Continuous Adipose Tissue Loss
(A Geriatric Problem)

Retention of normally positioned adipose tissue within the bony orbital wall at the time of enucleation decreases according to the age of the patient.  A slight or moderate superior sulcus depression may begin to appear simply as a gravitational displacement of fatty tissue to the floor of orbit.  This event can occur with patients in the mid to late twenties which is just beyond their growing years.  With advancing years (at the time of a simple enucleation) the superior orbital depression can become markedly deeper not only because of settling tissues, but also a breakdown of the fatty tissue itself, and laxity in the eyelids orbicularis (closing) and levator (elevator) muscles.  Fortunately, oculoplastic surgeons have developed several different implants designed to alleviate this upper orbital deficiency, and will either insert one at the time of enucleation.  Or in cases, where there is late post enucleation (acquired) marked enophthalmos, a surgical procedure can replace the primary implant with a secondary volume enhancing implant of proper size and design.

This case presents trauma to the left eye that caused a retinal detachment resulting in two surgical procedures in an attempt to restore vision.  Unfortunately, the eye became blind and painful requiring an enucleation at the age of 70.  Because of conjunctival scarring and contraction of tissue caused by the prior surgeries, only a 16 mm silicone ball could be inserted within the cavity.  Evaluation of the palpebral fissure without a conformer or prosthesis gave a wider aperture than the fellow eye.  There was also a backward rotational shifting of the upper eyelid causing ectropion (outward rolling of the lid and eyelashes).  Examination of the cavity, found the upper fornix was shallow and would not allow for any prosthesis to fit any deeper than the upper tarsal lid fold.  This restriction made it impossible to compensate for the noticeable superior sulcus depression.  This patient because of her age had no desire to undergo socket reconstruction.

Figure 19A The completed ocular prosthesis for this 70 year old patient was asymmetrical in the lid aperture and displayed a deep superior sulcus depression with ectropion of the upper eyelid.

Figure 19B When finger pressure was applied to the lower eyelid it demonstrated how the remaining adipose tissue that had settled to the floor could be forcibly returned to the superior sulcus and simultaneously reposition the upper lid eliminating the eyelid and lash ectropion.  This photo was taken 16 months later, after three adjustments were made to the prosthesis to improve cosmesis.

Figure 19C At the age of 80, bilateral anatomical changes in the eyelid structure improved facial balance more than could be accomplished with the prosthesis.  Please note there was significant adipose tissue loss in the superior sulcus of the sighted eye, and the weakened orbicularis muscle now shows the right aperture to be wider.