Fitting into the unfit – Contracted socket

A contracted socket is a socket that is poorly fitting or fails to retain any artificial eye. It is a common entity that an oculoplastic surgeon manages. It is a challenging scenario that might require repeated surgeries and follow-ups over a lifespan. The goal is to restore/maintain a reasonable-sized socket to fit an aesthetically appealing artificial eye. It is important to understand the underlying cause of loss/absence of the eye and severity of contraction; congenital nature, orbital irradiation, associated orbital fracture, multiple socket surgeries, and presence of eyelid deformity are some poor prognostic factors. The commonest indication of enucleation is an advanced intraocular tumor, whereas evisceration is post-traumatic atrophic/phthisis or endophthalmitis/panophthalmitis. It is imperative to restore the orbital volume and the spatial architectural arrangement of the orbital structures by placing an appropriately sized orbital implant, if possible, during the primary surgery. This is to prevent the development of post-enucleation socket syndrome, which is hypothesized to occur because of sagging and atrophy/contraction of the tissues, mainly extraocular muscles and fat, in the absence of an orbital implant. Furthermore, timely placement and regular use of a snugly fitting artificial eye help maintain the shape and size of the socket. Appropriate care of the artificial eye surface and edges helps delay the process of socket shrinkage. The major areas to tackle in the reconstruction of the contracted socket are the socket augmentation and restoration of orbital volume. The patient work-up mainly includes assessment of facial asymmetry/deformity, orbital cavity dimensions, horizontal and vertical palpebral aperture (mm), presence of sulcus deformity/entropion/ectropion and tendon laxity, the status of conjunctiva (dry/wet, discharge/inflammation, scarred/bands), depth of fornices (mm), the status of eyeball/implant, palpation of the socket (implant, recurrence of tumor, presence of fracture), and inspection of the artificial eye for signs of aging (discoloration, loss of surface luster, surface/edges irregularities, etc.). The grading of socket contraction severity helps to tailor the management approach. A mild grade of contracted socket generally requires modification of the artificial eye, fornix formation sutures, eyelid tightening procedure, and/or correction of ectropion/entropion. The moderate grade of contracted socket is mostly treated by restoring the conjunctival surface with oral mucosa and the orbital volume by placement of an appropriate size orbital implant or biogenic graft such as dermis-fat graft (DFG), generally harvested from the gluteal region. Labial mucosa from the inner surface of the lower lip is thinner, less keratinized, and easier to harvest than the buccal mucosa. The author leaves it raw to heal by secondary intention, which takes approximately 2–3 weeks to heal completely, with tolerable post-operative recovery and negligible donor site morbidity.[1] The amniotic membrane graft was introduced in 2006 to augment the conjunctival surface in patients with a mild-to-moderate grade of socket contraction with relatively healthy conjunctiva, with encouraging results, and is routinely used by the author in such cases.[2] Severe contraction grade involves significant shortening of all four fornices, phimotic palpebral aperture, associated periorbital soft and bony tissue deformity, repeated surgeries, etc. Generally, more than one graft for socket surface augmentation is required, mostly a combination of mucosal graft and amniotic membrane/split thickness skin graft. The surgical procedure and choice of graft vary according to the clinical scenario, the surgeon's choice, and experience.[3] The placement of the orbital implant for orbital volume restoration, in the same sitting, depends on tissue status, especially the tenon's closure over the implant. The author prefers combining the surface and orbital volume restoration in the same sitting with minimal complications. Smith and Petrelli (1978) first reported DFG for the simultaneous replacement of orbital volume and socket lining enlargement.[4] In a retrospective analysis (2014) of 468 patients, the authors reported complete necrosis of the DFG in 6.1% of secondary cases and 3.5% in primary cases.[5] There are reports on the beneficial role of anti-metabolites (5-fluorouracil, mitomycin C) in reducing the post-operative fibrosis. The possibility of repeat/failure of surgery has to be explained to the patient. The fitting and appearance of a customized artificial eye are considered better than ready-made artificial eye. The author follows a 6-month inspection and polishing of the artificial eye and replacement in the presence of signs of aging. Daily removal of the artificial eye is not advisable, and good hygiene is imperative.