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Year : 2009  |  Volume : 46  |  Issue : 2  |  Page : 177--178

A modified enucleation technique for children with retinoblastoma

SS Qureshi 
 Department of Surgical Oncology, Tata Memorial Centre, Ernest Borges Road, Parel. Mumbai-400 012, India

Correspondence Address:
S S Qureshi
Department of Surgical Oncology, Tata Memorial Centre, Ernest Borges Road, Parel. Mumbai-400 012
India




How to cite this article:
Qureshi S S. A modified enucleation technique for children with retinoblastoma.Indian J Cancer 2009;46:177-178


How to cite this URL:
Qureshi S S. A modified enucleation technique for children with retinoblastoma. Indian J Cancer [serial online] 2009 [cited 2022 Jun 30 ];46:177-178
Available from: https://www.indianjcancer.com/text.asp?2009/46/2/177/49163


Full Text

Sir

Retinoblastoma is a malignant tumor of the embryonic neural retina and is the most common intraocular malignancy in children. [1] The conservative treatment of retinoblastoma with chemoreduction and an array of focal treatment have largely replaced this surgery. [2] Nevertheless enucleation is still considered for large tumors with no vision and occasionally on failure of conservative treatment. The standard enucleation technique involves transection of the optic nerve and hemostasis is achieved either with pressure or vasoconstrictor solution. [3],[4] Exasperating hemorrhage with occasional development of hematoma, after enucleation, is not uncommon. Subsequent attempts at achieving hemostasis add up to the surgical time and at the same time require a lot of retraction and handling, which complicates oculoplastic procedures. Occasionally if revision of the optic nerve stump is required due to the inadvertent presence of tumor at the optic nerve cut margin it becomes difficult due to the recession of the nerve into the optic canal.

A novel and simple technique of enucleation is described, which provides effective hemostasis and in addition is useful in instances when revision of the stump is required.

The initial steps of enucleation remain unchanged. Briefly a 360 peritomy is performed at the sclerocorneal junction. Tenon's fascia is opened in all four quadrants and the rectus muscles are hooked. The muscles may be secured with sutures if required or may be transected leaving at least 2 mm of the muscle stump for traction. The oblique muscles are also isolated and divided. The only attachment to the globe now is the optic nerve. Traction to the optic nerve is achieved by grasping the insertion of the rectus muscle. The optic nerve is identified and space is created on either side of the nerve with a curved scissor. At this stage a surgical clip is applied on the optic nerve, far posterior, till there is resistance from the bony orbit. A curved scissor is inserted into the orbit along the optic nerve and the nerve is transected in front of the surgical clip [Figure 1].

Hemostasis is achieved satisfactorily due to the surgical clip. If the optic nerve stump requires revision due to the presence of tumor at the cut margin, the nerve is identified readily because of the presence of the surgical clip at the stump, which can be revised. Although patients with an optic nerve stump positive for tumor certainly require intensive management with chemotherapy and radiotherapy, if a tumor-free margin can be achieved without an extensive procedure (craniofacial resection) it is worth a try, particularly since the importance of a tumor-free margin is well established. The length of the optic nerve is no different from that attained with the conventional technique. Since the clip is applied flush to the optic nerve, damage to the other nerves or levator muscle and subsequent ptosis is not a concern.

The rest of the procedure is standard.

References

1Abramson DH, Niksarli K, Ellsworth RM, Servodidio CA. Changing trends in the management of retinoblastoma: 1951-1965 vs 1966-1980. J Pediatr Ophthalmol Strabismus 1994;31:32-7.
2Shields CL, Honavar SG, Meadows AT, Shields JA, Demicri H, Singh A, et al . Chemotherapy plus focal therapy for retinoblastoma: Factors predictive of need for treatment with external beam radiotherapy or enucleation. Am J Ophthalmol 2002;133:657-64.
3Shields JA, Shields CL, De Potter. Enucleation technique for children with retinoblastoma. J Pediatr Ophthalmol Strabismus 1992;29:213-5.
4Moshfeghi DM, Moshfeghi AA, Finger PT. Enucleation. Surv Opthamol 2000;44:277-301.