SIVA TEJA CHALLA

ANOPHTHALMIC SOCKET

• Anophthalmia absence of globe

• Microphthalmia underdeveloped eye

• Cryptophthalmos  complete or partial failure of development of eyelids. It is usually associated with varying degrees of incomplete development of eyeball

ANOPHTHALMIA• Anophthalmia is absence of globe

• Congenital or acquired

CONGENITAL ANOPHTHALOMS• Very rare condition

• optic vesicle fails to develop

• 0.2–0.6 per 10,000 births

• Many cases initially diagnosed as anophthalmos contain remnants of an underdeveloped eye, or vestigial eye tissue, and are more appropriately termed microphthalmos

CAUSES• Idiopathic/sporadic

• Inherited as dominant, recessive, or sex-linked

• Trisomy 13-15

• Maternal infections or teratogenic exposure

• 75% associated with syndromes

OCULAR FINDINGS

• Orbital findings– Small orbital rim and entrance– Reduced size of bony orbital cavity– Extraocular muscles usually absent– Lacrimal gland may be absent– Small and mal developed optic foramen

• Eyelid findings– Foreshortening of the lids in all directions– Absent or decreased levator function with decreased lid

folds– Contraction of orbicularis oculi muscle– Shallow conjunctival fornix, especially inferiorly

ACQUIRED ANOPHTHALMOS

• After enuceation/evisceration/exenteration

ANOPHTHALMIC SOCKET

DEFINITION

• Defined as an orbit not containing an eye ball, but with orbital soft tissues and eye

• rarely congenital but usually is acquired

• The most common cause is an enucleation of the globe

• The optimal time to achieve the best functional and cosmetic result for the anophthalmic patient is at the time of enucleation

IDEAL ANOPHTHALMIC SOCKET

1.A centrally placed, well-covered, buried implant of adequate volume, fabricated from a bio-inert material

2. A socket lined with healthy conjunctiva and fornices deep enough to retain a prosthesis and to permit horizontal and vertical excursion of an artificial eye

3. Eyelids with normal position and appearance, as well as adequate tone to support a prosthesis

4. A supratarsal eyelid fold that is symmetric with the supratarsal fold of the contralateral eyelid

5. Normal position of the eyelashes and eyelid margin

6. Good transmission of motility from the implant to the overlying prosthesis

7. A comfortable ocular prosthesis that looks similar to the sighted, contralateral globe and in the same horizontal plane

CHANGES ASSOCIATED

POST ENUCLEATION SOCKET SYNDROME

• Term introduced by tylers and collin

• Sequelae of an enucleation are orbital volume deficiency and changes in the orbital soft tissue architecture leading to the clinical picture of ‘post-enucleation socket syndrome (PESS)

Clinical features :

o Enophthalmos

o An upper eyelid sulcus deformity

o Ptosis or eyelid retraction

o Laxity of the lower eyelid

o A backward tilt of the ocular prosthesis

typical features of a right post-enucleation socket syndrome (PESS) are seen

lateral view of the patient demonstrating a typical backward tilt to the prosthesis

left upper eyelid retraction and an upper eyelid sulcus defect

same patient demonstrating lagophthalmos.

examination of the socket reveals that superior fornix contracture is the cause of her lagophthalmos

OTHER CHANGES

• Tear production and outflow may also diminish with time in the anophthalmic socket and may not become manifest for several years after the initial procedure

• socket discharge is common in an anophthalmic socket

• mucous secretion from the conjunctival goblet cells may increase, which is often interpreted as an infection by the patient.

MANAGEMENT

COMPLICATIONS AND TREATMENT

Enophthalmos & superior tarsal sulcus deformity results from poor orbital volume

result of inadequate volume replacement at the time of surgery or

subsequently due to atrophy of fat and inferior migration of implant.

Cont…..

Most socket reconstructive surgeries are required to address the following problems:

1. A volume deficit following loss of the globe

2. Contracture of the socket

3. Orbital implant exposure, extrusion, and malposition

• orbital implant is typically placed at the time of evisceration or enucleation

• ocular prosthesis is fitted subsequently.

FABRICATION, CARE, AND MAINTENANCEOF THE ARTIFICIAL EYE

enucleation, evisceration, or

secondary implantation surgery

Conformer is placed in the conjunctival

fornices to maintain the conjunctival

space

conformer is replaced with a

custom-made ocular prosthesis typically

fashioned 4–6 weeks

Non integrated Semi integratedFully integrated Expandable implants

IMPLANTS

PROSTHESIS

Modified impression technique

impression of the socket is taken

Once the impression material sets to a firm

consistency, the shape is copied into a

wax mold

prepared iris–cornea piece is positioned on

the front surface of the wax pattern.

mold is placed into the socket and modifi

ed (reshaped) for comfort and to

improve cosmesis

The wax shape is then translated (using additional molds) into fine quality acrylic (from methyl

methacrylate resin), painted, cured, and polished.

TREATMENT OF VOLUME DEFECIT

Treatment of enophthalmos :

• placement of a secondary orbital implant if no implant was placed at the time of primary surgery

• Dermis fat graft (DFG) is an option in patients with associated surface contracture

• Orbital floor implants.

Autologous bone grafts

Non autologous medpor

Treatment of superior sulcal deformity

• implantation of fascia lata / sclera / bone / fat/ alloplastic material in upper eyelid

DERMIS FAT GRAFT

DERMIS FAT GRAFT TO UPPER LID

Lax socket and inferior fornix shelving : Lax socket results from shifting of tissues within the

orbit

With time there is involutional relaxation of the supporting tissues of the inferior eyelid

the weight and pressure effect of the prosthesis causes laxity of the lid resulting in inability to retain the prosthesis

Treatment

Use prosthesis of optimal weight and size

Lateral tarsal strip

fornix formation sutures to increase the depth of inferior fornix

FORNIX DEEPENING SUTURES

Anophthalmic ptosis• Inadequate implant size

• Migration of the orbital implant

• Poorly fit prosthesis

• Laxity of the fibrous connective tissue

• Orbit trauma from the original injury/surgery

• Senile dehiscence of the levator aponeurosis

• Frequent manipulation of the eyelids to insert and remove the artificial eye also stretches the upper eyelid tissues drooping eyelid.

Treatment• The mechanisms producing anophthalmic ptosis are

mutifactorial and should be assessed carefully

• Small amounts of ptosis may be managed by modification of the prosthesis

• correction of socket volume deficiency should be considered prior to levator surgery

• Once the other factors contributing to ptosis in the anophthalmic socket have been addressed tightening of the levator aponeurosis can be done

Anophthalmic ectropion• Ectropion of the lower eyelid is common in the

anophthalmic socket and is frequently associated with significant lower eyelid laxity

• A large or heavy prosthesis or frequent prosthesis removal may contribute to a stretching of the medial and/or lateral canthal tendons

• rotation of the orbital contents inferiorly and anteriorly contribute to a shallow inferior fornix, tilt of the prosthesis, and lower eyelid ectropion

Treatment• If the prosthesis is >5 years old, a new one may be

required

• If the prosthesis is large then a thinner or lighter prosthesis may help correct the eyelid malposition

• Tightening the lateral or medial canthal tendo n may remedy the situation

• Correction of eyelid retraction by recession of IR/ grafting of mucus membrane tissue in inferior fornix

OTHER COMPLICATIONS

EXPOSURE AND EXTRUSION OF IMPLANT

• Implant exposure may occur with any type of implant or at any time (early versus late) may lead to implant extrusion or explantation

• Porous orbital implants have a lower incidence of implant exposure than traditional nonporous implants

Factors predisposing

1. closing the wound under tension

2. poor wound closure techniques

3. Infection

4. mechanical or inflammatory irritation from the speculated surface of the porous implant

5. Delayed ingrowth of fibrovascular tissue with subsequent tissue breakdown

Preventive measures :

• proper placement of the implant within the orbit followed by a two-layered closure of anterior Tenon’s capsule and conjunctiva

• The rectus muscles are then attached to the wrapped implant

Treatment :

If few weeks,

• No infection,simple reclosure or with a patch graft (e.G., Sclera, temporalis fascia) is required

• If infection is suspected and treated vigorously with topical and systemic antibiotics, an extrusion and removal of the implant may be avoided.

beyond 4–6 months,

• If non porous implant,The defect should not be closed, and secondary orbital implant surgery should be arranged

• If porous,

exposure<3mm >3mm

Treat conservativelyWait 8 weeks for spontaneous closure

no

Close with scleral patch graft

surgical repair is indicatedUsing sclera patch graft or temporalis fascia patch graft

CONTRACTED SOCKET• A contracted socket is defined as the shrinkage and

shortening of orbital tissues causing a decrease in depth of fornices and orbital volume ultimately leading to inability to retain prosthesis.

• Guibor has classified clinically contracted socket into 4 morphological types

CAUSES

Etiology related・ Alkali burns

・ Radiation therapy

Surgery related• Fibrosis from the initial injury

• Poor surgical techniques during previous surgeries -enucleation /evisceration with extensive dissection of orbital tissue

• Excessive sacrifice of the conjunctiva and tenons capsule

• Traumatic dissection within the socket leading to scar tissue

• Multiple socket operations

Cont……

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

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