94

INTRODUCTION
Removing an eye that is ill, damaged, or has little or
no vision is a challenge to the ophthalmic surgeon.
The psychological trauma and the physical disability
are extreme and the patient needs compassion and
support in order to return to a productive life. The
preparation for surgery, postoperative appearance,
and prosthesis ftting should be discussed prior to the
procedure. The surgery must be performed in a way
to provide the best conditions for a perfect prosthesis,
which should look similar to the fellow eye, follow its
movements, be comfortable and aesthetically pleas-
ing. Nevertheless the desired results are obtained in
only one-third to half of the cases, especially due to
conjunctival retraction.
1
The loss of an eye causes severe changes to the
anatomy and physiology of the orbit resulting in
deformities that affect the relationship between the
socket and the prosthesis. Surgical procedures should
be performed meticulously to attain the best func-
tional and cosmetic result and avoid complications
and deformities.
Evisceration consists in the complete removal of
the ocular contents through a corneal or a scleral inci-
sion, while preserving the conjunctiva, sclera, extra
ocular muscles and orbital fat. The preservation of
the cornea will depend on its clinical presentation and
upon the surgeons evaluation.
Enucleation is the removal of the entire eye follow-
ing the desinsertion of the extra ocular muscles and
the section of the optic nerve. If possible, an ocular
implant should be placed during the procedure to
restore the volume and preserve the movements.
Evisceration achieves a better cosmetic result than
enucleation because it is less traumatic to the orbital
tissues and the extra ocular muscles.
2
The incidence
of implant extrusion is also lower with evisceration.
3

There are reports of rare cases of sympathetic oph-
thalmia following the procedure. It is a bilateral dif-
fuse granulomatous uveitis characterized by keratic
precipitates, ciliary injection, aqueous cells and fare,
posterior synechiae, vitreitis, retinal vascular sheath-
ing, and disc edema. Treatment includes aggressive
anti-infammatory therapy and immunosuppressors.
Prognosis is reserved.
INDICATIONS
Evisceration is performed in every situation that
requires the removal of the eye due to trauma,
glaucoma, unaesthetic eyes for which the use of
a prosthesis is not possible, and in some cases of
Seminars in Ophthalmology, 25(3), 9497, 2010
Copyright 2010 Informa UK Ltd.
ISSN: 0882-0538 print/ 1744-5205 online
DOI: 10.3109/08820538.2010.488575
Evisceration and Enucleation
caro Perez Soares,
1
and Valnio Perez Frana
2
1
Clnica de Olhos Hospital Mater Dei; Centro Oftalmolgico de Minas Gerais; Policlnica oftalmolgica - Oculi;
Belo Horizonte, Minas Gerais, Brazil
2
Clnica de Olhos Hospital Mater Dei; Centro Oftalmolgico de Minas Gerais; Policlnica oftalmolgica - Oculi;
Hospital So Geraldo, Federal University of Minas Gerais
ABSTRACT
Evisceration and enucleation are delicate procedures that result in psychological trauma and
physical disability. The preparation is as important as the surgery itself to assure that the patient
will return to a productive life. The procedure must be performed in a way to provide the best con-
ditions for a perfect prosthesis, which should look similar to the fellow eye, follow its movements,
be comfortable and aesthetically pleasing. Indications and contra-indications, surgical techniques,
pre- and post-operative care and complications are discussed in this paper.
KEYWORDS: evisceration; enucleation
Correspondence: caro Perez Frana, Rua Timbiras 3468, Barro
Preto. CEP 30140-062, Belo Horizonte (MG), Brazil.
00 00 0000
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2010 Informa UK Ltd.
2010
Seminars in Ophthalmology
0882-0538
1744-5205
10.3109/08820538.2010.488575
25
94
97
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Evisceration and Enucleation 95
2010 Informa UK Ltd.
endophthalmitis or uveitis. The absence of light percep-
tion should be confrmed in every case. The procedure
is contra-indicated if an intraocular tumor is suspected
and cant be ruled out by imaging studies. In cases of
trauma with severe anatomy disruption and uveal
prolapse there is a risk of sympathetic ophthalmia
after evisceration. With an intact scleral shell the pro-
cedure is relatively safe if performed carefully and
all the uveal tissue is removed.
2
Endophthalmitis is a
very important indication for evisceration because an
enucleation could expose the orbit and central nervous
system to the infection.
Enucleation is indicated in suspected or confrmed
intraocular cancer, confrmed or suspected sympathetic
ophthalmia, in cases of severe phthisis bulbi, and clini-
cally resistant bacterial endophthalmitis.
PREOPERATORY CARE
The patient and family should be extensively
informed about the procedure and its consequences,
and should make a clear decision about the surgery.
The total absence of light perception should be well
documented and demonstrated to the patient and
family. For elective surgeries, anticoagulants should
be discontinued prior to the surgery. Psychological
support is essential, because the removal of the eye
is a mutilating procedure and may cause severe emo-
tional trauma.
EVISCERATION TECHNIQUE
There are two main evisceration techniques: with or
without the retention of the cornea, both requiring
the use of an ocular implant. The retention of the
cornea provides a more suitable socket for a larger
implant, resulting in better functional and aesthetic
appearance. Some contraindications for the reten-
tion of the cornea are: keratitis, corneal ulcers, thin
corneas under risk of rupture, and degenerations. In
very selected cases, the surgeon may choose to pre-
serve the cornea even in the presence of inadequate
condition (such as phthisis bulbi or thin cornea) in
order to have a good size socket that will allow the
use of an implant.
EVISCERATION WITH RETENTION
OF THE CORNEA
The procedure can be done under local anesthesia and
sedation. In addition to the periocular block, subcon-
junctival infltration of lidocaine and epinephrine helps
reducing the bleeding.
An incision is made through the conjunctiva and
Tenon capsule between the insertion of the superior
rectus muscle and the limbus, approximately 6mm
from the limbus, comprising 180 (9 to 3 oclock). The
tissues are dissected towards the cornea, creating a
limbus-based conjunctival fap. A better exposition
of the area may be achieved using a 5-0 silk traction
suture at the superior rectus.
The sclerotomy is performed using an 11 blade,
beginning at the 12 oclock position, between the
insertion of the superior rectus muscle and the limbus
(closer to the limbus) extending laterally and medially
to comprise 180. The conjunctival incision should not
overlap the scleral incision but completely cover it in
the end of the surgery.
A long ciclodialysis spatula is passed between the
sclera and the uvea antero-posteriorly and rotated 360.
This separates the ocular contents, contained by the
uveal tract, from the sclera, with no vitreous leakage.
An evisceration spoon is used to remove all ocular
contents. Uveal remains are scraped off with a curette
or gauze wrapped around the tip of a clamp. The inner
surface of the sclera is copiously irrigated and bleeding
is stopped using bipolar cauterization. Special attention
must be paid at the optic nerve area due to the pres-
ence of larger blood vessels. Postoperative bleeding is
an important complication and may lead to implant
extrusion.
The implant is placed inside the scleral cavity and
the sclerotomy margins are closed using 6-0 absorb-
able sutures in inverted separate stitches. There
should be no tension over the implant. If a porous
implant is chosen, a 360 sclerotomy at the equator
is advised to prevent it from rubbing against the
inner surface of the cornea and to facilitate vascular
ingrowth into the implant. Additionally, this incision
A
C D
B
FIGURE 1 Evisceration technique; (A) Pre operative aspect
of the eye; (B) 180 sclerotomy; (C) removal of ocular con-
tents; (D) placement of the medpor implant.
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96 V. Perez Frana and . Perez Soares
Seminars in Ophthalmology
makes it possible to insert large implants in small
cavities.
The conjunctiva and Tenon capsule are closed using
inverted 6-0 absorbable sutures. There is no need to use
a symblepharon ring after the surgery, except in cases
where a conjunctival fap was used, in order to prevent
fornix retraction.
EVISCERATION WITH
KERATECTOMY
A 360 peritomy is performed and the subtenonian
space is dissected posteriorly towards the fornix. An
11 blade is used for the paracenthesis at the 12 oclock
position. The sclerotomy is extended 360 with scis-
sors and the cornea is excised. The ocular contents are
eviscerated, the inner scleral surface cleaned, and the
implant placed as described above.
Two small scleral triangles at 3 and 9 oclock are
excised in order to change the opening of the ocu-
lar cavity from round to elliptic in shape, making
it easier to suture the sclera. The conjunctiva and
Tenon are closed in a way that the suture line does
not overlap the scleral suture. The conjunctiva must
be fxated onto the underlying sclera using a trans-
fxating suture preventing the rubbing of the sclera
against the inner face of the conjunctiva during eye
movements.
ENUCLEATION TECHNIQUE
The anesthesia is performed as described above. A
360 limbal peritomy is done and the conjunctiva and
Tenon capsule are dissected posteriorly towards the
rectus muscle insertions. Blunt-tipped scissors are
inserted into each of the oblique quadrants and all
the adhesions are eliminated. The muscle insertions
are identifed and isolated using a muscle hook. 5-0
double-armed absorbable sutures are woven through
each muscle 2 mm from its insertion. The rectus mus-
cles are cut close to the sclera and anchored around
the surgical feld using the sutures. The two oblique
muscles are also severed and left loose inside the
orbit.
The next step is the section of the optic nerve. The
surgeon must immobilize the eye holding it by the
remnant tissue of the lateral rectus muscle insertion,
which was left purposefully on the sclera, and pull
the eye medially and upwards. This maneuver will
allow the curved hemostat to be placed inside the orbit
from the lateral to the medial side. With the tip of the
hemostat the surgeon can feel the optic nerve as a rigid
string attached to the bottom of the eye. The nerve
is clamped the furthest into the orbit as possible by
sliding the hemostat towards the optic canal (at least
6mm or 10mm in case of tumors). Enucleation scis-
sors are introduced over the hemostat and the nerve
is sectioned. The eye can be now removed from the
orbit. The optic nerve pedicle is cauterized; the hemo-
stat is released and can be removed if no bleeding is
detected.
The chosen implant, unwrapped or wrapped in
sclera or fascia lata, is placed inside the cavity. Large
implants must be avoided in order to prevent compres-
sion of the orbital tissues that will cause atrophy and
supra tarsal depression, as well as exophthalmia after
the prosthesis. The four rectus muscles are sutured
to the implant. The surgeon must try to restore the
muscle topography. The Tenon capsule is attached
to the implant using absorbable 6-0 separate sutures.
The conjunctiva is closed with a continuous suture.
A symblepharon ring should be used to maintain the
fornices.
IMPLANTS
The implants are classifed as natural (biological
or non-biological) and synthetic. Some examples
are: natural biological coralline hydroxyapatite;
natural non-biological aluminum oxide; synthetic
polyethylene and acrylic. Some composite implants
are under investigation but nowadays the most used
materials are natural hydroxyapatite, bioceramic,
and high density polyethylene (Medpor

). Another
frequently used implant, natural and autologous, is
the dermofat graft whose most important advantage
is the absence of rejection (Figure 2). The selection of
the implant depends upon cost, surgeons preference,
extrusion rates, availability, desired motility, and other
factors.
C
A B
FIGURE 2 Dermofat graft (A) Enucleation; (B) dermofat
graft placement; (C) Final aspect after 30 days.
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Evisceration and Enucleation 97
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The frst implant inserted after an evisceration was
a glass sphere (Mules, 1885). Recently, several inte-
grated implants have been introduced. They allow the
ingrowth of fbrovascular tissue through their porous
structure, resulting in better fxation and less extrusion.
Some implants have a pin or a peg on their anterior
surface to be coupled with the prosthesis.
Most implants need to be wrapped before inserting
into the orbital cavity after an enucleation, to facilitate
the reattachment of the extraocular muscles. Several
wrapping materials have been used: preserved donor
sclera, Dura-mater, bovine pericardium, fascia lata, and
other synthetic substances like Tefon. The authors
preference has been the Mules implant due to its low
cost, availability, uncomplicated technique, low extru-
sion rates, satisfactory motility, and excellent cosmetic
results. Integrated implants present high long-term
extrusion rates, especially if used in evisceration with
retention of the cornea.
POSTOPERATIVE CARE
Systemic antibiotics are used for 5 to 7 days. No- steroi-
dal anti-infammatory drugs, analgesics, and ice packs
are necessary during the frst 72 hours. Antibiotic and
steroid drops should be maintained for 30 days. Fit-
ting of the prosthesis should begin 3 or 4 weeks after
surgery.
COMPLICATIONS
The most frequent complication of evisceration and
enucleation procedures is the exposure of the implant,
which occurs in 28% of the cases.
1
Short-term compli-
cations include dehiscence of the suture, which can
happen at the scleral site, exposing the implant, or at
the conjunctiva, exposing the sclera. The exposure of
the implant is a serious complication and if too exten-
sive may require a new surgical procedure. However,
if only a small area is exposed there may be no need
for any additional surgery, since the implant will still
be covered by the conjunctiva and Tenon capsule. If
the sclera is exposed, instead of the implant, the con-
junctiva may spontaneously reepithelize over it. The
patient should be examined frequently because of the
risk of scleral melting due to ischemia. If necessary, a
conjunctival fap must be used to cover the area. Most
cases of dehiscence are secondary to the use of large
implants or inadequate suture.
Melting of the donor sclera was reported after
enucleation with scleral wrapped implants, possibly
secondary to inappropriate conservation of the sclera
by the tissue bank. In these cases it is not possible
to salvage the implant and there is no option but to
replace the sclera and insert a new implant.
Exposure of the implant may occur as a late compli-
cation, especially due to inadequate prosthesis. This is
more frequent in cases with retention of the cornea in
which there is friction between the external prosthesis
and the cornea or between an integrated implant and
the inner surface of the cornea. This can be greatly
avoided by performing a 360 sclerotomy posteriorly
to the equator of the eye as described above.
The exposure can lead to infection and extrusion of
the implant and early intervention is mandatory. There
are several different approaches to solve this complica-
tion: (a) replacement of the implant with one of smaller
size and suture of the sclera; (b) use of a scleral or
auricular cartilage patch and a conjunctival fap over
it; (c) enucleation of the eye and its reinsertion into the
orbit upside-down so that the area of exposure will face
the bottom of the orbit. If the extrusion of the implant
is inevitable a dermofat graft is recommended.
The most feared complication is infection of the
ocular cavity spreading to the orbit. The main causes
are poor prosthesis care, trauma, and sinusitis. The
treatment will require hospitalization and IV antibiotic
therapy to prevent septicemia.
REFERENCES
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[2] Smith BC, Nesi FA, Lisman RD, Levine MR, et al. Ophthal-
mic Plastic and Reconstructive Surgery. 2
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ed. St Louis:
Mosby -Year Book Inc., 1998.
[3] Rafo GT. Enucleation and Evisceration. In: Duane TD, Jae-
ger EA, eds. Clinical Ophthalmology, Philadelphia: Lippen-
cott-Raven, 1995.
[4] Soares, EJC. rbita, vias lacrimais e plpebras In: Petroianu
A. Anatomia Cirrgica. Rio de Janeiro: Guanabara Koogan,
1998.
[5] Jordan DR. Problems after evisceration surgery with porous
orbital implants: experience with 86 patients. Ophthal Plast
Reconstr Surg. 2004 Sep;20(5):374380.
[6] Kohlhaas M, Walter A, Schulz D. Primary orbital implant
dislocation. A retrospective study. Ophthalmologe. 1998
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[7] Chuah CT, Chee SP, Fong KS, Por YM, Choo CT, Luu C,
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