CONTRACTED_SOCKET presentation DHB .pptx

CONTRACTED_SOCKET presentation DHB .pptx

1. CONTRACTED SOCKET PRESENTER: DR MUSKAN SETHI (1 ST YEAR DOMS RESIDENT) MODERATOR : DR URMILA KUMARI DHIR HOSPITAL AND PG INSTITUTE OF OPHTHALMOLOGY

2. DEFINITION OF IDEAL SOCKET An Ideal Anophthalmic Socket A socket lined with healthy conjunctival epithelium Centrally placed implant of adequate volume Adequately deep inferior and superior fornices to retain the prosthesis Optimal implant-prosthesis coupling to ensure motility of the artificial eye Normal position and adequate tone of eyelids Well-fitted prosthesis that looks similar to the contralateral eye

3. DEFINITION OF CONTRACTED SOCKET Contracted socket, or socket contracture, is defined as Shrinkage and shortening of all or a part of orbital tissues causing a decrease in depth of the fornices and orbital volume Inability to retain an ocular prosthesis It can either be due to soft tissue or bony contraction.

4. CAUSES OF CONTRACTED SOCKET Congenital causes Acquired causes

5. IMPORTANCE OF PLACING IMPLANT Appropriately sized orbital implant help reducing the risk of post-enucleation socket syndrome from volume loss after enucleation or evisceration The average volume of the globe is 7.2 ml, and the combined volume of the implant and prosthesis should equal the volume of the removed globe The average volume of a prosthesis is 2.5  ml; thus the implant needs to equal almost two thirds of the volume of the globe Increasing the volume of the prosthesis may result in mechanical ectropion of the lower eyelid from the heavier weight

6. POST ENUCLEATION SOCKET SYNDROME Deepening of the upper eyelid sulcus (superior sulcus deformity) Upper eyelid ptosis (with upper eyelid dysfunction/ lagophthalmos ) Lower eyelid laxity and ectropion

7. GOPAL KRISHNA CLASSIFICATION Soft tissue socket contraction is graded from grade 0 to 5 Grade-0: Socket is lined with healthy conjunctiva and has deep and well-formed fornices Grade 1 : Shallow or shelving/shortening of the lower fornix Grade 2: Loss of upper and lower fornices Grade 3: Loss of upper, lower, medial and lateral fornices Grade 4: Loss of all fornices and reduction of palpebral aperture in horizontal and vertical dimensions Grade 5: Recurrence of socket contracture despite repeated reconstruction attempts

8. OTHER CLASSIFICATION Mild: Only one fornix is involved (usually lower fornix) + shortening of posterior lamellae of the eyelids Moderate: Both superior + inferior fornices are involved (decrease in area) Severe: All fornices are involved + phimosis of palpebral aperture (loss of area + volume) Malignant: Severe loss of area, volume , with associated bony contracture

9. CLASSIFICATION OF SOCKET CONTRACTURE WAS DESCRIBED BY TAWFIK ET AL. Grade 1 : Minimal or no actual contracture . Complains : Inability to retain the prosthesis ( horizontal eyelid laxity with subsequent prolapse of the inferior fornix ) Grade 2: Mild contracture of the inferior or superior fornix . Complain : Rolling-in of the upper and lower eyelid margins Grade 3: Scarring is more advanced . Complaint : Impossible to wear the prosthesis. Cicatrization involves the entire upper and lower fornices Grade 4: Severe phimosis of the palpebral fissure both vertically and horizontally. H/o : Recurrent cases

10. HISTORY AND EXAMINATION History of prior surgical procedures , type of implant placed, any complication. Time interval between the procedure and onset of fibrosis Etiology of primary procedure : malignancy, trauma or congenital malformation. Detailed clinical evaluation includes volume assessment, surface area, depth, wet or dry socket, Palpation, eyelids, motility Imaging : CT scan to assess for orbital cavity size, bony contracture and any associated fracture.

11. DETAILED CLINICAL EVALUATION Volume assessment: Superior sulcus deformity is a sign of volume loss Depth: A shallow/shortened inferior fornix leads to poor fitting of the prosthesis Right superior sulcus deformity showing a deep hollowed sulcus, as well as ptosis of the upper eyelid..(a) Inferior fornix shelving with socket tissue prolapse limits the ability to retain a prosthesis. (b) Inferior fornix shortening. Pinch test of the patient shows that the surface is adequate, but depth of fornix is inadequate to hold the prosthesis. (c) Poor stability of prosthesis and inferior scleral show , suggesting lower eyelid laxity

12. Surface area of the socket and depth of the fornices are noted .Assess the socket lining Fibrous bands and symblepharon in the socket.. Multiple granuloma formation in the socket may be secondary to poor tissue closure technique, poor prosthesis fit with chronic surface irritation, or other inflammatory etiology…Large exposure of a silicone implant

13. Moisture : Dry or wet Palpation : Presence and position of the implant. An inferiorly displaced implant can often obliterate the inferior fornix Eyelids : Excessive eyelid or canthal tendon laxity that should be addressed Motility : Extraocular movements and tone of the orbicularis muscle CT scan to assess for orbital cavity size (hypoplastic in congenital anophthalmos ), bony contracture, and associated orbital fractures contributing to a sunken appearance (cases with previous trauma) to ascertain the presence, size, and position of an orbital implant

14. MANAGEMENT OF CONTRACTED SOCKET AIM :to create a healthy socket which is able to hold stable ocular prosthesis along with reasonable symmetry of palpebral apertures , canthal angles and superior sulci

15. AQUIRED CONTRACTED SOCKET MANAGEMENT

16. MILD CONTRACTED SOCKET: Inability to retain prosthesis Cause : lower eyelid laxity with minimal shortening of fornix With adequate fornix : Treatment options Transverse blepharotomy with marginal rotation of eyelid Horizontal eyelid shortening, if lid laxity coexist

17. With shortening of fornix (usually inferior): Closed method fornix repair done

18. With shallowing of fornix and fat prolapse: An open method for fornix repair may be preferred Fornix reconstruction requires conjunctival incision , complete release of fibrosis by dissection under the conjunctiva to the orbital rim, horizontal tightening , and posterior lamellar lengthening with buccal mucous membrane grafts (a) Preoperative image showing a shelved inferior fornix with fat prolapse . (b) Preoperative image demonstrates a poor fitting ocular prosthesis with upward rotation and lower eyelid laxity. (c) Conjunctival undermining to the orbital rim

19. . (d) Fornix-deepening sutures are passed through the conjunctival fornix . The sutures are externalized and tied over bolsters. (e) Lateral canthal tendon tightening is performed. (f) Prosthesis is in optimal position at the end of the procedure

20. MUCOUS MEMBRANE GRAFTING Indications : Conjunctival fibrosis Moderate to severe contracture (Moist socket): Gold standard Donor site Oral buccal mucosa Hard or soft palate Skin of labia and rectum

21. Preparation of donor site: Site is marked with a surgical pen Infiltrated with lidocaine plus adrenaline Stensen duct identified Full thickness graft is removed with a 15 Bard-Parker blade Ideal graft should be 25% larger than the defect Donor site closed

22. HARVESTING OF BUCCAL MUCOUS MEMBRANE GRAFT (a) Harvesting of buccal mucosal graft from inside the lower lip . (b ) Submucosal tissue is trimmed from the posterior aspect of the graft

23. Preparation of Recipient site : Site is infiltrated with 2% lidocaine plus adrenaline Conjunctiva is incised horizontally below the tarsus Dissection of conjunctiva from underlying cicatrix and fibrotic tissue Subconjunctival dissection done until lower lid is freely mobile MMG is placed with mucosal side facing ocular surface Sutured to recipient fornix and conjunctiva with 6-0 polyglactin suture Fornix reformation sutures are passes and tied on the skin through bolsters

24. . (c) Dissection is performed in the inferior fornix to release the scar tissue. (d) The harvested mucous membrane graft is trimmed and sutured to the host bed with polyglactin or chromic gut sutures (e) Postoperative photo demonstrates adequate surface and improvement in fornix depth

25. DERMAL FAT GRAFTING Autologous implant It consist of the de-epithelialized dermis layer that is attached to and supplies nutrients to the adjacent subcutaneous fat tissue Readily available, inexpensive and negligible allergy risk Indication Volume and surface loss in moderate to severe contracted socket Donor site Gluteal region (upper outer) Lower abdomen Inner thigh

26. DERMIS FAT GRAFT Donor site preparation Area marked with surgical marker Site is 5 cm below the mid point of line joining ant iliac spine and ischial tuberosity Ideally 20-25 mm area is marked Epidermis is carefully shaved with a 15 no blade Incision should be superficial to dermis Perpendicular incision through the dermis is made Fat plug of 20-30 mm deep is excised Graft is oversized to account for shrinkage Donor site closed (a) A 25 mm diameter circle is marked on the skin of the gluteal region(b ) Epidermis is incised superficially until minute pinpoint bleeding is visible. (c) The harvested dermis fat graft is 20–30  mm in depth.

27. Recipient site preparation Conjunctiva is excised horizontally and released of all cicatrix Graft is placed deep inside the orbit with dermal side facing the conjunctiva Conjunctiva is sutured to the edge of dermis with 6-0 polygalactin interrupted suture Pressure patch applied for 2-3 days. Subconjunctival dissection is performed to prepare the host bed. (e) The dermis fat graft is transferred to the orbital recipient site. (f) The dermis fat graft completely sutured into the socket without excessive tension

28. COMPLICATION OF DERMAL FAT GRAFT Atrophy of fat graft Pressure necrosis of graft Donor site wound dehiscence Scar formation and deformity

29. GRADE V CONTRACTED SOCKET Difficult to manage: Recalcitrant/ Malignant socket Characterized by socket that has underwent multiple procedures Recommendations for management: Exenteration Customised osseo -integrated facial prosthesis

30. TREATMENT OF DRY AND GROSSLY CONTRACTED SOCKET Socket Split-thickness skin grafting (a) Split-thickness skin graft is harvested from the inner aspect of the thigh. (b) Harvested split-thickness graft is demonstrated. (c) Grossly contracted socket

31. . (d) Conjunctival incision and dissection to create the recipient bed. (e) Split-thickness skin graft is sutured to the host bed. (f) The postoperative image demonstrates improved volume and surface area of the socket after split-thickness skin grafting

32. CONGENITAL CONTRACTED SOCKET

33. Congenital contracted socket In both Anophthalmos and Microphthalmos, there is Shortening of the vertical and horizontal dimensions of eyelids leading to phimosis Shortened conjunctival fornices with deficiency of palpebral and bulbar conjunctiva Hypoplasia of the bony orbit, and facial asymmetry due to reduction in soft tissue volume Treatment should commence as early as possible as early intervention will help stimulate the growth of the orbital bones and the periocular and midfacial tissues

34. STEPS OF RECONSTRUCTION

35. EXPANSION OF HORIZONTAL AND VERTICAL EYELID APERTURES Gold standard of serial conformers Expanding hydrogel conformers can also stimulate socket expansion for expanding the palpebral fissures The socket expanders are small when dry , ranging from 6 to 9 mm in diameter, for easy insertion Due to high hydrophilic properties, they expand to 11, 14, and 18  mm when fully hydrated, which typically takes 2–4 weeks. Can be replaced with a larger expanding conformer for additional results Serial conformers used to expand socket

36. Expandable hydrogel socket implants Hydrogel sphere in conjunctival cul-de-sac

37. ORBITAL EXPANSION Intraorbital implantation of non-expanding orbital implants Balloon expanders Dermis fat grafts Hydrogel expanders Integrated orbital tissue expander 3D osteotomies for small bony sockets

38. Orbital Implants (Non-expanding) :Traditionally, static orbital implants were used but smaller implants failed to expand the orbit adequately and larger implants carried a high risk of extrusion Balloon (Inflatable Soft Tissue) Expanders: typically implanted through an orbitotomy or bicoronal approach, with the balloon inflated with monthly injections of saline through an external inflation port. Advantage of predictable orbital and soft tissue growth

39. HYDROGEL EXPANDERS Co-polymer : Methylmethacrylate and N- vinylpyrrolidone . Expand up to 6–12 times their original volume, and thus the orbital tissues, by osmotically imbibing tissue fluid Can be molded into desired shapes and their expansion can be precisely controlled They are self-inflating without injection ports , have less complications related to inflation, such as sudden pressure necrosis. Hydrogel pellet (0.2 cm 3 ) is inserted into trochar and deposited into the posterior orbit

40. Integrated Orbital Tissue Expander (OTE) Consists of a flexible expander anchored to the lateral orbital wall by a titanium plate As the expander is fixed to the orbital wall , it has the advantage of sustained and unidirectional expansion Induce growth of the associated frontal, maxillary, and zygomatic bones A 1 cc syringe with a 30 gauge needle is used to expand the OTE via an injection port to apply increasing pressure to the orbit These expanders can therefore be inflated and deflated, as needed Safe and effective in managing the anophthalmic socket with good long-term outcome

41. 3D OSTEOTOMIES FOR SMALL BONY SOCKETS C- and U-shaped osteotomies can be created to expand the roof, lateral wall, and orbital floor The osteotomy segments are advanced forward and away from the center of the orbital cavity The orbital floor and rim are placed at a higher level compared to the normal side to provide better support to the prosthesis Bone grafts are used to fill the defect

42. THAKYOU  REFERENCES:2019_BOOK_OCULOFACIALORBITALANDLACRIMAL SURGERY

43. With adequate fornix presenting as lower eyelid entropion or laxity: Cicatricial shortening of the posterior eyelid lamella can result in entropion but with adequate fornices Transverse blepharotomy with marginal rotation of eyelid Horizontal eyelid shortening if eyelid laxity coexists In recurrent or severe cicatricial cases, lengthening of the posterior eyelid lamella requires a free graft interposed inferior to the tarsus (tarsus, hard palate, ear cartilage, acellular dermix matrix)

44. Dumbbell-shaped or champagne glass configuration acrylic conformers:help expand soft tissues and encourage bony growth by transmitting pressure to the socket by application of tape over its external component Custom scleral shells : can be useful in cases of microphthalmic eyes to promote orbital growth. Custom clear shells can be made for mild to moderate microphthalmia with positive response to visual evoked potential testing, in order to allow the eye to achieve its maximum visual potential