Update on enucleation and evisceration surgery

The best operative results with fewest complications after enucleation surgery can be achieved by following basic principles, some of which are those of conservative tissue excision, using spherical implants placed behind Tenon's capsule into the muscle cone and avoiding surgical techniques that overlap the extraocular muscles (especially the superior rectus) over the front of the implant. The presence of an intraocular tumor demands that an enucleation be done. When the possible development of sympathetic ophthalmia is not present, the surgeon should consider doing an evisceration because of the cosmetic and motility advantages. Mention is made of some developments in enucleation surgery, such as the scleral cap reinforcement, the "baseball" implant technique using donor sclera, the use of liquid nitrogen to freeze intraocular tumors before removal of the eye, the dermis-fat orbital graft, and the use of two spherical orbital implants instead of one.     

Double sphere orbital implantation in enucleation and evisceration

A simple technique of orbital implantation of two hollow spheres at enucleation or evisceration is described. The procedure sufficiently replaces lost volume in the enucleated or eviscerated orbit, facilitates prosthesis motility, and diminishes simulated enophthalmos and superior sulcus depression. The risk of implant migration or extrusion is not increased.     

Rabbit orbital measure evaluations after enucleation and evisceration

PURPOSE: To assess orbital volume in weaned rabbits, submitted to enucleation and evisceration, with orbital volume reconstitution using porous polyethylene (PP) spheres, analyzed by computed tomography, by the water displacement test and external orbital measures using Image-J software. METHODS: This experimental randomized study consisted of 48 albino rabbits, with 42 days of life, submitted to enucleation (EN) and evisceration (EV), with (WI) or without (NI) implantation of a 10 mm PP sphere. After 1 month (M1), 3 months (M2) and 6 months (M3), 4 animals of each group were sacrificed. The skulls were prepared for dry bone study using the maceration technique. The orbital volume was calculated by computed tomography and by the water displacement test. The results suggest that orbital development in rabbits above 42 days of life is not different regarding evisceration or enucleation, or when an orbital implant is used. The water displacement test showed similar results compared with computed tomography, making a morphometric method in experimental studies worthwhile.     

Risk factors in endophthalmitis leading to evisceration or enucleation

BACKGROUND AND OBJECTIVE: This study aimed to evaluate the risk factors associated with evisceration or enucleation in endophthalmitis cases. PATIENTS AND METHODS: A retrospective analysis was conducted of all cases of endophthalmitis in a single unit over a 10-year period. The cases were divided into two groups. The group 1 consisted of patients with endophthalmitis who underwent evisceration or enucleation. The group 2 included patients with endophthalmitis who recovered with intravitreal injection or vitrectomy. RESULTS: During the 10-year study period, 86 patients with endophthalmitis were admitted for treatment. Evisceration or enucleation was undergone by 20 patients (23.2%) (Group 1); Group 2 consisted of 66 patients. Older age (P = 0.03), no light perception at presentation (P < 0.0001), endophthalmitis associated with corneal ulcer (P < 0.0001), and endogenous endophthalmitis (P = 0.048) were statistically significant factors associated with the need for evisceration or enucleation.     

Inferior oblique muscle location after enucleation and evisceration.

PURPOSE: To report the location of the inferior oblique muscle after enucleation without primary attachment of the muscle to the orbital implant and after evisceration. METHODS: Interventional case series. Retrospectively, eight orbital magnetic resonance imaging (MRI) studies were analyzed, four after enucleation and four after evisceration, to assess the position of the inferior oblique muscle relative to the orbital implant and the point of insertion. RESULTS: In the enucleation patients, the inferior oblique muscle was anteriorly displaced and the muscle appeared to insert into an inferior subconjunctival scar mass in three of the four patients. In all four of the evisceration patients, the inferior oblique muscle appeared normally positioned and inserted onto the implant in the normal location. CONCLUSION: Enucleation without suturing of the inferior oblique muscle to the implant is associated with healing in an abnormal anterior location and into an inferior subconjunctival scar mass. Evisceration does not appear to disrupt the normal position or insertion of the inferior oblique muscle.     

开放性眼外伤玻璃体切除术后眼球摘除23例临床分析

目的 探讨开放性眼外伤玻璃体切除术后眼球摘除的原因和相关危险因素.方法 回顾性分析1997年1月至2007年1月收治的开放性眼外伤玻璃体切除术后眼球摘除23例(23只眼)患者的临床资料,采用Logistic多因素分析法筛选危险因素.结果 眼球摘除的原因:玻璃体切除术后视网膜脱离复发19只眼,玻璃体切除术中视网膜复位不良2只眼,外伤性眼内容炎不能控制1只眼,玻璃体切除术后玻璃体出血药物治疗长期不能吸收1只眼.眼外伤时伤口大小、有无异物伤、有无眼内炎、PVR分级、眼球摘除前视力、手术次数与眼球摘除相关.结论 开放性眼外伤玻璃体切除术后眼球摘除的危险因素为外伤时伤口长大于10mm、伴异物或眼内炎,玻璃体切除时PVR分级C2或以上,眼球摘除前视力无光感,眼球摘除前手术次数≥3次.     

眼球摘除及眼内容剜出89例临床分析

目的:探讨眼球摘除及眼内容剜出的危险因素及改善预后的方法。方法:收集2006-01以来南京军区福州总医院眼科89例眼球摘除及眼内容剜出病例,从年龄分布、就诊原因、术式选择等方面进行一系列回顾性分析。结果:眼外伤是近年来造成眼球摘除及眼内容剜出的最主要危险因素。结论:做好自我防护及外伤后及时有效的处理是争取保留眼球的关键。恰当的术式及合适的义眼台植入时机将对患者预后有极大帮助。     

Effects of axial length and corneal curvature on corneal biomechanics in elderly population

目的:本研究旨在应用可视化角膜生物力学分析仪(Corneal Visualization Scheimpflug Technology,Corvis ST)研究不同眼轴长度(Axial Length,AL)和角膜曲率的老年人角膜生物力学特点.方法:横断面研究.收集拟接受白内障手术的患者220例(426眼),将其中AL在22-24 mm之间、K值在42-44 D范围之间的研究对象按性别进行分组,男性44眼,女性49眼.进而对K值在42-44 D之间的研究对象按AL值的不同进行分组: 22-24 mm,共99眼;24-26 mm,共22眼;大于26 mm,共12眼.对AL在22-24 mm之间的研究对象按K值的不同分组: 42-44 D,共88眼;大于44 D,共102眼.应用可视化角膜生物力学分析仪(Corvis ST)测量角膜生物力学参数,并对不同性别、不同眼轴、不同角膜曲率患者的角膜生物力学参数进行比较性分析,采用单因素方差分析、独立样本t检验等对数据进行统计并分析各组生物力学参数间的相关性.结果:男女之间角膜生物力学参数差异无统计学意义(P>0.05),不同角膜曲率间平均第一压平长度、平均第二压平长度,差异具有统计学意义(P<0.05).不同眼轴长间:AL为22-24 mm和AL为24-26 mm两组间只有第二压平长度、角膜中央厚度差异具有统计学意义(P<0.05),AL为22-24 mm和AL大于26 mm两组间第二压平长度、最大形变幅度、中央角膜厚度、第一压平时间、眼压、矫正眼压差异均具有统计学意义(P<0.05),而AL为24-26 mm和AL大于26 mm两组间各参数比较,差异均无统计学意义(P>0.05).患者眼轴长度与最大形变幅度、眼压、矫正眼压值均呈线性正相关(r=0.263,P=0.002;r=0.463,P=0.000;r=0.449,P=0.000),与角膜厚度、第二压平长度均呈线性负相关(r=-0.240,P=0.006;r=-0.344,P=0.000).结论:角膜曲率和眼轴长度可能是影响角膜生物力学特性的一个因素,眼轴长度越长,角膜厚度越薄,角膜越容易发生形变,而且随着眼轴长度的增加眼压也升高.在探讨白内障手术切口的选择是否受到患者自身因素的影响,应该考虑其角膜曲率和眼轴长度的不同.     

年龄相关性白内障患者眼轴和角膜曲率对角膜生物力学的影响

目的：探讨应用可视化角膜生物力学分析仪(corneal visualization Scheimpflug technology,Corvis ST)研究不同眼轴长度(axial length,AL)和角膜曲率的老年人角膜生物力学特点。

方法：横断面研究。收集拟接受白内障手术的患者161例297眼,将研究对象按AL值的不同进行分组：22～24mm者190眼,24～26mm者54眼,>26mm者53眼。将AL为22～24mm、K值42～44D之间的研究对象按性别进行分组,男44眼,女44眼; 对AL为22～24mm的研究对象按K值的不同分组：42～44D者88眼,>44D者102眼; 应用可视化角膜生物力学分析仪(Corvis ST)测量角膜生物力学参数,并对不同性别、不同眼轴、不同角膜曲率患者的角膜生物力学参数进行比较性分析,采用单因素方差分析、独立样本t检验等对数据进行统计,并分析各组生物力学参数间的相关性。

结果：男女之间角膜生物力学参数比较,差异无统计学意义(P>0.05),不同角膜曲率间只有第一压平长度、第二压平长度比较,差异有统计学意义(P<0.05)。不同眼轴长组间：第二压平速度、最大形变幅度、中央角膜厚度、眼压的组间比较,差异有统计学意义(P<0.05)。眼轴与最大形变幅度及眼压呈线性正相关(r=0.429、0.278,P<0.001),与中央角膜厚度、第二压平速度呈线性负相关(r=-0.291、-0.415,P<0.001)。

结论：角膜曲率和AL可能是使角膜力学属性发生改变的角膜相关参数,角膜厚度会随着眼轴的增长呈现变薄的趋势,角膜也较容易发生形变,而且眼压也会随着眼轴的增长而逐渐增高。     

Long-term follow-up of porous polyethylene spherical implants after enucleation and evisceration

PURPOSE: To present long-term follow-up data on enucleations and eviscerations carried out with placement of spherical porous polyethylene implants. METHODS: A retrospective, interventional, noncomparative case series of all patients undergoing primary evisceration or enucleation surgery from one teaching hospital ophthalmology department. RESULTS: In total, 106 cases were identified. Eighty patients (75.5%) underwent enucleation (group A) and 26 (24.5%) underwent evisceration (group B). Patient demographics were similar in both groups. Mean implant size in group A was 20.5 mm and 17.2 mm in group B. Mean follow-up in group A was 40 months (range, 12 to 80 months). Mean follow-up in group B was 63 months (range, 12 to 72 months). Six cases (7.5%) in group A had complications (excluding implant exposure), whereas one case (3.8%) in group B had a complication (excluding implant exposure). Five patients (6.3%) in group A had implant exposure; 14 cases (53.8%) of implant exposure occurred in group B. CONCLUSIONS: Our case series revealed a significantly higher incidence of implant exposure after evisceration than after enucleation. Our data suggest that enucleation should be the procedure of choice when removing an eye to minimize the risk of subsequent complications, particularly orbital implant exposure.     

UK national survey of enucleation, evisceration and orbital implant trends

AIM: To evaluate current clinical practice in the UK in the management of the anophthalmic socket; choice of enucleation, evisceration, type of orbital implant, wrap, motility pegging and complications. METHODS: All consultant ophthalmologists in the UK were surveyed by postal questionnaire. Questions included their practice subspecialty and number of enucleations and eviscerations performed in 2003. Specific questions addressed choice of implant, wrap, motility pegging and complications. RESULTS: 456/896 (51%) consultants responded, of which 162 (35%) had a specific interest in oculoplastics, lacrimal, orbits or oncology. Only 243/456 (53%) did enucleations or eviscerations. 92% inserted an orbital implant after primary enucleation, 69% after non-endophthalmitis evisceration, whereas only 43% did so after evisceration for endophthalmitis (50% as a delayed procedure). 55% used porous orbital implants (porous polyethylene, hydroxyapatite or alumina) as their first choice and 42% used acrylic. Most implants inserted were spherical, sized 18-20 mm in diameter. 57% wrapped the implant after enucleation, using salvaged autogenous sclera (20%), donor sclera (28%) and synthetic Vicryl or Mersilene mesh (42%). A minority (7%) placed motility pegs in selected cases, usually as a secondary procedure. 14% of respondents reported implant exposure for each type of procedure and extrusion was reported by 4% after enucleation and 3% after evisceration. CONCLUSIONS: This survey highlights contemporary anophthalmic socket practice in the UK. Most surgeons use porous orbital implants with a synthetic wrap after enucleation and only few perform motility pegging.     

Unsuspected and misdiagnosed posterior uveal melanoma following enucleation and evisceration in Ottawa-Gatineau

Objective

There is a gap in the recent literature on the topic of clinically misdiagnosed and unsuspected posterior uveal melanomas (PUM) with a calculation of the frequency of these events for a specific geographical area. As the only ophthalmic pathology laboratory in our region, we determined the rate of these outcomes over a 16-year period.

Current trends in managing the anophthalmic socket after primary enucleation and evisceration

PURPOSE: To evaluate current trends in the management of the anophthalmic socket after primary enucleation and evisceration. METHODS: The active membership of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) was surveyed regarding primary enucleations and eviscerations performed between January and December 2002. Survey questions included practice demographics, orbital implant use, wrapping materials, placement of a motility peg, reasons for implant choice, and complications encountered. RESULTS: A total of 2,779 primary orbital implants were reported, comprising 1,919 (69.1%) enucleations and 860 (30.9%) eviscerations. The high-density porous polyethylene implant was used most frequently for enucleations (42.7%), followed by coralline hydroxyapatite (27.3%) and nonporous alloplastic implants (19.9%). For eviscerations, the high-density porous polyethylene implant was the most commonly used implant (42.3%), followed by hydroxyapatite (25.9%) and nonporous alloplastic implants (25.7%). The top 3 reasons for implant choice were outcome (69.3%), cost (43.6%), and experience (39.5%). Most implants were either not wrapped (59.8%) or were wrapped in donor sclera (25.2%) or polyglactin mesh (7.2%). Pegs were used in 8.1% of all implants reported. The most frequent complications encountered for unpegged implants were exposure (3.2%) and infection (0.4%). For pegged implants, the most common complications reported were pyogenic granuloma (13.7%), exposure (5.7%), and discharge (5.7%). CONCLUSIONS: In managing the anophthalmic socket, ASOPRS survey respondents preferred to use the porous polyethylene implant after primary enucleation and evisceration. Most orbital implants were not wrapped, and most surgeons preferred not to place a motility post or peg in the implant.     

Autologous dermis graft at the time of evisceration or enucleation

Aim

To present a new technique using autologous dermis graft at the time of enucleation or evisceration to replace the ocular surface area lost when the corneal scleral button is excised.

Methods

A retrospective, interventional, non‐comparative case series of patients who had an autologous dermis graft placed to assist in closure of Tenon''s capsule and conjunctiva at the time of enucleation or evisceration. Medical records were reviewed and the following variables were recorded: age, sex, history of previous ocular surgery or radiation treatment, indication for surgery, type of surgery, laterality, type of orbital implant, size of implant, length of follow up, and complications.

Results

Nine patients were identified (three male, six female) Five had enucleation with implant placement and four had evisceration with implant placement. Four individuals received unwrapped porous polyethylene spherical implants, three received silicone implants, and two received hydroxylapatite implants. Follow up ranged from 30 to 112 weeks (mean (SD), 61 (28) weeks). No operative or early complications were observed. One patient who had enucleation after two rounds of brachytherapy for uveal melanoma developed subsequent late exposure of the implant. There were no complications involving the graft donor site.

Conclusions

This small series shows that the use of a dermis graft is a safe and effective new technique to facilitate orbital rehabilitation. It is hypothesised that the extra surface area produced with a dermis graft preserves the fornices and allows a larger implant. It may also allow the implant to be placed more anteriorly which assists with both implant and prosthesis motility.     

Study of the indications and changing trends of enucleation and evisceration in West Malaysia

AIM: To study the demographic pattern and indications for enucleation and evisceration in West Malaysia, and to evaluate the changing trends of the same over the past three decades. · METHODS: In a retrospective hospital based study, case records of all patients who underwent enucleation and evisceration at University of Malaya Medical Centre over a period of 20 years (1985/2004) were reviewed. Age, gender, ethnicity of patients, indications for enucleation and evisceration were evaluated. · RESULTS: Out of 160 patients, enucleation was done in one eye in 85 patients and evisceration was done in one eye in 75 patients during the study period. The mean age of patients was 36.4 years with a range of 6 months to 90 years. In our study, panophthalmitis (26.9%) and retinoblastoma (18.8%) were the most common causes of evisceration and enucleation respectively. Infections of the eye contributed to 72.0% of eviscerations while tumors contributed to 51.8% of enucleations. There was a significant decrease in the removal of eyes over the past three decades in our hospital. The number of removal of eyes for glaucoma and trauma-related causes significantly reduced while removal for infection- related causes and painful blind eyes significantly increased when compared to the figures reported three decades ago from our hospital. · CONCLUSION: Panophthalmitis and intraocular tumors are the major indications for the removal of eyes. Although the frequency of removal of eye has significantly decreased over time in our country, the indications for the same suggest that there is a need of further improvement of eye care services in Malaysia.