Contracted anophthalmic socket poses challenge for surgeon weighing rehabilitative procedures

The rehabilitation of the contracted anophthalmic socket may be challenging for the surgeon. In order to retain and support an ocular prosthesis, there must be adequate orbital volume, mucosal lining of the fornices and the fundus of the socket, a properly sized prosthesis, and adequate support from the upper and lower eyelids. David E. Holck, MD, reviews the pathophysiology of the contracted socket and possible surgical options that can be undertaken in collaboration with an ocularist.

Key Points

San Antonio, TX-Patients who present with contracted anophthalmic socket often experience several functional effects, such as abnormal tearing and pain, but also must deal with significant psychological effects associated with this cosmetic deformity. The ophthalmic surgeon needs to understand the pathophysiology of the contracted socket and possible surgical options that can be undertaken in collaboration with an ocularist, according to David E. Holck, MD.

"Counseling is absolutely critical for these patients," explained Dr. Holck, director of oculofacial plastics and residency director, Department of Ophthalmology, Wilford Hall Medical Center, San Antonio, TX. "A normal facial and periocular appearance in primary position may be the ideal, but that can be very difficult to obtain in many cases. Normal cosmesis may be extremely difficult in severe cases, depending on the deformity that is present within the eyelids. Some patients may be unable to be fitted with a prosthesis, and aggressive surgical techniques can often make this condition worse."

Classification of contracture

The pathophysiology of the contracted socket in patients after enucleation has been debated in the literature. During the 1980s, David Soll undertook thermographic studies to show that there was inadequate anterior anophthalmic socket vascularity. Another researcher, Sara Kaltreider, delved even further, explaining that the anterior soft tissues of the contracted socket healed with scar tissue that was avascular while the posterior soft tissues were not affected in this way. In 1990, Jan Kronish published two reports on the pathophysiology of the anophthalmic socket and found no significant difference between normal and anophthalmic sockets in terms of capillary blood flow in animal studies using radioactive microsphere analysis.

The Kronish study, however, examined anophthalmic sockets, while those authors postulated that socket contracture occurred from disruption of the normal spatial architecture, Dr. Holck said.

One of the main goals of contracted socket rehabilitation is the ability to retain and comfortably support an ocular prosthesis.

"This requires adequate orbital volume, mucosal lining of the fornices and the fundus of the socket, a well-fitted prosthesis, and adequate support from the upper and lower eyelids," Dr. Holck emphasized. "Unfortunately, in severely contracted sockets, this is often not attainable."

In certain cases, he noted, surgical rehabilitation of the contracted socket is not possible, such as sockets that have been repaired numerous times and have developed extensive scar tissue, sockets that have suffered massive injuries, sockets that are chronically infected, sockets that have been irradiated, and sockets with severely abnormal eyelids.

When surgery is an option, the surgeon must work with the ocularist to provide the best possible cosmetic and functional result. Recently, surgeons have used a variety of materials to handle the contracting socket, including specially designed conformers of irregular shapes and sizes that are fixed to the periosteum with sutures, room-temperature vulcanizing silicone that also is fixed to the periosteum, and Kirschner wires. In 2004, Robert Mazzoli reported on the use of hydrogel expansile materials for expanding the contracted sockets in the congenitally anophthalmic orbit. The implants are placed in the socket in their dry state and gradually expand, producing up to a 10-fold increase in volume.

"Surgeons can also augment orbital volume as well as mucous membrane or conjunctival surface area with the help of tissue expanders," Dr. Holck said. "Certainly, surgical techniques have to involve minimal cautery, incision of the cicatrix without extensive excision, meticulous technique, and attention to avoid intraoperative and postoperative hemorrhage or infection."

Dermis-fat grafts have also been used to expand the contracted socket in terms of volume and surface area. Instances of graft necrosis have been reported, however, because of poor underlying socket vascularization, he noted.