**3. Surgical techniques**

#### **3.1. Enucleation surgical technique**

**1.** It is absolutely mandatory to ensure we will remove the correct eye. Sometimes it is obvious which eye should be enucleated, like in a severely traumatized eye, but in other cases, the eye can be morphologically perfect and doubts can arise. This can be the case of a choroidal melanoma. We strongly recommend to read the patients notes and ask the patient to identify the eye that should be removed. Once sure, the eye should be marked with pen with an arrow or letters on the side of the forehead of that eye. We also like to dilate the eye with tropicamide [14]. This marks the side to operate on and allows the surgeon to check the tumor inside the globe in the operating room.


**Figure 1.** 360° limbal peritomy

**8.** Blunt dissect Tenon's capsule from the globe. Introduce your dissection scissors beneath the conjunctiva and Tenon in the limbus in any of the four quadrants limited by the four rectus muscles and smoothly direct your dissection posteriorly and around the globe until you feel you are close to the optic nerve. Repeat this maneuver in the other three quadrants (Figure 2).

**Figure 2.** Blunt dissection of Tenon´s capsule

dilate the eye with tropicamide [14]. This marks the side to operate on and allows the

**2.** Once in the operating room, we ask the patient to identify calling out his name and surname and age. We ask again which eye is the one to be removed and to signal it for us

**3.** Although we are aware some surgeons prefer intravenous sedation and local anesthesia, it is of our preference and of our patients to undergo general anesthesia. Even in cases of general anesthesia, some surgeons also inject local anesthesia so as to obtain local vasoconstriction, which will aid the surgeon making the surgery "cleaner" and faster. Two percent lidocaine with 1:100,000 epinephrine can be used for superficial injection like in the subconjunctival space. Retrobulbar anesthesia is made with a combination of 2%

**4.** Intravenous antibiotic is usually used 30 min prior to surgery in the presurgery prepara‐

**5.** We prep and drape in the standard fashion using povidone iodine for the skin and conjunctiva. We like to cover the other eye, but some may prefer to let the other eye

**6.** We use a lid speculum, taking care to protect the field from eyelashes. If eyelashes enter the field, these can be cut or stuck to the eyelid with an adhesive skin closure.

**7.** Using Westcott scissors or dissection scissors, perform a 360° limbal peritomy trying to leave on the limbus no more than 1 mm of conjunctiva. Remember to be as careful as possible. The conjunctiva, once closed at the end of the surgery, will be the first defensive

**8.** Blunt dissect Tenon's capsule from the globe. Introduce your dissection scissors beneath the conjunctiva and Tenon in the limbus in any of the four quadrants limited by the four

surgeon to check the tumor inside the globe in the operating room.

lidocaine and 1:100,000 epinephrine mixed 1:1 with 75% bupivacaine.

with his hand before he lies on the operating table.

tion area.

28 Advances in Eye Surgery

uncovered and closed.

**Figure 1.** 360° limbal peritomy

layer of the anopthalmic socket (Figure 1).

**9.** Localize each rectus muscle with one or two muscle hooks. Ensure you isolate the insertion of the muscle. If this is not visible, some Tenon tissue may be present. Remove it with blunt forceps, pulling it away from the muscle insertion (Figure 3).

**Figure 3.** Muscle insertion isolation

**10.** Pass a 5/0 absorbable suture in a whiplock fashion on either side of the muscles insertion. Cauterize with a monopolar (Colorado needle) or bipolar cautery to avoid bleeding and then cut the insertion of the muscle with a scissor leaving 1 or 2 mm of insertion on the globe (this stump will be useful in the future to pull the eye out of the orbit). Clamp the sutures for the four rectus muscles away from the surgical field with bulldog clamps or hemostats. The muscles will "spread" away from the globe (Figures 3-5).

**Figure 4.** Muscle insertion is cut

**Figure 5.** Four rectus muscles are isolated

**11.** Isolate the inferior oblique muscle in the inferotemporal quadrant with a muscle hook sweeping it from posterior to anterior toward where the inferior rectus was located. As with the rectus muscles, cauterize and cut. Some surgeons like to reinsert the inferior oblique muscle in the orbital implant. In our experience, it is not necessary to achieve a correct implant motility (Figure 6).

**Figure 6.** Inferior oblique exposure

then cut the insertion of the muscle with a scissor leaving 1 or 2 mm of insertion on the globe (this stump will be useful in the future to pull the eye out of the orbit). Clamp the sutures for the four rectus muscles away from the surgical field with bulldog clamps or

**11.** Isolate the inferior oblique muscle in the inferotemporal quadrant with a muscle hook sweeping it from posterior to anterior toward where the inferior rectus was located. As with the rectus muscles, cauterize and cut. Some surgeons like to reinsert the inferior oblique muscle in the orbital implant. In our experience, it is not necessary to achieve a

hemostats. The muscles will "spread" away from the globe (Figures 3-5).

**Figure 4.** Muscle insertion is cut

30 Advances in Eye Surgery

**Figure 5.** Four rectus muscles are isolated

correct implant motility (Figure 6).


**Figure 7.** Hemostat placed on optic nerve which is cut with scissors

**Figure 8.** Sagital view of the orbita showing the optic nerve being cut

**15.** Once the nerve is cut and you pull with your silk sutures, you may feel something is retaining the globe in the orbit. It is usually small segments of retained Tenon's capsule. Cut this Tenon's tissue with care as it may contain small vessels that may bleed. We recommend you cut this tissue as close to the globe as possible in order to avoid inadver‐ tent injury to other tissues like muscles or orbital fat (Figure 9).

**Figure 9.** Globe removed from the orbit. Optic nerve stump compressed by hemostat


**Figure 8.** Sagital view of the orbita showing the optic nerve being cut

32 Advances in Eye Surgery

tent injury to other tissues like muscles or orbital fat (Figure 9).

**Figure 9.** Globe removed from the orbit. Optic nerve stump compressed by hemostat

minutes is enough to stop small hemorrhages.

removed eye was in phthisis.

**16.** Place the globe in an auxiliary table and prepare it to send to the pathologist.

**17.** Release the hemostat around the stump of the optic nerve. Apply pressure in the socket and coagulate the optic nerve with the monopolar or bipolar cautery if there is generous bleeding. Avoid excessive cauterization in the socket as it may predispose to future complications of the cavity such as its contraction or implant displacement. Sometimes gentle pressure with gauze soaked in thrombin, saline, or hydrogen peroxide for a few

**18.** Once the socket is ready, the next step is to introduce the orbital implant. The size of which should have been chosen depending of the axial length of the eye or the fellow eye if the

**15.** Once the nerve is cut and you pull with your silk sutures, you may feel something is retaining the globe in the orbit. It is usually small segments of retained Tenon's capsule. Cut this Tenon's tissue with care as it may contain small vessels that may bleed. We recommend you cut this tissue as close to the globe as possible in order to avoid inadver‐


**Figure 10.** Sagital view of the orbit showing four rectus muscles sutured to the implant

**Figure 11.** Frontal view of the orbit showing four rectus muscles sutured to the implant

**24.** Meticulous closure of Tenon's capsule is very important. We recommend interrupted buried 5/0 absorbable (polyglactyn) sutures, but some may prefer a running suture. It is extremely important to avoid tension when closing Tenon's layer (Figure 12).

**Figure 12.** Tenon´s capsule sutured beneath conjunctiva


**Figure 13.** Conjunctiva sutured under an acrylic conformer

#### **3.2. Evisceration surgical technique**

**Figure 11.** Frontal view of the orbit showing four rectus muscles sutured to the implant

**Figure 12.** Tenon´s capsule sutured beneath conjunctiva

maintain the conformer in place for 1 or 2 weeks.

**27.** Tight application of eye patches will finish our surgery.

analgesia.

34 Advances in Eye Surgery

**24.** Meticulous closure of Tenon's capsule is very important. We recommend interrupted buried 5/0 absorbable (polyglactyn) sutures, but some may prefer a running suture. It is

**25.** A running 6/0 absorbable suture is used to close the conjunctiva, once again, avoiding not too close tissue under tension. Nerad [14] recommends local anesthetic injection into the retrobulbar space for postoperative pain relief (Figure 13). We prefer intravenous

**26.** Abundant antibiotic and steroid ointment should be placed in the socket, and finally an acrylic conformer should be placed. Some surgeons perform a temporal tarsorrhaphy to

extremely important to avoid tension when closing Tenon's layer (Figure 12).


**Figure 14.** Keratectomy is started with number 15 or number 11 blades

**Figure 15.** Choroid is dissected from sclera


point in the posterior sclera. The four sclerotomies reach one another to form four separate scleral petals, each containing one rectus muscle insertion. This last option allows in our experience an easier insertion of the orbital implant in the intraconal space and secondarily makes complete cover of the implant very simple (Figure 16).

**Figure 16.** Four sclerotomies performed with scissors

**10.** 9. Gently pull the four petals out of the socket so the implant can be placed as deep as possible using a Carter sphere introducer or your fingers. The further the implant enters the orbit, the easier it will be to bring the four petals anterior to the implant. Because the petals are independent from each other and from the optic nerve, the sclera can cover any size of implant without tension. The vertical petals are sutured to each other in front of the implant using a continuous 5/0 absorbable suture. The horizontal petals are sutured in the same way over the vertical petals. Make sure that sutures are tied with no tension (Figures 17-20).

**Figure 17.** Four petals stretched wide appart

**Figure 15.** Choroid is dissected from sclera

36 Advances in Eye Surgery

and remove retained uveal tissue with gauze.

**Figure 14.** Keratectomy is started with number 15 or number 11 blades

**8.** Wipe the internal scleral surface with cotton-tipped applicators soaked in absolute alcohol

**9.** Upon this point of the surgery, there are different options to prepare the sclera to accom‐ modate the orbital implant. Some authors prefer to make 10-15 mm radial scleral incisions in the four oblique quadrants, avoiding the insertions of the rectus muscles [13]. Others prefer a complete posterior sclerotomy, transecting the sclera from the superior nasal and inferior temporal limbus to the optic nerve. Sclera is then trimmed from the optic nerve in a circular fashion. We prefer the four-petal technique described by Sales-Sanz and Sanz-Lopez [15]: four sclerotomies are performed from the limbus, between the rectus muscle insertions, to the optic nerve with Stevens scissors. The optic nerve is cut at its insertion

**Figure 18.** Impant placed between petals pressed deep inside the orbit

**Figure 19.** Implant wrapped with sclera from the upper and lower petals with muscles attached


**Figure 20.** Sagital view of orbit showing correct wrapping of implant with four petals of sclera


#### **3.3. Exenteration technique**

Technically, orbital exenteration has several variations, each with its own indications.

#### **3.4. Total exenteration**

**Figure 18.** Impant placed between petals pressed deep inside the orbit

38 Advances in Eye Surgery

**Figure 19.** Implant wrapped with sclera from the upper and lower petals with muscles attached

close tissue under tension (Figure 13).

**11.** Meticulous closure of Tenon's capsule is very important. We recommend interrupted buried 5/0 absorbable (polyglactyn) sutures; again, some may prefer running sutures. It

**12.** A running 6/0 absorbable suture is used to close the conjunctiva, once again avoiding to

is extremely important to avoid tension when closing Tenon's layer (Figure 12).


**Figure 21.** Frontal view of implant wrapped in scleral petals with attached rectus muscles

**Figure 22.** Skin incisión with number 11 or number 15 blades following the inner surface of the orbital rim

**6.** Once the periorbita is reached, incise it with a scalpel blade, a monopolar cautery, or a Freer periosteal elevator. Sometimes it is difficult to elevate the periorbital periostium as it is firmly stuck to the underlying bone, especially in the frontal bone and the frontal process of the maxillary bone (Figure 23).

**Figure 23.** Detail of the periorbita being incised. Note ROOF being rejected temporally and lateral tarsal ligament being rejected nasally

**7.** Once elevated the periorbital periostium, continue elevating the orbital periosteum. Care should be taken where the periosteum is more tightly adhered to the bone: anterior and posterior lacrimal crests, insertion of the inferior oblique muscle, trochlea, lateral orbital tubercule, and superior and inferior orbital fissures (Figure 24).

**Figure 24.** Freer periostal elevator dissecting periorbita

**Figure 22.** Skin incisión with number 11 or number 15 blades following the inner surface of the orbital rim

**Figure 21.** Frontal view of implant wrapped in scleral petals with attached rectus muscles

process of the maxillary bone (Figure 23).

rejected nasally

40 Advances in Eye Surgery

**6.** Once the periorbita is reached, incise it with a scalpel blade, a monopolar cautery, or a Freer periosteal elevator. Sometimes it is difficult to elevate the periorbital periostium as it is firmly stuck to the underlying bone, especially in the frontal bone and the frontal

**Figure 23.** Detail of the periorbita being incised. Note ROOF being rejected temporally and lateral tarsal ligament being


**Figure 25.** Dissection is carried on deep back towards the orbital apex

**Figure 26.** Avoid damaging important vessels such as the Anterior Ethmoidal Artery

**13.** Continue the dissection until the apex is reached. Carefully cauterize the superior orbital fissure and the posterior orbital tissues, including the optic nerve. We recommend to be patient and slowly cauterize and cut in small bits to avoid bleeding that may be difficult to control and may frighten the surgeon (Figure 27).

**Figure 27.** Sagital view of Freer periostal elevator dissecting the periorbita posteriorly


**Figure 28.** Frontal view of the exenterated orbit showing bone landmarks and hemostasis of the orbital apex

#### **3.5. Eyelid-sparing exenteration**

**13.** Continue the dissection until the apex is reached. Carefully cauterize the superior orbital fissure and the posterior orbital tissues, including the optic nerve. We recommend to be patient and slowly cauterize and cut in small bits to avoid bleeding that may be difficult

to control and may frighten the surgeon (Figure 27).

**Figure 26.** Avoid damaging important vessels such as the Anterior Ethmoidal Artery

**Figure 25.** Dissection is carried on deep back towards the orbital apex

42 Advances in Eye Surgery

**Figure 27.** Sagital view of Freer periostal elevator dissecting the periorbita posteriorly

We prefer this procedure when the disease does not affect the eyelid because the skin and orbicularis muscle can be used as "primers" to initiate the cavity's granulation and epitheli‐ alization. The difference with the previously described technique is that the skin incisions are placed 2 mm above the lash line and are joined at the medial and lateral canthus. Dissection is carried out in the preseptal plane or in the preorbicularis plane. We prefer the preseptal plane; it is easy to follow and allows a good blood supply to the future granulation tissues.

In conclusion, with this procedure, we partly cover the orbital bones, and we add a vascular supply to our skin flap, reducing the time the socket needs to granulate.

#### **3.6. Subtotal exenteration**

It may be performed when the disease involves anterior orbit or conjunctiva as in conjunctival melanoma or sebaceous cell carcinoma without evidence of deep orbital invasion. It spares orbital tissues from the deep orbit; thus, the socket should heal earlier, but orbital prosthesis fixation can be complicated since there is less space.

The technique is similar to that of total exenteration but subperiosteal dissection is not carried out as far posteriorly. Orbital tissues are cut, and thorough hemostasia is performed.

#### **3.7. Extended exenteration with bone removal**

Unfortunately, high-grade malignancies or osteolytic processes will require total exenteration and the removal of the bones of the orbit. Help from other surgeons such as neurosurgeons, otolaryngology, or maxillofacial surgeons is mandatory in these cases.

#### **3.8. Reconstruction of the exenterated orbit**

The decision to reconstruct the exenterated socket depends on what is planned for that orbit. When the patient desires an orbital prosthesis, spontaneous epithelialization, skin grafts, or thin local flaps are good options. Some surgeons argue that spontaneous granulation permits a better follow-up of the cavity in order to treat as soon as possible if disease recurs. Others prefer to fill the cavity with temporalis muscle flap but this increases the difficulty to adapt an orbital prosthesis for the ocularist.

#### **3.9. Spontaneous granulation**

It is the fastest way to finish the surgery, and it reduces surgical morbidity in other sites but requires very frequent postsurgical care, initially three times a week and later on every 1 or 2 weeks until complete epithelialization is observed. This can take up to 2 or 3 months more than when split thickness grafts are used. Usually, gauzes with antibiotic ointment are applied in the first month.

#### **3.10. Skin grafting**

Split thickness grafts, usually harvested from the thigh with an automated dermatome, are used, which is technically simple to perform and takes less time than a more complex flap reconstruction. In order to adapt the graft to the socket, slits can be performed with scalpel or a number 15 blade. The edges are sutured to the borders of the surgery with absorbable 6/0 sutures. Gauze soaked in antibiotic ointment is packed in the socket, and a pressure dressing is placed for 1 week. Once this is removed, the gauze will be changed every 2 or 3 days until the graft is correctly stuck to the bone beneath.

#### **3.11. Soft tissue reconstruction**

alization. The difference with the previously described technique is that the skin incisions are placed 2 mm above the lash line and are joined at the medial and lateral canthus. Dissection is carried out in the preseptal plane or in the preorbicularis plane. We prefer the preseptal plane; it is easy to follow and allows a good blood supply to the future granulation tissues. In conclusion, with this procedure, we partly cover the orbital bones, and we add a vascular

It may be performed when the disease involves anterior orbit or conjunctiva as in conjunctival melanoma or sebaceous cell carcinoma without evidence of deep orbital invasion. It spares orbital tissues from the deep orbit; thus, the socket should heal earlier, but orbital prosthesis

The technique is similar to that of total exenteration but subperiosteal dissection is not carried

Unfortunately, high-grade malignancies or osteolytic processes will require total exenteration and the removal of the bones of the orbit. Help from other surgeons such as neurosurgeons,

The decision to reconstruct the exenterated socket depends on what is planned for that orbit. When the patient desires an orbital prosthesis, spontaneous epithelialization, skin grafts, or thin local flaps are good options. Some surgeons argue that spontaneous granulation permits a better follow-up of the cavity in order to treat as soon as possible if disease recurs. Others prefer to fill the cavity with temporalis muscle flap but this increases the difficulty to adapt an

It is the fastest way to finish the surgery, and it reduces surgical morbidity in other sites but requires very frequent postsurgical care, initially three times a week and later on every 1 or 2 weeks until complete epithelialization is observed. This can take up to 2 or 3 months more than when split thickness grafts are used. Usually, gauzes with antibiotic ointment are applied in

Split thickness grafts, usually harvested from the thigh with an automated dermatome, are used, which is technically simple to perform and takes less time than a more complex flap reconstruction. In order to adapt the graft to the socket, slits can be performed with scalpel or a number 15 blade. The edges are sutured to the borders of the surgery with absorbable 6/0

out as far posteriorly. Orbital tissues are cut, and thorough hemostasia is performed.

supply to our skin flap, reducing the time the socket needs to granulate.

otolaryngology, or maxillofacial surgeons is mandatory in these cases.

fixation can be complicated since there is less space.

**3.7. Extended exenteration with bone removal**

**3.8. Reconstruction of the exenterated orbit**

orbital prosthesis for the ocularist.

**3.9. Spontaneous granulation**

the first month.

**3.10. Skin grafting**

**3.6. Subtotal exenteration**

44 Advances in Eye Surgery

Some surgeons advocate primary reconstruction during exenteration surgery. Volume loss in the socket can be replaced with vascularized free flaps. They are useful to cover alloplastic implants or other kind of flaps used for bony reconstruction. One of their disadvantages is donor site morbidity. Another one is that aesthetics in the donor site and the socket may seem unnatural. Many local flaps have been used, including temporoparietal fascia, temporalis muscle, or frontalis muscle. As said previously, these flaps can potentially affect postoperative tumor surveillance, making imaging techniques, especially MRI, essential and increasing the cost for the National Health Service or the insurance company. On the other hand, orbital obliteration with a flap reconstruction may confer less pain, improve personal hygiene, and reduce the risk of sino-orbital fistula formation [17]. Spiegel et al [18] reported that orbital obliteration reduces the risk of intracranial infections and facilitates dosage calculation of radiotherapy by providing a more consistent and predictable tissue density.

#### **3.12. Rehabilitation of the socket**

Once exenterated, eviscerated, or enucleated, the socket is perceived by the patient and the family as a very significant facial deformity. Initially, the simplest way to mask the socket is with eye patches. However, once the cavity has healed, the patient can benefit from the experience of an ocularist.

Enucleated or eviscerated cavities will have a temporal prosthesis fitted in 4 or 6 weeks after surgery. Later on, a prosthesis will be made using a modified impression technique, so a custom-made prosthesis will be designed and adapted at the ocularist. It is very common that artificial eyes need to be adapted several times after the initial fitting before the patient feels comfortable with them. The patient will be followed at the ocularist once or twice a year to check if the prosthesis fits correctly in the socket, if it is affecting the lower eyelid (the weight of the prosthesis is a key factor) or if its surface needs polishing. The ophthalmologist will check the prosthesis position, the presence or absence of discharge, whether the fornices look normal, how the superior sulcus is, eyelid malpositions, eyelash malposition, relative enoph‐ thalmos, etc., when the patient visits the clinic.

Exenterated orbits are more difficult to deal with. Orbital prostheses are made by experienced anaplastologists or ocularists. The material used is completely different, usually silicone. Some patients may find glasses useful to mask the skin silicone interface. Sometimes, especially in shallow orbits, the prosthesis may tend to fall; therefore, magnetic coupling with osseointe‐ grated screws can be fitted in, typically several months after epithelialization of the orbit is complete. Unfortunately, some patients might find that the lack of movement of these prostheses may make other people feel uncomfortable, and prefer to use just an eye patch.
