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Enucleation Surgery—Orbital Implants and Surgical Techniques
Yacoub A Yousef
Department of Surgery, King Hussein Cancer Center, Amman, Jordan
Abstract Enucleation consists of surgical removal of the entire eye globe with preservation of the conjunctiva, extraocular muscles, orbital fat, and optic
nerve. This surgical procedure is generally accepted treatment for intraocular malignancies, blind painful eye, severely traumatized eye, phthisis
bulbi, and to improve cosmetic appearance. Once the eye is removed, orbital volume enhancement typically requires implantation of spherical
materials that can be classified into two major groups: non-porous and porous orbital implants. Different surgical techniques have been
described in the literature, including muscle imbrication technique and the myoconjunctival enucleation technique (both with a non-integrated
implant) and the more recent integrated orbital implants technique that results in less implant-migration and improved prosthesis movement.
In this review, we discuss indications, orbital implant choices and the main enucleation surgical techniques reported in the literature.
Keywords Enucleation, porous orbital implant, rectus muscle, tumor
Disclosure: Yacoub A Youssef has nothing to declare in relation to this article. No funding was received in the publication of this article.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and
reproduction provided the original author(s) and source are given appropriate credit.
Received: February 9, 2016 Accepted: February 17, 2016 Citation: US Ophthalmic Review, 2016;9(1):46–8
Correspondence: Yacoub A Yousef, Consultant Ocular Oncologist, King Hussein Cancer Centre, Queen Rania Street, PO Box 1269 Al-Jubeiha, Amman 11941 Jordan.
Enucleation, or surgical removal of the entire eye globe, was described
by Bartisch in 1583, and was described in combination with orbital
volume replacement (implant) by Mules in 1585. 1–3 In the US, trauma is the
leading indication for enucleation (40.9% of cases), followed by tumors
(28% of cases). 4,5 Other indications include painful blind eye, phthisis
with degeneration, congenital anophthalmia, severe microphthalmia,
unresponsive endophthalmitis, and for improvement of cosmesis
in a blind eye. 4
Various materials may be used to create orbital implants, including
cartilage, bone, fat, gold, silver, cork, rubber, aluminum, ivory, silk,
wool, petroleum jelly, acrylics, silicone, glass, titanium, quartz, and
porous materials such as hydroxyapatite (HA) and polyethylene. 6–15
Unfortunately, however, several reports describe the associated
complications of using such materials, such as exposure, displacement,
extrusion, and orbital infection. 7,14,16
The orbital implant and overlying prosthesis work together to allow
excellent overall cosmesis and eye movement after enucleation. Most
patients are pleased with the result and few require secondary cosmetic
surgery. After healing, the appearance of the anophthalmic patient’s
affected eye should be similar in all aspects to their other, normal eye. 17
Herein, we briefly review the main types of orbital implants, and the main
enucleation surgical techniques reported in the literature.
46 Types of Implants and Enucleation
In the modern era, several types of orbital implants are available for
volume replacement after removal of the eye. They can be classified
into two major groups: non-integrated orbital implants (primarily
polymethylmethacrylate [PMMA]) and integrated porous orbital implants
(typically plastic, bone, or coral). 18–24 The difference between these two
major groups is that integrated implants allow fibrovascular invasion or
incorporation into the living orbit. Graue and Finger demonstrated that on
positron emission tomography (PET)/computed tomography (CT) imaging,
porous orbital implants absorb 18-fluorodeoxyglucose contrast, indicating
metabolic activity within the implanted device. 25 That fibrovascular
invasion does not occur with non-integrated implants.
Enucleation surgery is usually done under general anesthesia. First, the
surgeon resects the conjunctiva from the surgical limbus (periotomy),
followed by dissection of the Tenon’s capsule (tenotomy). Then the four
recti muscles (with or without the two oblique muscles) need to be
isolated, tied by 6–0 absorbable suture, followed by muscle resection
from the insertion, and homeostasis. Then the eye globe should be
pulled anteriorly (either from the stump of the medial rectus, assisted
by cryotherapy, or by sutures at the limbus from two sites), followed by
resection of the optic nerve (the length should be 8–12 mm in cases of
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