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Removal of the eye (Enucleation /evisceration) and orbital implants

Removal of the eye is indicated for following reasons:

1. Intra ocular tumour
2. Trauma beyond repair
3. Trauma resulting in un repairable eye, to prevent sympathetic inflammation of the good eye
4. Painful blind eye.
5. Unsightly blind eye

There are techniques available for removal of the eye. Operation is usually performed under general anaesthesia.

Enucleation: Here the 6 muscles attached to the eye and the optic nerve is cut and the globe in totality is removed from the socket.

Often an appropriate size implant is placed in the socket to replace the lost volume of the globe. The superficial layers of socket are sutured over the implant. A plastic shell is placed over the implant for 6 weeks. Then a matching artificial eye is built by the prosthetic department and worn over the implant.

A properly built artificial eye matches the other eye in colour and size of pupil. Movements however are much reduced. Attempts are made to improve the movement by selection certain implant material and pegging the artificial eye to the implant

Evisceration: Here only the content of the globe is removed. Often an implant is then placed within or behind the remaining coats. The postoperative care is the same as enucleation. The movement of artificial eye is usually better with evisceration.

The choice between the enucleation and evisceration

Your surgeon will discuss the options with you. And will go through advantages and disadvantages of each procedure and the type of implant.

1 Intraocular tumours: enucleation is the only option.

2. Painful blind eye/blind unsightly eye. As cosmetic outcome is better, evisceration is preferred.

The risk of sympathetic inflammation should be considered particularly if previous intraocular procedures are performed. With both enucleation and evisceration. there is an extremely small chance that pain will l not be relieved.

3. Unsightly blind eye. As cosmetic outcome is better, evisceration is preferred.

The risk of sympathetic inflammation should be considered particularly if previous intraocular procedures are performed.

4.Trauma. After Trauma, every effort will be made to salvage the eye. This usually requires general anaesthesia. The wound is sutures and the prolapsed tissue is replaced or excised.

Even if the eye is unsalvageable primary repair is always undertaken. In extreme cases this is not technically possible and the eye has to be removed at the time of primary repair. this would have been discussed with you before the operation.

Sympathetic endophthalmitis

Sympathetic endophthalmitis is inflammation of one eye following accidental or surgical penetration of the other eye. It is a rare condition (0.03 per 1000000 population).

t can occur after accidental trauma leading to penetration of globe (0.16%) as well as surgical trauma (vasectomy 0.06%, intraocular surgery 0.007%) .

80 % of sympathetic ophthalmitis occurs within the first 3 months and 90% within the first year of trauma.

It can be treated with steroids and other immunosuppression.

Prevention of inflammation is dependent on early removal of injured eye (first 2 weeks). There is however one or two report in literature where patient developed sympathetic despite removal of the eye within first 2 weeks. This is extremely rare. Removal of the eye after two weeks will not prevent the sympathetic endophthalmitis.

If the reason for removal is prevention of sympathetic, enucleation is preferred.

Although controversial, recent studies have indicate that evisceration is also appropriate as it might offer better cosmetic outcome.

Once the eye or the content is removed an implant is used to replace the lost volume.

Choices of Implants

There are number of implants available:

1. Non-porous: This is made of material similar to hard contact lens covered by autologous or synthetics material. With good surgical technique, the result can be as good as porous materials, which are more expensive and have higher rate of early exposure.

2. Porous material - Medpor or hydroxyappetite

These have small pores that allow socket tissue to be incorporated into the implant Motility is thought to be better only if the artificial eye is pegged to the implant later on. The risk of exposure is higher (5-20%) particularly after pegging. Generally the risk of early exposure is more than non porous even with equally good surgical technique.