Review Article

Evisceration in the Modern Age

Laura T. Phan1,2, Thomas N. Hwang3, Timothy J. McCulley1,2

ABSTRACT Access this article online Website: Evisceration is an ophthalmic surgery that removes the internal contents of the www.meajo.org followed usually by placement of an orbital implant to replace the lost ocular volume. DOI: Unlike enucleation, which involves removal of the entire eye, evisceration potentially causes 10.4103/0974-9233.92113 exposure of uveal antigens; therefore, historically there has been a concern about sympathetic Quick Response Code: ophthalmic (SO) associated with evisceration. However, critical review of the literature shows that SO occurs very rarely, if ever, as a consequence of evisceration. Its clinical applications overlap with those of enucleation in cases of penetrating ocular trauma and blind painful , but it is absolutely contraindicated in the setting of suspected intraocular malignancy and may be preferred for treatment of end-stage endophthalmitis. From a technical standpoint, traditional evisceration has a limitation in the orbital implant size. Innovations with scleral modification have overcome this limitation, and accordingly, due to its simplicity, efficiency, and good cosmetic results, evisceration has once again been gaining popularity.

Key words: Endophthalmitis, Enucleation, Evisceration, Intraocular Tumors

INTRODUCTION While the risk of sympathetic ophthalmia continues to be a contentious issue, evisceration has gained popularity in the visceration (removal of intraocular contents) and enucleation past few decades. This is based largely on the perception E(removal of the entire eye) are competing techniques, with that evisceration provides superior functional and cosmetic fluctuating favor since their inception. Enucleation may be the results compared to enucleation. Several modified evisceration oldest operation in ; literature from as early as techniques have been described in past decades, each proclaiming 1 2600 BC described a Chinese “god of ocularists.” Centuries improved results.7-16 later in 1817, Bear introduced evisceration when he removed the remaining intraocular contents of an eye following an expulsive This review will provide an in-depth look at evisceration by hemorrhage.2 In 1874, Noyes described evisceration for the examining the published literature that supports and refutes its management of intraocular infection.3 In 1884, Mules described association with sympathetic ophthalmia, and then describing its placing a hollow glass sphere into the eviscerated cavity.4 advantages and disadvantages in different clinical scenarios, and Because evisceration unlike enucleation disrupts the integrity finally discussing the basic technique as well as recent technical of the globe, there is a theoretical risk of exposing uveal modifications. antigens, which could incite an autoimmune reaction known as sympathetic ophthalmia (SO) in the contralateral eye. The SYMPATHETIC OPHTHALMIA first report of sympathetic ophthalmia occurring in association with evisceration was in 1887.5 Despite this, evisceration gained Sympathetic ophthalmia is a potentially devastating autoimmune popularity until 1972 when Green et al. reignited the concern condition characterized by bilateral panuveitis, where the injured of inciting sympathetic ophthalmia with a report of four alleged eye incites inflammation in the fellow (sympathizing) eye.17 Its cases.6 specific pathophysiology remains elusive. It is believed to be an

1Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, 2King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, 3Department of Ophthalmology, The Permanente Medical Group, Redwood City, California Corresponding Author: Dr. Timothy J McCulley, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Wilmer 110, Baltimore, MD 21287. E-mail: [email protected]

24 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 Phan, et al.: Evisceration in the Modern Age immunologic response to exposure of previously sequestered the clinical appearance; histopathologic confirmation was not tissue.17,18 Proposed antigens include retinal S-antigen, retinoid established. binding protein, melanin associated antigen, or those from the retinal pigment epithelium.18-21 Signs and symptoms of uveitis In 2006, Freidlin et al.32 reported the first case of sympathetic have been reported to develop between 5 days22,23 and 66 years24 ophthalmia found in a soldier since World War II. This 21-year- from the time of injury. Sixty-five percent of the cases occur old man sustained shrapnel wounds while in combat and between 2 weeks and 2 month with roughly 90% present within underwent evisceration the day of injury. Within a month of a year of injury.25-27 surgery, he developed panuveitis in his remaining eye with conjunctival injection, vitreous floaters, and paracentral scotoma. Evisceration, along with a number of other intraocular He responded favorably to immunosuppressant therapy. After procedures, has been implicated as a potential cause of 6 months of oral and topical steroid treatment, best-corrected sympathetic ophthalmia.6,28 Whether or not evisceration can visual acuity was 20/20 in this “sympathetic” eye. Interestingly, incite sympathetic ophthalmia is one of the most notorious histologically proven uveal tissue was found and removed from controversies in oculoplastic surgery.29 We will present what the subconjunctiva of the eviscerated eye at the onset of his evidence exists supporting and refuting this relationship. symptoms. The authors hypothesized that this residual uveal tissue induced the inflammation. Given the failure to remove Supportive evidence all uveal tissue, this case does not support evisceration as an Evidence suggesting a causal relationship between evisceration inciting event. However, it does stress the need to perform and sympathetic ophthalmia lies almost entirely in a handful of eviscerations properly and in appropriately selected patients. case observations. This and the previous case illustrate the additional point that in at least some cases, good vision can be preserved in the Earliest reports of sympathetic ophthalmia following sympathetic eye with treatment. evisceration include 47 cases from various ophthalmologists in the United States and the United Kingdom from 1887 to There is good evidence that potentially any type of intraocular 1909.30 Unfortunately, many of these cases did not have exam surgery can incite sympathetic ophthalmia. Previous retrospective documentation of the fellow eye at the onset of injury or even studies estimated the incidence of sympathetic ophthalmia to be after the sympathetic occurrence. Therefore, definitive time anywhere from 0.02% to 0.06% for intraocular surgery,33,34,35 of onset of sympathetic ophthalmia and association to original and 0.28% to 1.9% for nonsurgical penetrating injury.35-37 injury versus evisceration were dubious to say the least. Moreover, These surveys implicated various intraocular surgeries, including these cases were often initially diagnosed as endophthalmitis or cataract extractions, glaucoma procedures, and vitrectomies neuroretinitis. None had records of intraocular histopathology but not eviscerations. In a prospective surveillance, Kilmaren studies. Little else was published until 1972 when Green et al. et al. estimated the incidence of sympathetic ophthalmia to described four cases.6 Two occurred earlier in the first half of the be 0.03 per 100,000.38 Ocular surgery, particularly retinal century (1927 and 1949) and the others in the latter half of the surgery, was the most common cause in this group, as opposed century (1968 and 1969). The first two cases provided strong to previous reports where accidental trauma overwhelmingly evidence. Slides of the scleral shells that were subsequently prevailed.6,37 Between July 1997 and September 1998, all removed demonstrated granulomatous inflammation consistent permanently employed ophthalmologists in the United Kingdom with sympathetic ophthalmia. Green et al. did not provide the were sent monthly report cards to notify any newly diagnosed number of cases performed during the study period; therefore, cases of sympathetic ophthalmia. There were 23 valid cases the relative risk of sympathetic ophthalmia following evisceration of sympathetic ophthalmia reported during this period, but could not be estimated base on this study. only 17 that were reported in last 12 consecutive months were included in Kilmarin et al.’s estimation of the incidence. Of In this past decade, there have been two case reports of alleged these patients, one underwent an enucleation for recurrent post-evisceration sympathetic ophthalmia. In 2005 Griepentrog choroidal melanoma, but none had evisceration. Of note, the et al.31 reported a case of presumed sympathetic ophthalmia patient with a history of enucleation also twice underwent pars after evisceration in a 75 year-old man, who had a blind, painful plana . eye after a penetrating globe injury that caused neovascular glaucoma. Notably the injury occurred 66 years prior. The Although these studies fail to establish evisceration as a definitive patient developed ciliary injection, mild cataract, vitreous cells, causation for sympathetic ophthalmia, they do stress that any and macular retinal pigment epithelium mottling and serous type of intraocular surgery may be causative. Logic follows that detachment in the fellow eye fourteen weeks post-operation. evisceration has the potential to incite sympathetic ophthalmia. His vision improved from 20/200 to 20/25 nine months later on a tapered steroid dose. The diagnosis was based entirely on In summary, the assertion that sympathetic ophthalmia may be

Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 25 Phan, et al.: Evisceration in the Modern Age incited by evisceration is largely theoretical, supported only by Table 1: Indication for eviscerations and enucleations a handful of single or small series of questionable cases. Study Dates Number Type of Most Common Assessed of Surgery Indications (%) Refuting evidence Cases There have been a number of series looking at cohorts of patients Erie et al. 1956-1988 99 Enuc Trauma (35) Spraul et al. 1941-1995 513 Enuc Trauma (41) who underwent evisceration, where no cases of sympathetic Neoplasm (24) ophthalmia were identified. Studies involving over 3000 Setlur et al. 1950-2006 3,264 Enuc Neoplasm (51)* eviscerations failed to identify a case of sympathetic ophthalmia Trauma (13)* 5,39-41 Glaucoma (23)** between 1980s and 1990s. A more recent review by du Trauma (21)** 42 Toit et al. also failed to identify sympathetic ophthalmia in Davenger et al. 1963-1967 207 Enuc Trauma (51) 491 primary eviscerations or 11 secondary eviscerations for Corneal disease (18) penetrating injury at a tertiary hospital in Cape Town, South Sigurdsson et al. 1963-1992 200 Enuc/ Blind, painful eye (46) evis Africa from 1995 to 2004. This is similar to a previous report Neoplasm (25) made by Rudemann of his 15-year experience between 1947 and Kaimbo et al. 1988 143 Enuc Trauma (37) 1962.30 He failed to identify any case of sympathetic ophthalmia Haile et al. 1995 282 Enuc Trauma (33) in the 506 eviscerations performed. Neoplasm (21) Dado et al. 1990-1999 146 Evis Endophthalmitis (79) Trauma (21) In 1998 Levine et al.40 assessed the association between Rasmussen et al. 1996-2003 345 Enuc/ Blind, painful eye (36) evisceration and sympathetic ophthalmia. He reviewed 51 of evis Neoplasm (34) his own patients who underwent evisceration between 1980 Chaudhry et al. 2000-2003 187 Evis Endophthalmitis (46) and 1996. The follow-up period ranged from 3 to 180 months Phthisis (20) (mean, 48 months). No cases of sympathetic ophthalmia were Eballe et al. 2002-2010 48 Enuc/ Endophthalmitis (48) identified. In addition, they queried members of the American evis Neoplasm (21) Society of Ophthalmic Plastic and Reconstructive Surgery Enuc: Enucleation, Evis: Evisceration, *in the year 2000’s, **in the year 1950’s (ASOPRS), American Uveitis Society, and Eastern Ophthalmic Pathology Society. Of the 880 reported eviscerations from responding members of the three societies, members of the Table 2: Indication vs contraindication for evisceration and ASOPRS “recalled” five and the other two groups “recalled” enucleation several cases of sympathetic ophthalmia. These cases were Indication Evisceration Enucleation anecdotal, not documented clinically or histologically and thus Neoplasm - ++ excluded as positive findings. Based on their findings, Levine Penetrating trauma ± + et al. concluded that “evisceration is a safe procedure with little Blind, painful eye + + risk of sympathetic ophthalmia.” However, this conclusion has Endophthalmitis + ± += indicated, ++= absolute, indicated, ±= controversially indicated, -= not been challenged. Bilyk argued that, simply due to the rarity indicated of sympathetic ophthalmia and low number of evisceration performed, the risk of sympathetic ophthalmia is likely underestimated.43 It has also been pointed out that, based on evisceration and enucleation for individual indications. In previously estimated occurrence rates of sympathetic ophthalmia, most cases, when globe removal is required, either surgery is some cases should have been identified if Levin’s review method adequate, and the surgeon may choose their personal preference. was reliable. Regardless, since Levine’s publication, evisceration However, there are circumstances where one is preferable or, seems to have been gained favor once again. in some cases, contraindicated. Traditionally, enucleation has been recommended for management of intraocular neoplasm In summary, evidence for the association between evisceration and prevention of sympathetic ophthalmia following penetrating and sympathetic ophthalmia is lacking. However, given the trauma,44-48 whereas evisceration is usually recommended for extremely low incidence of sympathetic ophthalmia, rare management of endophthalmitis.49 Opinions vary with regards occurrences cannot be entirely excluded. It is probably safe to to which surgery is preferable for management of blind, painful, say that the risk of sympathetic ophthalmia following evisceration phthisical, or otherwise cosmetically unacceptable eyes.16,50 Each is, at most, extremely low. one will be explored.

INDICATIONS Malignancy Malignancy is an absolute contraindication to evisceration. An Table 1 outlines published indications for evisceration and enucleation should be performed whenever managing an eye enucleation. Table 2 compares and contrasts the benefits of suspected or known to harbor an intraocular malignancy.44-47

26 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 Phan, et al.: Evisceration in the Modern Age

Penetrating trauma et al.65 found 85% of the patients with severely traumatized eye One of the most common indications for evisceration is and no evisceration or enucleation remained comfortable with penetrating ocular trauma despite the possible association with no or only rare pain. The other fifteen percent had intermittent sympathetic ophthalmia. Removal of the eye (or its contents) pain. Accordingly, when possible, the decision to remove the prior to sensitization is felt to be preventive. Classic teaching eye should be postponed until a stable state has been reached. is to perform surgery within 14 days of injury. The origin of this teaching is unclear, although it may stem from a study Another potential pitfall is the continued pain following removal indicating that visual outcome improves significantly if surgery of an eye. In a series described by Shah-Desai et al., removal of is performed within two weeks of injury, given that sympathetic an eye failed to relieve eye pain in seven of 24 patients.49 Most ophthalmia has not developed.26 of the pain was related to post-operative complications that required additional medical or surgical treatments. Although traditionally enucleation has been recommended in the setting of penetrating trauma, evisceration is also routinely The patient’s socio-economic status also needs to be factored performed for the purpose of protecting against sympathetic in the decision. For example, for a patient with limited access 51-55 ophthalmia [Table 1]. In cases with extensive disruption to health care, one may lean towards a conjunctival flap and of the globe, removal of all uveal tissue may be difficult via an scleral shell. Resources needed for routine evaluation and the evisceration; therefore, enucleation may better safeguard against maintenance required of an anophthalmic socket and prosthetic retained uveal tissue, a risk factor for sympathetic ophthalmia. eye may not be available. Whereas for patients with abundant This point is nicely illustrated in the case published by Freidlin resources, one might prefer avoiding a conjunctival flap because et al., where the patients sclera was severely disrupted with 32 it may complicate a future evisceration if it fails. Knowing that uveal tissue prolapsed into the orbit. However, in cases where the patient would be able to obtain and maintain a well-fitted the sclera is largely intact, and the intraocular contents are prosthesis would be useful before initiating evisceration. contained and identifiable, an evisceration may be a reasonable alternate. The selection is usually based on surgeon’s judgment It has been argued that enucleation is preferable to evisceration or preference. in the setting of phthisis. With older techniques, this is true. The diminished size of the intrascleral space precludes placement of Blind eyes an adequately sized implant. However, with modern techniques, Blind eyes are commonly removed for both pain control which incorporate volume-enhancing sclerotomies, implants and improvement of cosmesis [Table 1]. Both enucleation 11-13,15 and evisceration are effective in these settings.50,56 Again, the equal in size to those used in enucleation can be placed. choice of procedure usually depends on the surgeon’s personal This is discussed in detail below. experience and preference. Evisceration in the management of Endophthalmitis blind eyes, for both pain control and cosmesis, is the authors’ In some developing countries, endophthalmitis is the most preferred technique. common reason for evisceration and enucleation.66-68 Before Removal of blind eyes should be viewed as a last resort. Patients the advent of antibiotics, surgeons fairly uniformly advocated often fend better if able to retain their natural globe. The term evisceration over enucleation. Evisceration leaves the optic “scleral shell” is used for a prosthesis, which is made to fit over nerve intact and thus avoids the spread of intraocular microbials 49 the patient’s eye. Often this is all that is required for phthisical into the subarachnoid space. A study in 1987 argued that eyes. A scleral shell in conjunction with a conjunctival flap is an endophthalmitis should not be considered a contraindication 69 underutilized combination that may best serve some patients. to enucleation in the modern era of antiobiotics. In this retrospective study, no cases of postoperative intracranial The decision to remove an eye or its contents for pain control infection were identified in a cohort of 165 patients who should not be made whimsically. Pain can, at times, be controlled underwent enucleation for endophthalmitis. with a retrobulbar injection of alcohol or chlorpromazine.57-59 Corneal-related discomfort can, in select cases, be managed The weakness of many such retrospective studies is that the with a conjunctival flap.60-64 implications of the study are often overextended. Although relatively large (a cohort of 165 patients in the above example), Less invasive means of controlling pain as outlined above should all that can be said is that the occurrence rate is likely less be weighed against eye removal. In the case of eyes expected than 2.21% (P=0.05). For such a potentially devastating to become phthisical, classic teaching has been to recommend consequence, that is, bacterial meningitis, even taking this small globe removal. However, recent data has suggested that, in most risk might not be prudent. For this reason, many surgeons still cases, pain either will develop mildly or not at all.65 Brackup prefer evisceration for endophthalmitis.70-72

Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 27 Phan, et al.: Evisceration in the Modern Age

SURGICAL TECHNIQUE SCLEROTOMY

Although minor variations exist, there are core surgical steps, The two main goals during an evisceration are replacing lost which remain fairly constant. Each will be discussed briefly with volume with an appropriately sized implant and achieving emphasis on the authors’ preferred technique. maximum implant motility. These two features optimize symmetry and therefore good cosmesis. 1. Peritomy Following placement of an speculum, a subconjunctival With classic evisceration technique, the largest implant that will injection of epinephrine containing anesthetic facilitates a fit inside the scleral cavity and still allow for closure of the sclera 360° peritomy. Care is taken to preserve as much conjunctiva without undue tension is 18 mm and, in many cases, less.75,76 as possible. For this reason, evisceration was rarely performed in phthisical 2. Removal of the eyes, as only very small implants could be placed. A full-thickness limbal incision is made with an #11 blade Several different methods of sclerotomies and relaxing incisions scalpel. The remainder of the limbus is cut with scissors, have been described to increase the size of the cavity in which the allowing for removal of the corneal button. Historically, the implant is placed.7-16 In 1987, Stephenson reported performing cornea was not removed.73 Currently, most surgeons elect multiple radial expansion sclerotomies as well as a posterior spiral to remove the cornea, providing better pain control.74 sclerotomy.7 In addition, he placed fixation sutures between the 3. Removal of the intraocular contents implant and scleral shell to prevent implant migration. In 1995, 8 The intraocular contents are then removed with the aid Kostick and Linberg described a posterior sclerotomy. In the of an “evisceration spoon,” a round relatively flat curette. same year, Lee et al. reported the creation of scleral windows 9 Careful attention is given to the complete removal of all posterior to each of the rectus muscle insertion. In 1997, uveal tissues. In theory this decreases (possibly eliminates) Jordan and Anderson described disinserting the optic nerve and 10 the risk of sympathetic ophthalmia. performing small radial sclerotomies. In the same year, Yang et al. described a “scleral quadrisection” technique, which left 4. Application of alcohol the optic nerve intact.11 Long et al.12 reported opening the scleral The inner surface of the sclera is then bathed in alcohol. cavity posteriorly and placing the implant behind the sclera in The purpose of this step is to denature any residual the muscle cone. In 2001, Massry and Hold described obliquely protein that might otherwise incite inflammation, that is, splitting the scleral cavity in two, releasing the flaps from their sympathetic ophthalmia. Cautery should be avoided, due to optic nerve attachments.13 More recently in 2007, Sales-Sanz the flammability of residual alcohol, until the surgical field and Sanz-Lopez described a technique wherein they performed has been thoroughly irrigated with saline. four complete sclerotomies from the limbus to the optic nerve with optic nerve disinsertion.15 This created four petals that 5. Sclerotomy contained a rectus muscle each. The petals were then brought Performing a sclerotomy, allowing for placement of larger anteriorly to cover the implant. Also in 2007, Masdottir and implants, has become popular in recent years and is Sahlin reported their experience using a split-sclera technique performed at this stage. Specific techniques are discussed similar to Massry’s and Hold’s, where 5% developed exposure in detail below. or extrusion of implant, but 78% of the patients felt pleased or very pleased with the operation.77 Most recently in 2011, 6. Implant placement Smith et al.78 reported their experience with Massry’s and There is much variation in the preferred type of implant. Hold’s technique. Sixteen of the 201 patients reported minor This is one of the greatest areas of disagreement among complications, while three reported major ones during a mean oculoplastic surgeons and beyond the scope of this text. The follow-up period of 31.62 months (range, 3–98 months). Also in authors’ preference is a simple silicone sphere. Previously, 2011, Georgescu et al.16 described a new evisceration technique the largest implant possible was placed. However, with the advent of modern sclerotomies, essentially any sized implant for patients with phthisis bulbi and microphthalmos. Eighteen can be used, and implant size is chosen to match prominence patients underwent evisceration, where a 5-mm wedge of of the fellow eye. sclera was excised nasally and temporally and a 360° equatorial scleral incision was made, dividing the scleral into anterior and 7. Closure posterior halves. The final step is closure. All techniques include the closure of multiple layers, including the sclera, Tenon’s membrane and, In most of the above reports, good results were achieved with lastly, conjunctiva. Meticulous closure is felt to be essential complications similar to those seen when a sclerotomy was not in preventing implant extrusion. performed. The advantage with a sclerotomy is the ability to place

28 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 Phan, et al.: Evisceration in the Modern Age implants up to or even larger than 20 mm in a large proportion superior sulcus deformity.78,85 However, with the advent of of patients. These enhanced volume augmentations diminishes modern sclerotomy techniques, enucleation no longer has this the “sunken-in” look often seen in anophthalmic patients. Also, advantage over evisceration. in the few studies that assessed motility, dismantling the sclera did not adversely affect implant excursion or patients’ overall Evisceration also provides superior socket motility. A prospective satisfaction.79 study in 2007 compared the motility and complications of 50 patients who underwent evisceration with sclerotomy We routinely perform a sclerotomy. Our preferred technique, and allosplastic implantation (Group 1) and 50 patients who nicknamed “the swinging sclera,” is a 180° horizontal cut, bisecting underwent enucleation and hydroxyapatite implantation both horizontal rectus muscle insertions and passing just above (Group 2).75 For the eviscerations, scleral quadrisections were the attachment of the optic nerve. By leaving the optic nerve performed at 1.5, 4.5, 7.5, and 10.5 clock hours from the attached to the inferior half of the sclera, a supportive hammock limbus to the optic nerve without disinserting the nerve. Group is formed that helps prevent inferior migration of the orbital 1 fared statistically significantly better than Group 2 in motility. implant. The mean horizontal excursion was 10.25 + 1.99 (5.9–15) for Group 1 and 6.90 + 1.74 (3.2–12) for Group 2. The OUTCOME mean vertical excursion was 8.45 + 1.89 (4.3–12) for Group 1 and 5.69 + 1.63 (3–10) for Group 2. Covariant analysis The increasing number of eviscerations performed in recent indicated operation time as a statistically significant predictor decades is due to several perceived benefits. Often cited in movement. Deep superior sulcus and exposure or extrusion advantages include the perception that evisceration is simpler was not significantly different between the two groups. and faster than enucleation.80 Since evisceration leaves the and optic nerve intact, it also has less risk Modern evisceration techniques with sclerotomies, allowing for for significant bleeding.81 placement of large implants, achieve better results that previously possible. Patients enjoy relatively good socket motility common Ultimately, superior cosmetic outcome depends on volume to all evisceration techniques. With the introduction of the replacement, socket motility, deep fornices, and normal- sclerotomy, implant size is no longer a limitation. appearing and functioning .82,83 Evisceration allows for better preservation of orbital anatomy, improved mobility and Complications therefore enhanced cosmesis.8,75-77,84 It has been proposed Table 3 summarizes the more commonly encountered that evisceration requires less manipulation and consequently complications. Potential complications, common between less inflammation and scarring of orbital tissues: fornices and enucleation and evisceration, include infection, hemorrhage, and suspensory ligaments remain uncompromised. This in turn is implant extrusion. Long-term complications include sunken/ thought to help maintain the implant. These factors translate to deep superior fornix, lower eyelid laxity and , upper better motility, less risk of superior sulcus deformity and thus eyelid , socket contraction, conjunctival cyst formation, an enhanced cosmetic result for the patients. implant migration and late extrusion of the implant.70,86–99 More common and/or serious complications will be addressed Historically, enucleation allowed for placement of a larger in detail. implant.77,79 The largest implant possible, whether involving enucleation or evisceration, helps prevent enophthalmos and Infection and hemorrhage are common to all surgical procedures;

Table 3: Common complications of evisceration and enucleation Study Complication (%) Enophthalmos Deep Ptosis Exposure/ Implant Socket Fornix Pyogenic superior extrusion migration edema contraction granuloma sulcus Shoamanesh et al. Evisceration (n=147) 6.8 18.4 4.1 0 8.8 8.8 5.4 Enucleation (n=180) 9.4 12.2 1.7 0.5 15.0 13.3 4.4 Nakra et al. Evisceration (n=52) 7.7 3.8 12.5 3.8 Enucleation (n=32) 15.6 12.5 27.5 3.1 Tari et al. Evisceration (n=50) 20.0 4.0 Enucleation (n=50) 14.0 2.0

Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 29 Phan, et al.: Evisceration in the Modern Age evisceration is no exception. Fortunately, hemorrhage is usually If there is not an adequate view of the fundus, appropriate self-limited and, even in the most severe cases, can be controlled imaging should be obtained prior to surgery. A couple of series with a firmly placed pressure patch. The authors usually place have addressed inadvertent evisceration of eyes containing a temporary at the close of the case, which malignancy.119,120 Eagle et al.119 described seven such cases. Of prevents conjunctival prolapse should post-operative bleeding note, three of patients had not undergone preoperative imaging. be encountered. Sterile technique with peri- and postoperative Retrospectively, two had suspicious findings on computed systemic antibiotics limits the risk of infection. Delayed tomography (CT) that escaped further investigation, and one placement of the orbital implant reduces the risk of infection underwent evisceration despite having a known history of uveal in the setting of endopthalmitis.100 When encountered, removal melanoma. In Rath et al.’s series, five of the six patients did not 120 of the implant with delayed reconstruction is often necessary. undergo preoperative imaging prior to evisceration. These cases serve as reminder that patients should undergo diligent Despite placement of a large implant, patients may still develop fundus examination and appropriate imaging when adequate a “sunken-in” appearance. Several mechanisms have been visualization is not possible. proposed for deep superior sulcus and subsequent ptosis. Hypotheses include (1) decreased circulation with cicatrization SUMMARY of orbital tissue and fat atrophy;101 (2) disturbance in the normal spatial architecture and tissue relationships of the orbit;102 (3) Evisceration remains a popular and effective surgery. Uncertainty grossly underestimated orbital volume loss and inadequate surrounding the risk of sympathetic ophthalmia following volume replacement;103 (4) contracture of the remaining evisceration has caused some surgeons to prefer enucleation. soft tissues, with an equivalent effect as inadequate volume However, this fear seems to be largely unfounded, based entirely replacement;43 (5) orbital expansion following unidentified on a very small number of reports. Most cases were either orbital fractures.104 Deep superior sulci are managed with orbital confounded by a history of trauma or intraocular surgery or were volume augmentation. Techniques include implant exchange not confirmed histologically. Recent advances in techniques, largely centered on various types of sclerotomies, allow for and autologous fat transfer. The authors’ preferred method is placement of larger implants. Given the superior cosmetic and placement of an “enophthalmic wedge.” functional results of evisceration, it is the authors’ preferred method of eye removal when not contraindicated. One of the most dreaded and challenging complications is socket contracture. The spectrum of this disorder ranges from posterior lamella shortening to complete obliteration of the REFERENCES 84 fornices. Mild contraction may result in nothing more than 1. Moshefeghi DM, Moshefeghi AA, Finger PT. Enucleation. Surv inward rotation of the eyelashes. With further contraction Ophthalmolo 2000;44:277-301. eyelid mobility is reduced. In the most extreme cases, patients 2. Meltzer MA, Schaefer DP, Della Rocca RC. Evisceration. In: Della are unable to retain a prosthesis. Management consists of Rocca RC, Nesi FA, Lishman RD, editors. Smith’s ophthalmic removal of any inciting irritant. Smoking has been linked plastic and reconstructive surgery. Vol. 2. St. Louis: CV Mosby; 1987. p. 1300-7. with socket contraction. All anophthalmic patients should be 3. Noyes HD. Discusio ́n of E Warlomont’s paper on sympathetic counseled regarding smoking cessation. A properly fitted and ophthalmia. In: Report of the Fourth International Congress, maintained prosthesis is also essential to a healthy socket. Once London, Aug 1872:27. contraction has occurred, management usually consists of fornix 4. Mules PH. Evisceration of the globe, with artificial vitreous. reconstruction with mucous membrane grafting. Trans Ophthalmol Soc UK 1885;5:200-6. 5. Cytryn AS, Perman KL. Evisceration. In: Enucleation, evisceration and exenteration of the eye. In: Migliori ME, editor. Implant extrusion usually relates to placement of an oversized Boston: Butterworth-Heinermann; 1999. p. 105-12. implant, inadequate sclerotomy or poor closure. Management 6. Green WR, Maumenee AE, Sanders TE, Smith ME. Sympathetic of an extruding implant is complex with many varied opinions. uveitis following evisceration. Trans Am Acad Ophthalmol Small exposed areas may heal spontaneously and are often Otolaryngol 1972;76:625-44. just observed. Larger areas may be closed with a variety of 7. Stephenson CM. Evisceration of the eye with expansion 105-117 sclerotomies. Ophthal Plast Reconstr Surg 1987;3:249-51. flaps, grafts, and even donor or synthetic materials. Most 8. Kostick DA, Linberg JV. Evisceration with hydroxyapatite often, exposure is the result of anterior pressure. Even with implant. Surgical technique and review of 31 case reports. the most deftly executed anterior reconstruction techniques, Ophthal Mology 1995;102:1542-9. recurrences are common. Implant exchange or repositioning 9. Lee SY, Kwon OW, Hong YJ, Kim HB, Kim SJ. Modification may be required.118 of the scleral openings to reduce tissue breakdown and exposure after hydroxyapatite implantations. Ophthalmologica 1995;209:319-22. Another relevant issue is the possibility of unintended evisceration 10. Jordan DR, Anderson RL. The universal implant for evisceration of a malignancy-baring eye. For this reason a dilated fundus surgery. Ophthal Plast Reconstr Surg 1997;13:1-7. evaluation is mandatory prior to performing an evisceration. 11. Yang JG, Khwarg SI, Wee WR, Kim DM, Lee JH. Hydroxyapatite

30 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 Phan, et al.: Evisceration in the Modern Age

implantation with scleral quadrisection after evisceration. J Ophthalmol 1982;93:552-8. Ophthal Surg Lasers 1997;28:915-9. 35. Allen JC. Sympathetic ophthalmia: A disappearing disease. 12. Long JA, Tann TM, Girkin CA. Evisceration: A new technique JAMA 1969;209:1090. of transcleral implant placement. Ophthal Plast Reconstr Surg 36. Liddy BS, Stuart J. Sympathetic ophthalmia in Canada. Can J 2000;16:3225. Ophthalmol 1972;7:157-9. 13. Massry GG, Holds JB. Evisceration with scleral modification. 37. Kraus-Mackiw E, Muller-Ruchholtz W. Sympathetic eye Ophthal Plast Recosntr Surg 2001;17:42-7. disease: diagnosis and therapy. Klin Monatsbl Augenheikd 14. Ozgur OR, Akcay L, Kmil O. Evisceration via superior temporal 1980;176:131-0. sclerotomy. Am J Ophthalmol 2005;139:78-86. 38. Kilmarin DJ, Dick AD, Forrester JV. Prospective surveillance of 15. Sales-Sanz M, Sanz-Lopez A. Four-petal evisceration: A new sympathetic ophthalmia in the UK and Republic of Ireland. Br technique. Ophthal Ophthal Plast Reconstr Surg 2007;23:389-92. J Ophthalmol 2000;84:259-63. 16. Georgescu D, Vagefi MR, Yang CC, McCann J, Anderson RL. 39. Hansen AB, Petersen C, Heegaard S, et al. Review of 1028 Evisceration with equatorial sclerotomy for phthisis bulbi and bulbar eviscerations and enucleations: Changes in etiology microphthalmos. Ophthal Plast Reconstr Surg 2010;3:165-7. and frequency overa a 20-year period. Acta Ophthalmol Scand 17. Gasch AT, Foster CS, Grosskreutz CL, Pasquale LR. Postoperative 1999;77:331-5. sympathetic ophthalmia. Int Ophthalmol Clin 2000;40:69-84. 40. Levine MR, Pou CR, Lash RH. The 1998 Wendell Hughes 18. Rao NA, Robin J, Hartmann D, Sweeney JA, Marak GE Jr. The Lecture. Evisceration: Is sympathetic ophthalmia a concern in role of penetrating wound in the development of sympathetic the new millennium? Ophthal Plast Reconstr Surg 1999;15:4-8. ophthalmia. Arch Ophthalmol 1983;101:102-4. 41. Walter WL. Update on enucleation and evisceration surgery. 19. Hirose S, Kuwabara T, Nussenblatt RB, Wiggert B, Redmond Ophthal Plast Reconstr Surg 1985;1:243-52. TM, Gery I. Uveitis induced in primates by interphotoreceptor 42. du Toit N, Motala MI, Richards J, Murray AD, Maitra S. The retinoid-binding protein. Arch Ophthalmol 1986;104:1698-702. risk of sympathetic ophthalmia following evisceration for 20. Chan CC, Hikita N, Dastgheib K, Whitcup SM, Gery I, penetrating eye injuries at Groote Schuur Hospital. Br J Nussenblatt RB. Experimental melanin-protein-induced uveitis Ophthalmol 2008;92:61-3. in the Lewis rat. Immunopathologic processes. Ophthalmology 43. Bilyk JR. Enucleation, evisceration, and sympathetic ophthalmia. 1994;101:1275-80. Curr Opin Ophthalmol 2000;11:372-86. 21. Broekhuyse RM, Kuhlmann ED, Winkens HJ. Experimental 44. Shields JA. Current approaches to the diagnosis and autoimmune posterior uveitis accompanied by epitheloid cell management of choroidal melanomas. Surv Ophthalmol accumulations (EAPU). A new type of experimental ocular 1977;31:449-63. disease induced by immunization with PEP-65, a pigment 45. Manschot WA, van Peperzeel HA. Choroidal epithelial polypeptide preparation. Exp Eye Res 1992;55:819-29. melanoma. Enucleation or observation? A new approach. 22. Fuchs E. Uber sympathisierende entzundung zuerst Arch Ophthalmol 1980;98:71-7. bemerkungeen uber serose traumatische iritis. Graefes Arch 46. Shields JA. Introduction to management melanomas. In: Rvan Clin Exp Ophthalmol 1905;61:365-456. SR, editor. Retina Vol. 1. St Louis: CV Mosby; 1989. p. 683-6. 23. Thies O. Gedaken uber den ausbruch der sympathetischen 47. Shields JA, Shields CL. Malignant melanoma of the posterior ophthalmie. Klin Monatsbl Augenheilkd 1947;112:185-7. uvea. In: Fraunfelder FT, Roy FH, editors. Current Ocular 24. Zaharia MA, Lamarche J, Laurin M. Sympathetic uveitis 66 years Therapy. 3rd ed. Philadelphia: WB Saunders; 1990. p. 394-8. after injury. Can J Ophthalmol 1984;19:240-3. 48. Albert DM, Diaz-Rohena R. A historical review of sympathetic 25. Duke-Elder S, Perkins ES. Sympathetic ophthalmitis. In Diseases ophthalmia and its epidemiology. Surv Ophthalmol 1989;34: of the Uveal Tract. St. Louis: Mosby, 1966. p. 558. 1-14. 26. Lubin JR, Albert DM, Weinstein M. Sixty-five years of 49. Randolph RL. The question about enucleation in purulent sympathetic ophthalmia. A clinicopathologic review of cases panophthalmitis. JAMA 1910;LIV(25):2023-6. (1913–1978). Ophthalmology 1980;87:109-21. 50. Shah-Desai SD, Tyers AG, Manners RM. Painful blind eye: 27. Goto H, Rao NA. Sympathetic ophthalmia and Vogt-Koyanagi- Efficacy of enucleation and evisceration in resolving ocular Harada syndrome. Int Ophthalmol Clin 1990;30:279-80. pain. Br J Ophthalmol 2000;84:437-8. 28. Chan CC, Whitcup SM, Nussenblatt RB. Sympathetic 51. Erie JC, Nevitt MP, Hodge D, Ballard DJ. Incidence of enucleation ophthalmia and Vogt-Koyanagi-Harada syndrome. In: Tasman in a defined population. Am J Ophthalmol 1992;113:138-44. W, Jaeger EA, editors. Duane’s Ophthalmology 2006 Edition 52. Setlur VJ, Parikh JG, Rao NA. Changing causes of enucleation (CD-ROM). Philadelphia: Lippincott Williams & Wilkins; 2005. over the past 60 years. Graefes Arch Clin Exp Ophthalmol 29. Hwang TN. How do I decide whether to perform an evisceration 2010;248:593-7. or enucleation? In: Kersten RC, McCulley TJ, editors. 53. Davenger M. Causes of enucleation in Uganda. Br J Ophthalmol Curbside Consultation in Oculoplastics. New Jersey: SLACK 1970;54:252-5. Incorporated; 2011. p. 173-6. 54. Kaimbo K. Causes of enucleation in Zaire. J Fr Ophthalmol 30. Rudemann AD Jr. Sympathetic ophthalmia after evisceration. 1988;11:677-80. Trans Am Ophthalmol Soci 1963;61:274-314. 55. Haile M, Alemayehu W. Causes of removal of the eye in 31. Griepentrog GJ, Lucarelli MK, Albert DM, Nork TM. Sympathetic Ethiopia. East Afr Med J 1995;72:7358. ophthalmia following evisceration: a rare case. Ophthal Plast 56. Custer PL, Reistad CE. Enucleation of blind, painful eyes. Reconstr Surg 2005;21:316-8. Ophthal Plast Reconstr Surg 2000;16:326-9. 32. Freidlin J, Pak M, Tessler HH, Putterman AM, Goldstein DA. 57. Maumenee AE. Retrobulbar alcohol injections; relief of Sympathetic ophthalmia after injury in the Iraq War. Ophthal ocular pain in eyes with and without vision. Am J Ophthalmol Plast Reconstr Surg 2006;22:133-4. 1949;32:1502-8. 33. Allen JC. Sympathetic uveitis and phacoanaphylaxis. Am J 58. Faran MF, al-Omar OM. Retrobulbar alcohol injection in blind Ophthalmol 1967;63:280-3. painful eyes. Ann Ophthalmol 1990;22:460-2. 34. Gass JD. Sympathetic ophthalmia following vitrectomy. Am 59. Chen TC, Ahn Yuen SJ, Sangalang MA, Fernando RE,

Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 31 Phan, et al.: Evisceration in the Modern Age

Leuenberger EU. Retro- bulbar chlorpromazine injections for evisceration, or prosthetic fitting over globes. Ophthalmology the management of blind and seeing painful eyes. J Glaucoma 1985;92:1249-55. 2002;11:209-13. 81. Hui JI. Outcomes of orbital implants after evisceration and 60. Gundersen T. Conjunctival flaps in the treatment of corneal enucleation in patients with endophthalmitis. Curr Opin disease with reference to a new technique of application. Arch Ophthalmol 2010;21:375-9. Ophthalmol 1958;60:880-8. 82. Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv 61. Gundersen T, Pearlson HR. Conjunctival flaps for corneal Ophthalmol 2000;44:277-301. disease. Trans Am Ophthalmol Soc 1969;67:78-95. 83. Migliori ME. Enucleation versus evisceration. Curr Opi 62. Paton D, Milauskas AT. Indications, surgical technique, and Ophthalmol 2002;13:298-302. results of thin conjunctival flaps on the cornea: A review of 84. Walter WL. Update on enucleation and evisceration surgery. 122 consecutive cases. Int Ophthalmol Clin 1970;10:329-45. Ophthal Plast Reconstr Surg 1985;1:243-52. 63. Insler MR, Pechous B. Conjunctival flaps revisited. Ophthalmic 85. Kaltreider SA, Lucarelli MJ. A simple algorithm for selection Surg 1987;18:455-8. of implant size for enucleation and evisceration: A prospective 64. Alino AM, Perry HD, Kanellopoulos AJ, Donnenfeld ED, Rahn study. Ophthal Plast Reconstr Surg 2002;18:336-41. EK. Conjunctival flaps. Ophthalmology 1998;105:1120-3. 86. Bartlett RE. for the enucleation patient. Am J 65. Brackup AB, Carter KD, Nerad JA, Folk JC, Pulido JS. Long-term Ophthalmol 1966;61:68-78. follow-up of severely injured eyes following globe rupture. 87. Laiseca A, Laiseca D, Laiseca J, Laiseca J Jr. Correcting Ophthal Plast Reconstr Surg 1991;7:194-7. superior sulcus deformities. Adv Ophthal Plast Reconstr Surg 66. Dada, T, Ray M, Tandon R, Vajpayee RB. A study of the 1990;8:229-42. indications and changing trends of evisceration in north India. 88. Schaefer DP. Evaluation and management of the anophthalmic Clinical and Experimental Ophthalmol 2002;30:120-3. socket and socket reconstruction. In: Nesi FA, Lisman 67. Chaudhry IA, Al-Kuraya HS, Shamsi FA, Elzaridi E, Riley FC. RD, Levine MR, editors. Smith’s Ophthalmic Plastic and Current indications and resultant complications of evisceration. Reconstructive Surgery. 2nd ed. St. Louis: Mosby–Year Book, Ophthalmic Epidemiol 2007;14:93-7. Inc.; 1998. p. 1079-124. 68. Eballe AO, Dohvoma VA, Koki G, Oumarou A, Bella AL, Mvogo 89. Heinz GW, Nunery WR. Anophthalmic socket: evaluation and CE. Indications for destructive eye surgeries at the Yaounde management. In: McCord CD, Tanenbaum M, Nunery WR, Gynaeco-Obstetric and Paediatric Hospital. Clin Ophthalmol editors. Oculoplastic Surgery. New York: Raven Press; 1995. 2011;11:561-5. p. 609-937. 69. Afran SI, Budenz DL, Albert DM. Does enucleation in the 90. Neuhaus RW, Hawes MJ. Inadequate inferior cul-de-sac in the presence of endophthalmitis increase the risk of postoperative anophthalmic socket. Ophthalmology 1992;99:153-7. meningitis? Ophthalmology 1987;94:235-7. 91. Bosniak SL. Reconstruction of the anophthalmic socket: state 70. Ozgur OR, Levent A, Dogan OK. Primary implant placement with of the art. Adv Ophthal Plast Reconstr Surg 1987;7:313-48. evisceration in patients with endophthalmitis. Am J Ophthalmol 92. Petrelli RL. Use of autogenous materials in reconstructing 2007;143:902-4. the anophthalmic socket. Adv Ophthal Plast Reconstr Surg 71. Tawfik HA, Budin H. Evisceration with primary implant 1990;8:153-69. placement in patients with endophthalmitis. Ophthalmology 93. Rose GE, Sigurdsson H, Collin R. The volume-deficient orbit: 2007;114:1100-3. Clinical characteristics, surgical management, and results after 72. Birkman LW, Bennett DR. Meningoencephalitis following extraperiorbital implantation of Silastic block. Br J Ophthalmol enucleation for cryptococcal endophthalmitis. Ann Neurol 1990;74:545-50. 1978;4:476-7. 94. Goldberg RA, Holds JB, Ebrahimpour J. Exposed hydroxyapatite 73. Burch FE. Evisceration of the globe with scleral implant orbital implants: Report of six cases. Ophthalmology and preservation of the cornea. Trans Am Ophthalmol Soc 1992;99:831-6. 1939;37:272-82. 95. Kim YD, Goldberg RA, Shorr N, Steinsapir KD. Management 74. Migliori ME. Enucleation, evisceration, and exenteration. In: of exposed hydroxyapatite orbital implants. Ophthalmology Albert D, Miller J, Azar D, Blodi B, editors. Albert & Jakobiec’s 1994;101:1709-15. Principles and Practice of Ophthalmoloby. 3rd ed. (CD-ROM). 96. Nunery WR, Heinz GW, Bonnin JM, Martin RT, Cepela MA. Philadelphia: Saunders; 2008. Exposure rate of hydroxyapatite spheres in the anophthalmic 75. Stephenson CM. Evisceration. In: Hornblass A, editor. socket: Histopathologic correlation and comparison with Oculoplastic, Orbital and Reconstructive Surgery. Vol. 2. silicone sphere implants. Ophthal Plast Reconstr Surg Baltimore, MD: Williams & Wilkins; 1990. p. 1194-9. 1993;9:96-104. 76. Woog JJ, Angrist RC, White WL, Dortzbach RK. Enucleation, 97. Remulla HD, Rubin PA, Shore JW, Sutula FC, Townsend DJ, evisceration, and exenteration. In: Dortzbach RK, editor. Woog JJ, et al. Complications of porous spherical orbital Ophthalmic Plastic Surgery: Prevention and Management implants. Ophthalmology 1995;102:586-93. of Complications. New York, NY: Raven Press; 1994:251-68. 98. Smit TJ, Koomneef L, Zonneveld FW. Conjunctival cysts in 77. Masdottir S, Sahlin S. Patient satisfaction and results after anophthalmic orbits. Br J Ophthalmol 1991;75:342-3. evisceration with a split-sclera technique. Orbit 2007;26:241-7. 99. Zolli CL. Implant extrusion in eviscerations. Ann Ophthalmol 78. Smith RJ, Prazeres S, Fauquier S, Malet T. Complications 1988;20:127-35. of two scleral flaps evisceration technique: Analysis of 201 100. Shore JW, Dieckert JP, Levine MR. Delayed primary wound procedures. Ophthal Plast Reconstr Surg 2011;27:227-31. closure. Use to prevent implant extrusion following evisceration 79. Tari AS, Malihi M, Kasaee A, Tabatabaie SZ, Hamzedust K, for endophthalmitis. Arch Ophthalmol 1988;106:1303-8. Musavi MF, et al. Enucleation with hydroxyapatite implantation 101. Soll DB. The anophthalmic socket. Ophthalmology 1982;89: versus evisceration plus scleral quadrisection and alloplastic 407-23. implantion. Ophthal Plast Reconstr Surg 2009;25:130-13. 102. Kronish JW, Gonnering RS, Dortzbach RK, Rankin JH, Reid DL, 80. Dortzback RK, Woog JJ. Choice of procedure. Enucleation, Phernetton TM, et al. The pathophysiology of the anophthalmic

32 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 Phan, et al.: Evisceration in the Modern Age

socket, part II: analysis of orbital fat. Ophthal Plast Reconstr 112. Kim YD, Goldberg RA, Shorr N, Steinsapir KD. Management Surg 1990;6:88-95. of exposed hydroxyapatite orbital implants. Ophthalmology 103. Thaller VR. Enucleation volume measurement. Ophthal Plast 1994;101:1709-15. Reconstr Surg 1997;13:18-20. 113. Shields CL, Shields JA, De Potter P, Singh AD. Problems 104. Ataullah S, Whitehouse RW, Stelmach M, Shah S, Leatherbarrow with the hydroxyapatitie orbital implant: Experience with 250 B. Missed orbital wall blow-out fracture as a cause of post- consecutive cases. Br J Ophthalmol 1994;78:702-6. enucleation socket syndrome. Eye 1999;13:541-4. 114. Levine MR. Extruding orbital implant: prevention and treatment. 105. Lu L, Shi W, Luo M, Sun Y, Fan X. Repair of exposed Ann Ophthalmol 1980;12:1384-6. hydroxyapatite orbital implants by subconjunctival tissue flaps. 115. Helveston EM. Human bank sclera patch. Arch Ophthalmol J Craniofac Surg 2011;22:1452-6. 1969;82:83-6. 106. Basterzi Y, Sari A, Sari A. Surgical treatment of an exposed 116. McCord CD. The extruding implant. Trans Am Acad Ophthalmol orbital implant with vascularized superficial temporal fascia Otolaryngol 1976;81:587-90. flap. J Craniofac Surg 2009;20:502-4. 117. Soll DG. Donor sclera enucleation surgery. Arch Ophthalmol 107. Tawfik HA, Budin H, Dutton JJ. Repair of exposed porous 1974;92:494-5. polyethylene implants utilizing flaps from the implant capsule. 118. Wiggs EO, Becker BB. Extrusion of enucleation implants: Ophthalmology 2005;112:516-23. Treatment with secondary implants and autogenous temporalis 108. Lee MJ, Khwarg SI, Choung HK, Kim NJ, Yu YS. Dermis-fat fascia or fascia lata patch grafts. Ophthalmic Surg 1992;23:472-6. graft for treatment of exposed porous polyethylene implants 119. Eagle RC Jr, Grossniklaus HE, Syed N, Hogan RN, Lloyd WC in pediatric postenucleation retinoblastoma patients. Am J 3rd, Folberg R. Inadvertent evisceration of eyes containing uveal Ophthalmol 2001;152:244-50. melanoma. Arch Ophthalmol 2009;127:141-5. 109. Wu AY, Vagefi MR, Georgescu D, Burroughs JR, Anderson 120. Rath S, Honavar SG, Naik MN, Gupta R, Reddy VA, Vemuganti RL. Enduragen patch grafts for exposed orbital implants. Orbit GK. Evisceration in unsuspected intraocular tumors. Arch 2011;30:920-5. Ophthalmol 2010;128:372-9. 110. Sagoo MS, Olver JM. Autogenous temporalis fascia patch graft for porous polyethylene (Medpor) sphere orbital implant exposure. Br J Ophthalmol 2004;88:942-6. Cite this article as: Phan LT, Hwang TN, McCulley TJ. Evisceration in the modern age. Middle East Afr J Ophthalmol 2012;19:24-33. 111. Massry GG, Holds JB. Frontal periosteum as an exposed orbital implant cover. Ophthal Plast Reconstr Surg 1999;15:79-82. Source of Support: Nil, Conflict of Interest: None declared.

Author Help: Reference checking facility

The manuscript system (www.journalonweb.com) allows the authors to check and verify the accuracy and style of references. The tool checks the references with PubMed as per a predefined style. Authors are encouraged to use this facility, before submitting articles to the journal. • The style as well as bibliographic elements should be 100% accurate, to help get the references verified from the system. Even a single spelling error or addition of issue number/month of publication will lead to an error when verifying the reference. • Example of a correct style Sheahan P, O’leary G, Lee G, Fitzgibbon J. Cystic cervical metastases: Incidence and diagnosis using fine needle aspiration biopsy. Otolaryngol Head Neck Surg 2002;127:294-8. • Only the references from journals indexed in PubMed will be checked. • Enter each reference in new line, without a serial number. • Add up to a maximum of 15 references at a time. • If the reference is correct for its bibliographic elements and punctuations, it will be shown as CORRECT and a link to the correct article in PubMed will be given. • If any of the bibliographic elements are missing, incorrect or extra (such as issue number), it will be shown as INCORRECT and link to possible articles in PubMed will be given.

Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 33 Copyright of Middle East African Journal of Ophthalmology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.