Evisceration and Intrascleral Prosthesis
In 2006, Freidlin et al. reported the first case of sympathetic ophthalmia found in a soldier since World War II. This 21-year-old man sustained shrapnel wounds while in combat and underwent evisceration the day of injury. Within a month of surgery, he developed panuveitis in his remaining eye with conjunctival injection, vitreous floaters, and paracentral scotoma. He responded favorably to immunosuppressant therapy. After 6 months of oral and topical steroid treatment, best-corrected visual acuity was 20/20 in this “sympathetic” eye. Interestingly, histologically proven uveal tissue was found and removed from the subconjunctiva of the eviscerated eye at the onset of his symptoms. The authors hypothesized that this residual uveal tissue induced the inflammation. Given the failure to remove all uveal tissue, this case does not support evisceration as an inciting event. However, it does stress the need to perform eviscerations properly and in appropriately selected patients. This and the previous case illustrate the additional point that in at least some cases, good vision can be preserved in the sympathetic eye with treatment.
How much does evisceration with a prostectic eye …
Because evisceration unlike enucleation disrupts the integrity of the globe, there is a theoretical risk of exposing uveal antigens, which could incite an autoimmune reaction known as sympathetic ophthalmia (SO) in the contralateral eye. The first report of sympathetic ophthalmia occurring in association with evisceration was in 1887. Despite this, evisceration gained popularity until 1972 when Green et al. reignited the concern of inciting sympathetic ophthalmia with a report of four alleged cases.
End stage procedures, such as enucleation, evisceration with intrascleral prosthesis, and chemical ablation of the ciliary bodies are then recommended to address chronic discomfort in buphthalmic and blind eyes.
Ocular evisceration with placement of an intrascleral prosthesis:
In this past decade, there have been two case reports of alleged post-evisceration sympathetic ophthalmia. In 2005 Griepentrog et al. reported a case of presumed sympathetic ophthalmia after evisceration in a 75 year-old man, who had a blind, painful eye after a penetrating globe injury that caused neovascular glaucoma. Notably the injury occurred 66 years prior. The patient developed ciliary injection, mild cataract, vitreous cells, and macular retinal pigment epithelium mottling and serous detachment in the fellow eye fourteen weeks post-operation. His vision improved from 20/200 to 20/25 nine months later on a tapered steroid dose. The diagnosis was based entirely on the clinical appearance; histopathologic confirmation was not established.
Evisceration with intrascleral prosthesis; Orbitotomy;
There is good evidence that potentially any type of intraocular surgery can incite sympathetic ophthalmia. Previous retrospective studies estimated the incidence of sympathetic ophthalmia to be anywhere from 0.02% to 0.06% for intraocular surgery,,, and 0.28% to 1.9% for nonsurgical penetrating injury.– These surveys implicated various intraocular surgeries, including cataract extractions, glaucoma procedures, and vitrectomies but not eviscerations. In a prospective surveillance, Kilmaren et al. estimated the incidence of sympathetic ophthalmia to be 0.03 per 100,000. Ocular surgery, particularly retinal surgery, was the most common cause in this group, as opposed to previous reports where accidental trauma overwhelmingly prevailed., Between July 1997 and September 1998, all permanently employed ophthalmologists in the United Kingdom were sent monthly report cards to notify any newly diagnosed cases of sympathetic ophthalmia. There were 23 valid cases of sympathetic ophthalmia reported during this period, but only 17 that were reported in last 12 consecutive months were included in Kilmarin et al.'s estimation of the incidence. Of these patients, one underwent an enucleation for recurrent choroidal melanoma, but none had evisceration. Of note, the patient with a history of enucleation also twice underwent pars plana vitrectomy.
Evisceration with intrascleral prosthesis.
outlines published indications for evisceration and enucleation. compares and contrasts the benefits of evisceration and enucleation for individual indications. In most cases, when globe removal is required, either surgery is adequate, and the surgeon may choose their personal preference. However, there are circumstances where one is preferable or, in some cases, contraindicated. Traditionally, enucleation has been recommended for management of intraocular neoplasm and prevention of sympathetic ophthalmia following penetrating trauma,– whereas evisceration is usually recommended for management of endophthalmitis. Opinions vary with regards to which surgery is preferable for management of blind, painful, phthisical, or otherwise cosmetically unacceptable eyes., Each one will be explored.