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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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  Table of Contents 
REVIEW ARTICLE
Year : 2012  |  Volume : 19  |  Issue : 1  |  Page : 24-33  

Evisceration in the modern age


1 Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, USA; King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
2 Department of Ophthalmology, The Permanente Medical Group, Redwood City, California, USA

Date of Web Publication20-Jan-2012

Correspondence Address:
Timothy J McCulley
The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Wilmer 110, Baltimore, MD 21287, USA

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-9233.92113

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   Abstract 

Evisceration is an ophthalmic surgery that removes the internal contents of the eye followed usually by placement of an orbital implant to replace the lost ocular volume. Unlike enucleation, which involves removal of the entire eye, evisceration potentially causes exposure of uveal antigens; therefore, historically there has been a concern about sympathetic ophthalmic (SO) associated with evisceration. However, critical review of the literature shows that SO occurs very rarely, if ever, as a consequence of evisceration. Its clinical applications overlap with those of enucleation in cases of penetrating ocular trauma and blind painful eyes, but it is absolutely contraindicated in the setting of suspected intraocular malignancy and may be preferred for treatment of end-stage endophthalmitis. From a technical standpoint, traditional evisceration has a limitation in the orbital implant size. Innovations with scleral modification have overcome this limitation, and accordingly, due to its simplicity, efficiency, and good cosmetic results, evisceration has once again been gaining popularity.

Keywords: Endophthalmitis, Enucleation, Evisceration, Intraocular Tumors


How to cite this article:
Phan LT, Hwang TN, McCulley TJ. Evisceration in the modern age. Middle East Afr J Ophthalmol 2012;19:24-33

How to cite this URL:
Phan LT, Hwang TN, McCulley TJ. Evisceration in the modern age. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2017 Sep 22];19:24-33. Available from: http://www.meajo.org/text.asp?2012/19/1/24/92113


   Introduction Top


Evisceration (removal of intraocular contents) and enucleation (removal of the entire eye) are competing techniques, with fluctuating favor since their inception. Enucleation may be the oldest operation in ophthalmology; literature from as early as 2600 BC described a Chinese "god of ocularists." [1] Centuries later in 1817, Bear introduced evisceration when he removed the remaining intraocular contents of an eye following an expulsive hemorrhage. [2] In 1874, Noyes described evisceration for the management of intraocular infection. [3] In 1884, Mules described placing a hollow glass sphere into the eviscerated cavity. [4]

Because evisceration unlike enucleation disrupts the integrity of the globe, there is a theoretical risk of exposing uveal antigens, which could incite an autoimmune reaction known as sympathetic ophthalmia (SO) in the contralateral eye. The first report of sympathetic ophthalmia occurring in association with evisceration was in 1887. [5] Despite this, evisceration gained popularity until 1972 when Green et al. reignited the concern of inciting sympathetic ophthalmia with a report of four alleged cases. [6]

While the risk of sympathetic ophthalmia continues to be a contentious issue, evisceration has gained popularity in the past few decades. This is based largely on the perception that evisceration provides superior functional and cosmetic results compared to enucleation. Several modified evisceration techniques have been described in past decades, each proclaiming improved results. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16]

This review will provide an in-depth look at evisceration by examining the published literature that supports and refutes its association with sympathetic ophthalmia, and then describing its advantages and disadvantages in different clinical scenarios, and finally discussing the basic technique as well as recent technical modifications.


   Sympathetic Ophthalmia Top


Sympathetic ophthalmia is a potentially devastating autoimmune condition characterized by bilateral panuveitis, where the injured eye incites inflammation in the fellow (sympathizing) eye. [17] Its specific pathophysiology remains elusive. It is believed to be an immunologic response to exposure of previously sequestered tissue. [17],[18] Proposed antigens include retinal S-antigen, retinoid binding protein, melanin associated antigen, or those from the retinal pigment epithelium. [18],[19],[20],[21] Signs and symptoms of uveitis have been reported to develop between 5 days [22],[23] and 66 years [24] from the time of injury. Sixty-five percent of the cases occur between 2 weeks and 2 month with roughly 90% present within a year of injury. [25],[26],[27]

Evisceration, along with a number of other intraocular procedures, has been implicated as a potential cause of sympathetic ophthalmia. [6],[28] Whether or not evisceration can incite sympathetic ophthalmia is one of the most notorious controversies in oculoplastic surgery. [29] We will present what evidence exists supporting and refuting this relationship.

Supportive evidence

Evidence suggesting a causal relationship between evisceration and sympathetic ophthalmia lies almost entirely in a handful of case observations.

Earliest reports of sympathetic ophthalmia following evisceration include 47 cases from various ophthalmologists in the United States and the United Kingdom from 1887 to 1909. [30] Unfortunately, many of these cases did not have exam documentation of the fellow eye at the onset of injury or even after the sympathetic occurrence. Therefore, definitive time of onset of sympathetic ophthalmia and association to original injury versus evisceration were dubious to say the least. Moreover, these cases were often initially diagnosed as endophthalmitis or neuroretinitis. None had records of intraocular histopathology studies. Little else was published until 1972 when Green et al. described four cases. [6] Two occurred earlier in the first half of the century (1927 and 1949) and the others in the latter half of the century (1968 and 1969). The first two cases provided strong evidence. Slides of the scleral shells that were subsequently removed demonstrated granulomatous inflammation consistent with sympathetic ophthalmia. Green et al. did not provide the number of cases performed during the study period; therefore, the relative risk of sympathetic ophthalmia following evisceration could not be estimated base on this study.

In this past decade, there have been two case reports of alleged post-evisceration sympathetic ophthalmia. In 2005 Griepentrog et al. [31] reported a case of presumed sympathetic ophthalmia after evisceration in a 75 year-old man, who had a blind, painful eye after a penetrating globe injury that caused neovascular glaucoma. Notably the injury occurred 66 years prior. The patient developed ciliary injection, mild cataract, vitreous cells, and macular retinal pigment epithelium mottling and serous detachment in the fellow eye fourteen weeks post-operation. His vision improved from 20/200 to 20/25 nine months later on a tapered steroid dose. The diagnosis was based entirely on the clinical appearance; histopathologic confirmation was not established.

In 2006, Freidlin et al.[32] reported the first case of sympathetic ophthalmia found in a soldier since World War II. This 21-year-old man sustained shrapnel wounds while in combat and underwent evisceration the day of injury. Within a month of surgery, he developed panuveitis in his remaining eye with conjunctival injection, vitreous floaters, and paracentral scotoma. He responded favorably to immunosuppressant therapy. After 6 months of oral and topical steroid treatment, best-corrected visual acuity was 20/20 in this "sympathetic" eye. Interestingly, histologically proven uveal tissue was found and removed from the subconjunctiva of the eviscerated eye at the onset of his symptoms. The authors hypothesized that this residual uveal tissue induced the inflammation. Given the failure to remove all uveal tissue, this case does not support evisceration as an inciting event. However, it does stress the need to perform eviscerations properly and in appropriately selected patients. This and the previous case illustrate the additional point that in at least some cases, good vision can be preserved in the sympathetic eye with treatment.

There is good evidence that potentially any type of intraocular surgery can incite sympathetic ophthalmia. Previous retrospective studies estimated the incidence of sympathetic ophthalmia to be anywhere from 0.02% to 0.06% for intraocular surgery, [33],[34],[35] and 0.28% to 1.9% for nonsurgical penetrating injury. [35],[36],[37] These surveys implicated various intraocular surgeries, including cataract extractions, glaucoma procedures, and vitrectomies but not eviscerations. In a prospective surveillance, Kilmaren et al. estimated the incidence of sympathetic ophthalmia to be 0.03 per 100,000. [38] Ocular surgery, particularly retinal surgery, was the most common cause in this group, as opposed to previous reports where accidental trauma overwhelmingly prevailed. [6],[37] Between July 1997 and September 1998, all permanently employed ophthalmologists in the United Kingdom were sent monthly report cards to notify any newly diagnosed cases of sympathetic ophthalmia. There were 23 valid cases of sympathetic ophthalmia reported during this period, but only 17 that were reported in last 12 consecutive months were included in Kilmarin et al.'s estimation of the incidence. Of these patients, one underwent an enucleation for recurrent choroidal melanoma, but none had evisceration. Of note, the patient with a history of enucleation also twice underwent pars plana vitrectomy.

Although these studies fail to establish evisceration as a definitive causation for sympathetic ophthalmia, they do stress that any type of intraocular surgery may be causative. Logic follows that evisceration has the potential to incite sympathetic ophthalmia.

In summary, the assertion that sympathetic ophthalmia may be incited by evisceration is largely theoretical, supported only by a handful of single or small series of questionable cases.

Refuting evidence

There have been a number of series looking at cohorts of patients who underwent evisceration, where no cases of sympathetic ophthalmia were identified. Studies involving over 3000 eviscerations failed to identify a case of sympathetic ophthalmia between 1980s and 1990s. [5],[39],[40],[41] A more recent review by du Toit et al.[42] also failed to identify sympathetic ophthalmia in 491 primary eviscerations or 11 secondary eviscerations for penetrating injury at a tertiary hospital in Cape Town, South Africa from 1995 to 2004. This is similar to a previous report made by Rudemann of his 15-year experience between 1947 and 1962. [30] He failed to identify any case of sympathetic ophthalmia in the 506 eviscerations performed.

In 1998 Levine et al. [40] assessed the association between evisceration and sympathetic ophthalmia. He reviewed 51 of his own patients who underwent evisceration between 1980 and 1996. The follow-up period ranged from 3 to 180 months (mean, 48 months). No cases of sympathetic ophthalmia were identified. In addition, they queried members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), American Uveitis Society, and Eastern Ophthalmic Pathology Society. Of the 880 reported eviscerations from responding members of the three societies, members of the ASOPRS "recalled" five and the other two groups "recalled" several cases of sympathetic ophthalmia. These cases were anecdotal, not documented clinically or histologically and thus excluded as positive findings. Based on their findings, Levine et al. concluded that "evisceration is a safe procedure with little risk of sympathetic ophthalmia." However, this conclusion has been challenged. Bilyk argued that, simply due to the rarity of sympathetic ophthalmia and low number of evisceration performed, the risk of sympathetic ophthalmia is likely underestimated. [43] It has also been pointed out that, based on previously estimated occurrence rates of sympathetic ophthalmia, some cases should have been identified if Levin's review method was reliable. Regardless, since Levine's publication, evisceration seems to have been gained favor once again.

In summary, evidence for the association between evisceration and sympathetic ophthalmia is lacking. However, given the extremely low incidence of sympathetic ophthalmia, rare occurrences cannot be entirely excluded. It is probably safe to say that the risk of sympathetic ophthalmia following evisceration is, at most, extremely low.


   Indications Top


[Table 1] outlines published indications for evisceration and enucleation. [Table 2] compares and contrasts the benefits of evisceration and enucleation for individual indications. In most cases, when globe removal is required, either surgery is adequate, and the surgeon may choose their personal preference. However, there are circumstances where one is preferable or, in some cases, contraindicated. Traditionally, enucleation has been recommended for management of intraocular neoplasm and prevention of sympathetic ophthalmia following penetrating trauma, [44],[45],[46],[47],[48] whereas evisceration is usually recommended for management of endophthalmitis. [49] Opinions vary with regards to which surgery is preferable for management of blind, painful, phthisical, or otherwise cosmetically unacceptable eyes. [16],[50] Each one will be explored.
Table 1: Indication for eviscerations and enucleations

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Table 2: Indication vs contraindication for evisceration and enucleation

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Malignancy

Malignancy is an absolute contraindication to evisceration. An enucleation should be performed whenever managing an eye suspected or known to harbor an intraocular malignancy. [44],[45],[46],[47]

Penetrating trauma

One of the most common indications for evisceration is penetrating ocular trauma despite the possible association with sympathetic ophthalmia. Removal of the eye (or its contents) prior to sensitization is felt to be preventive. Classic teaching is to perform surgery within 14 days of injury. The origin of this teaching is unclear, although it may stem from a study indicating that visual outcome improves significantly if surgery is performed within two weeks of injury, given that sympathetic ophthalmia has not developed. [26]

Although traditionally enucleation has been recommended in the setting of penetrating trauma, evisceration is also routinely performed for the purpose of protecting against sympathetic ophthalmia [Table 1]. [51],[52],[53],[54],[55] In cases with extensive disruption of the globe, removal of all uveal tissue may be difficult via an evisceration; therefore, enucleation may better safeguard against retained uveal tissue, a risk factor for sympathetic ophthalmia. This point is nicely illustrated in the case published by Freidlin et al., where the patients sclera was severely disrupted with uveal tissue prolapsed into the orbit. [32] However, in cases where the sclera is largely intact, and the intraocular contents are contained and identifiable, an evisceration may be a reasonable alternate. The selection is usually based on surgeon's judgment or preference.

Blind eyes

Blind eyes are commonly removed for both pain control and improvement of cosmesis [Table 1]. Both enucleation and evisceration are effective in these settings. [50],[56] Again, the choice of procedure usually depends on the surgeon's personal experience and preference. Evisceration in the management of blind eyes, for both pain control and cosmesis, is the authors' preferred technique.

Removal of blind eyes should be viewed as a last resort. Patients often fend better if able to retain their natural globe. The term "scleral shell" is used for a prosthesis, which is made to fit over the patient's eye. Often this is all that is required for phthisical eyes. A scleral shell in conjunction with a conjunctival flap is an underutilized combination that may best serve some patients.

The decision to remove an eye or its contents for pain control should not be made whimsically. Pain can, at times, be controlled with a retrobulbar injection of alcohol or chlorpromazine. [57],[58],[59] Corneal-related discomfort can, in select cases, be managed with a conjunctival flap. [60],[61],[62],[63],[64]

Less invasive means of controlling pain as outlined above should be weighed against eye removal. In the case of eyes expected to become phthisical, classic teaching has been to recommend globe removal. However, recent data has suggested that, in most cases, pain either will develop mildly or not at all. [65] Brackup et al. [65] found 85% of the patients with severely traumatized eye and no evisceration or enucleation remained comfortable with no or only rare pain. The other fifteen percent had intermittent pain. Accordingly, when possible, the decision to remove the eye should be postponed until a stable state has been reached.

Another potential pitfall is the continued pain following removal of an eye. In a series described by Shah-Desai et al., removal of an eye failed to relieve eye pain in seven of 24 patients. [49] Most of the pain was related to post-operative complications that required additional medical or surgical treatments.

The patient's socio-economic status also needs to be factored in the decision. For example, for a patient with limited access to health care, one may lean towards a conjunctival flap and scleral shell. Resources needed for routine evaluation and the maintenance required of an anophthalmic socket and prosthetic eye may not be available. Whereas for patients with abundant resources, one might prefer avoiding a conjunctival flap because it may complicate a future evisceration if it fails. Knowing that the patient would be able to obtain and maintain a well-fitted prosthesis would be useful before initiating evisceration.

It has been argued that enucleation is preferable to evisceration in the setting of phthisis. With older techniques, this is true. The diminished size of the intrascleral space precludes placement of an adequately sized implant. However, with modern techniques, which incorporate volume-enhancing sclerotomies, implants equal in size to those used in enucleation can be placed. [11],[12],[13],[15] This is discussed in detail below.

Endophthalmitis

In some developing countries, endophthalmitis is the most common reason for evisceration and enucleation. [66],[67],[68] Before the advent of antibiotics, surgeons fairly uniformly advocated evisceration over enucleation. Evisceration leaves the optic nerve intact and thus avoids the spread of intraocular microbials into the subarachnoid space. [49] A study in 1987 argued that endophthalmitis should not be considered a contraindication to enucleation in the modern era of antiobiotics. [69] In this retrospective study, no cases of postoperative intracranial infection were identified in a cohort of 165 patients who underwent enucleation for endophthalmitis.

The weakness of many such retrospective studies is that the implications of the study are often overextended. Although relatively large (a cohort of 165 patients in the above example), all that can be said is that the occurrence rate is likely less than 2.21% (P=0.05). For such a potentially devastating consequence, that is, bacterial meningitis, even taking this small risk might not be prudent. For this reason, many surgeons still prefer evisceration for endophthalmitis. [70],[71],[72]


   Surgical Technique Top


Although minor variations exist, there are core surgical steps, which remain fairly constant. Each will be discussed briefly with emphasis on the authors' preferred technique.

1. Peritomy

Following placement of an eyelid speculum, a subconjunctival injection of epinephrine containing anesthetic facilitates a 360° peritomy. Care is taken to preserve as much conjunctiva as possible.

2. Removal of the cornea

A full-thickness limbal incision is made with an #11 blade scalpel. The remainder of the limbus is cut with scissors, allowing for removal of the corneal button. Historically, the cornea was not removed. [73] Currently, most surgeons elect to remove the cornea, providing better pain control. [74]

3. Removal of the intraocular contents

The intraocular contents are then removed with the aid of an "evisceration spoon," a round relatively flat curette. Careful attention is given to the complete removal of all uveal tissues. In theory this decreases (possibly eliminates) the risk of sympathetic ophthalmia.

4. Application of alcohol

The inner surface of the sclera is then bathed in alcohol. The purpose of this step is to denature any residual protein that might otherwise incite inflammation, that is, sympathetic ophthalmia. Cautery should be avoided, due to the flammability of residual alcohol, until the surgical field has been thoroughly irrigated with saline.

5. Sclerotomy

Performing a sclerotomy, allowing for placement of larger implants, has become popular in recent years and is performed at this stage. Specific techniques are discussed in detail below.

6. Implant placement

There is much variation in the preferred type of implant. This is one of the greatest areas of disagreement among oculoplastic surgeons and beyond the scope of this text. The authors' preference is a simple silicone sphere. Previously, the largest implant possible was placed. However, with the advent of modern sclerotomies, essentially any sized implant can be used, and implant size is chosen to match prominence of the fellow eye.

7. Closure

The final step is closure. All techniques include the closure of multiple layers, including the sclera, Tenon's membrane and, lastly, conjunctiva. Meticulous closure is felt to be essential in preventing implant extrusion.


   Sclerotomy Top


The two main goals during an evisceration are replacing lost volume with an appropriately sized implant and achieving maximum implant motility. These two features optimize symmetry and therefore good cosmesis.

With classic evisceration technique, the largest implant that will fit inside the scleral cavity and still allow for closure of the sclera without undue tension is 18 mm and, in many cases, less. [75],[76] For this reason, evisceration was rarely performed in phthisical eyes, as only very small implants could be placed.

Several different methods of sclerotomies and relaxing incisions have been described to increase the size of the cavity in which the implant is placed. [7],[8],[9],[10],[11],[12],[13],[14],[15],[16] In 1987, Stephenson reported performing multiple radial expansion sclerotomies as well as a posterior spiral sclerotomy. [7] In addition, he placed fixation sutures between the implant and scleral shell to prevent implant migration. In 1995, Kostick and Linberg described a posterior sclerotomy. [8] In the same year, Lee et al. reported the creation of scleral windows posterior to each of the rectus muscle insertion. [9] In 1997, Jordan and Anderson described disinserting the optic nerve and performing small radial sclerotomies. [10] In the same year, Yang et al. described a "scleral quadrisection" technique, which left the optic nerve intact. [11] Long et al.[12] reported opening the scleral cavity posteriorly and placing the implant behind the sclera in the muscle cone. In 2001, Massry and Hold described obliquely splitting the scleral cavity in two, releasing the flaps from their optic nerve attachments. [13] More recently in 2007, Sales-Sanz and Sanz-Lopez described a technique wherein they performed four complete sclerotomies from the limbus to the optic nerve with optic nerve disinsertion. [15] This created four petals that contained a rectus muscle each. The petals were then brought anteriorly to cover the implant. Also in 2007, Masdottir and Sahlin reported their experience using a split-sclera technique similar to Massry's and Hold's, where 5% developed exposure or extrusion of implant, but 78% of the patients felt pleased or very pleased with the operation. [77] Most recently in 2011, Smith et al.[78] reported their experience with Massry's and Hold's technique. Sixteen of the 201 patients reported minor complications, while three reported major ones during a mean follow-up period of 31.62 months (range, 3-98 months). Also in 2011, Georgescu et al.[16] described a new evisceration technique for patients with phthisis bulbi and microphthalmos. Eighteen patients underwent evisceration, where a 5-mm wedge of sclera was excised nasally and temporally and a 360° equatorial scleral incision was made, dividing the scleral into anterior and posterior halves.

In most of the above reports, good results were achieved with complications similar to those seen when a sclerotomy was not performed. The advantage with a sclerotomy is the ability to place implants up to or even larger than 20 mm in a large proportion of patients. These enhanced volume augmentations diminishes the "sunken-in" look often seen in anophthalmic patients. Also, in the few studies that assessed motility, dismantling the sclera did not adversely affect implant excursion or patients' overall satisfaction. [79]

We routinely perform a sclerotomy. Our preferred technique, nicknamed "the swinging sclera ," is a 180° horizontal cut, bisecting both horizontal rectus muscle insertions and passing just above the attachment of the optic nerve. By leaving the optic nerve attached to the inferior half of the sclera, a supportive hammock is formed that helps prevent inferior migration of the orbital implant.


   Outcome Top


The increasing number of eviscerations performed in recent decades is due to several perceived benefits. Often cited advantages include the perception that evisceration is simpler and faster than enucleation. [80] Since evisceration leaves the extraocular muscles and optic nerve intact, it also has less risk for significant bleeding. [81]

Ultimately, superior cosmetic outcome depends on volume replacement, socket motility, deep fornices, and normal-appearing and functioning eyelids. [82],[83] Evisceration allows for better preservation of orbital anatomy, improved mobility and therefore enhanced cosmesis. [8],[75],[76],[77],[84] It has been proposed that evisceration requires less manipulation and consequently less inflammation and scarring of orbital tissues: fornices and suspensory ligaments remain uncompromised. This in turn is thought to help maintain the implant. These factors translate to better motility, less risk of superior sulcus deformity and thus an enhanced cosmetic result for the patients.

Historically, enucleation allowed for placement of a larger implant. [77],[79] The largest implant possible, whether involving enucleation or evisceration, helps prevent enophthalmos and superior sulcus deformity. [78],[85] However, with the advent of modern sclerotomy techniques, enucleation no longer has this advantage over evisceration.

Evisceration also provides superior socket motility. A prospective study in 2007 compared the motility and complications of 50 patients who underwent evisceration with sclerotomy and allosplastic implantation (Group 1) and 50 patients who underwent enucleation and hydroxyapatite implantation (Group 2). [75] For the eviscerations, scleral quadrisections were performed at 1.5, 4.5, 7.5, and 10.5 clock hours from the limbus to the optic nerve without disinserting the nerve. Group 1 fared statistically significantly better than Group 2 in motility. The mean horizontal excursion was 10.25 ± 1.99 (5.9-15) for Group 1 and 6.90 ± 1.74 (3.2-12) for Group 2. The mean vertical excursion was 8.45 ± 1.89 (4.3-12) for Group 1 and 5.69 ± 1.63 (3-10) for Group 2. Covariant analysis indicated operation time as a statistically significant predictor in movement. Deep superior sulcus and exposure or extrusion was not significantly different between the two groups.

Modern evisceration techniques with sclerotomies, allowing for placement of large implants, achieve better results that previously possible. Patients enjoy relatively good socket motility common to all evisceration techniques. With the introduction of the sclerotomy, implant size is no longer a limitation.

Complications

[Table 3] summarizes the more commonly encountered complications. Potential complications, common between enucleation and evisceration, include infection, hemorrhage, and implant extrusion. Long-term complications include sunken/deep superior fornix, lower eyelid laxity and ectropion, upper eyelid ptosis, socket contraction, conjunctival cyst formation, implant migration and late extrusion of the implant. [70],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96],[97],[98],[99] More common and/or serious complications will be addressed in detail.
Table 3: Common complications of evisceration and enucleation

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Infection and hemorrhage are common to all surgical procedures; evisceration is no exception. Fortunately, hemorrhage is usually self-limited and, even in the most severe cases, can be controlled with a firmly placed pressure patch. The authors usually place a temporary tarsorrhaphy at the close of the case, which prevents conjunctival prolapse should post-operative bleeding be encountered. Sterile technique with peri- and postoperative systemic antibiotics limits the risk of infection. Delayed placement of the orbital implant reduces the risk of infection in the setting of endopthalmitis. [100] When encountered, removal of the implant with delayed reconstruction is often necessary.

Despite placement of a large implant, patients may still develop a "sunken-in" appearance. Several mechanisms have been proposed for deep superior sulcus and subsequent ptosis. Hypotheses include (1) decreased circulation with cicatrization of orbital tissue and fat atrophy; [101] (2) disturbance in the normal spatial architecture and tissue relationships of the orbit; [102] (3) grossly underestimated orbital volume loss and inadequate volume replacement; [103] (4) contracture of the remaining soft tissues, with an equivalent effect as inadequate volume replacement; [43] (5) orbital expansion following unidentified orbital fractures. [104] Deep superior sulci are managed with orbital volume augmentation. Techniques include implant exchange and autologous fat transfer. The authors' preferred method is placement of an "enophthalmic wedge."

One of the most dreaded and challenging complications is socket contracture. The spectrum of this disorder ranges from posterior lamella shortening to complete obliteration of the fornices. [84] Mild contraction may result in nothing more than inward rotation of the eyelashes. With further contraction eyelid mobility is reduced. In the most extreme cases, patients are unable to retain a prosthesis. Management consists of removal of any inciting irritant. Smoking has been linked with socket contraction. All anophthalmic patients should be counseled regarding smoking cessation. A properly fitted and maintained prosthesis is also essential to a healthy socket. Once contraction has occurred, management usually consists of fornix reconstruction with mucous membrane grafting.

Implant extrusion usually relates to placement of an oversized implant, inadequate sclerotomy or poor closure. Management of an extruding implant is complex with many varied opinions. Small exposed areas may heal spontaneously and are often just observed. Larger areas may be closed with a variety of flaps, grafts, and even donor or synthetic materials. [105],[106],[107],[108],[109],[110],[111],[112],[113],[114],[115],[116],[117] Most often, exposure is the result of anterior pressure. Even with the most deftly executed anterior reconstruction techniques, recurrences are common. Implant exchange or repositioning may be required. [118]

Another relevant issue is the possibility of unintended evisceration of a malignancy-baring eye. For this reason a dilated fundus evaluation is mandatory prior to performing an evisceration. If there is not an adequate view of the fundus, appropriate imaging should be obtained prior to surgery. A couple of series have addressed inadvertent evisceration of eyes containing malignancy. [119],[120] Eagle et al.[119] described seven such cases. Of note, three of patients had not undergone preoperative imaging. Retrospectively, two had suspicious findings on computed tomography (CT) that escaped further investigation, and one underwent evisceration despite having a known history of uveal melanoma. In Rath et al.'s series, five of the six patients did not undergo preoperative imaging prior to evisceration. [120] These cases serve as reminder that patients should undergo diligent fundus examination and appropriate imaging when adequate visualization is not possible.


   Summary Top


Evisceration remains a popular and effective surgery. Uncertainty surrounding the risk of sympathetic ophthalmia following evisceration has caused some surgeons to prefer enucleation. However, this fear seems to be largely unfounded, based entirely on a very small number of reports. Most cases were either confounded by a history of trauma or intraocular surgery or were not confirmed histologically. Recent advances in techniques, largely centered on various types of sclerotomies, allow for placement of larger implants. Given the superior cosmetic and functional results of evisceration, it is the authors' preferred method of eye removal when not contraindicated.

 
   References Top

1.Moshefeghi DM, Moshefeghi AA, Finger PT. Enucleation. Surv Ophthalmolo 2000;44:277-301.  Back to cited text no. 1
    
2.Meltzer MA, Schaefer DP, Della Rocca RC. Evisceration. In: Della Rocca RC, Nesi FA, Lishman RD, editors. Smith's ophthalmic plastic and reconstructive surgery. Vol. 2. St. Louis: CV Mosby; 1987. p. 1300-7.  Back to cited text no. 2
    
3.Noyes HD. Discusio ìn of E Warlomont's paper on sympathetic ophthalmia. In: Report of the Fourth International Congress, London, Aug 1872:27.  Back to cited text no. 3
    
4.Mules PH. Evisceration of the globe, with artificial vitreous. Trans Ophthalmol Soc UK 1885;5:200-6.  Back to cited text no. 4
    
5.Cytryn AS, Perman KL. Evisceration. In: Enucleation, evisceration and exenteration of the eye. In: Migliori ME, editor. Boston: Butterworth-Heinermann; 1999. p. 105-12.  Back to cited text no. 5
    
6.Green WR, Maumenee AE, Sanders TE, Smith ME. Sympathetic uveitis following evisceration. Trans Am Acad Ophthalmol Otolaryngol 1972;76:625-44.  Back to cited text no. 6
    
7.Stephenson CM. Evisceration of the eye with expansion sclerotomies. Ophthal Plast Reconstr Surg 1987;3:249-51.  Back to cited text no. 7
    
8.Kostick DA, Linberg JV. Evisceration with hydroxyapatite implant. Surgical technique and review of 31 case reports. Ophthal
Mology 1995;102:1542-9.   Back to cited text no. 8
    
9.Lee SY, Kwon OW, Hong YJ, Kim HB, Kim SJ. Modification of the scleral openings to reduce tissue breakdown and exposure after hydroxyapatite implantations. Ophthalmologica 1995;209:319-22.  Back to cited text no. 9
    
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    Tables

  [Table 1], [Table 2], [Table 3]


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