Removal of the Eye

Removal of the eye may be necessary for a variety of reasons, including intraocular tumor, a blind painful eye, or severe trauma with loss of sight and inability to repair the eye.  Surgical options include evisceration, enucleation, or exenteration.  

In evisceration, only the cornea and intraocular contents are excised, leaving the sclera in place, with the extraocular muscles and optic nerve attached.  At the time of surgery, and orbital implant (usually spherical) is placed in order to replace the soft tissue volume lost when the eye is removed.  Otherwise, the socket will appear "sunken-in."  A porous implant, such as hydroxyapatite (coral) or Medpor (high-density porous polyethylene), is usually preferable since there is a lower incidence of implant migration and extrusion, despite a higher risk of implant exposure.  In evisceration, the implant is placed within or behind the scleral pouch and is covered by the patient's own sclera to prevent implant exposure.  Porous implants also permit drilling of the implant and placement of a motility peg in order to improve movement of the prosthesis and better simulate a normal eye. 

In enucleation, the entire globe is removed, after detaching it from the extraocular muscles and optic nerve. An orbital implant is placed within the orbital fat, and the muscles may be attached to it to provide more socket movement.  A porous implant which is the preferred type should be covered by a graft to inhibit implant exposure.  While cadaver tissue may be used to cover the implant, it has a number of potential disadvantages.   My preference is a deep temporal fascia graft, taken from the temple through a scalp incision behind the hairline.  

Exenteration refers to more extensive orbital soft tissue removal and may be categorized as total or subtotal.  This may include removal of the globe, orbital fat, extraocular muscles, optic nerve, periosteum, and /or bone.  The major indication for this procedure is a malignant orbital tumor. 

While enucleation is the procedure of choice for an intraocular tumor or an irreparable ruptured globe (lacerated eye), either evisceration or enucleation may be performed for a blind, painful or cosmetically unacceptable eye.  There are pros and cons for each procedure, and often surgeon preference and experience dictate whether evisceration or enucleation is undertaken  (in cases in which either technique is appropriate). Evisceration and placement of a porous implant offer the best chance for an excellent functional and cosmetic result with long-term stability.  Compared with enucleation, evisceration probably provides better prosthesis motility (false eye movement) and carries less chance of late enophthlamos (a sunken-in appearance to the eye). However, there is a rare risk of sympathetic ophthalmia with evisceration. 

The surgeries described above are almost always performed under general anesthesia, and patients are admitted to the hospital for one to two days for pain control.  The socket is patched for about a week.  A plastic shell, called a conformer, may be temporarily placed behind the eyelids (at the end of surgery) until a prosthesis is made.  One week postoperatively, the patch is removed, and eye drops and/or ointment are initiated.  Assuming there are no problems, and ovular prosthesis (false eye), made to closely match the opposite eye, is created by an ocularist approximately six weeks following surgery.