Cosmetic management of contracted socket important
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The orbital socket forms the most visible part of the face. It holds the eyeball and surrounding muscles with neurovascular soft tissues.
Due to inadvertent accidents and infections, including globe injuries and autoimmune conditions, the ocular soft tissues can be affected, which leads to shrinkage of the globe.
Source: Dhivya Ashok Kumar, MD, FRCS, FICO, and Amar Agarwal, MS, FRCS, FRCOphth
There are clinical conditions that require removal of the globe, such as ocular infection, panophthalmitis, tumors or painful blind eye. Such conditions leave the orbit anophthalmic with volume loss. Additional surgical procedures are needed to reconstruct the orbital volume and provide a good cosmetic outlook, especially in young patients. In this column, we address the causes and cosmetic management of contracted socket.
Etiologies for socket contraction
Contracted socket is defined as loss of orbital volume or surface area (Figure 1), causing the inability to place a prosthesis. Conditions such as chemical burns, electric burn injuries, irradiation, and autoimmune conditions such as Stevens-Johnson syndrome and ocular cicatricial pemphigoid cause surface contraction. Penetrating injury can lead to vitreous loss and uveal prolapse, causing volume reduction and phthisis bulbi. Additionally, improper socket maintenance after surgical eye removal procedures can lead to contracted socket.
Post-surgery anophthalmos
Enucleation and evisceration are the two surgical interventions performed as eye removal procedures for various clinical situations. Large globe rupture following penetrating injuries or nonrepairable scleral tear and absolute painful blind eye are some of the etiologies for enucleation. For an intraocular tumor in which the eye is not salvageable, enucleation is performed. Enucleation involves the removal of the entire globe and its intraocular contents, with preservation of all other periorbital and orbital structures. In evisceration, the ocular contents are removed, leaving the intact sclera (Figure 2). However, a radical third procedure, called exenteration, involves the removal of the entire orbital contents, including the globe and soft tissues. It is performed for extensive orbital involvement of malignancies or invasive fungal infections.
Effects of enucleation and evisceration
Because surgical removal of the eyeball affects the orbital volume, it can lead to signs related to volume deficiency and support. Post-enucleation socket syndrome will have a sunken superior sulcus, ptosis in the upper lid, a narrow palpebral and lid laxity. The ocular motility is lost in enucleation unless appropriate measures such as implant placement and muscle suturing are performed intraoperatively. However, as the sclera is retained in evisceration, the motility of the surface is retained to an extent. Therefore, from a cosmetic aspect, evisceration can provide better motility as the muscle insertions are intact. Post-surgical anophthalmos-induced contracted socket is the long-term complication if proper postoperative precautions are not maintained after enucleation or evisceration. Intraoperative conjunctival preservation, avoiding excess hemorrhage, immediate postoperative conformer placement, control of infection and proper hygiene are vital in prevention of contracted socket after eye removal surgery.
Contracted socket
Loss of orbital soft tissue due to a small globe, absence of the globe or reduction in surface due to mucosal contraction can lead to contracted socket. It has been graded from grade 0 to 5.
Grade 0: Socket is lined with healthy conjunctiva and has deep and well-formed fornices.
Grade 1: Socket is characterized by the shallow lower fornix or shelving of the lower fornix.
Grade 2: Socket is characterized by the loss of the upper and lower fornices.
Grade 3: Socket is characterized by the loss of all fornices.
Grade 4: Socket is characterized by the loss of all fornices and reduction of palpebral aperture in horizontal and vertical.
Grade 5: In some cases, there is recurrence of contraction of the socket after repeated trial of reconstruction.
Cosmetic management in contracted socket
Eyes with shelving of the fornix and anophthalmos can be treated by fornix formation sutures with placement of an ocular prosthesis (Figure 3). If associated volume contraction is there, an appropriate-sized orbital implant (polymethyl methacrylate/porous polyethylene) placement under anesthesia should be performed. Orbital implants provide good volume replacement in enucleated or eviscerated eyes, thereby preventing socket contraction. Eyes with only surface area loss with fornices loss can be managed by fornix formation sutures (FFS) with mucous membrane graft (MMG). Mucosa from oral buccal mucosa can be cleaned and used intraoperatively for MMG. In the mild form, FFS with amniotic membrane graft can also be performed. Another option in volume and surface loss is dermis fat graft. Dermis fat is dissected from the same patient from the upper thigh or gluteal region and placed in the socket. In post-exenterated socket in bony contracture in infections/trauma/post-irradiation, one can use an adhesive prosthesis. A spectacle mount prosthesis (Figure 4) can also be used in eyes with multiple surgeries performed in grade 5 socket contraction or post-exenterated socket.
Customized prosthesis
When fornices are well formed and a clinically healthy conjunctival surface is observed, a prosthesis can be placed. Ciliary tenderness should be ruled out before prosthesis placement. If evisceration has been performed and an implant is in situ, a customized prosthesis impression can be taken at 6 weeks postoperatively. Color and painting can be done after assessment to match with the fellow normal eye for a good aesthetic appearance. Regular shell cleaning, hygiene and follow-up are to be explained for routine maintenance. An annual examination should address changes in color/ridge abnormalities in the prosthesis and fitting challenges.
Conclusion
Socket contraction can occur in various clinical scenarios after trauma, surgery or disease. Understanding the clinical manifestations early and prevention of further contraction are vital in regular practice. Proper surgical planning, diligent postoperative care and regular prosthesis maintenance are key for good cosmetic outcomes in contracted socket.
- References:
- Bhattacharjee K, et al. Indian J Ophthalmol. 2014;doi:10.4103/0301-4738.128593.
- Jovanovic N, et al. Ophthalmic Plast Reconstr Surg. 2020;doi:10.1097/IOP.0000000000001610.
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- Kumar S, et al. Orbit. 2006;doi:10.1080/01676830600575527.
- Nesi FA, et al. Evaluation and current concepts in the management of anophthalmic socket. In: Smith’s Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. Mosby; 1998:1079-1124.
- Shah-Desai SD, et al. Br J Ophthalmol. 2000;doi:10.1136/bjo.84.4.437.
- Soares IP, et al. Semin Ophthalmol. 2010;doi:10.3109/08820538.2010.488575.
- Tawfik HA, et al. Curr Opin Ophthalmol. 2009;doi:10.1097/ICU.0b013e32832ed85b.
- Tyers AG, et al. Trans Ophthalmol Soc U K (1962). 1982;102 (Pt 1):90-92.
- Yousuf SJ, et al. Orbit. 2012;doi:10.3109/01676830.2011.639477.
- For more information:
- Amar Agarwal, MS, FRCS, FRCOphth, director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, is the author of several books published by SLACK Books, sister company of Healio publisher Ocular Surgery News, including Phaco Nightmares: Conquering Cataract Catastrophes, Bimanual Phaco: Mastering the Phakonit/MICS Technique, Dry Eye: A Practical Guide to Ocular Surface Disorders and Stem Cell Surgery and Presbyopia: A Surgical Textbook. He can be reached at aehl19c@gmail.com; website: www.dragarwal.com.
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