JANUARY/FEBRUARY 2010

Volume 8, Issue 1
AS PRESENTED IN THE
ROUNDS OF THE DEPARTMENT
OF OPHTHALMOLOGY
AND VISION SCIENCES,
FACULTY OF MEDICINE,
UNIVERSITY OF TORONTO
Department of Ophthalmology
and Vision Sciences,
Faculty of Medicine,
University of Toronto,
60 Murray St.
Suite 1-003
Toronto, ON M5G1X5
The editorial content of
Ophthalmology Rounds is determined
solely by the Department of
Ophthalmology and Vision Sciences,
Faculty of Medicine, University of Toronto
Department of Ophthalmology
and Vision Sciences
Jeffrey Jay Hurwitz, MD, Editor
Professor and Chair
Martin Steinbach, PhD
Director of Research
The Hospital for Sick Children
Elise Heon, MD
Ophthalmologist-in-Chief
Mount Sinai Hospital
Jeffrey J. Hurwitz, MD
Ophthalmologist-in-Chief
Princess Margaret Hospital
(Eye Tumour Clinic)
E. Rand Simpson, MD
Director, Ocular Oncology Service
St. Michaels Hospital
Alan Berger, MD
Ophthalmologist-in-Chief
Sunnybrook Health
Sciences Centre
William S. Dixon, MD
Ophthalmologist-in-Chief
University Health Network
Toronto Western Hospital Division
Robert G. Devenyi, MD
Ophthalmologist-in-Chief
Issues in the Management of the Anophthalmic
Socket: Clinical, Comfort, and Cosmetic
BY MI CHAE L C. F. WE B B , BADO, BCO, FASO
Ophthalmologists have many different perspectives on the terms artificial eye or
ocular prosthetic. Indeed, it is not the last resort for enucleation and evisceration
and, as the field of ocularistry has advanced, so too has the relationship with
ophthalmologists. To fully recognize enucleation and evisceration as a multidisci-
plinary approach is to offer patients the best option for a truly successful procedure.
The role of the ocularist does not end with the completion of the ocular prosthetic,
and the involvement of an ophthalmologist does not end with the surgery to
enucleate or eviscerate. To utilize the field of ocularistry to its full potential is to
understand the types of services and expertise available for the initial surgery and
long-term care of the patient. This issue of Ophthalmology Rounds reviews the
problems leading to an anophthalmic socket and the surgical and medical condi-
tions involved in treating these difficulties.
Enucleation and evisceration
A careful evaluation of these procedures may determine the long-term success for
the patient, and the following list of preferences suggest the most desirable situations for
ocular prosthesis or scleral lens success from the most preferred (top) to least preferred
(bottom):
Evisceration hydroxyapatite (HA) pegged implant
Enucleation HA or porous polyethylene pegged implant
Evisceration with implant
Phthisis bulbi
Enucleation stable, centrally located sphere implants. Muscles attached in proper
anatomical position.
Enucleation high-motility implants
Microphthalmia
Phthisis bulbi exotropic or esotropic
Dermis fat graft
Enucleation no implant
Exophthalmos lens to be fit over larger globe
Congenital anophthalmia
Contracted sockets Grade 1-3
Contracted, post-radiation sockets Grade 4-5
Orbital exenteration
The preferences relate to the incidence and severity of anomalies in the
anophthalmic socket syndrome.
1,2
When choosing the procedures of enucleation and
evisceration, it must be understood that evisceration is not always an option. The pre-
existing condition of the eye due to either trauma or a tumour may dictate the proce-
dure required. The fear of sympathetic ophthalmia is a consideration for enucleation;

Department of
Ophthalmology and
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Ophthalmology
ROUNDS
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however, the decision must relate to the individual
circumstances. Sympathetic ophthalmia is not a defin-
itive reason for enucleation without considering
evisceration, since the potential for development is
low if the eye is not enucleated, particularly given the
current anti-inflammatory medications and ocular
management techniques.
3
If the eye socket of the
patient is relatively high on the list of preferences, it is
less likely that anophthalmic socket syndrome anom-
alies will be a factor in fitting the ocular prosthetic.
Anophthalmic socket syndrome
The anophthalmic socket syndrome or postenu-
cleation syndrome encompasses several anomalies:
2,4,5
Superior sulcus deformity
Ptosis
Enophthalmos
Ectropion with lax lower lid, or rarely, entropion
These anomalies are less frequent in the eviscer-
ated socket than the enucleated socket, but they
rarely occur following an evisceration.
4
Several key
factors in an enucleation allow a good socket for
fitting an ocular prosthesis. One is a sufficient poste-
rior depth for the implant offering good closure of
the overlying tissues.
6
Other factors are the size and
design of the implant; for example, if the implant is
too small, it contributes to enophthalmos, but if it is
too large, it may restrict movement of the ocular
prosthesis and may cause ptosis.
7, 8
An excessively
large implant will often restrict the depth of the pros-
thesis anterior chamber, giving the artificial eye an
unnatural balance. This is particularly true if the
prosthesis is a biointegrated style of implant such as
HA or porous polyethylene.
The most common complications for patients
with an ocular prosthesis after enucleation are reces-
sion of the upper lid sulcus, absence of the superior
lid fold, and progressive enophthalmos.
2
These
complications have been attributed to the degenera-
tion of the inactive extraocular muscles, orbital fat
atrophy, and the tendency for enophthalmos due to
aging.
9
All of these factors should be considered
when a decision must be made regarding either
primary or secondary surgery.
Anophthalmic ptosis
Anophthalmic ptosis is a situation requiring a
separate classification because the anatomy varies in
relation to the orbit contents, necessitating a wide
range of implants, as well as various sizes of globes.
However, the presence of a phthisical or microph-
thalmic globe is a contradiction for the anophthalmic
ptosis classification.
7
In these situations, ocularists
may sometimes repair a drooping lid by a change in
the shape or volume of an ocular prosthesis or the
scleral lens.
Surgeons handle ptosis corrections differently
than ocularists. The ocularist is often expected to
repair these situations prosthetically, but if this is
impossible, then surgical correction is undertaken.
If an appropriately fitted prosthesis can minimize the
degree of correction required, surgical repair may
be facilitated.
Classification
7
Pseudoptosis usually results from a lack of orbital
volume, and often may be a result of microph-
thalmos, enophthalmos, phthisis, or a poorly fitted
prosthesis. Pseudoptosis may also become apparent
with a rapid regression of edema or an atrophy of
the posterior orbital tissues (Figure 1A).
Persistent ptosis is commonly attributed to accidental
or surgical trauma (aponeurotic sheath attached to
the levator muscle becomes disinserted). There may
also be myogenic, neurological, or congenital
causes. As well, a superiorly migrated sphere that
causes the levator muscle and tarsus to be pushed
forward and downward may produce a ptosis.
Temporary ptosis most commonly occurs after
enucleation or evisceration during the first few weeks
to several months. It is usually caused by edema of
the orbital tissues pressing the upper edge of the
tarsus forward; subsequently, the upper lid moves
anteriorly or inferiorly. Infection, inflammation, and
steroid myopathy also result in this type of ptosis.
Intermittent ptosis may often be secondary to a
medical problem such as transient Horner syndrome,
myasthenia gravis, or third-nerve paralysis. Waking
or morning ptosis may also be intermittent ptosis
and pseudo-intermittent types of ptosis may result
from protein deposits on the surface of the pros-
thesis. Fatigue-type ptosis results from the exhaus-
tion of the levator muscle and is also intermittent.
Progressive ptosis and pseudoptosis may be the result
of a familial ptosis such as blepharophimosis or a
tumour in the orbit. A growing tumour will usually
manifest in a progressive manner. Atrophy of the
posterior orbital fatty tissues or rapid regression of
edema may also manifest itself as progressive ptosis.
7
Prosthetic correction
After the assessment and classification of an
anophthalmic ptosis, a prosthetic correction is
undertaken (Figure 1B). At this point, relatively few
options are available for an ocularist. The 2 main
components for correction are a ptosis shelf or a
ptosis crutch; both options have merits and limita-
tions. A ptosis shelf is the most effective and recom-
mended method of correction for those patients
with normal lid function (Figure 2A). The superior
portion of the ocular prosthesis is redesigned and
cut away approximately 11 mm superiorly, allowing
socket is crucial and identifying realistic goals is
critical. To positively identify these goals, both the
ocularist and the ophthalmologist must fully under-
stand the others capabilities. Most importantly, the
patients needs and desires should be fully explored,
since the lack of communication between all involved
frequently results in failure and/or disappointment.
An ocularist has several options or devices avail-
able to deal with contractions and/or the contracted
socket; however, to completely understand the
options, proper categorization of the condition will
assist in determining the type of correction, both
prosthetically and surgically. The following is a classi-
fication of contracted sockets.
10
Grade 0: The socket is lined with a healthy con-
junctiva and has deep and well-formed fornices
(Figure 3A).
Grade 1: The socket is characterized by a shallow
lower fornix or shelving of the lower fornix. In this
case, the lower fornix is converted into a downwards
sloping shelf that pushes the lower lid down and out,
preventing retention of an artificial eye (Figure 3B).
Grade 2: The socket is characterized by the loss of
the upper and lower fornices (Figure 3C).
Grade 3: The socket is characterized by the loss
of the upper, lower, medial, and lateral fornices
(Figure 3D).
Grade 4: The socket is characterized by the loss of
all fornices and reduction of the palpebral aperture
in horizontal and vertical dimensions (Figure 3E).
Grade 5: In some cases, there is recurrence of
contraction of the socket after repeated trial of
reconstruction (Figure 3F).
This is an excellent format for classification from
the ophthalmology point of view; however, minor
changes to this classification are suggested for ocular-
ists. Grades 3 and 4 are very similar (loss of all
fornices), but a distinction is made about the loss of
the palpebral aperture or a diminished fissure. If all
fornices are contracted, there is almost invariably a
diminished palpebral fissure. Grade 5 makes no
attempt to characterize the condition of the fissures,
only that the recurrence of contraction occurred
postoperatively. Grades 4 and 5 often occur after
radiotherapy. Grade 5 represents loss of all fornices
due to contraction postoperatively, after surgery
completed within the last year, achieving an unsuc-
cessful result. After 1 year, if nothing is done surgi-
cally or prosthetically to this socket to correct this
situation, it should be reclassified as Grade 4. Thus,
Grade 5 indicates a recent failed attempt at socket
reconstruction; this is important because many
surgeons prefer to wait a specific period of time
before making a second attempt at full reconstruc-
tion, usually a full year.
an alteration of the position of the tarsal plate in
relation to the cut away section of the prosthesis,
thus elevating the lid.
A ptosis crutch is more functional cosmetically
and structurally for neurological causes or third-
nerve paralysis (Figure 2B). A ptosis crutch creates a
physical obstruction on the anterior surface of the
prosthesis that supports the upper lid. If an ocularist
assesses and/or refits the prosthesis prior to surgery,
the results of ptosis correction are maximized. A
pseudoptosis is often present; therefore, appropriate
prosthetic fitting may eliminate the need for surgery,
or at least minimize the degree of correction.
Contracted sockets
Contracted sockets offer difficult management
problems for the ocularist and the oculoplastic
or ophthalmic surgeon, and management is best
approached as a team. Understanding the mechanics
and anatomy of both the normal and contracted
Figure 2: Prosthesis with ptosis shelf (A), and
ptosis crutch (B).
Figure 1: A patient with pseudoptosis before (A) and
after (B) prosthetic correction
A
B
A B
Ptosis shelf Ptosis crutch
There are several management tools, both
prosthetically and surgically, in the management
of contracted sockets. The most effective for a
Grade 3, 4, or 5 is the custom design conformer
(CDC; Figure 4);
11
however slight modifications
are often necessary. First, the design should be
custom-made for the individual patient and local
ocularists can usually supply at least 3 progres-
sively sized CDCs. The objective is to understand
Ophthalmology
ROUNDS
both the dynamics of the socket, the surgical
approach, and the desired realistic result. The
socket should be designed from a realistic
surgical approach both in size and graft avail-
ability. An ocularist can design the multiple
CDCs based on this configuration. The socket
reconstruction is not designed for a device, the
device should be designed for the socket (Figure
5). Once the design is chosen, the conformer is
lined with buccal mucous membrane (Figure 6).
Two superior and inferior fornix-deepening
sutures of 4-0 braided polyester are passed
through the lids and tied over bolsters.
12
In more
severe cases, as in Grade 3 or 4, it is advisable to
pass sutures through superior and inferior holes
in the conformer then through the periosteum to
securely fix the conformer in position.
12
Once the surgery is complete and the CDC
is anchored properly, the role of the ocularist is
critical, since the future success of this operation
may depend on their skills. The CDC is usually
ready for removal 6-12 weeks after its insertion,
depending on the classification of the socket. The
best option to is to remove the sutures and free
the conformer, but not fully remove it. At this
point, the ocularist should be prepared to insert
a new custom conformer designed for that partic-
ular socket to help maintain the fornices. There
should be no time lapse between removal of the
Figure 4: A custom design conformer (CDC).
Figure 3: Contracted sockets Grade 0 (A),
Grade 1 (B), Grade 2 (C), Grade 3 (D),
Grade 4 (E), Grade 5 (F).
E F
Figure 5: Superior and inferior anchoring
sutures are aligned.
Figure 6: An oral mucous membrane is attached to
the CDC and sutured into the socket.
A B
C D
CDC and the insertion of the new conformer.
Failure to adhere to this principle will compro-
mise the potential success of the surgery.
The ocularist is also required to instruct the
patient in several methods of pressure treatment
for the socket that will help possible future post-
operative contractions of this socket. Allowing a
CDC or ocular prosthesis to remain out of the
socket at any time up to 1 year after this surgery
will almost invariably result in a cicatricial
contraction of the socket or the complete loss of
the ability to retain an ocular prosthesis by the
reconstructed socket.
Several methods of postoperative manage-
ment of the contracted socket are available for
ocularists. The most successful are the capillary
traction device (Figure 7) and the Lafuente pres-
sure mask (Figure 8).
13
The first device offers
several options; for instance, the design allows
proactive management of the socket by utilizing
the pressure at night. This method also allows
the pressure to be applied on active cicatricial
contraction in the socket, which can often be
critical to the success or failure of the recon-
structed socket.
If it appears that the socket is contracting and
the ability of the fornices to retain a device or
ocular prosthesis may be lost (Figure 9), the next
option is to make a Lafuente pressure mask. The
design of this mask allows a more concentrated
pressure focus with a compensating spring or
elastic that adapts to the fluctuating cicatricial
contraction (Figure 10). A pressure stent is
applied to one or both fornices or a custom
conformer is mounted on the pressure stent to
force this socket to adapt to the shape of the
desired conformer. This may often be the last
resort or manoeuvre by the ocularist to retain a
conformer or, subsequently, an ocular prosthesis,
as shown in this final result (Figure 11). Leaving
the mask on for 20-60 minutes can create a suffi-
cient fornix to retain a prosthesis in situations
when the retension is crucial. Open lines of
communication must be maintained between the
ocularist and the ophthalmologist for the best
possible chance of success in these difficult cases.
Fortunately, it is a rare circumstance that a
Ophthalmology
ROUNDS
Figure 7: A capillary traction device is taped in the
socket under pressure.
Figure 9: A contracted socket Class 3.
Figure 8: A Lafuente pressure mask.
Figure 11: The prosthesis is successfully retained and
tted using a Lafuente pressure mask in
the patient shown in Figures 9 and 10.
Figure 10: A contracted socket management utilizing
a Lafuente pressure mask.
8. Allen L. The argument against imbricating the rectus muscles over
spherical implants after enucleation. In: Bosniak SL, Smith BC, eds.
The Anophthalmic Socket. New York, NY: Pergamon Press; 1990:
184-191.
9. Kennedy RF. Effects of enucleation on socket anatomy. Journal of
Ophthalmic Prosthetics. 1997;2(1):43-46.
10. Krishna G. Contracted sockets-1 (aetiology and types). Indian J
Ophthalmol. 1980;28(3):117-120.
11. Harrington JN. Conformer design. The Journal of the American
Society of Ocularists. 1979;10:11-14.
12. Molgat YM, Hurwitz JJ, Webb MCF. Buccal mucous membrane-fat
graft in the management of the contracted socket. Ophthalmic Plast
Reconstr Surg. 1993;9(4):267-272.
13. Scott R. C.T.D.: A unique suction device. The Journal of the American
Society of Ocularists. 1986;17:11-14.
Upcoming Scientic Meetings
26 29 June 2010
Canadian Ophthalmological Society 2010
Annual Meeting and Exhibition
Qubec, Quebec
CONTACT: E-mail: [email protected]
Website: http://www.eyesite.ca/annualmeeting/
2010/index_e.php
University of Toronto
Department of Ophthalmology and Vision Sciences
Upcoming events
4 5 December 2010
Update in Ophthalmology 2010
CNIB Centre, 1929 Bayview Avenue
Toronto, Canada
For Further Information:
Ofce of Continuing Education & Professional Development
Faculty of Medicine, University of Toronto
TEL: 416.978.2719/1.888.512.8173
FAX: 416.946.7028
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prosthesis cannot be satisfactorily fitted, leaving the
following options:
Remove all of the orbital soft tissue and fit an osseo-
integrated prosthesis
Remove all of the orbital soft tissue and attach an
orbital prosthesis to glasses or use adhesives to
attach to skin
Allow the socket to fully contract and wear dark
glasses or a black patch
Conclusion
The complete understanding of the field of
ocularistry by the ophthalmologist is imperative for
success in utilizing an effective multidisciplinary
approach. The benefits to the patient of this team
approach are immeasurable. Prior to any type of recon-
structive surgery or modification of the anophthalmic
socket, the prosthesis should be in its optimum condi-
tion. The ocularist can assess this condition as well as
make any modifications necessary; this may minimize
the degree of surgical correction required or
completely eliminate the need for surgery.
Mr. Webb is President, Webb Ocular Prosthetics, Inc., Toronto,
Ontario, and Member, Board of Directors, Canadian Society
of Ocularists..
References
1. Workman CL. Prosthetic reduction of upper eyelid ptosis. In:
Bosniak SL, Smith BC, eds. The Anophthalmic Socket. New York, NY:
Pergamon Press; 1990:184-191.
2. Vistnes LM, Iverson RE, Laub DR. The anophthalmic orbit. Surgical
correction of lower eyelid ptosis. Plast Reconstr Surg. 1973;52(4):346-
351.
3. Lindsey RN, Soper MP. Sympathetic ophthalmis following eviscera-
tion: a review of the literature. The Journal of the American Society
of Ocularists: 1977-1996; 17
th
Edition. St. Petersburg, FL: ABI
Professional Publications: 28-30.
4. Spaeth PG. Superior sulcus deformity and ptosis. In: Shannon GM,
Connelly FJ, eds. Oculoplastic Surgery And Prosthetics. Boston, MA:
Little, Brown and Company; 1970:791-797.
5. Cowen DE, Antonyshyn O. The vascularized temporoparietal
fascial ap for correction of the deep superior sulcus. Ophthal Plast
Reconstr Surg. 1995;11(2):100-108.
6. Jahrling RC. Prosthetics for upper lid deformities. In: Shannon GM,
Connelly FJ, eds. Oculoplastic Surgery And Prosthetics. Boston, MA:
Little, Brown and Company; 1970:813-822.
7. Allen L. Reduction of upper eyelid ptosis with the prosthesis, with
special attention to a recently devised, more effective method. In:
Guibor P, Guibor M, eds. Techniques of Anophthalmic Cosmesis. New
York, NY: Symposia Specialists; 1976:3-25.
2010 Department of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, which is solely responsible for the contents. Publisher: SNELL Medical
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