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Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 123-125  

Volumetric expansion of ocular defect with progressive conformers: An objective assessment


Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission19-May-2018
Date of Acceptance13-Nov-2018
Date of Web Publication07-Jun-2019

Correspondence Address:
Dr. Saumyendra Vikram Singh
Department of Prosthodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.NJMS_43_18

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How to cite this article:
Aggarwal H, Shah V, Singh SV, Arya D. Volumetric expansion of ocular defect with progressive conformers: An objective assessment. Natl J Maxillofac Surg 2019;10:123-5

How to cite this URL:
Aggarwal H, Shah V, Singh SV, Arya D. Volumetric expansion of ocular defect with progressive conformers: An objective assessment. Natl J Maxillofac Surg [serial online] 2019 [cited 2019 Oct 17];10:123-5. Available from: http://www.njms.in/text.asp?2019/10/1/123/259832



Surgeries such as enucleation, evisceration, and exenteration have devastating consequences for the patient.[1] The loss of an eye whether by surgery or trauma often results in scar tissue leading to contraction. Postenucleation socket syndrome (PESS) is a common late complication of enucleation therapy.[2] It is also known as anopthalmic socket syndrome and encompasses several anomalies such as ptosis, superior sulcus deformity, enophthalmos, and ectropion.[3] PESS is associated with severe contracture leading to poor prosthesis esthetics and difficulty in insertion.

Placement of a conformer to fit the contours of the cavity has been advocated to prevent contraction of the socket.[4] Conformers can be either stock or custom fabricated. Progressive expansion therapy involves the fitting of plastic stents or silicone expanders over time to develop the contracted ocular socket for optimal prosthetic results.[5],[6] Surgical correction with graft placement can be tried once the socket has been expanded to improve esthetics.[7]

Use of progressive expansion therapy with custom conformers to increase socket size has been documented in literature. However, volumetric expansion of socket after using conformers has not been quantified.[8] This article aims to quantify this expansion.

A young patient with a history of retinoblastoma treated by enucleation followed by chemotherapy and external beam radiotherapy (EBRT) presented with PESS of the right eye. After thorough evaluation and interdisciplinary consultation, it was planned to manage the severe contraction by progressive expansion therapy followed by reconstructive socket surgery. The treatment plan was explained and informed consent obtained from the parents of the 9 years old. The following technique was followed:

  1. Make an impression of the anopthalmic socket in irreversible hydrocolloid (Opthalmicmoldite; Milton Roy Co., Sarasota, FL) and pour a two-piece split cast mold from the same [Figure 1] and [Figure 2]
  2. Fabricate wax pattern on the mold and try in the patient's ocular defect
  3. Finalize the pattern and invest
  4. Fabricate custom ocular conformer in clear polymethyl methacrylate (PMMA) resin (Trevalon; Dentsply Pvt. Ltd.,) after dewaxing [Figure 3]
  5. Prepare a closed cylinder from a 5/10 ml syringe by blocking its nozzle
  6. Fill the syringe with few ml of water and calculate conformer volume by noting the increase in this volume when placing the conformer in the syringe
  7. This is considered as the baseline ocular defect/conformer volume
  8. Instruct the patient to wear the conformer continuously for 3 weeks
  9. Prepare the sequentially larger custom conformer followings steps 1–4. Measure ocular defect/conformer volume as outlined in step 6 and note the increase in volume
  10. Repeat procedure at the third visit after another 3 weeks.
Figure 1: Right ocular defect with postenucleation socket syndrome

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Figure 2: Two-piece mold obtained from the impression of the defect

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Figure 3: Custom ocular conformer

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Following this, a comparative evaluation of volume expansion with sequentially larger sizes of conformers was done which showed an increase from a baseline of 2.0 to 2.4 ml and further to 2.6 ml [Figure 4] volume increase of approximately 30%.
Figure 4: Progressively larger conformers. (a) Baseline conformer (b and c) progressively larger sizes of conformer, respectively. Note the increase in volume objectively measured wherein (c) > (b) > (a)

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At the end of progressive expansion therapy, the patient was prepared to undergo surgery.

Progressive expansion therapy has been documented to be an important part of the management of severely contracted orbital socket. Recently, self-inflating polymer expanders have been introduced. These lens-shaped expanders are implanted in the orbital tissue where they absorb lacrimal fluid from the mucosal socket or tissue fluid and swell.[9] However, it is difficult to customize them and control the amount of expansion.[9]

The method described in this article used is a simple yet accurate and validates expansion achieved by conformer therapy. Objective measurement of expansion offers several advantages such as better visualization of progress and further treatment planning like the size of orbital implant to be used or amount of graft required. Thus, the importance of measuring orbital expansion cannot be underplayed. However, this report is of a stand-alone case, and there may be more advanced instruments available to quantify the expansion. The authors intend to present a thought-provoking idea for further research into the same.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Perman KI, Baylis HI. Evisceration, enucleation, and exenteration. Otolaryngol Clin North Am 1988;21:171-82.  Back to cited text no. 1
    
2.
Aggarwal H, Singh SV, Kumar P, Kumar Singh A. Prosthetic rehabilitation following socket reconstruction with blair-brown graft and conformer therapy for management of severe post-enucleation socket syndrome – A clinical report. J Prosthodont 2015;24:329-33.  Back to cited text no. 2
    
3.
Lindsey R, Soper M. Sympathetic ophthalmia following evisceration: A review of the literature. J Am Soc Ocularists 1986;17:28-30.  Back to cited text no. 3
    
4.
Beumer J, Marunick MT, Esposito SJ. Maxillofacial rehabilitation: Prosthodontic and surgical management of cancer-related, acquired, and congenital defects of the head and neck. 3rd ed. IL, USA: Quintessence Publication; 2011. p. 301-10.  Back to cited text no. 4
    
5.
Tucker SM, Sapp N, Collin R. Orbital expansion of the congenitally anophthalmic socket. Br J Ophthalmol 1995;79:667-71.  Back to cited text no. 5
    
6.
Sykes LM, Essop AR, Veres EM. Use of custom-made conformers in the treatment of ocular defects. J Prosthet Dent 1999;82:362-5.  Back to cited text no. 6
    
7.
Merritt J, Trawnik R. Prosthetic and surgical management of congenital anophthalmia. J Ophthal Prosthet 1997;2:1-14.  Back to cited text no. 7
    
8.
Osborn KL, Hettler D. A survey of recommendations on the care of ocular prostheses. Optometry 2010;81:142-5.  Back to cited text no. 8
    
9.
Wiese KG, Vogel M, Guthoff R, Gundlach KK. Treatment of congenital anophthalmos with self-inflating polymer expanders: A new method. J Craniomaxillofac Surg 1999;27:72-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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