# Enucleation of the Eyeball: Veterinary Surgery Guide Enucleation of the eyeball is the complete surgical removal of the globe, the conjunctiva, and the intraorbital contents, leaving an empty orbit that heals by granulation and contraction. It is the definitive treatment for a globe that is permanently blind and painful, for an eye harboring a tumor that cannot be managed with globe-sparing surgery, and for an eye destroyed by trauma or infection that threatens the patient's health. The procedure permanently removes the source of pain, eliminates a nidus of infection, and provides tissue for histopathology. The operation is one of the most commonly performed procedures in veterinary ophthalmology practice. It is also one of the most misunderstood by owners, who often fear that removing an eye will disfigure their pet or change its personality. A well-executed enucleation produces a comfortable, cosmetic result within a few weeks, and most dogs and cats adapt to monocular or anophthalmic vision without any detectable change in behavior. Hands-on surgical time for a routine transpalpebral enucleation in a dog is typically 30 to 45 minutes for an experienced surgeon. Total anesthesia time, including aseptic preparation, regional block placement, and closure, usually runs 45 to 70 minutes. Cats and small patients are faster. Cases with severe periocular cellulitis, orbital abscessation, or extensive neoplasia can take considerably longer because the surgeon must dissect through inflamed, friable tissue planes. This article is educational and is not a substitute for veterinary diagnosis or treatment. ## Indications for Enucleation of the Eyeball The decision to remove an eye is never made casually. Enucleation is indicated when the globe itself is the problem and no globe-sparing option will restore comfort or vision. The five classic indications are a painful blind eye, glaucoma, intraocular tumor, severe trauma, and panophthalmitis. ### Painful Blind Eye A blind eye that is comfortable can often be left in place. A blind eye that is painful cannot. Chronic uveitis, lens luxation with secondary glaucoma, and end-stage retinal disease all produce a globe that no longer serves vision but continues to generate nociceptive input. Enucleation removes that input permanently. ### Glaucoma [Glaucoma in dogs](/knowledge/veterinary-medicine/clinical-methods/canine-glaucoma-diagnosis-management) is a chronic, progressive disease in which elevated intraocular pressure (IOP) damages the optic nerve and retina, causing severe pain, irreversible blindness, and impaired quality of life [1]. When medical and surgical IOP-lowering therapies fail, enucleation is recommended as a definitive treatment for pain relief [1]. A globe that has become buphthalmic (enlarged) is a particularly strong candidate, because the stretched sclera and cornea are themselves a source of discomfort. Pharmacologic ciliary body ablation with intravitreal cidofovir is a globe-sparing alternative in selected refractory cases. In one case series of four dogs with silicone oil-filled eyes, a single intravitreal cidofovir injection reduced IOP to 3 to 7 mmHg at the first recheck 14 to 28 days later and provided adequate pain control over a median follow-up of 306.5 days [2]. That option requires a globe with enough remaining structure to tolerate the injection, and it does not remove an eye that is already blind and enlarged beyond salvage. ### Intraocular Tumor Intraocular tumors in dogs are uncommon and often present with nonspecific signs such as vision loss, corneal opacity, or hyphema [3]. Melanocytic tumors of the iris are rare among them [3]. When an intraocular mass is large, when it is associated with elevated IOP, or when it cannot be sampled without risking tumor seeding, enucleation provides both treatment and a complete histopathology specimen. A 16-year-old Shih Tzu with an iridal melanoma and an IOP of 99 mmHg in the affected eye underwent enucleation, and histopathology confirmed the diagnosis with an uneventful recovery [3]. Not every intraocular mass requires enucleation. Sector iridectomy was performed in 13 dogs with prominent, well-isolated iris masses, and all eyes remained visual and comfortable up to 6.2 years after surgery with no clinically identifiable local recurrence [4]. Enucleation was reserved for two dogs with extensive lesions [4]. The choice between globe-sparing surgery and enucleation depends on tumor extent, location, and the likelihood of complete excision. ### Severe Trauma A globe that has been ruptured, avulsed, or crushed beyond repair is a candidate for enucleation. Severe purulent and malodorous ocular injury in a local-breed ox was managed with transpalpebral enucleation under a Peterson nerve block with 2% lidocaine, orbital packing, and skin closure, with an uncomplicated recovery after suture removal on day 14 [5]. The same principle applies in small animals: a globe that cannot be salvaged and that is a source of pain or infection should be removed. ### Panophthalmitis Panophthalmitis is infection involving all layers of the eye and the adjacent orbital tissues. It is a sight-threatening and potentially life-threatening condition. A 9-month-old Saint Bernard with periorbital swelling, severe uveitis, and secondary glaucoma underwent enucleation after aggressive medical management failed, and histopathology confirmed severe necrosuppurative panophthalmitis and periocular cellulitis with filamentous gram-positive bacteria [6]. Clinical improvement followed enucleation and continued medical management [6]. When the globe is a sealed abscess, antibiotics alone cannot sterilize it, and enucleation is both therapeutic and diagnostic. ### Other Situations Enucleation is also performed for globe perforation with uveal prolapse that cannot be repaired, for severe chemical or thermal injury, for proptosis with optic nerve avulsion and no visual potential, and for cosmetically unacceptable phthisis bulbi with chronic discharge. In each case, the deciding question is whether the globe can be made comfortable and whether it poses a risk to the patient. ## Decision Flowchart for Eye Removal The flowchart below traces the main decision path from presentation to surgery. ```mermaid flowchart TD A[Eye presented for evaluation] --> B{Is vision present} B -->|Yes| C[Attempt globe sparing therapy] B -->|No| D{Is the eye painful} D -->|No| E[Monitor with topical care] D -->|Yes| F{Is the globe salvageable} F -->|Yes| G[Medical or surgical salvage] F -->|No| H{Is infection or tumor present} H -->|Yes| I[Enucleation with histopathology] H -->|No| J[Enucleation for comfort] I --> K[Analgesia and closure] J --> K K --> L[Postoperative monitoring] ``` ## Preoperative Assessment and Owner Communication Before surgery, confirm that the eye has no visual potential and that the patient is stable for anesthesia. A complete physical examination, minimum database, and thoracic imaging in tumor or systemic infection cases help identify concurrent disease. In the Saint Bernard with panophthalmitis, chest radiographs showed evidence of pneumonia alongside the ocular disease [6], which changed the perioperative plan. Owner communication matters as much as the surgery itself. Owners should understand that the eyelids will be closed permanently, that the orbit will appear slightly sunken after healing, and that hair will grow over the surgical site. In a survey of owners whose dogs underwent enucleation, satisfaction with postoperative outcomes was similar to that of owners whose dogs received an intraocular prosthesis, even though the prosthesis group had a much higher complication rate (54.1% versus 15.3%) [7]. That finding is useful when an owner asks whether a prosthesis is necessary for a good cosmetic result. ## Materials and Reagents | Item | Working concentration or specification | Purpose | |--|--|--| | Chlorhexidine or povidone-iodine scrub | Standard surgical scrub concentration | Aseptic skin preparation around the orbit | | Sterile saline | 0.9% NaCl | Ocular surface and orbital lavage | | Bupivacaine 0.5% | 0.5% solution | Retrobulbar or peri-incisional local anesthesia | | Lidocaine 2% | 2% solution | Adjunctive local anesthesia and Peterson block | | Hydromorphone | Per institutional protocol | Systemic opioid analgesia | | Meloxicam | Per institutional protocol | Systemic NSAID analgesia | | Absorbable gelatin hemostatic sponge | Sterile, cut to fit orbit | Hemostasis and local anesthetic delivery | | Liposome-encapsulated bupivacaine | Per manufacturer labeling | Extended-release peri-incisional analgesia | | Absorbable suture, 3-0 to 4-0 | Monofilament or braided | Closure of conjunctiva, muscle, and subcutaneous layers | | Nonabsorbable suture, 3-0 to 4-0 | Monofilament | Skin closure where removable sutures are preferred | | Sterile gauze sponges | Weighed dry before use | Orbital packing and gravimetric blood loss estimation | | Isotonic crystalloid fluids | Per anesthesia protocol | Intraoperative support | ## The Transpalpebral Technique The transpalpebral approach removes the globe together with the eyelids, conjunctiva, and intraorbital contents through a single circumferential skin incision. It is the most widely taught technique and the one used in most of the clinical studies cited here [8][9][10][5]. A subconjunctival approach preserves the eyelids and is used when the surgeon wants a more cosmetic result or when the eyelid tissue is needed for reconstruction, but it is associated with a different blood loss profile [11]. ### Step 1: Anesthesia and Regional Block General anesthesia with a balanced protocol is standard. Premedication typically includes an opioid such as hydromorphone with a benzodiazepine, induction with propofol, and maintenance with isoflurane in oxygen [9][10]. Place the local anesthetic block before the incision. A retrobulbar block with 0.5% bupivacaine is the most studied regional technique. In a randomized controlled trial of 22 dogs, 9 of 11 control dogs required rescue hydromorphone after enucleation, while only 2 of 11 dogs that received a retrobulbar bupivacaine block required rescue [10]. Mean time to treatment failure in the control group was 0.56 hours after extubation [10]. A retrospective study of 167 dogs found that dogs without retrobulbar bupivacaine had a 17.0 percentage point greater risk of a postoperative recovery complication (38.6% versus 21.6%) [8]. A peri-incisional line block with liposome-encapsulated bupivacaine placed at closure is an equally effective alternative. In a randomized trial of 39 dogs, preoperative retrobulbar bupivacaine blocks and postoperative liposome-encapsulated bupivacaine line blocks produced similarly low rescue rates and similarly low complication rates [12]. A separate randomized trial of 30 dogs found that liposome-encapsulated bupivacaine significantly reduced the odds of needing rescue analgesia (OR 0.14) and the odds of having a higher pain score across the study (OR 0.38) compared with saline [13]. Lidocaine-bupivacaine-infused absorbable gelatin hemostatic sponges placed in the orbit after globe removal are another option. In a randomized case-control study of 19 dogs, this technique produced analgesia comparable to retrobulbar injection, with significant differences over time in comfort level, response to touch, behavior, heart rate, and total pain score [9]. Systemic analgesia is not optional. Opioids and NSAIDs are given perioperatively and continued after discharge. Meloxicam is commonly used, and one study found no significant difference in hemorrhage associated with its administration [11]. ### Step 2: Aseptic Preparation Clip the hair around the orbit widely, extending at least 2 to 3 cm beyond the eyelid margins. Scrub the skin with chlorhexidine or povidone-iodine solution, taking care not to spill scrub solution onto the cornea if the eye is still intact. Flush the conjunctival sac with sterile saline. Drape the patient so that the entire orbit and the surrounding surgical field are isolated. ### Step 3: Eyelid Closure Suture the eyelids closed with a simple interrupted or continuous pattern using 3-0 or 4-0 suture. Closing the eyelids seals the conjunctival sac and prevents spillage of orbital contents and bacteria into the surgical field during dissection. It also gives the surgeon a single tissue plane to grasp. ### Step 4: Circumferential Incision Make an elliptical or circular skin incision around the closed eyelids, leaving a margin of 3 to 5 mm of eyelid skin. The incision should extend through the skin and the underlying orbicularis muscle. In the ox case, the technique used a transpalpebral elliptical incision [5]. In dogs, the same principle applies: the incision must be wide enough to allow the surgeon to reach the orbital apex without excessive traction. ### Step 5: Blunt Dissection of Conjunctiva and Extraocular Muscles Undermine the skin and subcutaneous tissue with blunt dissection using a combination of sharp scissors and a cotton-tipped applicator. Identify the conjunctiva at the fornix and dissect it free from the orbital rim. Continue dissection around the globe, isolating the four rectus muscles, the two oblique muscles, and the retractor bulbi. Transect the extraocular muscles close to their insertions on the globe, or clamp and ligate them if they are large. The goal is to free the globe completely except for the optic nerve and the vascular pedicle at the orbital apex. Incomplete dissection of the conjunctiva or the extraocular muscles leaves tissue behind that can become a nidus for infection or a source of continued pain. ### Step 6: Clamping and Transecting the Optic Nerve and Vessels Once the globe is free, place a curved hemostatic forceps across the optic nerve and the ophthalmic vessels at the orbital apex. Clamp firmly, then transect the pedicle distal to the clamp with curved scissors. The clamp controls hemorrhage from the ophthalmic artery while the pedicle is ligated or the clamp is left in place briefly. Hemorrhage from the ophthalmic artery is the most feared intraoperative complication. A prospective study of 121 dogs (130 eyes) measured surgical blood loss by the gravimetric method and found a median absolute blood loss of 12 mL (range 1.6 to 116 mL) and a median relative blood loss of 1.3% of circulating blood volume (range 0.1% to 6.7%) [11]. Higher relative blood loss was associated with a bupivacaine splash block versus a retrobulbar nerve block (1.9% versus 1%), transpalpebral versus subconjunctival approach (2.2% versus 1.3%), and small versus large breed dogs (1.7% versus 1.1%) [11]. No dog in that study required supportive intervention for surgical hemorrhage [11]. A modified lateral enucleation technique that avoids clamping or ligating the optic nerve has been described. In 1296 enucleations reviewed retrospectively, the overall complication rate was 2.31% and the surgical site infection rate was 2.08% [14]. Estimated relative intraoperative blood loss was 2.2% in 43 dogs and 4.1% in 29 cats [14]. The authors concluded that the modified technique is safe and fast [14]. This is a reasonable alternative for surgeons comfortable with the approach. ### Step 7: Orbital Packing and Hemostasis After the globe is removed, pack the orbit with sterile gauze to control oozing and to inspect the cavity for remaining tissue. Remove any residual conjunctiva, gland of the nictitating membrane, or orbital fat that could serve as a nidus for infection. The nictitating membrane and its gland are common sites of incomplete removal. Leaving the gland behind can produce a chronic draining tract or a recurrent orbital cyst. If a hemostatic sponge infused with lidocaine and bupivacaine is used, place it in the orbit at this point [9]. Otherwise, achieve hemostasis by pressure, ligation, or electrocoagulation. ### Step 8: Closure in Layers Close the orbit in layers. The first layer reapproximates the extraocular muscle remnants and the orbital fascia. The second layer closes the subcutaneous tissue. The third layer closes the skin. Use absorbable suture for the deep layers and either absorbable or nonabsorbable suture for the skin, depending on surgeon preference. In the ox case, skin closure used an interlocking silk suture pattern with sutures removed on day 14 [5]. A peri-incisional line block with liposome-encapsulated bupivacaine can be placed in the subcutaneous eyelid tissues immediately before skin closure [13]. This provides extended postoperative analgesia. ### Step 9: Postoperative Recovery Recover the patient in a quiet, warm area with continuous monitoring. Assess pain using a validated scale such as the Glasgow Composite Measure Pain Scale or the University of Wisconsin Ocular Pain Scale [12]. Provide rescue analgesia if the pain score exceeds the institutional threshold. Keep an Elizabethan collar on the patient to prevent self-trauma. ## Expected Results and How to Read Them A successful enucleation produces a comfortable patient within 24 hours. The surgical site is swollen for the first 3 to 5 days, then gradually subsides. By 2 weeks, the incision is sealed and the orbit is contracting. By 4 to 6 weeks, the orbit is noticeably sunken and hair is growing over the site. Complications are uncommon. In a review of 138 dogs, the complication rate after enucleation was 15.3%, compared with 54.1% after evisceration with intraocular prosthesis [7]. In a separate review of 1296 enucleations, the overall complication rate was 2.31% and the surgical site infection rate was 2.08% [14]. The incidence of surgical site infection after enucleation in dogs has been reported at 5% in a study of 280 dogs, with no identified risk factors [15]. That study also found that dogs receiving cephalexin as a prophylactic postoperative antibiotic were statistically more likely to develop surgical site infection than dogs receiving a different postoperative antibiotic, though the clinical significance of this finding is unclear, and prophylactic postoperative antibiotics overall did not reduce infection risk [15]. ## Postoperative Care by Indication | Indication | Approach | Postoperative care | |--|--|--| | Painful blind eye | Transpalpebral enucleation | Opioid and NSAID analgesia, Elizabethan collar, cold compress for 48 hours, recheck at 10 to 14 days | | Glaucoma | Transpalpebral or subconjunctival enucleation | Continue glaucoma medications for the contralateral eye if indicated, monitor IOP in the remaining eye, analgesia as above | | Intraocular tumor | Transpalpebral enucleation with wide margins | Submit globe for histopathology, thoracic imaging if indicated, oncology follow-up, analgesia as above | | Severe trauma | Transpalpebral enucleation | Antibiotics if contaminated, analgesia, wound care, recheck at 5 to 7 days | | Panophthalmitis | Transpalpebral enucleation | Culture and histopathology, systemic antibiotics guided by culture, analgesia, monitor for systemic spread | ## Troubleshooting | Symptom | Likely cause | Fix | |--|--|--| | Profuse bleeding from the orbit | Ophthalmic artery not controlled | Apply pressure, identify and ligate the vessel, use hemostatic sponge | | Swelling that increases after 72 hours | Hematoma or seroma | Warm compress, drain if fluctuant, reassess for infection | | Purulent discharge from the incision | Surgical site infection | Culture, appropriate antibiotics, open and drain if abscessated | | Persistent pain after 5 days | Incomplete removal of orbital tissue or nerve stump neuroma | Reassess, image the orbit, consider revision surgery | | Sunken orbit with a draining tract | Retained nictitating membrane gland | Explore the orbit, remove the gland, close in layers | | Corneal or conjunctival irritation in the remaining eye | Self-trauma or exposure | Elizabethan collar, topical lubrication, ophthalmic examination | ## Variations on the Technique The subconjunctival approach preserves the eyelids and is associated with lower relative blood loss than the transpalpebral approach (1.3% versus 2.2%) [11]. It is a good choice when the eyelids are healthy and the surgeon wants a more cosmetic result. The modified lateral enucleation technique avoids clamping or ligating the optic nerve [14]. It is safe and fast in experienced hands, with a low complication rate [14]. Enucleation with placement of an orbital implant is a cosmetic variation. A case series of 11 dogs with advanced glaucoma described transconjunctival enucleation with implantation of a 3D printed polylactic acid prosthesis, which improved post-surgical adaptation and reduced the risk of secretion accumulation and infection compared with an empty orbit [1]. This is a niche option and is not required for a good outcome. ## Storage and Stability Notes Suture materials, hemostatic sponges, and local anesthetics should be stored according to the manufacturer's labeling. Bupivacaine and lidocaine solutions should be kept at room temperature and protected from light. Liposome-encapsulated bupivacaine should not be mixed with other local anesthetics before injection, because the liposomal formulation can be disrupted. Absorbable gelatin sponges should be kept sterile and used before their expiration date. Gravimetric blood loss estimation requires that gauze sponges be weighed dry before surgery and weighed again immediately after use, so keep a calibrated scale in the operating room. ## Clinical Relevance, Limitations and Common Mistakes Enucleation is a definitive procedure that permanently removes an eye. The most common mistakes are technical and preventable. Incomplete removal of the nictitating membrane or its gland is a frequent error. The gland sits at the base of the nictitating membrane and can be left behind when the surgeon dissects only the conjunctiva. A retained gland can produce a chronic draining tract, a recurrent orbital cyst, or a nidus for infection. Dissect the nictitating membrane and its gland completely before closing the orbit. Incomplete removal of orbital tissue is another common mistake. Leaving conjunctiva, muscle, or fat behind creates dead space that can fill with fluid and become infected. Inspect the orbit after globe removal and remove any residual tissue that is not needed for closure. Hemorrhage from the ophthalmic artery is the most dramatic intraoperative complication. It is usually controlled by clamping and ligating the pedicle, but a torn vessel that retracts into the orbit can be difficult to find. Pack the orbit with gauze and apply pressure, then identify the bleeding point under good lighting. The median blood loss in dogs is low, and no dog in one prospective study required supportive intervention for surgical hemorrhage [11], but a patient with a coagulopathy or a small circulating volume can decompensate quickly. Inadequate analgesia is a common and avoidable mistake. A retrobulbar bupivacaine block dramatically reduces the need for rescue analgesia [10], and liposome-encapsulated bupivacaine line blocks are equally effective [12][13]. Systemic opioids and NSAIDs are still required. Do not rely on local anesthesia alone. Prophylactic postoperative antibiotics are not supported by the evidence. In a study of 280 dogs, prophylactic postoperative antibiotics did not reduce the risk of surgical site infection, and no risk factors for infection were identified [15]. Reserve antibiotics for confirmed infection or for contaminated wounds. Individual cases vary, and every patient needs a veterinarian who can examine the eye, assess the systemic status, and choose the right procedure. This article is educational and is not a substitute for veterinary diagnosis or treatment. ## Frequently Asked Questions ### Will my pet be in pain after enucleation? Pain is well controlled with a combination of local anesthesia, opioids, and NSAIDs. Most pets are comfortable within 24 hours. ### How long does enucleation surgery take? A routine transpalpebral enucleation takes about 30 to 45 minutes of surgical time, with total anesthesia time of 45 to 70 minutes. ### Will my pet look different after the eye is removed? The orbit will appear slightly sunken after healing, and hair will grow over the surgical site. Most owners find the result cosmetic. ### Can my pet still see with one eye? Yes. Most dogs and cats adapt well to monocular vision, though depth perception is reduced. ### Does my pet need antibiotics after enucleation? Prophylactic postoperative antibiotics are not supported by current evidence. Antibiotics are reserved for confirmed infection or contaminated wounds. ### What are the signs of a complication after enucleation? Increasing swelling after 72 hours, purulent discharge, persistent pain, or a draining tract all warrant a recheck. ### Can the eye grow back or need a second surgery? No. The globe is removed permanently. A second surgery is needed only if residual tissue causes a complication. ### Is a prosthesis necessary for a good cosmetic result? No. Owner satisfaction is similar after enucleation and after prosthesis placement, and enucleation has a much lower complication rate. ## Related Articles - [Veterinary Surgery Principles for the NAVLE](/knowledge/veterinary-medicine/navle-exam-prep/veterinary-surgery-principles-navle) - [Mass removal exotic pet surgery](/knowledge/veterinary-medicine/exotic-animal-medicine/mass-removal-in-exotic-pets-surgical-planning-and-anesthetic-considerations-for-reptiles-birds-and-s) - [Dog Ate Chicken Bones Surgery](/knowledge/veterinary-medicine/clinical-methods/dog-ate-chicken-bones-surgery) - [Why Is My Dog Coughing And Gagging After Surgery](/knowledge/veterinary-medicine/symptom-guides/why-is-my-dog-coughing-and-gagging-after-surgery) - [Hemostasis in Surgery: Techniques and Products](/knowledge/veterinary-medicine/veterinary-surgery/hemostasis-surgery-techniques-products) - [Ferret Insulinoma: Diagnosis, Medical Management, and Surgery](/knowledge/veterinary-medicine/small-mammal-care/ferret-insulinoma-diagnosis-medical-management-surgery) - [Sand Fly: Biology, Diseases, and Veterinary Importance](/knowledge/veterinary-medicine/parasitic-diseases/sand-fly-biology-diseases-and-veterinary-importance) - [Ranitidine in Veterinary Medicine: Uses and Dosing](/knowledge/veterinary-medicine/clinical-pharmacology/ranitidine-in-veterinary-medicine-uses-and-dosing) ## Sources 1. 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