Evisceration is a surgical technique used to remove the eye’s contents but leaves the sclera, surrounding muscles and orbital tissue intact. An orbital implant is then placed to replace lost ocular volume. Evisceration is performed in a blind eye when there is severe infection, end-stage endophthalmitis (inflammation of the eye’s interior), and in cases of penetrating trauma or injury to the eye. Surgery should be performed within 14 days of penetrating trauma to help with improved visual outcomes. It is not done in patients with intraocular malignancy or cancer because it leaves behind tissues that may be malignant.
Preparation & Expectation Before Surgery
Evisceration is a one-day procedure though the patient should be driven home and avoid spending the first 24 hours on their own. The patient is advised against eating or drinking anything at least six hours before the surgical procedure (unless they are essential medications).
The doctor examines the patient to ensure s/he is in good physical condition and discusses possible risks and benefits of evisceration. The patient is encouraged to wear shatterproof glasses to protect the uninvolved eye.
Types, Purpose & Procedure
Evisceration may be performed routinely as a form of protection against sympathetic ophthalmia. To control and improve cosmesis, evisceration is performed on a blind eye. However, surgeons view a blind eye’s removal as a last resort since some patients prefer to retain their natural globe.
General anesthesia, sedation, or local anesthesia will be administered.
To perform evisceration, the surgeon will:
- Facilitate a 360-degree peritomy by injecting anesthetic with epinephrine on the subconjunctival after placing an eyelid speculum.
- Make a full-thickness incision on the limbus using an #11-blade scalpel. S/he then cuts the remaining limbus with scissors to allow for the corneal button’s removal. This enables better pain control.
- Use an 'evisceration spoon' (round, relatively flat curette) to remove the intraocular contents. The surgeon ensures that he has completely removed all uveal tissue that can cause sympathetic ophthalmia.
- Bathe the sclera's inner surface in alcohol to avoid inflammation and subsequently, sympathetic ophthalmia.
- Only perform cautery (burning) after the site has thoroughly been washed with saline.
- Place an implant (usually spherical and made of plastic and silicone) in the remaining shell. Sometimes the implant is wrapped with sclera from a deceased person after thorough tests so that the muscles can easily be attached to the implant.
- Close the sclera and Tenon’s membrane over the implant. S/he finally closes the conjunctiva.
- Place a clear plastic shell (conformer) to help with eye socket shape.
- Suture and place a pressure bandage over the lids.
Risks, Side Effects & Complications
Pain may be present the first few days following surgery, and a mild headache for approximately two weeks after surgery. The doctor will prescribe anti-nausea and anti-pain medications, as well as antibiotics. Ointments and eye drops will also be prescribed to facilitate faster healing and prevent infection. In the case of edema and discomfort, the patient can use a dressing and an ice-cold compress. To help control swelling and retain the conformer, the surgeon can temporarily sew the eyelid.
Evisceration has the potential to expose uveal antigens, which may trigger sympathetic ophthalmia in the seeing eye. In rare cases, the socket may shrink, leading to eyelid laxity. Sometimes, irritation may arise when the prosthesis tissue irritates the implant's surface or back of the eyelid.
Complications may include blood accumulating in the retrobulbar space, exposure of the implant, implant extrusion (being pushed out) and discharge. Others include a new abnormal growth, eye socket irritation, bleeding, and infection. If the lower eyelid loosens or eye socket tissue breaks down after wearing a prosthesis (even years after the procedure), additional surgery may be required.
After Care, Recovery & Results
The pressure bandage can be taken off six to 14 days after the procedure. The patient has a choice of whether to wear a patch over the eye until a prosthesis is put in place. Sometimes the conformer may fall out. The patient should wash it with water and soap and try reinserting it between the eyelids but can seek professional intervention if unable to.
The patient should avoid a dirty environment, strenuous activities, and swimming. They should also avoid cleaning or rubbing inside the eye.
The first follow-up visit should be in about two to six weeks to detect any complications and if they require additional attention. Afterwards, to ensure that the socket stays healthy, the patient is followed up every 6-12 months.
Evisceration results in a largely unchanged outer appearance of the eyeball despite the eye not being functional. The procedure improves the external appearance of what would have been an unsightly eye. It reduces pain and creates a suitable pocket where the prosthetic eye will be inserted.