For an evisceration, the contents of the eye are removed and the sclera is retained (Figure 3). Eviscerations are often performed for blind, painful eyes. Eviscerations are not performed for eyes that have tumors; in fact, it is mandatory to image (ultrasound) the eye prior to an evisceration to make sure there is not an unknown or undetected tumor.4
Advantages of evisceration are faster surgery (<30 minutes) and less manipulation of the orbit with extraocular muscles left in their normal anatomical position. In addition, research has shown that the movement of the prosthesis is better after evisceration compared to an enucleation.5 Disadvantages include a theoretic concern for sympathetic ophthalmia (extremely rare) and a poor anatomic specimen for the pathologist.
This surgery can be performed with the patient awake or asleep. An incision is made 360°
posterior to the limbus, and the cornea is removed. An evisceration spoon is used to remove the contents of the eye so only the sclera remains. An implant is placed within the scleral shell or behind it, and the sclera and conjunctiva are closed over the implant.
Postoperative care is similar to an enucleation. Complications are fewer with an evisceration compared to an enucleation. There is a lower incidence of implant exposure, and volume problems are less common.
In exenteration, the entire eye is removed as well as the soft tissue of the eye socket (Figure 4). This is a disfiguring surgery and usually performed when the patient’s life is at stake. Indications include malignant tumors and extensive infections of the orbit. Skin cancers (e.g., basal cell carcinoma, squamous cell carcinoma) that have invaded the orbit, primary malignant tumors of the orbit, and malignant sinus tumors which have invaded the orbit are indications for exenteration, although recent advances with molecularly targeted agents are resulting in fewer exenterations.6
An exenteration is performed with the patient asleep. An incision is made through the skin, and dissection is carried out to the underlying orbital rims. The covering of the bone (periosteum) is elevated from the bone completely around the orbit, and the orbital apex is transected with scissors to remove the orbital contents. The socket can be allowed to granulate, or a split thickness skin graft or free flap can be placed depending on a number of factors. Sometimes enough skin can be retained from the eyelids to cover the bare bone.
The patient can be fitted with an oculofacial prosthesis after the surgery. This prosthesis differs from the prosthesis after an enucleation or evisceration because the eyelids do not blink and the eye does not move.
After any of the above procedures, it is important to take more time postoperatively with the patient, who is understandably anxious about how things will look and whether there will be pain.
It is important for patients to wear glasses with polycarbonate lenses after any of these procedures. This will protect their only eye from an incidental trauma, and the glasses will camouflage any asymmetry.
Overall, I have found that results from nucleation, evisceration, and exenteration are excellent. I can promise that all of us have met a person with an artificial eye that we did not notice.
1. Galor A, Davis JL, Flynn HW Jr, Feuer WJ, Dubovy SR, Setlur V, Kesen MR, Goldstein DA, Tessler HH, Ganelis IB, Jabs DA, Thorne JE. Sympathetic ophthalmica: incidence of ocular complications and vision loss in the sympathizing eye. Am J Ophthalmol. 2009 Nov;148(5):704-710.