Astley Bertulfo

Jebson Baliton

Enucleation

Purpose

Enucleation is performed to remove large-sized eye tumors or as a result of traumatic injury

when the eye cannot be preserved. In the case of tumors, the amount of radiation required to
destroy a tumor of the eye may be too intense for the eye to bear. Within months to years,
many patients who are treated with radiation for large ocular melanomas lose vision, develop
glaucoma, and eventually have to undergo enucleation.

The two types of eye tumors that may require enucleation are:

 Intraocular eye melanoma. This is a rare form of cancer in which malignant cells are
found in the part of the eye called the uvea, which contains cells called melanocytes that house
pigments. When the melanocytes become cancerous, the cancer is called a melanoma. If the
tumor reaches the iris and begins to grow, or if there are symptoms, enucleation may be
indicated.
 Retinoblastoma. Retinoblastoma is a malignant tumor of the retina. The retina is the
thin layer of tissue that lines the back of the eye; it senses light and forms images. If the cancer
occurs in one eye, treatment may consist of enucleation for large tumors when there is no
expectation that useful vision can be preserved. If there is cancer in both eyes, treatment may
involve enucleation of the eye with the larger tumor, and radiation therapy for the other eye.

Description

Following anesthesia, the surgeon measures the dimensions of the eye globe, length of the
optic nerve, and horizontal dimensions of the cornea. The surgeon then illuminates the globe of
the eye before opening it. A dissecting microscope is used to detect major features and possible
minute lesions. The eye is opened with a sharp razor blade by holding the globe with the left
hand, cornea down against the cutting block, and holding the blade between the thumb and
middle finger of the right hand. Enucleation proceeds with a sawing motion from back to front.
The plane of section begins adjacent to the optic nerve and ends at the periphery of the cornea.
The plane of section is dependent on whether a lesion has been detected. If not, the globe is
cut along a horizontal plane, using as surface landmarks the superior and inferior oblique
insertions and the long postciliary vein. If a lesion has been found, the plane of section is
modified so that the lesion is included in the slab.

Diagnosis/Preparation
Enucleation may be performed under general or local anesthesia. In either case, the injection is
given in the retro bulbar space. An antibiotic and an anti-inflammatory medication such as
dexamethasone are also given intravenously.
Aftercare
Because the eye is surrounded by bones, it is much easier for patients to tolerate enucleation
than the loss of a lung or kidney. When surgery is performed under general anesthesia, patients
do not feel or see anything until they regain consciousness. Additional local anesthesia is often
given at the end of the surgery so that the patient will have the least pain possible when waking
up in the recovery room. Most patients have a headache for 24–36 hours after surgery that is
relieved with two regular headache medication pills, such as Tylenol, every four hours. A firm
pressure dressing is maintained for four to six days, such oral antibiotics are given for one week;
and steroids, as prednisone, adjusted according to patient status, are given three times daily for
four days. The socket is evaluated after removal of the pressure dressing. If the edema has
disappeared, the sutures are removed. Topical antibiotics are applied four times daily for four
weeks.

Risks
Enucleation surgery is very safe; only rarely do patients experience major complications.
Complications include the following: bleeding, infection, scarring, persistent swelling, pain,
wound separation, and the need for additional surgery. Complications may also occur with the
orbital implants routinely used with patients who have undergone enucleation. Among these is
the risk of infection.

Normal results
Within two to six weeks of enucleation surgery, patients are sent for a temporary ocular
prosthesis (plastic eye). Besides the swelling and the black eye, patient features look normal.
After a final prosthetic fitting, 90% of patients are usually quite happy with the way they look;
80% say others cannot even tell that they have only one eye.

Morbidity and mortality rates

In a study performed by the National Eye Institute on melanoma patients, at five-year follow-
up, 82% of the patients who underwent enucleation remained alive. At a 10-year follow-up,
31% remained alive. As of 2003, the study is still ongoing and will follow all patients for up to 15
years.

Alternatives
There are no alternatives to enucleation because it is a procedure of last resort performed
when other treatments have failed.