"NO-TOUCH" CRYOSURGICAL ENUCLEATION: A MINIMAL TRAUMA TECHNIQUE FOR EYES

HARBORING INTRAOCULAR MALIGNANCY

R. SLOAN WILSON, MD

FREDERICK T. FRAUNFELDER, MD LITTLE ROCK, ARKANSAS

Current surgical approaches for can­cer are emphasizing minimal trauma­the so-called no-touch technique of tumor removal. Tumor seeding through the circulatory system seems reason­able, particularly with friable and ne­crotic tumors. Attempts to reduce meta­static seeds should originate with the original procedure.

Enucleation of nontumor eyes with simultaneous intraocular manometry has shown which surgical maneuvers elevate intraocular pressure and how ocular massage can be avoided.

Our surgical procedure involves a delicate surgical technique coupled with transscleral cryocoagulation to immo­bilize the tumor's blood supply.

INTRODUCTION AND RATIONALE

CURRENT surgical approaches for cancer are emphasizing minimal trauma-the so-called no-touch tech­nique of tumor removal. Tumor manipulation with resultant seed­ing through the circulatory system

Submitted for publication Oct 3, 1977.

From the Retinal Group, LTD (Dr Wilson), and the Department of Ophthalmology, University of Arkansas Medical Sciences, College of Medicine, and United States Veterans Administration Hos­pital, Little Rock pital, Little Rock (Drs Wilson and Fraunfelder).

Presented at the Eighty-second AnnuNI Meeting of the American Academy of Ophthalmology and Otolaryngology, Dallas, Oct 2-6, 1977.

Reprint requests to University of Arkansas Medi­cal Sciences, 4301 Markham, Little Rock, AR 72201 (Dr Wilson).

seems reasonable, particularly with friable and necrotic tumors. Log­ically, attempts to reduce or pre­vent metastatic seeds should origi­nate with the original procedure. The no-touch technique of Turnbull1

has increased the five-year survival by 50% in certain malignancies of the colon. His technique involves ligation of the lymphatics and vas­cular supply of the tumor prior to any manipulation of the tumor area. Clinical studies have ques­tioned the value of enucleation of human choroidal malignant mela­nomas,24 since there is little evi­dence that enucleation increases patient survival. Enucleation tech­niques vary but, ordinarily, are not considered delicate eye surgery. Fraunfelder et al5 have shown in­creased longevity in hamsters with melanomas after a traumatic enu­cleation compared with traumatic enucleation. In human experiments, the same authors found pressure spikes to 400-mm Hg during an ordinary enucleation. Such pressures conceivably could cause showers of tumor cells into the blood stream leading to distant metastasis. If an approach similar to Turnbull's no­touch technique could be applied to eyes, harboring intraocular malignan­cies, patient longevity might increase.

This paper illustrates our enucle­ation procedure, which combines a delicate surgical approach with transscleral cryocoagulation to im­mobilize the tumor's blood supply

1170

~~~~~~E~5 1 978 "NO TOUCH" CRYOSURGICAL ENUCLEATION 1171

while the eye is being manipulated and removed.

MATERIALS AND METHODS

In order to determine the poten­tial effectiveness of our technique, we monitored the intraocular pres­sure through an anterior chamber manometer during a no-touch cryo­enucleation procedure. Figures 1 and 2 graphically depict the pres­sure changes at various stages dur­ing a routine enucleation procedure compared with the no-touch tech­nique. The manometric changes prove that certain elevations in pressure can be reduced by altera­tion in technique. Those that are unavoidable in spite of gentleness in technique, eg, transsection of the optic nerve, require another approach.

Anesthetic Retrobulbar

Injection

Massage

Speculum Insertion

100

.Conw, ntlolloll

200 300 400

mm Hg

Fig I.-Manometric anterior chamber pressure variations comparing techniques with variables as listed.

We developed an instrument that would immobilize the tumor's blood supply with cryocoagulation, yet could be applied easily and quickly during the operation. The adjust­able Cryo-Ring prototype was re­ported by Wilson,6 and recently refined (Fig 3). The cryocoagulation source is liquid nitrogen, enabling

Conjunctivi l Incision

Hemostasis : Cotton 5Mb YJ. : :

Cellose Sponge

Muscle Hook

Transsectlon Optic Ntf'I.

. .......-

100 200 300 400

mmHg

Fig 2.-Manometric anterior chamber pressure variations comparing techniques with variables as listed.

.. .... :: .. .. ••• ••••••• : •••• • '0, .~ . e'

.. : .... .. .. .......... . ,, ' (,

; .. ... .... .... ~:: .. . ::" . .... . .

... .. . . . ' .

' ,- "

' . . "'~ . . . . . . . .

/ .. ....... .

:

. ............ , .. \ .. ' .. ..... ) : . : ............. :

.... ): '.' .,'

............... \ i , .

:' :~ ........... ;'

Fig 3.-Adjustable Cryo-Ring.

a quick, deep freeze sufficient to immobilize the tumor's circulation (Fig 4).

1172 WILSON AND FRAUNFELDER OPHTH AAOO

Fig 4.-Diagrammatic application of Cryo-Ring using liquid nitrogen.

PRINCIPLES

The technique embodies certain general and specific surgical princi­ples.

The general surgical considera­tions include the following: (1) All surgical maneuvers should be done with utmost delicateness, similar to intraocular surgery. (2) External pressures, eg, rubbing, massage, or touching, should be avoided. (3) Manipulations and rotations should be slow and gentle.

Specific ocular surgical principles include the following: (1) Conjunc­tiva and Tenon's are lifted away from the eye. (2) Care should be taken to avoid hooking the rectus muscles. (3) Cellulose sponges should be used instead of stick cotton swabs, which can elevate pressure. (4) Muscle stumps are sutured with the needle parallel to the globe. (5) Gentle rotation of eye is permis­sible, since even extreme rotation does not significantly elevate pres­sure.

SURGICAL PROCEDURE

The usual enucleation procedure is modified for this technique.

Conjunctival P~itomy

After the usual a~sthesia (a gentle local injection or general endotracheal), preparation (without vigorous scrubbing over the eye­lids), and drape, and careful inser­tion of the lid speculum, a 2-mm conjunctival peritomy is performed using the utmost delicacy. Cel­lulose sponges are the preferred method of hemostasis, since cotton swabs elevate the pressure signifi­cantly. All tissue should always be lifted away from the eye, and in­struments never should press on the globe (Fig 5), since these ma­neuvers significantly raise intra­ocular pressure.

Fig 5.-Gentle conjunctival incision using cellulose sponge for hemostasis.

Muscle Transsection

The muscles near the tumor are usually transsected, and sutures are placed through the stumps. This allows easy placement of the Cryo-Ring (or 32P, if this precedes the Cryo-Ring). The muscle stumps are not hooked, but rather one end is held with forceps while scissors are placed beneath the edge. While the muscle is being pulled away from the eye, the muscle is trans­sected with scissors (Fig 6).

~~~~~~E~51978 "NO TOUCH" CRYOSURGICAL ENUCLEATION 1173

Fig 6.-Incision of rectus muscle without using muscle hooks.

Muscle Stump Fixation

A 4-0 silk with a spatula needle is placed through the muscle stump three or four times. Caution should be used not to press on the globe with the needle while sliding it through the base of the stump and gently pulling away from the eye with the forceps holding the muscle stump. After the suture has been properly placed and tied, the eye may be gently rotated without fear of pressure elevation (Fig 7 and 8).

Fig 7.-Suturing rectus muscle stump without pressure on the globe.

Fig B.-Lifting muscle stump.

Placement of the Cryo-Ring or 32p

The Cryo-Ring is adjustable and should be large enough to com­pletely encircle the tumor. Adjacent structures should be protected from freezing with thin, gas-sterilized sheets of Styrofoam (Fig 9).

Fig 9.-Sheets of liB-in Styrofoam used to insulate orbital contents from Cryo-Ring.

Tumor Cryocoagulation

U sing a liquid nitrogen thermos­type unit, an intermittent amount of liquid nitrogen should be passed

1174 WILSON AND FRAUNFELDER OPHTH AAOO

through the system to maintain a continuous freeze around the tu­mor. The freeze is monitored with indirect ophthalmoscopy. After an initial 2- to- 3-minute freeze, the tumor should turn white. The flow is then regulated to 5 to 10 seconds on and 5 to 10 seconds off during the remainder of the enucleation procedure. Continuous freezing would completely freeze the eye and cause the eye to be frozen to the orbital contents (Fig 10).

Fig lO.-Freezing tumor with Cryo-Ring.

Transsection of the Optic Nerve

While the tumor is solidly frozen, the enucleation scissors are passed around the optic nerve. The eye is lifted upward with the Cryo-Ring, which is solidly fixed to the eye. The nerve is transsected, and the attached muscles are removed as the eye is brought out of the orbit (Fig 11). Freezing is discontinued.

The remainder of the enucleation procedure is carried out in a routine manner according to the surgeon's preference in handling the muscles, implants, and suture materials.

Fig ll .-While tumor and blood supply are frozen, optic nerve is transsected, and globe, enucleated.

SUMMARY

This paper describes a surgical technique that immobilizes a tu­mor's blood supply during enuclea­tion and stresses delicate ocular surgical principles.

In early small tumors without significant tissue invasion, manip­ulation probably has little effect. However, as the tumor increases in size, becomes more friable or necro­tic, or has intratumor hemorrhages, manipulation has the potential to cause showers of cells into the blood stream.

The authors have discovered sev­eral points to keep in mind: (1) Use the utmost gentleness with scleral depression or 32p testing in eyes with suspected ocular tumors. (2) When doing a conventional enu­cleation, avoid any manipulation that causes pressure or indentation on the eye. Treat the eye gently, lift all tissue, and avoid cotton swabs

~gt~~~E~5197B "NO TOUCH" CRYOSURGICAL ENUCLEATION 1175

on the eye. (3) Consider the no­touch technique as described for enucleation of ocular choroidal mel­anomas.

ACKNOWLEDGMENTS

Frances N. Jones supplied technical as­sistance; Calvin Jackson helped refine and produce the instrument; Ron Tribell pro­duced the graphs and drawings; the Univer· sity of Arkansas for Medical Sciences, Medi· cal Photography, photographed the surgical procedure; Loyce Neldon recorded the ante­rior chamber pressure readings; and David Wilkes, MD, tested various manufacturers' liquid nitrogen cryocoagulation units.

Key Words: Intraocular tumor; mela­noma; cryocoagulation; enucleation; metastasis; no-touch.

REFERENCES

1. Turnbull RB Jr: The no-touch isolation technique·-ofresection. JAMA 231:1181·1182, 1975.

2. Paul EV, Parnell BL, Fraker M: Prog· nosis of malignant melanomas of the cho­roid and ciliary body. Int Ophthalmol Clin 2(pt2):387·402, 1962.

3. Stallard HB: Malignant melanoblas­toma of the choroid. Bibl Ophthalmol 75: 16·38, Hlp8.

4. Westerveld-Brandon ER, Zeeman WP: The prognosis of melanoblastomata of the choroid. Ophthalmologica 134:20-29, 1957.

5. Fraunfelder Fr, Boozman FW, Wilson RS, et al: No-touch technique for intraocular malignant melanomas. Arch Ophthalmol 95:1616-1620, 1977.

6. Wilson RS: Tubular cryocoagulation: Instrumentation for "notouch" melanoma enucleation and 3600 scleral buckling. Trans Am Acad Ophthalmol Otolaryngol 83:0P· 890·0P·891, 1977.