Scleral Patch Graft for Exposed Orbital Implant
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This is Richard Allen at the University of Iowa. This video demonstrates repair of an exposed orbital implant with a scleral patch graft. The exposure is demonstrated and the area is infiltrated with lidocaine with epinephrine. Westcott scissors are the used to freshen the edge of the conjunctiva and widely undermined the conjunctiva and Tenons from the surface of the implant. It is important to mobilize this tissue enough so that the edges of the conjunctiva can be closed without tension. The exposure is noted and if closure is performed horizontally, you may compromise the inferior fornix. Therefore, usually I will close these incisions vertically. The exposure is then measured with calipers. The scleral patch graft is oversized by two millimeters in each dimension to cover the exposure adequately. The sclera is then placed over the implant and under the Tenons. A 6-0 vicryl is then placed medially approximately 5 mm medial to the edge of the conjunctiva. This suture is then placed through the medial central portion of the sclera and then back through the Tenons and conjunctiva. A similar suture is placed laterally. These sutures are placed so that when tied, the conjunctiva and Tenons will be advanced over the sclera to completely cover it. I think it is important to be able to completely cover the scleral with no tension on the conjunctival edges. I do not think that the scleral should be left bare to epithelialize. The lateral suture is then tied followed by the medial suture. This results in advancement of the conjunctiva and Tenons over the donor sclera. The conjunctival edges can then be closed with interrupted 7-0 vicryl. At the conclusion of the case a conformer is placed and the patient is patch for 2-3 days. The patient returns in one week for reevaluation. I like to keep the patient out of their prosthesis for one month.
