Enucleation with implant
This video demonstrates an enucleation with placement of a porous polyethylene implant. The patient in this video had a choroidal melanoma. A 360 degree conjunctival peritemy is performed with Westcott scissors. Dissection is then performed in each of the quadrants between the rectus muscles with Stevens scissors. A Von Graefe muscle hook is used to hook the medial rectus muscle. This is often then transferred to a Green hook. The rectus muscle is then tagged with a 5-0 Vicryl suture on a spatula needle placed in a locking fashion. The muscle is then disinserted from the globe with Westcott scissors. A portion of the muscle insertion is left remaining for the medial and lateral rectus muscle for future traction suture placement while the inferior and superior rectus muscles are disinserted flush with the globe. The inferior rectus muscle is the tagged and disinserted, as is the lateral rectus and superior rectus. A 4-0 silk suture is then placed through the stumps of the medial and lateral rectus muscles for traction. The superior oblique tendon is then hooked and transected with Westcott scissors. The inferior oblique muscle is then hooked and transected with cautery. Enucleation scissors are then used to identify the optic nerve from the lateral approach. With the scissors closed, the optic nerve is felt both from above and below, then the blades of the scissors are opened and the nerve is transected. The posterior tenons is removed from the globe and pressure with a 4 by 4 guaze is placed for approximately 5 minutes to insure hemostasis. Any remaining bleeders are identified and cauterized. The orbital implant is then placed. This is a 20 mm porous polyethylene implant with predrilled holes. The rectus muscles are then attached to the implant using the predrilled holes. This is performed with each of the four rectus muscles insuring that none of the conjunctiva is advanced with the rectus muscles. The conjunctiva and tenons are inspected and then the Tenons is then closed with interrupted 5-0 Vicryl suture placed in a buried fashion with the knot deep. The Tenons is closed to insure adequate apposition and also to insure that none of the conjunctiva is buried in the closure. The conjunctiva is then closed with a running 7-0 vicryl suture. A conformer is placed and then the eye is patched for at least 3 days.