This surgery demonstrates the replacement of an extruded orbital implant, using a porous polyethylene implant wrapped in GoreTex.
Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Thomas Johnson, Bascom Palmer Eye Institute, University of Miami
Dr.Johnson: So she had an extruded implant on the right side. What we’re going to do is we’re going to open the socket up, put a new implant in. She may also have some socket contracture, so you’ll see, she has a little bit of scarring in the socket. So what I’ve already done in this case is I’ve injected some anesthetic, some lidocaine with epinephrine. So we injected two and a half CCS. She has some previous suture material here, so we’re going to take this out and you can see also where her previous incision was. And she has a small pyogenic granuloma right here, so we’ll just excise that little granuloma as well.
Then what I’m going to do, I’m going to try to use her previous incision to open the socket and get into this normal fat. So usually when a patient’s had socket contracture, there’s an amount of scarring that occurs anteriorly. So you have to kind of go through this scar tissue first, but once I get deeper in the socket, I don’t like to over cauterize because I don’t want to damage the fat because that’ll give me more volume deficiency. Implant materials, there are several implants you can use in an anophthalmic socket. You could use PMMA, that works very well. You can use porous polyethylene, you can really use any implant, but what I like to do if possible is, I like to wrap the implant.
Some of the wrapping materials that are commonly used are eye bank sclera. And that works very well because it’s already in the shape of the implant. I just really have been dissecting through scar tissue, and now I’m into this normal, healthy appearing, orbital fat. And that’s what I like to see, because I want to get through all this scar tissue and get into this interorbital fat plane. So, because that’s where I want my implant to go deep into the socket. So once I have this open, I actually just use my little finger and I go into the socket and I just kind of go deep in the socket and kind of lice any scar tissue with my little finger. I don’t think we’re going to be able to get an 18 in there. We were kind of planning on 18. So I think I’m going to opt to use a 16.
There’s a little more scar tissue here temporarily that they’re going through. This is an implant we’re going to use. This is a porous polyethylene, and this is Gore-Tex. So what I’m going to do is I’m going to wrap this in Gore-Tex. So we’re going to just trim this excess Gore-Tex. Those are other materials you can use besides Gore-Tex, there is a Vicryl mesh you can buy commercially, you can use fascia lata, or you can use temporalis fascia. We’re going to just kind of wrap this around like this, and I’d like to leave a little bit of this open. And then I make a sclera, the part that you leave uncovered, is basically where the cornea used to be. And you always put that posteriorly because that’s where blood vessels and fibrous tissue can actually grow into the implant. And it kind of makes it a living part of the socket, it makes it resist extrusion and becomes a vascularized part of the socket.
Here’s our implant. This is an introducer, you can see it has a, like a plunger here and then it has these things to hold onto. So what I do is, I kind of push all these foot plates inward, so they’re all deep in the socket like this. And then I try to orient the implant to the way I want it to sit in the socket. So I like these little wings to be medial and lateral. So I kind of do that and just kind of work this around.
So I’ve got to just inject this deep in the socket. And then you could kind of massage it again. I’m tucking these wings deep underneath the tissue, because that helps. So I’m going to just hydrate the tenon’s capsule a little bit. Let me get a 5-0 Vicryl please, to suture the tenon’s. Well, the complications you want to avoid are extrusion, Migration, the implant extrusion. So that’s why, you know, we’re trying to really carefully close this tenon’s over it. And then we’ll close another layer over that to close the conjunctiva over tenon’s to try to prevent that from happening. It’s well closed, you can see we have the conjunctiva is closed over the tenon’s. We took care of just the conjunctiva, before this to close it in two separate layers. So I think that’s going to be good. We are just going to inject a little marcaine in to each of the quadrants. So I think she has good replacement of the volume, she’s got a good closure over the implant.
March 12, 2020