| "Do not go where the path may lead, go instead where there is no path - and leave a trail." ~ Ralph Waldo Emerson ~ |
| Enucleation and Artificial Eyes |
| ORPHANS OF THE CANCER STORM |
Enucleation is the surgical removal of an eye. It is used only when absolutely necessary, to prevent spread of the tumour, and only then after full consultation with the child's family and other members of the medical team. Enucleation will be a likely course of action for the management of optic nerve glioma and retinoblastoma in the following instances: - When the tumour is very large and there is no hope of useful remaining vision in the affected eye - When the tumour(s) threatens, or has already spread to, the optic nerve, choroid or orbit - When other treatments have failed to destroy the tumour(s) - When vitreous haemorrhage or cataracts inhibit thorough examination of the retina (in retinoblastoma) During the surgery, the entire globe will be removed, whilst preserving the eye muscles as much as possible. In cases of retinoblastoma, a section of the optic nerve will also be removed for pathology examination. Once the eye has been removed, an orbital implant will be inserted, to which the healthy muscles are attached. On very rare occasions, an implant cannot be used. With retinoblastoma, the surgery usually takes between 45 minutes and 1.5 hours. Enucleation in cases of optic nerve glioma often take considerably longer due to additional neurosurgery to remove more extensive portions of the optic nerve. In such cases, surgery may last 5-6 hours. Implants are used to replace the volume lost from the socket by removal of the eye. They are permanently inserted during the enucleation surgery, immediately after the eye has been removed. Implants are not the same as artificial eyes (prostheses), which are inserted only several weeks after surgery. A variety of implants are now available: Ball or sphere plastic implants: these conventional implants have been used for many years and are the simplest and easiest to insert. However, prosthetic movement is not as good as that offered by more recent innovations. Motility implants: these have special mounds which allow for greater movement than conventional implants. Hydroxyapatite implants: also known as a "corralline" or "bio-eye", these are the most advanced orbital implants available. They are created from naturally occurring marine coral and thus become biointegrated into the body by allowing orbital tissues to bond with implant. As muscles become attached to the bio-eye, this implant offers the greatest possible movement. In some instances, a peg can be inserted in to the the implant to improve potential mobility of the prosthesis. If this happens, it is likely to take place about six months after the enucleation. Before any decisions are finalised, a bone scan or gadolinium enhanced MRI will be performed to determine complete healing. Once this has been confirmed, a small hole will be drilled into the implant and a peg inserted. The back of the prosthesis can then be connected to the peg, giving almost completely natural movement via the tiny ball and socket joint. Due to the bony structures surrounding the eye, there is likely to be some significant bruising around the socket for several days. However, this looks much worse than it is, and should not cause too much discomfort. If your child wears glasses, they may increase discomfort at pressure points around the nose. Some children experience headaches for up to several days following surgery. These are usually treatable with regular painkillers such as paracetamol/tylanol. Ask your child's anaesthetist to administer a local anaesthetic before s/he leaves the operating room. This will reduce post-enucleation pain as much as possible. Your child will wear a pressure patch for several days to protect the surgery site and reduce the risk of infection. Once this is removed, you may see some bruising, but this is normal and will heal within a few days. The empty socket will look just like the inside of the mouth, and your child will wear a clear plastic shell called a conformer (or proformer) until the prosthesis is made about six weeks after surgery. The conformer is warn to protect the socket from infection and to maintain its shape after surgery. There are several small holes in the conformer, through which antibiotic and local anaesthetic drops can be administered. Many parents find this an extremely emotional time. It is important to own your feelings and know that they are a natural reaction. Talk to your child's doctors and share any concerns you may have. They will be able to offer guidance on preparing for this stage of the enucleation process. In the United States, enucleation for retinoblastoma is often carried out as an out-patient surgery, whilst children treated in the United Kingdom are almost universally admitted for at least one night. Your doctor will discuss these plans with you prior to surgery. If you have any concerns, you can ask for your child to be admitted overnight, and if you are in any doubt about their wellbeing following surgery, insist on an admission for observation. Enucleation for optic nerve glioma will almost always require admission due to the concurrent neurosurgery involved. The artificial eye (ocular prosthesis) looks like a large contact lens, and can be removed, polished and replaced on a regular basis. About six weeks after enucleation, when the surgical wound has healed, the ocularist will make an impression of your child's socket, using a fast-setting wax, and then create an ocular prosthesis from the mould. For babies and young children, this can be a traumatic process and is often performed during an EUA. You should discuss this possibility with your child's doctors. Initially, your child may be fitted with a temporary, off-the-shelf prosthesis whilst the permanent eye is made and individually painted so that both eyes match and look as natural as possible. Ocularists are extremely skilled professionals who perform regular "miracles" through the creation of each completely unique prosthesis. Ptosis: a droopy eyelid can be repaired when necessary with a simple procedure under anaesthesia. You should discuss this with your child's surgeon. Reduced growth of eye socket: this is common in young children when an eye is removed. However, preservation of a healthy remaining eye will stimulate the natural growth of facial bones around the socket. Regular prosthetic build ups and new prostheses will also aid bone growth. Superior sulcus deformity: this sunken appearance occurs when the volume of the orbit is reduced with removal of the eye. It is a rare side effect and can be corrected in the majority of patients if necessary. Scarring of the socket: this can result in an inability of the socket to hold the prosthetic shell. As with changes in orbit size, this occurs only in a small number of patients, and can be surgically corrected. Extrusion or loss of the orbital implant: this may occur with excessive scarring or infection. Surgical replacement of the implant can be done once infection is eradicated. Exposure of the implant: With all orbital implants, exposure of the anterior (frontal) surface of the implant usually results in extrusion and loss of the implant. This is also an issue with the new hydroxyapatite orbital implants. Sympathetic ophthalmia: This is an extremely rare complication of evisceration (different from enucleation), which results in loss of vision in the remaining eye. As only the contents of the eye (iris, lens, vitreous, retina, and choroid) are removed during evisceration, the antigen that leads to sympathetic ophthalmia cannot always be completely removed with this type of surgery. This is NOT a complication associated with enucleation. If your child is old enough, explain what the enucleation process involves. Be honest, but use age appropriate language they will understand. Young children will be satisfied with simple explanations like "your eye has a boo boo inside and the doctor needs to take it away to make you better. When he has taken your eye out, you won't be able to see from it any more, but the boo boo will be gone, and you will get a new pretend eye that will look just like the old one". You can give more information to older children as their comprehension ability allows. (Institute for Families of Blind Children) and "My Pretend Eye" (UK National Artificial Eye Service) are two useful books designed specifically for young children facing the loss of an eye. It can be good preparation to read one of these books with your child(ren), and if they are of pre-school/school age, you might suggest their use in class to the teacher, in order that peers are more equipped to understand your child's experience. The UK Childhood Eye Cancer Trust and National Artificial Eye Service have developed a delightful soft toy with artificial eye to help children understand and cope with enucleation. You can read about Dino the Dinosaur and how to order him here. Introducing your child to others with an artificial eye may help to reduce their feelings of anxiety. Your doctor may be able to put you in touch with other families in your area who have experienced enucleation. This will also be an opportunity for you to share your feelings with other empathetic parents. There are several e-groups which offer superb support to families. Look under the support group sections within ORbIT and FamilySONGS for specific sites. - Why is enucleation being suggested? - What are the pros and cons of enucleation? - Are there any other options which will preserve the eye, what are they, and how do they compare to enucleation? - When will the surgery take place? - How many paediatric enucleations has the surgeon performed? - Will a neurosurgeon be involved in the surgery (for optic nerve glioma indicated enucleation) - How long will the surgery last? - What type of implant will be used and why? - How much experience has the treatment centre had with this type of implant, and over what time-scale? - What will my child's post-operative treatment protocol involve? - Will my child be admitted overnight? - When will the patch be removed? - When will my child see the ocularist, and how does the referral process work? Go back to GENERAL TREATMENTS index. Go back to ORbIT TREATMENTS index. Go back to SONGS TREATMENTS index. |
| Disclaimer This information page has been prepared by an individual who does not have medical training. However its contents have been reviewed by appropriately qualified medical professionals for accuracy and quality. This page is intended for information purposes only and should not be used as a guide to diagnosis or treatment. If this information raises any concerns about your child’s condition or care protocol, discuss them with his or her paediatrician, oncologist, or other appropriate medical professional who has knowledge of the case. |