Kirti Kumari, B. Optom, F. Optom

Oculoplasty Optometrist, Dr. Shroff’s Charity Eye Hospital, New Delhi, India



Contracted sockets are one of the leading complications of enophthalmos, which refers to shrinkage of orbital tissue with a reduction in the orbital volume along the decrease in the forniceal depth that results in complications of sustaining a prosthesis with significant functional as well as psychosocial disability.(1) Anophthalmic sockets are rarely congenital, with a prevalence of 0.2 to 0.3 per 10,000 live births.(2)

Patients having contracted sockets have difficulty in sustaining a prosthesis with commonly discharge complaints resulting from poor prosthetic fitting and extruding implants with poor  ocular prosthesis movement, poor cosmetic appearance, entropion, ectropion, infections and ptosis.(3)

Reconstruction of these sockets helps in improving the quality of life with prevention of the subsequent disastrous inability of the contracted sockets. (4)


There are various factors leading to contracted socket

  • Congenital Anophthalmia, Microphthalmia
  • Ill-fitted Prosthesis and Implant migration
  • Fibrosis in initial trauma, Poor Evisceration /Enucleation, Multiple socket surgeries
  • Poor vascular supply, Keloid formation in the socket
  • A Cicatrising disease of conjunctiva
  • Alkali Burns
  • Irradiation in some Retinoblastoma (5)

Evaluation of socket grading

The most widely used clinical classification is the Gopal Krishna classification, where the contracted socket is divided into five grades (Grade 0-5) (6)

  • Grade 0: A healthy socket with deep and well-formed fornices
  • Grade 1: Shelving or shallowing of the lower fornix
  • Grade 2: Loss of the superior fornix along with the inferior fornix
  • Grade 3: Involvement of all four fornices(superior, inferior, lateral, and medial)
  • Grade 4: Involvement of all four fornices along with a reduction in the horizontal palpebral fissure length(HPFL)
  • Grade 5: Recurrence of contraction after repeated failed attempts at reconstruction (7)


These contracted sockets are a grave complication, along with every failure, an ability to retain prosthesis deteriorates due to which the morbidity increases.

Flap or graft-related complications like necrosis, fat atrophy, the formation of deep sub-conjunctival cysts, post-operative hematoma, granuloma formation, ulceration.

Implant-related complications involve implant exposure, extrusion, migration, infection, and orbital volume deficiency. (8)

Graduated Conformer

These are designed to help in expanding the socket tissues with eyelid openings making the affected eye symmetrical to the child’s fellow eye and optimal for prosthetic eye. (9)

The stock conformers mainly maintain the socket size and prevent scar tissue contractures, therefore custom-made conformers can also be used to enlarge unfavourably small sockets and stimulate eyelid movement. (9)

In Infant patients, the therapy with these can be started after the age of 1 week old.

Post-operative conformer therapy can actually be detrimental to the healing eye socket , as it protects the eye from infection, restricting unwanted particles from the surrounding while being the transparent protective layer.

Figure 1: Karunamoyee Prosthetic Eye Clinic (Painted Conformer)
[Picture courtesy –]


Ophthalmologists along with ocularists can achieve enough symmetrical space in the socket through graduated conformer therapy. (10) The difference in the orbital volume can be observed from pre-insertion to the two years of follow -up. Success can be defined with no extrusion of the prosthesis; palpebral fissure of the affected eye correlates with the fellow eye in unilateral cases along with the gradual increase in conformer size in follow ups without any complications also leads to success of increasing the socket volume along with fornix formation. (10)

Figure 2: Prosthetic Eyes
[Picture courtesy – Conformer Shell (]


  1. Rasmussen ML, Ekholm O, Prause JU, Toft PB. Quality of life of eye amputated patients. ActaOphthalmol. 2012 Aug; 90(5):435-40. [PubMed]
  2. Contracted Socket – StatPearls – NCBI Bookshelf”
  3. Bohman E, RoedRassmusen ML, Kopp ED. Pain and discomfort in the anophthalmic socket. CurrOpinOphthalmol. 2014 Sep; 25(5):455-60.
  4. Ahn JM, Lee SY, Yoon JS. Health-related quality of life and emotional status of anophthalmic patients in Korea. Am J Ophthalmol. 2010 Jun; 149(6):1005-1011.e1.
  5. Farokhfar A, Ahmadzadeh-Amiri A, Sheikhrezaee MR, Gorji MAH, Agaei N. Common Causes of Eye Enucleation among Patients. J Nat SciBiol Med. 2017 Jul-Dec; 8(2):150-153.
  6. Krishna G. Contracted sockets–I (aetiology and types). Indian J Ophthalmol. 1980 Oct; 28(3):117-20.
  7. Bhattacharjee K, Bhattacharjee H, Kuri G, Das JK, Dey D. Comparative analysis of use of porous orbital implant with mucus membrane graft and dermis fat graft as a primary procedure in reconstruction of severely contracted socket. Indian J Ophthalmol. 2014 Feb; 62(2):145-53.
  8. Axmann S, Paridaens D. Anterior surface breakdown and implant extrusion following secondary alloplastic orbital implantation surgery. ActaOphthalmol. 2018 May; 96(3):310-313.
  9. “Treating Microphthalmia, Prosthetic Eyes | Carolina Eye Prosthetics”
  10. Cureus | Eye Conformers as Socket Expanders in … Author:NusratChangal, Rajiv B KhandekarPublish Year: 2021