Indication for and perform the basic the

Anophthalmic
 
Socket
 INTRODUCTION
• Patients can present with conditions that lead to the removal of an eye or
the orbital contents in order to safeguard life, to preserve vision in the
fellow eye, or to enhance comfort and cosmesis.
• The goals of anophthalmic socket surgery are:
- maximizing orbital implant volume with good centration within the
orbit
- achieving optimal eyelid contour, volume, and tone
- establishing a socket lining with deep fornices to retain the prosthesis
- transmitting motility from the implant to the overlying prosthesis
- achieving comfort and symmetry
 ENUCLEATION AND EVISCERATION
• Enucleation
- Enucleation involves first releasing the extraocular muscles from the
sclera, then removing the globe.
- Enucleation can be performed satisfactorily under local or general
anesthesia; however, most patients prefer general or monitored
anesthesia when an eye is removed.
- Enucleation is the procedure of choice if the nature of the intraocular
pathology is unknown or if an ocular tumor is suspected in an eye with
no view of the posterior pole.
- Enucleation is indicated for primary intraocular malignancies that are
not amenable to alternative types of therapy
 ENUCLEATION AND EVISCERATION
• Evisceration
- Evisceration involves the removal of the contents of the globe, leaving the
sclera, extraocular muscles, and optic nerve intact.
- Evisceration should be considered only if the presence of an intraocular
malignancy has been ruled out.
- Advantages of evisceration: less disruption of orbital anatomy, better
motility of prosthesis, treatment of endophthalmitis, a technically simpler
procedure, lower rate of migration or extrusion of the implant, and
subsequent reoperation, easier prosthesis fitting by the ocularist
- Disadvantages of evisceration: not every patient is candidate, theoretical
increased risk of sympathetic ophthalmia, evisceration affords a less
complete specimen for pathologic examinations
 ENUCLEATION AND EVISCERATION
• Intraoperative Complication of Enucleation and Evisceration
- Removal of the wrong eye
- Ptosis and extraocular muscle damage
 ORBITAL IMPLANTS
• Orbital implant’s function is to replace lost orbital volume, maintain the
structure of the orbit, and impart motility to the overlying ocular
prosthesis.
• After enucleation, implants are placed either within the Tenon capsule or
in the muscle cone behind the posterior Tenon capsule.
• After evisceration, implants are placed either behind or within the sclera.
 PROSTHESES
• An ocular prosthesis is generally fitted 4 weeks after enucleation or
evisceration.
• The ideal prosthesis is custom fitted to the exact dimensions of the
patient’s conjunctival fornices after postoperative edema has subsided.
• Eviscerations may be more amenable to prosthetic fitting.
 ANOPHTHALMIC SOCKET
COMPLICATIONS AND TREATMENT
• Conjunctival changes in anophthalmic socket
- Conjunctival cyst; poor wound closure during enucleation is typically the
cause. Treatment is typically not necessary unless the cyst size interferes
with comfortable prosthesis wear.
 ANOPHTHALMIC SOCKET
COMPLICATIONS AND TREATMENT
• Conjunctival changes in anophthalmic socket
- Giant papillary conjunctivitis; commonly
develops with prosthesis wear, due to the
mechanical friction between the palpebral
conjunctival surface and the prosthesis.
Patients typically present with constant
mucus discharge; the discharge has a
stringy consistency. Treatment consists of
topical corticosteroids and occasionally
prosthetic modification.
 ANOPHTHALMIC SOCKET
COMPLICATIONS AND TREATMENT
• Exposure and extrusion of the implant
- Implants may extrude if placed too far forward, if closure of anterior Tenon
capsule is not meticulous, or if the irregular surface of the implant
mechanically erodes through the conjunctiva.
- Postoperative infection, poor wound healing, poorly fitting prostheses or
conformers, pressure points between the implant and prosthesis, and
compromised vascularity may also contribute to exposure of the implant.
 ANOPHTHALMIC SOCKET
COMPLICATIONS AND TREATMENT
- The formation of a pyogenic granuloma is suggestive of an implant exposure.
- Most exposures should be covered with scleral patch grafts or autogenous
tissue grafts with a sufficient vascular bed to promote conjunctival healing.
- When implants are deeply seeded with infection, removal of the implant is
usually required, followed by an autogenous dermis-fat graft
 ANOPHTHALMIC SOCKET
COMPLICATIONS AND TREATMENT
• Contracture of fornices
- Preventing contracted fornices includes preserving as much
conjunctiva as possible and limiting dissection in the fornices. Placing
extraocular muscles in their normal anatomical positions also
minimizes shortening of the fornices.
- It is recommended that the patient wear a conformer in the immediate
postoperative period to maintain soft-tissue anatomy and minimize
conjunctival shortening.
- Conformers and prostheses should not be removed for periods greater
than 24 hours.
 ANOPHTHALMIC SOCKET
COMPLICATIONS AND TREATMENT
• Contracted Sockets
- Sockets are considered contracted when the fornices are too small to
retain a prosthesis
- Causes of contracted sockets include: radiation treatment, extrusion of
an orbital implant, severe initial injury, poor surgical techniques,
multiple ocular and/or socket operations, removal of the conformer or
prosthesis for prolonged periods
- Socket reconstruction procedures involve incision or excision of the
scarred tissues and placement of a graft to enlarge the fornices.
THANKS