Enucleation and evisceration. ophthalmology contains the two methods of eye ball removal, with indications, surgery, complications, treatment, etc its has animated clips and picture wonderful slide i have prepaired can be used for clinical as well as educational purpose

1. Kushal kumar

2. Definition
■ Enucleation :
– it is the surgical removal of the entire
globe from the orbit.
■ Evisceration
– it is the surgical removal of entire
content of the globe leaving the scleral
shell.

3. Indication
■ Enucleation & Evisceration
– Pain full blind eye
– Intraocular tumours
■ Retinoblastoma
■ Malignant melanoma
– Severe trauma with risk of sympathetic
ophthalmia
– Phthisis bulbi
– Microphthalmia
– Endophthalmitis/ panophthalmitis
– Cosmetic deformity

4. ■ Indication for eye donation from cadaver is
presently the most common indication for
enucleation
■ in cases of suspected or documented intra ocular
malignant tumours evisceration is contraindicated.
■ So a pre operative ocular ultra sound is mandatory
to rule out occult malignancy
■ Similarly evisceration should not be used in
atrophicbulbi and hypoplasia in childhood because
an adequate sized implant cannot b placed inside
the scleral shell and an eye with atrophicbulbi may
harbor and unsuspected malignancy.

5. Surgery
■ Anastheasia
– Local anesthesia
– General anasthesia may be given for
psycological and occasionally for medical
reasons
– 0.5% bupivacaine with 1:1,00,000 adrenaline
is used
– Most evisceration surgeries are performed
under LA with IV sedations
– 2% lignocaine with 1:1,00,000 epinephrine is
injected in retro bulbar fashion into the muscle
cone

6. Specific techniques
■ Enucleation
– A self retaining speculum is placed to expose
the entire epibulbar surface
– 360˚ conjunctival peritomy is performed
– Tenons facia is bluntly dissected away from
the sclera in all four quadrants

7. – All the rectus muscle are sequentially gathered on a
muscle hook, secured with a 6-0 vicryl suture and
detached from the globe.
– The superior oblique tendon is severed and detach
from the globe

8. – The inferior oblique muscle should be hooked and
secured with a 6-0 vicryl suture, detached and saved for
later attachment to the inferior border of lateral rectus
muscle
– The optic nerve is severed

9. ■ Anterior traction on the globe is useful when cutting the
optic nerve and can be achieved with a curved hemostat
applied to the medial rectus tendon
■ The eye ball is prolapsed out by stretching and pushing
down the eye speculum. The eye ball is pulled out with
the help of suture passed through muscle stump.
■ Eye ball is pulled out of the orbit by incising the
remaining tissue adherent to it, and hemostasis is
achieved by packing the orbital cavity with a wet pack
and pressing it back

10. ■ Inserting an orbital implants
– Placement of an orbital prosthesis is almost
universally performed in conjunction with an
enucleation
– The silicone sphere, hydroxyapatite and porous
polyethylene implants are used currently
– An appropriate sized implants should be
inserted into the orbit and sutured with rectus
muscle

11. ■ Closure of conjunctiva and tenon’s capsule is
done separately
■ Tenons capsule is sutured horizontally with 6-0
vicryl suture and conjunctiva is sutured vertically
with 6-0 silk suture
■ After surgery broad-spectrum antibiotic is
applied
■ Medium sized clear acrylic lid conformer is
placed and pressure bandage is applied.

12. ■ Evisceration
– 360˚ conjunctival peritomy is performed
– Tenons fascia is separated from the underlying
sclera in all 4 quadrants
– A full thickness incision around the corneal
limbus is made with a scalpel blade and
corneal button is removed

13. – Sclera is grasped with forceps and a
cyclodialysis spatula is used to separate iris
root and ciliary body from the sclera
– Remaining uveal tissue is dissected away from
the scleral wall around the optic nerve with an
evisceration spoon.
– Intraocular content are lifted from the scleral
shell

14. – Cotton tip applicator saturated with 70%
ethanol is used to cleanse the scleral shell
– A PMMA spherical implant is placed in the
eviscerated scleral shell
– Scleral edges are closed with 6-0 vicryl
sutured
– Conjunctiva is closed with 6-0 plain gut suture
– Dressing and post op care is same as
enucleation

15. Enucleation

16. Evisceration

17. Complication
■ Early enucleation complications
– Hemorrhage
– Infection
– Orbital apex injury
■ Early evisceration complication
– Evisceration is usually not associated with
complications of orbital apex injury or intra cranial
spread of infection through optic nerve.
– Bleeding is less likely than enucleation
– Implant exposure and extrusion however are more likely

18. ■ Late enucleation complications
– Implant migration and extrusion
– Volume deficit of implant
– Contracted socket
– Eyelid malposition
– Painful socket and persistent discharge