Causes of Enucleation: A Clinicopathological Study

Background.

Enucleation is an approach used for unresponsive end-stage ocular disease often resulting in blind, painful or cosmetically unacceptable eyes.

Methods.

We reviewed the clinicopathological data on 3506 enucleations performed over a 50-year period, 1945-1995. Histopathological data were divided into eight groups according to the causes leading to enucleation: trauma, phthisis, corneal disease, inflammation, vitreoretinal disease, glaucoma, tumors and infections.

Results.

The study considered 3506 enucleated eyes of 3482 patients, 2467 (70.8%) males and 1011 (29.1%) females (4 sex unspecified). The z-test showed there were significantly more enucleations in males for phthisis (p<5.05), infections (p<0.01), trauma (p<0.01) and inflammation (p<0.01) and more enucleations for tumors in females (p<0.01). There were no differences between males and females with regard to enucleations for glaucoma, vitreoretinal and corneal diseases (p>0.05). The 0–9 years age group was most frequently affected, accounting for 29.7% of the cases. Patients aged less than 30 years constituted 53.6% of all enucleations. The primary or underlying causes leading to enucleation were tumors (1185 eyes, 33.8%), phthisis (587 eyes, 16.7), glaucoma (561 eyes, 16.0%), vitreoretinal diseases (320 eyes, 9.1%), infections (259 eyes, 7.4%), corneal disease (229 eyes, 6.5%), trauma (209 eyes, 6.0%) and inflammation (156 eyes, 4.4%). Time trends in enucleating eyes with different causes showed the number of enucleations for phthisis, infections, corneal diseases, trauma and inflammations had dropped during the ten-year period 1986–1995 compared to 1976–1985 (z-test, p<0.01). There were no real changes in enucleations for glaucoma and vitreoretinal diseases and there was an increase in the number of enucleations for tumors (p<0.01).

Conclusions.

Improved diagnostic and therapeutic methods, widespread use of photocoagulation in vascular disorders and vitreoretinal surgery in traumas, effective antimicrobial treatment, increasing use of corticosteroids and immunosuppressants, have contributed to the decreasing frequency of enucleation. Tumor patients generally presented late with advanced tumors totally filling the eye, not salvageable by other non-invasive treatment methods. Prompt diagnosis of intraocular malignant tumors (retinoblastoma and malignant melanoma) may reduce the need for enucleation.

Enucleation and evisceration: 20 years of experience

OBJECTIVE

To determine the indications, relative frequencies, surgical times, and complications for enucleation and evisceration performed at a single academic center.

METHODS

Medical records of all patients who underwent an enucleation or evisceration between January 1st, 1990 and December 31st, 2009 at a single academic center were reviewed. Patient demographics and surgical indications, times, and complications were recorded.

RESULTS

A total of 85 eyes in 85 patients underwent enucleation (n = 31; 36%) or evisceration (n = 54; 64%) during the study period. Almost all patients were of African descent (96%). The most common underlying cause leading to eye removal was trauma. On average, eviscerations (47.3 ± 10.3 minutes) took significantly less time to perform than enucleations (89.6 ± 10.1 minutes; p < 0.01). Complications included implant exposure, infection, lower lid laxity, fornix insufficiency, and need for subsequent surgery; the occurrence of these complications was found to be similar between the two groups (p = 0.77). No case of sympathetic ophthalmia or inadvertent evisceration of an eye with an occult intraocular malignancy was noted. From the first decade for which data were available (1990- 1999) to the second decade (2000- 2009), the average number of enucleations decreased (p = 0.02) and the average number of eviscerations (p = 0.04) increased.

CONCLUSION

Evisceration was found to be a safe and quicker alternative to enucleation in our study. A change in surgical preference from enucleation to evisceration was seen during the 20-year study period.

The eye amputated - consequences of eye amputation with emphasis on clinical aspects, phantom eye syndrome and quality of life

In this thesis the term eye amputation (EA) covers the removing of an eye by: evisceration, enucleation and exenteration. Amputation of an eye is most frequently the end-stage in a complicated disease, or the primary treatment in trauma and neoplasm. In 2010 the literature is extensive due to knowledge about types of surgery, implants and surgical technique. However, not much is known about the time past surgery.

THE PURPOSE OF THE PHD THESIS WAS

To identify the number of EA, the causative diagnosis and the indication for surgical removal of the eye, the chosen surgical technique and to evaluate a possible change in surgical technique in Denmark from 1996 until 2003 (paper I); To describe the phantom eye syndrome and its prevalence of visual hallucinations, phantom pain and phantom sensations (paper II); To characterise the quality of phantom eye pain, including its intensity and frequency among EA patients. We attempted to identify patients with increased risk of developing pain after EA and investigated if preoperative pain is a risk factor for a later development of phantom pain (paper III); In addition we wanted to investigate the health related quality of life, perceived stress, self rated health, job separation due to illness or disability and socio-economic position of the EA in comparison with the general Danish population (paper IV).

THE STUDIES WERE BASED ON

Records on 431 EA patients, clinical ophthalmological examination and an interview study of 173 EA patients and a questionnaire answered by 120 EA patients.

CONCLUSIONS

The most frequent indications for EA in Denmark were painful blind eye (37%) and neoplasm (34%). During the study period 1996-2003, the annual number of eye amputations was stable, but an increase in bulbar eviscerations was noticed. Orbital implants were used with an increasing tendency until 2003. The Phantom eye syndrome is frequent among EA patients. Visual hallucinations were described by 42% of the patients. The content were mainly elementary visual hallucinations, with white or colored light as a continuous sharp light or as moving dots. The most frequent triggers were darkness, closing of the eyes, fatigue and psychological stress. Fifty-four percent of the patients had visual hallucinations more than once a week. Ten patients were so visually disturbed that it interfered with their daily life. Approximately 23% of all EA experience phantom pain for several years after the surgery. Phantom pain was reported to be of three different qualities: (i) cutting, penetrating, gnawing or oppressive (n=19); (ii) radiating, zapping or shooting (n=8); (iii) superficial burning or stinging (n=5); or a mixture of these different pain qualities (n=7). The median intensity on a visual analogue scale, ranging from 0 to 100, was 36 [range: 1-89]. One-third of the patients experienced phantom pain every day. Chilliness, windy weather and psychological stress/fatigue were the most commonly reported triggers for pain. Factors associated with phantom pain were: ophthalmic pain before EA, the presence of implant and a patient reported high degree of conjunctival secretion. A common reason for EA is the presence of a painful blind eye. However, one third of these patients continue to have pain after the EA. Phantom sensations were present in 2% of the patients. The impact of an eye amputation is considerable. EA patients have poorer health related quality of life, poorer self-rated health and more perceived stress than does the general population. The largest differences in health related quality of life between the EA patients and the general population were related to role limitations due to emotional problems and mental health. Patients with the indication painful blind eye are having lower scores in all aspects of health related quality of life and perceived stress than patients with the indication neoplasm and trauma. The percentage of eye amputated which is divorced or separated was twice as high as in the general population. Furthermore, 25% retired or changed to part-time jobs due to eye disease and 39.5% stopped participating in leisure activities due to their EAs.

Causes of enucleation in Northern India (1995-2005)

PURPOSE

There are limited data concerning the reasons for surgical removal of eyeball. The present retrospective study was undertaken to evaluate the frequency of diseases requiring surgical removal of eyeball and to study the histopathologic changes in these specimens.

METHODS

Forty-eight surgical eyeball specimens received between January 1999 and June 2005 were included in the study. Age, sex, and clinical diagnoses were recorded in each case. Specimens were classified on the basis of surgical procedure. Gross and microscopic findings were noted for all the specimens.

RESULTS

Between January 1995 and June 2005, there were 139,092 outpatients, 6,574 hospital admissions, 12,044 ophthalmic operations, and a total of 48 enucleations in 47 patients. Of these 47 patients, 24 were male and 23 female with almost equal male:female ratio. Right eye was involved in 29 cases while left was involved in 17 cases. Bilateral eye involvement was seen in one case. Surgical specimens included enucleation (28 cases, 58.3%), exenteration (12 cases, 25%), and evisceration (8 cases, 16.6%). On histopathologic examination, the lesions were categorized into two broad groups: neoplastic (8 cases, 16.6%) and non-neoplastic (40 cases, 83.4%). Both groups were further subcategorized and correlated with clinical diagnosis.

CONCLUSIONS

In our setting, non-neoplastic lesions are the main cause of eyeball surgery, as compared to the West, where trauma followed by neoplasms constitute important causes. Pathologic examination of eyeballs is a must for proper postoperative management of the patient.

Twenty year review of histopathological findings in enucleated/eviscerated eyes

BACKGROUND/AIMS

To evaluate the need for routine histopathological analysis of enucleated/eviscerated eyes and changes in indications for eye removal.

METHODS

Retrospective review of all enucleation/evisceration histopathology reports over 20 years. Clinical history was correlated with pathological findings. Two 10 year periods (1984-93, 1994-2003) were compared to detect changes in indications for eye removal.

RESULTS

In total, 285 histopathology results were traced from 1984 to 2003; 161 and 124 were evisceration and enucleation specimens, respectively. Glaucoma, malignant melanoma, trauma, and retinal detachment were the most frequent diagnoses 1984-1993. Ocular trauma was the most frequent diagnosis 1994-2003, followed by phthisis bulbi and endophthalmitis. Three cases were diagnosed as metastatic carcinoma; all were suspected preoperatively. A fourth case was a diagnostic surprise: adenocarcinoma found in an eye removed for pain and phthisis. Comparison of two 10 year periods showed a decrease in the number of enucleations/eviscerations, perhaps reflecting a decrease in the number of specimens sent. A preference for eviscerations was evident over the 20 years.

CONCLUSION

The number of eyes removed and histologically analysed decreased in the period 1994 to 2003, perhaps because of better treatment options, allowing globe preservation. There was a significant shift in the diagnosis in the two time periods, and a preference for evisceration in both. Only one diagnostic surprise was discovered (0.35%). This study does not support the need to send all globes/contents for histopathological examination. However, because of the one unexpected finding, it is recommended where the examination is incomplete or the history of visual loss is unclear.

Retinoblastoma in Victoria, 1976-2000: changing management trends and outcomes

PURPOSE

To describe changes in the management of retinoblastoma in Victoria and to review the effect of newer, conservative treatments on preservation of eyes, visual outcome and mortality by comparing a similar group of patients treated over successive time intervals.

METHODS

A retrospective analysis of all cases of retinoblastoma diagnosed and treated in Victoria between 1956 and 2000 was conducted. Historical data on 77 cases previously published by O'Day et al. was used for the period 1956-1976 (series 1). Data on 88 cases recorded in the Royal Children's Hospital (Melbourne) Retinoblastoma Database was used for the period 1976-2000. The latter group was subdivided into those treated between 1976 and 1989 (series 2), prior to the advent of modern eye saving treatments, and those treated subsequent to their introduction from 1990 to 2000 (series 3).

RESULTS

In unilateral retinoblastoma, final enucleation rates for 1956-1976 (series 1) and 1976-1989 (series 2) were almost identical, being 98% and 97% of affected eyes, respectively (P = 1.00). Despite the newer treatments used after 1990 (series 3), 88% of affected eyes were still enucleated, representing a statistically similar outcome to series 2 (P = 0.33). In bilateral retinoblastoma, primary enucleation of the more involved eye was similar for series 1 (84%) and 2 (80%) but series 3 (41%) was substantially less than series 2 (P = 0.04) following the increased use of conservative treatments. In series 3, 59% of more involved eyes were treated conservatively compared with 16% (P = 0.007) and 20% (P = 0.04) for series 1 and 2, respectively. Despite attempts at eye salvage, the failure rate was higher in series 3 (29%) yielding a final enucleation rate of 70%, which represented a modest downward trend in the numbers of eyes finally enucleated; 84% (series 1), 73% (series 2) and 70% (series 3) (test for trend, P = 0.33). Bilateral enucleation rates were significantly lower, from 36% and 30% in series 1 and 2, respectively, to 7% in series 3 (test for trend, P = 0.02). As a consequence, more eyes were preserved over time, being 20/50 (40%) in series 1, 15/30 (50%) in series 2 and 21/34 (62%) in series 3. Comparison of visual outcome was hampered by incomplete data in series 1 but it appeared series 2 and 3 achieved better visual acuities with 67% and 62% of preserved eyes in bilateral cases measuring equal to or better than 6/12. Mortality rates in all series were low, being 7.8% in series 1, 4.5% in series 2 and nil in series 3.

CONCLUSIONS

Following the introduction of new conservative treatments, there has been an increase in preservation of eyes and improved visual outcome, and a dramatic decrease in numbers of bilateral enucleations without adversely affecting survival.

Clinicopathologic correlations in 646 consecutive surgical eye specimens, 1990-2000

All surgical eye specimens examined in our pathology laboratory between January 1, 1990, and July 31, 2000 (N = 646), were classified by surgical procedure (enucleation, evisceration, or exenteration) and pathologic diagnosis. Among 523 enucleated globes (81.0%), 252 (48.2%) contained tumors, of which 208 were intraocular malignant melanomas. Nonneoplastic causes for enucleation included glaucoma (67/523 [12.8%]), phthisis bulbi (61/523 [11.7%]), and recent trauma (59/523 [11.3%]). Sixty-seven specimens (10.4%) had been eviscerated. Fifty-six specimens (8.7%) were obtained by exenteration performed to manage malignant tumors originating in or invading the orbit. Between 1990 and 2000, the percentage of procedures performed to remove neoplasms decreased from 65% to 38%, procedures performed to treat glaucoma increased from 4% to 29%, and those to treat phthisis bulbi increased from 8% to 13%. The numbers of procedures remained relatively constant for trauma and for infectious and inflammatory diseases.

Recent developments in the management of retinoblastoma

The management of retinoblastoma has gradually changed over the past few decades. There is a trend away from enucleation and external beam radiotherapy toward focal conservative treatments. This is primarily because of earlier detection of the disease and more focused treatment modalities. Enucleation is still employed for retinoblastoma that fills most of the eye, especially when there is a concern for tumor invasion into the optic nerve or choroid. After enucleation, an integrated orbital implant, provides improved motility and appearance of the prosthesis. External beam radiotherapy continues to be an important method of treating less advanced retinoblastoma, especially when there is diffuse vitreous or subretinal seeding. Plaque radiotherapy is useful for controlling small- to medium-sized retinoblastomas, even those with focal vitreous seeds. Tumors that recur after failure of other methods are often suitable for plaque treatment. When plaque radiotherapy is employed in a child receiving chemotherapy, eventual radiation retinopathy can occur. Cryotherapy and photocoagulation provide excellent control of selected small tumors. Advanced laser delivery systems, particularly those that have been adapted to the indirect ophthalmoscope, have facilitated the visualization for treatment of tumors. Thermotherapy is the newest focal method for retinoblastoma. When combined with chemotherapy, thermotherapy provides satisfactory tumor control, leaving the child with a reasonably small scar, thus preserving more vision. Chemoreduction, using intravenous or subconjunctival routes, is often employed to reduce initial tumor volume and thus allow for focal treatment to eradicate the residual smaller tumor. Many children with advanced retinoblastoma can be spared external beam radiotherapy and enucleation mostly as a result of chemoreduction and focal methods. Chemoreduction combined with cryotherapy, thermotherapy, and plaque radiotherapy plays an important role in the current management of many children with retinoblastoma.

Changing indications for enucleations in Hadassah University Hospital, 1960-1989

The frequencies of various indications for enucleations have changed during the past decades. Knowledge of these trends may aid us in assessing the efficacy of early diagnostic techniques and improved modes of treatment. This study was designed to evaluate the indications for enucleations and their changes during a period of thirty years in a major Israeli medical center. We present a retrospective review of 463 enucleations performed between 1960 and 1989 at the Hadassah University Hospital, Jerusalem, Israel, and analyze the changes in the indications for enucleations. In our study, fewer enucleations were performed in the last two decades: 105 in the 1970's and 111 in the 1980's, as opposed to 247 in the 1960's. The incidence of enucleations due to glaucoma and to traumatic complications decreased significantly, from 22.3% in the 1960's to 7.7% glaucoma-related enucleations in the 1970's and 1980's, and 7.2% trauma-associated enucleations in the 1980's as opposed to 11.3% in the 1960's, reflecting improved medical management of these conditions. No significant change was noted in the frequency of enucleations due to inflammation, congenital disease or retinal detachment, nor in the number of malignant melanoma-related enucleations. The number of enucleations due to retinoblastoma rose in our study between 1960 and 1989.

Causes of removal of the eye in Ethiopia

The causes of removal of the eye in 282 patients are presented. A decreasing linear trend with increasing age as causes of removal of the eye is observed. The most common causes of removal of the eye were: traumatic globe rupture (33%) malignancy (21%), ugly corneal staphyloma (11%) and panophthalmitis without external cause (11%). The M:F ratio was 2.2:1 and relative frequency of causes of removal of the eye in males and females is shown to be different. Findings on other demographic data, duration of clinical history, causes of trauma and mode of surgery is reported. The need for early presentation is discussed and preventive measures are suggested.

Incidence of enucleation in a defined population

We conducted a population-based study of long-term trends in the incidence of enucleation. From 1956 through 1988, enucleation was performed on 99 residents (55 males and 44 females) of Olmsted County, Minnesota. The mean annual age-adjusted incidence per 100,000 population for males (5.17) was 50% greater than that for females (3.49; P = .04). An increase in the enucleation rate was noted with increasing age (P = .001), with the highest incidence in patients who were 70 to 79 years of age. A decrease in the incidence of enucleation over time (P = .002) was observed in Olmsted County residents who were at least 40 years of age and was caused primarily by the decreasing incidence of neovascular glaucoma and tumor-related enucleations. The incidence of traumatic enucleations did not significantly decrease (P = .25) over this three-decade study period.

Decreasing frequency of enucleation in patients with retinoblastoma

We reviewed our 15-year experience with the management of 324 cases of retinoblastoma. There has been a definite trend away from enucleation in both unilateral and bilateral cases during recent years. In cases of unilateral retinoblastoma, the affected eye was salvaged in 4% of cases (two of 49) during the five-year interval from 1974 through 1978, in 14% of cases (seven of 50) from 1979 through 1983, and in 25% of cases (20 of 80) from 1984 through 1988. In cases of bilateral retinoblastoma, both affected eyes were salvaged in 4% of cases (one of 24) from 1974 through 1978, in 18% of cases (nine of 50) from 1979 through 1983, and in 25% of cases (18 of 71) from 1984 through 1988. Earlier diagnosis of retinoblastoma and refinements in conservative methods of management are believed to be the main reasons for this trend away from enucleation.