Evisceration is a surgical technique that removes all intraocular contents (uvea, lens, vitreous, and retina) while preserving the scleral shell, extraocular muscle insertions, and orbital adnexa. After removal, an orbital implant (socket implant) is placed in the cavity to maintain orbital volume.
Historically, it was first reported in 1817 by James Bear as a treatment after expulsive hemorrhage. In the late 19th century, Noyes developed it for treating intraocular infections, and Mules established the placement of orbital implants.
As for the epidemiology of eye injuries, 55 million eye injuries occur worldwide each year, and 90% are said to be preventable. Blindness due to eye injury is estimated at about 1/100,000 people per year1).
This procedure removes the intraocular tissues while leaving the sclera with the extraocular muscles attached, so placing an implant in the scleral cavity causes less sunken eye appearance and is slightly better cosmetically than enucleation. Even without implant placement, the sunken appearance is less severe than with enucleation. In Japan, there is no orbital implant approved by the Ministry of Health, Labour and Welfare.
Evisceration preserves the scleral shell, extraocular muscles, and orbital adnexa, and removes only the intraocular contents. Enucleation removes the entire eyeball. Evisceration offers better prosthetic motility, is less invasive, and has an advantage cosmetically. See Comparison of surgical methods for details.
Eyes that are candidates for evisceration are almost all blind. The main subjective symptoms are as follows.
The main diseases for which evisceration is indicated are as follows.
Main indications
Endophthalmitis: A severe bacterial or fungal infection inside the eye.
Penetrating ocular trauma: Severe trauma that cannot be repaired in the early period after injury.
Painful blind eye: a blind eye with pain that does not respond to narcotic analgesics.
Painful phthisis bulbi: only when intraocular tumor has been ruled out.
Absolute glaucoma: end-stage glaucoma resistant to medication and surgery.
Contraindications
Intraocular malignant tumor: if known or suspected, this is an absolute contraindication. Enucleation is recommended because of the risk of tumor cell seeding from retained uveal tissue.
Phthisis bulbi and microphthalmos: relative contraindications. There may not be enough scleral volume to hold the implant.
As a selection criterion in trauma, enucleation is chosen when scleral damage or uveal prolapse is severe, while evisceration is chosen when the patient presents early and repair under microscopy is possible.
A special indication is self-enucleation (Oedipism). The annual number of cases of this condition in the setting of mental illness is said to be about 500, with schizophrenia and chronic depression each accounting for about 50%. It is most common in people in their 40s to 50s 1). In such cases, multidisciplinary collaboration among psychiatry, ophthalmology, and the police is important.
Because evisceration leaves uveal tissue behind, there is a risk of tumor cell seeding into the orbit. It has been reported that incidentally discovered intraocular tumors account for 1.95% of 13,591 cases. If a malignant tumor is suspected, enucleation is recommended.
The following tests are important for preoperative evaluation.
It can be performed under either general anesthesia or local anesthesia. Retrobulbar injection of an anesthetic with epinephrine can reduce bleeding and postoperative pain. Subconjunctival injection of local anesthetic (to help hemostasis and make the boundary with Tenon’s capsule clearer) or preoperative 10% phenylephrine eye drops may also be used.
The outline of the procedure is as follows.
Remove the scleral buckle and any glaucoma drainage device if present. Irrigate out silicone oil before the circumferential incision.
The main implant materials are as follows.
| Region | Main materials |
|---|---|
| Japan | PMMA (resin sphere)・acrylic sphere・silicone sphere・autologous bone fragments |
| Western countries | hydroxyapatite・Medball・alumina ceramic・porous polyethylene |
Preference for immediate and delayed (secondary) implantation varies by surgeon (in a survey of 206 oculoplastic surgeons, 46% chose immediate and 43% chose secondary). In 67 cases of endophthalmitis, the complication rate with immediate implantation was 12%.
It is not essential, but placing one helps preserve orbital volume and reduce enophthalmos. In Japan, there is no orbital implant approved by the Ministry of Health, Labour and Welfare, so its use is currently off-label.
The conformer (temporary prosthesis) is fitted immediately after surgery. Adjustment of the final prosthesis is done by visiting an ocularist 6 to 8 weeks after surgery. A custom-made prosthetic eye is made after the conjunctival sac has stabilized. As a guideline, start once pain and inflammation have eased, about 2 to 4 weeks after surgery.
Advantages of evisceration
Less invasive: The surgery is shorter, the procedure is simpler, and it is more cost-effective.
Better prosthesis movement: Because the extraocular muscles and orbital tissues are preserved, the artificial eye moves more naturally.
Advantageous for infection control: In cases of endophthalmitis, the risk of spread to the nervous system is lower.
Less pain and lower anesthesia risk: General anesthesia may be avoided.
Disadvantages of evisceration
Risk of sympathetic ophthalmia: There is a theoretical risk because uveal tissue is exposed during surgery. However, no confirmed cases were recorded in a survey of 880 cases.
Risk of intraocular tumor seeding: Tumor cells may spread because uveal tissue remains.
Implant exposure rate: The exposure rate of porous implants is 0–3.3% after evisceration (1.5–21.6% after enucleation)2).
In a prospective study (100 patients), evisceration with four-split sclera and an alloplastic implant was compared with enucleation using a hydroxyapatite implant, and the evisceration group showed a wider implant range of motion and lower cost. In a retrospective study (32 enucleation cases vs 52 evisceration cases), evisceration also had better motility and fewer postoperative complications, and there was no significant difference in the final cosmetic outcome.
Theoretically, when uveal tissue is immunologically exposed during surgery, there is concern that an autoimmune response against the fellow eye (sympathetic ophthalmia) may occur. However, in a survey of 880 cases, there is no definitive record of sympathetic ophthalmia after evisceration. Also, the 14-day rule that says evisceration within 14 days can prevent sympathetic ophthalmia is considered to have no scientific basis.
The HC-HA/PTX3 complex abundant in the umbilical cord amnion upregulates IL-10 and downregulates IL-12, inducing macrophages toward the M2 (anti-inflammatory) phenotype and promoting anti-inflammatory, anti-scarring, and tissue-regenerating effects2).
In children, attention to orbital development is necessary. By age 5, orbital volume reaches 80% of adult volume (which is completed at 14–15 years of age), and eye volume increases threefold from birth to puberty. Because mechanical stimulation to bone is essential for orbital growth, appropriate implant selection and long-term follow-up are important in children.
Umbilical cord amnion has been reported as a new reconstruction method for wound dehiscence after evisceration (one of the most common local complications).
Bunin (2022) performed evisceration (with insertion of at least a 16 mm hydroxyapatite implant) in a 51-year-old woman with a painful blind eye due to proliferative diabetic retinopathy, and then reconstructed postoperative dehiscence of the conjunctival suture using a donor scleral shell and a 2.5×2.0 cm AmnioGuard (Bio-Tissue, Miami) 2). Umbilical cord amnion is about 10 times thicker than ordinary amnion and is rich in HC-HA/PTX3. At 6 weeks after surgery, mobility was good; by 7 weeks, prosthesis fitting was completed; and good cosmetic results were maintained even 8 months later.
An improved technique (reported by Long et al.) has been described for placing the implant behind the posterior sclera during evisceration. After a posterior scleral incision, the optic nerve is cut, and a large 22–23 mm implant is placed behind the posterior and anterior scleral flaps. Covering the front with two layers of sclera is said to reduce the risk of wound dehiscence and exposure.
A method has been reported in which an anterior scleral ring and DFG are sutured during primary implantation in evisceration. As an alternative to an exposed implant, it has the advantage that the grafted fat can grow as the child grows, especially in children under 5 years old.
In cases involving self-inflicted eye injury (Oedipism), postoperative psychiatric support contributes to better outcomes.
Narang et al. (2021) performed evisceration plus primary closure without a spherical implant for a 3 mm central corneal perforation and spontaneous evisceration caused by self-inflicted injury to the left eye in a patient with schizophrenia (58-year-old man) 1). Evisceration was chosen to prevent further self-injury and reduce the risk of sympathetic ophthalmia. At 5 months after surgery, his mental state and compliance were good. The importance of coordination by a multidisciplinary team of psychiatry, ophthalmology, and police is emphasized.
