Blind, painful eye
Following severe trauma (ie, irreparable open globe injury; concern for risk of sympathetic ophthalmia)
Intraocular tumor (specifically as primary or secondary treatment for retinoblastoma)
Rarely congenital or progressive phthisis bulbi (ie, chronic poorly controlled uveitis from juvenile idiopathic arthritis). Unexplained phthisis bulbi should be investigated for retinoblastoma.
Have a detailed discussion with patient’s parents or guardian regarding the goals of the enucleation (ie, tumor staging, prevention of sympathetic ophthalmia, pain control), and plans for postoperative steps for reconstruction with an ocularist.
Select device for severing the nerve (ie, snare, curved enucleation scissors +/− Wells enucleation spoon).
Select type of implant (ie, porous implants are more commonly used in developed countries2 vs. nonporous implants; Table 37.1 describes more commonly used implants).
SURGICAL PROCEDURE: ENUCLEATION (VIDEO 37.1)
Ensure that the correct eye is marked and draped using a redundant check system among multiple team members to eliminate the possibility of removing the wrong eye. Once the patient is under general anesthesia, the nonsurgical eye is taped closed by the surgeon.
In cases where the select eye is not readily identifiable externally (ie, intraocular tumors, posterior globe rupture) prior to surgical incision, indirect ophthalmoscopy or repeat B-scan ultrasound is performed to ensure that the appropriate eye is being removed.
TABLE 37.1. Various Available Orbital Implants
Implant Type
Implant Material
Benefits
Drawbacks
Nonporous
Glass
Acrylic
Silicone
Improved prosthesis movement with myoconjunctival technique (each muscle sutured to respective fornix) compared to porous implants3
Muscle reattachment to a scleral shell rather than the implant itself can result in implant displacement and migration
Higher rates of extrusion and infection4
Porous
Hydroxyapatite
Synthetic hydroxyapatite
Bioceramic
Medpor
Provide improved implant movement because of direct attachment of extraocular muscles to the implant
Associated with less migration, extrusion, and lower risks of infection5
More expensive
More prone to implant exposure6 and postoperative inflammation
Other
Dermis fat graft
Maintains orbital bone growth with soft tissue volume expansion over time
Can be used with implant in older children (>5 years old)7
Can result in contracted fornices and cosmetically significant enophthalmos4 (though less common in children) when used independently
No implant
Allows for follow-up of tumor extension prior to implant placement (can also stage implant placement at a later date)
No prevention of socket contraction or stunted orbital bone development resulting in poor orbital cosmesis and development
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