Removal of orbital implants in a painful anophthalmic socket
This is Richard Allen at the University of Iowa. This video demonstrates removal of both an orbital floor wedge implant as well as an orbital implant in a patient who has a history of pain in an anophthalmic socket. My preferred treatment for these patients who have pain in an anophthalmic socket is to remove all the implants and place a dermis fat graft. A trans-conjunctival incision is made inferior to the inferior border the tarsus. Dissection is then carried out between the orbicularis muscle and the orbital septum to the inferior orbital rim. A Freer periosteal elevator is then used to expose the inferior orbital rim and the previously placed orbital implant. The screw which fixated the implant is removed and the implant is elevated with the Freer. The implant is then able to be removed. This is a porous implant so there is some adhesion of tissue.
Attention is then directed to the orbital implant. The implant is exposed with Wescott scissors. The muscles which are attached to the implant are identified. This is a quasi-integrated nonporous implant. The muscles are tagged with 5–0 Vicryl suture. The implant is then able to be removed. A scleral shell was placed with this implant. The re-remaining scleral shell is then removed. I will usually send this tissue to the pathologist and they often will see inflammation in the tissue around the implant. The transconjunctival incision is then closed with interrupted 7–0 Vicryl sutures.
The dermis fat graft is then then harvested. The fat graft is then placed into the socket by engaging the edge of the dermis with the previously placed 5–0 Vicryl sutures. Again, it should be difficult to place the dermis fat graft. In general they should be oversized and difficult to place as they will shrink significantly postoperatively. After the 5–0 Vicryl sutures have been tied, the edge of the conjunctiva can be sutured to the edge of the dermis. This is performed with 7–0 Vicryl sutures. The dermis will then epithelialize from the conjunctiva. A large conformer is placed. In patients with dermis fat grafts I will usually place a temporary tarsorrhaphy postoperatively. This will remain for at least 2 weeks. This is placed with 5-0 chromic suture in a mattress fashion. At the conclusion of the case, erythromycin ophthalmic ointment is placed over the area. A double eye pad will then be placed.
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