September 2007

 

OPHTHALMOLOGY NEWS

 

Evisceration or enucleation?


by Matt Young EyeWorld Contributing Editor

 

 

Study explores value of evisceration

Patients after evisceration and prothesis having an excellent cosmeis Source: Imtiaz Chaudhry, M.D.

When it’s the end of the road, and vision can’t be saved, patients and physicians still have options. So, what’s best: evisceration or enucleation? A new study finds that in fact, evisceration provides a good alternative to enucleation. “When the loss of an eye is unavoidable, evisceration under local anesthesia with orbital implant may be the best alternative for optimal cosmesis and lower incidence of post-operative complications,” notes Imtiaz A. Chaudhry, M.D., Ph.D., Senior Academic Consultant, Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, in the March/April 2007 issue of Ophthalmic Epidemiology.

End-stage alternative

Dr. Chaudhry described evisceration as a procedure in which intraocular contents are removed but sclera, Tenon’s capsule, conjunctiva, and optic nerve are preserved. Enucleation involves removal of the entire eyeball.

Dr. Chaudhry and colleagues analyzed 187 patients that underwent evisceration. A painful blind eye was the primary symptom in 117 (62.6%) patients; 38 (20.3%) patients had an unsightly eye. Clinical indications included the following: endophthalmitis (85 patients; 45.5%), phthisis bulbi (38 patients; 20.3%), traumatic injury (36; 19.2%), and glaucoma (14; 7.5%). Orbital implants were used in the vast majority of procedures—176, or 94.1%—while none was used in 11 (5.9%). Sphere implants were used in 145 cases (82.4%), and hydroxyapatite implants were used in 31 (17.6%). Average follow-up was 15.6 months, and 29 complications were observed. These included implant exposure/extrusion in 10 (5.7%), eyelid ptosis/swelling in eight (4.5%), pyogenic granuloma in four (2.2%), socket infection in four (2.2%), and fornix insufficiency in three (1.6%). Among those patients with the most common complication—implant exposure/extrusion—five needed other procedures, including implant exchange in four sockets and mucus membrane graft placement, which covered the exposure. “In two patients, implant exposures healed without any intervention except removal of prosthesis for one week,” Dr. Chaudhry reported. Perhaps more interesting were the complications—and rate of complications—that did not arise. No patient developed sympathetic ophthalmia, which of course is a serious inflammation that develops in both eyes after trauma to one. “In the setting of severe ocular trauma, some surgeons prefer enucleation over evisceration because of the perceived risk of sympathetic ophthalmia,” Dr. Chaudhry wrote. “However, recent evidence suggests that evisceration is an effective and safe procedure in the setting of new techniques for evisceration and the era of corticosteroids.”

Furthermore, at 2.2%, the incidence of socket pyogenic granuloma formation was much lower in this study than in a previous study of enucleation, Dr. Chaudhry noted. That study found the rate after enucleation to be 14.8%. Dr. Chaudhry noted that the number of endophthalmitis cases requiring evisceration have been on the decline lately in developing countries mainly due to improvement in ophthalmic care, introduction of new antibiotics and better access to health care.

Other benefits and drawbacks

Evisceration as a surgical procedure is simpler and faster than enucleation, Dr. Chaudhry noted. Thus, it may be the choice procedure for those who cannot undergo general anesthesia (evisceration is frequently performed under local anesthesia), Dr. Chaudhry concluded. “The disadvantage of evisceration is that the submitted intraocular contents are distorted and may preclude detailed anatomical and histopathological examination,” Dr. Chaudhry wrote. Walter Sekundo, M.D., Eye Clinic of the Gutenberg University, Mainz, Germany, said he prefers evisceration to enucleation when possible.

“I do like evisceration,” Dr. Sekundo said. “No one likes to remove the eye, but in terms of mobility of the implant [evisceration is preferable].”

That’s because with enucleation, if an implant is used, either it is covered with donor sclera and a Vicryl mesh (Ethicon, Somerville, N.J.) and muscles are sutured to the implant eyeball, Dr. Sekundo said. But the natural attachment of eye muscles to the globe, which occurs with evisceration, provides for much better implant mobility, he said. Of course, evisceration would be contraindicated if a patient had a malignant tumor in the eye. In that case enucleation would be carried out, he said. “But if someone is blind because of, for instance, an old retinal detachment, you cannot repair any longer and you have the beginning of shrinkage of the globe, then evisceration is a wonderful procedure,” Dr. Sekundo said. “You open the eye above the limbus. You scrape the cornea and remove the contents of the eye and place an implant.”

There was a time when eviscerations were not popular because physicians associated it with sympathetic ophthalmia, but those days are long gone, Dr. Sekundo said. As the field of ophthalmology develops and saves more vision, hopefully both enucleation and evisceration will become even less common. But until then, evisceration may be the best option for many blind patients.

Editors’ note: Dr. Chaudhry has no financial interests related to this study. Dr. Sekundo has no financial interests related to his comments.

Contact Information

Chaudhry: orbitdr@hotmail.com

Sekundo: +49 (0) 61 31/17-5445, sekundo@augen.klinik.uni-mainz.de

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