The Challenging Anophthalmic Socket
Updated May 2024
Evan H. Black, MD; Edward J. Wladis, MD; Francisco Castillo, MD
Establishing the diagnosis
- Postenucleation socket syndrome: a constellation of findings including shallow inferior fornix, deep superior sulcus, ptosis, lower eyelid laxity, and volume deficiency with apparent enophthalmos of the prosthesis.
- Multiple possible mechanisms
- Volume deficit, fat atrophy, contraction of myofibroblasts (i.e., wound healing), disruptions in normal tissue components of socket (Camezind, Oper Techn Oculoplastic Orbital Reconstr Surg, 2001).
- Dry socket: dry secretions on the ocular prosthesis and conjunctival metaplasia.
- Loss of corneal reflex and innervation can contribute to reduced tear production (Allen, Ophthalmology 1980).
- Meibomian gland dysfunction can be a complementary and separately treatable condition (Jang, Br J Ophthalmol, 2013).
- Socket contracture: shrinkage and shortening of orbital tissues leading to surface area deficiency and fornices that do not allow for retention of a prosthesis
- Implant migration: migration of the orbital implant, typically along the path of least resistance, most commonly superotemporally or inferonasally
- The conditions can be interrelated; migration increases the risk of developing a postenucleation socket syndrome.
- Implant migration can create pressure on the conjunctival tissues and cause exposure or extrusion of the orbital implant.
- Implant exposure: creates an environment conducive for implant infection.
- Implant infection: risk increases with porous implants and dead spaces conducive to bacterial colonization.
- Absent or under-sized orbital implant: Need for large prosthesis to compensate for decreased orbital volume. Places extra stress on lower lid.
History
- How long since removal of the eye?
- Indication for removal? Past ophthalmic history? Focus on possible reasons for loss of normal orbital structures and conjunctival foreshortening.
- History of ocular carcinoma and associated adjuvant therapies (e.g. radiation)?
- Type of surgery: enucleation versus evisceration?
- Postenucleation socket syndrome is less common after evisceration.
- What type of orbital implant was inserted?
- Any prior socket revisions? Any history or exposure?
- Chemical burn or underlying cicatrizing condition (e.g., ocular cicatricial pemphigoid)?
- How long since last cleaning and polishing of ocular prosthesis?
- Annual or semi-annual visit to ocularist suggested
- Is prosthesis worn daily?
- What is daily maintenance?
- Daily removal not needed
- How comfortable is the fit?
- Dry socket causes pain and discharge
- Prosthesis “sticks” to eyelid
- How stable is the prosthesis in the socket?
- Is patient wearing polycarbonate lenses?
- All monocular patients should be encouraged to wear polycarbonate lenses for protection of seeing eye.
Clinical features
- Fit and movement of prosthesis
- Eyelid position with prosthesis in place
- Assessment of levator function
- Lower eyelid laxity
- Eyelid malposition?
- Direction of eyelashes?
- Forniceal foreshortening?
- Depth of superior sulcus
- Quality of conjunctiva under the prosthesis
- Areas of erosion: staining with rose bengal or fluorescein
- Papillae or giant papillae
- Immunohistochemical analysis of 18 biopsies from prosthesis associated giant papillary conjunctivitis showed an allergic pattern with mast cell, eosinophil and lymphocytic infiltration (Bozkurt, Clin Experiment Ophthal 2007).
- Secretions
- Dryness
- Conjunctival cysts
- Typically lined by non-keratinizing stratified squamous epithelium without goblet cells containing fluid with mucinous strands (McCarthy, Ophthalmology 1981)
- Pyogenic granuloma: inflamed, well-vascularized granulation tissue
- Might be a sign of underlying implant exposure (Naser, OPRS 2006).
- Might also signal poor fitting prosthesis and mucosal irritation
- Implant exposure and wound dehiscence
- Primary conjunctival disorders
- It is paramount that the ophthalmologist removes the prosthesis and carefully inspects the entire conjunctival surface at least once a year
- Trauma is a risk factor for degeneration of conjunctival lesions into malignant tumors. New conjunctival lesions should be biopsied as clinically indicated
- Patients may develop papillary conjunctivitis with longer-term prosthesis use
- Oncologic surveillance if enucleation was done for ocular malignancy
- B-scan for routine surveillance
- CT or MRI if recurrence if suspected
- Serial examination of socket to assess for visible or palpable lesions
- Quality of prosthesis
- Jagged edges
- Smooth vs. irregular polish
- Dry secretions on prosthesis
- Size of prosthesis
- Areas where prosthesis has been built up
- Areas removed to accommodate adhesions
Risk Factors
- Dry eye is a risk factor for dry socket.
- Might progress with age
- Decreased tear production following enucleation secondary to abscent corneal stimulus
- Chronic inflammation
- Underlying pathology or poor prosthesis fit
- Small orbital implant
- Need for large, heavy prosthesis to compensate for decreased orbital volume
- Nonporous orbital implant
- History of orbital trauma
- Progressive orbital fat atrophy following extensive trauma
- Radiation
- Devascularization
- Reduced tear production
- Proinflammatory state promotes cicatrization
- Orbital fat atrophy
- Chemotherapy and systemic disease
- Implant exposure: etiology
- Exposure may occur at any time
- Early exposure: 0–3 months
- Poor wound closure
- Tension on wound
- Suture abscess
- Socket infection
- Intermediate exposure: 3–12 months
- Inadequate seating of the implant with slow anterior migration
- Early postoperative trauma
- Poor tissue healing
- Radiation
- Concomitant chemotherapy
- Systemic immunosuppression
- Systemic illness
- Late exposure
- Pressure points from poorly fitted prosthesis
- Inflammation
- Chronic low-grade infection
- Important to rule out tumor recurrence with any significant late socket changes
Differential diagnosis
- Lower-lid laxity
- Prosthesis
- Poor fitting
- Rotated
- Over- or under-sized
- Occult fracture
Management
- Prevention
- Orbital implant adequate size: 70%–80% of orbital volume
- Place conformer immediately after surgery
- Adequate size prosthesis: 20%–30% or orbital volume
- Custom made prosthesis
- Off-the-shelf prostheses are common in developing countries, rare in the United States.
- Avoid frequent removal of prosthesis by the patient
- Usually no more often than once a month for cleaning
- Medical management of dry socket
- 97 sockets (enucleation or evisceration) averaged similar Schirmer I and II, compared with contralateral eyes, which measured higher tear production without anesthesia (Allen, Ophthalmology 1980).
- In above study, dry sockets had half the tear production of those with no complaints.
- Punctum plugs might be beneficial (Vardizer, Orbit 2007).
- Artificial tears 6 times per day
- Light mineral oil 1–2 times per day
- Silicone oil 1–2 times per day
- Orbital surgery to correct enophthalmos
- Correct bony orbital defects if present
- Subperiosteal orbital implant can be placed over intact orbital floor and inferior fornix mucosal graft can be performed at same time to treat post-enucleation socket syndrome (Kim, Plast Reconstr Surg 2014).
- Dermis-fat grafts are viable options to increase orbital volume
- Vagefi and coauthors reported 15 patients who received calcium hydroxylapatite injections, and noted a reduction of 2.4 mm of enophhtalmos/syringe of filler (Vagefi, OPRS, 2011)
- Treatment of conjunctival cysts
- Can be marsupialized or excised
- Can be injected with 20% trichloroacetic acid solution (Naser, Ophthal Plast Reconstr Surg 2005)
- Correction of ptosis
- Can avoid need for socket reconstruction
- Can be in conjunction with prosthesis revision
- Typically levator advancement
- Muller’s conjunctival resection can shorten superior fornix but a conjunctival-sparing approach can be considered.
- Correction of upper lid entropion and/or eyelash ptosis
- Mild contraction causes minimal posterior rotation
- Can shorten anterior lamella with lid crease fixation
- Might need tarsal fracture
- Can augment posterior lamella with mucous membrane graft
- Might require allogeneic or xenogeneic graft
- Can replace tarsus and improve structural support of the eyelid
- Correction of ectropion
- Horizontal lid tightening
- Might require full thickness skin graft to augment anterior lamella
- Correction of deep sulcus
- Replace migrated orbital implant
- Autologous fat injection
- Dermal fat graft to superior sulcus
- Injectable fillers
- Correction of socket contracture
- Substrate grafts: amniotic membrane graft
- Requires healthy conjunctiva to reepithelialize
- Substitute grafts
- Buccal mucosa
- Hard palate
- Volume and surface area replacement
- Might be unable to retain even a small prosthesis
- Motility severely compromised
- Might require multiple staged procedures to achieve an acceptable outcome
- Function is primary goal followed by cosmetic appearance
- Dermis fat graft to correct contraction and enophthalmos
- Temporalis muscle flap with split thickness skin can also correct volume and surface area deficiency
- Mucosal graft to augment surface area.
- A custom conformer secured to the orbital rim might be necessary to secure the graft in place
- Correct implant exposure: < 3 mm
- Usually best to treat promptly
- Consider vaulting the prosthesis over the defect to promote reepithelialization
- Allow eight weeks with close observation
- Topical and/or systemic antibiotics to prevent infection
- Might consider conjunctival advancement flap
- Very small exposures may close spontaneously, although observant management requires diligent serial monitoring to avoid the development of an infection
- Correct implant exposure: > 3 mm
- Attempt can be made at covering the defect
- If no evidence of orbital implant infection
- Typically more viable with porous implant if implant is well vascularized.
- Bipedicled conjunctival flap
- Tenon’s fascia flap
- Tarsoconjunctival flap or graft
- Allogeneic or xenogeneic scleral patch
- Temporalis fascia flap
- Fascia lata graft
- Hard palate graft
- Dermal fat graft
- Consider explantation if evidence of infection, lack of reepithelialization or failed reconstruction.
- Refit prosthesis to prevent recurrent trauma.
References and additional resources
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