During an evisceration , the intraocular contents are removed while leaving the extraocular muscle insertions and majority of the sclera intact. The surgery can be performed under general anesthesia or retrobulbar block along with monitored anesthesia care. A lid speculum is placed, and a 360° conjunctival peritomy is performed. Gentle dissection with Stevens scissors is carried out between the sclera and Tenon’s capsule in each of the four quadrants between the rectus muscles. A number 11 Bard-Parker blade is used to make a paracentesis, entering the anterior chamber at the corneoscleral limbus. Keratectomy is performed using Westcott scissors. Often an abundant amount of purulent material presents during keratectomy. Cultures should be taken at this point, and antibiotic therapy can later be adjusted depending on culture results. An evisceration spoon is then used to gently separate the scleral spur and uveal contents off the scleral wall 360° just behind the iris plane. The spoon is run along the inside of the sclera from the anterior lip toward the posterior pole, detaching the uveal contents from the sclera, clock hour by clock hour. Attempt should be made with a larger evisceration spoon to remove the uveal contents intact, but this may not be possible. The surgeon should make every effort to remove all of the uveal tissue to minimize the risk of sympathetic ophthalmia. The inside of the sclera is next scrubbed with cotton tip applicators soaked in absolute ethanol, taking care to avoid the alcohol from coming into contact with the conjunctiva. After several sweeps with the absolute ethanol, copious irrigation is then performed with an antibiotic solution such as gentamicin to remove any residual alcohol. Posterior sclerotomies can be performed to allow placement of a large implant and facilitate vascularization of a porous implant. If the sclera looks healthy and noninfected, an acrylic or porous orbital implant is placed in the sclera, and the sclera is closed over the implant using 5–0 Vicryl or Mersilene sutures. Tenon’s capsule is then closed with interrupted sutures of 5–0 Vicryl, taking care to bury the knots. The conjunctiva is closed with a running 6–0 plain gut suture. Subconjunctival injection of an antibiotic is then placed. Finally, a proper-sized conformer and a firm pressure patch are placed, with the pressure patch staying in place for 1 week. Treatment with systemic antibiotics is continued for another week. If the sclera appears necrotic, as often happens with Pseudomonas or streptococcal infections, the necrotic sclera can be trimmed and the sclera packed with Betadine gauze. The gauze is then removed a few days after the procedure, and the tissues are allowed to heal by secondary intention. A secondary implant can be placed later when the infection is completely cleared. Usually it is best to wait about 3 months to ensure complete healing and resolution of infection and inflammation.

Enucleation involves the complete removal of the eye. As in evisceration, it can be performed under general anesthesia or local anesthesia with retrobulbar block and sedation. The procedure starts with the placement of a lid speculum, and a 360° conjunctival peritomy is performed with Westcott scissors. Stevens scissors are then used to clear the quadrants between the rectus muscles separating Tenon’s capsule from the underlying sclera. The four rectus muscles are then isolated with muscle hooks, and a 5–0 Vicryl suture is woven through the muscle insertions and locked on each end (Figs. 16.2a, b). Each of the rectus muscles is then disinserted from the globe, and the sutures are secured to the surgical drapes with seraphim clamps to keep them from becoming tangled together. The superior and inferior oblique muscles are next isolated with muscle hooks and disinserted from the globe and allowed to retract into the orbit. Stevens scissors are used to gently dissect tissue off the sclera back to the posterior pole of the eye. The optic nerve is palpated with a hemostat and then clamped posterior from its medial aspect. The clamp is left in place for 1 min to help with hemostasis before it is removed. The optic nerve is cut with an enucleation scissors. Care is taken to remove a long segment of the nerve and not to cut into the back wall of the eye. The globe is gently lifted out of the orbit and inspected to ensure an adequate resection of the optic nerve before being passed off and sent for histopathology. Hemostasis is then obtained by packing the socket with gauze soaked in gentamicin solution. After hemostasis has been secured, acrylic implants are then tried to determine the size of the orbital implant to select. Usually one places the largest orbital implant that can be inserted that allows closure of the Tenon’s and conjunctiva without tension. In adults this is usually a 20–22 mm sphere. Either a porous or nonporous implant can be placed. This author usually selects a nonporous implant in severely infected cases. The socket is irrigated with an antibiotic solution before placing the implant. A wrapping material such as eye bank sclera can be used to encase the implant, and the windows are cut corresponding to the rectus muscle insertions (Fig. 16.3a, b). A tulip inserter is often used to inject the implant deep into the socket and to avoid dragging anterior tissues posteriorly and causing a “cactus syndrome” with late exposure and extrusion of the implant. The double-armed 5-0 Vicryl sutures connected to the extraocular muscles are then brought into the windows of the wrapping material and tied (Fig. 16.4). Tenon’s and conjunctiva are then closed in an identical fashion as that described for evisceration. Subconjunctival injections of antibiotics are given, and a conformer is placed. Pressure patch is placed for a week. Systemic antibiotics are continued for another week.