Enucleation & Evisceration Eye Surgery

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What is an Enucleation?

Enucleation is a surgical technique that removes the eyeball from the eye socket. It is a type of reconstructive surgery. 

This surgery includes the removal of the globe and intraocular contents but preserves the other periorbital and orbital structures. It also includes implant placement resulting in a natural appearance. 

Enucleation is most commonly used for someone diagnosed with a cancerous tumor. Many people diagnosed with eye cancer keep their eyes intact despite losing vision. However, in severe cases, removal is necessary. 

Enucleation results in blindness on the side where the eyeball was removed but does not affect the other intact eye.

When is Eye Removal Surgery Necessary?

Eye removal surgery treats:

  • Intraocular malignancy or high suspicion of malignancy, including uveal melanoma and retinoblastoma.
  • A blind eye that causes pain 
  • Trauma or severe injury
  • Severe infection that poses a risk of blindness
  • Microphthalmos, which is an eye abnormality that develops before birth and causes one or both eyeballs to be abnormally small. Sometimes it looks as if the eyeball is missing.
  • Sympathetic ophthalmia, which is the inflammation of the uveal tract (uveitis) occurring after injury or surgery to the other eye.

There is also a risk of sympathetic ophthalmia in the uninvolved eye when patients undergo enucleation. Most doctors rule out all other options before recommending enucleation. 

Enucleation vs. Evisceration Eye Removal

Evisceration and enucleation are similar because they involve full or partial eye removal. But the surgical procedure of enucleation allows for examination of an intact globe and optic nerve. 

Once removed, doctors can perform a biopsy and examine for suspected malignancy.

Evisceration removes the contents of the eye but leaves the white part of the eye (sclera) and the muscle around the eye behind. It is recommended when someone has a severe eye injury, pain in a blind eye, or severe infection.

Long-term, there is little aesthetic difference between the procedures.

Enucleation is believed to decrease the risk of sympathetic ophthalmia because it avoids exposure to antigens that occur when doctors use evisceration, although this is very rare. 

What to Expect During Enucleation Surgery

During enucleation surgery, the entire contents of the eye are removed. Only the muscles that control eye movement are left intact. They are re-sewn to the spherical orbital implant (artificial eyeball) and an implant is put in its place.

Done on an outpatient basis and under general anesthesia, patients don’t feel or see anything until they awaken. Patients also receive local anesthesia to reduce discomfort during and after the procedure.

In some cases, especially when infection plays a role, implant positioning is postponed until a second procedure. 

What to Expect During Evisceration Surgery

During evisceration surgery, the contents of your eye are removed. But unlike enucleation, some tissue (the sclera) is left behind. 

Once the globe contents are removed and the implant is in place, the white of the eye is closed over the implant and a conformer shell is placed to prevent the eye socket from misshaping. The surgeon then sutures the eyelid closed and applies a bandage.

What to Expect After Surgery

Following surgery, most patients have a headache for up to 36 hours. The loss of the eye rarely hurts, but over-the-counter pain relief is usually enough to ease any pain that does occur. Some doctors also prescribe analgesics, antiemetics, and prophylactic antibiotics.

Patients remain bandaged for approximately a week after surgery and then return to their doctor for bandage removal.

Doctors place a temporary prosthesis during surgery or at the time of bandage removal to help the eye socket maintain its shape and give a natural appearance. 

Approximately six weeks later, once the conjunctiva closure heals, patients undergo an ocular prosthetic eye fitting for their permanent prosthesis. 

Prosthetic eyes do not restore vision, but they provide aesthetic improvement and reduce the psychological trauma of losing an eye.

Patients undergoing enucleation have many options for prosthetic eyes. They come in a variety of sizes and different materials. The goal of a prosthetic eye is to create symmetry by matching the patient’s natural eye as closely as possible.

Prosthetic eye options include porous implants such as hydroxyapatite, porous polyethylene, and protoplast varieties. This anchors the extraocular muscles with the proliferation of fibrovascular tissues into the implant itself.

Doctors use both pegged or unpegged implants. To install a pegged implant, doctors drill a hole into the implant and install a peg that attaches to the prosthesis. This allows for optimal motility. However, there is evidence that some types of pegged implants have a high risk of complication.1

Side Effects of Enucleation & Evisceration Eye Surgery

Side effects of enucleation and evisceration include:

  • Removal of the wrong eye
  • Damage to extraocular muscles
  • Hemorrhage (rare)
  • Perforation of the eye
  • Infection
  • Wound dehiscence, which is when all or part of the wound breaks apart
  • Contraction of the socket and reduction of the fornices
  • Extrusion of the conformer, which is the clear acrylic shell placed after enucleation
  • Exposure or extrusion of the implant
  • Migration of the implant
  • Pain
  • Ptosis
  • Ectropion, which occurs when the eyelid sags or turns outwards and causes irritation in the inner eyelid
  • Entropion, which occurs when the eyelid fold inwards and results in the skin and eyelashes rubbing the eyeball causing irritation and discomfort
  • Hollow or deep superior sulcus causing a sunken appearance
  • Enophthalmos, caused by loss of fat within the eye socket that causes the eye to fall back into the socket inhibiting proper eyelid function
  • Poorly fitted prosthesis
  • Socket contracture
  • Orbital cellulitis, which is an ophthalmic emergency caused by infection of the soft tissues behind the orbital septum.

Infection following enucleation is rare and usually treatable with antibiotics. 

How Long Does it Take to Heal from Eye Removal Surgery?

Most enucleation procedures heal quickly within two to eight weeks. Patients should not lift more than 10 pounds or strain or rub their eyes for at least two weeks after surgery. 

Alternative Treatment Options

Most doctors consider enucleation a last resort because of the psychological damage caused by the loss of an eye. Alternatives to enucleation include:

  • Local resection is the surgical removal of the tissue that is affected by the disease to treat uveal melanoma
  • Low-energy long-exposure laser heats and destroys tissue and cancer cells
  • Ruthenium plaque therapy surgically places plaque made from the radioactive isotope of Ruthenium over the tumor in your eye

Treatments that are under investigation include:

  • Chemotherapy
  • Drugs that target the immune system to treat cancer (immunotherapy)
  • Use of cold to destroy cancerous tissue (cryotherapy)
  • Drugs that target specific proteins believed to play a role in tumor growth

These treatments are not an option in every case. You and your doctor should discuss your options if enucleation is a possibility.

Resources
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(1) “Enucleation - EyeWiki.” Eyewiki.aao.org.  

(2) Foulds, W. S., and B. E. Damato. “Alternatives to Enucleation in the Management of Choroidal Melanoma.” Australian and New Zealand Journal of Ophthalmology, vol. 14, no. 1, 1 Feb. 1986, pp. 19–27.

(3) Hong, Mei, et al. “Clinical Observation of Local Resection or Enucleation for Uveal Melanoma.” Chinese Medical Journal, vol. 127, no. 19, 2014, pp. 3459–3463.

(4) “Enucleation and Evisceration: What to Expect.” Uiowa.edu, 2018.

(5) “Enucleation Surgery - Removal of the Eye» New York Eye Cancer Center.” New York Eye Cancer Center, 31 May 2016.

(6) “Eye Removal Surgery: Enucleation and Evisceration.” American Academy of Ophthalmology, 20 Nov. 2019.

(7) “Ocular Melanoma - NORD (National Organization for Rare Disorders).” NORD (National Organization for Rare Disorders), NORD, 2019.

(8) Kubicka-Trząska, Agnieszka, et al. “Ruthenium-106 Plaque Therapy for Diffuse Choroidal Hemangioma in Sturge-Weber Syndrome.” Case Reports in Ophthalmological Medicine, vol. 2011, 2011.

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