anophthalmic socket,post enuclation socket syndrome

1. SIVA TEJA CHALLA
ANOPHTHALMIC SOCKET

2. • 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

4. ANOPHTHALMIA
• Anophthalmia is absence of globe
• Congenital or acquired

5. 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

6. CAUSES
• Idiopathic/sporadic
• Inherited as dominant, recessive, or sex-linked
• Trisomy 13-15
• Maternal infections or teratogenic exposure
• 75% associated with syndromes

7. 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

8. ACQUIRED ANOPHTHALMOS
• After enuceation/evisceration/exenteration

9. ANOPHTHALMIC SOCKET

10. 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

11. 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

12. CHANGES ASSOCIATED

13. 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

14.  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

15. 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

16. 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.

17. MANAGEMENT

18. 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…..

19. 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

20. • orbital implant is typically placed at the time of
evisceration or enucleation
• ocular prosthesis is fitted subsequently.

21. FABRICATION, CARE, AND MAINTENANCE
OF 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

22. Non integrated Semi integrated
Fully integrated Expandable implants
IMPLANTS

23. PROSTHESIS

24. 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.

26. TREATMENT OF VOLUME DEFECIT

27. 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

28. DERMIS FAT GRAFT

30. DERMIS FAT GRAFT TO UPPER LID

31. 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

34. FORNIX DEEPENING SUTURES

35. 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.

37. 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

38. 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

39. 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

40. OTHER COMPLICATIONS

41. 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

42. • 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

43. 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.

44. 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 conservatively
Wait 8 weeks for spontaneous closure
no
Close with scleral patch graft
surgical repair is indicated
Using sclera patch graft or
temporalis fascia patch graft

45. 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

46. 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……

47. 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

49. THANK YOU