Enucleation medial approach to the optic nerve
This is Richard Allen at the University of Iowa. This video demonstrates enucleation with placement of a porous polyethylene implant with approach to the optic nerve from the medial direction. The patient had a choroidal melanoma. A 360 degree conjunctival peritemy is performed with Westcott scissors. This followed by dissection into each of the quandrants between the rectus muscles with Stevens scissors. The medial rectus muscle is then hooked with a Von Graefe muscle hook. This is then transferred to a Green hook. The muscle is tagged with a double armed 5-0 vicryl suture on a spatula needle. The suture is placed in a locking fashion. The medial rectus is then disinserted from the globe with a stump remaining for future traction suture placement. Attention is then directed to the inferior rectus muscle which is hooked followed by transfer to a Green hook and tagging with a 5-0 vicryl suture in a locking fashion. The muscle is then disinserted flush with the globe with Westcott scissors. The lateral rectus muscle is then hooked, tagged, and disinserted from the globe leaving a small stump for future traction suture placement. The superior rectus muscle is then identified, hooked, tagged and disinserted from the globe flush with the sclera. A 4-0 silk traction suture is then placed through the stumps of the medial and lateral rectus muscles. The superior oblique tendon is then identified with the muscle hook and transected with Westcott scissors. The inferior oblique muscle is then identified and transected with cautery. The optic nerve is then approached from the medial direction in this video. With the scissors closed, the nerve is felt from below and above, and then the blades of the scissors are opened and the optic nerve is transected. Posterior tenons is detached from the surface of the globe. The socket is then packed with a 4 by 4 guaze for five minutes. Inspection of the socket for any residual bleeders shows the transected optic nerve. A 22 mm porous polyethylene implant is then placed. This implant has predrilled holes to which the rectus muscles can be attached. It is useful to pass the needle backwards through the predrilled holes for ease of passage. After attachment of each of the rectus muscles, the tenons is closed with interrupted 5-0 vicryl sutures placed in a buried fashion with the knot deep. This closure is very important to prevent subsequent implant exposure. The edges of the conjunctiva are then identified and the conjunctiva is closed with a running 7-0 Vicryl suture. Again, it is important to insure that the conjunctival edges are not buried in the closure to prevent inclusion cyst formation and future implant exposure. At the conclusion of the case, a conformer is placed with antibiotic ointment and the eye is patch or at least four days.