陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 7熏晕燥援 4熏 Aug.18, 圆园14 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 窑ClinicalResearch窑 Enucleationandevisceration:indications,complications andclinicopathologicalcorrelations

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1DepartmentofOphthalmologyandVisualSciences, results. Malignant tumors (retinoblastoma: 47.5%, UniversityofIllinoisatChicago,Chicago,Illinois60612, malignantmelanoma:27.3%)werethemostcommon USA pathologicaldiagnosesfollowedbyphthisisbulbi(25.8%). 2DepartmentofOphthalmology,EyeResearchCenter, Themostcommonprocedure-relatedcomplicationswere RassoulAkramHospital,IranUniversityofMedical majoreyedischarge(39.6%),andimplantexposureand Sciences,Tehran40211,Iran discharge(20.8%). 3SchoolofMedicine,TehranUniversityofMedicalSciences, ·CONCLUSION:Traumaandmalignanttumorsarethe Tehran40261,Iran leading causes of enucleation-evisceration. Despite 4DepartmentofOphthalmology,BaqiyatallahUniversityof developingnewtechniquesandmaterials,enucleationis MedicalSciences,Tehran41570,Iran still associated with considerable postoperative 5DepartmentofNeurosurgery,ImamKhomeiniHospital, complications. TehranUniversityofMedicalSciences,Tehran40211,Iran ·KEYWORDS: enucleation;evisceration;retinoblastoma; Correspondenceto: AliKordValeshabad.Departmentof malignantmelanoma;ocularinjury OphthalmologyandVisualSciences,UniversityofIllinoisat DOI:10.3980/j.issn.2222-3959.2014.04.17 Chicago,1855WestTaylorStreet,ChicagoIL60612,USA. [email protected] KordValeshabadA,NaseripourM,AsghariR,ParhizgarSH, Received:2013-11-28Accepted:2014-03-12 ParhizgarSE,TaghvaeiM,MiriS.Enucleationandevisceration: indications,complicationsandclinicopathologicalcorrelations. 2014;7(4):677-680 Abstract ·AIM: To assess main indications, postoperative INTRODUCTION complications and clinicopathological correlation of nucleationisanacceptablesurgeryforend-stageocular ocularenucleation-evisceration. E diseaseswhicharenotcurablewithmedicaltreatments, ·METHODS:Atotalof107subjectswhounderwent suchasinexpiabletraumadamage,intraocularmalignancies enucleation and/or evisceration and received andphthisisbulbi.Inenucleationsurgeonremovesthewhole hydroxyapatiteimplants (Scleralwrapormesh)were eyeball,whereasineviscerationscleraandextraocular assessed.Foreachpatientclinicopathologicaldatawas muscleareleftintactandismostlyaccountedasacosmetic collected which included demographic information, procedure[1]. clinicalhistory,primaryclinicaldiagnosis,maincauseof Sincethedescriptionofthefirstenucleationsurgeryin1583 ophthalmicsurgery (traumatic,non-traumatic),typeof byBartisch,itsindicationsandimplantedmaterialshave surgical procedure (enucleation, evisceration) and beenchangedthroughthetimeinordertoobtainthebest pathologicalreport.Patients'postoperativeclinicalvisits motilityandperformance,andtolessencomplicationrate [2]. werecheckedforprocedure-relatedcomplicationsduring Themainclinicalindicationsofenucleationorevisceration firstyearaftersurgery. varyacrossdifferentcountries[3-5].Themostcommonoriginal ·RESULTS:Onehundredandsevenpatients(male: causesofenucleationaretraumaandmalignanttumors[5,6].In 65.4%;meanage:26y)underwentenucleation( =100)or tertiarycentersocularmalignanciessuchasmalignant evisceration ( =7)duetotraumatic ( =41)andnon- melanoma(MM)andretinoblastomaexceedothercausesof traumatic ( =66)causes.Disfiguringpainfulblindeye enucleation [4,7].Differentmaterialsincludingcartilage,bone, wasthemostcommonindicationofsurgery (66.4%), followedbyleukocoria (19.6%)andendophthalmitis fat,cork,rubber,gold, silver,andpolyethyleneand (4.7%).Themaintypesofinjuryincludedfirecracker, hydroxyapatite(HA)havebeenusedtofororbitalimplants, trafficandworkaccidents,andsharpobjectperforating andaconsiderablenumberoforbitalimplantconfigurations injury.In53(80.3%)subjectsinnon-traumaticgroupthe areavailablenow[8].Currently,poroussphericalHAimplants initialclinicaldiagnosismatchedthehistopathological arethemostcommonimplantswhichwasfirstintroducedin 677 Indicationsandcomplicationsofocularenucleation

1985 [8].Therateofpost-enucleationorevisceration Table 1 Indications of enucleation/evisceration stratified by complicationsisdependentonmanyfactorslikeimplanted traumatic and non-traumatic groups. material,surgerytechniques,andprevious evisceration Indications n (%) surgery [9,10].ThemostcommonHAimplants-related Traumatic 41 (38.3) complicationsaredischarge,implantexposure,migrationor Disfiguring blind eye 22 (20.6) infection,conjunctivaldehiscence,andpyogenicgranuloma Painful blind eye 9 (8.4) formation [11,12]. Therearelimitedreportsaboutindications,complications Endophthalmitis 5 (4.7) andtheclinicopathologicalcorrelationof enucleation/ Painful eye 3 (2.8) evisceration.Thiswouldprovideaprimaryguidetoestablish Prevention of sympathetic ophthalmia 2 (1.9) preventivemeasuresforleadingcausesofenucleationbased Non-traumatic 66 (61.7) onthedomesticprevalencedata.Thepurposeofthisstudyis Blind eye 27 (25.2) toinvestigatecausesandindications, postoperative Leukocoria 21 (19.6) complications,and clinicopathological correlationof Painful blind eye 10 (9.3) enucleation-eviscerationusingHAimplants. Painful eye 8 (7.5) SUBJECTSANDMETHODS Table 2 Causes of ocular injury in 41 patients with Thisretrospectivereviewwasconductedon107subjects enucleation/evisceration. (eyes)whounderwentenucleationoreviscerationat Causes n (%) departmentofophthalmologyofatertiarycenterinIran, betweenSeptember2001andDecember2006.Thisresearch Firecracker 11 (26.8) studywasapprovedbyanInstitutionalReviewBoardatthe Traffic accident 10 (24.3) IranUniversityofMedicalSciences.Foreachpatient Work related 8 (19.5) clinicopathologicaldatawerecollectedwhichincluded Knife 5 (12.2) demographicinformation,clinicalhistory,primaryclinical Scissor 4 (9.8) diagnosis,maincauseofophthalmicsurgery,typeofsurgical Fist 2 (4.9) procedure(enucleation,evisceration)andhistopathological Explosion 1 (2.4) report.Alleyeimplantswerehydroxyapatite(sclera-wrapped ormesh).Foreachpatient,relatedproceduredataofused ageof26 22y(range:2.5moto78y)wererecruited.One materials,andtechniqueswererecordedinaprepared 依 datasheet.Patients'postoperativeclinicalvisitswerechecked hundredeyeswereenucleatedandsevenothersunderwent forpotentialprocedure-relatedcomplicationsduringthefirst evisceration.Sclera-wrappedHAwasthemostcommon yearfollowingsurgery.Patientsdividedintotraumaticand implantusedforenucleatedpatients(94.0%).Insixpatients non-traumaticgroupsbasedontheunderlyingindicationof HAmeshwasappliedasimplant.Ocularinjurywasthemost surgeries.Innon-traumaticgroup, subjects underwent commoncauseofthesurgeryandpatientswereclassified enucleationwhentheeyewasblind,hadverypoorvisionand basedontheunderlyingindicationofsurgeriesintotraumatic waspainful,hadsevere endophthalmitis,to prevent ( 41)andnon-traumatic( 66)groups.Table1lists = = sympatheticophthalmiaand/orduetocosmeticissues.In indicationsofenucleation/eviscerationstratifiedbytraumatic ordertomeasurethe clinicopathologiccorrelation, in andnon-traumaticgroups.Disfiguringpainfulblindeyewas non-traumaticgroup,samplesweresentforhistopathological themostcommonindicationofsurgery(66.4%),followedby studyandpathologicdiagnosesafterwardswerecomparedto leukocoria(19.6%)andendophthalmitis(4.7%). theinitialclinicaldiagnosis. Table2summarizesthecausesofocularinjuriesinpatients Statistical Analysis Resultswerereportedasmean whoreceivedenucleation/evisceration.Intraumaticgroup, 依 standarddeviation(SD)forquantitativevariablesand themaintypesofinjuryincludedfirecracker,trafficandwork numberandpercentageforcategoricalvariables.Thegroups accidents,andsharpobjectperforatinginjury.Among41 werecomparedusingtheStudent's -testforcontinuous patientswithoculartraumas,14enucleationswereperformed variablesandtheChi-squaretest(orFisher'sexacttestif primarily(including4eviscerations).Fivepatientsunderwent required)forcategoricalvariables.Statisticalsignificance parsplanavitrectomypriortosecondaryenucleation.Primary wasbasedontwo-sideddesign-basedtestsevaluatedatthe enucleationwasperformedwhentherepairofglobewasnot 0.05levelofsignificance.Allthestatisticalanalysiswere possibleduetounrecognizableeyecontentsorincaseof performedusingSPSSversion18.0(SPSSInc,Chicago,IL, avulsedopticnerve.Twentyseveneyeswererepaired USA)forWindows. primarily,butunderwentsecondaryenucleation(including3 RESULTS eviscerations).Amongthem,24patientshadnolight Atotalof107patients(eyes)(male:65.4%),withthemean perceptionandwereenucleatedduetopainfulblindeye( 9), = 678 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 7熏晕燥援 4熏 Aug.18, 圆园14 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 Table 3 Histopathological results of enucleation/evisceration causesofenucleationwhichwerematchedwithinitial (n=66) indicationofsurgery.Disfiguringpainfulblindeyewasthe Histopathological diagnosis n (%) mostcommonindicationofsurgery,followedbyleukocoria andendophthalmitis.Thepostoperativecomplicationrate Retinoblastoma 30 (45.5) washighinenucleatedeyeswhoreceivedHAimplants. Malignant melanoma 18 (27.3) Inpresentstudyinconsistencewithpreviousreports,ocular Phthisis bulbi 17 (25.8) injurywastheleadingindicationofenucleationinreferred PHPV 1 (1.4) subjects [6,13].Intraumaticgroup,themaintypesofinjury PHPV: Persistent hyperplastic primary vitreous includedfirecracker,trafficandworkaccidents,andsharp

Table 4 Postoperative complications in enucleated patients objectperforatinginjury.AreportfromtheUnitedKingdom during one year follow up (n=107). duringtheperiodof1994to2003alsoconfirmedeyetrauma Complications n (%) astheleadingcauseenucleation [3].However,invasiveocular Major discharge 19 (39.6) malignanciesandtheirconsequenceswerereportedasthe Exposure and discharge 10 (20.8) mostcommonindicationof enucleation/eviscerationin [4,7] Implant exposure 6 (12.5) tertiarycenters .Ourdepartmentisatertiarycenter,but oculartraumawasrankedasthemostcommonindicationof Cellulitis 5 (10.5) enucleation/eviscerationamongourpatients.Thismightbe Lid edema 3 (6.2) attributedtothespecificconditionsinourcountrywhichare Pyogenic granuloma formation 3 (6.2) associatedwithmoreinjurieslikefirework-relatedinjuries Conjunctivitis 2 (4.2) duringPersianNewYearFestival (ChaharshanbeSoori), Total 48 (100) whichisassociatedwithsevereandseveralinjuriesofhand, eye,legandface [14].Howevernewsurgicalprocedureshave disfiguredblindeye(=8),endophthalmitis( 5),and substantiallyreducedthenumberofcaseswithmechanical = preventionofsympatheticophthalmia( 2).Anadditional3 eyeinjurieswhofinallyneedenucleation,theseocular = eyeswithlightperceptionwereenucleatedforpain.All7 injuries,especiallyinseverecasesarenotassociatedwith caseswhounderwenteviscerationhadphtisisbulbidueto promisingoutcomesandstillleadtoagrimvisualoutcomeor [15] ocularinjuries(3caraccident,2workrelated,and1gun enucleation .Thisimpliestheimportanceofpoliticaland injuries).Fourpatientswereblindatpresentation,andthree educationalstrategiesasaprimarypreventionforthesetypes patientshadpainfuleye.Table3showsthepathological ofeyeinjurieswhicharemostlypreventable. diagnosisin66enucleatedeyesinnon-traumaticgroup.In53 Inthisstudy,malignanttumors,includingretinoblastomaand (80.3%)subjectsinnon-traumaticgrouptheinitialclinical MMwerethemostcommonfinaldiagnosesinhistological studies.Aretrospectivereviewof646eyesin644American diagnosismatchedthe histopathologicalstudyresults. patientswhounderwentenucleationalso revealed Malignanttumors(74.8%) werethemost common malignanciesastheleadingdiagnosisinhistologicalstudy[1]. pathologicaldiagnosesfollowedbyphthisisbulbi.Among48 Thesuggestedunderlyingexplanationforthepredomination subjectswithfinaldiagnoseretinoblastoma,24(50%)cases oftumorsovertraumamightbethehighpercentageof presentedwithleukocoria.Blindeye(69.0%)wasthemost referredpatientswithmalignantoculartumorstothetertiary commoncauseofreferinpatientswhowerefinally carecenters.Thisisinagreementwiththeresultofsome diagnosedasMM( 29).In13 (19.7%)theclinical = similarstudies[4,16].LeukocoriaanddecreasedVAarethemost diagnosiswasdifferentfromthepathologicalresultswhich commonsignsofretinoblastomaandMM,respectively [17-19]. includesphtisisbulbi( 8),retinoblastoma( 2),multiple = = Thesesignswerefoundinaconsiderableproportionofour myeloma( 2),andPHPV( 1). = = studiedpatientsaswellwhichiscompatiblewiththefinal Duringoneyearfollowup,48patients(44.8%)developed confirmedhistologicaldiagnosis.Phthisisbulbiwasthe procedure-relatedcomplications.Dischargewasthemost secondorderhistologicaldiagnosisinthisstudy.Saeed [3] commoncomplicationsaftersurgery.Table4lists andKitzmann [1] alsoreportedphthisisbulbiasthe postoperativecomplicationsofthepatientsduringfollow-up secondhistologicaldiagnosisinenucleatedpatients. period. Inourstudyprocedure-relatedcomplicationswererecorded DISCUSSION in48patients(44%),relativelycompatiblewithprevious Ocularenucleationisaccountedasthelastresortforend reportedrates(22%-48%)[9,19].Majoreyedischargewasthe stagesofmanyoculardiseaseslikeocularmalignanciesor mostcommoncomplicationoccurredin39.1%ofour otherclinicalcausesleadingtoapainfulblindeye [1]. patients.Lin [20] alsoreporteddischargeasthemost Eviscerationisanotheralternativewhichismainlyacosmetic commoncomplication.Highertemperatureofsubtropical procedureandisusedwhenamalignancydoesnotexist[1].In climatesandthedifficultiesinpostoperativewoundcare thisstudyocularinjuriesandmalignanciesweretwomain mightresultinincreaseddischargeinsomecases.Exposure 679 Indicationsandcomplicationsofocularenucleation anddischarge(20.8%)wasthenextcommoncomplication Rigshospitalet,Denmark. 2010;88(2):218-221 followedbyimplantexposure(12.5%).Implantexposurerate 5GeirsdottirA,AgnarssonBA,HelgadottirG,SigurdssonH.Enucleation reportedtorangefrom10%to22%ofpatients [20].Implant inIceland1992-2004:studyinadefinedpopulation. exposureratedependsonseveralfactorsincludingage(seen 2014;92(2):121-125 6GatonDD,EhrlichR,MuzmacherL,HamelN,LuskyM,WeinbergerD. moreinchildren),typeofimplant(seenmoreinHA Enucleationsandeviscerationsinalargemedicalcenterbetweentheyears implants),andsurgerytechniques(higherafterevisceration 1981and2007. 2008;147(10):758-762,840 vs.enucleation) [21,22].Inthisstudy,rateofcellulitis(10.5%) 7KnezevicM,PaovicJ,PaovicP,SredojevicV.Causesofeyeremoval: wasgreaterthanpreviousstudies.Ashworth [23] reported analysisof586eyes. 2013;70(1):26-31 cellulitisin4%oftheircases.Thehigherateofcellulitisin 8GoiatoMC,HaddadMF,dosSantosDM,PesqueiraAA,RibeiroPdoP, ourstudymightbeassociatedwiththeconsiderablerateof MorenoA.Orbitalimplantsinsertiontoimproveocularprosthesesmotility. 2010;21(3):870-875 eyedischargeandimplantexposure.Intraoperative 9JordanDRGS,BawazeerA.Corallinehydroxyapatiteorbitalimplant manipulationofextraocularmuscleandmotilityofthe (Bio-Eye):experiencewith158patients. [24] implantmaycauseedema .Lidedemawasdetectedinthree 2004;20(1):69-74 patientsinthisstudy.Granulomaformationoccurredinthree 10JordanDR.Problemsaftereviscerationsurgerywithporousorbital enucleatedeyeinthisstudy.Materialofimplantand implants:experiencewith86patients. 2004; conjunctiva-implantinterface(andtherewithmicrotrauma) 20(5):374-380 11TohT,BevinTH,MoltenoAC.Scleralwrapincreasesthelong-term mayaffecttherateofgranuloma.Duetotheaggressive complicationriskofbone-derivedhydroxyapatiteorbitalimplants. natureofprocedureconjunctivaisalsopronetodamageand 2008;36(8):756-761 infection.Inourstudyconjunctivitisoccurredintwo(4.2%) 12WangJK,LiaoSL,LinLL,KaoSC,TsengHS.Porousorbitalimplants, patients.Edelstein [25] reportedthreecaseswith wraps,andPEGplacementinthepediatricpopulationafterenucleation. conjunctivitisafterenucleation. 2007;144(1):109-116 Theretrospectivenatureofourstudylimitsourfindings. 13ChengGY,LiB,LiLQ,GaoF,RenRJ,XuXL,JonasJB.Reviewof 1375enucleationsintheTongRenEyeCentre,Beijing. 2008; Amongourpatienttherewereonly7casesofevisceration 22(11):1404-1409 while100patientsunderwentenucleation.Bothenucleation 14TavakoliH,KhashayarP,AmoliHA,EsfandiariK,AsheghH,RezaiiJ, andeviscerationaremajorophthalmicoperations,andthe SalimiJ.Firework-relatedinjuriesinTehran'sPersianWednesdayEve clinicalindicationsmightnotbethesame,howeverboth Festival(ChaharshanbeSoori). 2011;40(3):340-345 proceduresareconsideredthelastresort.Theprevalencerate 15AhmadabadiMN,KarkhanehR,ValeshabadAK,TabatabaiA,Jager andunfavorableoutcomeofsevereeyeinjuriesdueto MJ,AhmadabadiEN.Clinicalpresentationandoutcomeofperforating mechanicaltraumaespeciallyduringnationalfestivalsin ocularinjuriesduetoBBguns:acaseseries. 2011;42(5):492-495 16HansenAB,PetersenC,HeegaardS,PrauseJU.Reviewof1028bulbar developingcountrieslikeIranemergethenecessityof eviscerationsandenucleations.Changesinaetiologyandfrequencyovera nationally-widetargetedprogramonprimaryprevention. 20-yearperiod. 1999;77(3):331-335 Furtherprospectivestudiesareencouragedtoevaluatethe 17TokosovaE,UhmannovaR,HlinomazovaZ.Malignantmelanomaofthe impactofpoliticalandeducationalinterventiononreducing uveaintheDepartmentofOphthalmology,FacultyHospitalBrnoBohunice, therateofsevereeyeinjuries,andsubsequentenucleation. CzechRepublic,EU. 2008;64(1):30-33 Inconclusion,traumaandmalignanttumorsaretheleading 18AertsI,Lumbroso-LeRouicL,Gauthier-VillarsM,BrisseH,DozF, DesjardinsL.Retinoblastoma. 2006;25(1):31 causesofenucleation-evisceration.Despitedevelopingnew 19DamatoB.Doesoculartreatmentofuvealmelanomainfluencesurvival? techniquesandmaterials,enucleationisstillassociatedwith 2010;103(3):285-290 considerablepostoperativecomplications. 20LinCJ,LiaoSL,JouJR,KaoSC,HouPK,ChenMS.Complicationsof ACKNOWLEDGEMENTS motilitypegplacementforporoushydroxyapatiteorbitalimplants. 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