Enucleation, evisceration, exenteration

enucleation, evisceration, ocular prosthesis

1. Enucleation, Evisceration , Exenteration Dr. Vinit Kumar SCEH, Lahan , Nepal O.A. 2 nd year class

2. Enucleation : INTRODUCTION Enucleation is the surgical procedure that involves removal of the entire globe & its intraocular contents, with preservation of all other periorbital and orbital structures. Enucleation is in contrast to evisceration , in which the ocular contents are removed from an intact sclera . Exenteration, in which the entire orbital contents, including the globe & soft tissues, are removed. The surgical removal of the eye was first reported in the 1500s as a procedure known as extirpation.

3. Indications The following are indications for enucleation : 1. Absolute indications are retinoblastoma and malignant melanoma. 2. Relative indications are painful blind eye, nonresponsive to conservative measure mutilating ocular injuries, non bleeding anterior staphyloma & phthisis bulbi 3. Indication for eye donation from cadaver is presently the most common indication for enucleation , Research purpose (keratoplasty ) Sympathetic ophthalmia Microphthalmos , trauma

4. Advantages In contrast to evisceration, enucleation allows for histologic examination of an intact globe and optic nerve . This is particularly important in settings of biopsy-proven or suspected intraocular malignancy, in which it is essential to determine the margins of the malignancy & invasion of the optic nerve, if present . Enucleation classically has been thought to decrease the risk of sympathetic ophthalmia as it avoids exposure to uveal antigens that may occur during an evisceration. However, more recent studies have reported no cases of sympathetic ophthalmia following evisceration .

5. Disadvantages A reduction in implant motility is often noted in enucleations . However,  no difference in prosthesis motility was noted between evisceration & enucleation patients. Eighty-two percent (82 %) of survey respondents believed that evisceration afforded the best ocular motility & best overall cosmetic outcome , & 94% percent believed that complications of enophthalmos were more common after enucleations .

6. Complications (intraoperative) Removal of the wrong eye Damage to or loss of extraocular muscles Hemorrhage Perforation of eye

7. Postoperative complications Postoperative: Infection . Hemorrhage . Wound dehiscence Extrusion of the conformer . Contraction of the fornices Exposure of the implant & Extrusion / migration of the implant Ectropion Entropion poorly fitting prosthesis Enophthalmos Socket contracture 

8. IMPLANTS Implants are made in distinct sizes, & intraoperative selection of the appropriately sized implant is determined by the size of the patient’s orbit & the size of the implant necessary to achieve symmetry with the fellow eye. Implants may be porous or nonporous. Porous implants allow for anchoring of the extraocular muscles with proliferation of fibrovascular tissues into the implant itself. These include hydroxyapatite, porous polyethylene & proplast . These are cheaper than non porous .

9. Different types of orbital implant ( semiintegrated ,non integrated, bio integrated , porous & non porous implant )

10. Surgical steps for enucleation

11. Surgical technique 1. Separation of conjunctiva & Tenon’s capsule 2. Separation of extraocular muscles 3. Cutting of optic nerve 4. Removal of eyeball 5. Inserting an orbital implant 6. Closure of conjunctiva and Tenon’s capsule 7. Fitting of artificial prosthetic eye Conformer may be used postoperatively so that the conjuctival fornices are retained 8.deep prosthetic eye can be inserted for good cosmetic appearance after 6 wks

12. Postoperative Management Patching was done for a brief period postoperatively & instructed to return to clinic one week after the surgery . Medicines like analgesics & antiemetics given.  Once the conjunctiva closure has healed, generally about 4-8 weeks (after 2 months) postoperatively, an ocular prosthetic fitting was prescribed . Regular follow up is required & to maintain the health of their socket is required .

13. Nonporous implants do not allow for proliferation of tissues into the implant. Therefore, they may have decreased motility and greater risk of implant migration. Types of nonporous implants include glass, silicone, acrylic, and polymethylmethacrylate (PMMA). The rectus muscles still may be sutured over the implant to impart motility to the implant and prosthesis, or suture to a wrapped material. 

14. Evisceration : introduction Evisceration is a surgical technique by which all intraocular contents are removed while preserving the remaining scleral shell, extraocular muscle attachments, & surrounding orbital adnexa . The surgery often includes placement of an implant into the evisceration cavity to maintain appropriate orbital volume.

15. Indications for evisceration : Indications Endophthalmitis Penetrating ocular trauma Blind, painful eye Panophthalmitis Contraindications Known or suspected intraocular malignancy Phthisis bulbi and microphthalmia (relative)

16. Surgical procedure technique

17. Evisceration & orbital implant & artificial eye insertion

18. Advantages of Evisceration over Enucleation Shorter operative time Less complex surgery More cost efficient Less disruption of orbital tissues Improved motility Less chance of spread of infection to nervous system Less painful

19. Disadvantages of Evisceration over Enucleation Risk of sympathetic ophthalmia Risk of dissemination of intraocular tumors

20. Complications of evisceration Retrobulbar hemorrhage Orbital edema Dissemination of unexpected intraocular neoplasm Implant exposure Implant extrusion Common post-operative care include the use of a dressing, pressure patch, and/or ice cold compresses to help with post-operative edema and comfort. A temporary tarsorrhaphy can be used to help with conformer retention & early post-operative swelling

21. Orbital Exenteration Introduction Exenteration is a surgical procedure involving removal of the entire globe & its surrounding structures including muscles, fat, nerves & eyelids Its extent is determined by disease being treated

22. Orbital Exenteration : indications Exenteration is performed mostly for orbital malignancies in an attempt to become cure of cancer with tumor free margins. It is also performed in painful or life-threatening orbital infections or inflammations . Malignancies of the ocular adnexa are the most common causes of orbital exenteration include squamous cell carcinoma, basal cell carcinoma, sebaceous carcinoma with orbital extention & mucourmycosis . Other less common tumors include conjunctival malignant melanoma, adenoid cystic carcinoma of the lacrimal gland & uveal melanoma with extrascleral extension.

23. Different types of orbital exenteration Subtotal orbital exenteration = only the anterior orbital tissue is removed Total = orbital contents are removed in total or complete Radical = adjacent structures like paranasal sinuses are also sacrified Extended = one or more orbital bones are removed Other types : LID SPARING ORBITAL EXENTERATION & TOTAL ORBITAL EXENTERATION

24. Different types of orbital exenteration Lid Sparing vs. Total Exenteration

25. Orbital exenteration

26. Complications of orbital exenteration extensive bleeding , which may rarely necessitate a blood transfusion ethmoid bones can be fractured during the surgery, leading to an opening between the orbit and the nasal cavity CSF leaks can occur , Postoperative infection & wound leak Intracranial infections Obliteration of the cavity provides a protective barrier that protects the cranium from a potential infection . obliterating the cavity in its entirety with soft-tissue free-flaps

27. HOME WORK What is enucleation ? What are the indications for enucleation ? What are the types of orbital implant ? Classification with one example of each ? What are the complications after enucleation surgery ? What is evisceration ? What are the contraindication for evisceration surgery ? What are the indications for evisceration ? Explain in brief different surgical steps for evisceration & enucleation surgery ? What is orbital exenteration ? What sre the different types of orbital exenteration ? What are the indications for orbital exenteration ?

28. different types of ocular implant

29. CONSUMABLES & SURGICAL INSTRUMENTS GLOVES SYRINGES NEEDLE DRAPES ORBITAL IMPLANT SUTURE MATERIAL CONFORMER ARTIFICIAL / PROSTHETIC EYE

30. Surgical instruments

31. wire speculum, tenotomy scissor, muscle hook, suture material (4-0 mersilk , 6-0 vicrly ), needle holder, tooth or fixation forcep , evisceration spoon,

32. Artificial customized prosthetic eye, conformer, orbital implant

33. HOME WORK What is enucleation ? What are the indications for enucleation ? What are the types of orbital implant ? Classification with one example of each ? What are the complications after enucleation surgery ? What is evisceration ? What are the contraindication for evisceration surgery ? What are the indications for evisceration ? Explain in brief different surgical steps for evisceration & enucleation surgery ? What is orbital exenteration ? What sre the different types of orbital exenteration ? What are the indications for orbital exenteration ?

34. Thank You