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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 376-378

Computed tomography-based diagnostics and management of worsening postenucleation socket syndrome: A case report

1 Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russian Federation
2 S.N. Fedorov NMRC “MNTK “Eye Microsurgery”, Moscow, Russian Federation
3 Central Research Institute of Dental and Maxillofacial Surgery; I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation

Date of Submission27-May-2020
Date of Acceptance08-Sep-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Daria S Afanasyeva
Chekhova st. 3-83, Omsk
Russian Federation
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1654_20

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In the presented clinical case of a patient with worsening postenucleation socket syndrome, we demonstrate using of modern computed methods for preoperative diagnostics, surgery planning, and production of a custom implant. We consider that computed tomography being accompanied by three-dimensional reconstruction and parameter measurements of the orbital tissues in the medical images enable ophthalmologists to gain comprehensive and precise information. All these enable us to provide better clinical results and better quality of life for the patients with monolateral anophthalmos.

Keywords: 3D printing, computered exophthalmometry, silicone implant, step-by-step computed exophthalmometry

How to cite this article:
Gushchina MB, Afanasyeva DS, Gushchin AV, Chernenkiy MM, Brusova LA. Computed tomography-based diagnostics and management of worsening postenucleation socket syndrome: A case report. Indian J Ophthalmol Case Rep 2021;1:376-8

How to cite this URL:
Gushchina MB, Afanasyeva DS, Gushchin AV, Chernenkiy MM, Brusova LA. Computed tomography-based diagnostics and management of worsening postenucleation socket syndrome: A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2022 Dec 5];1:376-8. Available from: https://www.ijoreports.in/text.asp?2021/1/2/376/312335

Postenucleation socket syndrome (PESS) is not a rare complication after an eyeball enucleation. Progressive fat atrophy and changed orbital anatomy result in the worsening of the PESS symptoms even when the orbital implant was primary inserted. Clinical manifestations of PESS are numerous and treatment strategy should be individual. In this article, we present a clinical case of a patient with worsening PESS and demonstrate how digital technologies can support preoperative diagnostics and surgery planning.

  Case Report Top

A 48-year-old female patient with monolateral anophthalmos was referred to the hospital with complaints on the discomfort due to a thick ocular prosthesis, and cosmetic defect caused by its low motility. The patient's history revealed that her left eyeball was enucleated after chemical burn [Figure 1]a and “Bionik” orbital implant (hydrophobic acryl, “Reper-NN”, Nizhniy Novgorod, Russia, [Figure 2]a), was primary implanted into the socket. The diameter of the implant was 20 mm, while the contralateral globe length was 23.48 mm (3 mm were kept for a standard thickness of ocular prosthesis). Post-op period went without complications and an initially inserted prefabricated ocular prosthesis was replaced with a custom-made one [Figure 1]b. The patient was examined regularly, and changed her ocular prosthesis to the thicker one each year. Thus, her artificial eye became thicker, heavier, and less motile.
Figure 1: The patient's appearance in dynamics. (a) before enucleation of the left eye; (b) a year after enucleation with implantation of the orbital implant and placement of ocular prosthesis on the left side; (c) before implantation of silicone implant; (d) three weeks after implantation of silicone implant into the left orbit; (e) six months after implantation

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Figure 2: Original orbital implant, motility measurement and devices for this. (a) “Bionik“ orbital implant. (b) A pointer for fixation on post- enucleation stump, eye prothesis and fellow eye. (c) A mask with a 2-axis scale for post-enucleation stump or eye prothesis motility measurement. After the measurement, the results in millimeters can be converted into degrees. (d) Demonstration of the post-enucleation stump motility. Anterior pole of the stump has been marked with a brilliant green dot, which is replaced with black dot for better visualisation. The black arrows indicate the directions of gaze

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General examination revealed sunken appearance, superior sulcus deformity, and enophthalmos on the left side [Figure 1]c. The orbital implant in the anophthalmic socket was covered properly. According to the historical data, summarized motility of the post-enucleation stump had not changed significantly and was 128° ± 2° (measured with original method [Figure 2]b, [Figure 2]c, [Figure 2]d)[1], whereas motility of the ocular prosthesis decreased from 80° to 56° during the 5-year follow-up period. Upon examination of the existing ocular prosthesis, its thickness was 6.5 mm [Figure 3]a. Besides general ophthalmological examination, multi-spiral computed tomography (CT) with computered exophthalmometry (CE) and step-by-step computered exophthalmometry (SSCE) (Radiant DICOM Viewer software, “Medixant”, Poland) were performed to assess orbital content and position of the orbital implant, a value and a reason of enophthalmos [Table 1].[2],[3] Based on the revealed differences in the orbital component, we calculated a volume deficient, which amounted to 3.026 cm3 [Figure 4]a. The case was diagnosed as PESS based on these clinical and radiological findings. The treatment plan was discussed with the patient and an informed consent was obtained.
Figure 3: Spiral CT scans of the patient and surgery planning: (a and b) The axial spiral CT scans of the patient before implantation, (c) a general view of the orbit and implant wax model for the patient; (d) the planned implant position in the left orbit; (e and f) the axial spiral CT scans of the patient three weeks after implantation; (b and f) demonstration of the procedure of step-by-step computered exophthalmometry

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Table 1: The results of computered exophthalmometry and step-by-step computered exophthalmometry before and after implantation of patient-specific silicone implant (cm)

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Figure 4: 3D reconstruction of the facial soft tissues of the patient based on the spiral CT data and a table for calculation of the volume deficit. The tissue deficient area is marked with red. Volume unit — mm3. (a) before implantation; (b) six months after implantation

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Based on the CT data, 3D-orbital model was created with VSG Amira software (Germany). Using this model, the results of SSCE and computer-aided 3D reconstruction allowed us to design an additional orbital implant of needed form and volume [Figure 3]c and [Figure 3]d. Then, based on the wax model, a custom silicone implant was manufactured.

Implantation surgery was performed under endotracheal narcosis. After the standard preparation of the surgical area, the silicone custom orbital implant was inserted into the supraperiosteum created via incision along the low-orbital margin. After closing of the surgical wounds, we inserted a thin prefabricated ocular prosthesis to the conjunctival cavity, instilled antibiotic eye-drops and applied an aseptic compression pad on the left orbital area.

The post-op period went without any significant complications [Figure 1]d, and a new custom ocular prosthesis was matched.

To control the position of the inserted silicone implant, we performed spiral CT [Figure 3]e. CE and SSCE based on the control tomograms revealed a proper position of anterior margin of the ocular prosthesis compared to the right eyeball, increase of the orbital component on the left side because of the silicone implant, and decrease of the ocular prosthesis thickness [[Figure 3]a, [Figure 3]b, [Figure 3]e, [Figure 3]f and [Table 1]].

The [Table 1] demonstrates, that the use of the custom silicone implant for correction of the ocular prosthesis position allowed to decrease the difference between the length of the orbital component on the both sides, and consequently to align the proptosis of the ocular prosthesis against the right eyeball. Forward movement of the enucleation stump enables the patient to wear thinner custom ocular prosthesis––2.4 mm [Figure 3]e, characterized with more motility amounted to 78° in summary. Moreover, the patient noticed, that the orbital area became more symmetrical [Figure 1]d, upper eyelid got normal position and form, she remarked better aesthetics [Figure 1]e and more comfortable wearing of the ocular prosthesis. During the six months of the post-op period, her condition was stable [Figure 1]e and [Figure 4]b.

  Discussion Top

When surgical approach was chosen to correct the PESS, precise diagnostics and preoperative planning are essential to achieve the best possible functional and esthetic outcome.[4],[5],[6] CT being accompanied by 3D reconstruction and parameter measurements of the interested tissues in the medical images enables clinicians to gain comprehensive and precise information.[7],[8]

Surgical procedures to correct PESS are numerous and include soft tissue augmentation with autologous transplants, grafts or synthetic implants to restore orbital volume. Among others, surgical techniques using subperiosteal implants fixated on lower orbital margin are considered more advantageous, because they do not disrupt the intraperiorbital contents at operation, thereby reducing further orbital fat atrophy.[9] This was worth consideration in the presented clinical case of the worsening PESS. Custom-made silicone implant suits to the patient's orbital contour precisely. Being inserted into the supraperiosteal cavity of the orbital bottom and fixed with periosteum, the implant has no opportunity to migrate.

  Conclusion Top

Modern visualization methods along with the computer analysis and modeling, as well as technologies to produce medical products enable to create the most suitable patient-specific orbital implants. This allows for achieving better clinical results and a better quality of life for the patients with monolateral anophthalmos.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gushchina MB, Latypov IA, Egorova EV. Patent RF na izobretenie № 2569162/20.11.15. Byul. №32. Ustroistvo dlya izmereniya podvigznosti I sposob otsenki podvigznosti parnogo glaza, oporno-dvigatel'noi kul'ti I glaznogo kosmeticheskogo proteza. (In Russ.). Available from: https://findpatent.ru/patent/256/2569162.html. [Last accessed on 2020 May 14].  Back to cited text no. 1
Afanasyeva DS, Gushchina MB, Gerasimov MY, Borzenok SA. Computed exophthalmometry is an accurate and reproducible method for the measuring of eyeballs' protrusion. J. Craniomaxillofac Surg 2018;46:461-5.  Back to cited text no. 2
Gushchina MB, Afanasyeva DS, Gushchin AV. Novel method for complex diagnostics of globes' position. J. Craniofac Surg 2020;31:1418-20.  Back to cited text no. 3
Byun JS, Moon NJ, Lee JK. Quantitative analysis of orbital soft tissues on computed tomography to assess the activity of thyroid-associated orbitopathy. Graefes Arch Clin Exp Ophthalmol 2017;255:413-20.  Back to cited text no. 4
Hu H, Xu XQ, Liu H, Hong XN, Shi HB, Wu FY. Orbital benign and malignant lymphoproliferative disorders: Differentiation using semi-quantitative and quantitative analysis of dynamic contrast-enhanced magnetic resonance imaging. Eur J Radiol 2017;88:88-94.  Back to cited text no. 5
Kim JM, Chang MH, Kyung SE. The orbital volume measurement in patients with ventriculoperitoneal shunt. J. Craniofac Surg 2015;26:255-8.  Back to cited text no. 6
Nishida Y, Tian S, Isberg B, Hayashi O, Tallstedt L, Lennerstrand G. Significance of orbital fatty tissue for exophthalmos in thyroid-associated ophthalmopathy. Graefes Arch Clin Exp Ophthalmol 2002;240:515-20.  Back to cited text no. 7
Park SH, Yu HS, Kim KD, Lee KJ, Baik HS. A proposal for a new analysis of craniofacial morphology by 3-dimensional computed tomography. Am J Orthod Dentofac Orthop 2006;129:600.e23-34.  Back to cited text no. 8
Kamble VB. Prosthetic correction of postenucleation socket syndrome: A case report. J. Indian Prosthodont Soc 2014;14(Suppl. 1):S172-6.  Back to cited text no. 9


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

  [Table 1]


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