a three - year - old boy presented to us with a contracted right 
 socket and history of prosthesis instability , since one year .
he 
 had been enucleated elsewhere for retinoblastoma of the right 
 eye , one year prior to presentation , without orbital implant . 

subsequently , the right socket had received irradiation , details 
 of which were unavailable .
the fitted prosthesis was extremely 
 unstable with repeated extrusion . on examination , the left eye was unremarkable .
the right 
 socket was quiet , healthy with evidence of severe surface and 
 volume contracture .
the patient was started 
 on topical betamethasone eye drops and oral antibiotics ( an 
 ampicillin - cloxacillin combination was used ) , post surgery . 
 on review , a week later , the graft was taking up satisfactorily . 

the oral antibiotics were stopped , the topical steroids were 
 tapered off and the patient was asked to review with us six 
 weeks later . however , the patient presented to us three weeks 
 later with a painful inflamed socket . on examination ,
the socket inflammation was 
 treated with topical antibiotics , anti - inflammatory and systemic 
 antibiotic medication .
the patient was reviewed at one week 
 and at three weeks . at three weeks
the fornices were seen to be severely 
 shallow ( grade iv contracture)1 and there was severe volume 
 contracture ( grade iv),1 as before . at this stage ,
the options 
 of a second dfg or a larger prosthesis , to compensate for the 
 volume loss , were considered .
however , it was impossible 
 for the patient to retain a conformer or any prosthesis at this 
 stage , due to the extreme surface as well as volume contracture
. 
 considering the possible high risk of dfg failure , the patients 
 parents were not in favor of another surgical procedure .
it was 
 under these circumstances that a new technique was attempted , 
 with informed consent .
, a custom - made 
 stem pressure socket - expander was made from high - density 
 polymethyl methacrylate ( pmma ) and fitted a week later 
 [ fig .
this conformer was kept in situ for six weeks , with 
 pressure exerted by a tight sticking tape on the stem of the 
 conformer [ fig .
instructions to change this tape every 
 six - hourly , to ensure adequate sticking and sufficient pressure 
 to the socket expander , were given to the patient .
on review , six weeks later , the expander device was removed 
 and the socket examined .
the socket surface had completely 
 lined with the conjunctiva and the fornices had deepened 
 sufficiently to accommodate a conformer .
we documented 
 the expansion of the socket objectively with our ingeniously 
 devised slit - lamp measurement device.4 the patient was now fitted with a custom - made thicker 
 prosthesis made up of high - density pmma [ fig .
the patient has been 
 followed up for a year and the prosthesis has remained stable .
in a case of failed dfg in an irradiated socket ; expansile 
 expanders can be used .
other useful described techniques 
 include prefabricated temporalis muscle and/or fascia pedicled 
 flap along with fornix formation sutures , which are to be 
 retained for a minimum of three weeks .
we treated a patient with dfg necrosis and a severely 
 contracted anophthalmic socket with a custom - made stem 
 pressure socket expander device .
the prosthesis was thicker to ensure adequate volume 
 replacement and was made up of high - grade pmma to 
 ensure lesser weight .
this prosthesis also had a superior shelf 
 extending backwards into the socket , to provide additional 
 stability .
we documented the expansion of the socket objectively with 
 the slit - lamp measurement device . though it might be difficult 
 to envisage socket expansion solely due to the mechanical 
 pressure exerted by a tape running from the forehead to the 
 cheek , the expansion was possibly due to a combination of the 
 shape of the socket expander , its reach deep into the socket 
 and the mechanical force applied by the sticking tape , changed 
 repeatedly , to ensure proper sticking .
the use of a pressure conformer has been previously 
 described in the literature,5 but to the best of our knowledge , 
 the entire procedure of fitting a special prosthesis post socket 
 expansion , in these patients with severely contracted sockets , 
 has not yet been described in the literature
. however , it is 
 worthwhile to remember that this case of single - time placement 
 of a non - expansile custom - made stem pressure socket expander 
 in an avascular irradiated socket needs to be conducted on a 
 larger sample size with a longer duration of follow - up , to judge 
 the true efficacy of this procedure .
 dermis - fat graft ( dfg ) is often the only promising option in cases 
 of severely contracted sockets . 
 however , there is an increased risk 
 of graft failure in irradiated sockets with decreased vascularity . 
 in such difficult cases , 
 repeat dfg implantation also has higher 
 risks of graft failure.we describe an ingenious method of successful management 
 of an irradiated anophthalmic socket following dfg infection and 
 necrosis , with acceptable cosmetic results . at surgery , 
 an orbital 
 impression was taken with ophthalmic grade alginate . 
 based on 
 this measurement , a custom - made stem pressure socket - expander 
 made up of high density polymethyl methacrylate ( pmma ) was 
 fitted , a week post surgery and kept in situ for six weeks.on review , the fornices had considerably deepened . 
 the 
 expander device was removed and the patient was now fitted 
 with a custom - made thicker prosthesis made up of high - density 
 pmma . 
 the patient has followed up for a year subsequently and 
 the prosthesis has remained stable . 
Case Report
Discussion