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ISSUE THIRTY FOUR: SUMMER 2005

O C C A S I O N A L U P D AT E F R O M T H E R O YA L C O L L E G E O F O P H T H A L M O L O G I S T S

Removal of the Eye

he prospect of ocular excision fills most patients (and
many ophthalmologists) with horror. Patients fear loss
of visual function and the cosmetic implications of a
glass eye. We may inadvertently reinforce these
negative perceptions when we talk about losing the eye. In fact
the loss of a healthy eye has already occurred. In addition,
some patients may have suffered pain and poor cosmesis for a
long time. We should therefore regard removal of a diseased eye
in a more positive light and concentrate on providing the patient
with an ideal anophthalmic socket. The features of the ideal
socket are comfort, normal lid positions and contours, prosthetic
motility, and the ability to blink and close the lids normally.

Pre-operative care
Pre-operative counselling is vital and should be tailored
according to the patients circumstances. Patients with a blind,
painful eye who request surgery tend not to require as much
counselling as those with newly diagnosed intraocular
malignancy in a seeing eye. Many of the patients anxieties may
be allayed by explaining what he/she should expect during
their stay in hospital; the fact that they may still legally drive, (if
visual function in the remaining eye is normal), and that a
bespoke prosthesis will be fitted which will look like their eye
and have some degree of movement.
Selection of Procedure
Evisceration is usually performed for a blind, painful eye. It is
contraindicated in the presence of intraocular malignancy and
remains controversial where sympathetic ophthalmia is
considered a risk. B-scan ultrasonography should be performed
pre-operatively to exclude an intraocular tumour if clinical
examination cannot.
Enucleation is most commonly performed for intraocular
malignancy, a blind, painful eye, and to prevent sympathetic
ophthalmia following severe trauma.1
Exenteration is a disfiguring procedure reserved mainly for
control of aggressive malignancies (e.g. sebaceous cell
carcinoma, melanoma) or advanced squamous or basal cell
carcinomas with orbital involvement. It may rarely be
performed for pain or disfigurement in benign orbital disease.2
Surgical considerations
Every precaution should be taken to ensure the correct eye is
removed. This should include examination on the operating
table, following draping, with indirect ophthalmoscopy if the
pathology is located in the posterior segment.
Evisceration involves removal of ocular contents, preserving
the sclera, and leaving the extraocular muscles and optic nerve
intact. In order to replace as much volume as possible and
reduce the risk of forward extrusion, superior and inferior flaps
may be created by division of the sclera at the 1 and 7 o'clock
positions, extending posteriorly to the optic nerve. The nerve is
then excised on a small islandof sclera. The implant is inserted

posterior to the flaps, thereby reducing the risk of forward

extrusion, and allowing placement of a larger implant than
otherwise possible. Advantages of evisceration over enucleation
are reduced anatomical disruption, greater motility and often
improved cosmesis as a result.
Enucleation involves removal of the globe from the orbit,
preserving the adnexal tissues except for a stump of anterior
optic nerve. Intraoperative haemorrhage may be reduced by
using a retrobulbar injection of 5 ml of long-acting local
anaesthetic (e.g. chirocaine 7.5%) with adrenaline 1:100,000 after
induction of general anaesthesia. It also reduces the need for
early post-operative analgesia.3 Following removal of the globe,
the orbital implant is inserted into the intraconal space using a
specialised inserter or sterile sheath to avoid dragging of
anterior tissues posteriorly. The extra-ocular muscles may be
sutured together in a cruciate fashion anterior to, or to the
surface of the implant/wrapping (depending on implant type
and use of wrapping material). The posterior Tenons, anterior
Tenons and conjunctiva should be closed with absorbable
sutures in separate layers to discourage implant extrusion. A
plastic conformer and pressure bandaging should be applied for
a minimum of two days.
Exenteration is a highly invasive technique, usually
performed in large, specialist centres and involving a
multidisciplinary team of ophthalmologists, maxillofacial and
neurosurgeons. Further surgical detail is beyond the scope of
this article.
Orbital Implants
There is no consensus on which implant type is optimal,
although it is now widely recognised that failure to replace
orbital volume results in poor motility and cosmesis,
characterised by the Post-Enucleation Socket Syndrome (PESSalso an acronym for its features, Ptosis, Enophthalmos and
Superior Sulcus).
Both integrated (e.g. hydroxyapatite, porous polyethylene)
and non-integrated implants (e.g. acrylic, silicone) are ideally
implanted at the time of enucleation or evisceration, in the
absence of infection.4
As a general rule, the largest implant which may be
accommodated should be implanted such that the volume of the
prosthesis does not exceed 2ml in order to avoid PESS.5 Most

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F O C U S O N : R E M O VA L O F T H E E Y E
adults will accommodate a 22mm for enucleations6, 20mm for
eviscerations.
Wrapping materials are used by some surgeons. Donor sclera
is now rarely employed in the United Kingdom (due to the
theoretical risk of transmissible encephalopathy). Other
materials may be autologous (e.g. sclera from the enucleated
eye, fascia lata) or synthetic (e.g. polyglactin mesh).
Integrated implants have the facility to retain a coupling peg,
which articulates with the prosthesis to increase prosthetic
excursions. Complications such as infection, chronic discharge,
and audible click are common, (37.5% in one series7), and
therefore enthusiasm for pegging has waned in recent years. The
considerable cost of intergrated implants leads some authorities
to argue that an inexpensive non-integrated implant should be
selected if a peg is not planned.
Complications of Implantation
Improper placement of the implant, particularly below inferior
rectus obliterates the inferior fornix and may preclude retention
of a prosthesis. Implants may also migrate or rotate within the
orbit over a number of years, particularly if undersized.
Exposure, following erosion through the superficial layers
occurs most commonly with hydroxyapatite implants due to
their rough surface.1 Vaulting of the prosthesis to relieve friction
over the exposure may be helpful. Burring down of the exposed
convexity of the implant, or patching with materials such as
hard palate or temporalis fascia may be necessary in refractory
cases.
Infection, characterised by chronic discharge and recurrent
pyogenic granulomata may occur in the absence of visible
exposure, and is a serious problem. Sockets where postoperative
inflammation and discharge fails to settle may have been
contaminated at the time of implantation. Integrated implants in
particular allow sequestration of bacteria beyond the reach of
systemic antibiotics and explantation may be necessary.
Extrusion tends to occur with the smooth, non-integrated
implants. It is usually possible to perform secondary
implantation in these instances.
Rehabilitation
The ocularist plays a key role in the postoperative rehabilitation
of the patient. In addition to fitting and maintaining the
prosthesis he/she will offer support and advice long after the
patient has been discharged from the ophthalmology clinic.
However, as the patients first visit to the artificial eye clinic is
not until six weeks postoperatively, good prosthetic handling
technique should be taught prior to discharge from hospital,

preferably with diagramatic or written instructions.

To insert; the prosthesis should be lubricated and slid high
into the superior fornix; a small downward movement will then
place the lower edge inside the inferior fornix. For removal;
gentle, posterior pressure on the lower lid will allow the
prosthesis to prolapse over the lid. Dragging down of the lower
lid during insertion and removal should be discouraged, as
should direct digital contact with the mucous socket lining. The
prosthesis should be worn at all times to discourage socket
shrinkage, and should not be manipulated excessively as this
will cause irritation and increase mucous discharge.
Post-Enucleation Socket Syndrome
The enucleated socket undergoes a number of anatomical soft
tissue changes postoperatively, which are particularly
pronounced if volume replacement is inadequate. These include
backward tilt of the superior fornix, with deepening of the
superior sulcus; shallowing and forward displacement of the
inferior fornix and lower lid stretching. In advanced cases,
contraction of the socket may lead to incomplete closure of the
lids over the prosthesis, upper and lower lid entropion, and
instability or inability to retain a prosthesis.
Correction of PESS involves orbital volume augmentation
(with secondary orbital or subperiosteal implants); increasing
the socket surface area (buccal mucosa or dermis fat graft)
correction of lid malposition and/or laxity (levator aponeurosis
advancement, lateral tarsal strip) or a combination of these.
Some highly motivated patients may be keen to undergo
multiple procedures in order to achieve the best cosmesis
possible. Others may only wish to retain a stable prosthesis.
Clear communication between the patient, surgeon and
ocularist is essential to determine the appropriate measures for
each individual patient.
Conclusion
Ocular excision should be considered primary orbital
reconstructive surgery. Sensitive counselling of patients; careful
consideration in choice of procedure and good surgical
technique minimises psychological trauma and provides the
patient with comfort, good cosmesis and a rapid return to
normal activities.
Julia Sen, Adnexal Fellow

Acknowledgements: Miss Jane Dickinson and Professor Bertil Damato

References:
1. Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Survey of Ophthalmology. 2000;44(4)277-301
2. Rose GE, Wright JE. Exenteration for benign orbital disease. Br J Ophthalmol. 1994 Jan;78(1):14-8
3. Yeatts RP, Doneyhue W, Scuderi PA, Brasington CR, James R Effect of preemptive retrobulbar analgersia on perioperative haemodynamics and
Postoperative pain after enucleation. Ophthal Plast Reconstr Surg. 2004:226-31
4. Smit TJ, Koornneef L, Wonneveld FW, Groet E, Otto AJ. Primary and secondary implants in the anophthalmic orbit. Preoperative and postoperative computed
tomographic appearance. Ophthalmology 1991;98(1):106-10
5. Kaltreider SA, Jacobs JL, Hughes MO. Predicting the ideal implant size before Enucleation. Ophthal Plast Reconstr Surg Jan;15(1):37-43
6. Adenis JP, Robert PY, Boncoeu-Martel MP. Abnormalities of orbital volume. Eur J Ophthalmol 2002 Sep-Oct;12(5):345-50.
7. Jordan DR, Cahn S, Mawn L, et al. Complications associated with pegging Hydroxyapatite orbital implants. Ophthalmology.1999 Mar;106(3):505-12

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