1. CONTRACTED EYE SOCKET RECONSTRUCTION
2. Questions to be answered • What is the eye socket? • What is the common causes for enucleation? • What is the contracture of socket? • What cause that? • how to prevent it? • Aims of surgery? • Types of surgery? • Types of implant?
3. • Enucleation is the removal of the eye that leaves the eye muscles and remaining orbital contents intact. • Exenteration – removal of the contents of the eye socket, including the eyeball, fat, muscles, and other adjacent structures of the eye.
4. • Tenon's capsule thin membrane which envelops the eyeball from the optic nerve to the limbus, separating it from the orbital fat and forming a socket in which it moves, In front it adheres to the conjunctiva. • After enucleation orbital implant iserted to the Tenon's capsule in order to keep the orbital size and to keep eye animation .
5. The term Eye socket is refer to: • Eyelids • Conjunctival fornices • Orbital structures(bony cavity and soft tissues)
6. Common causes requiring socket reconstruction • Congenital (anophthalmia ,microphthalmia) • Trauma • Tumour • scarring
7. contracture of socket It refer to : • extensive loss of conjunctiva surface area • deep scar formation • shrinkage of orbital fat • conjunctiva fornices contracture.
8. Causes of contracture of socket • irradiation of the socket as after enucleation in some cases of retinoblastoma. • severe socket infections. • faulty or non wearing of the artificial eye. • keloid like mass formation in the socket. • tissue loss due to injury. • scarring of the conjunctiva due to various factors(allergy for ex.)
9. Main compliants The main presenting complaint : • story of a gradually increasing difficulty in retaining the prostheses. • the patients are not satisfied with the cosmetic appearance.
10. Preoperative assessment the contracted sockets should be examined clinically and microbiologically. History :In every case, mode, circumstances and duration of the eye loss, and subsequent problems with the prostheses . The socket should be examined for fibrous bands, condition of the various fornices and the state of the conjunctiva.
11. • Never forget to Assess the prosthesis shape and size . • Look for orbital implant exposure.
12. Grades of contracted sockets. • The soft tissue sockets were divided into five grades for the sake of convenience in management of contracted sockets. Grade-0: Socket is lined with the healthy conjunctiva and has deep and well formed fornices. Grade-I: Socket is characterized by the shallow lower fornix or shelving of the lower fornix. Here the lower fornix is converted into a downwards sloping shelf which pushes the lower lid down and out, preventing retention of a artificial eye
13. • Frequently there is shallow lower fornix and deep upper fornix resulting in upward migration of the prosthesis.
14. Grade-II: Socket is characterized by the loss of the upper and lower fornices
15. Grade- III: Socket is characterized by the loss of the upper, lower, medial and lateral fornices
16. Grade-IV: Socket is characterized by the loss of all the fornices, and reduction of palpebral aperture in horizontal and vertical dimensions
17. Grade-V: In some cases, there is recur- rence of contracture of the socket after repeated trial of reconstruction
18. Aims of reconstruction • To establish stable fornices by increasing the surface area by (hard palate ,oral mucosal,skin graft) and if necessary by increasing size by orbital implant. • The ocular prostheses should be light and take its support from infraorbital rim not from the lids.
19. Prevention • By use of conformer made by ocularist placed inside orbit to help support the growth of eye socket and bones in the face. • the conformer used during healing for about 6 weeks then ocular shell prosthesis used there after.
20. Types of ocular prosthesis • Spherical or oval • Stock or custom made • Porous or non porous • Chemical make up • Presence or absence of motility post.
21. Surgical principle • First : obtain adequate palpepral aperture size (canthoplasty may be needed in grade3,4,5) • Second : create adequate fornixes (lower,upper,lateral) insicion central in grade 2 while it can be at inferior position in grade 1. • Third : perfect lining of the created fornix (hard palate ,oral mucosal,skin graft ,amniotic membrane) • Fourth be sure that the fornix created supported by orbital bony rim to create a stable and deep lower fornix, the lower edge of the graft should be sutured to the inferior orbital bone rim using anchor sutures .
22. • Fifth: the conformer used during healing for about 6 weeks then ocular shell prosthesis used there after. • Sixth : central temporary tarsorrhaphy may be used.
23. Orbital implant exposure • One of the most important aspect of eye socket reconstruction can present with or without socket contracture.
24. Orbital implant exposure
25. • Autogenous Derma-Fat Graft used usally in case of Exenteration and in cases of extrusion or implant exposure.
26. The extraocular muscles and conjunctiva is sutured into the border of the DFG
