Enucleation of the Eye (Eye Removal Surgery)

During enucleation, surgeons strive to leave extraocular muscles and remaining orbital contents intact. The structures help with the implant of a prosthetic eye six to eight weeks after the initial procedure. Although enucleation results in loss of visual function, the procedure is performed to enhance a patient’s quality of life.

Reasons for Enucleation

One of the most common reasons for eye removal surgery is to alleviate the pain in an eye that no longer functions or to prevent sympathetic ophthalmia in one eye from affecting the other eye. Sympathetic ophthalmia is an inflammation of the eye that causes blindness if untreated.

Enucleation is also the surgical option to treat tumors from one of several eye cancers, including retinoblastoma and uveal melanoma.

Doctors opt for this procedure in cases of severe eye injuries (automobile accidents, hunting accidents, etc.) If an eye cannot be saved or rescue attempts are unsuccessful, eye removal surgery could be necessary. A globe rupture is an example of an instance where enucleation of the eye may be the viable option.

Surgeons may recommend eye removal for end-stage glaucoma, which can cause a condition known as phthisis bulbi. This condition is characterized by a shrunken, non-functional eye. A prosthetic eye is often inserted after the eye removal surgery. 

Enucleation of the eye is also an indicated treatment option for a congenital cystic eye, a rare eye malformation where the eye does not develop correctly in the womb. Enucleation is performed, followed by insertion of an eye implant and prosthesis.

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Types of Eye Removal Surgery

There are two main types of eye removal surgery: enucleation of the eye and evisceration.

Enucleation vs. Evisceration

In enucleation of the eye, the eyeball is surgically removed. The eyelids and adjacent structures of the eye are left intact. In evisceration, the cornea, iris, and internal eye contents are surgically removed. The attached extraocular muscles and the scleral shell (white of the eye) are left intact. 

Both enucleation and evisceration can be performed to alleviate pain or mitigate infections in a blind eye. After enucleation and evisceration surgery, ocular implants and conformers are used to occupy the empty eye socket and conform the surrounding tissue in preparation for a prosthesis. 

Enucleation is a more invasive procedure and takes more time compared to evisceration. However, some patients, including those affected by eye trauma, cancer, or infection, may not be the right candidates for evisceration surgery.

The Procedure

Enucleation of the eye is a relatively straight-forward outpatient procedure. An eye surgeon usually performs an enucleation under general anesthesia, although it is possible to use local anesthesia. In such cases, the entire eye and socket tissue are numbed before surgery. 

The surgeon removes the eyeball through one of three main enucleation surgical techniques. They then place an orbital implant deep in the eye socket. The orbital implant resembles a marble and is slightly smaller than the natural eye. The surgeon sews the six extraocular eye muscles to the orbital implant. 

Next, the surgeon places a plastic prosthetic — known as a conformer — over the implant. The conformer helps with healing and acts as a placeholder until the custom prosthetic is fitted six to eight weeks later.

The surgeon may sew the eyelid shut to bolster the conformer and aid the wound healing process. A large pressure bandage is then taped over the eye to prevent bleeding, protect the wound, and reduce inflammation.

Enucleation surgery takes about an hour to complete.

Recovery

If you undergo enucleation surgery, you must arrange for a ride home. Doctors strongly recommend not driving following the procedure because of the amount of anesthesia needed. 

When scheduling surgery, you must consider your schedule and your lifestyle. Strenuous physical activity is not advised for two to four weeks after the procedure. As soon as you feel well enough, you may drive and resume your daily activities.

You will go home with a bandage covering your eye socket. Always keep the bandage dry.

Your doctor may prescribe antibiotics and pain medication. Over-the-counter pain relievers are usually sufficient for most people.

The day after surgery, you may remove the bandage that covers your eye. Your surgeon will advise you on how long you should keep it on.

About a week after enucleation surgery, you will undergo a follow-up examination. If you haven’t already, the surgeon will remove the bandage and assess the healing process. 

Risks and Potential Complications

While doctors perform enucleation to alleviate pain, treat disease and improve your quality of life, they acknowledge that the procedure does have risks. Among the risks and complications:

• Bleeding and bruising: It’s not uncommon to deal with bleeding and bruising around the eye socket because of the surrounding bony structures. There usually is not much pain or discomfort, and these issues typically resolve after a few days.
• Ptosis: Over time, a droopy eyelid can develop after enucleation surgery. A simple procedure under anesthesia can correct this side effect.
• Scarring: Scarring of the eye socket may affect the socket’s ability to hold an artificial eye. It usually occurs when a surgeon doesn’t insert an implant during the enucleation procedure. Eye socket scarring can be corrected with a second surgery.
• Superior Sulcus Deformity: This is a sunken appearance that occurs when the orbit volume is reduced when the eye is removed. Again, it usually can be corrected by another procedure.
• Implant exposure and extrusion: Exposure of the front part of the orbital implant can lead to tissue infection or tear. The implant may also break through the tissue and fall off the socket. An implant can be surgically replaced if this happens.

Prosthetic Eyes

When your surgeon declares your eye fully healed, you are ready to receive a custom prosthetic eye for your empty socket. An ocular prosthesis is a custom-made artificial eye that restores esthetics and cosmetics of your face following enucleation.

Most people who undergo enucleation are ready for a prosthetic about six to eight weeks following surgery.

With another procedure, your surgeon can attach your extraocular muscles to the new implant. Prosthetic eyes have better motility and lower rates of extrusion compared to other implants. 

The good news: a well-maintained prosthesis can last for decades. Follow-up visits with your surgeon are important to assess your eye socket health and clean the prosthetic.

FAQs

What is the process of enucleation?

Enucleation is a type of eye surgery where the eyeball is removed, leaving behind the eye muscles and other orbital structures.

Why is enucleation performed?

Surgeons perform enucleation to remove any pain in a blind or severely injured eye or to mitigate eye tumor growth or non-remitting infections.

References

1. Enucleation. (January 2022). American Academy of Ophthalmology.

2. Enucleation. (November 2021). StatPearls.

3. Enucleation. (May 2021). American Association for Pediatric Ophthalmology & Strabismus.

4. Sympathetic Ophthalmia. (March 2022). American Academy of Ophthalmology.

5. Enucleation and Evisceration: What to Expect. (September 2018). The University of Iowa: Ophthalmology and Visual Sciences.

6. Common Causes of Eye Enucleation among Patients. (July 2017). Journal of Natural Science, Biology, and Medicine.

7. Enucleation Surgery – Orbital Implants and Surgical Techniques. (April 2016). Touch Ophthalmology.

8. Enucleation and evisceration at a tertiary care hospital in a developing country. (September 2015). BMC Ophthalmology.

9. Enucleation and evisceration: indications, complications and clinicopathological correlations. (August  2014). International Journal of Ophthalmology.

10. Fabrication of a Custom Ocular Prosthesis. (July 2014). Middle East African Journal of Ophthalmology.

11. Congenital cystic eye associated with a low-grade cerebellar lesion that spontaneously regressed. (June 2014). BMC Ophthalmology.

12. Prosthetic rehabilitation of an ocular defect with post-enucleation socket syndrome: A case report. (January 2014). The Saudi Dental Journal.

13. Indications for and causes of enucleation in a rural United States population (June 2013). Investigative Ophthalmology & Visual Science.

14. Removal of an Eye, Artificial Eyes, and Socket Care (n.d). British Oculoplastic Surgery Society.