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CASE REPORT
Year : 2015  |  Volume : 42  |  Issue : 2  |  Page : 99-102

Basic principles of rehabilitation for lost eye: A dentist's perspectives


1 Department of Dentistry, FH Medical College, Tundla, Firozabad, Uttar Pradesh, India
2 Department of Prosthodontics and Dental Material Sciences, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication14-May-2015

Correspondence Address:
Simranjeet Kaur
Department of Dentistry, FH Medical College, Tundla, Firozabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.157042

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  Abstract 

Various maxillofacial prostheses are made from materials used in dentistry. The
treatment of the patient who loses one or both eyes is a challenging task for the clinician. A multidisciplinary approach is required to fulfill the needs and expectations of an anophthalmic patient. Dentists are now playing a major role in this regard as they are more familiar with the materials used for artificial eyes. Ocular prosthesis is an artifi cial replacement of the eye. The article describes the overall management and treatment of an anophthalmic patient, followed by a procedure for an easy fabrication of a custom-fi tocular prosthesis.

Keywords: Custom-fit prosthesis, ocular prosthesis, shell prosthesis


How to cite this article:
Baslas V, Kaur S, Yadav R, Aggarwal H, Jurel SK, Kumar P. Basic principles of rehabilitation for lost eye: A dentist's perspectives. J Sci Soc 2015;42:99-102

How to cite this URL:
Baslas V, Kaur S, Yadav R, Aggarwal H, Jurel SK, Kumar P. Basic principles of rehabilitation for lost eye: A dentist's perspectives. J Sci Soc [serial online] 2015 [cited 2020 Aug 7];42:99-102. Available from: http://www.jscisociety.com/text.asp?2015/42/2/99/157042


  Introduction Top

"It is the God-given right of every human being to appear human." Eyes, besides being an essential sense organ, are the beauty of the face. The disfigurement associated with the loss of an eye can cause significant social and psychological consequences. [1] It may have a serious impact on not only the individual involved, but also upon his family members, relatives and surroundings affecting the community as a whole. Most patients experience significant stress, primarily adjusting to the functional disability caused by the lost eye and to societal reactions. Thus, replacement of the lost eye at the earliest possible is necessary to promote physical and psychological healing for the patient and thus overall improve his quality of life.

Causes

Anophthalmia can be unilateral or bilateral and congenital or acquired. Indications for removal of an eye include irreparable trauma, tumor (e.g., Retinoblastoma), a blind painful eye, phthisis bulbi, the need for histological confirmation of a suspected diagnosis, the possible prevention of a sympathetic ophthalmia and cosmetic reason. [1] Rehabilitating an anophthalmic patient requires a multidisciplinary approach involving the combined and timely efforts of an ophthalmologist, a plastic surgeon and a skilled maxillofacial prosthodontist.

Surgical intervention

The minimal surgical procedure is evisceration-removal of the contents of the globe, leaving the sclera (and at times the cornea) intact. [2] A thin scleral cover or the shell type prosthesis is made. Advantages include excellent motility of the prosthesis due to intact extraocular muscles and light sclera shell not depressing the lower eyelid thus reducing postenucleation syndrome features. Disadvantages include sensitivity of the socket leading to poor fit and complex iris painting of the prosthesis. [1] Enucleation is removal of the entire eyeball after severing the muscles and optic nerve. Advantages include adequate space needed for fabrication of the ocular prosthesis. [3] Disadvantages include the need for implant placement prior to prosthesis fabrication. Exenteration, the most radical, is the removal of the entire contents of the orbit. [2] Implant is usually placed in the orbit to replace the lost tissues and provide some support for the accessory organs.

Postenucleation syndrome

Following surgical intervention, postenucleation syndrome is frequently seen. Computed tomography assessment [4] revealed that this syndrome not only to be caused by the intraorbital volume loss, but also by a rotatory displacement of orbital contents from superior to posterior and from posterior to inferior. Consequently the postenucleation socket syndrome includes the following symptoms:

  1. Enophthalmos,
  2. Retraction of the upper eyelid,
  3. Deepening of the superior sulcus,
  4. Backward tilt of the prosthesis, and
  5. Stretching of the lower lid.
This rotatory displacement of the orbital contents is precluded by the insertion of the intraorbital spherical implant and early fabrication of ocular prosthesis.

Materials and types of ocular implants

Mules, in 1884, was the first to use an intraorbital implant (hollow spherical glass) to achieve a better cosmetic appearance in anophthalmic patients. According to him, the loss of volume of 6-7 ml resulting from the removal of the eye was an important factor in the development of the disfiguring symptoms associated with an anophthalmic orbit. [5] Today, most implants are made of methyl methacrylate resin, but silicone rubber (medical grade) are becoming the material of choice, for it evokes less inflammatory response. [2] Other materials used include porous coral derived hydroxyapatite sphere implant [6] and autogenous dermal fat graft. [7]

Ocular implants can be classified [1] as integrated or nonintegrated and buried or nonburied. Integrated implants are designed to improve prosthesis motility by coupling to the overlying prosthesis either indirectly or directly through peg, pin or screw. Nonburied implant means implant exposure through the conjunctiva to be directly coupled to the prosthesis. The buried, nonintegrated implant is the most common method of replacing volume loss in the socket following evisceration or enucleation.

Special considerations

After surgical intervention and implant placement, a conformer (stock or custom-made) and corticosteroid antibiotic ointment is placed in the socket for 4-6 weeks to reduce edema, reduce postenucleation features and maintain the socket contours for the prosthetic eye. [1] Conformer should have drainage holes for the escape of mucoid discharge and insertion of postoperative medication.

Since every socket differs in size and shape, it is obvious that an individually designed prosthesis, made from an impression of the socket, is needed to utilize the full movement potential of any implant and also to provide maximum comfort and restore full physiologic function to the accessory organs of the eye. [2]

Materials for prosthesis

Before World War II, all ocular prostheses were made of glass and supplied in standard sizes and colors that could not be altered. [2] During the War, a scarcity of imported glass led to a search for another suitable material. In 1944, investigators at the Naval Graduate Dental School developed a custom-fitted methyl methacrylate resin ocular prosthesis. [8] Unlike a glass eye, an acrylic resin eye is easy to fit and adjust, unbreakable, inert to ocular fluids, aesthetically good, longer lasting and easier to fabricate. Silicone eye prosthesis is also being tried to provide better biocompatibility.

Ocular impressions

An accurate ocular impression facilitates a close adaption of the custom prosthesis to the tissue bed, resulting in better potential for movement. The different impression materials used are irreversible hydrocolloids (most common), [9] ophthalmic alginates, [1],[10] tissue conditioners, [11] polyvinyl siloxane impression materials [12] and dental impression waxes like Korecta wax no. 4 and Iowa wax. [13]

The article describes a technique for the fabrication of a custom-fitted ocular prosthesis in a patient of acquired unilateral anophthalmia.


  Case Report Top


A 33-year-old male patient came to the Department of Maxillofacial Prosthesis with a chief complaint of unaesthetic appearance of the face due to blindness in right eye [Figure 1]. On evaluation, history revealed irreparable trauma to the right eye, followed by enucleation. Two months after the surgical intervention, patient was given a stock eye, but he was dissatisfied with the fit and esthetics of the stock eye. On palpation, it was found that there was no associated pain, discomfort or residual edema. Thorough ophthalmic evaluation was done, and a custom-fitted ocular prosthesis was planned for the patient.
Figure 1: Preprosthetic view showing enucleated right eye

Click here to view


Procedure

  1. A prefabricated (stock) eye, whose iris and pupil closely matched that of the natural eye was selected and modified to comfortably and loosely fit the socket. This was duplicated with clear-heat cured PMMA (Trevalon, Dentsply India Pvt. Ltd., Gurgaon, India) and perforated for use as a tray in the impression procedure. Perforation of the tray was done to avoid any compression of the ocular tissues.
  2. The tray was placed in the socket, and the patient was asked to gaze at a distant point to accurately mark the pupil as per contralateral side, on the tray.
  3. Petroleum jelly was applied to the eyebrows for easy removal of the impression when it sets. A syringe without the needle portion was then attached to the point of papillary position on the custom tray to serve as a handle for the impression tray and through which the impression material could be easily injected into the defect area.
  4. A thin mix of ophthalmic alginate (Opthalmicmoldite, Milton Roy Co. Sarasota Fla.) was loaded into the syringe and then injected in the socket. The patient was asked to move his normal eye in all directions to allow the alginate to flow into all areas of the enucleated socket. Impression [Figure 2]a] was removed and examined for accuracy and cast was poured in two parts with the second part being poured after applying lubricant and making orientation grooves on the partially set first half [Figure 2]b].
    Figure 2: (a) Impression of ocular defect. (b) Cast obtained a�� er double pour technique. (c) Wax pa�� ern try in

    Click here to view
  5. The thin syringe portion was maintained as a sprue to pour the wax pattern and to transfer the pupillary point onto the cast.
  6. The iris portion of the stock eye was trimmed and oriented on the cast according to previously transferred pupillary mark.
  7. Carving wax mixed with yellow sticky wax was poured into the cast, taking care that the iris portion that was trimmed from the stock eye was maintained in its previously oriented position in the wax pattern.
  8. This stock eye-wax pattern combination was tested in the socket [Figure 2]c] and modified for adequacy of ocular movements, correction of pupillary alignment, proper palpebral movements, scleral contour and convexity.
  9. The adjusted and modified stock eye-wax pattern combination was invested and dewaxed in the usual manner.
  10. To reproduce the scleral shade of the normal eye, shade tabs were prepared by mixing and matching different shades and proportions of tooth-colored acrylic (SC 10, Pyrax, Roorkee, India) till the color of sclera of the other eye was replicated.
  11. Red silk fibers to mimic veins were placed on the cameo surface of the prosthesis in the dewaxed flask [Figure 3]a] and in the dough of the determined acrylic shade, followed by routine curing, finishing and polishing.
    Figure 3: (a) Invested wax pa�� ern. (b) Finished prosthesis

    Click here to view
  12. Finally, a thin film of the sclera was removed and replaced by a clear film of transparent heat-cured PMMA (Trevalon, Dentsply India Pvt. Ltd., Gurgaon, India) to simulate corneal translucency [Figure 3]b].
  13. The properly finished and polished prosthesis was inserted in the socket [Figure 4] after being disinfected and lubricated with an ophthalmic lubricant (Ecotears, Intas Pharmaceuticals Ltd., Ahmedabad, India) to maintain a tear film over the prosthesis and to improve eye movements.
    Figure 4: Postprosthetic view

    Click here to view

  Discussion Top


The treatment of patients who had lost one or both eyes had already commenced in the ancient times. To replace an eye that was lost by accident or disease or by an enucleation for medical reasons, artificial eyes (eye-prostheses) of various materials, shapes and sizes were used. With an enucleation defect, prosthetic treatment begins with the use of a spherical implant placement. Ocular prosthesis is an artificial replacement of the bulb of the eye. Today, three types of acrylic resin prosthesis are used: Stock eyes, stock eyes modified by various methods and custom-fitted eyes made from an impression of the socket. [2]

Custom-made prosthetic eye fabrication involves complex painting procedures in various stages that are time taking and depends mainly on the painting skills of the operator. The technique to fabricate ocular prosthesis in the present case report modifies prefabricated eye prosthesis to a custom-made fit and aesthetics. This technique of incorporating iris portion from a stock eye into the custom ocular prosthesis is relatively easy to perform, along with saving on laboratory time. The close adaptation of the custom-made ocular prosthesis to the tissue bed provides maximum comfort and restores full physiological functions of the eye.

Instructions should be given to the patient regarding proper care and hygiene maintenance techniques in order to facilitate successful adaptation of the prosthesis and the need for regular recall appointments should be emphasized. The use of ancillary products (e.g., lubricants, lubricant delivery systems, cleansers.) and procedures in order to help the patient adapt to the prosthesis should be recommended.


  Summary Top


The basic principles and concepts of rehabilitation of ocular defects have been discussed in the present article. Although it is a multidisciplinary approach, a dentist can play an important role in restoring the normal aesthetic appearance and facial symmetry of an anophthalmic patient, thereby improving one's social acceptance, self-confidence and overall quality of life. The custom-fit ocular prosthesis gives excellent support, fit, mobility and comfort especially where implant placement is not feasible due to any reason. Present case report eliminates the complex painting procedures and describes an easy method for fabrication of a custom-fit ocular prosthesis.

 
  References Top

1.
Beumer J 3 rd , Curtis TA, Marunick MT. Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. St. Louis: Ishiyaku Euro America; 1996. p. 417-31.  Back to cited text no. 1
    
2.
Bartlett SO, Moore DJ. Ocular prosthesis: A physiologic system. J Prosthet Dent 1973;29:450-9.  Back to cited text no. 2
[PUBMED]    
3.
Iliff CE, Iliff W, Iliff NT. Oculoplastic Surgery. Philadelphia: W.B. Saunders Co.; 1978.  Back to cited text no. 3
    
4.
Smit TJ, Koornneef L, Zonneveld FW, Groet E, Otto AJ. Computed tomography in the assessment of the postenucleation socket syndrome. Ophthalmology 1990;97:1347-51.  Back to cited text no. 4
    
5.
Mules PH. Evisceration of the globe, with artificial vitreous. Trans Ophthalmol Soc UK 1885;5:200-6.  Back to cited text no. 5
    
6.
Shields CL, Shields JA, De Potter P. Hydroxyapatite orbital implant after enucleation. Experience with initial 100 consecutive cases. Arch Ophthalmol 1992;110:333-8.  Back to cited text no. 6
    
7.
Smith B, Petrelli R. Dermis-fat graft as a movable implant within the muscle cone. Am J Ophthalmol 1978;85:62-6.  Back to cited text no. 7
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8.
Murphey PJ, Schlossberg L. Eye replacement by acrylic maxillofacial prosthesis. US Nav Med Bull 1944;43:1085-99.  Back to cited text no. 8
    
9.
Taylor TD. Clinical Maxillofacial Prosthesis. Chicago: Quintescence; 2000. p. 265-76.  Back to cited text no. 9
    
10.
Cain JR. Custom ocular prosthetics. J Prosthet Dent 1982;48:690-4.  Back to cited text no. 10
[PUBMED]    
11.
Ow RK, Amrith S. Ocular prosthetics: Use of a tissue conditioner material to modify a stock ocular prosthesis. J Prosthet Dent 1997;78:218-22.  Back to cited text no. 11
    
12.
Sykes LM. Custom made ocular prostheses: A clinical report. J Prosthet Dent 1996;75:1-3.  Back to cited text no. 12
    
13.
Schneider RL. Modified ocular prosthesis impression technique. J Prosthet Dent 1986;55:482-5.  Back to cited text no. 13
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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