This document discusses the anatomy and management of the anophthalmic socket. It begins by defining an anophthalmic socket as an orbit lacking an eye globe, usually due to enucleation. True anophthalmia can be congenital or acquired. The most common causes of acquired anophthalmia are enucleation, exenteration, or evisceration performed to treat painful, blind eyes or remove tumors. The document outlines techniques for each procedure and discusses complications that can arise like socket contracture and management strategies like grafting. It emphasizes the importance of socket maintenance with conformers and prosthetics to prevent complications. In summary, this document provides an overview of anophthalmic socket anatomy,

1. The Anophthalmic Socket
Dr. Niwar Ameen
Duhok Eye Hospital
2018

2. Definition
It is an orbit that is completely lack the eye
globe or contains remnants of it with other
orbital soft tissues, rarely congenital but
usually is acquired. The most common
cause is an enucleation of the globe.

3. ANOPHTHALMIA
• True anophthalmia is defined by Duke-Elder as
a total absence of tissues of the eye. It could be:
• Congenital
• Acquired

4. Congenital
• Primary anophthalmia is rare and usually bilateral
• Secondary anophthalmia is rare and lethal
• Consecutive anophthalmia presumably results from a
secondary degeneration of the optic vesicle.
• Features
1- orbits are small
2- hypoplastic eyelids and orbital adnexal structures
• Because orbital development is dependent on the size
and growth of the globe

8. Acquired
Due to
 Enucleation
 Exenteration
 Evisceration

9. What is the purpose of
removing an eye?

10. • Pain free
• Saving the fellow eye
• Saving the life
• Cosmetic issues and comfort

11. What to do prior to remove the
eye?

12. Discuss the following
• The procedure with patient and relatives
(advantages & disadvantages)
• Rehabilitation process
• Expected consequences such as loss of some
depth perception and VFs which lead to
occupational limitation.
• Reassurance and psychological support.

13. • Leave the last decision for the
patient
• Do not forget consent sign

14. How to chose the appropriate
procedure?

15. Enucleation
Involves removal of the entire globe
while preserving other orbital
tissues.

16. Indications
1. Primary IO tumor most common
Retinoblastoma & choroidal melanoma
2. Severely traumatized eyes to ↓ risk of SO
3. Blind painful eye e.g, end stage NV
glaucoma, chronic uveitis, previous
traumatized eye

17. Advantages?
• Provide complete histologic examination of
globe and optic nerve
• Reduces the risk of SO of the fellow eye

18. Disadvantages?
• Excessive disruption of orbital anatomy
• Less mobility of ocular prosthesis
• Technically difficult procedure
• High rate of migration and extrusion
• Reoperation may be required

19. Guidelines for Enucleation
• 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

22. Evisceration
Evisceration is the removal of the intraocular
contents (lens, uvea, retina, vitreous, and
sometimes cornea), leaving the sclera and
extraocular muscles intact.

23. Indications
• Evisceration should be considered only if
the presence of an intraocular malignancy
has been ruled out, as for painful blind
eye, endophalmitis and traumatized eye.

24. Advantages
• Less disruption of orbital anatomy.
• Good motility of the prosthesis.
• A technically simpler procedure.
• Lower rate of migration, extrusion, and
reoperation.

25. Disadvantages?
• Not every patient is a candidate. Evisceration
should never be performed if an ocular tumor is
suspected.
• Severe phthisis bulbi is a contraindication to
evisceration.
• Theoretical increased risk of sympathetic
ophthalmia.
• Evisceration affords a less complete specimen
for pathologic examinations.

28. Orbital Implants
1. To replace the lost volume
2. Maintain the structure of the orbit
3. Imparts motility to overlying ocular
prosthesis

29. Types of implants?
1. Spherical implants
 Inert materials like, silicone, glass, methylmethacrylate.
 Advantages:
• Provide comfort
• Low rates of extrusion.
• Cost-effective
 Disadvantages:
• Poor motility
• Implant migration

31.  Biointergrated like, hydroxyapatite or porous
polyethylene
 Advantages:
• Provide better ocular motility by peg implantation
6-12 months later of enucleation
 Disadvantages:
• Inflammation
• Exposure

32. Porous polyethylene orbital implant

33. Pegs

34. Guidelines for implantation?
• Implanted at the time of surgery (Evisceration, Enucleation)
• Within Tenon capsule or in muscle cone behind post Tenon
caps.
• Spheres may be Covered by sclera (homologous or cadaveric)
or autogenous fascia as a barrier to migration and extrusion.
• EOMs sutured to their normal anatomical location either
directly to the implant or to the sclera or fascia.
• Following enucleation surgery, an acrylic or silicone conformer
is placed in the conjunctival fornices to maintain the
conjunctival space that will eventually accommodate the
prosthesis.

36. Ocular Prosthesis
• An ocular prosthesis is fitted within 4-8
weeks after enucleation or evisceration.
• The ideal prosthesis is custom fitted to the
exact dimensions of the orbit after
postoperative edema has subsided.

38. Left ocular prosthesis

39. Exenteration
• Exenteration involves the removal of the
soft tissues of the orbit, including the
globe.

40. When exenteration should be
considered ?

41. In the following situations
• 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.
• Sarcomas and other primary orbital malignancies that do
not respond to nonsurgical therapy.
• Fungal infection. Subtotal or total exenteration may be
necessary for the management of orbital zygomycosis.

42. Types of Exenteration ?
• 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).

44. Anophthalmic Socket
Complications and
Management

45. 1- Deep Superior Sulcus (PESS)
• Deep superior sulcus deformity is caused by decreased
orbital volume.
Rx:
1. Placement of a subperiosteal secondary implant on the
orbital floor.
2. Dermis-fat grafts may be implanted in the upper eyelid
to fill out the sulcus.
3. Replacement of the original implant with a larger
secondary implant.

47. 2- Contracture of Fornices
• Preventing contracted fornices includes:
1. Preserving as much conjunctiva as possible and limiting dissection
in the fornices.
2. Placing extraocular muscles in their normal anatomical positions
also minimizes shortening of the fornices.
3. It is recommended that the patient wear a conformer as much as
possible postoperatively to minimize conjunctival shortening.
4. Conformers and prostheses should not be removed for periods
greater than 24 hours.
5. The prosthesis can be removed frequently and cleaned in the
presence of infection but should be replaced promptly after
irrigation of the socket.

48. 3- Exposure and Extrusion of Implant
• Implants may extrude if placed too far forward or
if closure of anterior Tenon fascia is not
meticulous.
• Postoperative infection, poor wound healing,
poorly fitting prostheses or conformers.
• Pressure points between the implant and
prosthesis may also contribute to extrusion of
the implant.

51. 4- Contracted Sockets
Causes of contracted sockets include
• radiation treatment
• extrusion of an enucleation implant
• severe initial injury (alkali burns or extensive lacerations)
• poor surgical techniques (excessive sacrifice or destruction of
conjunctiva and Tenon capsule; traumatic dissection within the
socket causing excessive scar tissue formation)
• multiple socket operations
• removal of the conformer or prosthesis for prolonged periods.

52. Rx:
• Involve incision or excision of the scarred tissues and
placement of a graft to enlarge the fornices.
• Full-thickness mucous membrane grafting is preferred
because it allows the grafted tissue to match conjunctiva
histologically. Buccal mucosal grafts may be taken from
the cheeks or from the upper lip, lower lip, or hard
palate.

54. 5- Anophthalmic Ectropion
• Lower eyelid ectropion may result from the loosening of
lower eyelid support under the weight of a prosthesis.
• Frequent removal of the prosthesis or use of a larger
prosthesis accelerates the development of lid laxity.
• Rx: Tightening the lateral or medial canthal tendon may
remedy the situation.is

55. 6- Anophthalmic Ptosis
Causes:
• Superotemporal migration of sphere implants,
cicatricial tissue in the upper fornix, or damage
to the levator muscle or nerve.
Rx:
• Small amounts of ptosis may be managed by
modification of the prosthesis.
• Greater amounts of ptosis require tightening of
the levator aponeurosis.

56. 7- Lash Margin Entropion
• Lash margin entropion, trichiasis, and ptosis of
the eyelashes are common in the anophthalmic
socket.
• Contracture of fornices or cicatricial tissue near
the lash margin contributes to these
abnormalities.
• Rx: Horizontal tarsal incisions and rotation of the
lash margin may correct the problem.

57. 8- Cosmetic Optics
• The style of frames and tinted lenses chosen for
spectacles can help camouflage residual defects
in reconstructed sockets.
• Plus (convex) lenses or minus (concave) lenses
may be placed in the glasses in front of the
prosthesis to alter the apparent size of the
prosthesis.
• Prisms in the glasses may be used to change
the apparent vertical position of the prosthesis.

58. References
• BCSC, Orbit, Eyelid, Lacrimal System, American
Academy of Ophthalmology, 2014 – 2015.
• Brad Bowling, Kanski’s Clinical Ophthalmology,
8th edition, 2016
• //www.ncbi.nlm.nih.gov/pmc/articles/PMC49627
61/

59. The End
Thanks