Loss of Orbital Fat (Adipose Tissue) in the Geriatric Patient

When a patient's eye is enucleated and there were no prior surgeries or trauma to the eye, there is full retention of the palpebral conjunctival tissue (posterior part of the upper and lower eyelids) and adequate bulbar conjunctiva (covering tissue over the scleral portion of the eye).  This is an ideal situation for an orbital motility implant.  Equally, this situation allows the ocularist ample space to properly fit an ocular prosthesis to complement the implant and its design for synchronized movement with the sighted eye.  However, a detriment to facial symmetry despite an excellent moving prosthesis is when there is loss or displacement of adipose tissue in the area of the superior sulcus (between the eyebrow and the upper lid margin).  This is of deep concern by the patient, the oculoplastic surgeon and the ocularist.  This condition more commonly affects the geriatric patients, especially if the remaining eye shows blepharochalasis (an excessive amount of skin in the upper eyelid).

This elderly patient had a simple enucleation of the left eye without complications.  A ball (enophthalmos reducing) implant had been placed within the cavity with no attachment of the rectus muscles.  When referred to this laboratory for an evaluation of her present ocular prosthesis there was question whether possible oculoplastic corrections were necessary for orbital volume enhancement and surgical elevation of her blepharoptotic (drooping) upper eyelid.  The (empirically fitted) plastic artificial eye being worn did fit comfortably and had adequate anterior projection, and its anterior surface was similar in curvature to the fellow eye.  An impression moulding of the cavity however, did show a deeper depth to the upper fornix that would require working up of a flush fitting wax prosthetic model to determine what could be first accomplished with a new impression moulded prosthesis.  The extension of the superior periphery of the prosthetic model immediately restored fullness to the upper sulcus, and a marked deviation to the anterior curvature of the model helped support the weakened levator muscle and lid.

Figure 17A This patient presented a typical case of geriatric upper lid depression accompanied with a severe ptosis (drooping) of the left upper lid.

Figure 17B A new impression moulded prosthesis with modification to the anterior surface above the upper tarsal lid fold successfully eliminated the enophthalmos.

Figure 17C The old custom made plastic ocular prosthesis (left) shows a conventional curvature, while the newer impression moulded prosthesis (right) shows an extended upper peripheral edge that fit deeper over the ball implant.  The front of the prosthesis was also radically modified to elevate the ptotic eyelid.