# Enucleation and evisceration: Disadvantages and Risks.

The eye is said to be a protrusion of the brain because its layers are extensions of the brain's own. Enucleation and evisceration are operations on the central nervous system. Enucleation is the surgical removal/amputation of the eye. Evisceration is the surgical removal/emptying of the eye's contents. Evisceration of the eye on the operating table is enucleation followed by autotransplantation: the eye is removed, emptied of its contents, then scraped/cleaned, and reinserted into the orbit, preferably in an inverted position. These operations are traumatic both anatomically and psychologically. These mutilating operations, known as reconstruction, are all arduous, extremely risky, and expensive. The potential consequences and secondary effects are numerous, including: intraoperative risks: severe intraoperative shock, which is very rare but possible (as Patrick experienced).

## Risks associated with general anesthesia.

Early postoperative complications:

- Eyelid swelling, infection,
- Suture rupture with or without scar detachment.
- Postoperative pain for 3 to 4 days, or even longer.
- Sagging and outwardly inverted lower eyelid.
- Mild, temporary ptosis of the upper eyelid due to volume deficit.

Serious postoperative risks:
- Implant exposure due to dehiscence, an abnormal opening in the conjunctiva, or a tear in the enclosing Tenon's capsule.
- Implant rejection, expulsion, total, permanent, irreversible, and irreparable necrosis of the entire orbital tissue of one half of the face, with complete loss of the orbital cavity and total loss of the eyelid.
- Requirement for facial epithesis/prosthesis (in Achmad).
- Secondary sympathetic nervous system damage in the healthy eye, which can lead to complete vision loss (in Kevin).

Paradoxically, one of the indications for surgery is to prevent the spread of disease to the other eye, yet one of the complications of that surgery is the occurrence of secondary damage to the other eye. There are many other risks: a significant risk that one or more re-interventions—either minor or major—will be required, along with a series of potential tertiary complications that accompany this. Anomalies or errors in the restoration or reconstruction of orbital volume, either due to excessive or insufficient volume. The newly obtained orbital volume is sometimes unsuitable for the placement of an ocular prosthesis; there is insufficient space for the prosthesis, or the volume is excessive, making the prosthesis too large and heavy. Re-intervention will be necessary. Secondary orbital fat volume reduction is sometimes significant, which can reach up to 50% of the volume inserted during surgery. Instability of the surgical and aesthetic results occurs, and sometimes the ophthalmic prosthetist must attempt to use a temporary prosthesis while the patient watches their face change over time, necessitating re-intervention.
Frequent occurrence of scar adhesions/secondary synechiae. Simply put, these are two areas of lesion that were originally facing each other and then fuse together. Synechiae are “bridges” of non-stretchable and non-compressible tendon tissue that can mechanically impede eyelid movement or the movement of prostheses, even implants. Synechiae can hinder volume insertion by the ophthalmologist and significantly affect the aesthetic outcome, as well as cause the prosthesis to dislodge when looking sideways. Synechiae can occur as a result of surgery or be caused by shaping devices or prefabricated prostheses with sharp edges and/or traumatic holes or surfaces. Such devices damage or destroy the surgeon's work. Traumatic conformers have been reported to the French medical device regulatory agency, but the reports have not been acted upon; the devices appear to have not been withdrawn from hospital supplies and are still widely used.
On the other hand, Indian-origin ophthalmic prostheses that function as conformers in Indonesia have been the subject of numerous articles. To address one or more synechiae, and if possible, ophthalmic prosthetists make one or more incisions in the device; sometimes it is preferable to perform a repeat intervention to remove one or more bridges. Surgeons are advised to ensure that the conformer does not cause trauma by carefully inspecting its edges and surfaces at the end of the procedure and before insertion. Implant migration. Malposition of the implant, which may be too attached to the internal canthus, for example, too high with a very large volume at the bottom... The appearance of cysts in the orbital cavity, on the implant, or in the conjunctival sac, which sometimes will cause pushing the prosthesis and/or causing rotation/malposition or rejection of the implant. Hair growth in the cavity, sometimes behind the prosthesis, due to hair follicles accidentally transplanted by the surgeon.
This is very annoying, irritating, and causes excessive and foul-smelling secretions. Excessive salivation on some implants made from oral mucosa during mealtimes; patients will tear before eating or at the sight of an appetizing dish. Organ dysfunction or loss: (disorders of the eyelids, tear glands, eye muscles, blood vessels, etc.). The surgeon cuts and sutures, removes and adds tissue. Fornices that are deformed and/or too shallow or too deep. Partial ptosis occurs when the eyelid is injured during surgery or incompletely closed postoperatively with poor or uneven distribution of the tear film, dryness of the front of the prosthesis, the eye being more or less open at night and the eyelid sticking to the prosthesis in the morning. Local fractures/folds in the eyelid arch at the eyelid margin, at the four corners of the support used during surgery, or at the point of tension of the threads applied during surgery. Incorrect positioning or even damage to the tear duct, which can impede its function and block the flow of tear secretions into the nasal cavity. More or less watery and colored secretions will flow directly onto the face or after stagnating for varying periods in the patient's inferior fornix and orbital floor; reoperation is necessary. Often severe motility disorders, as a result of the removal of "non-essential" oculomotor muscles, as well as the detachment/cutting and reattachment of other muscles. Chronic conjunctivitis and blepharitis of the lower eyelid, which can progress to eyelid retraction, are caused by untreated lower eyelid ectropion, as mentioned above.

Blinking movements of the upper eyelid and friction of the eyelashes during blinking can injure the lower eyelid. Partial or total eyelid entropion (possible but rare in the postoperative period, and often caused by the use of toxic ocular prostheses). Psychological trauma, often severe and lasting for varying durations, can cause phantom pain months or even years after surgery (A. Martel, "Phantom Eye Syndrome: Myth or Reality" https://dumas.ccsd.cnrs.fr/dumas-01681383/document). Nosocomial infections, which are estimated at around 5% according to INSERM (in Juan). Note: The above list is not exhaustive. Information sheet No. 27 of the Société Française d'Ophtalmologie, entitled "Enucleation and Evisceration of the Eye," states that these complications are "rare" (?).
While these complications are considered individually, this is true, considering all possible complications, the risk of experiencing at least one complication in the postoperative period is quite high. This information sheet is a consent form after receiving an explanation (?) that must be signed by the patient before undergoing enucleation or evisceration.