|Year : 1955 | Volume
| Issue : 4 | Page : 65-68
On a satisfactory last step of exenteratio orbitae
New York (U.S.A.) and Meran (Italy)
New York (U.S.A.) and Meran (Italy)
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Fuchs A. On a satisfactory last step of exenteratio orbitae. Indian J Ophthalmol 1955;3:65-8
When I was a young ophthalmologist an exenteration of the orbit was always a very disagreeable operation. It seemed so cruel to remove the whole content of the orbit including the periosteum and the after-treatment was exceedingly painful for thee patient; specially the last step of the exenteration was quite unsatisfactory. Even now some excellent eye surgeons do not perform an exenteration, for instance Arruga in Barcelona lets general surgeons take care of these patients.
Exenteration of the orbit is indicated either if a carcinoma of the neighborhood of the eye-mostly they are basal-cell carcinomas at the inner angle of the lids-has invaded the orbit, or if a retrobulbar tumor has perforated the sclera, or, and that is perhaps the most frequent, if a tumor of the eye has pervaded the sclera and is spreading in the retrobulbar tissue. This happened very frequently in Europe in olden times and is much rarer now since the people come earlier to the eye doctor and more eye doctors are available now. Nowadays only glioma of the retina (retinoblastoma) and melanosarcoma of the conjunctiva (malignant melanoma) require relatively frequently an exenteration.
The old method of exenteration as practised by Meller (1950) is stilt followed at some places. Meller covers the walls of the orbit by gauze forming a pouch which is then filled out with iodoform gauze, leading it out through the open palpebral fissure. Considerable amount of gauze is added upon the lids for resorption of the secretion of the wound.
After such an operation the removal of gauze from the orbit is very painful although one moistens the orbit with antiseptic fluid. It takes many weeks until the bony walls or the periosteum are covered by granulations and epithelization of the orbit is complete.
Thiel (1945) does not give much information about the last stage of total exenteration. He mentions that a plastic operation upon the naked orbital bone has poor auspices on account of infection coming from the sinuses. He mentions free transplantations of flaps of epidermis after Thiersch. He also notes the use of a pedunculated flap from the temporal part of the face used by Goldwin. He finally states that all attempts to cover the disfigurement due to exenteration by plastic operations are not very successful until now.
Other books on eye surgery advise other means for the last step of exenteration.
Spaeth (1944) for instance advises against the practice of packing an exenterated orbit posterior to the lids. Healing is not stimulated, recovery is delayed and the subsequent removal of this packing gives great pain to the patient. A taponlike mass of gauze soaked in petrolatum is prepared. This is adjusted into the exenterated orbit and then removed. A razor-cut graft is now placed over the tampon and graft and tampon forced into the orbit and a pressure dressing applied. Care should be taken to preserve the exits of the supra and infraorbital nerves.
Reese's (1951) advice does not differ much from that of Spaeth. He wraps a Thiersch's graft round a plug of fluffed gauze shaped to fit the orbit and which is covered with thin rubber tissue fixed by a rubber band and spread over with petroleum jelly. The whole is plugged into the orbital cavity. The redundant bit of the graft around the base of the tampon is then spread out over the inner and outer margins of the orbit and the skin of the lids that remains is tucked in around the roof and floor of the orbit. A pressure dressing is applied.
In England Stallard (1946) uses Dentacoll, an elastic plastic material for preparing the mould, round which the split skin graft is wrapped. This is placed in the orbital cavity. Two suggestions of mine will help the manoeuvering of such a plug. To prevent slipping of the graft over the slippery surface of the plastic material, the surface may be painted with Mastitsol before the graft is wrapped round it. A glass rod or a squarish handle of an old instrument stuck into the mould like a lollipop will help the manipulations.
An alternative to this is to swing down a thick frontal pedicle graft to fill in the orbit. This however, has the disadvantage of leaving scars in the forehead.
In France, Terrien (1939) recommends different methods of plastic closure if the lids remain, some of them similar to Wheeler's restoration of the conjunctival sack.
I was using a different way of ending an exenteration which is simple and leads to fast recovery - not more than two weeks. The original method, first described in the 16th edition of Ernst Fuch's bok (1939), consisted in exactly suturing whatever is left of the conjunctiva, and the skin or only the skin if the entire lids have been removed completely. Moderate pressure dressing is applied. The orbit is filled thus with blood, which later becomes organized and causes retraction of the overlying skin. In this way the cavity of the wound is neatly and quickly covered.
Conway (1955), the plastic surgeon has described two cases in which the orbital defect is bridged by a graft of skin. In a third case the defect was closed in a different way. He elevated the soft tissues from the forehead and caused their relaxation by horizontal incisions from the under (dissected) surface, through the periosteum and the fibers of the frontalis, but not through the skin. Similarly, the soft tissues from the anterior aspect of the maxilla were raised and mobilized so that the upper and lower edges of the defect could be bridged by linear sutures in a horizontal direction. The relaxation of the upper flap by use of the hidden relaxation incisions is the effective step in this technique. -'his method recognizes the fact that a dead space, provided by the cavity of the orbit, must eventually fill with serum and blood. The effect of such a concentration of fluid is fibrosis which results in a dimpled surface. The remnant of the eyebrow is however dislocated downwards.
I may mention that for a closure of a very big defect in which both lids have been entirely removed, a more simple procedure is possible. In 1928 I operated on a lady, 38 years of age, who had black disseminations of melanosarcoma (malignant melanoma) in the right upper and lower fornix conjunctivae. Both lids, the skin of the right side of the bridge of the nose, the tearsac and the ductus lacrymalis and orbital tissue were removed. Then I undermined with a knife the skin of the forehead and the cheek without touching the periosteum or the frontal muscle until I was able to push the cheek with my hand so far upwards that the skin, corresponding to the lower orbital margin, touched what was left of the upper lid. While my assistant kept the cheek in this position I united the upper and lower wound lips in a linear suture. I was not able, however, to cover the defect of the inner angle where an area, the size of less than a nickle remained uncovered. After application of some boracic vaseline and a piece of guttapercha on top of the operating field, all the time the cheek was pressed upwards by my assistant, I pulled the cheek by several strips of strong adhesive plaster to the forehead; I did not exert then special pressure as by the plaster strips such pressure was already exerted. Seven days later I loosened the upper ends of the plaster strips while my assistant pressed the cheek upwards without a moment's relaxation. I looked at the suture and removed the stitches. Without further procedure I fixed the same ends of the plaster to the forehead again. The same pressing of the cheek upwards was done, when I examined the wound on the eleventh day. By the fourteenth day the wound healed; only at the inner angle, between the bridge of the nose and the former lids was a spot 4 mm in diameter filled with granulations. I applied another dressing which pulled the cheek upwards, and sent the patient back to Roumania where she had come from. When I saw the lady 5 years later the orbit was closed by soft skin showing a slight indentation. The scar was not visible on it, the eyebrow was not pulled down.
The fact that in the case of Conway the eyebrow was dislocated downwards, while in my case the eyebrow remained in its original normal place is probably caused by the incisions through the frontalis muscle.
One can see by this case of mine that special incisions through periosteum and frontalis muscle are not necessary or essential.
| Summary|| |
The different methods for causing healing of the cavity left after an exenteration are described briefly.
A simple and quick method of closing the gap without causing dislocation of the eyebrow downwards is suggested after its successful application in a case where an extensive removal of both the lids, skin of the right side of the bridge of the nose along with the lacrimal sac and duct had been undertaken for a malignant nuclanoma of the conjunction.
| References|| |
Convey, H. (1955), Arch. of Ophth. 53, 600.
Fuch, A. (1927), Atlas of the Histopathology of the Eye. Fianz Deuticke, Vienna.
Fuchs, E. and Fuch, A. (1939), Lehrbucke du Augenheilkunder, Franz Deuticke (16th edition), Vienna.
Meller, J. (1950), Augenarztliche Eingriffe, Springer-Verlag, Wien, p. 190.
Reese, A. B. (1951), Tumours of the Eye. Paul B. Hoeber, New York, p. 555.
Samuels, B. and Fuchs, A (1952), Clinical Pathology of the Eye. P. Hoeber. New York.
Spaeth, E. (1944), Principles and Practice of Ophthalmic Surgery, Lea and Febinger, Philadelphia, p. 100.
Stallard, H. B. (1946), Eye Surgery, William Wilkins Co., Baltimore, p. 431.
Terrien, F. (1939), Traite D'Ophthalmologie, Masson et Cie, Paris. Vol. VII, p. 862.
Thiel, R. (1945), Ophthalmologische Operationslehre, Georg Theme, Leipzig, p. 732.
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