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. 2026 Jan 1;67(1):80–89.

Enucleation versus evisceration with intraocular silicone prosthesis in dogs: Postoperative complication rate and owner satisfaction comparison

Élizabeth De Maria 1,✉, Tristan Juette 1, Maria Vanore 1
PMCID: PMC12825721  PMID: 41586147

Abstract

Objective

This study compared complication rates and owner satisfaction following enucleation versus evisceration with intraocular prosthesis (EIOP) in dogs. The aim was to increase knowledge of both procedures in the literature.

Animals and procedure

We conducted a medical review of records for 138 dogs presented to the ophthalmology service of the Faculty of Veterinary Medicine, University of Montreal (Quebec) that underwent either enucleation from 2015 to 2022 or EIOP from 2008 to 2022. A survey of owner satisfaction conducted by email or telephone was done at the time of data collection, 4.1 ± 2.1 y (mean ± SD) post-enucleation and 11.8 ± 4.2 y post-EIOP.

Results

There was a difference in the complication rate between the 2 procedures, with EIOP much more prone to complications than enucleation (54.1 versus 15.3%; P < 0.001). No variable tested had a significant effect on the complication rate (age, size, sex, comorbidities, or brachycephalic syndrome). Further, the average duration of administration of topical medication after EIOP in this study (0.49 y) was much longer than intervals mentioned in the literature. The owner survey revealed similar levels of satisfaction regarding the postoperative outcomes of both procedures.

Conclusion and clinical relevance

Both procedures are viable options, but it is important to clearly communicate to the owner the complication risks and implications for providing extended postoperative care after EIOP. We concluded that EIOP can be a controversial procedure. Further, enucleation can produce a very satisfactory cosmetic result with a much-reduced postoperative burden.

INTRODUCTION

In domestic animals, enucleation is recommended in cases of vision loss associated with ocular pain, intraocular neoplasia, ocular trauma, panophthalmitis, and primary or secondary glaucoma (1–3). Exenteration is indicated for ocular neoplasia that can potentially extend beyond the globe (2,3). Although these surgical procedures are effective in resolving painful ocular disease, improving quality of life, and providing ocular tissue to aid in histopathologic diagnosis, their cosmetic results can be unacceptable to some owners (4,5). Some owners may even consider euthanasia instead of removing an affected and painful eye.

Many surgical techniques, such as evisceration, have been developed to improve cosmetic outcomes (6–8). Evisceration with intraocular prosthesis (EIOP) allows a better cosmetic result for some owners while retaining the function of the eyelids and resolving ocular pain (1,9–11). Evisceration with intraocular prosthesis has been suggested to have a superior cosmetic outcome compared to enucleation (1–3,10,12–15). The technique has been described in many species, including dogs (14–18), cats (16,17,19), horses (12,3,20,21), and birds (22,23).

In the literature, reports on postoperative complications following enucleation are scarce (4,5,24–26) and those directly comparing enucleation versus EIOP are even fewer (9,26,27). This study aimed to evaluate and compare post-surgical complications of enucleation and EIOP surgeries in dogs. It also sought to assess whether ocular disease or other factors such as age, sex, or breed were related to post-surgical complications. Finally, we used a survey to estimate the degree of owner satisfaction with these procedures. We tested 3 hypotheses: i) there are significantly fewer complications associated with the enucleation procedure than with EIOP, ii) the preoperative diagnosis affects the outcome, and iii) owners are more satisfied with the aesthetic outcome following the EIOP procedure.

MATERIALS AND METHODS

Study population

We reviewed medical records of dogs presented to the ophthalmology service of the Faculty of Veterinary Medicine, University of Montreal (Quebec), that underwent enucleation from 2015 to 2022 or EIOP from 2008 to 2022 and had complete files, including for full physical and ophthalmologic examinations. Only dogs with no postoperative follow-up were excluded from the study. No other exclusion criteria were used.

Every dog had a complete ophthalmologic examination before surgery, including a Schirmer tear test-1 (Color Bar; Corza Medical, Parsippany, New Jersey, USA), fluorescein staining (Minims Fluorescein Sodium 2%; Bausch and Lomb, Surrey, UK), and intraocular pressure measurement (Tono-Pen Vet; Reichert, New York, New York, USA or Tonovet; ICare, Vantaa, Finland). The examination was completed with slit lamp biomicroscopy (SL17; Kowa, Torrance, California, USA). Mydriasis was induced, when appropriate, by instilling a drop of tropicamide 1.0%, and a fundus examination was done with a 2.2 pan retinal or 30D lens. The procedure was conducted or supervised by a Board-certified ophthalmologist.

Surgical procedure

Enucleation was done using the subconjunctival approach, as described (28). Each dog underwent retrobulbar anesthesia according to the technique and medication determined by the attending anesthesiologist (29). After enucleation, the eye was submitted for histopathologic analysis by a Board-certified pathologist to confirm the clinical diagnosis.

The EIOP was done by scleral incision on the dorsal aspect of the globe (1–3). Each dog was fitted with an intraocular prosthesis made of black silicone (Ocular Implant; Jardon Eye Prosthetics, Southfield, Michigan, USA). The size of the prosthesis was determined by measuring the horizontal diameter of the contralateral cornea with a caliper (Jameson Caliper; CMF Medicon Surgical, Jacksonville, Florida, USA) and adding 1 mm. After removal, the contents of the globe were submitted for histopathologic analysis by a Board-certified pathologist to confirm the clinical diagnosis and exclude the presence of intraocular neoplasia.

Review of medical records

For each dog, information collected from the medical file included age, sex, breed, skull conformation, comorbidities, preoperative diagnosis separated by class of diagnosis (for enucleation: glaucoma, uveitis, corneal ulcer, mass, proptosis, and other; for evisceration: primary glaucoma, secondary glaucoma, uveitis, and other), surgical technique, procedure specifications (orbital prosthesis or mesh), histology report, intraoperative and postoperative medication, reevaluation, duration of medication administration, and complications. The latter were separated into major and minor complications.

For the enucleation group, major complications were those requiring a return to surgery. In this study, they included migration of the orbital implant or infection not responsive to medical treatment. Minor complications were conditions responding to medical treatment, including focal wound granuloma, infection, wound discharge treated medically, or temporary local bleeding. For the EIOP group, major complications were those putting in jeopardy the animal’s life or the integrity of the globe or requiring long-term treatment. These included requiring a 2nd surgery to remove the intraocular silicone implant, presence of a complicated corneal ulcer (deeper than midstromal or infected), keratoconjunctivitis sicca (KCS), or intraocular neoplasia confirmed histologically. Minor complications were uncomplicated corneal ulcer (shallow, not infected), intraocular inflammation, corneal granuloma, and infection. Changes in corneal appearance after evisceration, including pigmentation, cellular infiltration, and fibrosis, were not considered complications since these changes can be expected after an EIOP procedure. Ocular appearance was evaluated postoperatively for all EIOP cases with images obtained at follow-up appointments included in the files. However, ocular appearance for dogs in the enucleation group was not systematically included in the medical files.

At the time of data collection, 4.1 ± 2.1 y (mean ± SD) post-enucleation and 11.8 ± 4.2 y post-EIOP, owners’ opinions were obtained via an email or phone survey that queried complications during the recovery period, overall satisfaction with the cosmetic appearance of the eye or surgical site, and whether they would recommend the procedure. If an owner was dissatisfied, an explanation was requested. When an animal’s file was opened, the owner signed an informed-consent form providing agreement for their animal’s information and medical file to be used for future studies and giving their consent to be contacted in the future for follow-up regarding their animal.

Statistical methods

Descriptive statistics were obtained using Microsoft Excel for Mac 365 (Microsoft, Redmond, Washington, USA). Statistical analysis was done with R (Version 4.0.3; R Foundation for Statistical Computing, Vienna, Austria), using the ordinal, RVAideMemoire, and emmeans packages. Statistical tests used were cumulative link models (CLM) for the ordinal values and generalized linear models for the binary values. After these models were constructed, multiple comparison tests were completed to determine if there was an effect of the variable tested. Since these were multiple comparisons, the P-values were reported using the Benjamini-Hochberg method. For all analyses, P-values < 0.05 were considered statistically significant.

RESULTS

Medical records

We reviewed medical records from the ophthalmology department at the University of Montreal’s Faculty of Veterinary Medicine. Files on enucleations from 2015 to 2022 and EIOP procedures from 2008 to 2022 (n = 75 for each procedure) were reviewed; 52 enucleated dogs and 61 dogs with EIOP were retained. Of the original 75 files in each group, 23/75 (30.7%) and 14/75 (18.7%), respectively, were excluded for lack of follow-up. The average follow-up interval was 13.7 d and 1.3 y for the enucleation and EIOP groups, respectively.

Sex, age, comorbidities, skull conformation, and breed

There was no significant difference in sex distribution between the enucleated group and the EIOP group. Respectively, there were 20/52 (38.5%) and 17/61 (27.9%) neutered males, 19/52 (36.5%) and 33/61 (54.1%) neutered females, 6/52 (11.5%) and 5/61 (8.2%) intact males, and 7/52 (13.4%) and 6/61 (9.8%) intact females. Further, for these 2 groups, there were no significant differences in age distribution (6.5 ± 3.8 y and 7.3 ± 3.4 y) or comorbidities [20/52 (38.5%) and 20/61 (32.8%)]. There was a difference between groups in skull conformation, with more (P < 0.002) brachycephalic breeds in the enucleated group compared to the EIOP group [21/52 (40.4%) versus 9/61 (14.8%), respectively]. Furthermore, breed distribution was also different (P < 0.003), with spaniels prevalent in the EIOP group 14/61 (22.9%) but absent in the enucleation group.

Preoperative diagnosis

The distribution of diagnoses was vastly different between groups. In the enucleation group, the most common diagnoses (Figure 1 A) were corneal ulcer (13/52, 25.0%), primary glaucoma (9/52, 17.3%), secondary glaucoma (8/52, 15.3%), uveitis (8/52, 15.4%), proptosis (8/52, 15.4%), and other (6/52, 11.5%); the latter category included mass (4/6), traumatic hyphema (1/6) and phthisis bulbi (1/6). In the EIOP group, common diagnoses (Figure 1 B) were primary glaucoma (38/61, 62.3%), secondary glaucoma (17/61, 28.9%), uveitis (5/61, 8.2%), and trauma (1/61, 1.6%).

FIGURE 1.

FIGURE 1

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A — Preoperative diagnosis distribution in the enucleation group. B — Preoperative diagnosis distribution in the evisceration with intraocular prosthesis (EIOP) group.

Postoperative complications

In the enucleation group, complication rates were as follows: none in 45/52 (86.5%); purulent discharge from the surgical wound resolved with medical treatment in 3/52 (5.8%); and in 1/52 (1.9%) each, orbital abscess requiring a repeat surgical procedure, euthanasia following general state degradation, intraorbital prosthesis migration, severe hemorrhage during surgery, and wound granuloma. Complications were subdivided into 2 main categories: major 3/52 (5.8%) and minor 5/52 (9.6%), according to criteria detailed in the Materials and Methods section (Table 1 A, Figure 2).

TABLE 1.

Complication distributions in dogs after A. Enucleation or B. Evisceration with intraocular prosthesis (EIOP).

A. Enucleation group
Complication type Number
None 45
Purulent discharge managed medically 3
Orbital abscess requiring surgical removal 1
Euthanasia 1
Intraorbital prosthesis migration 1
Severe hemorrhage during surgery 1
Wound granuloma 1
B. EIOP group
Complication type Number
None 28
Keratoconjunctivitis sicca 8
Uncomplicated corneal ulceration 5
Lipido-calcific corneal degeneration 5
Complicated ulcer resulting in enucleation 3
Complicated corneal ulceration 3
Purulent discharge from the wound 2
Intraocular neoplasia 2
Marked corneal vascularization 1
Immune-mediated keratitis 1
Lower palpebral entropion 1
Severe corneal edema 1
Intraocular inflammation 1
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FIGURE 2.

FIGURE 2

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Comparison of major and minor complication rates following enucleation (blue bars) or evisceration with intraocular prosthesis (gray bars).

In the EIOP group, complication rates were as follows: none in 28/61 (45.9%); KCS in 8/61 (13.1%); uncomplicated corneal ulcer in 5/61 (8.2%); corneal degeneration in 5/61 (8.2%); complicated ulcer resulting in enucleation in 3/61 (4.9%); corneal ulcer with granuloma in 2/61 (3.3%); purulent discharge from the surgical wound in 2/61 (3.3%); intraocular neoplasia in 2/61 (3.3%); and indolent ulcer in entropion, corneal edema, intraocular inflammation, immune-mediated keratitis, and corneal vascularization in 1/61 (1.6%) each. These were further classified into major 17/61 (27.9%) and minor 16/61 (26.2%) complications, according to criteria described in the Materials and Methods section (Table 1 B, Figure 2).

Postoperative treatment period

The duration of treatment administration after an enucleation or an EIOP was 13.7 ± 10.2 d or 178.9 ± 445.3 d, with 60% of dogs still receiving topical medication after 90 d and 24% after 180 d post-EIOP. The most frequently used medication in the EIOP group was a steroidal anti-inflammatory drug combined with antibiotics (dexamethasone, neomycin, and polymyxin B) (Maxitrol; Alcon, Geneva, Switzerland), prescribed to suppress inflammation inside the globe while it adjusted to the prosthesis.

Correlations

Using the CLM, there was an effect of the procedure on the complication class (CLM: LR X2 = 19.33, Df = 1; P-value < 0.001). To simplify calculations, complication classes were assigned a number: none = 0, minor = 1, and major = 2. The enucleation group had complications distributed as major (5.8%, 3/52) and minor (9.6%, 5/52). For the evisceration group, the distribution was major (27.9%, 17/61) and minor (26.2%, 16/61). Using the numerical scale, the enucleation group had a lower mean score (0.23 ± 0.80) than the EIOP group (0.82 ± 0.11; P < 0.001). The percentages of cases with no complications were 84.9% for the enucleation group and only 45.9% for the EIOP group (P < 0.004).

For both groups, there were no significant effects of age, sex, weight class, skull conformation, presence of comorbidities, or preoperative diagnosis on the postoperative complication rate.

Ocular appearance

Some ocular appearance changes were not considered complications for either procedure. Skin and subcutaneous tissues sinking into the orbit were not considered as a complication following the enucleation procedure (Figure 3 A). The change in ocular appearance following EIOP was more variable than that following enucleation. For the EIOP group in the immediate postoperative period, the following changes were considered normal: hyphema, corneal edema, corneal vascularization, fibrosis, and pigmentation (Figure 3 B, Figure 4).

FIGURE 3.

FIGURE 3

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Comparison of postoperative appearances of enucleation versus evisceration with intraocular prosthesis in dogs. A — Image obtained 3 y post-enucleation of the right eye of a Samoyed. B — Image obtained 2 y post-evisceration with intraocular prosthesis of the right eye of a Pomeranian.

FIGURE 4.

FIGURE 4

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Range of ocular appearances following evisceration with intraocular prosthesis in dogs. A — Pigmentary keratitis, shih tzu, 6 mo post-surgery. B — Fibrosis with lipido-calcific corneal degeneration, cocker spaniel, 6 mo post-surgery. C — Dense superficial and deep corneal vascularization, Doberman, 1 mo post-surgery. D — Secondary hyphema, Jack Russell terrier, 1 wk post-surgery. E — Dense corneal edema, cocker spaniel with primary glaucoma, 3 wk post-surgery. F — Dense corneal edema, cocker spaniel with primary glaucoma, 4 wk post-surgery.

Owner survey

Data were collected via a survey (Appendix 1, available online from: Supplementary Materials) sent by email to all owners for whom we had an email address on file; owners with no email address were contacted by phone. All telephone interviews were conducted by the same person. Twenty questionnaires were completed in the enucleation group and 17 in the EIOP group. In the enucleation group, 17/20 (85.0%) of responders were from the “no complication” class, 2/20 (10.0%) were from the “minor complication” class, and 1/20 (5.0%) was from the “major complication” class. In the EIOP group, 10/17 (58.8%) of responders were from the “no complication” class, 4/17 (23.5%) were from the “minor complication” class, and 3/17 (17.6%) were from the “major complication” class.

In each group, only 1 owner reported a complication after the procedure. In the enucleation group, 1 dog had some mild discharge from the wound that was managed medically. In the EIOP group, 1 dog had corneal ulcers following the procedure that were also managed medically. Both these complications reported by the owners were considered minor. One owner mentioned the time-consuming postoperative care associated with EIOP but specified they were made aware of that eventuality before the procedure.

Each owner was asked to grade the aesthetic outcome of their dog following the surgery on a scale of 1 to 10 (with 1 being very unsatisfied and 10 being very satisfied). There was no significant difference between the 2 groups. The average grades were 9.8 ± 0.7 in the enucleation group and 9.2 ± 1.2 in the EIOP group. Further, in both groups, all owners contacted indicated they would recommend the procedure that their dog had undergone.

DISCUSSION

There were significant differences between groups in the study population, mostly regarding breed distribution. Brachycephalic breeds were overrepresented in the enucleation group, whereas cocker spaniels were much more common in the EIOP group. However, whether brachycephalic breeds are overrepresented in ophthalmology consultations at the University of Montreal’s Faculty of Veterinary Medicine is unknown. Different types of procedure are suitable for different preoperative diagnoses. In fact, brachycephalic breeds are prone to proptosis and to developing complicated corneal ulcers that cannot be treated with EIOP (26,30). Conversely, primary glaucoma is one of the eye diseases most associated with EIOP, and the predisposition of spaniel breeds to this disease explains their high prevalence in this population (31,32). This also explains why the distribution of preoperative diagnoses was very different between groups, with glaucoma (primary and secondary) accounting for 87.2% of cases in the EIOP group but only 27.9% of cases in the enucleation group. Many of the common diagnoses in the enucleation group were less suited or unsuited to EIOP; namely, proptosis, trauma, masses, and corneal ulcers (1–3,10,26,33,34).

Duration of administration of topical medication following EIOP was noteworthy. From the literature, medication is given in the immediate postoperative period of 2 to 4 wk (2). In this study, the duration was much longer, with a mean of 0.49 y, 60% of dogs still receiving medication after 3 mo, and 24% still receiving it after 6 mo. Perhaps the definition of an inflamed globe necessitating medication can vary among ophthalmologists. The most frequently used medication was a steroidal anti-inflammatory drug combined with antibiotics (Maxitrol; Alcon), prescribed to suppress inflammation inside the globe while it adjusted to the prosthesis. Prolonged administration of anti-inflammatory drugs explained the low rate (5%) of chronic postoperative inflammation in our population compared to 15% in another study (11). The postoperative ulcer rate was in the median range at 21%, compared to 12 to 52% (11,26,34).

There was a small, but not statistically significant, effect of preoperative diagnosis on the complication rate only in the EIOP group, with glaucoma more prone to complications than uveitis. This was probably explained by the distribution of preoperative diagnoses, with most of the cases involving a glaucoma diagnosis. This could also be partially explained by changes in globe anatomy during progression of ocular disease to its terminal phase. Collagen fibers in the sclera can be elongated and more dispersed when the eye becomes buphthalmic, decreasing structural strength and forcing the globe through more postoperative changes when acclimating to the smaller intraocular prosthesis. Buphthalmic eyes will also cause an increase in corneal exposure due to the widened palpebral opening and decreased corneal sensitivity, thus increasing the risk of ulcers. Tear film quality can also be affected by this disease, further diminishing corneal resistance to ulcers (1,11,34–36).

General complication rates were higher in this study than in the literature for both procedures (2,11,26). This can be explained by the fact that some minor complications in this study were not considered complications in others [e.g., lipido-calcific corneal degeneration (4/61), corneal edema (1/62), and corneal vascularization (1/61)]. Also, all dogs without a follow-up were excluded from this study. Those without need for a follow-up most likely had no complications, which would have significantly reduced the complication rate for this study.

Contrary to one of our hypotheses, brachycephalic dogs did not have a higher risk of complications after surgery (26,36). This study confirmed the reported higher complication rate with the EIOP procedure than with enucleation (9). Even considering this higher complication rate, the rate of postoperative KCS 8/61 (13.1%) was similar to that reported in the literature (10 to 14.5%) (11,26). Considering the in-person follow-up interval in this study (mean: 1.3 y), perhaps a longer postoperative follow-up period would have increased the value of these data.

The ocular appearances after the 2 procedures are very different and can be highly variable. A few months after enucleation, skin sinks into the orbit to varying degrees. This change in appearance was not considered a complication since it is a well-known long-term effect of the procedure. This skin sinking is due to stretching of the skin into the orbit to fill the void left by globe removal. It is more noticeable in certain individuals, such as those from breeds with short hair and deep orbits, but more subtle in longhaired dogs (Figure 3 A). For the EIOP group, a wide range of appearances is considered normal, including hyphema, corneal edema, corneal vascularization, fibrosis, and pigmentation (Figure 3 B, Figure 4). Dogs with preoperative diagnosis of primary glaucoma had more severe corneal changes, since the cornea and sclera were already subject to morphologic changes caused by buphthalmos.

The authors are aware that the EIOP procedure is controversial in the ophthalmology community. The ethics of this procedure are questioned because the known postoperative complications are more frequent, as confirmed by this study and previous reports (9–11,16,26), which can cause prolonged discomfort to the patient. Enucleation is considered as a more terminal procedure with fewer complications. However, in certain circumstances, EIOP still has a place in current clinical practice.

From our experience, removal of an animal’s eye is difficult to accept for many owners, much more so than the fact that the animal has no vision. Providing an alternative option that is more aesthetically pleasing and/or less emotionally taxing is important, allowing quicker decision-making for animals with painful eyes whose owners do not want to proceed with an enucleation.

Alternative procedures, such as EIOP, chemical ablation of the ciliary body, and cyclophotocoagulation, are subjects of recent studies (4,12,15,18–20,26). Evisceration with intraocular prosthesis is generally not recommended for suspected cases of intraocular neoplasia or for diseases that compromise corneal integrity (1–3). Despite these contraindications, EIOP has been done in cases of known intraocular neoplasia (17) or corneal perforations (15,18). We infer that some owners may consider EIOP a more acceptable option despite the presence of neoplasia or conditions that may increase risk of postoperative complications (e.g., corneal wounds).

Almost all owners surveyed indicated they would choose the same procedure even considering the postoperative treatment burden, postoperative appearance, or postoperative complications. However, the distribution of survey responses was not completely representative of the complication class distribution in the EIOP group, with more surveys collected in the “no complication” class 10/17 (58.8%) than the initial complication distribution [28/61 (45.9%)]. An owner who experienced their animal’s postoperative complications may have had a less favorable opinion. However, the distribution for the enucleation group was not significantly different.

This study had many limitations. The main limitation was the small sample size. Postoperative complications were therefore grouped into major and minor classes to facilitate interpretation of results. The small sample size, mostly for the owner survey, could be attributed to the fact that owner contact information had changed in the years between the procedures and the data collection. Further, the elapsed time may have decreased owner recall of complications, which might have influenced the high satisfaction rates of owners in both groups.

In conclusion, contrary to our 3rd hypothesis, there was no significant difference between groups in owner satisfaction, with each having a very good satisfaction grade (averages: 9.8 ± 0.7 and 9.2 ± 1.2 for enucleation and EIOP, respectively). All owners contacted reported they would recommend the procedure their dog had undergone. Only 1 owner mentioned the time-consuming postoperative care associated with EIOP but also noted they were made aware of that eventuality before the procedure. This indicated that, even with different complication rates and different levels of postoperative care required, owner education and expectation management can lead to both procedures providing excellent outcomes, according to owners. This study emphasized the importance of considering multiple factors before choosing an EIOP procedure over an enucleation; e.g., the higher risk of painful postoperative complications and a longer postoperative management period.

Supplementary Information

ACKNOWLEDGMENTS

The Start-up Research Fund of the Université de Montréal supported this study. Results were presented to the academic community of the Faculté de Médecine Vétérinaire de l’Université de Montréal during the Department of Clinical Sciences seminars. CVJ

Footnotes

Unpublished supplementary material (Appendix 1) is available online from: Supplementary Materials.

Copyright is held by the Canadian Veterinary Medical Association. Individuals interested in obtaining reproductions of this article or permission to use this material elsewhere should contact permissions@cvma-acmv.org.

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