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In conjunction with this issue's special focus on oculoplastic and reconstructive surgery, Ocular Surgery News convened a panel of experts to discuss enucleation and evisceration.
Mark Levine, MD, of Cleveland, led the discussion. He was joined by Robert C. Della Rocca, MD, of New York City; Richard P. Carroll, MD, of Minneapolis; Allen M. Putterman, MD, of Chicago; and J. Justin Older, MD, of Tampa, Fla.
February 15, 1996
--- Mark Levine
Mark Levine, MD: I would like to discuss enucleation vs. evisceration together with implant decisions. What are your indications for doing an evisceration or an enucleation?
Richard P. Carroll, MD: My indications for doing an evisceration would be endophthalmitis and some cases of trauma and glaucoma. I don't do many eviscerations.
--- J. Justin Older
J. Justin Older, MD: I agree with the indications, and I also don't do many eviscerations.
Robert C. Della Rocca, MD: I usually do evisceration for severe endophthalmitis or panophthalmitis. Unfortunately, some eyes that have undergone trauma are already partly eviscerated. If globe lacerations are extensive, I usually wait until a primary repair of the globe is done and then make decisions regarding the indication for enucleation. I prefer enucleation not evisceration in this instance.
Levine: I try to do evisceration for everything I can, except when I suspect an intraocular tumor. The nice thing is its simplicity; it probably takes one-third of the surgical time of doing an enucleation. Obviously, because all the muscles are attached, the motility is good, and the patient rehabilitates a little more quickly. I pick my patients, but I do hydroxyapatite implants within the evisceration and then decide later whether I need to place a peg. Have you seen or heard of sympathetic ophthalmia occurring with evisceration in the modern era?
Older: I haven't run into sympathetic ophthalmia at all. In fact, often when I'm presented with a blind eye that's not painful or a traumatized eye where one would think about sympathetic ophthalmia, I'll recommend keeping the eye in and using a shell rather than removing it because I think the risk of sympathetic ophthalmia is very low.
Carroll: I have treated three patients with sympathetic ophthalmia that developed after the eye was not removed following trauma; however, I have not seen any instances of sympathetic ophthalmia after enucleation or evisceration.
Della Rocca: Following evisceration or enucleation, I have not seen the development of sympathetic ophthalmia in the contralateral eye. I should add, however, that after we've determined that the eye has no vitality, enucleation is done in a relatively short time after the trauma. I don't believe sympathetic ophthalmia is a concern with evisceration. I'm not convinced that there is any advantage in terms of rehabilitation following enucleation vs. evisceration. It may be a one-week difference as to getting on with the prosthesis, but certainly with the newer techniques and integrated implants, the situation is pretty good related to the socket following enucleation or evisceration. In both instances it can work well, particularly with the use of the integrated implant.
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Levine: In what percentage of your cases do you use hydroxyapatite implants?
Older: I have not yet used hydroxyapatite implants.
Levine: Any reason for not using the implant?
Older: Maybe we're ready to start now, but from what I understand and read, there are complications. I've used a methylmethacrylate ball for 21 years. I've never had an extrusion, and I've never had an exposure from a primary implantation that I've done, so I'm basically waiting until the complication rate comes down a bit.
Carroll: I think the hydroxyapatite implant is overused. I am very selective in its use and use it in only 10% to 15% of primary enucleations. I believe there are many other factors to consider besides increased motility before deciding on the implant type. For example, the configuration of the orbital opening — patients with a small orbital opening tend to have heavier looking eyelids that effectively camouflage any well-fitting prosthesis, regardless of the type of implant used.
Levine: I use hydroxyapatite in about one-third of patients, and my selection is based primarily on age. I will use them in young children, teenagers and middle-aged adults. Once patients are in their 60s and 70s, there's some question as to whether I want to run the added expense of a hydroxyapatite implant for the added motility. How often do you put in a peg? I try to avoid it because sometimes the peg gives you too much motility, and the peg may pop out of the little hole in the prosthesis.
Della Rocca: I don't drill more than 20% to 30% of the implants. In a fair percentage of the cases, the motility is significantly enhanced vs. with the hydroxyapatite alone compared with the placement of a silicone sphere.
Levine: How long would you wait to drill the peg if you decided to do it? Three months, six months, a year or would it depend upon radiographic techniques to show vascular enhancement?
Carroll: I'll usually wait approximately six months.
Della Rocca: I don't like to consider doing it before a 10 to 12-month period, and I don't do any imaging. I've seen some nice MRI studies, but the clinical impression is most important in evaluating when it can be done.
Levine: I won't drill a peg for six months; probably the longer, the better. An MRI to determine vascularity is $1,000 or so, and a CT scan is roughly $300 to $400, so a safe time frame is six months to a year in waiting.
Older: What's the advantage of using the hydroxyapatite implant with an evisceration, especially if you don't drill?
Levine: Because I always have the potential, if the motility is not as good as I'd like, I put in that peg. If I just put in a sphere and the motility is not as good as the patient or I would like, I don't have many choices. Then I would have to open up my scleral envelope, take out the ball, put in a hydroxyapatite implant. It gives me another alternative. In terms of material that you use to wrap the hydroxyapatite, the choices are bank sclera or a fascia lata. What do you prefer to use?
Carroll: I've only used sclera.
Della Rocca: I use sclera primarily. I've used fascia as well. You do need a lot of fascia to do it. There tends to be some shrinkage with the fascia when surrounding the implant, but you don't have to cover the implant completely posteriorly if you are using fascia.
Levine: I really hesitate to use the sclera.
Della Rocca:Is that why you do eviscerations primarily, so you can use the patient's sclera?
Levine: That's one reason. Another is if I do enucleations, I almost always use autogenous fascia lata. I agree that you don't need to cover it completely, especially posteriorly, because you want the biggest exposure to vascularized ingrowth.
Carroll: In a couple of patients, we've used Vicryl mesh, and that has worked.
Levine: Let's talk about the role of dermis fat grafts.
Older: I've done several, but I don't usually do dermis fat grafts for primary enucleations. I've stayed with the methylmethacrylate spheres.
--- Allen M. Putterman
Allen M. Putterman, MD: Dermal fat grafts are my procedure of choice for secondary implants. I choose to do this for secondary implants because they not only add volume, but they also add to the surface area of the ocular cul-de-sac. In a primary enucleation, I'm still giving patients the choice of the dermal fat graft, Medpor or hydroxyapatite implants. For most patients, I'm still doing dermal fat grafts as my primary choice because the ocularist I work with feels that my results are comparable to the other two choices and there is less chance of extrusion.
Carroll: I don't use them in primary enucleations at all. I have used some in secondary-type problems, but that's been a small number, so I really don't have much experience with dermal fat grafts in either of those situations.
Della Rocca: I use the dermal fat grafts for secondary socket problems. I think they're effective where we need to fill out the superior aspect of the socket. Also, I'm reasonably pleased using them with moderate contraction of sockets. I still use them for enucleation at times. It's been effective, although I've gotten better results related to increased motility with hydroxyapatite implants.
Levine: Allen, we know at least historically in the literature that you can get 15% to 20% fat atrophy, you can grow out cilia and you can have cysts that cause problems with prosthetic fit. Has that been a problem for you?
Putterman: Dermal fat graft atrophy or having too much fat has been unusual as my experience has increased. There's no doubt that experience has been helpful in determining how much fat to put in. Initially, I was putting in too much fat or too little fat. It still can happen, but it's been much rarer. In terms of cilia, if you have a male patient who has a lot of hair on his buttocks, I have had hairs that continue to grow despite removal of the epidermis. If this occurs and isn't relieved by epilation, then I apply cryotherapy to the dermis or the dermal fat graft, and this is helpful in eliminating the hairs. I've had two cysts that occurred behind the dermis, which responded to excision and placement of a conjunctival graft. The main problem I've had is chronic discharge; the keratin causes a creamy discharge and patients have to wipe this off. If this is chronic, I've applied cryotherapy to the dermis of the dermal fat graft with good success in eliminating the keratinization and discharge. I take dermal fat grafts from the buttocks; others take them from the abdomen. I prefer to form a domed shape dermis by taking off four triangles at four quadrants of the periphery of the dermis; this creates a convex dermis and leads to better movement of the artificial eye. I don't attach the medial rectus muscle to the dermal fat graft, but attach it to the medial cul-de-sac. This, also, leads to better movement. I believe that the variation in how the dermal fat graft procedure is performed may alter the results.
Della Rocca: Regarding extruding implants, the dermis fat graft has significant value when we have displaced implants or when there's a lot of thinning of the conjunctiva. You can generally write off the use of a secondary hydroxyapatite when there's been a significant displacement of an implant, disruption of the position of the extraocular muscles and fibrosis. Here, the dermal fat graft has particular importance.
Ocular Surgery News: Mark, you mentioned a Vicryl wrap, a Vicryl mesh. Was that used to wrap secondaries?
Levine: No, it was primarily primaries.
Ocular Surgery News: Does it work? Has anybody tried it?
Della Rocca: With secondaries, it probably could. We've done it with some primaries. I know in Canada there's a group that does a lot of primary enucleations and has been pleased with them.
Carroll: We've done a couple of them with hydroxyapatite, and it has been satisfactory.
Levine: Regarding evisceration, one other thing that I didn't know how to deal with for a number of years is most of the time you can predict how big a scleral pouch you're going to have, but sometimes you get in there and you find that the scleral pouch is only going to hold a 12-mm or 14-mm sphere. You worry about that, because it's either not a big enough implant, or if you try to use a larger sphere, the tissues are going to break down over the implant. What I've found to be very helpful is doing expansion sclerotomies. If you're in a position where the scleral pouch is not large enough doing expansion sclerotomies horizontally, you can take a small pouch that may seem to be inadequate and make it an awfully big pouch. If you're going to put a hydroxyapatite implant in, by doing these sclerotomies, you're going to get good vascularization into the hydroxyapatite implant. That's been helpful to me.
Putterman: It's been a long time since I've done an evisceration, and I've stayed away from them because of the fear of sympathetic ophthalmia, but when I was doing them, it was always my impression that if you removed the cornea and put in an implant, that you were not really getting better movement than you would with methylmethacrylate, whereas if you retained the cornea, the movement was definitely superior to almost any other kind of enucleation. Mark, when you're doing this, are you removing cornea?
Levine: I almost always remove the cornea. I can't think of a good reason not to.
Putterman: It hasn't altered your motility?
Levine: Not at all. I've always had really good motility with eviscerations. With enucleations, before hydroxyapatite, there was always one field of action where I had some limitation.
Della Rocca: But when you're doing evisceration now, you're using the integrated implant now?
Levine: Yes.
Della Rocca: Mark, doing the evisceration in the severely traumatized, perforated globe, you mentioned one of the advantages of evisceration was perhaps decreased operating time. To carefully deal with the uvea when you have a traumatic situation and to salvage the extraocular muscles, don't you find that to do a really meticulous job on the uvea the procedure is lengthened?
Levine: I have found in a really traumatized eye with a lot of edema and hyperemia that doing an enucleation takes more time, and there's probably a lot more bleeding than in doing a 360° peritomy, removing the cornea and correcting the uvea. I'll then take some half-strength hydrogen peroxide, which not only softens the uveal tissue, but has a hemostatic effect. I just irrigate the scleral pouch, scrape out the uvea and then meticulously suture up the sclera from the inside and put in either a sphere or a hydroxyapatite implant.
Della Rocca: Generally speaking, we don't enucleate the first time that the patient is being seen unless it's a horribly traumatized globe. We prefer to wait a short period, particularly in instances where the edema may be significant so that we have a better operative opportunity.
Levine: How long do you wait? Five days?
Della Rocca: Seven to 10 days.
Levine: My remarks were pertinent to the seven to 14 days following the trauma.
Della Rocca: I understand.
Levine: Jay, as you watch the patient postoperatively from ocular trauma, what makes you decide to enucleate vs. watch?
Older: If it's severe trauma, we'll probably enucleate. If there's pain involved, then I'll enucleate, but I've had very good experience. I've had good results with the shell. Pain is the main factor, assuming there's enough of an eye there to put a shell on.
Levine: In the early postoperative period, are you giving patients a lot of antibiotic steroid drops to reduce inflammation and discomfort?
Older: No, not necessarily. I give them antibiotics. I don't give a lot of steroids. We watch them. The pain usually does not develop until months later. If it's constantly painful in the immediate postop period, then the eye is probably shriveled and traumatized badly, and then we'd enucleate.
Putterman: I see a number of patients with pain who are referred to me for alcohol injections. I'm concerned about creating ptosis and poor motility. Are any of the panel still using alcohol injections in patients who have blind, painful eyes rather than enucleating?
Older: There's no question about it — I'll enucleate it.
Della Rocca: I don't use alcohol injections. At times I think there may be an occasion where it may work, but I have seen some situations where, if anything, the problem was intensified.
Carroll: I agree. I have seen patients who have had alcohol injections referred for enucleation. I have not used alcohol injections myself.
Levine: I have used alcohol injections, but they've only lasted at best six months. I tend to do that in somebody who's in the extremely older age group with some significant medical problems that may contraindicate taking the patient to surgery. I may try an alcohol block first.