Retinoblastoma: Enucleation

Despite the progress of various conservative modalities, enucleation remains the most commonly employed technique for treating retinoblastoma worldwide. There are several indications for enucleation such as unilateral advanced tumors (particularly with extensive seeding) with negligible visual potential (group D or E), a blind eye with recurrent disease following chemotherapy and/or radiation, any eye with suspected optic nerve, anterior segment, choroidal, scleral, or extraocular tumor involvement, and if the active tumor in the eye and cannot be followed due to obscured media (e.g., vitreous hemorrhage or phthisis). It is important to discuss with the parents the technical aspects of the surgery and the expected postoperative course. Certain surgical steps can facilitate obtaining the minimum 15 mm of optic nerve stump recommended in all enucleation cases for retinoblastoma. After inspection of the enucleated globe for extra scleral extension, a small sclero-choroidal window is created, 5–6 mm away from the tumor base near the equator with an 8 mm corneal trephine to obtain harvested fresh tissue for genetic studies. Once hemostasis is achieved, we routinely use porous polyethylene spherical implants as they do not require wrapping, have a low rate of migration, and allow the attachment of the extraocular muscles to the anterior surface of the implant. This chapter will focus on specific technical issues related to performing enucleation for retinoblastoma, including some “surgical pearls” that have been very effective in the authors’ experience.