Continuous versus Interrupted Sutures for Closure of Scleral Pocket and Conjunctiva after Evisceration and Placement of Acrylic Ocular Implant

Ocular evisceration, involving the removal of the ocular contents while preserving the sclera, is an important surgical treatment for blind painful eyes, severe ocular damage, and refractory endophthalmitis [1, 2]. It is a valuable choice for non-salvageable disfiguring eyes and has gained acceptance as a viable alternative to enucleation due to its faster surgical recovery timeframes, greater cosmesis, and comparable postoperative outcomes [2]. However, there are reported complications of evisceration such as implant exposure or extrusion [3]. The reported incidence of implant exposure after evisceration varies from 2.4% to 22% [4‒6]. Several factors affect the occurrence of implant exposure after evisceration, e.g., type of implant, surgical technique, preexisting infection in the eye, previous ocular surgeries, porous implants, preexisting infection, and multiple previous surgeries have been reported to be associated with a higher rate of implant exposure [3]. There are no previous studies [5], which have analyzed the outcomes in relation to the suturing technique of the wound. This study aimed to examine the efficacy of continuous versus interrupted sutures for closure of scleral pocket and conjunctiva after evisceration and acrylic ocular implants in non-infected cases with no previous ocular surgeries.

This is a retrospective cohort study that was conducted at South Valley University Hospital, a tertiary hospital in Egypt. The study reviewed all patients who underwent evisceration surgeries with acrylic implants by the two surgeons (Ah or Ab) during the period from 1 March 2019 to 31 March 2024. For each patient, clinical data were reviewed, which included patients’ demographics, immediate indications for evisceration, operative details, and postoperative follow-up data. An in-depth evaluation was undertaken to include factors such as suturing technique, suture type, surgical time, wound integrity, and incidence of complications (including infection, implant exposure/extrusion, and wound dehiscence). Cosmetic patient satisfaction was measured using the visual analog scale (VAS) which is a simple scale where patients rate a percent of their satisfaction with the appearance and function of the artificial eye. Patient satisfaction was achieved if the average percentage of the patients was more than 80%.

Informed consent was obtained from all patients and the study was approved by the Ethical Committee of Qena Faculty of Medicine of South Valley University (approval code: SVU/MED/OPH026/4/24/7/885) and the study was adherent to the tenets of the Declaration of Helsinki. The surgical procedure and its prognosis along with complications were discussed with patients and only those patients who accepted surgery were included in the study.

• -

  Previous evisceration surgery.

• -

  Any implants other than acrylic type.

• -

  Ocular infection, especially endophthalmitis.

• -

  Any systemic disease affecting wound healing, e.g., uncontrolled diabetic mellitus and collagen diseases.

Evisceration was done under local anesthesia in most patients. Anesthesia was given via retrobulbar approach using 5 mL of 2% xylocaine with 75 IU hyaluronidase. Lieberman eye speculum was used to separate the eyelids. A 360-degree conjunctival peritomy was performed. Limbal incision using Parker Blade No. 11 was then extended 360° by corneal scissors to enter the anterior chamber after removal of the cornea. After the evacuation of the ocular contents, the remnants of uveal tissue were systematically separated from the sclera and optic nerve 360° using a metal scoop. Irrigation of the globe with povidone-iodine 5% preceded before placement of an acrylic spherical implant with the appropriate size (from 16 to 22 mm). Two scleral incisions were made at 6 and 12 o’clock positions to allow closure of the scleral pocket.

Lastly, there were two broad methods of closure of the sclera and conjunctiva that were adopted:

• A: the scleral pocket was closed by a continuous suture with a lock using Vicryl 6-0. Then the conjunctiva/tenon capsule complex was closed horizontally with palpebral fissure by continuous suture with lock using Vicryl 6-0 suture. Figure 1 shows the final wound closure with the continuous technique.

• B: the scleral pocket was closed by interrupted sutures using Vicryl 6-0. Then the conjunctiva/tenon capsule complex was closed horizontally with palpebral fissure by interrupted sutures using Vicryl 6-0 suture.

In all cases, the conformer was fitted in the conjunctival sac, followed by the application of antibiotic eye ointment and after 2 months, an ocular prosthesis was applied. All patients were followed up on the 1st, 3rd, and 7th days and in the 1st, 2nd, 6th, and 12th months postoperatively. During the follow-up, the patients were assessed for infection, wound healing, and exposure or extrusion of the implant. Implant extrusion refers to the actual protrusion or migration of the implant from its intended site, whereas implant exposure refers to the visibility or accessibility of the implant as a result of inadequate wound healing or dehiscence.

Data were analyzed using IBM-SPSS 24.0 (IBM-SPSS Inc., Chicago, IL, USA). Descriptive statistics including means, standard deviations, medians, ranges, frequency, and percentages were calculated. As a test of significances, the chi-square test was used to compare the difference in the distribution of frequencies among different groups. As a test of normality, the Shapiro-Wilk test was used to test the normality of continuous variables. For continuous variables with two categories, the independent sample t-test and Mann-Whitney U test were calculated to test the differences in mean and median between groups as appropriate. A p value <0.05 was considered significant.

Forty-seven patients were included in this study. Twenty-seven were in group A (continuous sutures) and 20 patients were in group B (interrupted sutures). The mean age of patients in group A was 38.52 ± 12.8 years, while the mean age of patients in group B was 39.35 ± 14.5 (p value = 0.839). Males represented 51.9% (14/27) and 50% (10/20) of groups A and B, respectively, with p value = 0.901. Regarding the surgical indications of evisceration between the 2 groups, absolute glaucoma was the indication in 5 (18.5%) and 3 (15%) patients in groups A and B, respectively; anterior staphyloma was the indication in 7 (25.9%) and 5 (25%) patients, respectively; and atrophia/phthisis was the indication in 6 (22.2%) and 5 (25%) patients, respectively, while old trauma was the indication in 9 (33.3%) and 7 (35%) patients, respectively, with p value = 0.769. Figure 2 shows the indication of evisceration in both groups. The median size of the acrylic implant used was 20 mm (range: 16–28 mm) in group A and 20 mm (range: 16–33 mm) with no statistically significant difference detected between the 2 groups (p value = 0.957). Table 1 shows the sociodemographic and clinical characteristics of patients in the 2 groups. The mean postoperative follow-up duration in group A was 20.19 ± 3.2 months, while in group B, it was 19.95 ± 3.4 months (p value = 0.812). During this follow-up, no cases of infection or implant extrusion were observed in both groups. However, in group B, there were 3 cases (15%) of wound dehiscence and implant exposure, while no reported cases in group A (0%) with clinically significant p value (0.029). Table 2 summarizes the surgical outcome between the 2 groups.

To maintain wound integrity and reduce problems such as implant exposure or wound dehiscence, the suturing technique used during ophthalmic procedures, such as evisceration, is of considerable importance. This study shows that interrupted sutures offer a less secure closure than continuous sutures. Better tension distribution over the wound is made possible with the continuous approach, which contributes to the lower likelihood of complications.

Old trauma, anterior staphyloma, atrophia/phthisis bulbi, and absolute glaucoma represented 34% (16/47), 25.5(12/47), 23.4(11/47), and 17(8/47), respectively. There is a diversity between different studies in different countries regarding the indications of evisceration [7], e.g., in the Middle East trauma is the main cause [8] in Jordan, while in Saudia Arabia [9], endophthalmitis is the predominant indication. We excluded infection cases from this comparative study due to the suspected effect of infection on the process of wound healing. Paying meticulous attention to surgical technique is a crucial part of minimizing the postoperative complication of evisceration with implant insertion [10]. Various surgical techniques have been proposed to prevent this complication of implant extrusion. For example, a study by Babty et al. [11] reported a novel technique in 5 patients with the use of an autologous scleral button graft to close the anterior defect and showed no postoperative implant extrusion or exposure up to 48 months postoperative follow-up. Another study by Nadal et al. [12] showed a lower incidence of implant exposure (1.5%) with the use of autogenous scleral graft to close the scleral wound, but this study had used bioceramic implants. A more simplified surgical scleral wound management technique [13] performed quadrisecting the sclera and covering the implant with 2 layers of sclera with zero incidence of implant exposure or extrusion. However, this study used only a porous polyethylene implant which is an integrated implant, unlike the non-integrated acrylic implants involved in the current study. A more simplified technique used by another study [14] assessed the closure of the conjunctival wound either in a single layer with the tenon capsule or in separate layers and reported rates of acrylic implant exposure or extrusion were 2.5% and 2.7%, respectively, with no statistical difference between both; however, this studied did not report the sutural technique itself either interrupted or continuous suturing. Another modification of scleral wound closure was reported by Chiu et al. [4] who closed the wound either in 3 two layers (sclera and Tenon’s capsule as one layer and conjunctiva as a separate layer or in three layers (sclera, Tenon’s capsule, and conjunctiva) with implant exposure occurred in 8.3% of cases, but this study handled infection cases and did not report the type of suturing either interrupted or continuous. Chaudhary et al. [15] who closed the sclera with an interrupted suture using 6-0 prolene and closed the conjunctiva by interrupted suture using 6-0 silk suture, reported conjunctival dehiscence in 6.6% of implanted cases and 20% of non-implanted cases But 92% of the studied cases were panophthalmitis and endophthalmitis cases and this higher rate of wound dehiscence infection cases ensure our exclusion of infection cases from this comparative study of 2 suturing techniques. Kumar et al. [16] performed ocular evisceration with acrylic implant placement with interrupted suture closure in a 3-layer fashion, i.e., sclera then tenon capsule and closed the conjunctiva by continuous suturing. They reported 16.6% conjunctival wound dehiscence during the follow-up with 12.5% implant exposure by the end of the second week and 4.1% implant extrusion by the end of the 4th week. But they used 6-0 prolene suture for the sclera, 6-0 chromic catgut for the tenon capsule, and 6-0 silk suture for the conjunctiva. Another study [17] used continuous scleral and conjunctival suturing techniques using vicryl material after acrylic implant use and reported that one of the evisceration cases had implant extrusion (7.1%); however, this case had comminuted orbital fractures and did evisceration as secondary procedure 21 days after trauma and regarding the ease of closure or the quality of the remaining sclera, no remarks were made. A Middle East study [8] used a continuous suturing technique in the closure of the sclera and conjunctiva and tenon capsule and reported an incidence of implant exposure of 7.1%; however, this study used silicone implants rather than acrylic ones. Regarding comparing silicon and acrylic implants in the incidence of exposure or extrusion, Chiu et al. [4] reported only 2 cases of 24 cases (8.3%) with implant exposure, one with acrylic and the second with silicone implants. In the current study, the continuous suturing technique showed no postoperative wound dehiscence or implant exposure, while there were 15% of cases of the interrupted suture technique with wound dehiscence and implant exposure, with significant difference between the 2 groups. Regarding the size of the acrylic implant used, there was no statistically significant differences between the 2 groups with a median size of 20 mm in groups A and B, respectively. Some studies [17] showed no association between implant size and complications and this is emphasized by what was also reported by Gupta et al. [10] that a larger size of the implant was not a risk factor for exposure.

No cases of sympathetic ophthalmitis (SO) were reported in either group, and it is expected that the sutural technique does not affect the occurrence of SO after evisceration because SO is thought to comprise autoimmune cell-mediated mechanisms in which sensitization of the immune system by the uveal antigen of the injured eye resulting in granulomatous pan-uveitis affecting both the injured and uninjured eyes [18, 19]. Also, this incidence of SO in the current study is the same as other studies [17, 20, 21].

The study had some limitations, including its retrospective nature. The relatively small sample size will limit the generalizability of the findings. Additionally, the exclusion criteria, such as previous ocular surgeries and ocular infections, should be borne in mind when extrapolating the findings of our study.

This study suggests that continuous sutures, as opposed to interrupted sutures, produce better wound outcomes when used to close the scleral pocket and conjunctiva following evisceration with acrylic ocular implants.

The study was approved by the Ethical Committee of Qena Faculty of Medicine of South Valley University (Approval No.: SVU/MED/OPH026/4/24/7/885) and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients.

The authors have no conflicts of interest to declare. Z.G. was a member of the journal’s Editorial Board at the time of submission.

There were no funding sources or financial disclosures.

All authors read and approved the final manuscript. A.A.A. revised the manuscript and contributed to the preparation of the study protocol. H.N. contributed to manuscript revision and data analysis. H.N., I.A., H.O.A.O., and M.A.A.M. contributed to the preparation of the study protocol, data collection, and conducted statistical analyses. A.M.G., M.A.A.M., and A.A.E. drafted the manuscript, contributed to preparation of the study protocol, and conducted statistical analyses. M.A.E., M.E., and Z.G. were supervisors.

The data that support the findings of this study are not publicly or freely available due to privacy and ethical restrictions. Data can be available upon individual requests which can be made to the lead supervising author (M.A.E.) and corresponding author (Z.G.).