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1 This article was downloaded by:[canadian Research Knowledge Network] On: 9 September 2007 Access Details: [subscription number ] Publisher: Informa Healthcare Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Ophthalmic Epidemiology Publication details, including instructions for authors and subscription information: Current Indications and Resultant Complications of Evisceration Online Publication Date: 01 March 2007 To cite this Article: Chaudhry, Imtiaz A., AlKuraya, Hisham S., Shamsi, Farrukh A., Elzaridi, Elsanusi and Riley, Fenwick C. (2007) 'Current Indications and Resultant Complications of Evisceration', Ophthalmic Epidemiology, 14:2, To link to this article: DOI: / URL: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. Taylor and Francis 2007

2 Ophthalmic Epidemiology, 14:93 97 ISSN: print / online Copyright c 2007 Informa Healthcare DOI: / Current Indications and Resultant Complications of Evisceration Imtiaz A. Chaudhry, 1 Hisham S AlKuraya, 2 Farrukh A. Shamsi, 3 Elsanusi Elzaridi, 4 and Fenwick C. Riley 5 1 Oculoplastic and Orbit Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia 2 Retina Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia 3 Research Department, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia 4 Royal Infirmary, New Castle Upon Tyne, United Kingdom 5 Department of Pathology, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia ABSTRACT Purpose: Evisceration is an alternative treatment modality to enucleation for many end-stage eye diseases. No study has addressed the indications for evisceration of eyes in Saudi Arabia. The aim of this study was to determine the current clinical indications for evisceration in patients at a tertiary eye care center and attempt clinicopathological correlation. Methods: Clinical records of patients who had undergone evisceration at a tertiary eye care center over a 4-year period were reviewed retrospectively. The patients demographic data and clinical indications for evisceration were studied, and the results from histopathological findings were correlated with the clinical diagnosis. Results: Evisceration of the eyes was performed in 187 patients. Males outnumbered females in a ratio of 1.3:1 (105 males and 82 females). Blind painful eye was the primary presenting symptom in 117 (62.6%) patients and unsightly eye in 38 (20.3%) patients. Clinical indications for evisceration included endophthalmitis in 85 (45.5%), phthisis bulbi in 38 (20.3%), traumatic injury in 36 (19.2%), and glaucoma in 14 (7.5%) patients. Sixty-three patients (33.7%) had prior history of cataract surgery, penetrating keratoplasty, glaucoma surgery, or retina surgery. Clinicopathological correlation was 100% in cases with definite clinical diagnosis of endophthalmitis. Conclusion: Blind painful eye, endophthalmitis, phthisis bulbi, severe traumatic injury, and glaucoma were the major indications for eviscerations in a tertiary eye care center. INTRODUCTION Evisceration is a procedure in which the intraocular contents are removed while the sclera, Tenon s capsule, conjunctiva, and optic nerve are preserved. 1 Von Graefe first advocated the use of evisceration in the presence of severe endophthalmitis as a means of preventing intracranial spread of infection. 2 Over the years, indications for evisceration have expanded to include both infectious and noninfectious intraocular inflammation resulting in total loss of vision with no potential for any useful vision, end- Received 15 May 2005; Accepted 4 August Keywords: Indications, Evisceration, Complication, Endophthalmitis, Trauma. Correspondence to: Imtiaz A. Chaudhry, MD, PhD, FACS Oculoplastic and Orbit Division King Khaled Eye Specialist Hospital P.O. Box 7191 Riyadh Saudi Arabia orbitdr@hotmail.com stage glaucoma, and posttraumatic severe ocular injuries. With the advent of modern technology and rapid access to modern eye care in the developed countries, many eyes with endophthalmitis, glaucoma, and severe ocular trauma are being saved without the need for evisceration or enucleation. However, in developing countries, because of the delay in access to modern health care and appropriate diagnostic and therapeutic intervention, many eyes lose visual potential. Eventually, many of these patients present with end-stage diseases; therefore, evisceration or enucleation may be the only available option. The purpose of this study was to determine the underlying ocular conditions leading to evisceration in a major tertiary eye care center in Saudi Arabia and to correlate clinical and histopathological diagnoses. METHODS Clinical records of all patients who underwent evisceration from January 2000 through December 2003, at the King Khaled Eye Specialist Hospital, a tertiary eye care referral center in Riyadh, Saudi Arabia, were retrospectively reviewed. Patient demographics and indications for evisceration were evaluated. Ophthalmic Epidemiology March April

3 Information regarding patient s symptoms, clinical history, diagnosis, examination, investigational studies, clinical, and final diagnoses were collected from case records. Additional information for previous trauma, earlier treatment, length of time before seeking medical help, and presence of systemic disease was obtained. For the purpose of data collection, indications were assigned on the basis of the most recent clinical diagnosis. Forexample, a patient with a prior history of trauma or surgery who presented with intraocular inflammation was considered as having endophthalmitis. Results of diagnostic studies, such as ultrasonography (U/S) or computed tomography (CT), were collected where available. Indications for evisceration for each operated eye were obtained. Results from the histopathological diagnosis of the eviscerated intraocular contents were correlated with the clinical diagnosis made prior to evisceration. The predisposing causes for the final diagnosis were categorized as infectious etiology, blind painful eyes, cosmetically disfigured eyes, posttraumatic, postsurgical, and others. All patients were further categorized by age and divided into two groups: 15 years or older or under 15 years. Any eye with suspicion for intraocular malignancy based on clinical or diagnostic studies was enucleated and not eviscerated. The data were analyzed by using Fisher s exact test, chi-square test, and ANOVA. RESULTS One hundred eighty-seven eyes were eviscerated during the study period between January 2000 and December There were 105 male patients (56%) and 82 (44%) female patients. The age of these patients ranged from 2 to 95 years (mean 53.8 years). The most common presenting symptom was blind painful eye in 117 (62.6%) patients followed by unsightly eye in 52 (27.8%) patients. U/S was performed in 146 eyes because of opaque media, and CT scan was performed in 6 orbits to rule out any associated orbital abscess in cases of panendophthalmitis. The clinical indications for evisceration are presented in Table 1. Endophthalmitis was the most common clinical indication accounting for evisceration in 85 (45.4%) patients, followed by phthisis bulbi in 38 (20.3%), traumatic injury in 36 (19.3%), and glaucoma in 14 (7.5%) patients. Delayed presentation to the hospital before correct diagnosis and appropriate treatment could be rendered was the major reason for loss of vision in many of these patients. There was a delay in the initiation of appropriate therapy in many cases, which ranging from 3 to 95 days. In patients with history of trauma, the frequency of trauma varied significantly with the age group and sex. In all age groups, males were found to be more prone to ocular injury than females. The mean age for evisceration due to injury was 28.6 ف 13.2 years. Road traffic accidents were the main cause of ocular injury in our study, leading to subsequent evisceration in 16 (8.6%) eyes. The group with acute injuries included 10 eyes with trauma of recent onset (<1 month) that led to evisceration. Among the less common injuries leading to evisceration included firecrackers in 2 eyes and chemical injury in 2 eyes. Of all the patients undergoing evisceration, 13 (6.9%) were below 15 years and 174 (93.1%) above 15 years. Sixty-three patients (33.7%) had prior history of cataract surgery, penetrating keratoplasty, glaucoma surgery, or retina surgery. Prior to evisceration, 5 eyes had visual acuity of light perception, where clinically or by any diagnostic testing there was no potential to improve vision with any intervention. The clinicohistopathological correlation was 100% in the group with clinical diagnosis of endophthalmitis. This diagnosis was based on evidence of inflammatory changes observed from the contents of the eviscerated eye globes. Evidence of corneal pathology (abscess or ulcer) was noted in 105 of the eviscerated ocular contents. Thirty-eight eyes diagnosed clinically and by U/S as phthisical were considered for evisceration to improve cosmesis by posterior scleral expansion to accommodate a larger orbital implant. Orbital implants were used in 176 (94.1%) evisceration procedures, and no implant was used in 11 (5.9%) eviscerations because of severe endophthalmitis or panendophthalmitis. Five patients who did not receive primary implant received secondary orbital implants after resolution of their infection, and 6 refused any further surgical procedure because acceptable cosmesis was achieved by a larger prosthesis. Sphere implants (acrylic or silicon) were used in 145 (82.4%) eviscerations and hydroxyapatite in 31 (17.6%) eviscerations. The average size implant introduced into the scleral shells measured 18 mm (range mm). Following evisceration, all the patients received topical antibiotics, and 73 patients (39%) received systemic antibiotics as well. The average time for prosthetic fitting after evisceration was 3 months (range 1 12 months). The average follow-up after evisceration was 15.6 months (range 2 weeks to 36 months). During this time period, no evidence of sympathetic ophthalmia was encountered in the fellow eye of these patients. Twenty-nine (16.2%) complications were identified during this follow-up period (Table 2). The most common complication was implant exposure or extrusion, which was noted in 10 (5.7%) eviscerations where insertion of orbital implant had been carried out. Implant exposures (7 patients) or extrusions (3 patients) were discovered within 15 days to 6 months after the procedure. Six of these patients had a history of endophthalmitis, two had undergone prior multiple surgeries and one had severe Table 1. Clinical diagnosis in eyes undergoing evisceration (n = 187) Indications Number of eyes (%) Endophthalmitis 85 (45.5) Phthisis bulbi 38 (20.3) Traumatic injury 36 (19.2) Glaucoma 14 (7.5) Others 14 (7.5) Table 2. Postoperative complications (n = 29) Complications Number of Eyes (%) Implant exposure/extrusion 10 (5.7) Eyelid ptosis/swelling 8 (4.5) Pyogenic granuloma 4 (2.2) Socket infection 4 (2.2) Fornix insufficiency 3 (1.6) 94 March April 2007 Ophthalmic Epidemiology

4 trauma before undergoing evisceration. Five of these patients required secondary procedures that included implant exchange in four sockets and mucus membrane graft placement to cover their exposures. In two patients, implant exposures healed without any intervention except removal of prosthesis for 1 week. Among the three patients with implant extrusions, two patients had a history of endophthalmitis. Both of these were fitted with a thicker prosthesis as they showed no interest in any further surgery. Dermis fat graft was used in the third patient 3 months after the primary procedure. Delayed eyelid swelling or ptosis was noted in eight patients after evisceration, all of which were resolved within 2 3 months. Less common postoperative complications included formation of pyogenic granuloma in four sockets, infection in four, and fornix insufficiency in three sockets; all of these required intervention. None of the patients who underwent evisceration developed sympathetic ophthalmia. DISCUSSION Blind painful eyes followed by unsightly eyes emerged as the major reasons for patients presenting for evisceration in the present study. Blind painful eyes occurred primarily due to endophthalmitis, ocular injury, neglected corneal ulcers, and postoperative infection after cataract surgery. Endophthalmitis was responsible for evisceration in 85 (45.5%) patients in this study. In the literature, depending on the geographic location, endophthalmitis has been reported to be the cause for evisceration in 23.3% 78.6% of cases. 2,3 The number of endophthalmitis cases have been on the decline lately in developing countries. For example, a recent study from India reported a significant decrease in eviscerations due to endophthalmitis from 91.2% during the first 5-year period ( ) to 50% during the second 5-year period ( ). 2 The authors rationale for this decline was improvement in ophthalmic care, introduction of newer antibiotics, availability of better trained health care professionals, and better access to health care. Trauma from road traffic accidents and penetrating sharp objects, mostly in young males, was responsible for devastating ocular injuries and subsequent eviscerations in 19.2% of cases in our study. This was similar to the results previously reported by other observers in India, Ireland, and Sweden. 2,4,5 Glaucoma was responsible for eviscerations in 7.5% of the eyes in this study, which is lower than reported in previous studies. 3 This trend could be due to the introduction of more potent anti-glaucoma medications and early surgical intervention in recent years. As in other case series, there was predominance of males undergoing evisceration in this study. 2,4,6 Predominance of males undergoing enucleation has also been reported in previous studies 7,8 This may be related to males being more prone to trauma because of their high-risk professions and outdoor activities. Postoperative complications after evisceration occurred in 16.2% of the patients in this study, falling within the reported 10% 28% of complication range for eviscerations. 9 The most common complication in this study, implant exposures (5.7%) after evisceration, was significantly lower than the reported implant exposures (9% 23.5%) after enucleation Avariety of factors may be implicated as the cause of orbital implant, exposure, including infected surgical field, poor wound closure, insertion of a larger implant and poorly fitting conformer or prosthesis. Some of the exposures in this study occurred in those sockets where eviscerations had been performed in the setting of endophthalmitis, or patients had a prior history of severe trauma or multiple eye surgeries. Results from this study support previous recommendations in which insertion of orbital implant in the setting of severe endophthalmitis is discouraged. 9 Evisceration involves the complete evacuation of the intraocular contents while preserving the scleral shell and all of the extraocular appendages. 1,2 Because ocular contents are removed, the only definite diagnosis with evisceration one can make is that of endophthalmitis, where inflammatory process can be identified. In the present study, this correlation was found to be 100% in all cases that were clinically suspected of endophthalmitis. Sympathetic ophthalmia (SO) is a prototypical autoimmune disease in which injury to one eye causes sight-threatening inflammation in the otherwise normal contralateral eye. Although the precise immunopathogenesis is not known, the initiating injury to the exciting eye is thought to disrupt uveoscleral tissue and to compromise the relative immune privilege of the eye. Subsequent sensitisation leads to posterior uveitis associated with granuloma formation at the retino-choroidal interphase, affecting both eyes with a potential for blinding. 16 Although rare, the reported incidence is 0.03 in 100,000 persons. 17 SO is a clinical diagnosis and there are no known specific tests. The diagnosis is suggested by the appearance of uveitis associated with pain, photophobia, and blurred vision in the sympathizing eye. Optic disc swelling, retinal edema, small yellow-white exudates in the retinal pigment epithelium (Dalen-Fuchs nodules), and peripheral area of choroiditis are distinctive posterior segment findings. 18 It is not possible to predict who will develop SO after ocular trauma or surgery, nor is it possible to determine the outcome of the disease based on clinical signs observed at presentation. 19 Many surgeons and ocularists prefer evisceration over enucleation because it is associated with improved cosmesis and motility and hence better patient acceptance. In the setting of severe ocular trauma, some surgeons prefer enucleation over evisceration because of the perceived risk of sympathetic ophthalmia. 20 However, recent evidence suggests that evisceration is an effective and safe procedure in the setting of new techniques for evisceration and the era of corticosteroids. 3,21 Refinement in the surgical approaches involve careful and complete excision of uveal tissue followed by application of absolute alcohol for any uveal remnant inside the scleral shell and meticulous closure of sclera, Tenon s, and conjunctiva in layers. During the study period no cases of SO were discovered in the contralateral eyes of the patients studied. Because disruption of orbital anatomy and physiology is minimal during evisceration compared to enucleation, 22 the relationship of the eyelids and the extraocular muscles with the scleral wall is maintained, resulting in fewer incidences of ptosis. None of the patients in this study required surgical intervention to Ophthalmic Epidemiology March April

5 correct postoperative transient ptosis. To decrease the risk of postoperative ptosis, the Universal implant has been suggested as an alternative to sphere implant in evisceration. 23 Because of retention of the scleral shell, orbital fat atrophy is less pronounced following evisceration and hence the prospects for the development of significant postoperative volume loss, enophthalmos, and a deep superior sulcus are less prominant. 1 Consequently, only three (1.6%) patients in this study showed evidence of fornix insufficiency and four (2.2%) showed evidence of socket pyogenic granuloma formation. In our study, the incidence of socket pyogenic granuloma formation (2.2%) was significantly lower than a previously reported study of this complication (14.8%) after enucleation. 24 Evisceration is technically simpler and faster than enucleation and may be the indicated procedure in patients with poor health who cannot sustain general anesthesia or a lengthy procedure and therefore can be performed under local anesthesia. 25 Indeed, 73 (39%) of the eviscerations in our study were performed under local anesthesia. In the absence of need for wrapping material, cost for evisceration is significantly lower than that of enucleation. The disadvantage of evisceration is that the submitted intraocular contents are distorted and may preclude detailed anatomical and histopathological examination. In the past, unsuspected intraocular malignancies in eyes with opaque media were cited in up to 10% 16% of the operated eyes. 1 However, with the current use of diagnostic modalities such as U/S, when there is no clear view of the posterior segment, the risk of having an intraocular malignancy is minimal. We recommend that eyes with opaque media should be studied with U/S in addition to a thorough clinical examination to exclude the possibility of any malignancy prior to evisceration. In this study, U/S was performed on 146 (78.1%) eyes where the media prohibited adequate evaluation of the posterior segment. Furthermore, CT scan was performed on six orbits where panendophthalmitis resulted in proptosis, and orbital abscess was excluded before proceeding with evisceration. There are some limitations of retrospective study; for example, many of the categories listed as indications for evisceration overlap. One may wonder how indications were assigned when trauma, endophthalmitis, and phthisis may all be part of the same process in a single patient. The data presented in this study have been collected from a tertiary eye care center where the cases referred to the ophthalmic plastic division were at the end stage of the disease process; therefore, only the last diagnosis was entertained. Some of these patients were referred after trauma, whereas others had prior history of ocular surgery and had subsequently become phthisical. For example, a patient who had unsuccessful cataract surgery and subsequently developed endophthalmitis with no potential for useful vision was considered as having endophthalmitis, an indication for evisceration. The eye care system in Saudi Arabia is at the crossroads of developing countries. 26 It is expected that with improvement in eye care, the advent of modern surgical techniques, and the use of newer antibiotics, many of these eyes can be saved from evisceration or enucleation in the future. Public education, health safety regulations, implementation of safe working and living environments, along with early diagnosis of the eye diseases and timely intervention by well trained health care workers, may avoid loss of vision. However, when the loss of an eye is unavoidable, evisceration under local anesthesia with orbital implant may be the best alternative for optimal cosmesis and lower incidence of postoperative complications. REFERENCES 1. Dortzbach RK, Woog JJ. Choice of procedure: Enucleation, evisceration, or prosthetic fitting over globes. Ophthalmology 1985;92: Dada T, Ray M, Tandon R, Vajpayee RB. A study of the indications and changing trends of evisceration in north India. 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6 21. Levine MR, Pou CR, Lash RH. The 1998 Wendel Hughes Lecture. Evisceration: Is sympathetic ophthalmia a concern in the new millennium? Ophthal Plast Reconstr Surg. 1999;15: Tyers AG, Collin JRO. Orbital implants and post enucleation socket syndrome. Trans Ophthalmol Soc UK. 1982;102: Jordan DR, Anderson RL. The Universal implant for evisceration surgery. Ophthal Plast Reconstr Surg. 1997;13: Jordan DR, Klapper SR. A new titanium peg system for hydroxyapatite orbital implants. Ophthal Plast Reconstr Surg. 2000;16: Baylis H, Shorr N. Evisceration, enucleation, and exenteration. In: McCord CD Jr, ed. Oculoplastic Surgery. New York: Raven Press, 1981; Wagoner MD, al-rajhi AA. Ophthalmology in the Kingdom of Saudi Arabia. Arch Ophthalmol. 2001;119: Ophthalmic Epidemiology March April