ENUCLEATION_and_EVISCERATION.pptx BY Dr Ravindrakumar

ENUCLEATION_and_EVISCERATION.pptx BY Dr Ravindrakumar

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  DESCRIPTIVE KNOWLEDGE OFEVISCERATION AND ENUCLEATION SURGERY PRESENTER DR RAVINDRAKUMAR 3RD YEAR PG SCHOLAR DEPT OF SHALAKYA TANTRA GAMC BANGALORE. UNDER THE GUIDANCE OF DR SYED MUNAWAR PASHA PROFESSOR AND HOD DEPT OF PG AND Phd STUDIES IN SHALAKYA TANTRA GAMC BANGALORE
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   CONTENTS : 1)INTRODUCTION 2) EVISCERATION  4 Petals evisceration Technique  Frill evisceration Technique  Equatorial sclerotomy 3) ENUCLEATION  Myoconjunctival technique 4) REFERENCE
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  1) INTRODUCTION  Enucleationand evisceration is an acceptable surgery for end- stage ocular diseases which are not curable with medical treatments, such as ocular trauma, intraocular malignancies and phthisis bulbi,severe eye infection. Evisceration is a surgical technique by which all intraocular contents are removed while preserving the remaining scleral shell. Enucleation involves removal of entire eye ball and its contents,with preservation of all the orbital contents.
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   The surgeryoften includes placement of an implant into the cavity to maintain appropriate orbital volume.  Olden days different implant materials used like cartilage, bone, fat, rubber, gold, silver, have been used to for orbital implants,  Currently, using porous spherical hydroxyapatite (HA) implants are the most common implants which was first introduced in 1985
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  2) EVISCERATION  Removingthe contents inside the eye but leaving behind the white outer coating of the eye i.e sclera.  Sclera, extra ocular muscles, optic nerve, conjunctiva remains intact.  The surgery often includes placement of an implant into the cavity to maintain appropriate orbital volume.
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   Blind painfuleye : Blind painful eyes are commonly removed for both pain control and improvement of cosmesis . Both enucleation and evisceration are effective in these condition.
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   Expulsive hemorrhage Bleeding Ant. staphyloma Again, the choice of procedure usually depends on the surgeon's personal experience and preference. Pain can, at times, be controlled with a retrobulbar injection
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   Contraindications  Knownor suspected intraocular malignancy  Relative Contraindications  Phthisis bulbi
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   Microphthalmia Evisceration maybe more difficult in cases of phthisis bulbi or microphthalmos due to a lack of sufficient scleral shell volume to adequately encase the implant.
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   While enucleationis generally the preferred surgical choice in pthisis bulbi and micropthalmia patients,  several modified evisceration techniques have been described whereby the globe is divided by various types of posterior or equatorial sclerotomies, allowing the placement of a larger implant in these cases.
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   Surgical technique Pre operative steps:  Proper written consent should be taken.  Explain the procedure and nil visual prognosis to the patient and his/her relative.  Pre-operative antibiotic coverage (either topical or i.v.).  Xylocaine sensitivity.
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  Anastheasia  0.5% bupivacainewith 1:1,00,000 adrenaline is used as LA  Most evisceration surgeries are performed under LA with IV sedations
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   2% lignocainewith 1:1,00,000 epinephrine is injected in retro bulbar fashion.  Retrobulbar administration of anesthetic with epinephrine is often given to reduce intraoperative bleeding and postoperative pain.
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   General anasthesiamay be given for psycological,children and occasionally for medical reason.  Propofol: The most common IV general anesthetic, which can be used to induce sleep or unconsciousness. Propofol acts quickly, and reduces nausea.
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   Careful pre-operativeevaluation should be performed to ensure there is no intraocular malignancy in the operative eye when planning an evisceration.  If there is no view to the posterior pole, B-scan or CT scan should be used to rule out malignancy, if intraocular malignancy can not be ruled out enucleation is the preferred surgery.
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  Painting and drapingof the respective eye. Application of eye speculum.
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   EVISCERATION OPERATIVESTEPS: 1) PERITOMY  Following placement of an eyelid speculum, a subconjunctival injection of epinephrine containing anesthetic facilitates A 360 degree conjunctival peritomy is then made at the Limbus utilizing Wescott scissor.  Care is taken to preserve as much conjunctiva as possible.
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  2) REMOVAL OFCORNEA  A cut at the limbus is made with 11 no. scalp blade and then the cornea is excised in a circumferential manner with corneoscleral scissors.
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  3) REMOVAL OFINTRAOCULAR CONTENTS  All intraocular contents, including uveal tract, crystalline lens, vitreous humor, and retina are then removed.  Techniques for removing the intraocular contents include use of an evisceration spoon, spatula, suction, or other instruments.
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   These contentsare sent for histopathologic identification and examination  Hemostasis of the nerve and vortex veins may then be achieved with cautery and direct pressure.
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  4) Application ofalcohol Absolute or 70% alcohol may then be instilled to denature and remove all remaining uveal material and microorganisms from the scleral shell.  Cautery should be avoided, due to the flammability of residual alcohol, until the surgical field has been thoroughly irrigated with saline.
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   Some surgeons,however, prefer to avoid this practice arguing that it may create additional irritation and edema. 5) Sclerotomy  Performing a posterior sclerotomy or radial scleral relaxing incisions allowing for placement of larger implants, has become popular in recent years and is performed at this stage.
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   The surgeonevaluates and chooses the best implant size to restore orbital volume while ensuring appropriate position.  Some surgeons choose to further bathe the scleral shell in antibiotic solution prior to implant placement. 6) INSERTING ORBITAL IMPLANT
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   implant materialis surgeon-dependent and includes spherical implant choices of 1) Silicone 2) acrylic or PMMA (Poly methyl methacrylate) 3) porus polyethylene hydroxyapatite(HA)
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   The implantmay be placed directly into the scleral shell or may be first wrapped in donor sclera, mesh, or other materials.  Other techniques include opening the posterior sclera, releasing the optic nerve, and placing the orbital implant behind the scleral shell, and closing a double- layer of sclera over the anterior implant,
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   This allowsplacement of a large orbital implant, which decreases superior sulcus hollowing and ptosis, which ultimately results in a better cosmetic result. SUPERIOR SULCUS HOLLOW
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  1. Scleral shell.2.Placing the implant. 3 and 4. Closure of scleral shell, Tenon's and conjunctiva
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  .  The anteriorsclera, Tenon's capsule, and conjunctiva is then carefully closed in a layered approach before placement of a conformer.  Sclera is sutured with interrupted 6-0 Vicryl  Conjunctiva with running mattress 6-0 Vicryl CONFORMER CONFORMER
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   A temporarytarsorrhaphy may be performed to help the conformer remain in place to maintain the fornices till prosthesis can be placed Temporary tarsorrhaphy
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  Post operative care: Perioperative and/or postoperative antibiotics are often administered and are especially important in cases of evisceration in the setting of endophthalmitis.  The duration of antibiotic therapy range from 10 days to several weeks, depending on the nature of the infection 6) AFTER COMPLETION OF SURGERY  Antibiotic ointment applied and lid are closed and dressing is done with sterile eye pads and a bandage.
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   A pressurepatch may be applied and kept in place for approximately 5 days following surgery.  Ice cold compresses help with post-operative edema and comfort.  Remove pad and bandage.  Additionally, temporary tarsorrhaphy can be used to help with conformer retention and early post-operative swelling  Apply Dark goggles (safety and cosmetic purpose)
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   Once theconjunctiva closure has healed, generally about 4-8 weeks postoperatively, patients are referred to an ocularist for fitting of an ocular prosthetic fitting.
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   SPECIAL TECHNIQUEOF EVISCERATION 1) 4 PETAL OF EVISCERATION  After removing the all intra ocular contents The sclera is divided into four separate petals,  Each petals containing one rectus muscle insertion
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   4 PetalOf Evisceration allows placement of a larger implant  The sclera is sutured in two layers covering the implant without tension on the wound.
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  2) Frill eviscerationTechnique  only 3mm frill (edge) of sclera is left around Optic Nerve. 3) Evisceration with keratectomy: The most common type of evisceration, this procedure begins with a complete keratectomy (cornea) to access the intraocular contents. 4) Evisceration with cornea left in place: This procedure is performed when the cornea is healthy.
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  5) Sclerotomy: Sclerotomyis a general term for surgical incisions made in the sclera ,A popular technique that allows for the placement of larger implants. •Equatorial sclerotomy: Sclera is divided into 2 part, This technique allows for a larger implant and is associated with a lower rate of implant exposure and extrusion. •Four-petal technique: Sclera is divided into four separate petals,
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  SPECIAL CONSIDERATIONS 1) If ascleral buckle or glaucoma drainage device is present in the eviscerated eye, it should be removed. 2) If silicone oil is present within the eye, the limbus can be incised and the silicone oil irrigated from the eye prior to peritomy.
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   Improve thevisibility: clear the visual axis ,allowing for better visualization during the peritomy.  Interference with healing: silicone oil can interfere with the healing process by creating a barrier between tissues.  Reduce complications such as inflammation,fibrosis.
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  1) Retrobulbar haemorrhage 2)Orbital edema 3) Dissemination of unexpected intraocular neoplasm 4) Implant exposure  Complications of evisceration
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   Advantages ofEvisceration over Enucleation 1) Shorter operative time 2) More cost efficient 3) A technically simpler procedure 4) A less invasive procedure (important in cases when GA is contraindicated or in bleeding disorders)
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  5) Less disruptionof orbital tissues  chance of injury to EOM, nerves and fat atrophy is reduced  Relationships between the muscles, globe, eyelids, and fornices remain undisturbed.  Less chance of spread of infection to nervous system
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  6) Less painful. 7)Better cosmesis. 8) Good motility of the prosthesis- EOM remain attached to the sclera. 9) Lower rate of reoperation and socket complications. 10) Preferred by some surgeons in cases of endophthalmitis as drainage of the ocular contents can be done without invasion of the orbit.
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   Disadvantages ofEvisceration over Enucleation 1) Risk of sympathetic ophthalmia 2) Risk of dissemination of intraocular tumor
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  3) Enucleation:  Enucleationis a surgical procedure that removes the entire eyeball and part of the optic nerve, while leaving the eyelids, lashes, eyebrows, and surrounding skin intact.
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   INDICATION OFENUCLEATION:  The decision for enucleation can be one of the most difficult to make and discuss with the patient. The main indications for enucleation are  Intraocular malignancy or high suspicion for intraocular malignancy (most commonly uveal melanoma and retinoblastoma) Blind, painful eye Severe infection without visual potential For eye donation from cadaver
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   End stageof glaucoma  Sympathetic ophthalmia  Microphthalmos  Traumatic eye injuries.  Cosmetic deformity
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   SURGICAL TECHNIQUE PREOPERATIVE Proper written consent should be taken. Explain the procedure and nil visual prognosis to the patient and his/her relative. Per-operative antibiotic coverage (either topical or i.v.). Xylocaine sensitivity
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  Performed under GAor LA retrobulbar block of local anesthetic with epinephrine is administered to aid in hemostasis and postoperative pain management. Lateral canthotomy done to get adequate space (especially in paediatric RB)
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   A retrobulbarblock of local anesthetic with epinephrine is administered to aid in hemostasis and postoperative pain management.  Painting and draping of the respective eye.  Application of eye speculum Retro bulbar
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  ENUCLEATION OPERATIVE STEPS A360 degrees limbal conjunctival peritomy is performed with Wescott scissors.
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   Tenons faciais bluntly dissected away from the sclera in all four quadrants.
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  2) SEPARATION OFEXTRAOCULAR MUSCLES:  The rectus muscles are pulled out by one by one with the help of a muscles hook. Muscle hook
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   Traction sutureplaced at muscle insertion and tag suture placed 4– 5 mm away from traction suture. Traction suture Tag suture
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  Extra ocular musclecut  Then the muscles cut with the help of tenotomy scissors.  This procedure is repeated till all 4 recti muscles are dis-insected.
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   Then Superiorand inferior oblique muscles also identified ,hooked out and cut near the globe. Superior oblique Inferior oblique
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  3) TRANSECT (CUT)OF OPTIC NERVE :  Once the globe is determined to rotate freely, The globe prolapsed out of the socket with the help of traction sutures .
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   the enucleationscissors is then introduced along the lateral wall up to the posterior aspect of the eyeball. optic nerve felt and the cut with enucleation scissors or an enucleation snare wire.
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   Some surgeonsprefer to first clamp the optic nerve with a curved hemostat prior to transection to encourage further hemostasis.  An attempt should be made to cut a long segment of the optic nerve, particularly in situations of intraocular malignancy where histologic examination of the optic nerve is crucial.
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  4) REMOVAL OFEYE BALL:  The eyeball pulled out of the orbit by incising the remaining tissue adherent to it and additional hemostasis is then achieved with direct pressure in the intraconal space and cautery of the optic nerve if needed.  Send the globe for detailed histopathology analysis.
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   A sizingset can also be used to determine the appropriate size of impant intraoperatively to ensure there is not too much tension when closing. sizing set
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  5) INSERTING ORBITALIMPLANTS:  An implant is then placed in the intraconal space to replace volume lost by the enucleated globe, achieve cosmetic symmetry with the fellow socket, and allow for motility of the prosthesis.
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   After placingimplant, the extraocular muscles are generally 1) sutured directly to a porus or wrapped implant. OR 2) Myoconjunctival technique
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   IMPLANTS : Implants may be porous or nonporous.  Porous implants allow for anchoring of the extraocular muscles with proliferation of fibrovascular tissues into the implant itself.  These include hydroxyapatite, porous polyethylene, POROUS NON POROUS
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  Hydroxyapatite implants(porous) Becauseof their rough surface, they are typically wrapped with material such as donor sclera, dermis, or pericardium. Donor sclera wraping. Rectus muscle sutured on donor sclera wrapped on implant
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  Additional wrapping materialsinclude autologous tissue grafts, such as temporalis fascia or fascia lata ,dermis with fat and synthetic meshes. Fascia lata Temporalis fascia
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  synthetic mesh aswrapping material on implant Suture the extraocular muscles Directly to the mesh wrapped implant
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   Gently removethe dermofat graft from buttock or inner thigh.  Place the dermofat graft into the socket with the dermis anteriorly  Rectus muscles sutured to edge of dermis.
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  A two layeredclosure is then carried out with absorbable sutures, first of Tenon’s capsule and then of the conjunctiva. 6) CLOSER OF TENNO’S CAPSULE F/B CONJUNCTIVA: Posterior Tenon’s capsule is sutured Anterior Tenon’s capsule is sutured Conjunctiva is sutured
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  Adequate size conformeris placed Suture tarsorrhaphy is performed  Antibiotic ointment is applied, a cl plastic conformer is placed over th closed conjunctiva A temporary tarsorrhaphy may be placed as well to be removed in 5-7 days.
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  A pressure patchis placed over the socket for 2-3 days depending on surgeon preference. Once the conjunctiva closure has healed, generally about 4-8 weeks postoperatively, patients are referred to an ocularist for fitting of an ocular prosthetic fitting. ocular prosthetic
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   ADVANTAGES; This isimportant in biopsy of proven or suspected intraocular malignancy, where it is essential to determine the margins of the malignancy and invasion of the optic nerve, if any. Enucleation allows for histologic examination of an intact globe and optic nerve.
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  DISADVANTAGES:  A reductionin implant motility is often noted in enucleation.  COMPLICATIONS: INTRAOPERATIVE •Removal of the wrong eye •Damage to or loss of extraocular muscles •Hemorrhage •Perforation of eye
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   Post operativecomplication :  Infection  Hemorrhage  Extrusion of the conformer  Exposure of the implant  Ptosis  Pain  Ectropion  Entropion  Hollow or deep superior sulcus  Enophthalmos  Orbital cellulitis Exposure of PMMA, Porous polyethylene, hydroxyapatite implants Left upper eyelid anophthalmic ptosis
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  4) REFERENCE 1) COMPREHENSIVEOPHTHALMOLOGY BY A K KHURANA, 9TH EDITION 2) TEXTBOOK OF OPTHALMOLOGY BY HV NEMA,NITIN NEMA ,6TH EDITION 3) CLINICAL METHODS IN OPTHALMOLOGY BY DADAPEER K ,2ND EDITION. 4) KANSKI”S CLINICAL OPHTHALMOLOGY ,8TH EDITION