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Eye Removal
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17
17.1 Overview
•
Eye evisceration,
•
Eye enucleation.
Eye removal is a treatment of last resort for symptom control or local tumour
management. Never underestimate its psychological impact. Loss of an eye can
trigger a prolonged bereavement reaction. Forewarn patients and their families
about this possibility.
Eye removal can be performed in one of three ways:
1. Evisceration—Removal of the cornea and all the eye’s contents (uvea) leaving
the empty sclera fully attached.
2. Enucleation—Complete removal of the intact eye by cutting all its attachments.
3. Exenteration—Radical en bloc removal of the orbital contents (including the
eyelids, conjunctiva, and periosteum), as far back as possible.
17.2 Specific Indications
Exenteration is very mutilating and fortunately only seldom required for the control
of tumour confined to the orbit. It will not be discussed further.
Enucleation is indicated for the complete removal of an intraocular tumour that
cannot be managed by less destructive means.
Evisceration is performed for severe, non-responsive endophthalmitis (effec-
tively abscess drainage) to avoid spreading the infection into the orbital tissues.
The removal of blind, painful, or unsightly eyes, which cannot be managed by
other means (topical G. Atropine 1% and G. Prednisolone 1% are very effective at
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_17
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controlling pain), can be done either by enucleation or by evisceration. Except for
the above specific indications, the choice is largely down to personal preference
and current fashion.
17.3 Evisceration V Enucleation
Evisceration is technically easier, quicker, and less invasive than enucleation and
results in marginally less volume loss. Hence it fits the philosophy of this book.
However, as it carries a small risk of inciting Sympathetic Endophthalmitis in the
remaining eye, great care must be taken to remove all the uveal contents leaving
no pigmented tissue behind to stimulate an immune response. Evisceration is more
painful in the immediate postoperative period as the nerve supply to the sclera
remains intact. Send the evisceration contents for histology to look for pre-existing
sympathetic uveitis or unsuspected intraocular malignancy. However, anatomical
histology cannot be obtained from an evisceration specimen.
Enucleation involves systematically dividing all the structures holding the eye
in place, including the optic nerve. An enucleated eye allows good anatomical
histopathology of suspected tumours including their degree of scleral and vortex
vein invasion. Theoretically it causes a slightly greater orbital volume loss than
evisceration, but this is not clinically significant. The extra dissection involved
results in more post-operative swelling, but there is less pain as all the sensory
nerves have been divided.
Any form of eye removal results in significant orbital volume loss which needs
to be addressed by volume replacement as part of the surgical rehabilitation.
Volume replacement is dealt with in the next chapter.
17.4 Evisceration (Fig. 17.1)
17.4.1 Principle
Remove the cornea and all the ocular contents (uvea).
17.4.2 Steps
1. Cut the conjunctiva and tenons fascia from the corneoscleral limbus through
360° (Fig. 17.1a).
2. Bluntly dissect them back with a cotton bud, no further than the rectus muscle
insertions.
3. Incise the sclera immediately behind the limbus to enter the eye.
4. Extend this incision through 360
epithelial stem cells) (Fig. 17.1b).
°
to remove the cornea (including the limbal
17.4 Evisceration (Fig. 17.1) 235
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a b
c d
Fig.17.1 Evisceration. a Cut the conjunctiva and tenons fascia from the corneoscleral limbus
through 360°. b Incise the sclera at the limbus and extend this to remove the cornea. c Develop
a cyclodialysis plane using an evisceration spoon. d Lift the entire eye contents out of the scleral
using the evisceration spoon
5. Develop a 360° cyclodialysis plane using an evisceration spoon (Fig. 17.1c).
Do this by holding the scleral edge on tension with toothed forceps and peeling
the iris root and attached ciliary body from the scleral spur. Gradually work
around the whole perimeter.
6. Deepen the cleft in the same manner to detach the choroid from the sclera up
to the equator all the way round.
7. Continue separating in this plane until you reach the optic nerve exit point.
Transect this final attachment with the evisceration spoon.
8. Lift the entire eye contents out of the scleral shell and into a histology pot
using the evisceration spoon (Fig. 17.1d). In young patients the contents come
out as a single, jelly-like, lump. In the elderly with liquified vitreous this runs
out before you are able to lift out the collapsed uveal tissue.
9. Examine the now empty sclera to ensure that you have not left any pigmented
uveal tissue behind. This is to minimize the risk of inciting sympathetic
uveitis. Scrape any remaining uvea out with the spoon.
10. You will have decided whether to place an orbital implant as part of the preoperative planning and consenting process. The default position should be to
implant, as volume replacement gives the best rehabilitation. Delay implantation when infection is present (endophthalmitis, suppurative keratitis). Do
not implant if it is important to minimise the risk of late complications. An
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implant introduces the additional risks of infection, implant migration, and/
or exposure requiring revision surgery. (Implantation is dealt with in the next
chapter).
11. In the absence of an implant or of infection, close the sclera horizontally
with five 6/0 absorbable sutures. Close the tenons and conjunctiva with a
continuous 6/0 absorbable suture.
12. In the presence of infection do not suture. Leave the sclera open to drain. It
will usually heal spontaneously.
13. Insert a correctly sized* conformer shell to maintain the conjunctival fornices and prevent conjunctival prolapse. Consider placing a central suture
tarsorrhaphy to stop the conformer from falling out.
14. Apply antibiotic ointment and a pressure dressing.
*Note: Use the largest conformer shell that fits in the socket while still allowing
the eyelids to just close.
17.5 Enucleation (Fig. 17.2)
17.5.1 Principle
Divide all the eye’s connections and remove it.
17.5.2 Steps
1. Cut the conjunctiva and tenons fascia from the corneoscleral limbus through
360° (Fig. 17.2a).
2. Bluntly dissect them back with a cotton bud, to beyond the rectus muscle
insertions (Fig. 17.2b).
3. Place a Chevasse squint hook under the inferior rectus muscle close to its
insertion and use a cotton bud or the flat end of a dry ‘bread swab’ to tear
back the muscle sheath to fully expose the insertion (Fig. 17.2c).
Note: It doesn’t matter which rectus you expose first.
4. Insert a double armed ¼ circle 6/0 absorbable suture into each edge of the
muscle with a double locking pass (see Chap. 19, Fig. 19.4) and clip the
suture ends together with an artery clip (Fig. 17.2d).
5. Lift the squint hook and completely divide the muscle insertion from the globe
(Fig. 17.2e). The weight of the artery clip will retract the muscle insertion.
6. Repeat steps 3–5 above for the remaining three rectus muscles (Fig. 17.2f).
7. Insert a squint hook between the eye and the tenons infero-temporally to
engage the inferior oblique muscle insertion. Do this by feel.
8. Once you identify the inferior oblique retract it with this hook and place a
curved artery clip across the inferior oblique muscle insertion. Again, do this
by feel rather than by direct visualization.
17.5 Enucleation (Fig. 17.2) 237
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a b
c
e
d
f
g h
Fig.17.2 Enucleation. a Cut the conjunctiva and tenons fascia from the corneoscleral limbus
through 360°. b Bluntly dissect to beyond the rectus muscle insertions. c Place a Chevasse squint
hook under the inferior rectus muscle and tear back the muscle sheath to fully expose the insertion.
d Insert a double a rmed absorbable suture into the muscle with double locking passes. e Lift the
squint hook and completely divide the muscle insertion from the globe. f Repeat for the remaining
three rectus muscles. g Tag and detach the inferior oblique and the superior oblique tendon from
the globe. h Tighten the snare wire loop until it is only slightly larger than the eye. Attach a pair
of straight artery forceps to the far side of the wire loop. Use these to guide the loop posteriorly
between the globe and the detached medial rectus. i Once the snare loop is behind the eye slowly
tighten it. At the same time use the stem to push it posteriorly between the globe and lateral rectus.
j Expect strong resistance to the final snare tightening. Once the optic nerve is transected, you can
lift the eye out of the socket. There will be no bleeding
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i j
Fig.17.2 (continued)
9. Cut between the artery clip and the sclera to divide the inferior oblique
insertion from the globe.
10. Now that it is free, pull the muscle insertion out with the clip and tag it with
a single armed 6/0 absorbable suture using a double pass locking throw. Clip
the suture ends together. The single needle distinguishes this from the rectus
muscles (which have two needles attached).
Note: The inferior oblique looks like an earthworm.
11. Repeat step 9 supero-temporally to isolate the superior oblique tendon from
the globe (Fig. 17.2g).
Note: The tendon is fibrous and runs anteromedially toward the trochlea.
12. The remining attachments holding the eye include the optic nerve, the ophthalmic and ciliary arteries, and the vortex veins. Crush and divide them using
an enucleation snare as follows:
(a) Tighten the snare wire loop until it is only slightly larger than the eye.
(b) Attach a pair of straight artery forceps to the far side of the wire loop so
that they are equidistant from the stem (Fig. 17.2h). Use this clip to guide
the loop posteriorly between the globe and the detached medial rectus.
Ask an assistant to keep the loop behind the globe by pushing down on
the artery clip.
(c) Slowly tighten the snare loop by turning the snare ratchet wheel. At the
same time use the stem to push it posteriorly between the globe and lateral
rectus, until it is behind the eye.
(d) Now remove the artery clip from the loop and continue tightening the
snare wire. Maintain posterior pressure with the stem of the snare to
keep the loop behind the globe. While you do this, your assistant lifts
the globe anteriorly using artery clips attached to the cut rectus insertions
(Fig. 17.2i).
(e) Expect strong resistance to the final snare tightening. This is dependent
on the snare wire thickness (a thicker gauge giving greater resistance).
You will feel a sudden ‘give’ as the optic nerve is finally transected. You
can now lift the eye freely out of the socket. There will be no bleeding
(Fig. 17.2j).
17.6 Take Home Message 239
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17.5.3 Notes
•
It is the complete absence of bleeding when the eye is removed that makes
the enucleation snare my preferred choice. The alternative of using enucleation
scissors offers no advantages, only copious bleeding.
•
An enucleated eye allows detailed histological examination.
17.6 Take Home Message
Eye removal has huge psychological impact.
Socket Reconstruction
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18
18.1 Overview
•
Implantation following evisceration
•
Implantation following enucleation
•
Orbital implant complications.
The disfigurement resulting from eye removal is primarily due to loss of orbital
volume leading to the Post Enucleation Socket Syndrome (PESS) (see below) coupled with reduced socket movement. The latter occurs because the extraocular
muscles are no longer attached to an eye and are therefore not working at their
former mechanical advantage. Artificial eye (prosthesis) movement is reduced further by slippage in the socket. An adequately sized intraconal implant addresses
these problems (apart from the slippage).
Perform primary orbital implantation by default unless there is a positive contraindication, such as lack of access to follow-up treatment for possible late
complications.
18.2 Socket Lining
The largest possible artificial eye that a socket can accommodate is determined
by the surface area of its conjunctival lining. Four millilitres is about the maximum volume. A socket with insufficient conjunctival lining to accept an adequate
prosthesis must have its fornices augmented with mucous membrane grafts (never
skin which desquamates and smells in a moist socket). Therefore, treat conjunctiva with respect, preserve it at eye removal surgery, and prevent it from shrinking
post-operatively by inserting a maximally sized conformer shell to maintain the
fornices until a custom prosthesis can be fitted.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_18
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18.3 Orbital Implantation (Fig. 18.1)
Carry out orbital implantation at the time of eye removal unless there is a strong
contraindication (such as infection). Insert a 22 mm diameter solid ball implant
(acrylic or silicone) into the orbital muscle cone using a ‘no touch’ technique.
Attach the extraocular muscles to it to keep it in place within the muscle cone and
to maximize movement.
Following evisceration place the implant within the recipient’s, now empty,
scleral shell. After enucleation wrap the implant in stored human donor sclera
(or other suitable material) and attach the extraocular muscles to the covering in
approximately their anatomical positions.
18.3.1 Implant Considerations
Measure enucleated eye volume by the water it displaces in a measuring cylinder
(Archimedes’ principle) (Fig. 18.2). The volume of tissue removed during enucleation is about 7–9 ml [1], which is more than many standard texts suggest. The
volume loss from evisceration is slightly less. The actual volume loss in a particular individual depends on the size of the eye removed. This lost volume must be
completely replaced if the PESS deformity is to be avoided. Share the replacement
volume between a buried ‘motility implant’, that allows the extra-ocular muscles
to work at their optimal mechanical advantage (frontal plane diameter similar to
that of the removed eye), and an eye prosthesis (artificial eye) held in place by
the eyelids (Fig. 18.3). The prosthesis should be as light as possible to reduce
Fig.18.1 Ball too small.
Inadequate volume
replacement causes the post
enucleation socket syndrome
18.3 Orbital Implantation (Fig. 18.1) 243
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Fig.18.2 Enucleated eye volume. Measure enucleation orbital volume loss by water displacement
5 - 7 ml
Fig.18.3 Ideal motility implant dimensions. Share the volume replacement between the prosthesis and the implant. A realistic prosthesis requires a volume of 2 ml and a central thickness of 4 mm.
The implant vertical diameter should equal that of the removed eye
2 ml
4 mm
22 mm
the mechanical load on the lower lid to avoid it stretching over time. However,
the prosthesis does require a minimum central thickness of about 4 mm to give a
realistic anterior chamber appearance. The ideal prosthesis volume is 2 – 2
Subtracting this from the total volume loss leaves a volume deficit of 4
1
/2ml.
1
/2to 7 ml
that needs to be replaced by the implant.
The volume of a spherical implant is determined by the formula.
3
4/3r
where r is the radius of the implant. The largest commercially available orbital
implant has a diameter (Ø) of 22 mm (radius 11 mm) and a volume of 5.6 ml. A
20 mm Ø implant has a volume of only 4.2 ml and an 18 mm Ø sphere has a mere
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