Removal of an eye (an enucleation), or the inside of an eye (an evisceration), may be necessary for a variety of reasons. Regardless of the underlying disorder, and whether the eye sees or not, the decision to have an eye removed can be difficult and emotionally demanding. Nevertheless, skilled surgery combined with first class prosthetic care can lead to a very acceptable aesthetic result, and in many cases the symmetry and colour match between the artificial and the fellow eye can be very good indeed.
What are the possible treatments for an eye that does not see?
In general, it is better to avoid surgery if possible, with painted contact lenses, or shells (acrylic artificial eyes) worn over a blind eye often looking as good as a real eye. However, if a blind eye becomes painful in spite of the use of drops, or a contact lens or shell cannot be tolerated, or the patient does not have the manual dexterity required to remove the lens or shell each evening, then surgery should be considered as this addresses both the discomfort and allows an artificial eye (an ocular prosthesis) to be worn continuously with only a very occasional need for its removal for cleaning.
Is there anyone I can speak to who has had this operation?
Yes. Often other patients are happy to talk about their own experience. Such patients can be contacted via the department of ocular prosthetics in a number of specialist eye hospitals.
How is an eye removed?
Essentially, there are two approaches:
1. An enucleation: this involves the removal of the entire eyeball (this includes the white part of the eye referred to as the ‘sclera’). In its place a permanent solid spherical implant (or ‘ball’) is placed deep within the socket to compensate for the loss of volume, and the muscles which move the eye are reattached to this implant. The superficial membranes (including the conjunctiva) are stitched over the front surface of this implant (or ball, which remains permanently covered), and once the surface inflammation has settled (within a few weeks), an artificial eye, or ‘prosthesis’ (similar to a shell) can be worn on top. This is held in place by the eyelids. The deeper ball implant typically remains in place for life and usually requires no further attention. For some patients who are not suitable for such an implant, a dermis fat graft is used instead. This is taken from the abdomen or the upper outer quadrant of the buttock area.
2. An evisceration:in this operation the white part of the eye (the sclera) is not removed, but used as a natural wrapping material to cover the ball implant. This operation is easier to perform but cannot be undertaken for patients who have an eye tumour. It offers the advantage of a more rapid recovery for the patient.
I have heard that removal of an eye can cause inflammation in the other eye. What is this called and why does it occur?
An exceptionally rare form of inflammation, called ‘sympathetic ophthalmitis’, can occur in the healthy eye any time after an open eye injury or an operation on the other eye that exposes the uvea, the pigmented layer of the eye. This occurs because the exposed contents of an injured eye can activate the body’s immune system against the same tissues in the healthy eye. Although treatable in the vast majority of patients, such an inflammatory problem can rarely lead to loss of sight in the good eye.
The removal of an eye using the evisceration method (but not an enucleation) carries this theoretical risk of such an inflammation. It should be noted however that such eyes have usually had previous injury or surgery, and the other normal eye is therefore already at risk, even before the eye is removed. The true likelihood of developing sympathetic endophthalmitis in the good eye after an evisceration is very difficult to determine, but is considered to be in the order of 1: 50,000. However, sympathetic endophthalmitis is treatable, and overall many more eviscerations are now performed than enucleations for the reasons outlined above.
How long do I stay in hospital, and when is the artificial eye first fitted?
During surgery, the deep implant that is placed tends to result in a gentle stretching of the socket tissues. Because this can result in pain and nausea during the first 72 hours after surgery, patients are offered a 2 night stay in hospital, and regular strong analgesics and anti-sickness medications are given. Only when the patient feels ready to be discharged does he/she go home. The dressing is removed at home and a review is scheduled for 2 weeks later when stitches are removed which hold the lids together temporarily (a temporary suture tarsorrhaphy).
At surgery, a temporary clear ‘shell’ is placed behind the eyelids to help prevent the socket from contracting in the weeks after surgery. Thus, from the time of removing the temporary suture tarsorrhaphy until review by the ocularist in the department of ocular prosthetics at about 6-10 weeks after surgery, the eyelids are open and only a clear plastic shell can be seen. Generally, this is not troublesome or alarming, although some patients prefer to wear a patch or dark glasses over the eyelids until the artificial eye is fitted. The ocularist takes an impression of the socket in order to create a bespoke artificial eye (which matches the colour of the other eye), and this is fitted 3-4 months after the surgery when the wound is secure and all the swelling has subsided.
What problems can occur with wearing an artificial eye (prosthesis)?
The artificial eye should only be removed very infrequently for cleaning. It is wise to use artificial tears 3-4 times a day and at bedtime to keep the surface pristine e.g. Systane drops. The artificial eye should be checked and polished at least once a year by an ocularist and usually needs replacing after 5-7 years. The socket will be checked at the same time to ensure that there are no problems. With good attention to socket and eyelid hygiene and maintenance of the artificial eye problems such as discharge and discomfort are generally prevented.
How will I look after surgery, and when can I wear an artificial eye?
The artificial eye, or ocular prosthesis, is designed and fitted by specialised colleagues called ocularists or ocular prosthetists. They have considerable experience in both making and fitting a bespoke artificial eye, and monitoring the subsequent fit and health of the eye socket.
During the healing phase after surgery, the patient wears a clear plastic shell (a surgical conformer) inserted behind the eyelids to maintain the shape of the socket during the healing process. During this interval any socket inflammation and swelling gradually resolve. The bespoke artificial eye is then made, using the colour and characteristics of the fellow normal eye as a template. It is usually fitted as soon as the socket has completed healed. This can take 2-3 months. It is important that the artificial eye is not fitted too soon as this can disrupt the wound and predispose to exposure of the buried implant.
After this surgery, are any further operations ever needed?
With the simple measures mentioned above, most artificial eyes give many years of good service. However, there are certain conditions which may require drops or further surgery to enable an artificial eye to be worn successfully.
Why can the upper eyelid sometimes appear to be hollow when wearing the artificial eye?
The removal of an eye can result in the loss of some of the volume of a socket, giving the eyelids a ‘hollowed’ appearance, in spite of the use of an orbital implant. This is due to atrophy (shrinkage) of the fatty cushions deep within the socket. This ‘hollowed’ appearance (often referred to as ‘post enucleation socket syndrome’) can be addressed by increasing the volume deep in the socket, thus allowing a thinner (and therefore lighter) artificial eye to be worn. This can be done in a number of different ways e.g. by placing additional implants into a different surgical space in the socket.
Surely a larger artificial eye can address the appearance of ‘volume deficiency?
Increasing the size of the prosthesis to compensate for socket volume deficiency can indeed address small degrees of ‘hollowing’, and in many patients is either adequate or preferable to undergoing further surgery. However, over time a large prosthesis tends to weigh on the lower eyelid (causing laxity), and may not move as well as a lighter prosthesis. Although lid laxity can usually be treated by tightening the lid, if the main problem is volume deficiency, this also should be addressed.
The artificial eye is unstable – why?
For an artificial eye to sit comfortably in the socket, there needs to be a sufficiently large ‘pocket’ (conjunctival fornix) behind both the lower and upper eyelids. Shallowing of these fornices can lead to discomfort (due to irritation of the mucosal lining), mucus discharge, an unstable artificial eye, and difficulty inserting the artificial eye. This is addressed by ensuring that there is sufficient volume in the socket, and then enlarging the fornices either by redistributing local tissue, or by placing a graft of oral mucosa taken from the inside of the lower lip into the socket.
Am I allowed to drive after removal of any eye?
For private car or motorcycle drivers, if vision is normal in the other eye and there are no other medical conditions, the DVLA does not need to be informed:
Extract from the DVLA website:
“Monocularity and driving: Monocularity is a condition that you may need to tell the Driver and Vehicle Licensing Agency (DVLA) about.
Car or motorcycle driving licence holders: If you are a car or motorcycle driving licence holder – you will not need to tell DVLA about your medical condition.”
If you have any doubt about your fitness to drive, please contact the DVLA, using the following link: