Enucleation versus evisceration

Postoperative Pain Following Eye Enucleation: A Prospective Observational Study

Background and Objectives: Enucleation of an eye is the most invasive procedure in ophthalmologic surgery. It can be the result of various diseases (malignant/chronic/trauma/infection) and is nevertheless relatively rare, but leads to the loss of a strongly innervated neuronal organ. This study systematically evaluates postoperative pain levels following enucleation of the eye globe. Materials and Methods: This prospective single-center study enrolled twenty-four patients undergoing enucleation of the eye globe. Perioperatively all patients completed (preoperative day, day of surgery, 1st, 2nd, and 3rd day following surgery) standardized questionnaires concerning their pain experience and treatment-related side-effects (internal protocol, QUIPS, painDETECT®). Patients received usual pain therapy in an unstandardized individual manner. Results: Preoperatively, mean average pain intensity of all included patients was 3.29 ± 2.46 (range, 0-8), 3.29 ± 3.24 (range, 0-8) on the day of surgery, 4.67 ± 1.90 (range, 2-10) on day 1, 3.25 ± 1.39 (range, 1-6) on day 2, and 2.71 ± 1.30 (range, 1-6) on day 3 after surgery. Mean maximum pain intensity was 4.71 ± 3.28 (range, 0-10) preoperatively, 4.04 ± 3.78 (range, 0-10) on the day of surgery, 5.75 ± 2.01 (range, 2-10) on day 1, 4.25 ± 1.89 (range, 2-10) on day 2, and 3.88 ± 1.54 (range, 2-8) on day 3 after surgery. Nineteen patients (79.2%) stated that they would have preferred more pain therapy. Conclusions: Patients undergoing eye enucleation report pain sensations in need of intervention in this university hospital. Thus, effective standardized pain treatment concepts are now a high priority to be established in an interdisciplinary manner containing standardized regimens and continuous regional procedures. Awareness of this problem in the medical team should be sharpened through targeted training and information.

Outcomes of evisceration or enucleation by resident trainees in patients with recalcitrant endophthalmitis or panophthalmitis

To evaluate the surgical outcomes and complications of evisceration or enucleation with primary implantation, performed by ophthalmology resident trainees, in regards to patients with recalcitrant endophthalmitis or panophthalmitis. We also compared the surgical outcomes and complications between resident trainees and experienced staff. In this retrospective analysis, the clinical records of all patients diagnosed with endophthalmitis or panophthalmitis who underwent enucleation or evisceration with primary implantation over a 13-year period were reviewed. The factors predicting implant exposure or extrusion in regards to patients who underwent eye removal by trainees were identified using multivariate analysis. The percentages of successful prosthesis fittings and complications were also reported. Sixty-six patient records, median age of 46.8 years, who underwent eye removal by resident trainees were reviewed. Thirty-six (55%) out of 66 patients were diagnosed with panophthalmitis. Four patients (6%) had implant exposure, and 4 patients (6%) had implant extrusion. Multivariate analysis demonstrated that Pseudomonas aeruginosa infection (P = .02, adjusted odd ratio [aOR] = 33.75) and not receiving intravitreal antimicrobial drugs before the eye removal procedure (P = .02, aOR = 30.11) were associated with implant exposure or extrusion. Patients with panophthalmitis who underwent evisceration had a higher rate of implant exposure or extrusion than those who underwent enucleation (P = .03, aOR 38.38). At the last visit, 65 patients had a successful prosthesis fitting. Furthermore, there were similar rates of complications and successful prosthesis fittings between experienced staff and resident trainees. This study suggests that evisceration or enucleation with primary implant placement in patients with recalcitrant endophthalmitis or panophthalmitis can be performed by resident trainees with acceptable surgical outcomes and a low rate of serious complications.

Clinical Characteristics and Risk Factors for Evisceration in Trauma-Dominant Orbital Cellulitis: A 10-Year Review

Purpose

To analyze the clinical characteristics of trauma-dominant orbital cellulitis (OC) and evaluate the risk factors associated with evisceration.

Methods

This retrospective study included inpatients diagnosed with orbital cellulitis at the Zhongshan Ophthalmic Center between January 2010 and December 2020. The demographic features, etiology, clinical characteristics, microbiological isolates, and risk factors associated with evisceration were analyzed.

Results

Among 148 consecutive subjects (n = 148, 148 eyes), the mean age was 42.07 ± 20.35 years and 70.27% were male. Penetrating globe injuries were the most common (52.03%). No light perception (NLP) was recorded in 50% of patients on admission. Endophthalmitis was observed in 103 cases (69.59%), intraocular foreign bodies (IOFB) were detected in 43 cases (29.05%), and total corneal melting was observed in 31 cases (20.95%). Sixty patients (40.54%) underwent evisceration. Logistic regression analysis showed that total corneal dissolution [odds ratio (OR) = 83.019, P = 0.000], IOFB (OR = 3.402, P = 0.016), and NLP (OR = 0.185, P = 0.001) were risk factors for evisceration. Microorganism detection showed that Pseudomonas aeruginosa and Bacillus cereus were the leading pathogens.

Conclusion

Among hospitalized trauma-dominant OC patients, middle-aged men were the major subjects and penetrating globe injury was the major cause. Significant complications such as complete visual loss and evisceration were unavoidable in many patients with OC in the current study. NLP, IOFB, and total corneal melting were the risk factors for evisceration.

Two 11-Years Periods Statistics and Trends of Enucleation and Evisceration

Purpose:

The indications for evisceration and enucleation are still evolving and controversial. The study aims to describe trends of enucleation versus evisceration in one center.

Methods:

In period 1998–2019 were 353 patients were included in the study. Statistical results and Chi-square test for pair-wise comparisons for the statistical significance in comparing two subgroups (years periods 1998–2008 and 2009–2019) per category have been evaluated.

Results:

The enucleation was performed in 306 patients, and the evisceration was performed in 47 patients. In 221 patients with the tumor exclusively enucleation was indicated. For the operation technique, the authors got a chi-square value of 0.027, and the associated P value is at 0.8695, then the number of evisceration and enucleation in subgroups have not confirmed independency. For the tumor presence, the authors got a chi-square value of 5.4, and the associated P value is at 0.02, then the number of validated/nonvalidated tumor presence in subgroups confirmed independency.

Conclusions:

The performed enucleations had 98% cases uveal melanoma, 1% of cases of another type of malignancy (lymphoma non-Hodgkin type), and 1% cases with benign tumor. Enucleation is also today most frequently due to malignant intraocular tumors, whereas evisceration if most frequently for the phthisis eye after a trauma or a previous intraocular surgery. In our study in 22 years interval also in the second period, there was an increased trend of enucleation due to intraocular malignancy. It can have many reasons, especially, that patients are sent to oncology centers late in the advanced stage of tumor.

A decade of surgical eye removals in Ontario: a clinical-pathological study

OBJECTIVE

To assess patient demographics, clinical indications, and pathologic causes of surgically removed eyes over a decade in Ontario (Canada) and to identify areas of ocular disease management needing more attention.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

The surgically removed eyes of 713 consecutive mainly adult patients from 2004 to 2013.

METHODS

Demographic, clinical, and pathologic data were collected on all eyes received by the University of Toronto Ophthalmic Pathology Laboratory from 2004 to 2013.

RESULTS

Of the 713 eyes removed, enucleations accounted for 60% of cases, eviscerations for 39% of cases, and exenteration for 1% of cases. The most common clinical indications for surgical eye removal were blind painful eye (37%), neoplasm (35%), and trauma (6%). The leading pathologic causes of eye removal were neoplasm (36%), glaucoma (21%), infection or inflammation (17%), and trauma (16%). Glaucoma-related findings were the most common pathologic findings observed (38%), regardless of the primary cause.

CONCLUSIONS

A blind painful eye and neoplasms were the most commonly documented indications prior to removal of the eye. Common pathologies included glaucoma, neoplasms, infection/inflammation, and trauma. However, regardless of the primary cause, glaucoma-related pathologies were the most common pathologic findings. Refractory eye disease and pain continue to be important reasons for removal of eyes among patients in Ontario. More effective and targeted management strategies are needed to reduce the need for this radical eye surgery of last resort.

Indications for enucleation and evisceration in a tertiary eye hospital in Riyadh over a 10-year period

BACKGROUND

Enucleation and evisceration are eye removal procedures considered as palliative treatment when all other therapeutic options are exhausted.

OBJECTIVE

Describe the causes and histopathological findings leading to enucleation/evisceration, and correlate the clinical findings with the histopathological findings.

DESIGN

Retrospective, descriptive study.

SETTINGS

Tertiary care hospital, Riyadh, Saudi Arabia.

PATIENTS AND METHODS

The medical records of patients who underwent enucleation or evisceration from February 2005 to May 2015 were reviewed. Patients were classified into two categories based on indications of surgery: traumatic and nontraumatic. Causes of ocular injury in the traumatic group were documented, and the histopathological findings were reviewed for the nontraumatic cases.

MAIN OUTCOME MEASURE(S)

Number of enucleation and evisceration surgeries and their causes and histopathological findings.

RESULTS

One hundred ten patients underwent evisceration (n=69, 63%) and enucleation (n=41, 37%). Causes were traumatic in 38 (35%) and nontraumatic in 72 (65%). The median age was 50 years and there were 64 men and 46 women. Postoperative endophthalmitis was the most common indication for surgery (n=24, 21.8%), followed by painful blind eye (n=22, 20%). Ocular trauma was more predominant in men (n=29, 76%) than in women (n=9, 24%), and the leading mechanism of trauma was metallic nail injuries (n=6, 15.8%). In the nontraumatic group, endophthalmitis was the most common histopathological finding (n=25, 34.7%).

CONCLUSIONS

The majority of the eye enucleation/evisceration surgeries were due to nontraumatic causes, especially postoperative infections. However, severe eye trauma was still a main indication for this destructive procedure. Guidelines are needed to decrease the incidence/severity of work-related eye injuries and to detect and manage eye infections earlier and more promptly.

LIMITATIONS

Retrospective study, in one hospital in one area; therefore, results cannot be generalized.

Enucleation and evisceration at a tertiary care hospital in a developing country

Background

To analyze the demographics, indications, and surgical outcomes of anophthalmic surgery (enucleation and evisceration) at Jordan University Hospital during a 5-year period.

Methods

We conducted a retrospective chart review of patients who had undergone evisceration or enucleation between August 2006 and June 2011. The data collected included age at time of surgery, sex, affected eye, surgical indication, implant size, and postoperative complications.

Results

Anophthalmic surgery was performed for 68 eyes of 67 patients during the study period (42 (62 %) eviscerations and 26 (38 %) enucleations). Forty-three patients (64 %) were men, and 40 (59 %) eyes were right eyes. Trauma was the leading cause for anophthalmic surgery in 40 % of cases followed by a blind painful eye secondary to glaucoma (19 %) in the enucleation group and endophthalmitis (28.6 %) in the evisceration group. The most common anophthalmic surgery complication was wound dehiscence in 11.5 % of patients in the enucleation and 9.5 % in the evisceration groups. The mean and median sizes of the implants for evisceration were 16.6 and 18.0 mm, respectively; for enucleation, both were 20 mm.

Conclusions

Evisceration was the preferred anophthalmic surgery in our series unless contraindicated. Trauma was the most common predisposing factor for evisceration and enucleation in our tertiary care center followed by blind painful eyes and endophthalmitis. The most common complication was wound dehiscence in both groups.

Evisceration with Primary Orbital Implant in Fulminant Endophthalmitis/Panophthalmitis

PURPOSE

To compare the outcome of evisceration with primary orbital implant in blind eyes with and without fulminant infection (endophthalmitis/panophthalmitis).

METHODS

Retrospective nonrandomized comparative interventional case series. Patients with a minimum postoperative follow-up of 6 months were considered for inclusion. Thirty-four eyes of 34 patients were included. Sixteen eyes were infective and 18 noninfective. Nonporous silicone implants were used for all cases and the main outcome measure was successful retention of the primary implant. Major and minor complications and successful prosthesis fitting were also noted.

RESULTS

All except 3 cases were able to retain the primary implant successfully and all but 2 patients underwent successful prosthesis fitting. Major complications included implant extrusion in 3 cases (2 infective, 1 noninfective) and implant exposure in 1 case (noninfective). The difference in major complications between the groups was not statistically significant (p = 0.66, Fisher exact test).

CONCLUSION

Our data suggest that evisceration with primary orbital implant is a feasible option in fulminant endophthalmitis/panophthalmitis and provides a good postoperative cosmetic outcome to the anophthalmic socket at an economical cost.

A histopathologic review of undiagnosed neoplasms in 205 evisceration specimens

PURPOSE

Evisceration and enucleation are 2 ophthalmic surgeries used to treat blind and painful eyes. The benefits of evisceration over enucleation are many but this procedure is contraindicated in cases of a suspected intra-ocular mass. Given the lack of such studies in the literature, our aim was to review a large sample of eviscerated specimens to document the prevalence of unexpected neoplasms.

METHODS

During the study period (1994-2011), 13,591 human ophthalmic specimens were received at the Henry C. Witelson Ophthalmic Pathology Laboratory and Registry. Of those, 205 were evisceration specimens. Histopathologic reports were reviewed to retrieve relevant clinical information that included clinical diagnosis, age, gender, laterality, and final histopathologic diagnosis.

RESULTS

The total number of unexpected neoplasms was 4 (1.95%) including 2 (0.97%) malignancies: necrotic melanoma (1), ciliary body adenoma (1), iris nevus (1), and spindle cell melanoma (1). All the other remaining eyes had histopathologic findings that were consistent with the underlying diagnosis.

CONCLUSIONS

With proper pre-operative evaluation, including history, ophthalmologic examination, and imaging studies, the rate of unexpected neoplasms in evisceration specimens were low. Evisceration is a simpler and cheaper procedure when compared with enucleation, and our results corroborate its safety, whenever indicated to treat blind and/or painful eyes.

The results of evisceration with primary porous implant placement in patients with endophthalmitis

Purpose

To assess the results and long-term prognosis of evisceration with primary porous implant placement in patients with endophthalmitis.

Methods

A retrospective study was conducted to review the files of 27 patients (29 eyes) with endophthalmitis who underwent evisceration with primary porous implant placement from January 1997 to December 2007 at St. Mary's Hospital and Kangnam St. Mary's Hospital. The mean follow-up period was 12.24 months (range, 3 to 89 months) and the mean age of the patients was 63.6 years (range, 33 to 89 years).

Results

During the surgical procedure, primary implant placement was successfully completed, and any postoperative infection or inflammation rapidly resolved in all 27 patients (29 eyes). One of two porous implant materials was used. Hydroxyapatite was inserted in 14 eyes and Medpor was inserted in 15 eyes. Delayed implant exposure was noted in 1 eye, which was treated by inserting a hydroxyapatite implant 18 months after the first surgery. This was well treated by a preserved scleral graft. Implant infection was noted in 1 other eye at 20 days after the first surgery. All other minor complications healed without sequelae.

Conclusions

Evisceration with primary porous implant placement as the treatment for recalcitrant endophthalmitis resulted in rapid resolution of any infection and inflammation. Implant exposure and infection occurred in only 2 eyes, and these problems were well treated without long-term sequelae. Therefore, evisceration with primary porous implant placement is a treatment option for patients with endophthalmitis.

Late exposure of the bioceramic orbital implant

PURPOSE

To investigate the long-term outcome of the Bioceramic orbital implant.

DESIGN

A retrospective, comparative, nonrandomized study.

METHODS

Data were collected from the patients receiving Bioceramic orbital implants at National Taiwan University Hospital between June 1, 2001 and November 1, 2005. The implant was wrapped with Vicryl mesh, adding anteriorly with a scleral patch graft following enucleation with primary or secondary implantation. The unwrapped implant was inserted into an eviscerated globe with posterior sclerotomy and cornea preserved. Primary or secondary placement of sleeve was performed in some patients.

RESULTS

A total of 112 cases were reviewed. Four patients were excluded attributable to insufficient follow-up. The other 108 patients had a mean follow-up period of 35.8 +/- 10.6 months (range, 24 to 70 months). Fifty patients (46.3%) received the pegging procedure. Eight of 108 (7.4%) cases of late exposure were identified on average 20.7 months after implantation. We identified no cases of implant exposure in 30 cases of enucleation and eight cases of secondary implant when the implant was wrapped in Vicryl mesh and an anterior scleral cap was used. All exposures developed in eviscerated patients (70 cases): two without pegging, three with primary placement, and three with secondary placement of the sleeve. The exposure rate was higher in patients with eviscerated globes, pegged implants, and prior ocular operations (P < .005).

CONCLUSIONS

Late exposures of Bioceramic implants were found after long-term follow-up, associated with evisceration, pegging, and prior ocular surgeries. The modified wrapping technique can prevent exposure following secondary implantation and enucleation.

Sympathetic ophthalmia

BACKGROUND

Sympathetic ophthalmia (SO) is a rare, bilateral, non-necrotizing, granulomatous uveitis that occurs after ocular trauma or surgical procedures to one eye threatening sight in the fellow eye. The pathophysiology is not clearly understood, but it appears that the disrupted integrity of the inciting eye leads to an autoimmune hypersensitivity reaction against the exposed ocular antigens in the injured eye as well as in the sympathizing eye. More recently, vitreoretinal surgery has been noted to be a risk factor for the development of SO.

METHODS

Medline search for case reports of sympathetic ophthalmia with links to full text in English yielded articles for review of patient demographics, clinical presentation and examination, therapies and final visual acuity.

RESULTS

Eighty-six patients with SO were included in this review. Sixty-two patients were male and 24 were female with an average age of 46 years. Injuries accounted for 47% of patients while ocular surgery was reported in 44% of patients with pars plana vitrectomy occurring in 21%. Most patients reported reduced vision and presented with uveitis. Ninety-five percent of them received systemic corticosteroid therapy and 75% of patients also received immunomodulators. About 70% of patients had improved visual acuity in their sympathizing eye at their last reported evaluation.

CONCLUSIONS

Sympathetic ophthalmia warrants prompt evaluation and treatment to maintain a favorable visual outcome. Ocular surgeries including vitreoretinal surgery and cyclodestructive procedures have been noted to be risk factors for the development of sympathetic ophthalmia. With current medical management including corticosteroids and immunomodulators visual prognosis is relatively good.

Evisceration with Primary Implant Placement in Patients with Endophthalmitis

PURPOSE

To assess the feasibility of evisceration with primary implant placement in patients with endophthalmitis.

DESIGN

Pilot retrospective study.

PARTICIPANTS

Sixty-seven patients with endophthalmitis.

METHODS

A retrospective study was conducted to review the files of 67 patients with endophthalmitis who underwent evisceration with primary implant placement over an 8-year period. These patients' files were reviewed to evaluate the following: persistent infection and inflammation, spread of infection to contiguous or remote sites, implant exposure or extrusion, and successful fitting of the prosthesis.

MAIN OUTCOME MEASURES

Quiescence of the infection, complete healing of the socket, and long-term retention of the implant.

RESULTS

Sixty-three patients successfully retained their primary implant with rapid resolution of infection and inflammation. In 1 patient, attempts at implant placement were abandoned during surgery because of marked scleral necrosis. Delayed implant extrusion was noted in 2 patients, 10 and 12 days after surgery, respectively. In 1 diabetic patient, an orbital abscess developed that was evacuated with implant exchange. In a fourth patient, marked conjunctival prolapse developed in the early postoperative period with eventual obliteration of the inferior fornix. The patient declined further management. Minor complications included a central conjunctival dehiscence or necrosis (n = 2) and a pyogenic granuloma that was excised (n = 1). All minor complications healed without sequelae. Overall, 12 % of patients experienced complications (n = 8).

CONCLUSIONS

Based on the low overall complication rate in the present study (12%), the ease of evisceration, the convenience of a single procedure, the rapid resolution of infection, and the successful retention of the implant in most of our patients, it is plausible to offer evisceration with primary implant placement to patients with recalcitrant endophthalmitis or panophthalmitis. This would avoid a secondary surgical intervention in most patients, as opposed to delayed secondary implantation, in which case 100% of the patients would require, at least theoretically, another intervention.

Primary implant placement with evisceration in patients with endophthalmitis

PURPOSE

We report the results of 25 patients with endophthalmitis treated with evisceration with and without cornea preservation and primary orbital implants.

DESIGN

Retrospective observational case series.

METHODS

The records of 25 consecutive patients who underwent evisceration for endophthalmitis between June 1999 and November 2005 were reviewed. Ages ranged between three and 90 years (mean 57.6 years). The cause of endophthalmitis and bacterial agents were documented. All the patients were treated with topical, intravitreal, and intravenous antibiotics for endophthalmitis before evisceration.

RESULTS

The follow-up period was between two months and 79 months (mean 25.4 months). All patients had relief from their pain and were satisfied with their cosmetic appearance and motility. Implant exposure was noted in three (12%) patients and pyogenic granuloma in one (4%) patient, which were treated successfully. Eighteen of the patients had prosthesis fitting at least eight weeks after operation. Seven patients elected to not have prosthesis.

CONCLUSION

Unless the endophthalmitis is secondary to severe devastating trauma in which there is no sclera left, primary orbital implant placement with evisceration in these patients is an acceptable treatment.

Meniere's Disease: Prevalence of Contralateral Ear Involvement

OBJECTIVE

Determine the prevalence and time interval for conversion from unilateral to bilateral involvement in Meniere's disease and cochlear hydrops.

STUDY DESIGN AND SETTING

Retrospective chart review in a tertiary otologic referral center.

PATIENTS

232 patients diagnosed with Meniere's Disease (n=186) or cochlear hydrops (n=46) between 1959 and 2001, who visited the clinic over a five-year period between 1997-2001 and have at least 2 audiograms more than 12 months apart.

MAIN OUTCOME MEASURES

Prevalence of cochlear hydrops relative to Meniere's Disease, rate of progression from unilateral to bilateral involvement; interval between unilateral onset of symptoms and bilateral involvement; and rate of progression from cochlear hydrops to Meniere's disease.

RESULTS

Initial diagnosis was Meniere's disease in 71% and cochlear hydrops in 29% of all 950 hydropic patients presenting between 1997 and 2001. In the study sample, Meniere's disease was bilateral at presentation in 11%; an additional 12% (14% of unilaterals) became bilateral during the follow-up period. At presentation, 6.5% of cochlear hydrops patients were bilateral, with another 26% becoming bilateral. Conversion from cochlear hydrops to Meniere's disease occurred in 33% and some of these are included among the bilateral. The average time interval for conversion from unilateral to bilateral Meniere's was 7.6 years (SD=7.0 years).

CONCLUSION

Most otologists are aware of the potential for contralateral ear involvement and conversion from cochlear hydrops to Meniere's disease after diagnosis. These changes are significant, require long-term follow-up for detection, and may necessitate further treatment. Patients should be counseled regarding this potential when interventions are considered, especially with respect to ablative treatments.