1. ANOPHTHALMOS AND MICROPHTHALMIA

Anophthalmia is a condition that represents the absence of the eyeball and ocular tissue from the orbit. It may be congenital, where a child may be born with no eye or associated structures, or it may be acquired, when an eye is lost to trauma or surgery. ​True congenital anophthalmos is very rare. It may sometimes be associated with an orbital cyst.

Microphthalmia is a congenital anomaly in which one or both eyes are not fully developed with variable degrees of visual loss. In this condition, a very small globe is present within the orbital soft tissue, which sometimes may not be visible on initial examination.

  • It is important to recognize microphthalmia because the growth and development of the bony eye socket as well as the eyelids and hemiface depends on the presence of a normal- sized eyeball. Early treatment and reconstructive surgery allows us to achieve facial and ocular symmetry, which may not be possible once bony growth is complete.
  • It may sometimes be associated with other systemic disorders including malformations of the heart, renal or central nervous system and these needs to be addressed.

Sequentially enlarging the orbital soft tissue and socket with the help of confirmers is started as early as 2 - 3 months of age. The confirmer is replaced every 4-6 months with larger sized one. Orbital implants can be placed at a later age. In microphthlamia with cyst, management depends on the degree of maldevelopment of the microphthalmic eye, the size of the cyst and the cosmetic and functional status of the patient. The cyst may be excised with or without preservation of the globe. In some cases, a dermis fat graft or fat transfers may be performed to increase the soft tissue volume of the orbit. Our aim is to cosmetically rehabilitate the patient and allow use of a custom fit ocular prosthesis

Yes, a child can be fitted with a prosthesis; in fact, it is recommended to stimulate the growth of the socket. It is very safe, and will not damage the other eye. A patient can do all usual activities except swimming. For a child, the prosthesis will need to be changed as the child grows.

The prosthesis is to cleaned periodically. Once a year, come for a check-up to your oculoplastic surgeon and ocularist. The socket will be examined to make sure it is healthy, and the prosthesis will be polished. If well maintained, the same prosthesis can be used many years. A protective glass of unbreakable fibre is recommended to be used – this is for the protection of the good eye.

3. CONTRACTED SOCKET

A contracted socket is a complication of an anophthalmic socket which results in the inability to support the ocular prosthesis. A poorly fitting prosthesis results in subpar cosmesis, can be damaging to the psyches of patients and can result in additional injury and infection. It is a complex condition that may require multiple staged procedures in order to retain the prosthesis with reasonable cosmesis.

There are multiple risk factors in the development of a contracted socket including: failure to wear a prosthetic for prolonged periods, radiation exposure, infection, severe injury (trauma/chemical burns), prior orbital or recurrent anophthalmic surgery, poor surgical technique (destruction of conjunctiva, traumatic dissection) and certain autoimmune conditions (mucous membrane pemphigoid/Stevens-Johnson Syndrome/toxic epidermal necrolysis)

Management of this is usually very challenging and requires multiple staged surgeries. A lot of patience and perseverance is required on the part of both the patient and the surgeon. In most cases, it involves excision of all symblepharon followed by the placement of a graft or flap that promotes re-epithelization and increased conjunctival surface area. A secondary orbital implant may be placed in some cases. Since the presentation of a contracted socket can be extremely variable, management is always tailored to the specific needs of the patient.

2. PAINFUL BLIND EYE

This is a subject that is fraught with emotional issues; most patients avoid dealing with this problem and suffer a great deal. Many conditions can result in a blind, painful eye, including end stage glaucoma, chronic retinal detachment, trauma, and postoperative complications such as endophthalmitis and failed corneal grafts.

Phthisis bulbi is a shrunken, non-functional eye. It may result from severe eye disease, inflammation or injury, or it may represent a complication of eye surgery.

Medical treatment includes controlling pain and redness with topical steroid drops and lowering intraocular pressure with anti-glaucoma drops. The pain can generally be controlled for months on this regimen, although it does put patients at increased risk for developing ocular surface infections. Retrobulbar alcohol injections have been used to control the pain. Cyclocryo-therapy and cyclophotcoagulation can help control refractory glaucoma and relieve chronic pain.

When medical treatment fails to control the pain and the eye is cosmetically unacceptable, removal of the eyeball and placing an orbital implant is the treatment of choice.

  • An evisceration is the removal of the eye's contents, leaving the scleral shell and extraocular muscles intact. An appropriate sized orbital implant is placed with the sclera shell to replace the lost orbital volume.

Enucleation is the surgical procedure that involves removal of the entire globe and its intraocular contents, with preservation of all other periorbital and orbital structures. In contrast to evisceration, enucleation allows for histologic examination of an intact globe and optic nerve. This is particularly important in settings of intraocular malignancy, in which it is essential to determine the margins of the malignancy and invasion of the optic nerve, if any. An orbital implant is placed with the intraconal space after the eyeball is out.

An ocular prosthesis is fitted once the conjunctival lining (surface of the eye after surgery) heals to form a regular smooth surface; usually 6-8 weeks postoperatively.

Yes, a child can be fitted with a prosthesis; in fact, it is recommended to stimulate the growth of the socket. It is very safe, and will not damage the other eye. A patient can do all usual activities except swimming. For a child, the prosthesis will need to be changed as the child grows.

The prosthesis is to cleaned periodically. Once a year, come for a check-up to your oculoplastic surgeon and ocularist. The socket will be examined to make sure it is healthy, and the prosthesis will be polished. If well maintained, the same prosthesis can be used many years. A protective glass of unbreakable fibre is recommended to be used – this is for the protection of the good eye.