|Year : 1954 | Volume
| Issue : 3 | Page : 76-81
Complications in enucleation of the globe
New York Eve and Ear Infirmary, New York, USA
New York Eve and Ear Infirmary, New York
|How to cite this article:|
Fuchs A. Complications in enucleation of the globe. Indian J Ophthalmol 1954;2:76-81
In the majority of books on surgery, very little is mentioned about complications during an enucleation. Hardly mentioned at all is the most terrible accident. which is seemingly not rare, i.e. the removal of the wrong eyeball. Such cases were not published. Once in a while however, one can find a remark, that the healthy eyeball was nearly removed L. Mauthner ( 1881 ). A similar case was mentioined by Suarez-Villafranca ( 1949 ).
Traquair (1947) published an extensive paper on enucleation of the wrong eyeball, in which he mentions of a case where the surgeon committed suicide immediately after the operation and another one, in which the doctor, after having removed the healthy eye of a child with glioma, enucleated the fellow eye. L. Mauthner ( 1881) emphasises, that such a misfortune can happen, especially in a case of sympathetic ophthalmia, when both eyes are equally inflamed. Elschnig ( 1908 ) stresses, that bulbi with intraocular tumors may appear normal externally and that one has to be especially careful. Haab ( 1904) considers general anaesthesia as the main reason of these tragic accidents and that is certainly true. Traquair recommends, that the eyeball, which has to be enucleated, be marked by indelible pencil on the forehead, before the patient is brought into the operating theatre. Even then errors may occur and therefore Traquair advises to make the enucleation under local anaesthesia and also to examine the eve with the ophthalnioscope when the patient is on the operating table if the disease is not recognisable externally. He recommends also that the textbooks, in the chapter on enucleation, should stress this terrible possibility, namely to remove the healthy eye erroneously.
More frequently complications arise during the dissection of the optic nerve. There are two reasons for this complication. Either the optic nerve is cut too close to the sclera, or too much pull is exercised on the eyeball before cutting the nerve, especially if the sclera is thin posteriorly as in high myopia.
When the optic nerve is dissected too close to the sclera it would be a disaster if the case requires that the optic nerve be cut as far back as possible. These are the cases, in which the disease has attacked already the optic nerve and was growing along it, backwards. J. Meller (1931) says: "the optic nerve is generally cut immediately behind the eyeball". He mentions later on, that in cases of malignant tumors the optic nerve "is dissected as far back as possible from the eyeball". He also mentions, that in cases of iridocyclitis after injury, the optic nerve has to be cut as far back from the eye as possible, if the possibility of development of sympathetic ophthalmia exists.
A special long piece of the optic nerve has to be resected in all cases of glioma retina (retinoblastoma), because glioma, as opposed to sarcoma of choroid ( malignant melanoma ), has the special tendency to attack very early the papilla and to spread backwards along the optic nerve, sometimes even primarily along the sheath of the optic nerve.
I wrote in my book "Diseases of the Fundus Oculi ( 1943 ) : local recurrences and metastasis of glioma retina apparently do not develop, as long as the glioma has not pervaded the fibrous capsule. Therefore the prognosis in glioma is considerably better than in choroidal sarcoma. Lately, many statistics on prognosis in glioma were published, but nothing about this feature was mentioned.
Only one case speaks against my opinion, mentioned above. Law (1949 ) describes a boy, 6 months old, who had glioma in both eyes. The left eye was removed. The optic nerve was free. In the right eye a peripheral focus was destroyed by diathermy, but 3 months later 3 new foci had appeared on different localization in the retina. These foci shrunk after X-ray treatment. The boy died 8 months later and the post mortem examination revealed metastasis in brain and liver. This case was certainly quite unusual, because in the second eye new foci appeared later on.
In some books on ophthalmic surgery nothing is mentioned about pushing backwards the scissors, if one wants to cut the optic nerve, as for instance in the book by Duverger, Velter and Pregeat (1950 ). Stallard ( 1950) recommends to push the blades of the scissors backwards to be able to get a sufficiently long piece of the optic nerve. Ruedemann ( 1950) recommends to open the scissors, to put the blades as far back as possible without difficulty and then cut. He considers cutting the optic nerve as far back as possible, always advantageous, as one comes across cases, in which an eye with absolute glaucoma or panophthalmitis, which has to be removed, is found to have an intraocular tumor which was not even suspected. How important this is, is shown by Terry and Jones ( 1935 ). In 94 cases of intraocular tumors found histologically, 44% were clinically not suspected. It is therefore absolutely necessary to examine every eye, blind through absolute glaucoma or panophthalmitis see [Figure - 5], with transscleral Tran illumination and also to resect the longest piece possible of the optic nerve during enucleation.
If sympathetic inflammation shows up, the injured blind eye has to be removed and the optic nerve must be cut as far back as possible on account of the possible participation of the optic nerve. I examined the slides of 100 bulbi with sympathetic ophthalmia; not everyone of them showed a long piece of optic nerve. 20 of these optic nerves, however, were infiltrated beneath the pia mater and in 5 cases nodules were found in the tissue of the optic nerve; the most posterior nodule was found 9 mm. behind the eye.-Fuchs ( 1925 ).
We have to realise, that there is also danger of sympathetic ophthalmia for some time, even when the fellow eye does not show symptoms of inflammation at the time of the enucleation of the injured eye. Of the 100 cases I examined anatomically myself, 10 showed the manifestation of sympathetic ophthalmia only after enucleation. Therefore one should resect an especially long piece of the optic nerve in each case where an eyeball with common endophthalmitis and beginning atrophia bulbi after an injury or after operation has to be enucleated.
A very long resection of the optic nerve is indicated also in cases of absolute glaucoma and in cases of high hyopia. In both diseases it is not so rare that the papilla is excised and the content of the eye flows out, if the optic nerve is cut immediately behind the globe. I have emphasised this complication-Fuchs (1936).
In absolute glaucoma the optic nerve can be excavated moderately or very deeply. I saw once a case with the ophthalmoscope, in which the excavation had a depth of 9 D which corresponds to about 3 mm.: if this eye would have to be enucleated, a much larger piece of the optic nerve would have to be excised than the majority of surgeons are used to resect, to avoid an opening of the globe. In absolute glaucoma the papilla is very frequently excavated 1 mm. so that the lamina cribrosa is lying behind the sclera as one can see in fig. 127 in the book by B. Samuels and A. Fuchs( 1952 ). If such an optic nerve is cut immediately behind the sclera, the eye is opened and the contents flow out.
Therefore I follow the rule to excise the optic nerve as far back as possible whenever I have to make an enucleation.
In high myopia conditions are different, the sequelze however are the same, when the optic nerve is excised very close to the sclera. Two factors play a role for this complication
(1) The sclera is very thin on the posterior pole of the eye. If one pushes the scissors backwards to dissect the optic nerve and pulls at the same time on the bulbus, the thin sclera can easily form a funnel-shaped bulging around the papilla. This funnel-shaped distortion around the papilla can happen the more, as in high myopia normal tension is often low, frequently 10-12 mm. Schiotz, a fact which does not seem to be known generally. If the optic nerve is cut very close, this tent-shaped end of the eyeball, together with the papilla, may easily be excised.
(2) von Graefe described cases with high myopia, without glaucoma, in which the sclera, around or temporal to the papilla, was ectatic. I drew attention to the clinical appearance of such papilla and showed sections of such ectasias several times-Fuchs (1924) and emphasised the importance of these ectasias in enucleations.
One or both factors, thinness of sclera in eyes with relative softness and circumpapillary ectasia, may therefore cause excision of the papilla in cases of high myopia, when the advice, to excise the optic nerve far backwards, is neglected.
The same happens, much more often, if an eye is very soft, for instance if enucleation has to be performed on account of iris prolapse, perforated ulcer cornea or extensive injury. This complication is mentioned both by Meller ( 1931 ) and Ruedemann ( 1949 ). The former mentions also the common event, that during enucleation of eyes with partly destroyed cornea or wound of an operation, the surgeon pulls too much and lens and possibly the vitreous are pressed out of the resulting opening, by which the sclera collapses; hence it easily happens, that the papilla is excised.
Such a case I saw lately, where a surgeon had made a paracentesis of the cornea in a case of glioma of the retina and then enucleated the eye. Pulling on the insertion of a rectus, a part of the content came out of the corneal wound; the eye became quite soft and the surgeon fenestrated the posterior sclera.
During enucleation the pressure in the eye may be raised especially if after resection of the optic nerve the surgeon tries to lift the globe out of the orbit with closed scissors. By this manoeuvre, also scarrified iris prolapses and slightly closed wounds after operations may be opened again and parts of content of the eye may be expressed see [Figure - 6]. In cases, in which the corneo-scleral envelope is not intact, it is advisable to perform a canthotomy before enucleation.
Arruga ( 1952) enumerates as cause for perforation during enucleation either insufficient technique during resection of the optic nerve or the presence of intercallary staphyloma. Here too, the attempt to express the eye ball out of the orbit after the resection of the optic nerve is the reason for this complication.
The injury of the papilla by insufficient technique is caused by pressing the scissors too much against the posterior pole of the eye: this injury can happen in different degrees, of which I want to give some anatomic examples, by the help of these figures.
Injury of the slightest degree happens when the lamina cribrosa is incised from behind and the papilla itself is not injured.
I have given here a few examples to show some poorly made enucleations. These are not rare and one should not believe, that enucleation is a simple operation.
The queerest sequelx of enucleation I saw in a specimen where a piece of the papilla was pushed beneath the retina and layed between retina and choroid. A connection between this piece of papilla and the papilla itself or the optic nerve was not present.
This dragging of a papilla-piece beneath the retina does not seem to be rare as Dr. Samuels Gartner told me, that, he had the opportunity to see 3 such cases.
The cause of thee injury to the papilla is seemingly that the surgeon keeps too close to the sclera especially when the surgeon dissects the optic nerve from the nasal side. Without doubt it is easier to cut into the sclerotico-choroidal canal if one introduces the scissors from the nasal side, especially so, when scissors are employed with one or two sharply pointed blades.
A third, much rarer complication happens in the anterior part of the eyeball. Elschnig ( 1908 ) emphasized that an eyeball may be opened, if a muscle of the eye is cut away without caution and that this can specially happen, if an eye is very soft. He considers such fenestration as especially dangerous in the presence of sympathetic opthalmia or endophthalmitis. Elschnig does not mention the excision of the papilla. Spaeth ( 1948) draws attention to the thinness of the sclera behind the insertion of the recti; he says, it is not rare, that surgeons performing a tenotomy, cut through the sclera. The same thing could also happen during enucleation and that is also specially mentioned by Ruedemann (1950 ).
I saw this once as I assisted a doctor performing a tenotomy. While cutting the tendon of the rectus medialis, the surgeon pressed the scissors upon the sclera flatly and after the dissection was made, a black pearl of vitreous appeared. We finished the operation immediately by closing the wound and no bad event followed.
The reason why the sclera is so easily fenestrated behind the insertion of the muscle is, that the sclera is here very thin; if the scissors are flatly pressed upon this region, a bulging of the thin area of the sclera may follow and this scleral elevation may be cut, when the muscle is dissected. It is very important that the scissors are not resting flat upon the sclera and that one does not press them on the sclera during the dissection; the scissors should be turned in such a way, that only the edge of one blade touches the sclera. During enucleation it is not important how large a piece of the tendon is left at the insertion [Figure - 7].
A fourth complication seems to be extremely rare, it is severe hemorrhage after enucleation. Philp ( 1950 ) writes in his book "haemorrhages are never serious". This is not correct. My father experienced in one case such severe haemorrhage, lasting through many hours, coming out of the orbit, in a case of simple enucleation and he was very worried about it. I experienced once a similar intensive haemorrhage in a case of an old inflammatory and painful detachment of the retina. It took hours and all possible procedures to stop the haemorrhage. Dr. Franz Subal, a friend of mine, had a similar complication enucleating an eye with absolute glaucoma. During the haemorrhage the patient collapsed and transfusions of blood had to be made.
The cause of such haemorrhage is probably a special rigidity of the arteria ophthalmica which was possibly cut, because general examination of these cases did not reveal any cause of such abundant haemorrhages.
In the last 24 years, we find very little in literature about enucleation and its complications. Only Redslob (1949) discusses the danger of excising the sclera posteriorly during enucleation.
Pereira (1938 ) describes new instruments for dissecting the optic nerve in the correct way, for instance a neurotome by Joseph and a wire-loop by Wright and describes a new instrument composed of two parts, to cut the optic nerve as far backwards as possible. If one follows, however, the advice of good surgeons, strongly curved scissors with two blunt-pointed blades are excellent.
After World War II numerous papers were published on different implants after enucleation. Many ophthalmologists are not enthusiastic about them, because implants cause very often troubles later and are extruded. Choyce (1952 ) reports on 98 cases, which were examined out of 200 enucleated patients. Of these, 98 cases, in nearly half of them the implants were extruded after 2 years on account of chronic infections. Drucker, Kreft, Pearlman, Rosenau and Snip (1951) report, that 75% of enucleated patients were exceedingly happy with the implant while 25% had considerable difficulties in healing. They mentioned, that after expulsion a secondary implant may be tried.
| Summary|| |
The operation of enucleation is not altogether easy and is fraught with several snags.
- A wrong eyeball may be removed.
- The optic nerve may be cut too short. Six degrees of this mistake are described.
- The sclera may be cut at the insertion of the muscles.
- The eyeball may burst open at points of previous perforation or operation wounds.
- Uncontrolable haemorrhage may take place.
The implication of each of these mistakes and the means of avoiding the same are described.
| References|| |
|1.||Arruga, H., ( 1952) Ocular Surgery. p. 825. McGraw Hill Co., New York. |
|2.||Choyce ( 1952) Brit. J. Ophth. 36, 123. |
|3.||Drucker, Kreft, Pearlman. Rosenau and Snip, (1951) Amer. J. Ophth. 34, 1483. |
|4.||Duverge. Velter et Pregeat. ( 1950) Therapeutique Chirurgicale Ophthalmologique. Elsching, ( 1908) 11. Auflage von Czermark's Augenerzlichen Operationen 1. p. 434. |
|5.||Fuchs. A., ( 1924) Amer. J. Ophth. 7, 257. |
|6.||( 1925) Z. Augenheilk 56, 275. |
|7.||( 1932) Arch. Oftal. B. Aires 7, 67. |
|8.||( 1936) Arch. Ophthal. 16, 341. |
|9.||( 1943) Erkrankungen des Augenhintergrundes, p. 172. |
|10.||Haab, ( 1904) Operationslehre, p. 279. |
|11.||Law, F., ( 1949) Trans. Ophth. Soc. U.K. 68, 377. |
|12.||Mauthner. ( 1881 ) Vortraege aus dem Gcsamtgebiet der Augenheilkunde 1. 100. |
|13.||Meller. ( 1931) Ophthalmic Surgery p. 157. P. Blakiston & Co., Philadelphia. |
|14.||Pereira ( 1938) Acta 1. Congr. argent. oftal. 2, 179. |
|15.||Philps ( 1950) Ophthalmic Operations p. 353. Balliere Tindall and Cox, London ( 1950 ). |
|16.||Redslob ( 1949) Ann. Occulist, Paris 182, 768. |
|17.||Reese. ( 1951) Tumors of the Eve p. 253. Paul B. Hoeber Inc., New York. |
|18.||Ruedemann, ( 1949) in Beren's The Eve and its Diseases, p. 983. W. B. Saunders & Co., Philadelphia. |
|19.||Samuels and Fuchs, ( 1952) Clinical Pathology of the Eve. Fig. 127. Paul B. Hoeber Inc., New York. |
|20.||Stallard (1950) Eye Surgery p. 606. John Wright & Sons Ltd., Bristol. |
|21.||Suarez-Villafranca, ( 1949) Arch. Soc. Oft. hisp.-amer. 9, 67. |
|22.||Terry and Johns, ( 1935) Amer. J. Ophthal. 18, 903. |
|23.||Traquair, ( 1947) Brit. J. Ophth. 31, 8. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]