Enucleation is a procedure in which a blind painful eye, or an eye harboring a tumor is removed, and the volume of eye is replaced with an implant. This procedure is performed in the operating room as a day surgery procedure.
The day prior to surgery you will meet with the surgical team which generally consists of Dr. Wilson and one of his fellows. The purpose of this meeting is to review what to expect the day of surgery, and how to manage medication, food and fluid intake the 24 hours prior to surgery. There will also be a chance to answer any remaining questions, and you will be asked to sign a consent form that describes the surgery and any possible complications.
Day of surgery
On the day of surgery report to the 6th Floor of the Casey Eye institute, 3375 SW Terwilliger Blvd (Marquam Hill at the top of the tram). It is important that you have someone that can take you home following surgery. Even if you are returning home by taxicab, you must have someone that can accompany you as the sedation from surgery can leave you groggy. A preoperative nurse will start an intravenous fluid line and dilate your pupil. Any family members or companions may stay with you until you leave the preoperative area to go to the operating room.
The surgery is typically done under local anesthesia. Local anesthesia around the eye is very similar to that used in dentistry. You will be given some strong sedation through the IV so that you generally do not remember the injection of the local anesthetic. The anesthetic is given as an injection behind the eye, and the effects of the anesthetic generally last for 12 hours. Following the injection, the level of IV sedation is lessened but will be maintained at a level so that you are not anxious during surgery.
The surgery itself consists of detaching the globe from the muscles that move eye, the optic nerve, and the conjunctiva (the tissue that lines the surface of the eye). Once the eye is removed from the orbit, the volume occupied by the eye is replaced with an implant. There are several different types of implants, but the one we use is made of hydroxyapatite, and will be wrapped in donor tissue from the eyebank. This donor tissue is sclera, the white tissue from the outside of a donor eye, that has been isolated from the other ocular tissues. The purpose of wrapping the implant in donor sclera is to provide a surface that will promote healing of the conjunctiva over the implant, and to have a surface to which the eye muscles can be firmly attached. With the muscles attached to the implant, the implant will move in conjunction with the other eye’s movements. At the end of surgery the implant will be completely covered by the tissues that surround the eye and will be attached to the muscles that move the eye. A thin plastic “conformer” which is like a large contact lens is placed behind the eyelids to reserve the space that the prosthesis will occupy.
Enucleation is associated with a moderate degree of postoperative pain. Pain is extremely variable from patient to patient, and the amount of pain that a particular patient encounters is dependent on many factors. The pain is generally controlled by the local anesthetic for 8-12 hours following surgery. As the local anesthetic wears off, you will need to augment pain control with oral pain medications. It is best to initially use nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen. It is best to avoid acetaminophen (Tylenol) initially as many of the stronger medications also contain acetaminophen. In some patients nonsteroidal agents alone will be sufficient, but most patients will require stronger medications for adequate pain control. All of the stronger pain medications have nausea as a potential side effect, so in addition to the pain medication you will be given medication in the form of a suppository to help treat or prevent nausea. The post surgical pain subsides quickly over the first 48 hours following surgery and pain control can generally be achieved with nonsteroidal medications once the pain begins to recede.
Eight weeks after surgery to remove the eye, the tissues will be healed sufficiently to permit fitting of the prosthesis. The prosthesis is like a large contact lens, and fits behind the eyelids. The prosthesis is custom made by the ocularist to match the fellow eye. This fitting takes place over a two day appointment with the ocularist, and at the end of the 2nd day the prosthesis will be completed and ready for wear.
Some patients note transient phantom images following removal of an eye. These images typically resolve over a 6-8 week period. One patient's artistic representation of these images is shown in the series of paintings below. The last photograph in the series illustrates the location of these images in the patient’s visual field.