orbit / plastic surgery session-ii - All India Ophthalmological Society

ORBIT/ PLASTIC SURGERY SESSION-II 

413 

ORBIT / PLASTIC SURGERY SESSION-II 

Chairman: Dr. Ashok Kumar Grover, Co-Chairman: Dr. S.C. Das 

Convenor: Dr. Usha Singh, Moderator: Dr. Swarup Pathak 

AUTHORS’S PROFILE: 

DR. DEBRAJ SHOME, M.B.B.S. (2000), Grant Medical College, Mumbai University; D.O. 

(2003), Sankara Nethralaya, Chennai; D.N.B. (2004); FRCS (2003) (Glasgow); M.R.C.S. (Part-I) 

(2003) (Edinburgh); ICO Basic Sciences Assessment (2002), Fellowship in Ophthalmic Plastic 

Surgery, Orbit and Ocular Oncology, L.V. Prasad Eye Institute, Hyderabad. Formerly, 

Consultant Ophthalmic Surgeon at Rotary Eye Hospital, Navasari, Gujrat. Recipient of Best FP 

Award in Orbit and Inflamation Session, AIOC-2006, Bhopal. Presently Consultant, Orbit and 

Ocular Oncology, Aditya Jyot Eye Hospital Pvt. Ltd., Wadala, Mumbai. 

Implant and Prosthetic Motility – Is There Really A Difference 

between Expensive Porous Polyethylene Implants and The Humble 

Inexpensive Silicone Implant — A Randomized Controlled Trial 

Dr. Debraj Shome, Dr. Kuldeep Raizada, Dr. Deepa Rani, Dr. Santosh G Honavar 

(Presenting Author: Dr. Debraj Shome) 

Enucleation of the eye is often considered a 

failure for an ophthalmologist and the end of 

a professional relationship. On the contrary, it is 

the beginning of a new relationship aimed at 

providing optimal cosmesis and maintaining a 

healthy socket. For a patient who has already lost 

vision in his eye, good cosmesis can often be 

equated with greater self-esteem. 

Motility of implants and subsequently movement 

of the overlying prosthesis is an important aspect 

of cosmesis. Implants used can be integrable or 

non-integrable with orbital tissues. 

Non integrated implants are inexpensive, 

technically uncomplicated, well tolerated, and 

have very few complications. However, nonintegrated 

implants do not allow direct or 

indirect integration with the orbital structures or 

with the prosthesis. Such implants have no direct 

attachment to the prosthesis. Although various 

materials have been used to make nonintegrated 

implants in the past, the current favourite is 

silicone. Silicone is less prone to migration 

because a layer of fibrous tissue sequestrates it. 

In contradistinction, integrable implant materials 

like porous polyethylene get bio-integrated to the 

orbital soft tissues and are reported to provide 

better implant and prosthetic motility. The 400- 

micron large pore size of this material allows 

fibrovascular ingrowth and causes integration. 

However, these implants are very expensive and 

can get exposed because of the presence of an 

outer rough surface. 

Enucleation, at present, consists of three main 

techniques; all done with a view of improving 

implant motility and subsequent prosthetic 

motility. 

These are: 

1. Enucleation by the traditional ‘muscle to 

muscle imbrication’ technique 

2. Enucleation by the myoconjunctival 

technique 

3. Enucleation with the use of integrable porous 

polyethylene or hydroxyapatite implants. 

The present study attempts to compare the 

differences in implant and prosthetic motility 

amongst all these three techniques. 

To Evaluate implant and prosthesis motility via 

three techniques: Post silicone implant insertion 

with muscle imbrication (the traditional age-old 

technique of enucleation), post silicone implant 

insertion by myoconjunctival technique (MT) 

(the extra-ocular muscles are sutured to the 

fornices insted of to each other) & post porous 

polyethylene implantation via the scleral cap 

technique. 

Study Design 

Randomised Controlled Double-Blind, 

Prospective, Interventional Study.

414 AIOC 2009 PROCEEDINGS 

Materials and Methods 

75 patients per group were included in this multicentric 

trial. Patients were randomized using 

stratified randomisation. All patients were 

operated by two experienced surgeons. 

Implant and prosthesis motility were the primary 

outcome measures. 

Custom-made acrylic prostheses by a trained 

ocularist were fitted six weeks post surgery in all 

patients. A masked observer measured implant 

and prosthesis motility using a custom-made slitlamp 

device with real-time video and still 

photographic documentation. The measurement 

was repeated by a second masked observer on 

the computer using the photos of movements in 

all gazes captured and an average of the 

measurements of the first and the second 

observers were taken. If the difference in 

measurements between the two observers was 

greater than 2 Standard Deviations, the 

measurements were repeated. 

Surgical Technique 

Until the eyeball is enucleated, all the steps are 

similar in all three techniques. 

An orbital implant is placed either posterior to 

the posterior Tenon’s (nonintegrated implants) or 

within the Tenon’s capsule (integrated implants). 

There are two options to deal with the 

extraocular muscles if a nonintegrated implant is 

placed – one is to imbricate the lateral rectus to 

the medial rectus and the superior rectus to the 

inferior rectus; over the posterior tenons. 

The other is the myoconjunctival technique 

where each of the recti is attached to the posterior 

aspect of conjunctiva-Tenons close to the 

respective fornix. The muscles are then passed 

thru the anterior Tenon’s and the conjunctival 

layer and then sutured to the respective fornices. 

This technique of muscle suturing is supposed to 

impart greater implant motility as well as deeper 

fornices, post surgery. Thus, myoconjunctival 

technique may provide better prosthesis mobility 

and reduce the risk of implant displacement (the 

“sling effect” of the imbricated recti is one of the 

causes of implant displacement). 

Porous polyethylene implants are implanted via 

the ‘scleral cap’ technique. A scleral disc is cut out 

from donor sclera and is sutured to the implant 

with 6-0 vicryl sutures. The implant is inserted 

via an inserter, which is included with the 

implant. This implant is placed anterior to the 

posterior tenon layer. The muscles are then 

sutured to the disc with the 6-0 vicryl sutures. 

The muscles can be attached to integrated 

implants either directly (porus polyethylene or 

coated hydroxyapatite implants) or to the 

wrapping material. Exaggerated anterior 

attachment of the muscles within 5 mm of the 

implant's central axis is currently advocated. This 

is believed to result in more posteriorly 

positioned implant, reducing the risk of 

exposure. 

The subsequent steps of closure and conformer 

insertion are similar in all three techniques. 

Measurement device and technique 

An independent observer measured motility 

using a custom-made slit-lamp device with realtime 

video documentation. The measurement 

device was indigenously made in-house at our 

institute. 

The device has two millimeter rulers, having the 

dimension of 15mm and 5mm respectively. The 

larger ruler represented the X axis while the 

smaller one represented the Y axis. The larger 

horizontal ruler was fixed from the Center while 

the vertical one was arranged such that it could 

be moved along the X axis. The complete 

measurement device was mounted on a rod of 

length 15 mm and with the overall diameter of 

6mm, which was then attached to the Slit lamp 

biomicroscope in the Hruby lens holder. This 

Hruby Lens holder can be moved in 5mm in each 

direction from its center, while the whole 

Instrument can be moved in Y axis as per the 

individual patient and can also be fixed for the 

particular individual. 

The implant motility, prosthesis measurement 

and prosthetic motility were checked after 6 

weeks post-surgery in all patients. 

Once it was established that the socket was 

healthy, then topical anaesthesia was instilled. 

Using a non-toxic colour marker (Sharpie ADA 

approved), the center of the palpebral fissure was 

marked. The patient was made to comfortably sit 

on the slit lamp biomicroscope. The external 

digital camera was aligned to face the patient.


415 

This camera was kept at a prior marked distance 

of 1.5 ft and the zoom was kept at 2.3 x in all 

patients for standardization. 

Using a wire speculum the visible mark was 

viewed and then ductions in all directions were 

photographed. 

Once the prosthesis was ready, it was placed in 

situ in the socket and the center of the pupil of 

the prosthesis was marked with an erasable 

white marker. The prosthetic movement was 

then measured in all directions with 

photographs. 

The photograph was downloaded onto the 

computer and then the measurement was carried 

out via Adobe Photoshop version 6.0. This was 

done to avoid parallax error which could have 

occurred if assessment was done directly with 

the patient on the slit lamp. 

Fornix depth and implant displacement were 

also noted. 

Result 

In the myoconjunctival group, the mean implant 

motility on adduction was 3.67mm,on abduction 

4 mm and the total motility was 7.66mm in the 

horizontal meridian; the upward motility was 

2.82mm, the downward motility was 3.18mm 

and the total motility was 6 mm in the vertical 

meridian. The prosthetic motility was 4.22mm for 

adduction, 3.78 mm for abduction and 8 mm total 

in the horizontal meridian and 3.22 mm for 

supra-duction, 3.56 mm for infra-duction and 

6.77 mm totally in the vertical meridian. 

In the traditional enucleation with silicone 

implant group, the mean implant motility on 

adduction was 3.82 mm, on abduction 1.32 mm 

and the total motility was 3.27 mm in the 

horizontal meridian and the upward motility 

was 1.36 mm, the downward motility was 1.32 

mm and the total motility was 3.68 mm in the 

vertical meridian. The prosthetic motility was 

1.82 mm for adduction, 2.30 mm for abduction 

and 3.90 mm total in the horizontal meridian and 

1.36 mm for supra-duction, 2 mm for infraduction 

and 3.36 mm totally in the vertical 

meridian. 

In the porous polyethylene group, the mean 

implant motility on adduction was 3.50 mm, on 

abduction 3.60 mm and the total motility was 

7.10 mm in the horizontal meridian and the 

upward motility was 2.75 mm, the downward 

motility was 2.95 mm and the total motility was 

5.80 mm in the vertical meridian. The prosthetic 

motility was 3.80 mm for adduction, 3.65 mm for 

abduction and 7.45 mm total in the horizontal 

meridian and 3 mm for supra-duction, 3.30 mm 

for infra-duction and 6.30 mm totally in the 

vertical meridian. 

Analysis was done by the Mann-Whitney U test. 

As the sample size was small, statistical level of 

significance was fixed at 10%. 

As three groups were present, P value of ≤0.03 

was considered significant. 

MT silicone implant motility was better than 

traditional silicone (P = 0.001) & similar to porous 

polyethylene. Even more surprisingly, prosthesis 

motility post MT insertion was better than post 

both traditional silicone (P = 0.001) & porous 

polyethylene (P = 0.002). 

Differences in implant motility were not 

significant in both meridia between the porex 

and the myoconjunctival group. 

Thus, Myoconjunctival silicone implant showed 

better motility and fornix depth than the 

traditional route and the porous polyethylene 

group. Only traditional silicone implants tended 

to displace. 

Discusion 

Silicone implant by myoconjunctival technique 

provides better implant and prosthesis motility 

and may be preferred over expensive porous 

polyethylene implant. 

To the best of our knowledge, this is the first 

study of its kind comparing implant and 

prosthesis motility in these groups of enucleation 

with implants. 

References 

1. Moshfeghi DM, Moshfeghi AA, Finger PT. 

Enucleation. Surv Ophthalmol 44;4:277-301. 

2. Yadava U, Sachdeva P, Arora A. Myoconjunctival 

Enucleation for Enhanced Implant Motility. Result 

of a Randomised Prospective Study. Indian J 

Ophthalmol 2004;52:221-6.



DR. ASHOK KUMAR GROVER: M.B.B.S.(’76), Maulana Azad Medical College, New Delhi; 

M.S. (’80), Dr. Rajendra Prasad Centre for Ophthalmic Science, AIIMS, New Delhi. He was on 

the faculty of Maulana Azad Medical College as chief of Oculoplastic service. Received the 

prestigious Col. Rangachari Award, AIOC. President Elect of Oculoplastic Association of India. 

Past president, Federation of Ophthalmic Research and Education Centers (India) and Delhi 

Ophthalmological Society (DOS). Presently, Chairman of the Dept. of Ophthalmology at Sir 

Ganga Ram Hospital, New Delhi. 

Surgical Techniques in The Management of Contracted 

Anophthalmic Socket — A Retrospective Study 

Dr. Ashok Kumar Grover, Dr. Pracheer R. Agarwal, Dr. Rituraj Baruah, 

Dr. Shaloo Bhageja 

(Presenting Author: Dr. Ashok Kumar Grover) 

Contracted socket at times becomes a major 

aesthetic concern for the patient as well as 

the treating surgeon leading to multiple 

surgeries. A number of proven surgical 

techniques are at the disposal of the surgeon but 

assessing the condition and the correct 

application of the technique to get the optimum 

acceptable result is the key to the success. 

Successful reconstruction of the contracted socket 

requires that a stable fornix with adequate depth 

be established by increasing the surface area with 

the use of grafts, and if necessary volume 

replacement with orbital implants. 

Evaluation of different surgical techniques in the 

management of contraction of the anophthalmic 

socket. 


This is a retrospective study of 39 patients who 

presented with contraction of anophthalmic 

socket between February 2003 and October 2007. 

Meticulous history was taken to find out the 

sequence of events. History or records of 

techniques and any other treatment modalities 

like radiotherapy etc used were elicited. 

The socket contraction was first categorised into 

mild (9), moderate (10) and severe (20). 

Associated abnormalities like granuloma 

formation, partial or complete extrusion of 

implant, laxity of lower eyelids, volume 

deficiency with sulcus deformity, band formation 

etc were looked for. 

After carefully assessing the cases, appropriate 

treatment modality was decided and executed 

accordingly. 

Techniques used were prosthesis modification (2 

cases), fornix forming suture (7 cases), mucous 

membrane graft (23 cases), dermis fat graft (5 

cases) and epidermal graft (2 cases). Granuloma 

excision was carried out in 3 cases. 

Post operatively, all patients were examined to 

record whether they were able to retain a 

cosmetically acceptable prosthesis and maintain 

good function of the orbit and eyelids. Patients 

were followed for a period varying from 6 

months to 4 years. 

Results 

Of the 39 cases of contracted socket 29 were male 

and 10 were female. Age varied from 5 years to 

54 years. Thirty of the patients had a satisfactory 

surgical outcome so that a well fitting prosthesis 

could be fitted. In nine cases either adequate 

space could not be created or a recurrence of 

contraction supervened. This tended to occur in 

the severe group, especially in patients with 

previous radiotherapy. 

Discussion 

As it is already established, mucus membrane 

lining the socket often tends to shrink with time. 

Bouts of low grade infection, failure to used a 

correctly fitted conformer, implant extrusion and 

migration, sharp edge of artificial eye , faulty 

techniques of enucleation with injudicious 

sacrifice of bulbar conjunctiva are the common 

causes of contracted socket. 

Reconstruction of mild to moderate contraction 

can be optimally tackled with mucus membrane 

graft. Dermis fat graft is of utmost importance 

when increase volume and surface area are


417 

Mild Moderate Severe 

Dermis fat graft in case of deep 

Shallow inferior 

fornix 

Cicatricial band 

Granulation 

tissue 

Shallow inferior socket with fornix forming suture 

MM Grafting 

desired. The dermis enhances the 

vascularization, decrease the incidence of fat 

atrophy and act as a barrier against fatty 

augmentation. Extensive socket contraction can 

be dealt with full or partial thickness oral 

mucosal graft. However, grafting the palpebral 

surface requires rigidity which is absent with 

these mucosal graft. 

Complete restoration of space for prosthetic eye 

can achieved in the milder group with fornix 

1. Sihota R, The fat pad in dermis fat grafts. 

Ophthalmology 1994;101:231-4. 

2. Puterman AM. A surgical technique for the 

successful and stable reconstruction of the totally 

contracted ocular socket. Ophthalmic surg. 

1988;19;193-201. 

The established treatment for ptosis with poor 

levator function is frontalis sling suspension 

surgery. The upper ptotic lid is attached to the 

frontalis muscle and the lid is elevated actively 

on elevating brow. Various different materials 

References 

Superior sulcus deformity with levator resection 

forming suture in 7 of our cases. Dermis fat graft 

gave excellent results. However, in the severe 

group, 4 cases where adequate space could not 

be maintained for a longer period had history of 

exposure to radiotherapy. 

Surgical techniques like mucous membrane 

grafting, epidermal and dermis fat grafting give 

satisfactory results in patients of socket 

contraction, when done in appropriate cases with 

meticulous surgical technique. 

3. SM Betheria, Surgical management of contracted 

socket. IJO 1988;36/2:79-81. 

4. Raizada K. Management of an irradiated 

anophthalmic socket following dermis fat graft 

rejection: a case report. IJO 2008;56:147-8. 

Evaluation of Frontalis Sling Surgery Using Silicone Rod for 

Correction of Blepharoptosis in Indian Population in a Tertiary 

Eye Care Centre 

Dr. Usha R., Dr. Gagan Dudeja 

(Presenting Author: Dr. Gagan Dudeja) 

have been used for frontalis suspension such as 

non absorbable sutures, sclera, suture reinforced 

sclera, autogenous and preserved fascia lata, 

temporalis fascia, skin strips, GoreTex strips, 

silicone bands and rods.


Tillet et al in 1966 first described frontalis 

suspension with No. 40 silicone strip used in 

retinal detachment surgery. Several other 

workers have reported use of silicone material in 

different physical configuration. 

We report our experience with silicone rod (BD - 

Visitec frontalis suspension set with silicone rod 

and malleable needle) for frontalis Sling 

suspension surgery for correction of ptosis. 


65 lids of 56 consecutive patients meeting the 

inclusion criteria were enrolled for the study. 

The inclusion criteria were severe congenital 

ptosis with poor levator function i.e. upper lid 

margin and pupillary reflex distance (MRD 1) of 

0 to 1 mm and poor levator function < 4mm 

(Burke’s method), Third nerve palsy, Chronic 

progressive external ophthalmoplegia (CPEO), 

Myasthenia gravis (MG), Post traumatic Levator 

disinsertion, Myotonic dystrophy and Congenital 

ocular fibrosis syndrome. 

Exclusion criteria were acquired ptosis e.g. 

Horner’s syndrome, Blepharochalasis, 

Dermatochalasis, Mechanical ptosis, Mild or 

Moderate congenital ptosis (MRD 1 >1) 

The surgery was performed under local 

anaesthesia in adults and general anaesthesia in 

children. Frontalis Sling Suspension was 

performed using modified Fox pentagon 

technique using Visitec silicone rod frontalis 

suspension set. Five incision sites for Fox 

pentagon were marked. First two marks were 

made in upper lid lateral to temporal limbus and 

medial to medial limbus 2 mm above lash line. 

Next two marks were made just medial and 

lateral to lid incision above superior brow hairs. 

A forehead incision was then marked midway 

about 1 cm above brow. The five incisions were 

then made with Elllman RF cautery. A pocket 

was dissected beneath frontalis muscle 

superiorly for burying the sleeve . The needle of 

sling suspension set was then slightly bent and 

passed from central forehead incision to lid 

incision and back to forehead incision in 

clockwise manner to form a pentagon. Lid Guard 

was used to protect the cornea and support the 

lid. The two Needles were then passed through 

the sleeve and the sling was tightened to obtain 

required lid height and contour. The silicone rod 

was then cut and the sleeve was buried in pocket 

made between frontalis muscle. The forehead 

incision was then closed with 6’0 Vicryl Suture. 

Frost suture was then taken and left in place for 

one day. Post operatively lid height, contour, 

lagophthalmos and corneal exposure was 

assessed in all the patients. 

In case of a bilateral frontalis sling surgery ideal 

upper lid height post operatively is ½ mm below 

superior limbus. But in case of an unilateral 

surgery it needs to be matched with the lid height 

of the other eye. Under correction is desirable in 

cases having poor Bells phenomenon such as 

CPEO, MG and Third nerve palsy. The post 

operative correction was graded as good if the lid 

height was equal to or 1 mm lower than the 

desired correction, fair if it was 1 to 2mm lower 

than the desired level and poor if it was more 

than 2 mm lower than the desired level. 

Intraoperative and postoperative complications 

were recorded. The patients were followed up 

post operatively for a minimum period of six 

months. 

Results 

The age of patients ranged from 4 months to 55 

years. 36 patients were male and 20 patients were 

female. The pre operative diagnoses were Simple 

severe congenital Ptosis in 32 (57 %) cases, 

Blepharophimosis syndrome in 6 (11%) cases, 

Synkinetic Ptosis in 11 (20%) cases, third nerve 

palsy in 1 (1.8%) case, post traumatic LPS 

disinsertion 3 (5.4%) cases Myotonic Dystrophy 

in 1(1.8%) case, CPEO in 1 (1.8%) case and 

Congenital ocular fibrosis syndrome 1 (1.8%) 

case. 

Pre operatively 9 patients had poor Bells 

phenomenon. Surgical procedure performed was 

Frontalis Sling suspension in 38 patients, YV 

plasty and Frontalis Sling in 10 patients and 

Levator disinsertion and Frontalis Sling in 11 

patients. 

Postoperative 56 (86.15%) eyes had good 

correction. 8 (12.30%) patients had fair correction 

and 1 (1.50%) patient had poor correction. 

Lagophthalmos was grade 1 in 10 (15.40 %)eyes, 

grade 2 in 50 (77 %) eyes and grade 3 in 5 (7.70%) 

eyes. 

Complications encountered were corneal 

exposure in 4 patients 2 of them underwent 

loosening of sling and 2 were managed by use of 

topical lubricants and taping at night .1 patient


419 

developed pre septal cellulites and was managed 

on parenteral antibiotics and removal of sling. 1 

Patient had recurrence of Ptosis due to slippage 

of silicone rod over tarsus. 1 patient had 

granuloma formation, which was managed 

conservatively. 3 patients underwent sling 

readjustment. 

Discussion 

Ever since 1966 when Tillet et al reported use of 

Silicone band No. 40 for frontalis sling 

suspension surgery the material has been found 

to have excellent biocompatibility. Various 

different types of silicone rods and bands along 

with different surgical techniques have been used 

and reported but all of them in a small number 

of patients. There are no published reports for 

Indian population. Our series presents the results 

of frontalis sling suspension using silicone rod 

material in Indian population. 

1. Tillett CW, Tillett GM. Silicone sling in the 

correction of ptosis. Am J ophthalmol. 1966;62(3):521- 

3. 

2. Leone CR Jr, Rylander G. A modified silicone 

frontalis sling for the correction of blepharoptosis. 

Am J Ophthalmol 1978;85:802-5. 

3. Carter SR, Meecham WJ, Seiff SR. Silicone frontalis 

slings for the correction of blepharoptosis: 

indications and efficacy. Ophthalmology 

1996;103:623-30. 

4. Green JP, Wojno T.Removal of an infected silicone 

Orbital cellulitis can be classified as preseptal 

and post septal cellulitis based on the 

anatomic landmark, the orbital septum. The 

septum forms a barrier separating the spread of 

superficial infection into the deeper orbit. Orbital 

infection limited anterior to the septum is called 

preseptal cellulitis and that posterior to septum 

is termed as post-septal cellulitis or orbital 

cellulitis. Clinical distinction of the two is 

important as the ocular morbidity and prognosis 

differs. 

Preseptal cellulitis is characterized by lid edema, 

References 

Silicone Rod as a material has: 

1) Excellent Biocompatibility that is well tolerated 

by body tissues, 2) It has good elasticity, which 

provides for good lid closure. 3) It can be easily 

adjusted because of use of sleeve. 

Severe unilateral or bilateral congenital ptosis 

may result in abnormal head posture and 

amblyopia due to occlusion of visual axis. 

Therefore surgical intervention is indicated at an 

early age. Fascia lata cannot be harvested in 

children below three years of age, which 

mandates the use of non-autogenous material 

like Silicone Rod. The ptosis may be of variable 

progression in some conditions such as CPEO, 

MG and Myopathy and it may increase with 

worsening of myopathy or may improve as in 

cases of myasthenia gravis. All these conditions 

may need sling adjustment, which is easily done 

in case of a silicone sling surgery. 

rod frontalis sling without recurrence of ptosis. 

Ophthal Plast Reconstr Surg. 1997;13:285-6. 

5. Bernardini FP, de Conciliis C, Devoto MH. Frontalis 

suspension sling using a silicone rod in patients 

affected by myogenic blepharoptosis. Orbit 

2002;21:195-8. 

6. Ben Simon GJ, Macedo AA, Schwarcz RM, Wang 

DY, McCann JD, Goldberg RA. Frontalis suspension 

for upper eyelid ptosis: evaluation of different 

surgical designs and suture material. Am J 

Ophthalmol. 2005;140:877-85. 

Nine Years Review on Preseptal and Orbital Cellulitis in A 

Tertiary Care Hospital in South India 

Dr. Datta Gulnar Pandian, Dr. Ramesh Babu K, Dr. Chaitra S., Dr. Anjali A 

(Presenting Author: Dr. Datta Gulnar Pandian) 

warmth, erythema and tenderness. Distinctive 

features of orbital cellulitis are proptosis and 

limitation of ocular movements. 1 Additional 

useful signs are chemosis of bulbar conjunctiva, 

reduced visual acuity, afferent pupillary defect 

and toxic systemic symptoms. Prompt diagnosis 

and treatment of orbital cellulitis is vital as it is 

associated with serious complications like 

cavernous venous thrombosis, visual loss, 

meningitis and sepsis. 1,2 

In this study we reviewed the in-patient records 

of patients with pre- and post-septal cellulitis


over nine years in a tertiary care hospital. The 

clinical findings, causative organism, 

management and complications of the two 

conditions are illustrated. 


The in-patient records of patients with preseptal 

and orbital cellulitis were reviewed from 1998 to 

2006. The clinical details of the patients were 

noted and analysed. Patients were classified as 

having preseptal or orbital cellulitis. 

The factors reviewed in the study included ocular 

findings aiding in the distinction of the two 

clinical conditions, the duration of symptoms at 

the time of presentation, the duration of hospital 

stay, microbiological culture report of pus or 

wound swab, blood culture, drugs used for 

treatment, response to therapy and 

complications. Other parameters studied were 

general physical examination, systemic blood 

counts and temperature. Wound swab was taken 

either from the site of infection or ulceration or 

conjunctival sac. This was immediately sent for 

culture and sensitivity. Pus was examined by 

Gram's staining, KOH mount and cultured on 

blood agar, chocolate agar and Sabourauds 

dextrose agar. Radiological investigations like x- 

ray or CT orbit and paranasal sinuses were taken 

in all cases of or suspected orbital cellulitis. Both 

clinical improvement and improvement in vision 

were considered in outcome measures. 

Results 

Hundred and ten cases of orbital cellulitis were 

reviewed. Seventy seven patients had preseptal 

cellulitis and thirty three patients had post septal 

cellulitis. It was noted that all cases with 

suspected orbital cellulitis and cases of preseptal 

cellulitis in the pediatric age group were 

admitted. Adult patients with preseptal cellulitis 

were admitted if there was tense swelling of the 

lids with inability to open the lids, lid abscess, 

systemic toxemia or poor response to therapy 

with oral antibiotics. 

Age and sex distribution 

Among patients with preseptal cellulitis, 78% 

(n=58) were children while adults accounted for 

25% (n=19) of cases. The mean age was 3.62 yrs 

and 34.2 yrs in the pediatric and adult group, 

respectively. Sex distribution was equal in adults 

with male preponderance in children. In patients 

with orbital cellulitis, 58% (n=19) were adults 

while children accounted for 42% (n=14) of cases. 

The mean age was 4yrs and 45 yrs in the pediatric 

and adult group respectively. Sex distribution 

was equal in children with male preponderance 

in adults. 

Predisposing factors 

Important factor predisposing to both clinical 

entities was injury, 21% in preseptal cellulitis and 

24% in orbital cellulitis. In children, additional 

predisposing factors noted were insect bite (10%), 

molluscum contagiosum of lid with secondary 

bacterial infection and stye. Among adults, since 

most of them were laborers injury with stick and 

thorn while at work was the presdisposing factor 

in 24% cases and sinusitis in 15% patients. One 

patient had fungal pansinusitis. 

Duration of symptoms and hospitalization 

The average duration of symptoms for patients 

with preseptal cellulitis was four days in the 

adult group and 5.6 days in the pediatric group. 

The average duration of hospital stay was five 

days. Majority of them, 89.6% (n=69) were 

treated in ten days or less while 10.4% (n=8) cases 

were hospitalized for a longer duration. Visual 

acuity at presentation was better than 20/60 in 

most of the patients in the adult age group. 

In those with postseptal cellulitis, the average 

duration of symptoms was nine days in the adult 

group and 11 days in the pediatric group. 

Patients who presented late and those with 

associated sinusitis had increased ocular 

morbidity. The average hospital stay was 13.69 

days. Larger proportion of patients, 61.6% (n=19), 

had a prolonged hospital stay of more than 10 

days. Visual acuity at presentation was less than 

20/60 in most of them except in two cases who 

had visual acuity of 20/20. Three patients 

couldn’t perceive light at presentation. 

Blood culture 

Blood was cultured only in patients with 

suspected septicemia; 17 patients with preseptal 

cellulitis and all cases with orbital cellulitis. There 

was no growth in the former group, while 

organisms were isolated in two cases of orbital 

cellulitis. 

Conjunctival/wound swab 

Among the culture positive patients, 

Staphylococcus aureus was the most common


421 

Organism isolated 

Table-1: Organisms isolated 

Preseptal cellulitis 

number percentage 

Staphylococcus aureus 25 52 

Streptococcus pyogenes 8 17 

Bacillus anthracis 7 15 

Enterobacter 4 8 

Acinetobacter 2 4 

Pseudomonas aeruginosa 2 4 

Methicillin resistant 

Orbital cellulitis 

number percentage 

staphylococcus aureus 10 39 

Coagulase negative staphylococcus 6 23 

Staphylococcus aureus 4 15 

Streptococcus pyogenes 4 15 

Aspergillus 1 4 

Klebsiella 1 4 

Drugs 

Table-2: Drugs used for treatment 

Preseptal Cellulitis 

Children 

Adult 

Crystalline Penicillin 46 12 

Gentamicin 50 13 

Cloxacillin 7 1 

Metronidazole 4 4 

Amoxicillin 4 0 

Ampicillin 3 2 

Cephalexin 2 0 

Ceftriaxone 1 4 

Ciprofloxacin 1 0 

Orbital Cellulitis 

Children 

Adult 

Crystalline Penicillin 9 14 

Gentamicin 12 16 

Cloxacillin 6 3 

Ampicillin 1 1 

Ceftazidime 1 1 

Cefotaxime 0 1 

Vancomycin 1 0 

Ciprofloxacin 0 1 

organism isolated in both groups. Wound swab 

culture was positive in 78.78% cases (n=26) of 

post septal cellulitis. MRSA was cultured from 

39% cases followed by coagulase negative 

staphylococcus (23%) and staphylococcus aureus 

(15%). The other organisms isolated were 

streptococcus pyogenes, klebsiella and 

aspergillus (Table 1). Conjunctival and wound 

swab cultures showed no growth in 52% of 

patients of preseptal cellulitis and 21.22% of 

orbital celllulitis. 

Anthrax prevalence 

Five percent (n=3) of children and 21% (n=4) of 

adults presented with cutaneous anthrax 

contributing to the preseptal cellulitis. None of 

the patients with orbital cellulitis had such 

lesions. 

Radiological investigations 

In patients with preseptal cellulitis radiological 

investigations were done only in whom there 

was a suspicion of spreading cellulitis, to rule out 

orbital cellulitis and sinusitis. No abnormality 

was detected in patients in whom these 

investigations were performed. 

Evidence of haziness of one or more sinuses 

associated with orbital cellulitis was present in 

plain PNS roentgenograms and CT scans of 15% 

patients. While sinusitis was the most common 

radiological finding in the adult group, lid 

abscess, intraconal abscess and panophthalmitis 

were the findings seen on radio-imaging in the 

pediatric group. 

Treatment 

All patients were treated with parenteral 

antibiotics. The following table display the 

antibiotics used. Crystalline Penicillin and 

Gentamicin were the most frequently used 

antibiotics in both groups of patients. Other 

antibiotics were substituted or added for some 

patients based on the culture sensitivity reports 

and in whom response was poor even after four 

days to one week of therapy (Table-2). Surgical 

treatment in the form of incision and drainage of 

abscess was done in patients with lid or orbital 

abscess. 

Ocular complications 

In preseptal cellulitis patients, associated 

complications in the form of facial cellulitis and 

lid abscess were seen in 8 children and 2 adults. 

In children two cases each of acute dacryocystitis, 

lid abscess and facial cellulitis were noted. 

Complications were more frequent in the 

postseptal group, in adults in the form of 

retrobulbar abscess, lid and scleral abscess, 

choroiditis, panophthalmitis, papillitis and


retinal detachment. Children with orbital 

cellulitis had lid abscess, intraconal abscess and 

panophthalmitis as associated complications. 

Clinical outcome 

A majority of patients in the preseptal group 

showed clinical improvement with treatment. At 

initial presentation itself, visual acuity remained 

unaffected in most of these patients. In the 

postseptal group, improved outcome, either 

clinical or visual was seen in 60.60% (n=20) cases. 

Adults had slightly better outcome; 63% 

improved, while in children improvement was 

seen only in 57% cases. 

Discussion 

Amongst the cases of orbital cellulitis, preseptal 

celullitis constituted 70% and postseptal cellulitis 

30%. Children constituted majority of cases with 

preseptal cellulitis while the more serious orbital 

cellulitis was more frequently seen in the adult 

population. Staphylococci followed by 

streptococci were the leading causative 

organisms in our series which is similar to other 

previous reports. 1,3 Thirty nine percent cases with 

postseptal cellulitis were caused by methicillin 

resistant staphylococcus aureus (MRSA). But 

none of these patients had recent hospitalization 

implying that the infection was community 

acquired (CA-MRSA). Another study has shown 

that CA-MRSA is emerging as a common cause 

of preseptal cellulitis. 4 

Bacillus anthracis was isolated from seven cases 

(15%) with preseptal cellulitis. The significance is 

that anthrax of the eyelid can lead to cicatrisation 

and ectropion 5-7 In our series all patients 

responded well to intravenous penicillin and 

didn’t develop complications. 

In older series, Computerized tomography 

helped in diagnosis when clinical features were 

not yet marked, aided in localizing the pathology 

to the anatomical spaces in the orbit and ruling 

out any associated sinusitis. 2,8 In our series, CT 

scan aided to diagnose intraconal and extraconal 

orbital abscess in two patients and to diagnose 

panophthalmitis in two cases with orbital 

cellulitis. All cases were empirically treated with 

intravenous penicillin and gentamicin to cover 

both gram positive and negative organisms. 

Cephalosporins, vancomycin and other 

antibiotics were given based on the sensitivity 

pattern, and if there was no clinical improvement 

with empirical therapy. Case records of patients 

in the recent past indicate the need for switching 

on to higher generation antibiotics, forty-five 

percent cases in orbital cellulitis and fifteen 

percent cases in pre-septal cellulitis group. This 

may be due to the change in the sensitivity 

pattern of the organisms.All patients with 

preseptal cellulitis resolved without any 

sequelae. Ocular complications occurred in the 

postseptal group. Six patients lost vision due to 

postseptal cellulitis. 

Based on this nine years review, it can be 

concluded that preseptal cellulitis remains the 

commonest among orbital infections of which 

Staphylococci and Streptococci are the most 

common causative organisms. Communityacquired 

MRSA is often implicated in orbital 

cellulitis which is associated with more ocular 

morbidity and prolonged hospital stay. This long 

term retrospective study has helped in 

identifying emerging organisms causing orbital 

infections and their sensitivity patterns. It 

indicates the need for modifying our empirical 

antimicrobial therapy, especially in orbital 

cellulitis. 

1. Liu IT, Kao SC, Wang AG, Tsai CC, Liang CK, Hsu 

WM. Preseptal and orbital cellulitis: A 10-year 

review of hospitalised patients. J Chin Med Assoc. 

2006;69:415-22. 

2. Bergin DJ, Wright JE. Orbital cellulitis. Br J 

Ophthalmol. 1986;70:174-8. 

3. Hodges E, Tabbara KF. Orbital cellulitis: review of 

23 cases from Saudi. 

4. Arabia. Br J Ophthalmol. 1989;73:205-8. 

5. Blomquist PH. Methicillin-resistant Staphylococcus 

aureus infections of the eye and orbit. Trans Am 

References 

Ophthalmol Soc. 2006;104: 322-45. 

6. Thappa DM, Karthikeyan K, Rao VA. Cutaneous 

anthrax of the eyelid. Indian J Dermatol Venereol 

Leprol. 2003;69:55. 

7. Soysal HG, Kirath H, Recep OF. Anthrax as the 

cause of preseptal cellulitis and cicatricial ectropion. 

Acta Ophthalmol Scand. 2001;79:208-9. 

8. Amraoui A, Tabbara KF, Zaghloul K. Anthrax of the 

eyelids. Br J Ophthalmol. 1992;76:753-4. 

9. Zimmerman RA, Bilaniuk LT. CT of Orbital 

Infection and Its Cerebral Complications. AJR. 1980; 

134:45-50.


423 


DR. ASHOK KUMAR GROVER: M.B.B.S.(’76), Maulana Azad Medical College, New Delhi; 

M.S. (’80), Dr. Rajendra Prasad Centre for Ophthalmic Science, AIIMS, New Delhi. He was on 

the faculty of Maulana Azad Medical College as chief of Oculoplastic service. Received the 

prestigious Col. Rangachari Award, AIOC. President Elect of Oculoplastic Association of India. 

Past president, Federation of Ophthalmic Research and Education Centers (India) and Delhi 

Ophthalmological Society (DOS). Presently, Chairman of the Dept. of Ophthalmology at Sir 

Ganga Ram Hospital, New Delhi. 

Surgical Techniques for Management of Symblepharon: 

A Retrospective Study 

Dr. Ashok Kr Grover, Dr. Pracheer R. Agarwal, Dr. Rituparna Baruah, Dr. Shaloo Bageja 

(Presenting Author: Dr. Pracheer R. Agarwal) 

Symblepharon is always associated with 

functional as well as cosmetic concern to the 

patient. Symblepharon occurs basically as a 

consequence of abnormal cicatricial processes or 

of erroneous placement of flaps in the 

conjunctival wound. Intervention is attempted 

once the inflammatory process is under complete 

control. In cases of abnormal position of lids due 

to symblepharon, correction of the conjunctival 

anomalies is to be dealt first followed by the 

correction of the palpebral part. The tension 

Chemical injury AM in situ Post op pic. 

caused by the subepithelial scar tissue and the 

Tenon’s capsule on the conjunctival surface is 

Pre and post operative pictures of limbal grafting 

released allowing it to return to its original place 

and the exposed defect is covered with a graft if 

required. Different treatment modalities have 

evolved for the same but applying the correct one 

at the correct time matters the most. 

To evaluate different surgical techniques for 

release of symblepharon. 

Symblepharon corrected with Mucus Membrane graft. 


A retrospective analysis of the case records along 

with the photograph of patients of partial and 

complete symblepharon operated between 

February 2003 and October 2007 was done. 

31 patients operated during that period were 

included in the study. Case records were 

analysed to find the 

cause of the 

symblepharon, presenting 

state of the eye, 

stage of the disease 

process, associated 

relevant findings of the 

ocular surface, 

Partial symblepharon treatment received etc. 

Basic principle of surgically treating 

symblepharon though remains the same but 

operative extent and aggressive post surgical 

treatment varies with the cases. 

Simple release of symblepharon with 

approximation of conjunctival defect was used in 

4 cases. Z plasty or VY plasty was carried out in 

4 cases, mucous membrane grafting in 13, 

conjunctival grafting in 8 and amniotic 

membrane grafting in 2 cases. 

Results 

A total of 31 patients (20 males, 11 female) were 

operated on during that period. The average age 

at the time of surgery varied from 6 years to 74 

years.


The underlying causes of symblepharon were 

chemical burns (14), thermal burns (3), 

mechanical trauma (8), congenital (2) and 

previous surgical procedure (4). 

Clinical success was assessed in the follow up 

period of 6 months to 5 years. The results were 

gratifying in all groups with successful release of 

symblepharon and reformation of fornix. 

One of the patients where Z plasty was done 

required a later mucous membrane graft. 

Recurrence occurred in 3 cases where chemical 

burn was the aetiological factor. 

1. Honavar SG. Amniotic membrane transplantation 

for ocular surface reconstruction. Ophthalmology. 

2000;107:975-9. 

2. Shi W. Management of severe ocular burns with 

symblepharon. Graefes Arch Clin Exp Ophthalmol. 

2008. 

Evisceration of the eyeball is a commonly 

performed technique, either for functional or 

for cosmetic reasons. Enucleation is mandatory 

in cases of intraocular tumors and may be 

preferred in situations wherein a risk of 

sympathetic ophthalmia exists, for example 

following trauma or multiple intraocular 

surgeries. In most other situations either 

enucleation or evisceration may be performed. 

Evisceration is preferred by many 

ophthalmologists since it is a quicker procedure 

and is believed to result in better cosmesis and 

implant motility. One of the problems with the 

traditional evisceration technique, however, is 

that it does not allow placement of a large-sized 

orbital implant. Since volume replacement with 

an orbital implant is one of the main 

determinants of a good cosmetic outcome, 

numerous modifications of the standard 

evisceration technique have been proposed to 

allow for larger orbital implant placement. We 

describe our results with one such technique, the 

References 

Discussion 

Symblepharon release can be achieved by the 

different techniques described by the different 

authors. But the basic principle remains the same. 

Grafting can be done with mucus membrane like 

buccal mucosa or conjunctiva, amniotic 

membrane. 

We got gratifying results in most of our cases 

where grafting was done with any of these 

material, however, chemical burn was notorious 

as it had its toll in 3 of our cases. 

Symblepharon can be managed with extremely 

gratifying results by a judicious choice of surgical 

technique. 

3. Kheirkhan A. Surgical strategies for fornix 

recontruction based on symblepharon severity. Am 

J ophthalmol 2008; 146(2): 266-275. 

4. Azuara–Blanco A. Amniotic membrane 

transplantation for ocular surface reconstruction. Br 

J O. 1999;83:1410-1. 

Orbital Implant Placement with A Modified Split-Sclera 

Technique of Evisceration 

Dr. C. P. Venkatesh, Prof Dinesh Selva 

(Presenting Author: Dr. C. P. Venkatesh) 

modified split-sclera technique with optic nerve 

disinsertion, that allows placement of large sized 

orbital implants. 


This was a retrospective, interventional case 

series. Patients posted for evisceration or for 

secondary orbital implant placement following 

previous evisceration surgery were included in 

the study. Following detailed informed consent, 

the modified split-sclera technique was 

performed. In the primary technique, following 

standard evisceration, 2 oblique cuts were made 

in the sclera starting anteriorly and extending to 

the equator at 5 and 11o’clock. A circumferential 

incision was then made around the optic nerve 

head, disinserting the optic nerve from the sclera. 

Two other incisions were made at 7 and 2 o’clock 

starting posteriorly and extending to the equator. 

The orbital implant (PMMA acrylic implants in 

all cases) was placed behind the sclera into the 

orbital fat. A 20 or 22mm implant were used in


425 

all cases. The sclera was closed in doublebreasted 

fashion in front of the implant and the 

Tenon’s capsule and conjunctiva were then 

closed in layers. A similar procedure was 

followed in the secondary cases. Post-operative 

care included a tight pad over the operated eye 

for 5 days to reduce post-operative edema. A 5- 

day course of oral prednisolone 25mg and oral 

antibiotics were also given. After removing the 

pad, antibiotic ointment was prescribed twice a 

day. A custom-made ocular prosthesis was 

placed 6 weeks following the implant placement. 

Both implant and prosthesis motility were 

recorded subjectively. 

Results 

Eight patients (5 male; 3 female, age range 23-75 

years) underwent orbital implant placement 

following evisceration over an 18 month period: 

6 primary and 2 delayed. All surgeries were 

uncomplicated. Follow-up period ranged from 3 

to 18 months. No case of implant exposure or 

extrusion were noted. Reasonable movement of 

the prosthesis was seen in all cases and all 

patients were satisfied with the procedure. 

Discussion 

To our knowledge this is the first series to report 

cosmetic and functional outcomes with this 

particular technique of evisceration. While 

numerous modifications of the spilt-sclera 

technique have been reported, the chief element 

in our technique is the optic nerve disinsertion. 

While this has been alluded to in the literature, 

we are unaware of any study that reports 

outcomes with this technique. 

The split-sclera technique with disinsertion of the 

optic nerve allows placement of large-sized 

orbital implants thereby providing optimum 

volume augmentation and cosmesis. 


DR. KULDEEP RAIZADA: Presently Consultant Ocularistry, HOD, Dept. of Ocularistry, L V 

Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad-34, AP; Visiting Consultant, 

Naryana Netralaya, Bangalore, MGM Eye Institute, Raipur, Aditya Jyot Eye Hospital, Mumbai. 

E-mail: kuldeep_ocularist@gmail.com; Contact: 9849193447 

Management of Sliding Socket Syndrome 

Dr. Kuldeep Raizada, Dr. Deepa Raizada, Dr. Ramesh Murthy, Dr. Santosh G Honavar 

(Presenting Author: Dr. Kuldeep Raizada) 

Loss of an eye can lead to socket deformity 

which can be corrected with a well fitted 

custom made ocular prosthesis. How ever in 

certain conditions, these socket develops Sliding 

socket syndrome which is identified by the 

features of tilting up of prosthesis, frequent 

popping out of prosthesis, ectropion of the lower 

lid, very wide palpebral fissure, socket tilt 

outwards at the lower lid, position of implant 

very low in the socket, shallow inferior orbital fat 

and forward bulge without presence of the 

implant. 

To evaluate the outcome of management of 

sliding socket syndrome “SSS” and their possible 

management with ocular and facial prosthesis. 


Retrospective review of patients with sliding 

socket syndrome fitted with a custom made 

ocular prosthesis over a period of 3 years. 

Results 

On review success in terms of cosmesis and 

subjective improvement was achieved in 90% of 

cases while 10% of cases use of socket expander 

in the form of pressure conformer and later on 

prosthesis was performed. 

The procedures employed in 57 patient where 

tilting of prosthesis was 16% , frequent popping 

out of prosthesis 9%, prosthesis appears to be 

falling out 7%, ectropion of the lower lid 12%, 

very wide palpebral fissure 10.52%, socket tilt 

outwards at the lower lid 1.72%, position of 

implant very low in the socket 14%, inferior 

orbital fat may sit low 10.52% and bulge forward 

without presence of the implant 19.2%. All the


patients were fitted with custom made ocular 

prosthesis, tilting of prosthesis up was corrected 

in 14.2%, frequent popping out of prosthesis 

7.9%, prosthesis appears to be falling out 6.3%, 

ectropion of the lower lid 11.05%, very wide 

palpebral fissure 9.47%, socket tilt outwards at 

the lower lid 1.57%, position of implant sit very 

low in the socket 12.63%, inferior orbital fat may 

sit low 9.47% and bulge forward without 

presence of the implant 17.36%. 

Discussion 

Patient with sliding socket syndrome have 

vertically shallow fornix and need to be 

evaluated carefully with a custom made ocular 

prosthesis. Most cases need a combination of 

modifications of special prosthesis. 


DR. (PROF.) V. P. GUPTA: MD, AIIMS, DNB. Worked as Lecturer, Reader, University College 

of Medical Sciences, Delhi. Head, Dept of Ophthal. Currently Professor and Head, Dept of 

Ophthal, University College of Medical Sciences & G.T.B. Hospital, Delhi-110095. 

Address: 275, Vihar, Delhi–110051. Contact: 30902962, 9818164208, 

E-mail: vpge15gtbh@yahoo.co.in 

Prospective Randomized Controlled Study To Compare The 

Results of Transcutaneous Versus Transconjunctival Frontalis 

Suspension for Congenital Ptosis with Poor Levator Function 

Frontalis suspension remains the gold 

standard for treatment of severe congenital 

ptosis with poor levator function. In brow 

suspension (frontalis suspension) ptosis repair 

ptotic lid is attached to the frontalis muscle using 

strips of sling material so that overaction of 

frontalis muscle elevates the ptotic lid. Bilateral 

congenital cases are most suited for this surgery. 

A variety of sling materials are available in the 

literature including autogenous fascia lata and 

synthetic materials. Fresh autogenous fascia lata 

still remains the most effective and most 

commonly used sling material. Fox’s pentagon 

technique and Crawford’s double triangle 

technique are two commonly used techniques. 

Autogenous fascia lata insertion using Fox’s 

pentagon technique is author’s preferred 

technique. Transcutaneous frontalis suspension 

using fascia lata has been the gold standard. 

Transconjunctival frontalis suspension (TCJFS) to 

elevate ptotic lid for congenital ptosis with poor 

levator action has been described as a safe and 

effective method. 1-2 However, only two studies 

are available in the literature. There is no study 

available from India. Therefore, TCJFS needs to 

be evaluated. This study was undertaken to 

Dr. V. P. Gupta 

(Presenting Author: Dr. V. P. Gupta) 

compare the results of transcutaneous versus 

transconjunctival frontalis suspension to elevate 

severe congenital ptosis with poor levator 

function. 


This prospective randomized controlled study 

included 30 patients of severe congenital ptosis 

with poor levator function (


427 

transconjunctival approach for insertion of mini 

strip of fascia lata (TCJFS) was performed 

through two vertical incisions in tarsus at the 

junction of medial two third and lateral 1/3rd 

and medial 1/3rd with lateral 2/3rd. Two 

forniceal incisions were made, one each in lateral 

and medial aspect of superior fornix. The fascia 

lata strip was finally taken out through single 

central brow incision about 10 mm above brow. 

The ends of fascia lata strip were tied after 

adequate lid elevation was achieved as described 

by the author. 3 Brow incisions were sutured with 

6-0 prolene in both the groups. Frost suture was 

applied. Pad and bandage was done after putting 

antibiotic eye ointment. Frost suture was 

removed after 24 hours. Patients were put on 

frequent lubricating eye drops. Weekly followup 

was done for 4 weeks and then monthly for a 

minimum period of 3 months. Operative 

parameters included the ease of insertion of the 

strip, bleeding, number of skin incisions, 

duration of surgery, effectivity, surgeon’s control 

over the procedure etc. Postoperatively patients 

were evaluated for ptosis correction , over / 

undercorrection, lagophthalmos, lid lag, 

symmetry, cosmesis, any other complication etc. 

Results were compared with preoperative values 

and also with the other group. Follow-up period 

ranged from 3 months to 15 months. Criteria for 

successful results: just/desired correction or 

under/over correction (within 1 mm). 

Results 

There were 18 females and 12 males in the age 

group of 4 years to 20 years. There were 8 

bilateral and 7 unilateral cases (23 eyes ) in each 

group. All cases were congenital simple severe 

cases of ptosis. Degree of ptosis was 4-7 mm and 

levator action was 2-4 mm. Intraoperatively Gr I 

(TCTFS) required 5 skin incisions with more 

bleeding compared to single brow incision with 

less bleeding in Group-II. Duration of surgery 

1. Dailey RA, Wilson DJ, Wobig JL. Transconjunctival 

frontalis suspension (TCFS). Ophthal Plast Reconstr 

Surg. 1991;7:289-97. 

2. Loff HJ, Wobig JL, Dailey RA. Transconjunctival 

References 

was 38 to 50 minutes in group I and 35 to 40 

minutes in group II. Surgeon had more control 

over the insertion of fascia lata in group I 

compared to group II though TCJFS was easier 

and simpler. Successful results were achieved in 

20/23 eyes (86.96%) in group I and 18/23 eyes 

(78.26%). Undercorrection of temporal part of lid 

was seen in 4 eyes in gr I. Functional 

undercorrection occurred in 2 eyes in each group. 

No entropion, exposure keratopathy, 

overcorrection, infection, granuloma or 

recurrence was encountered in either group. Skin 

scars were not cosmetically unsightly. 

Discussion 

Transconjunctival frontalis suspension for 

congenital severe ptosis with poor levator 

function was first described by Dailey et al in 

1991. 1 The technique was further clinically 

evaluated by Loff et al in 1999. 2 No other study 

is available in the literature. The present study 

evaluated and compared the operative and 

postoperative results of TCJFS with those of skin 

approach for frontalis suspension. The success 

rate of TCTFS (86.96%) was more than TCJFS 

(78.26%) though it was not statistically 

significant. TCJFS was simpler and less time 

consuming compared to TCTFS. However, at 

times author felt that TCJFS was a blind 

technique with lesser control over fascia lata 

insertion which might explain undercorrection of 

temporal part of lid in few cases. No major 

operative or postoperative complications were 

noted in either group. Skin scars in group I were 

of no concern to the patient. 

It is thus concluded that transconjunctival 

frontalis suspension appears to be a technically 

simpler, faster and effective technique for 

correction of congenital severe ptosis with poor 

levator function. It may be the viable alternative 

to transcutaneous approach of frontalis 

suspension. 

frontalis suspension: a clinical evaluation. Ophthal 

Plast Reconstr Surg. 1999;15: 349-54. 

3. Gupta VP. Brow suspension ptosis repair using 

mini fascia lata strip: a new modification. Proceed All 

Ind Ophthal Soc Conf. 2001;7-8.



DR. KULDEEP RAIZADA: Presently Consultant Ocularistry, HOD, Dept. of Ocularistry, L V 

Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad-34, AP; Visiting Consultant, 

Naryana Netralaya, Bangalore, MGM Eye Institute, Raipur, Aditya Jyot Eye Hospital, Mumbai. 

E-mail: kuldeep_ocularist@gmail.com; Contact: 9849193447 

Graduated Socket Expansion and Prosthesis 

Dr. Kuldeep Raizada, Dr. Deepa Raizada, Dr. Ramesh Murthy, Dr. Santosh G Honavar 

(Presenting Author: Dr. Kuldeep Raizada) 

Contracted socket can be defined as shrinkage 

of the fornices of the eye. It can be congenital 

(in the form of congenital anophthalmia or 

microphthalmia) or acquired following injury, 

surgical interventions, etc. Contracted sockets 

can be classified as mild, moderate and severe 

and depends on the severity of the shrinkage. 

Contracted sockets can be managed nonsurgically 

by graduated socket expanders and 

surgically by socket reconstruction surgery. 

To review the cases with contracted sockets that 

were managed by the use of graduated socket 

expander in the form of serial conformers/ 

molded socket expander. 


Patients with contracted socket who had 

undergone socket expansion therapy with 

graduated conformers, then fitted with custom 

made ocular prosthesis between January 2006 

and December 2007 were retrospectively 

reviewed. 

Results 

There were total of 15 patients with socket 

contraction associated with anophthalmia 

(congenital and acquired anophthalmia) and 

Ocular adnexal lymphomas present usually as 

a primary disease and a localized disease 

involving the orbital soft tissue, conjunctiva, and 

eyelid and the lacrimal gland. 2,3 These tumors 

originate from B-cells in the eye and related 

microphthalmia who had undergone socket 

expansion therapy and fitted with customised 

prosthesis during this period. 8 patients had mild 

contracted socket and 6 had moderate socket 

contraction and 1 had severe socket contraction. 

Mean age was 30.33 (range was 5 to 65 years). All 

patients were well managed by serial conformers 

of gradually increasing size followed by custom 

made ocular prosthesis fitting. Mean duration 

between date of presentation and date of 

prosthesis fitting was 13.8 weeks (range 6 weeks 

to 36 weeks). Satisfactory socket expansion to fit 

with a well-fitting prosthesis was achieved in all 

patients. Subjective perception of cosmesis with 

the custom ocular prosthesis was satisfactory in 

12 patients, 3 patients complained of smaller 

appearance with prosthesis compared to the 

other eye who were subsequently managed by 

cosmetic optics ( prescription of plus spherical 

and cylindrical lenses in front of prosthetic eye). 

Discussion 

Satisfactory socket expansion and cosmesis can 

be achieved by graduated conformers followed 

by custom made ocular prosthesis fitting in cases 

with mild to moderate contracted sockets. 

Ocular Adnexal Lymphoma - A Clinico-Pathological Study in 

Tertiary Eye Care Centre 

Dr Usha Kim, Dr. Mihir Mishra 

(Presenting Author: Dr. Mihir Mishra) 

tissues. Most patients with ocular adnexal 

lymphoma have stage IE disease, most common 

type being the extranodal marginal zone B-cell 

lymphoma of mucosa-associated lymphoid 

tissue (B-EMZL), although diffuse large cell B-cell


429 

lymphomas (B-DLCL), mantle cell lymphomas 

(B-MCL), follicular lymphomas may also be seen 

². Staging is done by REAL⁸ and Ann Arbor 

classification. Ocular adnexal lymphomas can be 

an initial presentation of NHL, either solitary or 

systemic and may present with symptoms of 

painless proptosis and/or diplopia due to an 

orbital mass, conjunctival salmon patches, or 

ptosis from eyelid involvement, and may spread 

locally or disseminate systemically.² Management 

is by excisional biopsy, radiotherapy, 

chemotherapy, and various combinations. 

The purpose of this study is to focus on the 

clinical spectrum and staging of histologically 

proven ocular adnexal lymphoma and its 

correlation with final outcome. 


Retrospective study was done from 1998 to 2007 

of all cases who presented to Aravind Eye 

Hospital, Madurai. Clinical data was analyzed 

for each patient with review of histopathological 

slides and medical records, scans in relation to 

epidemiological characteristics, clinical staging, 

histopathological staging and final outcome. 

Complete ophthalmologic assessment 

comprising of visual acuity, diplopia chart, 

description of functional symptoms, evaluation 

of eye movements, slit lamp findings, and ocular 

fundus findings for any associated extra ocular 

compression by the tumor was tabulated. The 

anatomic localization of ocular adnexal 

lymphoma was defined as orbital, conjunctival, 

lacrimal gland, and eyelid, based on 

ophthalmologic examination and computed 

tomography (CT) or magnetic resonance imaging 

(MRI) of the orbits. Full physical examination, 

hematological and chemical survey findings 

were noted. CT of the neck, chest, abdomen, and 

pelvis, bone marrow biopsy and aspiration 

cytology reports were also taken into 

consideration. All pathologic specimens were 

reviewed and the histopathological analysis was 

done based on the Revised European American 

Lymphoma (REAL) classification⁸ and Ann 

Arbor classification. 

Results 

Number of cases taken was 83 with male to 

female ratio being 2:1, orbital lymphoma was the 

most common primary orbital malignancy, 

median age was 56 years (1.5 to 83 years). 

Common age of presentation was 41-70 years in 

55 (66%), followed by 21-40 years in 15 (18.07%), 

71-90 in 10 (12.05%) and 0-20 years in 3 (3.62%). 

Unilateral presentation was in 76 (92%) and 

bilateral in 7 (8%) of the cases, with most 

common presentation clinically being a palpable 

mass 60 (72%), followed by proptosis in 46 

(55.4%) ,salmon patch in 23 (27.71%), ptosis in 22 

(26.71%), pain in 16 (19.27%), diminution of 

vision in 9 (10.84%) , diplopia in 9 (10.84%) and 

lymphadenopathy in 4 (4.82%) and no palpable 

mass in 23(27.71%). Most common location of 

palpable mass was superomedially in 24 (40%), 

superolaterally in 20 (33.3%), Superomedial and 

inferiorly in 6 (10.0%) and isolated inferiorly in 

10 (16.67%). The most common lid location being 

upper lid medially in 12 (60%), lowerlid medially 

in 5 (25%), upperlid laterally in 2 (20.0%) and 

lower lid laterally in 2 (20.0%). Most common 

conjunctival location was superiorly in 14 (60%), 

inferiorly in 6 (26.09%) and medially in 3 

(13.05%). Lacrimal gland involvement was in 7% 

of cases. According to Ann Arbor system, 77 

(92.8%) patients had stage I Extranodal Mantle 

zone lymphoma (stage IE), 2(2.4%) patients had 

stage IIE and 1 (1.2%) patient had stage IV 

Diffuse Large Cell Lymphoma, 2 (2.4%) patients 

had stage IV Mantle Cell Lymphom , and 1(1.2%) 

patient had stage III follicle cell lymphoma. Extra 

nodal marginal zone lymphoma 58 (69%) was the 

most common histopathological diagnosis 

according to the REAL Classification, followed 

by diffuse large cell lymphoma in 17 (20.48%), 

follicle centre lymphoma–I in 4 (4.82%), follicle 

centre lymphoma-II in 2 (2.41%) and Mantle cell 

lymphoma in 2 (24.1%). 

Disscussion 

In our case series of Ocular adenexal lymphoma, 

the male predominance is seen in contrast to 

many studies⁶, with most common presentation 

as a palpable mass ⁷, with most common 

histopathological type being extra nodal 

marginal zone lymphoma (B-EMZL )stage I , 

similar data were obtained in other studies². Our 

study disclosed that age, sex, side of 

involvement, anatomic localization of the lesion, 

did not have prognostic significance during a 

follow-up period . HPE analysis and site of tumor 

is not statistically significant. Several major 

criteria must be considered in the initial 

assessment of the disease like the histopathologic


subtype of lymphoma; extension of the disease, 

inside and beyond the periocular region; 

prognostic factors related to the patient and to 

the disease; the impact of the ocular adnexal 

lymphoma on the eye(s) and visual function. 

Vision is rarely affected except in cases of large 

tumors. Longer followup is required for 

detecting systemic manifestation and clinical 

staging is an important predictor for associated 

nonocular systemic disease for which extensive 

work up is required to rule out non-ocular 

1. Rootman J, Chang W, Jones D. Distribution and 

differential diagnosis of orbital disease. In: Rootman 

J, ed. Diseases of the Orbit. Philadelphia, PA: 

Lippincott Williams and Wilkins 2003:53-85. 

2. Coupland SE, Krause L, Delecluse HJ, et al. 

Lymphoproliferative lesions of the ocular adnexa: 

analysis of 112 cases. Ophthalmology. 1998;105:1430- 

41. 

3. Nakata M, Matsuno Y, Katsumata N, et al. 

Histology according to the Revised European- 

American Lymphoma Classification significantly 

predicts the prognosis of ocular adnexal lymphoma 

Leukemia Lymphoma. 1999;32:533–543. 

4. Coupland SE, Hummel M, Stein H. Ocular adnexal 

lymphomas: five case presentations and a review of 

References 

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orbit / plastic surgery session-ii - All India Ophthalmological Society

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