 3D osteotomies for small bony sockets

18. IMPLANTS &SOCKET EXPANDERS
1 hemispherical socket expander(0.4-2ml)
• sutured on the conjunctiva to expand palpebral fissure.
• diameters of 6, 8 ,9 mm (dry )11, 14 ,18mm (fully hydrated in 30 days).
2 spherical orbital expanders(1-5ml)
• if socket is adequate to fit a prosthesis kept for orbital expansion
• surgically placed in the deep orbital cavity and the overlying tissue covered
in two layers.
• various sizes .
• Correction of the superior sulcus deformity & Stimulates facial growth
3 Pin SETE’s (0.24ml)
• Residual enophthalmos/microphthalmos
spherical acrylic implants of increasing size.
• < 5 yrs-dermis-fat graft or orbital tissue expander.
• A large fixed-sized orbital implant > 5 years of age.
• Examine the child every monthly

19. `

21. EVALUATION OF ANOPHTHALMIC SOCKET
GOALS
• replace orbital volume, maximize motility and
provide the most comfortable and aesthetically
symmetric appearance.
• understand the changes :orbital fat atrophy and low
orbital circulation & tear production,discharge +ve .
• orbital implant placement complications & its
management .
• children:Enucleation/eviscerationdevelopment
of bony orbit,⁰ midfacial asymmetry

22. HISTORY
• Does the patient have pain with the prosthetic in?
• Does the prosthesis fall out?
• Is there discharge or bleeding from the socket?
• How old is the current prosthetic and when was the
last time it was polished?
• Does the patient have polycarbonate glasses to
protect the seeing eye?
• Is the patient happy with the cosmesis and
movement of the prosthetic?

23. COMPLICATIONS:ANOPHTHALMIC SOCKET
• post-enucleation socket syndrome (PESS)
Clinical features :
• Enophthalmos & upper eyelid sulcus deformity
• Ptosis or eyelid retraction
• Laxity of the lower eyelidshelved inferior fornix
• Implant extrusion / exposure.
• Contraction of socket and associated abn/l.
• Migration of implant
• A backward tilt of the ocular prosthesis

24. TREATMENT OF COMPLICATIONS
ENOPHTHALMOS & SUPERIOR TARSAL SULCUS DEFORMITY
CAUSES : poor orbital volume
:inadequate volume replacement at the time of sx
:due to atrophy of fat & inferior migration of implant.
Enophthalmos :
• if no implant :placement of a 2⁰ implant.
• non-surgical fix, placing a +2 D sphere or higher i/l magnify the
eye socket  enophthalmos less noticeable
• if primary implant + : fat grafting & autologous/non autologous
floor implants
• Associated surface contracture :Dermis fat graft (DFG) .
Superior sulcus deformity
• loss of orbital volume + traction of fascial attachments of SR to
levator complex and sagging of lower eyelid.
• implantation of fascia lata / sclera / bone / fat/ alloplastic material
in upper eyelid.

27. ANOPHTHALMIC PTOSIS:
• drooping eyelid.
Results from
•Inadequate implant size & Supero temporal migration of implant .
• Poorly fit prosthesis
• Cicatricial tissue in upper fornix.
• Damage to levator or its nerve by orbital injury/sx/Senile dehiscence
• secondary to enophthalmos or volume deficiency.
• Lower lid laxity
• Frequent manipulation to insert and remove the artificial eye stretches the
upper eyelid .
Management:
• Mild ptosis
– Prosthesis modification
− correction of socket volume deficiency prior to ptosis surgery
– Fasanella servat
• Moderate ptosis
– Levator tightening
– Frontalis suspension – less satisfactory

29. ANOPHTHALMIC ECTROPION:
Results from
-poor prosthesis or lower lid laxity.
Managed by:
- if the prosthesis is >5 years old, replace a new one.
- less bulky thinner/lighter prosthesis corrects eyelid
malposition
- Lower lid tightening at lateral/medial canthal tendon depending
on laxity.
- Correction of eyelid retraction by recession of IR/grafting of mucus
membrane tissue in inferior fornix
LASH MARGIN ENTROPION:
• due to contracture of fornices/cicatricial tissue near lash margin.
Managed by:
– Tarsal rotation procedure (Weis)
– Marginal mucous membrane graft

30. LAX SOCKET OR INFERIOR FORNIX SHELVING
• Results from
• shifting of tissues within the orbit (involutional
relaxation of the supporting tissues of the inferior
eyelid).
• weight and pressure effect of the prosthesis
inability to retain the prosthesis.
Management
• Horizontal lid laxity :eyelid tightening by Lateral
tarsal strip procedure +/- fornix formation sutures
to increase the depth of inferior fornix.
• fornix shelving ( - ) lid laxity, fornix formation
sutures by either closed method or with open
method

33. fornix formation sutures

34. IMPLANT EXTRUSION/ EXPOSURE
• early post operative period :inadequate surgical closure or
infection.
• Late exposures : fibrous contraction/pressure atrophy of
tissues overlying the implant as closing the wound under
tension
• mechanical or inflammatory irritation from the speculated
surface of the porous implant
• Delayed ingrowth of fibrovascular tissuetissue
breakdown
• Porous orbital implants have a lower incidence.
• Preventive measures :
• proper placement 2 layered Tenon’s capsule &
conjunctival closure.
• The rectus muscles attached to the wrapped implant

35. MANAGEMENT
• if few weeks:
• small exposure: conservative treatment /close the defect
with graft.
• large exposures /frank extrusion:implant removal &
replacement.
• In a clean socket :in single stage, replace the extruded
implant with smaller implant close tissues in layers.
• If infection is suspected treat vigorously with topical and
systemic antibiotics, avoid extrusion and removal of the
implant .
• in infected socket :remove the implant wait for the
infection to settle 2 ⁰ implant later by Careful dissection
of tissues & good haemostasis

37. • patch grafting :in conjunctival shortening
:fascia lata /sclera to cover defect.
:Tenons and conjunctiva is anchored to
A graft surface in layers.
:mobilise conjunctiva to cover the patch
for graft viability.
:sandwitch a scleral graft between
tenons & conjunctiva to decrease scleral melt

38. ORBITAL PAIN IN THE ANOPHTHALMIC SOCKET
• prosthetic irritation or migration/ extrusion of the implant to
depression
• lacrimal insufficiency,
• inflammation (scleritis, sympathetic ophthalmia,7 and GPC)
• recurrent tumors.
• Amputation neuromas (pain with movement)
• Brain and sinus diseases(referred socket pain )
• Reflex sympathetic dystrophy(burning socket pain associated
with facial trauma/infection/tumor)
• Psychogenic factors(drug-seeking behavior)diagnoses of
exclusion
• management
• referral to ocularist 4 assessment,prosthetic modification
/polishing.
• If the etiology is not clear/persists after prosthetic polishing
and lubrication:needs CT scan to aid in diagnosis

39. CONTRACTED SOCKET
• A socket unable to retain a prosthesis is called Contracted socket.
• Causes for Contracted Socket
• congenital /acquired
• Etiology related ・Alkali burns
・Radiation therapy
• Surgery related
• Fibrosis from the initial injury
• Poor surgical techniques during previous sx
• Excessive sacrifice of conjunctiva and tenons capsule
• Traumatic dissection within the socketscar
• Multiple socket operations
• Site related
• Poor vascular supply
• Severe ischemic ocular disease in the past
• Cicatrizing conjunctival diseases
• Chronic inflammation and infection
• implant and prosthesis related
• Implant migration
• Implant exposure
• Not wearing a conformer/prosthesis • Ill fitting prosthesis

40. Evaluation
• history
• External examination
• Examination of cavity
• Examination of shell

43. Examination of Shell
• Color match
• Surface
• Edges
• ASSOCIATED ABNORMALITIES:
– Fibrous bands
– Symplepharon formation
– Granulomas

44. MORPHOLOGICAL CLASSIFICATION

45. GRADING: CONTRACTED SOCKET
• Four categories
• Grade 1-Minimal /no actual contraction
Inability to retain the prosthesis for a long time
Large implant/anteriorly placed implant
• Grade 2 -Mild contracture of upper and/or lower fornix
• Grade 3- Advanced scarring of both upper and lower fornices
• Grade 4 -Severe palpebral phimosis both vertically and horizontally

47. • Mild socket contraction:
• shortening of the inferior fornix :Prosthesis is still retained.
• Moderate socket contraction:
• Inferior & superior both fornices are shortened.
• Signs & symptoms
• Inability to retain prosthesis
• Poor motility of prosthesis
• Non-closure of eye
• Loss of normal lid fold
• Persistent discharge and irritation
• Enophthalmos with posteriorly displaced prosthesis if
volume loss +
• Severe socket contracture

48. TREATMENT

49. by Mucous Membrane Graft, Amniotic membrane grafting
adequate scar excision

50. Severe socket contracture:
• Mucosa is often inadequate .
• Split thickness skin grafts alone or combined with buccal
mucosa.
severe / recurrent scarring contracted sockets
• flaps with intact vascular supply such as radial artery forearm
flap with minimal risk of loss of viability of the forearm.
• Temporalis fascia flaps
• Temporalis muscle transfer
• Orbital osteotomies
• orbital /spectacle prosthesis is the only option.
Conformer is placed at the end and replaced by artificial
eye later.
• Localized symblepharon & fibrous bands :Z-plasty or V-
y plasty.

54. MAINTENANCE OF OCULAR PROSTHESIS
• Wash hands before handling the prosthesis
• Cleaning can be done once in a month
• Use light soap/Johnsons baby shampoo for cleaning
• Eye lubricants can be used to smoothen lid
movements and ensure closure of lids.
• Polishing must be done once a year.