Orbital exenteration is a surgical procedure involving the removal of the eye and the surrounding tissues within the eye socket. This includes the muscles that move the eye, the optic nerve, and the fatty tissue that cushions these structures. The eyelids may also be removed, depending on the extent of the disease being treated. This operation is reserved for situations where less extensive treatments are not sufficient to address the underlying medical condition.
Medical Reasons for the Procedure
The most frequent reason for orbital exenteration is a malignant tumor that threatens to spread. Primary orbital malignancies, which are cancers that begin within the eye socket, often require this procedure. An example in children is rhabdomyosarcoma, a cancer of the muscle tissues.
Cancers from adjacent structures can also invade the orbit. For example, squamous cell or basal cell carcinoma on the eyelid may grow deeper into the eye socket. Cancers originating in the paranasal sinuses, the air-filled spaces next to the nose, can also expand into the orbital area, requiring removal of the contents.
Intraocular cancers, which start inside the eyeball, can also lead to this surgery if they extend beyond the globe. Uveal melanoma, a cancer of the pigmented layer within the eye, is one such example. If this melanoma grows through the wall of the eye and into the surrounding socket, exenteration may be necessary.
Beyond cancer, other conditions can make orbital exenteration necessary. Severe fungal infections unresponsive to medication, such as the life-threatening infection mucormycosis, may require removal of affected tissues to prevent spread to the brain. Severe trauma, where the eye and surrounding structures are damaged beyond repair, is another reason.
The Surgical Procedure
Orbital exenteration is performed in a hospital under general anesthesia. The surgery takes about one hour, though this can vary with complexity. A multidisciplinary team is led by an oculoplastic surgeon, who specializes in surgery of the eye and surrounding facial structures, and may include a neurosurgeon or an ENT surgeon if the disease involves the brain or sinuses.
The extent of tissue removal defines the type of exenteration. A total exenteration involves removing all contents of the orbit, including the eyeball, muscles, nerves, fat, and eyelids. A subtotal exenteration is more limited, sparing the eyelids to aid in later reconstruction. An extended exenteration may be necessary for invasive disease, including the removal of adjacent bone or parts of the sinus cavities.
The surgical objective is to remove all diseased tissue with “clear margins,” meaning the tumor or infected tissue is removed along with a border of healthy tissue. This practice reduces the likelihood of the disease recurring locally. The approach is tailored to the patient based on pre-surgical imaging and examination.
Once the orbital contents are removed, the surgeon addresses the resulting socket. The socket is often lined with a split-thickness skin graft, a thin layer of skin harvested from the patient’s thigh. This graft covers the exposed area and promotes healing.
The Recovery Process
Following surgery, the patient is monitored in a recovery area. A hospital stay is required, with the duration depending on the individual’s health and the extent of the surgery. Pain is managed with prescribed medication, and resting with the head elevated is recommended for the first few weeks to reduce swelling.
A large pressure dressing is applied over the socket immediately after the operation to minimize bleeding and swelling. This bandage remains in place for about a week and should not be removed by the patient. Light bleeding that stains the dressing is normal in the first few days.
The first follow-up appointment occurs about a week after surgery, where the surgeon removes the dressing and any stitches. The patient receives instructions on home care for the socket. This care involves cleaning the surrounding skin and applying ointment to the socket multiple times a day to keep it moist and aid healing. Patients are advised to avoid blowing their nose forcefully for several weeks to prevent introducing bacteria into the socket.
Life After Surgery and Reconstruction
Adjusting to life after surgery involves functional and aesthetic changes. A primary functional change is the shift to monocular vision, resulting in the loss of stereoscopic depth perception. This can make tasks like pouring liquids or navigating stairs challenging at first. The field of vision on the affected side is also lost, requiring a person to turn their head more to see.
Once the socket has fully healed, which can take several months, an orbital prosthesis can be used to restore appearance. A prosthesis is a custom-made artificial eye, eyelid, and surrounding facial portion designed to match the patient’s features. It is created by a specialized professional called an anaplastologist.
The prosthesis can be attached with medical-grade skin adhesives or to a pair of eyeglasses. For a more secure fit, small titanium implants can be surgically placed into the bone around the orbit. These implants connect to the prosthesis with magnets. Some individuals may opt not to have a prosthesis and instead choose to wear an eye patch.
In some cases, surgical reconstruction using tissue flaps from other parts of the body may be performed to fill the socket’s volume. Regular follow-up appointments with the medical team are necessary for up to five years. These appointments monitor for any signs of disease recurrence and manage the health of the socket.