Controversy remains regarding the advantages and disadvantages of each procedure [9, 10]. In the past, most surgeons preferred enucleation for various indications mainly because of the fear of sympathetic ophthalmia that can occur after evisceration.  sympathetic ophthalmia, a potentially devastating and blinding autoimmune condition characterized by panuveitis, in which the injured eye incites inflammation in the fellow sympathizing eye, was first reported in association with evisceration in 1887 [12, 13]. Even though evisceration and enucleation surgeries successfully control pain,  many surgeons believe that enucleation controls pain better than evisceration and evisceration is more painful postoperatively than enucleation, [14, 15] and because of the fear of sympathetic ophthalmia,  enucleation previously was preferred by most surgeons for various indications. However, Shah-Desai et al.  found that ultimate pain relief was achieved in all patients after enucleation or evisceration at an average of 3 months with no difference in postoperative pain between the eviscerated or enucleated groups  and recent studies have reported that evisceration is safe and associated with a low risk of sympathetic ophthalmia [17, 18].
Evisceration recently has become increasingly popular for many reasons ; there is no solid evidence that evisceration is associated with an increased risk of sympathetic ophthalmia  and the surgery requires less manipulation and consequently less inflammation and scarring of orbital tissues and extraocular muscles resulting in better implant motility and cosmetic outcome than enucleation [9, 21]. Furthermore, evisceration is simpler, faster, and associated with lower risk of bleeding intraoperatively and fewer postoperative complications, such as ptosis, implant migration, implant extrusion, socket contracture, and the deep superior sulcus syndrome [8, 21–23]. Similarly, we preferred performing evisceration rather than enucleation unless contraindicated or not feasible; therefore, 62 % of our patients in the current study underwent evisceration rather than enucleation. The most common cause of anophthalmic surgery in our series was trauma in 40 % of cases followed by a blind painful eye secondary to absolute glaucoma with phthisis bulbi and degeneration in the enucleation group and endophthalmitis in the evisceration group.
Moshfeghi et al. conducted a review of enucleation and reported trauma as the leading indication for enucleation worldwide and for 40.9 % of cases in the United States,  and trauma has been the leading cause for both types of anophthalmic surgeries in some reports [10, 25–29]. Similarly, trauma was the reason for most cases of anophthalmic surgery in the current series, mainly for ocular trauma patients who presented with no light perception (NLP) vision, expulsion of the intraocular contents, and lacerations involving zone III. Trauma accounted for 40 % of the indications in our series (50 % in the enucleation group, and 33.3 % in the evisceration group). In cases with extensive globe disruption, removal of all uveal tissue may be difficult via evisceration; therefore, enucleation may better safeguard against retained uveal tissue. However, in cases in which the sclera is largely intact, and the intraocular contents are contained and identifiable, evisceration may be a reasonable alternative based on surgeon preference and experience [30, 31]. However, post-traumatic early enucleation or evisceration should not be performed because of an initial vision of NLP alone, since Agrawal et al.  found that one third of traumatized eyes with a preoperative visual acuity of NLP had ambulatory vision or better after surgery. Other reports also showed improvement of NLP vision after surgical repair due to advances in vitreoretinal surgery [33–35]. Moshfeghi et al.  also reported that intraocular tumors were the second leading cause of enucleation in 24 to 28 % of cases, while only three patients in the current series had tumors (two retinoblastoma and one choroidal melanoma). Intraocular tumors accounted for 4.4 % of anophthalmic surgery in the current series since almost all cases of ocular tumors were referred and managed in a nearby, specialized cancer center in Jordan that was established in 1997 .
The complication rates of enucleation and evisceration have ranged from 6 to 100 %, with erosion being the most commonly encountered complication [24, 29, 37]. In the current series, around 1/3 of patients reported minor or major local side effects, with wound dehiscence and implant exposure being the most common (Table 5). Even though insertion of the largest implant possible, whether during an enucleation or evisceration procedure, may be associated with increased risk of implant exposure or extrusion, it can prevent enophthalmos and superior sulcus deformity; therefore, recent advances in evisceration techniques largely focused on various types of posterior sclerotomies to allow for placement of larger implants (up to or even larger than 20 mm) in a large percentage of patients [30, 38].
The impact of suturing the muscles in relation to the implant for the sake of prosthesis motility after enucleation is still a controversy in the literature. Some surgeons are suturing the muscles directly to the implant or to a mesh around the implant, [29, 39, 40] while others suture the muscles together in front of the implant (imbrication) . In the other hand, some surgeons prefer the myoconjunctival technique in which they suture the muscles to the conjunctiva in the fornix rather than to the implant and they report motility that is better than suturing the muscles in front the implant and equal motility (with less migration, and exposure) to direct suturing of the muscle to an integrated implant [42, 43]. In another technique (as we did in this series) the muscles were cut near their insertions to the globe and left without suturing to the implant nor in front of the implant, with meticulous suturing of the tissues anterior to the implant to decrease the risk of implant extrusion or exposure. No single eye in this series had contracted socket, and this is not unexpected for us basically since no single patient in this series had received radiation which is the most important risk factor for contracted socket.
In cases of endophthalmitis, evisceration is preferred to enucleation because evisceration is thought to have less risk of postoperative meningitis or encephalitis . In the current series,12 of the 13 patients with endophthalmitis (92 %) underwent evisceration with silicone sphere orbital implant insertion at the time of primary surgery in an attempt to save the patient a secondary implant insertion, which recently has been reported to be most successful [4, 23, 44, 45]. We also did not notice an increased risk of infection or implant extrusion in these cases. Postoperative orbital infection developed in three cases in the current series, i.e., in one patient after a massive globe injury during a motor vehicle accident with eyelid swelling and orbital pain 3 months after enucleation and in one patient each after keratitis and endophthalmitis. All three cases were treated conservatively with oral antibiotics without removal of the orbital implant.
In the current series, the enucleation group was significantly younger than the evisceration group (25.24 ± 16.50 years compared to 47.12 ± 24.11 years, p = 0.001), which may be due to trauma and tumors; 23 of the trauma patients were younger than 50 years and only four patients were older than 50 years (Table 3), and due to enucleations for retinoblastoma being done at younger ages. Furthermore, patients who developed endophthalmitis and keratitis usually had previous intraocular surgery and are of older age that primarily underwent evisceration. In addition, since about two-thirds of our trauma cases where men, we had a male preponderance with a ratio of about 2:1, similar to other reports [31, 46, 47].