Enucleation with dermis-fat graft for microphthalmos
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 05:05
This video demonstrates an enucleation with placement of a dermis fat graft in a patient with a history of microphthalmos. I believe that this condition is most effectively treated with enlarging conformers at an early age. Once the conformers reach a volume that results in poor movement or difficulty with retention of the conformer, I believe that enucleation of the microphthalmic globe with placement of a dermis fat graft is the best treatment. This can usually be performed at the age of 1 to 2 years. A Jaffe lid speculum is placed and the small globe is demonstrated with a Desmarres retractor. Westcott scissors are then used to perform a 360° conjunctival peritemy. This can be difficult with small globes. Stevens scissors were then used to bluntly dissect in the 4 quadrants in the area between the rectus muscles. Again, with small globes this can be somewhat difficult. A muscle hook is then used to attempt to hook the lateral rectus muscle. The muscle is identified and then tagged with a double-armed 5–0 Vicryl suture. The muscle is detached from the globe. The superior rectus is then identified and tagged and disinserted. The medial and inferior rectus muscles are then identified and disinserted. 4-0 silk sutures are placed as traction sutures at the area of the insertion of the medial and lateral rectus muscles. Metzenbaum scissors then used to transect the nerve. As is demonstrated the globe is very small and the optic nerve and cornea are noted. During the enucleation, the sutures of the medial rectus were cut. The area of the medial rectus is then tagged with the 5–0 Vicryl suture. The socket is inspected. The dermis fat graft is then harvested which is demonstrated in another video. The dermis fat graft is then engaged with the inferior rectus 5–0 Vicryl sutures at the edge of the dermis. The same is then performed for the superior rectus sutures. In general, it should be difficult to place the dermis fat graft as one wants as much volume as possible. The lateral rectus sutures are then used to engage the dermis. The sutures are then tied and the medial fat is then placed into the socket. In this case it is difficult to place all of the fat which is the preferable situation so that one attains good volume. After the fat is placed into the orbit, a 7–0 Vicryl suture is used to suture the edge of the conjunctiva to the edge of the dermis. This is placed with a few running sutures. Care is taken not to bury any of the conjunctival epithelium. If this is performed, a conjunctival inclusion cyst may occur later. After all the edges of the conjunctiva have been sutured to the edge the dermis, there appears to be good volume. Some of the long ends of the 6-0 Vicryl suture are excised. A medium to large conformer is placed. In almost all dermis fat grafts I will place a temporary tarsorrhaphy. This is performed with 5-0 chromic suture. Usually 3 mattress sutures can be placed. A double eye pad is placed and the patient will follow up in approximately 1 week.
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