OUTLINE I INTRODUCTION AND HISTORY A ARTIFICIAL EYES DATE

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16338 VERSION 3 PAGE 3 OF 3 OUTLINE HOW

OCULAR PROSTHETICS TODAY AND

OUTLINE

I. Introduction and History

A. Artificial eyes date back to at least 5 B.C.

B. Materials used to make eyes varied and included gold, ivory, porcelain, glass and plastic

C. Acrylic resin (methyl methacrylate resin) is primarily used today to fabricate the eyes

D. Eye fitters and makers are called ocularists

E. An estimated 50,000 Americans lose an eye each year

F. Optometrists are uniquely positioned as primary care providers to use their knowledge and training in anatomy, physiology, optics and contact lenses to participate in this specialty

II. Types of Prosthetic Devices

A. Reform Eye (Artificial eye)

1. Curved disc of plastic having a center thickness of 2mm or greater

2. Can be coupled to an implant or not

3. Colored to match natural eye

4. Can be trial fit or custom molded

B. Shell Eye

1. Curved disc of plastic with a center thickness of less than 2mm

2. May incorporate optics

3. Colored to match natural eye

C. Corneal Prosthetic Contact Lens

1. Covering the cornea

2. Optics may be incorporated

3. Color may be added to mask disfigurement

D. Hydrophilic Prosthetic Contact Lens

1. Hydrophilic soft contact lens with/without optics

2. Pupil and/or iris pigmentation/tint possible

III. Surgical Procedures and Implant Types

A. Simple Enucleation/No Implant

1. The eye may be removed and conjunctiva closed without an implant

2. The four recti muscles are sutured together to form a stump which may assist the support and motility of the prosthesis

3. The prosthetic eye will be large and thick

B. Enucleation with an Implant

When the eye is removed, an implant is placed in the socket at the time of surgery

C. Evisceration

1. The contents of the globe are removed and replaced with a spherical implant

2. The cornea may or may not remain

3. The size of the sphere used governs the thickness of the prosthetic

D. Exenteration

1. The entire contents of the orbit are removed

2. A large, thick eye may be used, if there remains lids to hold the prosthetic in place

3. Facial restoration may be needed

E. Types of Implants

1. Spheres

2. Muscle – Attached

3. Bio – Eye hydroxyapatite ocular implant

4. Polyethylene implant

F. Secondary Implants

Patients with enucleations and eviscerations using the earlier type of implants may be possible candidates for replacement using newer hydroxyapatite or polyethylene implants

G. Problems with Implants

1. Migration

2. Extrusion

3. Motility

4. No support for the artificial eye

5. Foreign material exposed

6. Infections

IV. Examination

A. History

1. Date of loss and which eye

2. Cause, surgeries done, who and when

3. Prosthetics used and how long for each

4. Fitter

5. Care and wearing time

6. Symptoms and complaints

7. Frequency of polishing

8. Document natural eye

9. Complete ocular examination on natural eye

B. Socket Concerns

1. If artificial eye is present, have the patient remove the eye

2. Examine the socket

3. Check the socket for an implant

4. If implant is present, what type?

5. Is there motility?

6. What is the condition of the lids?

7. Is there swelling, puffiness, lesions and/or discharge?

8. Check the prosthetic for cracks, chips, scratches, crazing, separation of layers or surface debris

V. In-Office Procedures

A. Prosthetic Evaluation

1. Observe the patient and prosthetic at different heights and angles

2. Note the motility of the device and the tracking ability

3. Check the underlying tissue and/or implant for proper coupling with eye

4. Note any displacement or gaps

5. Have the patient remove the device and check the tissue or socket

6. Check the ball and socket to be sure the tissue is healthy and implant is stationary (for reform/shell eyes), check the cornea (for soft and corneal devices)

7. Clean / polish the device and replace or refit if needed

B. Prosthetic Cleaning and Polishing

1. Polishing Techniques

a. Contact lens modification unit and sponge tools (for reform, shell, and corneal)

b. Power tools with pumice and rouge (for reform and shell)

2. Common Problems

a. Formation of deposits on the surface of the device

b. Scratches and nicks in the surfaces

c. Dry eye sensations

d. GPC

e. Hazy surface/dull appearance

f. Poor wetting properties

3. How to Clean a Hydrophilic Prosthetic Lens

a. If the material is known, clean with recommended solutions

b. If the material is not known recommend Purilens System

4. How to Clean a Corneal Prosthetic Lens

a. Use traditional RGP cleaners and wetting solutions

b. Light hand polishing using RGP polish and a soft sponge disc may be used

5. How to Clean a Prosthetic (reform or shell)

a. Can use RGP cleaners

b. Commercially available specific products

6. PRODUCTS / PROCEDURES NOT TO USE ON A PROSTHETIC

Alcohol
Lysol
iodine
microwave
autoclave
boiling
solvents

7. Wetting Agents

Enuclean
Vivadrops
Thera Tears
Celluvisc
Sil-Ophtho

C. Refitting in the Optometric Practice

Can be accomplished with:

Trial fitting eye set
Scleral contact lenses
Modification of existing prosthetic as a starter shape
Use of fitting white shapes
Impression molding techniques

D. Insertion of Prosthetic Eyes

With or without suction cup:

Pull Upper lid upward
Insert superior aspect of prosthetic under the upper eyelid
Pull the lower lid down
Push prosthetic in place within lid margins

E. Removal of Prosthetic

With or without suction cup:

Depress lower lid
Gently press in on the lower lid under prosthetic edge
Slide eye down and out

F. Reform and Shell Eye Wearing Schedule

Generally the prosthetic can be worn 1 to 2 weeks before cleaning
The eye can be left out overnight but not for extended periods due to tissue atrophy

G. Replacement of Prosthetic Devices

Hydrophilic: 12-18 months
Corneal Cosmetic: 12-24 months
Shell Eyes: 3-6 years
Reform Eyes: Glass – 2 years

Plastic – 3-6 years

H. Case Presentations

VI. Reading References

1. Gugelmann HP: The evolution of the ocular motility implant. In Shannon G.M. Connelly FJ (eds): Oculoplastic Surgery and Prosthetics. (Internal Ophthalmology Clinics, Vol 10.) Boston, Little Brown, 1970, p. 689.

2. Perry AC: Volume of anophthalmic implants. Presented at the Combined Meeting of the American Society of Ophthalmic, Plastic and Reconstructive Surgery and the American Society of Ocularists. San Francisco, November 2, 1983.

3. Pratt SG. Evisceration techniques. Adv Ophthal Plast Reconstr Surg 1988 (7):247-53.

4. Perry AC: Advances in enucleation. Opthalmic Plast Reconstr Surg 1991(4):173-177.

5. Estrada, LN, Rosenstiel CE. Prosthetic contact lenses: a role in the treatment of ruptured RK incision with iris damage. CLAO J. 2002 March; 28(3):107-108.

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