Evisceration + Enucleation

Two weeks ago, a lady came in with a horrible looking corneal ulcer of the right eye.  It was large, necrotic, and causing a great deal of pain.  Her vision was light perceptions only.   

Her left eye was fine.  I started her on frequent antibiotic eye drops, but told her she would likely need a tectonic graft in the near future.  I saw her again last week; the nasty redundant necrotic tissue had cleared slightly, and now I could see that there was a large desmetocele centrally with iris poking forward.  But I had a dilemma.  The only corneal trephines I have are one size (8.5 mm for the donor, 8.0 mm for the host cornea).  I have been attempting to order other sizes from India, but they have been slow in coming.  This lady needed a limbus-to-limbus transplant in order to make this tectonic graft work.  Her ulcer was just way too large.  I told her to come back in 3 days while I tried to find a large trephine. 

Apparently, I was too optimistic about how long the desmetocele would hold.  The next morning, she presented stating that last night she felt a “gush of fluid” and felt like “there was a hole in the eye.”  I knew immediately that she did indeed have a hole in the eye.  And I realized that I did not have the technology or resources to fix her.  I explained to her the imminent need for an evisceration (scooping out the contents of an eyeball), and we proceeded to the operating theatre.  

I haven’t done an evisceration since my residency days, so I felt a little rusty, but the surgery itself went smoothly.  Unfortunately, we don’t have orbital implants available at our facility, so I had to leave the scleral shell empty.  Nonetheless, closure was straightforward and hemostasis was obtained with time and pressure.  

That same day, we also did an enucleation on a poor little 2 year old child with leukocoria of the right eye.   

The week prior, we had performed an exam under anesthesia and determined that she had a large intraocular tumor very suspicious for retinoblastoma.  I had the honors of cutting the optic nerve.  

 

This globe will be sent to pathology at the University Teaching Hospital in Lusaka, and we will be able to determine whether or not it is retinoblastoma. 

This is probably the driest orbit I have ever seen in an enucleation.  Fortunately, we were able to find a single orbital implant...the only one in the hospital.  But it was a size 20.  It seemed far too big for this young patient, but fortunately for this orbit, it fit perfectly!  

Last week on Monday, I did another glycerol corneal transplant on a patient with another horrible corneal ulcer/desmetocele.

 Although we still don’t have all the supplies that we need (corneal block and trephines are currently on their way from India) and I have to punch the tissue on an eye shield, at least the eye looked intact postoperatively.   

And on postoperative week #1 she was already counting fingers at 1 meter!  Unlike the first patient, she avoided an evisceration,...at least for the time being.