Evisceration and Enucleation
Ernest Skidmore, MD
INDICATIONS FOR SURGERY
Enucleation and evisceration should be considered in cases of severe trauma with essentially no chance for visual recovery, in cases of blind eyes that are either chronically painful or cosmetically unsatisfactory to the patient, or in cases of malignant neoplasms that must be removed.
In cases of trauma, the patient may be acutely impaired by the trauma or substance use, and unable to provide valid informed consent for this irreversible procedure.
Avoid primary enucleation or evisceration for acute globe injury even if the visual prognosis is poor.
Attempt to repair an acute ruptured globe to give the patient time to emotionally process the situation.
Obtain second or subspecialty opinions before removing the eye.
Patients are generally more accepting of eye removal when satisfied that every effort has been attempted to save the eye.
MANAGEMENT OPTIONS
The surgeon must decide between evisceration, enucleation, retrobulbar pain management, or observation.
Evisceration — removal of the intraocular contents with sparing of the sclera
Advantages
Arguably better cosmetic and functional outcomes
Orbital anatomy remains less disturbed.
Socket motility and eyelid function are less disturbed.
Because suspensory apparatus of the orbit is not violated, there is less chance of ptosis of the muscle cone.
Shorter, less complex procedure
Disadvantages
Enucleation — removal of the entire globe
Advantages
Better procedure for pathology, especially intraocular tumors
Less risk of residual choroidal tissue that could trigger sympathetic ophthalmia
Removes potentially diseased sclera in relevant circumstances
Disadvantages
More invasive to orbit, so cosmetic outcome may be decreased.
Diminished socket motility
Eyelid malpositions more common than with evisceration
Implant may migrate, moving the prosthetic eye out of position.
Ptosis of muscle cone and orbital contents may occur
Higher risk of orbital cellulitis or even meningitis with severed optic nerve giving access to the subarachnoid space. Note that the infection risk is usually low with prophylactic antibiotics.
Retrobulbar pain management with absolute alcohol or chlorpromazine can give long-term pain relief. If pain returns, the injections may be repeated. These injections do not always work well in the setting of very high intraocular pressure.
Perform standard retrobulbar anesthetic injection (see the section “Anesthesia”).
Inject either 1 mL of 50% to 100% ethyl alcohol or 25 mg (1 mL) of chlorpromazine (Thorazine) into the retrobulbar space.
If chlorpromazine is used, observe for postural hypotension for 20 to 30 minutes prior to discharge.
Observation
Blind eyes without pain or other pathology may be observed.
This is especially appropriate for patients who are not emotionally prepared for eye removal or are poor surgical candidates.
SURGICAL DESCRIPTION
Anesthesia
General anesthesia is most common, along with retrobulbar block (RBB) anesthesia.
May be done under local/retrobulbar anesthesia, especially if the patient is high risk for general anesthesia. If done under local anesthesia, add local anesthetic into upper and lower eyelids as well for comfort.
Having an eye removed is quite an emotional trauma to a patient, and general anesthesia eases this burden.
For RBB, inject 2% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine without epinephrine in a 1:1 mixture with Wydase (hyaluronidase). Use 5 to 6 mL. Repeat the retrobulbar injection at the end of the procedure for longer postoperative pain relief.
Evisceration
Confirm the correct eye. Consider having the surgeon drape the operative eye.
FIGURE 35.1. Create a 360° peritomy and dissect Tenon’s capsule and conjunctiva up to the insertions of the four recti muscles using Westcott scissors.
Place lid speculum and perform a 360° fornix-based conjunctival peritomy at the limbus using Westcott scissors (Figure 35.1).
Bluntly dissect Tenon’s capsule and conjunctiva up to the insertions of the four recti muscles using Westcott scissors.
Maintain hemostasis with bipolar electrocautery.
Remove cornea
Make a stab incision using a scalpel (1 mm blade works well) through the sclera just posterior to the limbus, entering the anterior chamber in front of the iris.
Extend the incision with the blade enough to insert a scissor (corneal scissor or Westcott).
Excise the cornea, taking a small cuff (1 mm) of the sclera.
Remove intraocular contents
Use 0.5 forceps to hold the scleral edge to stabilize the globe and use an evisceration spoon against the sclera to separate the iris and ciliary body from the sclera.
Continue using the spoon in anterior to posterior motions, scraping toward the optic nerve to separate the retina and choroid from the sclera and scoop out the intraocular contents (Figure 35.2).
The cornea and intraocular contents are sent for histopathology, and if there is concern for infection, culture and sensitivity samples are submitted to the microbiology laboratory.
Maintain hemostasis with suction and an insulated monopolar needle-tip cautery.
Reinspect the scleral pouch for any residual choroid and meticulously remove any pigmented tissue using the evisceration spoon or a curette. Consider using cotton-tipped applicators with 70% ethanol to scrub the sclera and denature any remaining uveal tissue. Leaving uveal tissue behind raises the risk of sympathetic ophthalmia. Note that sometimes the sclera will have some pigment staining that simply cannot be removed.
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