"There is a wide spectrum of how contracted sockets manifest," he said. "They can include the conjunctival surface area only, eyelid skin surface area, bony orbit, and face, or a combination of these, which is most difficult to treat."
Dr. Kikkawa is professor of clinical ophthalmology and chief, Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, University of California, San Diego, in La Jolla. He covered five practical tips for managing these challenging cases with specific examples on preparing the socket for grafting.
"If I am going to place an orbital implant, I tend to place them in the eyelid crease through an eyebrow incision," he said. "An alternative is placement through an infraciliary incision through the lower eyelid."
Dr. Kikkawa advised surgeons who wanted to proceed with surface area grafting to wait 3 to 6 months for the contracted socket to stabilize following other reconstructive surgery.
Dr. Kikkawa showed the case of a woman who was unable to retain an ocular prosthesis even though her eyelids were in good position and her bony orbit was intact. The deficiency was in the conjunctival surface area only. In another example, a patient who had been in an automobile accident had avulsion injuries, losing the lower eyelid and sustaining traumatic enucleation, representing a combined conjunctiva and skin shortage. These cases are among the more difficult to reconstruct.
Developmental defects also can be challenging for the oculoplastic surgeon. Amniotic banding can be problematic, as was the case of child whose entire face was affected. The child had a cleft that affected the eyelids and the left side of the bony orbit, involving multiple layers of complexity.
Congenital microphthalmos tends to involve all the categories, including eyelid, surface area, and bony orbit. "With three-dimensional CT scanning, one can see the marked bony hyperplasia," Dr. Kikkawa said.
Another example is hemifacial microsomia, another developmental defect that can involve both eyelids and socket, he noted.
To increase vascularization, surgeons can use pedicle flaps as well as temporalis fascia grafts. "In severe cases, we will resort to microvascular free flaps," Dr. Kikkawa said.