Evisceration

Procedure: The procedure shown in this video is an evisceration surgery with the placement of a 16mm silicone implant in a patient with a blind, painful eye. Introduction: Evisceration of a globe involves removal of the cornea and intraocular contents, leaving the sclera with the extraocular muscles attached. The purpose of an evisceration surgery is primarily to alleviate discomfort and, when relevant, infected tissues in patients with a blind, painful eye. Indications/Contraindications: The most common indications for this procedure include endophthalmitis and a blind painful eye due to an etiology that does not involve the risk of intraocular malignancy. Contraindications for the procedure include known or suspected intraocular malignancy and significantly compromised scleral integrity or size. Materials/Methods: Standard evisceration surgical instruments were used. Important steps include removal of all uveal tissue to prevent possible sympathetic ophthalmia and proper sizing of the implant to ensure adequate scleral and conjunctival closure. Results: The patient tolerated the procedure well with successful resolution of the orbital pain. Conclusion: Evisceration surgery can be an effective procedure to manage a blind and painful eye that meets the aforementioned criteria.

Evisceration of a globe involves the removal of the cornea and intraocular contents, leaving the sclera with extraocular muscles attached. Compared to enucleation, where the surgeon removes the entire globe and intraocular contents, evisceration causes less disruption of the orbital anatomy and may result in decreased postoperative complications.1-3 After evisceration, the final cosmetic result depends on socket motility, adequate volume replacement, fornix depth, and proper eyelid function and positioning. During evisceration, there is less manipulation of the orbital tissues compared with enucleation, which may result in less post-operative edema and fibrosis. The risk of sympathetic ophthalmia following evisceration surgery drives some surgeons to choose enucleation, but this remains controversial as it is based on a small number of reports.4 The most common indications for the procedure include endophthalmitis and a blind, painful eye.2 Contraindications for the procedure include known or suspected intraocular malignancy and significantly compromised scleral integrity or size. Some also argue that globe trauma is a contraindication, given the increased risk of sympathetic ophthalmia. The sclera is vital to a successful evisceration closure. Reduced scleral integrity can result from a traumatic scleral rupture, necrotizing scleritis, or infection involving the sclera. The size of the eye needs to be considered as a sufficient scleral shell volume is required for successful closure, as such patients with phthisis bulbi and microphthalmia may not be good candidates for evisceration.2 Potential complications and risks include orbital edema, retrobulbar hemorrhage, implant exposure, implant extrusion, dissemination of unexpected intraocular neoplasm, and conjunctival cyst formation.3

Preoperative workup: A complete ocular history should be obtained with particular attention to previous diagnosed intraocular malignancy or ocular trauma. The eye exam, including slit lamp bio-microscopy and a dilated fundus exam, should be performed to ensure no intraocular malignancy or scleral perforation is present. If there is no clear view of the posterior pole, a B-scan ultrasound scan should be used to rule out an intraocular mass. If the size of the eye appears small then an axial length could be obtained. Setup: Standard evisceration surgical instrumentation is used for this procedure. Important instruments include small-toothed forceps, Westcott scissors, curved Stevens scissors, evisceration spoon, and Castroviejo needle holder. A suction is recommended, and consideration of an implant sizer set should be given. A spherical implant is usually placed and may be solid silicone or acrylic versus porous, in which case posterior scleral windows should be considered to allow for vascular ingrowth into the implant. A conformer is needed at the end of the procedure to maintain the fornices. Hydrogen peroxide or absolute alcohol are needed to destroy any remaining uvea inside the sclera. Procedure Steps: A 0.5 Castroviejo forceps and Wescott scissors are used to form a 360 conjunctival limbal peritomy making sure to stay as close to the cornea as possible. Care should be taken to not buttonhole the conjunctiva with the forceps. Next, a curved Steven’s scissor is used to spread in the four oblique quadrants to later allow for adequate mobilization of these tissues during closure. An 11- blade is used to make a stab incision at the limbus. Next, Wescott scissors are used to advance to the left and right of this incision at the corneal-limbal junction to remove the cornea in its entirety. Care should be taken to not leave behind any corneal remnants while not removing any excess sclera. The cut edge of the sclera is inspected to ensure that there are no residual areas of infection or necrosis. Next, the evisceration spoon is used to remove the vitreous and the uvea. Then, the sclera is scraped carefully with the evisceration spoon to remove any small adherent pieces of uvea. Next, hydrogen peroxide or absolute alcohol is used to carefully clean the inside of the sclera. Care is taken to prevent these liquids from contacting any tissue other than the inside of the sclera, as it can be toxic and prevent wound healing. Wescott scissors are used to create relaxing incisions in the horizontal meridian of the sclera so that the implant can be placed. A 16 mm silicone ball was chosen in this case as it was small enough to achieve scleral overlap during the closure. An end-to-end scleral closure should not be performed as it will dehisce post-operatively. The scleral edges were overlapped and were closed with 5-0 vicryl mattress sutures. Sutures were placed along the length of the scleral opening to secure a tight closure. Tenon's capsule was then closed with a 5-0 vicryl buried running suture. Care was taken not to implant any conjunctiva into the closure or buttonhole the conjunctiva with the tenon’s suture bites. Finally, the conjunctiva was closed with 5-0 vicryl running sutures. Care was taken to unroll the edges because any implanted conjunctiva could result in an enlarging cyst in the postoperative period, requiring additional procedures. The speculum is removed. A rigid conformer is placed. Next, a temporary tarsorrhaphy was performed with 4-0 silk suture and two foam bolsters. This is placed to prevent prolapse of the conjunctiva and to keep the conformer firmly in place during the postoperative period. The tarsorrhaphy remains in place for 1-2 weeks after surgery. Finally, ophthalmic antibiotic ointment, telfa, and eye pads are placed as a pressure dressing.

In our case, the primary goal of the evisceration surgery was to eliminate the ocular pain the patient was experiencing. Additionally, the 16mm silicone implant served to replace the lost volume in the anophthalmic orbital socket. Post-operatively, there should be improvement or resolution of the ocular pain. Potential negative outcomes include post-operative complications such as infection, retrobulbar hemorrhage, implant exposure, in sulcus contour defects, and enophthalmos. 1,2

The purpose of an evisceration surgery with an implant can serve various purposes. It is primarily intended for blind, painful eyes.2 Blind eyes are often removed for pain control and cosmesis. Both enucleation and evisceration surgeries can be effective in these settings. Less invasive options for controlling pain, such as retrobulbar injection of alcohol or chlorpromazine should be considered as options against eye removal, particularly in medically complex patients that are not good surgical candidates. If evisceration surgery is indicated, a good surgical technique is essential to avoid post-operative complications that may require additional medical or surgical treatments. Some doctors favor enucleations because of the potential risk for sympathetic ophthalmia with evisceration surgery.4 Lately, evisceration has gained traction because new techniques have allowed for the placement of a larger implant, such as opening the sclera posteriorly. Larger implant size decreases the enophthalmic appearance and sulcus deformities of the anophthalmic socket, but this should be balanced with sufficient scleral overlap during closure.5 One evisceration technique include the 4-petal technique which allows placement of a larger implant by enabling double-breasting of scleral coverage, and the vertical closure of the conjunctiva retains the depth of the lower fornix.4 An implant is used to replace lost volume in anophthalmic orbital sockets. A silicone, acrylic, hydroxyapatite, or porous polyethylene implant are commonly used. Because patients with phthisis bulbi or microphthalmos have insufficient scleral shell volume to encase the implant, evisceration can be contraindicated.1,2 However, recent evisceration techniques as mentioned above, have been implemented to allow adequate implant placement.1 When choosing evisceration, critical steps include proper selection of patients that meet criteria, including taking great care to rule out intraocular masses that could represent malignancies, careful removal of all intraocular contents to reduce the likelihood of infection and sympathetic ophthalmia, placement of a small enough implant that there is adequate scleral overlap, and meticulous closure to avoid post-operative complications such as implant exposure.

Dr. Freitag is a consultant for Sling, Viridian, Horizon, Poriferous, Medtronic, WL Gore and receives textbook royalties from Thieme and Springer.

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1. Georgescu D, Vagefi MR, Yang CC, McCann J, Anderson RL. Evisceration with equatorial sclerotomy for phthisis bulbi and microphthalmos. Ophthalmic Plast Reconstr Surg. 2010;26(3):165-167. doi:10.1097/IOP.0b013e3181b8c895 https://pubmed.ncbi.nlm.nih.gov/20489539/ 2. Kord Valeshabad A, Naseripour M, Asghari R, et al. Enucleation and evisceration: indications, complications and clinicopathological correlations. Int J Ophthalmol. 2014;7(4):677-680. Published 2014 Aug 18. doi:10.3980/j.issn.2222-3959.2014.04.17. https://doi.org/10.3980/j.issn.2222-3959.2014.04.17 3. Chaudhry IA, AlKuraya HS, Shamsi FA, Elzaridi E, Riley FC. Current indications and resultant complications of evisceration. Ophthalmic Epidemiol. 2007;14(2):93-97. doi:10.1080/09286580600943598.https://doi.org/10.1080/09286580600943598 4. Ranno S, Serafino M, Nucci P. Four petal evisceration versus standard technique: A retrospective study. Eur J Ophthalmol. 2021;31(4):2156-2159. doi:10.1177/1120672120950160. https://pubmed.ncbi.nlm.nih.gov/32799549/ 5. Long JA, Tann TM 3rd, Girkin CA. Evisceration: a new technique of trans-scleral implant placement. Ophthalmic Plast Reconstr Surg. 2000;16(5):322-325. doi:10.1097/00002341-200009000-00003 https://pubmed.ncbi.nlm.nih.gov/11021379/