Management of an irradiated anophthalmic socket following dermis-fat graft rejection: a case report.

Dermis-fat graft (DFG) is often the only promising option in cases of severely contracted sockets. However, there is an increased risk of graft failure in irradiated sockets with decreased vascularity. In such difficult cases, repeat DFG implantation also has higher risks of graft failure. We describe an ingenious method of successful management of an irradiated anophthalmic socket following DFG infection and necrosis, with acceptable cosmetic results. At surgery, an orbital impression was taken with ophthalmic grade alginate. Based on this measurement, a custom-made stem pressure socket-expander made up of high density polymethyl methacrylate (PMMA) was fitted, a week post surgery and kept in situ for six weeks. On review, the fornices had considerably deepened. The expander device was removed and the patient was now fitted with a custom-made thicker prosthesis made up of high-density PMMA. The patient has followed up for a year subsequently and the prosthesis has remained stable.

Dermis-fat graft (DFG) is often the most promising option in maintaining orbital volume, preserving the fornices and conserving the conjunctiva in cases of complicated orbits and contracted sockets. Although significant atrophy of primary grafts does not occur very frequently,1 irradiated sockets may have decreased vascularity and increased risks of graft infection and failure. In such difficult cases, repeat DFG orbital implantation may also suffer a slightly increased frequency and amount of graft absorption.2,3

We describe a method of successful management of an irradiated anophthalmic socket following DFG infection, with acceptable cosmetic results.

We performed a Medline search with the key words ″anophthalmic socket″, ″contracted socket″ ″socket expansion″ ″dermis-fat graft failure″ and various combinations thereof. All cross-references in citing literature were included in our search and referenced. To the best of our knowledge, a similar technique has not been reported previously on irradiated socket.

Case Report

A three-year-old boy presented to us with a contracted right socket and history of prosthesis instability, since one year. He had been enucleated elsewhere for retinoblastoma of the right eye, one year prior to presentation, without orbital implant. Subsequently, the right socket had received irradiation, details of which were unavailable. The fitted prosthesis was extremely unstable with repeated extrusion.

On examination, the left eye was unremarkable. The right socket was quiet, healthy with evidence of severe surface and volume contracture. The patient underwent DFG implantation, under general anesthesia. A conformer for socket maintenance was inserted, on table, post surgery. The patient was started on topical betamethasone eye drops and oral antibiotics (an Ampicillin-Cloxacillin combination was used), post surgery. On review, a week later, the graft was taking up satisfactorily. The oral antibiotics were stopped, the topical steroids were tapered off and the patient was asked to review with us six weeks later. However, the patient presented to us three weeks later with a painful inflamed socket. On examination, the socket was severely infected with copious discharge. The DFG had sloughed off completely [Fig. 1A]. The socket inflammation was treated with topical antibiotics, anti-inflammatory and systemic antibiotic medication. The patient was reviewed at one week and at three weeks. At three weeks, the orbital inflammation had subsided completely. The fornices were seen to be severely shallow (Grade IV contracture)1 and there was severe volume contracture (Grade IV),1 as before. At this stage, the options of a second DFG or a larger prosthesis, to compensate for the volume loss, were considered. However, it was impossible for the patient to retain a conformer or any prosthesis at this stage, due to the extreme surface as well as volume contracture. Considering the possible high risk of DFG failure, the patient′s parents were not in favor of another surgical procedure. It was under these circumstances that a new technique was attempted, with informed consent.

Fig. 1A

(A) Custom-molded socket expander device: external photograph of patient presenting with a painful inflamed right socket

An orbital impression was taken with ophthalmic grade alginate [Fig. 1B]. Based on this measurement, a custom-made stem pressure socket-expander was made from high-density polymethyl methacrylate (PMMA) and fitted a week later [Fig. 1C]. This conformer was kept in situ for six weeks, with pressure exerted by a tight sticking tape on the stem of the conformer [Fig. 1D]. Instructions to change this tape every six-hourly, to ensure adequate sticking and sufficient pressure to the socket expander, were given to the patient.

Fig. 1B

(B) Custom-molded socket expander device: photograph of orbital impression taken with ophthalmic grade alginate

Fig. 1C

(C) Custom-molded socket expander device: external photograph of patient fitted with custom-made stem pressure socket-expander

Fig. 1D

(D) Custom-molded socket expander device: external photograph of patient fitted with custom-made stem pressure socket-expander, with tape

On review, six weeks later, the expander device was removed and the socket examined. The socket surface had completely lined with the conjunctiva and the fornices had deepened sufficiently to accommodate a conformer. We documented the expansion of the socket objectively with our ingeniously devised slit-lamp measurement device.4

The patient was now fitted with a custom-made thicker prosthesis made up of high-density PMMA [Fig. 2A]. Cosmesis was satisfactory [Figs. 2B and C]. The patient has been followed up for a year and the prosthesis has remained stable.

Fig. 2A

(A) Custom-molded socket expander device: photograph of thicker prosthesis made up of high-density PMMA

Fig. 2B

(B)Custom-molded socket-expander device: external photograph of patient fitted with custom prosthesis

Fig. 2C

(C)Custom-molded socket-expander device: external photograph of patient fitted with custom prosthesis

Discussion

In a case of failed DFG in an irradiated socket; expansile expanders can be used. Other useful described techniques include prefabricated temporalis muscle and/or fascia pedicled flap along with fornix formation sutures, which are to be retained for a minimum of three weeks.

We treated a patient with DFG necrosis and a severely contracted anophthalmic socket with a custom-made stem pressure socket expander device. This device helped deepen the fornices, with stable prosthesis placement subsequently. The prosthesis was thicker to ensure adequate volume replacement and was made up of high-grade PMMA to ensure lesser weight. This prosthesis also had a superior shelf extending backwards into the socket, to provide additional stability. This provided acceptable cosmesis, under the circumstances.

We documented the expansion of the socket objectively with the slit-lamp measurement device. Though it might be difficult to envisage socket expansion solely due to the mechanical pressure exerted by a tape running from the forehead to the cheek, the expansion was possibly due to a combination of the shape of the socket expander, its reach deep into the socket and the mechanical force applied by the sticking tape, changed repeatedly, to ensure proper sticking.

The use of a pressure conformer has been previously described in the literature,5 but to the best of our knowledge, the entire procedure of fitting a special prosthesis post socket expansion, in these patients with severely contracted sockets, has not yet been described in the literature. However, it is worthwhile to remember that this case of single-time placement of a non-expansile custom-made stem pressure socket expander in an avascular irradiated socket needs to be conducted on a larger sample size with a longer duration of follow-up, to judge the true efficacy of this procedure.