Eye removal surgical techniques
* Impact factor according to the SCIENCE INDEX 2017
M.B. Gushchina1, N.S. Yuzhakova2, N.A. Gavrilova2, T.S. Kondratenko3
1Central Research Institute of Dental and Maxillofacial Surgery, Moscow, Russian Federation
2A.I. Evdokimov Moscow University of Medicine and Dentistry, Moscow, Russian Federation
3Goldberg-Klinik Kelheim GmbH, Kelheim, Germany
About 12.000 eye removal surgeries are performed in Russian Federation every year. More than 50% of these patients are young working age individuals. Two major techniques of eye removal are used in clinical practice, i.e., evisceration and enucleation. However, systematic approach to the choice of surgical technique in certain clinical circumstances is not developed yet. This paper addresses foreign and domestic published data, indications and contraindications to evisceration and enucleation considering potential complications, their advantages and disadvantages depending on clinical situation. It was demonstrated that minimal risks of tumor cell dissemination and sympathetic ophthalmia as well as the possibility to perform detailed morphology of excised tissues are the advantages of enucleation. However, enucleation is associated with higher risks of postoperative complications resulting from orbital implant exposure. Considering this, it is important to select proper size-, construction-, and biocompatibility-matched orbital implant when choosing enucleation as an eye removal surgical technique.
Keywords: enucleation, evisceration, orbital implant, stump, artificial eye, sympathetic ophthalmia, anophthalmic socket syndrome, implant exposure.
For citation: Gushchina M.B., Yuzhakova N.S., Gavrilova N.A., Kondratenko T.S. Eye removal surgical techniques. Russian Journal of Clinical Ophthalmology. 2020;20(1):–48. DOI: 10.32364/2311-7729-2020-20-1-37-48.
Two major techniques of eye removal are used in clinical practice, i.e., evisceration and enucleation as well as their various modifications [1, 3-5]. Both techniques have advantages and disadvantages. However, systematic approach to the choice of surgical technique in certain clinical situations is not developed yet [6, 7].
Eye removal is the oldest ocular surgical technique as it was described in an ancient Chinese manuscript as early as in 2600 up to AD . Many centuries later, in 1555, J. Lange was the first one in Europe who described eye removal surgery. In 1583, G. Bartisch published a textbook of ophthalmology “Ophthalmodouleia” and described in detail his technique of eye removal with surrounding tissues [1, 5]. In 1841, A.A. Bonnet and A.J. O’Ferral independently of each other proposed a technique of the entire eyeball removal from Tenon’s capsule (enucleation). In 1859, F. Arlt developed a technique of “classic” enucleation which involves 360-degree conjunctival incision, conjunctiva and Tenon’s capsule separating from the underlying sclera, step-by-step cutting of extraocular muscles and optic nerve, eyeball removal, and wound closure .
In 1817, J. Bear had to remove eye’s content leaving sclera intact due to the expulsive hemorrhage occurred during iridectomy for glaucoma . It was the first time when alternative eye removal technique, evisceration, was applied. Later, in 1872, H.D. Noyes described in detail his own technique of evisceration to manage severe intraocular purulent inflammation . Principal, classic method of evisceration survived until modern time was developed by A. Graefe in 1884. This technique involved 360-degree conjunctival incision, separation of conjunctiva from the globe to extraocular muscle attachments, 360-degree scleral incision at 1-2 mm from the limbus, cornea, perilimbal sclera, and intraocular content removal, hemostasis securing, careful lavage of eye socket with antiseptic solution, and layer-by-layer wound closure [3, 9]. This technique preserved scleral attachments of extraocular muscles.
In the second half of the 19th century, significant soft tissue loss after eye removal was attempted to be replaced by various materials (i.e., rubber, silver, aluminum, wool, cotton, paraffin, agar, sponge, ivory etc.) to improve cosmetic and functional surgical outcomes. In 1885, M. Chibet reported on the implantation of rabbit eye into human orbit. However, this procedure failed due to the incompatibility of rabbit and human tissues . In 1885, P.H. Mules described implantation of hollow glass sphere to replace soft tissue loss; this procedure improved cosmetic surgical outcome . Since then, hundreds of orbital implants of various design and materials were developed to create a stump after eye removal using various surgical techniques . As a result, surgical technique has changed. When performing enucleation, extraocular muscle tendons are sutured before cutting while rectus muscles are sutured together over the implant or sutured to the implant. When performing evisceration, sclera is incised in each oblique quadrant. The implant is placed into the socket [1, 6, 9].
Sympathetic ophthalmia following evisceration
Since 1887, as evisceration was introduced into clinical practice, some authors reported on sympathetic ophthalmia after this procedure [10, 11]. The results of the studies on the causes of this complication have demonstrated that evisceration is associated with the risk of incomplete removal of uveopigmentary tissue and retinal fragments near optic nerve head, in perineural spaces, and along scleral nerves and vessels thus resulting in autoimmune reactions and sympathetic ophthalmia [11, 12]. To eliminate this defect, modified technique of evisceration involving neurotomy, emissary coagulation, and additional resection of internal scleral layers was introduced [4, 13]. Later, it was demonstrated that the rate of this complication is rather low (~2%) [7, 10, 12, 14]. In recent decades, occasional cases of sympathetic ophthalmia after evisceration are documented [15, 16]. This is accounted for by improved surgical technique as well as postoperative use of novel steroids which effectively prevent autoimmune reactions [12, 17].
Published data suggest that evisceration is not at higher risk of sympathetic ophthalmia than other intraocular surgeries and penetrating ocular injuries [14, 16-18]. Therefore, evisceration does not exclude sympathetic ophthalmia in patients with prior intraocular surgery or eye injury. Hence, the choice of eye removal technique should be balanced and rational.
Indications to eye removal
Published data suggest that primary indications for eye removal are malignant intraocular tumors (i.e., retinoblastoma, uveal melanoma) not eligible for eye preservation, low-grade uveitis (traumatic and non-traumatic) of a blind non-functional eye, painful absolute glaucoma (primary, secondary, congenital), buphthalmia with scleral staphyloma, corneal thinning, and orbital fat atrophy, severe eye infections (endophthalmitis, panophthalmitis) not eligible for eye preservation, eye injuries with globe rupture not eligible for eye preservation, and cosmetically unacceptable eyes with deformed ocular surface preventing ocular prosthetics [1, 2].
Some authors report that eye injuries and their complications (i.e., phthisis bulbi, traumatic uveitis etc.) are the most common indications for eye removal (on average, 14.0% to 79.9% of cases) [2, 7, 19, 20]. Other authors declare that intraocular tumors are the most common indications for eye removal (12.0% to 79.6% of cases) [21, 22]. Most authors report that the number of eye removals for painful absolute glaucoma has significantly reduced in recent years. Published data demonstrate that eye removal for this disorder was performed in more than 29.0% in 1964-1992 but in 3.5% to 6.0% only after 1998 [2, 23-25]. This phenomenon is probably accounted for by more effective treatment and surgery for glaucoma. Eye removal for severe eye infections is performed in 1.0-8.1% [22, 23].
Malignant intraocular tumors
Published data demonstrate that malignant intraocular tumors not eligible for eye preservation are indications for enucleation but absolute contraindications for evisceration (see Table 1). Clear advantage of enucleation over evisceration is minimal risk of tumor dissemination [1, 7, 26]. According to W.A. Manschot, early enucleation for uveal melanoma reduces mortality by 50-100% . Evisceration, in turn, increases the risk of tumor recurrence [9, 11, 26]. In addition, enucleation allows detailed examination to verify the diagnosis and tumor dissemination in sclera and optic nerve membranes. Notably, preoperative diagnostics is of crucial importance for the choice of eye removal technique. Thus, published data on purulent inflammation (considered as infectious endophthalmitis or panophthalmitis) occurred in a blind eye with opaque media are available. As a result, evisceration was performed in this patient. However, later on, it was demonstrated that necrotic uveal melanoma accounts for this purulent inflammation . Despite small number of preoperatively undiagnosed tumors (resulting from the development of imaging technologies, i.e., ultrasound, CT, and MRI), evisceration is contraindicated in any suspicion of intraocular tumor if found impossible to provide preoperative differential diagnosis [1, 26-28].
Some foreign authors suggest that various eye injuries, e.g., recent penetrating ocular injuries not eligible for eye preservations are an indication for evisceration despite potential risk of sympathetic ophthalmia [25, 26]. It is believed that early radical eye removal before antigenic sensitization occurs (up to 2 weeks after injury) prevents sympathetic ophthalmia [12, 29]. To prevent sympathetic ophthalmia, some authors recommend early enucleation after penetrating ocular injuries, in particular, in case of multiple scleral ruptures or delayed surgery for eye injuries associated with incarceration of intraocular tissues in the wound when uveal tissue cannot be totally excised by evisceration [2, 4, 16]. Repeated injuries of blind eye are of particular importance since they are associated with higher risk of sympathetic ophthalmia as compared with the primary injury. Considering this, enucleation is also recommended for these patients (see Table 1) [12, 16]. There is a view that eye removal is challenging in case of thick episcleral scars resulting from repeated extrascleral surgeries for retinal detachment (scleral buckling etc.). Therefore, evisceration is the first-line surgical choice for these patients . However, scleral buckle protruding into the vitreous cavity associated with local inflammation often occurs due to ischemic scleral necrosis. As a result, these pathological changes make it difficult to create a stump after evisceration.
Phthisis bulbi and low-grade uveitis
There are no clear preferences for either eye removal technique in phthisis bulbi and low-grade uveitis (including non-traumatic uveitis) without incarceration of intraocular tissues in scleral scars. Most authors declare that evisceration as well as enucleation can be performed (see Table 1) [13, 30]. However, there are exceptions, i.e., low-grade uveitis with positive response to uveopigmentary antigens as demonstrated by immunoassay. In this case, enucleation and detailed morphology of enucleated eye to clarify the etiology and pathogenesis of uveitis (if failed to perform that preoperatively) are indicated (e.g., in endogenous uveitis of unknown etiology which results in phthisis bulbi). This study is of crucial importance due to the potential similar pathological condition of the fellow eye [11, 16].
Absolute glaucoma, buphthalmia, and cosmetically unacceptable blind eyes
In these cases, pain relief and/or cosmetic rehabilitation are the primary goals of eye removal. The choice of eye removal technique depends largely on surgeon’s preferences (see Table 1) . Both surgical techniques provide adequate pain relief associated with ocular hypertension . However, most authors declare that evisceration is preferable in these patients due to less traumatization and better functional and cosmetic outcomes [20, 25, 31].
In severe purulent inflammation not eligible for eye preservation (purulent corneal ulcer with corneal perforation or lysis in blind eyes, endophthalmitis, panophthalmitis), most authors prefer evisceration since no optic nerve cutting is required. As a result, dissemination of infection along perineural spaces in the cranial cavity and severe complications are prevented [2, 26, 31]. Therefore, in infectious inflammatory conditions, evisceration is superior to enucleation since it leaves scleral barrier intact thus preventing dissemination of infection in the cranial cavity and orbital tissues. However, retrospective review by S.I. Afran et al. has demonstrated no cases of meningitis after enucleation in 165 patients with endophthalmitis due to the extensive antibacterial therapy. The authors concluded that enucleation is safe in these patients . Nonetheless, final choice of eye removal surgery in infectious inflammatory ocular disorders requires a personalized approach to each patient considering all features of the pathological process. Thus, in purulent melting of sclera (scleromalacia or scleral abscess), enucleation is the only possible surgery for eye removal while in purulent corneal wound and endophthalmitis, evisceration is more useful (see Table 1) [2, 33]. Therefore, the choice of eye removal technique is obviously determined by the nature of pathological process.
Two-step postoperative rehabilitation is the specificity of eye removal surgery for infectious diseases. The first step is eye removal and the second, delayed, step (after purulent inflammation has reduced) is stump creation and orbital implantation [2, 4]. Any implantation of a foreign material or autograft should be performed in particularly sterile conditions.
Stump creation and orbital implants
According to the current guidelines, endoprosthesis replacement is required after eye removal to gain maximum functionality and aesthetics as well as to prevent anophthalmic socket syndrome [2, 4, 5, 19]. A number of orbital implants varying in material’s properties and construction were designed:
· structured and unstructured autografts (i.e., fat, cartilage, cellulocutaneous or fascial flaps etc.) ;
· allografts (i.e., cadaver costal cartilage, bone etc.) [35-37];
· wrapped and non-wrapped implants of natural or synthetic hydroxyapatite and ceramic implants [38, 39];
· polymeric implants (i.e., polyethylene, polytetrafluorethylene, hydrogel, silicone etc.) [40, 41];
· metallic implants (i.e., of titanium nickelide etc.) ;
· unstructured synthetic implants (i.e., carbon felt, collagen hemostatic sponge etc.) [1, 43].
Meanwhile, most of these orbital implants are tailored to the implantation into post-evisceration socket and designed to replace soft tissue loss . Even higher requirements are applied to post-enucleation stump. In these cases, orbital implants of stable shape and structure providing its safe fixation to extraocular muscles and orbital tissues are used. In addition, the surface of orbital implant should not damage surrounding tissues . Metered connective tissue ingrowth into the implant is also important since this provides safe fixation of the implant to orbital tissues and does not result in its “sealing” and reduced mobility in the late postoperative period (occurring in deep and total ingrowth into connective tissue) [2, 9, 45]. In addition, some authors suggest that the muscles are sutured directly to the implant when creating post-enucleation stump since this provides direct contact and the transmission of movements from extraocular muscles to orbital implants thus resulting in better stump mobility [9, 19, 44]. When the muscles are sutured over the implant, it moves by virtue of surrounding tissues and contractions of conjunctival fornices only .
Therefore, tissue-integrated orbital implant is required to provide adequate mobility and stability of post-enucleation stump. However, the structure of most orbital implants prevents their safe fixation to orbital tissues and extraocular muscles. According to published data, this is associated with unfavorable functional and cosmetic outcomes and various postoperative complications .
Complications after eye removal can occur both in the early and late postoperative period being directly associated with the surgery itself or stump creation.
Early (1-2 weeks) postoperative complications (infectious and hemorrhagic) are nonspecific. They result from the surgery itself and are generally common for evisceration and enucleation .
Infectious complications in the early postoperative period are rare due to the current regimens of sterility in the operating room and sterilization of surgical items and implants as well as careful patient selection [9, 46]. In addition, pre-, intra-, and postoperative (for 7-10 days) local and systemic antibacterial treatment using novel antibiotics minimizes the risk of infectious complications. Occasionally, these complications may require reoperation (wound revision and orbital implant removal) [3, 46].
Hemorrhagic complications (hemorrhage or hematoma) after evisceration or enucleation are often local and easy to address. To prevent these complications, anticoagulants should be discontinued before the surgery after consulting a specialist. Intraoperatively, eye socket tamponade with sanitary napkins or hemostatic sponge or using electrocauterization is performed to prevent bleeding. Postoperatively, temporary blepharorrhaphia is performed or compression bandage is applied for several days [47, 48]. These measures typically minimize hemorrhagic complications. However, orbital implants with rough surface provoke severe bleedings. The result is orbital implant exposure.
Orbital implant exposure, pushing out, and extrusion are a separate group of complications occurring both in the early and late postoperative period . Wound dehiscence, incorrect implantation technique, and inappropriate size, structure, physical chemical properties, and bioavailability of orbital implants (which results in implant displacement, postoperative exogenous or endogenous infection) account for these complications [4, 7, 40, 43]. Post-evisceration orbital implant exposure occurs less often (3% to 20%) since the thickness of remaining scleral shell is greater [4, 7, 20]. Post-enucleation orbital implant exposure occurs more often (8.2% 84%) being probably associated with the type and characteristics of orbital implant material as well as an incorrect technique of implantation or wound closure [21, 49]. In addition, the use of orbital implants with rough traumatic surface (of non-wrapped bioceramics or hydroxyapatite), in particular, after enucleation, is associated with maximum (20% to 100%) risk of exposure [20, 38, 39].
In the late postoperative period (3 months and later), deformation of conjunctival fornices and lids (i.e., conjunctival cysts, cicatricial contractures, ptosis, ectropion, lagophthalmos etc.) as well as stump displacement and shape change (i.e., retraction, ptosis, inadequate mobility etc.) can occur both after enucleation and evisceration. These complications are typically associated with surgical technique, inappropriate size or shape of orbital implants, and long-term use of inadequate ocular prosthesis [20, 21, 47] as well as progressive orbital fat atrophy resulting from the primary injury, buphthalmia, or eye removal surgery itself. Final cosmetic outcome depends on the volume of replaced tissue, stump stability, fornix depth, lid functionality, and ocular prosthesis mobility .
It is accepted that cosmetic and functional surgical outcome depends on the range of motion of ocular prosthesis . However, the mobility of ocular prosthesis is always less than the mobility of healthy eye or stump since the range of motion of ocular prosthesis is limited by conjunctival fornices . It is well-known that the volume of motion of healthy eye in all four directions is 180-200°. The volume of motion of ocular prosthesis should be at least a half of that of the fellow eye (i.e., 90-100°) for a natural look . Therefore, high stump mobility does not ensure optimal functional and esthetic outcome. The efficacy of ocular prosthetics determines the ratio of ocular prosthesis mobility to stump mobility. To quantify functional cosmetic surgical outcome, the coefficient of ocular prosthetics effectiveness (COPE) was proposed which is the ratio of ocular prosthesis mobility to stump mobility in percentage :
According to I.A. Filatova (2009), average overall stump mobility is 69.9 ± 8.9°after enucleation and 149.8 ± 3.2° after evisceration. Average overall ocular prosthesis mobility is 59.6 ± 7.8° after enucleation and 93.8 ± 2.1° after evisceration. COPE is 85.2% and 62.6%, respectively. This coefficient is significantly higher in less stump mobility and significantly lower in greater stump mobility . Therefore, greater stump mobility does not ensure greater ocular prosthesis mobility.
The analysis of published data help systematize indications and contraindications to enucleation and evisceration.
Absolute contraindications to evisceration are malignant intraocular tumors requiring eye removal, suspected intraocular tumor, recent eye injuries with multiple scleral ruptures, incarcerated intraocular tissues in the scar tissue after eye injury, and low-grade traumatic uveitis with high risk of sympathetic ophthalmia of the fellow eye. In these cases, enucleation is the first-line choice since this technique provides minimum risk of tumor dissemination and sympathetic ophthalmia of the fellow eye. In addition, enucleation allows detailed morphology of the eyeball.
In painful absolute glaucoma, phthisis bulbi, low-grade traumatic and non-traumatic uveitis uveitis without incarceration of intraocular tissues, severe purulent inflammatory disorders (purulent corneal ulcer with corneal perforation or lysis in blind eyes, endophthalmitis, panophthalmitis), and cosmetically unacceptable eyes after injuries or diseases, both evisceration and enucleation can be performed. The choice of eye removal technique depends on a certain clinical situation and surgeon’s preferences.
However, enucleation is associated with higher risks of postoperative complications resulting from orbital implant exposure. Considering this, it is important to select proper size-, construction-, and biocompatibility-matched orbital implant when choosing enucleation as eye removal surgical technique.
About the authors:
1Marina B. Gushchina — MD, PhD, Researcher of the Division of the Development of High-tech Methods of Reconstructive Maxillofacial Surgery, ORCID iD 0000-0003-1134-8064;
2Natalia S. Yuzhakova — MD, ophthalmologist, postgraduate of the Department of Eye Diseases, ORCID iD 0000-0002-5361-0393;
2Natalia A. Gavrilova — MD, PhD, Professor, Head of the Department of Eye Diseases, ORCID iD 0000-0003-0368-296X;
1Tatiana S. Kondratenko — MD, ophthalmologist, ORCID iD 0000-0002-6096-2215.
1Central Research Institute of Dental and Maxillofacial Surgery. 16, Timur Frunze str., Moscow, 119991, Russian Federation.
2A.I. Evdokimov Moscow University of Medicine and Dentistry. 20/1, Delegatskaya str., Moscow, 127473, Russian Federation.
3Goldberg-Klinik Kelheim GmbH. 3, Traubenweg, Kelheim, 93309, Germany.
Contact information: Natalia S. Yuzhakova, e-mail: firstname.lastname@example.org. Financial Disclosure: no authors have a financial or property interest in any material or method mentioned. There is no conflict of interests. Received 24.09.2019.
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