ecallenIn Part 1, we covered Dr. Broadwater’s revolutionary dorsal positioning technique. Now discover the three specialized instruments that make enucleation surgery dramatically easier, plus his refined step-by-step surgical approach that consistently delivers 15-20 minute procedures.
Essential Specialized Instruments for Eye Removal Surgery
Dr. Broadwater emphasizes that while general surgical instruments can complete an enucleation, these three specialized tools make the procedure significantly easier, safer, and faster.
Enucleation Scissors - The Game Changer
Why they’re essential:
- Curved design follows orbital bone curvature – works with anatomy instead of against it
- Allows safe approach to optic nerve – reduces risk of excessive traction
- Critical for preventing contralateral optic nerve damage – curved approach minimizes pulling forces
- Especially important for cats and swollen glaucomatous eyes – tight spaces require precise instrument control
Dr. Broadwater’s insight: “The curved design isn’t just convenient – it’s a safety feature. Straight scissors force you to pull harder on the globe to access the optic nerve, which can damage the opposite eye’s vision.”
Stevens Tenotomy Scissors - Precision Dissection
Use these for all extraocular muscle dissection and fine tissue work around the globe. The narrow tips allow you to work in tight spaces without damaging adjacent structures. Key advantages:
- Narrow tips provide precision for delicate tissue work – essential for thin orbital tissues
- Enable controlled blunt dissection of extraocular muscles – reduces accidental tissue damage
- Superior to Mayo scissors for fine orbital work – size and design optimized for small spaces
Bishop Harmon Forceps (8mm) - Gentle Tissue Handling
These forceps excel at grasping conjunctiva and other delicate orbital tissues without the excessive trauma that larger instruments can cause.
Design benefits:
- Small rat-tooth design ideal for thin conjunctival tissue – provides secure grip without tearing
- Less traumatic than standard Brown-Adson forceps – reduced tissue crushing
- Particularly valuable for smaller patients – appropriate scale for delicate work
Step-by-Step Enucleation Surgery Technique
Dr. Broadwater’s modified subconjunctival approach incorporates key modifications that dramatically improve efficiency and outcomes.
Initial Exposure - Key Modifications
1. Transect lateral canthus for improved exposure
- Make clean incision through lateral canthal ligament
- Creates significantly wider surgical field
- Essential for comfortable instrument access
2. Remove eyelids early in procedure (not at end as traditionally taught)
- Traditional teaching removes lids last – this is inefficient
- Early removal provides immediate improved visualization
- Eliminates tissue that obscures the surgical field
3. Remove third eyelid completely, including gland, early in process
- Complete removal prevents future cyst formation
- Early timing improves access for subsequent steps
- Include the gland to ensure no retained secretory tissue
Conjunctival Management Technique
Strategic incision placement:
- Begin conjunctival incision 5-6mm from limbus – provides tissue margin for manipulation
- Leave tissue rim for globe manipulation – creates “handle” for rotating the eye
- Systematically remove all pigmented conjunctival tissue – prevents future cyst complications
Dr. Broadwater’s rule: “If it’s pigmented tissue, remove it.” This simple guideline prevents the majority of post-surgical complications.
Extraocular Muscle Dissection Protocol
Systematic muscle identification and transection:
- Superior rectus – easiest to identify, start here
- Ventral rectus – follow inferior orbital rim
- Medial rectus – closest to nasal cavity
- Lateral rectus – toward temporal side
- Superior oblique – runs through trochlea
- Ventral oblique – smallest muscle, easy to miss
Critical checkpoint: Test complete muscle release by rotating globe 360 degrees. If you feel resistance, identify and transect the remaining attachments.
Instrument technique: Use Stevens tenotomy scissors for precise separation. The narrow tips allow you to dissect individual muscles without damaging adjacent structures.
Optic Nerve Transection - The Critical Step
Safe approach technique:
- Use curved enucleation scissors following orbital curvature – natural anatomical approach
- Approach dorsally-laterally for optimal exposure – best visualization and control
- Minimize traction to protect contralateral optic nerve – excessive pulling can damage the opposite eye
Key safety point: The optic nerves connect at the chiasm. Aggressive traction on one side can compromise vision in the opposite eye. The curved scissors reduce this risk significantly.
Pain Management Protocol for Eye Removal Surgery
A comprehensive anesthetic approach includes pre-medication:
- First choice: Fentanyl and midazolam
- Alternative: Buprenex and midazolam if fentanyl unavailable
- Provides excellent baseline analgesia and anxiolysis
Induction and maintenance:
- Induction: Propofol for smooth, controlled induction
- Maintenance: Isoflurane with fentanyl CRI for balanced anesthesia
Retrobulbar Nerve Block Technique
Dr. Broadwater performs blocks on all appropriate cases using specific technique and dosing.
Equipment: 1.5-inch, 22-gauge spinal needle
Technique:
- Walk needle tip along orbital bone to stay away from globe
- Penetrate muscle cone for effective anesthesia
- Inject slowly to avoid tissue damage
Dosing protocols:
- Dogs/cats under 10kg: 0.5ml lidocaine + 0.5ml bupivacaine + 0.1ml epinephrine
- Dogs over 10kg: 1ml lidocaine + 1ml bupivacaine + 0.2ml epinephrine
Important contraindications: Avoid retrobulbar blocks if infection or cancer present due to potential seeding risk.
Surgical Timeline Results
Dr. Broadwater reports remarkable consistency in surgical times using this refined approach:
- Setup and positioning: 3-5 minutes
- Surgical procedure: 12-15 minutes
- Closure and cleanup: 3-5 minutes
- Total time: 15-20 minutes consistently
Efficiency Factors
The time savings come from:
- Optimal positioning reducing fumbling with instruments
- Specialized instruments designed for the specific tasks
- Systematic approach eliminating wasted motion
- Early tissue removal providing immediate better visualization
Implementation Strategy
While specialized instruments require upfront investment, the time savings and improved outcomes justify the cost for practices performing regular enucleations.
Learning curve: Most veterinarians adapt to the new instruments within 1-2 procedures. The improved control is immediately apparent.
Procedural Changes
Staff preparation: Brief your surgical team on the modified sequence, particularly the early eyelid and third eyelid removal.
Practice recommendations: Dr. Broadwater suggests starting with straightforward cases to build confidence with the new approach.
Coming Up: Part 3
In our final installment, discover Dr. Broadwater’s advanced strategies for managing orbital bleeding using Vetigel® Hemostatic Gel and preventing the most common post-surgical complications that lead veterinarians back to surgery.
The combination of proper positioning (Part 1) and specialized instruments (Part 2) sets the foundation for successful enucleation surgery. Part 3 will complete your toolkit for confident, efficient procedures.
Discover how Zomedica’s innovative solutions enhance surgical outcomes. Learn more about our veterinary product portfolio designed specifically for veterinary professionals.
This is Part 2 of a 3-part series on Dr. Broadwater’s enucleation technique.
Read Part 1: Setup & Positioning
Continue to Part 3: Bleeding Control & Complications.
*Dr. Broadwater was paid by Zomedica, Inc. for his webinar presentation, which you can watch here.
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