Unfortunately it is sometimes necessary to remove an eye surgically.
The main reason for removing an eye is when it has become blind and painful. Many people with a blind, painful eye ask for it to be removed to ease the pain and improve the appearance. Blind painful eyes are often unsightly. The other reason for eye removal is tumour (cancer) growing inside the eye. In this situation the eye may not be blind or painful but may need to be removed to completely excise the tumour. Many diseases can result in blind, painful eyes: glaucoma, diabetic eye disease, trauma, and infection. The aim of surgery is to remove the eye and then create a socket that will be able to hold an ocular prosthesis (artificial or ‘glass’ eye). The socket is the shallow space between the inside of the eyelids and the conjunctiva. Usually an orbital implant is inserted at the time of surgery. This is a spherical ball about the same size as an eyeball. It is inserted in order to replace the volume of tissue that is lost when the eyeball is removed. There are two types of surgery to remove an eye: enucleation and evisceration.
The normal orbit
What is an enucleation?
An enucleation is an operation to remove an eye and create a socket that will hold an ocular prosthesis. During this operation the whole eyeball is removed. The 4 rectus muscles that move the eye are detached and then reattached to an orbital implant. The implant may be made of plastic or of hydroxyapatite (coral). The implants need to be wrapped so that the eye muscles can be sutured back onto the implant. The plastic implant is wrapped in Vicryl mesh – a man made material that dissolves gradually over time and is replaced by a tough capsule around the implant. Blood vessels do not grow into the implant. A hydroxyapatite implant is also wrapped in vicryl mesh. By the time it has dissolved muscles have stuck to it and blood vessels have grown into the implant.
The orbital implant is inserted to replace the volume of tissue lost when an eye is removed. If an implant is not placed, the socket will be very deep. As a result the ocular prosthesis will need to be large to fill the space. A large implant will not move very well and may lead to Post Enucleation Socket Syndrome (PESS): lower eyelid laxity; shrinkage of the conjunctiva; loss of the conjunctival fornix; chronic discharge from the socket; an unstable ocular prosthesis that easily falls out.
The orbit after an enucleation
The orbit after eye removal surgery without an orbital implant. Note the larger socket space between the conjunctiva and the inside of the eyelids
What is an evisceration?
An evisceration is an operation to remove an eye and create a socket that will hold an ocular prosthesis. During this operation, most of the eyeball is removed but the sclera (white of the eye) is left in place. The muscles that move the eye attach to the sclera so they don’t have to be detached and then reattached. A plastic implant is placed in the orbit. The sclera is cut and moved forwards to cover the front of the implant. Eventually the implant becomes surrounded by scar tissue holding it in place. The operation is very similar to an enucleation.
The orbit after an evisceration
Which operation should I have?
If the reason for the removal of the eye is a tumour, an enucleation must be carried out so that the tumour can be removed intact.
An evisceration is a quicker simpler procedure. If you have other medical problems and a shorter anaesthetic is desirable, an evisceration may be the better choice. Most ophthalmic surgeons who carry out this procedure have a preference of either enucleation or evisceration. Mr. McCormick is able to offer a choice of either. One of the factors that influences peoples decision making is a potential but very rare complication called sympathetic ophthalmitis.
The right eye has been removed and an ocular prosthesis fitted
What is sympathetic ophthalmitis?
This is a type of uveitis or inflammation of the eye. It may occur after any eye surgery or trauma to an eye. The inflammation affects both eyes. In the case of eye removal surgery this means that the only remaining eye is affected. It is caused by the immune system inappropriately attacking the healthy eye. In its most severe form it may cause blindness but with modern treatments it is usually treatable with vision preserved. The chance of developing this condition is extremely small. It is estimated that the chance of developing sympathetic after an evisceration is 1 in 60 000 operations. After an enucleation it is estimated to be 1 in 5 000 000 operations. This risk is therefore extremely small and it is the opinion of Mr. McCormick that although the chance of developing sympathetic ophthalmitis is greater after evisceration than enucleation, it is still so small that it probably shouldn’t influence the decision making considerably.
What is an ocular prosthesis?
This is the piece of bespoke hand made plastic that looks like an eye. It is also known as a ‘glass eye’ or an ‘artificial eye’. Many years ago they were made from glass but the weight of these made them troublesome. Modern, low allergy plastic materials achieve excellent results. They are made by ocularists. These are specially trained healthcare professionals who are dedicated to making and maintaining ocular prosthesis. They are also usually your first port of call if you are having problems with your prosthesis or socket. Mr. McCormick is in regular contact with local ocularists regarding mutual patients. Each prosthesis is hand made and hand painted to match your other eye. This process may take some weeks so some ocularists place a temporary prosthesis whilst your permanent one is completed. A mould of the socket (space behind eyelid) is made. This is used to shape the back of the prosthesis. This ensures that the prosthesis fits ‘snugly’. A good fit will mean that when the base of the socket moves, the prosthesis will also move. This is one of the reasons for using an orbital implant when carrying out eye removal surgery: it creates a shallow socket that can be coupled with the prosthesis in this way. After eye removal surgery the socket will be swollen. This swelling has to settle before an ocular prosthesis may be fitted. This can take 8 - 10 weeks. During this period you will not be able to wear an ocular prosthesis. Instead a clear plastic temporary conformer is inserted at the time of initial surgery. This sits behind the eyelids just like the prosthesis. Its purpose is to maintain the space into which the prosthesis will eventually fit.
Photographs of an ocular prosthesis from the front and the side. This is placed in the socket, which is the space between the eyelid and the conjunctiva. Note the concave back-surface of the prosthesis. This is created by taking a mould from the socket behind the eyelids. An orbital implant, placed at the time of eye removal surgery, helps to create a convex socket that allows it to grip the back of the ocular prosthesis and move it to simulate eye movement.
What is an orbital implant?
An orbital implant is a spherical ball of man made material that is inserted at the time of eye removal surgery. It is inserted to compensate for the loss of tissue that occurs when an eye is removed. If not inserted the volume of tissue in the orbit will be reduced and the socket (the space between the inside of the eyelids and the conjunctiva) will be large. This results in Post Enucleation Socket Syndrome or PESS. In addition the sulcus or concavity between the eyebrow and eyelid will be pronounced giving a sunken appearance. There are two main types of orbital implant: porous (hydroxyapatite or coral like) and non porous (acrylic or plastic). The implant is wrapped in material to enable the eye muscles to be sutured to it. Wrap materials include vicryl mesh or the patient’s own sclera, salvaged after the eye is removed. It is not the ocular prosthesis. It should never normally be visible after surgery as it is buried deep in the orbit. If it becomes visible it may be a case of implant extrusion, which is a complication of orbital implant surgery.
Hydroxyapatite implant. Note the porous nature of the implant. These pores allow blood vessels to grow into it enabling it to become integrated. Acrylic implants are not absorbed but held within a capsule of scar tissue.
Are there alternatives to surgery?
If the reason for eye removal surgery is a tumour there usually isn’t an alternative to surgery. There are alternatives to eye removal surgery for certain types of eye tumour but this should already have been discussed with you by your ocular oncologist. If he/she have suggested that the only way to treat the tumour is to remove the eye then there is no alternative.
If you have an eye tumour you should see a specialist ocular oncologist. In the United Kingdom there are 4 dedicated ocular oncology units located in Liverpool, Sheffield, London and Glasgow. Other departments may have an ophthalmologist who specialises in these problems. If the eye is painful it may be possible to control your pain with pain killer medication either with your GP or through a specialist pain team. Mr. McCormick will examine your eye to determine if he can make your eye more comfortable without surgery. If the main concern is the appearance of a blind eye, a special contact lens may be fitted to improve the appearance.
What will happen if I decide not to have surgery?
It is not advisable to leave an eye with a tumour untreated. If you do it may increase the chance of a tumour spreading to the rest of the body. Eventually the eye may become blind, painful and infected.
If the main concern is pain and you decide not to have the eye removed, the pain is likely to continue. Your GP or a specialist pain team may be able to help control the pain.
If the main concern is the appearance of a blind eye, this will not improve with time. It is however perfectly reasonable to not have the eye removed if you are not troubled by this appearance. Over time blind eyes often turn opaque white and shrink.
What will happen before surgery?
Before the operation Mr McCormick will see you in the clinic. He will ask you about the eye problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). He will examine your eyes. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia - in this case general anaesthesia. You will be asked to read and sign a consent form after having the opportunity to ask any questions. You will also see a preoperative assessment nurse. She/he will carry out blood tests and an ECG (heart tracing) if required. She/he will also advise you when you need to starve before the operation.
What should I do about my medication?
Mr. McCormick will want to know all the medication that you take and about any allergies you have. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, apixaban, dabigatran, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and your GP, surgeon or anaesthetist has instructed you. This will be discussed with you before surgery. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.
What are the risks and possible complications of surgery?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in these operations. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding. A collection of blood (haematoma) may be massaged and will usually settle without further surgery. After any surgery on the eyeball, including eye removal surgery, there is a risk of sympathetic ophthalmitis. This is inflammation of the other remaining eye and is discussed earlier in this document. The risk is estimated to be 1 in 60 000 operations after evisceration and 1 in 5 000 000 operations after enucleation i.e. extremely rare. Most people who have had eye removal surgery require minor further surgery to their eyelids or socket at some point in their lifetime. You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.
What should I expect after surgery?
You will stay in overnight after surgery. The main reason for this is to ensure that you have adequate pain control. Mr McCormick will have injected local anaesthetic at the end of the operation into the orbit. This will ease most of the pain in the first 12 - 24 hours. You will have access to a range of pain killers to control pain so that you should not be in pain overnight. The amount of pain experienced is very variable. Some feel hardly anything whilst for others it is moderate. Usually a pad will be placed on the eye, which will remain for 3 days after which you can remove it. For 5 days following this the eyelids should be cleaned using boiled water that has cooled down and sterile cotton wool balls. For the first 2 weeks, until you are seen in clinic again, your eyelids will be sutured together. This is a smooth blue suture that will be held in place by small rubber tubing. This is to hold the conformer in place behind the eyelids and to prevent swollen tissue bulging forwards between the eyelids. After the pad is removed, antibiotic ointment should be applied to the eyelids three times a day for 2 weeks. It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve. The time when you can return to normal activities varies from person to person. Many are happy to carry out light activities after 7 days and most after 2 weeks. Most people take 2 weeks off work although this may need to be extended in some cases. Once you have been seen 2 weeks after surgery, Mr. McCormick will refer you to an ocularist to fit an ocular prosthesis. This process will begin in approximately 8 weeks after surgery to allow swelling to settle. During this time the eyelids will sit closed or slightly open over a clear plastic conformer shell. Some people cover the operated side with an eye-patch or white eye pads from clinic. Others leave it open, it is an individual choice.
Postoperative Instructions
Leave the eye pad and bandage for 24 hours. After this you may remove both. For the first 10 days clean the eyelids using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls. Chloramphenicol ointment to the eyelids, three times a day for 2 weeks. The need for pain control medication is very variable. For many simple paracetamol or cocodamol are adequate. Ibuprofen or other non steroidal tablets may be added if required. Always read the label before taking medications. Follow up appointment 2 weeks later.
