Orbital Implant Exchange
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This is Richard Allen at the University of Iowa. This video demonstrates an orbital implant exchange in a patient with an anophthalmic socket with a history of a chronically exposed orbital implant, status post multiple attempts at repair. Inspection of the conjunctiva shows that there is enough conjunctiva available so that a dermis fat graft does not need to be performed. Dissection is then performed along the surface of the implant with Stevens scissors. In this case, the rectus muscles will not be isolated, but if desired, they could be. A towel clip is very useful to engage the porous implant. Additional dissection is carried out along the surface of the implant. After the implant is removed from the orbit, I think it is useful to send it for culture. Hemostasis is attained with pressure. I try to use minimal cautery in order to prevent fat atrophy. A PMMA implant is then place deep in the socket in the intraconal space. A double Tenon's closure will then be performed. The posterior Tenon's is closed over the implant with interrupted 4-0 Vicryl sutures. After the implant has been adequately covered, attention is then directed to the anterior Tenons. This is closed with interrupted 5-0 Vicryl suture placed in a buried interrupted fashion. After this closure, there should be minimal tension on the conjunctiva. I think that the double Tenons closure is important to prevent subsequent implant issues. The conjunctiva can then be closed with 7-0 Vicryl sutures. For implant exchange, I will use interrupted sutures. It is important to carefully oppose the edges of the conjunctiva. Epithelium should not be buried to prevent inclusion cysts. At the conclusion of the case, the patient has good closure. A conformer is placed showing that the conjunctiva has adequate surface area. The patient is patch for one week.
