CHAPTER 56 Management of post-enucleation socket syndrome
Terminology and pathophysiology
An enucleation of the eyeball causes orbital volume deficiency and changes in the orbital soft tissue architecture leading to the clinical picture of a post-enucleation socket syndrome (PESS). The term PESS was introduced by Tyers and Collin with the clinical features of an enophthalmos of the artificial eye, a deep upper eyelid sulcus, lower lid laxity, and eyelid malpositions such as ptosis or lid retraction1. Smit2 then added the feature of a tilting of the prosthesis associated with an anterior-to-posterior and superior-to-inferior rotation of orbital tissues. This reallocation of orbital soft tissues in combination with a lack of eyeball volume – and not orbital fat atrophy – is responsible for the development of a PESS3. This undesirable condition of PESS can be prevented best by a primary insertion of an adequate and safe orbital implant (see Chapter 55).
A contracted socket is defined as the shrinkage and/or shortening of (soft) tissues in the anophthalmic orbit, which makes the fitting of a satisfactory cosmetic prosthesis impossible4. Pathophysiologically this is a consequence of conjunctival and subconjunctival scar formation involving fibroblasts and their contraction after wound healing or inflammation. Causes are mechanical and surgical trauma, thermal and chemical burn, irradiation and – probably most commonly – chronic inflammation. The latter is mainly due to prosthesis problems with poorly fitted, too large, and not well-maintained artificial eyes with rough surfaces and sharp edges. At early stages therefore it is promising to administer conservative treatment using lubricants, anti-inflammatory therapy (i.e. topical steroids), and prosthesis modification or polish.
Post-enucleation socket syndrome
Surgical principles (volume augmentation)
If no orbital implant is present, secondary implantation using alloplastic implants or autologous transplants is used. However, extensive dissection in the deep orbital soft tissues in order to locate and visualize the extraocular muscles should be avoided. It usually causes tissue alteration and persistent damage. It has been shown that repeated and extensive surgical dissection will cause a significant shrinkage of orbital fat tissue with a loss of orbital volume, undoing any volume augmentation initially intended3. For this reason it is advisable to avoid any gratuitous dissection in the soft tissue planes of the orbit, including the exposure of the extraocular muscles. An alloplastic implant should be positioned intraconally in the depth of the orbit, possibly behind the remnants of the posterior Tenon’s capsule.
Technique (secondary alloplastic orbital implant insertion)
Before the surgery, which usually is performed under general anesthesia, the motility of the socket without an artificial eye is checked during slit-lamp examination. The virtual sagittal axis, along which the anterior surface of the socket is moving, is marked on the conjunctival surface with a marker pen. At the beginning of the procedure, the conjunctiva is opened horizontally at this mark. Scar tissue, if present, is dissected and excised. This is followed by mainly blunt dissection into the depth of the orbit to create a space to accommodate the orbital implant. This should be performed in as atraumatic a manner as possible to avoid damage to the soft tissues and bleeding, with only minimal use of cauterization. A solid or porous orbital implant – according the preferences of the surgeon – is wrapped with donor sclera or Vicryl™ mesh. The size of the implant depends on the amount of volume deficiency and the space available, and sphere diameters may vary from 18 to 22 mm. However, undue pressure in the socket caused by a too large an implant increases the risk of extrusion. It can be helpful to use a sizer. Also the correct insertion technique of the secondary orbital implant is mandatory to prevent later exposure. To avoid gradual tissue restitution after forced ball implantation (‘cactus syndrome’) as described by Rose5, a polythene glide can be used – comparable to an injector in intraocular lens implantation. The best position for the implant is deep into the apex of the orbit, behind the posterior Tenon’s capsule.
Closure of Tenon’s capsule over a baseball implant may result in shortened fornices exacerbating a pre-existent mild form of socket contraction. To avoid this, the conjunctiva is dissected far into the fornices. However, in cases with shallow fornices baseball implantation should be avoided and secondary dermis-fat grafting is preferred as a safe alternative6.
Surgical principles (dermofat graft [DFG])
A dermis-fat graft consists of de-epithelialized skin (dermis) with adjacent fatty tissue, preferably harvested from the gluteal area. It is transplanted into the socket, where it is attached to the orbital soft tissue components (Fig. 56.1
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