Enucleation, Evisceration and Exenteration 2

7/23/2019 Enucleation, Evisceration and Exenteration 2

http://slidepdf.com/reader/full/enucleation-evisceration-and-exenteration-2 1/14

DEFINITIONS

• Enucleation: surgical removal of the entire globe

• Evisceration: surgical removal of the entire contents of the globe leaving a scleral shell

• Exenteration: removal of the entire orbit including the globe, eelid, and orbital contents!

usuall "erformed for malignant tumors

INT#OD$%TION

Enucleation, evisceration, and exenteration surger all involve the "ermanent removal of the

"atient&s ee' In this cha"ter the im"ortant as"ects of each "rocedure are em"hasi(ed, including:

• Indications for surger

• )reo"erative "atient counseling

• Surgical techni*ues

• )osto"erative management

• %om"lications of surger

)#EO)E#+TIE E+-$+TION +ND DI+.NOSTI% +))#O+%/

Indications for Surger

Enucleation or evisceration surger ma be indicated for a blind "ainful ee, endo"hthalmitis, or

cosmetic im"rovement of a deformed ee' In cases of intraocular neo"lasms or the treatment of

severe ocular trauma 0ith a ru"tured globe, 0here sm"athetic o"hthalmia is a concern,

enucleation is a""ro"riate and evisceration is contraindicated' Other indications for enucleation

ma include "rogressive "hthisis bulbi and severe micro"hthalmia'

In the vast ma1orit of situations, the indication for exenteration surger is to eradicate life2threatening malignanc or life2threatening orbital infection' The extent of the "rocedure should

be ex"lained to the "atient, es"eciall 0hich tissues are to be removed 3this includes the eeball,

orbital soft tissues, and "art or all of the eelid structures4' The surgeon should avoid length

discussions regarding the 5mutilating6 nature of the "rocedure but rather should hel" su""ort the

"atient to remain focused on the treatment of this "otentiall life2threatening "roblem through

the life2saving nature of the exenteration surger'



+ summar of the indications for surger is given in 7ox 892 '

)reo"erative %ounseling

Faced 0ith the "ermanent loss of an ee, a "atient re*uires the "hsician&s reassurance, caring

ex"lanations, and "schological su""ort, both before and after the surger' The "atient 3andfamil4 should understand that evisceration and enucleation surger involve the com"lete,

"ermanent removal of the diseased or deformed ee' The general nature of the ano"hthalmic

soc;et should be ex"lained to the "atient, 0ho must be informed that an ocular "rosthesis 0ill be

fitted secondaril a""roximatel < 0ee;s follo0ing the surger' The indication for surger,

0hether it is "ain, "oor visual "rognosis, the ris; of sm"athetic o"hthalmia, or the "resence of

an intraocular neo"lasm, should be clearl ex"lained' The "atient should be informed of the

choices bet0een enucleation and evisceration surger and of the availabilit of a variet of

orbital im"lants, including common allo"lastic im"lants=> =?> 3e'g', "olmethl methacrlate

s"here4, ne0er im"lants designed to maximi(e ultimate ocular "rosthesis motilit =@> =A> =B> =<>

3e'g', hdroxa"atite im"lants4, or autologous tissue orbital im"lants =9> =C> =8> => 3e'g',

dermis2fat grafts4'

The "atient should understand the ris;s and benefits of 0ra""ing orbital im"lants 0ith either

autologous tissues or "reserved donor tissue and that donor tissues ma carr the ris;s of

communicable diseases, such as s"hilis, he"atitis, and human immunodeficienc virus' It

should be ex"lained to the "atient that if a hdroxa"atite im"lant is used in "rimar enucleation

or evisceration surger, a delaed second2stage "rocedure 3i'e', second2stage drilling of the

hdroxa"atite im"lant 0ith "lacement of the motilit "eg4 ma be needed in order to maximi(e

the ocular "rosthesis motilit' + thorough ex"lanation allo0s the "atient and famil to ma;e a0ell2informed decision regarding surger' +lthough the s"ecific decision for surger is to be

made b the "atient and famil, it is reasonable for the surgeon to ma;e a best21udgment

recommendation to hel" 0ith the mriad of choices available 3e'g', enucleation versus

evisceration and the variet of t"es of orbital im"lants4'

Follo0ing enucleation or evisceration, most "atients undergo a grief reaction to varing degrees'

The "atient, therefore, re*uires "schological su""ort from the "hsician' The exenteration

candidate must also be informed of the nature of the surger and the more radical amount of

tissue to be resected' +lthough the "atient must be given a full and truthful ex"lanation regarding

exenteration surger, the surgeon should avoid overl gruesome details so as not to deterinadvertentl the "atient from receiving necessar treatment, such as for a "otentiall life2

threatening neo"lasm'

#emoval of the rong Ee



#emoval of the 0rong ee "resents one of the greatest disasters that can occur to the o"hthalmic

surgeon and "atient' Ever o"hthalmologist and surgeon must be a0are of this "ossibilit, no

matter ho0 remote' )reo"erativel, the surgeon ma mar; the forehead or trim the lashes on the

a""ro"riate side' These methods, ho0ever, are not fool"roof' In the o"erating room, the surgeon

should thoroughl revie0 the chart, including the o"erative "ermit and the examination notes' It

is im"ortant, then, that the surgeon him2 or herself "re"ares and dra"es the "atient' Tra*uair=>

suggested the use of local anesthesia to "revent removal of the 0rong ee, although not even this

method is fail2safe' It must never, never ha""en that a surgeon hurries into the

Indications for Surgery

EN$%-E+TION

• 7lind "ainful ee

• Intraocular tumor

• Severe trauma 0ith ris; of sm"athetic o"hthalmia

• )hthisis bulbi

• icro"hthalmia

• Endo"hthalmitisG"ano"hthalmitis

• %osmetic deformit

EIS%E#+TION

• +s for enucleation, exce"t for intraocular tumors or ris; of sm"athetic o"hthalmia

EHENTE#+TION

• %utaneous tumors 0ith orbital invasion

• -acrimal gland malignancies



• Extensive con1unctival malignancies

• Other orbital malignancies

• ucormcosis

• %hronic orbital "ain

• Orbital deformities

o"erating room 0here the "atient is alread under general anesthesia and begins the o"eration

0ithout an a""ro"riate revie0 of the situation'

Once a sterile o"erative field is set u", the surgeon must again verif that the correct ee is about

to undergo enucleation' Follo0ing severe trauma, the correct ee is often externall deformed' In

cases 0here the external a""earance of both ees is normal, the surgeon must com"ulsivel

reexamine the fundus to verif the "atholog'

The finalit of the enucleation "rocedure cannot be overstressed' No degree of thoroughness is

excessive in order to avoid removal of the 0rong ee'

+NEST/ESI+

Enucleation surger usuall is "erformed using local anesthesia' For "schological reasons, and

occasionall for medical reasons, general anesthesia ma be em"loed' $nder an circumstance,

agents should be used that maximi(e intrao"erative hemostasis, su""ress the oculocardiac reflex,

=?> and minimi(e "osto"erative "ain' The author&s choice is to instill "henle"hrine ee2

dro"s into the con1unctival cul2de2sac to achieve intense vasoconstriction, and to infiltrate

extensive retrobulbar and "eribulbar bu"ivacaine 'B 0ith e"ine"hrine 3adrenaline4 :,

and haluronidase' +fter ade*uate time, an excellent anesthetic and vasoconstrictive effect isachieved'

ost evisceration surgeries are also "erformed under local anesthesia 0ith intravenous sedation'

+ mixture of lidocaine 3lignocaine4 ? 0ith e"ine"hrine :,, bu"ivacaine 'B 0ith

:, e"ine"hrine, and haluronidase is in1ected in retrobulbar fashion into the muscle cone'

The use of intravenous anesthetic sedatives "revents either the local anesthetic in1ection or the



surgical "rocedure itself from being un"leasant or "roducing anxiet' Exenteration surger is

usuall "erformed under general anesthesia, 0hich ma be combined 0ith bu"ivacaine and

e"ine"hrine infiltration to aid hemostasis and "rovide "osto"erative analgesia'

S)E%IFI% TE%/NIJ$ES

Enucleation

The indications for enucleation surger and im"ortant as"ects of "reo"erative counseling have

alread been discussed' /ere t0o surgical techni*ues are described:

• Enucleation 0ith "lacement of a sim"le s"here im"lant

• Enucleation 0ith "lacement of a sclera20ra""ed hdroxa"atite im"lant for im"roved motilit

Figure 892 Enucleation "rocedure' Follo0ing a @<K con1unctival "eritom, a small "air of

tenotom scissors is used to dissect bluntl Tenon&s fascia in all four *uadrants'

7efore describing the s"ecifics of enucleation surger, a fe0 as"ects in regard to Tenon&s fascia

must be mentioned' Tenon&s ca"sule is the fibroelastic tissue that surrounds the ee and

extraocular muscles in the anterior orbit 3see %ha"ter C@ 4' +nteriorl, Tenon&s fascia fuses 0ith

the con1unctiva near the corneal limbus' +t its "osterior extent, Tenon&s fascia encircles and fuses0ith the dura over the o"tic nerve' The four recti muscles originate from the annulus of Linn and

extend anteriorl to the eeball' )osterior to the e*uator of the globe, the rectus muscles

"enetrate through Tenon&s ca"sule before inserting into the sclera' That "art of Tenon&s fascia

anterior to the rectus muscles is anterior Tenon&s, and that "art of Tenon&s fascia "osterior to the

site of the rectus muscle "enetrations is "osterior Tenon&s' It is criticall im"ortant to understand

this anatomical conce"t in order to achieve the "ro"er, desirable orbital im"lant "lacement during

enucleation surger'

EN$%-E+TION IT/ SI)-E S)/E#E I)-+NT'

+ self2retaining lid s"eculum is "laced to ex"ose the entire e"ibulbar surface' + @<K

con1unctival "eritom is "erformed 3 Fig' 892 4' Tenon&s fascia is bluntl dissected a0a from

the sclera in all four *uadrants' Each of the four rectus muscles is se*uentiall gathered on a

muscle hoo;, secured 0ith double2armed <2 icrl suture, and detached from the globe' The

su"erior obli*ue tendon is severed and detached from the globe' The inferior obli*ue muscle

should be hoo;ed and secured 0ith a <2 icrl suture, detached, and saved for later attachment



to the inferior border of the lateral rectus muscle' This use of the inferior obli*ue muscle is

"erha"s more im"ortant as an eventual 5hammoc;6 for the orbital im"lant than to enhance

meaningfull ano"hthalmic soc;et motilit'

+fter the extraocular muscles are detached, the surgeon is read to sever the o"tic nerve' +nterior

traction on the globe is useful 0hen cutting the o"tic nerve and can be achieved 0ith a curved

hemostat a""lied to the medial rectus tendon or 0ith a double2armed A2 sil; suture se0n

through the medial and lateral tendon insertions' In most cases it is the author&s "reference to

clam" the o"tic nerve 0ith a curved hemostat inserted behind the globe in the su"eronasal

direction 3 Fig' 892? 4' ith the hemostat in "lace, a slender curved et(enbaum scissors is used

to

Figure 892? Each of the four rectus muscles is tagged 0ith a double2armed <2 icrl suture and

detached from the globe' Some A2 sil; sutures ma be "laced through the medial and lateral

recti muscle stum"s to "rovide anterior traction on the globe, as a slender curved hemostat is

used to clam" the o"tic nerve'

Figure 892@ The globe has been removed and cauter is a""lied to the o"tic nerve stum" to

maintain meticulous hemostasis'

transect the o"tic nerve, and the entire eeball is removed' The surgeon should ins"ect the entire

globe for intactness andGor unusual findings before submitting the s"ecimen for histo"athological

examination' alleable retractors are "laced so as to visuali(e directl the still clam"ed cut edge

of the o"tic nerve, and the central retinal vessels are cauteri(ed to obtain meticulous hemostasis

before removing the clam" 3 Fig' 892@ 4' If the o"tic nerve is not clam"ed, such as for intraocular

tumors, orbital "ac;ing 0ith direct "ressure for BM minutes can be a""lied to achieve ade*uate

hemostasis' In select enucleations, as 0ith tumors in contact 0ith the o"tic disc, it ma be

necessar to obtain a long segment of o"tic nerve'=@> =A>

For the average2si(ed adult orbit a ?mm "olmethl methacrlate orbital im"lant is usuall

ade*uate' The im"lant



Figure 892A +n orbital im"lant has been "laced behind "osterior Tenon&s fascia' This laer is then

closed 0ith multi"le, interru"ted <2 icrl sutures' The four rectus muscle stum"s remain free

0ith the <2 icrl sutures attached'

t"e and si(e can, of course, var, and it ma also be 0ra""ed in either autologous fascia or

donor sclera' The orbital im"lant is inserted behind "osterior Tenon&s fascia, through the central

rent left b cutting the o"tic nerve' ulti"le interru"ted <2 icrl sutures securel close

"osterior Tenon&s fascia that overlies the orbital im"lant'

Each of the four rectus muscles is sutured to the ad1acent fornix b "assing the "reviousl "laced

double2armed icrl sutures full2thic;ness through Tenon&s fascia and con1unctiva=B> 3see Fig'

892A 4' This 0ill "rovide motilit to the ocular "rosthesis' %are should be ta;en to avoid

advancing the su"erior rectus suture too close to the midline to avoid inadvertent tension or

traction on the su"erior rectus muscle, 0hich could induce an u""er lid "tosis' +fter anterior

Tenon&s fascia is closed in the midline 0ith <2 icrl sutures 3 Fig' 892B 4,=<> the con1unctival

edges are loosel rea""roximated 0ith a <2 "lain gut running suture'

+t the end of the "rocedure an additional dee" orbital in1ection 0ith bu"ivacaine 'B,

e"ine"hrine, and haluronidase is given' + broad2s"ectrum o"hthalmic antibiotic ointment is

a""lied to the con1unctiva' + medium2si(ed clear acrlic lid conformer is "laced and a firm

"ressure bandage a""lied over the soc;et'

The "ressure bandage remains intact for @MA das "osto"erativel and, u"on removal, the "atient

uses to"ical cool com"resses 0ith crushed ice' )ain medication is "rescribed as a""ro"riate' This

"erio"erative and "osto"erative management regimen allo0s the large ma1orit of enucleation "rocedures to be "erformed as out"atient "rocedures, 0ith ade*uate control of "osto"erative

"ain'

EN$%-E+TION IT/ /D#OH+)+TITE I)-+NT'

The "ur"ose of the hdroxa"atite im"lant is to allo0 the "otential for maximum motilit of the

ocular "rosthesis' %oralline hdroxa"atite contains Bm diameter "ores that are similar to the

structure of the haversian sstems of cancellous bone' The microstructure of this im"lant allo0s

fibrovascular ingro0th of the host tissues in the ano"hthalmic soc;et'=@> =A> Once the

hdroxa"atite im"lant is 0ell vasculari(ed, it can be secondaril drilled and fitted 0ith amotilit "eg im"lant' This motilit "eg is then cou"led to the ocular "rosthesis to enhance

maximall "rosthesis motilit'

+ standard enucleation techni*ue is "erformed, as alread described' The soc;et ma be 5si(ed6

using sterile trial s"heres, but



Figure 892B Enucleation surger!final closure' The <2 icrl rectus sutures are se0n onto their

res"ective fornices b "assing the sutures through Tenon&s fascia and con1unctiva' The anteriorTenon&s is closed 0ith <2 icrl and the con1unctiva 0ith a running <2 "lain suture'

in most cases an Cmm or a ?mm hdroxa"atite im"lant is a""ro"riate' Pee" in mind that

0ra""ing the im"lant 0ith sclera or fascia adds a""roximatel M'Bmm to the overall diameter

of the im"lant'

In most situations, the hdroxa"atite im"lant is 0ra""ed in donor sclera' The scleral shell

should be cut to the a""ro"riate si(e and sha"e to enclose the im"lant securel' ulti"le

interru"ted <2 icrl sutures are suitable for securel closing the sclera' The hexagonal rosettes

of the hdroxa"atite exos;eleton should be aligned in the anterior2"osterior direction and an

o"en scleral 0indo0 should be "resent at the "osterior a"ex of the hdroxa"atite im"lant,

corres"onding to the site of the corneal button removal' #ectangular 0indo0s, a""roximatel ?M

Amm, are cut through the sclera located 0ithin CMmm from the anteriormost a"ex of the

im"lant' To "romote further fibrovascular ingro0th into the im"lant, a handheld ?2gauge needle

is used to create drill holes in the hdroxa"atite at the site of each 0indo0 and at the site of the

"osterior round corneal 0indo0'=9>

The 0ra""ed hdroxa"atite im"lant is "laced into the ano"hthalmic orbit and the four rectus

muscles are secured to the anterior li" of the corres"onding rectangular scleral 0indo0' +nterior

Tenon&s fascia is sutured 0ith multi"le interru"ted <2 icrl sutures' The con1unctiva can be

closed 0ith a loosel running <2 "lain suture, 0hich is tied and cut on each end' Some authors

re"ort a higher ex"osure rate 0ith hdroxa"atite =C> =8> =?> =?> com"ared 0ith allo"lastic

s"here im"lants, =??> thus em"hasi(ing the need for meticulous closure' +s is the case 0ith an

enucleation "rocedure, a "olmethl methacrlate lid conformer is "laced in the con1unctival

cul2de2sac 0ith broad2s"ectrum antibiotic ointment and a "ressure bandage a""lied'

The uni*ue "ro"erties of a hdroxa"atite im"lant allo0 fibrovascular ingro0th and integration

of the im"lant 0ith the ocular "rosthesis' ithout "lacement of the motilit "eg, no demonstrable

motilit difference exists bet0een a sclera20ra""ed hdroxa"atite im"lant and a similarl0ra""ed "olmethl methacrlate im"lant'=?@> Thus hdroxa"atite im"lantation is most

a""ro"riate for "atients 0ho ex"ress a strong interest in eventual second2stage drilling of the

im"lant to maximi(e "rosthesis motilit' These titanium motilit "egs are surgicall inserted after

ade*uate fibrovascular ingro0th into the hdroxa"atite im"lant has occurred' =?A> =?B> =?<>



Evisceration

OE#IE'

Evisceration is the surgical techni*ue that removes the entire intraocular contents of the ee

0hile leaving the scleral shell and extraocular muscle attachments intact' Evisceration surger isa sim"ler "rocedure than enucleation surger and offers better "reservation of the orbital

anatom=?9> and natural motilit of the ano"hthalmic soc;et tissues'

In cases of documented or sus"ected intraocular malignant tumors, evisceration is

contraindicated' Similarl, evisceration ma be contraindicated if "recise histo"atholog of the

s"ecimen is needed' Evisceration surger ma be more difficult in ees 0ith severe "hthisis or

scleral contracture or that are severel deformed' Finall, the issue of "otential sm"athetic

o"hthalmia should be considered' =?C> =?8> =@> =@> Evisceration surger in a "reviousl in1ured

ee carries a definite small ris; of sm"athetic o"hthalmia in the a""osing ee because some

uveal tissue is al0as left behind in scleral canals'=?C>

Figure 892< Evisceration "rocedure' + @<K con1unctival "eritom is made, follo0ed b

com"lete excision of the corneal button'

S$#.I%+- TE%/NIJ$E'

+lthough some surgeons "erform evisceration 0ith "reservation of the cornea, this author "refers

removal of the cornea' The "rocedure begins 0ith a @<K con1unctival "eritom 3 Fig' 892< 4'

Tenon&s fascia is bluntl se"arated from the underling sclera in all four *uadrants' + full2

thic;ness incision around the corneal limbus is made 0ith a shar" scal"el blade and the entire

corneal button removed' The sclera is gras"ed 0ith a force"s, and a cclodialsis s"atula is used

to se"arate the iris root and ciliar bod from the sclera' The remainder of the uveal tissue is

dissected a0a from the scleral 0all bac; to the attachment around the o"tic nerve 0ith an

evisceration s"oon 3 Fig' 8929 4' The intraocular contents are lifted from the scleral shell and

submitted for histo"athologic examination' +ll remaining uveal tissue is carefull removed from

the scleral shell 0ith a small curette or the shar" end of a caudal "eriosteal elevator' %otton2ti"

a""licators saturated 0ith 9 ethanol ma be used to cleanse the interior of the scleral shell anddenature an remaining uveal "igmented tissue' %auter is a""lied if needed to control the

oo(ing of blood'

+ "olmethl methacrlate or hdroxa"atite s"herical im"lant is "laced in the evisceration

scleral shell 3 Fig' 892C 4' hen the cornea is removed, it is unusual to "lace an im"lant larger

than AM<mm' The scleral edges are closed 0ith multi"le interru"ted <2 icrl sutures, 0ith



the medial and lateral scleral edges cut to reduce an dog ears 3 Fig' 8928 4' The con1unctiva is

gentl closed 0ith a running <2 "lain gut suture' If a larger im"lant is desired, it is necessar to

"erform radial relaxing sclerotom incisions "osteriorl=@?> bet0een the rectus muscles 3 Fig'

892 4' If a hdroxa"atite im"lant is used, such sclerotom o"enings are necessar to enhance

vascular ingro0th'=@@>

Dressing and "osto"erative care are as for enucleation'

Exenteration

OE#IE'

Exenteration surger involves com"lete removal of the eeball, the retrobulbar orbital soft

tissues, and most or all of the eelids' The most common indication for exenteration surger is

for the treatment of e"ithelial malignanc 0ith orbital invasion'=@A> =@B>

hen exenteration is "erformed for orbital malignancies, "eriorbita is usuall excised to remove

com"letel all "otentiall involved tissues' The bare orbital bone can slo0l heal b secondar

Figure 8929 +n evisceration s"oon is used to detach the ciliar bod and bluntl elevate the

choroid from the scleral 0all'

intent, but in most situations the exenterated orbit is covered 0ith a s"lit2thic;ness s;in graft at

the time of the "rocedure' +s there is "otential for recurrent tumor, reconstruction 0ith thic;,

bul; tissue grafts, 0hich could obscure recurrence, is avoided' In ver select situations,

ho0ever, a variet of ancillar reconstructive techni*ues ma be of use, such as those involving

i"silateral tem"oralis muscle fla"s, =@<> free dermis2fat grafts,=@9> latissimus dorsi mocutaneous

free fla"s,=@C> osseointegrated im"lant techni*ues,=@8> and other "rocedures' =A> =A> =A?> =A@>

S$#.I%+- TE%/NIJ$E'

The area of the "ro"osed exenteration incision is mar;ed 0ith ade*uate 0ide margins 0here

necessar for tumors, et 0ith "reservation of as much normal "eriocular soft tissue as "ossible 3

Fig' 892 4' If necessar, ad1acent areas of the medial canthus, tem"le, or forehead are included

in the excision site' hen surger is necessar for a con1unctival or dee" orbital tumor, a

subciliar incision around the eelid margins and 0ra""ing around the inner canthus "reserve the

eelid s;in and orbicularis muscle, 0hich can be used for reconstruction'=A@>



The s;in is incised along the mar; and an orbicularis muscle to be s"ared dissected in a

suborbicular "lane' The dissection is carried do0n through "eriorbita to ex"ose the orbital rim' +

"eriosteal elevator is used to elevate "eriosteum over the orbital rim and "eriorbita from the

orbital 0alls 3 Fig' 892? 4' Firm attachments to bone are encountered at the lateral orbital

tubercle, the su"erior obli*ue trochlea, the medial canthal tendon, the distal lacrimal sac as it

enters the bon nasolacrimal canal, the inferior obli*ue origin near the "osterior lacrimal crest,

and the su"erior and inferior orbital fissure attachments 3 Fig' 892@ Q see %ha"ter C@ 4' Exce"t

for these sites of resistance, the "eriorbita can be elevated *uite easil' ediall, the surgeon

should use "articular care 0hen elevating "eriorbita so as to avoid inadvertent "enetration of the

lamina "a"racea into the ethmoid sinus air cells, 0hich could result in a chronic sino2orbital

fistula'

Su"eriorl, the su"erior orbital bone ma be *uite attenuated in elderl "atients and atro"hic

bon defects ma be "resent' ono"olar cauter to the orbital roof should be avoided, as this

ma cause inadvertent cerebros"inal fluid lea;age'=AA> It is generall safe to use bi"olar cauteralong the orbital roof and dee" orbital tissues 0ithout the ris; of cerebros"inal fluid lea;age'

The "eriorbital lining is mobili(ed along all orbital 0alls to0ard the orbital a"ex' The dissection

and mobili(ation of soft tissues must extend "osteriorl beond the extent of tumor invasion' +

thin curved hemostat can be used to clam" the a"ical

Figure 892C + s"here introducer is used to "lace the orbital im"lant into the evisceration scleral

shelf'

tissues 0hile a slender "air of et(enbaum scissors are used to excise the exenteration s"ecimen

anterior to the clam" 3 Fig' 892A 4' +n enucleation snare ma also be used to incise the a"ical

stum" to com"lete the severing of the exenteration s"ecimen'=AB> hen necessar, fro(en

section "atholog analsis of the a"ical stum" tissues should be used to verif that the margins of

resection are free and clear of neo"lasm' The orbital bone should be carefull ins"ected for

subtle bone "itting or other signs of bone erosion or destruction'

In "atients 0ho have ver bul; or massive orbital neo"lasms, exenteration ma be difficult,

0ith little s"ace in 0hich to se"arate "eriorbita from orbital bone' It ma be hel"ful here first toenucleate the eeball to ma;e enough room for access to the dee"er a"ical soft tissues under

good visuali(ation'

In most "atients the orbit 0ill be lined 0ith a s"lit2thic;ness s;in graft harvested from the

anterior surface of the thigh' It is



Figure 8928 The scleral o"ening is closed 0ith multi"le, interru"ted <2 icrl sutures'

%on1unctiva is subse*uentl closed over the scleral 0ound using running <2 "lain gut sutures'

Figure 892 + uni"olar cauter is used to incise relaxing sclerotom slits to ex"and the scleral

shell' This sclerotom techni*ue to enlarge the scleral shell volume is 5o"tional6 0ith

"olmethl methacrlate s"here im"lants' Sclerotom slits are 5mandator6 0hen using

hdroxa"atite s"heres in order to facilitate vascular ingro0th'

usuall "referable to ex"and the s;in graft in a mesher' ulti"le interru"ted <2 icrl sutures

secure all residual host s;in edges to the meshed s;in graft' The graft is tam"onaded 0ithin theorbit 0ith a Telfa dressing and Heroform gau(e "ac;ing under "ressure'

If the u""er lid and lo0er eelid s;in and muscle are "reserved, it ma be "ossible in elderl

"atients 0ith a lot of loose

Figure 892 %ross2sectional vie0 of surgical "lanes of dissection for exenteration surgicaltechni*ues: total exenteration, subtotal exenteration 0ith s"aring of mocutaneous eelid tissue,

and enucleation 0ith "artial soc;et ablation'

Figure 892? Exenteration "rocedure' + @<K s;in incision is made do0n to the "eriosteum of the

orbital rim' + "eriosteal elevator is used to begin reflecting the su"erior "eriorbita do0n0ard'

eelid s;in sim"l to suture the s;in edges together and then "lace a "ressure dressing to

tam"onade the mocutaneous edges against the bare bone'

)OSTO)E#+TIE +N+.EENT'

The orbital "ac; and "ressure dressing should remain in "lace for a""roximatel BM9 das'

Follo0ing removal of the dressing, the "atient can use gentle



9B8

hdrogen "eroxide rinses to cleanse the soc;et' .enerall, these orbits heal best 0hen left o"en

to the air, so the "atients should 0ear a "atch onl 0hen going out in "ublic' The surgeon shouldremain vigilant to the "ossibilit of infection of the s;in graft, es"eciall b )seudomonas,

Sta"hlococcus, or Stre"tococcus' Sstemic antibiotics ma be necessar if these infections

arise' In some "atients, the exenterated orbit retains chronic, moist, ulcerated areas intermixed

0ith areas of health ;eratini(ing e"idermis' The use of a gentle handheld hair drer can hel"

5cure6 these slo0er healing areas'

+ combined eelid2ocular "rosthesis can be made b an ana"lastologist' an exenteration

"atients "refer sim"l to 0ear a blac; "atch'

Figure 892@ 7on orbit demonstrating the normal sites of increased resistance to dissection

during orbital exenteration'

Figure 892A )eriorbita has been elevated for @<K' For0ard traction is a""lied to the orbital

contents as a hemostat is used to clam" the a"ical orbital tissues'

%O)-I%+TIONS

Evisceration

)osto"erative infection is al0as of concern 0hen evisceration surger is "erformed in the

setting of endo"hthalmitis or "ano"hthalmitis' The use of broad2s"ectrum sstemic antibiotics

usuall minimi(es this ris;, and the surgeon can generall use a "rimar orbital im"lant')osto"erative extrusion of the orbital im"lant is a com"lication of evisceration surger that ma

be related to "osto"erative scleral shell shrin;age, to "oor 0ound healing of the scleral edges, or

to im"ro"er selection of the orbital im"lant si(e' )osto"erative "ain is more common 0hen the

cornea is retained'

Enucleation



Orbital im"lant extrusion is also a com"lication of enucleation surger' eticulous attention to

careful Tenon&s fascia 0ound closure and the "ro"er selection of im"lant si(e are im"ortant

"rinci"les in avoiding this outcome' #is; of im"lant extrusion is increased 0ith "rior irradiation

treatment of the ee and orbit, severe traumatic in1uries to the ee and orbit, and severe ee and

orbital infections' -ong2term com"lications of the ano"hthalmic soc;et are numerous, including

generali(ed volume deficienc of the ano"hthalmic soc;et, lo0er eelid laxit 0ith "oor

"rosthesis su""ort, orbital im"lant migration, u""er eelid "tosis, and chronic con1unctivitis and

mucoid discharge'

Exenteration

Exenteration surger carries the ris; of severe blood loss' It is im"ortant "reo"erativel to

discontinue as"irin and all other medicines that could adversel affect blood clotting' Other

com"lications uni*ue to exenteration surger include cerebros"inal fluid lea;age via orbital roof

transgression of the dura and chronic sino2orbital fistulas through the region of the lamina

"a"racea and ethmoid sinus air cells' During the first fe0 0ee;s of healing, free s;in grafts are

susce"tible to infection' )atients ma re*uire treatment 0ith broad2s"ectrum sstemic antibiotics

for coverage of Sta"hlococcus, Stre"tococcus, )seudomonas, and

9<

other bacteria' The administration of sstemic antibiotics is combined 0ith maintenance of

vigorous to"ical hgiene of the s"lit2thic;ness s;in graft using hdrogen "eroxide rinses' -ong

term, the surgeon should al0as remain vigilant for the "ossible recurrence of tumor'

▪ Enucleation: surgical removal of the entire globe. ▪ Evisceration: surgical removal of the entire contents of the globeleaving a scleral shell. ▪ Exenteration: removal of the entire orbit including the globe, eyelid,and orbital contents – usually performed for malignant tumors.

Evisceration is the removal of the contents of the globe while leaving the scleraand extraocular muscles intact. Enucleation is the removal of the eye from theorbit while preserving all other orbital structures. Exenteration is the most radicalof the three procedures and involves removal of the eye, adnexa, and part of thebony orbit.

Enucleation, Evisceration and Exenteration 2

Documents

Transcript of Enucleation, Evisceration and Exenteration 2