Evisceration, Enucleation and the Ocular Prosthesis

At HG Hospital in Kahramanmaraş, Türkiye, by Dr. Nejmi Öztürk, ophthalmologist — evisceration, enucleation and the fitting of an ocular prosthesis afterwards

What are evisceration and enucleation?

Evisceration and enucleation are operations in which an eye that has permanently lost its sight, and has become a source of medical problems, is either emptied surgically or removed. Neither is an easy decision to reach; but where pain does not settle, where inflammation cannot be brought under control, or where there is a tumour that threatens life, they protect the patient from more serious consequences.

The information on this page is there to help you understand the process before the decision is taken together with your doctor. Which method is appropriate is determined by assessing the state of the eye, the underlying disease and whether examination of the tissue is required.

Evisceration

In evisceration the outer wall of the eye, the sclera (the white, tough layer of the eye), is left in place; after the cornea has been removed, the inner tissues of the eye (the iris, the lens, the retina and the vitreous) are emptied out. An orbital implant is placed inside the remaining scleral shell to make up the volume. Because the muscles that move the eye keep their attachment to the sclera, the movement of the prosthesis is usually more natural.

Enucleation

In enucleation the eyeball is removed as a whole, including its sclera; the attachments of the eye muscles are detached and the optic nerve is cut at a certain length as the eye is taken out. An orbital implant is placed in the space that is left, and the muscles are stitched over the implant. The eye that has been removed can, where necessary, be examined in a pathology laboratory — where an intraocular tumour is suspected, this examination is decisive.

The difference between the two

Comparison	Evisceration	Enucleation
What is removed	The cornea and the inner tissues of the eye; the sclera remains	The eyeball is removed as a whole
Eye muscles	Their attachment to the sclera is preserved	Detached, then stitched back over the implant
Movement of the prosthesis	Usually greater	Varies with the muscle-suturing technique
Tissue examination	The whole eye cannot be examined	The eye removed can be examined in pathology
Suspected intraocular tumour	Not appropriate	The method that is preferred
Length of the operation	Usually shorter	Usually longer

When are they considered?

Situations in which evisceration is considered

• A blind, painful eye: Persistent pain that does not respond to medication and drops and that disturbs sleep.
• Intraocular inflammation that cannot be controlled (endophthalmitis): An infection that does not settle despite antibiotic treatment and vitrectomy.
• A severely shrunken, shrivelled eye (phthisis bulbi): Where the eye has lost its shape and its volume.
• A blind eye beyond repair after earlier trauma or operations.

Situations that call for enucleation

• Intraocular tumours: In tumours such as retinoblastoma and choroidal melanoma that are seated inside the eye and cannot be controlled by other methods.
• Severe eye injuries: Trauma in which the eyeball has been damaged beyond repair.
• The risk of sympathetic ophthalmia: In selected cases where the injured eye carries a risk of stimulating the immune system and affecting the healthy eye as well.
• Situations where the diagnosis must be clarified: Cases in which pathological examination of the eye removed is essential.

These operations are not carried out on any eye in which sight can still be regained. The decision is supported by examination, ultrasound and, where needed, imaging such as CT or MRI. If you wish to obtain a second medical opinion before the decision, that is entirely appropriate and is a normal part of the process.

Assessment before surgery

• A full eye examination: The level of vision in both eyes, the intraocular pressure and an assessment of the anterior and posterior segments.
• Ocular ultrasound: Where the media are cloudy, to assess the inside of the eye and any possible mass.
• Imaging: Orbital CT or MRI where a tumour or trauma is suspected.
• General preparation: Blood tests, an anaesthetic assessment, and the adjustment of any blood thinners with the doctor who prescribed them.
• Information and consent: The fact that the procedure cannot be reversed, the prosthesis process and what to expect are all discussed in detail.

How is the surgery done?

Evisceration

1. Anaesthesia: Usually carried out under general anaesthesia; in suitable cases regional anaesthesia may be preferred.
2. Removal of the cornea: The cornea is taken out through a circular incision at its margin.
3. Emptying of the contents: The intraocular tissues are cleared from inside the scleral shell and the shell is washed out.
4. Making up the volume: An orbital implant is placed inside the scleral shell; where necessary, relaxing incisions are made in the edges of the sclera.
5. Closure: The sclera, Tenon’s capsule and the conjunctiva (the clear membrane covering the eye) are stitched layer by layer.
6. Conformer: A clear mould (a conformer) is placed to keep the shape of the lids, and a pressure dressing is applied.

Enucleation

1. Anaesthesia: Carried out under general anaesthesia.
2. Opening the conjunctiva: The conjunctiva and Tenon’s capsule are separated from around the eye.
3. Detaching the muscles: The four straight muscles that move the eye are freed after sutures have been placed at their ends.
4. Removal of the eye: The optic nerve is cut at an appropriate length and the eyeball is removed; in tumour cases care is taken to obtain a sufficient length of the nerve.
5. Placing the implant: The orbital implant is set into the space and the detached muscles are stitched over the implant.
6. Closure and conformer: Tenon’s capsule and the conjunctiva are closed and a conformer is placed.

The orbital implant

The orbital implant is a rounded filler that makes up the volume left by the tissue removed and prevents the eye socket from sinking in. It stays permanently in the socket and is not visible from outside; the part that is seen from outside is the prosthesis fitted later. The size of the implant is chosen according to the volume of the socket and the age of the patient; in children, bone development is taken into account. Which type of material the implant is chosen from, and how the muscles are stitched, are technical details the surgeon determines according to the operative plan.

Recovery

Period	What to expect	What to do
Days 1–5	Swelling and bruising of the lids; there may be a dull ache and a headache	The pressure dressing is kept on for the period your doctor states; painkillers and antibiotics are taken regularly
Week 1	The swelling begins to subside; the conformer stays in place	The drop and ointment routine, and a check-up examination
Weeks 2–4	The conjunctiva heals and the discharge decreases	Avoiding heavy lifting and work that involves bending over
Weeks 4–8	The socket becomes ready for a prosthesis	A referral is made for the prosthesis to be measured
Months 3–6	Tissue swelling resolves completely and the fit of the prosthesis settles	Regular check-ups and care of the prosthesis

In the early days a slightly bloody or yellowish discharge from the socket is to be expected. If pain increases, a fever develops, redness of the lids spreads rapidly or there is heavy inflamed discharge, seek advice without delay.

The ocular prosthesis (artificial eye)

An ocular prosthesis is a thin, spoon-shaped shell placed between the lids after surgery. Contrary to what is widely assumed, it is not a round ball and it is not “screwed into” the socket; it sits over the implant, between the lids and the conjunctiva. It does not provide sight; its purpose is to preserve facial symmetry and a natural appearance, and to support the shape of the lids.

When is it fitted?

A temporary conformer is fitted immediately after surgery; this clear mould prevents the lid and conjunctival space from contracting during healing. The permanent prosthesis is usually made after weeks 4–8, once the swelling has resolved and the socket has become suitable for a mould to be taken. The timing varies from person to person; there is no rush, since intervening too early can disturb the healing of the tissue.

How is it made?

1. Taking the measurement: The shape of the socket is captured by taking a mould, by ocularists trained in this work.
2. Shaping: The prosthesis is shaped according to the lid opening and the position of the other eye.
3. Painting: The colour of the iris, the vessels in the white of the eye and the diameter of the pupil are worked by hand, taking the healthy eye as the model.
4. Fitting and adjustment: Once in place, lid movement and position are assessed and fine adjustments are made where needed.

Care and everyday use

• The prosthesis is taken out and cleaned as often as your doctor or ocularist advises; removing and replacing it more often than necessary can irritate the conjunctiva.
• For cleaning, the recommended solutions are used rather than soap or products containing alcohol.
• There may be dryness and discharge in the socket; lubricating drops reduce this complaint.
• The surface of a prosthesis roughens over time; it generally needs polishing or replacing every few years. In children the interval is shorter, because facial development is still going on.
• It is possible to sleep with the prosthesis in; whether to take it out is decided according to your doctor’s advice.
• Protecting the healthy eye now matters more than ever: glasses with shatterproof lenses against knocks, and regular eye examinations, are recommended.

Risks and limitations

• The procedure cannot be reversed: The eye removed, or the contents emptied out, cannot be regained; there is permanently no sight in that eye.
• Bleeding and infection: As in any surgery, these can occur.
• Exposure of the implant: Can arise when the tissue covering it opens up; a further repair may be needed.
• A sunken look to the socket: If the volume is not sufficiently made up, a hollow may appear in the upper lid.
• Changes in lid position: Drooping or looseness of the lid may develop; where necessary this is corrected with eyelid surgery.
• Phantom sensation: Pain or a sensation of light may be described as though the eye removed were still there; this usually lessens with time.
• Movement of the prosthesis is limited: It does not move as much as a natural eye; after evisceration, movement is generally greater.

Adjusting, and support

Losing an eye is not a surgical process alone. In the early weeks it is usual to struggle with depth perception, to notice objects coming from the side late, and to feel uneasy going up and down stairs; within a few months the brain adapts to this situation to a large extent. For driving, the vision requirements set out in the driving licence regulations need to be assessed separately.

Worry about appearance, sadness and a reluctance to be around others are common at this stage, and they are understandable. If these feelings continue, seeking psychological support should be regarded as part of the treatment; do not hesitate to share it with your doctor.

Evisceration, enucleation and the ocular prosthesis in Kahramanmaraş

These operations are carried out at Private HG Hospital in Kahramanmaraş by Dr. Nejmi Öztürk, ophthalmologist. The examination, ocular ultrasound and any imaging required are planned at the same hospital; the check-ups after surgery and the referral for the prosthesis process are also handled from there. For patients coming from Elbistan, Afşin, Göksun, Ekinözü and Nurhak, the examination and the tests are scheduled on the same day as far as possible. To make an appointment you can use the details on the contact page.

Surgical options in intraocular inflammation and severe retinal problems are described on the vitrectomy and retinal diseases pages, while painful conditions related to intraocular pressure are covered on the glaucoma page.

Frequently asked questions

Sources

• Turkish Ophthalmological Society — todnet.org
• American Academy of Ophthalmology (AAO) — aao.org
• National Eye Institute (NEI) — nei.nih.gov

Related pages

• Eyelid aesthetic surgery
• Vitrectomy
• Glaucoma
• Corneal diseases

This page is for information only; diagnosis and treatment decisions are made after an examination. The results of any surgical or interventional procedure may vary from person to person. You are advised to obtain detailed advice from your physician before any procedure.