National Center For Ocular & Facial Prosthesis: India

Evisceration remains a popular and effective surgery. Uncertainty surrounding the risk of sympathetic ophthalmia following evisceration has caused some surgeons to prefer enucleation. However, this fear seems to be largely unfounded, based entirely on a very small number of reports. Most cases were either confounded by a history of trauma or intraocular surgery or were not confirmed histologically. Recent advances in techniques, largely centered on various types of sclerotomies, allow for placement of larger implants. Given the superior cosmetic and functional results of evisceration, it is the authors’ preferred method of eye removal when not contraindicated.


  • Painful Blind Eye
  • Endopthalmitis
  • Penetrating trauma

ContraIndications for Evisceration of Eye:

  • Malignancy is an absolute contraindication to evisceration. An enucleation should be performed whenever managing an eye suspected or known to harbor an intraocular malignancy


Although minor variations exist, there are core surgical steps, which remain fairly constant. Each will be discussed briefly with emphasis on the authors’ preferred technique.

1. Peritomy

Following placement of an eyelid speculum, a subconjunctival injection of epinephrine containing anesthetic facilitates a 360° peritomy. Care is taken to preserve as much conjunctiva as possible.

2. Removal of the cornea

A full-thickness limbal incision is made with an #11 blade scalpel. The remainder of the limbus is cut with scissors, allowing for removal of the corneal button. Historically, the cornea was not removed.73 Currently, most surgeons elect to remove the cornea, providing better pain control.74

3. Removal of the intraocular contents

The intraocular contents are then removed with the aid of an “evisceration spoon,” a round relatively flat curette. Careful attention is given to the complete removal of all uveal tissues. In theory this decreases (possibly eliminates) the risk of sympathetic ophthalmia.

4. Application of alcohol

The inner surface of the sclera is then bathed in alcohol. The purpose of this step is to denature any residual protein that might otherwise incite inflammation, that is, sympathetic ophthalmia. Cautery should be avoided, due to the flammability of residual alcohol, until the surgical field has been thoroughly irrigated with saline.

5. Sclerotomy

Performing a sclerotomy, allowing for placement of larger implants, has become popular in recent years and is performed at this stage. Specific techniques are discussed in detail below.

6. Implant placement

There is much variation in the preferred type of implant. This is one of the greatest areas of disagreement among oculoplastic surgeons and beyond the scope of this text. The authors’ preference is a simple silicone sphere. Previously, the largest implant possible was placed. However, with the advent of modern sclerotomies, essentially any sized implant can be used, and implant size is chosen to match prominence of the fellow eye.

7. Closure

The final step is closure. All techniques include the closure of multiple layers, including the sclera, Tenon’s membrane and, lastly, conjunctiva. Meticulous closure is felt to be essential in preventing implant extrusion.


The increasing number of eviscerations performed in recent decades is due to several perceived benefits. Often cited advantages include the perception that evisceration is simpler and faster than enucleation.Since evisceration leaves the extraocular muscles and optic nerve intact, it also has less risk for significant bleeding.

Ultimately, superior cosmetic outcome depends on volume replacement, socket motility, deep fornices, and normal-appearing and functioning eyelids. Evisceration allows for better preservation of orbital anatomy, improved mobility and therefore enhanced cosmesis. It has been proposed that evisceration requires less manipulation and consequently less inflammation and scarring of orbital tissues: fornices and suspensory ligaments remain uncompromised. This in turn is thought to help maintain the implant. These factors translate to better motility, less risk of superior sulcus deformity and thus an enhanced cosmetic result for the patients.

Historically, enucleation allowed for placement of a larger implant.The largest implant possible, whether involving enucleation or evisceration, helps prevent enophthalmos and superior sulcus deformity. However, with the advent of modern sclerotomy techniques, enucleation no longer has this advantage over evisceration.

Evisceration also provides superior socket motility. A prospective study in 2007 compared the motility and complications of 50 patients who underwent evisceration with sclerotomy and allosplastic implantation (Group 1) and 50 patients who underwent enucleation and hydroxyapatite implantation (Group 2). For the eviscerations, scleral quadrisections were performed at 1.5, 4.5, 7.5, and 10.5 clock hours from the limbus to the optic nerve without disinserting the nerve. Group 1 fared statistically significantly better than Group 2 in motility. The mean horizontal excursion was 10.25 ± 1.99 (5.9–15) for Group 1 and 6.90 ± 1.74 (3.2–12) for Group 2. The mean vertical excursion was 8.45 ± 1.89 (4.3–12) for Group 1 and 5.69 ± 1.63 (3–10) for Group 2. Covariant analysis indicated operation time as a statistically significant predictor in movement. Deep superior sulcus and exposure or extrusion was not significantly different between the two groups.

Modern evisceration techniques with sclerotomies, allowing for placement of large implants, achieve better results that previously possible. Patients enjoy relatively good socket motility common to all evisceration techniques. With the introduction of the sclerotomy, implant size is no longer a limitation.