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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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