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Evisceration, enucleation, exenteration


Introduction

The emotional distress which frequently accompanies the removal of an eye is reduced considerably by a cosmetic final result. The appearance of the prosthesis will be enhanced and its mobility will be improved if a buried orbital implant is inserted (see Ch. 13 ) following an evisceration or enucleation.

12.1

Evisceration with removal of the cornea

12.1a–c

Make a 360 degree conjunctival incision and recess the conjunctiva and Tenon's capsule for a few millimetres from the limbus. Make a 360 degree limbal incision to remove the cornea – start with a scalpel blade or Graefe knife and complete the incision with scissors.

Fig. 12.1a, Perilimbal conjunctival incision.

Fig. 12.1b, Removal of the cornea with a Graefe knife.

Fig. 12.1c, Completion of corneal removal with scissors.

12.1d–f

Remove the ocular contents with an evisceration spoon and ensure complete removal of all pigmented tissue by careful cleaning of the scleral envelope.

Make two scleral relieving incisions on opposite sides of the limbus to allow the placement of a 22 mm ball implant within the scleral envelope.

Fig. 12.1d, Cornea removed. Plane between uveal tract and sclera ( arrow ).

Fig. 12.1e, Evisceration spoon inserted between uveal tract and sclera.

Fig. 12.1f, Ocular contents removed. Relieving incision.

12.1g–i

Identify the optic nerve head. Cut around it to separate it from the remaining sclera. A Colorado cutting diathermy needle or a Surgitron (Ellman) radiofrequency needle is a convenient instrument for this but a scalpel may be used instead.

Make relieving incisions at opposite points in the circular defect created by separation of the optic nerve. The intraconal fat is now clearly seen.

Fig. 12.1g, Full-thickness scleral incision around optic nerve.

Key diag. 12.1g

Fig. 12.1h, Sclera separated from optic nerve.

Fig. 12.1i, Relieving incisions in posterior sclera. Arrow marks inferior nasal incision.

Key diag. 12.1i

12.1j–l

Place a 22 mm sizer (see Figs 5.13 , 13.1aA ) or acrylic ball ( 13.1aB ) into the scleral envelope to check that it can be accommodated. Using an introducer, if available, insert the implant into the sclera, ensuring that it is placed well posteriorly, within the posterior sclera and anterior intraconal fat.

Fig. 12.1j, A 22 mm ball inserted with introducer.

Fig. 12.1k, Ball in situ – to be pushed more posteriorly by scleral closure.

Fig. 12.1l, Ball inserted well posteriorly in scleral envelope.

12.1m–o

Close the sclera over the implant with 6/0 absorbable sutures. If any of the ball is exposed place a patch of donor sclera over the repair (see 13.10 ).

Close Tenon's capsule and the conjunctiva in two layers with 7/0 absorbable sutures, burying the knots. Place a conformer in the socket.

Fig. 12.1m, Anterior sclera closed.

Fig. 12.1n, Tenon's capsule and conjunctiva closed.

Fig. 12.1o, Conformer in situ.

Fig. 12.1 post, Three months after evisceration with 22 mm acrylic sphere implant and with prosthesis fitted.

Complications and management

Chemosis and lid oedema are common after evisceration. Providing infection does not occur the swelling will settle without treatment.

The risk of sympathetic ophthalmitis in the fellow eye is extremely small but during the follow-up period the fellow eye should be examined.

12.2

Enucleation

12.2a–c

Reflect the conjunctiva from the limbus for 360 degrees. Locate and detach the rectus muscles, placing a suture through each tendon for later identification.

Fig. 12.2a, A 360 degree perilimbal conjunctival incision. Inferior rectus muscle isolated.

Fig. 12.2b, Inferior rectus muscle tendon cut. Suture on tendon.

Fig. 12.2c, All rectus muscles cut and tagged with sutures.

12.2d–f

Detach the oblique muscles and tag the inferior oblique for later reattachment. Introduce an artery clip or snare along the nasal side of the globe. Clamp and cut the optic nerve. Traction on 4/0 sutures placed through the original rectus muscle insertions facilitates removal of the globe.

Fig. 12.2d, Inferior rectus muscle identified.

Fig. 12.2e, Clamp on optic nerve.

Fig. 12.2f, Optic nerve cut with enucleation scissors.

12.2g–i

Cauterise the stump of the nerve and take time to achieve complete haemostasis.

Insert an appropriate implant and close the socket as described in Ch. 13 , Sect. A , depending on the implant chosen. If no implant is inserted leave the rectus muscles free within the orbit and close the conjunctiva with interrupted absorbable sutures.

Fig. 12.2g, Clamp on optic nerve.

Fig. 12.2h, Posterior Tenon's capsule opened to enter intraconal fat.

Fig. 12.2i, Implant wrapped in Vicryl mesh being inserted (see Ch. 13 Sect. A ).

Complications and management

Haemorrhage from the ophthalmic artery and other vessels close to the orbital apex may be difficult to control and may result in a postoperative orbital haematoma. The risk of haemorrhage may be reduced by the use of a snare to cut the optic nerve. The risk of early extrusion of the orbital implant is increased if a haematoma occurs. Care with haemostasis, if necessary by packing the orbit for 7 to 10 minutes during surgery, is time well spent.

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