|Year : 2019 | Volume
| Issue : 2 | Page : 62-64
Reconstructing the socket
Santanu Das, Nayana Nagesh, Raghuraj Hegde
Department of Ophthalmology, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India
|Date of Submission||26-Sep-2019|
|Date of Decision||22-Oct-2019|
|Date of Acceptance||29-Oct-2019|
|Date of Web Publication||09-Mar-2020|
Dr. Santanu Das
70, Ananda Mohan Bose Road, Kolkata - 700 074, West Bengal
A 23-year-old male patient presented with a history of trauma to his right eye with a stick at the age of 1 year for which enucleation was done. No prosthesis was placed at that time. On examination, right eye fornices were contracted. Dermis fat grafting (DFG) with fornix formation sutures (FFS) was done. Postoperatively, there was shrinking of the inferior fornix. Buccal mucosal grafting with amniotic membrane grafting and inferior FFS was done. Postoperatively, the inferior fornix was well-formed. After 8 weeks, prosthesis was placed which fitted perfectly and gave good cosmetic results. Late presenting contracted anophthalmic sockets are difficult to manage. DFG takes care of both surface and volume deficit in an adult anophthalmic socket. When DFG is combined with FFS followed by a good ocular prosthesis, one can achieve excellent prosthesis even in such challenging cases.
Keywords: Anophthalmic socket, dermis fat grafting, fornix formation sutures
|How to cite this article:|
Das S, Nagesh N, Hegde R. Reconstructing the socket. Sudanese J Ophthalmol 2019;11:62-4
| Introduction|| |
Reconstructing an anophthalmic eye or a severely contracted socket post enucleation or evisceration poses a great amount of difficulty for an ophthalmic surgeon. They usually present with shrinkage of orbital tissue, deep superior sulcus, and shallow fornices which lead to severe cosmetic aberration., The conventional autografts that can be used are mucous membrane graft, skin graft, hard palate graft, temporalis fascia, muscle flap, and dermis fat graft (DFG). Among all these, DFG is the most preferable option as it can lead to both volume and surface area augmentation.,,,,,, Since it is an autologous graft, there are no risks of transmission of infection and does not need special storage, preparation, or transportation. In this case report, we will share our experience of reconstructing a severely contracted socket using DFG.
| Case Report|| |
A 23-year-old male patient presented to us with a history of injury to the right eye with a stick 22 years back when he was only 1 year old, following which he had pain and discharge in the right eye. He had undergone enucleation at the age of 1 year. No orbital implant was placed post enucleation, and he presented to us with a severely contracted socket.
The left eye had a vision of 6/60 with right-beating nystagmus, cortical cataract, and nanophthalmos. The remaining anterior segment was within the normal limits.
In the right eye, both the fornices were severely contracted with shortening of the conjunctival cul-de-sac.
Computed tomography scan of the orbits was ordered which showed severely contracted socket on the right side while the left orbit was within the normal limits.
A diagnosis of right-sided Grade 3 anophthalmic contracted socket was made as shown in [Figure 1].
|Figure 1: (a-c) shows the saggital, axial, and coronal view of right-sided contracted socket; (d) showing severe contraction of the upper and the lower fornix|
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The left eye had nanophthalmos, cortical cataract, and refractive amblyopia.
DFG with fornix formation sutures (FFS) was done. The DFG was harvested from the buttocks which was approximately twice the size of the socket and was placed in the socket and sutured to the surrounding orbital tissue. FFS was done for both the superior and the inferior fornix. An iris conformer was placed, and tarsorrhaphy was done as shown in [Figure 2].
|Figure 2: (a) The dermis fat graft being harvested from the buttocks of the patient of approximately twice the size of the socket; (b) shows the contracted upper and lower fornix along with a severely contracted socket; (c and d) shows the dermis fat graft of approximately twice the size of the socket being placed inside the right socket and sutured to the surrounding structures for volume augmentation|
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Postoperatively, there was no wound infection; regular cleansing of the wound with povidone-iodine was done; healthy red granulation tissue was seen; the graft site was healthy with sutures intact, but there was shrinkage of the inferior fornix and extrusion of the conformer because of inadequate space as shown in [Figure 3].
|Figure 3: (a) Immediate postoperative picture showing all the fornix formation sutures and tarsorrhaphy sutures in place; (b and c) shows the iris conformer not fitting properly because of lack of space in the inferior fornix, whereas the superior fornix is well-formed|
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A second surgery was planned 8 weeks after the first surgery for inferior fornix augmentation.
Buccal mucosal grafting with FFS and amniotic membrane grafting was done so that the inferior fornix was well formed to hold the prosthesis in place.
A buccal mucosal graft was harvested from the lower lip and placed over the inferior fornix followed by inferior FFS were placed. The buccal mucosal defect was covered with an amniotic membrane. A conformer was placed, and tarsorrhaphy was done as shown in [Figure 4].
|Figure 4: (a) During the second surgery, buccal mucosal graft is being harvested for formation of the inferior fornix; (b) the buccal mucosal graft is being placed over the inferior fornix; (c) the immediate postoperative picture showing the iris conformer in place with the inferior fornix formation sutures intact; (d) after the second surgery, the inferior fornix is well-formed with the iris conformer in place|
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Postoperatively, there was no wound infection, and the inferior fornix was well-formed and was holding the iris conformer in place. After waiting for about 6–8 weeks for complete healing of the wound, a customized prosthesis was placed and a good cosmesis was achieved after two surgeries as shown in [Figure 5].
|Figure 5: (a and b) shows a contracted right socket at presentation and the final outcome after 8 weeks postoperative where the right-sided socket is well formed holding the prosthesis in place|
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| Discussion|| |
Grading of an anophthalmic socket is as follows:
- Grade 0: Socket is lined with healthy conjunctiva and has deep and well-formed fornices
- Grade I: Shallow lower fornix or shelving of the lower fornix pushing the lower lid down and out and preventing retention of an artificial eye
- Grade II: Loss of the upper and lower fornices
- Grade III: Loss of the upper, lower, medial, and lateral fornices
- Grade IV: Loss of all the fornices and reduction of palpebral aperture in horizontal and vertical dimensions
- Grade V: Recurrence of contraction of the socket after repeated trial of reconstruction.
As the name suggests, DFG is composed of dermis and subcutaneous fat. The epidermis is stripped off, and the dermis is retained as it increases graft vascularization and decreases the incidence of fat atrophy.
From its inception, DFG has been quite popular because of easy accessibility of the donor site, less morbidity, and low cost, and since it is an autologous graft, there are no chances of graft rejection. In this case, the DFG we harvested from the buttocks was approximately 50% more than the size of the socket because Smith et al. reported >40% atrophy of the fat in their study. Sihota et al. stated that thicker the graft the better is the outcome, whereas Galindo-Ferreiro et al. used a graft which was 30% more than the size of the measured defect.,
DFG can be used effectively as primary implantation post enucleation and evisceration, whereas it can also be used as secondary implantation post irradiation. It is contraindicated in cases where the orbital vascularity has been compromised like in cases of severe trauma, chemical burns, etc.
| Conclusion|| |
Reconstructing an anophthalmic socket is a challenge. DFG is an effective technique as it allows volume augmentation, surface area augmentation as well as maintains the conjunctiva and the fornices. There are no chances of rejection, and it is economical as it does not need any special handling, storage, or transportation. Meticulous planning and multiple surgeries are often needed to achieve good cosmetic as well as functional outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]