Chapter 15
Removal of an Eye
Removal of an eye
An eye is removed if it is blind and painful, usually as a result of chronic or secondary glaucoma, if there is severe infection or malignancy, or following severe trauma.
There are three operative procedures for removal of an eye. The decision of the surgeon to opt for a particular method is determined by the nature of the pathology (Jones, 2001).
(1)Enucleation This is the surgical removal of the eyeball itself. The extra-ocular muscles and remaining orbital contents are conserved. The muscles are utilised to create movement of the prosthetic eye. It is performed when the eye is blind and painful; following trauma to the globe; or for malignancy which is confined to the globe, such as a malignant choroidal melanoma or retinoblastoma. In cases of malignancy a length of optic nerve must be removed as well to ensure that the disease has not spread along the nerve fibres. If the nerve is found to be involved, radiotherapy will be given to the socket. Cases where the patient has enucleated their own eye, whilst rare, do happen. Such patients usually have underlying psychological or psychiatric problems.
(2)Evisceration is the removal of the contents of the globe leaving the sclera intact. This is performed following trauma and in cases of severe infection, the sclera being left in situ to prevent infection spreading into the brain via the optic nerve and ophthalmic blood vessels. The sclera provides scaffolding for any subsequent implant and prosthetic eye.
(3)Exenteration is the removal of the total contents of the orbit and if necessary the eyelids, plus any involved bone. This is performed for malignancy that is outside the eyeball, such as a basal cell carcinoma of the eyelid that has eroded structures behind it.
Removal of the eye should never be performed before a second opinion is obtained as to its necessity.
Patient’s needs
Some patients will already be in hospital following trauma or infection when the decision to remove the eye is taken. Others will need to be admitted. If
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the eye is blind and painful, the patient may be relieved at the thought of its removal. Some people, though, resist having the eye removed despite severe pain, preferring to rely on analgesics or nerve blocks for pain relief. It may be worth pointing out to these patients that a blind eye gradually shrinks (phthisis bulbi) and becomes unsightly.
Removal of an eye is an emotive subject and most patients will be highly anxious about the social, physical and psychological effects and will need much support. The patient’s reaction to having an eye removed will vary according to his individual personality, family support, age and gender as well as the circumstances surrounding the cause of the removal.
A very young child will not understand fully what is happening and may quickly adapt to a prosthesis as he will have known little else. However, the parents will be feeling very differently, requiring a great amount of support. They may be suffering acute guilt feelings, especially if the child had an accident for which they blame themselves. Siblings and friends may also be upset, especially if they have been involved in, or caused, the accident.
All patients of any age will go through a period of loss for their eye, including feelings of anger and resentment, while coming to terms with their condition. Teenagers may be particularly concerned about their appearance and body image, which may prevent them from socialising with their peers. All age groups and both sexes will be very aware of their changed appearance. They will be much more critical of their prosthesis, noting minute differences to their other eye. It is worth pointing out to them that no two natural eyes in the same face are exactly similar.
Some families and friends will be able to give the patient the necessary support, but others may not feel able to. Some family members may require help from the nurse to come to terms with the patient’s loss.
Nursing action
•Admit the patient to hospital.
•Give psychological and practical help. Explain about prostheses (see below) to the patient, pointing out that these days they are very good matches and need not be removed. It may be helpful to put him in touch with a patient who already has a prosthesis. A visit by the prosthetist before the operation will result in the patient having a better understanding of the processes involved in creating the artificial eye. The patient needs to understand that the prosthesis will not be placed in the socket at the time of surgery but at a later stage. In addition they should be advised that post-operatively they will have a dressing of pad and bandage, worn undisturbed for a week. First dressing takes place in the outpatient setting. They should be advised also that it is not unusual to suffer nausea and vomiting immediately post-operatively. They should be reassured that the nurse will give analgesia and anti-emetics as required (Waterman et al., 1998). If the patient is a child, the parents must be totally involved in his care.
•Give pre-operative care.
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•Give post-operative care:
Remove pressure dressing at the first dressing, clean socket and instil prescribed antibiotic ointment. Subsequently the socket will be cleaned regularly and the ointment instilled. No further dressing is applied.
If the socket is clean, fit a temporary shell into it.
Teach the patient or parents to remove, clean and replace the shell (see p. 45), and instil antibiotic ointment.
•On discharge, ensure that the patient has an appointment with the prosthetist and give him the assurance that he can return at any time to the hospital if there are any problems with the shell.
Complications
•The socket may become infected at any stage following removal of the eye. This requires cleaning of the socket and antibiotic treatment, usually ointment.
•The socket may shrink with time, causing the prosthesis to protrude and making it appear much larger than the other eye. A new prosthesis will need to be made.
Prostheses
Once the initial socket dressing has been removed following surgery and the socket is clean, a temporary shell is inserted into the socket to maintain the shape of the eyelids, to prevent them retracting. The patient is taught to remove, clean and replace this and make sure the socket is clean.
At four to six weeks following surgery the patient is fitted with a temporary artificial eye by the prosthetist. This may be fitted earlier if the patient’s needs warrant it. Initially a temporary prosthesis is fitted which will match as nearly as possible the patient’s other eye. Meanwhile a permanent individualised prosthesis will be made from an impression of the socket. The colour of the sclera, the pattern of the conjunctival vessels, the colour and pattern of the iris and the position of the pupil will be painted on by hand, carefully matching the other eye. Prosthetists are perfectionists who pay attention to the smallest of details.
Prostheses are nowadays made of an inert plastic material which can remain in the socket for up to a year. If there are no problems, the prosthesis is cleaned and polished annually to smooth any rough surfaces.
A prosthesis will need to be removed if it becomes too big for the shrinking socket or if the colour of the other eye changes – as it does with age – the sclera becoming less white and the conjunctival blood vessels more pronounced. The iris may change colour and an arcus senilis may appear.
Prostheses are made to measure and with careful matching of the other eye it is often difficult to tell an artificial eye from a real one (Fig. 15.1). Sometimes the movement of the prosthesis is not as good as in a normal eye. Fol-
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Fig. 15.1 A prosthesis.
lowing an evisceration, movement should be nearly normal as the extraocular muscles are still in place and can move the prosthesis. During an enucleation the extra-ocular muscles are cut from their insertion in the sclera and sutured together in the socket. This affords some movement of the prosthesis. Primary socket implantation can be carried out, whereby an acrylic or coralline hydroxyapatite implant is placed in the socket to which the extraocular muscles are attached by sutures. This affords more movement of the prosthesis. Implants can be rejected and they tend to extrude after about 20 years, requiring replacement although the hydroxyapatite type aims to overcome this. Being a naturally-derived material from coral, with a similar structure to bone, it is not rejected by the body. The body tissue actually grows into the implant. A peg can be used to attach the prosthesis to the hydroxyapatite implant to afford greater movement of the prosthesis when it is in situ (Dutton, 1991). After an exenteration, it is not possible to fit a prosthesis into the socket without further plastic surgery. A prosthesis can be attached to spectacles for patients not wishing to undergo further surgery.