1. Intermediate Format Enucleation/Evisceration/Exenteration
Procedures
Intermediate Format
Enucleation/Evisceration/Exenteration
Purpose of opthalmic surgery: to preserve or restore a patient’s optimal vision which may be endangered by congenital defects, injury, or disease.
Enucleation is en block removal of a structure—usually of the eye. The removal of an eye seems like a drastic measure to most people. Although many patients who require this surgery have no vision in the affected eye, those persons who do have vision in the affected eye recognize that the enucleation procedure will result in instantaneous, permanent, and total blindness of that eye. All patients who undergo this procedure will require an artificial eye (ocular prosthesis) as a cosmetic substitute for their natural eye.
Evisceration is sometimes performed rather than enucleation, which allows the shrunken remnants of the eye to be retained. Evisceration allows the patient to wear a prosthetic eye that will have mobility and a better cosmetic result—as it eliminates corneal sensitivity.

2. Objectives
Assess the related terminology and pathophysiology of the eye.
Analyze the diagnostic interventions for a patient undergoing an enucleation.
Plan the intraoperative course for a patient undergoing_____________.
Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for enucleation.
Describe the care of the specimen

4. Terms and Definitions Globe
Enucleation vs Exenteration vs Evisceration
Eyeball
Enucleation: removal of the entire eyeball for malignant tumors of the eyeball, trauma, or blind, painful glaucoma and (hopeless) infections; muscle stumps are preserved to form a pocket into which the prosthesis is secured
Exenteration of the eye: removal of all of the contents of the orbit, including periorbital fat, for advanced tumors which are usually malignant or tumors of the lids or the eyeball that have extended into the orbit
Evisceration of the eye: Removal of the contents of the eye, leaving the sclera intact and the muscles attached to the sclera to reduce the danger of transmission of intraocular infection to the orbit and brain, and to provide points for attachment of a prosthesis (According to MAVCC, this is performed in eyes that have been lost by infection).

5. Definition/Purpose of Procedure
Removal of the globe of the eye
Reasons
Intraocular malignant neoplasm
Penetrating ocular wound
Painful blind eye
Extensive damage/disfigurement
To eliminate a malignant tumor that has developed within the eye
Dr Fowler stated that this is called a melanoma of the eye. In Dorland’s illustrated Medical Dictionary, it states: an ocular malignant melanoma arises from the structures of the eye, usually the choroid, ciliary body, or the iris, and occurs most often in the 5th and 6th decades of life; the most common site of metastasis is the liver, hepatic metastasis being followed rapidly by death.
Another type of malignancy is Retinoblastoma (Dorland--) A malignant congenital blastoma, occurring in both hereditary and sporadic forms, composed of tumor cells arising from the retinoblasts, appearing in one or both eyes under 5 yrs of age, and usually diagnosed initially by a bright white or yellow pupillary reflex (leukokoria) Also called glioma retinae. Named by location of origin—also there is glioma endophytum, which is a retinoblastoma which originates in the inner layers of the retina and spreads toward the center of the globe. AND there is glioma exophytum—which begins in the outer layers of the retina and spreads away from the center of the globe.
To alleviate uncontrollable pain in a blind eye
To reduce the risk of "sympathetic" inflammation of the remaining eye when one eye has been severely injured and blinded

6. Pathophysiology Symptoms
Retinoblastoma is a malignant tumor (cancer) of the retina (part of the eye) that generally affects children under the age of 6.
Retinoblastoma occurs when a cell of the growing retina develops a mutation in the RB gene (a tumor suppresser gene). This mutation causes the cell to grow out of control and become cancer. Sometimes this mutation develops in a child whose family has never had eye cancer, but other times the mutation is present in several family members. If the mutation runs in the family, there is a 50% chance that an affected person's children will also have the mutation and a high risk of developing retinoblastoma.
One or both eyes may be affected. A visible whiteness in the pupil may be present. Blindness can occur in the affected eye, and the eyes may appear crossed. The tumor can spread to the eye socket, and to the brain, by means of the optic nerve. This is a rare tumor, except in families that carry the RB gene
Symptoms
A white glow in the eye that is often seen in photographs taken with a flash; instead of the typical "red eye" from the flash, the pupil may appear white or distorted
Pupil, white spots
Crossed eyes
A red, painful eye
Poor vision
The iris may be a different color in each eye.
Signs and tests
An examination of the eye with dilation of the pupil
A CT scan of the head to evaluate tumor and possible spread
An ultrasound of the eye (head and eye echoencephalogram)
Treatment Treatment options depend upon the size and location of the tumor. Small tumors may be treated by laser surgery. Radiation and chemotherapy may be needed if the tumor has spread beyond the eye. The eye may need to be removed if the tumor does not respond to other treatments. It is important to seek treatment from a physician with experience treating this rare type of tumor.
If the cancer has not spread beyond the eye, almost all patients can be cured, though cure may require aggressive treatment and even removal of the eye to be successful.

7. Surgical Intervention: Special Considerations
Patient Factors
Pediatric measures: prevention of hypothermia, communication techniques, distraction
Room Set-up
Anesthesia
General anesthesia preferred over local
Retrobulbar injection
Why is general preferred? Because of the psychological effects of surgery
Retrobulbar block is anesthetic injection behind the eyeball to block the ocularcardiac reflex that is produced by manipulation of the extraocular muscles. Usually the injection is !% lidocaine with epinephrine

8. Surgical Intervention: Positioning
Position during procedure
Supine
Supplies and equipment
Head donut headrest
Special considerations: high risk areas
Prep: betadine paint from hairline to mouth and from nose to ear on operative side (avoid in eyes or ears)
Irrigate globe w/NS using bulb syring, from inner to outer canthus; one gtt of ½ strength povidone-iodine solution may be instilled into eye before irrigation

9. Surgical Intervention: Special Considerations/Incision
State/Describe incision

10. Surgical Intervention: Supplies
General
Specific
Suture
Medications on field
BSS to moisten eye/irrigate anterior chamber—STSR may be responsible to irrigate cornea w/BSS q seconds to prevent drying of tissues
Catheters & Drains
Retrobulbar Block: 5 mL syringe & 1/1/2 inch needle

11. Surgical Intervention: Instruments
General (Basic): eye speculum &/or lid retractors, muscle hooks, knife handles (#3 and micro-beaver), scissors (Stevens tenotomy, Wescott), forceps (fine and heavy Bishop-Harmon), calipers, needleholders (micro and heavy), irrigating cannula (for BSS use bulb tipped; for instilling intraocular meds/air use 27 g angled blunt)
Specific: see eye extras; conformers & spheres--prosthetics
A. Instruments are small, wit fine, delicate tips
Tips and cutting surfaces need to be protected—usually stored in special instrument container to prevent damage 2. Points are inspected under magnification 3. Instruments are not allowed to touch each other or metal surface
Instrument cleaning: Instruments are wiped with distilled water on the sterile field. Ultrasonic cleaning with distilled water is used to dislodge materials not wiped
Instruments may be “milked” –lubricant used to keep functioning smoothly.
B. Other tips: Do not pass instruments or supplies directly over an exposed globe. Remember that surgeon may not be able to look away from microscope –place in a working position into surgeon’s hand

12. Instruments for surgery of globe or orbit
From Alexander’s p. 688.
1. Kerrison rongeur 2. Orbital implant or sphere 3. Lacrimal chisel 4. Freer elevator 5. Lacrimal sac retractor 6. Exenteration spoon 7 Arruga orbital retractor 8 enucleation scissors
1. Serrefine scissors 2. Wells evisceration spoon 3. Sphere introducer and holder Jameson recession forceps 5/6. Von Graefe muscle hooks
For a good selection of eye instruments by classification, see Fuller pp

13. Some other instruments, conformers
b. Castroviejo caliper c. Arruga lacrimal trephine d. West lacrimal chisel
Chalzion currettes f. Grieshaber trephine h. Bell erisophake I. Troutman alpah-chymotrypsin cannula j. Air injection cannula
Cyclodialysis cannula l. Castroviejo blade breaker n..sphere introducer
Wells enucleation spoon p. Kirby lens loop q. New Orleans lens loop
r. Castroviejo cyclodialysis spatula s. Troutman iris spatula t. Universal conformers u. Eye (Fox) shield.

14. Surgical Intervention: Equipment
General
Specific
Operative microscope
Bipolar ESU
Operative microscope:
Floor or ceiling mounted
Usually uses a mm focal distance lens
Foot controls allow for microscope adjustment /focusing by surgeon while working
Care of optics (post procedure): 1. remove loose particles with a clean soft brush or ear syringe Using a circular motion, remove blood solutions with a cotton –tipped applicator moistened with distilled water 3. Special cleaning solution is needed for removing oil or fingerprints

15. Surgical Intervention: Procedure Steps Overview
Traction sutures are placed in upper and lower eyelids
Conjunctiva is incised
Eye muscles are severed
Recti and inferior oblique muscles are anastomosed
Optic nerve is severed
Globe is removed
Sphere is introduced into the socket
Conjunctiva and Tenon’s capsule are sutured over the sphere

16. Surgical Intervention: Procedure Steps
Surgeon places suture (4-0 silk on fine cutter) thru upper eyelid and tags it with fine hemostat.
Same step at lower eyelid
The above sutures retract the levator muscles away from the area o of dissection & prevent their injury
Surgeon makes a 350 degree incision around the cornea in the conjuntiva as close to the limbus as possible. Incision is made w/ # 15 Bard-Parker blade or delicate iris scissors.
This saves as much conjunctiva as possible for closure later on
Using the iris scissors, the surgeon undermines the conjunctiva and Tenon’s capsule and prepares to sever the recti and oblique muscles from the globe
Where is the limbus? The limbus is the area where the cornea joins the sclera

17. Fuller p. 591: A. A 350-degree incision is made as close to the limbus as possible. B. Implant sphere is sutured in place

18. Surgical Intervention: Procedure Steps
Because the recti muscles will be sutured to the inferior oblique muscle, both muscles are tagged with suture of silk or Dexon, size 4-0 or 5-0.
The superior oblique muscle is severed and allowed to retract back.
The surgeon then severs the previously tagged inferior oblique muscle, secures it to the lateral rectus muscle with 4-0 silk suture, and pulls the globe anteriorly (forward).
STSR will have a muscle hook available now.
Surgeon passes the hook around the globe to ensure that all connections except the optic nerve have been severed.
Surgeon places a Mayo clamp across the optic nerve seconds to effect hemostasis

19. Surgical Intervention: Procedure Steps
Surgeon removes the clamp and uses curved enucleation scissors to sever the optic nerve across the area crushed by the Mayo clamp. This frees the globe, which is passed to the STSR for specimen.
If any intraocular contents have extruded into the socket, they must be cleaned out with irrigant and 4x4 gauze sponges.
Once the globe is removed, an implant must be placed and sutured to the socket to give it shape.
STSR will have several sizes of implant spheres –usual adult range is mm.
Surgeon selects the implant and conformer, and the sphere is introduced into the orbit
The implant is called a SPHERE over which a CONFORMER is placed.

20. Surgical Intervention: Procedure Steps
STSR passes 4-) Dexon to surgeon, with scleral biting forceps.
Tenon’s capsule is pulled the sphere and sutured in place.
Surgeon sutures the recti muscles to their appropriate positions on the sphere with 4-0 or 5-0 Dexon. The conjunctiva is closed with 5-0 Dexon.
STSR passes conformer to surgeon
Silk retraction sutures are removed. Surgeon instills antibiotic ointment.
Dressing of cotton eye pad is secured with tape.
In 4-6 weeks, a prosthesis may be fitted (not a surgical procedure).
The prosthesis is shaped very much the same as the conformer it replaces. The patient can remove and insert it himself.

21. Fuller p. 591: C. Tenon’s capsule is closed over the sphere.

22. Counts Initial—sponges and sharps First closing Final closing Sponges

23. Specimen & Care
Identified as eyeball rt vs lt
Handled: routine, etc.

24. Postoperative Care Pressure Patch Pain Eye drops and oral meds
At the conclusion of the enucleation procedure, a pressure patch is applied over the eyelids. This patch is intended to minimize the swelling of the socket tissues. The pressure patch is generally kept in place for about 12 hours after the surgery (up to hrs) . While the pressure patch is in place, the patient commonly experiences difficulty opening the lids of the unoperated eye. Fortunately, the difficulty in opening the eyelids generally resolves itself after the first post-operative day. Moderate post-enucleation pain in the socket generally occurs during the first 24 hours, but pain relievers are prescribed as needed to reduce this discomfort.
After the pressure patch is removed, the eyelids are swollen and black-and-blue for a few days. Antibiotic eyedrops and oral medications are usually started as soon as the pressure patch has been removed.
Within a week, a temporary prosthesis called a conformer is fitted into the empty socket. The permanent prostheisis is individually designed to closely resemble the patient’s other eye. It can be fitted 1-2 months after surgery.

25. Complications
The most common complications are hemorrhage and infection. Another complication is spread of the tumor to the brain or other lcoations..
Ptosis or droopy eyelid-this can be repaired easily under local anesthesia.
A superior sulcus deformity or sunken appearance occurs in a small number of patients as the volume of the orbit is reduced with the removal of the eye. In the majority of patients this can be corrected at a later date if warranted.
Scarring of the socket can lead to an inability of the socket to hold the prosthetic shell. It occurs in a small number of patients and surgery is available to correct it at a later date.
Extrusion or loss of the orbital implant The orbital implant may come out due to excessive scarring or infection. Surgical correction with replacement of the implant can be carried out when the infection resolves.
Exposure of the implant With prior orbital implants exposure of the anterior surface of the implant invariably led soon to extrusion and loss of the implant. With the new hydroxyapatite orbital implants exposure of the anterior surface is not uncommon. However even with this exposure extrusion is rare.
Sympathetic ophthalmia can occur very rarely in patients undergoing evisceration as some of the antigen that leads to sympathetic ophthalmia cannot always be completely removed. The benefits of evisceration with improved movement of the prosthesis must be weighed by the patient in light of the remote possibility of this sympathetic ophthalmia occurring.
Reduced growth of eye socket in young children can occur when an eye is removed. The presence of a healthy eye stimulates the growth of bones in the face that making up the eye socket. In most cases progressively larger prostheses can be make to help stimulate bony growth

26. Ocular Prosthesis Above from Internet Steen-Hall eye institute
What is an Ocular Prosthesis? An ocular prosthesis is an artificial eye that may be placed in the eye socket after the enucleation procedure. The most common type of ocular prosthesis is the Hydroxyappetite Integrated Implant. The implant inserted deep into the socket after removal of the eye may have the ability to be surgically attached to the eye muscles. These implants exhibit better motility and have a lower extrusion rate than other types of implants. Occasionally, it is inappropriate to use the integrated implant and the standard sphere may be used. For more information about the Hydroxyappetite Integrated Implants, please see Ocular Prosthesis: Hydroxyappetite Integrated Implants.
Above from Internet Steen-Hall eye institute

27. Resources www.steen-hall.com STST pp. 571-573
Alexander’s pp. 687 – 689
Complete Review for Surgical Technology by Boegli, Rogers, McGuinness
Lemone & Burke p. 1489

28. Which term refers to complete removal of the eye? Vitrectomy
Lensectomy
Enucleation
Evisceration
C. Enucleation

29. The procedure involving removal of all orbital contents is called:
Enucleation
Evisceration
Vitrectomy
Exenteration
D. Exenteration is the removal of all orbital contents and is generally performed for malignancy.

30. The space between the lens and the iris/pupil is called the:
Anterior cavity
Posterior cavity
Anterior chamber
Posterior chamber
D. Posterior chamber: The anterior chamber is the space between the cornea and the iris/pupil. Both the anterior and the posterior chamber are contained in the anterior cavity of the eye. The posterior cavity contains vitreous humor.

31. A trephine is an instrument used to Make a circular cut
Remove a cataract
Scrape diseased tissue
Coagulate tissue A.
Instrument for removing a buttonhole section, generally from the cornea

32. An opacity of the crystalline lens is referred to as a/an Petergyium
Strabismus
Chalazion
Cataract D.

33. The Trigeminal nerve is also known as the Optic nerve
Fifth cranial nerve
Oculomotor nerve
Third cranial nerve B.

34. BSS is used intraoperatively to Constrict the pupil
Replace vitreous humor
Irrigate the cornea
Prevent infection C.

35. Why is hydroxyapatite used following enucleation?
Provide a stent during reconstruction of the lacrimal system
Provide a base of support for the artificial eye
Replace the cornea
Replace the crystalline lens B.

36. The operative microscope in opthalmic surgery often uses which objective lens distance?
100
175
250
400
175 mm-objective lens.
A 100 mm objective lens would require the microscope to be too close to the patient. A 250-mm objective lens is used for ear procedures nad a 400-mm lens is used for Microlaryngoscopy.

37. Drapes included in the eye pack are 1. Split sheet 2
Drapes included in the eye pack are 1. Split sheet 2. Plastic eye sheet 3. Head drape. The order in which they will be used is:
1, 2, 3
2, 3, 1
3, 1, 2
3, 2, 1
C. Head drape is applied with adhesive strip above the brow line; adhesive towel is secured over the nose if general anesthesia is used; split sheet is used to cover the OR bed; and a clear plastic adhesive drape is placed over the operative eye and secured.

38. 2 mL were put in the right eye five times at 3-minutes intervals
Preoperative drops administered were recorded as “Clyclogel gtts ii O.S. q 5 min times 3.” This means:
11 drops of medicine were put in the patient’s left eye five times, 3 mintues apart
2 mL were put in the right eye five times at 3-minutes intervals
2 drops were placed in both eyes three times at 5-minute intervals
2 drops were placed in the left eye three times at 5-minute intervals D.

39. Sodium hyaluronate (Healon) Hyaluronidase (Wydase)
The medication which may be added to a local anesthetic to increase absorption and dispersion/spreading is:
Sodium hyaluronate (Healon)
Hyaluronidase (Wydase)
Alpha-chymotrypsin (Chymar)
Epinephrine (Adrenalin) B.

40. Acetylcholine (Miochol) Methylprednisolone (Depo-Medrol)
Which drug/solution would be used to constrict the pupil immediately following removal of a cataract?
Acetylcholine (Miochol)
Methylprednisolone (Depo-Medrol)
Tropicamide (Mydriacyl)
Tetracaine Hydrochloridae (Pontocaine) 0.5 %
The miotic drug acetylcholine , or Miochol.
Depomedrol is a steriod
Mydriacyl is a midriatic used to dilate the pupil
Pontocaine is a local anesthetic

41. The classification of medications used to dilate the pupil while inhibiting the ability to focus are:
Mydriatics
Cycloplegics
Hyperosmotic agents
Miotics
Cycloplegics—
Mydriatics dilate the pupil BUT permit focusing
Miotics cause pupils to constrict
Hyperosmotic agents are diuretics

42. Miotic agents include all of the following EXCEPT: Phenylephrine
Acetylcholine
Miostat
Pilocarpine
Miostat (acetylcholine) and Piolocarpine are miotic agents used to constrict the pupils. Neosynephrine (phenylephrine) is a mydriatic used to dilate the pupil.

43. Injectable agents for opthamologic anesthesia include all of the following EXCEPT:
Xylocaine
Wydase
Tetracaine HCL
Sodium hyaluronidase
C. Pontocaine (tetracaine hydrochloride) is a topical anesthetic agent used for eye anesthesia. Xylocaine and Wydase are both injectable, and sodium hyaluronidase is an agent that aids in the spread of anesthetic agents injected around the Optic Nerve.