|Year : 1988 | Volume
| Issue : 2 | Page : 79-81
Surgical management of contracted socket
SM Betharia, Harsh Kumar
Dr. RP. Centre, A.I.I.M.S., Ansari Nagar, New Delhi-110 029. (INDIA), India
S M Betharia
Dr. RP. Centre, A.I.I.M.S., Ansari Nagar, New Delhi-110 029. (INDIA)
Source of Support: None, Conflict of Interest: None
Results of repair of contracted sockets by mucous membrane grafting obtained from the lip and cheek in 21 eases is presented. Finer points in mucous membrane grafting are highlight led. A snugly fitting conformer with multiple holes is a prerequisite for proper reconstruction of the socket The value of a larger size thin graft with the use of fornix forming sutures and tarsorrhaphy are emphasized.
|How to cite this article:|
Betharia S M, Kumar H. Surgical management of contracted socket. Indian J Ophthalmol 1988;36:79-81
| Introduction|| |
In the modem day world, when cosmetic satisfaction for the patient has become a necessity and not a luxury, the importance of a well reconstructed socket cannot be over emphasised. A good reconstruction of the socket gives the opportunity to the ocularist for fitting a cosmetically acceptable prosthetic eye, the demand for which is ever increasing. Mucous membrane grafting for contracted socket is accepted as the most physiological method for reconstruction. We are reporting a large series of repair of contracted sockets, by using mucous membrane grafting„ highlighting the results and the problems encountered.
| Material and Methods|| |
21 patients, 11 females and 10 males in the age group of 9 to 63 years with an average age of 27.1 years were operated for contracted socket
| Surgical steps|| |
The preoperative preparation of the patients consisted of taking a swab for culture and sentivity from the socket and starting local antibiotic drops till the cultures were sterile. Condys (Kmno4) mouth washes were given three times a day to all the patients for 3 days prior to surgery.
The patients were operated under general anaesthesia with nasotracheal intubation and packing of the oropharyngeal area The socket was washed with saline and antibiotic The lids were separated by a retractor.
The incision was put in the centre of the socket The fibrous tissue was excised along with the fibrous bands. Then pressure haemostasis was done. The use of cautery was preferably avoided A large mucous membrane graft was taken from the lower lip or cheek which was 30% larger than the size of the defect The area of the graft to be taken from the mucous membrane was first marked by gentian violet and later on infiltrated with 20% xylocaine with adrenaline so as to obtain a good plane of cleavage and achieve the haemostasis. Care was taken not to injure the opening of Stensori s duct while taking the graft from the cheek area, not to damage the frenulum and keeping at least 2 mm of the mucous membrane around which helps in suturing after proper undermining of the edges. Key pattern sutures were passed for closing the defect in the lip, whereas interrupted sutures were passed for mucous membrane closure of the cheek The passage of a stay suture helped in lifting up the mucous membrane graft during dissection from the underlying fatty tissue. Around bladed No. 15 Bard Parker knife and rounded tip curved scissors along with the support from the pulp of the index finger helped in the clean dissection. The great was then placed in position, and four sutures to properly fix the graft were first applied. Thin 6'o black silk interrupted sutures were used to suture the graft after ensuring proper haemostasis. Upper and lower fomix fixation sutures were passed keeping an adequate depth of the lower and the upper fornix After this a snugly fitting conformer with multiple holes was placed in the reconstructed socket so that adequate pressure is maintained on the graft and the area of the fornices. Tarsorrhaphy was done at the end of the reconstruction.
| Results|| |
Out of 21 sockets reconstructed we were able to give good cosmetic results in 16 cases and adequate size prosthesis could be retained in these cases [Figure - 1][Figure - 2][Figure - 3]. Complications noted were shrinkage of the graft in 5 cases, improper take up of the graft in 3 cases, granuloma formation in 3 cases resulting in inability to retain the prosthesis.
| Discussion|| |
Repair of the infected contracted socket is a tedious job and usually these cases are neglected. Low grade inflammation, implant extrusion and migration, sharp and chipped off edges of the artificial eye, faulty technique of enucleation with loss of bulbar conjunctiva are the usual determining factors in the production of contracted socket . Use of suitable type of implants and conformers and a proper technique of enucleation with haemostasis and asepsis go a long way in preventing this problem . Though the conjunctiva and the buccal mucosa  are the best sources for socket reconstruction, a large number of substitutes like peritoneum, prepucial skin, vaginal mucosa, nasal mucosa and split and partial thickness skin grafts were used from time to time ,,.
We have used the buccal mucosa mostly from the lower and upper lips and from the cheek The grafts obtaind from the cheek were thicker and were technically difficult to remove as the cheek had to be turned out sufficiently to get an adequate exposure. We have not used Castroviejo s electromucotome since it only gives a small strip of thin mucous membrane as usually bigger grafts are needed for successful repair.
While taking the graft from the lower lip the frenulum should not be damaged while care should be taken to avoid the opening of the duct of the parotid gland. Enough time was spent in taking out the thin mucous membrane and dissecting out the underlying submucosal tissue and fat while taking the graft Toothed forceps and colibri forceps should not be used for handling the graft Use of a stay suture and pressure by the pulp of the index finger alongwith the use of the round edge of the Bard Parker knife and round tipped scissor helped a great deal in successful removal of a large sized graft
For successful take up of the graft the haemostasis must be perfect The use of cautery should be avoided and excision of all the fibrous tissue is extremely important.
A large number of techniques were described for placement and suturing of the donor mucosa. Strampellib placed two pieces of mucosa one in the upper and one in the lower fomix Dortzbach and Callahan  relined the socket with mucosa covered mould fixed to the orbital rims. Soll  used mucous membrane with an expandable silicone tire conformer wired to the orbital floor. We have made an incision in the central part of the fundus of the socket as given by Fox and placed the mucosal graft in the centre. The fornices were formed by passing double armed sutures above and below in the upper and lower lids taking out the sutures with deep bites of the periosteum of the orbit The depth of the fornix was very important for retaining the artificial eye and the depth of the lower fomix of the opposite normal eye gave a good guideline for achieving such a depth A canthotomy and cantholysis was profotnied in case of smaller horizontal dimensions of the contracted sockets Putting in of the proper size of snugly fitting conformer with holes was the most important step to prevent post-operative contracture of the mucosa The lids came into approximation once the reconstruction was adequate. We have not used any wire suture to hold the conformer against the lower orbital rim as suggested by Smith . Temporary tarsorrhapy was done so that adequate pressure over the graft and the fomices was ensured. Irrigation of the reconstructed socket was done with antibiotic solution The tarsorrhapy was opened on the 8th day and sutures were removed. The conformer was replaced by the artificial eye after a period of six weeks At no time the reconstructed socket was kept without a conformer or an artificial eye lest graft contracture occured rapidly Jeoparadizing the results.
| References|| |
Fox, S.A Ophthalmic Plastic Surgery, Grune and Stratton. New York, P. 514, 1976.
Guiber P. and Gongelmann, H.P. Problems and treatment of enucleation, evisceration and exposure Stratton Intercontinental medical book corporation, New York, p. 43.
Greear, J. N. Am J. Ophthalmol, 31 : 445, 1948.
Clay, G.E. and Baited, J.M., J.M.M.A 107: 1122, 1936.
Mustarde, J.GRepair and reconstruction in the orbital region A practical guide. Churchill Livingstone Edinburgh, p. 222, 1980
Strampelli, B Bull. Ocul. 37: 682, 1958
Dortzbach, R K and Callahan A Am J. Ophthalmol, 70: 800, 1970.
Soll, D.R, Arch. Ophthalmol, 82: 218, 1969
Smith, R Arch. Ophthalmol, 71 : 517, 1964
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2], [Table - 3]