Contracted Socket Research Articles

Strategies to prevent anophthalmic socket contraction in retinoblastoma patients

Abstract Purpose: The combination of enucleation plus irradiation often leads to a significant orbital volume loss and severe enophthalmos in retinoblastoma patients. Our purpose is to discuss the strategies to prevent anophthalmic socket related complications. Methods: In this retrospective study we reviewed our retinoblastoma patients who underwent enucleation. We evaluated the enucleation technique, possible causes and preventive factors for anophthalmic socket contraction. Results: In our clinic, four patients developed severe anophthalmic socket contraction following retinoblastoma treatment. One of these patients had bilateral enucleation and three patients had only one eye removal. The patient who had bilateral enucleation also had external orbital irradiation. All patients had small orbital implants (12 to 14 mm in diameter) and smaller orbital volumes. One patient had severe ectropion and one patient had severe entropion with granuloma formation. Conclusions: Surgical technique, adjunctive radiotherapy, implant diameter, orbital growth retardation and fat atrophy are important factors in development of anophthalmic socket contraction in retinoblastoma patients. Most of these factors are preventable with appropriate surgical approach in enucleation.

Factors affecting orbital abnormal development and its relevant treatments

Orbital development is associated with the growth of the eyeball. During the development period, congenital or acquired changes of volume of the eyes and radiation treatment in ocular region influence the development of the orbit. Abnormal development of the orbit influences craniomaxillofacial growth and person's overall aesthetics of the face afterwards. Reconstruction of contracted sockets and shrunken orbits poses significant difficulties and obstacles that often results in universal frustration and disappointment results. Various methods have been used to improve these abnormalities. There are substantial different opinions regarding which method offers the best outcome. Traditional methods involve using progressively enlarging conformers, static spherical orbital implants, demis-fat grafts, and inflatable balloon expanders for orbital enlargement. Recently, the self-expander hydrogel tissue expander is available that expanders our option. This article reviews the influence of ocular abnormalities on the development of the orbit, as well as the advantages and disadvantages of various treatments for promoting the development of the orbit.

Secondary Orbital Implant Insertion in an Anophthalmic Patient after Orbital Reconstruction

The authors report the case of a 20-year-old man who underwent enucleation of his right eye with teratoma when he was an infant, without volume replacement by an implant. As a result, an underdeveloped shallow bony orbit finally occurred. Also, a contracted socket was present with shallow lower fornix, making ophthalmic prosthesis fitting almost impossible. The patient underwent surgical reconstruction of the orbit with expansion of the orbit vertically and horizontally. A secondary implant with an adequate volume was inserted to correct the orbital volume deficit. The previous expansion of the orbit allowed the insertion of an 18 mm-diameter hydroxyapatite implant wrapped in fascia lata. The lower fornix was expanded with a mucosal graft in order to overcome the socket contraction and the conjunctival shortage. The authors conclude that the final result of this approach is satisfactory. Almost 20 years after enucleation of an eye with teratoma, an attempt was made to correct most of the difficult problems dealing with a malformed shallow orbit and a contracted socket. The young patient is now able to wear a fine ophthalmic prosthesis and his appearance is greatly improved.

Eyelid Switch Flap Technique for the Management of Congenital Anophthalmos Associated with Contracted Socket

Congenital anophthalmos with contracted socket can occasionally present in the second or third decade for cosmetic correction of the deformity. Placement of ocular prosthesis is not possible due to reduced dimensions of the palpebral aperture and contracture of the bony socket. Horizontal widening of the palpebral aperture using an eyelid switch flap technique followed by placement of ocular prosthesis anterior to the hypoplastic orbit achieves good cosmetic correction of this deformity.

Evaluation of Amniotic Membrane Grafting in the Reconstruction of Contracted Socket

To study the use of amniotic membrane for the reconstruction of mild to moderate grades of contracted socket and compare it to mucous membrane grafting. A total of 20 patients with acquired, anophthalmic contracted socket of mild to moderate grades were studied and divided into two groups: the amniotic membrane graft (AMG) group (10 patients) and the mucous membrane graft (MMG) group (10 patients). The preoperative and postoperative measurements of forniceal depth and volume of socket were compared. After surgery, motility of the prosthesis was also compared. The mean preoperative depth of the lower fornix in the AMG group and the MMG group was 1.5 mm and 1.4 mm, and after surgery, at final follow-up was 5.4 mm and 5.5 mm, respectively. The preoperative mean height of the upper fornix in the AMG group and the MMG group was 10.3 mm and 10.7 mm, and after surgery, at final follow-up was 12.6 mm and 13.2 mm, respectively. The mean preoperative volume of the socket was 0.84 ml in the AMG group and 0.80 ml in the MMG group, and after surgery, at final follow-up was 1.43 ml and 1.48 ml, respectively. The various quantitative parameters including motility of the prosthesis were comparable in the two groups. Amniotic membrane grafting gave cosmetically and functionally acceptable results in cases of mild to moderate grades of anophthalmic socket contraction. The results were comparable to those of mucous membrane grafting.

Amniotic Membrane Transplantation Versus Mucous Membrane Grafting in Anophthalmic Contracted Socket

Purpose: Amniotic membrane has been successfully used for treatment of various ocular surface disorders, but there have been no published reports untill now regarding its use in the treatment of contracted socket. The aim of this study was to determine the role of amniotic membrane and to compare the results with mucous membrane grafting in anophthalmic contracted socket. Methods: A prospective study of 20 eyes with mild to moderate anophthalmic contracted socket was carried out. Two groups, each with 10 eyes, were formed randomly. Group A underwent amniotic membrane transplantation, and Group B mucous membrane grafting. Prosthesis was fitted 6–8 weeks post operatively. The volume and fornices’ length was compared preoperatively and at 3, 6 and 12 months postoperatively. Results: Apart from measurements, patient satisfaction was an important criteria in defining the success of the procedure. At the end of 12 months, the relative increase between the 2 groups in the fornix and volume measurements were statistically significant (SF-0.001,IF-0.001,V-0.001) with better patient comfort in group A. There was no statistical significance regarding the rate of complications between both the groups (p = 0.29). Conclusion: Amniotic membrane emerges as a viable alternative to established mucous membrane grafting as it causes less patient morbidity, faster recovery and better fitting of prosthesis. No contracture is observed with amniotic membrane as against mucous membrane. It is cheap and easily available and has no significant complications associated with it.

Surgical Management of the Severely Contracted Socket Following Reconstruction

Purpose: To present a surgical technique for the early maintenance of the severely contracted socket following reconstruction. Methods: Two patients with severely contracted sockets following multiple procedures and recurrent failure were identified over a 1 year period. Following fornix and eyelid reconstruction, silicone fixative was injected into the fornix through a standard conformer. The silicone fixed around a pre-placed K-wire passed from the lateral orbital rim to the posterior lacrimal crest. Both silicone and wire were removed at 3 months. Results: Both patients were able to wear and maintain an acceptable prosthesis following the surgical procedure. Conclusion: This is a safe and effective method for the early maintenance of a severely contracted socket. This technique minimizes cheesewiring or extrusion and avoids damage to superior and inferior muscles and structures.

Use of self-expanding, hydrophilic osmotic expanders (hydrogel) in the reconstruction of congenital clinical anophthalmos

Rehabilitation of the congenitally anophthalmic orbit is frustrating to both the parents and physician. Traditional methods involve using progressively enlarging static acrylic conformers to expand the conjunctival socket, followed by placement of conventional static spherical orbital implants, dermis-fat grafts, or inflatable balloon expanders for orbital enlargement. Limitations of these methods typically result in less-than-optimal cosmetic outcomes, with retardation of bony orbital and overlying soft tissue growth adversely affecting midfacial growth and symmetry. Recent advances in tissue expansion technology may offer additional, novel alternatives to conventional therapies. Hydrogel tissue expanders were recently adapted for use in congenital anophthalmia. The expanders are placed in their dry, contracted states, and expand gradually to their full size via osmosis of surrounding tissue fluid, with up to a 10-fold increase in volume. Offering the benefit of predictable and controllable self-expansion, hydrogel expanders may offer yet another alternative or adjunctive therapy to the early rehabilitation of the contracted socket. Separate appliances are used for conjunctival and orbital reconstruction. Initial results appear promising. Tempering the enthusiasm for their use, however-particularly in terms of implanted orbital expanders-is the recent spate of long-term complications reported from previous uses of hydrogels as scleral buckling material. Self-expanding hydrogel tissue expanders appear to offer an intriguing reconstructive alternative to the frustrating condition of congenital anophthalmia. Long-term safety of the material as an orbital implant has not yet been demonstrated, but early results are promising.

Dermis-fat graft. Possibilities and limitations

Various alloplastic orbital implants, preferably with a spherical configuration, are employed for the routine care of an enucleated socket. Alternately, an autologous dermis-fat graft can also be used. It represents a safe alternative to alloplastic orbital implants. The method does not require preserved sclera, thus excluding even theoretically possible transfer of pathogens such as viruses or prions in sclera preserved in alcohol. Loss of the transplant or other serious complications were only very rarely observed, late extrusion is unknown. Due to its high degree of safety concurrent with excellent functional and cosmetic results, the dermis-fat transplant is particularly advantageous for young patients. In cases of complicated orbits and contracted sockets the method of dermis-fat transplantation often represents the only promising option.

Graft Contraction

In Brief Purpose To compare graft contraction rates of acellular dermis versus hard palate mucosa when used as free spacer grafts in lower eyelid surgery and to provide clinical outcome data. Methods A prospective, nonrandomized clinical trial involving the placement of 19 spacer grafts in the lower eyelids of 14 patients was performed. Indications for spacer graft placement included lower eyelid retraction and mildly contracted socket. Patients with lower eyelid retraction also underwent an endoscopic subperiosteal midface lift. For all procedures, the height of each graft was measured during and after surgery. The amount of contraction was measured for each graft, and a mean was calculated for each spacer material. The clinical success was evaluated for all procedures, based on improvement of the functional concern being addressed. Results The mean graft contraction rate was 57% for the acellular dermis and 16% for the hard palate mucosal grafts (P <0.005). Of the 7 procedures using acellular dermis for lower eyelid retraction, 6 were considered a success, and 1 was considered a partial success. Of the 6 procedures using hard palate for lower eyelid retraction, 5 were considered a success, and 1 was considered a failure unrelated to the graft. Of the 5 procedures with acellular dermis used for mildly contracted socket, 2 were considered a success, 2 were considered a partial success, and 1 was considered a failure because of graft contraction. The one case using hard palate for mildly contracted socket was considered a success. Conclusions Acellular dermis contracts significantly more than hard palate mucosa when used as a lower eyelid spacer graft. Acellular dermis and hard palate mucosa were both associated with a high rate of clinical success in all categories except for patients with a mildly contracted socket who received acellular dermis; more than 60% of these patients (n=5) had only partial success or failure caused by graft contraction. Acellular dermis has a significantly greater contraction rate than hard palate mucosa in lower eyelid surgery, although clinical success may be achieved with both materials.

Socket Reconstruction With Combined Mucous Membrane and Hard Palate Mucosal Grafts

To evaluate the use of combined mucous membrane and hard palate mucosal grafts in the reconstruction of contracted eye socket. Thirteen eyes of 13 patients with contracted sockets underwent socket reconstructive surgery with combined mucosal membrane and hard palate mucosal grafts. The average follow-up period was 33 months. Five of 13 patients required additional surgery after initial socket reconstruction. However, all patients who underwent socket reconstruction with hard palate mucosal grafts were able to wear a cosmetically acceptable ocular prosthesis postoperatively. Combined mucosal membrane and hard palate mucosal grafts can be effectively used in the reconstruction of contracted sockets.

The outcome of oral mucosal grafts to the orbit: a three-and-a-half-year study

A 3 1/2 year audit of the outcome of oral mucosal grafts was conducted at the occuloplastic service of Wentworth Hospital, Durban, South Africa. We studied 17 consecutive patients with ages ranging from 2 years to 83 years; young males predominated. The causative pathologies included six gunshot wounds, three retinoblastomas, two congenital abnormalities, two childhood traumas, a chemical burn, an occular pemphigoid, a stab wound and a firework injury. We treated 14 patients for a contracted socket, and performed mucosal grafts to the globe in the other three. Prostheses were successfully fitted in 12 of the patients with a contracted socket and in one patient with microphthalmia. Of the former patients, 10 had a good result and two had a fair result. Out of the 14 patients with a contracted socket, 10 required a repeat procedure. An onlay prosthesis was used instead of an inlay prosthesis in one patient because of the child's social circumstances; one patient was lost to follow-up. During the first year of the study, a thermoplastic conformer of Stent's composition was used. This was later changed to a plug of medicated paraffin gauze, which was easier to use. A permanent prosthesis was fitted 1 week postoperatively. The crucial factor for success was that there should be no delay between removing the plug and inserting the prosthesis. A single-stage reconstruction of the orbital wall and socket using costal cartilage and temporalis fascia together with an oral mucosal graft is discussed for reconstruction following gunshot wounds or retinoblastoma enucleation and radiotherapy. Oral mucosal grafts can be used successfully to reconstruct the conjunctiva on the globe and in the fornices.

Pediatric enucleation: analysis of volume replacement.

To determine the percent volume replacement by an implant and prosthesis, the long-term sequelae of poor volume replacement, and specific guidelines for volume replacement in pediatric patients. A retrospective observational study of 16 pediatric patients who underwent enucleation (group 1) and 31 adult patients enucleated in childhood (group 2) was performed. The total volume replacement and the volume replacement by the implant were determined. The incidence of secondary surgical procedures for superior sulcus deformity, enophthalmos, ptosis, ectropion, and socket contraction was determined. The average percent volume replaced by the implants in group 1 patients was 68%. The average percent volume replaced by the implants in group 2 patients was 21%. Seventy-one percent of patients in group 2 underwent secondary implant surgery to augment volume and eliminate superior sulcus deformity and enophthalmos. The placement of an adequately sized implant in pediatric patients may obviate the need for secondary augmentation of socket volume in adulthood. The authors suggest an implant 2 mm less in diameter than the axial length of the eye in pediatric patients.

LONG-TERM FOLLOW-UP OF CHILDREN WITH RETINOBLASTOMA

Twenty-one pediatric retinoblastoma (RB) patients treated between 1976 and 1994 were evaluated for late treatment-related complications. Median age at diagnosis was 24 months; median age at follow-up was 12 years; median follow-up time was 12 years. Of the 21 patients, 14 had unilateral RB and 7 had bilateral RB. Thirteen patients had received external radiotherapy and 8 children were treated by chemotherapy. Twenty-one patients had undergone enucleation. Radiation-induced cataracts were found in 3 patients, radiation retinopathy in 1, enucleation and postradiotherapy contracted socket in 1, very low visual acuity postradiotherapy in 3, severe hypotelorism in 2, growth hormone deficiency in 2, neurocognitive disorders in 6, and orbital deformation due to radiation bone atrophy was moderate-severe in 12 patients. Azoospermia was found in 1 patient treated by cyclophosphamide and vincristine. The most frequent sequela in this group of RB-cured children were postradiotherapy orbital deformation due to bone atrophy and neurocognitive disabilities. Late radiation effects must be avoided by using modern, innovative, and more sophisticated radiotherapeutic techniques. Late treatment-related complications justify the long-term follow-up of childhood RB survivors.

Prefabricated temporalis fascia pedicled flap for previously skin-grafted contracted eye socket.

The use of free skin, mucous membrane, or dermis-fat grafts in eye socket reconstruction proved to be unsatisfactory in long-term follow-up because of the progressive contraction of the socket. For achieving eye socket expansion of proper size and shape and a good vascularized lining that can last despite eventual fibrosis, a prefabricated temporalis fascia flap pedicled on the superficial temporal bundle is described in this report. In this technique, a split-thickness skin graft is applied over the termporalis fascia to create a sort of prefabricated flap, on which the proper dimensions of the socket can be fabricated on the grafted temporalis fascia. This study was conducted on 17 patients who had previously undergone eye socket reconstruction with skin graft after posttraumatic enucleation. All patients presented with a contracted eye socket, which manifested clinically by extrusion and migration of the ocular prosthesis. The procedure was performed in two stages. The purpose of prefabrication was to provide the proper shape and size of the newly created socket after release of skin-graft contracture to get a proper fit of the prosthesis, because the flap is thin and can be shaped well. The follow-up period ranged between 1 and 5 years, and the results were good.

The ideal ocular prosthesis: analysis of prosthetic volume.

An ocular prosthesis should complement the volume of the intraconal implant to achieve complete replacement of the volume that is removed by enucleation. This study investigates the limitations on the prosthetic volume in achieving this goal. Prosthetic volume and thickness were measured in 70 patients who underwent enucleation. Patients in group 1 (n = 17) were adults enucleated in childhood, and patients in group 2 (n = 53) were enucleated as adults. Clinical problems after enucleation were documented to determine problems potentially related to prosthetic volume. None of the ocular prostheses in this patient series was greater in volume than 4.2 ml (range, 0.75-4.2 ml). The average prosthetic volume for patients with implant diameters of 14 mm to 22 mm was 2.2 ml. A prosthetic volume > or =1.8 ml provided an anterior to posterior dimension of 7 mm. Anterior malposition of the implant and the presence of severe socket contraction were noted in patients with the smallest and the thinnest prostheses. In group 2, larger prostheses were associated with ptosis and lower eyelid laxity (p < 0.05; p < 0.01). One should not depend on the ocular prosthesis to supply more than 4.2 ml of volume in the anterior compartment of the socket. Adult patients with normal bony development, noncontracted sockets, and an average axial length should not receive implant sizes <20 mm, if one intends to achieve complete replacement of the volume removed by enucleation. Children should receive the largest implant possible.

Reconstruction of the contracted ocular socket with free full-thickness mucosa graft

Reconstruction of the contracted ocular socket with free full-thickness mucosa graft

Hard palate mucosal grafts in the treatment of the contracted socket.

The treatment of the traumatic contracted anophthalmic socket is challenging. The ability to wear an ocular prosthesis may require multiple operations to replace orbital volume, mucosa, or both. Hard palate mucosal grafts are a logical choice to augment mucosa and volume in the reconstruction of a contracted socket. Ten patients with severely contracted sockets underwent socket reconstruction using hard palate mucosal grafts. The mucosal surface lining the contracted sockets was undermined and recessed toward the lid margins. Hard palate mucosal grafts that were harvested freehand and by using a radiofrequency instrument were placed in the socket fundus and sutured to the recessed mucosal edges. Forniceal sutures were placed full thickness through the lids, and custom conformers were placed in the sockets. In six patients, fixation sutures were passed through the conformer, fornices, and full thickness through the lid. In four patients, temporary tarsorrhaphies were placed for a minimum of 4 weeks postoperatively. Postoperatively, 8 of the 10 patients were able to wear an ocular prosthesis comfortably. Cosmesis was acceptable. Two patients had recurrent socket contracture and were unable to wear a prosthesis. Hard palate mucosal grafts are a useful option in the surgical rehabilitation of contracted sockets. A mucosal surface, resistance to contracture, ease of harvesting, and ability for additional harvesting are advantages over other graft materials.

Reconstruction of the irradiated contracted socket with an expanded superficial temporalis fascial flap

PURPOSE: To describe the reconstruction of an irradiated contracted socket with an expanded superficial temporalis fascial flap and oral mucosa. METHODS: A superficial temporalis fascial flap was first expanded with tissue expansion techniques and then rotated into the orbit to revascularize the socket. The mucosal surface of the socket was secondarily grafted with buccal and hard palate mucosa. RESULTS: The expanded superficial temporalis fascial flap was used to revascularize the socket for grafting with hard palate and buccal mucosa. This resulted in the successful retention of an ocular prosthesis. CONCLUSION: The expanded superficial temporalis fascial flap is a useful technique in reconstruction of the contracted socket.

Surgical reconstruction of the contracted eye socket and orbitozygomatic hypoplasia in a one-stage operation.

To correct the contracted eye socket and orbitozygomatic hypoplasia simultaneously secondary to previous surgery and radiotherapy, we employed a one-stage surgical reconstruction that used a postauricular skin flap and temporal fascial flap, which were rotated for eye socket reconstruction and bone graft coverage. Hydroxyapatite was inserted as an onlay bone graft substitute to enlarge the orbitozygomatic region. In our 12-case experience the results were satisfying and encouraging with minor complications, which are presented.