Indications for eye removal surgeries

Discussion

In our study, patients who underwent evisceration were younger than the patients who underwent enucleation, according to which a statistically significant difference was found. The mean ages, gender distribution, evisceration/enucleation rates and the most frequent indications according to studies conducted in various countries are summarized in Table 2. In the literature, the reported mean age was 29-53 years, and it was observed that in developing countries, eye removal surgeries occur at younger ages, whereas in developed countries they occur in older ages.2,3,5,6,9 In our study, the most frequent indication in evisceration surgeries was trauma, whereas it was malignancy in enucleation surgeries, which explains the younger age of evisceration patients, and the older age of enucleation patients.

Among all patients who underwent eye amputation in our study, there was a male predominance (male/female = 2.97). Likewise, the ratio was similar in patients who underwent evisceration (male/female = 3.1) and enucleation (male/female = 2.5). In the literature,5 the higher rate of male patients is due to the fact that men are more frequently subject to occupational accidents, as well as injuries in the military field.5

The most commonly used eye removal method in our study was evisceration (evisceration/enucleation = 3.4). Evisceration operations take a shorter time, and are simpler and more predictable compared to enucleation operations.4,6 In addition, as the sclera is not surgically removed in evisceration operations, there is a more suitable bed support for implants.3,4 If the lesion (tumor, infection, and so forth) involves the sclera, then enucleation should be preferred. In our series, we applied enucleation as the single eye removal method in advanced malignancy cases. Various studies have shown that in the last decade the number of eye removals due to endophthalmitis, painful blind eye, and absolute glaucoma decreased. However, surgery due to trauma increased, therefore, an increase was experienced in the rate of evisceration/enucleation.6,10,11 Our clinical approach is to prefer evisceration surgery as an eye removal surgical method except for eye malignancy cases.

In our study, the most common indications of eye removal surgery were trauma, followed by malignancy, painful blind eye and absolute glaucoma, endophthalmitis, phthisis bulbi, and cosmetic reasons. Trauma has become the most common indication in evisceration surgery because our hospital is a referral center to which severe injury cases are transferred. Traumas that occur in military operations are more severe than injuries that occur in civilian areas due to the fact that they are caused by high energy explosives, lead to more serious eye injuries,12 worse initial visual acuity, and occur with injuries in multiple systems.13,14 The improvised explosive devices (road bombs) and land mines are frequently used by terrorist groups worldwide and responsible for almost all terror related eye injuries in Turkey.15 Many of these injuries happened during vehicle convoy operations. Because of the higher impact of these explosives at the roadside, and the lack of protection combined with the high velocity impact and fragmentary nature of these weapons such as rocks, metal, or glass fragments has led to significant mortality and morbidity in our study. We believe that the use of protective eyewear will decrease the number of severe eye traumas and evisceration surgeries. It was also reported in various studies that the use of protective eyewear in military operations result in fewer and minor injuries and better final visual acuity.14,16

In eye malignancy in general, there is an opportunity for local ophthalmic intervention treatment methods at the early stages such as cryotherapy, laser photocoagulation, thermotherapy, chemotherapy, radiotherapy, and surgical resection.17 Enucleation can be applied as the last resort in the treatment of intraocular malignancy at the advanced stages when effects on the entire eye are detected.18 Early discovery of intraocular malignancy (especially retinoblastoma and malignant melanoma) may reduce the need for enucleation.19 Infectious reasons make the most common eye removal indications in countries or regions of low socioeconomic conditions.8,9 The developments in the diagnosis and treatment of endophthalmitis in recent years, the existence of effective antimicrobials and their intravitreal applications enable medical therapy for endophthalmitis.5 In our study, no eye removal surgery was performed after 2005 for the indication of endophthalmitis.