Recurrent contracted sockets treated with personalized, three-dimensionally printed conformers and buccal grafts

Abstract

Purpose: Recurrent contracted sockets are complex situations where previous surgeries have failed, disabling the wear of an ocular prosthesis. A combined method of surgery and long-term fixation using custom-made, three-dimensional (3D) printed conformers is evaluated.

Methods: Retrospective case series of nine patients with recurrent excessive socket contraction and inability to wear a prosthesis, caused by chemical burns (n = 3), fireworks (n = 3), trauma (n = 2) and enucleation and radiotherapy at childhood due to optic nerve glioma (n = 1) with three average previous socket surgeries (range 2-6). Treatment consisted of a buccal mucosal graft and personalized 3D-printed conformer designed to be fixated to the periosteum and tarsal plates for minimal 2 months. Primary outcome was the retention of an ocular prosthesis. Secondary outcome was the need for additional surgeries.

Results: Outcomes were measured at final follow-up between 7 and 36 months postoperatively (mean 20 months). Eight cases were able to wear an ocular prosthesis after 2 months. Three cases initially treated for only the upper or only the lower fornix needed subsequent surgery for the opposite fornix for functional reasons. Two cases had later surgery for cosmetic improvement of upper eyelid position. Despite pre-existing lid abnormalities (scar, entropion, lash deficiency), cosmetic outcome was judged highly acceptable in six cases because of symmetric contour and volume, and reasonably acceptable in the remaining two.

Conclusions: Buccal mucosal transplant fixated with a personalized 3D-designed conformer enables retention of a well-fitted ocular prosthesis in previously failed socket surgeries. Initial treatment of both upper and lower fornices is recommended to avoid subsequent surgeries for functional reasons.

Keywords: Anophthalmic socket; cornea/external disease; eyelid disease: eyelid reconstruction; immune disease of conjunctiva; oculoplastic eyelid/lacrimal disease; orbital disease; orbital surgery; orbital trauma.

Figure 1.

(a) shows the patient preoperatively, (b) the geometry in 3D image of the contralateral, normal eye. The cornea is hard to capture on 3D imaging due to reflections, (c) by mapping the 3D photograph of the patient over the geometry file, it is possible to select the eyelid contour, (d) by selecting this contour, a best fitted sphere is estimated for this contour, which is used as the anterior curvature for the conformer. The thickness is then defined as a standard 2 mm, or thinner/thicker in consultation with the ophthalmologist, (e) the height of the conformer is generally preset at 16-18-20 mm, and checked to fit within the expected bony orbital rims, (f) the conformer is designed within these contours, adding an extension lip and fixation holes, and (g) digital image of the patient with the conformer.

Figure 2.

Example of a personalized 3D-printed conformer with horizontal extension “lip” and fixation holes.

Figure 3.

Illustration rendering a conformer in place with: (a) 4× double-armed 6-0 absorbable sutures from the conformer, entering the fornices and extending through the skin where they are fixed to a silicone tube and (b) fornix-deepening as well as tarsal sutures to the horizontal extension lip.

Figure 4.

Pre-operative and post-operative photographs of case no 5. Retainment of the conformer is in stable condition. The remaining entropion and superior sulcus volume loss may be treated in a later stage.