The anophthalmic socket refers to an orbit that has had the globe removed. Characteristics of an ideal anophthalmic socket were outlined by Gougelman et al. and are as follows [3]:

The goal of anophthalmic surgery is to attain a painless, noninflamed socket with an ocular prosthesis that looks and moves as close to the unaffected eye as possible. Figure 8.2 illustrates the relationship between the anophthalmic socket, the orbital implant, and the overlying ocular prosthesis.

The ophthalmologist should take a detailed ophthalmic history and perform a careful physical evaluation of the globe and surrounding soft tissues. The mechanism of injury, specifically blunt versus penetrating injury and the presence of possible foreign bodies are crucial steps in the initial management. The extent of penetrating injury is determined by the size of the object, its speed at the time of impact and its composition. Sharp objects such as broken glass or knives cause well-defined lacerations of the globe. Air gun pellets, although large, have a high kinetic energy and can thus cause considerable ocular damage. Esmaeli et al. [4] demonstrated that the predictors of excellent final visual acuity in penetrating ocular trauma included a sharp mechanism of injury. In contrast, blunt or missile injury was associated with poor visual outcome [4]. Finally, the factors predicting enucleation were similar to those predicting poor vision [4].

An intraocular foreign body may cause mechanical damage, introduce infection, or be toxic to intraocular structures as they can lodge anywhere in the anterior or posterior segment. Mechanical effects include cataract formation, vitreous liquefaction, and retinal tears. Stone and organic foreign bodies are associated with a higher rate of infection. Other substances such as glass, many plastics, gold, and silver are inert and less worrisome. CT of the orbits without contrast with thin axial and coronal cuts is used to detect and localize a metallic foreign body. MRI is contraindicated if there is a possibility of metallic foreign bodies. Patel et al. [5] showed that of 74 surgically confirmed intraocular foreign bodies in patients presenting with traumatic open globe injuries, clinical eye examination at presentation identified the foreign body in 34 (46%) of 74 patients and CT scan identified the foreign body in 56 (95%) of 59 patients.

Initial management of trauma patients should include a search for more serious or life threatening bodily injuries by clinical exam and imaging. Insults from head injuries and chest trauma are paramount and may require emergent surgical exploration that will take priority over globe exploration and repair. Medical history and surgical risk including cardiac risk factors should be assessed. The goals of anophthalmic surgery should be discussed with the patient and family, including the removal of the eye, restoration of orbital volume with an implant, and an aesthetically pleasing result with later prosthesis fitting [6].

The patient and family are informed about wearing a patch over the surgical site for about 5 days and use of an acrylic conformer until about 6 weeks after surgery when the patient can have a custom ocular prosthesis fitting with an ocularist. Postoperative pain, time away from work, and required follow-up visits should also be discussed. Finally, the ophthalmologist should review the risk of surgical complications such as infection, exposure, or migration of the implant, and the need for additional surgery [1, 6].

Finally, a porous or nonporous orbital implant must be selected. A porous implant refers to an implant with numerous interconnected pores or channels throughout its structure that permits fibrovascular ingrowth after surgery. Examples of such materials are hydroxyapatite, aluminum oxide, and porous polyethylene. A nonporous implant is solid and does not allow fibrovascular ingrowth. Examples include polymethylmethacrylate and silicone materials. The advantage of porous implants lies in the system of interconnecting pores that allow host fibrovascular ingrowth which potentially reduces the risk of migration and infection. The rough surface of porous implants can irritate and eventually thin the overlying tenons fascia and conjunctiva and thus produce higher rates of exposure of the anterior surface of the implant that carries risk of discharge and discomfort. The smoother nonporous implants have lower rates of exposure, but higher rates of migration. The biggest advantage of nonporous implants is that they are considerably less expensive than their porous counterparts. Porous polyethylene implants have a smoother surface than hydroxyapatite that allows for easier implantation and less irritation of the overlying tissues after placement [7, 8].

Sympathetic ophthalmia is a bilateral granulomatous panuveitis that can rarely occur after penetrating trauma to one globe. The injured eye is referred to as the exciting eye, whereas the uninjured fellow eye is termed the sympathizing eye. Intraocular uveal prolapse is often a feature of the initially traumatized ruptured globe. Specifically, the role of the penetrating wound appears important in sympathetic ophthalmia because of the access it provides for intraocular antigens to reach regional lymph nodes. The intraocular compartment has no lymphatic drainage, and it has been suggested that a penetrating wound exposes uveoretinal antigens to conjunctival lymphatics thereby inducing an immunopathologic response [9]. Although the precise autoantigen responsible is still inconclusive, the uveal pigment is thought to be the antigenic stimulus. Retinal S-antigen, interphotoreceptor retinoid binding protein, melanin associated antigens, and antigens derived from the retinal pigment epithelium and choroid have all been implicated as possibilities [9]. Histologically, a diffuse granulomatous nonnecrotizing inflammatory reaction appears within the uveal tracts composed of lymphocytes and epithelioid histiocytes containing phagocytosed melanin pigment [9]. Immunohistochemical techniques have been used to show that CD4+ T lymphocytes are important early in the disease with CD8+ T lymphoyctes evident later [9]. Presentation in trauma-induced cases is typically between 2 weeks and 3 months after initial injury but has been reported as late as 50 years following trauma [9]. The incidence of sympathetic ophthalmia is 0.2–0.5% after ocular trauma from a penetrating wound, but these estimates are based on retrospective studies [10], A prospective study estimated that 3 out of every 10 million cases of penetrating injury or surgery resulted in sympathetic ophthalmia [10]. Enucleation traditionally has been the surgical technique used to decrease the risk of sympathetic ophthalmia as the entire globe is removed including any possible inciting uveal antigens. Conversely, evisceration (removal of intraocular contents while leaving the scleral shell) carries a theoretical risk of not removing all the uveal tissue and thus not eliminating the potential for sympathetic ophthalmia. Primary enucleation should be considered within the first 2 weeks following trauma and ideally as soon as possible once the globe is judged to be non-salvageable [1, 2]. A comprehensive chapter on sympathetic ophthalmia is included in this textbook.