Long Term Prosthetic Absence Results in Prolapsed Lower Lid and Loss of Fornix
 

This middle-aged gentleman demonstrates traumatic loss of his right eye that resulted in superior sulcus depression of the upper eyelid.  In other words, a gravitational rotation of adipose (fatty) tissue from the area between the upper eyelid and eyebrow to the front floor of the orbit.  This caused a weaken lower eyelid that was compounded as a result of the patient never wearing an artificial eye for many years following the enucleation.

Evaluation of the adnexa did show:  (1) a hyper-extended eyebrow that made the (2) superior sulcus depression (loss of adipose) more prominent.  The eyelid aperture showed weakness in the (3) levator muscle causing moderate ptosis of the upper lid and (4) an atonal and prolapsed orbicularis muscle.  A study of the orbital tissues revealed (5) contraction of the upper palpebral conjunctiva (beneath the eyelid) resulting in (6) a shallow upper fornix.  Because of this lack of a superior cul-de-sac, it meant there would be limitations as to gaining any close semblance of upper eyelid symmetry, even with a modified impression moulded ocular prosthesis.  When observing the prolapsed lower eyelid, there was (7) exposure of the palpebral conjunctiva and (8) displacement of the bulbar and adipose tissues along the floor of the orbit.  The latter two conditions in turn resulted in the (9) loss of definition of the lower cul-de-sac, and the (10) chronic exposure the palpebral conjunctival tissue caused it to (11) toughen and discolor.

Course of Action:

A mushroom stem conformer of proper size and shape acted as a depressor when placed into the anophthalmic cavity and had its pressure applied into the juncture of the lower lid's palpebral and bulbar conjunctiva.  The constant pressure was applied for one month and after that short a time it helped reform the fornix and restored the function of the orbicularis muscle once it regained its normal supportive position for a volume enhancing ocular prosthesis.

Figure 23A This case shows a long term prolapse of the lower eyelid with loss of the lower fornix.  This was caused by never having worn a supportive ocular prosthesis.  The discoloration of the palpebral conjunctiva was due to chronic exposure and irritation caused by the upper eyelashes rubbing on the under part of the eyelid.

Figure 23B Application of a pressure stem conformer for a period of one month was sufficient time to restore the lower fornix (cul-de-sac) and rejuvenate the orbicularis muscle.

Figure 23C Retention of the ocular prosthesis with wearing comfort was the primary achievement, although the overall cosmesis was far from being symmetrical. You will note the hyper elevation of the eyebrow accentuated the superior sulcus depression, and the partial ptosis (lid droop). The lack of an upper tarsal lid fold was also due to inadequate space under the upper eyelid (fornix).