Introduction <p>The prevalence of incidental intraocular malignancy in eye removal cases due to phthisis bulbi remains poorly understood. This retrospective study evaluates the prevalence of unsuspected intraocular malignancies in eye removal specimens.</p> Methods <p>Retrospective study of 1897 evisceration and enucleation specimens submitted for histopathological examination in the UK between 2014 and 2023 submitted to Department of Eye Pathology (DEP), a laboratory within the National Specialist Ophthalmic Pathology Service (NSOPS).</p> Results <p>Among 664 cases meeting inclusion criteria, the incidence of unsuspected malignancy was 0.75% (<i>n</i> = 5). All cases involved evisceration, with malignancies including melanoma, squamous cell carcinoma in situ, and undifferentiated spindle cell tumours, involving one case of malignancy of a corneal button. One case changed to suspected malignancy intraoperatively due to the findings noted during evisceration. Preoperative clinical assessments, including B-scan ultrasonography, failed to detect malignancies in these cases, highlighting the importance of comprehensive preoperative evaluation.</p> Conclusion <p>These findings underscore the need for histological examination in end-stage eyes to identify hidden malignancies and inform treatment decisions. While the overall risk of unsuspected intraocular malignancy remains low, this study reinforces the necessity of considering enucleation when intraocular tumours cannot be reliably excluded preoperatively. This data also emphasises the importance of informed consent and shared decision-making, incorporating the small but material risk of malignancy into pre-operative discussions with patients.</p>