What is Contracted Socket?
A contracted socket, a feared consequence of losing an eye (anophthalmos), occurs when the eye socket tissue shrinks. This shrinkage, which also reduces the space in the eye socket and depth of the eye socket’s folds, can make it impossible to use an artificial eye. This condition can be both unsightly and uncomfortable and can significantly reduce a person’s quality of life and their ability to interact with others.
Efficient rebuilding of these affected eye sockets and careful monitoring afterwards can help enhance the patient’s quality of life. This approach can also help avoid the potential severe problems associated with a contracted socket.
What Causes Contracted Socket?
Several theories have been proposed to understand why a person may end up with a contracted eye socket:
1. Trauma and Surgery-related Causes:
* Scarring from the original injury
* A rigorous eye operation
* Poor surgical procedures such as evisceration (removal of the eye’s contents) or enucleation (whole eye removal)
* Repeated operations on the eye socket
2. Causes Related to the Eyelid or Outer Surface of the Eye:
* A disease that causes scarring on the conjunctiva (the skin-like tissue that covers the white part of the eye)
* Severe infection and inflammation in the eye socket
* Formation of a keloid (a type of thick scar) in the eye socket
* A poor supply of blood
3. Causes Related to Artificial Eye or Implant:
* Not using an artificial eye
* A poor or incorrect fit of the artificial eye
* Movement or exposure of the implant
4. Causes Related to the Underlying Problem:
* Chemical burns from alkali substances
* Radiation treatment following enucleation in certain patients with retinoblastoma (a type of eye cancer)
Risk Factors and Frequency for Contracted Socket
Anophthalmic socket, the condition of being born without an eye, is quite rare, occuring in about 0.2 to 0.3 out of every 10,000 live births. On the other hand, the condition can also be acquired due to surgical procedures, which is actually far more common. The prevalence of this type of acquired anophthalmia, often following the removal of an eye, is 2.6 to 5 out of every 100,000 individuals. There is no clear relationship between a person’s age or gender and the extent of shrinkage of the socket. For reasons that are not quite clear, the left eye tends to be affected more than the right eye.
Signs and Symptoms of Contracted Socket
Contracted sockets in patients means they can’t effectively support an artificial eye. Discharge may occur often and can be because the prosthetic eye doesn’t fit well or an implant is sticking out. Other related problems can involve how well the artificial eye moves, how it looks, inward or outward folding of the eyelid (entropion or ectropion), infection, or drooping of the eyelid (ptosis).
- Discharge due to poor prosthetic eye fit or implant protrusion
- Poor movement of prosthetic eye
- Unsatisfactory appearance
- Entropion (inward folding of the eyelid)
- Ectropion (outward folding of the eyelid)
- Infections
- Ptosis (drooping of the eyelid)
Several patients even experience misplacement of their eyelids such as inward or outward folding, and drooping, which also necessitate surgical procedures.
Testing for Contracted Socket
If you have a prosthetic eye or a contracted socket (a shrunken cavity that holds the eye), a comprehensive check-up is really important. This includes comparing the look and symmetry of the prosthetic eye or the socket to the other eye. Each element of the prosthetic eye, including its movement, size, shape, and color, needs to be examined. In addition, if you have any abnormalities with your eyelid such as lopsidedness, inward turning, drooping, or improper functioning of the eyelid-raising muscle, these should also be assessed.
If you don’t have a prosthetic eye, the health care provider will check your eye area for signs of scarring and any structural changes. The cavity should be checked for inflammation and any changes in depth or blood supply.
Another vital aspect of the check-up is to find out whether your socket is dry or moist, as the care for each condition differs. The tissue, or mucosa, in a moist socket looks healthy and clean. However, in a dry socket, it seems dry and the surface is covered with hardened, unsavory-smelling mucous.
You’ll be categorized into one of five grades which describe how contracted, or shrunken, your socket is. It ranges from a healthy socket with depth (Grade 0), to sockets with varying levels of shrinking (Grades 1-4), up to a situation where reconstructive attempts have repeatedly failed (Grade 5).
If you do have a prosthetic eye, it plays a vital role in keeping your socket healthy, making you feel comfortable and balanced in terms of facial appearance. There are two types: ready-made artificial eyes and custom-made prosthetic eyes, with the custom-made ones providing a better fit and look.
The process for the custom-made prosthesis includes taking a mold or impression of your socket and marking the area for the iris. A material called acrylic is then heated to make a white model and painted to match your other eye. The aim is to make your prosthetic eye look as natural as possible.
There’s another type called an orbital implant, which is used to replace lost volume in your socket and allow movement of the prosthetic eye. The sizes and types of these implants differ, and a technique known as A-scan ultrasonography can help determine the optimal size for you before surgery.
Treatment Options for Contracted Socket
Correct management of a shrunken eye socket (also known as a contracted socket) focuses on improving movement and achieving symmetry between the eye socket and eyelids. Optimal results come from a detailed approach during removal of the eye, maintaining the conjunctiva (the protective surface of the eye) and part of the covering of the eye socket, using a suitably-sized socket implant, and careful layered closure following the implant. The specific treatment largely depends on the severity of the contraction and remaining socket space.
For minor cases, where there is some shallowing in the lower part of the eye socket, effective treatment involves securing sutures to form the socket (known as fornix-forming sutures). This deepens the socket by placing sutures over an insert made of silastic – a silicone and plastic material – or by operating on the tendon at the corner of the eye alongside socket reconstruction. This surgery is followed by fitting a custom artificial eye a few weeks after the procedure. Some cases may need horizontal lid shortening and grafts from various body parts, like nasal septum, ear cartilage, sclera, hard palate, or a connective tissue known as fascia lata to lengthen the back of the eye socket.
Moderate contraction requires a graft be placed in the eye socket. Full-thickness grafting of mucous membrane (MMG) from the oral mucosa of cheeks and lips, hard palate, or preputial skin of labia is preferred due to its lesser tendency to shrink over time. This graft must be about 40-50% larger than necessary to allow for any shrinkage and healing. Although there can be some downsides to these grafts, such as unpleasant mouth odors and shrinkage after surgery, alternative materials like the amniotic membrane can be used. Although these membranes have some limitations, such as low tensile strength and fragility, they also offer quick recovery and minimal shrinkage and have anti-inflammatory, anti-scarring, and anti-microbial properties.
Severe cases, with significant volume and surface loss, may require an additional orbital implant or a dermis fat graft (skin and fat graft) from the gluteal region (buttocks) to compensate for the lost volume. Although this is a highly effective treatment, it can sometimes lead to complications like fat necrosis, fat atrophy, cyst formation, post-operative bleeding, granuloma (inflammatory mass) formation, ulceration, and split at the donor site. To avoid these complications, the graft must be carefully harvested without including the epidermis (outermost layer of the skin). Inserting vascular flaps in situations like a dry eye socket, can provide a blood supply to enhance graft survival and add volume to the socket.
The most advanced cases of a contracted socket, where multiple surgical attempts have failed, may require removal of all the contents of the eye socket and fitting a prosthesis. A form-fitting mold is generally placed to position the graft against the socket’s blood supply and must be left in place.
What else can Contracted Socket be?
It’s essential to distinguish between a shrunken eye socket and something known as post-enucleation socket syndrome (PESS). PESS is a condition identified by an unusual hollowing in the upper part of the eye socket, a loose lower eyelid, and potential lid problems like droopiness or retraction. It also includes a prosthetic eye that doesn’t fit well.
The use of silicone implants, covered in a natural eye tissue called the sclera, can help replace the lost volume in the socket. This solution usually results in good movement of the artificial eye post-surgery and satisfactory results.
What to expect with Contracted Socket
Conducting a careful initial surgery (like evisceration or enucleation) and placing an orbital implant is crucial to get a good outcome. Some factors can make the result less positive. These include dry or excessively treated sockets, infections, scarring, a history of past surgeries that didn’t work out, a higher degree of shrinkage, and existing eye surface diseases. It’s important to spot and treat these issues early and properly based on how severe they are. The ultimate goal is to create a socket that is capable of holding a prosthesis.
Possible Complications When Diagnosed with Contracted Socket
A contracted socket, or the shrinking of the area where the eye used to be, is a serious issue. Each time an attempt to insert an artificial eye fails, it becomes increasingly difficult to use a prosthetic eye and the patient’s condition worsens. Procedures to fix this often come with a higher risk of infection, especially for patients with weakened immune systems.
Complications related to using tissue flaps or grafts to repair the socket can also arise. These complications can include necrosis (dead tissue), fat degeneration, formation of deep eye cysts, post-operative bruising, creation of granulomas (small areas of inflammation), ulcers, and openings at the donation site of the tissue graft.
Similarly, complications related to the implant of an artificial eye include implant exposure (the implant becoming visible through the skin), extrusion (the implant being pushed out), movement of the implant, infection, and lack of enough space in the eye socket.
Common Complications:
- Difficulty in retaining a prosthesis
- Risk of infection, especially for those with a weak immune system
- Necrosis and fat degeneration
- Formation of deep eye cysts, post-operative bruising
- Granulomas and ulcers
- Opening up at the donation site of the tissue graft
- Implant exposure, extrusion, and movement
- Infection and lack of enough space in the eye socket
Preventing Contracted Socket
The patient themselves, not just medical professionals, play a crucial role in managing the negative effects of a shrunken eye socket. When a patient’s artificial eye can’t stay in a shrunken socket, it affects their appearance and can have a deep emotional impact on them and their family.
Regular check-ups after the operation and learning about keeping clean and caring for oneself are crucial to prevent serious complications. Ensuring the use of a properly fitted artificial eye, keeping it well cleaned, replacing it when necessary, and seeking advice from eye specialists when needed, can lead to improved appearance and function.
