FP1585 : Outcomes of Volume Replacement After Evisceration and Enucleation with Implant

Dr. Tarjani Dave, D13684, Dr. Swathi Kaliki, Dr. Milind Naik, Dr. Mohd Javed Ali

Authors: Tarjani Vivek Dave, Swathi Kaliki, Mohammad Javed Ali, Milind N Naik

Abstract:

Purpose: To test if empirically selecting an implant size for patients undergoing evisceration and enucleation yields an acceptable volume replacement.

Methods:

Retrospective review of charts of 115 eyes operated for enucleation or evisceration with non-porous implant between January to December 2014 was done to record demographic data, type of surgery, implant diameter, post operative superior sulcus deformity(SSD), enophthalmos, prosthesis weight and volume. Enophthalmos of less than 2 mms and not more than SSD of grade 1 were considered to have adequate volume replacement

Results: Enucleation was performed in 58% (pediatric 48% and adult 2%) and evisceration in 42%. The average implant diameter was 18.97+0.99 mm. Implant diameter of 20 mm or more was used in 40%. Post operatively the mean enophthalmos was 0.7+0.9 mm. Adequate volume replacement was observed in 98%. SSD of grade 0 or 1 was observed in 90%.  The mean prosthesis volume was 2.32+0.59ml

Conclusions: Empirical selection of an implant size on the surgical table yields satisfactory post-operative volume replacement

Introduction:

Evisceration involves complete removal of the contents of the eye with preservation of the sclera and the extra ocular muscle attachments. It is preferable to enucleation when a suspected or diagnosed intra ocular tumor is ruled out because orbital anatomy, volume and prosthesis motility are better preserved, leading to superior cosmetic and functional results.^1-3 Enucleation involves the complete removal of the eyeball including the sclera. Extraocular muscles are preserved in the myoconjunctival technique of enucleation.

Evisceration without scleral modification does not allow for the placement of an implant larger than 13-16 millimeters (mms) in diameter.⁴ An implant of this size will replace 1.15 to 2.15 milliliters (ml) of orbital volume.⁵ The volume of the intraocular contents that are lost during evisceration is equal to 4 to 5 ml. This can be provided by an implant that is around 20 mms in diameter.⁶ Adequate volume replacement prevents post evisceration socket syndrome which is characterized by volume loss, superior sulcus deformity, ptosis and lower eyelid laxity.⁷ In situations where a relatively smaller implant is used the weight of the custom ocular prosthesis (COP) tends to be more. The gravitational effect of a heavier prosthesis coupled with lower eyelid laxity as seen in post evisceration socket syndrome, eventually leads to a contracted socket.

In the last 2 decades the understanding of socket volumetrics has evolved to overcome this problem of inadequate volume replacement. This was seen with the advent of sclerotomy techniques that enlarge the scleral rim, expand the internal surface area of the sclera and release the optic nerve from the sclera, allowing for placement of a larger implant with superior functional and cosmetic results.^8-17

However the ideal implant diameter remains a matter of debate. While some surgeons prefer to use implant diameter calculation formulae, others select an implant empirically such that it is the largest possible implant for that socket without tension on the closure line. This study reviews the volume replacement after empiric selection of implant in patients undergoing evisceration and enucleation.

Methods:

Study approval, Design and Subjects

This is a single-centre retrospective consecutive comparative case series comparing the outcomes of evisceration and implant with two surgical modifications. Institutional Review Board (IRB)/Ethics Committee approval was obtained. A computerized database search was conducted for the surgical coding of “evisceration with implant” and “enucleation with implant” from January 2014 to December 2014. The medical records of all patients were reviewed.          Exclusion criteria included cases that received a porous implant, patients in whom a primary implant was not placed and those who did not complete a 6 months post-operative follow up visit. All patients had a COP placement at the two-month post-operative visit.

Outcome measures:

The primary outcome measure was the grade of superior sulcus deformity and the volume of the custom ocular prosthesis. The secondary outcome measures were implant related complications like exposure, extrusion and migration.

Data Collection:

The data collected included the demographic details, the indication for surgery and the pre-operative diagnosis, the axial length of the eviscerated eye and the fellow eye, the surgical technique, the implant diameter and the surgical steps as detailed in the medical records. Post-operative complications like implant migration, exposure and extrusion were noted. The quadrant of decentration and migration within the orbit was noted. Socket examination findings at the two-month and six-month postoperative visit included the (a) examination of the socket with the prosthesis, (b) examination of the socket without the prosthesis and (c) the examination of the prosthesis. The grade of superior sulcus deformity with the prosthesis and the volume of the COP were noted.

Surgical Technique:

Evisceration was performed with and without sclerotomies and optic nerve release and enucleation with the myoconjuctival technique. The diameter of the implant selected was empirical with the placement of an implant that was large enough, but still allowed for closure without tension. The wound closure was in three layers, i.e. sclera, anterior  Tenon’s and conjunctiva each closed separately with 6.0 polyglactin sutures in evisceration and the posteriorTenon’s, anterior Tenon’sand conjunctiva closed similarly in enucleation. An adequate sized conformer was placed and a suture tarsorrhaphy performed which was removed at the 1-week postoperative visit. Standard post-operative care was given to all patients.

Statistical Analysis:

       

The data were arranged on an Excel spreadsheet. Relevant statistical analysis was done using MedCalc version 12.2.1.0. Continuous parametric data were reported as mean (+ standard deviation) and nonparametric data were reported as median with range. Variables between comparative groups were compared using paired t test for parametric distribution and Mann-Whitney U test for non-parametric distribution. A P value of <0.05 was assigned as statistically significant.

Results:

Mean age 21.44+/- 20.10years, median 14 (range 1-76). The demographic data is as shown in table 1

Table1: Demographic data, indications for surgery and the type of surgery performed

Age (years)	21.44±20.1 Median 14 yrs Range 1-76 yrs
Adult cases	54
Pediatric cases	64
Laterality Right eye Left eye	62 (52.54%) 56 (47.46%)
Diagnosis Phthisis bulbi Absolute painful eye Intraocular tumor Open globe post trauma Questionable intraocular tumor Anterior staphyloma Infectious keratitis Adherent leucoma Retinoblastoma Anophthalmic socket Microphthalmia	24 23 9 9 1 14 3 2 31 1 1
Type of surgery Evisceration+non porous implant Enucleation +non porous implant	51 67

Enucleation was performed in 58% (pediatric 48% and adult 52%) and evisceration in 42%. The average implant diameter was 18.97+0.99 mm. Implant diameter of 20 mm or more was used in 40%. Post operatively the mean enophthalmos was 0.7+0.9 mm. Adequate volume replacement was observed in 98%. SSD of grade 0 or 1 was observed in 90%.  The mean prosthesis volume was 2.32+0.59ml

Discussion:

This study attempts to analyze the volumetric outcome in patients after enucleation or evisceration. This study has intrinsic limitations because of its retrospective design. Furthermore, several outcome measures in this study are subjective and are difficult to quantify. Nevertheless, this study takes a first step toward a more detailed understanding of superior sulcus deformity and enophthalmos that occur after enucleation and evisceration. Our results demonstrate that empiric selection of the largest implant that allows a tension free closure gives an acceptable aesthetic outcome in terms of superior sulcus deformity and post-operative enophthalmos.

In our experience during preoperative discussions, patients are most concerned with the postoperative appearance and motility function of their prosthetic eye, eyelids, and orbit. Both enucleation and evisceration result in relative enophthalmos and sulcus defects. Sulcus defects correlate with a worse aesthetic outcome. Thus, the primary outcome measure identified in this study was the aesthetic outcome. Maximizing orbital volume replacement may minimize the sulcus deformity and enophthalmos.

The empiric selection of implant allows avoidance of axial length calculation of the contralateral eye and gives an intraoperative assessment of the volumetric replacement. It avoids taking into perspective complex formulae and the patient’s refractive status.

In conclusion, management of the anophthalmic socket after primary enucleation and evisceration continues to evolve. On the basis of the results of this study empiric selection of implant diameter to maximize volume replacement gives a satisfactory aesthetic outcome. To further validate these findings, however, additional long-term studies may be necessary.

References:

1. Migliori ME. Enucleation versus evisceration. Curr Opin Ophthalmol 2002;13:298 –302.
2. Tucker N. Evisceration: A good technique. Tech Ophthalmol 2005;3:31–5.
3. Custer PL. Enucleation: past, present and future. Ophthal Plas Recostr Surg 2000;16:316 –21.
4. Zolli CL. Implant extrusion in evisceration. Ann Ophthalmol 1988;20:127–35.
5. Chen WPD. Enucleation, evisceration and exenteration. In: McCord CD, Tanenbaum MT, Nunery WR, eds. Oculoplastic surgery. 3rd ed. New York: Raven Press, 1995: 581–608.
6. Kaltreider SA, Lucarelli MJ. A simple algorithm for selection of implant size for enucleation and evisceration: a prospective study. Ophthal Plast Reconstr Surg 2002 Sep;18(5):336-41.
7. Shah CT, Hughes MO, Kirzhner M. Anophthalmic syndrome: a review of management. Ophthal Plast Reconstr Surg 2014 Sep-Oct;30(5):361-5.
8. Huang D, Yu Y, Lu R, et al. A modified evisceration technique withscleral quadrisection and porous polyethylene implantation. Am J Ophthalmol 2009 May;147(5):924-8, 928.e1-3.
9. Yang JG, Khwarg SI, Wee WR, et al. Hydroxyapatite implantation with scleral quadrisection after evisceration. Ophthalmic Surg Lasers 1997 Nov;28(11):915-9.
10. Tari AS, Malihi M, Kasaee A, et al. Enucleation with hydroxyapatite implantation versus evisceration plus scleral quadrisection and alloplastic implantation. Ophthal Plast Reconstr Surg 2009Mar-Apr;25(2):130-3.
11. Massry GG, Holds JB. Evisceration with scleral modification. Ophthal PlastReconstr Surg 2001 Jan;17(1):42-7.
12. Jordan DR, Parisi J. The scleral filet technique for secondary orbitalimplantation surgery. Can J Ophthalmol 1996 Dec;31(7):356-61.
13. Masdottir S, Sahlin S. Patient satisfaction and results after eviscerationwith a split-sclera technique. Orbit 2007 Dec;26(4):241-7.
14. Su GW, Yen MT. Current trends in managing the anophthalmic socket after primary enucleation and evisceration. Ophthal Plast Reconstr Surg 2004Jul;20(4):274-80.
15. Viswanathan P, Sagoo MS, Olver JM. UK national survey of enucleation,evisceration and orbital implant trends. Br J Ophthalmol 2007 May;91(5):616-9.
16. Vijlbrief JW, Hafezi F, Paridaens D. Anterior surface breakdown following evisceration : “Classic”, “scleral modification”, and “scleral patch techniques”. Ophthalmologe 2010 Mar;107(3):246-50.
17. Sales-Sanz M, Sanz-Lopez A. Four-petal evisceration: a new technique. Ophthal Plast Reconstr Surg 2007 Sep-Oct;23(5):389-92.