Retinoblastoma-ENUCLEATION A STEP BY STEP APPROACH Pre-operative evaluation Bone marrow and cerebrospinal fluid analysis Orbital imaging – MRI (magnetic resonance imaging ) -to rule out extrascleral tumour extension or gross optic nerve involvement Gross optic nerve thickening or extrascleral extension- chemoreduction –enucleation is performed as a secondary treatment GA fitness and relevant Labs Blood Hb levels of a minimum of 10-12 grams per decilitre White blood cell count of <15,000 per cubic millimetre A platelet count of >100,000 per cubic millimetre of blood Consent with all possible complications and risks Must note who is signing and accompanying the child Re-Counselling Confirm whether parents/caretakers understand what we are going to do Eye removal Stoned eye(Prosthesis) will not see The extent of the disease will be demonstrated by the histopathology Post Sx - systemic chemotherapy & regular follow-ups

1. Enucleation For
Retinoblastoma:
A Step-By-Step Approach
Dr Shabana Choudhary
FCPS (Pak), FRCS (Glasg.), MCPS (Pak), ICO, FICO (Aus), MME
Fellowship in Paeds. Ophth. (Aus)
Fellowship in Adult Strabismus & Paeds. Ophth. (UK)
Fellowship in Retinoblastoma & Paeds. Ophth. (UK)
Assist. Professor Paediatric Ophthalmology COAVS/Mayo
Hospital/KEMU
Lahore, Pakistan

2. Learning
Objectives
• Able to
• Demonstration of the surgical steps of enucleation
for Retinoblastoma

3. Indications

4. The Pre-requisites Of The
Surgery
• Pre-operative evaluation
• Bone marrow and cerebrospinal fluid analysis
• Orbital imaging – MRI (magnetic resonance imaging ) -to
rule out extrascleral tumour extension or gross optic nerve
involvement
• Gross optic nerve thickening or extrascleral extension-
chemoreduction –enucleation is performed as a
secondary treatment
• GA fitness and relevant Labs
• Blood Hb levels of a minimum of 10-12 grams per decilitre
• White blood cell count of <15,000 per cubic millimetre
• A platelet count of >100,000 per cubic millimetre of blood
Kaliki S. How to do an enucleation for retinoblastoma. Community Eye Health. 2018;31(101):20-22

5. • Consent with all possible complications and risks
• Must note who is signing and accompanying the
child
• Re-Counselling
• Confirm whether parents/caretakers understand
what we are going to do
• Eye removal
• Stoned eye(Prosthesis) will not see
• The extent of the disease will be demonstrated by
the histopathology
• Post Sx - systemic chemotherapy & regular follow-
ups

6. What Should
Bring In The OT?
• Consent form
• Pathology form
• Patient’s
File/documents
• Labs
• B-scan
• MRI –(films/reports)

7. Roles of the teams Surgeon/staff/GA team/assistant
surgeons
Indirect
Ophthalmoscopy
Confirmation of
the eye before and
after the drapping
Assistant/Paramedics
• Dilatation of both eyes- Tropicamide
• Identification of the patient
• Marking of the eye
• Working GA machine checked
• Working Cautery Checked
• Normal Saline in refrigerator
• Prosthesis in Pyodine + Gentacin
soln.
• Sterilized Surgical trolly
• Sterlized X-ray film

8. Where to start from?
• Perform indirect ophthalmoscopy before
starting the operation to confirm the eye
procedure will be done on the correct eye
• Confirm through the file/notes as well
• Confirm that surgical trolly and cautery are
available
• Confirm that the blood cross-matched
donor is on standby
• Confirm the consent is signed
• Confirm the eye again while drapping the
eye (prep and drape the eye yourself –do
not leave it to the staff or the assistant
• Scrub yourself

9. Step By Step
Surgical Procedure
• Look for any gross extrascleral extension/NVIs - under a
microscope
• Gently place a wire speculum
• Instill a drop of Adrenaline
• Perform a lateral canthotomy to increase the working
space- Conjunctival Scissor
• Perilimbal conjunctival peritomy around the whole eye-
Use conjunctival scissors
• Perform a tenotomy in either 2 or all four quadrants- use
curved tenotomy scissors
• The dissection should be carried out to the
equator of the globe to ease the prolapse of the
globe in the later stages of surgery

10. What’s
Next?
• Identify Recti muscles and gently hook the muscles - a muscle hook
• Place muscle traction sutures 2 to 3 mm from the muscle insertion
• Pass absorbable 6/0 Vicryl sutures through the muscle, 4 to 5 mm from the insertion
• Be gentle during needle entry into the muscle to avoid globe perforation
• We prefer the order of cutting the rectus - first medial, then inferior, then lateral, and finally the superior rectus

11. • Cauterise gently or crush muscle with straight artery forceps between sutures and the insertion
or traction sutures leaving the muscle stum
• Cut the muscles in between the traction suture and tag suture- with conjunctival scissors
• The superior oblique and inferior oblique muscles are now identified and cut

12. • After all six of the extraocular muscles have been
severed, use the four traction sutures to exert gentle
traction on the globe and facilitate globe prolapse
• If there is resistance to globe prolapse
• Tight eye speculum -replace it with the correct eye
speculum.
• Too narrow surgical space (due to a small orbit)-
perform a small lateral canthotomy or a relaxing
horizontal conjunctival incision laterally.
• Due to incomplete severing of extraocular muscles-
Recheck all muscles and adhesions
• Clean the globe, and maintain hemostasis- we take a
gauze and encircle the globe –gently push the gauze into
orbit while gently retracting the globe –to confirm all
adhesions are broken and enough space to reach optic
nerve

13. Optic nerve removal
• Curved tenotomy scissors/ enucleation scissors are
then inserted by the lateral approach and the optic
nerve is identified near the orbital apex –
• Go straight to the orbital apex-identifies as bony
touch
• Slightly rotate the globe medially
• Now cut the ON
• Ensures adequate length of the optic nerve (>15
mm)
• Give hypotensive anaesthesia to ensure minimal
bleeding during this step

14. Marking the Sample
• Pack the socket immediately with a finger and then followed
by gauze and keep it in place for 5-10 minutes to stop
bleeding and avoid the formation of a haematoma
• Inspect the enucleated globe for any evidence of extrascleral
extension of the tumour.
• Measure the length as well as the width of the optic nerve
using callipers
• Mark the Optic nerve 2 mm from the cut end (to save the cut
end Histopath) – 6/0 Vicryl
• Mark MR 4/0 black silk
• Send the globe for detailed histopathology analysis

15. Implant Placement
• After stopping the bleeding, identify the posterior Tenon's capsule.
Place an adequate-sized implant in the intraconal space
• Use the X ray film to make a cone to place the implant in position
• In the Myoconjunctival technique –
• The implant is secured in place by suturing the posterior
Tenon's capsule with absorbable sutures
• Pass the double-ended (tag) sutures attached to the cut end of
the recti muscles are then brought out externally through the
conjunctival fornices in all four quadrants-tag sutures are then
knotted to each other
• In Conventional Technique (PMMA implant)-
• Muscle cross over the implant
• If Sahaf implant/ or PMMA ball is covered with Vicryl Mesh –suture
muscles over to the mesh or /and together

16. Closure
• The anterior Tenon's capsule and the
conjunctiva are then closed with absorbable
sutures in two layers
• Placement of a conformer with a draining pore
is then placed in the socket
• The conformer can be secured in place with
central suture tarsorrhaphy (optional)
• A pressure patch is applied for 24 hours

17. Postoperative care
• The pressure patch is removed after 24 hours
• Rx
• Oral antibiotics for 1-week
• Topical antibiotics for 2-weeks
• Topical steroids are tapered over 6-weeks
• The suture tarsorrhaphy is removed after 1-week- if done
• Based on the histopathology report, further treatment may be required
• Dispense customised ocular prosthesis 6-weeks after enucleation

18. Questions
•Thanks