Dr. Raghuraj S Hegde, H14510
Introduction
An Anophthalmic Socket is an orbit with absence of an eye which can be either congenital absence or removal due to the ophthalmic cancers (for example Retinoblastomain children or choroidal Melanoma in adults), irreparable eye injury (due to trauma to the globe, orbital soft tissues or bones in children & adults), cosmetically disfigured eyeball (due to trauma or disease) with no hope of visual rehabilitation or a painful blind eye.
An anophthalmic socket needs rehabilitation in the form of surgery. The aim of such a surgery is to reduce disfigurement by either restoring volume deficit caused by anophthalmia or/and restoring surface deficit as in contracted sockets. The volume deficit in the socket can be corrected by several methods- either by placing an appropriately sized orbital implant at the time of surgery or by placing autologous fat or other soft tissue grafts. After the socket heals, the rehabilitation reaches an end point by fitting the patient with an adequately sized customized ocular prosthesis
The rehabilitation of an anophthalmic socket requires two professionals
- Ophthalmologist- the Ophthalmologist (preferably an Oculoplastic surgeon) is responsible for the surgical part of the procedure.
- Ocularist- a person who is trained in the design and fabricatesthe customized artificial eye prosthesis after the surgery and post-operative healing is complete.
The failure to place an implantafter removal of the eye is responsible for postenucleation socket syndrome (PESS), whose features include enophthalmos, ptosis or lid retraction, deep upper lid sulcus, lower lid laxity, and shallowing of the inferior fornix.This paper presents a case series of 3 challenging cases of anophthalmic sockets and its reconstructions using various techniques
Methods
This case series consists of three cases where the patients were victims of trauma causing disfigured or deformed orbits presenting as challenging scenarios for socket reconstruction. A full informed consent for all the surgical procedures from all the patients has been taken. A separate photo consent was taken from all the patients whose photos appear in this paper for use of clinical photographs, scans, reports for use in teaching, presentations, academic, educational and scientific journals.
Case 1
SB is a 35 year old female who met with a road traffic accident 8 years earlier. Her left eye was badly injured. The left eye was enucleated but no primary implant was placed after enucleation. Left side of the face reconstructed with vascularised free flap by a general plastic surgeon. A cover on prosthesis was provided without placing a secondary orbital implant. Consequently, over time PESS developed in the socket with obliteration of inferior fornix resulting in the cover on prosthesis slipping off the lower lid with lot of discharge. There was lower lid induration since anterior lamellae of the lower lid was a free flap. CT scan showed that signs of an old Left orbital and zygomatico-facial fracture which was well repaired.
It was decided to proceed with the placement of a secondary implant with Fornix Forming Sutures (FFS). A PMMA implant of 18mm was placed in the orbit after isolating all the extraocular muscles and fixing it to the four fornices (Myo-conjunctival technique). Lower lid fornix forming sutures were placed using 4/0 prolene sutures using bolsters taking a bite from the periosteum of the inferior orbital margin.
The sutures were removed after 6 weeks and sent to the ocularist for Ocular prosthesis fabrication. Adequate cosmetic and functional results were obtained.
Case 2
CM is a 51 year old male who suffered from an industrial accident and a wire-cutter hit his left eye with force. He had a penetrating globe injury with a scleral perforation. The scleral laceration extended from anterior to the lateral rectus to superior limbus to medial rectus with prolapse of uveal tissue. There was an eyelid laceration at the left lateral canthal angle. The globe and eyelid wounds were repaired. Post repair, the left eye was found to have no perception of light. CT scan showed a large orbital medial wall fracture with avulsion of optic nerve. The optic nerve avulsion seen in the CT scan was confirmed by a negative signal on the VEP. The retina surgeon confirmed that the left eye was not salvageable.
It was decided that an orbital fracture repair along with enucleation of the deformed globe followed by implantation of an orbital implant would give the best cosmetic outcome. Since there was no solid bone left in the medial wall to place an implant, the medial wall was repaired using a titanium combined floor and medial wall prefabricated orbital implant placed using a subciliary incision and dissection. Enucleation of the deformed globe was performed. A 20mm Porous Polyethylene implant covered with donor sclera was placed in the orbit. The posterior and anterior tenon’s capsule was sutured followed by conjunctival closure. A conformer was placed to maintain the fornices along with a temporary tarsorraphy.
CM was sent to the ocularist for a customized ocular prosthesis 6 weeks after second surgery. The ocularist was able to fit an adequately sized ocular prosthesis giving good functional and cosmetic results.
Case 3
VK is a 23 year old male. He had his right eye enucleated when he was 5 years of age after a penetrating globe injury. An enucleation was performed at the time of injury to avoid sympathetic ophthalmia but no orbital implant was placed in its place. No other details of the first surgery were available. VK presented to the author at the end of 18 years after the first event and wished for a prosthetic eye to be placed in the eye socket. On examination he had hemifacial hypoplasia on the right side of the face. Both upper and lower fornices were obliterated. A CT orbit was done to evaluate the orbital volume. The CT scan confirmed the clinical diagnosis- an orbital volume deficit, surface lining deficit and the obliteration of the fornices.
It was decided that a DFG would be appropriate to address the volume as well as surface deficit. Fornix forming sutures for both the upper and lower eyelids would take care of the fornix formation. Dermal fat grafting for the right socket along with Fornix formation sutures was planned electively. Due to the constant pull of the FFS on the conjunctiva on both lids, the socket took 10 weeks to heal and completely epithelialize. The patient was sent to the ocularist who could not fit an ocular prosthesis because the inferior fornix was too shallow to have a stable prosthesis despite the fornix forming sutures. The DFG could not take care of the surface deficit completely.
It was decided that a mucous membrane grafting (MMG) was required to increase the surface area of the cul-de-sac of the socket. A mucous membrane graft was harvested from the lower lip area and the raw area covered with an amniotic membrane graft. Space was created in the inferior forniceal area and the mucous membrane graft was sutured to the two ends of the conjunctiva with 5/0 vicryl. Fornix formation sutures were again placed in the lower lid taking bite through middle of the graft and also a bite through the periosteum of the inferior orbital rim.
After 6 weeks of the second surgery, VK was sent to the Ocularist who could now fit a good sized prosthesis providing good symmetry with the other eye.
Discussion
When the removal of an eye is done without the placement of an orbital implant in its place,a functional and cosmetic change in the orbit is inevitable. To prevent postoperative orbital volume deficit, various alloplastic orbital implants have been developed over the years for volume augmentation of the anophthalmic socket. These alloplastic implants are sometimes associated with a small chance of postoperative complications such as implant migration and exposure. The first alloplastic implants were not biologically inert either which created problems in assimilation with the rest of the orbital soft tissues.
Autologous free fat grafts was proposed so as to overcome some of the problems associated with alloplastic materials. Early attempts in the late 1800s using autologous free fat grafts,resulted in pronounced atrophy of the implanted fat and this technique was discarded as a means of volume augmentation for many years. Many years later composite grafts consisting of dermis and fat resulted in less volume loss after implantation.The deepithelialized dermal portion of this graft served as a scaffold for conjunctival growth over the superficial surface of the graft. For this, the conjunctiva is sutured to the implant to only partially coat it, leaving the central part of the implant surface uncovered. With this technique, the depth of the conjunctivalfornices can be preserved. Additionally, the extraocular muscles are attached to the more rigid dermal portion of the implant allowing for postoperative motility of the implant. Dermis-fat grafting (DFG) could also be done for socket rehabilitation such as in cases of contracted sockets. DFGs can be used for primary and secondary reconstructions of orbital volume deficits in adults and children. DFG provides volume augmentation to the socket as well as surface lining augmentation with the conjunctiva growing over the dermis. In the pediatric age group, DFGs have the added advantage of fat in the graft growing in size along with the growth of the child. However in adults the fat in the graft atrophies by upto 50% of the original size, so whenever DFGs are used in adults an oversized graft placement is the norm.
Conclusion
It is possible to get acceptable cosmesis in patients who have unfortunately lost an eye and wish to look normal again. This prevents stigmatization by society as well as increases the confidence of the patients who have lost an eye thus justifying the extensive reconstructive surgeries.
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