ENUCLEATION

It is excision of the eyeball. It can be performed under
local anaesthesia in adults and under general
anaesthesia in children.
Indications
1. Absolute indications are retinoblastoma and
malignant melanoma.
2. Relative indications are painful blind eye,
mutilating ocular injuries, anterior staphyloma
and phthisis bulbi.
Surgical techniques (Fig. 11.38).
1. Separation of conjunctiva and Tenon’s capsule
(Fig. 11.38A): Conjunctiva is incised all around
the limbus with the help of spring scissors.
Undermining of the conjunctiva and Tenon’s
capsule is done combinedly, all around up to the
equator, using blunt-tipped curved scissors. This
manoeuvre exposes the extraocular muscles.
2. Separation of extraocular muscles (Fig. 11.38B):
The rectus muscles are pulled out one by one
with the help of a muscle hook and a 3-0 silk
suture is passed near the insertion of each
muscle. The muscle is then cut with the help of
tenotomy scissors leaving behind a small stump
carrying the suture. The inferior and superior
oblique muscles are hooked out and cut near the
globe.
3. Cutting of optic nerve (Fig. 11.38C): The eyeball
is prolapsed out by stretching and pushing down
the eye speculum. The eyeball is pulled out with
the help of sutures passed through the muscle
stumps. The enucleation scissiors is then
introduced along the medial wall up to the
posterior aspect of the eyeball. Optic nerve is felt
and then cut with the scissors while maintaining
a constant pull on the eyeball.
4. Removal of eyeball: The eyeball is pulled out of
the orbit by incising the remaining tissue adherent
to it.
5. Haemostasis is achieved by packing the orbital
cavity with a wet pack and pressing it back.
6. Inserting an orbital implant (Fig. 11.38D):
Preferably an orbital implant (made up of PMMA
Medpor or hydroxyapatite) of appropriate size
should be inserted into the orbit and sutured
with the rectus muscles.
7. Closure of conjunctiva and Tenon’s capsule is
done separately. Tenon’s capsule is sutured
horizontally with 6-0 vicryl or chromic catgut.
Conjunctiva is sutured vertically so that
conjunctival fornies are retained deep with 6-0
silk sutures (Fig. 11.38 E) which are removed after
8-10 days.
8. Dressing. Antibiotic ointment is applied, lids are
closed and dressing is done with firm pressure
using sterile eye pads and a bandage.
Fitting of artifial prosthetic eye
Conforme may be used postoperatively so that the
conjuctival fornices are retained deep. A proper sized
prosthetic eye can be inserted for good cosmetic
appearance (Fig. 11.39) after 6 weeks when healing of
the enucleated socket is complete.