Retinoblastoma-ENUCLEATION A STEP BY STEP APPROACH.pptx

Retinoblastoma-ENUCLEATION A STEP BY STEP APPROACH

Pre-operative evaluation
Bone marrow and cerebrospinal fluid analysis
Orbital imaging – MRI (magnetic resonance imaging ) -to rule out extrascleral tumour extension or gross optic nerve involvement
Gross optic nerve thickening or extrascleral extension- chemoreduction –enucleation is performed as a secondary treatment

GA fitness and relevant Labs

Blood Hb levels of a minimum of 10-12 grams per decilitre
White blood cell count of 100,000 per cubic millimetre of blood

Consent with all possible complications and risks
Must note who is signing and accompanying the child


Re-Counselling
Confirm whether parents/caretakers understand what we are going to do
Eye removal
Stoned eye(Prosthesis) will not see
The extent of the disease will be demonstrated by the histopathology
Post Sx - systemic chemotherapy & regular follow-ups

1. Enucleation For Retinoblastoma: A Step-By-Step Approach Dr Shabana Choudhary FCPS (Pak), FRCS (Glasg.), MCPS (Pak), ICO, FICO (Aus), MME Fellowship in Paeds . Ophth. (Aus) Fellowship in Adult Strabismus & Paeds . Ophth. (UK) Fellowship in Retinoblastoma & Paeds . Ophth. (UK) Assist. Professor Paediatric Ophthalmology COAVS/Mayo Hospital/KEMU Lahore, Pakistan

2. Learning Objectives Able to Demonstration of the surgical steps of enucleation for Retinoblastoma

3. Indications Primary enucleation In eyes with advanced unilateral intraocular retinoblastoma (Group E in the International Intraocular Retinoblastoma Classification) Secondary enucleation Eyes that have failed conservative treatment strategies Pthisical eye post-chemotherapy

4. The Pre-requisites Of The Surgery Pre-operative evaluation Bone marrow and cerebrospinal fluid analysis Orbital imaging – MRI (magnetic resonance imaging ) -to rule out extrascleral tumour extension or gross optic nerve involvement Gross optic nerve thickening or extrascleral extension- chemoreduction –enucleation is performed as a secondary treatment GA fitness and relevant Labs Blood Hb levels of a minimum of 10-12 grams per decilitre White blood cell count of <15,000 per cubic millimetre A platelet count of >100,000 per cubic millimetre of blood Kaliki S. How to do an enucleation for retinoblastoma. Community Eye Health. 2018;31(101):20-22

5. Consent with all possible complications and risks Must note who is signing and accompanying the child Re-Counselling Confirm whether parents/caretakers understand what we are going to do Eye removal Stoned eye(Prosthesis) will not see The extent of the disease will be demonstrated by the histopathology Post Sx - systemic chemotherapy & regular follow-ups

6. What Should Bring In The OT? Consent form Pathology form Patient’s File/documents Labs B-scan MRI –(films/reports)

7. Roles of the teams Surgeon/staff/GA team/assistant surgeons Assistant/Paramedics Dilatation of both eyes- Tropicamide Identification of the patient Marking of the eye Working GA machine checked Working Cautery Checked Normal Saline in refrigerator Prosthesis in Pyodine + Gentacin soln. Sterilized Surgical trolly Sterlized X-ray film

8. Where to start from? Perform indirect ophthalmoscopy before starting the operation to confirm the eye procedure will be done on the correct eye Confirm through the file/notes as well Confirm that surgical trolly and cautery are available Confirm that the blood cross-matched donor is on standby Confirm the consent is signed Confirm the eye again while drapping the eye (prep and drape the eye yourself –do not leave it to the staff or the assistant Scrub yourself

9. Step By Step Surgical Procedure Look for any gross extrascleral extension/NVIs - under a microscope Gently place a wire speculum Instill a drop of Adrenaline Perform a lateral canthotomy to increase the working space- Conjunctival Scissor Perilimbal conjunctival peritomy around the whole eye-Use conjunctival scissors Perform a tenotomy in either 2 or all four quadrants- use curved tenotomy scissors The dissection should be carried out to the equator of the globe to ease the prolapse of the globe in the later stages of surgery

10. What’s Next? Identify Recti muscles and gently hook the muscles - a muscle hook Place muscle traction sutures 2 to 3 mm from the muscle insertion Pass absorbable 6/0 Vicryl sutures through the muscle, 4 to 5 mm from the insertion Be gentle during needle entry into the muscle to avoid globe perforation We prefer the order of cutting the rectus - first medial, then inferior, then lateral, and finally the superior rectus

11. Cauterise gently or crush muscle with straight artery forceps between sutures and the insertion or traction sutures leaving the muscle stum Cut the muscles in between the traction suture and tag suture- with conjunctival scissors The superior oblique and inferior oblique muscles are now identified and cut

12. After all six of the extraocular muscles have been severed, use the four traction sutures to exert gentle traction on the globe and facilitate globe prolapse If there is resistance to globe prolapse Tight eye speculum -replace it with the correct eye speculum. Too narrow surgical space (due to a small orbit)- perform a small lateral canthotomy or a relaxing horizontal conjunctival incision laterally. Due to incomplete severing of extraocular muscles-Recheck all muscles and adhesions Clean the globe, and maintain hemostasis - we take a gauze and encircle the globe –gently push the gauze into orbit while gently retracting the globe –to confirm all adhesions are broken and enough space to reach optic nerve

13. Optic nerve removal Curved tenotomy scissors/ enucleation scissors are then inserted by the lateral approach and the optic nerve is identified near the orbital apex – Go straight to the orbital apex-identifies as bony touch Slightly rotate the globe medially Now cut the ON Ensures adequate length of the optic nerve (>15 mm) Give hypotensive anaesthesia to ensure minimal bleeding during this step

14. Marking the Sample Pack the socket immediately with a finger and then followed by gauze and keep it in place for 5-10 minutes to stop bleeding and avoid the formation of a haematoma Inspect the enucleated globe for any evidence of extrascleral extension of the tumour. Measure the length as well as the width of the optic nerve using callipers Mark the Optic nerve 2 mm from the cut end (to save the cut end Histopath ) – 6/0 Vicryl Mark MR 4/0 black silk Send the globe for detailed histopathology analysis

15. Implant Placement After stopping the bleeding, identify the posterior Tenon's capsule. Place an adequate-sized implant in the intraconal space Use the X ray film to make a cone to place the implant in position In the Myoconjunctival technique – The implant is secured in place by suturing the posterior Tenon's capsule with absorbable sutures Pass the double-ended (tag) sutures attached to the cut end of the recti muscles are then brought out externally through the conjunctival fornices in all four quadrants-tag sutures are then knotted to each other In Conventional Technique (PMMA implant)- Muscle cross over the implant If Sahaf implant/ or PMMA ball is covered with Vicryl Mesh – suture muscles over to the mesh or /and together

16. Closure The anterior Tenon's capsule and the conjunctiva are then closed with absorbable sutures in two layers Placement of a conformer with a draining pore is then placed in the socket The conformer can be secured in place with central suture tarsorrhaphy (optional) A pressure patch is applied for 24 hours

17. Postoperative care The pressure patch is removed after 24 hours Rx Oral antibiotics for 1-week Topical antibiotics for 2-weeks Topical steroids are tapered over 6-weeks The suture tarsorrhaphy is removed after 1-week- if done Based on the histopathology report, further treatment may be required Dispense customised ocular prosthesis 6-weeks after enucleation

18. Questions Thanks