<img height="1" width="1" alt="" style="display:none" src="https://www.facebook.com/tr?id=1479416332329403&amp;ev=PixelInitialized" /> Skills Laboratory: How to perform transpalpebral enucleation

Skills Laboratory: How to perform transpalpebral enucleation

Do you need to remove a patient's painful, nonvisual eye but think your ocular surgical skills may need a bit of polishing? Have no fear—just follow this step-by-step guide to performing this common surgery.
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Mar 08, 2013

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Enucleation is a common ocular surgery performed by general practitioners. It is indicated for patients with a painful or nonvisual eye that is nonresponsive to medical therapy. Removing an eye may not only be therapeutic but may also serve as a diagnostic measure when intraocular neoplasia (primary or metastatic) or infectious, primary, or secondary glaucoma cannot be defined clinically.

Potential complications
The most common problem encountered with this surgery is an inability to accurately distinguish all secretory tissues and completely excise them, depending on the surgical approach chosen. The secretory tissues often left behind are the conjunctiva and the nictitating membrane. These tissues will continue to secrete, causing cyst formation. In our experience, this complication is most common when the transconjunctival technique is used.
The second most common complication encountered during surgery is exerting excessive force and traction on the globe before cutting the optic nerve, causing displacement of and traction on the optic chiasm, which can lead to permanent blindness in the remaining eye. This complication is more likely to occur when you are treating brachycephalic

dog
breeds or
cats
, since the optic chiasm is closer to the posterior globe, and if excessive force is used, it can result in ischemia of the chiasm.1

Surgery approaches
There are two approaches for enucleation surgery: transconjunctival (also referred to as subconjunctival) and transpalpebral.

The transconjunctival approach involves an initial incision around the bulbar conjunctiva and has the advantages of reduced orbital tissue loss and subsequent orbital sinking with time, less hemorrhaging intraoperatively, and a faster procedure time. This approach should not be used in a patient with a suspected or known intraocular infection. It is important to identify and remove all conjunctival tissue and nictitating membrane with glands to avoid the postoperative complications mentioned above.

The transpalpebral approach is recommended for any indication when removing an eye. With this approach, an elliptical incision is made around the eyelids, and the globe and all secretory tissues (eyelids, conjunctiva, nictitating membrane) are removed within the conjunctival sac.

It is recommended that you learn one method and commit to performing that approach so you are comfortable trouble-shooting when unexpected intraoperative complications arise. Because the transpalpebral approach is the more versatile of the two, it is the recommended approach for performing enucleation surgery.

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