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Anophthalmic socket (evisceration, enucleation, exenteration)
- 1. Anophthalmic socket and orbitalreconstruction Haitham Al-Mahrouqi Oculoplasty course May 2019
- 2. Outline • Indications • Typesof anophthalmic socket operations • Orbital implants • Complications
- 3. References • AAO • Techniquesin Ophthamlic plastic surgery by Jeffery Nerad • Google images
- 4. Anophthalmic socket • Indications: •Pain • Cosmesis • Save the other eye • Save life
- 5. Anophthalmic socket • Psychologicallydistressing • 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 toanophthalmic 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 anophthalmicsurgery • 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 involvesthe 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.
- 10. The 4-petal techniqueof 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 Eviscerationcan 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 procedureCannot 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 thenature 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.
- 15. Enucleation Advantages Disadvantages Avoiding sympatheticophthalmia 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 yearold man with right eye pain, redness, photophobia and floaters.
- 17. Sympathetic ophthalmia • Enucleationmust 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 tumorsextending 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 ConformerOcular prosthesis/scleral shell
- 23. Orbital implants • Usedto 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 • Typesof 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.
- 27. Discharging anophthalmic socket •Management: • According to the cause
- 28. How to removeocular 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: Poorfitting of the prosthesis leading to shortening of the posterior lamella. • Management: • Custom fit prosthesis • Grafting of the posterior lamella • Entropion surgery
- 34. Ectropion • Cause: Heavylarge 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: smallor non-custom fitted prosthesis or due to GPC. • Management: • Custom fit prosthesis to modify the superior lift. • Treat GPC
- 36.
Editor's Notes
- #10 Posterior scleral relaxing incisions allows placement of a large implant.
- #23 Prosthesis is fitted 4-6 weeks later
- #25 A buried implant implies that the entire implant is covered with a closure of conjunctiva. Exposed implants were used primarily in the 1940s when a portion of the implant was allowed to project through an opening in the conjunctiva. This exposed portion of the implant was physically linked or “integrated” to the prosthesis. These implants failed because of chronic infection and eventual extrusion. Almost all implants in use today are covered with conjunctiva or buried. Medpor smoother surface than HA and thus lower rate of migration.