|Year : 2016 | Volume
| Issue : 1 | Page : 12-16
Indications for destructive eye surgeries at a Nigerian tertiary eye care centre: A ten-year review
Kareem Olatunbosun Musa, Olufisayo Temitayo Aribaba, Adeola Olukorede Onakoya, Adekunle Rotimi-Samuel, Folasade Bolanle Akinsola
From the Department of Ophthalmology, Guinness Eye Centre, Lagos University Teaching Hospital/College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||13-Apr-2016|
Kareem Olatunbosun Musa
From the Department of Ophthalmology, Guinness Eye Centre, Lagos University Teaching Hospital/College of Medicine, University of Lagos, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Background: Destructive eye surgeries are terminal treatment modalities for some ophthalmic conditions with psychological, emotional and cosmetic implications, especially for the patients and their relatives.
Objective: The aim of this study was to determine the frequency and indications for destructive eye surgeries at an Eye Centre of a Nigerian Tertiary Hospital with a view to identifying the preventable indications for which appropriate preventive measures could be recommended.
Patients and Methods: A retrospective, descriptive study of all patients who underwent evisceration, enucleation or exenteration at the Guinness Eye Centre, Lagos University Teaching Hospital from January 2003 to December 2012 was performed. Their outpatient, ward and theatre records were retrieved and reviewed. Information obtained included age, sex, eye affected, duration of symptoms before presentation, visual acuity of affected eye at diagnosis, indication for surgery and type of destructive surgery.
Results: A total of 186 eyes of 185 patients were surgically removed constituting 4.8% of a total of 3866 surgeries performed during the period of study. Children below 16 years accounted for 33.5% of the cases while 30.3% were in their first decade of life. Overall, the most common indication for destructive eye surgery was trauma (36.2%) followed by tumour (27.6%) and ocular infection (18.4%). However, tumour (73.2%) was the most common indication in the first decade of life with retinoblastoma accounting for 92.7% of these.
Conclusion: Ocular trauma, tumour and infection were the most common indications for destructive eye surgery in this centre.
Keywords: Destructive, eye surgeries, indications, Nigerian, tertiary
|How to cite this article:|
Musa KO, Aribaba OT, Onakoya AO, Rotimi-Samuel A, Akinsola FB. Indications for destructive eye surgeries at a Nigerian tertiary eye care centre: A ten-year review. Niger Postgrad Med J 2016;23:12-6
|How to cite this URL:|
Musa KO, Aribaba OT, Onakoya AO, Rotimi-Samuel A, Akinsola FB. Indications for destructive eye surgeries at a Nigerian tertiary eye care centre: A ten-year review. Niger Postgrad Med J [serial online] 2016 [cited 2019 Aug 19];23:12-6. Available from: http://www.npmj.org/text.asp?2016/23/1/12/180119
| Introduction|| |
Destructive eye surgeries are surgeries performed for the removal of the eye. They include evisceration, enucleation and exenteration. Evisceration involves the removal of the contents of the eyeball, leaving the sclera and the optic nerve intact while enucleation is the removal of the whole eyeball and part of the optic nerve.  In exenteration, all the contents of the orbit, with or without the eyelids and part of the bony wall, are removed. 
The difficult decision to remove a patient's eye is often a terminal treatment modality for some ophthalmic conditions with psychological, emotional and cosmetic implications, especially for the patients and their relatives. This decision may be necessary for severe ocular infections unresponsive to medical treatment, severe eye injury with no visual potential as well as to treat intraocular malignancies.  It may also serve as a relief to a painful eye and a cosmetic improvement of a disfigured eye. 
The indications for destructive eye surgeries are similar globally, but the prevalence of the ocular morbidities necessitating these procedures differs from place to place.  This variation could be a reflection of the pattern of severe ophthalmic diseases in a particular community as well as the level of sophistication in the management of these diseases.  Several reports from developing countries ,,,,, implicated ocular infections as the most common indication for destructive eye surgeries whereas malignant tumours accounted for most of the indications in developed countries. ,,, However, trauma seems to be common to both developing and developed countries. ,,,,,,, Evisceration and enucleation could both be performed in relieving pain in painful blind eye, severe ocular infections or in improving cosmetic appearance. , However, evisceration should never be performed if a tumour is suspected.  Although inadvertent evisceration of eyes containing uveal melanoma was reported by Eagle et al,  enucleation is usually the procedure of choice in primary intraocular malignancies with failed conservative treatment as well as ocular conditions in which the nature of intraocular pathology is unknown.  Exenteration is reserved for orbital tumours and intraocular tumours that have spread to the orbit. 
A similar study was conducted in this centre more than two decades ago which concentrated on the causes of enucleation alone.  The aim of this study was to determine the frequency and indications for destructive eye surgeries at the Guinness Eye Centre, Lagos University Teaching Hospital with a view to identifying the preventable indications for which appropriate preventive measures could be recommended.
| Patients and Methods|| |
This was a retrospective, descriptive study of all patients who underwent evisceration, enucleation or exenteration at the Guinness Eye Centre, Lagos University Teaching Hospital from January 2003 to December 2012. Their outpatient, ward and theatre records were retrieved and reviewed. Relevant information was obtained which include age, sex, eye affected, duration of symptoms before presentation, visual acuity of affected eye at presentation, indication for surgery and type of destructive surgery. Ethical approval was sought and obtained from the Health Research and Ethics Committee of the Lagos University Teaching Hospital.
Data obtained were analysed using the Statistical Package for Social Sciences (SPSS) version 17 (SPSS Inc., Chicago, IL). Frequency tables of variables were done. The association between categorical variables was analysed using cross-tabulation and Chi-square test, and a P < 0.05 was considered statistically significant. Fisher's exact P-value was used where applicable.
| Results|| |
One hundred and eighty six eyes of 185 patients were surgically removed during the period under review. One hundred and one (54.6%) patients had the left eye removed while 83 (44.9%) patients had the right eye removed. However, 1 (0.5%) patient had both eyes removed in a sequential manner on account of bilateral spontaneous globe rupture complicating bilateral infective corneal ulcers. She was a 67-year-old known diabetic of 20 years duration on insulin injection. Her visual acuity was no perception of light (NPL) in both eyes. The histopathological findings were consistent with bilateral, chronic, non-specific keratitis with co-existing right retinal detachment.
[Table 1] shows the age distribution of the 185 patients. There were 123 (66.5%) males and 62 (33.5%) females with a male: female ratio of 2:1. The mean age was 30.1 ± 23.7 years with a range of 2 months to 95 years while the median age was 28 years. Children below the age of 16 years accounted for 33.5% of the cases while 30.3% were in their first decade of life being the most commonly affected age group. All the eyes that underwent destructive eye surgeries were blind with 175 (94.1%) eyes having a visual acuity of NPL while perception of light and hand movement were recorded in 9 (4.8%) eyes and 2 (1.1%) eyes, respectively.
|Table 1: Age distribution of 185 patients who had destructive eye surgeries at Lagos University Teaching Hospital|
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One hundred and eighty six eyes were removed surgically out of the total 3866 eye surgeries performed over a 10 years period constituting 4.8% of all the eye surgeries performed. Evisceration was the most commonly performed destructive eye surgery done in 102 (55.1%) patients. This was followed by enucleation performed in 54 (29.2%) patients while exenteration (modified) was the least performed done in 29 (15.7%) patients.
The various indications for destructive eye surgeries are shown in [Table 2]. The most common indication was trauma documented in 67 (36.2%) patients. This was followed by tumour and ocular infection seen in 51 (27.6%) and 34 (18.4%) patients, respectively. [Table 3] shows the distribution of destructive eye surgery by age group and sex. Tumour was the most common indication in the first two decades of life being responsible for 42 (61.8%) out of the 68 cases in this age group (P = 0.00). It was also the most common indication in the first decade of life accounting for 41 (73.2%) of 56 cases. Thirty-eight (92.7%) of the 41 cases of tumour in the first decade of life were due to retinoblastoma. Twenty (52.6%) of the 38 cases of retinoblastoma had enucleation while the remaining 18 (47.4%) had modified exenteration due to the late presentation and attendant extra-ocular and orbital extension. Thereafter, trauma became the leading indication in the 21-40 years age group accounting for 38 (66.7%) of the 57 cases in this age group (P = 0.00). After the age of 60 years, ocular infection became the predominant indication responsible for 9 (36%) of the 25 cases (P = 0.02). Overall, the most common indication for destructive eye surgeries in males was trauma (46.3%) while the most common indication in females was tumour (38.7%) as shown in [Table 3]. The most common indication for enucleation was tumour which was documented in 22 (40.7%) of the 54 patients that underwent enucleation. This was followed by ocular infection in 13 (24.2%) patients [Table 4]. Retinoblastoma accounted for 20 (90.9%) of the 22 tumour cases that had enucleation while the remaining 2 (9.1%) were conjunctival squamous cell carcinoma cases. Eight (61.5%), 4 (30.8%) and 1 (7.7%) cases of panophthalmitis, endophthalmitis and perforated infective corneal ulcers, respectively, constituted the 13 cases of ocular infection that had enucleation. Trauma was the predominant indication for evisceration responsible for 58 (56.9%) of the 102 patients who had evisceration followed by ocular infection seen in 21 (20.6%) patients [Table 5]. All the cases of trauma that had either enucleation or evisceration were severe open globe injuries with globe perforation or rupture. Six (28.6%), 8 (38.1%) and 7 (33.3%) cases of panophthalmitis, endophthalmitis and perforated infective corneal ulcers, respectively, constituted the 21 cases of ocular infection that had evisceration. All the 29 (100%) patients who had their eyes exenterated were due to tumours involving the orbit, of which 18 (62.2%) were advanced retinoblastoma. The other pathologies that necessitated modified exenteration were invasive conjunctival squamous cell carcinoma 6 (20.8%), sinonasal tumour with orbital involvement 1 (3.4%), orbital inflammatory pseudotumour (lymphoid variant) 1 (3.4%) and orbital metastatic neuroblastoma 1 (3.4%). The remaining two cases were retrobubar mass and orbital mass with mandibular mass in a 4- and 5-year-old male patients, respectively, whose histological diagnosis were not available.
|Table 2: Indications for destructive eye surgeries at Lagos University Teaching Hospital|
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|Table 3: Distribution of the indications for destructive surgery by sex and age|
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|Table 4: Indications for enucleation at Lagos University Teaching Hospital|
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|Table 5: Indications for evisceration at Lagos University Teaching Hospital|
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| Discussion|| |
The mean age of patients who underwent destructive eye surgeries in this study was 30.1 years. This finding is comparable to the 29.69 years recorded by Bodunde et al.  but lower than the 40.8 years, 43.78 years and 45.6 years documented by Nwosu,  Eballé et al.  and Otulana and Majekodunmi  respectively. The observation that the first decade of life was most affected is similar to the experience in previous studies in Cameroun,  Ghana,  Nigeria,  and China.  This is worrisome because of the "blind years" ahead of these children as well as the potential facial asymmetry with attendant psychosocial implication and social outcast effect that could occur if prosthesis is poorly fitted or not fitted at all. The overall frequency of destructive eye surgeries was 4.8%. This was much lower than the 10.6% and 12.1% reported by Bodunde et al.  and Otulana and Majekodunmi,  respectively, from the same centre but higher than 3.4%, 2.7% and 1.4% documented by Nwosu,  Gyasi et al.  and Pandey,  respectively.
The most common indication for destructive eye surgeries was trauma. This is consistent with the findings in previous studies from Southwest Nigeria , and Ethiopia  but contrasts with observations from other parts of Nigeria, , Africa , and Asia  where ocular infection was documented to be the most common indication. In this study, trauma was the predominant indication among males and peaked between the ages of 21 and 40 years. This calls for concern because of the socioeconomic implication of the affectation of individuals in this age group who are meant to be economically active and productive. In addition, a majority of the circumstances of the trauma sustained were related to road traffic crashes, home, work and assault, which are largely avoidable.
Tumour was the second most common indication for destructive eye surgeries. Ocular tumour, mostly retinoblastoma, was the most common indication for eye removal in the first decade of life. This compares favourably with previous reports in the literature. ,,, The preponderance of tumour-related eye removal in this age group may not be unconnected with the fact that retinoblastoma is the most common childhood intraocular malignancy typically presenting in the first decade of life coupled with late presentation of the patients, leaving destructive eye surgeries as the only therapeutic option. Late presentation of retinoblastoma cases was particularly depicted in this study as nearly half of the retinoblastoma patients whose eyes were surgically removed over the 10 years under review had modified exenteration due to orbital involvement. This calls for concern because retinoblastoma is a treatable malignancy if patients present early with a good prospect of saving the life, the eyeball and even the vision. To this end, awareness campaign on symptoms and signs of retinoblastoma needs to be intensified to ensure early detection and presentation. This can be done through print and mass media, handbills and poster display in public places. Also, incorporation of red reflex assessment especially Bruckner's test into examination routine during immunisation visits of babies is advocated to facilitate early detection of retinoblastoma and other causes of leucocoria. Furthermore, genetic testing of parents and siblings of retinoblastoma patient is advocated to engender early detection and prompt treatment. Tumour was found to be the most common reason for destructive eye surgeries among females as previously observed by Gyasi et al.  and Günalp et al.  The reason for this is not clear and may need further evaluation in a larger study.
Ocular infection was an important indication for destructive eye surgery in this study, predominant after the age of 60 years. A majority (76.5%) of the infections were either due to endophthalmitis or panophthalmitis, which is in accord with findings in previous studies. ,,,,, This may be because individuals in this age group are less economically productive coupled with the non-availability of free health care delivery in Nigeria, probably leading to late presentation more so that close to 60% of these patients presented between 1 week and a month of the onset of symptoms. Therefore, it is imperative for the government to make available free health care services for all and sundry. Alternatively, universal health coverage with equitable, sustainable, compulsory national health insurance should be promoted thereby eradicating out-of-pocket payment for services that encourage catastrophic health expenditure and its attendant health system failure.
Evisceration was the most commonly performed destructive eye surgery in this study. This is in agreement with previous documentations in the literature. ,,,,,,,, The ease with which evisceration is performed compared to enucleation could be a contributory factor. Also, badly damaged eyes, either due to trauma or infection, being the most common indication for evisceration, were responsible for more than half of the eyes removed. Furthermore, the notion that evisceration has the advantages of relative tissue preservation, better mobility of prosthesis, less operation time, lower risk of orbital implant extrusion or transmission of infective materials into cavernous sinus causing intracranial infection in endophthalmitis/panophthalmitis, relative to enucleation could make it a natural preference. 
Enucleation was the second most commonly performed destructive eye surgery. Tumour was found to be the most common reason for the procedure, which is in agreement with the findings of Majekodunmi  in this centre over two decades ago. This is also consistent with observations in previous studies from other developing countries. ,, It is worthy of note from this study that apart from tumour that had either enucleation or modified exenteration, all the other indications had either enucleation or evisceration. The choice of the procedure seems to be the surgeon's preference. This same view was shared by Zheng and Wu  in a retrospective review of eyes that underwent enucleation or evisceration as a result of trauma.
Finally, orbital implants and good fitting prosthesis is advocated for good cosmetic appearance especially in children who are prone to facial asymmetry as well as reduction of the psychological trauma of losing an eye.
| Conclusion|| |
Ocular trauma, tumour and infection were the major indications for destructive eye surgeries in this study, significantly affecting the economically productive individuals below 50 years of age. These are largely avoidable through early presentation, prompt diagnosis and treatment. Therefore, improvement in eye health education, genetic counselling and provision of free health care to facilitate better access to quality eye care services cannot be overemphasised. Finally, there is need to provide a good fitting prosthesis for patients who underwent destructive eye surgeries to reduce the social outcast effect as well as a careful follow-up of the only eye.
This research was supported (in part) by the Medical Education Partnership Initiative in Nigeria grant (course on research methodology and data analysis) from the Fogarty International Center of the National Institutes of Health R24TW008878. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]