- Email: [email protected]
The enucleated eye socket
THE E N U C L E A T E D EYE SOCKET By H. J. H. FRY, M.S., F.R.C.S., F.R.A.C.S.
Honorary Assistant Plastic Surgeon, Department of Plastic and Maxillo Facial Surgery, Royal Melbourne Hospital, Melbourne, Australia IN the eye socket after enucleation where no implant has been inserted or where an implant has been rejected considerable problems o f cosmesis and comfort are often present. T h e s e difficulties exist quite apart f r o m actual contraction o f the eye socket
FIG. I
FIG. 2 Fig. I.--The tilted prosthesis, supratarsal sulcus and lower eyelid thrust are seen in this patient after enucleation of the left socket. Fig. 2.--The problem of the prosthetic attempt to correct the supratarsal sulcus is shown in this patient with enucleation of the left socket. The lower lid is pushed downwards and outwards. This becomes worse with the passage of time. Fig. 3.~Patient with enucleated left socket. He had the problems of the patients shown in Figures I and 2, added to which retention of the prosthesis was extremely difficult owing to a grossly contracted socket.
FIG. 3 itself, though contraction m a y exaggerate them. W h e n an ocular prosthesis is fitted to such a socket the direction of the u p p e r fornix (upwards and backwards) in combination with a shallow and forward sloping lower fornix tend to tilt and rotate the prosthesis (Fig. I). T h e thrust of the prosthesis is therefore taken largely on the lower lid. An a t t e m p t to enlarge the prosthesis to fill out the inevitable supratarsal sulcus usually increases the thrust on the lower eyelid without achieving substantial correction o f the supratarsal hollowing (Fig. 2). " E n o p h t h a l m o s " is often present. I n t h e c o u r s e of time 290
THE ENUCLEATED EYE SOCKET
29I
the lower lid sags downwards and outwards increasing the aesthetic disability (Fig. 3). The movement of the prosthesis is poor and discomfort is often present because of the peripheral contact of the prosthesis with the socket. The commonly used plastic implants are not entirely satisfactory since they may be discharged if the conjunctiva does not heal by first intention. Late rejection may occur at any time and does so at least as frequently as primary rejection. Partly exposed implants are sometimes left " i n s i t u " if the muscles remain attached. This unsatisfactory state of affairs has caused some ophthalmologists to abandon the insertion of plastic implants at the time of enudeation. Hence the present inquiry and attempt to alleviate the problems in such enucleated sockets. The technique to be described builds out the posterior wall of the socket into a convexity by cartilage grafting. This provides a firm surface which supports the prosthesis adequately, redudes substantially the problems of supratarsal hollow and virtually eliminates the thrust on the lower lid increasing comfort and movement. Angus (I962) described a technique using cartilage chips to fill the scleral cavity after evisceration. This work suggested the use of cartilage in the enucleated socket. Cartilage is a living graft and does not absorb unless it is prevented from gaining immediate nutrition from its surroundings by h~ematoma (Gibson, I964).
FI6. 4 FIG. 5 Figs. 4 and 5 . - - S a m e patient shown in Figure 3. A marginal fascial sling as well as the conventional lateral tarsorraphy failed to give substantial improvement. T h e fistula at the site of tarsorraphy is one of the causes of " a dirty socket ". The difficulties besetting the prosthetist in this socket are almost insuperable.
Operative Technique.--If lower fornix contraction exists, this must first be corrected by a full thickness mucosal graft. My preference is for nasal septal mucosa as the transplanted tissue appears and behaves so like conjunctiva. Oral mucosa also furnishes a good full thickness graft. Split thickness mucosal grafts inevitably contract too much to be useful. Skin grafts in the orbit are not advised as they often produce more problems than they solve. The socket is difficult to keep clean and the prosthesis will not slide smoothly over skin lining. When the lower fornix is adequate a one-stage procedure will enable the posterior wall of the orbit to be built out permanently. Cartilage is obtained from the costal margin and cut into lengths of ~ cm. or so. Perichondrium should be retained. A midposterior longitudinal incision is made in the conjunctiva of the socket being reconstructed and the conjunctiva is dissected off the scar tissue as far as the fornices. Into this space the cartilage pieces are inserted until an irregular convexity is produced. This result will give the prosthetist who uses a meticulous technique the best chance of providing a
292
BRITISH JOURNAL OF PLASTIC SURGERY
really good ocular prosthesis (Schulmeister, 1965). The conjunctiva is closed by a non-absorbable everting continuous running suture and a plastic " conformer" is left in the socket. Two sutures through the free margin of the lower lid, fixed to the forehead by strapping, complete the immobilisation. Post-operative discomfort is lessened by an eye pad over the normal eye for the first 48 hours. The first dressing is done on the fourth post-operative day.
FIG. 6
FIG 7
FIG 8 FIG. 9 Figs. 6 to 9.--Same patient as shown in Fig. 3. Result four months after treatment described in text. A nasal septal mucosal graft to enlarge the socket followed by a cartilage graft to build out the posterior wall of the socket were carried out in two operations. A new prosthesis provides an acceptable result. T h e tarsorraphy was undone as a part of the operative treatment. The appearance of the socket shows that the lower fornix is now adequate and the posterior wall is convex, supporting the prosthesis and taking the thrust off the lower lid. The junction of the conjunctiva and mucosal graft is clearly seen.
DISCUSSION
Transmission of movement from the ocular muscle stumps to the cartilage appears to be fairly direct since the increase in movement of the prosthesis (about x 2) is explicable on the basis of a longer lever now actuated by muscle action. The prosthesis is lighter and sits directly on the new posterior wall so that the transmission of movement to the prosthesis is more sensitive. This in turn virtually eliminates the lower lid thrust and allows the supratarsal hollow to be corrected more completely. All these factors combine to give the patient increased comfort. Once the conjunctiva has healed over
THE
ENUCLEATED
EYE S O C K E T
293
the graft, there is no risk of late rejection--the result is permanent. The appearance of enophthalmos on the cnucleatcd side is considerably reduced. So long as absorption of the graft does not occur (sec above) it must be considered to bc superior to a non-living implant under the same circumstances. I am indebted to Mr Alfred Schulmdster for posing this problem with such clarity, my discussions with him have helped to produce this technique. I would like to thank Mr John Hueston for asking me to treat these patients. REFERENCES ANGUS, R. (1962). Tram. o~hthal. Soc. Aust., 22, lO3. GIBSON, T. (1964). " M o d e r n Trends in Plastic Surgery ", p. 12. London : Butterworths. SCHULMEISTER A. (1965). Med. ~. Aust., 2, lO57.
Honorary Assistant Plastic Surgeon, Department of Plastic and Maxillo Facial Surgery, Royal Melbourne Hospital, Melbourne, Australia IN the eye socket after enucleation where no implant has been inserted or where an implant has been rejected considerable problems o f cosmesis and comfort are often present. T h e s e difficulties exist quite apart f r o m actual contraction o f the eye socket
FIG. I
FIG. 2 Fig. I.--The tilted prosthesis, supratarsal sulcus and lower eyelid thrust are seen in this patient after enucleation of the left socket. Fig. 2.--The problem of the prosthetic attempt to correct the supratarsal sulcus is shown in this patient with enucleation of the left socket. The lower lid is pushed downwards and outwards. This becomes worse with the passage of time. Fig. 3.~Patient with enucleated left socket. He had the problems of the patients shown in Figures I and 2, added to which retention of the prosthesis was extremely difficult owing to a grossly contracted socket.
FIG. 3 itself, though contraction m a y exaggerate them. W h e n an ocular prosthesis is fitted to such a socket the direction of the u p p e r fornix (upwards and backwards) in combination with a shallow and forward sloping lower fornix tend to tilt and rotate the prosthesis (Fig. I). T h e thrust of the prosthesis is therefore taken largely on the lower lid. An a t t e m p t to enlarge the prosthesis to fill out the inevitable supratarsal sulcus usually increases the thrust on the lower eyelid without achieving substantial correction o f the supratarsal hollowing (Fig. 2). " E n o p h t h a l m o s " is often present. I n t h e c o u r s e of time 290
THE ENUCLEATED EYE SOCKET
29I
the lower lid sags downwards and outwards increasing the aesthetic disability (Fig. 3). The movement of the prosthesis is poor and discomfort is often present because of the peripheral contact of the prosthesis with the socket. The commonly used plastic implants are not entirely satisfactory since they may be discharged if the conjunctiva does not heal by first intention. Late rejection may occur at any time and does so at least as frequently as primary rejection. Partly exposed implants are sometimes left " i n s i t u " if the muscles remain attached. This unsatisfactory state of affairs has caused some ophthalmologists to abandon the insertion of plastic implants at the time of enudeation. Hence the present inquiry and attempt to alleviate the problems in such enucleated sockets. The technique to be described builds out the posterior wall of the socket into a convexity by cartilage grafting. This provides a firm surface which supports the prosthesis adequately, redudes substantially the problems of supratarsal hollow and virtually eliminates the thrust on the lower lid increasing comfort and movement. Angus (I962) described a technique using cartilage chips to fill the scleral cavity after evisceration. This work suggested the use of cartilage in the enucleated socket. Cartilage is a living graft and does not absorb unless it is prevented from gaining immediate nutrition from its surroundings by h~ematoma (Gibson, I964).
FI6. 4 FIG. 5 Figs. 4 and 5 . - - S a m e patient shown in Figure 3. A marginal fascial sling as well as the conventional lateral tarsorraphy failed to give substantial improvement. T h e fistula at the site of tarsorraphy is one of the causes of " a dirty socket ". The difficulties besetting the prosthetist in this socket are almost insuperable.
Operative Technique.--If lower fornix contraction exists, this must first be corrected by a full thickness mucosal graft. My preference is for nasal septal mucosa as the transplanted tissue appears and behaves so like conjunctiva. Oral mucosa also furnishes a good full thickness graft. Split thickness mucosal grafts inevitably contract too much to be useful. Skin grafts in the orbit are not advised as they often produce more problems than they solve. The socket is difficult to keep clean and the prosthesis will not slide smoothly over skin lining. When the lower fornix is adequate a one-stage procedure will enable the posterior wall of the orbit to be built out permanently. Cartilage is obtained from the costal margin and cut into lengths of ~ cm. or so. Perichondrium should be retained. A midposterior longitudinal incision is made in the conjunctiva of the socket being reconstructed and the conjunctiva is dissected off the scar tissue as far as the fornices. Into this space the cartilage pieces are inserted until an irregular convexity is produced. This result will give the prosthetist who uses a meticulous technique the best chance of providing a
292
BRITISH JOURNAL OF PLASTIC SURGERY
really good ocular prosthesis (Schulmeister, 1965). The conjunctiva is closed by a non-absorbable everting continuous running suture and a plastic " conformer" is left in the socket. Two sutures through the free margin of the lower lid, fixed to the forehead by strapping, complete the immobilisation. Post-operative discomfort is lessened by an eye pad over the normal eye for the first 48 hours. The first dressing is done on the fourth post-operative day.
FIG. 6
FIG 7
FIG 8 FIG. 9 Figs. 6 to 9.--Same patient as shown in Fig. 3. Result four months after treatment described in text. A nasal septal mucosal graft to enlarge the socket followed by a cartilage graft to build out the posterior wall of the socket were carried out in two operations. A new prosthesis provides an acceptable result. T h e tarsorraphy was undone as a part of the operative treatment. The appearance of the socket shows that the lower fornix is now adequate and the posterior wall is convex, supporting the prosthesis and taking the thrust off the lower lid. The junction of the conjunctiva and mucosal graft is clearly seen.
DISCUSSION
Transmission of movement from the ocular muscle stumps to the cartilage appears to be fairly direct since the increase in movement of the prosthesis (about x 2) is explicable on the basis of a longer lever now actuated by muscle action. The prosthesis is lighter and sits directly on the new posterior wall so that the transmission of movement to the prosthesis is more sensitive. This in turn virtually eliminates the lower lid thrust and allows the supratarsal hollow to be corrected more completely. All these factors combine to give the patient increased comfort. Once the conjunctiva has healed over
THE
ENUCLEATED
EYE S O C K E T
293
the graft, there is no risk of late rejection--the result is permanent. The appearance of enophthalmos on the cnucleatcd side is considerably reduced. So long as absorption of the graft does not occur (sec above) it must be considered to bc superior to a non-living implant under the same circumstances. I am indebted to Mr Alfred Schulmdster for posing this problem with such clarity, my discussions with him have helped to produce this technique. I would like to thank Mr John Hueston for asking me to treat these patients. REFERENCES ANGUS, R. (1962). Tram. o~hthal. Soc. Aust., 22, lO3. GIBSON, T. (1964). " M o d e r n Trends in Plastic Surgery ", p. 12. London : Butterworths. SCHULMEISTER A. (1965). Med. ~. Aust., 2, lO57.