Best Technique to Repair Scleral Melt or Scleral Necrosis

Best Technique to Repair Scleral Melt or Scleral Necrosis

These are the best videos showing how to repair a scleral melt. I hope to put up my videos on YouTube as well.

1. This is an older technique that shows the classic, “score the rectangular area & remove necrotic & healthy sclera” all surgeons learned in residency.
I have always thought that it makes more sense to remove only the necrotic tissue and not healthy sclera, so I prefer to use the following videos. 

2. This video by Dr. Tseng shoes a more modern way of repairing scleral melts. This is my preferred technique. 

3. This is an older version of Dr. Tseng’s technique which uses multiple layers of Amniotic Membrane in the defect. This works well if the patient has no immune issues or underlying inflammatory conditions. If a patient has any active immune issues, this will not work and the melt will return. 

A sample operative note:
Risks, benefits, and alternative to surgery were discussed with patient. Patient agreed to surgery and consent was signed. Patient’s eye was prepped and draped in usual sterile manner. Sterile lid speculum was placed.  1:1000 Epinephrine drops were used to cause vasoconstriction and Lidocaine gel was used to for topical anesthesia. A traction suture of 7-0 vicryl was placed. Necrotic tissue was removed with a crescent blade and 0.12 forceps.
Sharp westcott scissors was used to dissect conjunctiva from the border of the scleral melt and isolate Tenons layer. Edges of defect were inspected and necrotic tissue and calcium deposits were removed. 
A full thickness corneal graft was used to patch the defect and provide tectonic support. The corneal graft was prepared by sizing the defect, removing endothelial cell layer, and tapering edges to fit the defect.
Fibrin glue was used to secure the graft. Fibrin glue was used to then secure the isolated Tenons layer. Glue was then used to apply Amniotic Membrane and then the conjunctival over the whole area. A muscle hook was used to apply  gentle pressure at each layer to secure tissue. 
After the area was examined to be sure all layers were fully secured, 5% betadine drops were placed in eye. A subconjunctival steroid injection was given. Antiobiotic drops and a bandage contact lens was placed on the eye. Eye was patched and patient went to the recovery room in stable condition.
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