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Evisceration, Enucleation & Exenteration - Ophthalmology Residency Notes

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Overview

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1. EVISCERATION

Definition

Technique (Kanski, Fig. 4.49)

1. Perilimbal conjunctival incision (360°)
2. Cornea removed with scissors
3. Evisceration spoon inserted between uveal tract and sclera; all intraocular contents scooped out
4. Complete removal of all pigmented tissue - critical to eliminate residual uveal remnants (reduces sympathetic ophthalmia risk)
5. Relieving incision in anterior sclera (allows implant placement)
6. 22 mm ball implant inserted with introducer into scleral envelope
7. Anterior sclera closed with 6-0 absorbable sutures
8. Tenon capsule and conjunctiva closed in two layers with 7-0 absorbable sutures
9. Conformer placed in socket

Indications

• Blind, painful eye (preferred procedure over enucleation for this indication)
• Blind, unsightly eye
• Endophthalmitis (when no malignancy suspected)
• After severe trauma without prospect of visual recovery (if no intraocular malignancy suspicion)

Advantages over Enucleation

• Better prosthesis motility - extraocular muscles stay attached to intact sclera; natural muscle mechanics retained
• Less operative bleeding
• Shorter procedure
• Better orbital volume maintenance

Key Contraindication

Caution: Phthisis bulbi

• Evisceration should not be performed on a phthisical (shrunken) eye - the scleral shell cannot accommodate an adequate-sized implant

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2. ENUCLEATION

Definition

Indications

1. Primary intraocular malignancy (e.g., uveal melanoma, retinoblastoma) where other treatments are not appropriate - globe kept intact for histopathology
2. Severe trauma with hopeless visual prognosis, particularly when risk of sympathetic ophthalmia is a concern
3. Blind, painful or unsightly eye (though evisceration is generally preferred)

Technique (outline)

1. Conjunctival peritomy 360°
2. All four rectus muscles isolated and sutures placed through each before detachment
3. Oblique muscles cut
4. Optic nerve transected as far posteriorly as possible (to minimize stump that could harbour posterior uveal melanoma seeding)
5. Globe removed; haemostasis achieved
6. Orbital implant inserted into Tenon's space
7. Rectus muscles sutured to implant (improves prosthesis motility)
8. Tenon's and conjunctiva closed in layers
9. Conformer placed

Timing After Trauma

• Enucleation (or evisceration) within 10-14 days of injury has historically been recommended to prevent sympathetic ophthalmia
• Based on anecdotal evidence; no high-quality RCT data

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3. EXENTERATION

Definition

Indications

1. Orbital malignancy - primary orbital tumours or tumours invading the orbit from eyelids, conjunctiva, globe, or adnexa when other treatments have very poor chance of success
2. Anteriorly sited tumours: relative sparing of posterior orbital tissue may be possible
3. Posterior tumours: may allow preservation of eyelid skin to line the socket
4. Rare non-malignant disease: orbital mucormycosis (life-threatening fungal infection - emergency)

Variants

• Total exenteration: entire orbital contents including eyelids
• Subtotal / lid-sparing exenteration: eyelid skin preserved to improve reconstruction
• Extended exenteration: orbital bone removed (for bony invasion)

Socket Rehabilitation after Exenteration

• Socket can be lined with:
  • Skin or split-skin graft
  • Left to heal by secondary intention
• Prostheses options:
  • Attached to surrounding skin with adhesive
  • Mounted on glasses (Fig. 4.51)
  • Secured with osseointegrated magnets on orbital rim bones

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4. ORBITAL IMPLANTS

Why Implants are Needed

• Enucleation/evisceration creates a volume deficit in the orbit
• A large prosthetic eye alone (without an underlying implant) causes:
  • Stretching and sagging of the lower lid under its weight
  • Poor motility of the prosthesis

Types of Implant Materials

• Porous implants allow fibrovascular ingrowth, which facilitates natural motility of the overlying prosthesis
• A peg can be inserted into porous implants for direct coupling to prosthesis (though the peg must be covered by socket tissue and cannot directly attach to the prosthesis)
• Unpegged implants also provide good motility if donor sclera or mesh wrap used and extraocular muscles secured to surface

Timing

• Implant usually inserted at time of surgery (primary implant)
• Secondary placement possible later, or previously inserted implant can be exchanged

Key Complication: Implant Extrusion

• Significant concern with all implants
• Prevention: careful placement - implant must be sufficiently deep and well covered with vascularised tissue
• Choice of implant material is less important than correct surgical technique

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5. POST-ENUCLEATION SOCKET SYNDROME (PESS)

Definition

Pathophysiology

• Without adequate volume, upper lid loses support → ptosis
• Prosthesis tilts backward and rotates upward
• This puts forward pressure on lower eyelid → shallow fornix + lower lid sag

Features (EUHS mnemonic)

• Enophthalmos
• Upper lid ptosis
• Hollowing of superior sulcus
• Sagging lower lid

Management

• (a) Insert a secondary implant if no implant present
• (b) Insert a silicone block into the inferior orbit (if implant already present)
• (c) Dermis-fat graft implantation

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6. OCULAR PROSTHESIS / REHABILITATION

After Evisceration or Enucleation

1. A conformer (silicone or acrylic) placed immediately postoperatively to support conjunctival fornices
2. Conformer remains until socket heals
3. Socket impression moulds taken at ~6-8 weeks postoperatively
4. Temporary artificial eye placed while custom prosthesis is manufactured
5. Custom prosthesis shaped to fit individual socket and matched to fellow eye

After Exenteration

• Adhesive prosthesis, glasses-mounted prosthesis, or osseointegrated magnet-secured prosthesis

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7. SYMPATHETIC OPHTHALMIA (SO) - Key Relevance

Evisceration vs. Enucleation Risk

• SO is a rare bilateral granulomatous uveitis triggered by penetrating trauma or surgery to one eye (the "exciting eye"), threatening the fellow eye (the "sympathizing eye")
• Enucleation within 10-14 days of injury is historically recommended for eyes with no visual potential to prevent SO
• Evisceration is acceptable provided all uveal tissue is meticulously removed during the procedure
• Risk of SO after evisceration historically thought higher than after enucleation, but this is debated in current literature

SO Treatment

• High-dose oral prednisolone (first-line), tapered over months
• IV methylprednisolone may initiate treatment
• Topical steroids + cycloplegics for anterior segment involvement
• Immunomodulatory therapy should be considered early

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8. QUICK COMPARISON TABLE

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9. HIGH-YIELD EXAM POINTS

1. Evisceration = contraindicated in suspected intraocular malignancy (disrupts globe, prevents histopathology)
2. Enucleation = preferred when malignancy is present (globe intact for histology)
3. Evisceration = preferred for blind painful eye over enucleation (better motility, simpler)
4. Phthisis bulbi = contraindication to evisceration (scleral shell too small for implant)
5. 10-14 day rule for enucleation/evisceration after penetrating trauma to prevent sympathetic ophthalmia
6. Evisceration + SO: acceptable if ALL uveal tissue removed
7. PESS: enophthalmos, ptosis, superior sulcus hollowing, lower lid sag - due to volume deficit
8. Porous implants (hydroxyapatite, polyethylene) allow fibrovascular ingrowth = better motility
9. Exenteration may include eyelid sparing (anteriorly sited tumours) or bone removal (extended)
10. Orbital mucormycosis = rare but important non-malignant indication for exenteration
11. Conformer placed immediately postoperatively; custom prosthesis fitted at 6-8 weeks

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Evisceration, Enucleation & Exenteration - Complete Ophthalmology Residency Notes

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1. EVISCERATION

Definition

Surgical Technique (Step-by-Step)

1. Perilimbal conjunctival incision 360° - recess conjunctiva and Tenon's capsule a few mm from limbus
2. Cornea removed - 360° limbal incision, start with scalpel/Graefe knife, complete with scissors
3. Evisceration spoon inserted between uveal tract and sclera - scoop all intraocular contents
4. Meticulous removal of all pigmented tissue from the scleral envelope - critical step (reduces sympathetic ophthalmia risk)
5. Identify optic nerve head - cut around it to separate from remaining sclera (in some techniques)
6. Scleral relieving incisions x2 on opposite sides of limbus (allows accommodation of implant)
7. 22 mm ball implant placed within scleral envelope using an introducer
8. Scleral closure with 6-0 absorbable sutures; patch of donor sclera if any ball exposed
9. Tenon's capsule + conjunctiva closed in two layers with 7-0 absorbable sutures, burying knots
10. Conformer placed in socket

Indications

• Blind, painful eye (this is the preferred procedure for this indication)
• Blind, unsightly eye
• Phthisis is a relative contraindication (scleral shell cannot hold adequate implant)
• Severe trauma with no visual potential - only if no malignancy suspected
• Endophthalmitis (no suspected malignancy)

Advantages over Enucleation

• Better prosthesis motility - extraocular muscles remain naturally attached to sclera
• Less operative time
• Less bleeding
• Less disruption of orbital tissues → less enophthalmos risk

Key Contraindications

Specific Note on Pain Relief

• Evisceration does not always eliminate pain because the posterior ciliary nerves are not cut (unlike enucleation where the optic nerve is transected); though this is debated clinically

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2. ENUCLEATION

Definition

Surgical Technique

1. Conjunctival peritomy 360° with Westcott scissors
2. Isolate all four rectus muscles - double-armed 6-0 absorbable sutures placed through each before detachment; muscles tagged and cut
3. Superior and inferior oblique muscles cut
4. Globe delivered forward from the orbit
5. Optic nerve transected as far posteriorly as possible with curved enucleation scissors
   • For retinoblastoma: minimum 10 mm of optic nerve must be excised (to clear potential retrolaminar spread)
   • For uveal melanoma: maximal posterior optic nerve excision; minimal globe manipulation to avoid haematogenous dissemination
6. Haemostasis with pressure and gauze
7. Orbital implant (18-22 mm sphere) placed into Tenon's space / intraconal space
8. Rectus muscles sutured to implant surface - improves prosthesis motility
9. Tenon's capsule closed with absorbable sutures
10. Conjunctiva closed
11. Conformer placed

Indications

1. Intraocular malignancy requiring histopathology (uveal melanoma, retinoblastoma group E) - globe must be kept intact
2. Severe trauma with no visual potential where sympathetic ophthalmia risk is significant
3. Blind, painful eye (if evisceration contraindicated or surgeon preference)
4. Neovascular glaucoma refractory to treatment

Specific Indications by Tumour

• Large tumour size
• Optic disc invasion
• Extensive ciliary body or anterior angle involvement
• Irreversible loss of useful vision
• Poor patient motivation to retain eye
• Note: Always confirm correct eye by ophthalmoscopy after draping; keep globe manipulation minimal

• Neovascular glaucoma
• Anterior chamber infiltration
• Optic nerve invasion
• Tumour occupies >50% vitreous volume
• Chemoreduction failure
• Diffuse retinoblastoma (poor visual prognosis, high recurrence risk)
• Note: Excise ≥10 mm of optic nerve; minimal eye manipulation; adjuvant chemotherapy (CEV) if retrolaminar or massive choroidal spread; external beam radiotherapy if optic nerve cut end involved

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3. EXENTERATION

Definition

Surgical Technique (General)

1. Skin incision around orbital rim (or through eyelids for total exenteration)
2. Periosteum elevated from all orbital walls
3. Entire orbital contents dissected free en bloc
4. Specimen sent for histology
5. Haemostasis; socket management

Variants

Indications

• Orbital malignancy (primary) unresponsive to other treatments
• Tumour invading orbit from: eyelids, conjunctiva, globe, adnexa - when other treatments very unlikely to succeed
• Sebaceous gland carcinoma, squamous cell carcinoma, basal cell carcinoma with orbital invasion
• Lacrimal gland malignancy with orbital extension

• Orbital mucormycosis - life-threatening fungal infection, often in diabetics/immunocompromised; requires emergency debridement

Socket Rehabilitation after Exenteration

1. Healing by secondary intention - socket granulates over weeks
2. Split-skin graft lining
3. Prosthesis attachment options:
   • Adhesive to surrounding skin
   • Mounted on glasses frame
   • Osseointegrated magnets on orbital rim bones (best motility and retention)

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4. ORBITAL IMPLANTS - Detailed

Why Volume Must Be Replaced

• Enucleation/evisceration removes ~7 ml of orbital volume
• Adult orbit volume ~30 ml
• Without replacement: prosthesis weight stretches lower lid → sags; motility poor; superior sulcus hollowing

Implant Materials

Sizes

• Standard implant: 18-22 mm sphere
• Typical: 20 mm for adult enucleation
• Evisceration: 22 mm ball (scleral envelope accommodates slightly larger)

Peg System (Integrated Implants)

• A titanium peg can be drilled into porous implant after fibrovascularisation (typically at 6 months)
• Peg must be covered by intact conjunctiva/socket tissue before placement
• Provides direct coupling between implant movement and prosthesis
• Complication: peg site granuloma, discharge, exposure

Key Surgical Principle

Correct placement technique is more important than implant material choice - implant must be sufficiently deep and covered with well-vascularised tissue to prevent extrusion

Implant Complications

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5. POST-ENUCLEATION SOCKET SYNDROME (PESS)

Definition

Pathophysiology

1. No implant (or inadequate implant) → volume deficit
2. Upper lid loses support → ptosis
3. Prosthesis tilts posteriorly and rotates upward
4. Prosthesis weight/pressure on lower lid → shallow inferior fornix + lower lid lag/sag
5. Fat atrophy over time worsens the deformity

Clinical Features (PESS tetrad)

• Enophthalmos (apparent)
• Upper lid ptosis
• Superior sulcus hollowing/deepening
• Sagging/lower lid ectropion

Management

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6. ANOPHTHALMIC SOCKET - CARE AND COMPLICATIONS

Normal Socket Examination

• Residency tip: Always remove the prosthesis to examine the socket - this is frequently neglected
• Inspect conjunctiva, fornices, implant position, socket discharge
• Work with a trained ocularist for long-term prosthesis management

Discharging Socket

• Mild mucoid discharge: normal; clean with saline
• Purulent discharge: infection; swab and treat
• Persistent discharge: consider implant exposure/extrusion

Prosthesis Fitting Timeline

1. Intraoperative: conformer placed
2. 6-8 weeks post-op: socket impression; temporary prosthesis
3. 3-6 months: custom-fitted, colour-matched permanent prosthesis
4. Annual: prosthesis polish and check; replace every 5-7 years

Superior Sulcus Syndrome (Stock Eye Syndrome)

• Occurs when a standard ("stock") prosthesis doesn't match the individual socket
• Prosthesis too small → doesn't fill volume → superior sulcus depression
• Solution: custom prosthesis; fat grafting; orbital volume augmentation

Prosthesis Motility Limitation

• Implant movement transmitted to prosthesis: ~10-15° (conversational range) - adequate for social interaction
• Not at extremes of gaze
• Enhanced by: rectus muscle attachment to implant, porous implant material, pegging

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7. SYMPATHETIC OPHTHALMIA (SO) - Full Notes

Background

• Bilateral granulomatous panuveitis triggered by penetrating ocular injury or intraocular surgery
• "Exciting eye" = injured eye; "Sympathizing eye" = fellow eye
• Uveal antigens exposed by injury → T-cell mediated autoimmune attack on both eyes
• Can occur days to decades after injury (peak: 2 weeks to 3 months; 80% within 1 year)

Histology

• Diffuse granulomatous infiltration of the choroid by lymphocytes and epithelioid cells
• Dalen-Fuchs nodules: granulomas between Bruch membrane and RPE - pathognomonic

Prevention with Surgery

• Enucleation OR evisceration within 10-14 days of penetrating injury with no visual potential
• Based on anecdotal evidence; no RCT proof
• Evisceration acceptable only if all uveal tissue meticulously removed
• Once SO has developed in the sympathizing eye, enucleating the exciting eye does not necessarily prevent progression but may reduce severity

Treatment

1. High-dose oral prednisolone - mainstay; taper over months based on response
2. IV methylprednisolone - for initiation in severe cases
3. Topical steroids + cycloplegics - for anterior segment involvement
4. Peri/intraocular steroids (slow-release intravitreal implants) - reduce systemic load
5. Immunomodulatory therapy (methotrexate, mycophenolate, azathioprine, cyclosporine) - start early in course

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8. SPECIAL SCENARIOS & EXAM PEARLS

Trauma Setting

• Primary evisceration/enucleation: extremely severe injuries where scleral repair is impossible and no visual prognosis
• Reduces rehabilitation time; allows rapid return to work
• Secondary evisceration/enucleation: after failed primary repair - blind, damaged, unsightly, uncomfortable eye
• Both are safe with low infection and complication rates

Neovascular Glaucoma (NVG)

• Enucleation or evisceration as last resort if all other treatments fail
• Treat underlying cause to protect fellow eye

Choosing Evisceration vs. Enucleation - Summary Decision Tree

Suspected intraocular malignancy?
    YES → ENUCLEATION (histology mandatory)
    NO ↓
Phthisis bulbi?
    YES → ENUCLEATION (sclera too contracted for evisceration)
    NO ↓
Blind painful/unsightly eye, endophthalmitis, trauma with no visual potential?
    → EVISCERATION (preferred: better motility, simpler, shorter)

Anaesthesia Options

• Both procedures can be performed under local (peribulbar/retrobulbar) anaesthesia in selected patients
• General anaesthesia more common for surgical comfort

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9. COMPLETE COMPARISON TABLE

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10. HIGH-YIELD MNEMONICS

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