Postenucleation Socket Syndrome Research Articles

Surgical management of orbital implant exposures after evisceration or enucleation: Retrospective study – Limoges University Hospital

Implant exposure is the most frequent complication after evisceration or enucleation, and multiple surgical techniques for the management of orbital implant exposure. The goal of our study is to investigate the success rate and risk factors for failure of various surgical procedures. This was a retrospective study performed at the University Hospital of Limoges. We collected data from the files of every patient operated on for implant exposure between January 2005 and December 2020. The main criterion was the percentage of success for each procedure. Secondary objectives were to identify risk factors for failure of Müller's muscle flaps and to determine the incidence of post-enucleation socket syndrome depending on whether the orbital implant was maintained. Fifty-one patients were included: 26 patients who underwent Müller's muscle flap, 16 dermis-fat graft, 3 conjunctival flap, 2 amniotic membrane graft, 1 temporalis fascia graft, 1 buccal mucosa graft, 1 implant rotation, and 1 implant exchange. The dermis-fat grafts were more successful (87.5%) than the Müller's muscle flaps (52.2%) (P=0.0213). The study highlighted the importance of good vascularization of the implant (OR=32.00, P-value=0.0245) for the success of Müller's muscle flaps, and we found no statistically significant difference between the patients who maintained their implants and those who did not (P=0.3865) with regard to the incidence of post-enucleation socket syndrome. Müller's muscle flap may remain a reasonable option in the management of medium-sized implant exposures of well-vascularized implants confirmed on MRI in patients with no systemic healing disorders. Dermis-fat graft remains the option of choice in other cases, especially in large exposures or complicated orbits.

Quantitative Assessment of Periocular Autologous Fat Transfer Survival Using 3D Stereophotogrammetric Imaging.

To assess periocular autologous fat transfer (AFT) survival by assessment of volume change with sequential 3D VECTRA imaging. Little is known about the patterns of graft survival of AFT in the periorbital region, especially in cases involving prior radiotherapy or trauma. The aim of this pilot study was to characterize fat survival following AFT in patients with a broad range of clinical indications, with and without a history of prior radiotherapy, for both periocular and orbital AFT, and in a subgroup of patients with an anophthalmic socket. A single-institution, prospective cohort study involving 18 applications of AFT for volume augmentation in the periocular and orbital area. All patients had sequential 3D VECTRA photographs following a validated standardized protocol. Patient demographics, including gender, age, ethnicity, underlying diagnosis, and volume of fat injected, were also collected. In total 13 patients were enrolled, 9 female (69.2%) and 4 male (31.0%). Mean age at the time of surgery was 47.8 years. Patients had volume deficiency secondary to a variety of causes; the most common cause was postenucleation socket syndrome following trauma in 6 patients (46.2%). The mean fat survival volume at the 1-month postoperative point was 70% and 55% by 6 months. AFT conducted with a multiport cannula for fat harvesting use had an initial higher rate of fat reabsorption with ANOVA p = 0.002, however, this was not observed at the later follow-up periods. There was no statistically significant difference in fat survival between abdominal or thigh donor fat sites. There was no statistically significant difference in residual injected volume at the early follow-up period between patients who had prior radiotherapy and those who did not p = 0.8496. AFT is an effective treatment for periorbital volume compromise with an acceptable survival rate in all categories of patients. Complex etiologies such as radiotherapy-related orbital and midface dysgenesis should not be a contraindication for AFT, with no difference in outcomes.

Socket outcomes following enucleation for uveal melanoma: post enucleation socket syndrome can be challenging.

To evaluate socket outcomes of enucleation for uveal melanoma. This study was a retrospective chart review conducted in December 2022 of all patients who underwent enucleation surgery for uveal melanoma between 2010 and 2015 in the Royal Victoria Eye and Ear Hospital, to evaluate socket outcomes including completion of revision surgery, type of surgery, and completion of multiple revision surgeries, and potential associations. Between June 2010 and December 2015, 72 patients underwent enucleation for uveal melanoma in the ocular oncology service, including 25 females and 47 males, mean age 65, range 11-91 years old. There were 68 primary enucleations and 4 secondary enucleations. Complete follow-up data was available for mean 4 years, range 1-11 years. Fourteen patients underwent further surgery, including one exenteration for local recurrence. Oculoplastic surgery (n = 6, 8%), implant exposure repair (n = 3, 6%), and orbit volume expanding surgery (n = 4, 6%) were also performed. Eight patients (11%) underwent one further surgery and five patients (7%) underwent a series of procedures. There was a significant association with younger age at enucleation (age <65) with undergoing further surgery (p = 0.03, Fisher's Exact Test (FET)), and also an association of younger age with undergoing multiple further surgeries (p = 0.02, FET). There was no association found with other predictor variables, including primary versus secondary enucleation status. Most patients (75%) with PESS underwent more than one surgery. Post enucleation surgery 82% of patients did not undergo further surgery, but younger patients were more likely to undergo anophthalmic socket revision or oculoplastic surgery. Management of post enucleation socket syndrome was challenging and usually involved a series of procedures.

Evisceration, enucleation and exenteration-Indications, techniques, and postoperative care

Various surgical techniques are available for the extirpation of an eye, depending on the underlying disease. Typical indications encompass tumors, inflammatory and infectious processes, glaucoma, trauma as well as congenital malformations. Surgical procedures include evisceration (resection of the intraocular space with preservation of the sclera), enucleation (extirpation of the entire eyeball including sclera and cornea) and exenteration (resection of the complete orbital soft tissue). The early detection of postoperatively manifesting complications, such as implant extrusion, conjunctivitis, postenucleation socket syndrome as well as the development of enophthalmus or ptosis, is of particular relevance in the context of postoperative care regarding functional, esthetic and social outcome. Special attention must be paid to ensuring acomplication-free rehabilitation process, including the supply of asuitable, precisely fitting prosthesis or epithesis. This ensures the patient's psychosocial reintegration, in which an integrated interdisciplinary cooperation with ocularists and psychologists is essential. The latter play a particularly important role, as the psychological stress resulting from the procedure is often associated with aconsiderable reduction in the quality of life.

Modified impression tray and iris positioning ocular prosthesis of post enucleation socket syndrome: case report

The cosmetic disfigurements which arise due to loss of orbital volume after enucleation of an eye include enophthalmus, superior sulcus deformity, upper eyelid ptosis, and lower eyelid laxity. The treatment can be either conservative or surgical. For patients who does not want to undergo further surgical procedures, the conservative treatment is simple, non-invasive, and appropriate. This case report describes modified impression tray and iris positioning technique of post enucleation socket syndrome to achieve aesthetics and function. A 65-year-old male patient reported to the Dental Hospital Universitas Sumatera Utara with the chief complaint of facial disfigurement due to loss of the right eye. Patient had enucleation 6 months ago and using conformer after surgery. The diagnosis was post enucleation socket syndrome. Clear acrylic sclera as a tray without handgrip will precisely records of the palpebre con- vexity and specified socket. The use of eyebrow ruler helps accurately determine the symmetrical iris position com- pared to only visually determining which is subjective with the possibility of interobserver errors. It was concluded that clear acrylic sclera as a tray and eyebrow ruler to determine the position of iris resulting in patient satisfaction due to aesthetics and function.

Management of post enucleation socket syndrome patients - A retrospective study

The aim of this retrospective monocentric study was to report the outcomes following the correction of post enucleation socket syndrome (PESS) as well as the factors predicting for a multistep management.Patients were included, if they had received surgery to manage PESS. Demographics and patient history were collected. The symptoms of PESS were clinically rated by the same surgeon and ocularist, preoperatively and after each procedure. The surgery was considered as successful when no PESS clinical symptoms were observed. A prognostic study was performed to investigate the surgical outcomes. ResultsThirty-six patients were included and eight of them had their PESS corrected after the first surgery. In the multivariate analysis (MVA), the deep upper lid sulcus symptom remained the main significant factor associated with an incomplete correction after the first surgery (OR 45.5, IC 95% (3.481–594.6), p = 0.004). For further corrections, the ptosis was the only significant prognostic factor requiring several surgeries (p = 0.005). At the end of the management, 94.4% of the patients had satisfying outcomes. ConclusionsThe management of a PESS involves the correction of both the orbital cavity and the soft tissues. Although its correction is complex and time consuming in the majority of cases, the patients should be informed that the final cosmetic outcomes remain good at the expense of several surgeries.

Iris positioning technique by using face symmetric measurement tool on the custom ocular prosthesis: a case report

Loss of eye can have a major psychological impact on the patient. To overcome this problem, an ocular prosthetic must have been fabricated similar with the natural eye. Various techniques are documented to determine the symme- trical bilateral iris position; these methods can be subjective and have no measurement guidelines. A 20-year-old male patient came to the Prosthodontic Clinic of Dental Hospital Universitas Sumatera Utara with the diagnosis is post enucleation socket syndrome. Determination of the iris position using the face symmetric measurement-tool by focus to the vertical and horizontal lines of the facial symmetry guide. Confirm the alignment of the vertical lines by connecting the trichion–glabella–subnasal–gnathion guide points so that they vertically divide the two sides of the face, then the two horizontal lines by connecting the left-right cheilon with the mesial-distal canthus of the right and left eyes. This tool is like a face mask with vertical and horizontal guidelines connecting the symmetrical guide points of the face accompanied by centimeters and millimetres making it easy to measure distances and sizes of the iris symmetrically. The use of this tool has given good results in determining the position of the iris because its simplicity and can see facial symmetry.

Hyaluronic acid injections in post-enucleation or evisceration socket syndrome: a case series

BackgroundOne of the primary goals of enucleation and evisceration surgery is the restoration of an adequate orbital volume through the use of appropriately sized alloplastic or autogenous tissues. In patients inadequately treated, post-enucleation or evisceration socket syndrome occurs. Fillers are an ideal alternative for eyelid and eyebrow arcade volume enhancement since their injection is easily performed in an outpatient setting avoiding several complications. The aim of this study is to report the use of hyaluronic acid (HA) fillers to treat volume deficits of the upper and lower eyelids, projecting the brow arcade and reducing the asymmetry.MethodsThirteen patients (2 male, 11 female, mean age 32.7 years) were treated from June 2012 to May 2020. Non-surgical treatment by HA filler injection for aesthetic rehabilitation of deep superior sulcus, inferior tear trough deformity, and scleral show was performed.ResultsNo complications as orbital-ache and/or vasovagal response were reported during the injections. Minor complications such as light swelling at the site of injection, self-resolved within 2 days, were recorded. Stable results were observed at follow-ups. In two cases, two successive treatments were required at 3 and 6 years from the first injection.ConclusionsHyaluronic acid fillers offer a versatile and safe method for replacing soft tissue lost from the upper eyelid/brow complex in cases of post-enucleation or evisceration socket syndrome.Level of evidence: Level IV, therapeutic study.

Non-surgical Approach to Improve Prognosis of Ocular Prostheses for Grade III and IV Contracted Sockets

Patients with Grade III or IV contracted ocular sockets, most often due to Post Enucleation Socket Syndrome (PESS), suffer from loss of ocular volume along with a lax lower eyelid, which complicates prosthetic rehabilitation in terms of fit as well as aesthetics. Surgical correction is preferable, though not always feasible. A non-invasive approach for prosthetic rehabilitation of such difficult cases, using bandaging and progressively larger conformers is described here.

Computed tomography-based diagnostics and management of worsening postenucleation socket syndrome: A case report

Computed tomography-based diagnostics and management of worsening postenucleation socket syndrome: A case report

Assessing full thickness oral mucosal grafting: complications and postoperative outcomes in a broad collective of patients

BackgroundConjunctival defects can be repaired with several mucosal tissues. The simplicity of harvesting oral mucosa and its wide availability makes it the preferred graft tissue for all indications requiring mucosal...

Computer technologies in diagnostics and treatment of worsening post-enucleation socket syndrome

To demonstrate the capabilities of modern computer technologies in diagnostics and treatment of patients with worsening post-enucleation enophthalmos. The retrospective study included 6 patients (4 male and 2 female) aged 29-68 years who exhibited signs of PESS in 2017-2018. To define the orbital condition, patients underwent multispiral computed tomography (MSCT) and magnetic resonance imaging (MRI) followed by image analysis with computed exophthalmometry and step-by-step computed exophthalmometry. Results of these examinations helped construct 3D-models of patients' orbits, which were then used to calculate the parameters of the silicone implants. Patient-specific silicone implants were implanted into their orbits during surgery under general anesthesia. Implantation of the patient-specific silicone implant resulted in increase of the volume behind orbital prosthesis and correction of post-enucleation enophthalmos in all patients allowing them to use thinner, more mobile ocular prosthesis, and restore normal eyelid position. The patients also noted better appearance of the eye and personal comfort. Modern visualization methods along with computer analysis and modelling, as well as technologies to produce medical products enable creation of the best suitable patient-specific orbital implants. This allows achieving better clinical results and better quality of life for patients with monolateral anophthalmos.

Unwrapped hydroxyapatite orbital implants: our experience in 347 cases.

To report the results of a large case series of enucleations with primary insertion of an unwrapped hydroxyapatite (HA) orbital implant. We retrospectively reviewed consecutive enucleations with primary orbital (HA) implant insertion performed at the Scottish Ocular Oncology Service, Glasgow between 1990 and 2014. The unwrapped hydroxyapatite orbital implant was placed in the posterior portion of the socket and recti muscles sutured end-to-end over the implant. Out of 347 consecutive enucleations, the indication for enucleation was tumour-related pathology in 59.7% and painful blind eye in 40.3%. Majority (70%) received an implant of 22-mm diameter. At an average follow-up of 3.5 years, complications included post-enucleation socket syndrome (11.5%), chronic discharge (9.2%), chronic pain (4.3%), recurrent conjunctival infection (2.3%),conjunctival cysts (2%), contracted socket (1.4%), implant exposure (1.2%), haematoma (0.6%) and ill-fitting prosthesis (0.6%). Implant exposure (1.2%, n = 4) occurred at a mean of 4.5 months post surgery and was managed by temporalis fascia graft (n = 1), tarsoconjunctival flap (n = 1), implant removal (n = 1) and observation (n = 1). Overall, 9.8% of patients needed further surgery including lower lid tightening (4.3%), ptosis repair (2.3%), conjunctival cyst excision (1.2%), fornix reconstruction (1.2%), graft/flap for exposure (0.6%) and implant removal (0.3%). A low rate of implant exposure indicates that absence of wrapping material around hydroxyapatite orbital implants does not compromise surgical outcomes and has the added benefit of reduced surgical time and avoidance of complications from wrapping materials. Posterior implant placement and end-to-end recti suturing contribute to the success of the procedure.

Rehabilitation of Anophthalmic Patients with Prosthetic Eyes in Germany Today - Supply Possibilities, Daily Use, Complications and Psychological Aspects

A smooth supply with a visually appealing prosthetic eye after enucleation is not just a cosmetic solution, it is also a key factor in successful social and psychological rehabilitation. This article provides an overview of the current state of medical and ocular care regarding prosthetic eyes in Germany. It focuses mainly on the newest clinical results, daily care, complications, and psychological aspects of wearing prosthetic eyes. The study is comprised of the newest clinical results and a current PubMed literature review. In Germany, enucleated patients normally get a double-walled, hollow prosthetic eye made of cryolite glass, and patients with a microphthalmic or phthisic eye receive a thin single-walled prosthesis. Anophthalmic patients wearing cryolite glass prosthetic eyes seem to be more satisfied with their appearance and the look of their prostheses than polymethylmethacrylate (PMMA) prosthetic eye wearers. Cryolite glass prosthetic eyes must be renewed at least each year, while PMMA prostheses need to be polished once a year and renewed after five years of wearing. Among children, the fit of the prosthetic eye must be checked, based on growth, semi-annually. A slightly higher risk of breakage of cryolite glass prostheses is, for most patients, not a great disadvantage in everyday life. Ocularists and ophthalmologists should determine an individual cleaning regime, together with the patient, that is dependent on the material of the ocular prosthesis and other external factors. Complications, such as allergic, giant papillary, viral and bacterial conjunctivitis and blepharoconjunctivitis sicca must be treated at an early stage to allow for a prosthetic eye. In the case of inflammation-caused socket shrinkage or post-enucleation socket syndrome, surgical interventions are needed to re-enable the use of a prosthetic eye. Since the health of the remaining eye is the major psychological burden of prosthetic eye wearers, good ophthalmological care and medical screenings are essential elements. A smooth supply with a prosthetic eye, adequate and early treatment of possible complications and attention to psychological aspects is essential for successful long-term rehabilitation of enucleated patients.

Anophthalmic Sockets in Retinoblastoma: A Single Center Experience.

To evaluate outcomes of anophthalmic sockets in retinoblastoma at a tertiary care center in Singapore. A retrospective study. Patients who underwent enucleation as sole/part of treatment for retinoblastoma were reviewed at our center from 2005-2017. Details including demographics, grouping and staging, adjuvant therapy, surgery, implant, and complications were collected. Of 42 patients with retinoblastoma managed over the period, the anophthalmic sockets of 31 patients who underwent enucleation were analyzed. Mean age at enucleation was 2 years. Twenty-three enucleations were performed at our institution and 8 enucleations had been performed elsewhere. Seventeen patients (52%) had porous polypropylene, 9 patients (27%) had polymethylmethacrylate, 1 patient (3%) had glass implant, and 3 (9%) had dermis fat graft. The sizes of implants varied from 10 to 20 mm. Twelve patients had attempts at globe salvation before enucleation. Out of 28 patients with primary orbital implants, 3 had implant exposure. The rates of repeat surgery among patients with and without primary implant were 66.67% (2 out of 3) and 10.7% (3 out of 28), respectively. One patient had postenucleation socket syndrome with stock eye. Five patients referred for enucleation were conservatively managed. Anophthalmic sockets in retinoblastoma have long-term implications if the primary procedure is not performed well. While the majority had good outcomes (structural and esthetic), a minority had complications requiring intervention. Ophthalmologists managing retinoblastoma must be aware of these. Primary implant had favorable outcome with minimal complications.

Lipostructure Plus Platelet Rich Plasma Injections for Enophthalmos Treatment in Patients Carrying Prosthetic Eye- Safety and Efficacy

Purpose: To describe one-year functional and aesthetic outcomes in patients with post-enucleation enophthalmos who underwent lipostructure plus platelet-rich plasma injections. Materials and Methods: 26 patients treated with orbital lipostructure and three platelet rich plasma injections at 1, 2 and 6 months after surgery were retrospectively assessed. Photographs of all patients were taken preoperatively and at 1 and 12 months after surgery. The area of each eye lid esthetic unit/subunit was calculated, both in frontal and profile images. Statistical analysis was performed using SPSS software (SPSS Inc., Chicago, Illinois, USA). Paired t-test was used to compare the unit/subunit areas before and after surgery. Differences were considered significant when P &lt;0.05. Results: Comparing baseline to 1-month images, an improvement of the enophthalmos appearance was observed in all patients. Analysis of each single esthetic units was performed, with an overall unit area reduction of 19.8%. Comparing the two postoperative images, the overall amount of resorption was 12.75%. The surgical procedure appeared to be well tolerated in all cases. Minor complications regarding the lower eyelid were recorded in 6 cases. Conclusions: lipostructure plus platelet rich plasma injections proved to be a valid and effective option for the treatment of post enucleation socket syndrome.

Orbital Volume Augmentation with Calcium Hydroxyapatite Filler in Anophthalmic Enophthalmos.

Purpose:To report the long-term results of orbital volume augmentation using calcium hydroxyapatite filler injections in patients with anophthalmic sockets.Methods:Twelve eligible patients with post-enucleation socket syndrome (PESS) and small orbital volumes were included in our study. In this investigation, 1.5 mL injectable calcium hydroxyapatite (Radiesse) was utilized in an off-label application under local anesthesia. We evaluated the effect of orbital volume augmentation for correction of enophthalmos.Results:Five women and seven men with a mean age of 35 years (range, 21-72 years) were included in the study. The mean follow-up was 19.5 months (range, 16-27 months). Enophthalmos and deep superior sulcus were reduced in all patients during all follow-up visits postoperatively. The mean improvement of enophthalmos was 2.58 mm (range, 1-5 mm) and the improvement in deformity grading of superior sulcus was 0.83 (range, 0-4 grade). The mean marginal reflex distance increased by 0.6 mm (range of -1 to 3 mm). Complications included increase in ptosis in two cases and extrusion of the filler accompanied by discoloration of the skin in one case.Conclusion:The use of injectable calcium hydroxyapatite for orbital volume restoration in anophthalmic sockets is a simple, fast, and minimally invasive method with considerable long-term effects and low complications.

Post enucleation socket syndrome - new and established surgical solutions

The orbital volume after enucleation or evisceration might shrink over time due to atrophy of the orbital fat and connective tissue. This can lead to prosthesis misfit and an unsatisfactory cosmetic result. This so-called post enucleation socket syndrome (PESS) needs a secondary orbital volume augmentation. The techniques for orbital volume augmentation are secondary orbital implants or implant exchange, orbital floor implants or injectable augmentation. The surgical possibilities are described and discussed with special attention to indications and chances.

Prosthetic rehabilitation of an ocular defect with post-enucleation socket syndrome: A case report

Ocular trauma can be caused by road traffic accidents, falls, assaults, or work-related accidents. Enucleation is often indicated after ocular injury or for the treatment of intraocular tumors, severe ocular infections, and painful blind eyes. Rehabilitation of an enucleated socket without an intraocular implant or with an inappropriately sized implant can result in superior sulcus deepening, enophthalmos, ptosis, ectropion, and lower lid laxity, which are collectively known as post-enucleation socket syndrome. This clinical report describes the rehabilitation of post-enucleation socket syndrome with a modified ocular prosthesis. Modifications to the ocular prosthesis were performed to correct the ptosis, superior sulcus deepening, and enophthalmos. The rehabilitation procedure produced satisfactory results.

Repositioning of a Traumatically Displaced Globe With Maxillary Antrostomy: Review of the Literature and Treatment Recommendations

Complete dislocation of the globe, inferiorly into the maxillary sinus, medially into the ethmoid sinus, or superiorly into the anterior cranial fossa, can occur with significant blunt facial trauma. The degree of injury to the globe, its adnexal structures, and the optic nerve is dependent on the extent of the dislocation. Complete traumatic subluxation of the globe into the maxillary sinus is associated with severe injury to the periocular structures and represents a challenging and unique reconstructive process rarely encountered in published studies. The present case report represents only the 15th reported case of complete orbital prolapse into the maxillary sinus. Controversy exists regarding the definitive treatment of traumatic globe dislocations, the risk of sympathetic ophthalmia (SO), the sequela of postenucleation socket syndrome, and prophylactic steroid treatment to decrease the incidence of SO and traumatic optic neuropathy.