Socket Reconstruction
Nicholas Ramey, MD
DISEASE DESCRIPTION
Socket reconstruction generally refers to efforts to rehabilitate an anophthalmic socket, preparing it to accept an ocular or orbital prosthesis. Several classification schemes exist to grade degrees of conjunctival contraction, orbital volume deficit, and bony hypoplasia/deformities.
INDICATIONS FOR SURGERY
Abnormal bulbar and/or palpebral conjunctiva of the anophthalmic socket, resulting in poorly fitting ocular prosthesis (Figure 37.1). This includes
Socket contracture
Shallow fornices
Conjunctival cyst
Other mechanical deformities
Anophthalmic socket volume deficits
Exenterated socket — demucosalized socket with variable cavity depth
Posttraumatic socket — multiple soft tissue and bony deformities possible
Infected anophthalmic implant
Eyelid malpositions contributing to poor cosmesis — management of blepharoptosis, lagophthalmos, and ectropion is discussed elsewhere.
 FIGURE 37.1. Common socket deformities requiring reconstruction. A, Socket contracture B, Shallow fornices. C, Infected anophthalmic implant. D, Volume deficit in congenital anophthalmos. |
MANAGEMENT OPTIONS
Nonsurgical management
Appropriate for high-risk surgical candidates.
Also acceptable for patients who have no cosmetic concerns with their socket.
Patients may apply strapped or adhesive patches.
Consult ocularist or anaplastologist for ocular or orbital prostheses.
Surgical management
Surgical plans are based on patients’ desired goals and anatomy.
Socket pathology varies widely.
Surgical techniques are frequently staged or combined simultaneously to achieve desired endpoints.
Autologous mucous membrane grafting
Generally harvested from the buccal mucosa or gingivobuccal sulcus and can be used to treat shallow fornices and socket contractures in patients with adequate orbital volume.
Described in detail in the section “Surgical Description.”
Dermis-fat grafting
Harvested from the thigh, abdomen, or buttocks and used to revolumize atrophic orbits, expand hypoplastic orbital bones in growing patients, and enlarge hypoplastic or contracted conjunctival sockets.
Described in detail in the section “Surgical Description.”
Serial enlargement with conformers
Serial enlargement of acrylic socket conformers can expand conjunctival fornices, provided the patient has enough orbicularis function to close the lids around the conformer.
Partial lateral and/or medial tarsorrhaphies placed around the conformers may be necessary for scarred or extremely tight sockets that poorly retain sizing conformers.
Conjunctivoplasty
Focal conjunctival abnormalities that cause mechanical issues with the fit of the prosthesis, such as conjunctival cysts and symblepharon, may be treated with direct excision or conjunctivoplasty.
Conjunctival Z-plasty can elongate conjunctival scars to deepen focal shallowing of fornices.
A plastic vented socket conformer is maintained at all times postoperatively.
Osmotic expanders
Self-expanding hydrophilic osmotic expanders may be implanted in the anophthalmic socket to expand orbital volume, which can help protect against the development of hypoplastic bony orbit in anophthalmic children.
They may also be used in the conjunctival socket to expand the fornices.
Inflammatory complications from these devices may limit their long-term usefulness.
Amniotic membrane grafting
Amniotic membrane grafts rely on existing conjunctival substrate for epithelialization and carry anti-inflammatory properties that help limit cicatrix formation.
Sockets with minimal or severely scarred conjunctiva may not reepithelialize well with these grafts.
In this technique, a recipient bed is prepared in a manner similar to that for a mucous membrane recipient bed, as described in the section “Surgical Description.”
The graft is stored and either rehydrated or thawed per supplier’s strict instructions.
The stromal surface (usually attached to the carrier paper from the vendor) of the graft is generally placed facing the deep tissues of the lid or socket.
Insetting is achieved with a combination of sutures and/or tissue adhesive.
Conjunctival cicatrization is notoriously difficult to correct. Intraoperative or postoperative injection of triamcinolone or 5-fluorouracil may help modulate the postoperative conjunctival and subconjunctival cicatrix formation in refractory orbits. Topical antimetabolites, such as 5-fluorouracil and mitomycin-c, may also be applied as an adjunctive therapy. Postoperative topical steroid/antibiotic ointment is tapered over 3 weeks.
SURGICAL DESCRIPTION
Autologous Mucous Membrane Grafting
Autologous mucous membrane grafts are generally harvested from the buccal mucosa or gingivobuccal sulcus and can be used to treat shallow fornices and socket contractures in patients with adequate orbital volume.
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