For many patients who have lost an eye for a variety of reasons eye socket reconstructive surgery is required to address the following problems:

• An orbital volume deficit following loss of the eye
• Contracture of the socket
• Orbital implant exposure, extrusion, malposition

(Note: an ocular prosthesis refers to an artificial eye which is made to mimic an eye as much as possible – an orbital implant is a device which is inserted into the eye socket surgically and which is not normally visible).

An artificial eye

An hydroxyapatite orbital implant

A patient with a blind painful eye and a ptosis following severe trauma

The patient fitted with an artificial eye a few months after undergoing a left enucleation with an orbital implant and following eyelid surgery

A patient demonstrating a left post enucleation socket syndrome with a droopy upper lid and a lax lower lid

The patient following a left Muller’s muscle resection and a lower lid lateral tarsal strip procedure

A patient with a blind painful unsightly left eye following an injury at work.

The patient following a left enucleation with placement of an hydroxyapatite orbital implant and fitting of an artificial eye.

Many patients have a condition referred to as the post enucleation socket syndrome (PESS).

The features of this are:

• Enophthalmos (a sunken appearance of the artificial eye)
• An upper eyelid sulcus deformity (a hollowing of the upper eyelid)
• Ptosis or eyelid retraction (a droopy or retracted upper eyelid)
• Laxity of the lower eyelid
• A backward tilt of the ocular prosthesis

Many of these features are amenable to surgical improvement. The surgery may have to be carried out in stages. You may have to accept a lengthy period of time (2-3 months) without the ocular prosthesis (artificial eye) during the recovery phase. Such surgery can have profound effects on a patient professionally, socially and emotionally.

Patients who present with a typical post enucleation socket syndrome may benefit from secondary orbital implant surgery, but the surgical procedure is more difficult and the results are less predictable than primary orbital implantation. Patients undergoing secondary orbital implantation are more likely to require additional surgical procedures. Although the volume deficiency improves following surgery, there is commonly a variable recurrence of the upper lid sulcus defect some months following surgery once postoperative swelling has completely resolved.

The type of orbital implant to be used needs to be determined taking a number of factors into consideration:

• The age and general health of the patient
• The condition of the socket
• The size, nature and complications of any orbital implant already present
• The degree of movement of the extraocular muscles
• The condition of the ocular adnexae
• The cost

The orbital implants of choice for secondary orbital implantation are:

• The “baseball” or acrylic sphere implant
• The hydroxyapatite implant (or “coral implant”)
• The porous polyethylene (Medpor) implant
• The bioceramic implant
• The dermis fat graft implant

1. The “baseball implant” is of use in older patients who do not wish to take advantage of the second stage placement of a motility peg. The implant can improve a volume deficiency but the motility results are unpredictable. If the degree of movement of the implant is good but that of the overlying ocular prosthesis poor, this has to be accepted as it cannot be improved surgically.
2. One of the modern porous implants e.g. the hydroyxapatite implant or the bioceramic implant, is ideally reserved for a patient who would wish to undergo a second stage placement of a motility peg if the movement of the artificial eye were poor in spite of acceptable movement of the implant itself. This type of implant is ideal for the patient who has an old extruding/tilted implant. An implant exchange is performed in the absence of any socket infection. The use of this type of implant is ill advised, however, following prior radiotherapy, in the presence of conjunctival inflammation or socket contracture, or for the reconstruction of a badly disorganised socket.
3. The dermis fat graft (which is taken from the abdominal wall or upper outer quadrant of the buttock) is preferred for the reconstruction of the socket that has mild to moderate contracture in addition to a volume deficiency. It is the implant of choice for the reconstruction of badly disorganised sockets, and when complications have necessitated the removal of a porous implant or an infected/extruding synthetic implant.

Such surgery is usually performed under general anaesthesia with a 1-2 night stay in hospital.

If a patient has a residual orbital volume deficiency in spite of the insertion of a secondary orbital implant of adequate size, the next options are:

• Placement of a subperiosteal implant
• Structural fat grafting to the orbital apex
• Intermittent injection of a hyaluronic acid filler into the orbital apex
• The injection of small hydrogel implants into the orbital apex

Although there are a number of implant options porous polyethylene (Medpor) is the preferred implant of choice. This synthetic implant is porous allowing fibrovascular ingrowth. It is malleable, and easy to shape and insert along the lateral and infero-lateral orbital wall through a small lateral canthal skin incision. The placement of a subperiosteal implant can be combined with a lateral tarsal strip procedure where there is lower lid laxity. This procedure can be performed under general anaesthesia or under local anaesthesia with intravenous sedation. This procedure can be undertaken on a day case basis.

Structural fat grafting is an alternative approach to orbital volume enhancement but is associated with an unpredictable degree of postoperative fat atrophy and the procedure may have to be repeated to achieve the desired result.

If the orbital volume deficit is to be addressed with the use of a subperiosteal implant or with structural fat grafting, you must be aware that a new ocular prosthesis may be needed.

The intermittent injection of a hyaluronic acid dermal filler (Restylane Sub-Q) into the orbital apex is a relatively quick and simple procedure. The dermal filler is injected along the posterolateral orbital wall and the effect of the injection on the upper lid sulcus is observed. The treatment is, however, expensive and lasts only for 9-12 months before a repeat injection is required. For this reason, it is not a practical solution for most patients but it can be undertaken on a trial basis to see the effect before consideing a more definitive procedure.

The injection of small self-expanding hydrogel implants into the orbital apex offers another minimally invasive option for permanent socket volume enhancement for carefully selected patients. The implants are injected using a blunt-tipped cannula.

Alternative or additional options are:

• A contralateral camouflage blepharoplasty
• A dermis fat graft insertion into the upper eyelid sulcus
• The placement of fat pearls into the upper eyelid sulcus

A contralateral blepharoplasty may be performed on the opposite upper eyelid to provide a more symmetrical appearance in a patient who has an upper lid sulcus deformity but who does not wish to undergo a subperiosteal implant procedure or Coleman fat injections. You must appreciate the small risks involved in such surgery performed around an only eye.

A small dermis fat graft can be inserted into the upper lid sulcus after exposing the orbital roof via a skin crease incision. The dermis is sutured to the periosteum of the orbital roof while the fat is placed in such a position as to mimic the preaponeurotic fat. The dermis fat graft is oversized to allow for some postoperative atrophy. If the graft remains oversized, it can be debulked. This does tend to create a rather bulky appearance to the upper eyelid.

Individual fat pearls can be harvested from the peri-umbilical area and placed directly into the pre-aponeurotic space via an upper lid skin crease incision. This can yield a good result, but the degree of postoperative fat atrophy is unpredictable.

Some patients require ptosis surgery. For the vast majority the procedure undertaken is a posterior approach Muller’s muscle resection, with no visible scar.

At your consultation you will be advised about:

• The advantages, disadvantages, risks and potential complications of a secondary implant procedure
• The implant options
• The options regarding implant wrapping materials
• Post-operative pain and its management
• The post-operative compressive dressing
• The use of a temporary suture tarsorrhaphy
• The use of a post-operative conformer
• The likelihood of a temporary post-operative ptosis
• The role of the ocularist and the timing of the fitting of the ocular prosthesis

It is extremely important that you remain under the long term care of an ocularist, who will ensure your artificial eye is polished at least on an annual basis. Topical lubricants should be prescribed e.g. Systane® drops, particularly if you have an incomplete blink. Your socket is examined by your ocularist to exclude any implantation cysts, papillary conjunctivitis or implant exposure. Failure to maintain the artificial eye will risk the future problem of conjunctival inflammation, discharge, conjunctival breakdown or implant exposure.

The risks associated with such surgery are small in the hands of a trained and experienced oculoplastic surgeon and include:

• Infection which might necessitate removal of the implant
• Malposition of the implant which might lead to instability or a poor fit of the ocular prosthesis
• Exposure of the implant which will require further surgery e.g. a patch graft
• Socket cyst formation requiring further surgery,
• Chronic inflammation, pain or chemosis. Informed consent should be obtained after the patient has had time to consider the options.

You should discontinue aspirin and any other anti-platelet drugs if medically permissible at least 2 weeks preoperatively. Likewise anticoagulants should only be altered or discontinued after discussion with a haematologist. Any bacterial conjunctivitis should be treated preoperatively and topical steroid drops used 2 hourly for 2 weeks prior to surgery to reduce any conjunctival inflammation. In addition, it is preferable for you to refrain from wearing an old ocular prosthesis and to wear a well-fitting surgical conformer for at least 2 weeks prior to surgery. Your ocularist can provide this

Key point: A CT scan of the orbits and paranasal sinuses should be performed if you have previously suffered orbital trauma to exclude the possibility of a missed orbital wall blowout fracture. If a significant fracture is discovered on the scan, this should be repaired at the same time as the implant is placed.

This will be made by your ocularist. Our ocularist team of choice is Chris Brammar and Susan Walker of Brammar & Walker Ocularists (http://www.brammarwalker.co.uk)

Each artificial eye is specially made for you, to fit your individually shaped socket and to conform to the shape of your irnplant. It will be hand painted in your presence to match your natural eye colouring. There will be no pain during the procedures and anaesthetics will not be necessary. You will be required to return for three separate appointments:

• First appointment

An impression is obtained of your socket by introducing cream which will set to a very soft, rubbery consistency and will record the shape of your socket. A painting to match your remaining eye is usually made at this stage. This is competed in your presence to obtain the best possible colour match. This appointment usually lasts one hour.

• Second appointment

A wax pattern will by now have been produced to fit the plaster model resulting from the impression of your socket obtained during your first appointment. This wax pattern will be tried in the socket and modified by careful sculpturing until an ideal compromise between fit, comfort, mobility, lid-line and contour is achieved. Lastly, the iris/cornea unit is positioned to match the remaining natural eye. This appointment will take about one hour.

• Third appointment

This is usually a simple matter of collecting your artificial eye prosthesis. There may be some minor adjustments necessary.

Cleaning

Your artificial eye need only be cleaned occasionally. You may sleep with your artificial eye in, in fact it is advisable to do so. However, when it is removed, it should be cleaned by using hard contact lens cleaner, as the most common problem is irritation and watering caused by a protein build up.

If not cleaned correctly this protein will collect upon the surface of the artificial eye as a crystalline coating which will eventually make the artificial eye feel gritty. The socket lining and the inner surface of the eyelids may become inflamed and sore with discharge in extreme cases.

It is also important to use artificial tear supplements 3-4 times a day and at bedtime. The best drops to use are SYSTANE eye drops.

Annual check ups and replacements

You are advised to return annually for a check up when any small fitting changes will be assessed and your artificial eye will be re-polished to remove deposits and any scratches. You will be advised when your prosthesis needs to be replaced. This can be required every two to five years as your body is constantly changing but this time-scale varies considerably from patient to patient.