Overview of Reconstructive Eye Surgery
Surgical removal of skin cancer of the eyelid is standard therapy. Depending on the size, depth, and location of the lesion, this can cause substantial loss of eyelid skin that may affect its function and appearance.
Surgeons attempt to preserve as much skin as possible and minimize scarring, while making sure that all of the cancer cells are removed. Moh's technique, (link) or frozen section control, for example, enables the surgeon to excise the tumor while leaving more healthy tissue intact. Some very small tumors may heal on their own, through a process called granulation.
A large tumor may require reconstructive surgery. Two methods used are skin flaps and skin grafts. Both procedures "borrow" skin away from the immediate operative area. In a skin flap, the tissue is borrowed from a nearby area and attached to the face. The incision is made to create a flap that will cover or partially cover the wound, once the tumor is excised.
When a skin flap is not possible due to location or size of the lesion, a skin graft is performed. This involves removing skin from another part of the body and using it to create a partial or entirely new eyelid. Skin grafts can be split thickness (i.e., just the surface layer of skin) or full thickness (i.e., includes underlying muscles and blood supply), depending on the individual case. Most skin grafts are successful, but repeat grafting may be needed if they do not heal well.
Graves' ophthalmopathy produces a condition called exophthalmos or proptosis (protrusion of the eyeball). The muscle tissues around the eyes swell, causing significant vision loss and disfigurement. This condition can often be treated with medication and radiation, but orbital decompression is sometimes needed to make more space for the eye and prevent vision loss.
In orbital decompression, bone tissue between the orbit (eye socket) and the sinuses is removed to provide more room for the eye, reducing the protrusion. The procedure is performed under general anesthesia and often requires a short hospital stay.
Orbital Decompression Complications
Following surgery, some patients experience numbness in the cheek, upper teeth, and lip on the affected side, which can last several months. Also, double vision may develop.
Enucleation is the removal of the eye. Intentional removal is a drastic measure, resulting in complete and permanent blindness. Reasons for this surgery include a malignant tumor in the eye, uncontrollable pain in an eye that has lost its sight, or traumatic injury that is beyond repair.
Surgery is performed under general anesthesia. The procedure involves making an incision around the cornea and detaching the eye from the surrounding structures. The eyeball is removed in one piece, along with part of the optic nerve. The eye muscles are preserved, if possible, to enable the movement of a prosthesis.
An ocular prosthesis is an artificial implant that is placed in the empty eye socket. The implant is not visible and maintains the natural structure of the orbit and supports the cosmetic prosthesis that fits over it. The substance of choice is hydroxyapatite. It is derived from a species of ocean coral, closely resembles human bone, and has been used for nearly 20 years. Because of its composition, it can be used as an integrated orbital implant (i.e., it essentially becomes a "living" part of the body).
The prosthetic eye is the visible structure that is handcrafted by an ocularist, a highly skilled specialist. The eye is crafted to match precisely the natural eye and is made of plastic or glass. It fits over the implant and under the eyelids, much like a large contact lens. It moves as the implant moves, resembling natural eye movement. To achieve greater motility, the prosthetic eye can be attached to the implant by drilling a hole in the front surface of the implant and inserting a peg. The peg is then attached to the back of the artificial eye.
A child born without an eyeball (congenital anophthalmos) usually has a small eye socket (orbit) because normal development did not take place in utero. The empty orbit does not grow as the child's face matures, making it impossible to use an implant and prosthetic eye as an adult. To counteract this, an expander or a dermis fat graft is used to encourage normal growth of the socket. A conformer is made of a soft, synthetic material that can be expanded inside the orbit, like a balloon to help keep the orbit open and help it grow.
The orbit can also be expanded surgically, if the conformer fails. One procedure involves going through the scalp to raise the top (roof) of the orbit. Another type of surgery expands the orbit by dividing it into three parts. Surgery is performed under general anesthesia in a hospital.
Rarely, a person who has undergone enucleation is unable to wear a prosthesis. Cosmetic procedures for children with congenital anophthalmos are sometimes unsuccessful. In some cases, the eyelids are too short and cannot be adequately lengthened, even with skin grafts. The orbits may not expand sufficiently, even with expanding devices and surgery. There may also be facial or bone deformities that do not allow for a natural-looking prosthesis.