Indications for destructive eye surgeries among adults in a tertiary eye care center in North CENTRAL Nigeria

Abstract

Background:

Destructive eye surgery is a management option offered patients when further retention of the globe is likely to affect ocular and general health or jeopardize survival. Indications for this procedure vary and could reflect the pattern of severe or end stage ocular morbidities in a given environment.

Aim:

To assess the indications for destructive eye surgeries and to ascertain the proportion avoidable.

Setting:

Jos University Teaching Hospital, Jos, Nigeria.

Methodology:

The ophthalmic surgical database of our facility was retrospectively reviewed to obtain information on patients who had destructive eye surgery from January 2008 - December 2015. These included demographics, clinical features, preoperative diagnosis, indication for surgery and type of destructive eye surgeries. The total number of ophthalmic surgeries within the study period was also computed. The data was entered into Epi Info statistical software, version3.4 (Epi InfoTM, Atlanta, Georgia,USA) and analyzed after validation by double entry.

Results

Eighty five destructive eye surgeries consisting of 2.5% of all surgical operations were performed on adults (aged ≥18years). There were 51(60%) males with a male: female ratio of 1.5:1 (p<0.005), mean age of 46.4 ± 19years. A sustained decline in the proportion of surgeries attributable to destructive eye surgeries was observed from the year 2012. A total of 75(88.2%) patients had evisceration, 3(3.5%) had enucleation and 7(8.2%) had exenteration. The main indications for destructive eye surgeries included trauma to the eyes in 39(45.9%), intractable infections in 32(37.6%), tumours in 7(8.2%) and painful blind eye in 3(3.5%); anterior staphyloma and phthisis bulbi each accounted for 2(2.4%). We observed that an adult male was four times more likely to lose an eye from trauma than a female (p<0.05). An individual was less likely to lose an eye to trauma with increasing age (p<0.05) but more likely to lose an eye to intractable infection with increasing age (p<0.001).

Conclusion

There is a downtrend in the frequency of destructive eye surgeries in our center with males more likely to lose an eye to trauma and the elderly more likely to lose an eye to infection. Most of the indications for eye removal are avoidable.

Introduction

Destructive eye surgery (DES) consists of evisceration, enucleation or exenteration1. It is a management option offered patients when further retention of the globe is likely to affect ocular and general health or jeopardize survival. Indications for DES vary and could reflect the pattern of severe or end stage ocular morbidities in a given environment2. It also gives an insight into the causes of uniocular blindness in a community3. The eyes contribute immensely to an individual’s overall appearance and self-image. The decision to remove an eye is often difficult for both surgeon and patient because of the enormous psychological sequelae. The loss of an eye often occurs suddenly due to trauma and infection in our environment and patients are often poorly prepared to deal with the decision. It is more grievous when the second eye is already blind.

Evisceration refers to the surgical removal of intraocular contents including the uvea but leaving the sclera and orbital contents. Important indications include a ruptured globe and a blind eye with an intractable infection (endophthalmitis or panophthalmitis) in which case evisceration of the eye is less likely to lead to the spread of infection to the cerebro-spinal fluid4. Enucleation is the removal of the eyeball from the orbit with severing of the optic nerve sheath1. Indications include a ruptured globe, painful blind eye, an unsightly blind eye and intraocular malignancy such as malignant melanoma1. The enucleation of a severely traumatized eye also serves as a prophylaxis against the development of sympathetic ophthalmia1,5. The latter is an autoimmune, lymphocytic attack on the uveal tract of both eyes following sensitization of lymphocytes to uveal tissue after penetrating trauma in one eye1,5. Enucleation of the injured eye prior to the development of sympathetic ophthalmia is very effective in preventing its occurrence. Thereafter, it has no beneficial effect1. In order to achieve acceptable cosmetic outcome, both enucleation and evisceration are usually accompanied by surgical placement of an orbital implant.

Exenteration, either radical or modified, involves removal of the eyeball and all contents of the orbit. These include the orbital fat, lacrimal gland, extraocular muscles, periorbita, eyelids and a varying amount of surrounding skin and bone. It is a disfiguring procedure with devastating functional, aesthetic and psychological consequences6. It is reserved for the treatment of potentially life-threatening malignancies arising from the eyeball, ocular adnexa, orbit and paranasal sinuses.

Destructive eye surgeries were last audited in our center 12 years ago. Since then, states served by our facility have witnessed civil disturbances and also attained developmental strides. With these socio-political and economic changes over time, the indications for DES may have changed hence a need for another audit. Information obtained will be useful for further planning and implementation of promotive, preventive, curative and rehabilitative eye care services. Therefore, in order to determine the pattern of destructive eye surgeries in this environment, we studied all such surgeries at the Jos University Teaching Hospital, Jos, Nigeria over a period of eight years.

Patients and Methods

The ophthalmic surgical database of Jos University Teaching Hospital, Jos, Nigeria was retrospectively reviewed to obtain information on patients who had DES from January 2008 - December 2015. These included the patients’demographics; clinical features, preoperative diagnosis, indication for surgery and type of DES. The total number of ophthalmic surgeries within the study period was also computed. The data was analyzed using Epi Info statistical software, version 3.4 (Epi InfoTM, Atlanta, Georgia,USA) and analyzed after validation by double entry. Descriptive statistics was used to determine frequencies, percentages and proportions. Analytical statistics using the student’s t test was applied and a p value <0.05 was considered statistically significant. Ethical approval was obtained from the Institutional Medical Research Ethics Committee of Jos University Teaching Hospital.

Results

A total of 3,355 ophthalmic surgeries were performed within the period of the study. Of these 121(3.6%) eyes of 120 persons were removed with an annual mean of 15±5 eyes. Eighty five destructive eye surgeries (DES) which constituted 2.5% of all surgeries were performed on adults aged 18years and above. No adult had both eyes removed; 51(60%) were males and 34(40%) were females with a male: female ratio of 1.5:1 (p<0.005). Their age ranged from 18 – 90 years with a mean of 46.4 years ±19 and the modal age was 30years. Destructive eye surgeries involved the 21-30 years age group most with 21(24.7%) patients. Up to 41(48.2%) patients were in the 18-40years bracket while 51(60%) were aged ≤50 years (figure 1).

Figure 1. Age distribution of the patients.

figure 2 shows a downward trend in DES with a sustained decline between the years 2012 and 2015 when DES accounted for 3.2% and 1.3% of all surgeries respectively. The main indications for DES included trauma in 39(45.9%) eyes, infections in 32(37.6%), tumour 7(8.2%) eyes and painful blind eye in 3(3.5%). Anterior staphyloma and phthisis bulbi accounted for 2(2.4%) eyes each. Up to 90% of DES was avoidable.

Figure 2. Destructive eye surgeries per year.

Evisceration was the main DES observed in 75(88.2%) patients (Table 1). Of 75 eviscerated eyes, trauma and infections accounted for 39(52%) and 32(42.6%) eyes respectively (Table 2).

Table 1. Age-sex distribution by type of destructive surgery .

Age Group(Years)	Evisceration		Enucleation		Exenteration		Total
	MaleNo (%)	FemaleNo (%)	MaleNo (%)	FemaleNo (%)	Male No (%)	FemaleNo (%)	No (%)
18-20	2 (4.3)	1 (3.5)	-	1(100)	-	-	4(4.7)
21-30	14 (30.4)	4 (13.8)	-	-	-	3(75)	21(24.7)
31-40	9 (19.6)	4 (13.8)	1(50)	-	2 (66.7)	-	16(18.8)
41-50	5 (10.9)	3 (10.3)	-	-	1 (33.3)	1(25)	10(11.8)
51-60	5 (10.9)	6 (20.7)	-	-	-	-	11(12.9)
61-70	8 (17.4)	5 (17.2)	1(50)	-	-	-	14(16.5)
71-80	3 (6.5)	4 (13.8)	-	-	-	-	7(8.2)
>80	-	2 (6.9)	-	-	-	-	2(2.4)
Total	46(100)	29 (100)	2 (100)	1(100)	3(100)	4 (100)	85 (100)

Table 2. Indications for destructive eye surgery .

Indication	Type of Destructive Surgery							Total
	Evisceration		Enucleation		Exenteration
	No	%	No	%		No	%		No	%
Trauma (ruptured globe)	39	52	-	-		-	-		39	45.9
Infections	32	42.6	-	-		-	-		32	37.6
Tumour	-	-	-	-		7	100		7	8.2
Painful blind eye	-	-	3	100		-	-		3	3.5
Anterior Staphyloma	2	2.7	-	-		-	-		2	2.4
Phthisis bulbi	2	2.7	-	-		-	-		2	2.4
Total	75	100	3	100		7	100		85	100

Thirty nine patients had an eye eviscerated due to trauma, 31(79.5%) males and 8(20.5%) females with male: female ratio = 3.9:1 (Table 3). An adult male was four times more likely to lose an eye from trauma than a female (p<0.05). The age group 21-30 years formed the highest proportion 12(30.7%) of trauma patients and up to 28(71.8%) were aged ≤50years. The main causes of injury included assault 11(27%), road traffic accident 8(20.5%), gunshot 6(15.4%), sharp objects 5(12.8%) and blunt eye injury from stones/woods 4(10.3%) as shown in figure 3. One case of assault was due to an attempt to remove the eye of a female for ritual purpose.

Table 3. Indication for evisceration by age group and gender .

AgeGroup(years)	Trauma		Infections		Anterior staphyloma		Pthisis bulbi		Total
	MaleNo (%)	FemaleNo(%)	MaleNo(%)	FemaleNo(%)	MaleNo(%)	FemaleNo(%)	MaleNo(%)	FemaleNo(%)	No	%
18-20	2(6.5)	-	-	-	-	1(100)	-	-	3	4
21-30	9(29)	3(37.5)	3(25)	1(5)	1(100)	-	1(50)	-	18	24
31-40	7(22.6)	1(12.5)	1(8.3)	3(15)	-	-	1(50)	-	13	17.3
41-50	5(16.1)	1(12.5)	-	2(10)	-	-	-	-	8	10.7
51-60	3(9.7)	1(12.5)	2(16.7)	5(25)	-	-	-	-	11	14.7
61-70	3(9.7)	-	5(41.7)	5(25)	-	-	-	-	13	17.3
71-80	2(6.4)	1(12.5)	1(8.3)	3(15)	-	-	-	-	7	9.3
>80	-	1(12.5)	-	1(5)	-	-	-	-	2	2.7
Total	31(100)	8(100)	12(100)	20(100)	1(100)	1(100)	2(100)	-	75	100

Figure 3. Causes of trauma.

Of the 32 patients who lost an eye to infection, 12(37.5%) were males and 17(62.5%) were females with a male: female ratio of 1:1.4, (p>0.5). Of these, 22(68.8%) patients were aged above 50 years. There were 21(65.6%) cases of endophthalmitis and 11(34.4%) panophthalmitis. The primary causes of infection included perforated microbial corneal ulcer in 16(50%) eyes, exposure keratopathy 2(6.3%) and perforated Mooren’s ulcer 1(3.1%). Others included endogenous uveitis 1(3.1%) and non-specific causes in 7(21.9%). Post-operative endopthalmitis was the cause of DES in 5 eyes.

Enucleation was done for 3 (3.5%) painful blind eyes, 2 of these resulted from intractable glaucoma and 1 was due to a disorganized globe from penetrating injury sustained 12 years ago. In this study no adult had enucleation due to intraocular malignancy.

Seven (8.2%) patients had orbital exenteration due to orbito-ocular malignancies (Table 2) and histopathology results revealed invasive squamous cell carcinoma in 4(57.1%) patients, lacrimal gland carcinoma in 2(28.6%) and Kaposi sarcoma in 1(3.4%) patient.

Discussion

The main finding from this study was that a male adult was more likely to lose an eye than a female. Most of the patients were in the productive age group with 60% aged 50 years or less. The main indication for DES included trauma (45.9%), intractable infection (37.6%) and tumour (8.2%). An adult male is four times more likely to lose an eye to trauma. The male preponderance observed is comparable to similar studies done in our center and elsewhere7^-13. This could be due to the fact that more males partake in high risk activities and occupations.

The high proportion of productive adults who lost an eye as observed is similar to an earlier report from our center7 and findings by Eze et al 10. In contrast however, Okoye et al in a study done in a rural setting reported only about 40% of patients aged 50 years or less15. This contrast could be due to the difference in the study setting (urban versus rural). Young people tended to migrate to urban areas and engage in high risk occupation. Examples include welders; carpenters, mechanics, sanders, sawyers, plumbers, grinding machine operators, industrial laborers and chemical process operators among others. Often workers do not use eye protective and safety devices. Young people also tend to engage in high risk activities (e.g sporting events and excessive consumption of alcohol). In contrast the elderly reside in rural areas and engage in agricultural activities.

Types of destructive eye surgeries

The most common type of DES observed was evisceration accounting for 88.2% of cases. This is similar to 88.3% reported in our center 12 years ago7. Similar studies globally show that evisceration is the most common DES8^-21. This may not be unrelated to the indications for DES most of which can be successfully managed with evisceration; which is technically easier and quicker to perform with fewer complications and can even be performed under local anaesthesia if need be. It is therefore of benefit to the severely ill and elderly patient1.

Exenteration was the second most common type of DES accounting for 8.2% and enucleation (3.5%) was the least common. This is in contrast to 3.9% and 7.8% respectively reported in our center 12 years ago 7. This difference may be due to slight changes in indications for DES related to an increase in the incidence of orbito-ocular malignancies associated with HIV/AIDS.

Indications for destructive eye surgeries

In this study as in the earlier study7in this centre on destructive eye surgeries, the main indications for destructive eye surgeries (DES) remained unchanged with trauma (45.9%) and infection (37.6%) accounting for 83.5% of cases, quite similar to 45.6% (trauma) and 34% (infection) observed in this same center 12 years ago7.

Trauma: Some studies in Nigeria and Ethiopia reported trauma as being the main indication for DES with the proportion ranging from 35.7% to 46.2 percent10,11,19,22,23. Studies in Jordan and China reported 40% and 62.5% of DES attributable to trauma respectively13,21. Some studies in the developed world have also reported trauma as a leading cause of DES2,14,24,25. Furthermore, we observed that the male gender (79.5%) was four times more likely to lose an eye from trauma compared to the female (p<0.001) similar to a finding by Ugboko et al who reported a male preponderance among patients who either became blind or developed severe visual impairment from severe mid face trauma in Nigeria26. A significant decline in the proportion of persons who lost an eye due to trauma with increasing age was observed with 30.8% of patients being in the 21-30 years age bracket while only 2.6% were aged over 80years (p<0.05). It is of great concern that most patients who lost an eye to trauma were adult males in the productive age group (Table 3) and this could have a negative impact on the economy.

Intractable Infection: was the second (37.6%) most common cause of DES. This is not much different from what pertained in our centre (34%) 12 years ago7. Eze et al in an urban setting and Enock et al in a semi-urban setting both reported infection as the second most important cause of DES accounting for 27.36% and 26.19% of cases respectively10,19. In contrast however, several studies in Nigeria reported intractable infection as the main cause of DES accounting for between 32.1%-60.6% of cases 9, 15,18,27^-29. Studies in other African countries and India also revealed intractable infections as the main cause of DES 12,16,30,31 . Okoye et al in South Eastern Nigeria and Kagmeni et al in Cameroun recorded a significantly higher proportion of infection (60.6% and 51.4% respectively)15,16. Their study setting was rural with a higher proportion of elderly patients. Contrary to the findings in Africa, ocular infections did not feature as major causes of DES in Turkey and China accounting for only 9.7% and 5.76% respectively13,21. This could be due to their level of socio-economic development, higher literacy level and better precaution at work places.

Most patients who lost an eye due to infection had corneal ulcers. Delayed presentation after minor ocular injuries and ocular surface infection was an important contributory factor. Furthermore, a significant proportion of these patients had used inappropriate orthodox medications (including steroids) and harmful traditional eye medications (HTEM) before presentation. The prevalence of corneal ulcers and resultant end stage ocular morbidities attributable to these harmful practices are well documented in literature12,27,32,33.

It was observed that more females lost an eye due to infection and that there was a significant increase in DES attributed to infection with increasing age (p<0.001) especially among patients aged 50years and above. This is similar to findings by Chinda et al8. In a typical African setting like ours, females and the elderly have less income, little control over finances and often do not have decision making power34. Thus, they were less likely to access eye care services and could give in to harmful traditional eye methods.

Tumour: No adult had enucleation due to intraocular malignancy attesting to how uncommon intraocular malignancy is in this age group compared to the paediatric age group. However we observed an increase in the proportion of DES attributable to malignancy (8.2%) compared to 3.9% reported 12 years ago7. Enhanced longevity of HIV/AIDS patients with subsequent development of ocular complications could be responsible for this observed difference as about two-thirds of tumours in this study were HIV related (i.e. squamous cell carcinoma of the conjunctiva and Kaposi sarcoma). A review of orbital exenteration in Ghana and Zimbabwe showed squamous cell carcinoma (SCC) of the conjunctiva was the main indication35^-37. Conjunctival SCC is known to be an aggressive disease in tropical and subtropical regions and tends to occur in younger patients38. HIV patients should be encouraged to seek ophthalmic care as soon as a conjunctival growth is noticed. In our study, orbital exenterations were performed mostly for neglected periorbital and ocular surface malignancies similar to a report from Ghana35.

Painful blind eye: accounted for 3.5% of DES compared to 6.8% observed 12years ago in this center. The causes observed is similar to findings by Okoye et al, Kagmeni et al, Ababneh et al and Enock et al who all reported absolute glaucoma as the main cause of a painful blind eye13,15,16,19. Topical medications are usually only temporarily effective, long term use of systemic analgesics such as narcotics is unjustifiable because of the possibility of addiction or drug abuse1. Retrobulbar alcohol blocks also provide temporary relief1.

Anterior staphyloma and phthisis bulbi: were the least common indications for destructive eye surgeries. Patients with anterior staphyloma had DES for cosmetic reasons. Eze et al10 and Nwosu27 did not report unsightly blind eye an indication for DES, because such patients did not give informed consent for destructive eye surgeries due to the socio-cultural beliefs in their study environments.

Outcome

Of 78 patients who had either evisceration or enucleation, 20(25%) are already using an artificial eye while 8(10.3%) refused the use of prosthesis. One patient developed a contracted (shallow) socket and had socket reconstruction. Four patients who had exenteration have been referred for radiotherapy in an oncology center.

Recommendation: This study revealed that over 90% of destructive eye surgeries were avoidable. A secured community, peaceful co-existence and regular road maintenance are very important in reducing the incidence of DES39,40. Public enlightenment that will promote ocular health and encourage early presentation is essential. Prompt recognition and appropriate treatment of minor ocular trauma and ocular surface infections at primary and secondary health facilities with prompt referral when necessary is vital. Claims by traditional healers on the efficacy of harmful traditional eye methods should be strongly discouraged.

Conclusions

In conclusion, there was a downward trend in the frequency of destructive eye surgeries in our center with males more likely to lose an eye from trauma while the elderly were more likely to lose an eye from infection. Most of the indications for eye removal are avoidable.