|Year : 1981 | Volume
| Issue : 2 | Page : 75-79
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|How to cite this article:|
Krishna G. Contracted sockets-II. Indian J Ophthalmol 1981;29:75-9
The inferior fornix of the socket is of greater importance than superior for the satisfactory fitting of a prosthesis. The upper fornix needs only be of sufficient depth to prevent the artificial eye from slipping out from the upper lid. The lower fornix does most of the weight bearing and must be deep enough to give firm anchorage for the prostheses to be held in upright position. In order to reconstruct the fornices in the contracted sockets various procedures such as mechanical enlargement of the socket by conformers, mattres sutures in the fornices, skin or mucous grafts,,,,, skin flaps different types of modification in the artificial eye, were used.
| Materials and methods|| |
The present study was planned to know the results, after various procedures for contracted sockets of various grades.
The various methods adopted were:
(A) Mechanical enlargement of the socket: Increasing sizes of acrylic conformers will enlarge grade I of contracted sockets in which the conjunctiva is healthy and some remnants of the fornix are present.
(B) Surgical repair :- Method I (without Graft)
(i) The lid margins were retracted by three traction sutures in each lid margins. The conjunctival base of the socket was incised horizontally from the lateral to the medial canthus and undermined up to the upper and lower lids with the help of scissors. The inferior fornix wax reconstructed by the brunt dissection close to the lid and carried down to the periosteum below the inferrior orbital rim. The prolapsed orbital fat was resected by the blunt dissection throughout the length of the lower fornix.
(ii) The conjunctival incision was closed by interrupted 6.0 silk sutures. The three double armed sutures, were passed equidistance through conjunctiva of the newly formed fornix below the tarsus, through the periosteum of the inferior orbital margin and skin and tied over glass beads on the surface of the skin [Figure - 1]. After placing the conformer of the suitable size in the socket, the cutaneous tarsal blepharorrhaphy was done [Figure - 2] and after a moderate pressure dressing was applied for 10 days.
b. Method 11 (With graft) 1. Step (i) was the same as in previous method.
2. Mucous membrane of the lower lip or epidermal graft from the arm was taken. After checking the bleeding, graft was applied and sewed into the position with the interrupted 4.0 silk sutures to cover the raw surface of the socket [Figure - 3]. Rest were the same as in the previous method.
c. Method III (with graft and lateral canthotomy)-A wide lateral canthotomy was done to facilitate the exposure and mobility of the lid. Dissection begins near the lid margin with thining of the tarsus to prevent undue thickness after the grafting. The dissection continue towards the orbital rim, below, lateral, medial and upwards. The dissection proceeds towards the superior orbital margin except in the central third, where the main portion of the levator tendon passes into the upper lid structure. All the cicatricial tissues and scarred conjunctiva were removed [Figure - 4]. An epidermal graft wrapped around the conformer with raw surface outwards and placed in the socket [Figure - 5] and the lid stiches were tied and a firm pressure dressing was applied.
After 15 days the lid stiches were cut and conformer was removed. Toileting of the socket was done with antibiotic solution and epithelial debris were removed and then conformer was reinserted. The toileting of the socket was done regularly biweekly for three months after which the final prosthesis was given.
| Observations|| |
[Table 1] shows the treatment given to the 52 cases of contracted sockets.
Following complications were encountered during the postoperative period :
Unequal pressure over the socket by the pressure bandage caused the coloboma of the upper lid due to the slipping of the upper part of the conformer, in one case. In 9 cases, delayed loss of the fornices occured, usually after 3 to 5 weeks of operation, in these cases inverted scleral contact lens were inserted and pressure bandage was applied for about 2 weeks, and the condition was brought under control. In 5 cases over sized conformers in post operative period caused the lower lid sagging. This was corrected by lateral tarsorraphy. In 3 cases incomplete closure of the upper lid occured due to the adhesion of the graft to the levator palpebrae superioris. This remains uncorrected, but some improvement was obtained in one case by modifying the artificial eye. Post operative shrinkage of the graft took place in 7 cases after 4 to 6 weeks of operation. This was controlled by the dumble shaped pressure conformers in 5 cases but in 2 cases after 5 months of socket repair, grade IV contraction occured due to the excessive fibrosis. In one case after total lining of the socket with epidermal graft, socket was restored, but still in one case after repeated attempt to reconstruct the socket failed and in this case spectacle prosthesis was given. 6 cases of the epidermal grafted socket complained either dryness of the socket and loss of the shining of the artificial eye or foul discharge from the socket, in first case the condition was relived by artificial tears while in later case 1 % silver nitrate paintaing of the socket relieved the symptoms.
| Discussion|| |
In Grade-I contracted socket, no lining of the socket was required because none had been lost. Grade II contracted socket, required dissection and removal of all the fibrous bands and scarred conjunctiva and replacement by the mucosa or epidermal graft. Grade III and IV contracted socket required extensive dissection and removal of fibrous tissues and scarred conjunctiva and replacement of the tissue loss by large epidermal graft. In grade V socket, spectacle was the treatment of the first choice.
Epidermal grafting in the socket was mainly indicated in cases where normal conjunctiva was scanty and large amount of fibrosis was present. But in few cases of epidermal grafted socket some problems were encountered in the form of offensive smell from the socket causing lusterless look of the artificial eye, adhering of the cilia to the prosthesis and some time even rejection of the graft. Mucous membrane grafting was usually indicated in cases where the sufficient amount of the normal conjunctiva with minimum amount of fibrosis is present and this grafting was more physiological and there was no foul discharge from the socket. This graft nearly always remains viable and has the short postoperative period in comparison to epidermal graft. As the amount of the post operative contraction is irregular, use of 30% larger graft is advisible to counteract post operative shrinkage.
Proper handling of the conformer is important to counteract postoperative graft contraction and maintenance of the shape of the socket.
Thus we may conclude that:
- Construction of largest possible socket, so that if a secondary contraction occurs, there is no interference to the essential operative aim i.e. to give an artificial eye.
- The absolute necessity for removing all the scar tissue and fibrous bands from the socket before applylng the graft.
- The socket should not be left without any conformer or artificial eye even for short periods
- Reoperation of the socket should not be done early.
| Summary|| |
In this study, 52 cases of contracted socket cases were evaluated from point of relief obtained by the various surgical procedures in different grades of the sockets.
| References|| |
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]