Dry Anophthalmic Socket Syndrome

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Article initiated by:

Hashem Abu Serhan

All contributors:

Kamel AbouJabal, Noor Alzeitawi, Nader Elfar, Mahran Zeno, Michael T Yen, MD, Hashem Abu Serhan

Assigned editor:

Annie Moreau, MD

Review:

Assigned status Up to Date

 by Michael T Yen, MD on October 24, 2025.

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Contributing Editors:	add

Disease Entity

Dry Anophthalmic Socket Syndrome (DASS) is a chronic, multifactorial condition affecting patients after enucleation or evisceration, resulting from tear film instability and inadequate lubrication of the anophthalmic socket. It causes discomfort, mucous discharge, and poor prosthesis tolerance due to surface dryness and chronic conjunctival inflammation.

Disease

Dry Anophthalmic Socket Syndrome (DASS) is a common condition that primarily occurs after enucleation or evisceration. Due to insufficient lubrication along with tear film instability of the conjunctival surface, it leads to increased levels of discomfort, frequent discharge, and prosthesis intolerance. Over time, these changes lead to surface dryness, mucous discharge, and chronic conjunctival inflammation, which can reduce prosthesis comfort.

Etiology

DASS is a multifactorial condition due to anatomical and physiological alterations following the removal of the eye globe:

• Reduced blinking frequency with incomplete closure of the eyelids. It is also important to note that the loss of the corneal reflex, which is universal in anophthalmic sockets, is a key mechanism contributing to DASS; a similar reduction in corneal sensitivity is seen after refractive surgery and corneal transplantation, both of which are known risk factors for dry eye.
• Mechanical irritation from the prosthesis inducing frequent microtraumas and conjunctival inflammation.
• Meibomian gland dysfunction leading to disturbance in the lipid layer with increased levels of evaporation.
• Mucin deficiency following decreased goblet cell density.

Risk Factors

1.Previous history of enucleation or evisceration with long-standing anophthalmic sockets.

2.Ill-fitting prosthesis, which leads to increased friction and mechanical trauma.

3.Infrequent cleaning and polishing of the prosthesis resulting in protein deposits.

4. Meibomian gland dysfunction and blepharitis with reduction in lipid layer secretions.

5.Senility with decreased tear production and conjunctival atrophy.

6.Low environmental humidity, air conditioning, and prolonged screen exposure, which exacerbate dryness.

7.Inadequate eyelid closure (lagophthalmos), which affects the distribution of the tear film over the prosthesis.

General Pathology

• Chronic conjunctival inflammation is noticed in long-standing cases.
• Some reports show decreased goblet cell density with an increase in the nucleus-to-cytoplasmic ratio.
• Atrophy of the Meibomian glands with squamous metaplasia, which further compromises the tear film.

Pathophysiology

The pathophysiology of DASS involves both mechanical and inflammatory components:

1. Repeated trauma from the interaction between the conjunctiva and the prosthesis triggers local inflammation along with the release of cytokines, interleukins, and prostaglandins, which lead to chronic inflammation.
2. Surface deposition and the presence of microbial biofilm on the prosthesis trigger further inflammatory responses, disturbing the tear film and the microenvironment.
3. Reduced tear production with disturbance in the tear composition adds to the vicious cycle of inflammation.

Primary Prevention

• Well-fitting prosthesis to decrease the frequency of microtraumas and friction.
• Use of artificial tears with frequent lid hygiene to minimize inflammation and ensure tear film stability.
• Ensuring regular screening for Meibomian gland morphological changes even before clinical signs appear.
• Frequent polishing and professional cleaning to prevent the formation of biofilm and protein build-up.

Diagnosis

Diagnosis of DASS is primarily clinical, based on patient symptoms such as discomfort, dryness, and discharge, combined with slit-lamp findings of conjunctival inflammation, reduced tear meniscus, and meibomian gland dysfunction. Standardized dry eye questionnaires (e.g., OSDI, DEQ-5, SANDE) support subjective assessment, while meibography, tear osmolarity, and MMP-9 tests can aid in confirming disease severity and monitoring response to treatment.

History

Any patient presents with anophthalmic socket complaints should  be asked a detailed history about timing of eye enucleation or evisceration and duration of prosthetic wear, as chronicity increases the chance of developing chronic inflammation that affect structures like meibomian glands, as well as hand washing before handling prosthetic eye, cleaning frequency and regimens used, as over cleanings and frequent removal of prosthetic eye will enhance the risk of mechanical irritation and tear film instability ; similarly longer replacement intervals and infrequent cleaning can also increase dryness and inflammation. The cause of eye removal whether medical or traumatic should be documented; since traumatic eye loss may cause more extensive morphological changes. The type of Material used in the prosthetic eye should also be noted.

External environmental factors such as weather changes, air conditioners, watching TV, work… etc , that may contribute to patient's discomfort due to the loss of corneal reflex.

The medical history is also important, including systemic disease causing eye dryness, previous diagnosis of blepharitis or MGs dysfunction, and the use of topical medications.

Physical Examination

Physical and ocular examination started by inspection of both eyes, comparing the anophthalmic socket to the healthy eye. Assessment of eyelid laxity, position (entropion/ ectropion) and lagophthalmos. Blinking rate, prosthesis fit, and surface condition should also be assessed.

Although ectropion should be observed, it is not linked to a higher risk of inflammation since lashes will contact the prosthetic eye itself rather than the conjunctiva. But it might affect the closure and wetting mechanism of blinking and the lid margin anatomy by inducing keratinization and MG metaplasia.

Signs

Conjunctival epithelium staining as a result of inflammation can be noticed, reduced MGs density on meibography or LSCM and reduced tear meniscus height due to uneven distribution rather than absolute lack of aqueous .

Symptoms

Most anophthalmic patients present with eye discomfort, often associated with foreign body sensation.

Clinical Diagnosis

Clinical presentation is the mainstay of DASS diagnosis. Rokohl et al., 2020 recommended that eye care practitioners should consider the next standard protocol to establish the diagnosis of DASS. This criterion include: at least one of the standardized questionnaires results (OSDI 13, DEQ-5 6, SANDE 13) to identify subjective measurements PLUS at least one of the following clinical conditions ( conjunctival staining due to inflammation, reduced tear meniscus height, anterior or posterior blepharitis).

Diagnostic Procedures

Diagnostic procedures include dry eye disease questionnaires (OSDI, DEQ-5, SANDE, SPEED); OSDI may be preferred in case of an artificial eye existing , while SPEED test provides a more advantage than previous tests as it doesn’t include a visual acuity assessment which is not applicable in DASS patients.

Slit-lamp examination is used to identify the suspected clinical abnormalities: anterior and posterior blepharitis, conjunctival socket inflammation, tear meniscus height. 

Supportive tests  that can be used to support diagnosis especially in symptomatic patients without signs of blepharitis, including goblet cells quantification , Meibography and LSCM, bacterial flora assessment, lacrimal drainage system evaluation and Schirmer I test. According to Rokohl et al., 2020, results of schirmer test vary depending on the material of prosthesis (PMMA vs Glass)

Laboratory Test

Laboratory tests are not routinely needed for DASS patients. However, it can be required if the diagnosis is uncertain or if the cause and severity of conjunctival inflammation cannot be fully explained by slit-lamp examination or unsatisfactory treatment responses, inflammatory markers such as matrix metalloproteinase 9 (MMP-9) and the tear film osmolarity test (TFO), can be measured to assess disease progression or treatment response.

Differential Diagnosis

• Several anophthalmic socket conditions present with similar complaints of DASS due to their overlapping features, these include Bacterial and viral conjunctivitis due to poor hygiene, giant papillary conjunctivitis which is a delayed allergic reaction due to prosthesis surface deposits, And Prosthesis-related conditions that cause mechanical irritation and discomfort due to an ill-fitting prosthesis or rough surface and edges.
• ‏Meibomian gland dysfunction and blepharitis should also be considered as they can be the primary cause of DASS.

Management

General Treatment

The management of DASS is multi-faceted. Aiming to restore moisture, reduce inflammation, break the cycle of irritation of the conjunctiva and ultimately improving prosthesis comfort and wear time. A stepwise approach is usually recommended, beginning with conservative medical therapy and advancing to surgical interventions for refractory cases.

Medical Therapy

• Artificial Tears and Lubricants:

-Artificial Tear substitutes are the Firstline cornerstone of therapy, as they provide symptomatic relief by supplementing the patient’s existing tear film and lubricating the socket-prosthesis interface. Because they're given usually frequently (>4 times daily), it is essential to avoid preservative-induced toxicity, which can exacerbate the underlying conjunctival inflammation. Lubricating ointments provide a more durable protective barrier and are particularly useful for nighttime lubrication. Applying a small amount of non-medicated ointment into the fornix at bedtime can prevent morning discomfort and adhesion of the prosthesis to the socket. The type of artificial tears and lubricants can be aimed towards the underlying cause (Aqueous deficiency vs Meibomian gland dysfunction)

• Mucolytics/mucus Layer Replacements:

In individuals with hydrophobic prostheses, or in sockets where goblet cell function is impaired, inadequate surface wettability could be a major factor leading to tear film instability. Mucolytic Agents such as Acetylcysteine , Hydroxypropyl Guar, or Carbomytheylcellulose can aid by increasing surface wettability and promoting uniform tear film distribution, and can be used concurrently with artificial tears.

• Anti-inflammatory Therapy:

Chronic inflammation is on the key drivers of discomfort in DASS.  Short-term pulses of a mild topical steroid (e.g., loteprednol etabonate, fluorometholone) can be used to rapidly control acute flares of significant inflammation. For chronic cases, a longer duration of immunomodulation is desired, topical calcineurin inhibitors such as cyclosporine and tacrolimus are preferred. They work by inhibiting T-cell activation and the associated inflammatory cascade. Studies have shown that their use can not only reduce symptoms but also increase goblet cell density over time, thereby improving the quality of the native tear film.

•  Prosthetic Care and Surface Wettability:

An essential aspect of reducing inflammation is ensuring that the prosthesis itself has a smooth, wettable surface. Prosthesis that has a scratched or coated surface creates friction and serves as a nidus for debris. Regular professional polishing by an Ocularist is crucial to prevent such occurrences. Additionally, Monthly cleaning by the patient with a mild, non-abrasive soap can help maintain surface quality between professional visits. Excessive cleaning can produce a paradoxical effect.

Surgery

Surgical intervention is reserved for patients who remain symptomatic despite an adequate trial of maximal medical therapy

1.      Punctal Occlusion:

Punctal occlusion helps improve the retention of tears in the anophthalmic socket.  While reflexive tear production is significantly diminished due to the lack of corneal stimulation, the palpebral and forniceal conjunctiva may still receive baseline lubrication from accessory lacrimal glands and conjunctival goblet cells. Punctal occlusion aims to conserve this limited baseline secretion, as well as any topically instilled artificial tears, preventing them from being drained too rapidly from the conjunctival sac, and help lubricate the prosthesis and socket lining

2.      Fornix-deepening Sutures/Reconstruction:

In patients with significant socket contracture and shallow fornices, the tear reservoir is functionally inadequate. Surgical reconstruction using techniques such as fornix-deepening sutures, placement of a conformer, or the use of mucosal grafts (e.g., buccal mucosa, amniotic membrane) can create a deeper space to hold a greater volume of lubricating fluid.

3.      Conjunctival Surface Reconstruction:

For advanced DASS with conjunctival keratinization or symblepharon, the goal is to restore a healthy, moist mucosal surface. Amniotic membrane transplantation is excellent for providing anti-inflammatory and pro-regenerative signals, while buccal mucosal grafting provides a robust, mucus-secreting epithelial surface to replace the keratinized conjunctiva.

Complications

DASS occurs when inadequate tear film and lubrication affect an anophthalmic (prosthesis-bearing) socket, leading to discomfort and poor prosthesis tolerance.

1. Surface-Related Complications

• Conjunctival dryness and keratinization: Chronic dryness may cause epithelial damage, keratinization, and metaplasia of the conjunctiva.
• Papillary conjunctivitis: Friction between the prosthesis and the conjunctival surface can lead to inflammation and mucous discharge.
• Socket discharge and irritation: Secondary to bacterial overgrowth or mechanical irritation.
• Epithelial breakdown and ulceration: In severe dryness, epithelial defects may develop.

2. Structural and Mechanical Complications

• Shallow or contracted fornices: Result from chronic inflammation and fibrosis, making prosthesis fitting difficult.
• Socket contraction: Progressive fibrosis leads to decreased socket volume and poor prosthetic retention.
• Lagophthalmos or incomplete closure: Especially in cases with inadequate eyelid tension or volume deficiency.

3. Prosthesis-Related Complications

• Intolerance or poor fit of the prosthesis: Due to discomfort, friction, or conjunctival changes.
• Deposits and roughening of the prosthesis surface: Aggravates irritation and increases bacterial colonization.

4. Infectious and Inflammatory Complications

• Recurrent bacterial or fungal infections: Chronic discharge and inflammation predispose to infection.
• Blepharitis and meibomian gland dysfunction: Commonly coexist and worsen dryness.

5. Psychosocial and Cosmetic Issues

• Reduced cosmetic satisfaction: Secondary to prosthesis instability, discharge, and redness.
• Psychological distress: Discomfort and appearance concerns may affect quality of life.

Prognosis

The prognosis of DASS is generally chronic but manageable, depending on the underlying cause, patient compliance, and prosthesis care.