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T. N. Hwang, L. S. Pereira, T. J. McCulley; Evisceration: The "Swinging Sclera" Modification. Invest. Ophthalmol. Vis. Sci. 2008;49(13):5258.
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Ocular evisceration may have advantage over enucleation in terms of implant motility, and for infectious endophthalmitis, it may prevent extension into the optic nerve. The negative aspect is limitation in orbital implant size. We report an evisceration technique involving a complete full-thickness horizontal sclerotomy that allows placement of larger orbital implants. A previous report described a full-thickness sclerotomy in the oblique quadrants to avoid disinsertion of the recti muscles or violation of the intermuscular septum, which could affect implant motility and stability respectively. Our results show that these issues are avoidable during a horizontal sclerotomy approach.
The study is a retrospective chart review of 9 consecutive patients (6M, 3F; mean age 72, range 49 to 95 years) who underwent evisceration (6 right, 3 left) by the ophthalmic plastics service at the University of California at San Francisco between 6/2006 and 10/2007.The initial steps are done in standard fashion. The cornea and intraocular contents are removed after a 360-degree conjunctival peritomy. The sclera is washed with alcohol. For infectious endophthalmitis, the sclera is sterilized with betadine solution and packed with iodoform gauze with orbital implantation done one week later. Otherwise, the implant is placed primarily. For the full-thickness horizontal sclerotomy, we use Westcott scissors and avoid disrupting the intermuscular septum. Except for a few early cases, we leave the optic nerve attached to the inferior scleral half to help prevent inferior implant migration. Posterior Tenon’s capsule is incised allowing implant placement within the intraconal space. The implant best-approximating the prominence of the fellow eye is chosen. Scleral halves are advanced and closed with interrupted 5.0 Vicryl horizontal mattress sutures with the knots buried between the overlapped scleral edges. Anterior Tenon’s capsule is closed with buried interrupted 6.0 Vicryl sutures, and conjunctiva closed with a running 6.0 plain gut suture.
The sclerotomy allowed placement of larger implants (two 16 mm, four 18 mm, six 20 mm) with excellent motility. Follow-up ranged from 1 to 4 months. None of the 12 implants had erosion. Each had horizontal motility equal to vertical motility. The sclerotomy does cut through the horizontal recti insertions but very little through the muscle bellies with no detrimental effect on motility.
Evisceration with a complete horizontal full-thickness sclerotomy is an effective technique that provides the advantage of larger orbital implant size without affecting implant motility or stability.
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