Evisceration with autogenous scleral graft and bioceramic implantation within the modified scleral shell: 133 cases over 17 years

Novel use of an autologous scleral button graft to close the anterior defect in evisceration surgery

PURPOSE

To present an alternative evisceration technique with long-term follow-up data. This technique involves the insertion of an acrylic implant into a modified scleral shell which is closed using an autologous scleral graft.

METHODS

This was a retrospective analysis of eviscerations performed in a district-general hospital in the UK. All patients underwent conventional ocular evisceration after total keratectomy. A full thickness scleral graft is harvested from the posterior sclera, using an internal approach, with an 8 mm dermatological punch. An 18-20 mm acrylic implant is placed into the shell, and the scleral graft is used to close the anterior defect. Demographic characteristics, implant size and type, and cosmetic results from pictures of all patients were recorded. All patients were invited for a review to measure motility, eyelid height, patient recorded satisfaction and complications.

RESULTS

Of the five patients identified, one had since died. The remaining four attended a review in person. The mean time between surgery and review was 48 months. The mean implant size was 19 mm. There were no cases of implant extrusion or infection. All four had a <1 mm asymmetry in measured eyelid height and ≥5 mm horizontal gaze motility. All patients self-reported "good" cosmesis. An independent assessment identified "mild asymmetry" in two cases and "moderate" in the other two.

CONCLUSION

Evisceration with this novel autologous scleral graft technique restores volume in the anterior orbit with good cosmetic results, and with no cases of implant exposure reported in this small case series. This technique should be compared prospectively to established techniques.

Anesthesia for ophthalmic surgery: an educational review

PURPOSE

Selecting an anesthetic agent for ophthalmic surgery has crucial implications for the surgeon, anesthesiologist, and patient. This educational review explores the common classes of anesthesia used in ophthalmology. Additionally, we discuss the considerations unique to cataract, glaucoma, strabismus, orbital, oculoplastic, and ocular trauma surgeries.

METHODS

A comprehensive Embase search was performed using combinations of the subject headings "anesthesia", "eye surgery", "ophthalmology" and "cataract extraction", "glaucoma", "strabismus", "vitreoretinal surgery", "retina surgery", "eye injury", and "eyelid reconstruction".

RESULTS

Topical anesthetics are the most commonly used form of ocular anesthesia, used in both an office and surgical setting, and carry a minimal side effect profile. Notably, topical anesthetics offer analgesia, but do not provide akinesia or amnesia. Regional blocks, such as are sub-Tenon's, peribulbar, and retrobulbar blocks, are used when akinesia is required in addition to analgesia. Recently, sub-Tenon's blocks have recently gained popularity due to their improved safety profile compared to other regional blocks. General anesthesia is considered for long, complex surgery, surgery in patients with multiple comorbidities, surgery in young pediatric patients, or surgery in patients intolerant to local or regional anesthetic.

CONCLUSION

Anesthetizing the eye has rapidly evolved in recent years, supporting the safety, efficacy and comfort of ocular surgery. Since there are many viable options of anesthetics available for ophthalmic surgery, a robust understanding of the patients needs, the skill of the surgical team, and surgery-specific factors ought to be considered when creating an anesthetic plan for surgery.

Demography, Clinical Settings and Outcomes in Evisceration with Implant: An Electronic Medical Records Driven Analytics of 2071 Cases

PURPOSE

To describe the demography, clinical settings and outcomes in 2071 patients undergoing evisceration across a multi-tier ophthalmology hospital network and comparison of results with the global scenario of clinical settings for evisceration.

METHODS

An analysis of 2071 patients undergoing evisceration and implant between 2013 and 2019.

RESULTS

The mean age at surgery was 39 ± 22 years. Children constituted 303(15%) of the cases. The four leading indications for surgery included painful blind eye in 760(37%), phthisis bulbi in 552(27%), staphyloma in 215(10%) and open globe injury in 195(9%) patients. The clinical settings encountered were trauma in 852(41%), ocular infection in 714(34%), glaucoma in 198(10%), post ocular surgery in 146(7%), congenital in 95(5%) and uveitis in 21(1%). Trauma and infection remained the commonest clinical settings in the urban (843,75%), rural (622,77%) and metropolitan (101,71%) areas. Decade wise distribution suggested trauma to be the commonest clinical setting in the first 4 decades and infection in the next 6 decades. The mean follow-up period was 351 ± 386 days (median 194). While trauma remained one of the commonest clinical setting in both the developed and the developing economies, painful blind eye and intractable glaucoma were other common clinical settings in the developed economies and infection was one of the leading clinical setting in the developing economies.

CONCLUSION

Most patients undergoing evisceration are young. The commonest indications for surgery include painful blind eye and phthisis bulbi. Trauma and infection remain the commonest clinical settings for evisceration in developed and developing economies.

Post-enucleation socket syndrome-a novel pathophysiological definition

BACKGROUND

The last definition of the post-enucleation socket syndrome (PESS) by Tyers and Collin-formulated almost 40 years ago in 1982-is predominantly based on the clinical characteristics and does not include the insights of newer studies into the pathophysiological mechanism of the PESS.

METHODS

A systematic PubMed literature review regarding the pathophysiological mechanism of the PESS was performed, and results were comprised to give an overview of the current knowledge of the PESS including the exact pathophysiological mechanism.

RESULTS

The primarily postulated pathophysiological mechanism of the PESS was the atrophy of orbital tissues, especially of fat, resulting in variable clinical findings. Newer studies using high-resolution computed tomography and magnetic resonance imaging or performing histopathological analyses found no orbital fat atrophy but rather a rotatory displacement of the orbital tissues from superior to posterior and from posterior to inferior together with the retraction of the extraocular muscles and a possible volume loss of the orbital implant by resorption if it is manufactured from hydroxyapatite. PESS results in a backward tilt of the superior fornix, a deep superior sulcus, a pseudo-ptosis, a lower eyelid elongation and laxity, a shallower inferior fornix, as well as enophthalmos and may lead to an inability of wearing ocular prostheses.

CONCLUSIONS

A novel and comprehensive definition of the PESS is proposed: PESS is a multifactorial and variable syndrome caused by a rotatory displacement of orbital contents together with the retraction of the extraocular muscles and possible resorption of the orbital implant if it is manufactured from hydroxyapatite.

Outcomes and complications of evisceration with primary implant: an electronic medical record driven analytics of 1800 cases

PURPOSE

To describe the surgical outcomes and implant complications in 1,800 patients undergoing evisceration with primary implant.

METHODS

An Electronic Medical Record-driven analysis of 1,800 patients undergoing evisceration with primary implant between 2013 and 2019. Implant sizing was performed intra-operatively to place the largest implant without tension on the wound closure. Outcome measures included implant complications, prosthesis measurements, and incidence of a good aesthetic outcome. Good outcome was defined as <2 mm enophthalmos and grade 1 or less superior sulcus deformity with a custom ocular prosthesis.

RESULTS

Eighteen hundred eyes of 1800 patients were included. The mean age at surgery was 36 ± 21 years (median 32 years). Implants used were poly(methyl methacrylate) (PMMA) in 1737 (97%) and porous polyethylene in 63 (3%) patients. Two-petal sclerotomy was performed in 1512 (88%) and four-petal sclerotomy in 165 (10%) patients. The mean diameter of the implant used was 19.35 ± 1.18 mm (median 20, range 10-22 mm). The implant extrusion rate was 3% (56) and implant displacement was seen in none. The mean prosthesis volume and thickness were 2.22 ± 0.67 ml (median 2, range 1-6.5 ml) and 6 ± 1 mm (median 6, range 2-9 mm). The mean difference in prosthesis projection on Hertel's exophthalmometer was 0.28 ± 1 mm (median 0, range 0-1 mm). Good outcome was observed in 93%. The mean follow-up period was 351 ± 386 days (median 194).

CONCLUSION

Evisceration with empirically selected primary orbital implant placement is associated with minimal implant complications and gives a good aesthetic outcome in 93% of the patients.

Conjunctival Epithelial Inclusion Cyst following Evisceration with Primary Orbital Implantation

A 29-years-old Turkish man who had undergone evisceration with primary orbital implantation 20 months prior complained of difficulty wearing his artificial eye. Slit-lamp examination revealed a conjunctival cyst in the center of the anophthalmic socket, with no evidence of scleral or orbital implant exposure. The cyst was completely excised under general anesthesia and did not require use of any sclerosing substance or dye. At 6 months postoperatively, there was no recurrence of the cyst or exposure of the sclera or orbital implant. As the upper and lower fornices were sufficiently deep, the patient could wear his artificial eye.

Combined retro-peribulbar and subconjunctival anesthesia for evisceration surgery

PURPOSE

To evaluate the efficacy of retro-peribulbar and subconjunctival anesthesia associated with intravenous sedation in patients undergoing evisceration and orbital implant placement.

METHODS

The charts of 217 patients who underwent evisceration with trans-scleral implant placement were reviewed. Midazolam and fentanyl were used for intravenous sedation. For local anesthesia, a combination of lidocaine with epinephrine and bupivacaine was injected into the retrobulbar, upper peribulbar, and subconjunctival areas. The intraoperative pain and need for supplemental anesthetic injection were recorded prospectively.

RESULTS

The surgery was performed with local anesthesia in 116 patients (53%) and with general anesthesia in 101 patients (47%). Patients were significantly older in the local anesthesia group than in the general anesthesia group (mean age, 59.9 years vs 45.2 years; P < .05). Supplemental retrobulbar anesthesia was required in 5 patients (4.3%). Transition to general anesthesia was required in 1 patient (0.9%) due to severe anxiety. Orbital hemorrhage developed after retrobulbar injection in 1 patient (0.9%), but did not preclude performing evisceration.

CONCLUSIONS

Combined retro-peribulbar and subconjunctival anesthesia with intravenous sedation can provide safe and effective intraoperative analgesia for evisceration surgery with trans-scleral implant placement.