The use of either enucleation or evisceration for the management of severe ocular trauma, intraocular malignancy, blind painful eye, endophthalmitis, and cosmesis has been compared for more than a century.1 Historically, enucleation has been preferred by many surgeons, perhaps due to the perceived risk of sympathetic ophthalmia after evisceration, but the latter has gained renewed interest with expanding indications that may offer fewer complications.2 We administered an Internet-based survey to members of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) to determine the current attitudes regarding enucleation and evisceration management and compared them to historical trends. The complete survey is available as supplemental material in the PDF version of this article.
Patients and Methods
E-mails were sent to 552 ASOPRS members inviting them to complete a 36-question Internet-based survey that compiled their answers anonymously. The questions focused on determining training background, preference for evisceration versus enucleation, imaging modalities, implant materials, wound-closure techniques, postoperative complications observed, and indications for which procedures were performed.
Many questions contained an option for participants to type in a response if their answer choice was not listed. Respondents were not required to answer every question and some questions allowed participants to select one or more answer. The data were entered into a database and statistical analysis was performed using OpenEpi software (Atlanta, GA).
A total of 113 surveys were completed, representing a 20.4% response rate. Based on the average number of procedures performed over the past year and number of years post-fellowship, this survey represents more than 11,000 eviscerations and 14,000 enucleations. Table 1 indicates the number of years since surgeons completed fellowship training, stratified further into whether they perform evisceration and/or enucleation. Overall, 94.6% of respondents perform evisceration and 97.8% perform enucleation; the indications for which these were performed are displayed in Table 2.
Table 1: Years of Experience and Practice Pattern
Table 2: Procedures Practiced With Specific Indications
Participants were asked to choose their top imaging modality to evaluate eyes with opaque media prior to enucleation or evisceration. The most common choice was B-mode ultrasonography, regardless of whether enucleation or evisceration was performed (Table 3). Participants were also asked to choose up to two favored implant materials used in evisceration or enucleation. Regarding implant materials, Medpor (Stryker Craniomaxillofacial, Portage, MI) and acrylic appeared to be slightly favored (Table 4). When placing an implant in evisceration or enucleation for infectious causes, the most common response was to place the implant in surgery primarily.
Table 3: Imaging Modalities Used
Table 4: Implant Preference
The most common method for wound closure and/or implant wrapping in either evisceration or enucleation for blind painful eyes not related to malignancy or infectious causes was closing conjunctiva and Tenon’s layer without additional tissue. Additional less preferred methods were selected and varied according to procedure type (Table 5).
Table 5: Preference in Wound Closure and/or Implant Wrapping
The complications experienced with evisceration and enucleation surgery are displayed in Figure 1. When ASOPRS members were further asked how many cases of sympathetic ophthalmia they had observed in their career following evisceration or enucleation, a total of 11 cases were reported after evisceration and 5 cases after enucleation. Members were also asked to indicate whether they favored enucleation, evisceration, or had no preference for the treatment of blind painful eye (non-infectious or non-malignancy), blind painful eye (infectious), and malignancy (Table 6). Among respondents who do not perform evisceration, the most common reason was concern for the presence of occult malignancy.
Figure 1. Percentage of postoperative complications experienced by respondents after evisceration and enucleation surgery. *Meningitis/intracranial refers to meningitis or intracranial spread of infection.
Table 6: Preference for Evisceration or Enucleation
Regarding the pediatric population, 29 surgeons (39.7%) indicated that they do not perform enucleation in children younger than 2 years. Otherwise, surgeons managed socket growth in that age group with sequential placement of larger implants (18 [24.7%]), silicone expanders (5 [6.8%]), placement of oversized implant primarily (20 [27.4]), and dermis fat grafts (10 [13.7%]).
We administered a national survey to understand current preferences in enucleation and evisceration in the United States. Responses to our survey represent more than 25,000 procedures from respondents’ total careers. We compared current preferences in procedure implementation for particular indications, types of implant material used, and the number of complications observed. We also documented preferences in closure techniques, imaging modalities, and current treatment of pediatric patients.
Historically, many ophthalmologists believed that evisceration was the procedure of choice for endophthalmitis.3 Today, a leading reference text describes both enucleation and evisceration as effective treatments.4 However, there is no consensus in the current literature; one article expresses the extreme importance of evisceration in endophthalmitis to prevent meningitis5 and another author argues that a landmark study and his own practice revealed no cases of post-enucleation meningitis among the hundreds of enucleations performed in the setting of endophthalmitis.6 Results from our survey indicate that there is still an inclination to perform evisceration for endophthalmitis, but the frequency of enucleations for this indication is more common than suggested by historical texts.3
A reference from a decade ago discusses enucleation with hydroxyapatite implant along with its increased cost and complication rate.7 A survey of ASOPRS members in 2003 described the most popular materials used in enucleation as high-density porous polyethylene (42.7%), coralline hydroxyapatite (27.3%), and nonporous alloplastic (19.9%) implants, all of which were used in eviscerations at similar rates.8 However, current references describing implant selection note coralline hydroxyapatite and porous polyethylene as popular materials.4 Our survey found similar results. Implants for enucleations were used at the following rate: nonporous alloplastic (43.2%), porous polyethylene (36.4%), and coralline hydroxyapatite (8.5%). For eviscerations, we observed a similar rate of cases using hydroxyapatite, but nonporous alloplastic (68.0%) was the predominant type used, followed distantly by porous polyethylene (25.3%). Despite the many pros and cons discussed for specific implants in the current literature, there are no firm conclusions that indicate a superior implant type.9 It is evident that there are a variety of viable implant options currently used by surgeons.
The occurrence of implant extrusion and exposure in respondents’ careers, which are closely identified with outcome measures, was higher with enucleation (experienced at some time by 83.0% and 42.0%, respectively) than with evisceration (experienced at some time by 44.9% and 24.7%, respectively). Historically, evisceration was thought to have higher incidences of sympathetic ophthalmia.3 However, evisceration outcomes have improved in recent years, so much that current literature reported no cases of sympathetic ophthalmia in studies of several thousand procedures.10,11 This is somewhat reflected in our respondents’ career-total complication rate of sympathetic ophthalmia, which was 0.094% in eviscerations and 0.034% in enucleations. The results of our survey in combination with the current literature suggest that more surgeons are practicing evisceration, perhaps because of the lower complication rate experienced.
We could find little in the recent literature describing the imaging modalities most commonly used. However, our results indicated B-mode ultrasound is the most frequently used modality for all indications in enucleation and all indications in evisceration except intraocular malignancy. This strongly supports the use of B-mode ultrasound as the initial imaging technique in the management of eviscerations and enucleations.
Recent studies have reported that patients 5 years of age and younger are ideal candidates for dermal fat grafts and/or orbital tissue expanders, whereas older patients can have fixed-size implants.12 Although we did not further stratify our pediatric population into age to assess for this, we observed several of our respondents used dermis fat grafting and a fixed-size implant primarily. However, it is notable that 40% of the respondents in our survey do not perform enucleations in patients younger than 2 years.
We received a slightly lower, but comparable, number of responses as a previous ASOPRS member survey that yielded a 37.7% response rate.13 We attribute the greater number of questions in our survey to the lower response rate because research has demonstrated decreased rates of reply to lengthier surveys.14 Limitations of this study include selection bias, recall bias, and the open nature of the survey: respondents were allowed to selectively answer questions and to provide more than one answer to each question. Additionally, although the ASOPRS e-mail list includes a large number of experienced surgeons, other physicians also evaluate and treat patients who require the removal of an eye. Finally, we removed the one respondent who identified his use of evisceration in cases of malignancy due to the fact that historic and current references maintain malignancy is the primary contraindication for evisceration3,4,7 and suggested that the respondent made an error in his survey. This is evidence of a potential downside of a survey such as this.
The practice patterns of ASOPRS members in our survey are valuable to current practitioners and seem to have followed the changing indications and techniques of evisceration and enucleation seen in the current literature. Controlled studies that confirm the outcomes observed in recent popular practices will also be beneficial.
- Migliori ME. Enucleation versus evisceration. Curr Opin Ophthalmol. 2002;13:298–302. doi:10.1097/00055735-200210000-00002 [CrossRef]
- Nakra T, Ben Simon GJ, Douglas RS, Schwarcz RM, McCann JD, Goldberg RA. Comparing outcomes of enucleation and evisceration. Ophthalmology. 2006;113:2270–2275. doi:10.1016/j.ophtha.2006.06.021 [CrossRef]
- Smith BC. Ophthalmic Plastic and Reconstructive Surgery, 1st ed. St. Louis: Mosby; 1987:1278–1305.
- Albert DM. Albert & Jakobiec’s Principles & Practice of Ophthalmology, 3rd ed. Philadelphia: W. B. Saunders; 2007:3519–3527.
- Soares IP, França VP. Evisceration and enucleation. Semin Ophthalmol. 2010;25:94–97. doi:10.3109/08820538.2010.488575 [CrossRef]
- Kahana A, Dutton J. Evisceration is useful in certain situations. Arch Ophthalmol. 2010;128:1496. doi:10.1001/archophthalmol.2010.262 [CrossRef]
- Bosniak SL, ed. Principles and Practices of Ophthalmic Plastic and Reconstructive Surgery. Philadelphia: W. B. Saunders; 1996:1035–1044.
- Su GW, Yen MT. Current trends in managing the anophthalmic socket after primary enucleation and evisceration. Ophthal Plast Reconstr Surg. 2004;20:274–280. doi:10.1097/01.IOP.0000129528.16938.1E [CrossRef]
- Hicks CR, Morrison D, Lou X, Crawford GJ, Gadjatsy A, Constable IJ. Orbital implants: potential new directions. Expert Rev Med Devices. 2006;3:805–815. doi:10.1586/174344220.127.116.115 [CrossRef]
- Hui JI. Outcomes of orbital implants after evisceration and enucleation in patients with endophthalmitis. Curr Opin Ophthalmol. 2010;21:375–379. doi:10.1097/ICU.0b013e32833b7a56 [CrossRef]
- du Toit N, Motala MI, Richards J, Murray ADN, Maitra S. The risk of sympathetic ophthalmia following evisceration for penetrating eye injuries at Groote Schurr Hospital. Br J Ophthalmol. 2008;92:61–63. doi:10.1136/bjo.2007.120600 [CrossRef]
- Chen D, Heher K. Management of the anophthalmic socket in pediatric patients. Curr Opin Ophthalmol. 2004;15:449–453. doi:10.1097/01.icu.0000137855.45573.02 [CrossRef]
- Aakalu VK, Setabutr P. Current ptosis management: a national survey of ASOPRS members. Ophthal Plast Reconstr Surg. 2011;27:270–276. doi:10.1097/IOP.0b013e31820ccce1 [CrossRef]
- Holbrook AL, Krosnick JA, Pfent A. The causes and consequences of response rates in surveys by the news media and government contractor survey research firms. In: Lepkowski JM, Tucker C, Brick JM, eds. Advances in Telephone Survey Methodology. New York: Wiley; 2008:499–528.
Years of Experience and Practice Patterna
|No. of Years Since Completion of Fellowship Training||No. of Respondents||Do You Perform Evisceration Surgery?||Do You Perform Enucleation Surgery?|
Procedures Practiced With Specific Indicationsa
|Blind painful eye (non-traumatic)||76 (85%)||71 (82%)|
|Blind painful eye (traumatic)||57 (64%)||75 (86%)|
|Painful eye with unrecoverable vision||51 (57%)||57 (66%)|
|Endophthalmitis||68 (76%)||47 (54%)|
|Panopthalmitis||31 (35%)||45 (52%)|
|Intraocular malignancy||1 (1%)||77 (89%)|
|Other||0 (0%)||1 (1%)b|
Imaging Modalities Useda
|Procedure/indication||B Mode US||Orbital CT||Orbital MRI||Other|
| Intraocular malignancy||5 (5.6%)||2 (2.2%)||4 (4.5%)||2 (2.2%)|
| Infectious etiology||37 (41.6%)||17 (19.1%)||7 (7.9%)||3 (3.4%)|
| Non-malignant, non-infection||61 (68.5%)||15 (16.9%)||12 (13.5%)||3 (3.4%)|
| Intraocular malignancy||54 (61.4%)||29 (33.0%)||27 (30.7%)||4 (4.5%)|
| Infectious etiology||31 (35.2%)||18 (20.5%)||9 (10.2%)||2 (2.3%)|
| Non-malignant, non-infection||40 (45.5%)||13 (14.8%)||6 (6.8%)||5 (5.7%)|
|Blind Painful Eye||Infectious Cause||Blind Painful Eye||Infectious Cause|
|Dermis fat graft||2%||1%||2%||1%|
|Bone or glass||0%||0%||0%||0%|
Preference in Wound Closure and/or Implant Wrappinga
|Close conjunctiva and Tenon’s layer without additional tissue||74 (84.1%)||56 (64.3%)|
|Donor sclera (around implant or otherwise)||5 (5.7%)||24 (27.6%)|
|Autogenous fascia lata||0||2 (2.3%)|
|Processed fascia lata||0||2 (2.3%)|
|Processed human pericardium||2 (2.3%)||2 (2.3%)|
|Pre-wrapped polyglactin||0||1 (1.1%)|
|Polyglactin mesh||1 (1.1%)||7 (8.0%)|
|Polyester mesh||0||1 (1.1%)|
|Other||19 (21.6%)b||10 (11.5)c|
Preference for Evisceration or Enucleationa
|Blind painful eye (non-infectious/non-malignant)||62%||34%||4%|
|Blind painful eye – (infection)||63%||30%||1%|
|Blind painful eye – (malignancy)||0%||98%||1%|