aCase 18a

by Dr.Chua

This 26 year-old man was assaulted one year ago with acid resulting in left visual loss and a contracted socket. He attended the oculoplastic clinic for a prosthesis to cover the phthisical left eye. The appearance of the left eye was as shown below.

Figure 1. Left phthisical globe with symblepharon and severe

shallowing of the fornices.

The eye shows symblepharon with severe loss of the depth of the fornices. Insertion of the prosthesis was not possible.

a. How can the socket be reconstructed to support a prosthesis?

In order for the contracted socket to support a prosthesis as in this case. It is essential to:

 

i. divide the symblepharon

 

ii. deepen the upper and lower fornices and silicone bands with mattress sutures are used as stents to maintain the depth of the fornices after reconstruction.

 

iii. replace the denuded area with graft such as buccal mucosal membrane graft.

 

In our patient, instead of using buccal mucosa as graft we employ the amniotic membrane (costing M$10 ringgits and obtainable from the Malaysian Tissue Bank, Universiti Sains Malaysia. The membrane is sterilized by irradiation and air dried. It comes as a dry square in a plastic bag and can be stored at room temperature.) with the aim of reducing donor site discomfort and infection.

Figure 2 shows the steps of socket reconstruction using a piece of amniotic membrane. The symblepharon were divided and the fornices deepened (b-c). The dry amniotic membrane was applied to the denuded surface to estimate the surface area required for graft (d). The amniotic membrane was soaked in normal saline for 5 minutes and applied to the denuded surface and the fornices. The membrane was sutured to the palpebral and bulbar conjunctiva using 6/0 vicryl. Silicone bands were used as stents to maintain the depth of the fornices (e-g). The membrane appeared yellowish the next day from blood-staining (h). Topical antibiotic and steroid eyedrops were prescribed.

References:

1. Poonyathalang A, Preechawat P, Pomsathit J, Mahaisaviriya P. Reconstruction of contracted eye socket with amniotic membrane graft. Ophthal Plast Reconstr Surg. 2005 Sep;21(5):359-62