**Eye Removal — Current Indications and Technical Tips**

César Hita-Antón, Lourdes Jordano-Luna and Rosario Díez-Villalba

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/61030

#### **Abstract**

The removal of the eyeball with or without other orbital tissues is always a complicat‐ ed decision to take and nearly always involves the beginning of a new and intense doctor-patient relationship. The loss of the globe results in the loss of binocular vision and depth perception, thus the patient is limited when applying for certain jobs or handling delicate or dangerous materials. They may also be prohibited to drive in some countries o may have to do so with special care where permitted. The psycho‐ logical impact on the patients´ life may be even greater as it may be perceived as a severe facial disfiguration. Some patients may prefer to stay at home and their social life may be deeply affected. Since facial and eye appearance is essential for normal hu‐ man relations and interaction, prosthetic eyes or orbits should imitate the eye, in most cases, or the whole orbit-eyelids-eye complex, which is less frequent.

**Keywords:** enucleation, evisceration, exenteration, orbital implant

#### **1. Introduction**

The need to remove an eye or other orbital contents is always difficult to digest for a patient. Many of them will experience the five stages of grief described by the Swiss psychiatrist Elisabeth Kübler-Ross in her 1969 book [1] *On Death and Dying*, inspired by her work with terminally ill patients. Older patients may think that these kinds of surgeries, especially exenteration, are not worth it. Younger patients are usually very worried about the cosmetic result rather than the difficulty of the surgery and the postoperative period. The ophthalmol‐ ogist will need a good dose of empathy and psychology skills to explain to the patient that the planned surgery is the only and best option. The oculoplastic surgeon must be ready to hear that some patients will wish to ask for a second opinion. This may annoy the doctor in charge of the patient, but despite of this, it is advisable to help the patient look for a second opinion with other colleagues. When dealing with these kinds of patients, it is crucial to take your time

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to explain with detail the surgical technique, the time the patient is expected to stay in the hospital, the need for frequent bandage changes in the hospital clinic, the possible complica‐ tions of the socket, and a long recovery period before a prosthesis can be fitted in.

Evisceration, enucleation, and exenteration are the three main surgical options. Evisceration is the removal of the contents of the globe while leaving the sclera and extraocular muscles intact. Enucleation is the removal of the eye from the orbit while preserving all the other orbital structures, and exenteration is the removal of the globe as well as the soft tissues of the orbit (connective tissue, fat, and muscles).

There is evidence that Egyptians and Sumerians used artificial eyes to decorate their mummies and their statues, respectively; however, there is no evidence to suggest that they used them for medical purposes in living people. Clay models resembling eyes were used in the Roman Empire around 500 BC to cover phthisical eyes. It was not until the 16th century that enuclea‐ tion surgeries were reported in the medical literature. In 1583, George Bartisch first described the extirpation of an eye. In 1817, Bear introduced evisceration in an eye with an expulsive hemorrhage when performing an iridectomy for an acute glaucoma [2].

It was in 1874 when Noyes reported the routine evisceration of the ocular contents when there was severe intraocular infection [3]. Later, in 1884, Mules reported for the first time the use of an orbital glass sphere implant in an eviscerated cavity, this becoming the bedrock of volume loss restoration and improving dramatically cosmetic results of this surgery [2,4]. In 1887, Frost inserted a crystal ball orbital implant inside Tenon's capsule after an enucleation procedure [5].

Since then, advances in surgical techniques, anesthesia, new implants, and wrapping materials and prosthetics over the past decade have greatly improved surgical outcomes and patient satisfaction. Today, most patients have good cosmetic results following the removal of and eye. However, even an exquisite surgical technique cannot prevent complications in the immediate and long-term follow-up of these sockets, making these patients challenging for the Oculoplastic Surgeon.

The decision to remove an eye must be individualized to each patient. Advantages and disadvantages exist among the different surgical techniques and implant materials.
