Year : 1969 | Volume
: 17 | Issue : 4 | Page : 151--153
Sub-total enucleation and ocular prosthesis
LK Trivedi, DB Massey, R Rohatgi
Kanpur Eye Hospital, Kanpur, India
L K Trivedi
Kanpur Eye Hospital, Kanpur
|How to cite this article:|
Trivedi L K, Massey D B, Rohatgi R. Sub-total enucleation and ocular prosthesis.Indian J Ophthalmol 1969;17:151-153
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Trivedi L K, Massey D B, Rohatgi R. Sub-total enucleation and ocular prosthesis. Indian J Ophthalmol [serial online] 1969 [cited 2021 Jun 14 ];17:151-153
Available from: https://www.ijo.in/text.asp?1969/17/4/151/38533
The first ocular prosthesis was fitted by Ambroise Pare in 1579 who used enamelled gold and silver. A blown glass shell was made in 1740. Since then several kinds of prostheses and implants have been tried, such as evisceration with buried implants originated by Mules (1885). Adam Frost (1886) was the first to use glass ball inserted into the Tenon's capsule and Ruedmann (1945) originated semiburied integrated prosthesis.
An ideal prosthesis is one which can anatomically and physiologically simulate the fellow eye. In brief we can enumerate the aims as follows:
1. Good stump with prominent floor
2. Deep and adequate fornices
3. Proper movement 4. No discharge
5. No ptosis and lagophthalmos
6. No deep sulcus of upper lid, with preservation of normal contour of lid.
The types of prosthesis being used at present are tabulated as follows
Material and Method
Having tried and followed the results of two out of three types of implants mentioned above, and finding them to be unsatisfactory in one or the other aspect, the technique of subtotal enucleation was performed by us as follows :
The eyes selected for this operation were those which were large and disfigured due to anterior and ciliary staphyloma, a condition commonly met with in India. The aim was to shorten the globe, retain the muscles with normal insertions and retain the vitreous so that the shape of the eyeball was maintained. As motion is transmitted to the prosthesis through the movement of the stump and conjunctival cul-de-sac, the conjunctiva was saved as much as possible during sub-total enucleation, because if the conjunctival cul-de-sac is small, motion is correspondingly limited. Motion is transmitted to the cul-de-sac by fascial and rectus muscle attachments and Tenon's capsule. Therefore, care was taken to damage them as little as possible during the operative procedure.
Technique Of Operation
Local or general anesthesia is given according to the age of the patient. Perilimbal conjunctival incision is made, conjunctiva and Tenon's capsule is undermined, the staphylomatous portion only is excised, avoiding vitreous loss. Cataractous lens is removed. Sclera is stitched with interrupted catgut suture vertically and conjunctiva and Tenon's capsule are stitched horizontally. A conformer is then inserted. The prosthesis is fitted after 8 to 10 days. Regular movements are established between four to six weeks.
The aim of prosthesis is to give natural shape and movements to the affected eye to match the fellow eye as much as possible. The matching is not very difficult to attain, but the problem lies in achieving normal movement of the prosthesis. In order to overcome this, many types of implants have been invented and tried through the ages.
A perfect prosthesis fulfilling all the criteria has not been achieved so far. The whole eye-ball transplanted from a cadaver would be an ideal prosthesis if it is not rejected and its shape and movements are normally retained. As such an ideal cannot be attained at present, prosthesis is the only solution. Movements to the prosthesis is imparted by the stump. We feel that an ideal stump would be the eyeball itself, complete with its muscular and fascial attachments, lying in the normal position. The stump made by sub-total enucleation is ideal because it retains the shape due to its contained vitreous. The movements are adequate because of the undisturbed muscular and fascial attachments. The cul-de-sac is also adequate to retain the prosthesis. The prosthesis is fitted directly over the stump leaving no dead space in between, thus movements are properly transmitted to the prosthesis.
An artificial material is not introduced, hence there is no foreign body reaction, granulation tissue formation or discharge. Migration and extrusion of the implant also does not occur.
The position of the stump is most important, as it is placed most anteriorly it requires a very light cosmetic shell type of prosthesis which is properly in contact. Movements are expected to be better under these conditions.
In our series of 60 cases of sub-total enucleation and fitting of prosthesis, and comparing with the other buried and intra scleral implants, we found that our method gives much better cosmetic results including movements. The problem of artificial implants is minimized.
The disadvantage of this type of stump is that it can only be tried in staphylomatous eyes. Such cases, however, are commonly met with in India and hence this method can be tried frequently.
A new method of making a stump for the fitting of prosthesis has been described. It is limited to staphylomatous eyes which can be shortened and approximated to the fellow eye by sub-total enucleation. Sixty cases have been treated with good cosmetic results, the stress being proper movements.
|1||MULES, P. H.: Glass-ball implants. Trans. Ophth. Soc. U.K. 5, 200, (1885). |
|2||RUEDMANN. A. D.: Trans. Amer. Ophth. Soc. 43, 304. 1945.|