Enucleation, Evisceration, and Exenteration

Definitions:

Enucleation: surgical removal of the entire globe.
Evisceration: surgical removal of the entire contents of the globe, leaving a scleral shell.
Exenteration: removal of the entire orbit, including the globe, eyelid, and orbital contents—usually performed for malignant tumors.

Key Features

Indications for enucleation, evisceration, or exenteration surgery.
Careful preoperative patient evaluation and counseling.
Detailed presentation of specific surgical techniques for enucleation, evisceration, and exenteration.
Postoperative management and possible surgical complications.

Introduction

Enucleation, evisceration, and exenteration surgery all involve the permanent removal of the patient’s eye. In this chapter the important aspects of each procedure are emphasized, including:

Indications for surgery
Preoperative patient counseling
Surgical techniques
Postoperative management
Complications of surgery

Preoperative Evaluation and Diagnostic Approach

Indications for Surgery

Enucleation or evisceration surgery may be indicated for a blind painful eye, endophthalmitis, or cosmetic improvement of a deformed eye. In cases of intraocular neoplasms or the treatment of severe ocular trauma with a ruptured globe, where sympathetic ophthalmia is a concern, enucleation is appropriate and evisceration is contraindicated. Other indications for enucleation may include progressive phthisis bulbi, severe microphthalmia, and biopsy in a bilateral process where one eye is blind and the other eye is not as involved.

In most situations, the indication for exenteration surgery is to eradicate life-threatening malignancy or life-threatening orbital infection. The extent of the procedure should be explained to the patient, especially which tissues are to be removed (this includes the eyeball, orbital soft tissues, and part or all of the eyelid structures). A summary of the indications for surgery is given in Box 12.11.1 .

Box 12.11.1

Indications for Surgery

Enucleation

Blind painful eye
Intraocular tumor
Severe trauma with risk of sympathetic ophthalmia
Phthisis bulbi
Microphthalmia
Endophthalmitis/panophthalmitis
Cosmetic deformity

Evisceration

As for enucleation, except for intraocular tumors or risk of sympathetic ophthalmia

Exenteration

Cutaneous tumors with orbital invasion
Lacrimal gland malignancies
Extensive conjunctival malignancies
Other orbital malignancies
Mucormycosis
Chronic orbital pain
Orbital deformities

Preoperative Counseling

Faced with the permanent loss of an eye, a patient requires the physician's reassurance, caring explanations, and psychological support. The patient (and family) should understand that evisceration and enucleation surgery involve the complete, permanent removal of the diseased or deformed eye. The indication for surgery should be clearly explained. The patient should be informed of the choices between enucleation and evisceration surgery and of the availability of a variety of orbital implants, including common alloplastic implants, newer implants designed to maximize ultimate ocular prosthesis motility, or autologous tissue orbital implants such as dermis fat.

The patient should understand the risks and benefits of wrapping orbital implants with either autologous tissues or preserved donor tissue, and that donor tissues may carry small risks of communicable diseases, such as syphilis, hepatitis, and human immunodeficiency virus. A thorough explanation allows the patient and family to make a well-informed decision regarding surgery.

Anesthesia

Enucleation surgery may be performed using local anesthesia. For psychological reasons, and occasionally for medical reasons, however, general anesthesia is usually used. Under any circumstance, agents should be used that maximize intraoperative hemostasis, suppress the oculocardiac reflex, and minimize postoperative pain. The author’s choice is to instill 10% phenylephrine eyedrops into the conjunctival cul-de-sac to achieve intense vasoconstriction and to infiltrate extensive retrobulbar and peribulbar bupivacaine 0.5% with epinephrine (adrenaline) 1:100,000 and hyaluronidase. After adequate time, an excellent anesthetic and vasoconstrictive effect is achieved.

Most evisceration surgeries are performed under local anesthesia with intravenous sedation. A mixture of lidocaine (lignocaine) 2% with epinephrine 1:100,000, bupivacaine 0.5% with 1:100,000 epinephrine, and hyaluronidase is injected in retrobulbar fashion into the muscle cone. The use of intravenous anesthetic sedatives prevents either the local anesthetic injection or the surgical procedure itself from being unpleasant or producing anxiety.

Exenteration surgery is usually performed under general anesthesia, which may be combined with bupivacaine and epinephrine infiltration to aid hemostasis and provide postoperative analgesia.

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