3. • Can be:
• Congenital/ True – very rare
• Acquired- more common
• Evisceration
• Enucleation
• Exenteration
• Results in small bony orbit, constricted socket,
short eyelids and reduced palpebral fissure
4. Congenital Anophthalmos
• True or Primary anophthalmos- very rare
• Complete absence of ocular tissues within orbit
• Occurs when neuroectoderm
of primary optic vesicle fails to
develop properly from anterior
neural plate of neural tube
5. • Results in improper development of orbit
• significant cosmetic deformity
• Treated with socket expansion with progressively
enlarging conformers until prosthesis can be placed
• Surgical:
• Inflatable expander
• Self-expanding hydrophilic, osmotic expanders
• Eyelid surgery
• Lateral canthotomy or cantholysis
• Combination of skin, mucosal, or cartilage grafts
Congenital Anophthalmos
6. Acquired anophthalmos
Most common reasons for surgical removal of
the eye or its contents are
• Blinding trauma
• Painful blind eyes
• Prevention of sympathetic ophthalmia
• Intraocular tumor
• Endophthalmitis
7. EOMS of the right eye viewed from antero-lateral
12. Historical Background
• The Chinese first performed enucleation as early as
2600 BC
• George Bartisch gave first report of enucleation in
1583- hook passed through the globe and eye was
severed from the orbit by sharp dissection
ENUCLEATION
Georg Bartisch (1535–1607)
13. Historical Background
• Fabrici de Hilden first reported a peritomy in 1646
• O’Ferrall and Bonnet in 1841 separately reported
their techniques- foundation for modern
enucleation technique
• Dissection within Tenon’s capsule
• Extraocular muscle disinsertion
ENUCLEATION
14. Indications:
• Painful blind eye
• Intraocular tumor
• Severe trauma with risk of sympathetic ophthalmia
• Phthisis bulbi
• Increased incidence of choroidal malignant melanoma
(4-15%)
• Microphthalmia
• Cosmetically disfiguring blind eye
ENUCLEATION
15. Guidelines:
• An orbital implant of sufficient volume centered
within the orbit
• A socket lined with conjunctiva or mucous
membrane with fornices deep enough to hold a
prosthesis
ENUCLEATION
16. • Eyelids with normal appearance and adequate
tone to support a prosthesis
• Good transmission of motility from the implant to
the overlying prosthesis
• A comfortable ocular prosthesis that looks similar
to the normal eye
ENUCLEATION
17. Preoperative counselling
• WHAT AND WHY??
• Reassurance
• Psychological support
• Written informed consent
ENUCLEATION/ EVISCERATION
18. Anesthesia
• General anesthesia
• Local anesthesia
• Retrobulbar or peribulbar block using a 50:50
mixture of 2% Lidocaine with epinephrine and
0.75% Bupivacaine
• “Augenblick phenomenon”
ENUCLEATION/ EVISCERATION
19. Specific surgical technique
• Two surgical techniques are described
• Enucleation with placement of a simple sphere implant
• Enucleation with placement of a sclera-wrapped
hydroxyapatite implant for improved motility
ENUCLEATION
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30. The ‘no touch’ technique
• Advocated by Fraunfelder and Wilson for
enucleation of eyes harbouring intraocular
malignancy
• Enucleation may precipitate metastatic spread
through dissemination of tumour emboli
ENUCLEATION
31. • No direct pressure on globe
• Extraocular muscles are cut without using
muscle hooks
• Transscleral cryocoagulation to immobilize the
tumor's blood supply
ENUCLEATION
32. Extended enucleation
• Entire globe including bulbar conjunctival lining and
rest of orbital tissues are removed en bloc
ENUCLEATION
34. Evisceration
• Removal of entire intraocular contents, leaving the
sclera, extraocular muscles, and optic nerve intact
• Introduced in 1817, by James Beer
• In 1885, Mules improved cosmetic results by
placing a hollow glass sphere within the scleral shell
35. Advantages
• Technically easier and faster
• Better preservation of orbital anatomy
• Good motility of prosthesis
Evisceration
36. Indications
• For some of same reasons as enucleation
• Blind eye with active, uncontrolled endophthalmitis
• Severely ill patient who cannot tolerate general
anaesthesia
• Blind eye in patients with severe bleeding disorder or on
anticoagulated drugs
Evisceration
37. Contraindications
• Documented or suspected intraocular malignant
tumors
• Precise histopathology of the specimen is needed
• Eyes with severe phthisis or scleral contracture
• Risk of potential sympathetic ophthalmia
Evisceration
38. Surgical technique
• Can be performed either under general or local
anaesthesia
• Cornea can either be preserved or removed
Evisceration
44. The scleral opening is closed with multiple, interrupted 6-0 Vicryl sutures.
Conjunctiva is subsequently closed over the scleral wound using running sutures
45.
46. Complications of enucleation and
evisceration
• Removal of wrong eye- most devastating
complication
• Early complications: haemorrhage, infection, and
dehiscence of the conjunctiva with exposure or
extrusion of the implant
47. • Late complications:
• Post- enucleation socket syndrome (PESS)
• Enophthalmos of artificial eye
• Deep upper eyelid sulcus
• Lower lid laxity
• Eyelid malpositions- ptosis or lid retraction
49. Exenteration
• Involves surgical removal of the entire orbital contents,
including
• Globe
• Optic nerve
• Extraocular muscles
• Lacrimal gland and
• Lacrimal drainage system as well as
• Orbital fibroconnective and adipose tissues
• 90% of orbital exenterations are performed as a last
resort for invasive neoplasm
50. Indications
• Tumors extending into the orbit from sinuses, face,
eyelids, conjunctiva or intracranial space
• Intraocular malignancies extending outside the globe
• Primary orbital malignancies not responding to
nonsurgical therapies
• Malignant epithelial tumors of lacrimal gland
• Non-malignant disease- orbital mucormycosis
Exenteration
51. Types of exenteration
• Depending on the amount of tissue removed:
• Subtotal or Anterior: Eye and adjacent intraorbital
tissues are removed
• Total: All intraorbital soft tissues, including
periorbita, are removed
• Extended: All intraorbital contents are removed
along with adjacent soft tissues, bone and paranasal
sinuses
Exenteration
53. A 360° skin incision is made down to the periosteum of the orbital rim. A periosteal
elevator is used to begin reflecting the superior periorbita downward.
54. Periorbita has been elevated for 360°. Forward traction is applied to the orbital
contents as a hemostat is used to clamp the apical orbital tissues
58. Complications
• Dehiscence or failure of skin grafts or flaps due to
compromised blood supply, hemorrhage or infection
• Cerebrospinal fluid leak following bone removal
• Sinoorbital fistulas can develop early or late
• Temporalis muscle transfer- depression in temporalis
fossa
• Contraction of periorbital skin can result in brow and
periorbital tissue being pulled into socket
Exenteration
60. Orbital implants
• Functions:
• Replace lost orbital volume
• Maintain structure of orbit
• Impart motility to overlying ocular prosthesis
• Three main types:
• Non- integrated
• Quasi integrated
• Integrated
• Dermis- fat grafts
61. Nonintegrated implants
• Mainstay of globe replacement for past 50 or more years
• Non-porous, inert
• Spherical or conical
• Glass, silicone or polymethyl methacrylate (PMMA)
62. Quasi-integrated implants
• Elevations on anterior surface
• Completely covered by conjunctiva
• Fit into depressions on posterior surface of prosthesis
• Allen, Iowa, Universal
64. • Advantages:
• Allows fibrovascular ingrowth into the implant
• Reduce risk of extrusion and migration
• Small exposures may heal spontaneously
• Allows muscles to be sutured directly to implant
65. • Wrapped with either autogenous fascia, cadaveric sclera or
fascia, bovine pericardium, or synthetic material such as
polyglactin mesh
wrapped in donor sclera, holes
faciltate vascularization
Extraocular muscles sutured directly to
porous polyethylene implant
66. • Once well vascularized, secondarily drilled and fitted with a
motility peg implant
• Directly connects implant to ocular prosthesis
• Enhance motility
• Granuloma formation and peg instability or extrusion may
require removal of the peg
67. • It is ideal for ocular implant to provide 65%-70% of
the volume of (lost) eye with remaining volume
(30%-35%) being ocular prosthesis
• The largest implant possible that leaves space for a
prosthesis and that can be buried without tension
should be placed
68. Dermal- fat grafts
• Used as a primary or secondary implant
• Particularly useful when for preexisting conjunctival
shortage
• Conjunctiva sutured to edges of dermis, increases amount
of conjunctiva available in fornices
• Extraocular muscles sutured to edge of dermis
69.
70. Ophthalmic conformers
• Placed in conjunctival fornices
• Maintains conjunctival space to eventually
accommodate prosthesis
71. Ocular prostheses
• ‘Artificial eye’
• Covers the eye socket tissue and underlying
(buried) orbital implant
• Fitted within 4-8 weeks after enucleation or
evisceration
78. Exposure or extrusion of implant
• Causes are:
• Postoperative infection
• Poor wound healing
• Poor fitting prosthesis or
conformer
• Pressure points between
implant and prosthesis
79. • Small defects:
• patched with a scleral, fascial, or dermal transplant
• Secondary insertion of an intraorbital implant
• Safest
• Use of dermal fat graft (DFG)
80. Anophthalmic Ptosis
• Results from
• Superotemporal migration of implants
• Cicatrical tissue in upper fornix
• Damage to levator muscle or nerve
• Management
• Prosthetic correction
• Anterior levator resection
81. Eyelid malpositions
• Lower eyelid laxity
• Lateral canthoplasty
• Entropion
• May result from contracture
of fornices or with cicatrical
component
• Jones procedure
82. Contracted socket
• When fornices are too small to retain a prosthesis
• Causes include:
• Post-radiationtherapy
• Implant extrusion
• Severe initial injury
• alkali burns or extensive lacerations
• Poor surgical techniques
• excessive sacrifice or destruction of conjunctiva and Tenon’s
capsule
• Multiple socket operations
• Prolonged removal of conformer or prosthesis
83. Classification
• Grade 0
• Socket is lined with healthy conjunctiva and has
deep well- formed fornices
Contracted sockets
84. • Grade I:
• Shallow lower fornix
• lower fornix converted into a downwards sloping
shelf that pushes the lower lid down and out,
preventing retention of a artificial eye
Contracted sockets
85. • Grade II:
• Socket is characterized by
loss of upper and lower
fornices
Contracted sockets
86. • Grade III:
• Socket is characterized by
loss of upper, lower, medial
and lateral fornices
Contracted sockets
87. • Grade IV:
• Socket is characterized by the
loss of all fornices, and
reduction of palpebral aperture
in horizontal and vertical
dimensions
Contracted sockets
88. • Grade V:
• Recurrence of contraction
of the socket after repeated
trial of reconstruction
Contracted sockets
90. Summary
• Anophthalmia refers to complete absence of globe and
ocular tissues from the orbit
• May be congenital or acquired
• Acquired anophthalmic socket- following enucleation,
evisceration and exenteration
• Managed with variety of implants and prostheses
• Proper surgical planning and technique minimize
complications, allows faster rehabilitation and result in
stable, comfortable sockets with good motility and cosmesis
91. Bibliography
• American Academy of Ophthalmology, BCSC, section 7 , 2013-2014.
chapter 8 pg.117- 127.
• Albert and Jakobiek, Principles and Practice of Ophthalmology, vol 3,
3rd edition, 2008, section 10, chapter 267, pg.3519-3527.
• Yanoff & Duker Ophthalmology, 4th edition, 2014. part 12, section 3,
chapter 12.14
• Ophthalmic surgery, principles & practice, 4th edition, section 6, chapter
55-56, page 441-450.
• Issues in the Management of the Anophthalmic Socket: Clinical,
Comfort, and Cosmetic; Ophthalmology Rounds; January/ February,
2010; volume 8, issue 1
• A Pictorial Anatomy of the Human Eye/Anophthalmic Socket: A Review
for Ocularists, Michael A. Hughes, Journal of Ophthalmic Prosthetics
• Gopal Krishna: Contracted sockets -I (Aetiology and types) Indian
Journal of Ophthalmology, Year 1980, Volume 28, Issue 3 [p. 117-
120]
Extreme microphthalmos seen more commonly in which a very small globe is present within the orbital soft tissues
Medscape…eyelid sx- to increase the interpalpebral space
While the indication for surgery is usually clear, the choice between enucleation and evisceration is often less clear and more controversial
Georg Bartisch (1535–1607) was a German physician
when Irish physician O'Ferrall and French physician Bonnet
Tumors-enucleation allows complete histologic examination of eye and optic nerve
Enucleation is done as precautionary measure as pthisical eye with opaque media may harbor melanomas if not enucleated eyes should be examined periodically with imaging techniques
Microphthalmia- Full orbital volume is essential for development of bony str. And this bony asymmetry can be minimized by early placement of a large orbital implant
Faced with the permanent loss of an eye..Yanoff-1339
GA is preferred..under LA stimulation of optic n. at the time of transection may lead to sudden, intense visual perception K/A augenblick phenol. Which may be distressing to the patient
either ocular or systemic. Local ocular complications include hematoma formation, optic nerve damage and perforation of the globe with possible blindness. Systemic complications include local anesthetic toxicity, brainstem anesthesia, and stimulation of the oculocardiac reflex. Most commonly, patients will report discomfort during the performance of the block, such as the sensation of the needle during insertion and/or pressure behind the eye during injection. In recent years, peribulbar block has become increasingly used because of its lower incidence of complications. 2% Lidocaine (Xylocaine) and 0.5% to 0.75% bupivicaine (Marcaine) are two commonly used agents. Avoid epinephrine, commonly mixed in with local anesthetics for vasconstriction, in seeing eyes as this can cause a central retinal artery occlusion. An enzyme, hyaluronidase, is frequently a component of the anaesthetic solution, as it accelerates and improves dispersal of the agent. Bupiva. Provides post op sustained anaesthesia
360° conjunctival peritomy, tenotomy scissors to dissect Tenon’s fascia
Curved hemostat to clamp optic nerve…If the optic nerve is not clamped, such as for intraocular tumors, orbital packing with direct pressure for 5–10 minutes can be applied to achieve adequate hemostasis. Thr should be atleast 5mm segment of optic n attatched to the globe. In select enucleations, as with tumors in contact with the optic disc, it may be necessary to obtain a long segment of optic nerve.
Globe Removed And Cautery Applied To Optic Nerve Stump
For the average-sized adult orbit a 20-mm polymethyl methacrylate orbital implant is usually adequate. The implant type and size can, of course, vary, and it may also be wrapped in either autologous fascia or donor sclera.
An orbital implant placed behind posterior Tenon’s fascia
Acrylic conformer placed in conjunctival cul-de-sac with antibiotic ointment and pressure bandage applied for 3-4 days
Fitting of custom prosthesis after 6-8 weeks
Spaeth-443
This technique avoids IOP elevations above 50 mm Hg before freezing completely around the tumor, thereby preventing flow of fluid and blood to or from the tumor prior to the manipulation necessary for enucleation.
With preservation of eyelid anatomy and is similar to eyelid sparing exenteration- done in cases of orbital retinoblastoma
1817- performed unintentionally by James Beer after an expulsive choroidal he
1885-after one year implantation used 4 enucleation and since then many materials and shapes have been tried from glass to metals, ivory to rubber, wool to cartilage and many others
AAO- 120
Evis.may b less likely to spread infection to CSF than enucleation,in which severing the optic n sheath z required. If infection has already spread thru the sclera, however enu. May b necessary to remove all the infected tissue.
Severely ill- evisceration of a blind eye z technically easier and quicker to perform under GA
Bleeding disorder- less orbital dissection in evisc.reduces the risk of orbital haemorrhage
Malignancy- evisc. May contribute to dissemination of tumour
Severe pthisis- if aplasia or severe hypoplasia in childhood- an adequate sized implant cannot b placed inside the scleral shell and also pthisical eyes may harbor unsuspected malignancy
Preserved cornea- if it is of N thickness and show no active corneal disease, advantage is placement of a larger implant
Removed- in presence of active disease in cornea and implant sutured within the sclera. Posterior relaxing incisions of the sclera (radially in each quadrant or concentric to the optic nerve) may be used to allow placement of a larger implant
Technique- yanoff-1342 and AAO-120
This sclerotomy technique to enlarge the scleral shell volume is “optional” with polymethyl methacrylate sphere implants. Sclerotomy slits are “mandatory” when using hydroxyapatite spheres in order to facilitate vascular ingrowth.
A polymethyl methacrylate or hydroxyapatite spherical implant is placed in the evisceration scleral shell When the cornea is removed, the largest implant that will fit in
most scleral cavities is 18 mm.
Monopolar versus bipolar — Electrosurgery can be performed using either a monopolar or a bipolar instrument. The main difference between these two modalities is that in monopolar surgery, the current goes through the patient to complete the current cycle. it produces more heat at the operative site. , while in bipolar surgery, the current only passes through the tissue between the two electrodes of the instrument
Antibiotic oint, conformer and eye patch
Jackobiek’s- ch.267
AAO- 126 adenoid cystic ca. primary adenoca., mucoepidermoid ca.,
Subtotal or eyelid sparing- spares either entire eyelid str. Or just the eyelid skin..if skin is to be spared incision is given 2-3 m above and below the lash lines in UL n LL respectively
oculofacial prosthesis can provide excellent cosmetic camouflage of the socket. The lids and periocular structures of the prosthesis are made of silicone, and the eye is made of polymethylmethacrylate. The prosthesis can be attached to a spectacle frame, or more commonly it is held in place with an adhesive.
Another method of fixation is using osseous integration pegs. These pegs are implanted into the bone of the orbital rim, and magnets embedded in the prosthesis hold the prosthesis in place
Anterior implant contour. If necessary the anterior surface of the ocular implant is manipulated to create more of a physical integration with the prosthesis transmitting movement to the prosthesis. These implants require a skilled custom fitting of the prosthesis to avoid pressure on the conjunctiva covering the elevations on the implant, which may cause discomfort or exposure of the implant
Porous polyethylene implants have pores similar to HA implants, but they are less uniform in size and more irregular in shape
Pollglactin mesh associated with a high exposure rate. Cadaver tissue has the potential risk of transmission of viral infections or prions, although this material is usually carefully screened. Harvesting autologous tissue for implant wrapping raises the risk of donor site infection or hemorrhage, adds a second surgical site, and increases operative time and postoperative morbidity
Vascularisation takes 8-12 months
18-20 mm if unwrapped…wrapping of sclera adds 1- 1.5 mm to the volume to be placed
Extraocular muscles sutured to edge of dermis, not only for optimum motility, but also to bring the long ciliary arteries along with the muscles into contact with the dermis.
Acrylic or silicone……kept till placement of prosthetic eye
This implant pushes the initial implant and superior orbital fat upward to fill out the superior sulcus- performed wid either a blepharoplasty incision or thru an inferior conjunctival cul-de-sac approach which involve a lateral canthoplasty, severing inferior crux of lateral canthal tendon and reflecting the lower eyelid down
DFG- usually graft is inserted upside down, dermis is fixed onto the periosteum of upper bony orbital margin..care not to damage supraorbital bundle and induce ptosis
Conformers and prostheses should not be removed for periods greater than 24 hours
exposure of the porous polyethylene orbital implant in a patient who had undergone evisceration for trauma
Spaeth-ch.48 Mild ptosis may be corrected with conjunctiva/ Muller muscle resection. Frontalis suspension is usually a less acceptable procedure because there is no visual drive to stimu late contracture of the frontalis muscle to elevate the eyelid. + ophthalmology rounds
Ectropion correction methods- Laxity- may result from the loosening of lower eyelid support under the weight of a prosthesis. Frequent removal of the prosthesis or use of a larger prosthesis
Grade 5 represents loss of all fornices due to contraction postoperatively, after surgery completed within the last year, achieving an unsuccessful result. After 1 year, if nothing is done surgically or prosthetically to this socket to correct this situation, it should be reclassified as Grade 4. Thus, Grade 5 indicates a recent failed attempt at socket reconstruction
Full-thickness mucous membrane grafting(for more advanced and severely contracted sockets) is preferred because it allows the grafted tissue to match conjunctiva histologically. Buccal mucosal grafts may be taken from the cheeks (beware of damaging the duct to the parotid gland) or from the upper lip, lower lip, or hard palate
