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Enucleation and Evisceration: Indications, Complications And

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Enucleation and Evisceration: Indications, Complications And 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 , 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
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