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Review Article

Evisceration in the Modern Age

Laura T. Phan1,2, Thomas N. Hwang3, Timothy J. McCulley1,2

ABSTRACT Access this article online

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Evisceration is an ophthalmic surgery that removes the internal contents of the eye www.meajo.org
followed usually by placement of an orbital implant to replace the lost ocular volume. DOI:
Unlike enucleation, which involves removal of the entire eye, evisceration potentially causes 10.4103/0974-9233.92113
exposure of uveal antigens; therefore, historically there has been a concern about sympathetic
Quick Response Code:
ophthalmic (SO) associated with evisceration. However, critical review of the literature shows
that SO occurs very rarely, if ever, as a consequence of evisceration. Its clinical applications
overlap with those of enucleation in cases of penetrating ocular trauma and blind painful eyes,
but it is absolutely contraindicated in the setting of suspected intraocular malignancy and
may be preferred for treatment of end-stage endophthalmitis. From a technical standpoint,
traditional evisceration has a limitation in the orbital implant size. Innovations with scleral
modification have overcome this limitation, and accordingly, due to its simplicity, efficiency,
and good cosmetic results, evisceration has once again been gaining popularity.

Key words: Endophthalmitis, Enucleation, Evisceration, Intraocular Tumors

INTRODUCTION While the risk of sympathetic ophthalmia continues to be a

contentious issue, evisceration has gained popularity in the

E visceration (removal of intraocular contents) and enucleation

(removal of the entire eye) are competing techniques, with
fluctuating favor since their inception. Enucleation may be the
oldest operation in ophthalmology; literature from as early as
2600 BC described a Chinese “god of ocularists.”1 Centuries
later in 1817, Bear introduced evisceration when he removed the
remaining intraocular contents of an eye following an expulsive
hemorrhage.2 In 1874, Noyes described evisceration for the
management of intraocular infection.3 In 1884, Mules described
placing a hollow glass sphere into the eviscerated cavity.4
Because evisceration unlike enucleation disrupts the integrity
of the globe, there is a theoretical risk of exposing uveal
antigens, which could incite an autoimmune reaction known
as sympathetic ophthalmia (SO) in the contralateral eye. The
first report of sympathetic ophthalmia occurring in association
with evisceration was in 1887.5 Despite this, evisceration gained
popularity until 1972 when Green et al. reignited the concern
of inciting sympathetic ophthalmia with a report of four alleged
cases.6
past few decades. This is based largely on the perception
that evisceration provides superior functional and cosmetic
results compared to enucleation. Several modified evisceration
techniques have been described in past decades, each proclaiming
improved results.7-16
This review will provide an in-depth look at evisceration by
examining the published literature that supports and refutes its
association with sympathetic ophthalmia, and then describing its
advantages and disadvantages in different clinical scenarios, and
finally discussing the basic technique as well as recent technical
modifications.
SYMPATHETIC OPHTHALMIA
Sympathetic ophthalmia is a potentially devastating autoimmune
condition characterized by bilateral panuveitis, where the injured
eye incites inflammation in the fellow (sympathizing) eye.17 Its
specific pathophysiology remains elusive. It is believed to be an

1
Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, 2King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia,
3
Department of Ophthalmology, The Permanente Medical Group, Redwood City, California
Corresponding Author: Dr. Timothy J McCulley, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Wilmer
110, Baltimore, MD 21287. E-mail: tmccull5@jhmi.edu

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Phan, et al.: Evisceration in the Modern Age
immunologic response to exposure of previously sequestered
tissue.17,18 Proposed antigens include retinal S-antigen, retinoid
binding protein, melanin associated antigen, or those from the
retinal pigment epithelium.18-21 Signs and symptoms of uveitis
have been reported to develop between 5 days22,23 and 66 years24
from the time of injury. Sixty-five percent of the cases occur
between 2 weeks and 2 month with roughly 90% present within
a year of injury.25-27
Evisceration, along with a number of other intraocular
procedures, has been implicated as a potential cause of
sympathetic ophthalmia.6,28 Whether or not evisceration can
incite sympathetic ophthalmia is one of the most notorious
controversies in oculoplastic surgery.29 We will present what
evidence exists supporting and refuting this relationship.
Supportive evidence
Evidence suggesting a causal relationship between evisceration
and sympathetic ophthalmia lies almost entirely in a handful of
case observations.
Earliest reports of sympathetic ophthalmia following
evisceration include 47 cases from various ophthalmologists
in the United States and the United Kingdom from 1887 to
1909.30 Unfortunately, many of these cases did not have exam
documentation of the fellow eye at the onset of injury or even
after the sympathetic occurrence. Therefore, definitive time
of onset of sympathetic ophthalmia and association to original
injury versus evisceration were dubious to say the least. Moreover,
these cases were often initially diagnosed as endophthalmitis or
neuroretinitis. None had records of intraocular histopathology
studies. Little else was published until 1972 when Green et al.
described four cases.6 Two occurred earlier in the first half of the
century (1927 and 1949) and the others in the latter half of the
century (1968 and 1969). The first two cases provided strong
evidence. Slides of the scleral shells that were subsequently
removed demonstrated granulomatous inflammation consistent
with sympathetic ophthalmia. Green et al. did not provide the
number of cases performed during the study period; therefore,
the relative risk of sympathetic ophthalmia following evisceration
could not be estimated base on this study.
In this past decade, there have been two case reports of alleged
post-evisceration sympathetic ophthalmia. In 2005 Griepentrog
et al.31 reported a case of presumed sympathetic ophthalmia
after evisceration in a 75 year-old man, who had a blind, painful
eye after a penetrating globe injury that caused neovascular
glaucoma. Notably the injury occurred 66 years prior. The
patient developed ciliary injection, mild cataract, vitreous cells,
and macular retinal pigment epithelium mottling and serous
detachment in the fellow eye fourteen weeks post-operation.
His vision improved from 20/200 to 20/25 nine months later
on a tapered steroid dose. The diagnosis was based entirely on
Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 25
the clinical appearance; histopathologic confirmation was not
established.
In 2006, Freidlin et al.32 reported the first case of sympathetic
ophthalmia found in a soldier since World War II. This 21-year-
old man sustained shrapnel wounds while in combat and
underwent evisceration the day of injury. Within a month of
surgery, he developed panuveitis in his remaining eye with
conjunctival injection, vitreous floaters, and paracentral scotoma.
He responded favorably to immunosuppressant therapy. After
6 months of oral and topical steroid treatment, best-corrected
visual acuity was 20/20 in this “sympathetic” eye. Interestingly,
histologically proven uveal tissue was found and removed from
the subconjunctiva of the eviscerated eye at the onset of his
symptoms. The authors hypothesized that this residual uveal
tissue induced the inflammation. Given the failure to remove
all uveal tissue, this case does not support evisceration as an
inciting event. However, it does stress the need to perform
eviscerations properly and in appropriately selected patients.
This and the previous case illustrate the additional point that
in at least some cases, good vision can be preserved in the
sympathetic eye with treatment.
There is good evidence that potentially any type of intraocular
surgery can incite sympathetic ophthalmia. Previous retrospective
studies estimated the incidence of sympathetic ophthalmia to be
anywhere from 0.02% to 0.06% for intraocular surgery,33,34,35
and 0.28% to 1.9% for nonsurgical penetrating injury.35-37
These surveys implicated various intraocular surgeries, including
cataract extractions, glaucoma procedures, and vitrectomies
but not eviscerations. In a prospective surveillance, Kilmaren
et al. estimated the incidence of sympathetic ophthalmia to
be 0.03 per 100,000.38 Ocular surgery, particularly retinal
surgery, was the most common cause in this group, as opposed
to previous reports where accidental trauma overwhelmingly
prevailed.6,37 Between July 1997 and September 1998, all
permanently employed ophthalmologists in the United Kingdom
were sent monthly report cards to notify any newly diagnosed
cases of sympathetic ophthalmia. There were 23 valid cases
of sympathetic ophthalmia reported during this period, but
only 17 that were reported in last 12 consecutive months were
included in Kilmarin et al.’s estimation of the incidence. Of
these patients, one underwent an enucleation for recurrent
choroidal melanoma, but none had evisceration. Of note, the
patient with a history of enucleation also twice underwent pars
plana vitrectomy.
Although these studies fail to establish evisceration as a definitive
causation for sympathetic ophthalmia, they do stress that any
type of intraocular surgery may be causative. Logic follows that
evisceration has the potential to incite sympathetic ophthalmia.
In summary, the assertion that sympathetic ophthalmia may be
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Phan, et al.: Evisceration in the Modern Age

incited by evisceration is largely theoretical, supported only by Table 1: Indication for eviscerations and enucleations
a handful of single or small series of questionable cases. Study Dates Number Type of Most Common
Assessed of Surgery Indications (%)
Refuting evidence Cases
There have been a number of series looking at cohorts of patients Erie et al. 1956-1988 99 Enuc Trauma (35)
Spraul et al. 1941-1995 513 Enuc Trauma (41)
who underwent evisceration, where no cases of sympathetic Neoplasm (24)
ophthalmia were identified. Studies involving over 3000 Setlur et al. 1950-2006 3,264 Enuc Neoplasm (51)*
eviscerations failed to identify a case of sympathetic ophthalmia Trauma (13)*
Glaucoma (23)**
between 1980s and 1990s.5,39-41 A more recent review by du Trauma (21)**
Toit et al.42 also failed to identify sympathetic ophthalmia in Davenger et al. 1963-1967 207 Enuc Trauma (51)
491 primary eviscerations or 11 secondary eviscerations for Corneal disease (18)
penetrating injury at a tertiary hospital in Cape Town, South Sigurdsson et al. 1963-1992 200 Enuc/ Blind, painful eye (46)
evis
Africa from 1995 to 2004. This is similar to a previous report Neoplasm (25)
made by Rudemann of his 15-year experience between 1947 and Kaimbo et al. 1988 143 Enuc Trauma (37)
1962.30 He failed to identify any case of sympathetic ophthalmia Haile et al. 1995 282 Enuc Trauma (33)
Neoplasm (21)
in the 506 eviscerations performed.
Dado et al. 1990-1999 146 Evis Endophthalmitis (79)
Trauma (21)
In 1998 Levine et al.40 assessed the association between Rasmussen et al. 1996-2003 345 Enuc/ Blind, painful eye (36)
evisceration and sympathetic ophthalmia. He reviewed 51 of evis
Neoplasm (34)
his own patients who underwent evisceration between 1980 Chaudhry et al. 2000-2003 187 Evis Endophthalmitis (46)
and 1996. The follow-up period ranged from 3 to 180 months Phthisis (20)
(mean, 48 months). No cases of sympathetic ophthalmia were Eballe et al. 2002-2010 48 Enuc/ Endophthalmitis (48)
evis
identified. In addition, they queried members of the American
Neoplasm (21)
Society of Ophthalmic Plastic and Reconstructive Surgery
Enuc: Enucleation, Evis: Evisceration, *in the year 2000’s, **in the year 1950’s
(ASOPRS), American Uveitis Society, and Eastern Ophthalmic
Pathology Society. Of the 880 reported eviscerations from
responding members of the three societies, members of the
Table 2: Indication vs contraindication for evisceration and
ASOPRS “recalled” five and the other two groups “recalled” enucleation
several cases of sympathetic ophthalmia. These cases were Indication Evisceration Enucleation
anecdotal, not documented clinically or histologically and thus Neoplasm - ++
excluded as positive findings. Based on their findings, Levine Penetrating trauma ± +
et al. concluded that “evisceration is a safe procedure with little Blind, painful eye + +
Endophthalmitis + ±
risk of sympathetic ophthalmia.” However, this conclusion has
+= indicated, ++= absolute, indicated, ±= controversially indicated, -= not
been challenged. Bilyk argued that, simply due to the rarity indicated
of sympathetic ophthalmia and low number of evisceration
performed, the risk of sympathetic ophthalmia is likely
underestimated.43 It has also been pointed out that, based on evisceration and enucleation for individual indications. In
previously estimated occurrence rates of sympathetic ophthalmia, most cases, when globe removal is required, either surgery is
some cases should have been identified if Levin’s review method adequate, and the surgeon may choose their personal preference.
was reliable. Regardless, since Levine’s publication, evisceration However, there are circumstances where one is preferable or,
seems to have been gained favor once again. in some cases, contraindicated. Traditionally, enucleation has
been recommended for management of intraocular neoplasm
In summary, evidence for the association between evisceration and prevention of sympathetic ophthalmia following penetrating
and sympathetic ophthalmia is lacking. However, given the trauma,44-48 whereas evisceration is usually recommended for
extremely low incidence of sympathetic ophthalmia, rare management of endophthalmitis.49 Opinions vary with regards
occurrences cannot be entirely excluded. It is probably safe to to which surgery is preferable for management of blind, painful,
say that the risk of sympathetic ophthalmia following evisceration phthisical, or otherwise cosmetically unacceptable eyes.16,50 Each
is, at most, extremely low. one will be explored.

INDICATIONS Malignancy
Malignancy is an absolute contraindication to evisceration. An
Table 1 outlines published indications for evisceration and enucleation should be performed whenever managing an eye
enucleation. Table 2 compares and contrasts the benefits of suspected or known to harbor an intraocular malignancy.44-47

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Phan, et al.: Evisceration in the Modern Age
Penetrating trauma
One of the most common indications for evisceration is
penetrating ocular trauma despite the possible association with
sympathetic ophthalmia. Removal of the eye (or its contents)
prior to sensitization is felt to be preventive. Classic teaching
is to perform surgery within 14 days of injury. The origin of
this teaching is unclear, although it may stem from a study
indicating that visual outcome improves significantly if surgery
is performed within two weeks of injury, given that sympathetic
ophthalmia has not developed.26
Although traditionally enucleation has been recommended in
the setting of penetrating trauma, evisceration is also routinely
performed for the purpose of protecting against sympathetic
ophthalmia [Table 1].51-55 In cases with extensive disruption
of the globe, removal of all uveal tissue may be difficult via an
evisceration; therefore, enucleation may better safeguard against
retained uveal tissue, a risk factor for sympathetic ophthalmia.
This point is nicely illustrated in the case published by Freidlin
et al., where the patients sclera was severely disrupted with
uveal tissue prolapsed into the orbit.32 However, in cases where
the sclera is largely intact, and the intraocular contents are
contained and identifiable, an evisceration may be a reasonable
alternate. The selection is usually based on surgeon’s judgment
or preference.
Blind eyes
Blind eyes are commonly removed for both pain control
and improvement of cosmesis [Table 1]. Both enucleation
and evisceration are effective in these settings.50,56 Again, the
choice of procedure usually depends on the surgeon’s personal
experience and preference. Evisceration in the management of
blind eyes, for both pain control and cosmesis, is the authors’
preferred technique.
Removal of blind eyes should be viewed as a last resort. Patients
often fend better if able to retain their natural globe. The term
“scleral shell” is used for a prosthesis, which is made to fit over
the patient’s eye. Often this is all that is required for phthisical
eyes. A scleral shell in conjunction with a conjunctival flap is an
underutilized combination that may best serve some patients.
The decision to remove an eye or its contents for pain control
should not be made whimsically. Pain can, at times, be controlled
with a retrobulbar injection of alcohol or chlorpromazine.57-59
Corneal-related discomfort can, in select cases, be managed
with a conjunctival flap.60-64
Less invasive means of controlling pain as outlined above should
be weighed against eye removal. In the case of eyes expected
to become phthisical, classic teaching has been to recommend
globe removal. However, recent data has suggested that, in most
cases, pain either will develop mildly or not at all.65 Brackup
Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 27
et al.65 found 85% of the patients with severely traumatized eye
and no evisceration or enucleation remained comfortable with
no or only rare pain. The other fifteen percent had intermittent
pain. Accordingly, when possible, the decision to remove the
eye should be postponed until a stable state has been reached.
Another potential pitfall is the continued pain following removal
of an eye. In a series described by Shah-Desai et al., removal of
an eye failed to relieve eye pain in seven of 24 patients.49 Most
of the pain was related to post-operative complications that
required additional medical or surgical treatments.
The patient’s socio-economic status also needs to be factored
in the decision. For example, for a patient with limited access
to health care, one may lean towards a conjunctival flap and
scleral shell. Resources needed for routine evaluation and the
maintenance required of an anophthalmic socket and prosthetic
eye may not be available. Whereas for patients with abundant
resources, one might prefer avoiding a conjunctival flap because
it may complicate a future evisceration if it fails. Knowing that
the patient would be able to obtain and maintain a well-fitted
prosthesis would be useful before initiating evisceration.
It has been argued that enucleation is preferable to evisceration
in the setting of phthisis. With older techniques, this is true. The
diminished size of the intrascleral space precludes placement of
an adequately sized implant. However, with modern techniques,
which incorporate volume-enhancing sclerotomies, implants
equal in size to those used in enucleation can be placed.11-13,15
This is discussed in detail below.
Endophthalmitis
In some developing countries, endophthalmitis is the most
common reason for evisceration and enucleation.66-68 Before
the advent of antibiotics, surgeons fairly uniformly advocated
evisceration over enucleation. Evisceration leaves the optic
nerve intact and thus avoids the spread of intraocular microbials
into the subarachnoid space.49 A study in 1987 argued that
endophthalmitis should not be considered a contraindication
to enucleation in the modern era of antiobiotics.69 In this
retrospective study, no cases of postoperative intracranial
infection were identified in a cohort of 165 patients who
underwent enucleation for endophthalmitis.
The weakness of many such retrospective studies is that the
implications of the study are often overextended. Although
relatively large (a cohort of 165 patients in the above example),
all that can be said is that the occurrence rate is likely less
than 2.21% (P=0.05). For such a potentially devastating
consequence, that is, bacterial meningitis, even taking this small
risk might not be prudent. For this reason, many surgeons still
prefer evisceration for endophthalmitis.70-72
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Phan, et al.: Evisceration in the Modern Age
SURGICAL TECHNIQUE
Although minor variations exist, there are core surgical steps,
which remain fairly constant. Each will be discussed briefly with
emphasis on the authors’ preferred technique.
1. Peritomy
Following placement of an eyelid speculum, a subconjunctival
injection of epinephrine containing anesthetic facilitates a
360° peritomy. Care is taken to preserve as much conjunctiva
as possible.
2. Removal of the cornea
A full-thickness limbal incision is made with an #11 blade
scalpel. The remainder of the limbus is cut with scissors,
allowing for removal of the corneal button. Historically, the
cornea was not removed.73 Currently, most surgeons elect
to remove the cornea, providing better pain control.74
3. Removal of the intraocular contents
The intraocular contents are then removed with the aid
of an “evisceration spoon,” a round relatively flat curette.
Careful attention is given to the complete removal of all
uveal tissues. In theory this decreases (possibly eliminates)
the risk of sympathetic ophthalmia.
4. Application of alcohol
The inner surface of the sclera is then bathed in alcohol.
The purpose of this step is to denature any residual
protein that might otherwise incite inflammation, that is,
sympathetic ophthalmia. Cautery should be avoided, due to
the flammability of residual alcohol, until the surgical field
has been thoroughly irrigated with saline.
5. Sclerotomy
Performing a sclerotomy, allowing for placement of larger
implants, has become popular in recent years and is
performed at this stage. Specific techniques are discussed
in detail below.
6. Implant placement
There is much variation in the preferred type of implant.
This is one of the greatest areas of disagreement among
oculoplastic surgeons and beyond the scope of this text. The
authors’ preference is a simple silicone sphere. Previously,
the largest implant possible was placed. However, with the
advent of modern sclerotomies, essentially any sized implant
can be used, and implant size is chosen to match prominence
of the fellow eye.
7. Closure
The final step is closure. All techniques include the closure of
multiple layers, including the sclera, Tenon’s membrane and,
lastly, conjunctiva. Meticulous closure is felt to be essential
in preventing implant extrusion.
28 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012
SCLEROTOMY
The two main goals during an evisceration are replacing lost
volume with an appropriately sized implant and achieving
maximum implant motility. These two features optimize
symmetry and therefore good cosmesis.
With classic evisceration technique, the largest implant that will
fit inside the scleral cavity and still allow for closure of the sclera
without undue tension is 18 mm and, in many cases, less.75,76
For this reason, evisceration was rarely performed in phthisical
eyes, as only very small implants could be placed.
Several different methods of sclerotomies and relaxing incisions
have been described to increase the size of the cavity in which the
implant is placed.7-16 In 1987, Stephenson reported performing
multiple radial expansion sclerotomies as well as a posterior spiral
sclerotomy.7 In addition, he placed fixation sutures between the
implant and scleral shell to prevent implant migration. In 1995,
Kostick and Linberg described a posterior sclerotomy.8 In the
same year, Lee et al. reported the creation of scleral windows
posterior to each of the rectus muscle insertion.9 In 1997,
Jordan and Anderson described disinserting the optic nerve and
performing small radial sclerotomies.10 In the same year, Yang
et al. described a “scleral quadrisection” technique, which left
the optic nerve intact.11 Long et al.12 reported opening the scleral
cavity posteriorly and placing the implant behind the sclera in
the muscle cone. In 2001, Massry and Hold described obliquely
splitting the scleral cavity in two, releasing the flaps from their
optic nerve attachments.13 More recently in 2007, Sales-Sanz
and Sanz-Lopez described a technique wherein they performed
four complete sclerotomies from the limbus to the optic nerve
with optic nerve disinsertion.15 This created four petals that
contained a rectus muscle each. The petals were then brought
anteriorly to cover the implant. Also in 2007, Masdottir and
Sahlin reported their experience using a split-sclera technique
similar to Massry’s and Hold’s, where 5% developed exposure
or extrusion of implant, but 78% of the patients felt pleased
or very pleased with the operation.77 Most recently in 2011,
Smith et al.78 reported their experience with Massry’s and
Hold’s technique. Sixteen of the 201 patients reported minor
complications, while three reported major ones during a mean
follow-up period of 31.62 months (range, 3–98 months). Also in
2011, Georgescu et al.16 described a new evisceration technique
for patients with phthisis bulbi and microphthalmos. Eighteen
patients underwent evisceration, where a 5-mm wedge of
sclera was excised nasally and temporally and a 360° equatorial
scleral incision was made, dividing the scleral into anterior and
posterior halves.
In most of the above reports, good results were achieved with
complications similar to those seen when a sclerotomy was not
performed. The advantage with a sclerotomy is the ability to place
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Phan, et al.: Evisceration in the Modern Age
implants up to or even larger than 20 mm in a large proportion
of patients. These enhanced volume augmentations diminishes
the “sunken-in” look often seen in anophthalmic patients. Also,
in the few studies that assessed motility, dismantling the sclera
did not adversely affect implant excursion or patients’ overall
satisfaction.79
We routinely perform a sclerotomy. Our preferred technique,
nicknamed “the swinging sclera,” is a 180° horizontal cut, bisecting
both horizontal rectus muscle insertions and passing just above
the attachment of the optic nerve. By leaving the optic nerve
attached to the inferior half of the sclera, a supportive hammock
is formed that helps prevent inferior migration of the orbital
implant.
OUTCOME
The increasing number of eviscerations performed in recent
decades is due to several perceived benefits. Often cited
advantages include the perception that evisceration is simpler
and faster than enucleation.80 Since evisceration leaves the
extraocular muscles and optic nerve intact, it also has less risk
for significant bleeding.81
Ultimately, superior cosmetic outcome depends on volume
replacement, socket motility, deep fornices, and normal-
appearing and functioning eyelids.82,83 Evisceration allows for
better preservation of orbital anatomy, improved mobility and
therefore enhanced cosmesis.8,75-77,84 It has been proposed
that evisceration requires less manipulation and consequently
less inflammation and scarring of orbital tissues: fornices and
suspensory ligaments remain uncompromised. This in turn is
thought to help maintain the implant. These factors translate to
better motility, less risk of superior sulcus deformity and thus
an enhanced cosmetic result for the patients.
Historically, enucleation allowed for placement of a larger
implant.77,79 The largest implant possible, whether involving
enucleation or evisceration, helps prevent enophthalmos and
Table 3: Common complications of evisceration and enucleation
Study
Enophthalmos Deep Ptosis
superior
sulcus
Shoamanesh et al.
Evisceration (n=147) 6.8 18.4
Enucleation (n=180) 9.4 12.2
Nakra et al.
Evisceration (n=52) 7.7
Enucleation (n=32) 15.6
Tari et al.
Evisceration (n=50) 20.0
Enucleation (n=50) 14.0
Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 29
superior sulcus deformity.78,85 However, with the advent of
modern sclerotomy techniques, enucleation no longer has this
advantage over evisceration.
Evisceration also provides superior socket motility. A prospective
study in 2007 compared the motility and complications of
50 patients who underwent evisceration with sclerotomy
and allosplastic implantation (Group 1) and 50 patients who
under went enucleation and hydroxyapatite implantation
(Group 2).75 For the eviscerations, scleral quadrisections were
performed at 1.5, 4.5, 7.5, and 10.5 clock hours from the
limbus to the optic nerve without disinserting the nerve. Group
1 fared statistically significantly better than Group 2 in motility.
The mean horizontal excursion was 10.25 + 1.99 (5.9–15)
for Group 1 and 6.90 + 1.74 (3.2–12) for Group 2. The
mean vertical excursion was 8.45 + 1.89 (4.3–12) for Group
1 and 5.69 + 1.63 (3–10) for Group 2. Covariant analysis
indicated operation time as a statistically significant predictor
in movement. Deep superior sulcus and exposure or extrusion
was not significantly different between the two groups.
Modern evisceration techniques with sclerotomies, allowing for
placement of large implants, achieve better results that previously
possible. Patients enjoy relatively good socket motility common
to all evisceration techniques. With the introduction of the
sclerotomy, implant size is no longer a limitation.
Complications
Table 3 summarizes the more commonly encountered
complications. Potential complications, common between
enucleation and evisceration, include infection, hemorrhage, and
implant extrusion. Long-term complications include sunken/
deep superior fornix, lower eyelid laxity and ectropion, upper
eyelid ptosis, socket contraction, conjunctival cyst formation,
implant migration and late extrusion of the implant.70,86–99
More common and/or serious complications will be addressed
in detail.
Infection and hemorrhage are common to all surgical procedures;
Complication (%)
Exposure/ Implant Socket Fornix Pyogenic
extrusion migration edema contraction granuloma
4.1 0 8.8 8.8 5.4
1.7 0.5 15.0 13.3 4.4
3.8 12.5 3.8
12.5 27.5 3.1
4.0
2.0
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Phan, et al.: Evisceration in the Modern Age
evisceration is no exception. Fortunately, hemorrhage is usually
self-limited and, even in the most severe cases, can be controlled
with a firmly placed pressure patch. The authors usually place
a temporary tarsorrhaphy at the close of the case, which
prevents conjunctival prolapse should post-operative bleeding
be encountered. Sterile technique with peri- and postoperative
systemic antibiotics limits the risk of infection. Delayed
placement of the orbital implant reduces the risk of infection
in the setting of endopthalmitis.100 When encountered, removal
of the implant with delayed reconstruction is often necessary.
Despite placement of a large implant, patients may still develop
a “sunken-in” appearance. Several mechanisms have been
proposed for deep superior sulcus and subsequent ptosis.
Hypotheses include (1) decreased circulation with cicatrization
of orbital tissue and fat atrophy;101 (2) disturbance in the normal
spatial architecture and tissue relationships of the orbit;102 (3)
grossly underestimated orbital volume loss and inadequate
volume replacement;103 (4) contracture of the remaining
soft tissues, with an equivalent effect as inadequate volume
replacement;43 (5) orbital expansion following unidentified
orbital fractures.104 Deep superior sulci are managed with orbital
volume augmentation. Techniques include implant exchange
and autologous fat transfer. The authors’ preferred method is
placement of an “enophthalmic wedge.”
One of the most dreaded and challenging complications is
socket contracture. The spectrum of this disorder ranges from
posterior lamella shortening to complete obliteration of the
fornices.84 Mild contraction may result in nothing more than
inward rotation of the eyelashes. With further contraction
eyelid mobility is reduced. In the most extreme cases, patients
are unable to retain a prosthesis. Management consists of
removal of any inciting irritant. Smoking has been linked
with socket contraction. All anophthalmic patients should be
counseled regarding smoking cessation. A properly fitted and
maintained prosthesis is also essential to a healthy socket. Once
contraction has occurred, management usually consists of fornix
reconstruction with mucous membrane grafting.
Implant extrusion usually relates to placement of an oversized
implant, inadequate sclerotomy or poor closure. Management
of an extruding implant is complex with many varied opinions.
Small exposed areas may heal spontaneously and are often
just observed. Larger areas may be closed with a variety of
flaps, grafts, and even donor or synthetic materials.105-117 Most
often, exposure is the result of anterior pressure. Even with
the most deftly executed anterior reconstruction techniques,
recurrences are common. Implant exchange or repositioning
may be required.118
Another relevant issue is the possibility of unintended evisceration
of a malignancy-baring eye. For this reason a dilated fundus
evaluation is mandatory prior to performing an evisceration.
30 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012
If there is not an adequate view of the fundus, appropriate
imaging should be obtained prior to surgery. A couple of series
have addressed inadvertent evisceration of eyes containing
malignancy.119,120 Eagle et al.119 described seven such cases. Of
note, three of patients had not undergone preoperative imaging.
Retrospectively, two had suspicious findings on computed
tomography (CT) that escaped further investigation, and one
underwent evisceration despite having a known history of uveal
melanoma. In Rath et al.’s series, five of the six patients did not
undergo preoperative imaging prior to evisceration.120 These
cases serve as reminder that patients should undergo diligent
fundus examination and appropriate imaging when adequate
visualization is not possible.
SUMMARY
Evisceration remains a popular and effective surgery. Uncertainty
surrounding the risk of sympathetic ophthalmia following
evisceration has caused some surgeons to prefer enucleation.
However, this fear seems to be largely unfounded, based entirely
on a very small number of reports. Most cases were either
confounded by a history of trauma or intraocular surgery or were
not confirmed histologically. Recent advances in techniques,
largely centered on various types of sclerotomies, allow for
placement of larger implants. Given the superior cosmetic and
functional results of evisceration, it is the authors’ preferred
method of eye removal when not contraindicated.
REFERENCES
1. Moshefeghi DM, Moshefeghi AA, Finger PT. Enucleation. Surv
Ophthalmolo 2000;44:277-301.
2. Meltzer MA, Schaefer DP, Della Rocca RC. Evisceration. In: Della
Rocca RC, Nesi FA, Lishman RD, editors. Smith’s ophthalmic
plastic and reconstructive surgery. Vol. 2. St. Louis: CV Mosby;
1987. p. 1300-7.
3. Noyes HD. Discusio ́n of E Warlomont’s paper on sympathetic
ophthalmia. In: Report of the Fourth International Congress,
London, Aug 1872:27.
4. Mules PH. Evisceration of the globe, with artificial vitreous.
Trans Ophthalmol Soc UK 1885;5:200-6.
5. Cytryn AS, Perman KL. Evisceration. In: Enucleation,
evisceration and exenteration of the eye. In: Migliori ME, editor.
Boston: Butterworth-Heinermann; 1999. p. 105-12.
6. Green WR, Maumenee AE, Sanders TE, Smith ME. Sympathetic
uveitis following evisceration. Trans Am Acad Ophthalmol
Otolaryngol 1972;76:625-44.
7. Stephenson CM. Evisceration of the eye with expansion
sclerotomies. Ophthal Plast Reconstr Surg 1987;3:249-51.
8. Kostick DA, Linberg JV. Evisceration with hydroxyapatite
implant. Surgical technique and review of 31 case reports.
Ophthal
Mology 1995;102:1542-9.
9. Lee SY, Kwon OW, Hong YJ, Kim HB, Kim SJ. Modification
of the scleral openings to reduce tissue breakdown and
exposure after hydroxyapatite implantations. Ophthalmologica
1995;209:319-22.
10. Jordan DR, Anderson RL. The universal implant for evisceration
surgery. Ophthal Plast Reconstr Surg 1997;13:1-7.
11. Yang JG, Khwarg SI, Wee WR, Kim DM, Lee JH. Hydroxyapatite
[Downloaded free from http://www.meajo.org on Friday, January 19, 2018, IP: 203.78.119.132]
Phan, et al.: Evisceration in the Modern Age
implantation with scleral quadrisection after evisceration.
Ophthal Surg Lasers 1997;28:915-9.
12. Long JA, Tann TM, Girkin CA. Evisceration: A new technique
of transcleral implant placement. Ophthal Plast Reconstr Surg
2000;16:3225.
13. Massry GG, Holds JB. Evisceration with scleral modification.
Ophthal Plast Recosntr Surg 2001;17:42-7.
14. Ozgur OR, Akcay L, Kmil O. Evisceration via superior temporal
sclerotomy. Am J Ophthalmol 2005;139:78-86.
15. Sales-Sanz M, Sanz-Lopez A. Four-petal evisceration: A new
technique. Ophthal Ophthal Plast Reconstr Surg 2007;23:389-92.
16. Georgescu D, Vagefi MR, Yang CC, McCann J, Anderson RL.
Evisceration with equatorial sclerotomy for phthisis bulbi and
microphthalmos. Ophthal Plast Reconstr Surg 2010;3:165-7.
17. Gasch AT, Foster CS, Grosskreutz CL, Pasquale LR. Postoperative
sympathetic ophthalmia. Int Ophthalmol Clin 2000;40:69-84.
18. Rao NA, Robin J, Hartmann D, Sweeney JA, Marak GE Jr. The
role of penetrating wound in the development of sympathetic
ophthalmia. Arch Ophthalmol 1983;101:102-4.
19. Hirose S, Kuwabara T, Nussenblatt RB, Wiggert B, Redmond
TM, Gery I. Uveitis induced in primates by interphotoreceptor
retinoid-binding protein. Arch Ophthalmol 1986;104:1698-702.
20. Chan CC, Hikita N, Dastgheib K, Whitcup SM, Gery I,
Nussenblatt RB. Experimental melanin-protein-induced uveitis
in the Lewis rat. Immunopathologic processes. Ophthalmology
1994;101:1275-80.
21. Broekhuyse RM, Kuhlmann ED, Winkens HJ. Experimental
autoimmune posterior uveitis accompanied by epitheloid cell
accumulations (EAPU). A new type of experimental ocular
disease induced by immunization with PEP-65, a pigment
epithelial polypeptide preparation. Exp Eye Res 1992;55:819-29.
22. Fuchs E. Uber sympathisierende entzundung zuerst
bemerkungeen uber serose traumatische iritis. Graefes Arch
Clin Exp Ophthalmol 1905;61:365-456.
23. Thies O. Gedaken uber den ausbruch der sympathetischen
ophthalmie. Klin Monatsbl Augenheilkd 1947;112:185-7.
24. Zaharia MA, Lamarche J, Laurin M. Sympathetic uveitis 66 years
after injury. Can J Ophthalmol 1984;19:240-3.
25. Duke-Elder S, Perkins ES. Sympathetic ophthalmitis. In Diseases
of the Uveal Tract. St. Louis: Mosby, 1966. p. 558.
26. Lubin JR, Albert DM, Weinstein M. Sixty-five years of
sympathetic ophthalmia. A clinicopathologic review of cases
(1913–1978). Ophthalmology 1980;87:109-21.
27. Goto H, Rao NA. Sympathetic ophthalmia and Vogt-Koyanagi-
Harada syndrome. Int Ophthalmol Clin 1990;30:279-80.
28. Chan CC, Whitcup SM, Nussenblatt RB. Sympathetic
ophthalmia and Vogt-Koyanagi-Harada syndrome. In: Tasman
W, Jaeger EA, editors. Duane’s Ophthalmology 2006 Edition
(CD-ROM). Philadelphia: Lippincott Williams & Wilkins; 2005.
29. Hwang TN. How do I decide whether to perform an evisceration
or enucleation? In: Kersten RC, McCulley TJ, editors.
Curbside Consultation in Oculoplastics. New Jersey: SLACK
Incorporated; 2011. p. 173-6.
30. Rudemann AD Jr. Sympathetic ophthalmia after evisceration.
Trans Am Ophthalmol Soci 1963;61:274-314.
31. Griepentrog GJ, Lucarelli MK, Albert DM, Nork TM. Sympathetic
ophthalmia following evisceration: a rare case. Ophthal Plast
Reconstr Surg 2005;21:316-8.
32. Freidlin J, Pak M, Tessler HH, Putterman AM, Goldstein DA.
Sympathetic ophthalmia after injury in the Iraq War. Ophthal
Plast Reconstr Surg 2006;22:133-4.
33. Allen JC. Sympathetic uveitis and phacoanaphylaxis. Am J
Ophthalmol 1967;63:280-3.
34. Gass JD. Sympathetic ophthalmia following vitrectomy. Am
Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012 31
J Ophthalmol 1982;93:552-8.
35. Allen JC. Sympathetic ophthalmia: A disappearing disease.
JAMA 1969;209:1090.
36. Liddy BS, Stuart J. Sympathetic ophthalmia in Canada. Can J
Ophthalmol 1972;7:157-9.
37. Kraus-Mackiw E, Muller-Ruchholtz W. Sympathetic eye
disease: diagnosis and therapy. Klin Monatsbl Augenheikd
1980;176:131-0.
38. Kilmarin DJ, Dick AD, Forrester JV. Prospective surveillance of
sympathetic ophthalmia in the UK and Republic of Ireland. Br
J Ophthalmol 2000;84:259-63.
39. Hansen AB, Petersen C, Heegaard S, et al. Review of 1028
bulbar eviscerations and enucleations: Changes in etiology
and frequency overa a 20-year period. Acta Ophthalmol Scand
1999;77:331-5.
40. Levine MR, Pou CR, Lash RH. The 1998 Wendell Hughes
Lecture. Evisceration: Is sympathetic ophthalmia a concern in
the new millennium? Ophthal Plast Reconstr Surg 1999;15:4-8.
41. Walter WL. Update on enucleation and evisceration surgery.
Ophthal Plast Reconstr Surg 1985;1:243-52.
42. du Toit N, Motala MI, Richards J, Murray AD, Maitra S. The
risk of sympathetic ophthalmia following evisceration for
penetrating eye injuries at Groote Schuur Hospital. Br J
Ophthalmol 2008;92:61-3.
43. Bilyk JR. Enucleation, evisceration, and sympathetic ophthalmia.
Curr Opin Ophthalmol 2000;11:372-86.
44. Shields JA. Current approaches to the diagnosis and
management of choroidal melanomas. Surv Ophthalmol
1977;31:449-63.
45. M a n s c h o t W A , v a n P e p e r z e e l H A . C h o r o i d a l
melanoma.
Enucleation or observation? A new approach.
Arch Ophthalmol 1980;98:71-7.
46. Shields JA. Introduction to management
melanomas. In: Rvan
SR, editor. Retina Vol. 1. St Louis: CV Mosby; 1989. p. 683-6.
47. Shields JA, Shields CL. Malignant melanoma of the posterior
uvea. In: Fraunfelder FT, Roy FH, editors. Current Ocular
Therapy. 3rd ed. Philadelphia: WB Saunders; 1990. p. 394-8.
48. Albert DM, Diaz-Rohena R. A historical review of sympathetic
ophthalmia and its epidemiology. Surv Ophthalmol 1989;34:
1-14.
49. Randolph RL. The question about enucleation in purulent
panophthalmitis. JAMA 1910;LIV(25):2023-6.
50. Shah-Desai SD, Tyers AG, Manners RM. Painful blind eye:
Efficacy of enucleation and evisceration in resolving ocular
pain. Br J Ophthalmol 2000;84:437-8.
51. Erie JC, Nevitt MP, Hodge D, Ballard DJ. Incidence of enucleation
in a defined population. Am J Ophthalmol 1992;113:138-44.
52. Setlur VJ, Parikh JG, Rao NA. Changing causes of enucleation
over the past 60 years. Graefes Arch Clin Exp Ophthalmol
2010;248:593-7.
53. Davenger M. Causes of enucleation in Uganda. Br J Ophthalmol
1970;54:252-5.
54. Kaimbo K. Causes of enucleation in Zaire. J Fr Ophthalmol
1988;11:677-80.
55. Haile M, Alemayehu W. Causes of removal of the eye in
Ethiopia. East Afr Med J 1995;72:7358.
56. Custer PL, Reistad CE. Enucleation of blind, painful eyes.
Ophthal Plast Reconstr Surg 2000;16:326-9.
57. Maumenee AE. Retrobulbar alcohol injections; relief 
of
ocular pain in eyes with and without vision. Am J Ophthalmol
1949;32:1502-8.
58. Faran MF, al-Omar OM. Retrobulbar alcohol injection in blind
painful eyes. Ann Ophthalmol 1990;22:460-2.
59. Chen TC, Ahn Yuen SJ, Sangalang MA, Fernando RE,
[Downloaded free from http://www.meajo.org on Friday, January 19, 2018, IP: 203.78.119.132]
Phan, et al.: Evisceration in the Modern Age
Leuenberger EU. Retro- bulbar chlorpromazine injections for
the management of blind and seeing painful eyes. J Glaucoma
2002;11:209-13.
60. Gundersen T. Conjunctival flaps in the treatment of corneal
disease with reference to a new technique of application. Arch
Ophthalmol 1958;60:880-8.
61. Gundersen T, Pearlson HR. Conjunctival flaps for corneal
disease. Trans Am Ophthalmol Soc 1969;67:78-95.
62. Paton D, Milauskas AT. Indications, surgical technique, and
results of thin conjunctival flaps on the cornea: A review of
122 consecutive cases. Int Ophthalmol Clin 1970;10:329-45.
63. Insler MR, Pechous B. Conjunctival flaps revisited. Ophthalmic
Surg 1987;18:455-8.
64. Alino AM, Perry HD, Kanellopoulos AJ, Donnenfeld ED, Rahn
EK. Conjunctival flaps. Ophthalmology 1998;105:1120-3.
65. Brackup AB, Carter KD, Nerad JA, Folk JC, Pulido JS. Long-term
follow-up of severely injured eyes following globe rupture.
Ophthal Plast Reconstr Surg 1991;7:194-7.
66. Dada, T, Ray M, Tandon R, Vajpayee RB. A study of the
indications and changing trends of evisceration in north India.
Clinical and Experimental Ophthalmol 2002;30:120-3.
67. Chaudhry IA, Al-Kuraya HS, Shamsi FA, Elzaridi E, Riley FC.
Current indications and resultant complications of evisceration.
Ophthalmic Epidemiol 2007;14:93-7.
68. Eballe AO, Dohvoma VA, Koki G, Oumarou A, Bella AL, Mvogo
CE. Indications for destructive eye surgeries at the Yaounde
Gynaeco-Obstetric and Paediatric Hospital. Clin Ophthalmol
2011;11:561-5.
69. Afran SI, Budenz DL, Albert DM. Does enucleation in the
presence of endophthalmitis increase the risk of postoperative
meningitis? Ophthalmology 1987;94:235-7.
70. Ozgur OR, Levent A, Dogan OK. Primary implant placement with
evisceration in patients with endophthalmitis. Am J Ophthalmol
2007;143:902-4.
71. Tawfik HA, Budin H. Evisceration with primary implant
placement in patients with endophthalmitis. Ophthalmology
2007;114:1100-3.
72. Birkman LW, Bennett DR. Meningoencephalitis following
enucleation for cryptococcal endophthalmitis. Ann Neurol
1978;4:476-7.
73. Burch FE. Evisceration of the globe with scleral implant
and preservation of the cornea. Trans Am Ophthalmol Soc
1939;37:272-82.
74. Migliori ME. Enucleation, evisceration, and exenteration. In:
Albert D, Miller J, Azar D, Blodi B, editors. Albert & Jakobiec’s
Principles and Practice of Ophthalmoloby. 3rd ed. (CD-ROM).
Philadelphia: Saunders; 2008.
75. Stephenson CM. Evisceration. In: Hornblass A, editor.
Oculoplastic, Orbital and Reconstructive Surgery. Vol. 2.
Baltimore, MD: Williams & Wilkins; 1990. p. 1194-9.
76. Woog JJ, Angrist RC, White WL, Dortzbach RK. Enucleation,
evisceration, and exenteration. In: Dortzbach RK, editor.
Ophthalmic Plastic Surgery: Prevention and Management
of Complications. New York, NY: Raven Press; 1994:251-68.
77. Masdottir S, Sahlin S. Patient satisfaction and results after
evisceration with a split-sclera technique. Orbit 2007;26:241-7.
78. Smith RJ, Prazeres S, Fauquier S, Malet T. Complications
of two scleral flaps evisceration technique: Analysis of 201
procedures. Ophthal Plast Reconstr Surg 2011;27:227-31.
79. Tari AS, Malihi M, Kasaee A, Tabatabaie SZ, Hamzedust K,
Musavi MF, et al. Enucleation with hydroxyapatite implantation
versus evisceration plus scleral quadrisection and alloplastic
implantion. Ophthal Plast Reconstr Surg 2009;25:130-13.
80. Dortzback RK, Woog JJ. Choice of procedure. Enucleation,
32 Middle East African Journal of Ophthalmology, Volume 19, Number 1, January - March 2012
evisceration, or prosthetic fitting over globes. Ophthalmology
1985;92:1249-55.
81. Hui JI. Outcomes of orbital implants after evisceration and
enucleation in patients with endophthalmitis. Curr Opin
Ophthalmol 2010;21:375-9.
82. Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv
Ophthalmol 2000;44:277-301.
83. Migliori ME. Enucleation versus evisceration. Curr Opi
Ophthalmol 2002;13:298-302.
84. Walter WL. Update on enucleation and evisceration surgery.
Ophthal Plast Reconstr Surg 1985;1:243-52.
85. Kaltreider SA, Lucarelli MJ. A simple algorithm for selection
of implant size for enucleation and evisceration: A prospective
study. Ophthal Plast Reconstr Surg 2002;18:336-41.
86. Bartlett RE. Plastic surgery for the enucleation patient. Am J
Ophthalmol 1966;61:68-78.
87. Laiseca A, Laiseca D, Laiseca J, Laiseca J Jr. Correcting
superior sulcus deformities. Adv Ophthal Plast Reconstr Surg
1990;8:229-42.
88. Schaefer DP. Evaluation and management of the anophthalmic
socket and socket reconstruction. In: Nesi FA, Lisman
RD, Levine MR, editors. Smith’s Ophthalmic Plastic and
Reconstructive Surgery. 2nd ed. St. Louis: Mosby–Year Book,
Inc.; 1998. p. 1079-124.
89. Heinz GW, Nunery WR. Anophthalmic socket: evaluation and
management. In: McCord CD, Tanenbaum M, Nunery WR,
editors. Oculoplastic Surgery. New York: Raven Press; 1995.
p. 609-937.
90. Neuhaus RW, Hawes MJ. Inadequate inferior cul-de-sac in the
anophthalmic socket. Ophthalmology 1992;99:153-7.
91. Bosniak SL. Reconstruction of the anophthalmic socket: state
of the art. Adv Ophthal Plast Reconstr Surg 1987;7:313-48.
92. Petrelli RL. Use of autogenous materials in reconstructing
the anophthalmic socket. Adv Ophthal Plast Reconstr Surg
1990;8:153-69.
93. Rose GE, Sigurdsson H, Collin R. The volume-deficient orbit:
Clinical characteristics, surgical management, and results after
extraperiorbital implantation of Silastic block. Br J Ophthalmol
1990;74:545-50.
94. Goldberg RA, Holds JB, Ebrahimpour J. Exposed hydroxyapatite
orbital implants: Report of six cases. Ophthalmology
1992;99:831-6.
95. Kim YD, Goldberg RA, Shorr N, Steinsapir KD. Management
of exposed hydroxyapatite orbital implants. Ophthalmology
1994;101:1709-15.
96. Nunery WR, Heinz GW, Bonnin JM, Martin RT, Cepela MA.
Exposure rate of hydroxyapatite spheres in the anophthalmic
socket: Histopathologic correlation and comparison with
silicone sphere implants. Ophthal Plast Reconstr Surg
1993;9:96-104.
97. Remulla HD, Rubin PA, Shore JW, Sutula FC, Townsend DJ,
Woog JJ, et al. Complications of porous spherical orbital
implants. Ophthalmology 1995;102:586-93.
98. Smit TJ, Koomneef L, Zonneveld FW. Conjunctival cysts in
anophthalmic orbits. Br J Ophthalmol 1991;75:342-3.
99. Zolli CL. Implant extrusion in eviscerations. Ann Ophthalmol
1988;20:127-35.
100. Shore JW, Dieckert JP, Levine MR. Delayed primary wound
closure. Use to prevent implant extrusion following evisceration
for endophthalmitis. Arch Ophthalmol 1988;106:1303-8.
101. Soll DB. The anophthalmic socket. Ophthalmology 1982;89:
407-23.
102. Kronish JW, Gonnering RS, Dortzbach RK, Rankin JH, Reid DL,
Phernetton TM, et al. The pathophysiology of the anophthalmic
[Downloaded free from http://www.meajo.org on Friday, January 19, 2018, IP: 203.78.119.132]

Phan, et al.: Evisceration in the Modern Age

socket, part II: analysis of orbital fat. Ophthal Plast Reconstr
Surg 1990;6:88-95.
103. Thaller VR. Enucleation volume measurement. Ophthal Plast
Reconstr Surg 1997;13:18-20.
104. Ataullah S, Whitehouse RW, Stelmach M, Shah S, Leatherbarrow
B. Missed orbital wall blow-out fracture as a cause of post-
enucleation socket syndrome. Eye 1999;13:541-4.
105. Lu L, Shi W, Luo M, Sun Y, Fan X. Repair of exposed
hydroxyapatite orbital implants by subconjunctival tissue flaps.
J Craniofac Surg 2011;22:1452-6.
106. Basterzi Y, Sari A, Sari A. Surgical treatment of an exposed
orbital implant with vascularized superficial temporal fascia
flap. J Craniofac Surg 2009;20:502-4.
107. Tawfik HA, Budin H, Dutton JJ. Repair of exposed porous
polyethylene implants utilizing flaps from the implant capsule.
Ophthalmology 2005;112:516-23.
108. Lee MJ, Khwarg SI, Choung HK, Kim NJ, Yu YS. Dermis-fat
graft for treatment of exposed porous polyethylene implants
in pediatric postenucleation retinoblastoma patients. Am J
Ophthalmol 2001;152:244-50.
109. Wu AY, Vagefi MR, Georgescu D, Burroughs JR, Anderson
RL. Enduragen patch grafts for exposed orbital implants. Orbit
2011;30:920-5.
110. Sagoo MS, Olver JM. Autogenous temporalis fascia patch
graft for porous polyethylene (Medpor) sphere orbital implant
exposure. Br J Ophthalmol 2004;88:942-6.
111. Massry GG, Holds JB. Frontal periosteum as an exposed orbital
implant cover. Ophthal Plast Reconstr Surg 1999;15:79-82.
112. Kim YD, Goldberg RA, Shorr N, Steinsapir KD. Management
of exposed hydroxyapatite orbital implants. Ophthalmology
1994;101:1709-15.
113. Shields CL, Shields JA, De Potter P, Singh AD. Problems
with the hydroxyapatitie orbital implant: Experience with 250
consecutive cases. Br J Ophthalmol 1994;78:702-6.
114. Levine MR. Extruding orbital implant: prevention and treatment.
Ann Ophthalmol 1980;12:1384-6.
115. Helveston EM. Human bank sclera patch. Arch Ophthalmol
1969;82:83-6.
116. McCord CD. The extruding implant. Trans Am Acad Ophthalmol
Otolaryngol 1976;81:587-90.
117. Soll DG. Donor sclera enucleation surgery. Arch Ophthalmol
1974;92:494-5.
118. Wiggs EO, Becker BB. Extrusion of enucleation implants:
Treatment with secondary implants and autogenous temporalis
fascia or fascia lata patch grafts. Ophthalmic Surg 1992;23:472-6.
119. Eagle RC Jr, Grossniklaus HE, Syed N, Hogan RN, Lloyd WC
3rd, Folberg R. Inadvertent evisceration of eyes containing uveal
melanoma. Arch Ophthalmol 2009;127:141-5.
120. Rath S, Honavar SG, Naik MN, Gupta R, Reddy VA, Vemuganti
GK. Evisceration in unsuspected intraocular tumors. Arch
Ophthalmol 2010;128:372-9.
Cite this article as: Phan LT, Hwang TN, McCulley TJ. Evisceration in the
modern age. Middle East Afr J Ophthalmol 2012;19:24-33.
Source of Support: Nil, Conflict of Interest: None declared.

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