A METHOD
TO CORRECT T H E CONTRACTED
SOCKET
J. H. WHITE, M.D. Newark, New Jersey
Contraction of the socket, a common late complication after ocular enucleation, may prevent retention of an artificial eye. Several of these cases seem to be caused by a rotation of the inferior tarsus that creates a horizontal shelf over which slips the lower edge of the prosthesis (Fig. 1). A similar condition occurs in tarsal ectropion in which the inferior tarsus rotates around the tarsal-tendon horizontal axis, possibly caused by contracture of the inferior rectus and inferior palpebral muscles. The surgical procedure used to correct tarsal ectropion may be used to correct tarsal rotation occurring in anophthalmos.
\
1
2
METHOD
A skin incision is made 3 to 4 mm below the lower eyelid margin (Fig. 1, B). The incision is continued horizontally, parallel to the lower border of the tarsus. The skin edges above and below the incision are undermined, separating the skin from the orbicularis oculi muscle. T h e incision is carried deeper through the orbicularis oculi muscle (Fig. 2 ) . T h e lower border of the tarsus is identified through the incision in the orbicularis oculi muscle. Pressure on the conjunctival surface of the tarsus with an eyelid plate assists in its identification. Occasionally, an incision along the lower border of the tarsus on the conjunctival side is required to divide the fibrous tissue that pulls the tarsus internally (Fig. 1, A ) . The lower 2 mm of the anterior tarsal surface is freed from the orbicularis oculi
Fig. 1 (White). Cross section of the contracted socket shows the tarsus retracted horizontally (arrows); conjunctival incision (A); and skin incision (B).
muscle along the length of the tarsus. Three double-armed 4 / 0 silk sutures are then placed horizontally into the anterior surface of the bared lower tarsus, one centrally and one on each side. These mattress sutures are brought through the skin 2 to 3 mm below the incision. T h e sutures are passed through small rubber strips, tightened to draw the skin against the tarsus, and tied (Fig. 3 ) . T h e skin incision is closed with interrupted 6/0 silk sutures (Fig. 4 ) . T h e skin sutures are
From the Comeo-plastic Service, Eye Institute of New Jersey, Newark, New Jersey. Reprint requests to J. H. White, M.D., Department of Ophthalmology, New Jersey Medical School— CMDNJ, 100 Bergen St., Rm. 1402, Newark, NJ 07103. 24
CONTRACTED SOCKET
VOL. 83, NO. 1
25
removed in five to seven days and the mattress sutures in ten to 14 days. DISCUSSION
After this procedure, the skin, which is surgically attached to the lower border of the tarsus, extends a downward pull and restores the tarsus to its normal vertical position. I prefer this method to suturing the conjunctiva to the lower orbital rim periosteum, a procedure that may result in an excessively low immobile lower eyelid. Both methods require an adequate amount of conjunctiva for mobilization, either from the upper fornix or from the depths of the socket. T h e contracted sockets of four patients 3
Fig. 3 (White). Cross section shows a tied mattress suture.
who had been unable to retain an artificial eye were corrected with this procedure. In each case the defect was not a shortage of conjunctiva but a horizontally directed floor to the socket. In all cases, sufficient depth of lower fornix was obtained to retain the lower edge of a prosthesis—in two cases for more than two years. A fifth case required an incision (Fig. 1, A) to mobilize the tarsus sufficiently to attain a vertical position before suturing. T h e subsequent small defect in the conjunctiva healed in a few weeks. Fig. 2 (White). Cross section shows a divided orbicularis oculi muscle.
T h e fitted prosthesis must b e shallow so that a narrow edge presses into the
26
AMERICAN JOURNAL O F OPHTHALMOLOGY
JANUARY, 1977
SUMMARY
Fig. 4 (White). Mattress sutures are in place and the skin incision is closed.
In four patients, rotation of the inferior tarsus around the tarsal-tendon horizontal axis caused a contracted socket with loss of lower fornix and the inability to retain an artificial eye. Exposure of the lower border of the inferior tarsus through a skin incision, separating the tarsus from the overlying orbicularis oculi muscle, and suturing its lower margin to the skin corrected the abnormality. REFERENCES
reconstructed fornix. T h e weight of the prosthesis then perpetuates the sulcus. This procedure does not replace mucous membrane grafting in generally contracted sockets with conjunctival shortage but is a simple corrective procedure in selected cases with sufficient conjunctiva but no lower fornix.
1. Jones, L. T.: The anatomy of the lower eyelid. Am. J. Ophthalmol. 49:29, 1960. 2. White, J. H.: Method of correction of tarsal ectropion. Am. J. Ophthalmol. 72:615, 1971. 3. Mustarde, J. C : Repair and Reconstruction in the Orbital Region. Edinburgh, E and S Livingstone, Ltd., 1966, p. 261.
TO CORRECT T H E CONTRACTED
SOCKET
J. H. WHITE, M.D. Newark, New Jersey
Contraction of the socket, a common late complication after ocular enucleation, may prevent retention of an artificial eye. Several of these cases seem to be caused by a rotation of the inferior tarsus that creates a horizontal shelf over which slips the lower edge of the prosthesis (Fig. 1). A similar condition occurs in tarsal ectropion in which the inferior tarsus rotates around the tarsal-tendon horizontal axis, possibly caused by contracture of the inferior rectus and inferior palpebral muscles. The surgical procedure used to correct tarsal ectropion may be used to correct tarsal rotation occurring in anophthalmos.
\
1
2
METHOD
A skin incision is made 3 to 4 mm below the lower eyelid margin (Fig. 1, B). The incision is continued horizontally, parallel to the lower border of the tarsus. The skin edges above and below the incision are undermined, separating the skin from the orbicularis oculi muscle. T h e incision is carried deeper through the orbicularis oculi muscle (Fig. 2 ) . T h e lower border of the tarsus is identified through the incision in the orbicularis oculi muscle. Pressure on the conjunctival surface of the tarsus with an eyelid plate assists in its identification. Occasionally, an incision along the lower border of the tarsus on the conjunctival side is required to divide the fibrous tissue that pulls the tarsus internally (Fig. 1, A ) . The lower 2 mm of the anterior tarsal surface is freed from the orbicularis oculi
Fig. 1 (White). Cross section of the contracted socket shows the tarsus retracted horizontally (arrows); conjunctival incision (A); and skin incision (B).
muscle along the length of the tarsus. Three double-armed 4 / 0 silk sutures are then placed horizontally into the anterior surface of the bared lower tarsus, one centrally and one on each side. These mattress sutures are brought through the skin 2 to 3 mm below the incision. T h e sutures are passed through small rubber strips, tightened to draw the skin against the tarsus, and tied (Fig. 3 ) . T h e skin incision is closed with interrupted 6/0 silk sutures (Fig. 4 ) . T h e skin sutures are
From the Comeo-plastic Service, Eye Institute of New Jersey, Newark, New Jersey. Reprint requests to J. H. White, M.D., Department of Ophthalmology, New Jersey Medical School— CMDNJ, 100 Bergen St., Rm. 1402, Newark, NJ 07103. 24
CONTRACTED SOCKET
VOL. 83, NO. 1
25
removed in five to seven days and the mattress sutures in ten to 14 days. DISCUSSION
After this procedure, the skin, which is surgically attached to the lower border of the tarsus, extends a downward pull and restores the tarsus to its normal vertical position. I prefer this method to suturing the conjunctiva to the lower orbital rim periosteum, a procedure that may result in an excessively low immobile lower eyelid. Both methods require an adequate amount of conjunctiva for mobilization, either from the upper fornix or from the depths of the socket. T h e contracted sockets of four patients 3
Fig. 3 (White). Cross section shows a tied mattress suture.
who had been unable to retain an artificial eye were corrected with this procedure. In each case the defect was not a shortage of conjunctiva but a horizontally directed floor to the socket. In all cases, sufficient depth of lower fornix was obtained to retain the lower edge of a prosthesis—in two cases for more than two years. A fifth case required an incision (Fig. 1, A) to mobilize the tarsus sufficiently to attain a vertical position before suturing. T h e subsequent small defect in the conjunctiva healed in a few weeks. Fig. 2 (White). Cross section shows a divided orbicularis oculi muscle.
T h e fitted prosthesis must b e shallow so that a narrow edge presses into the
26
AMERICAN JOURNAL O F OPHTHALMOLOGY
JANUARY, 1977
SUMMARY
Fig. 4 (White). Mattress sutures are in place and the skin incision is closed.
In four patients, rotation of the inferior tarsus around the tarsal-tendon horizontal axis caused a contracted socket with loss of lower fornix and the inability to retain an artificial eye. Exposure of the lower border of the inferior tarsus through a skin incision, separating the tarsus from the overlying orbicularis oculi muscle, and suturing its lower margin to the skin corrected the abnormality. REFERENCES
reconstructed fornix. T h e weight of the prosthesis then perpetuates the sulcus. This procedure does not replace mucous membrane grafting in generally contracted sockets with conjunctival shortage but is a simple corrective procedure in selected cases with sufficient conjunctiva but no lower fornix.
1. Jones, L. T.: The anatomy of the lower eyelid. Am. J. Ophthalmol. 49:29, 1960. 2. White, J. H.: Method of correction of tarsal ectropion. Am. J. Ophthalmol. 72:615, 1971. 3. Mustarde, J. C : Repair and Reconstruction in the Orbital Region. Edinburgh, E and S Livingstone, Ltd., 1966, p. 261.
