Seminars in Ophthalmology, 25(3), 9497, 2010 Copyright 2010 Informa UK Ltd.

. ISSN: 0882-0538 print/ 1744-5205 online DOI: 10.3109/08820538.2010.488575

Evisceration and Enucleation

caro Perez Soares,1 and Valnio Perez Frana2
Clnica de Olhos Hospital Mater Dei; Centro Oftalmolgico de Minas Gerais; Policlnica oftalmolgica - Oculi; Belo Horizonte, Minas Gerais, Brazil 2 Clnica de Olhos Hospital Mater Dei; Centro Oftalmolgico de Minas Gerais; Policlnica oftalmolgica - Oculi; Hospital So Geraldo, Federal University of Minas Gerais
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ABSTRACT Evisceration and enucleation are delicate procedures that result in psychological trauma and physical disability. The preparation is as important as the surgery itself to assure that the patient will return to a productive life. The procedure must be performed in a way to provide the best conditions for a perfect prosthesis, which should look similar to the fellow eye, follow its movements, be comfortable and aesthetically pleasing. Indications and contra-indications, surgical techniques, pre- and post-operative care and complications are discussed in this paper.
KEYWORDS: evisceration; enucleation

INTRODUCTION
Removing an eye that is ill, damaged, or has little or no vision is a challenge to the ophthalmic surgeon. The psychological trauma and the physical disability are extreme and the patient needs compassion and support in order to return to a productive life. The preparation for surgery, postoperative appearance, and prosthesis fitting should be discussed prior to the procedure. The surgery must be performed in a way to provide the best conditions for a perfect prosthesis, which should look similar to the fellow eye, follow its movements, be comfortable and aesthetically pleasing. Nevertheless the desired results are obtained in only one-third to half of the cases, especially due to conjunctival retraction.1 The loss of an eye causes severe changes to the anatomy and physiology of the orbit resulting in deformities that affect the relationship between the socket and the prosthesis. Surgical procedures should be performed meticulously to attain the best functional and cosmetic result and avoid complications and deformities. Evisceration consists in the complete removal of the ocular contents through a corneal or a scleral inci-

sion, while preserving the conjunctiva, sclera, extra ocular muscles and orbital fat. The preservation of the cornea will depend on its clinical presentation and upon the surgeons evaluation. Enucleation is the removal of the entire eye following the desinsertion of the extra ocular muscles and the section of the optic nerve. If possible, an ocular implant should be placed during the procedure to restore the volume and preserve the movements. Evisceration achieves a better cosmetic result than enucleation because it is less traumatic to the orbital tissues and the extra ocular muscles.2 The incidence of implant extrusion is also lower with evisceration.3 There are reports of rare cases of sympathetic ophthalmia following the procedure. It is a bilateral diffuse granulomatous uveitis characterized by keratic precipitates, ciliary injection, aqueous cells and flare, posterior synechiae, vitreitis, retinal vascular sheathing, and disc edema. Treatment includes aggressive anti-inflammatory therapy and immunosuppressors. Prognosis is reserved.

INDICATIONS
Evisceration is performed in every situation that requires the removal of the eye due to trauma, glaucoma, unaesthetic eyes for which the use of a prosthesis is not possible, and in some cases of 94

Correspondence: caro Perez Frana, Rua Timbiras 3468, Barro Preto. CEP 30140-062, Belo Horizonte (MG), Brazil.

Evisceration and Enucleation endophthalmitis or uveitis. The absence of light perception should be confirmed in every case. The procedure is contra-indicated if an intraocular tumor is suspected and cant be ruled out by imaging studies. In cases of trauma with severe anatomy disruption and uveal prolapse there is a risk of sympathetic ophthalmia after evisceration. With an intact scleral shell the procedure is relatively safe if performed carefully and all the uveal tissue is removed.2 Endophthalmitis is a very important indication for evisceration because an enucleation could expose the orbit and central nervous system to the infection. Enucleation is indicated in suspected or confirmed intraocular cancer, confirmed or suspected sympathetic ophthalmia, in cases of severe phthisis bulbi, and clinically resistant bacterial endophthalmitis.
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FIGURE 1 Evisceration technique; (A) Pre operative aspect of the eye; (B) 180 sclerotomy; (C) removal of ocular contents; (D) placement of the medpor implant.

PREOPERATORY CARE
The patient and family should be extensively informed about the procedure and its consequences, and should make a clear decision about the surgery. The total absence of light perception should be well documented and demonstrated to the patient and family. For elective surgeries, anticoagulants should be discontinued prior to the surgery. Psychological support is essential, because the removal of the eye is a mutilating procedure and may cause severe emotional trauma.

EVISCERATION TECHNIQUE
There are two main evisceration techniques: with or without the retention of the cornea, both requiring the use of an ocular implant. The retention of the cornea provides a more suitable socket for a larger implant, resulting in better functional and aesthetic appearance. Some contraindications for the retention of the cornea are: keratitis, corneal ulcers, thin corneas under risk of rupture, and degenerations. In very selected cases, the surgeon may choose to preserve the cornea even in the presence of inadequate condition (such as phthisis bulbi or thin cornea) in order to have a good size socket that will allow the use of an implant.

EVISCERATION WITH RETENTION OF THE CORNEA

The procedure can be done under local anesthesia and sedation. In addition to the periocular block, subcon 2010 Informa UK Ltd.

junctival infiltration of lidocaine and epinephrine helps reducing the bleeding. An incision is made through the conjunctiva and Tenon capsule between the insertion of the superior rectus muscle and the limbus, approximately 6mm from the limbus, comprising 180 (9 to 3 oclock). The tissues are dissected towards the cornea, creating a limbus-based conjunctival flap. A better exposition of the area may be achieved using a 5-0 silk traction suture at the superior rectus. The sclerotomy is performed using an 11 blade, beginning at the 12 oclock position, between the insertion of the superior rectus muscle and the limbus (closer to the limbus) extending laterally and medially to comprise 180. The conjunctival incision should not overlap the scleral incision but completely cover it in the end of the surgery. A long ciclodialysis spatula is passed between the sclera and the uvea antero-posteriorly and rotated 360. This separates the ocular contents, contained by the uveal tract, from the sclera, with no vitreous leakage. An evisceration spoon is used to remove all ocular contents. Uveal remains are scraped off with a curette or gauze wrapped around the tip of a clamp. The inner surface of the sclera is copiously irrigated and bleeding is stopped using bipolar cauterization. Special attention must be paid at the optic nerve area due to the presence of larger blood vessels. Postoperative bleeding is an important complication and may lead to implant extrusion. The implant is placed inside the scleral cavity and the sclerotomy margins are closed using 6-0 absorbable sutures in inverted separate stitches. There should be no tension over the implant. If a porous implant is chosen, a 360 sclerotomy at the equator is advised to prevent it from rubbing against the inner surface of the cornea and to facilitate vascular ingrowth into the implant. Additionally, this incision

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V. Perez Frana and . Perez Soares is clamped the furthest into the orbit as possible by sliding the hemostat towards the optic canal (at least 6mm or 10mm in case of tumors). Enucleation scissors are introduced over the hemostat and the nerve is sectioned. The eye can be now removed from the orbit. The optic nerve pedicle is cauterized; the hemostat is released and can be removed if no bleeding is detected. The chosen implant, unwrapped or wrapped in sclera or fascia lata, is placed inside the cavity. Large implants must be avoided in order to prevent compression of the orbital tissues that will cause atrophy and supra tarsal depression, as well as exophthalmia after the prosthesis. The four rectus muscles are sutured to the implant. The surgeon must try to restore the muscle topography. The Tenon capsule is attached to the implant using absorbable 6-0 separate sutures. The conjunctiva is closed with a continuous suture. A symblepharon ring should be used to maintain the fornices.

makes it possible to insert large implants in small cavities. The conjunctiva and Tenon capsule are closed using inverted 6-0 absorbable sutures. There is no need to use a symblepharon ring after the surgery, except in cases where a conjunctival flap was used, in order to prevent fornix retraction.

EVISCERATION WITH KERATECTOMY

A 360 peritomy is performed and the subtenonian space is dissected posteriorly towards the fornix. An 11 blade is used for the paracenthesis at the 12 oclock position. The sclerotomy is extended 360 with scissors and the cornea is excised. The ocular contents are eviscerated, the inner scleral surface cleaned, and the implant placed as described above. Two small scleral triangles at 3 and 9 oclock are excised in order to change the opening of the ocular cavity from round to elliptic in shape, making it easier to suture the sclera. The conjunctiva and Tenon are closed in a way that the suture line does not overlap the scleral suture. The conjunctiva must be fixated onto the underlying sclera using a transfixating suture preventing the rubbing of the sclera against the inner face of the conjunctiva during eye movements.

IMPLANTS
The implants are classified as natural (biological or non-biological) and synthetic. Some examples are: natural biological coralline hydroxyapatite; natural non-biological aluminum oxide; synthetic polyethylene and acrylic. Some composite implants are under investigation but nowadays the most used materials are natural hydroxyapatite, bioceramic, and high density polyethylene (Medpor). Another frequently used implant, natural and autologous, is the dermofat graft whose most important advantage is the absence of rejection (Figure 2). The selection of the implant depends upon cost, surgeons preference, extrusion rates, availability, desired motility, and other factors.
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ENUCLEATION TECHNIQUE
The anesthesia is performed as described above. A 360 limbal peritomy is done and the conjunctiva and Tenon capsule are dissected posteriorly towards the rectus muscle insertions. Blunt-tipped scissors are inserted into each of the oblique quadrants and all the adhesions are eliminated. The muscle insertions are identified and isolated using a muscle hook. 5-0 double-armed absorbable sutures are woven through each muscle 2 mm from its insertion. The rectus muscles are cut close to the sclera and anchored around the surgical field using the sutures. The two oblique muscles are also severed and left loose inside the orbit. The next step is the section of the optic nerve. The surgeon must immobilize the eye holding it by the remnant tissue of the lateral rectus muscle insertion, which was left purposefully on the sclera, and pull the eye medially and upwards. This maneuver will allow the curved hemostat to be placed inside the orbit from the lateral to the medial side. With the tip of the hemostat the surgeon can feel the optic nerve as a rigid string attached to the bottom of the eye. The nerve

FIGURE 2 Dermofat graft (A) Enucleation; (B) dermofat graft placement; (C) Final aspect after 30 days. Seminars in Ophthalmology

Evisceration and Enucleation The first implant inserted after an evisceration was a glass sphere (Mules, 1885). Recently, several integrated implants have been introduced. They allow the ingrowth of fibrovascular tissue through their porous structure, resulting in better fixation and less extrusion. Some implants have a pin or a peg on their anterior surface to be coupled with the prosthesis. Most implants need to be wrapped before inserting into the orbital cavity after an enucleation, to facilitate the reattachment of the extraocular muscles. Several wrapping materials have been used: preserved donor sclera, Dura-mater, bovine pericardium, fascia lata, and other synthetic substances like Teflon. The authors preference has been the Mules implant due to its low cost, availability, uncomplicated technique, low extrusion rates, satisfactory motility, and excellent cosmetic results. Integrated implants present high long-term extrusion rates, especially if used in evisceration with retention of the cornea.

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POSTOPERATIVE CARE
Systemic antibiotics are used for 5 to 7 days. No- steroidal anti-inflammatory drugs, analgesics, and ice packs are necessary during the first 72 hours. Antibiotic and steroid drops should be maintained for 30 days. Fitting of the prosthesis should begin 3 or 4 weeks after surgery.

Melting of the donor sclera was reported after enucleation with scleral wrapped implants, possibly secondary to inappropriate conservation of the sclera by the tissue bank. In these cases it is not possible to salvage the implant and there is no option but to replace the sclera and insert a new implant. Exposure of the implant may occur as a late complication, especially due to inadequate prosthesis. This is more frequent in cases with retention of the cornea in which there is friction between the external prosthesis and the cornea or between an integrated implant and the inner surface of the cornea. This can be greatly avoided by performing a 360 sclerotomy posteriorly to the equator of the eye as described above. The exposure can lead to infection and extrusion of the implant and early intervention is mandatory. There are several different approaches to solve this complication: (a) replacement of the implant with one of smaller size and suture of the sclera; (b) use of a scleral or auricular cartilage patch and a conjunctival flap over it; (c) enucleation of the eye and its reinsertion into the orbit upside-down so that the area of exposure will face the bottom of the orbit. If the extrusion of the implant is inevitable a dermofat graft is recommended. The most feared complication is infection of the ocular cavity spreading to the orbit. The main causes are poor prosthesis care, trauma, and sinusitis. The treatment will require hospitalization and IV antibiotic therapy to prevent septicemia.

COMPLICATIONS
The most frequent complication of evisceration and enucleation procedures is the exposure of the implant, which occurs in 28% of the cases.1 Short-term complications include dehiscence of the suture, which can happen at the scleral site, exposing the implant, or at the conjunctiva, exposing the sclera. The exposure of the implant is a serious complication and if too extensive may require a new surgical procedure. However, if only a small area is exposed there may be no need for any additional surgery, since the implant will still be covered by the conjunctiva and Tenon capsule. If the sclera is exposed, instead of the implant, the conjunctiva may spontaneously reepithelize over it. The patient should be examined frequently because of the risk of scleral melting due to ischemia. If necessary, a conjunctival flap must be used to cover the area. Most cases of dehiscence are secondary to the use of large implants or inadequate suture.

REFERENCES
[1] Soares EJC, Dantas RRA, Marback R, Matayoshi S, Frana VP. Cavidades anoftlmicas. In: Moura EM, Gonalves JOR. Cirurgia Plstica Ocular. So Paulo: Roca, 1997. [2] Smith BC, Nesi FA, Lisman RD, Levine MR, et al. Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. St Louis: Mosby -Year Book Inc., 1998. [3] Raflo GT. Enucleation and Evisceration. In: Duane TD, Jaeger EA, eds. Clinical Ophthalmology, Philadelphia: Lippencott-Raven, 1995. [4] Soares, EJC. rbita, vias lacrimais e plpebras In: Petroianu A. Anatomia Cirrgica. Rio de Janeiro: Guanabara Koogan, 1998. [5] Jordan DR. Problems after evisceration surgery with porous orbital implants: experience with 86 patients. Ophthal Plast Reconstr Surg. 2004 Sep;20(5):374380. [6] Kohlhaas M, Walter A, Schulz D. Primary orbital implant dislocation. A retrospective study. Ophthalmologe. 1998 May;95(5):328331. [7] Chuah CT, Chee SP, Fong KS, Por YM, Choo CT, Luu C, Seah LL. Integrated hydroxyapatite implant and nonintegrated implants in enucleated Asian patients. Ann Acad Med Singapore. 2004 Jul;33(4):477483.

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