This document discusses congenital anophthalmia and recent advances in its management. It describes how the introduction of hydrogel socket expanders and orbital expanders has modified the rehabilitation approach. The goals of treatment are to simultaneously expand soft tissues and orbital bones to replace lost volume, maintain orbital structure, and allow prosthesis motility. Various types of orbital implants and expanders are discussed, including advantages and disadvantages. Guidelines for successful socket reconstruction with adequate volume, fornices, eyelid tone and prosthesis motility and comfort are provided.

1. Congenital Anophthalmia:
Current concepts in
management
Current Opinion in Ophthalmology 2011,22:380384

2. Introduction

Congenital Anophthalmia – a rare
congenital eye anomaly due to
deficiency in development of primary
optic vesicle.
There is no detectable ocular tissue.
Associated with microblepharon,short
conjunctival sac, absence of
extraocular muscles.
Replaced completely by a cyst.

4. Purpose of review

The introduction of hydrogel socket &
orbital expanders has modified
approach towards rehabilitation of
congenital anophthalmia.

5. Recent advances
Hydrogel socket expander as an
outpatient procedure.
 Increased orbital volume confirmed by
CT ,MRI.
 Inflatable orbital tissue expander new
design


6. Clinical evaluation

Associate findings –
Coloboma,dermoids,sclerocornea,glaucoma,le
ns & optic nerve abnormalities.
-Canalicular stenosis
Systemic abnormalitiesAbnormalities of ears,palate,lower face
Cardiac,renal & genital anomalies,brain
abnormalities
- Anophthalmia-plus syndrome.
CT
Ultrasonography

7. Treatment

Goals:
-Simultaneous expansion of lids,soft
tissues,orbital bones /replace lost
volume
-maintain structure of orbit
-impart motility to prosthesis

8. 1.Positioning of progressively enlarging
static acrylic conformers asap after
birth
- Orbital cyst –dynamic expander like
conformer
Drainage or Excision – Rapid growth
- Uncomfortable
to wear
MRI to exclude connection to brain

9. Orbital implant
Spherical implants:
 Inert material:

glass,silicone,methylmethacrylate
 Biointegrated:
Hydroxyapatite, porous
polyethylene

10. Inert spherical implants
Advantages
 Provide comfort and low rates of
extrusion.
 Cost-effective choice in patients.
Disadvantages
 decreased motility and implant migration.
Buried motility implants
 anterior surface projections push the
overlying
prosthesis with direct force and can
improve prosthetic motility.
 may pinch the conjunctiva between the
implant and the prosthesis - painful

11. Hydroxyapatite and porous
polyethylene implants allow for drilling
and placement of a peg to integrate
the prosthesis directly with the moving
implant.
 Pegging is usually carried out 6-12
months after enucleation. Pegged
porous implants offer excellent
motility,


12. 
Locations for implants -within the Tenon capsule
/behind the posteri or Tenon capsule in the
muscle cone.

Spheres may be covered with other materials
such as

sclera (homologous or cadaveric) or autogenous
fascia,

Secure closure of Tenon fasci a over the anterior
surface of an anophthalmic implant is an
important barrier to later extrusion.

13. Types
Hard spherical implant
 Inflatable soft tissue expander
 Hydrogel osmotic expander


14. Hard silicone spheres
-
Need of series of surgeries
Multiple general anaesthesias
Repeated trauma to soft tissues

15. Inflatable soft tissue
expanders
-
Better orbital bone stimulation &
socket enlargement.
Difficult to control direction ,maintain
expansion pressure.
Chance of displacing
conformer,extrusion

16. Hydrogel expander implant
To stimulate growth of conjunctival sac
& eyelids followed by serial
implantation for Orbital volume with
temporary tarsorraphy.
 Methylmethacrylate & Nvinylpyrrolidone
materials.
 Small Soft tissue incision – quick
surgery , recovery


17. Injectable pellet expanders through
trocar tru skin at inferior orbital rim to
deep orbit.
 Safe & minimally invasive technique
 Easy to insert , biocompatible.
 Migration & extrusion.


18. Positioning with cyanoacrylate glue
- No suture related complications
- Avoids multiple general anaesthesias
- Outpatient procedure with topical
anaesthesia.


19. Dermis –fat grafts
Outcomes:
-Good orbital volume ,adequate
fornices
-No excessive growth / need of
surgery
-Allows lid & socket expansion
 Problems:
-second surgical site,unpleasant scar
-delay in healing,chronic discharge


20. 
A study on evaluation of an integrated
orbital tissue expander in congenital
anophthalmos . Am J Ophthalmol
2011
-
An inflatable silicone globe sliding on
titanium T- plate secured to lateral
orbital rim with screws.
Inflating with transconjunctival inj of
normal saline ,30 G needle.
-

21. Outcomes:
- ease of insertion
- Absence of displacement
- Uniform pressure
- Reduced trauma


22. Guidelines for enucleation

A functionally and aesthetically acceptable
anophthalmic socket must have following –
an orbital implant of sufficient volume centered
within the orbit
 a socket lined with conjunctiva or mucous
membrane with fornices deep enough to hold a
prosthesis.


eyelids with normal appearance and adequate
tone to support a prosthesis
good transmission of motility from the implant to
the overlying prosthesis
 a comfortable ocular prosthesis that looks similar
to the normal eye


23. Steps of Enucleation with
orbital implant

29. Removal of
contents

33. Advantages of Evisceration in
orbital implant
Less disruption of orbital anatomy.
 Good motility of prosthesis
 Lower rate of
migration,extrusion,reoperation.


36. Anophthalmic Socket
Complications and Treatment
Deep superior sulcus
 Contracture of fornices
 Exposure & extrusion of implant
 Contracted socket
 Anophthalmic ectropion
 Anophthalmic ptosis
 Lash margin entropion
 Cosmetic Optics
