The patient who has had the misfortune of losing an eye, be it secondary to disease or trauma, often has difficulty in getting the help he needs from the medical profession. Many ophthalmologists, being "eye surgeons," lose interest in a patient when the globe is gone. Many reconstructive surgeons hesitate to venture into this area which seems to be surrounded by a certain amount of mystique. Both may escape by referring the patient to an ocularist for continued care related to his appearance. The ocularist, who is not a medical doctor, often gains more practical knowledge of the problems of the anophthalmic state than does either the ophthalmologist or the reconstructive surgeon but, because he is unfamiliar with all possible reconstructive surgical techniques, he often fails to recommend reconstructive surgery when it is indicated. Lars M Vistnes, MD
- enophthalmos (eye appears sunken)
- superior sulcus depression (upper eyelid crease is too deep compared to normal eye)
- lower lid ptosis
- upper lid ptosis
- levator disinsertion
- atrophy of orbital fat
- loss of volume when the globe is removed
- depression in the floor of the orbit due to an unrecognized fracture in the floor (rare)
- malposition in the superior rectus muscle
- The normal lower eyelid, with the eyeball in a horizontal gaze, has its upper border at the level of the lower margin of the limbus. The curvature of this border is not uniform. In its lateral third it assumes a more superior direction. To recreate this normal curvature the lower eyelid requires a higher positioning of the orbital rim burr hole than once thought.
- A second consideration is the normal motor function of the inferior rectus. Through its connection into the capsulopalpebral ligament, the lower eyelid upon downward gaze is simultaneously pulled in a inferior direction. A static sling suspended between the medial canthal ligament and the orbital rim restricts this motion. Therefore, a static sling is most applicable in the case of an anophthalmic orbit in which a static lower eyelid does not interfere with vision.
Upper Lid Ptosis1. The optimal surgical correction must begin with an ideal prosthesis. Such a prosthesis is made to fit the socket and does not attempt to compensate for enophthalmos or lower or upper eyelid ptosis.2. The width of the fascial strip is 2 mm. By pulling on a smaller area of the lower lid, directly below the lash margin, the lid can be positioned more precisely.3. The use of the Wright's needle allows the fascia to be passed under the space anterior to the tarsal plate. The needle can be positioned immediately beneath the lash margin, and the fascial strip will seat itself in this track without displacing itself inferiorly on the tarsal plate. Low placement of the sling can result in eversion of the lash border ("tumbling" of the lid into ectropion).4. Positioning the orbital burr hole at approximately 5-6 mm above the level of the lateral canthal tendon will not recreate the normal anatomy. The proper site can be chosen by following the curvature of the normal lower eyelid and marking the point where the curve intersects the orbital rim. An identical point on the anophthalmic orbital rim is then marked. This is the appropriated site for the orbital burr hole.
The cause will fall into one or more of three main categories:
- the trauma which necessitated the enucleation
- the surgeon (ie iatrogenic)
- the surgery (ie the creation of an anatomical or pathomechanical situation that produces malfunction of a delicately balanced mechanism)
- the levator muscle tone and its adaptability
- the tightness or laxness of the check ligaments
- the size of the implants
- the size of the prosthesis
MANAGEMENT (according to Vistnes):
1) The volume deficit should be corrected first. In the cases of mild ptosis where an added mass (RTV silicone) is placed along the orbital floor, the pushing upward of the implant is often all that is required. This will also correct the enophthalmos and the superior sulcus depression.2) If lower lid ptosis is present, it should be corrected next (as a separate procedure). This correction will tend to push the prosthesis upward and may also correct the upper lid ptosis.3) Any ptosis of the upper lid should be corrected last -- and only after an experienced ocularist has been unable to correct it with a new prosthesis that is not out of proportion in appearance to the normal eye.
The Artificial Eye Clinic -- another good source of information on the actual prosthetics.