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Enucleation and evisceration
The document outlines the definitions, indications, surgical techniques, and potential complications related to enucleation and evisceration, both procedures for eye removal. Enucleation involves the complete removal of the eyeball, while evisceration removes the internal contents, leaving the scleral shell. It emphasizes the importance of pre-operative ultrasound to rule out malignancy and provides detailed surgical steps along with associated risks.
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Enucleation and evisceration
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- 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 foreye 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 – Localanesthesia – 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 therectus 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 inferioroblique 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 tractionon 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 anorbital 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 ofconjunctiva 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 isgrasped 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 tipapplicator 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
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- 17. Complication ■ Early enucleationcomplications – 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 enucleationcomplications – Implant migration and extrusion – Volume deficit of implant – Contracted socket – Eyelid malposition – Painful socket and persistent discharge