By Paul T. Finger, MD
Ocular Prostheses Can Offer an Excellent Cosmetic Result
Enucleation is removal of the eye. It is a form of treatment that allows your eye-cancer specialist to remove the tumor from your body. Unfortunately, when the eye is removed there is no chance that vision can be restored. Fortunately, most patients can see with their fellow eye, almost all patients are able to do all the things they used to do (before losing their eye) and with ocular prosthetics people are typically happy with how they appear.
The most well organized studies of enucleation surgery were performed as part of the Collaborative Ocular Melanoma Study (COMS). The COMS medium-sized choroidal melanoma trial found no survival benefit to eye removal. That is, for similarly sized choroidal melanomas, survival was the statistically equivalent whether patients were treated with an iodine-125 plaque therapy or removal of the eye. In the second COMS arm, the large tumor study, researchers found no benefit from pre-enucleation external beam radiation therapy.
Currently, enucleation is most commonly used to remove eyes with extra large-sized tumors, large tumor-bearing eyes with little or no vision and those with severe glaucoma. However, in 2012, the vast majority of choroidal melanomas diagnosed in developed countries can be treated with eye and vision sparing radiation techniques (plaque and proton beam). Most patients prefer to keep their eye even if vision is severely limited.
Most patients have their eye removed under anesthesia and can go home after surgery. Since your surgery will be performed under general anesthesia, you will not feel or see anything until you wake up. Dr. Finger gives an injection of local extra local orbital anesthetic at the end of your surgery, just before placing the pressure bandage over the wound. This injection of anesthetic allows for the least pain possible when you wake up in the recovery room. Most patients have a headache for 24-36 hours after surgery which goes away with two regular Tylenol every 4 hours. Many patients are concerned that the loss of the eye may hurt. But the eye is surrounded by bones, therefore it is much easier to tolerate removal of an eye as compared to loss of a lung or kidney.
At The New York Eye Cancer Center, we typically place a temporary prosthesis at the time of bandage removal. Thus, patients do not have to walk around without a temporary prosthetic eye. However, 6 weeks later patients typically start their ocular prosthesis fitting for a more permanent prosthesis. After a final prosthetic fitting 90% of our patients are happy with the way they look, and 80% say others can’t even tell they are monocular. It will take some time to adjust to using one eye, but most patients learn to compensate during the first year after surgery.
When an eye is removed, the patient loses all vision and the cosmetic use of the globe.
Reported complications include hemorrhage, infection and extrusion of the implant. In our review of Enucleation published in the Survey of Ophthalmology, we found that integrated implants were more likely to get infected or extrude. However, these complications are becoming less common and integrated implants offer less orbital migration and better cosmesis.
Post-operative hemorrhage is both rare and uncomfortable. Most patients who experience a significant post-enucleation orbital hemorrhage are either on blood thinners (e.g coumadin, plavix, heparin or aspirin) or are known to have a bleeding disorder. Such hemorrhages can be painful, but intervention is rarely helpful. Patients are typically treated with analgesic medications (pain-killers).
Orbital Infections are also rare. Most secondary orbital infections can be managed with antibiotics, covering or surgical removal of the orbital implant.
Implant extrusions can be managed by surgical replacement of the orbital implant.
Post treatment care
After your surgery you will have a pressure bandage over your eye. In our center, we ask patient to leave it in place for 5-days. On the 5th day, we remove the bandage and typically place a temporary prosthesis (plastic eye). In addition, we ask patients to take a topical antibiotic and steroid daily for up to a month. This helps the wound heal more safely and quickly.
After the patch has been removed, you may tear and the tears may contain a little blood. This is normal. You should gently wash the outside of your eyelid with a warm, clean, soapy wash cloth. Don’t let matter accumulate to form crust on your eyelids. During this time you should not rub your eyelids or run the shower on your operated eye for at least 10 days after surgery.
Returning to Work:
You will be able to return to normal activity soon after surgery. The orbit should heal quickly and you should be able to return to school or work within 2 to 6 weeks. You should not lift more than 10 pounds, strain, or rub your eye for at least 14 days after surgery. The enucleation patient should also not take aspirin or other blood thinners unless your internist says it is required. You will need to be examined at 5-7 days, 1 month and every 6 months after surgery. This is because there is an extremely small chance the tumor will regrow behind your prosthesis.
We recommend that you return for a complete ophthalmic oncology exam at least on a yearly basis. You should also have twice-yearly medical check-ups by your family doctor, internist, or medical or pediatric oncologist. Copies of your laboratory evaluations should be forwarded to your eye-cancer specialist’s office so they can be checked for metastatic disease. The law may require that you request this information in writing from your doctor.
After enucleation you will be a patient for the rest of your life. You must be followed by an eye-care specialist and may need a medical oncologist. You may want to take this into account in choosing your doctors and their location.
For additional information and support we suggest you read the book “A Singular View” by Frank Brady. It will help in your transition. This book was written by an airplane pilot who lost one eye.
- A Review of Enucleation By Moshfeghi DM, Moshfeghi AA, Finger PT. Survey of Ophthalmology 2000:44:277-301