Enucleation and Evisceration Chapter 23 ENUCLEATION AND EVISCERATION ASA D. MORTON, MD* INTRODUCTION HISTORY OF EYE REMOVAL AND PROSTHESES PREOPERATIVE PLANNING Decision to Remove the Eye Preoperative Counseling Goals of Rehabilitating the Anophthalmic Socket Decision to Enucleate or Eviscerate ENUCLEATION EVISCERATION IMPLANTS POSTOPERATIVE CARE COMPLICATIONS Blepharoptosis Lower-Eyelid Malposition and Laxity Enophthalmos Socket Contracture Implant Exposure SUMMARY *Commander, Medical Corps, US Navy; Chief, Oculoplastics Section, Naval Medical Center San Diego, San Diego, California 92134 405 Ophthalmic Care of the Combat Casualty INTRODUCTION Although historically the eyes have suffered an inordinately high rate of injury relative to the total body surface area in harm’s way,1 the loss of an eye in combat is an exceedingly costly, largely prevent- able catastrophe (Figure 23-1). During the Vietnam War, at least 1,200 eyes were removed secondary to a combat-related injury, and the US Library of Con- gress estimates that the long- and short-term costs associated with serious eye injuries in that war ex- ceeded $4 billion.2 The incidence of eye injuries has increased with each conflict in the 20th century. For example, World War I data document an incidence of eye injuries of 2.0% to 2.5%, but the rate of such injuries during the Persian Gulf War was 13%3; frag- ments from explosive munitions accounted for 78% Fig. 23-1. Massive retrobulbar hemorrhage associated of the serious eye injuries and 94% of the enucle- with a low-velocity metal fragment. Surgical attempts to ations reported during the latter war.4 Most of these repair this double, perforating globe injury (entrance and injuries could have been prevented with readily exit wounds) were unsuccessful, and the eye was enucle- available ballistic eye armor. Military ophthalmolo- ated. This injury could have been prevented with appro- gists must be versed in enucleation and eviscera- priate eye protection. tion, but greater efforts should be directed toward force education and injury prevention (Figure 23-2). HISTORY OF EYE REMOVAL AND PROSTHESES References to ocular surgical procedures predate cessful eye operations; for those procedures deemed 2000 BCE (before the common era). Sumerian law unsuccessful, the penalty was amputation of the limited what a practitioner could charge for suc- surgeon’s hands.5 In the mid 16th century, extirpa- a b Fig. 23-2. (a) A short-range thermal blast induced significant damage to the face of this individual. The periocular area was spared by the patient’s protective eyewear. (b) The polycarbonate lenses have been significantly pitted by the heat and flying debris. The blast was of sufficient intensity that its heat melted the side shields. 406 Enucleation and Evisceration tion of the eye was described.6 The disfiguring pro- the prosthesis, and inadequate volume replacement cedure was more akin to a subtotal exenteration, led to the development of several unique implants. including removal of portions of the conjunctiva, Shape and texture modifications sought to isolate extraocular muscles, and orbital fascia. The patient the extraocular muscles to their respective quad- could not be fitted with an ocular prosthesis. In the rants to limit implant migration. Anterior implant mid 1800s, O’Ferral and Bonnet7 developed a more projections, some with exposed coupling pegs, were accepted technique, which involved transecting the engineered to create a direct linkage with the pros- extraocular muscles at their scleral insertions and thesis and maximize motility. Several implants met preserving Tenon’s capsule. Their description is the goal of improved prosthesis motility but at the most consistent with enucleation as we know it to- expense of unacceptably high exposure and extru- day.8 sion rates. Others developed donor sclera–covering The first description of an evisceration is cred- techniques for the acrylic and silicone spheres, his- ited to Beer in 1817.9 While he was performing a torically the best tolerated of any implant design, glaucoma procedure, the eye experienced an expul- allowing the muscles to be sutured to the implant. sive hemorrhage and Beer removed the ocular con- The latter technique remains an acceptable adjunct tents. In 1874, Noyes10 published his experience in to enucleation surgery today, with the same acrylic removing the contents of severely infected eyes, and and silicone spheres acceptable as evisceration im- it is he who is credited with first using evisceration plants. as a routine procedure. Since the early to mid 1990s, porous implants In 1884, Mules11 placed a glass sphere into an (hydroxyapatite and porous polyethylene) have eviscerated scleral shell, initiating the search for the become the choice for many surgeons. The inter- perfect implant. The early implants were hollow connecting porous channels allow fibrovascular glass spheres and had unacceptably high extrusion ingrowth throughout the implant. This ingrowth rates. Throughout the early part of the 20th century, stabilizes the implant position and limits migration. numerous implant materials were investigated, in- After the implant has completely fibrovascularized, cluding gold, silver, vitallium (a cobalt–chromium it may be drilled and an anterior projecting cou- alloy), platinum, aluminum, cartilage, bone, fat, pling peg placed. Although early results of the peg- fascia lata, sponge, wool, rubber, silk, catgut, peat, ging process have been promising, recent reports agar, asbestos, cork, ivory, paraffin, and cellulose. of complications are emerging.12 The long-term Concerns about the simple spheres’ tendency to mi- prognosis for drilling of implants and placing of grate, incomplete translation of socket motility to pegs is not yet known. PREOPERATIVE PLANNING Decision to Remove the Eye patients should be assured that appropriate medi- cation will be provided. The patient must be pre- The psychological effect of losing an eye may pared to wear a conformer for 5 to 7 weeks until present greater difficulties for the patient than the the socket is ready to be fitted with a prosthesis. In physical disability.13 The preoperative time spent ad- addition, the patient must understand that the fit- dressing eye removal, as well as discussing life after ting process may require several appointments over losing an eye, will reap benefits in postoperative re- as many weeks. covery and acceptance. Photographs of other anoph- thalmic patients are useful as the prospective patient Goals of Rehabilitating the Anophthalmic Socket tries to understand the process. It may be helpful to facilitate a meeting between the patient facing eye Communication between the ophthalmologist removal and one who has completed the process. Psy- and the ocularist is integral to a good outcome. The chiatric referral is appropriate for patients who mani- ophthalmologist must select an implant of appro- fest increased difficulty coping with the loss. priate volume to allow for optimal prosthetic size. Too small an implant necessitates an inappropri- Preoperative Counseling ately large prosthesis to fill the orbital volume, and this may limit motility and transmit excess weight to It is vitally important that the patient be prepared the lower eyelid. Over time, the excess weight will for surgery and the rehabilitation to follow. Pain is result in laxity of the lower eyelid with a resultant variable in the immediate postoperative period, and asymmetric appearance. On the other hand, too 407 Ophthalmic Care of the Combat Casualty large an implant limits the ocularist’s ability to fash- enucleation (removal of the globe and a segment ion a prosthesis with simulated anterior chamber of the anterior optic nerve) and evisceration (removal depth without imparting a proptotic appearance to of the ocular contents with preservation of the the orbit. sclera and, in some cases, the cornea). The ophthal- The ocularist can modify the prosthesis to adjust mologist must guide the patient to the most lid position, correct for a shortened conjunctival cul- appropriate procedure if absolute indications de-sac, and improve motility. The posterior surface or contraindications exist. Some patients may of the prosthesis can be vaulted in cases of conjunc- take comfort in evisceration and equate the reten- tival irritation or breakdown. Patients who elect to tion of the scleral shell to keeping the eye. Con- undergo implant pegging to maximize prosthetic versely, the appropriately selected evisceration can- motility (discussed later) rely on the ophthalmolo- didate may find the minimal risk of sympathetic gist and the ocularist to coordinate their care. The ophthalmia to be unacceptable and elect for enucle- ocularist can provide a prosthetic template to as- ation. (Although a consensus does not exist, most sist the ophthalmologist in peg placement and authors agree that penetrating trauma increases the centration. Following the peg placement, the risk of sympathetic ophthalmia and is a contrain- ocularist will modify the implant to allow implant– dication to evisceration. For war-related ocular prosthetic coupling. trauma that leads to loss of useful vision, enucle- Eye removal and socket rehabilitation are not ation removes the uveal tissue implicated in incit- procedures to relegate to minimally supervised jun- ing inflammation in the sympathizing eye. For fur- ior residents. This is the primary procedure that will ther information, see Chapter 16, Sympathetic Oph- determine long-term success and promote rapid