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Evisceration, Enucleation and Exenteration

The eye is a complex structure. In the most basic sense, the orbit includes everything within the bony eye socket, including the periorbita, the orbital fat, the eye muscles, the optic nerve, the conjunctiva and the globe of the eye itself.

Each procedure listed in this section describes a slightly different extent of eye and eye socket removal and each is done for a different reason. Eye surgeons perform eviscerations and enucleations, and exenterations are done by head and neck surgeons with or without an eye surgeon.

Preparing for surgery

Your doctor and care team will share instructions for surgery preparation. In general, you should not eat or drink anything except essential medications anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital a few hours before the scheduled operation. This is so the nurses and anesthesiologist can confirm everything is in order for you to have as safe a surgery as possible. You will be evaluated by your surgeon before receiving the anesthesia and falling asleep, and you can any last-minute questions at that time.

What to expect

  • Evisceration: This is the removal of the contents of the eye but leaving the outer layer of the eyeball, or sclera, intact. This is performed by an eye surgeon in the case of infections, severe pain or problems inside the eye if vision is already lost. This should not be used for malignant tumors, or cancer.

This can be done with a regional nerve block without general anesthesia. However, a small dose of anesthesia may be given to keep you still. After the area is numb and you are sedated, your eye surgeon will make an incision and use a curette to remove the contents of the eye. At the end, the sclera will be left open to drain, in cases of infection, or sewn closed. Antibiotic ointment and a bandage are then applied. You will be discharged and sent home when the pain is under control and the swelling has decreased. An artificial eye can be placed at a later date.

  • Enucleation:
    This involves the removal of the eye, including the globe, but leaving the rest of the orbital (eye socket) contents in place. Examples of the orbital contents that are left in place include the bones of the orbit, extraocular muscles, fat and conjunctiva. Enucleations are done for infections or malignant cancers that are completely within the globe of the eye. This can be done for cancers such as retinoblastoma or other cancers in which vision is already gone, such as melanoma. Another reason to perform an enucleation is in the case of trauma to the eye that exposes the bloodstream to antigens inside the eyeball. If antigens are not removed quickly, the exposure can lead to an immune reaction that causes blindness in the other eye.

Enucleation can be done with the same type of anesthesia as evisceration. General anesthesia can be used, if required. The key difference in this operation is that the entire globe is removed. This requires cutting the six extraocular muscles as well as the optic nerve. At the end of the procedure, the conjunctiva will be sewn together and an antibiotic ointment and bandage will be applied. There is less post-operative pain and swelling with enucleation as compared with evisceration. You will be discharged and sent home when the pain is under control and the swelling has decreased. An artificial eye can be placed at a later date.

  • Orbital exenteration: This is the removal of all eye socket contents, including muscles, the lacrimal gland system, the optic nerve as well as varying parts of the bone of the orbit. The eyelid can be spared, depending on the extent of the tumor. This is done for large cancers of the eye, the skin over the eye or eyelid or cancers from other areas that extend into the eye socket, including the paranasal sinuses, maxilla, skin or a part of the eye. It can be required for very bad infections, such as aggressive fungal infections.

Orbital exenteration is done under general anesthesia. Since this procedure is done for the spread of a cancer into the eye socket from another location, this procedure is often done along with an associated procedure such as a maxillectomy or craniofacial resection. After the procedure, the eye socket can be left alone, lined with a skin graft or reconstructed with a flap if a large defect remains. If a large resection with a flap for reconstruction is required, your doctor might think it safest to perform a tracheotomy as well. For some cancers, a neck dissection might be recommended.

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Recovery and aftercare

The recovery course will depend on the extent of the surgery and reconstruction. With some surgeries, you could go home after a few hours of observation in the recovery room. Others might require a stay in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve.

If you stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before returning home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps. Prosthetic eyes are made a few months after surgery.

Risks

As with any procedure, there are risks in undergoing removal of the eye that you need to be aware of. You will not be able to see after the procedure. However, some other possible risks will include:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Infection: There is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection. Because the orbital cavity and the eye are so intimately associated with the brain, a risk of brain infection or other problems exists.
  • Other: Other risks will be associated with the adjunct procedure being performed, such as maxillectomy or craniofacial resection.