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[Eye Reports 2011; 1:e2] [page 3]

Enucleation assisted with filler
for open-globe injury 
Ayako Takahashi,1 Masayuki Akimoto,1,4
Sachiyo Hama,1 Yoko Shirai,2
Sachiko Minamiguchi3

Departments of 1Ophthalmology,
2Dentistry, 3Pathology, 4Clinical Research
Institute, Kyoto Medical Center, National
Hospital Organization, Kyoto Medical
Center, Japan

Abstract 

In cases of severe open-globe injury, it is
often difficult to reconstruct the globe and
maintain visual acuity. Ocular globe enucle-
ation may decrease the risk of sympathetic
ophthalmia in the fellow eye. However, the sur-
gical procedure is difficult to perform with an
open globe, because the injured globe is
inclined to collapse. We report the case of an
enucleation for an open-globe injury in which
we used alginate, which is often used for den-
tal impressions, as filler for the collapsed
globe. We were able to maintain the resistance
of the globe sufficiently well enough to perform
the procedure easily and without complication.
Thus, alginate may be a novel aid to assist in
enucleation by preserving globe resistance.

Introduction

Ocular globe enucleation is often a neces-
sary procedure following open-globe injury
when the eye is diagnosed as being incapable
of reconstruction. However, enucleation is
often difficult to perform in open globe
injuries, because the injured globe is inclined
to collapse, despite filling it up with air or liq-
uid. Here, we report a case in which enucle-
ation was performed easily and without com-
plication, using alginate as the filler. Alginate
is often used for dental impressions because it
is a soft gel that rapidly turns into a solid. 

Case Report

A 74-year-old man who was hit by a car and
suffered an open globe injury deemed inca-
pable of being reconstructed. His left eye was
perforated at the upper temporal corneal lim-
bus, from the 11 o'clock to the 5 o'clock posi-
tion, and totally collapsed (Figure 1A). In order
to prevent sympathetic ophthalmia (SO) of the
right eye, enucleation was deemed inevitable.

A decision was made to enucleate the left eye,
on the tenth day after the injury. Informed con-
sent was obtained; the operation was per-
formed in conformity with the Declaration of
Helsinki and was approved by our ethical com-
mittee. 
The operation was performed under general

anesthesia. Following standard sterile tech-
nique, the conjunctiva was incised at the
fornix base and the sclera was exposed. The
scleral wound was closed using interrupted 8-0
silk suture. Physiologic saline was injected
into the globe through the wound. An attempt
was made to aspirate the content of the globe;
however, only little amount was aspirated.
Then, alginate was prepared, just before its

use, because it begins to harden within 1
minute. A spoonful (8.4 g) of alginate powder
(Aroma Fine Plus® Normal Set, GC
International Corp., Tokyo, Japan), sterilized
by ethylene oxide gas and 20 mL of cold water
were vigorously mixed together with a spatula
and poured into a 10 mL syringe; cooler water
allows for a longer working time. Two 18 gauge
needles were inserted into the globe through
the corneal limbus. Carbon dioxide gas was
injected by insufflator (Alpha DuoLap, GIMMI,
Tuttlingen, Germany) through one of the nee-
dles to inflate the collapsed globe, and then
alginate was injected, up to approximately 3
mL through the second needle until the globe
had sufficiently recovered its resistance.
Excessive alginate that leaked out of the globe
was easily removed after it had solidified.
The globe was subluxated by tenotomy of the

4 recti and 2 oblique muscles, and the optic
nerve was cut. These procedures were much
easier following injection of the alginate,
because of the adequate resistance of the
globe. The globe was completely enucleated
without any further damage (Figures 1B-D). 

Discussion

Open-globe injury can induce SO in the fel-
low eye, which is believed to be an autoim-
mune inflammatory response. The incidence
of SO after open-globe injury has been report-
ed to be 0.1-0.3%.1-4 The time for SO to develop
varies from 2 weeks to 50 years, with approxi-
mately 90% of patients developing the disease
within 1 year of injury.5 SO is in itself a sight-
threatening disease. Definitive prevention of
SO requires prompt (within 2 weeks following
the injury) enucleation or evisceration of the
injured eye, especially when there is little pos-
sibility for the injured eye to regain any func-
tion.5 Enucleation is also performed for other
reasons such as painful or disfiguring blind
eye, neoplasm, and infection.6

In cases where the globe is collapsed, often
following open-globe injury, enucleation may

be a technically difficult procedure. Acquiring
sufficient resistance of the globe can make
enucleation easier and decrease the risk of
trauma to the remaining orbital structures.
Several innovative methods for enucleation
have been reported. Torres et al. invented a
new device which consists of surgical scissors
custom made to have two connectable arms
adapted to modified spoons and blades.7 Finger
et al. used an original cryotherapy probe to
induce proptosis during optic nerve transec-
tion.8 However, these ideas do not address the
issue of the collapsed globe.
Alginate is an anionic polysaccharide dis-

tributed widely in the cell walls of brown algae.
By binding with water, it forms a viscous gum,
which is universally used for dental impres-
sions. Alginate is also used in a variety of other
applications, including the treatment of peptic
ulcers and gastroesophageal reflux disease9

and as a substance for endoscopic hemostasis.
Further, calcium alginate is used in dressings
for traumatic wounds in order to promote heal-
ing and prevent infection. Tane et al. reported
that calcium alginate sheets were effective for
use in wound dressing in a case after ocular
evisceration.10 Alginate is also used in biologic
experiments for the immobilization of cells.
This wide use of alginate suggests its physio-
logic safety. In a manner similar to dental
application, ophthalmologists use alginate for
the fabrication of ocular prostheses before and
after enucleation.11

Tanaka et al. demonstrated that alginate

Eye Reports 2011; volume 1:e2

Correspondence: Masayuki Akimoto, Department
of Ophthalmology, National Hospital
Organization, Kyoto Medical Center, 1-1
Fukakusa-Mukaihatacho, Fushimiku, Kyoto 612-
8555, Japan. 
Tel: +81.75.641.9161 - Fax: +81.75-643.4325. 
E-mail: masayuki@akimoto3.com 

Key words: trauma, enucleation, filler, sympathet-
ic ophthalmia.

Contributions: AT, MA, SH original idea and dis-
cussions; AT, MA, surgical procedure; AT, manu-
script writing; YS, assisting in the use of the algi-
nate; SM, specimen sectioning and imaging.

Conflict of interest: the authors report no con-
flicts of interest. 

Received for publication: 27 April 2011.
Accepted for publication: 3 June 2011.

This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).

©Copyright A. Takahashi et al., 2011
Licensee PAGEPress, Italy
Eye Reports 2011; 1:e2
doi:10.4081/eye.2011.e2

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[page 4] [Eye Reports 2011; 1:e2]

impression materials were sterilized by ethyl-
ene oxide gas and useful as filler for removing
mucous retention cysts.12 This report encour-
aged us to use alginate as filler for the open
globe during enucleation to preserve the
resistance of the globe, which may be applica-
ble even if the globe is ruptured. Alginate is
inexpensive and easily commercially available.
Its preparation for use as filler and its injection
do not require any special technique. Thus,

except in cases in which a pathologic diagno-
sis of the enucleated tissue is necessary, algi-
nate may be a novel aid to assist in enucleation
by preserving the resistance of the globe. 

References

1. Kilmartin DJ, Dick AD, Forrester JV.

Prospective surveillance of sympathetic
ophthalmia in the UK and Republic of
Ireland. Br J Ophthalmol 2000;84:259-63. 

2. Zhang Y, Zhang MN, Jiang CH, Yao Y.
Development of sympathetic ophthalmia
following globe injury. Chin Med J (Engl)
2009;122:2961-6. 

3. Savar A, Andreoli MT, Kloek CE, Andreoli
CM. Enucleation for open globe injury. Am
J Ophthalmol 2009;147:595-600.e1.

4. Mansouri M, Faghihi H, Hajizadeh F, et al.
Epidemiology of open-globe injuries in
Iran: analysis of 2,340 cases in 5 years
(report no. 1). Retina 2009;29:1141-9. 

5. Sen HN, Nussenblatt RB. Sympathetic
ophthalmia: what have we learned? Am J
Ophthalmol 2009;148:632-3. 

6. Rasmussen ML, Prause JU, Johnson M,
Kamper-Jørgensen F, Toft PB. Review of
345 eye amputations carried out in the
period 1996-2003, at Rigshospitalet,
Denmark. Acta Ophthalmol 2010;88:218-
21.

7. Torres VL, Schor P, Erwenne CM. A new
device for ocular globe enucleation.
Ophthalmic Surg Lasers Imaging
2008;39:524-7. 

8. Finger PT. “Finger-tip” cryoprobe assisted
enucleation. Am J Ophthalmol 2005;139:
559-61.

9. Tytgat GN, McColl K, Tack J, et al. New
algorithm for the treatment of gastro-
oesophageal reflux disease. Aliment
Pharmacol Ther 2008;27:249-56. 

10. Tane N, Ohira A, Aihara M. Use of calcium
alginate for the eye socket wound dress-
ing. Jpn J Clin Ophthalmol 2009;63:1175-9.

11. Mathews MF, Smith RM, Sutton AJ,
Hudson R. The ocular impression: A
review of the literature and presentation
of an alternate technique. J Prosthodont
2000;9:210-6. 

12. Tanaka Y, Harada T, Naito S, Yoshimura Y.
Usefulness of Therapeutic Method for
Mucous Retention Cysts of Oral Floor
using Alginate Impression Material. J Jpn
Stomatol Soc 1999;48:134-7.

Case Report

Figure 1. (A) T2-weighted magnetic resonance image before enucleation, demonstrating
that the patient’s left globe had totally collapsed; (B) Injected alginate preserved the
resistance of the globe, which assisted with enucleation; (C) Good transection of the
optic nerve was observed, suggesting that enucleation was performed completely with-
out unnecessary trauma. Arrow indicates the stump of the optic nerve; (D) Alginate was
evenly distributed in the cavity of the globe. 

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