The purpose of this article is to describe the different reconstruction techniques for anophthalmic sockets. In preparing the anopthalmic socket for prosthesis. Enucleation and evisceration introduce the anophthalmic socket syndrome, which consists of enophthalmos due to orbital tissue shrinkage. Following enucleation or evisceration surgery, the anatomy and physiology of the orbit are changed. These changes affect not only the cosmetic appearance of.
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The Chinese possibly first performed enucleation as early as BC, but the first report was by Johannes Lange in The procedure advanced to a more modern technique in when Irish physician O’Ferrall and French physician Bonnet simultaneously reported their technique of extraocular muscle disinsertion.
Compared to the unaffected right eye, the left eye socket is sunken superiorly and the left lower eyelid is retracted. Evisceration seems to have first been performed unintentionally by James Beer in after anopthalmic expulsive choroidal hemorrhage; in J. Noyes completed the first planned evisceration.
Mules’ more modern version in Since that time, many materials and shapes have been tried from glass to metals, ivory to rubber, wool to cartilage and many others. In recent history the advent of inert plastics has changed the implants used. Today most implants are solid polymethyl methacrylate or siliconeanophhalmic hydroxyapatite and high-density polyethylene or autogenous dermis-fat grafts.
The most recent published survey in reported spherical porous polyethylene to be the most commonly used implant. Regardless of the implant used and the surgical technique, the goals of the surgeon socoet the same; treating the underlying condition, replacing orbital volume, maximizing motility and providing the most comfortable and aesthetically symmetric appearance. These changes and the placement of an orbital implant can lead to a variety of complications and management difficulties.
For these reasons it is important that the general ophthalmologist be able to adequately evaluate and treat simple problems of the anophthalmic socket. Does the patient have pain with the prosthetic in?
Does the prosthesis fall out? Is there discharge or anophthalnic 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? Besides the ptotic right upper eyelid, the patient has poor motility of the prosthesis. The anophfhalmic should also be observed with the prosthesis out of the socket.
If eyesocket motility is better than prosthesis motility, a motility peg or magnetic coupling device, or a better fitting prosthesis may improve motility. Ptosis eocket an anophthalmic socket can often be improved with a new prosthesis as well.
With the prosthetic in place the patient should be evaluated for enophthalmos or prosthetic malposition. The lower eyelid should be evaluated for laxity.
Evaluation of the Anophthalmic Socket
The superior sulcus should be checked for deepening and symmetry with the opposite side See Figure 1. The upper eyelid position should be noted for ptosis, and levator function should be evaluated. Poor movement can be due to fornix abnormalities, enophthalmos or poor prosthetic depth. If the prosthesis is thick it may be placing pressure on the lower lid and could be camouflaging low orbital volume.
The tissue over the implant should be examined for thinning, fistula or a defect. Lastly, on palpation of the socket, the presence or absence of an implant and the position of the implant should be noted. Of course the seeing eye must also have careful exams, with the frequency of exams determined by the patient’s age, history and the health of the eye. The commonly performed tarsal strip procedure can correct the laxity; less commonly, lower eyelid sling procedures are at times used.
Entropion must be carefully evaluated to determine if the etiology is due to horizontal laxity or mild socket contracture.
Socket contracture is treated surgically with sockeg variety of techniques, at times including grafting of mucous membrane or other reconstructive material. Upper eyelid ptosis is common in the anophthalmic socket. This can be a true ptosis or a pseudoptosis due to poor support from the prosthetic or poor orbital volume and implant location. As is well known, any orbital surgery, such as volume augmentation, should precede eyelid correction.
Once any socket problems have been corrected the ptosis can be addressed. If the ptosis is mild the ocularist can build up the prosthetic superiorly to support the upper eyelid.
However as this increases the weight of the prosthetic it can begin a cycle of problems in the future by inducing lower eyelid laxity, which then leads to a deeper superior sulcus and the need for a larger prosthetic in a perpetuating cycle. If the ptosis is to be addressed surgically the ophthalmologist should keep in mind that levator strength may be underestimated.
Anophthalmia with exposed implant, OD. In both cases the patient complained of discharge out of the right eye socket.
Figure A shows an exposure of a smooth, acrylic implant. In these cases, since the implant is not integrated to the eye socket tissue, the implant is usually replaced. Figure B shows an exposed, porous implant. These implants are integrated with the orbit soft tissue, and, therefore, the defect can often be repaired leaving the implant in place. Other conditions that may cause discharge are poor prosthetic fit, extruding implant See Figures 3a and bpyogenic granuloma in the socket, excessively deep fornices or nasolacrimal duct obstruction.
Psychogenic factors, such as drug-seeking behavior, can also lead to pain, but these anopthalmic diagnoses of exclusion.
Anophthalmic Socket | Oculoplastic Surgery at Wilmer Eye Institute
If the etiology is xocket clear and persists after prosthetic polishing and lubrication, the patient may need a CT scan to aid in diagnosis. The management of these patients should be carried out with close communication between the ophthalmologist and ocularist to achieve optimal comfort and cosmesis for patients.
A short history of enucleation. Int Ophthalmol Clin ; Enucleation and Allied Procedure. In Xnophthalmic Plastic Surgery, 4th Ed. Evisceration of the globe, with artificial vitreous. Trans Ophthalmol Soc UK ;5: Ophthal Plast Reconstr Surg. Nunnery WR, Cepela M. Levator function in the evaluation and management of blepharoptosis.
Indications and results in anophthalmic socket reconstruction using dermis-fat graft
Ophthalmol Clin North Am. Find a Job Post a Job. This article reviews the history anophthalmi discusses the evaluation techniques for the anophthalmic socket. History The Chinese possibly first performed enucleation as early as BC, but the first report was by Johannes Lange in Reproduction in whole or in part without permission is prohibited.