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Enucleation is the removal of the eye from the orbit and involves the separation of all tissue connections between the globe and the orbit. This is one of the oldest operations within the field of ophthalmology and is one of the most challenging therapeutic decisions to make. This activity reviews and highlights the role of the interprofessional team in evaluating and managing patients who undergo enucleation. Objectives: Identify the indications for performing enucleation. Describe the equipment, personnel, preparation, and technique in regards to the enucleation procedure. Outline appropriate evaluation of the potential complications and their clinical significance with enucleation. Explain interprofessional team strategies for improving care coordination and communication to advance enucleation and improve outcomes. Access free multiple choice questions on this topic.

Enucleation describes the removal of the entire globe, with separation of all connections from the orbit, including optic nerve transection. It is one of the oldest procedures in ophthalmology, with descriptions dating back to 2600BC.[1] The decision for enucleation can be one of the most difficult to make and discuss with the patient. The main indications for enucleation are trauma, painful eye, a blind eye, which is unsightly, intraocular malignancy, and as part of eye donation. Alternatives such as evisceration or exenteration can be considered according to the underlying diagnosis and condition of the eye. Management of the anophthalmic socket is challenging, and a decision on implant selection and wrapping material should ideally be made as part of the pre-operative plan. Wrapping materials can be synthetic, autologous, or human tissue sourced from an eye bank. Some patients can benefit from a peg placement for improved postoperative motility and cosmesis. However, this procedure has been largely abandoned because of the occurrence of late complications, including infections, exposure, discharge, and peg loss. Ultimately, the aims of enucleation are to remove diseased tissue, improve patient comfort, replace orbital volume, and give a good functional and cosmetic result for the patient.

Intraoperative Removal of the wrong eye is the most feared intraoperative complication and can be avoided by careful attention, good communication, pre-surgery checks, and marking of the eye to be enucleated. During surgery, the loss of a rectus muscle can occur and can be minimized by placing the traction sutures carefully. If the muscle is lost and retracts into the orbit, a detailed search among the soft tissues can be undertaken. Grasping of the Tenon's fascia with forceps in a hand-over-hand fashion can help to visualize the muscle. The inter-muscular septae that are present between the extraocular muscles can be used to identify the retracted muscle. Prior to surgery, the patient's anticoagulation status will need to be ascertained and, if appropriate, discontinued during the perioperative period. Careful dissection, tissue handling, and cautery can reduce the risk of intraoperative orbital hemorrhage. Retrobulbar injection of anesthetic with epinephrine will also decrease intraoperative bleeding. In the presence of an intraocular tumor such as melanoma or retinoblastoma, it may be necessary to obtain a long section of the optic nerve as there may be the posterior spread of the tumor along the optic nerve. When the globe is full of tumors, it can be difficult to remove an adequate length of the optic nerve (FIG 1). In these cases, usually children with large intraocular retinoblastomas, we use the superomedial approach to the orbit to identify the optic nerve and cut it under direct vision (Fig 2 & 3). This avoids the complication of transecting the globe accidentally or obtaining an inadequate length of the optic nerve.[28] Postoperative Early Postoperative

In the presence of an intraocular tumor such as melanoma or retinoblastoma, it may be necessary to obtain a long section of the optic nerve as there may be the posterior spread of the tumor along the optic nerve. When the globe is full of tumors, it can be difficult to remove an adequate length of the optic nerve (FIG 1). In these cases, usually children with large intraocular retinoblastomas, we use the superomedial approach to the orbit to identify the optic nerve and cut it under direct vision (Fig 2 & 3). This avoids the complication of transecting the globe accidentally or obtaining an inadequate length of the optic nerve.[28] Postoperative Early Postoperative Postoperative orbital hemorrhage after enucleation is rare with the use of compression bandages, and the precautions discussed earlier. If severe hemorrhage occurs, surgical exploration may be necessary, and separate incisions can decrease wound dehiscence and fat atrophy. Edema of the orbit after enucleation is common and usually settles down with time. Orbital infection is a rare complication but can lead to wound dehiscence, implant exposure, and extrusion. Symptoms can be increased chemosis and persistent pain in the socket. Infection can be more common with integrated orbital implants, and treatment with systemic antibiotics can be inadequate, necessitating implant removal.[29][30] If there is dislodging of the conformer, this can result in conjunctival prolapse and fornix shortening. The patient should be advised to replace the conformer in its original position after cleaning. The temporary tarsorrhaphy sutures mentioned above help to reduce the risk of conformer extrusion. Late Postoperative A lax socket can develop from the secondary effects of time, gravity, and stretching of the soft tissues of the orbit by the prosthesis. It is a common late complication following enucleation, leading to downward and anterior migration of the orbital implant. A larger and heavier prosthesis can provide temporary relief but will cause greater downward migration and deepening of the superior sulcus with lower lid laxity with time. The post-enucleation socket syndrome or anophthalmic syndrome (based upon the sterling work of Ton Smit [31]) comprises the following: Enophthalmos Deep superior sulcus Upper lid retraction/ptosis (one or both may occur) Lower eyelid laxity

A lax socket can develop from the secondary effects of time, gravity, and stretching of the soft tissues of the orbit by the prosthesis. It is a common late complication following enucleation, leading to downward and anterior migration of the orbital implant. A larger and heavier prosthesis can provide temporary relief but will cause greater downward migration and deepening of the superior sulcus with lower lid laxity with time. The post-enucleation socket syndrome or anophthalmic syndrome (based upon the sterling work of Ton Smit [31]) comprises the following: Enophthalmos Deep superior sulcus Upper lid retraction/ptosis (one or both may occur) Lower eyelid laxity The fullness of the lower eyelid and shallowing of the inferior fornix (caused by the rotation of the orbital tissues that occur in an enucleated socket) Posterior tilt of the prosthesis Enophthalmos may occur early or late. Many methods have been described at restoring the orbital volume. Rose et al. proposed sequential volume replacement, firstly using dermis fat graft or implant followed by a silastic block into the extraperiorbital space.[32] Complications following dermis fat grafts can include graft ulceration, fat atrophy, necrosis, wound dehiscence, granuloma formation, hematoma, and graft surface keratinization. These can be reduced by good surgical technique with careful tissue handling and donor site selection.[33]

Enucleation requires an interprofessional team consisting of a surgeon, ophthalmic nurse, theatre staff, and medical assistants. The team will identify patients suitable for the enucleation procedure and, during the operation, follow safe surgical protocols. They will be able to safely identify and check the correct surgical site prior to undertaking enucleation. The team will also undertake patient education prior to and after the enucleation procedure to ensure good patient rehabilitation and outcomes. [Level 5]

The interprofessional team will discuss the enucleation procedure with the patient and obtain informed consent prior to surgery. The patient's expectations, concerns, and psychological welfare regarding eye removal will be explored. Instrumentation and correct site checks will be performed by the theatre team. Communication with other team members before and after the procedure contributes to safe care standards. [Level 5]

There are early and late postoperative complications associated with the enucleation procedure. The multidisciplinary team will inform and maintain communication with the patient through the postoperative period to ensure they can manage their wound care, and be aware of red-flag symptoms upon which they should present back to the surgical team. The healthcare team will be closely involved in the patient review process in the hospital outpatients. [Level 5]