Clinical Ocular

Prosthetics

Keith R. Pine
Brian H. Sloan
Robert J. Jacobs

123
Clinical Ocular Prosthetics
Keith R. Pine • Brian H. Sloan
Robert J. Jacobs

Clinical Ocular Prosthetics

Keith R. Pine Robert J. Jacobs
School of Optometry and Vision Science School of Optometry and Vision Science
The University of Auckland The University of Auckland
Auckland Auckland
New Zealand New Zealand

Brian H. Sloan
New Zealand National Eye Centre
The University of Auckland
Auckland
New Zealand

ISBN 978-3-319-19056-3 ISBN 978-3-319-19057-0 (eBook)

DOI 10.1007/978-3-319-19057-0

Library of Congress Control Number: 2015944089

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.

springer.com)
Preface

Prosthetic eyes have a history that stretches back to at least 2,900 BC. Prosthetic eye
materials and techniques have evolved in keeping with the times: from clay, to wood
and ivory, to enamelled silver and gold, to glass and, finally, to (poly)methyl meth-
acrylate (PMMA) plastic. This last step (from glass to PMMA) was accompanied
by a change in the profession that supplied and fitted prosthetic eyes. PMMA eyes
could be custom-made, but this required a different skill set to the one that optom-
etrists had used successfully with glass for the previous 500 years. The technologi-
cal and professional dislocation that the change from glass eyes to PMMA eyes
brought about 70 years ago possibly accounts for the almost complete absence of
prosthetic eye literature today. The knowledge underpinning the modern practice of
ocular prosthetics appears to be based upon clinical observations acquired from
practicing ocular prosthetists (ocularists) and the analogous fields of dental technol-
ogy and contact lenses. This book has come about because of the sincere desire of
the authors to provide a more scientific knowledge base for the clinical practice of
ocular prosthetics by bringing together information from the literature on ophthal-
mology, prosthetic eyes and contact lenses and from experts working in these fields.
The genesis of this book started when Keith Pine approached the University of
Auckland’s School of Optometry and Vision Science to seek advice about how best
to go about writing it. He was introduced to Associate Professor Robert Jacobs who
supported the concept of the book but felt that the lack of scientific knowledge in the
field was a major drawback and that more formal research should be undertaken
into prosthetic eyes before a book should be contemplated. That was 6 years ago.
The discussion resulted in Keith Pine enrolling in a Master of Science programme
(later upgraded to a PhD) and undertaking a systematic set of individual investiga-
tions which has resulted in the publication of eight scientific papers to date. Associate
Professor Robert Jacobs and Dr Brian Sloan supervised the research and were co-
authors of the published papers.
The research began with a survey of anophthalmic patients to confirm a research
focus that most reflected their needs. The results of the survey highlighted the con-
cerns that patients had at the time of eye loss as well as their ongoing concerns after
at least 2 years of prosthetic eye wear. The health of the remaining eye was their
greatest concern at both occasions in time, but second on their list of ongoing con-
cerns was anxiety about mucoid discharge associated with their prosthesis. Frequent,

v
vi Preface

viscous discharge affects the quality of life of prosthetic eye wearers as it can be
difficult to live with a continuously suppurating eye that requires constant wiping.
Because of the high level of concern about discharge expressed by patients,
mucoid discharge associated with prosthetic eye wear was confirmed as a worth-
while research topic; however, the scale of the problem amongst the anophthalmic
population remained unknown. Also unknown were the demographics of anoph-
thalmic patients, the aetiology of eye loss and eye loss trends in New Zealand.
A second survey, larger than the first, was undertaken, and 430 prosthetic eye wear-
ers from throughout New Zealand completed a questionnaire about their experi-
ences with ocular prostheses. Included with the questionnaire was an invitation to
participate in further prosthetic eye research, and 330 prosthetic eye wearers agreed
to do so. The results of this survey confirmed that mucoid discharge associated with
prosthetic eye wear was indeed high on patients’ list of concerns and that mucoid
discharge was widespread in New Zealand even though patients had good access to
prosthetic eye services.
A search of the literature and of ocular prosthetists’ websites was undertaken to
investigate what was known about the causes of discharge and to gain an under-
standing of the range of treatments for mucoid discharge associated with prosthetic
eye wear. This search produced a comprehensive list of known specific causes of
mucoid discharge, but there remained a large and under-investigated group of
patients with non-specific discharge for which many contradictory and inconsistent
causes and treatments had been postulated. A survey of members of the American
Society of Ocularists in 2007 carried out by K. L. Osborn and D. Hettler also found
that a standardised set of treatment protocols for managing discharge was lacking.
Further analysis of the responses from the New Zealand survey provided evi-
dence of an association between the frequency of prosthetic eye cleaning and sever-
ity of discharge. Unfortunately, the direction of cause and effect could not be
established – either frequent cleaning was causing the discharge or the discharge
itself was the reason patients cleaned more frequently. To resolve this issue, further
research into the socket’s response to prosthetic eye wear was planned. This research
involved an examination of surface deposition on prosthetic eyes (which 47 % of
ocular prosthetists’ websites claimed was a main cause of mucoid discharge) and
examination of the conjunctiva of the anophthalmic socket.
However, surface deposits could not be investigated unless a technique was
found to enable them to be seen, and neither deposits nor the conjunctiva could be
examined unless measuring tools were developed for this purpose. A staining tech-
nique to make surface deposits more visible was found, and for the first time it was
possible to investigate changes in the amount and extent of deposition on prosthetic
eyes. It was then necessary to develop and test equal interval photographic grading
scales to measure these changes. At the same time, equal interval photographic
grading scales were also developed to measure the severity of conjunctival inflam-
mation in anophthalmic sockets.
The staining technique and the tools to measure surface deposition on prosthetic
eyes and the severity of conjunctival inflammation were used successfully to pro-
vide a quantitative assessment of prosthesis cleaning effectiveness and to identify
Preface vii

associations between deposits and discharge and deposits and conjunctival inflam-
mation. Again, the direction of cause and effect of these associations could not be
established at that stage. Evidence was found, however, that suggested that surface
deposits themselves did not inflame the conjunctiva or cause discharge in anoph-
thalmic sockets where the prosthesis was cleaned infrequently.
The next set of experiments was designed to understand more about the charac-
teristics of deposition and to find if a causal link could be established for the asso-
ciation between deposits, inflammation and discharge. The experiments involved
both in vitro and in vivo tests of surface wettability and deposition rates on different
prosthetic eye surface finishes. It was found from these experiments that rates of
deposition were influenced by surface finish and that the presence of deposits caused
a significant improvement in surface wettability. It seemed likely that the improved
surface wettability would allow prosthetic eyes to be lubricated more effectively by
the socket fluids, thereby reducing mechanical irritation of the conjunctiva. The
evidence was building to suggest that the presence of at least some deposits was not
only not harmful but actually beneficial, causing reduced conjunctival inflammation
and discharge in anophthalmic sockets with prosthetic eyes.
This concept was further explored in the next study. It described the build-up of
deposits over time and investigated the two distinctly different areas of deposition
revealed by the deposit staining process: the inter-palpebral zone where stained
deposits are mostly absent and the areas in continuous contact with the conjunctiva
where deposits mostly settle. The deposits in the inter-palpebral zone appeared to
behave like deposits on contact lenses where they may dry out and irritate the pal-
pebral conjunctiva, whereas the presence of deposits elsewhere on the prosthesis
appeared to be beneficial.
The combined results of all the investigations culminated in a hypothesis for a
three-phase model of the anophthalmic socket’s response to prosthetic eye wear and
a protocol for the management of non-specific mucoid discharge – these topics are
discussed fully in Chaps. 8 and 9, respectively.
This book, then, derives from the research described above and the successful
amalgamation of a research team comprising an ocular prosthetist, an optometrist
and an oculo-plastic surgeon. It contains a mix of scientific evidence and clinical
experience and includes inferences based on material from other disciplines that are
applied to the field of ocular prosthetics but which are in need of corroboration.
The book is written primarily for clinicians and caregivers who have contact with
prosthetic eye wearers including ocular, maxillofacial and anaplastology prosthe-
tists, ophthalmologists, ophthalmic nurses, optometrists and students of these disci-
plines. The book is also a useful resource for other health workers and family
members who care for prosthetic eye patients and for those patients who require a
deeper understanding of the issues affecting them and their prosthesis than what is
currently available elsewhere. The language used in the book may be more technical
for some readers than for others, but a glossary of terms is provided and over 400
illustrations add additional explanatory power to the text.
It is anticipated that most readers will consult individual chapters for specific
information or for leads to reference material on specific topics of interest. However,
viii Preface

many readers will be led down interesting byways because of the breadth of infor-
mation available and the linking of different topics within the text. For example, the
theory of colour is linked to iris painting; socket complications have both prosthetic
and surgical solutions; the anatomy of extraocular muscles is linked to orbital
implants and prosthetic eye motility.
The book opens with a discussion of the biosocial and psychological aspects of
eye loss and goes on to describe the anatomical and physiological features of the
face and eyes that are relevant to ocular prosthetics. The causes of anophthalmia and
disfigurement of the eye and the implications of congenital anophthalmia and
microphthalmia for young children are discussed, and surgical procedures for
removing the eye are described.
Subsequent chapters discuss techniques for evaluation of ocular prosthesis
patients; techniques for making and fitting ocular prostheses, scleral shell prosthe-
ses and prosthetic contact lenses; the response of the socket to prosthetic eyes; and
the ongoing care and maintenance of prosthetic eyes. The penultimate chapter pro-
vides advice for people who wear prosthetic eyes, and the final chapter summarises
the history of prosthetic eyes and identifies the various organisations that form the
foundation for the ongoing professional development in ocular prosthetics.
Acknowledgements

As lead author, it falls to me to firstly acknowledge the enormous contribution of my

fellow authors. We have worked together now for 6 years and their dedication and
commitment to the advancement of knowledge in the prosthetic eye field has been
an inspiration to me. The book has had input from many people but in particular,
Michael Williams, Maxillofacial prosthetist, Maxillofacial & Dental Unit, Waikato
Hospital who contributed valuable input to Chap. 5 in particular, Dr James Partridge,
Chief Executive of Changing Faces (UK) who provided expert advice while we
were preparing Chaps. 1 and 10, and Neil Handley, Curator of the British Optical
Association Museum who contributed both expert knowledge and photographs.
Julia Drok created the better diagrams in the book and converted text and photo-
graphs to Springer’s house style.
The University of Auckland has provided the scholarly environment for the cre-
ation of this book but support has also come from the many optometrists and oph-
thalmologists who work closely with the New Zealand Artificial Eye Service and
from the hundreds of anophthalmic patients who have given freely of their time to
be either research participants or photographic subjects. Springer is also thanked for
sharing the vision to bring this book to press.
Finally, no project of this magnitude can be accomplished without the support of
friends, partners and families, and we three authors are very grateful to ours for their
forbearance and love over many years.

Keith Pine

ix
Contents

1 The Anophthalmic Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Epidemiology of Eye Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2.1 Estimated Size of the Anophthalmic Population . . . . . . . . . 2
1.2.2 Aetiology of Eye Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2.3 Changing Causes of Eye Loss . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 Perceptual Changes Accompanying Eye Loss . . . . . . . . . . . . . . . . . 6
1.4 Psychosocial Issues Associated with Eye Loss . . . . . . . . . . . . . . . . 7
1.4.1 Loss of Body Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4.2 Novelty Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.4.3 The Psychological Importance of Prosthetic
Eye Comfort and Convenience . . . . . . . . . . . . . . . . . . . . . . 10
1.5 Phantom Eye Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.6 Concerns of Prosthetic Eye Wearers . . . . . . . . . . . . . . . . . . . . . . . . 11
1.7 Psychological Issues for Children . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.8 Personal Accounts of Eye Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

2 Anatomy and Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.1.1 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.2 Facial Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.3 Surface Anatomy of the Eye and Eyelids . . . . . . . . . . . . . . . . . . . . 28
2.4 The Skull and Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.1 The Skull . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.4.2 The Orbit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.5 Orbital Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.5.1 The Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.5.2 Optic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.5.3 The Extraocular Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.5.4 Levator Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.5.5 Lacrimal Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.5.6 Lacrimal Sac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

xi
xii Contents

2.5.7 Orbital Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

2.5.8 Blood Vessels and Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.6 Muscles of the Forehead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.6.1 Muscles of the Forehead . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.7 The Eyelids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.8 The Conjunctiva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.8.1 The Palpebral Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.8.2 The Bulbar Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.8.3 Forniceal Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.9 Sensitivity of the Conjunctiva and Cornea. . . . . . . . . . . . . . . . . . . . 44
2.10 Structure of the Conjunctiva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.10.1 The Substantia Propria Layer of the Conjunctiva . . . . . . . . 46
2.10.2 The Epithelial Layer of the Conjunctiva . . . . . . . . . . . . . . . 46
2.10.3 Goblet Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.10.4 Function of Mucus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.11 The Lacrimal Apparatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.12 Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.12.1 Function of Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.12.2 Tear Film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
2.12.3 Tear Output . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
2.12.4 Tear Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.13 Facial Changes Due to Ageing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.14 Loss of the Ocular Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
2.14.1 Prosthetic Eye Motility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.14.2 Conjunctiva of the Anophthalmic Socket . . . . . . . . . . . . . . 57
2.14.3 Tear Film with a Prosthetic Eye . . . . . . . . . . . . . . . . . . . . . . 59
2.14.4 Tear Output with a Prosthetic Eye . . . . . . . . . . . . . . . . . . . . 60
2.14.5 Tear Distribution with a Prosthetic Eye . . . . . . . . . . . . . . . . 60
2.14.6 Post-enucleation Socket Syndrome (PESS) . . . . . . . . . . . . . 61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

3 Anophthalmia and Disfigurement of the Eye . . . . . . . . . . . . . . . . . . . . 67

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2 Congenital Anophthalmia and Microphthalmia. . . . . . . . . . . . . . . . 68
3.2.1 Treatment for Anophthalmia and Microphthalmia
in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.3 Disfigurement of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.3.1 Corneal Tattooing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.4 Surgical Removal of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.4.1 Enucleation Versus Evisceration . . . . . . . . . . . . . . . . . . . . . 73
3.4.2 Enucleation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.4.3 Evisceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.4.4 Postsurgical Care Following Enucleation
and Evisceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.4.5 Postsurgical Conformer Shells . . . . . . . . . . . . . . . . . . . . . . . 80
3.4.6 Intraorbital Implants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Contents xiii

3.5 Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

4 Patient Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.2 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3 Psychological Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.4 Assessment of Visual Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.5 Health of the Remaining Sighted Eye . . . . . . . . . . . . . . . . . . . . . . . 94
4.6 Assessment of an Existing Prosthetic Eye In Situ . . . . . . . . . . . . . . 95
4.7 Assessment of Prosthetic Eye Ex Situ . . . . . . . . . . . . . . . . . . . . . . . 96
4.8 Assessment of the Anophthalmic Socket . . . . . . . . . . . . . . . . . . . . . 99
4.8.1 Assessment of Tears in Anophthalmic Sockets . . . . . . . . . . 104
4.9 Assessment of Inflammation of the Anophthalmic Socket . . . . . . . 110
4.9.1 Assessment of Meibomian Gland Loss . . . . . . . . . . . . . . . . 112
4.9.2 Assessment of Mucoid Discharge . . . . . . . . . . . . . . . . . . . . 112
4.9.3 Assessment of Surface Papillary Texture
of the Conjunctiva of the Socket . . . . . . . . . . . . . . . . . . . . . 113
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

5 Making and Fitting Prosthetic Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
5.2 Stock Versus Custom-Fit Prosthetic Eyes . . . . . . . . . . . . . . . . . . . . 118
5.3 Basic Colour Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
5.3.1 The Colour Wheel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
5.3.2 Characteristics of Colour . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5.4 Overview of Prosthetic Eye Making and Fitting . . . . . . . . . . . . . . . 122
5.5 Creating the Iris/Corneal Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
5.5.1 Premanufactured Iris Discs and Corneas . . . . . . . . . . . . . . . 124
5.5.2 Alternative Methods for Creating the Iris/Corneal Unit . . . . 125
5.6 Painting the Iris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
5.6.1 The Pupil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
5.6.2 The Collarette. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.6.3 The Stroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.6.4 The Limbus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
5.7 Impression Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
5.7.1 Ocular Tray Impression Technique . . . . . . . . . . . . . . . . . . . 131
5.7.2 Impression Mixing Gun Technique . . . . . . . . . . . . . . . . . . . 133
5.8 Casting the Impression and Preparing the Wax Pattern . . . . . . . . . . 134
5.8.1 Alternative Method for Creating the Wax Pattern
from an Impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
5.9 Trying in the Wax Pattern and Positioning the Iris/Corneal Unit . . . 138
5.9.1 Compromises and Trade-offs at the Try in Stage . . . . . . . . 139
5.9.2 Trying the Wax Pattern in the Socket and Positioning
the Iris/Corneal Unit When Fitting Bilateral
Prosthetic Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
xiv Contents

5.10 Processing the Wax Prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

5.11 Finishing the Prosthetic Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
5.12 Final Clinical Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

6 Scleral Shell Prostheses and Prosthetic Contact Lenses . . . . . . . . . . . 149

6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
6.2 Prosthetic Contact Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.1 Aniridia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.2 Corneal Leucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.3 Corneal Opacities or Scars . . . . . . . . . . . . . . . . . . . . . . . . . . 153
6.2.4 Iris Coloboma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.2.5 Cataract Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.2.6 Albinism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.2.7 Heterochromia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.2.8 Corneal Dystrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.2.9 In-House Tinting Systems for Soft Prosthetic
Contact Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.2.10 Hand-Painted Opaque Prosthetic Contact Lenses . . . . . . . . 158
6.3 Scleral Shell Prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6.3.1 Making and Fitting Medium or Thick Scleral Shell
Prostheses (1.5 mm to 2.5 mm Thickness) . . . . . . . . . . . . . 161
6.3.2 Making and Fitting Thin Scleral Shell Prostheses
(Less Than 1.5 mm in Thickness) . . . . . . . . . . . . . . . . . . . . 163
6.3.3 Thin Scleral Shell Prosthesis Design . . . . . . . . . . . . . . . . . . 163
6.3.4 Overview of the Making and Fitting Process. . . . . . . . . . . . 163
6.3.5 Taking an Impression of the Eye . . . . . . . . . . . . . . . . . . . . . 165
6.3.6 Trial Shell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
6.3.7 Construction of the Final Scleral Shell . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

7 Socket Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
7.2 General Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
7.3 Socket Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
7.3.1 Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
7.3.2 Granulomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
7.3.3 Chemosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
7.3.4 Giant Papillary Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . 180
7.4 Complications of Prosthesis Retention . . . . . . . . . . . . . . . . . . . . . . 180
7.4.1 Inadequate Socket Lining . . . . . . . . . . . . . . . . . . . . . . . . . . 180
7.4.2 Inadequate Fornix or Fornices . . . . . . . . . . . . . . . . . . . . . . . 184
7.4.3 Lower Eyelid Laxity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
7.4.4 Combined Surgical and Prosthetic Approach . . . . . . . . . . . 186
7.5 Complications of Prosthesis Stability . . . . . . . . . . . . . . . . . . . . . . . 190
Contents xv

7.5.1 Inadequate Prosthesis Retention . . . . . . . . . . . . . . . . . . . . . 190

7.5.2 Prosthesis Instability Within the Socket . . . . . . . . . . . . . . . 190
7.6 Complications of Prosthesis Motility. . . . . . . . . . . . . . . . . . . . . . . . 196
7.6.1 Inadequate Prosthetic Eye Motility . . . . . . . . . . . . . . . . . . . 197
7.6.2 Excessive Prosthetic Eye Motility . . . . . . . . . . . . . . . . . . . . 198
7.7 Orbital Volume Deficit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
7.7.1 Orbital Volume Replacement . . . . . . . . . . . . . . . . . . . . . . . . 200
7.7.2 Expanded Orbital Volume . . . . . . . . . . . . . . . . . . . . . . . . . . 204
7.8 Superior Sulcus Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
7.8.1 Prosthetic Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
7.8.2 Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
7.9 Eyelid Malposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
7.9.1 Ectropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
7.9.2 Entropion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
7.9.3 Ptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
7.9.4 Lagophthalmos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
7.10 Summary of Socket Complications and Surgical
and Prosthetic Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

8 Deposit Build-Up on Prosthetic Eyes

and a Three-Phase Model of Prosthetic Eye Wear . . . . . . . . . . . . . . . 219
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
8.2 Tear Protein Deposits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
8.2.1 Information About the Nature of Deposits
from Contact Lens Research . . . . . . . . . . . . . . . . . . . . . . . . 220
8.2.2 Deposit Build-Up on Prosthetic Eyes . . . . . . . . . . . . . . . . . 221
8.3 Effects of Prosthesis Removal, Cleaning and Reinsertion . . . . . . . . 228
8.3.1 Physical Stress Associated with Removal
and Reinsertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
8.3.2 Introduction of Bacteria and Foreign Material . . . . . . . . . . 229
8.3.3 Disturbed Socket Environment . . . . . . . . . . . . . . . . . . . . . . 230
8.3.4 Changed Surface Characteristics of the Prosthesis . . . . . . . 231
8.4 Three-Phase Model of Prosthetic Eye Wear . . . . . . . . . . . . . . . . . . 231
8.4.1 Establishment Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
8.4.2 Equilibrium Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
8.4.3 Breakdown Phase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
8.5 Application of Model to Personal Prosthetic Eye Maintenance . . . 236
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

9 Mucoid Discharge Associated with Prosthetic Eye Wear . . . . . . . . . . 241

9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
9.2 Specific Causes of Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
9.2.1 Viral or Bacterial Infections . . . . . . . . . . . . . . . . . . . . . . . . . 242
9.2.2 Eyelid-Related Pathologies . . . . . . . . . . . . . . . . . . . . . . . . . 243
xvi Contents

9.2.3 Environmental Allergens . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

9.2.4 Environmental Irritants and Eye Stress . . . . . . . . . . . . . . . . 247
9.2.5 Socket-Related Irritants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
9.2.6 Prosthesis-Related Irritants . . . . . . . . . . . . . . . . . . . . . . . . . 247
9.3 Non-specific Causes of Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . 251
9.4 Contact Lens Experience with Tear Protein Deposits,
Papillary Conjunctivitis and Discharge . . . . . . . . . . . . . . . . . . . . . . 252
9.5 Personal Prosthetic Eye Cleaning Regimes
and Professional Polishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
9.6 Proposed Protocol for Managing Non-specific Mucoid Discharge. . . 254
9.6.1 The Protocol Has Five Elements as Follows . . . . . . . . . . . . 255
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

10 Living with a Prosthetic Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
10.2 Handling Social Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
10.3 Reduced Peripheral Vision and Altered Depth Perception . . . . . . . 262
10.3.1 Compensating for Reduction of Horizontal Visual Range . 262
10.3.2 Compensating for Altered Depth Perception . . . . . . . . . . . . 263
10.3.3 Additional Cues to Depth Perception . . . . . . . . . . . . . . . . . 268
10.3.4 Utilizing Other Senses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
10.3.5 Driving with Monocular Vision . . . . . . . . . . . . . . . . . . . . . . 268
10.4 Personal Socket Hygiene and Prosthetic Eye Care . . . . . . . . . . . . . 272
10.5 Caregiver Guide to Removing and Inserting a Prosthetic Eye. . . . . 273
10.6 Patient Guide to Removing and Inserting a Prosthetic Eye . . . . . . . 275
10.7 Cleaning Prosthetic Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
10.8 Selecting Glasses for Protection and Camouflage . . . . . . . . . . . . . . 278
10.9 Further Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

11 History of Ocular Prosthetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
11.2 Ancient Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
11.3 3000 BC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
11.4 2000 BC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
11.5 Sixteenth Century. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
11.6 Seventeenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
11.7 Eighteenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
11.8 Nineteenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
11.9 Twentieth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
11.10 Twenty-First Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
11.11 Contact Lenses and Scleral Shell Prostheses . . . . . . . . . . . . . . . . . 310
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
List of Figures

Fig. 1.1 Eye loss as a function of age (using 10-year age bands)
Fig. 1.2 Main causes of eye loss. Medical and accidental causes are shown
separately
Fig. 1.3 Gender mix of eye loss due to accident
Fig. 1.4 Causes of eye loss in New Zealand over time
Fig. 1.5 Shadow stereopsis where images of shadows are fused stereoscopically
Fig. 1.6 The corneal opacity in this right eye, while less disfiguring than an
enucleated eye, is still psychologically distressing for this patient
Fig. 1.7 Concerns of patients when they first lost their eye compared with their
concerns at least 2 years later
Fig. 1.8 Fashionable impact-resistant glasses
Fig. 1.9 ‘Elli’ can be ordered free of charge for children with retinoblastoma via
email to [email protected]
Fig. 1.10 ‘When my husband Reese and I were fencing contractors, we moved
around a lot and lived in tents on the properties we worked on. In 1974
we were clearing old fencing wire from a kiwifruit orchard. I cut a wire
and one end sprang up and struck my right eye’. Mona Davies is a farmer
(emphatically not just a ‘farmer’s wife’!). She has worked hard all her
life and now lives comfortably on an 800 acre coastal farm. She and
Reese run sheep and cattle as well as four beachfront cottages which
they rent out to fishing parties and families. Their two children farm
their own coastal blocks on either side of Mona’s and Reece’s land, and
not a day goes by when Mona does not see them or her three grandchil-
dren. Mona took the loss of her eye like she does with most things in life:
‘she put up with it and moved on’. It wasn’t the damage to her appear-
ance that concerned her so much as the difficulty she had parking the car
and reading the ground hollows when going about the farm
Fig. 1.11 Natahlie is a bright and happy 3-year-old who lives on a farm. One
morning a rooster flew at the apple Natahlie was eating but pecked at
her right eye instead, resulting in Natahlie losing the eye. Natahlie was
excited about getting her prosthetic eye and couldn’t wait to check it out
in the mirror. In the years ahead, she will depend on her family, teachers
and friends to reinforce the positive aspects of being such a unique
individual

xvii
xviii List of Figures

Fig. 1.12 Greg’s right eye was injured during a difficult birth, and while surgeons
offered to operate on it at the time, his parents refused because they
could not bear for him to go through any more traumas. Indeed, the
experience was so painful for them that they ignored his eye’s different
appearance and never spoke about it. Partly because of this lack of
acknowledgment and partly because of the teasing he suffered from
other children at school, Greg developed very low self-esteem and a
shyness that limited his schooling and his ambitions. Even so, Greg
became a quality assurance manager, but it wasn’t until a new partner
(who happened to have a degree in psychology) persuaded him to seek
help that he obtained life-changing scleral shell prosthesis at age 31
Fig. 1.13 Sue (aged 60) lost the sight of her right eye to endophthalmitis follow-
ing a corneal transplant. For 2 years her eye became more and more
unsightly, but she could not face having it removed. ‘Eyes are the win-
dows of the soul. It is much harder to lose an eye than to lose other body
parts because of the emotional aspects’. Sue eventually plucked up the
courage to have her eye removed. ‘I should have had my eye out sooner.
I wish I had not put myself through such prolonged emotional turmoil’
Fig. 1.14 Mike (aged 50) lost his left eye when he fell on a metal fence post while
erecting a fence on a road construction assignment. He remembers that
his major concern at the time was not damage to his appearance, but
adjusting to using his right eye instead of his left for precision measur-
ing and sighting a theodolite. Mike overcame this problem and contin-
ued with his job as a roadwork supervisor where he often jokes about
his prosthetic eye with his fellow workers. ‘It’s a good excuse when I
make a mistake’. Mike’s open, pragmatic approach is genuine and
reflects the fact that for him, the loss of an eye was never a big issue. He
is careful to look after his remaining eye however and to ensure that his
prosthesis is properly maintained
Fig. 1.15 Tracey was born with a microphthalmic right eye. She was teased at
school to the point where she lost all self-confidence and belief. This
affected her attitude to life and her education, and she became a miser-
able teenager with anorexia and bulimia. Things improved for Tracey
after her eye was enucleated at age 21, and she had happier times in her
20s. Now in her 40s, Tracey is forward-looking and enthusiastic about
her job as a systems manager. She has accepted that there are many
more important things in her life than worrying about her eye
Fig. 1.16 Diane (aged 80) has worn a prosthetic eye since her right eye was
removed at age 12. Diane’s first prostheses were made of glass, and she
well remembers selecting her glass eyes from an assortment laid out on
trays. She also remembers breaking her glass eye and the drama and
stress this caused her poor mother who had to rush her to the optome-
trist to find a replacement. Diane always left her prosthesis out at night
and one morning she couldn’t find it. She was very upset because
nobody had ever seen her without her prosthesis, and she has vivid
recollections of ripping her bedroom apart before discovering the eye
List of Figures xix

mixed up in her blankets. Having only one eye has not prevented her
from doing anything she would not have done otherwise – ‘it’s just felt
different’
Fig. 1.17 When Raewyn’s right eye was lacerated by a piece of wire at age 40,
her life took a dramatic turn for the worse. Her eye became more and
more unsightly as her cornea opacified, and she became very self-con-
scious about her appearance. The stress contributed to the breakdown
of her marriage, but after this happened she was forced to take stock of
her situation. She had two children to bring up, looked awful and had
no career. So what did she do? She began training as a midwife, quali-
fying a few years later. Raewyn has delivered thousands of babies since
then and is now a pregnancy consultant providing expert advice to
young mothers. Raewyn’s disfigured eye was finally eviscerated in
2007, and she was fitted her new prosthetic eye. ‘The difference was
amazing. For years I put up with a horrible looking eye and in 6 short
weeks I was suddenly normal. I should have had my eye out years ago’.
Raewyn is proud of overcoming the loss of her eye and going on to
make a difference in her life and in the lives of others
Fig. 2.1 The ‘ideal’ face divides into horizontal thirds and vertical fifths
Fig. 2.2 In the adult face, the eyes are usually separated by one horizontal pal-
pebral width across the bridge of the nose
Fig. 2.3 The eyes are a principal determinant of the appearance of facial
symmetry
Fig. 2.4 Gross anatomy of the eye and eyelids
Fig. 2.5 The pupil is usually positioned supero-medial to the centre of the iris
Fig. 2.6 The medial third of the upper eyelid angles down towards the nose
Fig. 2.7 The upper eyelid crease is formed where the anterior expansions of the
levator aponeurosis muscle joins the skin
Fig. 2.8 The skull is made up of 21 bones immovably joined together and one
moveable bone, the mandible
Fig. 2.9 Transverse section of the skull showing the pyramidal shape of the
orbit. Note the short length of the lateral orbital wall compared to the
medial wall
Fig. 2.10 Enucleated human eye
Fig. 2.11 The eye
Fig. 2.12 Sagittal view of the extraocular muscles
Fig. 2.13 Anterior view of the extraocular muscles
Fig. 2.14 The supero-nasal notches in prosthetic eyes accommodate the trochlea
Fig. 2.15 Anterior view of the right eye showing the direction of movements of
the eye
Fig. 2.16 Eyelid characteristics differ between Asians and others
Fig. 2.17 Facial muscles of the eyes and forehead
Fig. 2.18 Orbicularis oculi
Fig. 2.19 Anatomical features of the eyelids
Fig. 2.20 The conjunctiva is a single continuous mucous membrane with three
main regions
xx List of Figures

Fig. 2.21 The palpebral conjunctiva may be subdivided into marginal, tarsal and
orbital zones
Fig. 2.22 Ducts of the meibomian glands and the punctum can be seen here in the
marginal conjunctiva of a lower eyelid
Fig. 2.23 The conjunctival sac of a normal eye showing the unextended depth of
the fornices
Fig. 2.24 The vertical lines of the meibomian glands can be seen through the
transparent conjunctiva of the lower eyelid. The whitish area is the apo-
neurotic expansion from the inferior rectus and inferior oblique
muscles
Fig. 2.25 Mean touch thresholds (in mg/mm2) for the conjunctiva and cornea
using a hand-held 0.12 mm nylon suture Cochet-Bonnet aesthesiome-
ter. The lower the threshold score, the more sensitive the area
Fig. 2.26 Distribution of goblet cells in the conjunctiva of an eye with eyelids
everted
Fig. 2.27 Epithelium of the conjunctiva with goblet cells
Fig. 2.28 Lacrimal apparatus
Fig. 2.29 Tear glands
Fig. 2.30 Stained tear protein deposits on the surface of a prosthetic eye
Fig. 2.31 Triple-layer structure of tear film
Fig. 2.32 A meniscus of tear fluid formed at the margin of the lower eyelid
Fig. 2.33 Same patient wearing a left prosthetic eye at age 40 (left) and at age 81
(right)
Fig. 2.34 The arcus senilis (the greyish-white ring) of the cornea becomes more
pronounced in old age
Fig. 2.35 Following the loss of the globe, the anatomical features of the eyelids
do not change
Fig. 2.36 Following the loss of the globe, the eyelids lose support and collapse
into the empty socket
Fig. 2.37 A prosthetic eye is inserted to restore the eyelids to their original posi-
tion where they look and function much as they did before eye loss
Fig. 2.38 Sagittal view of an anophthalmic socket with orbital implant and pros-
thetic eye
Fig. 2.39 Transectional view of the right anophthalmic orbit with implant and
prosthetic eye. The illustrations show how the rectus muscles combine
with the orbital implant to produce movement in the prosthesis
Fig. 2.40 Tear film with a prosthetic eye
Fig. 2.41 This glass eye was made and fitted in Germany in 2014
Fig. 2.42 The glass eye worn in Fig. 2.41
Fig. 2.43 Orbital tissue changes following enucleation
Fig. 2.44 Retraction of the superior muscle complex and the inferior rectus result
in a recessed socket. This photograph shows a recessed right socket
with prosthesis in place
Fig. 2.45 Elements of post-enucleation socket syndrome (PESS)
Fig. 2.46 Right upper eyelid ptosis over a prosthetic eye
List of Figures xxi

Fig. 2.47 The right prosthetic eye has tilted backwards causing it to gaze upwards
and place forward and downward pressure on the lower eyelid
Fig. 2.48 The left upper eyelid sulcus is much deeper due to orbital volume
deficit
Fig. 2.49 Advanced left post-enucleation socket syndrome. This patient has deep
upper eyelid sulcus, a contracted socket and a backward tilted prosthe-
sis. The upper eyelashes point upwards from a retracted upper eyelid,
the lower eyelid is entropic and the eyelids do not fully close over the
prosthesis
Fig. 3.1 Fourteen-year-old patient with untreated unilateral anophthalmia
adversely affecting facial symmetry
Fig. 3.2 Computed tomographic image of the skull of the young woman in Fig.
3.1. The left orbit is considerably smaller than the right orbit
Fig. 3.3 Unilateral microphthalmia
Fig. 3.4 Series of custom-made conformers used to stimulate socket growth
from age 1 month to when the socket is finally ready for a more perma-
nent ocular prosthesis
Fig. 3.5 Ten-month-old patient wearing clear conformers over his microphthal-
mic eyes. As well as stimulating orbital growth, the conformers lift the
eyelids away from the pupil, enabling ongoing visual stimulation,
which is vital for visual development
Fig. 3.6 Disfigured non-phthisical left eye fitted with a prosthetic contact lens
Fig. 3.7 Phthisical right eye fitted with a scleral shell prosthesis
Fig. 3.8 Collapsed remnant of the globe fitted with a prosthetic eye
Fig. 3.9 The eye is made ready for the enucleation procedure
Fig. 3.10 The corneal limbus is dissected and the conjunctiva and Tenon’s cap-
sule are drawn aside
Fig. 3.11 The extraocular muscles are tagged with sutures and cut away from the
globe
Fig. 3.12 The optic nerve is severed
Fig. 3.13 The globe is removed
Fig. 3.14 The orbital cavity without the eyeball. The free ends of the extraocular
muscles are held back with sutures
Fig. 3.15 A hydroxyapatite orbital implant is inserted into the cavity
Fig. 3.16 The conjunctiva is drawn over the wound and closed with sutures
Fig. 3.17 Painful inflamed eye with corneal ulcer and hypopyon
Fig. 3.18 An incision is made around the cornea and Tenon’s capsule is under-
mined back to the insertions of the extra ocular muscles
Fig. 3.19 The button of corneal tissue is excised
Fig. 3.20 The entire ocular content is removed with an evisceration spoon
Fig. 3.21 The sclera is cleaned and any residue of uveal pigment is denatured
with 100 % ethanol
Fig. 3.22 One or two radial slits are made inside the scleral cavity, allowing it to
expand to accommodate a silicon implant
Fig. 3.23 The edges of the scleral wound are about to be overlapped and secured
with mattress stitches
xxii List of Figures

Fig. 3.24 Tenon’s layer has been sutured and the conjunctiva closed. A postsurgi-
cal conformer is ready to be placed in the eye socket
Fig. 3.25 Conformers with holes to facilitate the flow of socket secretions. The top
three are made from PMMA and the lowest one is made from silicon
Fig. 3.26 Implants of various materials and designs range from a hollow glass
sphere used by Mules in 1885 (top left) to a hydroxyapatite orbital
implant introduced by Dr Arthur Perry 100 years later (bottom right). A
Troutman implant (middle left) used a magnet to hold the prosthesis
while the Castroviejo (middle) and the Allen (middle right) implants
were made of (poly) methyl methacrylate. Spheres of gold (middle top),
silicone (middle bottom) and acrylic (bottom left) have also been used
Fig. 3.27 Pegged hydroxyapatite implant
Fig. 3.28 Chronic mucoid discharge associated with a motility peg
Fig. 3.29 Total orbital exenteration
Fig. 3.30 Orbital exenteration with retained eyelid skin and orbicularis muscle
tissue
Fig. 3.31 Orbital exenteration has extended to the removal of additional diseased
bone
Fig. 3.32 Orbital exenteration with full-thickness skin graft
Fig. 3.33 Shallow or non-existent socket with limited room for a prosthesis
Fig. 3.34 This woman had her left orbit exenterated due to adenocystic carci-
noma (top photograph). Her eyelid skin and orbicularis muscle tissue
were conserved (middle photograph) and her eye was restored with an
adhesive-retained prosthesis (bottom photograph)
Fig. 3.35 Implants have been placed to support a prosthetic restoration
Fig. 3.36 Orbital prosthesis in mould. It incorporates magnets positioned to con-
nect with the implants seen in Fig. 3.35
Fig. 3.37 Orbital prosthesis held in place with implants and magnets
Fig. 4.1 Large variety of patients presenting for a prosthetic eye. They all have
different needs and expectations
Fig. 4.2 All iris colours and patterns are the result of genetics. This iris resulted
from the introduction of a blue-eyed Scotsman to a family line of
brown-eyed New Zealand Maori five generations previously
Fig. 4.3 The health of the remaining sighted eye is evaluated using a slit lamp
Fig. 4.4 Chart for recording measurements of prosthetic eye symmetry
Fig. 4.5 The right prosthetic eye and eyelids have slumped relative to the com-
panion eye. The top broken line indicates that the level of the upper
eyelid has dropped about 6.0 mm from the horizontal. The middle bro-
ken line indicates that the iris/pupil has dropped 4.0 mm, and the lower
broken line indicates that the lower eyelid has also dropped about
4.0 mm
Fig. 4.6 The left prosthetic eye is recessed 4.0 mm relative to the companion eye
Fig. 4.7 An entropic lower eyelid, evidence of mucoid discharge and dried tear
protein deposits on the surface of this prosthetic eye are apparent in this
photographic record
List of Figures xxiii

Fig. 4.8 Photographic record of the extent of medial and lateral movements of a
left prosthetic eye. The medial excursion is greater than the lateral
excursion, which is common
Fig. 4.9 Photographic record of patient looking down with one eye and involun-
tarily looking up with the other prosthetic eye
Fig. 4.10 The veneer has cracked at the limbus of a prosthetic eye
Fig. 4.11 Cracks (highlighted by staining) have appeared between the veneer and
the base material at the periphery of this prosthetic eye
Fig. 4.12 A prosthetic eye being lowered into a container of dental plaque dis-
closing gel diluted in .85 % saline solution. The active ingredient in this
staining solution is Rose Bengal
Fig. 4.13 Staining has revealed tooling marks on the posterior surface of this
poorly finished prosthetic eye
Fig. 4.14 A small chip is apparent on the periphery of this prosthetic eye
Fig. 4.15 General wear and tear over time has resulted in micro-scratches, a dull
surface and dried deposits on the surface of this prosthetic eye
Fig. 4.16 Crazed clear veneer due to the use of a solvent to clean the prosthesis
Fig. 4.17 Partial delamination of the PMMA veneer shows as speckles of light in
the pupil of this prosthetic eye
Fig. 4.18 Dried tear protein deposits can be seen on the palpebral surface of this
prosthetic eye
Fig. 4.19 Stained tear protein deposits on the surface of a prosthetic eye. Note the
absence of deposits in the inter palpebral area
Fig. 4.20 Deep right anophthalmic socket with no orbital implant
Fig. 4.21 Left anophthalmic socket with pegged hydroxyapatite orbital implant
Fig. 4.22 Right anophthalmic socket with epithelial tissue graft inside the lower
eyelid
Fig. 4.23 Right anophthalmic socket with full-thickness tissue reconstruction of
the lower eyelid
Fig. 4.24 Microphthalmic left eye
Fig. 4.25 Remnants of a ruptured left globe
Fig. 4.26 Phthisical left eye with opaque cornea
Fig. 4.27 Phthisical eye with a Gunderson conjunctival flap covering the cornea
Fig. 4.28 Enucleation due to acid burns. The superotemporal fornix needs to be
deepened before a prosthetic eye can be retained
Fig. 4.29 The PMMA spherical implant in the anophthalmic socket has migrated
forward and is covered by very thin conjunctival tissue. It is stable but
needs to be monitored
Fig. 4.30 The upper eyelid has been torn away, and surgery is required before a
prosthetic eye can be retained
Fig. 4.31 The Castroviejo implant in this socket has migrated forward and can
now be seen clearly through the thin conjunctival covering
Fig. 4.32 Exposure of a tantalum mesh orbital implant
Fig. 4.33 White sutures can be seen clearly through the conjunctiva. These may
become exposed and require removal
xxiv List of Figures

Fig. 4.34 A pyogenic granuloma has formed in this left socket due to wearing a
deeply vaulted stock prosthetic eye for many years
Fig. 4.35 The prosthesis that caused the pyogenic granuloma in Fig. 4.34
Fig. 4.36 The contact lens seen here is analogous with prosthetic eye use in that
a foreign material is in contact with the conjunctiva, and they both share
similar eyelid action, bathe in the same ocular fluids and accumulate
surface deposits
Fig. 4.37 A phenol red thread testing kit
Fig. 4.38 The phenol red thread test for measuring tear volume
Fig. 4.39 Type II ocular tear ferning pattern (tears from a prosthetic eye)
Fig. 4.40 Type III ocular tear ferning pattern (tears from a prosthetic eye)
Fig. 4.41 A Tearscope being used to measure tear film break-up time
Fig. 4.42 Equal interval photographic grading scales for measuring conjunctival
inflammation
Fig. 4.43 Photographic grading scales are in common use in optometry
Fig. 4.44 Two InflammaDry devices side by side. The display in the top device
shows a single band (no inflammation detected), while the window in
the bottom device shows a double band (inflammation detected)
Fig. 4.45 Meibomian gland loss is apparent in the left anophthalmic socket of
this patient compared with the right companion eye
Fig. 4.46 Visual analogue scales for measuring the four characteristics of mucoid
discharge
Fig. 4.47 The glob of mucoid discharge seen in this socket has collected behind
the prosthetic eye
Fig. 4.48 Photographic record of discharge severity. Mucoid discharge is not
associated with conjunctival inflammation in this socket
Fig. 4.49 A rough surface papillary texture is apparent in the lower tarsal and
forniceal conjunctiva of this anophthalmic socket
Fig. 4.50 Giant papillary conjunctivitis of the upper tarsal conjunctiva of an
anophthalmic socket
Fig. 5.1 Used stock PMMA prosthetic eye manufactured in India
Fig. 5.2 Rod and cone cells in the retina of the eye
Fig. 5.3 CMYK subtractive colour diagram
Fig. 5.4 A basic palette might include the colours (from left to right): ivory
black, titanium white, Vandyke brown, cobalt blue, yellow ochre, raw
sienna and burnt sienna
Fig. 5.5 A vernier gauge for measuring the iris diameter
Fig. 5.6 Assorted iris discs with matching corneal buttons
Fig. 5.7 Iris disc and clear corneal button with pupil
Fig. 5.8 Metal dies for making iris discs and clear corneal buttons
Fig. 5.9 Sticky wax rod attached to an iris disc for easy handling during
painting
Fig. 5.10 A drop of water previews the final appearance of iris colours when
sandwiched between the corneal button and the freshly painted iris
List of Figures xxv

Fig. 5.11 Custom-designed metal mould for creating iris/corneal units with four
black tinted cold-cure iris blanks ready for turning on a lathe
Fig. 5.12 PMMA blank is turned to the required iris diameter. The pupil is cre-
ated off-centre using a squared-off drill bit
Fig. 5.13 The iris disc is painted to match the patient’s iris
Fig. 5.14 A clear cornea is processed over the painted iris blank and turned to the
required iris diameter
Fig. 5.15 It is recommended that the iris is painted under a magnifying lamp
Fig. 5.16 Individual components of the iris
Fig. 5.17 An arcus senilis strongly characterises the appearance of this elderly
patient’s iris
Fig. 5.18 Polyvinylsiloxane impression taken without an impression tray. Note
the shape of the underside of the upper eyelid and the extension under
the lower tarsal plate
Fig. 5.19 Ocular impression tray
Fig. 5.20 Disposable syringe used in conjunction with an ocular impression tray
Fig. 5.21 Impression material has been injected into the socket via the hollow
stem of the ocular tray
Fig. 5.22 An impression mixing gun with disposable mixing tip and a cartridge
containing fast set, heavy body polyvinylsiloxane impression material
Fig. 5.23 The cotton thread embedded in this impression provides an excellent
means by which the impression can be retrieved from the socket of a
child
Fig. 5.24 The impression is trimmed of excess material and fully immersed in a
one-part silicon mould
Fig. 5.25 The impression is removed by sectioning the mould
Fig. 5.26 Preheated white ocular wax is poured into the mould
Fig. 5.27 The wax pattern is cooled down and removed
Fig. 5.28 The anterior surface of the wax pattern is being trimmed to approximate
the shape of the anticipated prosthetic eye
Fig. 5.29 The completed wax pattern is ready to be inserted into the eye socket
Fig. 5.30 A backing for the wax pattern is made from shellac base plate. The
backing supports the wax pattern during the try-in stage
Fig. 5.31 The wax pattern is tried in the socket
Fig. 5.32 A clear plastic iris/corneal blank is positioned with the rod aligned in
central gaze
Fig. 5.33 Matching prosthetic eyes for blind patients can be challenging. This
patient’s right socket is shallow and small while her left socket is deeper
and larger
Fig. 5.34 The rod attaches the iris/corneal unit to the mould
Fig. 5.35 The prosthesis is trial packed with white PMMA
Fig. 5.36 Set up for final iris painting and scleral colouring
Fig. 5.37 The second layer of iris colours being applied
Fig. 5.38 Fine veins are teased from red embroidery thread and carefully laid on
the sclera in the same manner and amount as observed in the patient’s
companion eye
xxvi List of Figures

Fig. 5.39 A clear veneer of PMMA is then processed over the anterior surface
locking in the iris and scleral colours and restoring the cornea to its
original shape
Fig. 5.40 The prosthesis is buffed with a wet pumice mix using a calico mop
Fig. 5.41 The fine marks left by the pumice are removed with a polishing com-
pound such as tripoli
Fig. 5.42 Final polishing of a concave posterior surface using a hand-piece and
small polishing wheel
Fig. 5.43 The use of pumice, then tripoli and then Kenda 244-Blue to polish
PMMA produced surfaces that most resisted the adherence of bacteria
compared with other polishing regimes
Fig. 6.1 The cornea may be seen underlying thin conjunctival tissue following a
Gundersen flap procedure
Fig. 6.2 Basic prosthetic contact lens designs. (a) Occluding pupil mask with
clear iris portion. (b) Peripheral mask with opaque black pupil. (c)
Peripheral mask with clear pupil. (d) Translucent tinted lens. (e)
Translucent tinted peripheral mask with clear pupil
Fig. 6.3 Iris flaw following iridectomy. It may be masked with prosthetic con-
tact lens with an opaque peripheral mask and clear pupil
Fig. 6.4 Aniridia. It may be masked with prosthetic contact lens with a tinted or
opaque peripheral mask and clear pupil
Fig. 6.5 Corneal leucoma. It may be masked with a prosthetic contact lens with
an opaque peripheral mask and a clear or black pupil depending on
where the leucomas are located
Fig. 6.6 Full-thickness, total corneal opacity. It may be masked with a prosthetic
contact lens with an opaque peripheral mask and a black pupil
Fig. 6.7 Iris coloboma. It may be masked with a prosthetic contact lens with an
opaque peripheral mask and a clear pupil
Fig. 6.8 Cataract. A clear prosthetic contact lens with a black pupil improves
cosmesis when cataract surgery is not an immediate option and vision
is not useful
Fig. 6.9 The red appearance as well as the photophobia (both caused by light
passing through the iris) may be relieved by fitting a translucent tinted
prosthetic contact lens with a clear pupil if the photophobia is moderate
or an opaque prosthetic contact lens with clear pupil if the photophobia
is more severe
Fig. 6.10 Heterochromia. The colour discrepancy between the two eyes (the
affected eye has a grey iris) may be lessened with the use of tinted pros-
thetic contact lenses or tinted prosthetic contact lenses with clear pupils
Fig. 6.11 Corneal dystrophy. If the eyes are blind and the pupil is not discernable,
clear lenses with black pupils will improve cosmesis. If the pupils are
discernable and dark, translucent tinted lenses may mask the greyness
of the cornea while not compromising the level of vision. Finally,
opaque lenses with clear pupils may be a better option than tinted lenses
if a wider range of colours is needed and the optimum level of vision is
to be maintained
List of Figures xxvii

Fig. 6.12 In-house colouring kit for soft contact lenses

Fig. 6.13 This commercially available soft opaque lens with clear pupil does a
good job of masking the iris coloboma in this patient’s left eye but has
an unnatural iris texture
Fig. 6.14 Two examples of soft hand-painted prosthetic contact lenses
Fig. 6.15 Opaque cornea with a smaller palpebral fissure than the companion eye
Fig. 6.16 Distorted cornea following trauma
Fig. 6.17 Left strabismic eye with opaque cornea is masked with a scleral shell
prosthesis
Fig. 6.18 Completed medium thickness scleral shell prosthesis
Fig. 6.19 Premanufactured two-dimensional curved iris discs with corresponding
corneas
Fig. 6.20 Metal moulds for making two-dimensional curved iris discs
Fig. 6.21 Thin scleral shell design showing relieved areas
Fig. 6.22 Tetracaine or oxybuprocaine anaesthetic eye drops are recommended
for patients with clear sensitive corneas
Fig. 6.23 Polyvinylsiloxane impression taken using an ocular impression tray
without stem
Fig. 6.24 The two-part mould is ready to be packed with clear PMMA dough
Fig. 6.25 Iris disc painted directly onto the surface of a semitranslucent shell
Fig. 6.26 Iris and scleral colours drying under a lamp
Fig. 6.27 A polyurethane sheet protects the painted surface when a clear PMMA
veneer is trial packed
Fig. 6.28 The PMMA veneer is processed according to the manufacturer’s
instructions
Fig. 6.29 The edges of the hole are smoothed with a cotton thread and pumice
Fig. 6.30 Completed thin scleral shell prosthesis in situ
Fig. 6.31 Rubber suction devices are handy for removing and inserting scleral
shell prostheses
Fig. 7.1 This granuloma developed in the inferior bulbar conjunctiva after the
patient wore a deep vaulted stock prosthetic eye for many years
Fig. 7.2 Chemosis of the conjunctiva formed under a conformer shell which was
inserted following enucleation of the globe 5 weeks previously
Fig. 7.3 Extreme chemosis has developed in this socket due to irritation caused
by an extruding orbital implant
Fig. 7.4 The GPC evident under the upper eyelid of this microphthalmic eye has
persisted for many years even though the prosthesis has been well
maintained and steroid drops have been used regularly to reduce mucoid
discharge
Fig. 7.5 Non-retentive contracted socket with a shortage of conjunctival lining
and an absence of the inferior fornix
Fig. 7.6 The pressure conformer is held in position by a bandage
Fig. 7.7 An incision is made in the socket, and the scar tissue is released as
much as possible
Fig. 7.8 A full-thickness mucous membrane is harvested from the inner lower lip
Fig. 7.9 Full-thickness mucous membrane tissue
xxviii List of Figures

Fig. 7.10 The graft site in the lower lip is closed with sutures
Fig. 7.11 The graft is sutured into the surgical defect in the socket
Fig. 7.12 A patient’s old prosthesis is placed in the socket and secured with a
tarsorrhaphy to stabilise the graft and resist graft contraction
Fig. 7.13 Adhesions are accommodated loosely while the margins extend into the
fornix on either side
Fig. 7.14 Sutures hold down a bolster to deepen the inferior fornix
Fig. 7.15 A ridge is added to the front of the inferior edge creating a negative
curve
Fig. 7.16 A second method to help resolve lower eyelid laxity is to redistribute
pressure from the centre of the lower eyelid to the sides
Fig. 7.17 A strip of the tarsal plate is prepared to reattach the lid to the lateral
orbital rim
Fig. 7.18 The sutures are placed through the periosteum of the lateral orbital rim
Fig. 7.19 The tarsal strip secured to the lateral orbital rim
Fig. 7.20 Left eyelid-sparing exenteration for squamous cell carcinoma of the
ethmoid sinuses
Fig. 7.21 Custom-made conformer
Fig. 7.22 Custom-made conformer in place
Fig. 7.23 Self-retentive prosthetic eye with satisfactory cosmesis
Fig. 7.24 Retentiveness is enhanced by hollowing the back of the prosthesis
Fig. 7.25 This patient’s orbital implant has migrated forwards displacing his right
prosthetic eye
Fig. 7.26 This spherical implant has migrated into a superolateral position but is
stable behind very thin conjunctival tissue
Fig. 7.27 A migrated but stable Castroviejo orbital implant in medial, central and
lateral gaze
Fig. 7.28 The posterior surface is reconfigured to accommodate a migrated
orbital implant
Fig. 7.29 Exposed orbital implant
Fig. 7.30 The patch graft procedure begins by freeing the conjunctiva from the
implant in the immediate area of the defect
Fig. 7.31 The edges of the detached conjunctiva are draped over the graft and
sutured
Fig. 7.32 This right prosthetic eye is made roughly triangular or elliptical in
shape, rather than round to prevent rotation within the socket
Fig. 7.33 There are three axes of movement for the prosthesis within the anoph-
thalmic socket
Fig. 7.34 The margins may be trimmed as shown to increase anterior curvature
and reduce extensions into the fornices
Fig. 7.35 A gap has opened medially under the prosthesis during abduction of the
right prosthetic eye
Fig. 7.36 PMMA material is removed from just behind the edge of the prosthesis
so that the edge will settle into closer contact with the conjunctiva
List of Figures xxix

Fig. 7.37 A posterior platform is added to the prosthesis. The platform is designed
to prevent backward rotation of the prosthesis, to allow for a narrow
lower edge to engage the inferior fornix and to reduce some of the bulk
(and weight) of the prosthesis
Fig. 7.38 The conical anterior surface supports and wedges the eyelids apart
while minimising the overall bulk of the prosthesis
Fig. 7.39 The four rectus muscles are identified and the intra-conal space is
defined
Fig. 7.40 The largest spherical implant that can comfortably be accommodated
by the socket is chosen
Fig. 7.41 The implant is placed in the intra-conal space and the rectus muscles
sutured to it
Fig. 7.42 Any available remnants of Tenon’s capsule are closed in front of the
implant, and then the conjunctiva is closed without tension
Fig. 7.43 A temporary tarsorrhaphy is placed to control post-operative conjuncti-
val swelling
Fig. 7.44 Subperiosteal implants are designed to displace the orbital tissues
upwards and forwards restoring lost orbital volume and filling out a
deep upper eyelid sulcus
Fig. 7.45 Extra bulk added anterior to the superior edge may help correct upper
eyelid sulcus deformity and restore the upper eyelid crease
Fig. 7.46 A second ridge in front of the inferior edge, in conjunction with thin-
ning of the lower edge from the back, sets the prosthesis upright and
counters the potential backward displacement of the bulkier upper edge
Fig. 7.47 The prosthetic eye has improved (reduced) this patient’s right lower
eyelid ectropion
Fig. 7.48 The inward rotation of the eyelashes that is part of upper and lower eyelid
entropion has caused an accumulation of mucous on the prosthesis
Fig. 7.49 The convex curvature of the anterior surface is made concave behind
the entropic eyelids
Fig. 7.50 This configuration attempts to resolve upper eyelid ptosis by filling
the superior fornix and lifting the levator aponeurosis muscle
Fig. 7.51 This patient’s ptosis on the medial side of the eyelid causes a marked
contour abnormality of the upper lid, drawing attention to the prosthetic
eye
Fig. 7.52 A diagonal ridge is added in the location shown by the dotted line
Fig. 7.53 A ptosis shelf can be seen on this prosthetic eye. It supports the upper
eyelid at its correct height but prevents the eyelid from closing
Fig. 7.54 Exposure of the levator and aponeurosis during ptosis repair surgery.
The pink levator muscle can be seen in the middle of the wound, with the
white aponeurosis below it and the yellow orbital fat above. The surgical
retractors are holding open the orbital septum and orbicularis muscles
Fig. 7.55 A suture is passed through the tarsal plate – usually at the apex of the
desired lid contour
xxx List of Figures

Fig. 7.56 The suture is then passed through the levator aponeurosis, reattaching it
to the tarsal plate. The suture is seen here tied in a temporary bow,
allowing the height and the shape of the lid to be checked, as the sur-
gery is performed under local anaesthetic. Once height and contour
appear satisfactory, the suture is tied
Fig. 7.57 In this case, two sutures were required to obtain a satisfactory lid height
and contour – they can be seen centrally and medially (to the right of
the picture). The orbicularis and skin are then closed, and the operation
is complete
Fig. 7.58 The gap between the eyelids that remains when the prosthesis is
removed is the maximum eyelid closure attainable through reducing the
size of the prosthesis
Fig. 8.1 Deposits on the temporal limbus area of a left prosthetic eye worn con-
tinuously for 3 months (magnification 400×)
Fig. 8.2 A contact lens in situ. Prosthetic eyes are analogous to contact lenses
Fig. 8.3 Staining technique for measuring the intensity and extent of deposit
formation on prosthetic eye surfaces
Fig. 8.4 Equal interval perceptual grading scales used to measure the build-up
of deposits on prosthetic eye anterior surfaces (left) and posterior sur-
faces (right)
Fig. 8.5 Photographic record of how tear deposits have built up on prosthetic
eyes when worn continuously by two subjects over the times indicated
Fig. 8.6 Graph quantifying the build-up of deposits on the prosthetic eyes worn
by the subjects in Fig. 8.5. The deposits were graded using the equal
interval grading scales shown in Fig. 8.4
Fig. 8.7 Regression analysis for mean extent and intensity of stained deposits on
prosthetic eyes worn continuously. Estimated mean deposit grades at 1
and 6 months are depicted by the dashed lines
Fig. 8.8 Two distinct zones of deposit build-up on prosthetic eyes are apparent.
The first is the inter-palpebral zone where deposits are exposed to the air
and the wiping action of the eyelids. The second is the retro-palpebral
zone where deposits are in continuous contact with the conjunctiva
Fig. 8.9 Deposit formation on the anterior and posterior surfaces of two pros-
thetic eyes. The prostheses were first cleaned and polished normally
and worn for 2 weeks. They were then cleaned and polished to optical
quality contact lens standard and worn for a further 2 weeks. Prosthesis
1 was worn by a 75-year-old man. Prosthesis 2 was worn by a 77-year-
old woman. The grades were measured using the equal interval photo-
graphic grading scales in Fig. 8.4
Fig. 8.10 Wettability of prosthetic eye being measured with a goniometer
Fig. 8.11 The wetting angle, θ°, is the angle formed by the water droplet at the
three-phase boundary where the water, air and artificial eye surface
intersect
Fig. 8.12 The wetting angle dramatically increased (the surface became much
less wettable) when surface deposits were cleaned off prosthetic eyes
List of Figures xxxi

Fig. 8.13 When a prosthetic eye is removed and reinserted, it is inevitable that the
micro-environment of the socket is disturbed to some extent
Fig. 8.14 Foreign material (a stray eyelash) fell into this anophthalmic socket
when the prosthesis was removed
Fig. 8.15 Slit lamp biomicroscope view of tear break-up on the surface of
a recently inserted prosthetic eye. The patient’s fingerprint which
smudged across the cornea is an example of foreign material entering
the socket during reinsertion of the prosthesis
Fig. 8.16 Three-phase model of prosthetic eye wear
Fig. 8.17 Scanning electron microscopy showing tear deposits on a 10-year-old
prosthetic eye. Note the adherent rod-shaped bacteria
Fig. 8.18 Over time tear protein deposits thicken and encroach into the inter-pal-
pebral zone of the prosthetic eye and dry out
Fig. 8.19 Epitheliopathy of Marx’s line in the lower eyelid of an anophthalmic
socket caused by prosthetic eye wear
Fig. 8.20 GPC can be seen on the caruncle in this anophthalmic socket
Fig. 8.21 This eye socket impression shows the cobblestone appearance of GPC
on the tarsal conjunctiva of the upper eyelid
Fig. 8.22 Excessive build-up of deposits on a prosthetic eye shown by staining.
The deposits may harbour harmful bacteria and/or environmental and
metabolic debris. The prosthesis was removed from the discharging
socket shown
Fig. 8.23 Mucoid discharge trapped in spaces behind the prosthesis
Fig. 8.24 Removing and cleaning prosthetic eyes monthly resulted in less dis-
charge than cleaning more frequently
Fig. 8.25 A cold cure PMMA patch on this prosthesis can be seen to have attracted
deposits, while the rest of the palpebral zone has remained clear
Fig. 9.1 Anophthalmic sockets with ranges of severity (mild on the left to severe
on the right) for mucoid discharge, inflammation and papillae
Fig. 9.2 Discharge resulting from a common cold
Fig. 9.3 Thicker yellow/green discharge and crusting is indicative of bacterial
infection
Fig. 9.4 Blepharitis with typical dandruff-like crusts appearing on the
eyelashes
Fig. 9.5 Obstructive MGD in the upper eyelid with waxy meibum issuing from
meibomian gland orifices, some of which are blocked
Fig. 9.6 This anophthalmic socket exhibits significant signs of meibomian gland
dysfunction and meibomian gland dropout in both upper and lower
eyelids
Fig. 9.7 Eyelid margin telangiectasia (spider veins)
Fig. 9.8 Lagophthalmos has impaired the normal function of the eyelids of this
patient causing mucus to collect on the surface and dry out
Fig. 9.9 Thinly covered implant sitting under an intact conjunctival membrane
Fig. 9.10 This tantalum mesh implant has extruded through the conjunctiva
Fig. 9.11 Undissolved sutures under an intact conjunctival membrane
xxxii List of Figures

Fig. 9.12 Pegged hydroxyapatite implant with associated mucoid discharge

Fig. 9.13 A silvery discoloration over the pupil (seen here) indicates delamina-
tion of the PMMA material making up the prosthesis
Fig. 9.14 Scratches and dull patches on well-worn prostheses are associated with
mucoid discharge
Fig. 9.15 The crazed surface of this prosthesis was caused by cleaning it with a
solvent
Fig. 9.16 Dried, gritty deposits (stained in this photograph) in the inter-palpebral
zone are a source of irritation leading to discharge
Fig. 9.17 A socket containing a glob of mucoid discharge which has pooled in
the space behind the deeply hollowed and poorly finished prosthetic
eye shown. Note the rough area (highlighted with stain) around the
upper edge of the prosthesis and its deeply hollowed back
Fig. 9.18 The duration of the effect on discharge experience of professional
repolishing
Fig. 9.19 Wetting angles of different PMMA surface finishes. High wetting
angles indicate that surfaces are less wettable than surfaces with low
wetting angles. Bars indicate standard error
Fig. 9.20 Summary of protocol for managing discharge associated with pros-
thetic eye wear
Fig. 9.21 Cleaning deposits with a dry tissue polishes surface deposits but does
not remove them
Fig. 10.1 Preplanning is important at the dinner table. Place the person you are
most interested in on your good side
Fig. 10.2 The discrete use of mirrors, strategically positioned on your blind side,
helps to overcome any problems at your workbench or desk
Fig. 10.3 When near objects move across other objects in the background, the
shift in their relative positions is picked up by the brain and used as a
measure of distance
Fig. 10.4 If you stand to one side as a ball approaches, the visual angle between
you and the ball changes enabling your brain to compute its approach
(a). The angle of approach does not change when a ball comes straight
at you and its distance is much harder to compute (b)
Fig. 10.5 The relative motion between the curb edge and the road surface
increases when the curb is higher (B) and decreases when it is lower (A)
Fig. 10.6 When moving your head from side to side, the background behind the
nearest object moves more (A, B) than the background behind the fur-
thermost object (C, D), thus enabling your brain to detect which object
is closest
Fig. 10.7 The depths between the various components of this photograph are
easy to interpret with one eye using cues to depth perception. Observe
the sizes of the girls’ hands for perspective and overlap and at the clar-
ity of the foreground compared to the background for contrast
Fig. 10.8 When pouring a cup of tea, extend the tea pot towards the cup and touch
it lightly before pouring. It is easier to come at the cup front-on rather
than swiping at it from the side
List of Figures xxxiii

Fig. 10.9 Hearing alone will not prevent you from being run down when crossing
the road, and you should get into the habit of looking carefully to each
side before stepping out
Fig. 10.10 The pattern of light on a wall changes as you approach and can be used
as a measure of how close you are when parking
Fig. 10.11 The socket may be cleansed with a syringe without removing the
prosthesis
Fig. 10.12 Removing a patient’s prosthetic eye. The caregiver’s forefinger slides
the lower eyelid under the prosthesis while the patient is looking
upwards
Fig. 10.13 Rubber suction cups make it easier to remove and insert prosthetic
eyes
Fig. 10.14 For orientation, the sharpest and/or pinkest point (indicated by the
arrow) is positioned towards the nose
Fig. 10.15 Removing your prosthesis. Look upwards and roll the prosthesis
upwards taking the top eyelid with it (Left). The forefinger of the free
hand then slides under the prosthesis and levers it out (Right)
Fig. 10.16 Inserting your prosthesis. Look downwards and use your finger to hold
the upper eyelid up while the prosthesis is inserted under it and held
Fig. 10.17 The coatings and films that build up on prosthetic eyes behave similarly
to biofilms found commonly in nature – e.g., the algal slime on the sea
wall shown here
Fig. 10.18 Some of the features to look for when selecting glasses
Fig. 10.19 Support and information for prosthetic eye wearers is available from a
number of organisations and books
Fig. 11.1 The Eye of Horus was part of an ancient Egyptian system for measuring
fractions
Fig. 11.2 An Eye of Horus amulet. The Eye of Horus is a powerful symbol of
protection in ancient Egypt
Fig. 11.3 The earliest known prosthetic eye was found buried with a woman in
Shahr-I Sokhta, Iran
Fig. 11.4 Prosthetic eyes for the dead helped Egyptians ‘see’ when they entered
the after-life
Fig. 11.5 Egyptian sarcophagi often had eyes made by filling bronze eyelids with
plaster and inserting irises of onyx
Fig. 11.6 This statue of Athena, Goddess of wisdom, war and the crafts, and
favourite daughter of Zeus has glass eyes
Fig. 11.7 Ambroise Paré (1510–1590) illustrated this prosthesis in his 1614 book
Fig. 11.8 In the sixteenth century, prosthetic eyes worn inside the socket were
made from gold or silver, with coloured enamel coatings
Fig. 11.9 In about 1710, William Boyse was succeeded by his son-in-law, James
Smith, seen here holding a glass eye
Fig. 11.10 In 1752, Dr. Heister of Nuremberg, recorded that he would prefer glass
eyes to metal eyes because metal eyes repelled tear fluid and lost their
brightness
xxxiv List of Figures

Fig. 11.11 Illustrations from Hazard-Mirault’s book entitled Traité pratique de

l’oeil artificial published in 1818. Removing a prosthetic eye with an
ocular hook (left) and re-inserting it (right)
Fig. 11.12 Extracts from Chapter XV of William Mackenzie’s A practical treatise
on the diseases of the eye – January 1, 1830, London (Longman, Rees,
Orme, Brown, & Green. M.DCCC.XXX)
Fig. 11.13 This article provides an entertaining and informative description of European
ocular prosthetics in the late eighteenth to early nineteenth centuries
Fig. 11.14 Auguste Boissonneau’s patent claimed the idea that separate right and
left prosthetic eyes could be replaced by a prosthesis with a form that
served both sides
Fig. 11.15 Friedrich Philipp Ritterich established the glass eye industry in
Germany
Fig. 11.16 Ludwig Müller-Ur (1811–1888) developed the cryolite glass eye
Fig. 11.17 This broken ‘Reform’ eye illustrates its form
Fig. 11.18 Glass blowing instruments and materials laid out on a workbench
Fig. 11.19 Callipers set to measure the dimensions of the prosthesis. Also glass
rods of various colours
Fig. 11.20 Instruments for handling glass eyes
Fig. 11.21 Glass eye prescription form
Fig. 11.22 The glass eye process begins by softening a pre-tinted hollow glass tube
Fig. 11.23 The tube is then sealed at one end and ‘blown’ to its correct size
Fig. 11.24 Coloured glass rods are melded into the body of the eye to create the iris
Fig. 11.25 A partially made eye together with glass rods of various colours includ-
ing black
Fig. 11.26 Creating the pupil
Fig. 11.27 A partially finished glass being compared with a completed one
Fig. 11.28 The softened glass is moulded under negative pressure to create a hol-
low posterior surface
Fig. 11.29 The flame is used to smooth out the posterior aspect of the eye
Fig. 11.30 Preformed glass eyes are demonstrating some of the steps during
manufacture
Fig. 11.31 Phillip Henry Mules’ obituary appeared in the British Medical Journal
in 1905
Fig. 11.32 A tray of assorted glass eyes imported from Germany by Peacock
Optometrists who practised in Auckland in the early 1900s
Fig. 11.33 This article comments on the glass eye industry in England early in the
twentieth century
Fig. 11.34 Prosthetic eyes have always been an easy target for black humour
Fig. 11.35 A page from Dr. Robert Coulomb’s 1905 book entitled L’oeil artificial
Fig. 11.36 Moveable eye article featured in the December 1948 issue of Life
Magazine
Fig. 11.37 Mid-twentieth-century ordering kit for plastic artificial eyes
List of Figures xxxv

Fig. 11.38 Late twentieth-century custom-made PMMA eye

Fig. 11.39 German glass eyes became unavailable at the start of World War II
Fig. 11.40 Early twentieth-century stock glass eyes
Fig. 11.41 Manufacturing PMMA prosthetic eyes using dental equipment and
materials. Two prosthetic eyes formed with red denture wax are seen
here invested in a denture flask
Fig. 11.42 These organisations promote the professional development of ocular
prosthetists by hosting conferences and disseminating information
about prosthetic eyes
Fig. 11.43 An optometry student at the University of Auckland adds artificial tears
to PMMA samples to test protein adherence to prosthetic eyes
Fig. 11.44 Thin glass lenses with a white body and clear corneal centres with vari-
able optics
Fig. 11.45 Adolf Fick created the first scleral shell prosthesis
List of Tables

Table 1.1 Approximate number of prosthetic eye wearers in various countries

Table 1.2 Ratios of men to women whose eye loss was due to accidents from
1960 to 2010
Table 5.1 Overview of prosthetic eye making and fitting
Table 5.2 Trade-offs that must be resolved during the positioning of the iris/cor-
neal unit and shaping of the wax prosthesis
Table 6.1 Overview for thin scleral shell making and fitting
Table 7.1 Socket complications broadly listed in descending order of importance
Table 7.2 Socket complications are listed in descending order of importance

xxxvii
About the Authors

Keith R. Pine, BSc (Psych), PhD (Optom), MIMPT trained as a dental techni-
cian before obtaining his advanced certificate in maxillofacial technology through
the City and Guilds of London programme and specialising in maxillofacial pros-
thetics. He founded a commercial dental laboratory in 1976 and over the next 27
years transformed it into Australasia’s largest private dental practice (now Lumino
the Dentists) employing over 100 professional staff. After selling the practice in
2003, he established the New Zealand Artificial Eye Service where he currently
works as an ocular prosthetist. He is a research fellow with the School of Optometry
and Vision Science, University of Auckland, and a member of the Institute of
Maxillofacial Prosthetists and Technologists in the UK.

Robert J. Jacobs, MSc, PhD Melb. LOSc, FAAO, FACO is a fellow of the
American Academy of Optometry, a fellow of the Australian College of Optometry,
an honorary member of the New Zealand Association of Optometrists, an associate
editor of the journal Clinical and Experimental Optometry and a director of the
Optometry Council of Australia and New Zealand. He is currently the academic
director of the Bachelor of Optometry programme in the Faculty of Medical and
Health Sciences at the University of Auckland.

Brian H. Sloan, MB ChB, MHB (Hons), FRANZCO had his general ophthalmic
training in New Zealand, followed by fellowships in the subspecialty of oculo-
plastic, lacrimal and orbital surgery in Melbourne, Australia; Cincinnati, Ohio,
USA; and Vancouver, Canada. He currently works in both private and public prac-
tices, training ophthalmic registrars and international oculo-plastics fellows. He is
an honorary senior lecturer in the University of Auckland Department of
Ophthalmology, a senior inspector of training posts for the Royal Australian and NZ
College of Ophthalmologists (RANZCO), president of the Australian and New
Zealand Society of Ophthalmic Plastic Surgeons, and the immediate past chairman
of the RANZCO NZ branch Qualifications and Education Committee.

xxxix
Glossary

Abduct Movement away from the midline of the body

Accommodation The act of changing the focus of the eye so that near objects can
be seen clearly
Acinar Of acini
Acini A lobule of a gland such as the lacrimal gland
Acrylic A common name for (poly) methyl methacrylate
Adduct Movement towards the midline of the body
Adenoid A mass of lymphatic tissue situated above the tonsils behind the nose
Adnexal tissue (adnexae) The tissues around the eye and related to it. Includes the
eyelids, lacrimal system, extra-ocular muscles and orbital fat
Aerial perspective (atmospheric perspective) Is where distant objects appear
duller and bluer than close objects and have less contrast
Albinism A genetic condition that prevents the body from producing melanin
which gives color to hair, skin and the iris of the eye
Allergen A substance that can cause an allergic reaction
Allergic reaction A reaction of the immune system to normally harmless sub-
stances in the environment
Alloplastic materials Inorganic, non-biological materials
Aluminium oxide paste An abrasive with specified particle sizes used in polishing
a variety of materials
Anaplastology A branch of medicine that deals with the prosthetic rehabilitation
of the face or body and includes the design and manufacture of orbital, nasal,
ocular and aural prostheses
Aniridia Absence of the iris
Annulus of Zinn A circular band of fibrous tissue surrounding the optic nerve at
the orbital apex
Anophthalmia The absence of one or both eyes. Complete absence of the eyeball
Anterior In front
Anterior lamellar deficiency In eyelid reconstruction, the anterior lamella is the
skin and orbicularis muscle (see posterior lamellar)
Antibody A protein produced by the immune system when it detects harmful
substances

xli
xlii Glossary

Antigen A substance that stimulates the production of an antibody as part of the

immune response. Examples of antigens include bacteria, fungi, parasites,
viruses and chemicals
Aphakia Absence of the lens
Aponeurosis Broad tendons in a layered formation
Arbor band An abrasive band that fits over a rubber wheel attached to a dental
lathe – used for grinding
Arcus-senilis An opaque ring that forms around the edges of the cornea and makes
the periphery of the iris appear pale
Artificial eye A device that stimulates neural impulses to help a blind person to
see. Another name for an ocular prosthesis
Asepsis The absence of living pathogenic microorganisms
Auricular Of the ear
Autogenous tissue Derived from an individual’s own tissue
Autologous bone Bone obtained for transplant from an individual’s own body
Bacteriologic Of bacteriology
Bacteriology A branch of microbiology which involves the study of all microor-
ganisms including bacteria and viruses
Binocular cues to depth Information about depth perception using two eyes
Binocular vision Two-eyed vision
Biosocial The combination and interaction of social and biological characteristics
Biosocial profile Biosocial characteristics of an individual or population
Blepharitis A chronic inflammation of the eyelid margins caused by staphylococ-
cus infection or a skin condition such as seborrheic dermatitis (dandruff)
Body image An emotional response to the way patients see themselves and how
they appear to others when their appearance changes
Bulbar Bulblike. In medicine, a rounded mass of tissue like the eyeball
Bulbar conjunctiva The area of conjunctiva covering the eyeball
Canthal tendons The lateral and medial canthal tendons connect the eyelids to the
orbital rim
Canthus Where the upper and lower eyelids meet at either side of the eye (inner
and outer canthi)
Capsulopalpebral fascia The fascia at the junction of the upper and lower eyelids
at the medial and lateral canthi
Caruncle The small fleshy tissue at the medial (inner) corner of the eye
Cataract Clouding of the crystalline lens inside the eye
Chroma The purity or saturation of a colour
Cicatricial Of cicatrix
Cicatrix A scar left by the formation and contraction of new fibrous tissue over a
flesh wound
CMYK subtractive color system A colour system in which all colours are
described as a mixture of Cyan, Magenta, Yellow and Black. CMYK is the stan-
dard colour system used in offset printing. The colours can be thought of as
blocking Red, Green, Yellow and White.
Cold cure PMMA A PMMA that is self curing – it does not require heat for
polymerization to take place
Collarette (of the iris ) The region of the iris that immediately surrounds the pupil
Glossary xliii

Concha (of the nose) Shell-like turbinate bones that protrude into the nasal cavity
Conformer A clear PMMA shell inserted into the socket to preserve the fornices
after eye enucleation
Congenital Present at birth
Conjunctiva Thin, transparent tissue that covers the inside of the eyelids and the
sclera
Conjunctivitis Inflammation of the conjunctiva caused by infection or irritation
Contrast sensitivity The ability to distinguish different shades of grey; distin-
guishing between black from white only requires low contrast sensitivity; distin-
guishing between very similar shades of grey requires high contrast sensitivity
Convergence (of eyes) Where the two eyes turn in so that the lines of sight align
on the same object
Cornea The clear domed window covering the iris and pupil
Corneal dystrophy A hereditary disorder of both eyes which appears as a greyish
white or crystalline clouding of the cornea
Corneal leucoma An opaque white patch present in the cornea
Corneal limbus The junction between the cornea and sclera of the eye
Cosmesis Physical appearance that has been either preserved, restored or enhanced
Cosmetic contact lens A contact lens that alters the appearance of the iris when
worn
Crazing A network of hairline cracks in the surface of a material
Creutzfeldt-Jakob Disease An incurable degenerative disease that progressively
affects the brain. It is caused by an infectious protein
Curvilinear perspective Where parallel lines become curved at the outer extremes
of the visual field
Cyanoacrolate adhesive An instantly setting contact adhesive (also known as
super glue)
Cyclotorsion Rotation of an eye around its visual axis. Cyclotorsion allows bin-
ocular vision to be maintained when the head is tilted
Cytological Of cells
Cytoplasm The contents of a cell excluding the nucleus
Dehiscence Splitting open of tissue, e.g. a wound splitting open
Delamination The separation of layers
Depress To pull or push something down
Dermis The deeper layer of the skin below the epidermis
Detached retina A serious eye condition where the retina separates from the tissue
and blood vessels supporting it
Diabetes A disease that causes poor control of sugar levels in the bloodstream
Dry eye syndrome A chronic condition caused by inadequate moisture on the sur-
face of the eye
Ectropion Outward rotation of the eyelid margin away from the surface of the eye
or prosthesis
Edema Swelling due to build-up of fluid in the tissue
Ekblepharon A prosthetic eye worn outside the socket
Elevate Raise
Endophthalmitis Inflammation (usually caused by infection) of the anterior and
posterior segments of the eye
xliv Glossary

Enophthalmos A backward displacement of the eye

Entropion Inward rotation of the eyelid margin towards the surface of the eye or
prosthesis
Enucleation Removal of the entire eye
Eosinophil A specialised white bloodcell – part of the immune system
Epidemiology The study of health and disease characteristics in defined populations
Epidermis The superficial layer of skin
Epiphora Spilling/overflow of tears onto the cheek
Epithelial cells Cells that line the surfaces of the body including the skin and all
internal cavities
Epithelial substrate The tissue underlying the epithelium
Epitheliopathy Disease that involves the epithelium
Epithelium The tissue that lines the surface of the body including the skin and all
internal cavities
Equilibrium A state of balance
Ethmoid Denoting or relating to the bone that separates the nasal cavity from the
brain and the ocular orbits
Ethmoid sinuses Air-filled cells within the ethmoid bone
Aetiology Cause
Everted Turned outwards
Evisceration Removal of the contents of the eye, leaving only the scleral shell with
or without the cornea
Excyclotorsion Rotation of the 12 o’clock position of the cornea away from the
midline
Exenteration Removal of the eye and a variable amount of orbital and adnexal
tissue
Exfoliate To cast off dead skin cells
Exophthalmos Forward displacement of the eyeball
Ex situ Off site
Extraocular muscles The six muscles that move the eye
Fascia The biological fabric or connective tissue that holds the body together
Fascia lata Deep fascia in the thigh and buttocks region
Fenestration A hole penetrating a surface
Fibromyalgia Chronic widespread pain in muscles and joints
Fibrosis Excess fibrous connective tissue in an organ or tissue
Fibrovascular Fibres and conducting cells together, and accompanied by a blood
supply
Fissure A narrow, long opening, a crack
Fluorescein dye An orange solution that is taken up by damaged cells of the epi-
thelium and that pools in irregularities on the surface of the eye. It glows green
(fluoresces) when illuminated with a blue or ultraviolet light
Foramen An opening or passage (usually through bone)
Forniceal Of the fornix
Fornix (fornices) The area where the epithelial tissue lining inside of the eyelids
joins epithelial tissue covering the globe
Fossa A depression or hollow (usually in bone)
Glossary xlv

Fourier-domain optical coherence tomography (FD OCT) An imaging tech-

nique that uses a broadband light source to obtain microscopic three-dimensional
images of living tissue
Giant papillary conjunctivitis (GPC) Conjunctivitis where associated papillae
(lumps or protruberances) are larger than 1 mm diameter
Glaucoma Damage to the optic nerve that causes painless loss of vision and that is
treated by lowering the pressure in the eye
Glycocalyx A polysaccharide or glycoprotein covering on the surface of cells
Glycoproteins A molecule made up of a protein plus a carbohydrate
Glycosylated Where carbohydrates are chemically attached to proteins to form
glycoproteins
Goblet cells Specialized epithelial cells that secrete mucus
Goniometer An instrument used for measuring angles
Gram-negative bacteria Bacteria that have a cell wall composed of a thin layer of
peptidoglycan
Granuloma An inflammatory mass
Gundersen flap procedure A surgical procedure that involves laying a flap of con-
junctival tissue over the cornea
Heterochromia Colour difference between the two eyes of the same individual
Homeostasis The body’s tendency to seek and maintain a state of equilibrium
within itself even when changes occur externally
Homologous bone Bone inherited from a common ancestor, e.g. bovine bone is
homologous with human bone (compare with autologous bone)
Hue Colour or shade
Hydrogel contact lenses Contact lenses made from material containing a propor-
tion of water molecules
Hydrophilic Attracting water
Hydrophobic Repelling water
Hydroxyapatite A coral-like material used for orbital implants
Hyperkeratinisation An excess of keratin in the surface layers of the skin
Hypoblepharae Prosthetic eyes worn inside the socket
Image blurring Objects in focus blur at the extremes of the visual field
Impression A negative mould
Inclusion cyst A cyst formed by the inclusion of displaced epithelial cells within
connective tissue
Incyclotorsion Rotation of the 12 o’clock position of the cornea towards the
midline
Inferior Below or lower
In situ In place or in position
Integrated orbital implant Implants made from hydroxyapatite or porous poly-
ethylene. They allow fibrovascular ingrowth
Inter-palpebral zone The area between the margins of the upper and lower eyelids
when the eye is open
Interposition A near object covers part of a distant object
Intraconal space The cone-shaped space inside the orbit behind the eye. It is
bounded by the extraocular muscles which run towards the back of the orbit to
form the apex and by the back half of the globe
xlvi Glossary

Intractable Not able to be treated or managed

In vivo Within living tissue
Involutional A decrease in size or a decline of function associated with the ageing
process
Ionicity Relating to ions which are atoms that have an electrical charge
Iridectomy A surgical procedure to remove part of the iris
Iris coloboma A congenital condition resulting in a keyhole-shaped pupil
Keratin The main material making up the outer layer of human skin, hair and nails
Keratoconjunctivitis sicca Dry eye syndrome
Lacrimal Relating to tears
Lacrimal gland A tear-producing gland
Lacrimal punctum The small opening on the lid margin through which tears begin
to drain from the eye
Lactoferrin A protein found in tears that may have an anti-inflammatory function
Lagophthalmos Inability to fully close the eyelids
Lamellae Thin plate-like structures lying close together
Lateral Away from the midline, outer (opposite of medial)
Limbus The border between the cornea and the sclera
Lipids Organic fatty molecules
Lissamine green dye A yellowish green dye that highlights membrane-damaged
or dead cells
Lymphocytes A type of white blood cell
Lymphoid Of lymphocytes, a type of white blood cell or tissue in which lympho-
cytes develop
Lysozyme An enzyme found in tears. It provides a degree of protection against
certain gram-positive bacteria
Mandible Lower jaw bone
Marx’s line The natural site of frictional contact between the eyelid margin and the
surface of the eye
Mast cells Cells found in connective tissue. They release substances such as hepa-
rin and histamine in response to injury or inflammation
Matrix porosity A matrix is the structure or frame surrounding empty spaces.
Porosity is the fraction of space in a porous material made up by the empty
spaces
Maxilla Upper jaw bone
Meatus Opening
Medial Closer to the midline (opposite of lateral)
Meibomian gland dropout The absence or loss of meibomian glands
Meibomian glands Oil-secreting (sebaceous) glands found in the eyelids
Meningioma A tumour that originates in the membranes (meninges) that surround
the brain and spinal cord
Meniscus The curve in the surface of a liquid when it is adjacent to another
surface
Metabolic Of metabolism
Metabolism The biochemical processes that occur within a living organism
Microphthalmia An underdeveloped or small eye
Glossary xlvii

Microvilli Microscopic folds on the surface of some cells

Morbidity A diseased state
Motility Movement
Motion parallax A depth cue whereby the relative movement of superimposed or
overlapping visual images is used to work out which object is further away or
closer and by how much
Mucin Mucins are a family of proteins that is the main constituent of mucus
Mucocutaneous The area of transition between mucosa (mucous membranes) and
skin
Mucoid discharge Mucus produced by goblet cells in response to irritation of the
eye or socket
Muco-purulent discharge Discharge containing mucus and pus
Mucormycosis An infection caused by Mucorales fungi
Mucus substrate A network of mucus formed by conjunctival goblet and epithe-
lial cells
Nasal Of the nose
Nasolacrimal drainage system The system that drains tears from the eye to the
nasal cavity
Nasolacrimal duct The tear duct connecting the lacrimal sac with the nasal
cavity
Neovascularisation Where new blood vessels are formed, e.g. where conjunctival
or scleral blood vessels grow into the cornea
Obstructive meibomian gland dysfunction Blocked meibomian glands
Occipital Of the occiput, which is the knob-like protruberance at the back of the
skull
Ocularist Ocular prosthetist
Orbit The bony cavity that houses the eye
Orbital implant An implant that is placed in the socket at the time of eye enucle-
ation or evisceration
Orbital prosthesis A facial prosthesis that restores the eye and eyelids
Palatine bones The two bones forming the posterior third of the hard palate in the
mouth
Palpebral Relating to the eyelids
Palpebral fissure The oval aperture between the open eyelids
Papilla Small nipple-like protuberance
Parietal bone A bone situated at the side of the skull behind the frontal bone
Patency The state of being open or unblocked
Periosteum The tissue lining bone
pH homeostasis The body’s tendency to maintain blood pH within a narrow range
Phenol red thread test A method for measuring tear production where an impreg-
nated thread changes colour when wetted with tears
Phenol red (phenolsulfonphthalein) A pH indicator used in disclosing whether a
thread has been wetted by tears
Photochromic lenses Lenses that darken in sunlight and lighten in shade
Photophobia Intolerence of light
Phthisical Of phthisis. Shrunken
xlviii Glossary

Phthisis Shrinkage of the globe and cornea

Plica semilunaris The fold of conjunctiva in the inside corner of the eye
Plication The act of folding a structure to shorten it
(Poly) methyl methacrylate (PMMA) A plastic material used for denture bases
and prosthetic eyes
Polymerization Where small molecules join together to make long chains of mol-
ecules called polymers
Polyvinylsiloxane A silicone elastomer used as an impression material
Posterior Behind, to the rear (opposite of anterior)
Posterior blepharitis Blepharitis affecting the meibomian glands and the inside of
eyelid margins
Posterior lamella In eyelid reconstruction, the posterior lamella is the tarsus and
conjunctiva
Post-traumatic stress disorder (PTSD) A state of severe depression and anxiety
that may occur in people who have survived or seen a traumatic event
Pre-septal In front of the orbital septum
Pre-tarsal In front of the thick plate of connective tissue (tarsus) that gives shape
to the eyelids
Primary orbital implant An orbital implant placed at the time the eye is removed
Processed acrylic Polymerized poly(methyl methacrylate)
Prolapse To fall forwards and downwards
Prosthesis A device that by design or function replaces a part of the body
Prosthetic contact lens A contact lens that masks a disfigured iris and/or improves
eye comfort
Prosthetic eye A prosthesis that restores the appearance of the eye and the function
of the eyelids following eye loss
Proteins Large, complex biological molecules that perform a wide variety of vital
functions within living cells
Protract To pull forwards
Psychological Relating to the mind
Psycho-social Pertaining to the relationship between social factors and individu-
als’ behaviour and thought
Ptosis An abbreviation of blepharoptosis – drooping of the upper eyelid
Purulent Containing pus
Recession (of eyelids) The state of being recessed or set back
Rectus muscles The main four muscles controlling movements of the eye
Resection The surgical removal of part or all of a biological structure
Retina The layer of light-sensitive tissue that lines the back of the eye
Retinal disparity Where objects are projected onto each eye at different angles
Retinoblastoma A malignant tumour arising from the retina. It may be present at
birth or may occur in the first few years of life
Retract To pull back
Retro-palpebral zone The part of a prosthetic eye that is in continuous contact
with the conjunctiva
Rigid gas permeable (RGP) contact lens A rigid contact lens that allows oxygen
to permeate through it
Glossary xlix

Rose Bengal A bluish red dye that highlights damaged conjunctival or corneal
cells
Scanning electron microscope A type of electron microscope that produces 3D
images of an object by scanning it with a focused beam of electrons
Schirmer tests The Schirmer tests (I and II) are used for measuring tear volume.
Version II of the test is when a local anaesthetic is administered before the test
Sclera The outer white casing of the eye made of collagen and elastic fibres
Scleral contact lens Contact lenses that extend over the sclera as well as the
cornea
Scleral shell prosthesis A prosthesis that fits over an existing disfigured eye
Sebaceous Secreting fat or sebum
Secondary orbital implant An orbital implant that is placed at a separate opera-
tion after the removal of the eye
Shade The base colour added to black
Shadow stereopsis The use of shadows as a cue to steroscopic depth perception
Shellac baseplate A thermoplastic material used in sheet form to support and
strengthen wax shapes
Sinus An air-filled pocket located in the skull
Sjögren’s syndrome An auto-immune disorder which dries the eyes, mouth and
other parts of the body
Slit lamp biomicroscope A common ophthalmic instrument for examining under
magnification the eyelids and the anterior and posterior segments of the eye
Sphenoid bone A compound bone located behind the eyes. It forms the base of the
cranium
Squamous cell carcinoma A form of skin cancer that develops in the squamous
(flattened) cells of the epidermis
Stevens-Johnson syndrome A rare disorder of the skin and mucous membranes
which may be a hypersensitive reaction to infection or medication
Strabismic A condition where the direction of gaze of one eye does not align with
that of the other. Sometimes termed turned eye, squint or wall eye.
Stroma of the iris The fibres that interlace throughout the upper layer of the iris
Subperiosteal Located between the bone and its covering tissue (the periosteum)
Subperiosteal implant An implant placed in the subperiosteal space on the floor
of the orbit. Used to restore lost orbital volume
Sulcus A groove or furrow
Superior Overlying, above
Superior sulcus The sulcus above the eye (upper eyelid sulcus) between the skin
on the upper eyelid and the skin of the eyebrow
Suppurate Fester, form pus
Surfactant A substance that reduces the surface tension of water
Sympathetic ophthalmia Inflammation in one eye caused by the immune sys-
tem’s reaction to injury of the other eye
Synergy An interaction that produces a whole that is better than the sum of its parts
Synovial fluid Viscous fluid found in joints
Tarso-conjunctiva The tarsus and its tightly adherent conjunctiva
Tarsorrhaphy Suturing the eyelids together
l Glossary

Tarsus A plate of dense connective tissue that gives shape to the eyelids
Tear break-up time test (TBUT) A measurement of the time it takes for the tear
film to break up after blinking
Tear ferning test A clinical test to measure the tear quality. A tiny drop of tear
fluid placed on a glass slide is allowed to dry, and the patterns of dried material
are examined
Tear meniscus The strip of tear fluid that forms along the inner edges of the upper
and lower eyelid margins. Sometimes called the tear prism
Temple The name given to the arms on each side of a pair of glasses
Temporal Of the temple area of the head
Tenon’s capsule The fascial layer of connective tissue that encapulates the globe
from the limbus to the optic nerve
Texture gradient One of the cues to depth perception that does not rely on binocu-
lar vision. An example is where finer details can be seen more clearly on close
objects
Tint The base colour added to white
Tone The base colour added to grey
Trabeculae The strands of connective tissue that support or anchor other tissues
Tripoly An abrasive impregnated wax bar commonly used for polishing dentures
Trochlea of the superior oblique A u-shaped pulley made of fibro-cartilage
through which the tendon of the superior oblique muscle passes
Value The lightness or darkness of a colour, is a measure of the amount of light
reflected from its surface (reflectance).
Vascular Containg vessels that carrry fluids
Veneer Outer covering
Vernal keratoconjunctivitis A seasonal allergic eye disease that inflames the con-
junctiva and especially affects young males
Visual analogue scale A rating scale used in questionnaires. The respondent views
a line that represents the range of possible responses and where the ends of the
line represent the lowest and highest responses. The respondent places a mark on
the line to indicate their response. The position of the mark is measured to pro-
vide the numerical response.
Visual field All that can be seen at any one time without moving the eye or eyes
Visual range The width or sometimes the depth of the visual field
Vital dye A dye used for staining living cells
Vitreo-retina surgery Surgery to treat problems inside of the eye, e.g. detached
retina
Vomer A flat bone that makes up part of the nasal septum
Vulcanite A hard black rubber that is more durable than natural rubber. Vulcanite
is produced by a chemical process called vulcanization, where natural rubber is
treated under heat with large amounts of sulphur
Zygomatic bone Cheek bone
The Anophthalmic Patient
1

Contents
1.1 Introduction ................................................................................................................... 1
1.2 Epidemiology of Eye Loss ............................................................................................ 2
1.2.1 Estimated Size of the Anophthalmic Population ............................................... 2
1.2.2 Aetiology of Eye Loss ....................................................................................... 3
1.2.3 Changing Causes of Eye Loss ........................................................................... 4
1.3 Perceptual Changes Accompanying Eye Loss .............................................................. 6
1.4 Psychosocial Issues Associated with Eye Loss ............................................................. 7
1.4.1 Loss of Body Image........................................................................................... 8
1.4.2 Novelty Eyes...................................................................................................... 9
1.4.3 The Psychological Importance of Prosthetic Eye Comfort and Convenience ....... 10
1.5 Phantom Eye Pain.......................................................................................................... 11
1.6 Concerns of Prosthetic Eye Wearers ............................................................................. 11
1.7 Psychological Issues for Children ................................................................................. 12
1.8 Personal Accounts of Eye Loss ..................................................................................... 13
References ............................................................................................................................... 22

1.1 Introduction

The biosocial and psychological aspects of eye loss are explored in this chapter in
order to better understand the extent of the anophthalmic population globally and
what it is like for people who lose an eye and wear an ocular prosthesis. The chap-
ter discusses the epidemiology of eye loss, the perceptual changes that confront
people who suddenly lose binocular vision and the psychosocial issues that
accompany eye loss – including the special issues that children face when they
lose an eye. The concerns of patients who wear prosthetic eyes are discussed in
the chapter, and several individual case studies are included to provide personal
perspectives about eye loss. Blind people who wear two prosthetic eyes are not
dealt with specifically in the chapter, but many of the issues discussed are relevant
to them.

© Springer International Publishing Switzerland 2015 1

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_1
2 1 The Anophthalmic Patient

1.2 Epidemiology of Eye Loss

1.2.1 Estimated Size of the Anophthalmic Population

There are virtually no reports on the size of the anophthalmic population of different
nations, but a New Zealand study in 2012 [1] estimated this country’s population of
prosthetic eye wearers to be 3000 people (one anophthalmic person for every
1440 in the general population). If this number is extrapolated to the rest of the
world (population 7,177,568,766 [2]), the total global population of prosthetic eye
wearers is approximately five million people (Table 1.1).

Table 1.1 Approximate number of prosthetic eye wearers in various countries

Approximate number
Country General population of prosthetic eye wearers
1,349,585,792 935,264
China
1,220,800,384 846,016
India
316,668,576 219,452
United States
207,964,528 144,120
Brazil
137,410,000 95,225
Russia
116,220,944 80,541
Mexico
105,720,640 73,264
Philippines
96,838,456 67,109
Ethiopia
85,294,384 59,109
Egypt
81,147,264 56,235
Germany
80,694,488 55,921
Turkey
67,448,120 46,742
Thailand
65,729,328 45,550
France
63,395,576 43,933
United Kingdom
61,482,296 42,607
Italy
48,601,096 33,681
South Africa
42,610,980 29,529
Argentina
38,383,808 26,600
Poland
Canada 34,568,212 23,956
22,262,500 15,428
Australia
1.2 Epidemiology of Eye Loss 3

New Zealand enjoys a First World standard of living with good health-care pro-
vision and may be compared reasonably with Australia, North America and Western
Europe. The estimates are for prosthetic eye wearers only and do not take into
account the many people who have lost or damaged their eyes but for various rea-
sons have not been provided with a prosthesis.
In spite of the inadequacy of available data on prosthetic eye wearers, the num-
bers here suggest that on a global scale, the condition of anophthalmia is not uncom-
mon and that the provision of prosthetic eyes is an important health issue for all
countries.

1.2.2 Aetiology of Eye Loss

The data introduced below are derived from the 2012 study of prosthetic eye wear-
ers in New Zealand [1]. The data are specific to New Zealand prosthetic eye wear-
ers, and while the information may not be directly applicable to other countries, it
provides an insight into the biosocial aspects of anophthalmic populations
generally.
The gender breakdown for prosthetic eye wearers in the New Zealand study was
59 % men and 41 % women. The highest proportion of eyes lost from all causes
occurred between ages 1 and 9 years inclusive (15 % of all eyes lost). After the first
10 years of life, eye loss from all causes occurred at a relatively even rate (varied
between 10 and 12 %) per decade as age increased until the 70–79 age band when
the rate reduced (Fig. 1.1). Eighty-two percent (82 %) of the total anophthalmic
population in New Zealand was 40 years of age or over.
The reported causes of eye loss in the New Zealand study were accident
(50 %), medical (43 %) and congenital (7 %). Eye loss due to tumours of various
kinds was the most prevalent medical cause followed by glaucoma, detached
retina, cataract and then diabetes. Workplace accidents were the most common

Age when eye lost

0.16

0.14
0.12
0.1
Percent

0.08
0.06

0.04
0.02
0
0–1 1–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+
Age cohort

Fig. 1.1 Eye loss as a function of age (using 10-year age bands) (Published with kind permission
of NZMA. All rights reserved)
4 1 The Anophthalmic Patient

Causes of eye loss

0.7
Medical cause % Accident cause %
0.6

0.5

0.4
Proportion
0.3

0.2

0.1

t
t

lt

e
or

es
a

en

t
l

en
a

en
ica

en

en
au
ac

r
tin
om

tu
m

et

cid
cid

cid

cid

id
r

ed

s
re

en
Tu

ab
ta
uc

As

cc
ac
ac

ac
rm

ac
Ca
d

dv
Di
la

ra
he

e
ce

isa
G

re

e
e

icl

e
c

m
th

la

isu

th
ta

lm
h
Ho
O

kp

O
De

Ve
le

ica
or

rt/
W

ed
o
Sp

M
Causes

Fig. 1.2 Main causes of eye loss. Medical and accidental causes are shown separately (Published
with kind permission of NZMA. All rights reserved)

Age when eye lost due to accident men vs women

0.16
0.14
0.12
0.1
Percent

0.08 Men
0.06 Women

0.04
0.02
0
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80+
Age cohort

Fig. 1.3 Gender mix of eye loss due to accident (Published with kind permission of NZMA. All
rights reserved)

type of accident followed by sporting/leisure accidents, home accidents, motor

vehicle accidents, assaults and lastly medical misadventures (Fig. 1.2). For ages
less than 40 years, eye loss due to accident was significantly greater in men than
women, but women and men over 40 lost eyes to accidents in similar numbers
(Fig. 1.3).

1.2.3 Changing Causes of Eye Loss

The cause of eye loss appears to be changing over time as eye loss due to accident
declined in the New Zealand study relative to medical causes [1]. Accidents were
1.2 Epidemiology of Eye Loss 5

Eye loss from all causes over time

1

0.9

0.8

0.7
Cause
0.6
Percent
0.5 Accident
Medical
0.4
Congenital
0.3

0.2

0.1

0
1920–40 1950s 1960s 1970s 1980s 1990s 2000–10

Decade

Fig. 1.4 Causes of eye loss in New Zealand over time (Published with kind permission of
NZMA. All rights reserved)

Table 1.2 Ratios of men to women whose eye loss was due to accidents from 1960 to 2010
Decade 1960–1969 1970–1979 1980–1989 1990–1999 2000–2010
Ratio: men to women 5:01 2.3:1 1.8:1 2.4:1 1.4:1
Published with kind permission of NZMA. All rights reserved

the main cause of eye loss before the 1990s, but since then medical causes of eye
loss have predominated (Fig. 1.4).
The gender mix of accident victims also changed over time with a decreasing
ratio of men to women (Table 1.2). The trend towards less accidents resulting in eye
loss is consistent with the decrease of work-related head and neck injuries between
2003 and 2010 reported by the New Zealand Accident Compensation Corporation
[3] and the decrease of automobile traffic injuries from a peak of 23,385 in 1973 to
14,541 in 2009 [4]. Improved medical management of eye injury has also played a
part in the reduction of eye loss from accident. These trends are consistent with
trends in Australia where the number of surgically removed eyes reduced from
576 in 1994 to 522 in 2003, in spite of an increase in total population [5, 6]. A num-
ber of these saved eyes may be blind and disfigured however and may still need to
be restored with prosthetic contact lenses and scleral shell prostheses (see Chap. 6).
International comparisons of the biosocial profile of prosthetic eye wearers have
not been made, but some information can be found on related topics. For example,
Chang et al. [7] described aetiologies and clinical characteristics of corneal opacities
leading patients to seek cosmetic treatments at the Department of Ophthalmology at
Seoul National University Hospital. They examined 401 patients with corneal opaci-
ties and reported characteristics of age and gender that were similar to the anophthal-
mic population in the New Zealand study. A notable exception was the considerably
younger age when injury occurred in the Korean study. The Eye Injury Snapshot Data
6 1 The Anophthalmic Patient

Summary, 2004–2008 from the USA [8], also contained characteristics of age, gender
and accident type that were reflected in the New Zealand study. The causes and gender
mix reported in a study of eye loss carried out in Dallas County, USA, from 1990 to
1994 [9] were also broadly in line with the New Zealand study except that the percent-
age of eye loss due to accident was slightly higher (59.8 % compared to 54 %).
A paper published in 2008 on the bio-psychosocial profile of patients with anoph-
thalmia in the south of Minas Gerais, Brazil, reported that the majority of males lost
their eye due to accidents, whereas the majority of females lost their eyes for medical
reasons. In the area where the survey was conducted, the average elapsed time
between eye loss and receiving a prosthetic eye was 8.6 years due to economic fac-
tors and a lack of public services that provide rehabilitative treatment [10].
While these studies are very diverse, they suggest that gender mix (more young
males) and causes of eye loss (more accidents) may be common to most present-day
anophthalmic populations.

1.3 Perceptual Changes Accompanying Eye Loss

The loss of an eye requires perceptual adaptations because of the loss of binocular
cues to depth and the reduction in visual field on the affected side. The following
personal comments from patients describe some of the problems they have experi-
enced with judging distance [11]:
“I do not drive on the motorway as cannot cope with traffic passing on both sides! So drive
in slow moving areas.”
“Judging distance was a big factor to begin with – over the years I have learned to cope
with it – still have the odd problem.”
“Judging distance at close up, i.e. reaching for a handed cup of tea and parking a car, in
reverse in particular.”
“I find difficulty in walking down stairs/steps. Hard to judge distance unless holding on
to rail. I am inclined to bump into things if I am turning right or moving to the right.”
“Around small children and toys limits one. Judging distance is relative to the loss of
sight, not to wearing an artificial eye. It causes greater problems with driving in older age.
Probably due to slowing down. ”
“I judge distance very well through experience.”

The loss of cues to depth perception as a result of loss of binocular vision occurs
at distances less than 7–8 m (and especially at distances less than 1 m), but at greater
distances there is little or no change. Binocular cues that are lost are retinal disparity
where objects are projected onto each eye at different angles: convergence, where
the two eyes focus on the same object producing kinesthetic (motion) sensations in
the extraocular muscles, and shadow stereopsis [12], where images of shadows that
are different between the two eyes are fused stereoscopically.
Cues to distance that are retained with monocular vision include motion parallax
(superimposing visual images by moving the head from side to side), relative size
(objects become smaller with distance), aerial perspective (distant objects are duller
and bluer than close objects and have less contrast), accommodation (focusing on
1.4 Psychosocial Issues Associated with Eye Loss 7

Fig. 1.5 Reflections help

determine an object’s shape
and spacial position

objects closer than 2 m produces kinesthetic sensations in the ciliary muscles of the
iris), superposition (a near object covers part of a distant object), curvilinear per-
spective (parallel lines become curved at the outer extremes of the visual field),
texture gradient (finer details can be seen more clearly on close objects), light and
shadow (reflections help determine an object’s shape and spatial position) (Fig. 1.5)
and image blurring (objects in focus blur at the extremes of the visual field) [13].
In a visually guided grasping experiment, anophthalmic subjects produced more
head movements than binocular subjects who had one eye covered suggesting that
anophthalmic people had been able to learn to use motion parallax to aid manual
reaching and grasping [14]. Nicholas, Heywood and Cowey [15] investigated con-
trast sensitivity in the remaining eye of anophthalmic subjects. They found that the
earlier in development that eye loss occurred, the greater the range of enhanced
contrast sensitivity of the remaining eye.
The loss of vision in one eye reduces the horizontal visual field by 10–20 % on the
affected side. This results in anophthalmic people needing to turn their heads more
frequently than people with binocular vision in order to make up for the lost portion
of the field. Additional concerns associated with the loss of one eye are safeguarding
the remaining eye, facial appearance, prosthetic eye maintenance and the need to
employ driving aids such as special mirrors [16]. Chapter 10 contains advice for
patients on coping with loss of depth perception and reduced visual range.

1.4 Psychosocial Issues Associated with Eye Loss

The loss of an eye through accident, from disease or from congenital causes is a
major event that impacts on a person’s self-image and well-being. It also requires
changes in routine associated with wearing and maintaining a prosthetic eye or
scleral shell prosthesis.
8 1 The Anophthalmic Patient

1.4.1 Loss of Body Image

Loss of body image is an emotional response to the way patients see themselves and
how they look to others when their appearance undergoes a change [17].
The loss of body image associated with eye loss is accompanied by a lack of
autonomy in that the patient’s condition is shared with others whether they like it or
not [18]. This situation is stressful for both the affected individual and the observer
and is the major source of difficulties for people with a disfigurement [19].
Research suggests that observers avoid individuals with disfigurement because
of an internal conflict over whether to stare at a novel sight (the person with a dis-
figurement) or to follow societal norms against staring. Staring decreases when
observers are themselves observed and also when the novelty wears off due to con-
tinued contact [20].
The following is a patient’s own account of loss of body image over time:
I had a retinal break in my right eye and underwent several surgeries at a leading Auckland
clinic to restore my retina and retain my vision. However, none of the surgeries succeeded
and I lost complete vision in my right eye. Since then, I have been living my normal life
with the help of my left eye which thankfully is normal. Over the past 7 years since the loss
of vision in my right eye, the eye itself is now starting to change colour into a greyish white
and therefore does not match the natural colour of my good eye which is dark brown. This
has started to affect my confidence, particularly a reluctance to meet people and socialize as
I usually did earlier. I do currently wear shaded glasses but don’t feel good about wearing
them particularly in late evenings and night social visits.

Prosthetic eye wearers have lower health-related quality-of-life scores than

healthy individuals in terms of their perceptions of their own social relationships
[21], and patients with acquired facial disfigurement have more trouble adjusting to
their situation and have more psychological problems than patients with congenital
facial disfigurement [22]. The severity of facial disfigurement does not appear to be
a good predictor of psychological distress because while minor disfigurement can
be extremely upsetting for some people (Fig. 1.6), others readily manage more
severe conditions. A better predictor is the behaviour of the affected individual and
his or her ability to influence the response of the observer [23]. Chapter 10 contains
advice for patients on effective communication.
When eye loss is sudden or unexpected, it is not uncommon for patients to go
through a grieving process similar to the grief process associated with the loss of a
loved one [24]. There appear to be five stages of grieving (denial, anger, bargaining,
grief and acceptance) although not everybody goes through all the stages or in the
order represented here. The grief phase is probably the most critical as this is when
patients realise that their life will never be the same again and they may experience
a deep sadness leading to depression.
Goiato et al. [25] surveyed 40 patients about their emotional experiences follow-
ing eye loss and wearing a prosthetic eye. Their results were specific to Brazilian
culture, but preoccupation with hiding their disfigurement was experienced ‘a great
deal’ by 32 % of patients, while 22.5 % felt sadness and 15 % felt shy at the time of
1.4 Psychosocial Issues Associated with Eye Loss 9

Fig. 1.6 The corneal opacity in this right eye, while less disfiguring than an enucleated eye, is still
psychologically distressing for this patient (Published with kind permission of NZ Artificial Eye
Service. All rights reserved)

eye loss. Feelings of shame, insecurity, fear, inferiority and anger were also felt ‘a
great deal’ by at least 10 % of the patients. The Goiato et al. study also found that
having a supportive family and social environment was a further important factor in
coping with disfigurement due to the loss of an eye.
This conclusion was supported in a UK study which found that prosthetic eye
wearers living alone had higher levels of depression than those living with a partner,
friend or family. Poor psychological well-being in this study was further related to
prosthetic eye wearers with a pessimistic outlook, their self-image and how accepted
they felt by society [26]. Neither this study nor the Goiato study investigated asso-
ciations of wearing comfort with psychological well-being.
Some patients may exaggerate their pre-injury good looks making the adjust-
ment process more difficult, and certain predisposing personality traits may also
make it more difficult for some patients to psychologically adapt to their altered
appearance [27]. The role of the clinician is to reassure patients with accurate and
honest information and with empathy for the situation the clinician has the privilege
to be part of. The clinician (using good communication skills) can be a positive fac-
tor that helps patients through their adjustment phases. Patients who appear to be
having prolonged difficulty dealing with their grief and anguish should be referred
to a professional counsellor.

1.4.2 Novelty Eyes

Occasionally, a patient (mostly male) will request a prosthetic eye that enables them
to stand out. They may want the iris to be a smiley face, a skull and crossbones, the
flag of their country, etc. Novelty eyes can be easily made by ocular prosthetists, but
patients should be counselled about their use before these types of eyes are
provided.
The use of humour to distance one’s self from a problem and provide perspective
is a common phenomenon associated with stressful situations [28, 29] and a useful
tool to help deal with eye loss. However, while novelty eyes may assist some patients
cope with their stress in the short term, they are unlikely to deliver long-lasting
benefits and should be discouraged for patients who have recently lost an eye. For
10 1 The Anophthalmic Patient

patients who have become accustomed to wearing a prosthetic eye, it is rare to

request a novelty eye as most have come to terms with their new self-image and
appreciate that they still have the option to stand out by showing off their prosthesis
or to blend anonymously with the crowd.

1.4.3 The Psychological Importance of Prosthetic Eye Comfort

and Convenience

Ocular prostheses attempt to restore the physical and cosmetic characteristics of the
original eye. However, the psychological success of prosthetic restoration depends
on both the physical appearance and the convenience of wearing the prosthesis.
This is why patients with implant-retained facial prostheses have better quality-
of-life scores than those with adhesive-retained facial prostheses [30] and why
patients with nasal prostheses show worse psychological and social adjustment than
those with ocular, orbital (eye with eyelids) or auricular (ear) prostheses [22].
It is therefore important that the optimum appearance and convenience aspects of
prosthetic eyes are delivered and that anophthalmic patients are provided with
sound information about how to maintain their prosthesis and the health of their eye
socket. The main problem experienced by prosthetic eye wearers appears to be
excessive mucoid discharge. The following personal comments illustrate the con-
cerns that patients have with this problem [11]:
“Discomfort. Sensitivity due to dry air, air conditioning, etc.”
“Suppurating, Stickiness, crusting.”
“Discharge was a real problem – but again have learned to live with it.”
“I have not been able to ascertain what causes crusting and discharge.”
“I have from time to time experienced excessive itching and inflammation of the eye
lids.”
“Some days are better than others. There is always a light dusting of crustiness upon
waking in the morning. I find splashing water over my face and eye, morning and evening
helps to keep it clean. Any discharge is easy to remove but if not removed the eye-lid
becomes inflamed and infected needing antibiotic ointment which then needs the eye to be
removed several times a day for several days. I have found that the less I remove the eye,
the less trouble I have. Keeping it clean in situ works for me.”
“One issue that does increase crustiness, discharge and discomfort is spending too much
time in front of a computer.”
“My eye waters and discharges more when I’m tired or run down.”
“Being around smoke or cigarette smoke aggravates the eye.”
“Watering happens often during the day. Wind and tiredness has a huge impact on
watering, crusting and discharge. Eyelid closes involuntarily when really tired. Eye very
dry during this time.”
“I stopped getting significant discharge when I changed jobs about 2.5 years ago.
Worked in heavy industry.”
“Watering, crusting and discharge seems to relate to tiredness, working night shifts, windy
conditions and general health. Drooping of top lid also seems to be affected by the same.”
“Rather than watering, it is dryness that concerns me.”
“The wind tends to dry my eye out which causes irritation and dryness.
1.6 Concerns of Prosthetic Eye Wearers 11

“Heavy discharge with blocked sinuses and heavy cold or sometimes feels like grit
under top lid towards the outside.”
“More discharge after cleaning the eye.”

Further information about the socket’s response to prosthetic eye wear is found
in Chaps. 8 and 9. Chapter 10 contains advice for patients about prosthetic eye
cleaning regimes and socket health.

1.5 Phantom Eye Pain

Phantom eye pain is a phenomenon reported in 23–28 % of cases [31]. The pain is
caused by the severing of sensory nerves at the time of eye removal surgery and is
defined as any painful sensation in which the patients refer to the removed eye and
where an anatomical cause of pain in the orbit or socket is absent [32]. Cold condi-
tions, windy weather, tiredness and stress are known to trigger phantom eye pain,
and it can occur several times a day or once every few months with attacks that last
for seconds or for several minutes. It can be quite intense (especially for those who
suffer daily attacks) and is more common in patients whose eye was blind and pain-
ful before it was removed. There is no association between phantom eye pain and
the type of surgery (enucleation or evisceration) although the presence of an orbital
implant is associated with phantom eye pain. The condition is difficult to treat, and
no treatment appears to permanently eliminate the pain [32].

1.6 Concerns of Prosthetic Eye Wearers

In a study carried out in 2011, 63 experienced prosthetic eye wearers identified their
concerns when they first lost their eye and compared them to their present-day con-
cerns at least 2 years later (Fig. 1.7) [11].
Patients’ main concerns when they first lost their eye, in order of importance,
were the continued health of the remaining eye, judging distance, receiving good
advice, adapting to reduced side vision and concerns about appearance. Patients’
main concerns about their new prosthetic eye were that it stayed in the socket,
looked in the right direction, was comfortable and had good movement.
After wearing a prosthetic eye for at least 2 years, these same patients had sig-
nificantly less concerns about judging distance, reduced side vision and appearance.
Their main current concerns at this later time were health of their remaining eye
followed by mucoid discharge from their anophthalmic socket.
An analysis of demographic variables associated with current levels of concern
showed that anophthalmic patients in public occupations were more concerned
about their appearance than patients in non-public occupations [11]. This result
might be expected, but the analysis also showed that patients in public occupations
had greater concerns about reduced peripheral vision. This suggests that anophthal-
mic patients feel more uncomfortable with their limited side vision in public set-
tings than in other situations.
12 1 The Anophthalmic Patient

Initial level of concern vs current level of concern

10
9 Initial
8 Current
Median (0–10)

7
6
5
4
3
2
1
0
ey
e ce ce on ye ey
e
nc
e ye ye ey
e
ey
e
ey
e ge ey
e
nc
e
tio
n on
an vi si le le le ar si
ng st ad vi ia o d a ra ia ia o d o d o d ch od a la era t vi
in
i di od de tif
ic go pe ifi
c
ifi
c
go go go di
s go fb op gh
a e si ar ap ar
t
ar
t o si
m dg go d to to to to & to ss m
re ju g ce of e to of of e e e g e fro om
of in u n t iv t t t iv t iv t iv t in t iv Lo t
to
ei
v
ed tio la ge for en la la la us la ai
n
an
lth ilit
y
ec en re n re re rr
e cr rr
e P Ph
ea
R
et ze ha om em it ze
Ab R C C ov rb ou g, ou
H R a o Si ol in t
fg M
of C er on
n
o s at d
c
io es W Li
ct lln e
ire Fu Ey
D

Concern

Fig. 1.7 Concerns of patients when they first lost their eye compared with their concerns at least
2 years later (Published with kind permission of Wiley. All rights reserved)

Aside from mucoid discharge, the artificial eye concerns that changed the least
over time were concerns about direction of gaze, size and eyelid contour. These
concerns largely relate to the characteristics of the eyelids and socket rather than to
the prosthetic eye itself.
The health of the remaining eye was anophthalmic patients’ chief concern
throughout, and this reinforces the wisdom of advising patients to undergo regular
eye examinations at periods appropriate for each particular patient. Protection of the
remaining eye with impact-resistant safety lenses together with an appropriately
safe frame design may also provide peace of mind for patients (Fig. 1.8) [33]. See
tips for selecting glasses in Chap. 10.
At the time of eye loss, it is important to carefully listen to patient’s concerns and
provide them with good information and advice about loss of body image and cop-
ing with sudden perceptual changes (see Chap. 10). Also, when counselling trauma-
tised patients about their prospects for the future, it is useful for carers to know that
the early concerns of patients are likely to decrease over time. However, this is not
an automatic process, and some patients never fully adjust without professional
help. New patients may take heart from a study by Song et al. [34] which reported
an overall rate of satisfaction with initial artificial eyes of 71.8 %.

1.7 Psychological Issues for Children

When an eye is lost at an early age because of congenital abnormality, cancer (e.g.
retinoblastoma) or accident, parents often feel the loss more than the child. This is
because self-awareness in children does not occur until about 2 years of age. This is
when they begin to recognise that their movements are somehow connected to their
reflections in a mirror. This novel experience is different from other things they see
1.8 Personal Accounts of Eye Loss 13

Fig. 1.8 Fashionable

impact-resistant glasses

around them, and further exploration ultimately leads them to become aware of
themselves as separate entities capable of being projected in the minds of others
[35]. They recognise themselves in photographs as ‘me’, and at about 3 years of age,
they become self-conscious and aware of how special they are to only have one eye.
Sometimes, young children stubbornly refuse to accept their prosthesis and prefer
not to wear it or to have anybody touch their socket. A German Eye Cancer Trust has
recognised this problem and has created a therapeutic tool in the form of a toy ele-
phant with a removable eye (Fig. 1.9). This toy is called ‘Elli’, and the trust makes
and donates Elli to children with retinoblastoma around the world – free of charge
[36]. The Ellis can be ordered via email from [email protected].
At about the age of 5 years, a child’s self-awareness differentiates into three cat-
egories: their social self, their school work persona and their physical self. Parents
of anophthalmic children may strengthen a child’s self-image through reassurance,
communication, support of hobbies and finding good role models.
Parents should acknowledge their child’s different appearance but not dwell on it
to the point where the child feels guilty for being the source of their parent’s anxiety.
Probably the most enduring harm to the self-esteem of anophthalmic children is
the impact of negative comments and hurtful teasing about the way they look from
classmates and peers. Although these hurtful comments often stem from ignorance,
they amount to bullying, and parents and teachers should be alert for any suggestion
of this happening and be ready to stop it immediately.
Low self-esteem and a negative body image affect many adolescents when they begin
puberty because of the numerous changes the body goes through. These changes come at
a time when adolescents want to feel accepted by friends, and they are often tempted to
compare themselves with others. This can be a difficult time for anophthalmic teenagers,
and the support of family and friends is most important during this period.

1.8 Personal Accounts of Eye Loss

The emotional experiences associated with eye loss are described in the following
personal accounts of eight prosthetic eye wearers (Figs. 1.10, 1.11, 1.12, 1.13, 1.14,
1.15, 1.16 and 1.17).
14 1 The Anophthalmic Patient

Fig. 1.9 ‘Elli’ can be

ordered free of charge for
children with retinoblastoma
via email to info@kinderau-
genkrebsstiftung.de

Fig. 1.10 ‘When my husband Reese and I were fencing contractors, we moved around a lot and
lived in tents on the properties we worked on. In 1974 we were clearing old fencing wire from a
kiwifruit orchard. I cut a wire and one end sprang up and struck my right eye’. Mona Davies is a
farmer (emphatically not just a ‘farmer’s wife’!). She has worked hard all her life and now lives
comfortably on an 800 acre coastal farm. She and Reese run sheep and cattle as well as four beach-
front cottages which they rent out to fishing parties and families. Their two children farm their own
coastal blocks on either side of Mona’s and Reece’s land, and not a day goes by when Mona does
not see them or her three grandchildren. Mona took the loss of her eye like she does with most
things in life: ‘she put up with it and moved on’. It wasn’t the damage to her appearance that con-
cerned her so much as the difficulty she had parking the car and reading the ground hollows when
going about the farm (Published with kind permission of NZ Artificial Eye Service. All rights
reserved)
1.8 Personal Accounts of Eye Loss 15

Fig. 1.11 Natahlie is a bright and happy 3-year-old who lives on a farm. One morning a rooster
flew at the apple Natahlie was eating but pecked at her right eye instead, resulting in Natahlie los-
ing the eye. Natahlie was excited about getting her prosthetic eye and couldn’t wait to check it out
in the mirror. In the years ahead, she will depend on her family, teachers and friends to reinforce
the positive aspects of being such a unique individual (Published with kind permission of NZ
Artificial Eye Service. All rights reserved)
16 1 The Anophthalmic Patient

Fig. 1.12 Greg’s right eye was injured during a difficult birth, and while surgeons offered to oper-
ate on it at the time, his parents refused because they could not bear for him to go through any more
traumas. Indeed, the experience was so painful for them that they ignored his eye’s different
appearance and never spoke about it. Partly because of this lack of acknowledgment and partly
because of the teasing he suffered from other children at school, Greg developed very low self-
esteem and a shyness that limited his schooling and his ambitions. Even so, Greg became a quality
assurance manager, but it wasn’t until a new partner (who happened to have a degree in psychol-
ogy) persuaded him to seek help that he obtained life-changing scleral shell prosthesis at age 31
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)
1.8 Personal Accounts of Eye Loss 17

Fig. 1.13 Sue (aged 60) lost the sight of her right eye to endophthalmitis following a corneal
transplant. For 2 years her eye became more and more unsightly, but she could not face having it
removed. According to Sue ‘Eyes are the windows of the soul. It is much harder to lose an eye than
to lose other body parts because of the emotional aspects’. Sue eventually plucked up the courage
to have her eye removed. ‘I should have had my eye out sooner. I wish I had not put myself through
such prolonged emotional turmoil’ (Published with kind permission of NZ Artificial Eye Service.
All rights reserved)
18 1 The Anophthalmic Patient

Fig. 1.14 Mike (aged 50) lost his left eye when he fell on a metal fence post while erecting a fence
on a road construction assignment. He remembers that his major concern at the time was not dam-
age to his appearance, but adjusting to using his right eye instead of his left for precision measuring
and sighting a theodolite. Mike overcame this problem and continued with his job as a roadwork
supervisor where he often jokes about his prosthetic eye with his fellow workers. ‘It’s a good
excuse when I make a mistake’. Mike’s open, pragmatic approach is genuine and reflects the fact
that for him, the loss of an eye was never a big issue. He is careful to look after his remaining eye
however and to ensure that his prosthesis is properly maintained (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)
1.8 Personal Accounts of Eye Loss 19

Fig. 1.15 Tracey was born with a microphthalmic right eye. She was teased at school to the point
where she lost all self-confidence and belief. This affected her attitude to life and her education,
and she became a miserable teenager with anorexia and bulimia. Things improved for Tracey after
her eye was enucleated at age 21, and she had happier times in her 20s. Now in her 40s, Tracey is
forward-looking and enthusiastic about her job as a systems manager. She has accepted that there
are many more important things in her life than worrying about her eye (Published with kind per-
mission of NZ Artificial Eye Service. All rights reserved)
20 1 The Anophthalmic Patient

Fig. 1.16 Diane (aged 80) has worn a prosthetic eye since her right eye was removed at age 12.
Diane’s first prostheses were made of glass, and she well remembers selecting her glass eyes from
an assortment laid out on trays. She also remembers breaking her glass eye and the drama and
stress this caused her poor mother who had to rush her to the optometrist to find a replacement.
Diane always left her prosthesis out at night and one morning she couldn’t find it. She was very
upset because nobody had ever seen her without her prosthesis, and she has vivid recollections of
ripping her bedroom apart before discovering the eye mixed up in her blankets. Having only one
eye has not prevented her from doing anything she would not have done otherwise – ‘it’s just felt
different’ (Published with kind permission of NZ Artificial Eye Service. All rights reserved)
1.8 Personal Accounts of Eye Loss 21

Fig. 1.17 When Raewyn’s right eye was lacerated by a piece of wire at age 40, her life took a
dramatic turn for the worse. Her eye became more and more unsightly as her cornea opacified, and
she became very self-conscious about her appearance. The stress contributed to the breakdown of
her marriage, but after this happened she was forced to take stock of her situation. She had two
children to bring up, looked awful and had no career. So what did she do? She began training as a
midwife, qualifying a few years later. Raewyn has delivered 1000s of babies since then and is now
a pregnancy consultant providing expert advice to young mothers. Raewyn’s disfigured eye was
finally eviscerated in 2007, and she was fitted her new prosthetic eye. ‘The difference was amaz-
ing. For years I put up with a horrible looking eye and in 6 short weeks I was suddenly normal. I
should have had my eye out years ago’. Raewyn is proud of overcoming the loss of her eye and
going on to make a difference in her life and in the lives of others (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)
22 1 The Anophthalmic Patient

References
1. Pine KR, Sloan B, Jacobs RJ. Biosocial profile of New Zealand prosthetic eye wearers. N Z
Med J. 2012;125(1363):29–38.
2. GeoBa.se. Available from: http://www.geoba.se/population.php?pc = world&type = 28.
Accessed 20 Nov 2014.
3. Work-related injury statistics 2002–2010. Available from: http://www.stats.govt.nz/tools_
and_services/tools/TableBuilder/injury-tables.aspx. Accessed 20 Nov 2014.
4. New Zealand Government. Motor vehicle crashes in New Zealand, 2011. Available from:
http://www.transport.govt.nz/research/Pages/motorvehiclecrashesinnewzealand.aspx .
Accessed 20 Nov 2014.
5. Australian Government. Department of Human Services. Available from: www.medicareaus-
tralia.gov.au. Accessed 20 Nov 2014.
6. Australian Bureau of Statistics. Available from: www.abs.gov.au. Accessed 20 Nov 2014.
7. Chang KC, Kwon J-W, Han YK, Wee WR, Lee JH. The epidemiology of prosthetic treatments
for corneal opacities in a Korean population. Korean J Ophthalmol. 2010;24(3):148–54.
8. American Academy of Ophthalmology. Eye injuries: recent data and trends in the United
States, 2008. Available from: http://www.aao.org. Accessed 20 Nov 2014.
9. Trawnik WR, Fitzimmons TD. Eye loss in the 1990s: a comparative study. J Ophthal Prosthet.
1996;1:7–13.
10. Cabral LGM, Martelli Júnior H, Leite DM, Sabatini Júnior D, de Freitas ABDA, Miranda RT,
Swerts MSO, de Barros LM. Biopsychosocial profile of patients with anophthalmia in the
south of Minas Gerais – Brazil. Arq Bras Oftalmol. 2008;71(6):855–9.
11. Pine KR, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing artificial
eyes. Clin Experiment Ophthalmol. 2011;39(1):47–52.
12. Medina PA. The power of shadows: shadow stereopsis. J Opt Soc Am A. 1989;6(2):309–11.
13. Chen WP. Oculoplastic surgery. The essentials. New York/Stuttgart: Thieme; 2001.
14. Ihrig C, Schaefer DP. Acquired monocular vision rehabilitation program. J Rehabil Res Dev.
2007;44:593–7.
15. Nicholas JJ, Heywood CA, Cowey A. Contrast sensitivity in one-eyed subjects. Vision Res.
1996;36(1):175–80.
16. Neuro Optometric Rehabilitation Association. Implications of acquired monocular vision (loss
of one eye). Available from: https://nora.cc/for-patients-mainmenu-34/loss-of-one-eye-main-
menu-70.html. Accessed 20 Nov 2014.
17. Slonim MD, Martino MD. Eye was there: a patient’s guide to coping with the loss of an eye
(Kindle Locations 299–313). Bloomington: AuthorHouse; 2011. Kindle Edition.
18. Sreedhar K. Disfigurement: psychosocial impact and coping. Open Dermatol J. 2009;3:54–7.
19. Macgregor FC. Facial disfigurement: problems and management of social interaction and
implications for mental health. Aesthetic Plast Surg. 1990;14:249–57.
20. Langer E, Fiske S, Taylor S, Chanowitz B. Stigma, staring and discomfort: a novel-stimulus
hypothesis. J Exp Soc Psychol. 1976;12:451–63.
21. Ahn JM, Lee SY, Yoon JS. Health-related quality of life and emotional status of anophthalmic
patients in Korea. Am J Ophthalmol. 2010;149:1005–11.
22. Atay A, Peker K, Günay Y, Ebrinc S, Karayazgan B, Uysal Ö. Assessment of health-related
quality of life in Turkish patients with facial prostheses. Health Qual Life Outcomes.
2013;11:11. doi:10.1186/1477-7525-11-11.
23. Clarke A. Psychosocial aspects of facial disFig.ment: problems, management, and the role of
a lay-led organization. Psychol Health Med. 1999;4:127–42.
24. Kübler-Ross E. On death and dying. New York: Simon and Schuster; 1969.
25. Goiato MC, Santos DM, Bannwart LC, Moreno A, Pesqueira AA, Haddad MF, Santos
EG. Psychosocial impact on anophthalmic patients wearing ocular prosthesis. Int J Oral
Maxillofac Surg. 2013;42:113–9. # 2012.
References 23

26. McBain HB, Ezra DG, Rose GE, Newman SP. The psychological impact of living with an
ocular prosthesis. Orbit. 2014;33(1):39–44.
27. De Sousa A. Psychological issues in acquired facial trauma. Indian J Plast Surg. 2010;43(2):200–5.
28. Martin RA, Lefcourt HM. Sense of humor as a moderator of the relation between stressors and
moods. J Pers Soc Psychol. 1983;45(6):1313–24.
29. Abel MH. Humor, stress, and coping strategies. Humor. 2008;15(4):365–81.
30. Chang TL, Garrett N, Roumanas E, Beumer 3rd J. Treatment satisfaction with facial prosthe-
ses. J Prosthet Dent. 2005;94:275–80.
31. Rasmussen ML, Prause JU, Toft PB. Phantom pain after eye amputation. Acta Ophthalmol.
2011;89:10–6.
32. Bohman E, Rassmussen ML, Kopp ED. Pain and discomfort in the anophthalmic socket. Curr
Opin Ophthalmol. 2014;25:455–60.
33. Vinger PF, Parver L, Alfaro 3rd DV. Shatter resistance of spectacle lenses. JAMA. 1997;277:142–4.
34. Song JS, Oh J, Baek SH. A survey of satisfaction in anophthalmic patients wearing ocular
prosthesis. Graefes Arch Clin Exp Ophthalmol. 2006;244:330–5.
35. Rochat P. Five levels of self-awareness as they unfold early in life. Conscious Cogn.
2003;12:717–31.
36. Kinder Augen Krebs Stiftung. Available from: http://www.kinderaugenkrebsstiftung.de/en/.
Accessed 20 Nov 2014.
Anatomy and Physiology
2

Contents
2.1 Introduction ................................................................................................................... 26
2.1.1 Terminology .................................................................................................... 26
2.2 Facial Architecture ........................................................................................................ 27
2.3 Surface Anatomy of the Eye and Eyelids ..................................................................... 28
2.4 The Skull and Orbit....................................................................................................... 30
2.4.1 The Skull ......................................................................................................... 30
2.4.2 The Orbit ......................................................................................................... 31
2.5 Orbital Contents ............................................................................................................ 32
2.5.1 The Eye ........................................................................................................... 32
2.5.2 Optic Nerve ..................................................................................................... 34
2.5.3 The Extraocular Muscles ................................................................................ 34
2.5.4 Levator Muscle................................................................................................ 37
2.5.5 Lacrimal Gland ............................................................................................... 37
2.5.6 Lacrimal Sac ................................................................................................... 38
2.5.7 Orbital Fat ....................................................................................................... 38
2.5.8 Blood Vessels and Nerves ............................................................................... 38
2.6 Muscles of the Forehead ............................................................................................... 38
2.6.1 Muscles of the Forehead ................................................................................. 38
2.7 The Eyelids ................................................................................................................... 40
2.8 The Conjunctiva ............................................................................................................ 41
2.8.1 The Palpebral Region ...................................................................................... 41
2.8.2 The Bulbar Region .......................................................................................... 43
2.8.3 Forniceal Region ............................................................................................. 43
2.9 Sensitivity of the Conjunctiva and Cornea.................................................................... 44
2.10 Structure of the Conjunctiva ......................................................................................... 46
2.10.1 The Substantia Propria Layer of the Conjunctiva ........................................... 46
2.10.2 The Epithelial Layer of the Conjunctiva ......................................................... 46
2.10.3 Goblet Cells .................................................................................................... 47
2.10.4 Function of Mucus .......................................................................................... 48
2.11 The Lacrimal Apparatus ............................................................................................... 48

© Springer International Publishing Switzerland 2015 25

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_2
26 2 Anatomy and Physiology

2.12 Tears .............................................................................................................................. 50

2.12.1 Function of Tears ............................................................................................ 50
2.12.2 Tear Film ......................................................................................................... 51
2.12.3 Tear Output ..................................................................................................... 52
2.12.4 Tear Distribution ............................................................................................. 53
2.13 Facial Changes Due to Ageing...................................................................................... 54
2.14 Loss of the Ocular Globe .............................................................................................. 55
2.14.1 Prosthetic Eye Motility ................................................................................... 57
2.14.2 Conjunctiva of the Anophthalmic Socket ....................................................... 57
2.14.3 Tear Film with a Prosthetic Eye ...................................................................... 59
2.14.4 Tear Output with a Prosthetic Eye .................................................................. 60
2.14.5 Tear Distribution with a Prosthetic Eye .......................................................... 60
2.14.6 Post-enucleation Socket Syndrome (PESS) .................................................... 61
References ................................................................................................................................ 64

2.1 Introduction

A sound appreciation of the characteristics of the face and the anatomy (structure)
and physiology (function) of the orbital tissues is a necessary precursor to under-
standing prosthetic eye performance and the response of the anophthalmic socket to
prosthetic eye wear.
This chapter provides an overview of the anatomical and physiological features
of the face and eyes that are relevant to ocular prosthetics. It begins with an over-
view of facial architecture and the surface anatomy of the eye and eyelids. The
anatomy of the skull and orbit are briefly outlined, and then the anatomy and
physiology of the eyelids, midface, conjunctiva and lacrimal system are explored
in some detail. This description of normal structure and function is followed by a
discussion of the changes that occur over time due to ageing and disease and to
adaptations of the socket to prosthetic eye wear, including the entity of ‘post-
enucleation socket syndrome’ which is introduced as an illustrative example of
pathophysiology.

2.1.1 Terminology

The relationships between various tissues of the head and neck are described in
reference to their anatomical positions as if you are sitting directly in front of the
subject. The terms superior (above) and inferior (below) are easy to understand.
Posterior is towards the back of the head; anterior is towards the front. Medial
means closer to the midline and lateral means further from the midline. Temporal is
used interchangeably with lateral, particularly in descriptions of the orbit. Terms
can be ‘stacked’ or ‘joined’ as required, so ‘superotemporal orbit’ means the upper
outer quadrant of the orbit.
2.2 Facial Architecture 27

2.2 Facial Architecture

Overall facial dimensions and proportions are important in the context of prosthetic eye
fitting as the eyes and eyelids are the main aesthetic units that determine facial sym-
metry and expression. The ‘idealised’ face may be divided into horizontal thirds: the
hairline to the eyebrows, the eyebrows to the base of the nose and the base of the nose
to the chin. The width of the idealised face may be divided into vertical fifths: the out-
side fifths extend from each ear to the nearest lateral canthus, the next innermost fifths
span the eyes from each lateral canthus to the corresponding medial canthus and the
central fifth extends between the medial canthi across the bridge of the nose (Fig. 2.1).
Palpebral fissures (the elliptical spaces between the open eyelids) may be used as
measuring units for the face. The ‘idealised’ face is five palpebral fissure widths
wide and eight palpebral fissure widths high [1]. Adult palpebral fissures are
7–11 mm high and 28–30 mm wide [2] (Fig. 2.2).

Fig. 2.1 The ‘ideal’ face divides into horizontal thirds and vertical fifths (Published with kind
permission of NZ Artificial Eye Service. All rights reserved)

Fig. 2.2 In the adult face, the

eyes are usually separated by
one horizontal palpebral
width across the bridge of the
nose (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
28 2 Anatomy and Physiology

Figure 2.3 illustrates a normal face, but on closer examination it can be seen that in
this figure, the nose and mandible (lower jaw) swing away to the subject’s right. This
is not abnormal as most faces have their own individual characteristics and seldom
conform to the ideal. In particular, faces are very rarely symmetrical, but symmetry
around the eyes is a potent cue to the illusion of more generalised facial symmetry.
The corollary of this is that asymmetry of the eyes is often readily noticeable.

2.3 Surface Anatomy of the Eye and Eyelids

Figure 2.4 illustrates the main anatomical features of the eye and eyelids. Figure 2.5
demonstrates the position of the pupil, which is usually supero-medial to the centre
of the iris.

Fig. 2.3 The eyes are a

principal determinant of the
appearance of facial
symmetry (Published with
kind permission of NZ
Artificial Eye Service.
All rights reserved)

Fig. 2.4 Gross anatomy

of the eye and eyelids
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
2.3 Surface Anatomy of the Eye and Eyelids 29

Fig. 2.5 The pupil is usually

positioned supero-medial to
the centre of the iris
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 2.6 The medial third of

the upper eyelid angles down
towards the nose (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

The margin of the upper eyelid hangs over the superior limbus of the cornea by
1–2 mm. The arch of the upper eyelid is asymmetrical as its highest point is medial
to the centre of the eyelid margin (Fig. 2.6). This peak gradually moves laterally
with age, changing the palpebral aperture to a more fusiform shape over time [3].
The corneal bulge lifts the upper eyelid margin, but this local elevation is indepen-
dent of the position of the eyelid peak.
The upper eyelid crease (Fig. 2.7) marks the transition between the relatively
fixed skin in front of the tarsal plate and the more mobile skin above it. The position
and appearance of the skin crease varies greatly with ethnicity and age and is
affected by previous surgery.
The lowest point of the arch of the lower eyelid is just lateral to the pupil at the
inferior limbus. During youth and middle age, the eyelids typically slope upwards
laterally, with the lateral canthus 2 mm higher than the medial canthus [4].
30 2 Anatomy and Physiology

Fig. 2.7 The upper eyelid

crease is formed where the
anterior expansions of the
levator aponeurosis muscle
joins the skin (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 2.8 The skull is made up of 21 bones immovably joined together and one moveable bone, the
mandible (Published with kind permission of NZ Artificial Eye Service. All rights reserved)

2.4 The Skull and Orbit

2.4.1 The Skull

The skull comprises the cranium which houses and protects the brain and the face
which forms the antero-inferior aspect. The cranium is made up of eight bones:
the occipital, the frontal, two parietals, two temporals, one sphenoid and one eth-
moid. The skeleton of the face consists of 13 bones immovably joined together
and one movable bone, the mandible. The 13 bones are two each of nasal, maxil-
lae, lacrimal, zygomatic, palatine, inferior nasal concha (total 12) and one vomer
(Fig. 2.8).
2.4 The Skull and Orbit 31

2.4.2 The Orbit

The orbit is a bony cavity that can be thought of as a four-sided pyramid, with a
floor, a medial wall, a lateral wall and a roof.

• The roof of the orbit forms the floor of the anterior cranial fossa which contains
the frontal lobes of the brain.
• The medial orbital wall is the thinnest and most delicate and separates the orbit
from the ethmoid sinuses. It runs approximately parallel to the midline and
extends approximately 45 mm from the rim to the optic foramen posteriorly.
• The floor of the orbit forms the roof of the maxillary sinus and carries the infra-
orbital nerve and artery in a groove or canal.
• The lateral wall of the orbit is formed mainly by the outer wing of the sphenoid
bone and is stoutest of the four walls. The lateral wall is shorter than the medial
wall and diverges from it at an angle of about 45°.

The orbit rim in an adult male is approximately 40 mm across and 35 mm high. The
rim is made up of the frontal, zygomatic and maxillary bones and is thick and strong.
The inferior orbital fissure runs along the junction of the lateral wall and floor, from
about 15 mm behind the orbital rim backwards towards the apex of the orbit, where it
merges with the superior orbital fissure. The superior orbital fissure runs forwards about
a third of the distance to the orbital rim along the junction of the roof and the lateral wall.
The optic foramen lies at the supero-medial aspect of the apex of the orbit and
transmits the optic nerve to the cranial cavity. The lacrimal groove lies at the infero-
medial edge of the orbit just inside the rim and carries the nasolacrimal duct from
the orbit into the nose. The supraorbital notch is located at a point about one third
along the superior orbital rim from the medial wall (Fig. 2.9). The infraorbital fora-
men lies in the same horizontal position, a few mm below the inferior orbital rim.

Fig. 2.9 Transverse section of the skull showing the pyramidal shape of the orbit. Note the short
length of the lateral orbital wall compared to the medial wall (Published with kind permission of
NZ Artificial Eye Service. All rights reserved)
32 2 Anatomy and Physiology

The orbit is completed anteriorly by the orbital septum. The bones of the orbit
are lined with periosteum, also known as the periorbita.

2.5 Orbital Contents

The contents of the orbit are the eye and optic nerve, the extraocular muscles, the
levator muscle, lacrimal gland, lacrimal sac, orbital fat, nerves and blood vessels.
Each will be briefly considered in turn.

2.5.1 The Eye

The eye is roughly spherical with a diameter of approximately 24 mm, a volume of

6–7 ml and a weight of about 7.5 g (Fig. 2.10). The eye grows rapidly from birth, and

Fig. 2.10 Enucleated human

eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
2.5 Orbital Contents 33

its diameter reaches 22.5–23 mm by age three and is usually fully grown by age 13.
These dimensions are surprisingly consistent among adults and across ethnicities.
The external wall of the eye has a three-layered structure (Fig. 2.11). The outer
layer is made up of the white sclera posteriorly and is continuous with the clear
slightly bulging cornea anteriorly. The sclera and the cornea meet at the limbus.
Both are made from tough connective tissue. The cornea has a diameter of approxi-
mately 10.0 mm at birth and 11.7 mm in adulthood, and women’s corneas are
slightly larger than men’s on average.
The middle layer of the wall of the eye is the vascular choroid which provides
part of the blood supply to the retina. The only visible part of the choroid is the iris
which has a central circular aperture – the pupil. The pupil constricts with light and
when a person attends to a near object and its average diameter becomes smaller
with increasing age.
The inner layer of the eye is the retina. This is the light-sensitive nerve tissue that
converts visual stimuli into electrical impulses.
The eye contains two fluid-filled spaces – the anterior segment (between the
cornea and lens), which is filled with the fluid aqueous humour, and the posterior
segment (between the lens and the retina), filled with the gel-like vitreous humour.
The anterior chamber is that part of the anterior segment in front of the iris.
Separating the anterior and posterior segments is the clear flexible crystalline
lens which is suspended from the surrounding ciliary body by the fine ligamentary
fibres of the zonules.

Ligamentary fibers of the zonules

Sclera
Choroid

Retina Lens

Central retinal
artery
Iris
Cornea
Optic nerve Pupil

Central retinal
vein

Posterior chamber Anterior chamber

(vitreous humor) (aqueous humor)

Fig. 2.11 The eye (Published with kind permission of NZ Artificial Eye Service. All rights
reserved)
34 2 Anatomy and Physiology

2.5.2 Optic Nerve

The optic nerve runs in a gentle s-shape from the back of the globe to the optic fora-
men. It is approximately 4 mm in diameter and carries all the impulses from the
retina of the eye to the brain.

2.5.3 The Extraocular Muscles

The extraocular muscles move the eye. They comprise the superior, inferior, medial
and lateral rectus muscles and the superior and inferior obliques (Figs. 2.12 and
2.13). The four rectus muscles and the superior oblique muscle arise from the orbital

Fig. 2.12 Sagittal view of

the extraocular muscles
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 2.13 Anterior view of

the extraocular muscles
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
2.5 Orbital Contents 35

apex, while the inferior oblique arises from the antero-medial floor of the orbit just
inside the orbital rim. The tendons of these muscles insert themselves into the super-
ficial layers of the sclera and merge with it.

2.5.3.1 The Rectus Muscles

The superior, inferior, medial and lateral rectus muscles each arise from the corre-
sponding part of the annulus of Zinn – a circular band of fibrous tissue surrounding
the optic nerve at the orbital apex. Each rectus muscle passes forwards in the orbit,
pierces Tenon’s fascia and inserts into the sclera anterior to the equator of the eye.
Each muscle has fascial attachments (sheets or bands of connective tissue fibres)
throughout the orbit and to the conjunctival fornices (see below). The most well
developed of these is the capsulopalpebral fascia – a fascial expansion of the sheath
of the inferior rectus, which attaches to the lower lid. Contraction of the inferior
rectus therefore also depresses the lower lid.

2.5.3.2 The Superior Oblique Muscle

The superior oblique muscle is the longest and thinnest of the extraocular muscles.
It arises from the supero-medial part of the orbital apex and passes forwards between
the roof of the orbit and its medial wall to the trochlea. The trochlea is a u-shaped
pulley made of fibrocartilage which is attached to the frontal bone just behind the
orbital margin. The superior oblique narrows into a tendon enclosed in a synovial
sheath as it passes through the trochlea. The pulley action allows the muscle to bend
downwards and backwards and then laterally through Tenon’s capsule where it
spreads out to its fan-like attachment on the sclera.
The trochlea influences the shape of prosthetic eyes in this area (Fig. 2.14).

2.5.3.3 The Inferior Oblique Muscle

The inferior oblique is the only extraocular muscle that does not originate at the
orbital apex. It arises from the medial orbit just inside the orbital rim, adjacent to the

Fig. 2.14 The supero-nasal

notches in prosthetic eyes
accommodate the trochlea
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
36 2 Anatomy and Physiology

nasolacrimal duct. It passes backwards and laterally between the inferior rectus and
the orbital floor and inserts into the globe under the lateral rectus at the posterior
lateral area of the eyeball.

2.5.3.4 Eye Motility

The ocular movement system is incredibly sophisticated, serving to keep both eyes
aligned and fixated on the point of interest despite movement of the head and the rest
of the body. The movements of each eye are described in terms of movements around
three axes passing through the centre of the pupil – elevation and depression around the
horizontal axis, abduction (movement away from the midline of the body) and adduc-
tion (movement towards the midline) around the vertical axis and incyclotorsion (rota-
tion of the 12 o’clock position of the cornea towards the midline) and excyclotorsion
(rotation of the 12 o’clock position of the cornea away from the midline) around an
anterior–posterior axis (Fig. 2.15).
Because the orbits lie at an angle to the midline and because the extraocular
muscles are at different angles to each other, contraction of a given extraocular
muscle does not result in “pure” movements such as elevation or depression,
and muscles are considered to have primary, secondary and tertiary actions. The
action of some muscles also changes dramatically with the position of the eye – for
instance in abduction (when the eye is looking away from the midline), the superior
oblique is an incyclotorter, but in adduction (when the eye is looking inwards) it
depresses the eye. Multiple extraocular muscles are usually acting synergistically in
each eye for every position of gaze, and of course further synergy is required for
each eye to align with and to look in the same direction as the other.
For our purposes, however, it is sufficient to regard the extraocular muscles in
terms of their primary actions, as long as one is aware that this is a gross simplifica-
tion. Hence, the superior rectus elevates, the inferior rectus depresses, the medial
rectus adducts, the lateral rectus abducts, the superior oblique incyclotorts and the
inferior oblique excyclotorts.

Fig. 2.15 Anterior view of

the right eye showing the
direction of movements of
the eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
2.5 Orbital Contents 37

2.5.4 Levator Muscle

The levator muscle (levator palpebrae superioris) which raises the upper eyelid is
not an extraocular muscle but is embryologically, anatomically and functionally
closely related to the superior rectus. It originates just above the superior rectus
and maintains this relationship as it runs forwards inside the orbit. The levator
changes direction at Whitnall’s ligament (superior transverse ligament at the
front of the orbit) and runs down towards the eyelid. The tendon of the levator
muscle is the fan-shaped aponeurosis which inserts onto the anterior surface of
the upper tarsal plate and also into the skin of the upper eyelid, helping to form
the upper lid crease. In Asians, the eyelid crease is often low or absent because the
orbital septum is inserted lower down on the tarsus [5]. Differences between
Asian and other eyelid characteristics affect prosthesis design which must
account for them in terms of inter-palpebral size, eyelid contour and blinking
efficiency (Fig. 2.16).

2.5.5 Lacrimal Gland

The lacrimal gland occupies a shallow depression in the anterior lateral part of the
roof of the orbit.
The gland wraps around the lateral horn of the levator aponeurosis which sepa-
rates the gland into orbital and palpebral lobes, which are continuous posteriorly.
The larger orbital part is situated superiorly in its fossa on the frontal bone in the
lateral area of the orbital roof where it is connected by trabeculae. The ducts from
the orbital portion pass through the smaller inferiorly placed palpebral portion. The
lacrimal gland consists of masses of lobules, each about the size of a pinhead and
separated by fat cells. The secretory units (acini) are made up of two layers of cells

Fig. 2.16 Eyelid characteris-

tics differ between Asians
and others (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
38 2 Anatomy and Physiology

surrounding a central canal. The acinar secretions pass on through very small inter-
lobular ducts to larger ducts before they finally open via 10–12 excretory ducts into
the superotemporal conjunctival fornix.

2.5.6 Lacrimal Sac

The lacrimal sac collects the tears draining from the front of the eye. It is situated in
the medial canthus and drains inferiorly through the nasolacrimal duct into the nose.
Blockage of the nasolacrimal duct and stagnation of its contents can result in abscess
formation in the lacrimal sac, which presents as a tender inflamed swelling just
below the medial canthal tendon.

2.5.7 Orbital Fat

Orbital fat fills up the space in the orbit not otherwise occupied and is a major con-
tributor to intraorbital volume. Injury or disease which damages the fat in an anoph-
thalmic socket therefore contributes to volume deficiency (see Chap. 7).

2.5.8 Blood Vessels and Nerves

In general, blood vessels and nerves enter via the orbital apex and run forward.
Those that leave the orbit do so through the inferior orbital fissure, medial wall and
floor or anteriorly through the orbital septum. The supraorbital nerve runs through
the superior orbit and leaves via the supraorbital notch, to supply sensation to the
entire scalp. The infraorbital nerve runs just beneath the orbital floor and through
the infraorbital foramen and supplies sensation to the midface from lower lid to
upper lip. Damage to these nerves from disease, trauma or surgery can therefore
cause extensive sensory loss.
There are relatively few connections between the blood supply of the orbits and
that of the eyelids and face except at the medial canthus.
Both vessels and nerves can be a route for disease to spread into the orbit – most
commonly infection and skin cancer, respectively.

2.6 Muscles of the Forehead

2.6.1 Muscles of the Forehead

Four pairs of muscles make up the facial musculature of the forehead and eyelids
(Fig. 2.17).
2.6 Muscles of the Forehead and Eyelids 39

Fig. 2.17 Facial muscles of

the eyes and forehead
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

2.6.1.1 Frontalis Muscle

The frontalis extends from above the hairline down across the forehead to where it
inserts into the tissues directly above the eyebrows. When fully contracted, the fron-
talis lifts the eyebrows and forehead upwards forming horizontal wrinkles. Each
frontalis muscle is made up of medial and lateral sections which operate relatively
independently of each other. The medial sections of the frontalis muscles lift the
brow and eyebrows at the centre of the forehead. Arching of the eyebrows occurs
when the lateral sections of the frontalis muscles are raised.

2.6.1.2 Corrugator Muscle

The corrugator muscles extend diagonally from the supra-medial rim of the orbits
to above the centre of each eyebrow. It draws the centre of the eyebrows downwards
and medially when frowning, creating vertical wrinkles between the eyebrows and
horizontal wrinkles above the nose.

2.6.1.3 Procerus Muscle

The procerus originates in the fascia of the upper nasal cartilage and nasal bone and
extends upwards in a fan shape to the centre of the forehead between the eyebrows.
When contracted it pulls the tissues at the centre of the forehead downward and
produces horizontal wrinkles across the bridge of the nose.

2.6.1.4 Orbicularis Oculi Muscle

The orbicularis oculi is a sphincter muscle which forms concentric circles
around the orbit and serves to narrow the eyelids and close the eye. Fibres arise
from the medial palpebral ligament and the supra-medial part of the orbital rim
and run around the eye to return below the lower eyelid to the ligament. The
40 2 Anatomy and Physiology

Fig. 2.18 Orbicularis oculi

(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

inner region (pretarsal orbicularis) is thought to be most active in gentle lid

closure, while contraction of the outer region (preseptal orbicularis) causes
forceful eye closure (Fig. 2.18). Laterally positioned ‘laughter lines’ are hori-
zontal skinfolds that are due to the action of the orbicularis oculi muscle. These
folds become immobile ‘crow’s feet’ when ageing is accompanied by thinning
of the dermis [2].

2.7 The Eyelids

The thinnest skin of the body is found in the eyelids which are given their form by
the dense fibrous tissue of the tarsal plates. The vertical height of the tarsus is
10–12 mm in the upper eyelid and 4 mm in the lower [6]. Their inner surface of
each eyelid is lined with tarsal conjunctiva, while the medial and lateral palpebral
ligaments anchor the tarsi (and eyelids) horizontally to the orbital rims (Fig. 2.19)
[2]. Horizontal tension to keep the eyelids pressed to the globe is provided by this
tarso-ligamentous band, as well as by the action of orbicularis oculi. Involutional
laxity of the ligaments or weakness of orbicularis (for instance due to facial nerve
palsy) therefore leads to ectropion (a sagging away of the lower eyelid from the
eyeball).
The orbicularis oculi muscle is the main eyelid protractor for the upper eyelid,
while the levator muscle is the main retractor. In upward gaze, contraction of both
the levator and frontalis muscles occurs. When looking down, the orbicularis mus-
cle plays no active part, and partial closure of the palpebral aperture is due to relax-
ation of the levator alone. The lower eyelid is depressed when gazing down due to
the action of the capsulopalpebral fascia which arises from the inferior rectus [2].
People blink about 12 times per minute [7, 8], but this rate varies between
individuals and in different circumstances such as when anxious or in a noisy
2.8 The Conjunctiva 41

Fig. 2.19 Anatomical

Insertion of the levator Medial canthal
features of the eyelids aponeurosis muscle ligament
(Published with kind Lacrimal sac
permission of NZ Artificial
Orbital septum
Eye Service. All rights
reserved)
Superior tarsus

Lateral canthal ligament

Inferior tarsus
Orbital septum

room. A dry atmosphere does not appear to alter the blink rate. A complete blink
takes about 1/3 of a second from start to finish. During a forced blink, the eye-
ball usually flicks upwards and sometimes inwards (called ‘Bell’s phenome-
non’) and back again. When people flinch reflexively in response to danger, the
head moves backward and the orbicularis and its accessory muscles contract
causing the lids to squeeze shut. Blinking closure occurs when the levator apo-
neurosis relaxes just prior to contraction of the pretarsal portion of the orbicu-
laris oculi [9].

2.8 The Conjunctiva

The conjunctiva is a thin, transparent mucus membrane that clothes the natural eye-
ball and continues as the lining on the inside of the eyelids. It therefore forms the
conjunctival sac so that nothing can move backward into the orbit. The average
circumference of the sac is about 95 mm and is determined by the width of the pal-
pebral fissure. The sac’s anterior epithelium merges with the epithelium of the cor-
nea at the limbus. The conjunctiva extends onto the eyelid margin, ending just
anterior to the line of the meibomian gland duct openings.
While the conjunctiva is a single continuous mucous membrane, it has three
main regions with different characteristics. They are the palpebral, bulbar and for-
niceal regions. The palpebral region attaches to the eyelids, the bulbar attaches to
the eyeball and the fornix region is the intermediate part that connects the other
regions and forms the fornices (Fig. 2.20).

2.8.1 The Palpebral Region

The palpebral region may itself be subdivided into marginal, tarsal and orbital zones
(Fig. 2.21).
42 2 Anatomy and Physiology

Conjunctival regions

Palpebral

Forniceal

Bulbar

Fig. 2.20 The conjunctiva is a single continuous mucous membrane with three main regions
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 2.21 The palpebral

conjunctiva may be
subdivided into marginal,
tarsal and orbital zones
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

2.8.1.1 The Marginal Zone

The marginal zone (Fig. 2.22) contains the ducts of the meibomian glands and the
lacrimal punctae. The marginal zone also contains Marx’s line which is a distinct
line of cells which form the frictional contact zone between the eyelids and the sur-
face of the globe [10]. Marx’s line is situated posteriorly to the meibomian gland
orifices and is 0.1 ± 0.09 mm wide.
2.8 The Conjunctiva 43

Fig. 2.22 Ducts of the

meibomian glands and the
punctum can be seen here in
the marginal conjunctiva of a
lower eyelid (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

2.8.1.2 The Tarsal Zone

The tarsal conjunctiva adheres closely to the tarsus throughout its entire extent. It is
thin, vascular and transparent enough for the underlying meibomian glands to be
clearly visible.

2.8.1.3 The Orbital Zone

The conjunctiva in the orbital zone lies loosely over the underlying Müller’s muscle
which lies between the superior border of the upper lid tarsal plate and the upper
fornix and over the lower lid retractors, between the inferior border of the lower lid
tarsal plate and inferior fornix. It is folded horizontally, allowing for movement of
the eyeball. When examined closely, the superior half of the orbital conjunctiva is
found to contain a series of shallow grooves and plateaux. These are not true papil-
lae but may become so when inflamed, such as when giant papillary conjunctivitis
(GPC) occurs in anophthalmic sockets.

2.8.2 The Bulbar Region

The bulbar conjunctiva lies loosely on the sclera which can be seen through it and is
in contact with Tenon’s capsule which covers the tendons of the recti muscles. At
about 3 mm from the cornea, Tenon’s capsule, sclera and the conjunctiva become
much more closely attached. At the point of union, a slight ridge in the conjunctiva
may be detected.

2.8.3 Forniceal Region

The conjunctiva of the fornix forms a complete circular sac that is interrupted on
the medial side by the plica semilunaris and the caruncle. It is divided into superior,
44 2 Anatomy and Physiology

Fig. 2.23 The conjunctival

sac of a normal eye showing
the unextended depth of the
fornices

medial, inferior and lateral portions. The superior fornix extends about 8–10 mm
above the limbus in a normal eye. The inferior fornix extends 8 mm below the
limbus and the lateral fornix, about 14 mm from the limbus or 5 mm from the lat-
eral canthus (Fig. 2.23). These measurements vary considerably in anophthalmic
sockets.
The conjunctival fornix adheres to loose, distensible fibrous tissue of the fascial
expansions of the sheaths of the levator and recti muscles, enabling these muscles to
deepen the fornix when they contract. The fibrous tissue contains the glands of
Krause and the muscle of Müller and becomes continuous with the tarsus centrally.
The medial and lateral regions of the superior fornix are in contact with the orbital
fat. The transparent conjunctiva of the inferior fornix enables its rich network of
blood vessels to be readily seen as well as the whitish aponeurotic expansion from
the inferior rectus and inferior oblique muscles. The vertical lines of the meibomian
glands can also be seen over the tarsal area of the eyelids (Fig. 2.24).

2.9 Sensitivity of the Conjunctiva and Cornea

The cornea is the most sensitive part of the body. Maximum sensitivity of the cornea
occurs at the centre with less sensitivity at the limbus, especially the superior aspect
which is normally covered by the upper eyelid. Sensitivity decreases progressively
from the limbus to the fornix where it is at a minimum. The marginal conjunctiva
has the same high sensitivity as the limbus, but the level of sensitivity decreases
2.9 Sensitivity of the Conjunctiva and Cornea 45

Fig. 2.24 The vertical lines

of the meibomian glands can
be seen through the
transparent conjunctiva of the
lower eyelid. The whitish
area is the aponeurotic
expansion from the inferior
rectus and inferior oblique
muscles (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 2.25 Mean touch

thresholds (in mg/mm2) for
the conjunctiva and cornea
using a hand-held 0.12 mm
nylon suture Cochet-Bonnet
aesthesiometer. The lower
the threshold score, the more
sensitive the area

rapidly towards the tarsal conjunctiva. Sensitivity at the narrow occlusal surface of
the eyelid is slightly less than at the marginal conjunctiva [11] (Fig. 2.25).
The sensitivity of the cornea and conjunctiva changes according to age with
young people having three times the sensitivity of older people whose sensitivity
reduces most rapidly between the ages of 50 and 65 years. Sensitivity is similar
between the eyes of the same person and between the sexes although women have
46 2 Anatomy and Physiology

reduced sensitivity during premenstruum and at the onset of menstruation and

during the latter stages of pregnancy.
Sensitivity is greater during the evening than in the morning and also differs
according to ethnic mix and iris colour. Blue-eyed people have more conjunctival
and corneal sensitivity than brown-eyed people of similar ethnicity. Caucasians
with blue eyes have four times the sensitivity of dark-skinned peoples with brown
eyes, and Caucasians with brown eyes have twice the sensitivity of dark-skinned
peoples with brown eyes.
The effect of wearing contact lenses on corneal sensitivity varies according to the
contact lens material. PMMA lenses reduce corneal sensitivity, and after some years
of daily wear, sensitivity will not return to normal with removal of the lens [11].

2.10 Structure of the Conjunctiva

Like all other mucous membranes, the conjunctiva consists of two layers: the deep
substantia propria and the epithelium, which lies above it. However, the structure of
these layers varies considerably in the different regions of the conjunctiva, and this
limits certain pathological processes to defined areas.

2.10.1 The Substantia Propria Layer of the Conjunctiva

The substantia propria is a connective tissue layer, which itself has two layers:
a superficial lymphoid layer or adenoid layer and a deeper fibrous layer. The ade-
noid layer is 50–70 μm in thickness and initially forms in the fornix at 3–4 months
of age where it, together with a growing conjunctiva, produces the horizontal folds
present in the forniceal conjunctiva. Lymphocytes are embedded in the adenoid
layer in large numbers, and when the layer stops at the sub-tarsal fold, the lympho-
cytes cease as well.
The fibrous layer underlies the thinner adenoid layer but is virtually absent over
the tarsus with which it merges. It encapsulates the glands of Krause, the smooth
muscle of Müller and the vessels and nerves of the conjunctiva.

2.10.2 The Epithelial Layer of the Conjunctiva

In the lower eyelid the epithelium of the tarsal conjunctiva has three or four (some-
times five) layers of cells over its entire area, unlike the epithelium of the upper
eyelid where two layers of cells are usually found. At the conjunctival margin on the
lids, the mucocutaneous junction divides dry and moist areas where the marginal
strips of tear fluid end sharply and where the openings of the meibomian glands are
found. On the cutaneous side, the eleidin and keratin layers of the skin end quite
sharply and give way to the squamous epithelium of the marginal conjunctiva. The
most superficial cells are flattened but still retain their nuclei, and the deepest layer
2.10 Structure of the Conjunctiva 47

contains high cylindrical cells followed by several layers of polyhedral cells.

Moving posteriorly, the layers of squamous cells gradually reduce, to be replaced by
columnar and cuboidal cells, and further back, goblet cells begin to appear and
become plentiful just beyond the sub-tarsal fold.
In the upper eyelid, the epithelium of the tarsal conjunctiva is composed of a
superficial layer of tall cylindrical cells and a deeper layer made up of cubical cells.
The superior forniceal epithelium is distinguished from the palpebral conjunctiva
by having a third layer of polyhedral cells arising between the other layers.

2.10.3 Goblet Cells

Goblet cells are unicellular mucous glands. They are present in all areas of the
conjunctival sac with the greatest numbers populating the medial third, least num-
bers in the superotemporal fornix and none at all in the bulbar conjunctiva at the
medial and lateral sides of the limbus (Fig. 2.26). They are large, oval cells with
flattened nuclei when they are near the base of the conjunctiva but become larger
and more oval as they rise to the surface from where they are formed among the
cylindrical cells of the deepest layer. The cytoplasm of the goblet cell is almost
entirely filled by a sac containing cylindrically shaped mucous granules which
contain mucoproteins GP1, GP2 and GP3M, consisting of glycoproteins, espe-
cially sialomucins. When the goblet cells reach the surface of the conjunctiva, the
sac ruptures and the granules are released and spread across the surface of the
conjunctiva where they readily attach themselves to the microvilli of the epithelial
cells. Collectively, the goblet cells secrete about 2–3 μL of mucus per day per eye
which is about 1/1000th of the total fluid produced. Goblet cells, and the mucins
they secrete, greatly increase when the conjunctiva becomes inflamed [12]
(Fig. 2.27). They also form the greatest source of mucus produced with prosthetic
eye wear.

Fig. 2.26 Distribution

of goblet cells in the
conjunctiva of an eye with
eyelids everted
48 2 Anatomy and Physiology

Fig. 2.27 Epithelium of the

conjunctiva with goblet cells
http://www.vetmed.vt.edu/
education/curriculum/
vm8054/eye/cnjnctva.htm
Goblet Cells

2.10.4 Function of Mucus

Mucus is composed mainly of mucins (a family of large, heavily glycosylated pro-

teins) and inorganic salts suspended in water. It covers many epithelial surfaces and
is secreted into fluids such as saliva and tears [13]. The lacrimal mucus is made up
of several types of glycoproteins which originate in the lacrimal glands, the epithe-
lial cells and the goblet cells where high molecular weight glycoproteins or true
mucus is produced. Glycoproteins have an immunological role (immunoglobulins,
transferrin); they transport metals (transferrin, ceruloplasmin), ions and other mol-
ecules (albumin) and are oxidative (ceruloplasmin). Glycocalyx is a surfactant and
together with the true mucus has an immunological role. The viscosity of true
mucus limits the spread of microorganisms which must have specialised mecha-
nisms to survive and develop in the mucus substrate. Mucus also cleans the ocular
surface by trapping exfoliated epithelial cells, miscellaneous surface debris and bac-
teria. Blinking causes the mucus network to collapse into single threads in the for-
nices where they move along to the medial canthus and out onto the skin surface
[14]. Mucus has a lubricating function which facilitates movement of the eye and
eyelids, and finally mucus acts as an intermediary layer that enables aqueous tears
to remain in contact with the hydrophobic epithelium [12].

2.11 The Lacrimal Apparatus

The lacrimal apparatus is composed of a number of glands that produce tears and a
drainage system that transports tears away from the eye, preventing stagnation or
overflow of the tear film.
Most tears originate in the lacrimal gland and its accessory glands and travel medi-
ally to the puncta located at the margin of the upper and lower lids. From there they
2.11 The Lacrimal Apparatus 49

Fig. 2.28 Lacrimal

apparatus (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

move first into the lacrimal canaliculus, then to the lacrimal sac and then onto the naso-
lacrimal duct which drains into the inferior meatus of the nose (Fig. 2.28). Under normal
circumstances, just enough tears are generated to replace those lost by evaporation, so
very little fluid passes down the nasolacrimal duct. Basic tears are supplemented by
reflex tears caused by psychogenic factors (weeping) or by mechanical or chemical irri-
tation. Excessive reflex tears that are not blinked away via the nasolacrimal duct spill
over the lower eyelid and onto the cheek. The technical word for this is ‘epiphora’.
The lacrimal gland is a serous gland, and its tears are supplemented by fluids
from the accessory lacrimal glands of Krause and Wolfring, the mucus-producing
conjunctival goblet cells and the sebaceous tarsal glands. In the accessory lacrimal
glands of the palpebral conjunctiva, the epithelial cells lining the ducts contain
secretory granules. These granules have a different electron density from those
found within the acinar secretory cells, suggesting that the ductal epithelial cells
produce mucoid secretion as well as goblet cells in the conjunctiva. If the lacrimal
gland is missing or its motor nerve supply is cut off, the eye remains moist but basic
tear secretion is radically reduced.
The glands of Krause have the same structure as the lacrimal gland. They are a
continuation downwards of the palpebral portion of the lacrimal gland, and most
(about 42 of them) are embedded in the connective tissue of the subconjunctiva of
the upper fornix between the palpebral portion and the tarsus. A further six to eight
can be found in the lower fornix, also on the lateral side. Similar glands to the
glands of Krause are found in the caruncle. The glands of Wolfring or Ciaccio are
larger than the glands of Krause. There are two to five situated above or in the upper
tarsus between the extremities of the tarsal glands and the superior border. Two
further glands are found in the inferior edge of the lower tarsus. The excretory ducts
are lined by a basal layer of cuboidal cells and a superficial layer of cylindrical cells
which are similar to the conjunctiva on which they open. Henle’s glands are proba-
bly not true glands but folds of mucous membrane cut transversely. They occur in
50 2 Anatomy and Physiology

Fig. 2.29 Tear glands

Superior fornix
(Published with kind
permission of NZ Artificial
Lacrimal gland Gland of Wolfring
Eye Service. All rights
reserved)
Gland of Krause

Glands of Manz

Bulbar conjunctiva Goblet cells

Crypts of Henle

Meibomian glands

Tarsal conjunctiva
Gland of Moll
Gland of Zeis
Bulbar conjunctiva
Glands of Manz

Inferior fornix

Gland of Krause

the palpebral conjunctiva between the tarsal plates and both the superior and infe-
rior fornices. They are lined by epithelium, which is similar to that of the surround-
ing conjunctiva (Fig. 2.29).

2.12 Tears

Tears are essential for the health of the natural eye and serve many of the same func-
tions in the anophthalmic socket such as lubricating the eyelids, cleansing the
socket, wetting the prosthesis and protecting against bacteria.

2.12.1 Function of Tears

In the normal eye the tear fluids with their antibacterial and lubricating properties
are essential for the health and optical properties of the cornea. The tears transport
atmospheric oxygen and ions to the cornea and flush away environmental debris.
Lysozyme is an enzyme contained in the tears that provides a degree of protection
against certain Gram-positive bacteria, while other antibacterial substances in tears
with more potency than lysozyme may be also be present. Lactoferrin is plentiful in
tears and may have an anti-inflammatory function which is effective in attacking the
cell membrane of Gram-negative bacteria. The antibody proteins, IgA and IgG, are
commonly found in tears, and other immunoglobulins may also be present.
2.12 Tears 51

Fig. 2.30 Stained tear

protein deposits on the
surface of a prosthetic eye
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 2.31 Triple-layer

structure of tear film

The secretory phospholipase A2 is not bactericidal against Gram-negative bacteria

(E. coli and Salmonella typhimurium and P. aeruginosa) but has enough concentra-
tion in the tear film to kill Gram-positive bacteria (Listeria monocytogenes and
Staphylococcus aureus) [15]. Tear proteins form deposits on the surface of pros-
thetic eyes and contact lenses (Fig. 2.30).

2.12.2 Tear Film

The pre-corneal tear film can be considered to be a triple-layer structure with an

aqueous centre, a thin superficial lipid layer produced by the meibomian glands of
each eyelid and a supporting basal layer of mucoproteins from the conjunctival
goblet cells (Fig. 2.31).
52 2 Anatomy and Physiology

The normal pre-corneal tear film measures from 6 to 9 μm in thickness immediately

after a blink and 20 % less after 5 s and 50 % less after 30 s. The presence of the lipid
layer on the surface of the pre-corneal tear film may be observed with a tear scope [15].
The lipid layer extends between the eyelid margins as the top cover of the tear film
which serves to reduce evaporation. It is approximately 0.1 μm thick, varying consider-
ably with the time of exposure and the size of the eye. It thins out gradually following
a blink but is compressed and thickened again when the eyelids close together. This
lipid layer stays within the palpebral aperture and does not normally drain into the
conjunctival sac with the rest of the tear film. Mucins from goblet cells in the conjunc-
tiva are essential for tear film stability as they form a hydrophilic base and interface
with the middle aqueous layer of the pre-corneal tear film. At the same time, the deep,
glycoprotein part of the mucin layer is hydrophobic enabling it to attach to the surface
epithelial cell membrane of the cornea. A meniscus of tear fluid, the marginal tear strip,
is formed at the margins of both upper and lower eyelids where the tears gather on
blinking and flow medially towards the puncta of each eyelid (Fig. 2.32).
When the eye opens, tears that have pooled in the marginal tear strips flood over the
cornea, but if the eye stays open too long, the tear film breaks up completely and dries.
Tear break-up time (TBUT) is the time it takes for the tear film to break up after the last
blink and is a measure of tear film quality. Norn [16] described tear film break-up time
as ‘corneal wetting time’. On average, TBUT is about 30 s, but it varies widely between
individuals. In older people tear break-up time is usually less. A TBUT of less than 10 s
is abnormal and indicative of meibomian gland dysfunction and/or dry eye [15].

2.12.3 Tear Output

The onset of lacrimation (including reflex lacrimation) occurs in most infants dur-
ing the first 4 weeks of life in response to hunger or pain. Basic tear secretion gradu-
ally decreases as people get older.

Fig. 2.32 A meniscus of tear

fluid formed at the margin of
the lower eyelid (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)
2.12 Tears 53

The daily volume of tears has been measured by a number of researchers who
have come up with different results depending on the type of test employed.
Estimates range from 1 g using the Schirmer test [17] to 15–30 g measured by the
phenol red thread test [16]. Despite the differences in results seen between such
tests, each can be of considerable clinical value in comparing the production of tears
between eyes in the same person or in documenting changes over time in a given
patient.
The less invasive test for tear volume is the phenol red thread test which utilises
a cotton thread impregnated with a dye (phenol) that changes colour from yellow to
red when it is wetted by tears. The thread has a kink at one end which is hooked over
the margin of the lower lid. The thread is left in place for 15 s, and when removed
the length of the red (wetted) portion is measured. Normal tear secretion gives mea-
sures of about 21 mm while 11 mm and below is considered low volume [15].

2.12.4 Tear Distribution

A meniscus of tear fluid, the marginal tear strip, is formed at the margins of both
upper and lower eyelids where the tears gather up against the exposed portion of the
eyeball. The tears forming the inferior marginal strip spread up the cornea for
1–2 mm due to the wettability of the conjunctiva and/or corneal surface. The tear
meniscus is present on a prosthetic eye but has been shown to be lower than on the
companion eye [18]. The openings of the meibomian glands and their lipid secre-
tions prevent tears from spreading anteriorly and spilling over the eyelid. The tears
forming the superior marginal strip spread down the cornea for 1–2 mm and end
abruptly in a sharp line. When the upper eyelids are lifted away from the globe, tear
fluid does not run down the cornea, but flows up towards the superior fornix because
of surface tension. When the lower eyelids are lifted away from the globe, tear fluid
flows down into the inferior fornix. The marginal tear strips immediately form again
when the eyelids are allowed to return to their normal position. The tears contained
in both the upper and lower marginal tear strips are continuous with the reservoir of
tears that forms at the lateral canthus. By means of this tear reservoir, the lacrimal
fluid under the upper eyelid is able to access the lower tear strip. In the natural eye,
the uniform thickness of the three-layered pre-corneal tear film is caused by the
spreading action of the palpebral conjunctiva over the cornea and the drawing out of
reconstituted and fresh lipids from the tarsal glands at the margins when the eyelids
open. Similarly, mucins are distributed over the cornea and conjunctiva by the move-
ment of the eyelids which are in close contact with the epithelium.
The tear strips at the eyelid margins drain medially towards the so-called lacri-
mal lake, where they bathe the caruncle which lies between the medial canthus and
the plica semilunaris. The tears moisten the caruncle but in normal circumstances
do not pool because the superior and inferior lacrimal punctae, resting against the
sclera, draw tears into the canaliculus by capillary attraction, gravity and negative
pressure. When the eyelids close, they meet first at the lateral canthus and progres-
sively drive the tears medially along the marginal tear strips towards the punctum
54 2 Anatomy and Physiology

and then into the canaliculus. When blinking occurs, the muscular activity creates a
milking or pump action that draws the tears through the puncta. A seal is maintained
between the eyelids and the globe and no tears enter the fornices.

2.13 Facial Changes Due to Ageing

Ageing of the face is a continuous process which first becomes noticeable in the
third decade of life. Early theories of ageing emphasised increased tissue laxity and
vertical descent as the principal factors, but attention is increasingly considering
volume loss or ‘deflation’ of soft tissues as a key factor. Of course skin changes,
exacerbated by sun exposure and smoking, are particularly important in the face,
with thinning of the skin and loss of elasticity.
The eyebrows flatten and move downwards, and the tissues under them form
upper eyelid folds and deep ‘crow’s feet’ along the smile lines at the lateral canthi.
The lateral canthi themselves descend relative to the medial canthi and drift medi-
ally, often resulting in a lax lower eyelid and lower lid retraction – ‘scleral show’
under the iris [9, 3]. The eyes may become sunken as the orbital fat settles, and this
results in a drooping of the upper eyelids and the formation of bags below the lower
eyelids (Fig. 2.33). Further down the face, the upper lip lengthens causing the cor-
ners of the mouth to droop and more of the upper teeth to be covered. The cheeks
also move downwards, and the jowls become prominent as they encroach on the
neck tissues which develop wrinkles and become baggy. As the soft tissues slump
and thin out, the underlying facial bones become more prominent, and a resem-
blance to ones’ parents may be revealed for the first time. The facial bones them-
selves also change, particularly the orbital rims, cheekbones and nasal fossa [19].
Further changes with age include elongation of the ears and nose and often the
development of a dorsal hump on the nose and a more bulbous tip. The changes to
the hard and soft tissues of the face are accompanied by a receding hairline, thicker
and greyer hair and eyebrows and the growth of ear and nasal hair. Many elderly

Fig. 2.33 Same patient wearing a left prosthetic eye at age 40 (left) and at age 81 (right) (Published
with kind permission of NZ Artificial Eye Service. All rights reserved)
2.14 Loss of the Ocular Globe 55

Fig. 2.34 The arcus senilis

(the greyish-white ring) of the
cornea becomes more
pronounced in old age
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

people have greyer or lighter eyes than when they were younger. This change in
appearance has several causes including a clouding of the lens which reduces the
blackness of the pupil, a loss of pigment from the iris and the formation of a greyish-
white ring (arcus senilis) in the cornea (Fig. 2.34). Age-related arcus senilis occurs
in 60 % of 40–60-year-olds and is present in nearly all people over the age of 80
years. It develops in women about 10 years later than in men. An arcus (juvenilis)
may also develop in younger eyes due to a disorder of the lipid mechanism which
may be an early indicator of coronary heart disease [9].

2.14 Loss of the Ocular Globe

Following the loss of the globe, the most obvious change is the loss of volume in the
orbit, offset to a variable extent by the orbital implant (if present) and the prosthesis.
Various structures and tissues within the anophthalmic socket also change position,
and these changes can progress over long periods of time.
The superficial anatomical features of the eyelids do not change, as demonstrated
in Fig. 2.35. With loss of support, the eyelids collapse into the empty socket
(Fig. 2.36). This necessitates the wearing of a prosthetic eye to restore the eyelids to
their original position where they look and function much as they did before
(Fig. 2.37).
When the globe is removed, the lacrimal gland loses some support but is other-
wise undisturbed, being held in its fossa by weak trabeculae and supported further
by the levator aponeurosis muscle. The 10–12 excretory ducts that open into the
superotemporal conjunctival fornix continue their normal tear production. Likewise,
the glands of Krause in the superior fornix, the glands of Wolfring in the two tarsi
and Henle’s glands in the orbital conjunctiva may be repositioned but remain
functional.
56 2 Anatomy and Physiology

Fig. 2.35 Following the loss of the globe, the anatomical features of the eyelids do not change
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 2.36 Following the loss

of the globe, the eyelids lose
support and collapse into the
empty socket (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 2.37 A prosthetic eye is

inserted to restore the eyelids
to their original position
where they look and function
much as they did before eye
loss (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
2.14 Loss of the Ocular Globe 57

2.14.1 Prosthetic Eye Motility

The main features of the anophthalmic socket with orbital implant and prosthetic
eye are illustrated in Fig. 2.38.
Motility of the prosthetic eye is made possible by rectus muscles working in
conjunction with the orbital implant. Shome et al. [20] measured prosthetic eye
motility over orbital implants and found that they had about 64 % of normal hori-
zontal excursions and 45 % of normal horizontal saccades and pursuit move-
ments [20] (Fig. 2.39).
The more powerful medial rectus muscle results in greater medial movement of the
prosthesis than lateral movement, while upward and downward movement is limited in
most cases. A fulsome implant is better for motility because the prosthesis will gain
more purchase from a wider foundation than a smaller one, but a heavier prosthesis will
not move as easily as a lighter one. Shome et al. [20] highlighted the significance of
surgical technique on prosthesis motility, finding that implants moved more when the
extraocular muscles were attached to the implant in positions close to their physiologi-
cal insertions, rather than imbricated (arranged to overlap) at the front of the implant.
Prosthesis design features that influence motility are the anterior curvature of the pros-
thesis and the forniceal extensions. A flat anterior curvature may meet eyelid resistance
making turning harder to achieve. The critical fit for optimising movement of the pros-
thesis is between the periphery of the prosthesis and the forniceal conjunctiva. This fit
must be close enough to support the central position of the prosthesis but loose enough
to allow relaxed conjunctival folds to straighten out during prosthetic eye movement.

2.14.2 Conjunctiva of the Anophthalmic Socket

Healthy conjunctiva is crucial to the comfort of a prosthetic eye and is a key struc-
ture to consider in any research into prosthetic eye wear. The conjunctiva cushions

Fig. 2.38 Sagittal view of

an anophthalmic socket with
orbital implant and
prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)
58 2 Anatomy and Physiology

Direction of gaze

Medial Lateral
rectus rectus
contracts contracts

Fig. 2.39 Transectional view of the right anophthalmic orbit with implant and prosthetic eye. The
illustrations show how the rectus muscles combine with the orbital implant to produce movement
in the prosthesis (Published with kind permission of NZ Artificial Eye Service. All rights reserved)

the prosthesis, and the epithelial layers of the conjunctiva contain various cells and
glands that are the source of secretions that, when excessive, causes problems for
the prosthetic eye wearer.
The loss of the globe is accompanied by a rearrangement of the conjunctiva, and
fitting of an ocular prosthesis is associated with changes in the cytological features
of the conjunctiva. After enucleation or evisceration, the loose conjunctival lining of
the newly formed socket adjusts as it heals and there is an inevitable loss of conjunc-
tiva area. The plica semilunaris becomes indistinguishable. The caruncle retains its
position, but its lateral border is often drawn posteriorly into the socket. The provi-
sion of a prosthetic eye restores the fornices, which may have temporarily foreshort-
ened, and returns the eyelids to their original positions where they resume their
normal function.
The anophthalmic socket has significantly lower goblet cell density than the
companion eye of the same patient, and goblet cells themselves have significantly
greater nucleus-to-cytoplasm ratios, especially in the lower tarsal conjunctiva [21].
2.14 Loss of the Ocular Globe 59

Patients who clean their prosthesis once a day show significantly less goblet cell
density and greater nucleus-to-cytoplasm ratios at the superior tarsal conjunctiva
than those who clean less often [21].

2.14.3 Tear Film with a Prosthetic Eye

The three-layered pre-corneal tear film does not form over the anterior surface of a
PMMA prosthetic eye, but a confluent tear film may form for a brief time depending
on the wettability of the surface of the prosthesis (Fig. 2.40). This is explored fur-
ther in Chap. 9.
Prosthetic eyes manufactured from PMMA are superior to glass eyes in many
respects, but glass eyes (when new) are more comfortable to wear due to their
hydrophilic surfaces and greater ability to wet and to maintain an aqueous tear film
(Figs. 2.41 and 2.42). Glass eyes are discussed further in Chap. 11.

Fig. 2.40 Tear film with a

prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 2.41 This glass eye was made and fitted in Germany in 2014 (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)
60 2 Anatomy and Physiology

Fig. 2.42 The glass eye worn in Fig. 2.41 (Published with kind permission of NZ Artificial Eye
Service. All rights reserved)

2.14.4 Tear Output with a Prosthetic Eye

The volume of basic tears in the anophthalmic socket is the same as in the compan-
ion eye, but because of the absence of reflex tears in the socket, overall tear produc-
tion is much less than in the companion eye [22]. Reflex tears are mostly generated
when the cornea is stimulated, but when the cornea is removed, reflex tears from
this source are no longer generated. The presence of the prosthetic eye also shields
against external stimulation although tears induced by emotion or from a foreign
body entering the socket continue as before. Fett et al. [23] evaluated the need for
additional lubrication in 200 anophthalmic patients and found that 23 % required
supplementation, while 77 % of anophthalmic patients had sufficient tears.

2.14.5 Tear Distribution with a Prosthetic Eye

An anophthalmic socket requires the presence of a prosthetic eye to restore func-

tional tear distribution and drainage. The efficacy of the lacrimal system in the
anophthalmic socket (with structures intact) greatly depends upon the fit of the
prosthesis. Optimal tear flow occurs when the prosthesis is in even contact with all
areas of the conjunctival sac and extends into the fornices to the point where motil-
ity is not restricted. Because socket tissues are soft and pliable, this does not mean
that the shape of the prosthesis must correspond exactly to the shape of the empty
socket. Rather, the prosthesis should roundly and smoothly mould the tissues and
support them near their original positions while leaving only limited spaces for
lacrimal fluids to pool. The even contact pressure against the orbital and tarsal
conjunctiva ensures that most of the tears produced find their way to the marginal
tear strips, most via the tear reservoir at the lateral canthus, but also via the medial
canthus. Effective tear drainage around a prosthetic eye also relies upon the ante-
rior surface having a similar curvature to the original globe to ensure that a proper
seal exists between Marx’s line on the eyelids and the surface of the prosthesis. The
2.14 Loss of the Ocular Globe 61

integrity of the seal has implications for the tear meniscus and the proper function-
ing of the puncta which should turn inwards naturally until they dip into the tear
strip adjacent to the surface of the prosthesis. Because the volume of basic tears is
not large, the tear flow mechanism appears to function satisfactorily in most cases,
although tear pooling may slow down the movement of tears through the socket/
prosthesis system.

2.14.6 Post-enucleation Socket Syndrome (PESS)

Tyers and Collin first introduced the term post-enucleation socket syndrome (PESS)
in 1982 [24] to describe a constellation of clinical findings seen mostly during the
first year or two following enucleation and more pronounced if the orbital implant
(inserted at the time of surgery) was too small.
The clinical features originally described were enophthalmos of the artificial
eye, a deep upper eyelid sulcus, ptosis and lower lid laxity. In 1990 Smit et al. [25]
used high-resolution computed tomography to further investigate PESS. They
found that the superior muscle complex sagged and retracted, the orbital fat was
redistributed downward and forward and the inferior rectus muscle retracted and
moved superiorly. This caused a rotatory displacement of orbital contents from
superior to posterior and from posterior to inferior. Fat atrophy, which had been
postulated as one of the pathophysiological mechanisms of PESS, was not found
[25] (Figs. 2.43 and 2.44).
These changes cause the superior fornix to tilt backwards, the superior sulcus to
deepen with the loss of the superior eyelid crease and the inferior fornix to become
shallower. The prosthesis moves in response to these changes in the soft tissues of
the socket and gazes upwards as it tilts backwards and puts forwards pressure on the
lower eyelid. The backward tilt causes the upper eyelid to lose support and drop
down over the prosthesis (pseudo-ptosis), while the forward pressure on the lower
eyelid causes it to slacken and droop (Figs. 2.45, 2.46, 2.47 and 2.48).

Superior muscle complex

sags and retracts
Superior lid sulcus
deepens

Superior fornix tilts

backwards
Implant

Fig. 2.43 Orbital tissue

changes following enucle- Inferior fornix
shallows
ation (Published with kind
permission of NZ Artificial
Eye Service. All rights Orbital fat redistributes
reserved) downward and forward
62 2 Anatomy and Physiology

Fig. 2.44 Retraction of the

superior muscle complex and
the inferior rectus result in a
recessed socket. This
photograph shows a recessed
right socket with prosthesis in
place (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Deep superior lid sulcus

Upper lid ptosis

Upwards
gaze

Implant

Fig. 2.45 Elements of

post-enucleation socket
syndrome (PESS) (Published Lower lid laxity
with kind permission of NZ
Artificial Eye Service. All
rights reserved) Recessed orbital contents

Fig. 2.46 Left upper eyelid

ptosis over a prosthetic eye
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
2.14 Loss of the Ocular Globe 63

Fig. 2.47 The right

prosthetic eye has tilted
backwards causing it to gaze
upwards and place forward
and downward pressure on
the lower eyelid (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 2.48 The left upper

eyelid sulcus is much deeper
due to orbital volume deficit
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Further development of PESS may lead to the eyelids not completely closing
over the prosthesis, socket contraction, upper and lower lid entropion, prosthesis
instability (rotation) and inability to retain the prosthesis (Fig. 2.49).
PESS illustrates the importance of understanding the normal anatomy and
physiology of the orbit and adnexa and of striving to replicate normal structure
and function in the very abnormal situation of wearing an ocular prosthesis. The
growing list of complications from PESS the longer it is present also demon-
strates that the functional relationships between the orbit, eyelids and conjunc-
tiva are deeply interrelated and that early recognition and treatment of problems
may be much simpler than late intervention.
64 2 Anatomy and Physiology

Fig. 2.49 Advanced left

post-enucleation socket
syndrome. This patient has
deep upper eyelid sulcus,
a contracted socket and a
backward tilted prosthesis.
The upper eyelashes point
upwards from a retracted
upper eyelid, the lower eyelid
is entropic and the eyelids do
not fully close over the
prosthesis (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

References
1. Tolleth H. Concepts for the plastic surgeon from art and sculpture. Clin Plast Surg.
1987;14(4):585–98.
2. Chen WP. Oculoplastic surgery. The essentials. New York/Stuttgart: Thieme; 2001.
3. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg. 2008;36:
319–27.
4. Worral E. What factors affect maxillofacial prosthetists in the rehabilitation of the anophthal-
mic patient. World Coalit Anaplastol J. 2014;1:17–20.
5. Doxanas MT, Anderson RL. Oriental eyelids. An anatomic study. Arch Ophthalmol.
1984;102(8):1232–5.
6. Lemke BN, Della Rocca RC. Surgery of the eyelids and orbit: an anatomical approach.
Norwalk: Appleton and Lange; 1990.
7. King DC, Michels KM. Muscular tension and the human blink rate. J Exp Psychol.
1957;53(2):113–6.
8. Carney LG, Hill RM. The nature of normal blinking patterns. Acta Ophthalmol (Copenh).
1982;60(3):427–33.
9. McMonnies C, Lowe R. After-care. In: Phillips AJ, Speedwell L, editors. Contact lenses. 5th
ed. Edinburgh: Butterworth Heinemann Elsevier; 2007. p. 388–9.
10. Donald C, Hamilton L, Doughty MJ. A quantitative assessment of the location and width of
Marx’s line along the marginal zone of the human eyelid. Optom Vis Sci. 2003;80(8):
564–72.
11. Ruskell GL, Bergmanson JPG. Anatomy and physiology of the cornea and related structures.
In: Phillips AJ, Speedwell L, editors. Contact lenses. 5th ed. Edinburgh: Butterworth
Heinemann Elsevier; 2007. p. 388–9.
12. Liotet S, Triclot MP, Perderiset M, Warnet VN, Laroche L. The role of conjunctival mucus in
contact lens fitting. CLAO J. 1985;11(2):149–54.
13. Bowen R. Mucus and mucins, 1998. Available from: http://www.vivo.colostate.edu/hbooks/
molecules/mucins.html. Accessed 27 Jun 2015.
14. Adams AD. The morphology of human conjunctival mucus. Arch Ophthalmol. 1979;97(4):-
730–4. [Research Support, U.S. Gov’t, P.H.S.].
15. Guillon JP, Godfrey A. Tears and contact lenses. In: Phillips AJ, Speedwell L, editors. Contact
lenses. Edinburgh: Elsevier Butterworth-Heinemann; 2007. p. 111–27.
References 65

16. Norn MS. Tear secretion in normal eyes. Estimated by a new method: the lacrimal streak
dilution test. Acta Ophthalmol (Copenh). 1965;43(4):567–73.
17. Schirmer O. Studienzurphysiologieundpathologie der tranenabsonderung und tranenabfuhr.
Graefes Arch Clin Exp Ophthalmol. 1903;56:197–291.
18. Kim SE, Yoon JS, Lee SY, Kim SE, Yoon JS, Lee SY. Tear measurement in prosthetic eye
users with Fourier-domain optical coherence tomography. Am J Ophthalmol. 2011;149(4):
602–7.
19. Shaw RB. Jr1, Kahn DM. Aging of the midface bony elements: a three-dimensional computed
tomographic study. Plast Reconstr Surg. 2007;119(2):675–81.
20. Shome D, Honavar SG, Raizada K, Raizada D. Implant and prosthesis movement after
enucleation. A randomized controlled trial. Ophthalmology. 2010;117:1638–44.
21. Kim JH, Lee MJ, Choung HK, Kim NJ, Hwang SW, Sung MS, et al. Conjunctival cytologic
features in anophthalmic patients wearing an ocular prosthesis. Ophthal Plast Reconstr Surg.
2008;24(4):290–5.
22. Allen L, Kolder HE, Bulgarelli EM, Bulgarelli DM. Prosthetic eyes and tear measurements.
Ophthalmology. 1980;87(2):155–7.
23. Fett DR, Scott R, Putterman AM. Evaluation of lubricants for the prosthetic eye wearer.
Ophthal Plast Reconstr Surg. 1986;2(1):29–31.
24. Tyers AG, Collin JRO. Orbital implants and post-enucleation socket syndrome. Trans
Ophthalmol Soc U K. 1982;102:90–2.
25. Smit TJ, Koornneef L, Mourits M, Groet E, Otto AJ. Primary versus secondary intraorbital
implants. Ophthal Plast Reconstr Surg. 1990;6:115–8.
Anophthalmia and Disfigurement
of the Eye 3

Contents
3.1 Introduction ................................................................................................................... 67
3.2 Congenital Anophthalmia and Microphthalmia ............................................................ 68
3.2.1 Treatment for Anophthalmia and Microphthalmia in Children ...................... 70
3.3 Disfigurement of the Eye .............................................................................................. 71
3.3.1 Corneal Tattooing ............................................................................................ 73
3.4 Surgical Removal of the Eye......................................................................................... 73
3.4.1 Enucleation Versus Evisceration ..................................................................... 73
3.4.2 Enucleation ..................................................................................................... 74
3.4.3 Evisceration..................................................................................................... 76
3.4.4 Postsurgical Care Following Enucleation and Evisceration ........................... 77
3.4.5 Postsurgical Conformer Shells ........................................................................ 80
3.4.6 Intraorbital Implants........................................................................................ 81
3.5 Exenteration .................................................................................................................. 84
References ................................................................................................................................ 89

3.1 Introduction

Anophthalmia (the absence of one or both eyes) may be congenital or it may be due
to trauma or disease requiring the surgical removal of the eye. Disfigurement of the
eye may also result from other congenital defects, trauma or disease, and in these
cases, it may be appropriate to use an ocular prosthesis to disguise the disfigure-
ment. Sometimes it will be more appropriate to remove the disfigured eye, and an
understanding of the surgical procedures employed is important for those dealing
with these patients.
This chapter discusses the implications of congenital anophthalmia and microph-
thalmia for young children and describes enucleation, evisceration and exenteration

© Springer International Publishing Switzerland 2015 67

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_3
68 3 Anophthalmia and Disfigurement of the Eye

procedures for the surgical removal of the eye. The different types of intraorbital
implants (commonly inserted into the orbit during enucleation and evisceration pro-
cedures) are discussed as well as changes to the anophthalmic socket that typically
take place over the longer term following eye removal surgery.

3.2 Congenital Anophthalmia and Microphthalmia

Congenital anophthalmia is the complete absence of the ocular globe while con-
genital microphthalmia is an underdeveloped or small eye. Cases of congenital
anophthalmia exhibit no clinically apparent eye tissue, but histologic sectioning
or CT scans often reveal remnants of lens epithelium and fibrovascular, neuro-
retinal and choroid-like tissue, indicating severe microphthalmia rather than true
anophthalmia.
Congenital microphthalmia affects about 1.5 per 10,000 people [1] and results
from a developmental abnormality of the optic vesicle which may be unilateral or
bilateral. Congenital anophthalmia or microphthalmia may be isolated or part of a
syndrome with other associated abnormalities and can be caused by inherited condi-
tions or by exposure of the developing foetus to the rubella virus or to drugs includ-
ing alcohol, thalidomide, retinoic acid, hydantoin and LSD [2]. The development of
a normal eye in utero appears to be required to drive normal development of the
ocular adnexa. The small or absent eye associated with congenital anophthalmia or
microphthalmia is therefore generally accompanied by reduced growth of the soft
tissues of the orbit, the eyelids, the bony orbit and surrounding face. In unilateral
cases, this will significantly distort facial symmetry if left untreated (Figs. 3.1 and
3.2). In bilateral cases, the asymmetry may be minimal, but the effects on facial
structure can range from barely noticeable to profound.

Fig. 3.1 Fourteen-year-old

patient with untreated unilat-
eral anophthalmia adversely
affecting facial symmetry
(Published with kind permis-
sion of Dr Raj Anand. All
rights reserved)
3.2 Congenital Anophthalmia and Microphthalmia 69

Fig. 3.2 Computed

tomographic image of the
skull of the young woman in
Fig. 3.1. The left orbit is
considerably smaller than the
right orbit (Published with
kind permission of Dr Raj
Anand. All rights reserved)

Fig. 3.3 Unilateral

microphthalmia (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

A similar picture is seen in some (now adult) patients who had early bilateral
enucleations followed by radiotherapy for retinoblastoma. The combination of early
surgery and radiotherapy had the capacity to cause profound midface hypoplasia.
Modern treatment modalities for retinoblastoma have fortunately eliminated these
complications.
Congenital microphthalmia is said to occur when the length of the eye from the
apex of the cornea to the back of the globe (the total axial length (TAL)) that is at
least two standard deviations below the mean for age. For example, in an adult eye,
the TAL might be 21.0 mm compared to a normal TAL of 23.8 mm. The condition
ranges from simple microphthalmia where the eye is anatomically intact except for
its short total axial length to severe microphthalmia where the globe is severely
reduced in size (total axial length less than 10 mm at birth or less than 12 mm after
1 year) and with a corneal diameter less than 4 mm [3] (Fig. 3.3).
70 3 Anophthalmia and Disfigurement of the Eye

3.2.1 Treatment for Anophthalmia and Microphthalmia

in Children

The first priority for children with microphthalmia is determining the visual poten-
tial of the eye, and careful assessment by a paediatric ophthalmologist is required as
soon as the condition is recognised. If the eye has uncertain or at least modest visual
potential, treatment of the orbit and eyelids must not occlude the pupil. This does
not necessarily preclude the use of orbital conformers, and provision for this may be
made by incorporating clear pupil into the conformers and prostheses.
For children with severe microphthalmia or anophthalmia who have no useful
visual potential, the goal of treatment is to stimulate hard and soft tissue growth of
the orbit to reduce any asymmetry of the face as much as possible as the child grows
into adulthood. The growth of the eye mostly occurs during the first 3 years of life
(it is especially rapid in the 1 year), and the microphthalmic eye grows by a variable
amount during this time depending upon the severity of the condition [4]. It is
important therefore to start treatment as soon as practical after birth – within the first
month if possible. The main treatment method is to support the eyelids in their natu-
ral position. The presence of the conformer stimulates orbital and adnexal growth
and a series of conformers of increasing size are fitted over the course of the 1 year
so that normal sizes and relationships can be maintained. Initially, conformers need
to be replaced weekly, then monthly, then at longer intervals until the socket is
finally ready for a more permanent ocular prosthesis (Figs. 3.4 and 3.5).
The size of the eyelids and palpebral aperture is an important feature in these
patients – patients with very small lids may never be able to accommodate a cos-
metically adequate prosthesis. Measuring the horizontal size of the palpebral aper-
ture (width from medial to lateral canthus) is a simple way to monitor treatment. In
unilateral cases, treatment can enter a maintenance phase once the horizontal palpe-
bral apertures are equal.
In cases where the anophthalmic or microphthalmic socket will not retain a con-
former, it may be necessary to hold it in place by suturing the eyelids together
(tarsorrhaphy). After 6 weeks or so, it may be possible to replace the initial con-
former with a larger one that is self-retained. If the second conformer will not stay
in place, another tarsorrhaphy will be necessary. A variation of this technique is to
suture or glue the eyelids closed over a conformer created out of hydrogel material

Fig. 3.4 Series of custom-

made conformers used to
stimulate socket growth from
age 1 month to when the
socket is finally ready for a
more permanent ocular
prosthesis (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
3.3 Disfigurement of the Eye 71

Fig. 3.5 Ten-month-old

patient wearing clear
conformers over his
microphthalmic eyes. As well
as stimulating orbital growth,
the conformers lift the eyelids
away from the pupil, enabling
ongoing visual stimulation,
which is vital for visual
development (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

(methylmethacrylate and N-vinylpyrrolidone) which is the same material soft con-

tact lens are made from. When dehydrated, this conformer is small and solid, and
when hydrated, it expands and becomes a firm gel [5]. The main limitation of this
technique at present is that the implants hydrate quickly, reaching maximal size over
about 48 h.
Other surgical approaches include the early insertion of orbital implants which
are then replaced with larger implants after a few years. Dermis fat grafting has also
been used as a self-expanding dynamic implant. When dermis fat grafts are used in
adults, there is always significant but variable loss of tissue volume. In children,
however, the grafts appear to grow and may even require debulking.
Balloon expander orbital implants which expand over time have also been used
to provide ongoing stimulation of orbital growth. These dynamic implants contain
a fluid chamber into which saline is injected to expand it. The technical complexi-
ties of this technique largely limit its use to the experimental setting at present.

3.3 Disfigurement of the Eye

There are numerous congenital and acquired conditions that disfigure the eye.
Further discussion of these conditions is beyond the scope of this book, but some
useful generalisations can be made about the management of disfigured eyes once
they become blind.
The first principle of management is to determine whether retaining the eye car-
ries any risk for the patient. A blind disfigured eye that is suspected of harbouring a
tumour, for instance, will be removed.
The next issue is patient comfort. A disordered eye may cause pain via multiple
mechanisms and may or may not be able to be controlled by medical means. The
so-called blind painful eye is a common indication for removal of the eye.
72 3 Anophthalmia and Disfigurement of the Eye

Fig. 3.6 Disfigured non-phthisical left eye fitted with a prosthetic contact lens (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 3.7 Phthisical right eye fitted with a scleral shell prosthesis (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)

Finally, the nature of the disfigurement is considered. The commonest appear-

ance of an end-stage blind eye, particularly after trauma, is phthisis. This is where
the entire globe shrinks. Once phthisis starts, it is often progressive and is usually
associated with shrinkage of the cornea, so measurement of the remaining corneal
diameter (normally 10–11 mm) is a useful gauge of the degree of phthisis. Mild
degrees of phthisis can be managed with a prosthetic contact lens (Fig. 3.6) or a
scleral shell prosthesis (Fig. 3.7), while more marked phthisis (Fig. 3.8) will require
a prosthetic eye. If the eye has severe phthisis, the prosthesis required to replace the
lost volume may be prohibitively large, and removal of the eye and placement of an
orbital implant will allow a smaller, cosmetically superior prosthesis to be used.
Non-phthisical eyes may also appear disfigured, largely due to abnormalities of
the cornea, iris and pupil. Corneal opacification (caused by scarring), leucocoria
(white pupil, dense cataract) and aniridia (partial or complete loss of the iris) can be
treated with prosthetic contact lenses or scleral shell prostheses. Corneal tattooing
(keratopigmentation) is also an option for some patients with dark irises.
3.4 Surgical Removal of the Eye 73

Fig. 3.8 Collapsed remnant of the globe fitted with a prosthetic eye (Published with kind permis-
sion of NZ Artificial Eye Service. All rights reserved)

3.3.1 Corneal Tattooing

The corneal tattooing procedure involves injecting a sterile tissue-marking dye

repeatedly into the corneal stroma until the treated area becomes dense with the
colour of the companion eye. Discolouration or fading of the tissue-marking dye is
relatively uncommon but can occur over time, necessitating additional tattooing [6].

3.4 Surgical Removal of the Eye

The eye can be surgically removed by evisceration, enucleation or exenteration.

Evisceration is removal of the contents of the eye, leaving only the sclera, with
or without the cornea; enucleation is the removal of the entire globe; and exentera-
tion is the removal of the eye and a variable amount of orbital and adnexal tissue.
The operation chosen depends on the underlying disease and, to a certain extent,
individual surgeon preference.

3.4.1 Enucleation Versus Evisceration

A 2003 survey of 456 ophthalmologists in the UK found that 718 enucleations and
699 eviscerations were performed in that year [7]. The evisceration procedure is
simpler and less invasive than enucleation and appears to provide better motility of
the prosthesis and better long-term stability of the anophthalmic socket [8].
However, more recent surgical techniques have improved enucleation outcomes to
the point where they rival the results of evisceration [9] and are preferred because
they provide better material for histological diagnosis, and a theoretically lower risk
of sympathetic ophthalmia.
74 3 Anophthalmia and Disfigurement of the Eye

Ocular prosthetists favour evisceration over enucleation [10] although their opin-
ions may be changing towards a more neutral stance with the improvement in enu-
cleation outcomes.

3.4.2 Enucleation

A description of the enucleation of an eye was first recorded in a renaissance manu-

script entitled Ophthalmodouleia Das ist Augendienst written by German ophthal-
mologist Dr Georg Bartisch in 1583. The surgical technique described in the book
involved securing the ocular globe with a suture threaded through the eyeball with
a needle and then pulling on the suture to draw the eye out while at the same time
cutting it from the extraocular muscles and optic nerve with a curved knife.
The modern enucleation procedure usually takes about 60 min to perform and is
usually carried out under general anaesthetic, often as an outpatient procedure. A
360° incision is made through the conjunctiva at the corneal limbus. The conjunc-
tiva and underlying Tenon’s capsule are dissected back to expose the insertions of
the extraocular muscles. The four rectus muscles and the inferior oblique muscles
are tagged with sutures and all muscles are cut away from the globe. Curved scis-
sors are then used to sever the optic nerve behind the eye, allowing the globe to be
removed from the socket (Figs. 3.9, 3.10, 3.11, 3.12, 3.13, 3.14, 3.15 and 3.16).

Fig. 3.9 The eye is made

ready for the enucleation
procedure (Published with
kind permission of David and
Carina Dalziel. All rights
reserved)

Fig. 3.10 The corneal

limbus is dissected and the
conjunctiva and Tenon’s
capsule are drawn aside
(Published with kind
permission of David and
Carina Dalziel. All rights
reserved)
3.4 Surgical Removal of the Eye 75

Fig. 3.11 The extraocular

muscles are tagged with
sutures and cut away from
the globe (Published with
the kind permission of David
and Carina Dalziel. All
rights reserved)

Fig. 3.12 The optic nerve is

severed (Published with kind
permission of David and
Carina Dalziel. All rights
reserved)

Fig. 3.13 The globe is

removed (Published with
kind permission of David
and Carina Dalziel. All
rights reserved)

Fig. 3.14 The orbital cavity

without the eyeball. The free
ends of the extraocular
muscles are held back with
sutures (Published with kind
permission of David and
Carina Dalziel. All rights
reserved)
76 3 Anophthalmia and Disfigurement of the Eye

Fig. 3.15 A hydroxyapatite

orbital implant is inserted
into the cavity (Published
with kind permission of
David and Carina Dalziel. All
rights reserved)

Fig. 3.16 The conjunctiva is

drawn over the wound and
closed with sutures
(Published with kind
permission of David and
Carina Dalziel. All rights
reserved)

In most cases, an orbital implant is placed into the socket at the time of enucle-
ation (‘primary’ orbital implant). The implant is placed in the empty Tenon’s cap-
sule. The tagged extraocular muscles are attached to the implant or its wrapping.
Tenon’s capsule and the conjunctiva are closed carefully in separate layers over the
orbital implant.

3.4.3 Evisceration

The first evisceration of an eye appears to have been carried out unintentionally by
James Beer in 1817 when treating a patient with a choroidal haemorrhage. J.F. Noyes
completed the first planned evisceration in 1874, and in 1884, P.H. Mules inserted
an orbital implant for the first time as noted in Chap. 11.
Evisceration takes around 40 min to perform. It can be done under general anaes-
thetic but can also be performed under local anaesthetic with a retrobulbar anaes-
thetic injection. This makes it a useful option for patients who are too unwell to
undergo a general anaesthetic. A 360° incision is made around the cornea, and
Tenon’s capsule is undermined back to the insertions of the extraocular muscles.
Most surgeons then remove the cornea, often en bloc with the anterior segment. If
the cornea is to be preserved, the corneal endothelium must be removed from its
posterior surface to prevent the development of cysts. The remainder of the globe’s
contents is then scraped out with a sharp evisceration spoon. The sclera is cleaned.
3.4 Surgical Removal of the Eye 77

Fig. 3.17 Painful inflamed

eye with corneal ulcer and
hypopyon (Published with
kind permission of Prof C. N.
Chua. All rights reserved)

Fig. 3.18 An incision is

made around the cornea and
Tenon’s capsule is under-
mined back to the insertions
of the extra ocular muscles
(Published with kind
permission of Prof C. N.
Chua. All rights reserved)

Some surgeons wipe the scleral cavity with 100 % ethanol to denature any residual
uveal tissue. A series of radial slits are then made through the sclera, allowing it to
expand to accommodate an orbital implant which is then inserted. The edges of the
scleral wound are then overlapped and secured with mattress stitches, and finally,
Tenon’s layer is drawn forwards and sutured and the conjunctiva is closed (Figs. 3.17,
3.18, 3.19, 3.20, 3.21, 3.22, 3.23 and 3.24).

3.4.4 Postsurgical Care Following Enucleation and Evisceration

Pain or discomfort following both enucleation and evisceration surgery is different

for each patient, depending on their tissue sensitivity and the complexity of the
surgery. Nausea may be present for a day or 2 after surgery and some discomfort
may result from moving the eye. Many patients, however, have much less pain in
their eye after surgery than they had before it, which is often why the eye needed to
be removed in the first place.
78 3 Anophthalmia and Disfigurement of the Eye

Fig. 3.19 The button of

corneal tissue is excised
(Published with kind
permission of Prof C. N.
Chua. All rights reserved)

Fig. 3.20 The entire ocular

content is removed with an
evisceration spoon (Published
with kind permission of Prof
C. N. Chua. All rights
reserved)

Fig. 3.21 The sclera is

cleaned and any residue of
uveal pigment is denatured
with 100 % ethanol
(Published with kind
permission of Prof C. N.
Chua. All rights reserved)

The post-operative care required by patients following enucleation or eviscera-

tion depends on the surgeon and can be considered in terms of systemic and topical
medications and wound care.
Antibiotics are usually given intravenously at the time of surgery, and there is
good evidence that this is all that is required. Some surgeons will favour a short
course of oral antibiotics (3–7 days) post-operatively. In the first few days, potent
3.4 Surgical Removal of the Eye 79

Fig. 3.22 One or two radial

slits are made inside the
scleral cavity, allowing it to
expand to accommodate a
silicon implant (Published
with kind permission of Prof
C. N. Chua. All rights
reserved)

Fig. 3.23 The edges of the

scleral wound are about to be
overlapped and secured with
mattress stitches (Published
with kind permission of Prof
C. N. Chua. All rights
reserved)

Fig. 3.24 Tenon’s layer has

been sutured and the
conjunctiva closed. A
postsurgical conformer is
ready to be placed in the eye
socket (Published with kind
permission of Prof C. N.
Chua. All rights reserved)

pain relief may be required, but simple analgesia is sufficient within the first post-
operative week.
Antibiotic drops or ointment (or both), with or without steroid, is usually pre-
scribed to use two to four times per day once the dressings are removed.
80 3 Anophthalmia and Disfigurement of the Eye

The socket is patched for 1–5 days after surgery to reduce bleeding and swelling.
A conformer shell is used by many surgeons (see below), and a temporary tarsor-
rhaphy (suturing the eyelids together) may also be employed.
After 4 weeks the swelling has usually subsided enough for a prosthetic eye to be
fitted but it is normal to wait between 6 and 8 weeks to ensure that the socket is
completely healed and stable.

3.4.5 Postsurgical Conformer Shells

Conformer shells are made of soft silicone or rigid (poly)methyl methacrylate

(PMMA) and often have holes which are claimed to facilitate the flow of socket
secretions (Fig. 3.25). Advocates for the conformer shell suggest that it protects the
sutured wound and maintains the fornices [11]. However, to achieve the latter, a
conformer would need to stretch out the conjunctival folds and place unnecessary
tension on the wound edge. Clearly, the fornices are not maintained by loose-fitting
conformers and their benefit is questionable. The conformer shell shields the raw
wound but the drainage holes often irritate the conjunctiva, causing inflammation
and excessive mucoid discharge. A variation of the postsurgical conformer shell is
the cosmetic conformer which is a normal conformer shell with pupil, iris and
scleral colouring. Patients appear to prefer the cosmetic conformer to the standard
clear conformer shell because the cosmetic conformer has a more acceptable
appearance [11].
A temporary tarsorrhaphy also protects the conjunctival wound and restricts con-
junctival swelling without causing as much irritation and is therefore a viable alter-
native to a post-operative conformer and is preferred by the authors.
If used, postsurgical conformer shells should be replaced with a prosthetic eye as
soon as possible after the tissues have healed and the swelling has subsided. During
this time some contracture of the socket may occur (whether a conformer shell is

Fig. 3.25 Conformers with

holes to facilitate the flow of
socket secretions. The top
three are made from PMMA
and the lowest one is made
from silicon (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
3.4 Surgical Removal of the Eye 81

present or not) as the conjunctiva adapts to its new situation. However, the conjunc-
tiva is pliable and able to be remoulded during the fitting of the ocular prosthesis.

3.4.6 Intraorbital Implants

As described in the procedures for enucleation and evisceration, intraorbital

implants are placed in the cavity created when the globe is either partially or com-
pletely removed. They restore lost volume and provide support for the extraocular
muscles to more effectively move the prosthetic eye.

3.4.6.1 History
Phillip Henry Mules placed the first orbital implant in 1885 (see Chap. 11) but it
wasn’t until the introduction of custom-made PMMA prostheses that the number of
different types of orbital implants rapidly expanded. Various implants of different
materials and designs have been used during the last 100 years. They include the
Troutman implant that used a magnet to hold the prosthesis, the Castroviejo and
Allen implants that had grooves to accommodate the rectus muscles, and spheres of
gold, silicone and PMMA (Fig. 3.26). Many anophthalmic sockets still contain
older-style implants but the rate of migration and extrusion has been unacceptable
and the search for better materials and designs has continued.
In 1985, Dr Arthur Perry inserted an orbital implant made of hydroxyapatite (a
material derived from ocean coral) [12]. This new ‘coral’ implant has an intercon-
nected porous matrix with a chemical structure similar to bone. The medical use of

Fig. 3.26 Implants of

various materials and designs
range from a hollow glass
sphere used by Mules in 1885
(top left) to a hydroxyapatite
orbital implant introduced by
Dr Arthur Perry 100 years
later (bottom right). A
Troutman implant (middle
left) used a magnet to hold
the prosthesis while the
Castroviejo (middle) and the
Allen (middle right) implants
were made of (poly) methyl
methacrylate. Spheres of gold
(middle top), silicone (middle
bottom) and acrylic (bottom
left) have also been used
(Published with kind
permission of Dr Arthur
Perry)
82 3 Anophthalmia and Disfigurement of the Eye

hydroxyapatite was pioneered by Professor Per-Ingvar Branemark who, in 1952,

placed a titanium implant with a hydroxyapatite coating in rabbit bone. When he
went to remove the implant, he found the implant had integrated with the bone so
thoroughly that it could not be budged. Initially, hydroxyapatite was used for dental
implants but in 1989 it was patented as an integrated orbital implant called the
‘Bioeye’ and approved by the US Food and Drug Administration.

3.4.6.2 Choice of Orbital Implant

The orbital implant needs to be considered in terms of material, shape, size and
wrapping tissue (if any). Many permutations and combinations therefore exist and
the following discussion should be considered introductory rather than exhaustive.

3.4.6.3 Material
The ideal implant is one that is stable and inert and which never migrates or extrudes
through the overlying conjunctiva [8]. Most implants used these days are alloplastic
nonbiologic material. Hydroxyapatite implants are derived from coral but exten-
sively modified during manufacture. Implants can be most conveniently thought of
as solid or porous. Solid implants are most commonly made of PMMA or silicone.
Mules’ glass spheres (see Chap. 11) are still available.
Porous implants allow fibrovascular ingrowth from the socket into the implant,
which proponents claim improves the stability of the implant. A vascularised
implant may also be able to support a motility peg, which can increase prosthesis
motility (Fig. 3.27). Porous implants were very popular for a time because they
provided excellent motility [13], but this technique has fallen out of favour due to
the need for additional surgery and complications due to pegging [8] (Fig. 3.28).
Porous implants have a small increased risk of exposure due to damage or dehis-
cence of the overlying conjunctiva and a moderately high rate of minor socket com-
plications such as granulomas, especially when a peg is placed.

Fig. 3.27 Pegged hydroxy-

apatite implant (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)
3.4 Surgical Removal of the Eye 83

Fig. 3.28 Chronic mucoid

discharge associated with a
motility peg (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Dermis fat grafts are an uncommon orbital implant but have a number of unique
advantages including that they are autogenous tissue (from the patient), contribute
both lining and volume to the socket and, finally, may grow if implanted in chil-
dren – this growth can be enough to maintain normal growth of the bony socket,
which otherwise lags significantly in the absence of a normal eye (see Chap. 2).

3.4.6.4 Shape
Spherical implants are by far the most common in current use, as these maximise
the implanted volume for a given linear size. The smooth anterior surface of a spher-
ical implant also reduces conjunctival pressure points between the implant and the
prosthesis and probably reduces the risk of implant exposure.

3.4.6.5 Size
The volume of the globe is approximately 6–7 ml depending on the size of the eye.
Ideally, this volume should be fully restored by the orbital implant occupying the
posterior region of the anophthalmic socket and the prosthetic eye occupying the
anterior region. The ideal implant is one that is sufficiently large so that the ocular
prosthesis can be kept as light as possible but not so large as to put pressure on the
closure of the tissues over the implant or restrict the space needed for the prosthetic
eye, which ordinarily requires at least 5 mm thickness in the iris/cornea region.
Also, a smaller prosthesis will have better motility than a large one, all other things
being equal (see above). The solution of these multiple requirements usually leads
to placement of an 18, 20 or 22 mm sphere implant.

3.4.6.6 Wrapping
Wrapping of the implant allows easy attachment of the extraocular muscles and cre-
ates another barrier to exposure and extrusion of the implant. Donor human sclera
fulfils these requirements well, but its use is limited by the risk of Creutzfeldt–Jakob
84 3 Anophthalmia and Disfigurement of the Eye

disease in countries where this is endemic. Alloplastic (inorganic) materials are

often used – these may be permanent or dissolving and may be incorporated in the
manufactured implant. Animal-derived material such as bovine pericardium is
sometimes used. Autogenous tissues such as fascia lata and temporalis fascia work
well but obviously require second-site surgery to harvest the material, adding to the
morbidity of the procedure.
The 2003 survey of 456 ophthalmologists in the UK mentioned earlier [7] found
that 92 % of ophthalmologists in the UK inserted an orbital implant after enucle-
ation, 43 % after evisceration for endophthalmitis cases and 69 % after evisceration
for non-endophthalmitis cases. In 2003, PMMA was the most popular implant
material (used by 41.5 % of ophthalmologists) followed by high-density porous
polyethylene (26.5 %), hydroxyapatite (15.7 %), natural coral (12.3 %) and others
(alumina or glass) (3.45 %). Fifty-seven percent (57 %) of implants were wrapped
when placed in the orbit. Vicryl mesh (32 %) was the most commonly used wrap
followed by donor sclera (29 %), salvaged sclera (22 %), Mersilene mesh (13 %)
and others (5 %). In 2003, motility pegging of implants was only used by 7 % of UK
ophthalmologists [7].
A report on orbital implants in enucleation surgery by the American Academy of
Ophthalmology [14] concluded that there was no difference in implant or prosthesis
motility between porous intraorbital implants and donor sclera-covered non-porous
spheres or between integrated and non-integrated implants. The Academy also com-
mented on the great variability of reported rates of implant exposure through the con-
junctiva for porous implants. Some surgeons reported a low incidence of exposure rates,
similar to that for non-porous implants while others documented significantly higher
exposure rates with porous implants. In the UK 14 % of ophthalmologists reported
cases of exposure after either enucleation or evisceration, 4 % reported extrusion (loss
of the implant through the conjunctiva) after enucleation and 3 % after evisceration.

3.5 Exenteration

Orbital exenteration was first described by Georg Bartisch in 1583. It is a surgical

procedure where some or all of the contents of the orbit, as well as the globe, are
removed. It is most commonly indicated for treatment of cancer and some forms of
infection (mucormycosis in particular) and may be performed with curative intent
or as part of palliative care for incurable disease. The vast majority of orbital exen-
terations are due to cancer of which basal cell carcinoma is the most common fol-
lowed by melanoma, sebaceous cell carcinoma and squamous cell carcinoma [15].
Orbital exenteration may involve the total removal of all the contents of the orbit,
including orbital fat, the conjunctival sac, the globe and the eyelids (Fig. 3.29), or if
the tumour is situated posteriorly, the eyelid skin and orbicularis muscle tissue may
be conserved (Fig. 3.30). As far as possible, the excision plane is subperiosteal, and
the bare bone left at the base of the socket makes reconstruction difficult. If the bone
of the orbit is invaded, the surgery may extend to complete removal of the diseased
bone (Fig. 3.31).
3.5 Exenteration 85

Fig. 3.29 Total orbital

exenteration (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 3.30 Orbital exentera-

tion with retained eyelid skin
and orbicularis muscle tissue
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Eyelid-sparing orbital exenteration surgery begins with the dissection of the

inside of the upper and lower eyelids to the orbicularis muscle. Then the periosteum
at the orbital rim is incised and the exenteration proceeds as for total exenteration
until the wound is closed by suturing the skin–muscle flaps of the eyelids together
[15].
Following exenteration, the exposed orbital bone is either lined with a split skin
graft (with or without meshing) or allowed to heal by granulation, which takes 3 or
4 months (Fig. 3.32). Free tissue transfers and transposed forehead tissue flaps may
also be used to cover large defects in the orbital walls or when radiotherapy has been
used or is planned. Unfortunately, the use of forehead or temporalis muscle flaps
may result in shallow or non-existent sockets with limited room for a prosthesis
(Fig. 3.33).
86 3 Anophthalmia and Disfigurement of the Eye

Fig. 3.31 Orbital exentera-

tion has extended to the
removal of additional
diseased bone (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 3.32 Orbital exentera-

tion with full-thickness skin
graft (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 3.33 Shallow or

non-existent socket with
limited room for a prosthesis
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
3.5 Exenteration 87

Fig. 3.34 This woman had her left orbit exenterated due to adenocystic carcinoma (top photo-
graph). Her eyelid skin and orbicularis muscle tissue were conserved (middle photograph) and her
eye was restored with an adhesive-retained prosthesis (bottom photograph) (Published with kind
permission of the NZ Artificial Eye Service)

Prosthetic restoration of the defect following orbital exenteration begins with the
fabrication of an ocular prosthesis which becomes the centrepiece around which the
rest of the orbital prosthesis is created. Fixing the prosthesis in place may be
achieved with adhesives (Fig. 3.34) or with bone implants coupled with magnets
inserted into the prosthesis (Figs. 3.35, 3.36 and 3.37). Orbital prostheses are made
88 3 Anophthalmia and Disfigurement of the Eye

Fig. 3.35 Implants have

been placed to support a
prosthetic restoration
(Published with kind
permission of Michael
Williams. All rights reserved)

Fig. 3.36 Orbital prosthesis

in mould. It incorporates
magnets positioned to
connect with the implants
seen in Fig. 3.35 (Published
with kind permission of
Michael Williams. All rights
reserved)
References 89

Fig. 3.37 Orbital prosthesis

held in place with implants
and magnets (Published with
kind permission of Michael
Williams. All rights reserved)

by maxillofacial prosthetists and anaplastologists whose discipline includes the

manufacture of all types of facial prostheses including nasal, auricular and dental
prostheses.

References
1. Kallen B, Robert E, Harris J. The descriptive epidemiology of anophthalmia and microphthal-
mia. Int J Epidemiol. 1996;25:1009–16.
2. Lammer EJ, Chen DT, Hoar RM, Agnish ND, Benke PJ, Braun JT, Curry CJ, Fernhoff PM,
Grix AW, Lott IT, Richard JM, Sun SC. Retinoic acid embryopathy. N Engl J Med. 1985;
313:837–41.
3. Gordon RA, Donzis PB. Refractive development of the human eye. Arch Ophthalmol.
1985;103:785–9.
4. Bardakjian T, Weiss A, Schneider A. Anophthalmia/microphthalmia overview. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20301552. Accessed 21 Jan 2015.
90 3 Anophthalmia and Disfigurement of the Eye

5. Bernardino CR. Congenital anophthalmia: a review of dealing with volume. Middle East Afr J
Ophthalmol. 2010;17(2):156–60.
6. Chang KC, Kwon J-W, Han YK, Wee WR, Lee JH. The epidemiology of cosmetic treatments
for corneal opacities in a Korean population. Korean J Ophthalmol. 2010;24(3):148–54.
7. Viswanathan P, Sagoo MS, Olver JM. UK national survey of enucleation, evisceration and
orbital implant trends. Br J Ophthalmol. 2007;91:616–9.
8. Chen WP. Oculoplastic surgery. The Essentials. Gumpert E, editor. New York: Thieme; 2001.
9. Deacon BS. Orbital implants and ocular prostheses: a comprehensive review. J Ophthalmic Med
Technol. 2008;4(2). Available from: http://www.jomtonline.com/jomt/articles/volumes/4/2/
orbital.pdf. Accessed 7th June 2015
10. Timothy NH, Freilich DE, Linberg JV. Evisceration versus enucleation from the ocularist’s
perspective. Ophthal Plast Reconstr Surg. 2003;19(6):417–20.
11. Avisar I, Norris JH, Quinn S, Allan D, McCalla M, Dugdale D, et al. Temporary cosmetic
painted prostheses in anophthalmic surgery: an alternative to early postoperative clear con-
formers. Eye (Lond). 2011;25:1418–22.
12. Bioeye orbital implants. Available from: www.ioi.com/default4.htm. Accessed 10 Jan 2015.
13. Ashworth JL, Rhatigan M, Sampath R, Brammar R, Sunderland S, Leatherbarrow B. The
hydroxyapatite orbital implant: a prospective study. Eye (Lond). 1996;10(1):29–37.
14. Custer PL, Kennedy RH, Woog JJ, Kaltreider SA, Meyer DR. Orbital implants in enucleation
surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2003;110(10):
2054–61.
15. Rahman I, Cook AE, Leatherbarrow B. Orbital exenteration: a 13 year Manchester experience.
Br J Ophthalmol. 2005;89(10):1335–40.
Patient Evaluation
4

Contents
4.1 Introduction ................................................................................................................... 91
4.2 Medical History ............................................................................................................ 93
4.3 Psychological Assessment ............................................................................................ 93
4.4 Assessment of Visual Perception .................................................................................. 94
4.5 Health of the Remaining Sighted Eye........................................................................... 94
4.6 Assessment of an Existing Prosthetic Eye In Situ ........................................................ 95
4.7 Assessment of Prosthetic Eye Ex Situ .......................................................................... 96
4.8 Assessment of the Anophthalmic Socket ...................................................................... 99
4.8.1 Assessment of Tears in Anophthalmic Sockets .............................................. 104
4.9 Assessment of Inflammation of the Anophthalmic Socket ........................................... 110
4.9.1 Assessment of Meibomian Gland Loss........................................................... 112
4.9.2 Assessment of Mucoid Discharge ................................................................... 112
4.9.3 Assessment of Surface Papillary Texture of the Conjunctiva of the Socket ......... 113
References ................................................................................................................................ 115

4.1 Introduction

A person may need a prosthetic eye for various reasons. They may have been born
without an eyeball (anophthalmia) or with an undeveloped eyeball (microphthal-
mia). Their eye(s) may have been blinded and scarred due to injury and perhaps
become phthisical. They may have had their eyeball removed surgically through
enucleation, evisceration or exenteration. They may be young or old; psychologi-
cally, medically and physically well or unwell; experienced prosthetic eye wearers;
or attending for their first prosthesis (Fig. 4.1). Each patient is unique with his or her
own personal history (Fig. 4.2), and all of them are attending to have their prosthetic

© Springer International Publishing Switzerland 2015 91

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_4
92 4 Patient Evaluation

Fig. 4.1 Large variety of patients presenting for a prosthetic eye. They all have different needs
and expectations (Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 4.2 All iris colours and

patterns are the result of
genetics. This iris resulted
from the introduction of a
blue-eyed Scotsman to a
family line of brown-eyed
New Zealand Maori five
generations previously
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

eye needs dealt with as competently and as efficiently as possible so that they can
resume their normal lives.
This chapter identifies and discusses various elements of patient evaluation
including psychological and perceptual assessment, assessment of an existing pros-
thetic eye (in situ and ex situ) and evaluation of the condition of the anophthalmic
socket. The chapter also suggests different methods for measuring various aspects
of prosthetic eyes, eyelids and sockets. While all of these measurement techniques
4.3 Psychological Assessment 93

may not be required for routine assessment of anophthalmic patients, they may be
helpful in particular cases.

4.2 Medical History

To determine the needs of each individual patient so that appropriate treatment can
be given, it is important that a medical history is taken at the first appointment. This
is best accomplished using a written questionnaire followed by an interview where
the clinician encourages the patient to talk about his or her experience and invites
questions. Good listening and observation skills are essential requirements for ocu-
lar prosthetics practice.
Many of the medical and behavioural problems that influence the comfort of
prosthetic eye wear should be revealed during the history taking process enabling
both the clinician and the patient to understand the issues and to find effective ways
to deal with them.
Blepharitis, dry eye syndrome, viral or bacterial infections, meibomian gland dys-
function, environmental allergens and environmental irritants are all conditions that
affect mucoid discharge associated with prosthetic eye wear. See Chap. 9 for a more
detailed discussion of these conditions. Stevens–Johnson syndrome, fibromyalgia,
postsurgical trauma to the lacrimal gland, chemical and thermal burns and radiother-
apy are other conditions that impact on the wearing comfort of prosthetic eyes [1].

4.3 Psychological Assessment

The psychological impact of eye loss was discussed in Chap. 1, and while formal
psychological assessment of patients is outside the role of ocular clinicians, it is
important to recognise adverse psychological symptoms and to refer patients to
appropriate specialists if they are encountered. Patients with depression may not
keep appointments and be disinterested in the progress of their prosthetic rehabilita-
tion. Usually, however, the symptoms of anxiety and depression do not meet the
threshold for referral for a psychological disorder, and the symptoms should not be
confused with normal reactions of grief and sadness over the loss of an eye, side
effects from medications or tiredness due to stress.
Receiving good advice is one of the main concerns expressed by patients when
they lose an eye [2], and this may be a significant source of anxiety for them if it is
not addressed. This is also emphasised in De Sousa’s comments about the various
psychological issues encountered in facial trauma patients. He concluded that the
most important ways in which clinicians can help patients’ psychosocial rehabilita-
tion is to be aware of the published clinical literature and to routinely ask patients
and their families how they are coping [3].
An additional concern for patients who have lost an eye through trauma is post-
traumatic stress disorder (PTSD). Patients with PTSD may experience nightmares
reliving the trauma. They may actively avoid situations, thoughts and emotions
associated with the trauma, have difficulty sleeping and experience increased
94 4 Patient Evaluation

irritability and nervousness. There is a significant overlap of symptoms of PTSD

with symptoms of anxiety and depression, but PTSD may be overlooked unless
specific questions are asked about the traumatic event. These questions give the
patient the opportunity to talk about the event and break down an important barrier
to treatment by providing a valid reason for the symptoms they are experiencing
[4, 5].

4.4 Assessment of Visual Perception

Perceptual changes that occur with acquired monocular vision such as ability to
judge distance and reduced visual range are discussed in Chap. 1, while advice for
patients to help them manage monocular vision is provided in Chap. 10.
The evaluation of perception following the loss of binocular vision and reliance
on monocular vision involves asking questions that will uncover difficulties and
observing patients’ behaviour with regard to movement (natural or hesitant), mobil-
ity (difficulty walking, climbing stairs, steps or curbs), bumping into things, pouring
liquids, reading (tiredness, losing place on page), awareness of people coming up on
the blind side, conversing with people on the blind side and driving (parking, dis-
tance to car in front, adequate rear view) [6].

4.5 Health of the Remaining Sighted Eye

The health and vision of the remaining sighted eye should be evaluated by an
optometrist and ophthalmologist as part of the initial assessment and every 2 years
after that (more frequently if warranted) (Fig. 4.3).

Fig. 4.3 The health of the remaining sighted eye is evaluated using a slit lamp biomicroscope
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)
4.6 Assessment of an Existing Prosthetic Eye In Situ 95

4.6 Assessment of an Existing Prosthetic Eye In Situ

The majority of anophthalmic patients already have a prosthesis and will be attend-
ing for an annual review or for the first time after many years.
The assessment of a prosthetic eye begins by observing the patient’s head, facial
and eye movements as he or she expresses him or herself during the interview ses-
sion. It is useful to note how naturally his or her eyes make eye contact and track in
tandem during conversation. An ocular prosthesis should have adequate movement
for maintaining eye contact during conversation and the same direction of gaze as
the companion eye when looking straight ahead. An objective method for measur-
ing prosthetic eye motility has been developed by Raizada et al. [7]. It uses a modi-
fied a slit lamp biomicroscope together with video and still photographs.
After general observations of the prosthesis have been made, specific measure-
ments of the prosthetic eye may be carried out and recorded using a chart similar to
the one shown in Fig. 4.4. A clear plastic ruler held across the bridge of the nose or
the forehead will assist the evaluation of horizontal balance and socket recession.
Standardised photographs and videos are an excellent alternative to directly mea-
suring and recording prosthetic eye symmetry and eyelid characteristics and are
recommended for routine record taking of all patients (Figs. 4.5, 4.6 and 4.7).
As well as providing a record of eyelid characteristics and prosthetic eye sym-
metry and motility, photographs are effective for demonstrating prosthetic eye
movements to patients who usually have difficulty doing this for themselves in a
mirror (Fig. 4.8). Other characteristics involving movement may also be recorded
with photographs or videos, such as the images in Fig. 4.9 which record a curi-
ous side effect following enucleation of the left eye to treat optic nerve sheath
meningioma.

Prosthetic eye symmetry

Horizontal plane iris/pupil

Lower mm Even Higher mm
–5 –4 –3 –2 –1 0 1 2 3 4 5
Upper eyelid
Lower mm Even Higher mm
–5 –4 –3 –2 –1 0 1 2 3 4 5
Lower eyelid
Lower mm Even Higher mm
–5 –4 –3 –2 –1 0 1 2 3 4 5
Depth of orbit
Posterior mm Even Anterior mm
–5 –4 –3 –2 –1 0 1 2 3 4 5
Upper eyelid sulcus
Very deep Equal Prominent
–5 –4 –3 –2 –1 0 1 2 3 4 5
Palpebral fissure
Very small Equal Very large
0 1 2 3 4 5 6 7 8 9 10

Fig. 4.4 Chart for recording measurements of prosthetic eye symmetry

96 4 Patient Evaluation

Fig. 4.5 The right prosthetic

eye and eyelids have slumped
relative to the companion
eye. The top broken line
indicates that the level of the
upper eyelid has dropped
about 6.0 mm from the
horizontal. The middle
broken line indicates that the
iris/pupil has dropped
4.0 mm, and the lower broken
line indicates that the lower
eyelid has also dropped about
4.0 mm (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.6 The left prosthetic

eye is recessed 4.0 mm
relative to the companion eye
as indicated by the break in
the dotted line (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

4.7 Assessment of Prosthetic Eye Ex Situ

After the prosthesis has been assessed in situ, it is removed and carefully inspected
for signs of surface deterioration and damage. This inspection is best done using a
slit lamp biomicroscope, but a magnifying glass with appropriate lighting may be
used. Particular attention should be paid to the area of the limbus and to the edges
of the prosthesis (Figs. 4.10 and 4.11). The detection of surface imperfections may
be aided by the use of vital dyes/stains such as lissamine green or Rose Bengal.
These vital dyes are commonly used in ophthalmology and optometry. Alternatively,
a dental plaque disclosing gel containing Rose Bengal may be used (Fig. 4.12).
4.7 Assessment of Prosthetic Eye Ex Situ 97

Fig. 4.7 An entropic lower

eyelid, evidence of mucoid
discharge and dried tear
protein deposits on the
surface of this prosthetic eye
are apparent in this photo-
graphic record (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.8 Photographic record of the extent of medial and lateral movements of a left prosthetic
eye. The medial excursion is greater than the lateral excursion, which is common (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 4.9 Photographic record of patient looking down with one eye and involuntarily looking up
with the other prosthetic eye (Published with kind permission of NZ Artificial Eye Service. All
rights reserved)
98 4 Patient Evaluation

Fig. 4.10 The veneer has

cracked at the limbus of a
prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.11 Cracks (high-

lighted by staining) have
appeared between the veneer
and the base material at the
periphery of this prosthetic
eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Occasionally, tooling marks and scratches incurred during manufacture may be

seen on the surface of a poorly finished prosthesis (Fig. 4.13). Surface imperfections
may also result from physical damage such as chipping (Fig. 4.14) or general wear
and tear over time (Fig. 4.15). Other signs of deterioration may include crazing of
the clear veneer through the improper use of cleaning agents (Fig. 4.16) and delami-
nation of the veneer due to the release of stresses in the (poly)methyl methacrylate
(PMMA) material, often as a result of the prosthesis drying out between periods of
wear (Fig. 4.17).
Tear protein deposits on the surface of the prosthetic eye show as dull patches on
the retro-palpebral surfaces but are more easily detected when they encroach on the
palpebral surface and dry out (Fig. 4.18). However, the thickness and extent of tear
protein deposits on the surface of prosthetic eyes are only fully revealed when
stained with a vital dye or disclosing gel (Fig. 4.19). Tear protein deposits are dis-
cussed in more detail in Chap. 8.
4.8 Assessment of the Anophthalmic Socket 99

Fig. 4.12 A prosthetic eye

being lowered into a
container of dental plaque
disclosing gel diluted in
.85 % saline solution. The
active ingredient in this
staining solution is Rose
Bengal (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.13 Staining has

revealed tooling marks on the
posterior surface of this
poorly finished prosthetic eye
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

4.8 Assessment of the Anophthalmic Socket

The anophthalmic socket varies considerably between individuals and its condition,
and form is influenced by the cause of eye loss, the surgical technique used to
remove the eye, implant type and size, how long the socket has accommodated a
prosthetic eye and the age of the patient. Figures 4.20, 4.21, 4.22, 4.23, 4.24, 4.25,
4.26 and 4.27 illustrate a variety of different anophthalmic sockets and disfigured
100 4 Patient Evaluation

Fig. 4.14 A small chip is

apparent on the periphery of
this prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.15 General wear and

tear over time has resulted in
micro-scratches, a dull
surface and dried deposits on
the surface of this prosthetic
eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.16 Crazed clear

veneer due to the use of a
solvent to clean the prosthesis
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
4.8 Assessment of the Anophthalmic Socket 101

Fig. 4.17 Partial delamina-

tion of the PMMA veneer
shows as speckles of light in
the pupil of this prosthetic
eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.18 Dried tear protein

deposits can be seen on the
palpebral surface of this
prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.19 Stained tear protein deposits on the surface of a prosthetic eye. Note the absence of
deposits in the inter palpebral area (Published with kind permission of NZ Artificial Eye Service.
All rights reserved)
102 4 Patient Evaluation

Fig. 4.20 Deep right

anophthalmic socket with no
orbital implant (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.21 Left anophthalmic

socket with pegged hydroxy-
apatite orbital implant
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.22 Right anophthal-

mic socket with hard palate
graft inside the lower eyelid
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.23 Right anophthal-

mic socket with full-thickness
tissue reconstruction of the
lower eyelid (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
4.8 Assessment of the Anophthalmic Socket 103

Fig. 4.24 Microphthalmic

left eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.25 Remnants of a

ruptured left globe (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.26 Phthisical left eye

with opaque cornea
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.27 Phthisical eye

with a Gunderson conjuncti-
val flap covering the cornea
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
104 4 Patient Evaluation

Fig. 4.28 Enucleation due to

acid burns. The superotempo-
ral fornix needs to be
deepened before a prosthetic
eye can be retained
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.29 The PMMA

spherical implant in the
anophthalmic socket has
migrated forward and is
covered by very thin
conjunctival tissue. It is
stable but needs to be
monitored (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.30 The upper eyelid

has been torn away, and
surgery is required before a
prosthetic eye can be
retained (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

globes which are all capable of being successfully rehabilitated with a prosthetic
eye. Not all sockets are healthy however, and the socket must be carefully inspected
for anomalies and complications such as those illustrated in Figs. 4.28, 4.29, 4.30,
4.31, 4.32, 4.33, 4.34 and 4.35. Socket complications and techniques for resolving
them are discussed in Chap. 7.

4.8.1 Assessment of Tears in Anophthalmic Sockets

A number of individual tests are available to test tear quality in natural eyes.
These include: Schirmer tests, Fourier domain optical coherence tomography (FD
OCT) and the phenol red thread test to assess tear volume, the Jones test to assess
4.8 Assessment of the Anophthalmic Socket 105

Fig. 4.31 The Castroviejo

implant in this socket has
migrated forward and can
now be seen clearly through
the thin conjunctival
covering (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.32 Exposure of a

tantalum mesh orbital
implant (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.33 White sutures can

be seen clearly through the
conjunctiva. These may
become exposed and require
removal (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.34 A pyogenic

granuloma has formed in this
left socket due to wearing a
deeply vaulted stock
prosthetic eye for many years
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
106 4 Patient Evaluation

Fig. 4.35 The prosthesis

that caused the pyogenic
granuloma in Fig. 4.34
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

nasolacrimal route patency, the tear ferning test to assess tear composition and qual-
ity and the tear break-up time test to assess tear film stability. However, aside from
Allen et al.’s 1980 experiment [8] using Schirmer I and II tests and the Fourier
domain optical coherence tomography test used by Kim et al. in 2011 [9], no pub-
lished reports appear to be available where these tests have been applied to anoph-
thalmic sockets.

4.8.1.1 Tear Volume

The assessment of tear volume can be an important procedure during the assessment
of prosthetic eye wear. Allen et al. [8] used Schirmer I and II tests for measuring tear
volume and reported that 78 % of anophthalmic sockets had less tears than their
companion eye. However, less tears is not necessarily a problem provided there is a
sufficient volume of tears to lubricate the prosthesis and clear away debris from the
anterior surface. Fett et al. [10] evaluated the need for additional lubrication in 200
anophthalmic patients and found that 23 % required supplementation. Their result
suggests that 77 % of patients had sufficient tear volume.
Insufficient tear volume is also a problem associated with the wearing of con-
tact lens. Contact lens wear is analogous with prosthetic eye use in that a foreign
material is in contact with the conjunctiva and they both share similar eyelid action,
bathe in the same ocular fluids and accumulate surface deposits (Fig. 4.36). Contact
lens intolerance is often associated with dry eye which is defined as ‘a disorder of
the tear film caused either by a tear deficiency or excessive tear evaporation that,
in turn, causes damage to the inter-palpebral ocular surface’ [11]. Tear deficiency
can be caused by reduced tear production or by excessive tear evaporation or both.
Excessive tear evaporation can occur when the surface oily layer of the tear film is
of poor quality because of meibomian gland disease. Healthy tears are central to
the successful wearing of contact lenses, which, when introduced to the eye, nearly
always result in an unstable tear film leading to discomfort if not managed properly.
4.8 Assessment of the Anophthalmic Socket 107

Fig. 4.36 The contact lens

seen here is analogous with
prosthetic eye use in that a
foreign material is in contact
with the conjunctiva, and they
both share similar eyelid
action, bathe in the same
ocular fluids and accumulate
surface deposits (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.37 A phenol red

thread testing kit

Many contact lens wearers suffer from dry eye or an inadequate tear film resulting
in scratchy, gritty, watery, burning or itchy eyes [12]. Difficulty with prosthetic eye
wear may have similar causes.
An open-eye phenol red thread test (Fig. 4.37) [13] is less invasive than Schirmer
tests and can be used to assess tear volume in the anophthalmic socket and the com-
panion eye [14]. To administer the test, the lower lid of each eye is gently pulled
down, and the folded 3 mm end of the thread is placed onto the palpebral conjunc-
tiva at a point 1/3 medially of the lateral canthus (Fig. 4.38). After 15 s, the thread
is removed, and the wetted stained portion is measured. A measurement of 10 mm
or less usually indicates inadequate tear volume.
Kim et al. used FD OCT to measure the height of the tear meniscus in prosthetic
eye wearers. The tear meniscus is seen as the line of tears that pool along the inner
edge of the lower lid against the eyeball or prosthesis. The height of this layer
increases when there is a greater tear volume. They found that the mean tear menis-
cus height was significantly less in the prosthetic eye than in the companion eyes of
108 4 Patient Evaluation

Fig. 4.38 The phenol red

thread test for measuring tear
volume (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

the same patient [9]. They concluded that FD OCT was a useful clinical tool and
that tear meniscus height was a useful parameter for estimating symptoms of ocular
dryness in both normal and prosthetic eyes.

4.8.1.2 Nasolacrimal Drainage System

The Jones test to assess nasolacrimal route patency involves instilling a drop of
fluorescein into the eye and waiting for the dye to show on a wetted cotton bud
placed in the same side nostril [15]. If dye is found on the cotton bud after 5 min,
this is a positive primary Jones test because tears containing the vital dye are
able to drain into the nose. If dye is not found after 5 min, a secondary Jones test
involving syringing of the nasolacrimal duct is carried out. These simple tests
determine the patency of the nasolacrimal drainage system, but they might also be
used in future to learn more about the behaviour of tears in anophthalmic sockets.

4.8.1.3 Tear Film Quality

The tear ferning test and the tear break-up time test may both be applied to anoph-
thalmic sockets with prosthetic eyes, but to date, no formal experiments appear to
have been carried out on anophthalmic patients using these tests.

Ocular Tear Ferning Test

The tear ferning test involves removing a tear drop from the tear meniscus of the
lower eyelid and placing it on a glass microscope slide where it is allowed to evapo-
rate. Crystalisation and arborisation (ferning) of the dried tears are then observed
under a microscope. The pattern of ferning is related to the amount of mucus in the
tears and is used as a diagnostic tool for dry eyes. A four-step classification system
has been devised to describe differences in tear ferning patterns with type I and II
patterns (with plentiful ferning) being associated with normal tears and type III and
IV patterns (with little or no ferning) being associated with dry eye syndrome (kera-
toconjunctivitis sicca) (Figs. 4.39 and 4.40) [16].
4.8 Assessment of the Anophthalmic Socket 109

Fig. 4.39 Type II ocular tear

ferning pattern (tears from a
prosthetic eye) (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 4.40 Type III ocular

tear ferning pattern (tears
from a prosthetic eye)
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Tear Break-Up Time (TBUT) Test

The TBUT test measures the stability and other characteristics of the tear film and
involves the use of a Tearscope (Fig. 4.41) and other ocular instruments designed to
view the tear film noninvasively. A Tearscope is usually used in conjunction with a
slit lamp biomicroscope. The patient is asked to rest his or her chin in front of the
instrument and sit still, while a moderate light (from a cold light source which mini-
mises any drying of the tear film) is shone onto the eye being examined. The patient
is then asked to blink a couple of times and then to not blink for a short period. It is
during this non-blinking period that TBUT is measured and the interference pattern
on the surface of the tear film is assessed. The tear film over a normal eye has three
distinct layers, but it is likely that the tear film over a prosthetic eye does not behave
in the same way.
110 4 Patient Evaluation

Fig. 4.41 A Tearscope being

used to measure tear film
break-up time (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

Fig. 4.42 Equal interval photographic grading scales for measuring conjunctival inflammation
(Published with kind permission of Wiley Publishers. All rights reserved)

4.9 Assessment of Inflammation of the Anophthalmic

Socket

Anophthalmic socket assessment should continue with measurements of conjuncti-

val inflammation which has been reported to be found in 69 % of sockets with
prostheses [17]. As conjunctival inflammation of the socket has many causes other
than those related specifically to prosthetic eye wear (e.g. including a sympathetic
response to the companion eye), the extent of inflammation in each eye should be
measured at the same visit. The difference between these two measures is the degree
of conjunctival inflammation that may be attributed to the prosthesis.
An equal interval photographic grading scale for measuring conjunctival inflam-
mation in anophthalmic sockets has been developed (Fig. 4.42) [18]. These scales
have been tested for inter-rater and test–retest reliability and may be utilised for
clinically measuring the extent of conjunctival inflammation in the same manner
that photographic grading scales are used in other fields of optometry and ophthal-
mology (Fig. 4.43).
An alternative to using grading scales to measure conjunctival inflammation
in anophthalmic sockets is InflammaDry™ technology [19]. This technology
detects the presence of inflammation, but not the degree of inflammation if present.
InflammaDry works by detecting matrix metalloproteinase enzymes that are pro-
duced by stressed epithelial cells on the conjunctival surface (Fig. 4.44).
4.9 Assessment of Inflammation of the Anophthalmic Socket 111

Fig. 4.43 Photographic grading scales are in common use in optometry. Reproduced with kind
permission from Efron N. [20]
112 4 Patient Evaluation

Fig. 4.44 Two InflammaDry

devices side by side. The
display in the top device
shows a single band (no
inflammation detected), while
the window in the bottom
device shows a double band
(inflammation detected)

Fig. 4.45 Meibomian gland loss is apparent in the left anophthalmic socket of this patient com-
pared with the right companion eye (Published with kind permission of NZ Artificial Eye Service.
All rights reserved)

4.9.1 Assessment of Meibomian Gland Loss

It has been shown that meibomian glands in anophthalmic sockets with prosthetic
eyes are often less numerous than in the companion eyes of the same patient
(Fig. 4.45) [16]. Jang et al. developed a zero to four photographic scale for measur-
ing meibomian gland loss where 0 = no meibomian gland loss, 1 = meibomian area
loss is less than one-third, 2 = meibomian gland area loss greater than one-third and
less than two-thirds and 3 = meibomian gland area loss greater than two-thirds [21].

4.9.2 Assessment of Mucoid Discharge

The successful monitoring of mucoid discharge associated with prosthetic eye wear
is important because wearing comfort and convenience is a critical ‘quality of life’
factor for anophthalmic patients. Mucoid discharge is the second most important
concern for experienced prosthetic eye wearers after health of their remaining eye
and affects 93 % of wearers – 60 % of these on a daily basis [2]. Mucoid discharge
is discussed further in Chap. 9.
The severity of mucoid discharge associated with prosthetic eye wear may be
assessed using a combination of clinical observation and patients’ responses to
questions about their discharge experience. The visual analogue scales may be used
4.9 Assessment of Inflammation of the Anophthalmic Socket 113

Frequency of discharge
Never Monthly Weekly Twiceweekly Daily Twicedaily Continuously
0 1 2 3 4 5 6 7 8 9 10
---------------------------------------------------------------------------------------------------------------------------
Color of discharge
Clear White Cream Yellow
0 1 2 3 4 5 6 7 8 9 10
---------------------------------------------------------------------------------------------------------------------------
Volume of discharge
Minimal Profuse
0 1 2 3 4 5 6 7 8 9 10
---------------------------------------------------------------------------------------------------------------------------
Viscosity (stickiness/thickness) of discharge
Runny Stringy Moderately thick Very thick
0 1 2 3 4 5 6 7 8 9 10
---------------------------------------------------------------------------------------------------------------------------

Fig. 4.46 Visual analogue scales for measuring the four characteristics of mucoid discharge
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 4.47 The glob of

mucoid discharge seen in this
socket has collected behind
the prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

to facilitate the measurement and recording of the colour, viscosity, volume and
frequency of mucoid discharge (Fig. 4.46) [17].
These scales have been designed to record the patient’s discharge experience
over several days and provide a more accurate measure of discharge severity than
clinical observation which can only be made at a single point in time. However,
signs of discharge are an objective measure of discharge severity, and photographs
are an excellent way to record this information (Figs. 4.47 and 4.48).

4.9.3 Assessment of Surface Papillary Texture

of the Conjunctiva of the Socket

Conjunctival papillae are small bumps on the conjunctiva that may enlarge and
combine to resemble a cobblestone appearance and lead to a condition called giant
papillary conjunctivitis (GPC). GPC associated with contact lens wear was first
114 4 Patient Evaluation

Fig. 4.48 Photographic

record of discharge severity.
Mucoid discharge is not
associated with conjunctival
inflammation in this socket
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 4.49 A rough surface

papillary texture is apparent
in the lower tarsal and
forniceal conjunctiva of this
anophthalmic socket
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

reported by Spring in 1974 [22]. The symptoms of GPC (excess mucus production
and itching) usually come before papillary conjunctivitis is observed, and there is a
poor correlation between symptoms and observed enlarged papillae. Studies of
GPC associated with prosthetic eye wear have concluded that prolonged wear of
prosthetic eyes is associated with GPC [23] and that GPC is an allergic disease of
the eye associated with increased numbers of mast cells, eosinophils and lympho-
cytes in the conjunctiva [24]. The signs of GPC are most apparent on the upper
tarsal conjunctiva but can be observed on the lower tarsal conjunctiva which is eas-
ier to access. The signs begin with hyperaemia (an excess of blood flow causing
redness) and fine papillae which become larger (0.3–1 mm diameter) and larger
(GPC >1 mm diameter) with oedema and excess mucus lying between the papillae
and fibrosis at the papillary tips (Figs. 4.49 and 4.50).
References 115

Fig. 4.50 Giant papillary

conjunctivitis of the upper
tarsal conjunctiva of an
anophthalmic socket
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

References
1. Worrell E. Medical conditions that affect the anophthalmic patient. J Maxillofac Prosthet
Technol. 2013;12(1):23–6.
2. Pine KR, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing artificial
eyes. Clin Experiment Ophthalmol. 2011;39(1):47–52.
3. De Sousa A. Psychological issues in acquired facial trauma. Indian J Plast Surg. 2010;43(2):
200–5.
4. Yehuda R. Post-traumatic stress disorder. N Engl J Med. 2002;346:108–14.
5. Bisson JJ, Ehlers A, Matthews R, Pilling S, Richards D, Turner S. Psychological treatments for
chronic post-traumatic stress disorder. Systematic review and meta-analysis. Br J Psychiatry.
2007;190:97–104.
6. Ihrig C, Schaefer DP. Acquired monocular vision rehabilitation program. J Rehabil Res Dev.
2007;44:593–7.
7. Raizada K, Shome D, Honavar SG. New measurement device and technique for assessing
implant and prosthetic motility. Ophthal Plast Reconstr Surg. 2007;23:59–60.
8. Allen L, Kolder HE, Bulgarelli EM, Bulgarelli DM. Prosthetic eyes and tear measurements.
Ophthalmology. 1980;87(2):155–7.
9. Kim SE, Yoon JS, Lee SY. Tear measurement in prosthetic eye users with fourier-domain opti-
cal coherence tomography. Am J Ophthalmol. 2011;149(4):602–7.
10. Fett DR, Scott R, Putterman AM. Evaluation of lubricants for the prosthetic eye wearer.
Ophthal Plast Reconstr Surg. 1986;2(1):29–31.
11. Lemp MA. Report of the National Eye Institute/ Industry workshop on Clinical Trials in Dry
Eyes. CLAO J. 1995;21:221–32.
12. Lalitha CMM. Medical aspects of contact lenses, diagnosis and treatment. In: Phillips AJ,
Speedwell L, editors. Contact lenses. 5th ed. Edinburgh: Butterworth Heinemann Elsevier;
2007. p. 409–22.
13. Zone-QuickTM Phenol red thread – FCI- Ophthalmics. Available from: http://www.fci-
ophthalmics.com/files/pdf/zone_quick_web.pdf. Accessed 21 Jan 2015.
116 4 Patient Evaluation

14. Espinosa GM, Israel H, Holds JB. Survey of oculoplastic surgeons regarding clinical use of
tear production tests. Ophthal Plast Reconstr Surg. 2009;25(3):197–200.
15. Austen D. Lacrimal dilation & syringing. Available from: http://www.academy.org.uk/tutori-
als. Accessed 21 Jan 2015.
16. Rolando M. Tear mucus ferning test in normal and keratoconjunctivitis sicca eyes. Chibret Int
J Ophthalmol. 1984;2:32–41.
17. Pine KR, Sloan B, Stewart J, Jacobs RJ. The response of the anophthalmic socket to prosthetic
eye wear. Clin Exp Optom. 2013. doi:10.1111/cxo.12004.
18. Pine KR, Sloan B, Jacobs RJ. The development of measuring tools for prosthetic eye research.
Clin Experiment Optom. 2012;96(1):32–40.
19. RPS Inflammadry Detector™. Available from: http://www.rpsdetectors.com/in/inflammadry-
distributors. Accessed 24 Nov 2014.
20. Efron N. Contact lens complications, 3rd Ed. Oxford: Elsevier-Saunders; 2012
(ISBN 978-0-7020-4269-0).
21. Jang SY, Lee SY, Yoon JS. Meibomian gland dysfunction in longstanding prosthetic eye wear-
ers. Br J Ophthalmol. 2013;97:398–402.
22. Spring TF. Reaction to hydrophilic lenses. Med J Aust. 1974;1(12):449–50.
23. Srinivasan BD, Jakobiec FA, Iwamoto T, DeVoe AG. Giant papillary conjunctivitis with ocular
prostheses. Arch Ophthalmol. 1979;97(5):892–5.
24. Bozkurt B, Akyurek N, Irkec M, Erdener U, Memis L. Immunohistochemical findings in
prosthesis- associated giant papillary conjunctivitis. Clin Experiment Ophthalmol. 2007;35(6):
535–40.
Making and Fitting Prosthetic Eyes
5

Contents
5.1 Introduction ................................................................................................................... 118
5.2 Stock Versus Custom-Fit Prosthetic Eyes ..................................................................... 118
5.3 Basic Colour Theory ..................................................................................................... 119
5.3.1 The Colour Wheel ........................................................................................... 120
5.3.2 Characteristics of Colour ................................................................................ 121
5.4 Overview of Prosthetic Eye Making and Fitting .......................................................... 122
5.5 Creating the Iris/Corneal Unit....................................................................................... 123
5.5.1 Premanufactured Iris Discs and Corneas ........................................................ 124
5.5.2 Alternative Methods for Creating the Iris/Corneal Unit ................................. 125
5.6 Painting the Iris ............................................................................................................. 128
5.6.1 The Pupil ......................................................................................................... 128
5.6.2 The Collarette.................................................................................................. 129
5.6.3 The Stroma ...................................................................................................... 129
5.6.4 The Limbus ..................................................................................................... 130
5.7 Impression Taking ......................................................................................................... 130
5.7.1 Ocular Tray Impression Technique ................................................................. 131
5.7.2 Impression Mixing Gun Technique ................................................................ 133
5.8 Casting the Impression and Preparing the Wax Pattern ................................................ 134
5.8.1 Alternative Method for Creating the Wax Pattern from an Impression .......... 137
5.9 Trying in the Wax Pattern and Positioning the Iris/Corneal Unit ................................. 138
5.9.1 Compromises and Trade-offs at the Try in Stage ........................................... 139
5.9.2 Trying the Wax Pattern in the Socket and Positioning
the Iris/Corneal Unit When Fitting Bilateral Prosthetic Eyes......................... 139
5.10 Processing the Wax Prosthesis ...................................................................................... 141
5.11 Finishing the Prosthetic Eye ......................................................................................... 144
5.12 Final Clinical Session ................................................................................................... 146
References ................................................................................................................................ 147

© Springer International Publishing Switzerland 2015 117

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_5
118 5 Making and Fitting Prosthetic Eyes

5.1 Introduction

This chapter discusses the manufacture and fitting of custom-made (poly)methyl

methacrylate (PMMA) prosthetic eyes. It describes at least two different techniques
for each stage of prosthetic eye construction and approaches the subject from a
broad perspective that is respectful of the many methods that ocular prosthetists
have developed to suit their own personal styles. The goal is not to advocate for one
method over another but to enable discussion about how best to achieve excellence
in prosthetic eye manufacture. The manufacture of glass eyes which were common
before the advent of PMMA eyes in the 1940s (see Chap. 11) is not described even
though one or two European ocular prosthetists still make and fit glass eyes claim-
ing greater wearing comfort due to their superior wetting properties.
Not everybody has the skill or the ability to make and fit prosthetic eyes, and an
enormous amount of practice is required before even a modest level of competency
can be achieved in this field. Patience and perseverance are critical success factors
for ocular prosthetists, and it is essential that these traits are applied to each step of
the construction process so that critical standards are met before moving on to the
next stage.
The chapter discusses differences between stock and custom-fit prosthetic eyes
and comments on basic colour theory which is necessary for understanding pros-
thetic eye colouring techniques. The chapter then provides an overview of pros-
thetic eye making and fitting before describing and discussing the detail involved in
creating an iris/corneal unit, painting the iris, taking an impression of the socket,
positioning an iris/corneal unit in a moulded wax pattern, processing the prosthesis
in PMMA, applying secondary iris colours and scleral detail and, finally, processing
a clear PMMA veneer over the anterior surface of the prosthesis and polishing it to
a high finish. The description of these procedures assumes some prior knowledge of
working with wax, gypsum plaster and PMMA.

5.2 Stock Versus Custom-Fit Prosthetic Eyes

There are two types of prosthetic eye – stock and custom made. Unlike custom-fit
prosthetic eyes, stock eyes, whether made from glass or PMMA, are premade and
come in a range of colours and sizes with a right and left standard shape. They are
usually deeply concave at the back (Fig. 5.1). The hollow back accommodates a
variety of orbital implant shapes and sizes but may allow socket secretions to pool
and stagnate in the spaces that are inevitable between the back of the prosthesis and
the orbital tissue. This space (if large) may also lead to tissue lesions (see Chap. 7).
The colour, fit, size and direction of gaze of a set of stock prosthetic eyes are neces-
sarily limited, but the prosthesis fitting can be successful if there is large selection
to choose from. The ability to modify the size and shape of stock prosthetic eyes
during fitting greatly enhances success.
The main advantage of stock prosthetic eyes is that they are inexpensive to man-
ufacture and, provided the selection is large enough, do not need to be fitted or
5.3 Basic Colour Theory 119

Fig. 5.1 Used stock PMMA prosthetic eye manufactured in India (Published with kind permis-
sion of NZ Artificial Eye Service. All rights reserved)

adjusted by an ocular prosthetist. This is an important consideration in countries

whose populations do not have access to custom-fit PMMA prosthetic eyes because
of cost. Few western countries use stock prosthetic eyes but provide either custom-
moulded prosthetic eyes or partially premanufactured eyes with, for example, pre-
painted iris/corneal units.
The chief advantage of custom-fit PMMA prosthetic eyes is that they can be
moulded and coloured for individual patients. This greatly improves the patient’s
prospects for receiving a comfortable and aesthetically pleasing prosthesis with
optimum motility. There are numerous techniques for manufacturing and fitting
custom-fit PMMA ocular prostheses [1–4].

5.3 Basic Colour Theory

It is outside the scope of this book to describe theories of colour in depth, but a
rudimentary understanding of colour is a necessary precursor to being able to match
iris and scleral colours during the creation of a prosthetic eye. Anybody considering
becoming an ocular prosthetist should be assessed for defective colour vision and
undergo additional colour tests to determine his or her strengths and weaknesses in
this area.
Visual perception in humans depends upon two types of light-sensitive cells in
the retina of the eye: rods and cones (Fig. 5.2). Rods are highly sensitive to low
levels of light, but cannot provide high-resolution images or signal the colour of an
object. The rods dominate the regions of the retina away from the line of sight and
are responsible for peripheral vision. Cones are sensors that require higher levels of
light and complement rods by providing high-resolution images and detecting
colour. Cones are divided into three types each of which is most sensitive to a dif-
ferent region of colours on the visual spectrum. The three types are red-sensitive
cones, green-sensitive cones and blue-sensitive cones. The ability of red-sensitive,
blue-sensitive and green-sensitive cones to detect individual colours determines
120 5 Making and Fitting Prosthetic Eyes

Ganglion cells
Choroid Retina
Sclera Receptors
Synapsis Rods

Cornea

Pigmented
Pupil
cells

Lens

Iris
Nerve Bipolar Cones
Ciliary fibers cells
body

Fig. 5.2 Rod and cone cells in the retina of the eye (From http://www.dsource.in/course/colour-
theory/science-colour/science-colour.html)

which colours are the primary colours in an additive method for producing a range
of colours. The additive process is used in television and computers which generate
images by mixing the colours of red, green and blue. When these colours of light are
mixed together in appropriate proportions, they are perceived as white light.
The additive method for producing colours is very different from the subtractive
method which is used by traditional artists and ocular prosthetists who create
colour by mixing pigments in paint. The primary colours in the subtractive method
are cyan (a blue-green colour), magenta (a pink-purple colour) and yellow which
when all mixed together theoretically absorb all colour and produce black.
However, because absorbance is not complete, the mixture produces grey, and an
additional pigment (black) is added as part of the subtractive colour system called
CMYK. The subtractive method of colour production creates its effect by blocking
out parts of the colour spectrum and preventing unwanted colours from reaching
the retina.

5.3.1 The Colour Wheel

Primary colours are sets of colours (three per set because human vision is trichro-
matic) that, when mixed together, are able to make a range of useful colours. They
are ‘primary’ because one primary is not able to be made from a mixture of the other
two primaries. In the additive system, the primary colours are usually chosen to be
red, green and blue. In the subtractive system, the primary colours are taken to be
cyan, magenta and yellow (black can be added). A different set of primary colours
5.3 Basic Colour Theory 121

Fig. 5.3 CMYK subtractive

colour diagram

(red, yellow and blue) is often taken in the subtractive system by artists and painters.
When mixing colours, a secondary colour is one that is created by combining two
primary colours together. A tertiary colour is made up by mixing three or more
colours together. The subtractive colour diagram (Fig. 5.3) illustrates these three
categories of colour.

5.3.2 Characteristics of Colour

The following terms and definitions describe the factors that are taken into account
by the prosthetist when painting the iris of a natural eye.
The hue is the colour of the pigments used. The value is the lightness or darkness
of a colour and is a measure of the amount of light reflected from its surface (reflec-
tance). For example, adding Vandyke brown to blue delivers a darker value of blue
that reflects less light from a painted iris. The chroma is the purity or saturation of a
colour. This is thought of as a measure of how little white, black or grey is in the
colour.
The more pale a colour is, the less saturated or less pure it is. For example, a
grey/blue iris is less saturated (less pure) than a high intensity blue iris which is
more noticeable (more pure). A tint is the base colour added to white. A tone is the
base colour added to grey. A shade is the base colour added to black [5].
Ocular prosthetists often have their own preferred colour palettes with which
they are familiar and which may be tailored to the ethnic origins of their patients. A
basic palette might include the colours: ivory black, titanium white, Vandyke brown,
cobalt blue, yellow ochre, raw sienna and burnt sienna (Fig. 5.4).
122 5 Making and Fitting Prosthetic Eyes

Fig. 5.4 A basic palette

might include the colours
(from left to right): ivory
black, titanium white,
Vandyke brown, cobalt blue,
yellow ochre, raw sienna and
burnt sienna (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Table 5.1 Overview of prosthetic eye making and fitting

Step Task
First clinical Take an impression of the socket
session Paint the iris disc to match the patient’s iris
Laboratory Cast the impression and make a wax pattern. Process or cement PMMA
processing cornea over the painted iris disc and polish
Second clinical Insert the wax pattern into the socket. Mark the iris position and remove.
session Embed the iris/corneal unit into the wax pattern. Adjust and retry until size,
shape and direction of gaze are correct
Laboratory Key the iris/corneal unit and invest the wax pattern in dental plaster in a
processing two-part metal eye flask. Remove the wax, pack the mould with white
PMMA and process. Remove the PMMA eye, roughen the surface and cut
back the cornea leaving a thin layer covering the painted iris beneath
Third clinical Apply a second layer of paint to the iris and the scleral colours. Tease out
session red cotton thread and lay down conjunctival veins
Laboratory Dry the paintwork and process a clear PMMA veneer over the front of the
processing eye. Polish to a high standard of finish
Fourth clinical Insert the completed prosthesis. Adjust and re-polish if necessary
session
Follow up After 1 month of wear, inspect the prosthesis and make final adjustments as
session needed

5.4 Overview of Prosthetic Eye Making and Fitting

A prosthetic eye is made up of two basic components – an iris/corneal unit and the
white scleral body of the prosthesis. An iris disc is painted to match the patient’s
companion iris and a cornea is added to this to make up the iris/corneal unit. This is
then incorporated into a wax pattern that has been formed from an impression of the
eye socket. The wax is moulded to suit the socket and used as a pattern for the final
PMMA prosthesis.
There are usually four clinical sessions interspersed with laboratory processing
that make up the process of prosthetic eye making and fitting (Table 5.1).
At the first clinical session, an impression is taken of the socket, and a PMMA
disc is trimmed to the diameter of the iris. The iris colours are matched directly to
the patient’s natural eye and applied to the disc using finest grade oil paints and the
5.5 Creating the Iris/Corneal Unit 123

smallest of sable hair brushes. When dry, a clear PMMA cornea is processed over
the top of the painted iris, and an iris/corneal unit is produced.
During the second clinical session, this iris/corneal unit is imbedded into a wax
pattern made from the impression of the socket, and the whole is inserted into the eye
socket. The wax is shaped and moulded until the size of the eye, direction of gaze
and the eyelid contour are established. After the session, a plaster mould is made,
and the wax pattern is replaced faithfully with white PMMA. The surface is rough-
ened and the cornea is cut back leaving a thin layer covering the painted iris beneath.
The third clinical session involves applying a second coat of paint to the iris and
colouring the sclera with yellows, blues and greys fine veins, teased from cotton
thread are then added to the sclera. Once this is done, a clear PMMA veneer is pro-
cessed over the surface of the prosthesis and finished off with a high polish.
At the fourth clinical session, the completed prosthetic eye is inserted into the
socket, and final adjustments are made.
The majority of prosthetic eyes are successfully completed within these four
clinical sessions, but if the appearance and/or function is not satisfactory, further
fittings and sometimes further surgery are required to achieve an optimum result.
Complicated sockets and eyelids are discussed in Chap. 7.

5.5 Creating the Iris/Corneal Unit

The process begins by measuring the iris diameter of the patient’s companion eye
using callipers or a vernier gauge (Fig. 5.5). The actual iris diameter is about 0.5 mm
greater than the physical iris diameter due to magnification by the cornea, and this
should be taken into account by using an iris disc about 0.5 mm smaller than the
measurement [2].
Techniques for creating an iris/corneal unit range from ordering finished
units from a catalogue or ordering kit [6], to purchasing premanufactured clear

Fig. 5.5 A vernier gauge for

measuring the iris diameter
124 5 Making and Fitting Prosthetic Eyes

Fig. 5.6 Assorted iris discs

with matching corneal
buttons (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.7 Iris disc and clear

corneal button with pupil
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

corneal buttons (with or without a pupil) used in conjunction with ready to paint
iris discs [6–9], to making up the iris/corneal unit without any premanufactured
components.
Whichever method is used for creating the iris/cornea, the process starts with the
patient seated in a comfortable position facing good light. Ideally the light should
be natural light (from a northerly direction in the northern hemisphere and from a
southerly direction in the southern hemisphere) to avoid the sun’s direct rays which
have less blue than the light coming from the sky.

5.5.1 Premanufactured Iris Discs and Corneas

Iris discs with accompanying clear corneal buttons with pupils are available in vari-
ous sizes from ocular supply companies [7–10] (Figs. 5.6 and 5.7). A major advan-
tage of using premade components is that it avoids the need for iris discs and corneal
buttons to be made from metal dies which are also available [10] (Fig. 5.8).
A rod of sticky wax is attached to an appropriately sized iris disc so that it can be
easily handled during the painting of the iris colours (Fig. 5.9). A drop of water may
5.5 Creating the Iris/Corneal Unit 125

Fig. 5.8 Metal dies for

making iris discs and clear
corneal buttons (Published
with kind permission of
James Strauss. All rights
reserved)

Fig. 5.9 Sticky wax rod

attached to an iris disc for
easy handling during painting
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

be applied periodically to the centre of the iris and the corneal button placed over it.
This will enable the colours to be seen as they will appear when the cornea is per-
manently sealed to the iris disc (Fig. 5.10).
On completion of the painting, the corneal button is cemented to the iris disc
using monomer–polymer syrup, cyanoacrylate adhesive or Dentsply triad light cure
gel with bonding agent [11]. The completed iris/corneal unit is now set aside ready
for the next stage.

5.5.2 Alternative Methods for Creating the Iris/Corneal Unit

Alternative methods for creating iris/corneal units include painting iris discs
stamped out of artists’ water colour paper. The painted iris is cemented directly on
126 5 Making and Fitting Prosthetic Eyes

Fig. 5.10 A drop of water previews the final appearance of iris colours when sandwiched between
the corneal button and the freshly painted iris (Published with kind permission of NZ Artificial Eye
Service. All rights reserved)

Fig. 5.11 Custom-designed

metal mould for creating
iris/corneal units with four
black tinted cold-cure iris
blanks ready for turning on a
lathe (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

to a marked position on a PMMA white blank which has been made from an impres-
sion and tried in the socket [2].
Another method uses metal moulds custom designed for creating iris/corneal
units (Fig. 5.11). Black tinted cold-cure PMMA is poured into the mould, and the
resultant blank is turned on a small lathe to the required iris diameter (Fig. 5.12).
In order to make an off-centre pupil similar to a natural iris, the blank is removed
from the lathe, and a metal shim or similar is placed on one of the chuck jaws so
that when the blank is returned it spins slightly off-centre. A shallow depression
for the pupil is made on the lathe using a squared-off drill bit of the appropriate
diameter. The iris blank is smoothed with a rubber wheel before being painted to
match the patient’s iris (Fig. 5.13). When this is completed, the painted iris blank
is dried before being returned to the metal mould. Clear PMMA is mixed, packed
into the mould over the painted iris blank, pressed, clamped and processed in a
curing tank. When curing is complete, the processed iris/corneal unit is removed
from the metal mould and turned on the lathe to the required iris diameter and
polished (Fig. 5.14).
5.5 Creating the Iris/Corneal Unit 127

Fig. 5.12 PMMA blank is

turned to the required iris
diameter. The pupil is created
off-centre using a squared-off
drill bit (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.13 The iris disc is

painted to match the patient’s
iris (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.14 A clear cornea is

processed over the painted
iris blank and turned to the
required iris diameter
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
128 5 Making and Fitting Prosthetic Eyes

Fig. 5.15 It is recommended

that the iris is painted under a
magnifying lamp (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

5.6 Painting the Iris

Oil pigments, such as Windsor and Newton, permanence AA can be used to paint
the iris – often mixed with monomer–polymer syrup to facilitate rapid drying of the
initial layers. The iris disc is painted to match the natural iris. The colour of the
limbus area is usually mixed first and applied as a base layer over which the colours
of the collarette and stroma are applied working from the centre outwards. Sable
hair brushes, size 0, 00 and 000, are typically used, and often the paint is applied in
small daubs using a 000 brush and streaked out with a dry 0 brush to create the deli-
cate interlaced fibres of the stroma. Finally, details such as freckles, spots and/or an
arcus senilis are applied if present. It is recommended that the iris is painted under
a magnifying lamp (Fig. 5.15).
Painting the iris is a systematic process that involves dealing with each individual
component of the iris in turn as follows (Fig. 5.16).

5.6.1 The Pupil

The pupil is arguably the most prominent feature in light-coloured eyes but of lesser
importance in dark eyes where it may sometimes be almost invisible. Its size
changes according the amount of light available, and the patient should be observed
in a range of lighting conditions before an average pupil size is chosen. In some
cases the provision of night and day prostheses may be necessary to overcome the
difference in pupil size at these different times.
The pupil is seldom positioned in the centre of the iris but is usually upwards and
inwards of centre (see Chap. 2). The pupil creates the direction of gaze, and if it is
placed in the centre, in most cases, the prosthetic eye will appear to gaze outwards
requiring the fit to be adjusted later to compensate.
5.6 Painting the Iris 129

Fig. 5.16 Individual

components of the iris
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

The edge of the pupil is soft and seems to dissolve into the collarette rather than
stand apart from it. This effect can only be achieved when applying a second layer
of paint to the iris at the stage when the scleral colours are laid down. The underly-
ing pupil is covered with a thin daub of black paint, and the collarette colour is
pushed into place around its edge. A dry brush is then used to sweep the collarette
colour into the black paint and then to sweep the black paint back out into the col-
larette. By this means, the two paints are mixed together, and the pupil edge is
softened. This method achieves a similar effect to Fredric Harwin’s method for
creating the illusion of a dilating pupil [12]. The process is completed when the
centre of the pupil is freshened with a daub of black paint.

5.6.2 The Collarette

The collarette is the area where the sphincter muscle (sphincter pupillae) contracts
the pupil in a circular motion. It is bounded on the inside by the soft edge of the
pupil and on the outside by the set of dilator muscles (dilator pupillae) which pull
the iris radially to enlarge the pupil. The colour of the collarette is often different
from the rest of the iris and should be mixed separately.

5.6.3 The Stroma

The stroma is the fibrovascular anterior layer of the iris containing striations which
are visible to a greater or lesser extent in all eyes but are virtually invisible in black
or dark brown eyes where the stroma is heavily pigmented. In lighter coloured eyes,
the pattern of the striations need not be copied exactly because no two eyes have
identical designs. However, the pattern of the striations along with spots, smears,
130 5 Making and Fitting Prosthetic Eyes

Fig. 5.17 An arcus senilis

strongly characterises the
appearance of this elderly
patient’s iris (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

cloudy areas and an arcus senilis (Fig. 5.17) should be copied if present, as they
strongly characterise the iris. The collaret is often distinguishable from the rest of
the iris as is the band of colour at the limbus.

5.6.4 The Limbus

The stroma is thinnest at the limbus where the underlying pigmented epithelial cells
show through and blend with the sclera. The outer edge of the limbus, like that of
the pupil, is an area that requires particular attention as the degree of diffusion is an
important feature in determining whether the prosthesis will appear natural or arti-
ficial. It is sharper in young patients and more diffuse in older patients where it may
be influenced by a developing arcus senilis.

5.7 Impression Taking

Anophthalmic sockets range from soft deep cavities (with small or non-existent
orbital implants) and shallow fornices to those with shallow cavities containing con-
vex or flat posterior aspects and deep fornices. The shape of the prosthetic eye is
initially determined by the impression although it is not uncommon for the shape to
be modified when moulding the wax pattern later in the manufacturing process. A
good impression extends fully into the fornices without over stretching the conjunc-
tiva and accurately records the shape of the posterior aspect of the socket. An
impression which has over extended the fornices may restrain the movement of the
prosthetic eye while one which has under extended the fornices may result in a
prosthesis that is unstable. The anterior shape of a prosthetic eye is not derived from
the impression but is moulded free hand to achieve its final contour at a later stage
in the manufacture of the prosthesis (Fig. 5.18).
5.7 Impression Taking 131

Fig. 5.18 Polyvinylsiloxane

impression taken without an
impression tray. Note the
shape of the underside of the
upper eyelid and the
extension under the lower
tarsal plate (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Two methods for impression taking are described: an ocular tray impression
technique and a mixing gun impression technique. The traditional stock tray tech-
nique is the most common, while the mixing gun impression technique has only
become an option since the introduction of dental impression guns in the late 1990s.
Both impression techniques commence with the patient seated in an upright posi-
tion with the head supported by a headrest. It is worthwhile to reassure the patient
at the outset that they are about to receive into their socket a cool, comforting gel
that is entirely painless and only requires about 60 s to set. There is generally no
need to anaesthetise the socket prior to taking an impression for a prosthetic eye
unless the patient is very sensitive and anxious.

5.7.1 Ocular Tray Impression Technique

This technique uses ocular impression trays to facilitate the introduction of the
impression material into the socket and to assist the flow of the material into the
fornices. Ocular impression trays (Fig. 5.19) are available from ocular prosthetic
suppliers [7–10]. They come in various sizes and are used in conjunction with a
disposable syringe (Fig. 5.20) containing non-irritating irreversible hydrocolloid or
silicon impression materials.
132 5 Making and Fitting Prosthetic Eyes

Fig. 5.19 Ocular impression

tray

Fig. 5.20 Disposable

syringe used in conjunction
with an ocular impression
tray

An appropriately sized ocular impression tray is selected and tried in the socket
to ensure that it can be aligned properly and the socket is not over extended.
The impression material is mixed and loaded into the syringe and injected into
the socket via the hollow stem of the ocular tray in sufficient quantity to lift the
eyelids to their normal contour (Fig. 5.21). As the material is injected, the tray
stem is aligned with the central direction of gaze and held steady in this position
until the impression material sets. Immediately the material has set, the eyelashes
are carefully released, and the impression tray is removed from the socket and
checked for defects. This method is particularly useful for sockets with fulsome
5.7 Impression Taking 133

Fig. 5.21 Impression

material has been injected
into the socket via the hollow
stem of the ocular tray
(Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

Fig. 5.22 An impression

mixing gun with disposable
mixing tip and a cartridge
containing fast set, heavy
body polyvinylsiloxane
impression material

implants and deep fornices but may distort the tissues when used with other socket
shapes.

5.7.2 Impression Mixing Gun Technique

This technique involves a single step and requires three items of equipment which
are readily obtainable from dental supply companies: an impression mixing gun, a
disposable mixing tip and a cartridge containing fast set, heavy body polyvinylsi-
loxane impression material (Fig. 5.22).
The polyvinylsiloxane impression material is mixed as it travels up the mixing
tip and may be introduced directly into the anophthalmic socket as it emerges from
the end. The impression material is directed under the upper eyelid first, and when
134 5 Making and Fitting Prosthetic Eyes

Fig. 5.23 The cotton thread

embedded in this impression
provides an excellent means
by which the impression can
be retrieved from the socket
of a child (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

the socket is filled, the gun is set aside. At this point the lower eyelid is held down
with the finger of one hand, while the impression material is pressed into the socket
with the thumb of the other hand. A moderate pressure is applied so that the material
extends the conjunctival folds of the socket. Immediately the material has set, and
the eyelashes are carefully released before the impression is removed from the
socket and checked for defects.
This one step, mixing gun technique, is fast and simple and causes minimum
discomfort for the patient. It produces a functional impression of the eye socket
that is not distorted by a tray. This method is particularly useful with children
where inserting an ocular tray can be difficult or impossible and a general anaes-
thetic is to be avoided. A good precaution to take in these cases is to embed the
centre of a length of cotton thread into the impression material just as it is about to
be introduced to the socket. The thread cannot be felt, and it provides an excellent
means by which the impression can be retrieved from the socket once it has set
(Fig. 5.23).

5.8 Casting the Impression and Preparing the Wax Pattern

When the ocular tray method technique is used, the final impression is trimmed of
excess material and fully immersed in a one-part silicon or two-part gypsum plas-
ter mould in preparation for reproducing the shape in wax (Fig. 5.24). The impres-
sion is removed by sectioning the mould (Fig. 5.25) and preheated white ocular
5.8 Casting the Impression and Preparing the Wax Pattern 135

Fig. 5.24 The impression is

trimmed of excess material
and fully immersed in a
one-part silicon mould
(Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

Fig. 5.25 The impression is

removed by sectioning the
mould (Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

wax is poured into it (Fig. 5.26). The resultant wax pattern is cooled down and
removed (Fig. 5.27). The posterior surface and margins reflect the shape of the
socket, while the anterior surface needs to be smoothed and shaped with a heated
wax knife to approximate the shape of the anticipated prosthetic eye (Figs. 5.28
and 5.29).
136 5 Making and Fitting Prosthetic Eyes

Fig. 5.26 Preheated white

ocular wax is poured into the
mould (Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

Fig. 5.27 The wax pattern is

cooled down and removed
(Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)
5.8 Casting the Impression and Preparing the Wax Pattern 137

Fig. 5.28 The anterior

surface of the wax pattern is
being trimmed to approxi-
mate the shape of the
anticipated prosthetic eye
(Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

Fig. 5.29 The completed

wax pattern is ready to be
inserted into the eye socket
(Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

5.8.1 Alternative Method for Creating the Wax Pattern

from an Impression

An alternative method is to cast the posterior half of the impression in a one-part

gypsum plaster mould. This method only records the posterior surface and margins
of the impression but has the advantage of allowing a shellac baseplate (used by
dental technicians to strengthen wax bite blocks) or cold-cure acrylic backing to be
applied to the plaster cast (Fig. 5.30). Softened wax is added to the base plate and
shaped to approximate the anterior contour of the eye. The backing helps preserve
the anatomical accuracy of the posterior surface and margins of the wax pattern dur-
ing the try-in process that follows. When a backing is used, the prosthetist has the
opportunity to use more pliable, more workable waxes as an alternative to hard,
brittle waxes that are necessary to maintain shape when no backing is used.
138 5 Making and Fitting Prosthetic Eyes

Fig. 5.30 A backing for the

wax pattern is made from
shellac base plate. The
backing supports the wax
pattern during the try-in stage
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.31 The wax pattern is

tried in the socket (Published
with kind permission of
Sachin and Shreya Gupta. All
rights reserved)

5.9 Trying in the Wax Pattern and Positioning the Iris/

Corneal Unit

The wax try-in stage is arguably the most important stage in the process of making
a prosthetic eye. The size of the eye, the direction of gaze, the curvature of the globe
and the contour of the eyelids are determined during this stage.
Firstly, the wax pattern is inserted into the socket, assessed and removed. Its
shape and volume are then modified if necessary using a wax knife heated in the
open flame of a Bunsen burner. The wax pattern is cooled in cold water before being
reinserted into the socket and assessed again. This process is repeated until the pal-
pebral fissure and the anterior curvature of the globe are as similar to the companion
eye as possible (Fig. 5.31).
Once the shape and fit of the wax pattern has been accomplished, the position of
the pupil is marked as a guide to placing the iris/corneal unit. The positioning of the
5.9 Trying in the Wax Pattern and Positioning the Iris/Corneal Unit 139

Fig. 5.32 A clear plastic iris/

corneal blank is positioned
with the rod aligned in central
gaze (Published with kind
permission of Sachin and
Shreya Gupta. All rights
reserved)

unit is sometimes achieved more easily by using a temporary metal or plastic sub-
stitute which has the same form as the unit. The blank is manoeuvred so that it is on
the same horizontal plane as the companion eye with its rod aligned in central gaze
(Fig. 5.32).
Once the position of the iris has been determined, a 2 mm strip of wax is added
to the lower edge of the wax prosthesis. This is a precautionary measure that ensures
that the iris will not settle too low in the socket when the prosthesis is completed.
The additional material is easily trimmed off if the iris position is too high.

5.9.1 Compromises and Trade-offs at the Try in Stage

During the shaping of the prosthesis and the positioning of the iris/corneal unit, it is
often necessary to make compromises or trade-offs because it is not always possible
to get perfect symmetry. The prosthetist should therefore have an a priori knowl-
edge of the trade-offs that work best and be able to explain the reasons for their
decisions to the patient. The trade-offs described in Table 5.2 are subtle and do not
fall into the category of socket complications which is the topic of Chap. 7. The
recommended solutions in Table 5.1 are subjective and will not be correct for all
situations nor agreed to by everybody – nor even recognised as an issue by others.
In the end, the patient will have the final say.

5.9.2 Trying the Wax Pattern in the Socket and Positioning

the Iris/Corneal Unit When Fitting Bilateral Prosthetic Eyes

When fitting prosthetic eyes to blind patients, it is important to explain what is being
done and to warn them verbally before touching their face. It is easier to create iris/
corneal units for people requiring two rather than one prosthesis, but it is a lot more
difficult to position the wax patterns of two eyes so that each eye has the same size,
140 5 Making and Fitting Prosthetic Eyes

Table 5.2 Trade-offs that must be resolved during the positioning of the iris/corneal unit and
shaping of the wax prosthesis
Trade-offs Recommendations solutions
Size of the palpebral fissure A smaller palpebral aperture is preferable if it achieves a relaxed
vs. eyelid contour and size ofupper eyelid that closes completely on blinking. A smaller
the companion eye aperture is also preferable to one that is too large although an
exception to this might be where a deep upper eyelid sulcus can
be made less noticeable by widening the palpebral fissure
Increased anterior curvature Increasing the anterior curvature and volume of the prosthesis to
vs. minor upper eyelid ptosis provide more support to the upper eyelid is preferable to ptosis,
even if the prosthesis protrudes a little as a consequence
Horizontally balanced iris Balance is important and should not be sacrificed lightly. It is
vs. an iris that has been better to have a horizontally balanced iris, regardless of the
lowered to better relate to a position of the lower eyelid
lax lower eyelid
The relationship between the The relationship between the iris and the upper eyelid is more
iris and the upper eyelid vs. important, especially if the horizontal balance is also maintained
its relationship with the
lower eyelid
Fully moulded posterior Stability of the prosthesis is paramount, and this can often be
surface vs. stability of the improved if the back is hollowed. Hollowing should be the
prosthesis in the socket minimum required to achieve stability so that there is minimal
space for socket secretions to pool

Fig. 5.33 Matching prosthetic eyes for blind patients can be challenging. This patient’s right
socket is shallow and small while her left socket is deeper and larger

eyelid contour and direction of gaze. This is because an adjustment to one eye
necessitates adjustments to the other eye and vice versa. The prosthetist should
concentrate on getting one of the eyes set up first and then matching the other eye to
it. It may then be necessary to adjust the first eye again to accommodate the final
positioning of the second eye. Often a compromise position is reached where both
eyes are relatively symmetrical and stable (Fig. 5.33).
5.10 Processing the Wax Prosthesis 141

5.10 Processing the Wax Prosthesis

Once the wax prosthesis (including the iris/corneal unit with rod) has been com-
pleted, it is invested in a two-part gypsum plaster mould. The rod keys the iris/cor-
neal blank so that it is not displaced in the mould. Once the plaster has set, the
mould is placed in hot water to soften the wax and allow the mould to be opened.
The wax and the iris/corneal unit are removed from the mould, and a coating of
separating solution is applied. White PMMA polymer powder is mixed with liquid
monomer, and when a dough stage is reached, a thin layer is applied under the iris/
corneal unit as it is placed back in the mould (Fig. 5.34). This ensures that the iris is
set deeper into the eye allowing adequate space for a clear veneer to be added later
in the process.
The mould is coated with a separating solution and trial packed with white
PMMA (Fig. 5.35). The PMMA flash is trimmed off, and polymerisation is carried
out by immersing the mould in water for at least an hour at 72 °C. When polymeri-
sation is complete, the PMMA eye is removed from the mould, and the anterior
surface of the prosthesis is roughened all over with an arbour band. The cornea is
then ground flat leaving about 1.0 mm of clear cornea covering the underlying iris
paintwork. The flattened cornea is smoothed with a rubber wheel, and the eye is
ready for final iris painting and scleral colouring (Fig. 5.36).
The second layer of iris colours is applied as described previously (Fig. 5.37),
and scleral colouring is achieved using oil pigments diluted with monomer–poly-
mer syrup. Fine threads that will become capillaries and veins on the prosthesis are
teased from red embroidery thread and carefully laid on the sclera in the same man-
ner and amount as observed in the patient’s companion eye (Fig. 5.38). The threads
should be controlled so that when a clear PMMA veneer is applied to the prosthesis

Fig. 5.34 The rod attaches the iris/corneal unit to the mould (Published with kind permission of
NZ Artificial Eye Service. All rights reserved)
142 5 Making and Fitting Prosthetic Eyes

Fig. 5.35 The prosthesis is

trial packed with white
PMMA (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.36 Set up for final iris

painting and scleral colouring
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.37 The second layer

of iris colours being applied
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
5.10 Processing the Wax Prosthesis 143

Fig. 5.38 Fine veins are

teased from red embroidery
thread and carefully laid on
the sclera in the same manner
and amount as observed in
the patient’s companion eye
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.39 A clear veneer of

PMMA is then processed
over the anterior surface
locking in the iris and scleral
colours and restoring the
cornea to its original shape
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

later, the free ends are not able to penetrate the veneer or come through between the
edge of the veneer and the body of the prosthesis. If this happens, they are likely to
irritate the conjunctiva.
When the final iris and scleral colours have been applied, they are dried under a
lamp, and the prosthesis is returned to the mould ready for a veneer of clear PMMA
to be applied. The veneer will lock in the iris and scleral colours and veins and
restore the cornea to its original shape (Fig. 5.39).
At this point, a 1.0 mm spacer is placed between the two halves of the mould to
allow space for the veneer, and a polythene sheet is placed over the prosthesis. The
sheet serves to protect the iris and scleral colours from being displaced by the
PMMA veneer when it is first packed into the mould. A monomer–polymer mix of
clear PMMA is prepared, and when it has reached a dough stage, it is packed into
144 5 Making and Fitting Prosthetic Eyes

Fig. 5.40 The prosthesis is

buffed with a wet pumice
mix using a calico mop
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

the mould over the polythene sheet. The two halves of the mould are closed under a
press and then opened again to allow the polythene sheet to be removed. The mould
is closed a final time and the PMMA veneer is then processed. It is important that
the final processing is done thoroughly according to the manufacturer’s instructions
because PMMA which has not been completely polymerised will severely irritate
the conjunctiva when the prosthesis is inserted. Patel et al. described two cases of
acute onset hypersensitivity reaction to a PMMA prosthetic eye. They resolved one
case by replacing the prosthesis with a glass eye and the other by subjecting the
prosthetic eye to an extended curing cycle. The reprocessed eye was refitted, and the
symptoms of marked papillary reaction, conjunctival oedema and severe discharge
disappeared after 1 month [13].

5.11 Finishing the Prosthetic Eye

The process for polishing prosthetic eyes involves four steps:

Step 1. The newly processed prosthesis is trimmed, and any pronounced irregulari-
ties on the fitting surface are smoothed over before the entire surface is ground
with a fine (120 grit) arbour band.
Step 2. The marks left by the arbour band are buffed off with a paste of pumice and
water applied with a calico mop followed by a felt cone if required (Fig. 5.40).
Step 3. The fine marks left by the pumice are removed with a polishing compound
such as tripoli (an abrasive-impregnated wax bar commonly used for polishing
dentures) applied with a dry calico or lamb’s wool polishing mop (Figs. 5.41 and
5.42).
Step 4. An optical quality contact lens standard of polish is obtained using aluminium
oxide paste [14], applied with a foam polyurethane rotating cone or wheel. This
final step reduces trace lines from the polishing mop and removes wax residues.
5.11 Finishing the Prosthetic Eye 145

Fig. 5.41 The fine marks

left by the pumice are
removed with a polishing
compound such as tripoli
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 5.42 Final polishing of

a concave posterior surface
using a hand-piece and small
polishing wheel (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Le Grand [15] recommended this standard for polishing prosthetic eyes, and
Pine et al. used in vivo and in vitro studies [16, 17] to show that an optical quality
contact lens standard of surface polish produced a more wettable surface than a
normal standard of finish.
In another study, Waddell and Pine [18] showed that using the four polishing
steps (arbour band grinding, pumice, tripoli and final polishing with Kenda 244-
Blue polishing compound) produced PMMA surfaces that most resisted the adher-
ence of bacteria compared with other polishing regimes (Fig. 5.43). A four-step
146 5 Making and Fitting Prosthetic Eyes

Number of yeast cells vs polishing technique

180

160
140
120
100
80
60
40
20
0

Pumice
Pumice &
Tripoly Tripoly &
Kenda Pumice &
244-Blue Kenda Pumice &
244-Blue Tripoly &
Kenda
244-Blue

Fig. 5.43 The use of pumice, then tripoli and then Kenda 244-Blue to polish PMMA produced
surfaces that most resisted the adherence of bacteria compared with other polishing regimes. The
numbers on the y axis of the graph represent individual yeast cells. (Published with kind permis-
sion of NZ Artificial Eye Service. All rights reserved)

optical quality contact lens standard of polish may be particularly important in the
inter-palpebral area of a prosthetic eye to assist the cleansing action of tears.

5.12 Final Clinical Session

The polished prosthetic eye is fitted at the final clinical session. The fit may require
minor adjustment in order to realign the direction of gaze and/or to improve the
stability the prosthesis in the socket. The position of the iris relative to the eyelids is
also finalised at this stage by trimming back any extra material added to the lower
edge when trying the wax pattern in the socket. Instructions are given for removing
and reinserting the prosthesis and for its ongoing maintenance. See Chap. 10 for
further discussion about advice to patients. It is recommended that a follow-up visit
is scheduled for a month after the prosthesis is fitted to ensure that it has settled in
comfortably and to answer any questions the patient may have about their new eye.
References 147

References
1. Cain JR. Custom ocular prosthetics. J Prosthet Dent. 1982;48(6):690–4.
2. Haug SP, Andres CJ. Fabrication of custom ocular prostheses. In: Taylor TD, editor. Clinical
maxillofacial prosthetics. Chicago: Quintessence Publishing; 2000. p. 265–7.
3. Jain A, Makkar S. Prosthetic rehabilitation of an ocular defect with a custom made ocular
prosthesis: a clinical case. J Maxillofac Prosthet Technol. 2013;12(1):12–5.
4. Brown KE. Fabrication of an ocular prosthesis. J Prosthet Dent. 1970;24(2):225–35.
5. New York University Computer Science. Colour theory. 2013. Available from: http://cs.nyu.
edu/courses/fall02/V22.0380-001/color_theory.htm. Accessed Dec 2014.
6. Cantor and Nissel. Custom manufacturer of lenses for the optical profession. Available from:
www.cantor-nissel.co.uk. Accessed Dec 2014.
7. Factor 2 Incorporated. Available from: http://www.factor2.com. Accessed Dec 2014.
8. Technovent Ltd. Available from: www.technovent.com. Accessed Dec 2014.
9. Oculo Plastique Incorporated. Available from: www.oculoplastik.com. Accessed Dec 2014.
10. James Strauss Products for the Ocularists Ltd. Available from: www.strausseye.com/Products.
aspx. Accessed Dec 2014.
11. Densply. Triad light cure materials. Available from: http://www.dentsply.com.au/triad-light-
cure-materials-vlc-bonding-agent-95765/w1/i1005028/. Accessed Dec 2014.
12. Harwin F. Creating the illusion of a dilating pupil. J Ophthalmic Prosthet. 2000;5(1):29–35.
13. Patel V, Allen D, Morley AMS, Malhotra R. Features and management of an acute allergic
response to acrylic ocular prostheses. Orbit. 2009;28(6):339–41.
14. Nexgen Optical Ltd. Polishing compounds. Available from: http://www.nexgenoptical.com/
polishing-compounds.php. Accessed Dec 2014.
15. LeGrand JA. Chronic exudate: an unnecessary evil. J Ophthalmic Prosthet. 1999;4(1):33–40.
16. Pine KR, Sloan B, Jacobs R. Deposit build- up on prosthetic eyes and the implications for
conjunctival inflammation and discharge. Clin Ophthalmol. 2012;6:1755–62.
17. Pine KR, Sloan B, Jacobs R. Deposit buildup on prosthetic eye material (in vitro) and its effect
on surface wettability. Clin Experiment Ophthalmol. 2013;7:313–9.
18. Waddell N, Pine KR. Effect of surface roughness on the bio-film adhesion in ocular prosthet-
ics. Presentation to the International Ocularist Conference, Brisbane, Australia; 2010.
Scleral Shell Prostheses and Prosthetic
Contact Lenses 6

Contents
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
6.2 Prosthetic Contact Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.1 Aniridia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.2 Corneal Leucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
6.2.3 Corneal Opacities or Scars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
6.2.4 Iris Coloboma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
6.2.5 Cataract Appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.2.6 Albinism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.2.7 Heterochromia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
6.2.8 Corneal Dystrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.2.9 In-House Tinting Systems for Soft Prosthetic Contact Lenses . . . . . . . . . . . . 157
6.2.10 Hand-Painted Opaque Prosthetic Contact Lenses . . . . . . . . . . . . . . . . . . . . . . 158
6.3 Scleral Shell Prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
6.3.1 Making and Fitting Medium or Thick Scleral Shell
Prostheses (1.5 mm to 2.5 mm Thickness) . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
6.3.2 Making and Fitting Thin Scleral Shell Prostheses
(Less Than 1.5 mm in Thickness) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
6.3.3 Thin Scleral Shell Prosthesis Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
6.3.4 Overview of the Making and Fitting Process. . . . . . . . . . . . . . . . . . . . . . . . . . 163
6.3.5 Taking an Impression of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
6.3.6 Trial Shell. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
6.3.7 Construction of the Final Scleral Shell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

6.1 Introduction

Where an eye has been enucleated or eviscerated, the fitting of a prosthetic eye is
appropriate. However, where the eyeball has become disfigured and unsightly, a
scleral shell prosthesis or a prosthetic contact lens is used to mask the defect. The
development of more complex vitreoretinal surgical techniques has meant that more
eyes are being saved (some with useful vision and others without sight) and that
more patients are spared the potential psychological trauma of eye removal.

© Springer International Publishing Switzerland 2015 149

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_6
150 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.1 The cornea may be

seen underlying thin
conjunctival tissue following
a Gundersen flap procedure
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

The retained eye provides a good foundation for scleral shell prostheses or pros-
thetic contact lenses, and these often have excellent motility.
Prosthetic contact lenses and scleral shell prostheses are devices that fit over a
sighted or blind eye to mask a disfigurement or to resolve a visual problem. These
prostheses should not be confused with cosmetic contact lenses which are designed
to influence the appearance of healthy sighted eyes for cosmetic or theatrical effect.
Optometrists with a special interest in prosthetic contact lenses also make and fit
scleral shell prostheses, while non-optometrist ocular prosthetists limit their prac-
tice to scleral shell prostheses for eyes that are blind or without useful vision. The
best outcome for patients occurs when ocular prosthetists and optometrists work
together and apply the special abilities they each bring to the care and treatment of
ocular disfigurement.
Obtaining an accurate likeness of an iris with a prosthetic contact lens or thin
scleral shell prosthesis is more difficult to achieve than it is with a prosthetic eye.
This is because a prosthetic eye has enough thickness to accommodate a curved
cornea over a flat iris, whereas thin scleral shell prostheses and prosthetic contact
lenses are fitted directly onto an underlying cornea with little room for a corneal
bulge over the top. This limits the cosmesis of prosthetic contact lenses and thin
scleral shells, but they may still provide a convincingly normal appearance, espe-
cially as they often have greater motility than a prosthetic eye. Occasionally, the
cornea is too sensitive to tolerate a prosthetic contact lens or a scleral shell prosthe-
sis and in these cases a Gundersen flap procedure may be undertaken. This proce-
dure involves laying a flap of conjunctival tissue over the sensitive cornea [1]
(Fig. 6.1) prior to the fitting of the contact lens or scleral shell.
This chapter introduces prosthetic contact lenses and scleral shell prostheses
and describes the conditions best suited to each type of prosthetic device. Different
prosthetic contact lens designs used for various situations are discussed and a
method for in-house tinting of standard soft contact lenses is described. The mak-
ing and fitting of scleral shell prostheses is also described and discussed in this
chapter. The approach taken is the same as in the previous chapter where the aim
6.2 Prosthetic Contact Lenses 151

was to enable discussion about how best to achieve excellence in prosthetic eye
manufacture rather than provide a complete step-by-step guide. The description of
these procedures assumes some prior knowledge of working with wax, gypsum
plaster and PMMA.

6.2 Prosthetic Contact Lenses

Prosthetic contact lenses are made from a range of rigid or soft (flexible) gas-permeable
materials. Their design disguises flaws in the appearance of the iris or pupil that may
have been caused by trauma, congenital anomalies or medical conditions.
Prosthetic contact lenses are also used to occlude light entering the eyes in cases
of diplopia [2], and occasionally an occluding prosthetic contact lens has been con-
sidered as part of amblyopia treatment where constant occlusion is required for
lengthy periods.
Prosthetic contact lenses are often the first choice for patients with intact eyes as
they are smaller and less expensive than scleral shell prostheses. They are also made
from materials that are more biocompatible than the PMMA used for scleral shells.
However, it is more difficult to achieve satisfactory cosmesis with a prosthetic con-
tact lens than with a scleral shell prosthesis. Prosthetic contact lenses are best suited
for eyes which are of equal or larger size than the companion eye and where the
cornea is of regular shape and where the eyes are correctly aligned. A scleral shell
prosthesis should be considered if the palpebral aperture is smaller than the com-
panion eye or the eye is misaligned (strabismus) or where a prosthetic contact lens
is unable to centre over a distorted cornea.
Prosthetic contact lenses have five basic designs (Fig. 6.2) and may be hand-
painted with opaque colours matching the natural eye or tinted or translucent. Each
basic design is suitable for use with a particular eye condition or deformity as
described below.

6.2.1 Aniridia

Aniridia (absence of the iris) may be partial as a result of an iridectomy operation

(Fig. 6.3) or complete due to trauma or congenital anomaly. Aniridia may accom-
pany aphakia (absence of the lens); in which case the prosthetic contact lens will
need to correct vision as well as match the natural iris and provide a clear pupil of
the appropriate size (Fig. 6.4).

6.2.2 Corneal Leucoma

Corneal leucoma (Fig. 6.5) may appear in the first year of life and can affect one or
both eyes. Leucomas may be translucent or opaque patches averaging 4–5 mm
across. Depending on where they are located on the cornea, they may be masked
with an opaque soft lens with a clear or black pupil.
152 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

a b c

d e

Fig. 6.2 Basic prosthetic contact lens designs. (a) Occluding pupil mask with clear iris portion.
(b) Peripheral mask with opaque black pupil. (c) Peripheral mask with clear pupil. (d) Translucent
tinted lens. (e) Translucent tinted peripheral mask with clear pupil (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)

Fig. 6.3 Iris flaw following iridectomy. It may be masked with prosthetic contact lens with an
opaque peripheral mask and clear pupil (Published with kind permission of NZ Artificial Eye
Service. All rights reserved)
6.2 Prosthetic Contact Lenses 153

Fig. 6.4 Aniridia. It may be masked with prosthetic contact lens with a tinted or opaque periph-
eral mask and clear pupil (Published with kind permission of NZ Artificial Eye Service. All rights
reserved)

Fig. 6.5 Corneal leucoma. It may be masked with a prosthetic contact lens with an opaque periph-
eral mask and a clear or black pupil depending on where the leucomas are located (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

6.2.3 Corneal Opacities or Scars

These are mostly the result of penetrating injuries and the visible scars have various
densities and dimensions (Fig. 6.6). They may be masked with an opaque soft lens
with black pupil.
154 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.6 Full-thickness, total corneal opacity. It may be masked with a prosthetic contact lens
with an opaque peripheral mask and a black pupil (Published with kind permission of NZ Artificial
Eye Service. All rights reserved)

Fig. 6.7 Iris coloboma. It may be masked with a prosthetic contact lens with an opaque peripheral
mask and a clear pupil (Published with kind permission of NZ Artificial Eye Service. All rights
reserved)

6.2.4 Iris Coloboma

Iris coloboma is a congenital condition and if it affects both eyes it is

usually accompanied by poor vision (rarely better than 6/24, 20/80)
(Fig. 6.7) [2].
6.2 Prosthetic Contact Lenses 155

Fig. 6.8 Cataract. A clear prosthetic contact lens with a black pupil improves cosmesis when
cataract surgery is not an immediate option and vision is not useful (Published with kind permis-
sion of NZ Artificial Eye Service. All rights reserved)

6.2.5 Cataract Appearance

Cataract is a common condition in older people, but congenital cataracts also occur.
Surgical removal of the cloudy lens and replacement with an intraocular lens is the
common treatment. Where surgery is not an immediate option and the appearance
of the pupil is unsightly, a clear prosthetic contact lens with an opaque black pupil
is a simple way to improve cosmesis (Fig. 6.8).

6.2.6 Albinism

Prosthetic contact lenses can reduce the effects of photophobia in albinos by con-
straining light passing into the eye to the area of the pupil. This action can reduce glare
and photophobia by reducing the amount of light that enters the eye by way of scatter
through the iris tissue. Photophobia associated with light entering the eye through the
iris and with light being reflected around once inside is a consequence of a lack of
pigment in the iris and retina. If the photophobia is moderate, it may be relieved by
fitting translucent tinted lenses (these will still allow some light to pass towards the
iris), but if the photophobia is more severe, opaque lenses with clear pupils will be
required. Both eyes are fitted with lenses so no colour matching is required (Fig. 6.9).

6.2.7 Heterochromia

The colour discrepancy between the two eyes may be reduced with the use of
a tinted prosthetic contact lens or a tinted prosthetic contact lens with an
156 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.9 The red appearance as well as the photophobia (both caused by light passing through the
iris) may be relieved by fitting a translucent tinted prosthetic contact lens with a clear pupil if the
photophobia is moderate or an opaque prosthetic contact lens with clear pupil if the photophobia
is more severe (Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 6.10 Heterochromia. The colour discrepancy between the two eyes (the affected eye has a
grey iris) may be lessened with the use of tinted prosthetic contact lenses or tinted prosthetic con-
tact lenses with clear pupils (Published with kind permission of NZ Artificial Eye Service. All
rights reserved)

untinted clear pupil. The advantage of tinted lenses over opaque lenses for
masking heterochromia is that the natural texture of the iris remains visible
(Fig. 6.10).
6.2 Prosthetic Contact Lenses 157

Fig. 6.11 Corneal dystrophy. If the eyes are blind and the pupil is not discernable, clear lenses
with black pupils will improve cosmesis. If the pupils are discernable and dark, translucent tinted
lenses may mask the greyness of the cornea while not compromising the level of vision. Finally,
opaque lenses with clear pupils may be a better option than tinted lenses if a wider range of colours
is needed and the optimum level of vision is to be maintained (Published with kind permission of
NZ Artificial Eye Service. All rights reserved)

6.2.8 Corneal Dystrophy

Corneal dystrophies usually affect both eyes and may progressively worsen
over time to the extent that a corneal transplant is required. The need for and
the design of prosthetic contact lenses for these cases are determined by the
amount of vision remaining and how dark the pupil appears. If the eyes are blind
and the pupils are not discernable, clear lenses with black pupils will improve
cosmesis [3].
If the pupils can be seen and if they are dark in appearance, transparent tinted
lenses may mask the greyness of the cornea while not compromising the level of
vision. Finally, opaque lenses with clear pupils may be a better option than tinted
lenses if a wider range of colours is needed and the optimum level of vision is to be
maintained (Fig. 6.11).

6.2.9 In-House Tinting Systems for Soft Prosthetic

Contact Lenses

Ready-made, mass-produced cosmetic contact lenses are available in a wide variety

of colours and styles, but contact lenses can also be designed to suit a particular
patient. Clear contact lenses made from soft hydrophilic materials may have a dark
pupil added or have a tint added to the peripheral part of the lens using an in-house
158 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.12 In-house colouring

kit for soft contact lenses

colouring system (Fig. 6.12). Tinting kits are available from various stockists such
as Softcrome [4] or Nextgen Optical Ltd. [5].
The process involves placing the lens on a domed spring loaded tinting jig which
is then locked into a container which masks out the area not to be dyed and holds
the dye solution over the exposed part of the lens. A number of tinting jigs (different
ones for each lens design) and a range of dye colours are available. After the lens
has been exposed to the dye solution for a set period of time, it is placed in a devel-
oping and fixing solution to set the dye and flush out non-fixed dye solution [4].
Tinted prosthetic contact lenses are transparent and are generally more effective
when used with dark brown eyes.

6.2.10 Hand-Painted Opaque Prosthetic Contact Lenses

Opaque and tinted contact lenses are manufactured for the commercial market.
These lenses are readily available in a wide range of colours and sizes and may offer
an inexpensive option for patients with disfigured eyes. However, they seldom
deliver an accurate colour match with the companion iris and often have an unnatu-
ral appearance (Fig. 6.13).
If ready-made lenses do not provide a good match, opaque prosthetic contact
lenses may be hand-painted to order by a number of manufacturers. These include
Capricornia in Australia [6], Cantor and Nissel [7] and UltraVision CLPL in the UK
6.2 Prosthetic Contact Lenses 159

Fig. 6.13 This commercially available soft opaque lens with clear pupil does a good job of mask-
ing the iris coloboma in this patient’s left eye but has an unnatural iris texture (Published with kind
permission of NZ Artificial Eye Service. All rights reserved)

Fig. 6.14 Two examples of soft hand-painted prosthetic contact lenses (Published with kind per-
mission of NZ Artificial Eye Service. All rights reserved)

[8] and Adventure in Colors [9] and Custom Contacts in the USA [10]. Numbered
sets of iris/corneal buttons may be provided for matching purposes, but increas-
ingly, clinicians are sending digital photographs of the natural iris to the manufac-
turers (JPG format is usually preferred, but individual manufacturers may have their
own preferences) together with details such as iris diameter, contact lens base curve,
lens power in diopters (if needed), pupil size and whether the pupil should be black
or clear.
The lenses are rendered opaque with a chemical reaction which introduces a
white or black pigment into the posterior surface of the lens matrix. Colour dyes are
applied by hand to the anterior surface of the lens with the photographs being used
to determine the correct iris colour and texture (Fig. 6.14).
160 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

6.3 Scleral Shell Prosthesis

As with prosthetic contact lenses, scleral shell prostheses can be obtained as a fin-
ished product from contact lens manufacturers who use design parameters and opti-
cal prescriptions for particular patients. However, better results may be achieved by
making and fitting custom scleral shell prostheses directly with the patient. Scleral
shell prostheses are indicated for all cases where the palpebral aperture needs to be
enlarged because it is smaller than that of the companion eye (Fig. 6.15), or where
the cornea is misshapen (Fig. 6.16), or where the disfigured eye is strabismic
(Fig. 6.17).

Fig. 6.15 Opaque cornea

with a smaller palpebral
fissure than the companion
eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 6.16 Distorted cornea

following trauma (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)
6.3 Scleral Shell Prosthesis 161

Fig. 6.17 Left strabismic eye with opaque cornea is masked with a scleral shell prosthesis
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 6.18 Completed

medium thickness scleral
shell prosthesis (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

The procedure for making and fitting a custom scleral shell prosthesis is deter-
mined by the desired thickness of the shell, which in turn is determined by the rela-
tive size of the palpebral aperture compared with the companion eye.

6.3.1 Making and Fitting Medium or Thick Scleral Shell

Prostheses (1.5 mm to 2.5 mm Thickness)

If the palpebral aperture is smaller than that of the companion eye and the eye to be
fitted can accommodate a scleral shell prosthesis with a thickness between 1.5 and
2.5 mm, the construction method is essentially the same as described for a pros-
thetic eye in Chap. 5 (Fig. 6.18). However, for these thinner prostheses,
162 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.19 Premanufactured two-dimensional curved iris discs with corresponding corneas
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)

Fig. 6.20 Metal moulds for

making two-dimensional
curved iris discs (Published
with kind permission of
James Strauss. All rights
reserved)

two-dimensional curved iris discs can be used to construct the iris/corneal compo-
nent of the prosthesis (Fig. 6.19). Premanufactured two-dimensional curved iris
discs (with corresponding corneas) are available from various ocular supply compa-
nies [11–14], while an alternative to using premanufactured components is to fash-
ion them in custom metal moulds (Fig. 6.20).
If the palpebral aperture is smaller than that of the companion eye and can
accommodate a scleral shell prosthesis with a thickness greater than 2.5 mm, it is
made the same way as described for prosthetic eyes in Chap. 5.
6.3 Scleral Shell Prosthesis 163

6.3.2 Making and Fitting Thin Scleral Shell Prostheses

(Less Than 1.5 mm in Thickness)

If the palpebral aperture is the same or only marginally smaller than that of the
companion eye, a scleral shell prosthesis of minimum thickness is required to avoid
making the eye appear too large. This requires a different manufacturing procedure
and also a different wearing regime than required for a thicker shell. It is more dif-
ficult to achieve a perfect result with thin shells (<1.5 mm thick), but these may still
be a better option than prosthetic contact lenses because they are more stable on the
eye and can offer better cosmesis, particularly with lighter coloured irises. Thin
scleral shells often fit the globe more tightly than thicker shells and may need to be
fenestrated to assist tear flow under the shell. They may also need to be removed
overnight to maintain oxygen supply to the anterior eye at minimum levels, unlike
thicker shells which are often worn for a month at a time.

6.3.3 Thin Scleral Shell Prosthesis Design

The design of thin shells is determined by the position and shape of the pole of the
existing cornea. This is where the globe is most prominent and where the thinnest
area of the shell often needs to be to ensure an appropriate lid contour. Thicker areas
towards the periphery will not affect the size of the palpebral aperture, and the extra
material will add strength to the final shell and allow the edges to be more fully
rounded and relieved (ground back to ease contact pressure) so that they do not dig
into the sclera. The limbus area should also be relieved so that blood vessels in this
region are not occluded (Fig. 6.21).
It is important that the scleral shell prosthesis does not create a sealed system (no
exchange of tears under the shell) as the normal build-up of metabolites will limit
wearing time to about 4 h (the eye begins to sting and the shell becomes intolerable).
If adequate tear exchange is prevented, the cornea will thicken (the cells on the back
of the cornea that continually pump water out of the cornea will not continue to
function properly) and become hazy, and this damage will cause new blood vessels
to appear on the surface of and within the cornea over time (neovascularisation).
The mechanisms that continually keep the cornea dehydrated are already damaged
in corneas with endothelial distrophies so it is important to maintain tear exchange
under scleral shells in these cases.

6.3.4 Overview of the Making and Fitting Process

Scleral shells are too thin to accommodate a separate iris/corneal component during
manufacture (unlike thicker shells and prosthetic eyes), and the iris is therefore
164 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Relieved limbus

Relieved periphery

Fig. 6.21 Thin scleral shell design showing relieved areas (Published with kind permission of NZ
Artificial Eye Service. All rights reserved)

painted directly onto the shell body. This requires more skill than positioning a
separate iris/corneal unit.
Thin scleral shell prostheses ideally require a trial shell to be manufactured and
worn so that adjustments to fit can be made before the final shell is constructed. The
manufacturing process usually involves five clinical sessions interspersed with lab-
oratory processing (Table 6.1) and begins with an impression of the eye followed by
the construction of a clear PMMA trial shell. The trial shell is inserted at the second
clinical session, and when all adjustments have been made, the patient is instructed
to wear it for progressively longer periods over the next few days to check wearing
comfort and tolerance.
Once the trial shell is stable and comfortable to wear, the anterior surface is
modified by grinding it thinner or by adding wax to make it thicker according to the
palpebral aperture size required and to match the eyelid contour of the companion
eye (third clinical session). The modified trial shell is then invested in a two-part
mould and duplicated in white or semitranslucent PMMA which forms the body of
the final prosthesis. A layer of material is removed from the anterior surface of the
duplicated shell leaving minimal thickness.
At the fourth clinical session, the trimmed shell is inserted and the positon of the
iris is marked with a waterproof marking pen. The shell is removed and a circular
6.3 Scleral Shell Prosthesis 165

Table 6.1 Overview for thin scleral shell making and fitting
Step Task
First clinical session Take an impression of the eye
Laboratory processing Cast the impression in dental stone and make a clear PMMA trial
shell
Second clinical session Insert the trial shell and check size and fit using a fluorescein dye to
detect pressure points. Instruct the patient to wear the trial shell for
progressively longer periods over the next few days to check wearing
comfort and tolerance
Third clinical session Once the trial shell is comfortable to wear, modify the anterior
surface by trimming it thinner or by adding wax to make it thicker
according to the size and eyelid contour required
Laboratory processing Duplicate the trial shell in white or semiopaque PMMA and trim the
anterior surface to a minimal thickness. Polish the anterior surface to
a low finish and the fitting surface and edges to a high finish
Fourth clinical session Insert the trimmed shell and mark the positon of the iris with a
waterproof marking pen. Remove and paint an iris disc directly onto
the shell using oil paints mixed with a fast setting paint medium.
Reinsert the shell and check the position and size of the iris disc.
When satisfied, dry off and add in the pupil and iris colours to match
the companion iris – then add scleral colours and veins
Laboratory processing Dry the paintwork and process a clear PMMA veneer over the front
of the shell. Polish to a high standard of finish
Fifth clinical session Insert the completed prosthesis and provide instructions for
removing, inserting and cleaning
Follow-up session After 1 month of wear, inspect the prosthesis and make final
adjustments as needed

iris shape is painted directly onto the surface using oil paints mixed with a fast set-
ting paint medium. The shell is then reinserted and the position and size of the
painted iris circle are checked and modified as necessary. When satisfactory, the
painted iris is thoroughly dried and the pupil and extra iris colours are added to
match the companion eye. The scleral colours and veins are added next and the shell
is returned to the original mould for a clear PMMA veneer to be processed over
the top.
When processing is complete, the shell is polished to a high standard of finish on
both the front and back surfaces and fitted over the patient’s eye at the fifth and final
clinical session. Instructions and training are given for removing, inserting and
cleaning the shell at this visit.
A follow-up session is recommended after 1 month to check the fit and to answer
any questions.

6.3.5 Taking an Impression of the Eye

The manufacture of a scleral shell prosthesis begins with the taking of an impres-
sion of the disfigured eye. The process is similar to taking an impression of an
anophthalmic socket using an ocular tray as described in Chap. 5 but with two
166 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.22 Tetracaine or

oxybuprocaine anaesthetic
eye drops are recommended
for patients with clear
sensitive corneas

important differences: Firstly, the intact eye will be more sensitive than an
anophthalmic socket and, secondly, the impression making process needs to
occur in the more restricted space behind and under the eyelids and in front of the
globe.
Topical anaesthetic eye drops such as tetracaine or oxybuprocaine (Fig. 6.22) are
recommended prior to taking the impression – especially for patients with clear
sensitive corneas. One or two drops are placed in the lower fornix when the lower
eyelid is drawn down and away from the eyeball. The drops work almost immedi-
ately and the effect lasts 10–30 min. The anaesthetic should also be allowed to cir-
culate under the upper eyelid.
The largest diameter ocular impression tray that can be readily inserted through
the palpebral aperture is chosen from a range of three or four different sizes [15].
The ocular tray should have smooth polished edges and should have a radius of
curvature appropriate to the shape of the globe. A tray that is too large will not fit
under the eyelids and a tray that is too small will not support the impression material
over a sufficiently wide area. The tray is carefully tried for size before the impres-
sion material (either ophthalmic alginate or medium grade polyvinylsiloxane) is
loaded via a syringe. If an ocular tray without a hollow stem is used, it is necessary
to load the tray with impression material before inserting it under the eyelids
(Fig. 6.23).
When the impression material has set, it is freed from the eyelashes and the tray
is carefully removed from the eye. The impression is then cast in dental stone.

6.3.6 Trial Shell

Scleral shell prostheses need to be very thin and must fit closely to the surface of the
eyeball. Because they are so thin, there is little room to relieve pressure points if
they occur under the shell and it is advisable to construct a trial shell (test shell)
before the final prosthesis is made.
6.3 Scleral Shell Prosthesis 167

Fig. 6.23 Polyvinylsiloxane

impression taken using an
ocular impression tray
without stem (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

The trial shell is constructed from the impression of the eye. The impression is
cast in dental stone and settled into one half of a two-part metal eye flask (metal
container). When the dental stone has set hard, the impression is removed and a
1.5 mm thick sheet of dental wax is softened and moulded over the dental stone cast.
The periphery is trimmed and the wax is sealed to the cast at the edges and smoothed
over. A plaster separating solution is applied to the dental stone and the second half
of the eye flask is assembled and topped up with another mix of dental stone. When
the stone has set, the halves of the eye flask are separated and the wax is discarded
(Fig. 6.24). The mould is packed with clear heat cure PMMA and processed accord-
ing to the manufacturer’s instructions. After processing, the PMMA shell is removed
from the mould, trimmed and polished.
The extension of the trial shell into the fornices is checked by observing the sta-
bility of the shell when the patient moves their eye from side to side and up and
down. If the shell is overextended in any direction, this will limit the extent to which
the shell can travel in that direction and it should be trimmed back and repolished.
If underextended, the shell will be less stable than it could be and the edges may
show. In this situation, the shell can be used as an impression tray for a second ocu-
lar impression that will ensure more complete coverage of the globe and a larger
trial shell will be constructed.
Once the forniceal extensions of the trial shell are accurately determined, the fit
of the shell can be checked with a fluorescein dye to determine tear layer thickness
over the cornea and beneath the shell (UV light source) and by looking for the
blanching of blood vessels over the conjunctiva and limbus (white light source).
Any pressure points over the conjunctiva must be relieved by polishing out as
they will cause the prosthesis to pivot and rotate if they remain. Adequate space for
a tear film over the cornea should also be allowed and the limbus area should be
relieved so that blood vessels in this region are not occluded. Once the adjustments
are made, the trial shell can be worn for progressively longer periods over a few
168 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.24 The two-part mould is ready to be packed with clear PMMA dough (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

days to check wearing comfort and tolerance. If the wearing time cannot be increased
to at least 12 h, the circulation of tears under the trial shell should be rechecked and
modified (e.g. with fenestrations) as required.

6.3.6.1 Fenestration of Scleral Shell Prostheses

Most scleral shell prostheses are made from PMMA which does not allow oxygen
to pass through the prosthesis material. Oxygen can only reach the tissues of the
front of the eye through circulation under the shell of tears containing dissolved
oxygen. Tear circulation is important for removal of the waste products of the
metabolism of the tissues of the cornea. Corneal edema due to low oxygen levels
was a common problem for PMMA contact lens wearers before the introduction of
gas-permeable lens materials [16]. It can still be a problem with soft extended wear
lenses although the symptoms are quickly reversed once the lenses are removed and
the eye is rested [17]. Scleral contact lenses made from gas-permeable materials are
produced for sighted eyes, but these materials offer no advantages for scleral shell
prostheses as the extra thickness of many shells and the blocking effect of iris paints
restrict oxygen getting through to the cornea.
Hypoxia can occur during wear of improperly designed PMMA contact lenses
or scleral shells, and when this occurs, the cornea will take up water, swell and
become cloudy. A secondary effect resulting from this damage is corneal neovas-
cularisation where conjunctival blood vessels begin to grow onto and into the
cornea. These problems are significant with PMMA shells and lenses because
6.3 Scleral Shell Prosthesis 169

they affect patients’ vision. However, they may not be so important for patients
requiring scleral shell prostheses when their eye is already blind or when there is
existing cloudiness and neovascularisation from other causes that have resulted in
poor vision. Hypoxia will however result in a build-up of metabolites which will
cause a burning sensation if there are tissues behind the prosthesis with intact
nerves.
A potential solution to the problem of corneal hypoxia associated with PMMA
contact lenses was to fenestrate the lens with 0.5–0.7 mm holes to allow oxygenat-
ing tears (and sometimes air if the lens was designed to include a bubble behind a
scleral contact lens) to move directly to the cornea [18] and to prevent the tear
reservoir behind the lens from becoming sealed so that no exchange of tears was
possible. However, the use of fenestration alone was not effective 1 mm beyond
the immediate vicinity of the hole [19], and at least 20 apertures around the periph-
ery of PMMA corneal lenses were required to reduce central corneal clouding to
clinically acceptable levels. The size of the apertures was as important as the num-
ber [16].
Based on empirical evidence but without the benefit of specific research known
to the authors, it is suggested that thin scleral shell prostheses should have at least
one 1.00 mm diameter fenestration in most cases. A 1.00 mm diameter fenestration
with smooth edges is small enough not to irritate the upper tarsal conjunctiva when
blinking and large enough not to clog with mucus or tear protein deposits. The hole
should tap into the space provided by relieving the limbus of the shell and be posi-
tioned in the temporal area. This will assist the flow of tears and oxygen under the
prosthesis during wear and equalise the pressure over and under the shell enabling
it to settle into a closer fit with the eyeball [18]. Fenestration will also allow the shell
to be removed more easily by permitting air to equalise the pressures between the
eye and the shell as the shell is being removed.

6.3.7 Construction of the Final Scleral Shell

Once the trial shell is stable and comfortable to wear, it is used as a pattern for the
final scleral shell prosthesis. The trial shell is invested in a two-part mould and
duplicated in white PMMA or a mixture of white and clear PMMA depending on
the degree of transparency required for the natural sclera to show through and the
need to mask the iris if it is visible behind the prosthesis.
The white, clear or semitranslucent shell is removed from the mould and trimmed
back to a minimal 0.25 mm thickness over the thinnest areas to allow room for the
iris and scleral colours to be applied and for a clear veneer to be processed over the
top. The anterior surface of the shell is polished with pumice to a flat finish and the
posterior surface and edges are highly polished.
The trimmed shell is inserted over the eye and the positon of the iris is marked
with a waterproof marking pen while the patient is looking directly to the front. The
shell is removed and a circular iris shape is painted directly on the anterior surface
using the base colour for the iris, mixed with a fast setting paint medium to hasten
170 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.25 Iris disc painted

directly onto the surface of a
semitranslucent shell
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 6.26 Iris and scleral

colours drying under a lamp
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

the drying time. The marked pupil is used as a guide to the iris position and the
diameter of the companion iris determines the diameter of the painted iris circle.
When the paint has dried, the iris circle is checked for position and size by rein-
serting the shell onto the eye. If the position is not accurate, it may be altered by
removing the shell and using a wax knife or similar instrument to scrape back over-
extended edges. Underextended edges are added to by applying more of the base
colour. The position of the painted iris circle may then be checked again by reinsert-
ing the shell onto the patient’s eye. When the position and size of the iris circle is
satisfactory, the pupil, collarette, stroma and limbus colours are added (Fig. 6.25).
The scleral colours (if required) are then applied using the same techniques described
in Chap. 5. Finally, the shell is returned to the mould and the iris and scleral colours
are dried under a lamp (Fig. 6.26).
When the paint is completely dry, a clear PMMA veneer is processed over the
top of the shell to seal in the colours and enable the shell to be polished. This is
achieved by trial packing the mould with clear PMMA using a polyurethane sheet
6.3 Scleral Shell Prosthesis 171

Fig. 6.27 A polyurethane

sheet protects the painted
surface when a clear PMMA
veneer is trial packed
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 6.28 The PMMA

veneer is processed according
to the manufacturer’s
instructions (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

to protect the paintwork from the soft PMMA dough (Fig. 6.27). After trial packing,
the polyurethane sheet is removed, and the two-part mould is reassembled and
clamped ready for the veneer to be processed under heat and pressure in accordance
with the manufacturer’s instructions (Fig. 6.28).
The processed thin scleral shell prosthesis is removed from the mould and pol-
ished using the same method for prosthetic eyes described in Chap. 5. Finally, a
1.0 mm fenestration is drilled in the temporal area into the space provided by reliev-
ing the limbus area of the shell. The edges of the hole may be polished by drawing
a cotton thread (initially impregnated with pumice and then with finer polishing
compounds) backwards and forwards through the hole (Fig. 6.29). The completed
scleral shell prosthesis is fitted at the fifth and final clinical session (Fig. 6.30), and
instructions and practice are given for removing, inserting and maintaining the
shell. Rubber suction devices to assist with the removal and insertion of scleral
shells are available from a number of ocular suppliers [12–15] (Fig. 6.31).
172 6 Scleral Shell Prostheses and Prosthetic Contact Lenses

Fig. 6.29 The edges of the

hole are smoothed with a
cotton thread and pumice
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 6.30 Completed thin scleral shell prosthesis in situ (Published with kind permission of NZ
Artificial Eye Service. All rights reserved)

Fig. 6.31 Rubber suction

devices are handy for
removing and inserting
scleral shell prostheses
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
References 173

Maintenance instructions are similar to those proposed for managing non-specific

mucoid discharge in Chap. 9 although in some cases, patients’ tolerance levels may
not allow continuous wear of the prosthesis and it may need to be left out
overnight.
A follow-up session is recommended 1 month after the scleral shell prosthesis is
inserted to check the fit and to answer any questions. By then the patient will have
some experience with the shell and maximum wearing times will have been
established.

References
1. Gundersen T. Conjunctival flaps in the treatment of corneal disease with reference to a new
technique of application. AMA Arch Ophthalmol. 1958;60(5):880–8.
2. Port M. Prosthetic contact lenses. Available from: http://www.optometry.co.uk/uploads/
articles/b8a4677d8b521ab405e94562e93c0080_prosthetic_contact_lenses031106.pdf .
Accessed 23 Jan 2015.
3. Lazarus M. Contact lenses. In: Phillips AJ, Speedwell L, editors. Cosmetic and prosthetic
contact lenses. 5th ed. Edinburgh: Butterworth Heinmann Elsevier; 2007.
4. Softcrome. In office tint system. Available from: www.softchrometinting.com. Accessed 27
Jun 2015.
5. Nextgen Optical Ltd. Spectra tint. Available from: http://www.nexgenoptical.com/spectratint.
php. Accessed 27 Jun 2015.
6. Capricornia. Contact lens. Available from: http://capricorniacontactlens.com.au. Accessed 27
Jun 2015.
7. Cantor and Nissel. Product guide. Available from: http://www.cantor-nissel.co.uk/docs/
brochure.pdf. Accessed 27 Jun 2015.
8. UltraVision CLPL. Prosthetic contact lenses. Available from: www.ultravision.co.uk. Accessed
27 Jun 2015.
9. Adventure in Colors. Hand painted contact lenses. Available from: http://www.techcolors.
com/ProductsandServices/HandpaintedIrisLenses. Accessed 23 Jan 2015.
10. Custom Contacts. Prosthetic lenses. Available from: http://www.customcontacts.com/
prosthetic-lenses. Accessed 27 Jun 2015.
11. Factor 2 Inc. Available from: www.factor2.com. Accessed 27 Jun 2015.
12. Technovent. Available from: www.technovent.com. Accessed 27 Jun 2015.
13. Oculo plastique. Available from: www.oculoplastik.com. Accessed 27 Jun 2015.
14. Strauss Eye Prosthetics Inc. Available from: www.strausseye.com/Products.aspx. Accessed 27
Jun 2015.
15. Pullum K. Scleral contact lenses. In: Phillips AJ, Speedwell L, editors. Contact lenses. 5th ed.
Edinburgh: Butterworth Heinmann Elsevier; 2007.
16. Harris MG, Barreto DJ, Matthews MS. The effect of peripherally fenestrated contact lenses on
corneal edema. Am J Optom Physiol Opt. 1977;54(1):27–30.
17. The Association of Optometric Contact Lens Educators. Corneal neovascularisation. Available
from: http://www.aocle.org/livingL/cornneo.html. Accessed 27 Jun 2015.
18. Stone J, Phillips AJ. Contact lenses. London: Barrie & Jenkins; 1972.
19. Hill RM, Leighton AJ. Effects of contact lens apertures on corneal respiration under dynamic
conditions. Am J Optom Arch Am Acad Optom. 1968;45(2):65–79.
Socket Complications
7

Contents
7.1 Introduction ................................................................................................................... 176
7.2 General Approach ......................................................................................................... 176
7.3 Socket Lesions .............................................................................................................. 178
7.3.1 Malignancies ................................................................................................... 178
7.3.2 Granulomas ..................................................................................................... 178
7.3.3 Chemosis ......................................................................................................... 179
7.3.4 Giant Papillary Conjunctivitis ......................................................................... 180
7.4 Complications of Prosthesis Retention ......................................................................... 180
7.4.1 Inadequate Socket Lining ............................................................................... 180
7.4.2 Inadequate Fornix or Fornices ........................................................................ 184
7.4.3 Lower Eyelid Laxity ....................................................................................... 185
7.4.4 Combined Surgical and Prosthetic Approach ................................................. 186
7.5 Complications of Prosthesis Stability ........................................................................... 190
7.5.1 Inadequate Prosthesis Retention ..................................................................... 190
7.5.2 Prosthesis Instability Within the Socket ......................................................... 190
7.6 Complications of Prosthesis Motility............................................................................ 196
7.6.1 Inadequate Prosthetic Eye Motility................................................................. 197
7.6.2 Excessive Prosthetic Eye Motility .................................................................. 198
7.7 Orbital Volume Deficit .................................................................................................. 199
7.7.1 Orbital Volume Replacement .......................................................................... 200
7.7.2 Expanded Orbital Volume ............................................................................... 204
7.8 Superior Sulcus Deformity ........................................................................................... 205
7.8.1 Prosthetic Technique ....................................................................................... 205
7.8.2 Surgical Technique .......................................................................................... 205
7.9 Eyelid Malposition ........................................................................................................ 207
7.9.1 Ectropion ......................................................................................................... 207
7.9.2 Entropion......................................................................................................... 208
7.9.3 Ptosis ............................................................................................................... 209
7.9.4 Lagophthalmos................................................................................................ 212
7.10 Summary of Socket Complications and Surgical and Prosthetic Solutions.................. 215
References ................................................................................................................................ 217

© Springer International Publishing Switzerland 2015 175

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_7
176 7 Socket Complications

7.1 Introduction

Most prosthetic eyes are cosmetically satisfactory and cause little trouble in use.
Sometimes, however, the socket and eyelids are distorted due to scarring, tissue loss
or through recession over time. These complicated sockets present a challenge to
the ocular prosthetist and the oculo-plastic surgeon. Modifications to the prosthesis
may go a long way towards improving cosmetic outcomes and, in many cases, offer
a satisfactory alternative to oculo-plastic surgery. However, surgical procedures pro-
vide more scope for improvement than modifying the prosthesis alone, and it is
important that patients are fully informed and made aware of the range of solutions
offered by both prosthetist and surgeon. One well-informed patient may happily
accept a partial solution to their problem to avoid the inconvenience of surgery,
while another might want everything done that can be addressed safely and effec-
tively. Surgical interventions used to address specific issues need be considered
within the context of the entire face as each change has implications for other facial
features. Often, the best results will be achieved through a combination of both
socket surgery and prosthesis modification.
This chapter is broadly organised by patient symptoms in descending order of
importance. For each problem, a range of contributory causes is identified. Both
prosthetic and surgical solutions are described, and the indications, merits and limi-
tations of each are discussed.
When addressing socket complications, it is important for clinicians to under-
stand that it is not vanity that motivates anophthalmic patients wishing to improve
their appearance so much as a simple desire to look as natural as possible and to fit
in with everybody else as they live their everyday lives.

7.2 General Approach

Not all socket complications are of equal significance, and some have simple solu-
tions, while the treatment of others may be complicated and costly in terms of
patients’ time, inconvenience and expense. Furthermore, several complications
often exist at the same time, and it is necessary to separate out the treatment options
for each in order to develop a staged approach individualised for each patient.
Working with the prosthetic eye is obviously less expensive and more convenient
for the patient than surgery, so the first step in addressing socket complications is
often to modify or renew the prosthesis. On the other hand, if surgery is inevitable,
a new prosthesis may be best deferred until after surgery. Finally, in some cases,
such as ptosis repair, pre-surgical assessment should only take place once the final
prosthetic eye is completed. If more than one surgical procedure is required to
address multiple defects, it is often necessary for the patient to be referred back to
the prosthetist to modify the prosthesis as each defect is attended to. This highlights
the importance of the prosthetist and oculo-plastic surgeon working collaboratively
7.2 General Approach 177

and in ways that are efficient and effective for each clinical scenario as suggested in
the following sections.
Socket complications may be broadly categorised by descending order of impor-
tance as described in Table 7.1. Naturally, the severity of individual complications
and/or their emotional impact on patients will alter their relative importance. Socket
surgery is also described in Chap.3.

Table 7.1 Socket complications broadly Socket lesions

listed in descending order of importance Malignancy
Granuloma
Chemosis
Giant papillary conjunctivitis
Prosthesis retention
Deficiency of lining
Deficiency of fornix
Adhesions
Lower eyelid laxity
Prosthesis stability
Adhesions
Lower eyelid laxity
Implant position/migration
Rotation
Prosthesis motility
Limited
No implant
Implant design
Implant motility
Excessive
Edge show
Popping or clicking
Gaps
Enophthalmos
Volume deficiency
No implant
Inadequate implant
Orbital changes (e.g. blowout fracture)
Superior sulcus deformity
Localised eyelid/sulcus changes
Secondary to volume deficiency
Eyelid malposition
Ectropion
Entropion
Ptosis
Eyelid retraction
Lagophthalmos
178 7 Socket Complications

7.3 Socket Lesions

7.3.1 Malignancies

While malignancies are rare, they are the most serious socket complication, and
their early detection is critical. Most eye health clinicians are trained to identify
malignancies and other lesions and either treat them or refer patients on to appropri-
ate specialists. Unfortunately, many clinicians, who routinely examine sighted eyes,
neglect anophthalmic sockets and rely upon ophthalmologists and ocular prosthe-
tists to do this work. This neglect can sometimes cause considerable and unneces-
sary distress for patients.
Malignant tumours in anophthalmic sockets have been reported in a number of
cases where no risk factors for cancer existed except for long-term wear of pros-
thetic eyes [1, 2]. In most of the reported cases, the key symptom leading to diagno-
sis was prosthesis discomfort. Bleeding from a socket may also arise from
granulomas (see below) but is a serious symptom which should be assumed to be a
sign of malignancy until proven otherwise.

7.3.2 Granulomas

Granulomas are vascular lesions that form in the socket in response to stimuli that
the body’s immune system perceives as foreign but cannot eliminate, such as suture
remnants or an ill-fitting or chipped prosthetic eye (Fig. 7.1). Granulomas are usu-
ally accompanied by severe conjunctival inflammation and purulent mucoid dis-
charge and are distressing for patients. In cases where the source of irritation is
obvious (e.g. irritation from a suture), this should be dealt with by removing the
cause. Where the cause is less obvious, the prosthesis should be replaced and the

Fig. 7.1 This granuloma

developed in the inferior
bulbar conjunctiva after the
patient wore a deep vaulted
stock prosthetic eye for many
years (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
7.3 Socket Lesions 179

granuloma monitored over a period of time. The granuloma will often disappear
when a new prosthesis is fitted, but surgical removal will be required if it persists.
Surgical excision (usually combined with cautery) is a simple procedure usually
performed under local or topical anaesthetic.

7.3.3 Chemosis

Chemosis is oedema of the conjunctiva which appears as a localised fluid-filled

blister. It may be caused by a prosthetic eye or conformer shell rubbing against the
conjunctiva (Fig. 7.2) and often disappears once the source of irritation is removed.
In extreme cases, chemoses may be severe enough to prevent the eyelids from clos-
ing (Fig. 7.3).

Fig. 7.2 Chemosis of the conjunctiva formed under a conformer shell which was inserted follow-
ing enucleation of the globe 5 weeks previously (Published with kind permission of NZ Artificial
Eye Service. All rights reserved)

Fig. 7.3 Extreme chemosis

has developed in this socket
due to irritation caused by an
extruding orbital implant
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)
180 7 Socket Complications

Fig. 7.4 The GPC evident

under the upper eyelid of this
microphthalmic eye has
persisted for many years even
though the prosthesis has
been well maintained and
steroid drops have been used
regularly to reduce mucoid
discharge (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

7.3.4 Giant Papillary Conjunctivitis

Conjunctival papillae are small bumps on the conjunctiva that may grow and
combine to resemble a cobblestone appearance and lead to a condition called
giant papillary conjunctivitis (GPC) (Fig. 7.4). Once established, GPC is diffi-
cult or impossible to eliminate, but a perfectly smooth prosthetic eye surface
and the use of steroids and other anti-allergy medications may alleviate
symptoms.

7.4 Complications of Prosthesis Retention

As listed in Table 7.1, a patient may be unable to retain a prosthesis because there is
inadequate lining tissue in the socket due to localised abnormalities (inadequate
fornices, adhesions) or because of eyelid malposition (usually lower eyelid laxity).
Simple observation is usually all that is required to identify the problem.

7.4.1 Inadequate Socket Lining

For a socket to maintain a prosthesis, it must, as an absolute minimum, have enough

lining tissue to form both a superior and an inferior fornix. Ideally a socket needs to
have enough lining to enable the eyelids to close comfortably over a prosthesis of
cosmetically adequate size. A socket that has less lining than this will either have
poor prosthesis retention (Fig. 7.5) or will have lagophthalmos and its complica-
tions (see below).
7.4 Complications of Prosthesis Retention 181

Fig. 7.5 Non-retentive

contracted socket with a
shortage of conjunctival
lining and an absence of the
inferior fornix (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 7.6 The pressure

conformer is held in position
by a bandage (Published with Custom pressure conformer
kind permission of NZ
Artificial Eye Service. All
rights reserved)

7.4.1.1 Prosthetic Technique

The objective of the prosthetic technique is to expand the socket and create forniceal
depth with the use of conformers to stretch and reshape the conjunctiva. The process
commences with the insertion of a thin conformer shell which has been reduced in
size until it fits into the anophthalmic socket. This initial shell is usually very unsta-
ble and will not remain in place by itself. However, it will likely bed in and become
self-retentive if the patient is able to hold the shell in place with their finger for a few
hours. If the patient is not able to retain the conformer, a custom-made pressure
conformer may be used [3] (Fig. 7.6). This is a conformer with an attached stem that
protrudes through the eyelids and supports a flat disc. The pressure conformer is
held in position by a bandage applied over the disc.
Once the initial conformer is able to be retained, it is replaced with a larger shell
which is often more stable and more retentive. The new shell is replaced with a still
larger one after a few days, and the process is repeated until a conformer of reason-
able size can be worn comfortably. It is then replaced with a custom-fitted prosthetic
eye.
182 7 Socket Complications

7.4.1.2 Surgical Technique

The surgical approach to a socket with inadequate lining is to graft tissue, often
combined with some form of conformer, as described above, to either stretch the
existing socket tissues, resist the post-operative scarring and graft shrinkage or both.
The choice of operation is dictated by the existing socket, the outcome that is con-
sidered achievable and the amount of inconvenience the patient is prepared to
tolerate.

Mucous Membrane Graft

The simplest and commonest procedure in this situation is a mucous membrane
graft. An incision is made in the socket, and scar tissue is released as much as pos-
sible. Full- or partial-thickness mucous membrane is harvested from the inner lower
lip, and the graft is sutured into the surgical defect in the socket. The patient’s old
prosthesis or a customised conformer may be placed in the socket and secured with
a tarsorrhaphy to stabilise the graft and resist graft contraction (Figs. 7.7, 7.8, 7.9,
7.10, 7.11 and 7.12). The donor site heals well enough to allow further grafts to be
harvested in the future – multiple grafts are often required to expand the socket
sufficiently.
Hard palate tissue may also be grafted into the socket to increase lining. Hard
palate tissue is best suited as a tarsal substitute but can also be used as a ‘spacer’
graft inferior to the tarsal plate of the lower lid and can therefore have a useful effect
in expanding socket lining.

Fig. 7.7 An incision is made

in the socket, and the scar
tissue is released as much as
possible (Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.8 A full-thickness

mucous membrane is
harvested from the inner
lower lip (Published with
kind permission of Sloan
Medical Ltd. All rights
reserved)
7.4 Complications of Prosthesis Retention 183

Fig. 7.9 Full-thickness

mucous membrane tissue
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.10 The graft site in

the lower lip is closed with
sutures (Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.11 The graft is

sutured into the surgical
defect in the socket
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.12 A patient’s old

prosthesis is placed in the
socket and secured with a
tarsorrhaphy to stabilise the
graft and resist graft
contraction (Published with
kind permission of Sloan
Medical Ltd. All rights
reserved)
184 7 Socket Complications

Dermis–Fat Graft
When a socket is deficient in both lining and volume, a dermis–fat graft may be a
useful option. This is a composite graft, usually harvested from just above the hip or
from the buttocks. The epidermis is excised and discarded. A plug-shaped graft can
be harvested directly, but it is more efficient to harvest a narrower ellipse of dermis–
fat and fold this in half to form a graft of the required shape. The graft is sutured into
the dissected socket, and the edges of the remaining conjunctiva are sutured to the
edges of the dermis. The dermis then acts as a substrate for the socket’s existing
conjunctiva to epithelialise. Dermis–fat grafts inevitably undergo a significant
amount of shrinkage in the early post-operative period, so in general the graft is
oversized by 30–50 % to compensate for this.

Skin
It is possible to line a socket with the skin or split-thickness skin grafts. The kerati-
naceous debris that such a socket produces makes this a last resort. On no account
should a socket contain both the skin and mucous membrane linings, as such sock-
ets usually produce copious amounts of foul-smelling debris.

7.4.2 Inadequate Fornix or Fornices

7.4.2.1 Prosthetic Technique

Adhesions are best dealt with by surgery (see below), but occasionally this is not con-
venient for the patient and a prosthetic solution is sought. This involves loosely accom-
modating the adhesion or adhesions while extending the margins of the prosthesis as
much as possible into the fornix on either side (Fig. 7.13). Note that before taking an
impression of the socket, adhesions must be carefully probed to ensure that they cannot
be surrounded by the impression material, with potentially disastrous consequences.

Fig. 7.13 Adhesions are

accommodated loosely while
the margins extend into the
fornix on either side
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved) Inlets to accomodate socket adhesions
7.4 Complications of Prosthesis Retention 185

7.4.2.2 Surgical Technique

A socket’s fornices may be inadequate because there is not enough lining tissue (see
above), because there are adhesions between the conjunctiva over the implant and
that of the eyelids or because the suspensory ligaments that maintain the fornices
have become weakened.
Adhesions may simply need to be divided or may need mucous membrane graft-
ing as well. In either event, the most important issue is to keep the healing tissues on
the implant and the eyelid apart so that adhesions do not re-form. The patient’s own
prosthesis or a customised conformer, with or without a temporary tarsorrhaphy, is
usually all that is required to achieve this.
Deficiency or prolapse of the fornix not due to adhesions or tissue shortage most
often occur inferiorly and appear to be due to disruption or weakening of the check
and suspensory ligaments – most notably the capsulopalpebral fascia. Surgically,
this is addressed by encouraging adhesions between the forniceal conjunctiva and
the tissues around the inferior orbital rim. This is done either indirectly, with sutures
tied over bolsters between the conjunctiva and skin, or directly via an incision in the
inferior fornix. Conformers are usually not used in either situation – they are unnec-
essary if bolstered sutures are in place and may put unwanted pressure on the surgi-
cal wound if a direct forniceal approach has been used (Fig. 7.14).

7.4.3 Lower Eyelid Laxity

The lower eyelid normally has to maintain some tension to hold its position against
the globe. Inadequate lid tension is the primary factor causing lower lid ectropion.
In the anophthalmic socket, the lower lid has to maintain the additional load of the
prosthesis, which may accelerate the development of excessive lower lid laxity or
frank ectropion. Prosthesis and implant designs that minimise the weight and tilt of
the prosthesis and prosthesis replacements that keep pace with socket changes may
forestall lower eyelid laxity. In spite of this, lower eyelid tightening is the most com-
mon surgical procedure associated with prosthetic eye wear.

Bolster
Fig. 7.14 Sutures hold down
a bolster to deepen the
inferior fornix (Published
with kind permission of NZ
Artificial Eye Service. All Suture
rights reserved)
186 7 Socket Complications

7.4.3.1 Prosthetic Technique

Lower eyelid laxity may be addressed by modifying the prosthesis in two ways.
First, a ridge is added to the anterior of the inferior edge. The ridge is designed to
extend under the lower tarsal plate and raise it along with the lower eyelid. The ridge
blends into the anterior surface of the prosthesis creating a negative curvature below
the iris (Fig. 7.15).
A second technique to help resolve lower eyelid laxity is to redistribute pressure
from the centre of the eyelid to the sides. This is achieved by adding new material
to the medial and lateral inferior edges of the prosthesis and removing it from the
centre (Fig. 7.16).

7.4.3.2 Surgical Technique

The surgical approach is dictated by the site of the eyelid laxity. Most commonly the
lateral canthal tendon weakens, and this is remedied by the lateral tarsal strip proce-
dure. The weakened lateral canthal tendon is resected, and a new tendon is fash-
ioned from the lateral part of the tarsal plate. This ‘tarsal strip’ is reattached to the
lateral orbital rim. The lateral tarsal strip procedure has the advantage of being a
powerful tightener of the eyelid, and good eyelid tension may be achieved with rela-
tively little sacrifice of normal tarsal plate (Figs. 7.17, 7.18 and 7.19).
A lower lid wedge excision can also be used to tighten the lid but is less efficient
than the tarsal strip procedure. The greater amount of tissue removed in a wedge
excision may be useful, however, if there is additional pathology to address. For
instance, a localised area of aberrant eye lashes or a suspicious skin lesion can be
removed at the same time as the lid is tightened.
Medial canthal tendon (MCT) laxity is less common, and its repair is greatly
complicated by the presence of the lacrimal drainage apparatus. Mild degrees of
MCT laxity are therefore commonly ignored, but moderate to severe degrees of lax-
ity need to be addressed. MCT stabilisation may be targeted at the anterior or the
posterior limb of the tendon (or both). A lateral tarsal strip procedure is often carried
out at the same time.

7.4.4 Combined Surgical and Prosthetic Approach

7.4.4.1 Expanded Conformer and Tarsorrhaphy

The patient shown in Fig. 7.20 had an eyelid-sparing exenteration for squamous cell
carcinoma of the ethmoid sinuses. The operation left him with an immobile socket,
severely reduced conjunctival sac and no inferior fornix. A mucus membrane graft
from inside his lower lip was placed in the inferior fornix. This created a shallow
fornix but not enough to retain a prosthetic eye at this stage.
A thin conformer shell was reduced in size until it fitted into the socket. This
shell was not self-retentive, but after being held in place by the patient for 2 h, it
bedded in. Another conformer shell was fashioned and used as an ocular impression
tray for a larger custom-made conformer (Figs. 7.21 and 7.22) which was then held
7.4 Complications of Prosthesis Retention 187

Fig. 7.15 A ridge is added to the front of the inferior

edge creating a negative curve (Published with kind
permission of NZ Artificial Eye Service. All rights
reserved)

Fig. 7.16 A second method

to help resolve lower eyelid
laxity is to redistribute
pressure from the centre of
the lower eyelid to the sides
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

in place by tarsorrhaphy sutures for 6 weeks. The conformer series stretched and
reshaped the conjunctiva/mucus membrane lining the socket, and these gains were
consolidated during the time the final conformer was held in the socket by the tar-
sorrhaphy sutures. The process culminated in the fitting of self-retentive prosthetic
eye with satisfactory cosmesis (Fig. 7.23).
188 7 Socket Complications

Fig. 7.17 A strip of the

tarsal plate is prepared to
reattach the lid to the lateral
orbital rim (Published with
kind permission of Sloan
Medical Ltd. All rights
reserved)

Fig. 7.18 The sutures are

placed through the perios-
teum of the lateral orbital rim
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.19 The tarsal strip

secured to the lateral orbital
rim (Published with kind
permission of Sloan Medical
Ltd. All rights reserved)
7.4 Complications of Prosthesis Retention 189

Fig. 7.20 Left eyelid-sparing

exenteration for squamous
cell carcinoma of the ethmoid
sinuses (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 7.21 Custom-made

conformer (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 7.22 Custom-made

conformer in place
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
190 7 Socket Complications

Fig. 7.23 Self-retentive

prosthetic eye with satisfac-
tory cosmesis (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

7.5 Complications of Prosthesis Stability

Prosthesis instability may comprise instability of prosthesis retention or instability

of prosthesis position within the socket.

7.5.1 Inadequate Prosthesis Retention

Inadequate prosthesis retention is generally caused by less severe examples of the

same issues discussed above, and the remedial options are much the same.

7.5.1.1 Prosthetic Technique

If the prosthetic eye threatens to fall out or is ejected when the patient gazes in dif-
ferent directions, retentiveness may be enhanced by modifying the prosthesis in two
ways. First, check that the prosthesis extends fully into the fornices and extend the
margins to achieve this if necessary. Second, hollow the back of the prosthesis and
reduce the thickness, but not the extent of the margins (Fig. 7.24). This should be
done in stages so that excessive hollowing that will create a reservoir for socket
secretions is avoided and so that the palpebral aperture is not closed more than nec-
essary and support for the upper eyelid is maintained.

7.5.2 Prosthesis Instability Within the Socket

Ocular prostheses may become unstable in the socket through the development of a
socket lesion (see above) or through migration and/or exposure of the orbital
implant. These conditions are often first noticed when the prosthetic eye becomes
displaced (Fig. 7.25).
7.5 Complications of Prosthesis Stability 191

Fig. 7.24 Retentiveness is enhanced by hollowing the

back of the prosthesis (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)

7.5.2.1 Orbital Implant Migration

An orbital implant ideally sits centrally in the cone of extraocular muscles and
deep enough to allow a prosthesis of satisfactory thickness to be worn. Implants
most commonly migrate anteriorly or superolaterally (Fig. 7.26). Implant migra-
tion is usually related to surgical technique and implant design and to a lesser
extent on the tissues in the orbit (Fig. 7.27). It is important to recognise if the
implant has become exposed or threatens to do so, as surgical management is then
semi-urgent. Surgical intervention for a stable migrated implant is optional and
elective.

Prosthetic Technique
If the implant has migrated but is covered with conjunctiva of reasonable thickness,
the existing prosthetic eye may be reconfigured to accommodate the implant in its
new position (Fig. 7.28). To ensure that the prosthesis does not bear on the implant
too heavily, a wash impression may be taken inside the prosthesis, and the area over
the implant is relieved [4].

Surgical Technique
Implants which look to be at risk of exposure may be managed with regular checks.
Careful modification to the prosthesis as described above will often stabilise the
tissues enough to eliminate the need for surgery.
192 7 Socket Complications

Fig. 7.25 This patient’s

orbital implant has migrated
forwards displacing his right
prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 7.26 This spherical

implant has migrated into a
superolateral position but is
stable behind very thin
conjunctival tissue (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Elective surgical revision of a stable migrated implant should only be considered

if all other options have been explored. The patient must be aware that surgical
complications might make the situation considerably worse. Intervention is most
often undertaken when the implant is not only migrated but also of inadequate size.
The motility of secondary implants is seldom as good as primary implants.

7.5.2.2 Orbital Implant Exposure

Exposure of an orbital implant may present with symptoms of increased pain, dis-
charge or the new development of bleeding from the socket. The patient may also
notice a change in the appearance of the socket (Fig. 7.29). As soon as a new orbital
7.5 Complications of Prosthesis Stability 193

Fig. 7.27 A migrated but

stable Castroviejo orbital
implant in medial, central and
lateral gaze (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

implant exposure is recognised, oculo-plastic review should be sought. The patient

should stop wearing their prosthesis immediately, until a definitive management
plan is in place.

Prosthetic Technique
The prosthesis should be carefully inspected for defects which may have contrib-
uted to implant exposure, such as cracking or chipping – especially on the posterior
surface.
In patients for whom no acute surgical management is indicated (see below), the
prosthesis may be modified as described in the previous section. In this setting, as
always, it is especially important that the prosthetist and surgeon liaise closely.
194 7 Socket Complications

Fig. 7.28 The posterior surface is reconfigured to

accommodate a migrated orbital implant (Published
with kind permission of NZ Artificial Eye Service. All
rights reserved)

Fig. 7.29 Exposed orbital

implant (Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Surgical Technique
Management of an exposed implant depends on the implant material. Inert alloplastic
implants (glass, silicone and PMMA most commonly) have an extremely high risk of
intractable infection once exposed and usually need to be removed. A secondary implant
can then be placed once the socket has healed and is clinically free of infection.
7.5 Complications of Prosthesis Stability 195

Fig. 7.30 The patch graft

procedure begins by freeing
the conjunctiva from the
implant in the immediate area
of the defect (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 7.31 The edges of the

detached conjunctiva are
draped over the graft and
sutured (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Exposed ‘integrated’ implants, such as hydroxyapatite or Medpor, may be able

to tolerate a period of exposure and resist infection by virtue of the blood vessel
growth within them. The most common form of surgical repair of small exposures
is to remove a small part of the exposed implant and then close the tissues over it,
either by advancing flaps of surrounding tissue or by grafting in new material
(Figs. 7.30 and 7.31). Grafts may either be epithelial (mucous membrane or hard
palate from the mouth or tarsoconjunctiva from the upper eyelid) or designed to be
an epithelial substrate (fascia lata, donor sclera, temporalis fascia). In general, the
success of repairs is best when the defect is small and recently developed. Removal
of the implant may still be necessary (see below), particularly if orbital imaging
suggests that the implant has vascularised poorly.
196 7 Socket Complications

Fig. 7.32 This right

prosthetic eye is made
roughly triangular or
elliptical in shape, rather than
round to prevent rotation
within the socket (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

7.5.2.3 Rotational Instability of the Prosthesis

Usually prosthetic eyes will only settle in the socket in two positions – right-side up
and upside down. If the prosthesis is rotated through rubbing with the fingers, it will
automatically return to its original position unless the rubbing is too vigorous, in
which case the prosthesis may settle into an upside-down position. Patients learn to
manage this situation and check in a mirror when they have disturbed the prosthesis.
Occasionally, however, a prosthesis may rotate independently of handling, and the
patient may be unaware that it is not in its correct position and not in central gaze.

Prosthetic Technique
The problem of prosthetic eye rotation often relates to the peripheral shape of the
prosthesis. Most prosthetic eyes are roughly triangular or ‘oval with a trochlear
notch’ and have a relatively flat lower edge to rest upon. When the peripheral shape
is round, however, there is little to prevent the prosthesis from rotating within the
socket. The solution to the problem is therefore to modify the periphery of the pros-
thetic eye to make it roughly triangular or elliptical in shape, rather than round. This
may be achieved by extending the prosthesis medially and laterally and straighten-
ing the lower edge (Fig. 7.32).
An additional measure to prevent rotation is to reline the posterior surface of the
prosthesis using a free flowing soft material for the wash impression. This will
ensure that the posterior surface engages with any irregularities in the socket,
increasing resistance to rotation.

7.6 Complications of Prosthesis Motility

Prosthetic eye motility is one of the key elements that contribute towards a success-
ful ocular prosthesis. This has motivated ophthalmologists to experiment with an
astonishing number of different orbital implant designs ranging from pegged
7.6 Complications of Prosthesis Motility 197

Fig. 7.33 There are three

axes of movement for the
prosthesis within the
anophthalmic socket
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

hydroxyapatite implants to magnets (see Chap.3). Modern surgical techniques have

improved prosthetic motility outcomes, but there remain a large number of anoph-
thalmic patients who have poor prosthesis motility and no viable treatment options.
Prosthetic eyes sit in a state of equilibrium within the soft tissues of the
socket. However, they are not anchored in place, and the equilibrium is con-
stantly disturbed through movement of the extraocular muscles and the orbicu-
laris muscles of the eyelids. There are three axes of movement for the prosthesis
within the socket: the horizontal axis around which the superior and inferior
edges move in upgaze and downgaze (could be thought of as an ‘x’-axis), the
vertical axis around which the medial and lateral edges move in medial and
lateral gaze (could be thought of as a ‘y’-axis) and the anterior–posterior axis
around which the prosthesis may rotate through 360° (could be thought of as a
‘z’-axis) (Fig. 7.33).
Prosthesis motility complications occur when there is either no movement,
inadequate movement or excessive movement.

7.6.1 Inadequate Prosthetic Eye Motility

Prosthesis motility may be due to poor motility of the underlying orbital implant –
most commonly with an implant that is too small or absent altogether. Previous
trauma (including surgical) often reduces implant motility further.

7.6.1.1 Prosthetic Technique

Generally, the lightest and smallest cosmetically acceptable prosthesis will have
the best motility. Sometimes good movement of the implant in the socket does
not translate well to the prosthetic eye, and motility is disappointing. There may
be two reasons for this. One reason may be that the prosthesis extends too far
into the fornices, straightening out the conjunctival folds and restricting their
198 7 Socket Complications

Fig. 7.34 The margins may Trimmed margin

be trimmed as shown to
increase anterior curvature
and reduce extensions into
the fornices (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

ability to permit movement. In these cases, the margins of the prosthesis are
reduced with care taken to ensure that the prosthetic eye continues to maintain
central gaze and that the edges are not exposed to view during movement of the
prosthesis. A second reason that socket/implant movement may not translate
well to the prosthetic eye could be that the curvature of the anterior surface of
the prosthesis is too flat, preventing the eye from turning with the ball and socket
ease. Sometimes this curvature may be addressed at the same time as the mar-
gins are reduced (Fig. 7.34).

7.6.1.2 Surgical Technique

Placing a secondary implant is the only potential solution for cases of poor motility,
but because of scarring, muscle retraction and other distorting elements, the desired
improvement in prosthetic eye motility cannot be guaranteed. Placing a secondary
implant is therefore not carried out for the sole purpose of improving motility, but it
may be a useful side effect of implant replacement surgery to restore lost orbital
volume (see Sect. 7.7).
If an integrated orbital implant has been used, a motility peg may be placed. This
carries some risk and minor complications such as granulomas are common. More
serious complications such as implant exposure or infection are less common but
well-recognised complications of pegging. See Chap. 3.

7.6.2 Excessive Prosthetic Eye Motility

Excessive prosthetic eye motility has the potential to cause problems with the fit of
the prosthesis and with its stability within the socket. Problems associated with up
and down movement around the horizontal axis have been addressed in the section
on lower eyelid laxity above. Prosthesis problems due to movement around the ver-
tical axis are associated with gazing left or right and include exposure of the medial
or lateral edges of the prosthesis, gaps that open up behind the prosthesis creating
popping or clicking sounds and, in extreme cases, total ejection of the prosthesis
from the socket.
7.7 Orbital Volume Deficit 199

Fig. 7.35 A gap has opened

medially under the prosthesis
during abduction of the right
prosthetic eye (Published
with kind permission of NZ
Artificial Eye Service.
All rights reserved)

7.6.2.1 Gaps, Clicking Noises and Edge Exposure

Gaps and edge exposure most commonly occur at the medial edge of the prosthetic
eye, but lateral edge exposure and gaps also occur. The popping or clicking sounds are
caused by air suddenly rushing into spaces behind the prosthesis when gaps open up
during eye movement or when blinking (Fig. 7.35). The gap causing the clicking may
not be directly observable, but the sound will provide a clue as to where the gap might
be located if it is associated with either lateral or medial movement. Often the sound
producing gap is in the trochlear notch area of the prosthesis.

Prosthetic Technique
Gaps and edge exposure are usually resolved together. PMMA material is removed
from the posterior surface of the prosthesis in the area directly behind the exposed
edge so that the edge will settle into closer contact with the conjunctiva.
If this simple remedy does not succeed, the edge of the prosthesis may be
extended into the gap by adding wax in the first instance and then replacing it with
heat cured PMMA of the appropriate colour (Fig. 7.36). If clicking and popping
persists, it may also be necessary to reline the posterior surface of the prosthesis
using a free flowing soft material for the wash impression. This will eliminate any
spaces behind the prosthesis.

7.7 Orbital Volume Deficit

Orbital volume deficiency occurs when the sum of volumes of the orbital implant
and the prosthetic eye is less than the volume of the tissues lost following enucle-
ation or evisceration. The socket tissues may also appear volume deficient after
orbital wall fractures or previous surgery which enlarges the capacity of the bony
orbit.
200 7 Socket Complications

Fig. 7.36 PMMA material is

removed from just behind the
edge of the prosthesis so that
the edge will settle into closer
contact with the conjunctiva
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Relative volume deficiency causes enophthalmos compared to the fellow eye,

and secondary changes may include deepening of the upper eyelid sulcus and
upper eyelid ptosis. The triad of enophthalmos, deepened upper eyelid sulcus
and ptosis, comprises the so-called post-enucleation socket syndrome or
PESS. See Chap. 2.

7.7.1 Orbital Volume Replacement

7.7.1.1 Prosthetic Technique

When an orbital implant is absent, prosthetic eye movement is limited (see above),
and a large cavity exists necessitating a large (and heavier) prosthetic eye. In this
situation the floor of the socket often slopes forwards filling the inferior fornix with
spongy tissue and making it difficult for the prosthesis to stand upright. One solu-
tion to this problem is to fabricate the prosthesis so that it has a posterior platform
which prevents backward rotation and allows for a narrow lower edge to engage the
inferior fornix. This form can reduce some of the bulk (and weight) of the prosthesis
and lighten the load carried by the lower eyelid (Fig. 7.37). Another solution is to
fill the entire cavity with a hollow, lighter prosthetic eye [5].
When an orbital implant is present but is of inadequate size, the most obvious
solution is to increase the overall size of the prosthetic eye to take up more space.
Of course, the prosthesis should not be made so large that the palpebral aperture is
wider than the companion eye, or the contour of the eyelids is altered to look unnat-
ural, or the eyelids are prevented from fully closing over the prosthesis. The risk of
these negative outcomes may be reduced or avoided by altering the shape of the
prosthesis while increasing its size.
The size of the prosthesis is increased by bringing the iris/corneal unit bodily for-
wards and angling it to ensure a level gaze. The anterior surface is then made as
7.7 Orbital Volume Deficit 201

Fig. 7.37 A posterior platform is added to the

prosthesis. The platform is designed to prevent
backward rotation of the prosthesis, to allow for a
narrow lower edge to engage the inferior fornix
and to reduce some of the bulk (and weight) of the
prosthesis (Published with kind permission of NZ
Artificial Eye Service. All rights reserved)

conical as possible with a more pronounced corneal bulge. This reduces bulkiness
and, at the same time, brings the globe forwards providing a more natural eyelid con-
tour than would be the case if the anterior of the larger prosthesis was flatter (Fig. 7.38).

7.7.1.2 Surgical Technique

Secondary Orbital Implant

If no implant is present, the ideal solution is to place a ‘secondary’ orbital implant
(a ‘primary’ implant is one which is placed at the time of evisceration or enucle-
ation). The patient needs to be aware that surgery will involve a period of post-
operative discomfort and that bruising and swelling will preclude the wearing of
any prosthesis for 4–6 weeks. A new prosthesis will need to be made at the end of
this period.
If an inadequate sized implant is present, this can be removed and a secondary
implant placed immediately. In this situation, the inconvenience and risks of surgery
are much the same as for introducing an implant where none exists, but of course
the benefit will be less marked.
Surgery is usually performed under general anaesthetic. The central conjunctiva of
the socket is opened, and the orbital tissues are dissected until the four rectus muscles
are identified, therefore defining the intra-conal space (Fig. 7.39). The largest spheri-
cal implant that can comfortably be accommodated by the socket is chosen (Fig. 7.40).
Orbital implants, including selection criteria, are discussed in Chap. 4. The chosen
202 7 Socket Complications

Fig. 7.38 The conical anterior surface supports

and wedges the eyelids apart while minimising
the overall bulk of the prosthesis (Published with
kind permission of NZ Artificial Eye Service. All
rights reserved)

Fig. 7.39 The four rectus

muscles are identified and the
intra-conal space is defined
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.40 The largest

spherical implant that can
comfortably be accommo-
dated by the socket is chosen
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)
7.7 Orbital Volume Deficit 203

Fig. 7.41 The implant is

placed in the intra-conal
space and the rectus muscles
sutured to it (Published with
kind permission of Sloan
Medical Ltd. All rights
reserved)

Fig. 7.42 Any available

remnants of Tenon’s capsule
are closed in front of the
implant, and then the
conjunctiva is closed without
tension (Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.43 A temporary

tarsorrhaphy is placed to
control post-operative
conjunctival swelling
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

implant/wrapping is placed in the intra-conal space and the rectus muscles sutured to
it (Fig. 7.41). Any available remnants of Tenon’s capsule are closed in front of the
implant, and then the conjunctiva is closed without tension (Fig. 7.42). A temporary
tarsorrhaphy is placed to control post-operative conjunctival swelling (Fig. 7.43).

Subperiosteal Implant
A number of different materials have been inserted into various orbital spaces to
increase orbital volume including homologous and autologous bone [6], dermal grafts
[6], PMMA [7], glass beads [8] and cartilage [9]. These materials and techniques have
204 7 Socket Complications

Fig. 7.44 Subperiosteal

implants are designed to
displace the orbital tissues
upwards and forwards
restoring lost orbital volume
and filling out a deep upper
eyelid sulcus (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
Implant

had variable success over the years, and the most common methods for surgical vol-
ume augmentation now involve the use of prefabricated subperiosteal implants, made
with PMMA [10], room-temperature-vulcanised silicone [11] or Proplast 2, a white
composite of polytretrafluoroethylene and alumina [12]. Subperiosteal implants are
designed to displace the orbital tissues upwards and forwards restoring lost orbital
volume and filling out any deep upper eyelid sulcus if present (Fig. 7.44).
Surgery is best performed via the ‘swinging eyelid’ approach. A small inci-
sion at the lateral canthus is the only skin incision and forms a well-camouflaged
and minimal scar. The remainder of the incision is in the conjunctiva of the
lower lid.
Once the inferior orbital rim is identified, an incision through the periosteum
allows formation of a subperiosteal pocket for the implant. A prefabricated silicone
or porous composite sled-shaped implant of the appropriate size is placed in the
pocket. The thicker posterior edge of the sled implant should extend behind the
equator of the orbital implant, and its leading edge should sit inside the infraorbital
rim. The largest implant that can be accommodated is placed – an implant that is too
large will be more prone to migration and exposure [13].

7.7.2 Expanded Orbital Volume

Orbital volume may have been increased because of previous surgery – treatment of
some forms of cancer may require the removal of the orbital floor and/or medial
wall at the time the eye is removed. Pre-existing orbital fractures are relatively com-
mon in anophthalmic sockets – particularly those where the eye was lost due to
trauma. In either case, orbital volume is increased, and the socket therefore becomes
more (relatively) volume deficient.
7.8 Superior Sulcus Deformity 205

7.7.2.1 Surgical Technique

Once this problem is recognised, it can be surgically addressed directly or indi-
rectly. The direct approach is to repair the fracture(s) and/or place subperiosteal
implants to restore the orbital floor and medial wall to their normal position.
If the problem is recognised at the time a secondary implant is being placed, then
a larger than normal spherical orbital implant can be used to compensate. This may
be an option when the increase in volume due to fracture is relatively small and does
not justify a second surgical procedure.

7.8 Superior Sulcus Deformity

The appearance of a deepened upper lid sulcus most often occurs in the setting of a
volume-deficient orbit but may also occur as an isolated finding. Its cosmetic impact
varies markedly. Males tend to have heavier, lower brows which can effectively
camouflage a significant degree of upper lid sulcus asymmetry, as do glasses. See
Chap. 10.

7.8.1 Prosthetic Technique

The appearance of superior sulcus deformity on the anophthalmic side may be made
worse due to the loss of the upper eyelid crease. The crease may sometimes be
restored by adding bulk to the prosthesis anterior to the superior edge as illustrated
in Fig. 7.45. The negative (concave) curve reduces bulk and helps to maintain the
upper eyelid contour.
A second ridge may be added to the anterior of the inferior edge. This second
ridge, in conjunction with thinning of the lower edge from the back, sets the pros-
thesis upright and counters potential posterior displacement of the bulkier superior
edge (Fig. 7.46).

7.8.2 Surgical Technique

The surgical techniques used for resolving orbital volume deficit (described above)
are also employed to resolve superior sulcus deformity. Eyelid procedures may also
be employed to try to improve symmetry.

7.8.2.1 Upper Eyelid Blepharoplasty

Two broad approaches are employed – the eyelid with the sulcus deformity can be
augmented, or the contralateral upper eyelid can have tissue removed. Commonly,
both approaches are used.
A contralateral upper eyelid (or more commonly bilateral upper eyelid) blepha-
roplasty may improve symmetry of the upper lid sulci. Often simple removal of skin
and careful reformation of the skin crease are sufficient. Judicious removal of fat
from the normal upper lid may also improve appearances, although it is important
206 7 Socket Complications

Fig. 7.45 Extra bulk added anterior to the superior

edge may help correct upper eyelid sulcus
deformity and restore the upper eyelid crease
(Published with kind permission of NZ Artificial
Eye Service. All rights reserved)

Fig. 7.46 A second ridge in front of the inferior

edge, in conjunction with thinning of the lower
edge from the back, sets the prosthesis upright and
counters the potential backward displacement of the
bulkier upper edge (Published with kind permission
of NZ Artificial Eye Service. All rights reserved)
7.9 Eyelid Malposition 207

that this is not overdone to the point where both eyes look abnormal! Detailed dis-
cussion with the patient is always necessary but is particularly important when oper-
ating on the ‘normal’ upper eyelid.

7.8.2.2 Dermis–Fat Graft and Fillers

The deepened upper eyelid sulcus may be effaced (obliterated) by localised volume
increase, in the form of a dermis–fat graft or fillers. Dermis–fat is harvested (see
section “Dermis–fat graft”) (Page 240) and grafted directly into the superior orbit
behind the upper eyelid sulcus. As with all dermis–fat grafts, the main difficulty is
unpredictable resorption of the fat.
Soft tissue fillers can be used for a less invasive option. Bovine collagen tissue
fillers were introduced in the 1970s, but problems with genetic differences caused
these fillers lose popularity and other varieties of collagen such as bioengineered
human dermis products, and micronised human cadaveric dermis and fascia have
taken their place. Another group of soft tissue fillers is based upon stabilised hyal-
uronic acid. Injected collagen and hyaluronic acid fillers are temporary solutions to
the problem of orbital volume deficit and need to be renewed after 6 months or so.
Longer-lasting injectable soft tissue fillers including poly-L-lactic acid, calcium
hydroxyapatite and polyacrylamide gel are also available for deep tissue augmenta-
tion within the orbit [14].

7.9 Eyelid Malposition

7.9.1 Ectropion

For a large percentage of ectropion cases, both the prosthetic and surgical approaches
for addressing lower eyelid laxity described above may also accomplish repair of
lower eyelid ectropion (Fig. 7.47).

Fig. 7.47 The prosthetic eye has improved (reduced) this patient’s right lower eyelid ectropion
(Published with kind permission of NZ Artificial Eye Service. All rights reserved)
208 7 Socket Complications

Fig. 7.48 The inward

rotation of the eyelashes that
is part of upper and lower
eyelid entropion has caused
an accumulation of mucous
on the prosthesis (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

7.9.2 Entropion

Entropion is inward rotation of the eyelid margin towards the surface of the eye or
prosthesis. In the anophthalmic patient, the ‘windscreen wiper’ effect that happens
when the lashes make contact on the prosthesis surface tends to cause accumulation
of dried mucous on the prosthesis ‘cornea’, which then triggers a cascade of allergic
conjunctivitis, increasing discharge and increasing discomfort (Fig. 7.48). The
wearer usually resorts to removing the prosthesis frequently to clean it, and the
increased manipulation of the socket adds to the problem.

7.9.2.1 Types of Entropion

Entropion is most usefully classified as either involutional or cicatricial. The two
have quite distinct treatments.

Involutional Entropion
Involutional entropion occurs when lid laxity and dehiscence of the lower lid retrac-
tors allows the lid to rotate against the globe when orbicularis muscle contracts. The
lid suddenly flips into entropion when the lids are squeezed shut, and normal lid
position can be restored by gently pulling the lower lid down. Surgical treatment is
aimed at increasing the stability of the eyelid by horizontally tightening the lid and
reinserting or ‘plicating’ the lower lid retractors.

Cicatricial Entropion
Cicatricial entropion is caused by conjunctival and subconjunctival scarring causing
posterior migration of the mucocutaneous junction of the eyelid margin. This scar-
ring is caused by chronic inflammation such as blepharitis and in the anophthalmic
socket may be exacerbated by inflammation, scarring and adhesions in the socket of
the conjunctiva.
7.9 Eyelid Malposition 209

7.9.2.2 Prosthetic Technique

It may be possible to improve eyelash direction by reversing the anterior curvature
of the prosthesis (Fig. 7.49).

7.9.2.3 Surgical Technique

In cases where the pathology is confined to the eyelid margin, surgical repair is
generally required. The eyelid margin is split into anterior and posterior lamellae
and everting sutures placed which externally rotate the anterior lamella away from
the prosthesis surface. If the distinction between anterior and posterior lamellae has
become obliterated by scarring, the tarsal plate is incised 1–2 mm behind the appar-
ent mucocutaneous junction. The everting sutures then rotate the terminal tarsus
into position to form a new eyelid margin.
If the entropion is part of a more generalised socket problem, prosthesis modifi-
cation may be sufficient. If it is not, the above surgical procedures may need to be
combined with other socket surgery such as fornix deepening, mucous membrane
grafting or hard palate tissue grafting, as described in previous sections.

7.9.3 Ptosis

Blepharoptosis (hereafter referred to as ptosis) is drooping of the upper lid margin

more than 2 mm below its usual position. The usual position of the upper lid margin

Fig. 7.49 The convex curvature of the anterior surface

is made concave behind the entropic eyelids (Published
with kind permission of NZ Artificial Eye Service. All
rights reserved)
210 7 Socket Complications

is generally considered to be 0–2 mm below the superior limbus of the cornea.

Ptosis is inevitable in the volume-deficient socket and hence cannot be adequately
assessed until a satisfactory prosthesis has been made.
Ptosis is categorised by levator function – the excursion of the eyelid margin
between downgaze and upgaze. Frontalis muscle action must be abolished when
measuring levator function, as frontalis is a potent secondary elevator of the upper
eyelid. Levator function can be categorised as normal (12–15 mm), reduced
(5–12 mm) or poor (<5 mm).

7.9.3.1 Prosthetic Technique

Upper eyelid ptosis may be resolved by making the anterior surface of the prosthesis as
conical as possible with a more pronounced corneal bulge as shown in Fig. 7.36. This
supports and wedges the eyelids apart exposing more of the iris which in turn reduces
the effect of the ptosis. Further bulk may be added to the area above the cornea and
blended into an extension of the superior edge of the prosthesis. This configuration
attempts to fill the superior fornix and lift the levator aponeurosis muscle (Fig. 7.50).
As described above for correcting a deep upper eyelid sulcus, a second ridge
anterior to the inferior edge, in conjunction with thinning of the lower edge from the
back, may be necessary to set the prosthesis upright and counter the potential pos-
terior displacement of the bulkier superior edge.
Ptosis may be more marked medially than laterally because the medial horn of
the levator aponeurosis is often weaker than the lateral and dehisces more readily.

Fig. 7.50 This configuration attempts to resolve

upper eyelid ptosis by filling the superior fornix
and lifting the levator aponeurosis muscle
(Published with kind permission of NZ Artificial
Eye Service. All rights reserved)
7.9 Eyelid Malposition 211

Fig. 7.51 This patient’s

ptosis on the medial side of
the eyelid causes a marked
contour abnormality of the
upper lid, drawing attention
to the prosthetic eye
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 7.52 A diagonal ridge is

added in the location shown
by the dotted line (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

This causes a marked upper lid contour abnormality, which can be cosmetically
more objectionable than a mild generalised ptosis (Fig. 7.51). This complication
can often be resolved by reducing the size of the prosthesis, but there is a limit to
how small it can be.
In cases where the palpebral aperture needs to be maintained or increased, a
diagonal ridge is added as shown by the dotted line in Fig. 7.52. The ridge tapers off
and blends into the temporal surface of the prosthesis but is quite thick where it
spreads out over the cornea. The added bulk over the cornea reverses the medial
ptosis, and the diagonal ridge serves to improve the contour of the upper lid margin.
Unfortunately, the altered cornea changes the way light reflects off the surface of the
prosthesis and may look unnatural.
A further technique to address upper eyelid ptosis is to add a clear PMMA shelf
across the anterior surface of the prosthetic eye. The shelf is shaped and positioned
212 7 Socket Complications

Fig. 7.53 A ptosis shelf can

be seen on this prosthetic eye.
It supports the upper eyelid at
its correct height but prevents
the eyelid from closing
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

to support the upper eyelid at the correct height. The shelf works well, but unfortu-
nately, it prevents the eyelid from closing and the technique should only be used
when surgical ptosis repair is not available (Fig. 7.53).

7.9.3.2 Surgical Technique

The surgical approach differs according to levator function.
Patients with normal levator function are generally treated with an aponeurotic
ptosis repair. Via a skin crease incision, the aponeurosis of the levator muscle is
advanced and sutured to the tarsal plate (Figs. 7.54, 7.55, 7.56 and 7.57).
Patients with reduced levator function usually require a levator resection. Via the
same skin crease incision, a graded amount of aponeurosis and levator muscle is
resected, and the shortened muscle reattached to the tarsus.
Patients with poor levator function will not do well with either of these pro-
cedures, and a frontalis sling procedure is often required. This enhances the
ability of the frontalis muscle to raise the upper eyelids by creating an internal
‘sling’ connecting the tarsal plate and the frontalis muscle in the brow. Alloplastic
material such as Gore-Tex® or Prolene suture or autogenous fascia lata can be
used for the sling. Fascia lata is less susceptible to infection but requires a sec-
ond surgical site to harvest. Alloplastic slings may be slightly easier to adjust at
a later date.

7.9.4 Lagophthalmos

Lagophthalmos is the inability of the eyelids to close completely over the globe or
prosthesis. In the patient with a prosthesis, lagophthalmos disrupts the tear flow
over the anterior surface of the prosthesis causing drying of the tear film. This
frequently leaves tenaciously adherent deposits of dried mucous which glue the
eyelids to the prosthesis.
7.9 Eyelid Malposition 213

Fig. 7.54 Exposure of the

levator and aponeurosis
during ptosis repair surgery.
The pink levator muscle can
be seen in the middle of the
wound, with the white
aponeurosis below it and the
yellow orbital fat above. The
surgical retractors are holding
open the orbital septum and
orbicularis muscles
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 7.55 A suture is passed

through the tarsal plate – usu-
ally at the apex of the desired
lid contour (Published with
kind permission of Sloan
Medical Ltd. All rights
reserved)

Fig. 7.56 The suture is then

passed through the levator
aponeurosis, reattaching it to
the tarsal plate. The suture is
seen here tied in a temporary
bow, allowing the height and
the shape of the lid to be
checked, as the surgery is
performed under local
anaesthetic. Once height and
contour appear satisfactory,
the suture is tied (Published
with kind permission of
Sloan Medical Ltd. All rights
reserved)
214 7 Socket Complications

Fig. 7.57 In this case, two

sutures were required to
obtain a satisfactory lid
height and contour – they can
be seen centrally and
medially (to the right of the
picture). The orbicularis and
skin are then closed, and the
operation is complete
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

It is important to note that lagophthalmos may be subtle – voluntary or forced

eyelid closure may be complete, but spontaneous blinks consistently incomplete,
leading to the same problems described above, although typically less severe.
Lagophthalmos may be caused by weakness of the orbicularis muscle (most
commonly after facial nerve palsy) or by (relative) deficiencies of tissue restricting
eyelid movement. Paralytic lagophthalmos is beyond the scope of this text and will
not be discussed further.

7.9.4.1 Prosthetic Technique

Lagophthalmos in anophthalmic sockets may be minimised by reducing the size of
the prosthesis. The maximum eyelid closure that can be obtained however is the gap
that remains when the prosthesis is removed (Fig. 7.58).

7.9.4.2 Surgical Technique

The surgical approach is different depending upon whether the anterior lamella
(skin/muscle), the middle lamella (orbital septum) or the posterior lamella (tarsus,
conjunctiva of eyelids and socket) has been affected.

Anterior Lamellar Deficiency

This is most commonly seen in burns and other trauma and previous surgery. Skin
grafts are usually required to address this problem. Skin can be harvested from the
contralateral upper lid, behind the ears, above the clavicle or from the upper inner
7.10 Summary of Socket Complications and Surgical and Prosthetic Solutions 215

Fig. 7.58 The gap between the eyelids that remains when the prosthesis is removed (left image) is
the maximum eyelid closure attainable through reducing the size of the prosthesis (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

arm. The site chosen depends on the amount required and the quality of the skin
available at each site.

Middle Lamella Deficiency

Scarring of the middle lamella most often occurs after penetrating trauma or surgery
affecting the orbital septum. A similar picture may be seen in patients after aggres-
sive ptosis repair, where the shortened levator aponeurosis complex tethers the
upper eyelid. If there is a discrete band of scar tissue palpable, this may be able to
be dissected and released. The tissue needs to be held on tension for at least a few
weeks post-operatively to reduce the risk of the scar recurring. Interposing orbital
fat can also reduce the chances of the scar band reforming.

Posterior Lamellar Deficiency

This situation was discussed previously when considering the socket with inade-
quate lining tissue. The deficiencies may be generalised throughout the socket or
localised in the form of adhesions. See Sect. 7.4.2 – release of adhesions with or
without mucous membrane grafting.

7.10 Summary of Socket Complications and Surgical

and Prosthetic Solutions

Table 7.2 summarises the socket complications and their prosthetic and surgical
treatments discussed in this chapter.
216 7 Socket Complications

Table 7.2 Socket complications are listed in descending order of importance

Complication Causes Surgical solution Prosthetic solution
Socket lesions Malignancy Excise
Granuloma Tarsorrhaphy. Remove Accommodate.
irritant Remove irritant
Chemosis Excise. Remove irritant Accommodate.
Remove irritant
GPC Medication High polish
Prosthesis retention Deficiency of lining Graft – mucosa, hard Hollow back
palate tissue, dermis–fat
Deficiency of fornix Graft mucosa or hard Extend margins
palate; fornix deepening
sutures
Adhesions Release ± mucosal graft Accommodate
Lower lid laxity Tighten
Prosthesis stability Adhesions Release ± mucosal graft Accommodate
Lower lid laxity Tighten
Implant migration Reposition
Rotational Extend horizontally
instability
Prosthesis motility No implant Secondary orbital implant
(limited) Implant design Secondary orbital implant Increase curvature.
Implant motility Reduce horizontally
Prosthesis motility Edge show Hollow back or extend
(excessive) margins
Popping Fill back
Orbital volume No implant Secondary orbital implant Maximise size
deficiency Lightweight prosthesis
Inadequate implant Secondary orbital Maximise size
implant. Subperiosteal
implant
Orbital changes (e.g. Fracture repair ± orbital Special design.
blowout fracture) floor implant Lightweight prosthesis
Superior sulcus Localised eyelid/ Blepharoplasty.
deformity sulcus changes Dermis–fat graft
Secondary to Sled implant Extend superior
volume deficiency margin
Ectropion Involutional Ectropion repair Modify shape
Entropion Involutional or Entropion repair Modify shape
cicatricial
Ptosis Involutional Levator aponeurosis
repair
Orbital volume Replace implant. Maximise eyelid
deficiency Subperiosteal implant support. Extend
superior margin
Lagophthalmos Eyelid retraction Levator recession Reduce bulk
Skin graft
Secondary to lining Scar release Reduce bulk
deficiency
Graft - mucus membrane,
hard palate or dermis fat
References 217

References
1. Nguyen J, Ivan D, Esmaeli B. Conjunctival squamous cell carcinoma in the anophthalmic
socket. Ophthal Plast Reconstr Surg. 2008;24(2):98–101.
2. Shibata M, Usui Y, Ueda S, Matsumura H, Nagao T, Goto H. A case of orbital sebaceous gland
carcinoma developing in an anophthalmic socket 65 years after enucleation. Clin Ophthalmol.
2013;7:1825–7.
3. Kelly K. A discussion of custom pressure conformers. J Am Soc Ocularists. 1991;1:19–24.
4. Dudash R. Prosthesis fabrication over extruding implants. J Am Soc Ocularists. 1990;1:9–14.
5. Worrell E. Hollow prosthetic eyes. J Maxillofac Prosthet Technol. 2014;13(1):8–12.
6. De Voe AG. Experiences with the surgery of the anophthalmic orbit. Am J Ophthalmol.
1945;28:1346–51.
7. Sugar HS, Forrester HJ. Methacrylate resin implants for sunken upper eyelid following enucle-
ation. Am J Ophthalmol. 1946;29:993–1000.
8. Smith B, Obear M, Leone CR. The correction of enophthalmos by glass bead implantation.
Am J Ophthalmol. 1967;64:1088–93.
9. Zbylski JK. Correction of lower eyelid ptosis in the anophthalmic socket with an autogenous
ear cartilage graft. Plast Reconstr Surg. 1977;61:220–3.
10. Dresner SC, Codère F, Corriveau C. Orbital volume augmentation with adjustable prefabri-
cated methylmethacrylate subperiosteal implants. Ophthalmic Surg. 1991;22(1):53–6.
11. Nasr AM, Jabak MH, Batainah Y. Orbital volume augmentation with subperiosteal room-
temperature-vulcanized silicone implants: a clinical and histopathologic study. Ophthal Plast
Reconstr Surg. 1994;10(1):11–21.
12. Shah S, Rhatigan M, Sampath R, Yeoman C, Sunderland S, Brammer R, et al. Use of Proplast
2 as a subperiosteal implant for the correction of anophthalmic enophthalmos. Br J Ophthalmol.
1995;79(9):830–3.
13. Chen W. Oculoplastic surgery the essentials. New York: Thieme; 2001.
14. Guthoff R, Katowitz J, editors. Oculoplastics and orbit. Heidelberg: Springer - Berlin; 2010.
Deposit Build-Up on Prosthetic Eyes
and a Three-Phase Model of Prosthetic 8
Eye Wear

Contents
8.1 Introduction ................................................................................................................... 219
8.2 Tear Protein Deposits .................................................................................................... 220
8.2.1 Information About the Nature of Deposits from Contact Lens Research ....... 220
8.2.2 Deposit Build-Up on Prosthetic Eyes ............................................................. 221
8.3 Effects of Prosthesis Removal, Cleaning and Reinsertion ............................................ 229
8.3.1 Physical Stress Associated with Removal and Reinsertion ............................ 229
8.3.2 Introduction of Bacteria and Foreign Material ............................................... 230
8.3.3 Disturbed Socket Environment ....................................................................... 230
8.3.4 Changed Surface Characteristics of the Prosthesis ......................................... 231
8.4 Three-Phase Model of Prosthetic Eye Wear ................................................................. 231
8.4.1 Establishment Phase........................................................................................ 232
8.4.2 Equilibrium Phase ........................................................................................... 233
8.4.3 Breakdown Phase ............................................................................................ 233
8.5 Application of Model to Personal Prosthetic Eye Maintenance ................................... 237
References ................................................................................................................................ 239

8.1 Introduction

How patients might best care for their anophthalmic socket and maintain their
prostheses in optimal condition is based upon an understanding of the anophthal-
mic socket’s response to prosthetic eye wear. Knowing the nature of tear protein
deposits that interface between the prosthesis and the conjunctival lining of the
socket is as important a part of this understanding as knowing how the micro-
environment of the socket might change during long periods of continuous wear.
This chapter begins with a discussion about deposit build-up on prosthetic eyes.
It then describes the physical and physiological effects associated with prosthesis

© Springer International Publishing Switzerland 2015 219

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_8
220 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

removal, cleaning and reinsertion before going on to propose a three-phase model

of prosthetic eye wear. The model provides a basis for understanding socket health
and prosthetic eye maintenance.

8.2 Tear Protein Deposits

Protein deposits build up on prosthetic eye surfaces and mediate between the prosthe-
sis and the conjunctival lining of the socket (Fig. 8.1). The presence of these deposits
has been found to be associated with less conjunctival inflammation and less severe
mucoid discharge in anophthalmic sockets [1, 2], and it is surprising therefore that the
nature of deposits on prosthetic eyes has had limited attention in the literature, even
though extensive literature describes deposit build-up on contact lenses. Prosthetic
eyes are somewhat analogous to contact lenses although made from different materi-
als and worn for very different reasons (Fig. 8.2). Both devices come into contact with
the conjunctiva, share similar eyelid action, bathe in the same ocular fluids and accu-
mulate surface deposits. Because of these similarities, relevant information from con-
tact lens investigations into deposits can be used to fill in the gaps where the literature
about deposits on prosthetic eyes falls short. For example, the composition of deposits
on contact lenses is likely to be similar to deposits on prosthetic eyes. Contact lens
deposits include tear proteins, lipids, mucin and contaminants such as skin lipids, dirt,
microorganisms and metallic and non-metallic debris [3].

8.2.1 Information About the Nature of Deposits from Contact

Lens Research

Four categories of contact lens deposits have been described [4]:

1. Discrete elevated deposits described as jelly bumps, calcium deposits, calcium

lipid deposits and mucoprotein deposits
Fig. 8.1 Deposits on the
temporal limbus area of a left
prosthetic eye worn
continuously for 3 months
(magnification 400×)
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
8.2 Tear Protein Deposits 221

Fig. 8.2 A contact lens in

situ. Prosthetic eyes are
analogous to contact lenses
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

2. Lens coatings, films or plaques of tear protein which are layered and may pro-
duce lens movement when they thicken due to lid friction
3. Discolouration due to lens material and/or care regime, for example, yellow dis-
colouration of denatured protein in and on the lens
4. Coloured microorganisms and fungi on and in the lens

Rates of deposition depend on the water content of the contact lens material and its
ionicity (especially protein deposition) [4], and there are wide differences in protein
adhesion between wearers and between the eyes of the same wearer [5]. The deposits
on nonrotating lenses form in the inferior area or in a horizontal band across the centre
of the lens where they have been left high and dry by inefficient blinking and/or lag-
ophthalmos [6]. Lens deposits form rapidly [7], especially lipids and proteins. Several
proteins, including lysozyme, can be detected after 60 s of wear [8].
Fowler and Allansmith [9] noted that 50 % of the anterior surface of the contact
lens was covered with ocular debris and mucus within 30 min of wear and 90 %
after 8 h.

8.2.2 Deposit Build-Up on Prosthetic Eyes

8.2.2.1 Rate of Deposit Build-Up

A technique for measuring the intensity and extent of deposit formation on pros-
thetic eye surfaces has been developed by Pine et al. [10] (Fig. 8.3). They stained
and photographed 156 prosthetic eyes to create two equal interval perceptual
grading scales (Fig. 8.4). The scales were assessed for inter-rater reliability and
test–retest reliability before being used as a measuring tool to investigate deposit
formation in a number of experiments [10]. Pine et al. used their staining tech-
nique to provide a photographic record of how deposition advanced on the
222 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Fig. 8.3 Staining technique

for measuring the intensity
and extent of deposit
formation on prosthetic eye
surfaces (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

prosthetic eyes of two subjects over time (Fig. 8.5). The graph shown in Fig. 8.6
uses Pine et al.’s grading scales to quantify the build-up of deposits over time, and
the same data is used for the regression analysis shown in Fig. 8.7. It appears from
this evidence that tear deposits build rapidly during the first 2 weeks of continu-
ous wear (to grade 5 on the scale in Fig. 8.4) and stabilise after that until at
6 months of continuous wear the level of deposit formation has reached about
grade 8 [1].

8.2.2.2 Zones of Deposit Build-Up

Two distinct zones of surface deposit build-up on prosthetic eyes are apparent. The
first is the inter-palpebral zone where deposits are exposed to the air and the action of
the eyelids, and the second is the retro-palpebral zone where deposits are in continu-
ous contact with the conjunctiva (Fig. 8.8). Palpebral zone deposits on prosthetic eyes
are influenced by wetting and drying cycles caused by the blinking action of the eye-
lids. They are a source of irritation if they dry out on the prosthesis, and while they do
not obscure vision as they do with contact lenses, the zone should be kept clear of
deposits as much as possible. However, this is not necessarily the case for deposits
covering those surfaces that are in continuous contact with the conjunctiva.

8.2.2.3 Effect of Surface Polish on Deposit Build-Up

In a further experiment by Pine et al. [1], 23 prosthetic eye wearers had their prosthe-
ses finished to a standard polish before being returned to the socket and worn con-
tinuously for 2 weeks. At the end of the 2-week period, the prostheses were removed
and their surface deposits were graded using the scales in Fig. 8.4. The prostheses
8.2 Tear Protein Deposits 223

Fig. 8.4 Equal interval perceptual grading scales used to measure the build-up of deposits on
prosthetic eye anterior surfaces (left) and posterior surfaces (right) (Published with kind permis-
sion of Wiley Publishers – Clinical and Experimental Optometry Journal. All rights reserved)
224 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Subject 1 Subject 2

No deposits No deposits

1 day 1 day

2 days 2 days

4 days 4 days

10 days 7 days

17 days 14 days

33 days 28 days

12 months 12 months

Fig. 8.5 Photographic record of how tear deposits have built up on prosthetic eyes when worn
continuously by two subjects over the times indicated (Published with kind permission of Dove
Medical Press Ltd. Clinical Ophthalmology Journal. All rights reserved)

were then cleaned and polished to a high ‘optical quality contact lens standard’
before being returned to participants and worn continuously for a further 2 weeks.
The results showed that (poly)methyl methacrylate (PMMA) surfaces with a high
finishing standard accumulated deposits at a slower rate than prosthetic eyes finished
with a standard polish (Fig. 8.9). The finding suggests that adherence of deposits
depends on surface matrix fineness compared to the size of the protein molecules in

Fig. 8.8 Two distinct zones of deposit build-up on prosthetic eyes are apparent. The first is the
inter-palpebral zone where deposits are exposed to the air and the wiping action of the eyelids. The
second is the retro-palpebral zone where deposits are in continuous contact with the conjunctiva
(Published with kind permission of Wiley Publishers – Clinical and Experimental Optometry
Journal. All rights reserved)
8.2 Tear Protein Deposits 225

Deposition build-up over time

10

7
Deposits grade

5
Participant 1
4 Participant 2
3

0
0 1 2 4 7 10 14 17 28 33 365
Days of continuous wear

Fig. 8.6 Graph quantifying the build-up of deposits on the prosthetic eyes worn by the subjects in
Fig. 8.5. The deposits were graded using the equal interval grading scales shown in Fig. 8.4. (Published
with kind permission of Dove Medical Press Ltd. Clinical Ophthalmology Journal. All rights reserved)

Regression line y = 1.8 + 2.9 Log(x)

Mean deposits versus wearing days
9
Fig. 8.7 Regression analysis 8
for mean extent and intensity 7
of stained deposits on
prosthetic eyes worn Mean 6
continuously. Estimated mean deposit 5
deposit grades at 1 and grade 4
6 months are depicted by the 3
dashed lines (Published with
kind permission of Dove 2
Medical Press Ltd. Clinical 1
Ophthalmology Journal. All 1 10 100 1,000
rights reserved) Days of continuous wear
226 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Contact lens polish Normal polish

Prosthesis 1

Grade 4.5 Grade 6.0

Grade 3.5 Grade 4.0

Prosthesis 2

Grade 4.8 Grade 6.8

Grade 5.4 Grade 5.9

Fig. 8.9 Deposit formation on the anterior and posterior surfaces of two prosthetic eyes. The
prostheses were first cleaned and polished normally and worn for 2 weeks. They were then cleaned
and polished to optical quality contact lens standard and worn for a further 2 weeks. Prosthesis 1
was worn by a 75-year-old man. Prosthesis 2 was worn by a 77-year-old woman. The grades were
measured using the equal interval photographic grading scales in Fig. 8.4 (Published with kind
permission of Dove Medical Press Ltd. Clinical Ophthalmology Journal. All rights reserved)
8.2 Tear Protein Deposits 227

Fig. 8.10 Wettability of

prosthetic eye being
measured with a goniometer
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 8.11 The wetting angle,

θ°, is the angle formed by the Water droplet
water droplet at the three-
phase boundary where the
water, air and artificial eye
surface intersect

Prosthetic eye surface

the deposits and that the surface of prosthetic eyes finished with a standard polish
enables protein molecules to adhere more readily than to prostheses with higher pol-
ishes. Surface matrix fineness also appears to be a factor influencing deposition on
contact lenses. For example, Franklin et al. reported that one of the reasons that
deposits take longer to build up on rigid gas-permeable (RGP) contact lenses than on
hydrogel contact lenses was due to RPG polymers having lower matrix porosity [4].

8.2.2.4 Effect of Deposits on Surface Wettability

Pine et al. used a goniometer (Fig. 8.10) to measure the angle formed by a water
droplet at the three-phase boundary where the water, air and artificial eye surface
intersect (Fig. 8.11) to demonstrate (in vivo and in vitro) that the presence of depos-
its dramatically increases the wettability of prosthetic eyes [1, 11] (Fig. 8.12).
These findings suggest that surface deposits may serve a useful function in the
conjunctival contact areas of the prosthetic eye. Most of the time, the prosthesis
sits in the soft conjunctival folds of the socket in a state of equilibrium. This
equilibrium is disturbed when the eye moves in response to the extra-orbital
muscles working on or around the orbital implant buried behind the socket.
228 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Wetting angle vs surface finish with and without protein

deposits
90

80

70

60

50
Wetting angle
(degrees) 40 With deposits
Without deposits
30

20

10

0
Low Normal High
Standard of polish applied to the disk surface

Fig. 8.12 The wetting angle dramatically increased (the surface became much less wettable)
when surface deposits were cleaned off prosthetic eyes (Published with kind permission of Dove
Medical Press Ltd. Clinical Ophthalmology Journal. All rights reserved)

Blinking has limited impact on the conjunctival contact areas because it involves
the wiping action of the more tightly fitting Marx’s line which is thought to be
the natural site of frictional contact between the eyelid margin and the surfaces
of the bulbar conjunctiva and cornea [12]. However, the tarsal conjunctiva fol-
lows Marx’s line over the palpebral zone of the prosthetic eye with each blink. If
the socket has insufficient tears or the tears do not flow over the prosthesis evenly,
eye movement and blinking may increase mechanical irritation of the conjunc-
tiva. The presence of surface deposits may facilitate the flow of tears over the
prosthesis because deposits significantly reduce surface hydrophobicity.
Not only did presence of deposits increase the wettability of prosthetic eyes, but
prostheses with a high standard of finish in the Pine et al. study also exhibited more
wettability than those with a normal standard of finish, to the point where there was
no statistical difference between prosthetic eyes with deposits and those which had
been polished to optical quality contact lens standard [1].
This fact, plus the finding that higher polished surfaces accumulate deposits at a
slower rate, might be particularly important for the surface finish of the inter-palpebral
zone of the prosthesis. The inter-palpebral zone needs to be as free from deposits as
possible to avoid dried deposits and conjunctival battering during blinking. As the
eyelids slide over the inter-palpebral zone of a prosthetic eye containing deposits and
debris, the area most likely to receive this battering is Marx’s line which has been
shown to exhibit epitheliopathy in contact lens patients with dry eye symptoms [13].
Clearly, deposits left in the inter-palpebral zone of prosthetic eyes are not likely
to be beneficial to wearing comfort. A high optical quality contact lens standard of
8.3 Effects of Prosthesis Removal, Cleaning and Reinsertion 229

Fig. 8.13 When a prosthetic

eye is removed and rein-
serted, it is inevitable that the
micro-environment of the
socket is disturbed to some
extent (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

finish may also facilitate the lubricating function of tears in the retro-palpebral zone
when the prosthesis is first inserted into the socket and before the layered coatings,
films or plaques of tear protein deposits become established. The finding that wet-
tability increase significantly when deposits were present in the retro-palpebral zone
may be the reason that surface deposits are associated with less severe conjunctival
inflammation in anophthalmic sockets and that more frequent cleaning of prosthetic
eyes (deposit removal) is associated with more severe discharge [1, 2]. By increas-
ing surface wettability, the deposits appear to improve the ability of socket fluids to
lubricate the prosthesis. If mucins are present in prosthetic eye deposits as they are
in contact lens deposits [9], components of glycoproteins such as the surfactant
glycocalyx [14] may also facilitate the lubricating function. The consequence of
these properties of deposits would be that less frictional irritation of the conjunctiva
occurs when deposits are present.

8.3 Effects of Prosthesis Removal, Cleaning and Reinsertion

Removing, inserting and cleaning prosthetic eyes are processes that disrupt the
micro-environment of the socket (Fig. 8.13). Physical forces stress the socket
tissues, foreign material and bacteria are introduced into the socket, the micro-
environment of the socket is disturbed and the surface of the prosthesis changes.
The main symptoms of the socket’s response to these disruptive processes are con-
junctival inflammation and excessive mucoid discharge.

8.3.1 Physical Stress Associated with Removal and Reinsertion

When the prosthesis is removed and reinserted, the conjunctiva and eyelids are
stretched and deformed. The thin tissue forming the lateral canthus is particularly
vulnerable to stress as the eyelids are held apart to allow the prosthesis to slide past.
230 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Removing and reinserting the prosthesis also produces frictional forces caused by
the prosthesis rubbing unnaturally against the conjunctiva.

8.3.2 Introduction of Bacteria and Foreign Material

The process of removing and reinserting the prosthesis inevitably introduces bacte-
ria and foreign material into the socket. Vasquez and Linberg [15] showed that
patients who frequently handled their prosthesis have a significantly higher propor-
tion of Gram-negative bacteria in their socket than in their companion eye compared
with patients who handled their prosthesis less often. It is important for patients and
caregivers to wash their hands before touching the prosthetic eye, but while this will
reduce bacterial contamination of the socket, it should be noted that the hands are
not the only source of bacterial contamination. Handwashing before touching the
prosthesis appears not to be associated with symptoms of discharge [15]. See Chap.
9 for a detailed discussion of discharge associated with prosthetic eye wear.
Foreign materials dragged into the socket when the prosthesis is inserted include
environmental dust and grime; make-up; skin cells and other metabolic debris from
fingers, eyelids, cheeks, etc.; stray eyelashes; and residues of cleaning or polishing
agents used to clean and repolish the prosthetic eye (Figs. 8.14 and 8.15).

8.3.3 Disturbed Socket Environment

Removing and reinserting the prosthesis disturbs the mucus substrate which is a
network of mucus formed by conjunctival goblet and epithelial cells and which

Fig. 8.14 Foreign material

(a stray eyelash) fell into this
anophthalmic socket when
the prosthesis was removed
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
8.4 Three-Phase Model of Prosthetic Eye Wear 231

Fig. 8.15 Slit lamp

biomicroscope view of tear
break-up on the surface of a
recently inserted prosthetic
eye. The patient’s fingerprint
which smudged across the
cornea is an example of
foreign material entering the
socket during reinsertion of
the prosthesis (Published
with kind permission of
Sloan Medical Ltd. All rights
reserved)

coats the conjunctiva. The conjunctival mucus substrate lubricates the prosthesis
and acts as a sponge that enables aqueous tears to remain in contact with the pal-
pebral conjunctival epithelium [14].
Rapid temperature reduction and evaporative drying of the conjunctiva also
occur when the prosthesis is removed, and temperature differences between the
socket and prosthesis also disturb the environment of the socket when the prosthesis
is reinserted.

8.3.4 Changed Surface Characteristics of the Prosthesis

Cleaning removes surface deposits and residual mucus from the surface of pros-
thetic eyes. While the removal of dried deposits and mucus from the inter-palpebral
zone of the prosthetic eye enables the eyelids to close smoothly over the prosthesis
and is beneficial, newly cleaned prostheses have reduced wettability overall [11]
and tears readily break-up when the prosthesis is first introduced to the socket
(Fig. 8.15). This interrupted tear coverage reduces the ability of tears to lubricate the
prosthesis and exposes the raw, unmediated surface of the prosthesis to the
conjunctiva.

8.4 Three-Phase Model of Prosthetic Eye Wear

This three-phase model describes the response of the socket to prosthetic eye wear.
The phases are an initial period of wear of a new (or newly polished) prosthesis
when homeostasis is being established within the socket, a second period (equilib-
rium phase) where beneficial surface deposits have built up on the prosthesis and
232 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Three phase model of prosthetic eye wear

Establishment of
homeostasis
Deposits build up.
Cleaning Recovery from
intervention effects of handling
the prosthesis.

Breakdown of Stable
homeostasis homeostasis
Stagnant socket fluids. Mucus substrate forms.
Build-up of metabolic Deposits facilitate lubrication.
and environmental Other elements balance
debris and thick layers out.
of deposits.

Fig. 8.16 Three-phase model of prosthetic eye wear (Published with kind permission of Elsevier
Publishers. Medical Hypotheses Journal. All rights reserved)

wear is safe and comfortable and a third period (breakdown phase) where there is an
increasing likelihood of harm from continued wear (Fig. 8.16).

8.4.1 Establishment Phase

The establishment phase is the phase when physiological homeostasis [16] is being
established (or re-established) within the socket. The phase begins when the pros-
thesis has been returned to the socket following the physical and physiological dis-
ruptions that occur when the prosthetic eye is removed, cleaned and reinserted.
The recovery time from the stresses of prosthesis removal and reinsertion appears
to be rapid (perhaps only a few minutes) [11]. However, the establishment of stable
physiological homeostasis may take longer because the conjunctival mucus sub-
strate needs to be redistributed evenly around the prosthesis, foreign materials need
to be encased with mucus and eliminated and the balance between tear production
8.4 Three-Phase Model of Prosthetic Eye Wear 233

and tear loss needs to be re-established. The build-up to a minimum depth of the
coatings and films that cover the prosthesis surface must also occur before stable
homeostasis is reached.

8.4.2 Equilibrium Phase

The equilibrium phase is when physiological homeostasis is being maintained

within the micro-environment of the socket.
Once the disturbing effects of reinserting, removing and cleaning the prosthesis
have abated and surface coatings and deposits have been established to a minimum
depth and coverage, a stable physiological homeostasis is established within the
socket. During this phase surface deposits mediate between the surface of the pros-
thesis and the conjunctiva and provide a wettable surface which improves the abil-
ity of socket fluids to lubricate the prosthesis (See the description of Sect. 8.2
above).
The mucus substrate which was disturbed when the prosthesis was removed is
redistributed evenly over the conjunctiva. This substrate, together with the coatings
of surface deposits that facilitate lubrication of the prosthesis, is probably the prin-
cipal component of physiological homeostasis in the socket.
Bacterial homeostasis may also play a role. Bacterial homeostasis refers to the
self-regulation of bacteria adjusting to their changing environmental conditions.
The main self-regulating mechanisms for bacteria include membrane lipid homeo-
stasis, iron homeostasis and pH homeostasis [17]. There appears to be no associa-
tion between bacterial load and symptoms of inflammation during the equilibrium
phase even though more Gram-negative bacteria are typically found in anophthal-
mic sockets than in companion eyes [18].

8.4.3 Breakdown Phase

This is the phase when homeostasis within the socket is no longer maintained with-
out difficulty and where there is an increasing likelihood of harm from continued
prosthesis wear. The physiological homeostasis in the micro-environment of the
socket gradually becomes less benign. Over time some minor inflammation and
discharges begin although it may not be enough to warrant attention by the wearer.
However, once the balance has shifted, further perturbations lead to homeostasis
breakdown. The breakdown may be initiated by an excessive build-up of layers of
deposits which harbour increasing amounts of harmful bacteria and/or environmen-
tal and metabolic debris. Sun et al. fixed three prosthetic eyes with platinum prior to
imaging using scanning electron microscopy. One prosthesis (3 months old) was
234 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Fig. 8.17 Scanning electron microscopy showing tear deposits on a 10-year-old prosthetic eye.
Note the adherent rod-shaped bacteria (Published with kind permission of M Sun, A Pirbhai and D
Selva. All rights reserved)

Fig. 8.18 Over time tear

protein deposits thicken and
encroach into the inter-
palpebral zone of the
prosthetic eye and dry out
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

clear of bacteria, while the other two (older than 5 years) had rod-shaped bacteria
adhering to them [19] (Fig. 8.17).
Over time the deposits thicken and encroach into the inter-palpebral zone of the
prosthetic eye and dry out (Fig. 8.18), and epitheliopathy of Marx’s line is increas-
ingly likely to occur (Fig. 8.19).
The components of these thicker deposits may also trigger an allergic reaction as
seen with giant papillary conjunctivitis (GPC) (Figs. 8.20 and 8.21). Studies of giant
papillary conjunctivitis in anophthalmic sockets with prosthetic eyes have con-
cluded that prolonged wear of prosthetic eyes is associated with GPC [20]. GPC is
an allergic disease of the eye associated with increased numbers of mast cells,
eosinophils and lymphocytes in the conjunctiva [21]. GPC associated with contact
lens wear is thought to be a combination of an immune response to antigenic protein
deposits and physical trauma to the conjunctiva adjacent to the surface and edge of
the lens [22]. Fowler et al. in the context of contact lens research reported that GPC
may be related to the amount of surface deposits because it occurred less with wear
8.4 Three-Phase Model of Prosthetic Eye Wear 235

Fig. 8.19 Epitheliopathy of

Marx’s line in the lower
eyelid of an anophthalmic
socket caused by prosthetic
eye wear (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 8.20 GPC can be seen

on the caruncle in this
anophthalmic socket
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 8.21 This eye socket

impression shows the
cobblestone appearance of
GPC on the tarsal conjunctiva
of the upper eyelid (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)
236 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Fig. 8.22 Excessive build-up of deposits on a prosthetic eye shown by staining. The deposits may
harbour harmful bacteria and/or environmental and metabolic debris. The prosthesis was removed
from the discharging socket shown (Published with kind permission of NZ Artificial Eye Service.
All rights reserved)

Fig. 8.23 Mucoid discharge

trapped in spaces behind the
prosthesis (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)

of hard contact lenses (which attracted less deposits) than soft contact lenses.
Interestingly, they also found that patients with GPC had contact lens deposits that
differed morphologically from deposits of asymptomatic patients and that after a
day of wear GPC patients had deposits on 90 % of the contact lens surface com-
pared with 5 % for asymptomatic patients [23].
Aside from overly thick deposits, another potential cause for the breakdown of
physiological homeostasis is an accumulation of environmental debris and meta-
bolic waste products in the deposits and elsewhere in the socket. Stagnation of
socket fluids and an overgrowth of normally unharmful bacteria may also occur, and
in cases with lowered resistance, bacteria may produce inflammation and discharge
(Fig. 8.22).
A further cause of breakdown of physiological homeostasis may include pooling
of socket fluids that become trapped in spaces behind the prosthesis (Fig. 8.23).
These secretions may act as a growth medium for bacteria causing recurrent
8.5 Application of Model to Personal Prosthetic Eye Maintenance 237

Cleaning regime vs mean discharge characteristics

10
9
8
7
6 Frequency
5 Colour
4 Volume
Viscosity
3
2
1
0
< =Weekly >Weekly<Monthly Monthly >Monthly

Fig. 8.24 Removing and cleaning prosthetic eyes monthly resulted in less discharge than clean-
ing more frequently (Published with kind permission of Dove Medical Press Ltd. Clinical
Ophthalmology Journal. All rights reserved)

discharge [24], while the accompanying inefficient socket drainage may result in an
accumulation of both environmental debris and the waste products of normal
metabolism, further upsetting homeostasis.

8.5 Application of Model to Personal Prosthetic Eye

Maintenance

The three-phase model of prosthetic eye wear suggests that there is an initial period
when physiological homeostasis is becoming established within the socket follow-
ing the insertion of a clean prosthetic eye. The length of this initial period is the time
taken for the socket to recover from the effects of manipulating the socket and pros-
thesis and for a sufficient coating of tear deposits to form on the prosthetic eye. An
estimate of the length of this initial period may be determined for the majority of
prosthetic eye wearers from Pine et al.’s finding that monthly cleaning resulted in
less discharge than cleaning more frequently [2] (Fig. 8.24). This improvement in
the incidence of discharge suggests that physiological homeostasis may be estab-
lished over a period that could extend for a month and that prosthetic eyes should be
left undisturbed for at least this long.
During this initial month for some wearers at least, the intensity and extent of
deposits may reach grade five or six on the 0–10 deposits scale (Fig. 8.4) after
2 weeks of continuous wear and increase more slowly after that.
Beyond a month when stable homeostasis has been reached, the length of time
before it starts to break down is likely to vary for individuals. For example, the
amount of deposit build-up on contact lenses varies between wearers and between
the eyes of the same wearer [5]. The length of time may also vary with medical
conditions. For example, contact lens-induced papillary conjunctivitis occurs more
238 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

Fig. 8.25 A cold cure

PMMA patch on this
prosthesis can be seen to have
attracted deposits, while the
rest of the palpebral zone has
remained clear (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

frequently in allergy sufferers [25]. The patient’s environment (e.g. dusty or windy
conditions) and behaviour (e.g. activities where concentrated visual tasks are under-
taken and blink rate is reduced [25]) may also affect the length of time stable
homeostasis lasts. Finally, the standard of surface polish on the prosthetic eye may
influence the period of stable homeostasis. Surface polish level has been shown to
affect the rate of deposit build-up (See above) and, potentially, the length of periods
of establishment and periods of stability of homeostasis (Fig. 8.9).
Evidence for the quality of surface finish and its effect on the accumulation of
deposits was also apparent in a case where a cold cure PMMA patch was used to
repair a blemish in the cornea of a prosthetic eye. Several years after the repair was
carried out, the area of the patch attracted deposits, while the rest of the anterior
surface of the prosthesis remained clear (Fig. 8.25).
No studies of GPC or conjunctival cytologic changes in anophthalmic sockets
have investigated the role of deposits, but if prolonged wear of prosthetic eyes is
associated with GPC [20], then a cause could be thicker layers of mature deposits
more likely to be containing antigens. Deposits of grade of eight on the graph in
Fig. 8.5 might be reached after 6 months of continuous wear and deposit build-up to
about grade nine is likely after 12 months [26]. This amount of deposit build-up
may be enough to provide the conditions necessary for GPC as suggested by Fowler
et al. [23] or for deposits to begin to encroach on the inter-palpebral zone where they
dry out and physically irritate the conjunctiva during blinking.
If the breakdown of physiological homeostasis is to be avoided, it is necessary to
intervene at some point and clean the prosthetic eye. When this should happen, it
will vary for individuals and it may be that wearers should judge for themselves how
often they clean their prosthesis. This was the opinion of 53 % of members of the
American Society of Ocularists who recommended to patients that they remove and
clean their prosthesis whenever the socket felt irritated or whenever it was dirty
[27]. This is a reasonable advice, but it suggests that the prosthesis should be cleaned
after the breakdown of physiological homeostasis has occurred rather than before.
A better recommendation for a prosthetic eye cleaning regime might be one that
References 239

allows for individual variability but sets a limit on how long the prosthesis should
remain in the socket before it is removed for cleaning. Based on the evidence avail-
able, it is suggested that a conservative estimate of this limit might be 6 months.
Taking account of the three-phase model of the socket’s response to prosthetic
eye wear and the evidence presented above, it is recommended that prosthetic eyes
should be cleaned not more frequently than monthly and not less frequently than six
monthly. The optimum cleaning regime for most individuals will lie within these
parameters.

References
1. Pine KR, Sloan B, Jacobs R. Deposit build-up on prosthetic eyes and the implications for
conjunctival inflammation and mucoid discharge. Clin Ophthalmol. 2012;6:1–8.
2. Pine KR, Sloan B, Stewart J, Jacobs RJ. The response of the anophthalmic socket to prosthetic
eye wear. Clin Exp Optom. 2013. doi:10.1111/cxo.12004.
3. Heiler DJ, Gambacorta-Hoffman S, Groemminger SF, Jonasse MS. The concentric distribu-
tion of protein on patient-worn hydrogel lenses. CLAO J. 1991;17(4):249–51.
4. Franklin VJ, Tigue B, Tonge S. Contact lens care: part 4 – contact lens deposit build-up, dis-
coloration and spoilation mechanisms. Optician. 2001;222(580):16–26.
5. Keith DJ, Christensen MT, Barry JR, Stein JM. Determination of the lysozyme deposit curve
in soft contact lenses. Eye Contact Lens. 2003;29(2):79–82.
6. McMonnies C, Lowe R. After-care. In: Phillips AJ, Speedwell L, editors. Contact lenses. 5th
ed. Edinburgh: Butterworth Heinemann Elsevier; 2007. p. 388–9.
7. Franklin VJ. Cleaning efficacy of single-purpose surfactant cleaners and multi-purpose solu-
tions. CLAO J. 1997;20(2):63–8.
8. Leahy CD, Mandell RB, Lin ST. Initial in vivo tear protein deposit build-up on individual
hydrogel contact lenses. Optom Vis Sci. 1990;67(7):504–11.
9. Fowler SA, Allansmith MR. Evolution of soft contact lens coatings. Arch Ophthalmol.
1980;98(1):95–9.
10. Pine KR, Sloan B, Jacobs RJ. The development of measuring tools for prosthetic eye research.
Clin Exp Optom. 2012;96(1):32–40.
11. Pine KR, Sloan B, Kyu Yeon IH, Swift S, Jacobs RJ. Deposit buildup on prosthetic eye mate-
rial (in vitro) and its effect on surface wettability. Clinical Ophthalmol. 2013;7: 313–319.
12. Donald C, Hamilton L, Doughty MJ. A quantitative assessment of the location and width of
Marx’s line along the marginal zone of the human eyelid. Optom Vis Sci. 2003;80(8):
564–72.
13. Korb DR, Greiner JV, Herman JP, et al. Lid-wiper epitheliopathy and dry-eye symptoms in
contact lens wearers. CLAO J. 2002;28(4):211–6.
14. Liotet S, Triclot MP, Perderiset M, Warnet VN, Laroche L. The role of conjunctival mucus in
contact lens fitting. CLAO J. 1985;11(2):149–54.
15. Vasquez RJ, Linberg JV. The anophthalmic socket and the prosthetic eye. A clinical and bac-
teriologic study. Ophthal Plast Reconstr Surg. 1989;5(4):277–80.
16. Biology online. Available from: http://www.biology-online.org/4/1_physiological_homeosta-
sis.html. Accessed 27 Jun 2015.
17. Zinni Y. Bacteria homeostasis. eHow. Available from: http://www.ehow.com/info_8706627_
bacteria-homeo-stasis.html. Accessed 27 Jun 2015.
18. Christensen JN, Fahmy JA. The bacterial flora of the conjunctival anophthalmic socket in glass
prosthesis-carriers. Acta Ophthalmol. 1974;52(6):801–9.
19. Sun MT, Pirbhai A, Selva D, Bacterial bio- films associated with ocular prosthesis. Discipline
of Ophthalmology and Visual Sciences, South Australian Institute of Ophthalmology and
Royal Adelaide Hospital, Adelaide. 2013.
240 8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear

20. Srinivasan BD, Jakobiec FA, Iwamoto T, DeVoe AG. Giant papillary conjunctivitis with ocular
prostheses. Arch Ophthalmol. 1979;97(5):892–5.
21. Bozkurt B, Akyurek N, Irkec M, Erdener U, Memis L. Immunohistochemical findings in
prosthesis-associated giant papillary conjunctivitis. Clin Experiment Ophthalmol. 2007;35(6):
535–40.
22. Donshik PC. Giant papillary conjunctivitis. Trans Am Ophthalmol Soc. 1994;92:687–744.
23. Fowler SA, Korb DR, Finnemore VM, Allansmith MR. Surface deposits on worn hard contact
lenses. Arch Ophthalmol. 1984;102(5):757–9.
24. Jones CA, Collin JR. A classification and review the causes of discharging sockets. Trans
Ophthalmol Soc U K. 1983;103(Pt 3):351–3.
25. Donshik PC. Extended wear contact lenses. Ophthalmol Clin North Am. 2003;16(3):305–9.
26. Pine K, Sloan B, Stewart J, Jacobs RJ. A survey of prosthetic eye wearers to investigate mucoid
discharge. Clin Ophthalmol. 2012;6:707–13.
27. Pine K, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing artificial
eyes. Clin Experiment Ophthalmol. 2011;39(1):47–52.
Mucoid Discharge Associated
with Prosthetic Eye Wear 9

Contents
9.1 Introduction ................................................................................................................... 241
9.2 Specific Causes of Discharge ........................................................................................ 242
9.2.1 Viral or Bacterial Infections ............................................................................ 242
9.2.2 Eyelid-Related Pathologies ............................................................................. 243
9.2.3 Environmental Allergens ................................................................................ 246
9.2.4 Environmental Irritants and Eye Stress ........................................................... 247
9.2.5 Socket-Related Irritants .................................................................................. 247
9.2.6 Prosthesis-Related Irritants ............................................................................. 247
9.3 Non-specific Causes of Discharge ................................................................................ 251
9.4 Contact Lens Experience with Tear Protein Deposits,
Papillary Conjunctivitis and Discharge ......................................................................... 252
9.5 Personal Prosthetic Eye Cleaning Regimes and Professional Polishing....................... 253
9.6 Proposed Protocol for Managing Non-specific Mucoid Discharge .............................. 254
9.6.1 The Protocol Has Five Elements as Follows................................................... 255
References ................................................................................................................................ 257

9.1 Introduction

Excessive mucoid discharge associated with prosthetic eye wear is a common occur-
rence that, according to a New Zealand survey of 431 prosthetic eye wearers, affects
93 % of wearers – 60 % of them on a daily basis [1]. This is a serious problem for those
involved in the care of anophthalmic patients because the success of prosthetic restora-
tion depends upon both the cosmesis and the convenience of wearing the prosthesis [2].
Mucoid discharge has been found to be the second highest concern for experienced
prosthetic eye wearers after the health of the remaining eye [1] and clearly impacts
negatively on the quality of life of anophthalmic patients who suffer it.

© Springer International Publishing Switzerland 2015 241

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_9
242 9 Mucoid Discharge Associated with Prosthetic Eye Wear

RANGE OF SOCKET CHARACTERISTICS

DISCHARGE

INFLAMMATION

PAPILLAE

Fig. 9.1 Anophthalmic sockets with ranges of severity (mild on the left to severe on the right) for
mucoid discharge, inflammation and papillae (Published with kind permission of NZ Artificial Eye
Service. All rights reserved)

Mucoid discharge has four basic symptomatic characteristics – frequency, colour,

volume and viscosity – and may be mild with only a small amount accumulating at
the medial canthus overnight or moderate with strands of thicker discharge sitting
on the eyelids, or it can be a severe mucopurulent discharge which causes the eye-
lids to stick together and is associated with itching or irritation. The increase in
mucus severity is usually although not always accompanied by general conjunctival
inflammation and the emergence of fine papillae which may become larger and
develop into giant papillary conjunctivitis (GPC) (papillae >1 mm diameter)
(Fig. 9.1).
Specific and non-specific causes of mucoid discharge associated with prosthetic
eye wear are discussed in this chapter, and a protocol for managing non-specific
mucoid discharge is proposed.

9.2 Specific Causes of Discharge

9.2.1 Viral or Bacterial Infections

Viral infections such as the common cold may cause acute discharge which abates
once the patient has recovered from the infection (Fig. 9.2). Bacterial infections
may result in severe purulent conjunctivitis accompanied by a thick yellow/green
discharge which crusts on the eyelashes and causes itching. The discharge clears up
quickly once antibiotics have been given (Fig. 9.3).
9.2 Specific Causes of Discharge 243

Fig. 9.2 Discharge resulting

from a common cold
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 9.3 Thicker

yellow/green discharge and
crusting is indicative of
bacterial infection (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

9.2.2 Eyelid-Related Pathologies

9.2.2.1 Blepharitis
Blepharitis is a chronic inflammation of the eyelid margins which leads to red, irri-
tated and itchy eyes with characteristic dandruff-like crusts appearing on the eye-
lashes (Fig. 9.4). There are two types of blepharitis: anterior and posterior.
Anterior blepharitis is caused by a staphylococcus infection of the anterior eyelid
margin or by skin conditions such as seborrhoeic dermatitis (dandruff). Posterior
blepharitis affects the moist inside eyelid margins and is mainly associated with
rosacea (a chronic inflammatory skin condition of the face) and seborrhoeic derma-
titis which can occur alongside meibomian gland dysfunction (MGD).
244 9 Mucoid Discharge Associated with Prosthetic Eye Wear

Fig. 9.4 Blepharitis with

typical dandruff-like crusts
appearing on the eyelashes
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

9.2.2.2 Dry Eye Syndrome

Dry eye syndrome (keratoconjunctivitis sicca) is a common disorder of the tear film.
It results from excessive tear evaporation due to insufficient lipid overlaying the tear
film or decreased tear production caused by autoimmune diseases such as rheuma-
toid arthritis, Sjögren’s syndrome or lupus or ageing and hormonal changes.

9.2.2.3 Meibomian Gland Dysfunction

Meibomian gland dysfunction (MGD), blepharitis and dry eye are commonly
described separately but may be considered to be a group of interacting pathologies
that affect the eyelids [3]. MGD is probably the main cause of evaporative dry eye
but may occur in combination with aqueous deficiency dry eye. MGD is either
hyposecretory (gland atrophy) or more often obstructive which results in the nor-
mally clear meibomian secretions becoming cloudy, thick and waxy (Fig. 9.5).
Obstructive MGD is linked to contact lens (CL) intolerance [4] and in anophthal-
mic sockets it is often accompanied by symptoms of discharge and itching. Jang
et al. [5] used noncontact meibography to investigate changes in meibomian gland
morphology associated with prosthetic eye wear and found that eyelids over pros-
thetic eyes had significant signs of MGD and meibomian gland dropout (Fig. 9.6)
compared to their companion eyelids, especially after more than 10 years of pros-
thetic eye wear [5]. It appears that wearing a prosthetic eye increases the potential
for hyperkeratinisation (an excess of keratin in the surface of the skin) to cause
obstruction of the meibomian glands. This may be made worse by a combination of
mechanical rubbing of the lid margins over the prosthesis during blinking, tear
meniscus deficiency [6] or tear protein deposits encroaching on the inter-palpebral
zone.
MGD contributes to prosthetic eye discomfort and it is important that routine
assessment of prosthetic eyes should include an examination of the eyelids paying
particular attention to the eyelid margins and meibomian gland orifices. If eyelid
9.2 Specific Causes of Discharge 245

Fig. 9.5 Obstructive MGD

in the upper eyelid with waxy
meibum issuing from
meibomian gland orifices,
some of which are blocked
(Published with kind
permission of Sloan Medical
Ltd. All rights reserved)

Fig. 9.6 This anophthalmic

socket exhibits significant
signs of meibomian gland
dysfunction and meibomian
gland dropout in both upper
and lower eyelids (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

margin telangiectasia (spider veins) is present (Fig. 9.7) and/or the meibomian glands
are obstructed or the meibum is thick and cloudy, the patient should be informed about
MGD and how it should be managed. Treatment includes warm compresses applied
to the eyelids daily for a minimum of 4 min followed by firm massaging to express
meibum from the glands. Increasing dietary omega-3 fatty acid intake [7], avoiding
environmental situations that increase tear evaporation, reducing (where possible)
systemic medications associated with drying effects. Using lubricating eye drops,
emollients, ointments and liposomal sprays may also be useful for alleviating the
symptoms of MGD. Punctal occlusion has also been shown to be effective in improv-
ing socket comfort for prosthetic eye wearers with low tear volume [8].
246 9 Mucoid Discharge Associated with Prosthetic Eye Wear

Fig. 9.7 Eyelid margin

telangiectasia (spider veins)
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 9.8 Lagophthalmos has

impaired the normal function
of the eyelids of this patient
causing mucus to collect on
the surface and dry out
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

9.2.2.4 Lagophthalmos
Lagophthalmos (inability to fully close the eyelids) is an additional eyelid condition
associated with more severe mucoid discharge. Lagophthalmos impairs the normal
function of the eyelids which results in less flushing of the socket, less lubrication
for the prosthetic eye and more potential for tear protein deposits and mucus to dry
out and become gritty (Fig. 9.8).

9.2.3 Environmental Allergens

Environmental allergens such as dust mites, pet dander (protein particles in dead
skin or hair), pollens, moulds, etc., affect 10–25 % of the population in Western
9.2 Specific Causes of Discharge 247

Fig. 9.9 Thinly covered

implant sitting under an intact
conjunctival membrane
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

countries [9]. These allergens commonly cause discharge when prosthetic eye wear-
ers with allergic rhinitis (hay fever) come into contact with them – often recurring
at the same time each year.

9.2.4 Environmental Irritants and Eye Stress

Environmental irritants are a common specific cause of acute discharge associated

with prosthetic eye wear and include anything from air conditioning that increases
evaporative drying of tears to dusty, windy conditions and face powder. Behaviours
that cause decreased blink rates such as prolonged night driving or staring at a com-
puter screen for long periods without rest will also impact on socket comfort and
stimulate mucoid discharge.

9.2.5 Socket-Related Irritants

Thinly covered implants (Fig. 9.9) or extruding implants (Fig. 9.10), undissolved
sutures with or without granulomas (Fig. 9.11), inclusion cysts, pegged hydroxy-
apatite implant (Fig. 9.12) and conjunctival membrane mixed with skin are exam-
ples of socket-related irritants that may stimulate mucoid discharge in anophthalmic
sockets.

9.2.6 Prosthesis-Related Irritants

Allergic response to (poly)methyl methacrylate (PMMA) prosthetic eye material is

a rarely reported event that has also occurred with PMMA dentures [10]. Patel et al.
described a case where a temporary prosthetic eye was inserted in a patient who
248 9 Mucoid Discharge Associated with Prosthetic Eye Wear

Fig. 9.10 This tantalum

mesh implant has extruded
through the conjunctiva
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 9.11 Undissolved

sutures under an intact
conjunctival membrane
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 9.12 Pegged hydroxy-

apatite implant with
associated mucoid discharge
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
9.2 Specific Causes of Discharge 249

developed upper eyelid swelling and itchiness 24 hours later and after 2 weeks had
significant upper eyelid oedema with a marked conjunctival papillary reaction and
conjunctival oedema [11].
The allergic response appears to be associated with free monomer remaining in
the PMMA material due to insufficient curing time during the final polymerisation
stage of prosthetic eye manufacture. Experiments with under-cured PMMA den-
tures stored in water have shown that free surface monomer leached out after 17 h
[12] but leaching may take longer with thicker PMMA prosthetic eyes and there is
no way of knowing whether the residual monomer has been completely eliminated.
The solution is to return the prosthesis to the mould and subject it to further curing
at 100 °C under pressure for an extended period. This will ensure that all the resid-
ual monomer is fully polymerised.
Extended reprocessing of the prosthetic eye should also be considered for
patients with chronic giant papillary conjunctivitis (GPC) where repolishing the
prosthesis has not been effective.
A small risk when reprocessing a prosthetic eye is that stresses released within
the PMMA material will cause delamination of the layers that make up the prosthe-
sis. Delamination appears as a silvery discolouration over the iris and/or pupil
(Fig. 9.13).
Other prosthesis-related irritants causing discharge include tooling marks and
residues left on the surface of freshly polished prosthetic eyes as well as chips,
scratches and dull patches (micro-scratches) on well-worn prostheses (Fig. 9.14).
Cleaning the prosthesis with a solvent may craze the surface and cause irritation and
discharge (Fig. 9.15).
The standard of surface finish on prosthetic eyes affects the rate of deposition on
the retro-palpebral zone where deposits are beneficial and on the inter-palpebral
zone where they are best swept away during blinking (see Chap. 8). The higher the
polish, the more wettable the prosthetic eye surface is and the less likely it is for
deposits to dry out in the inter-palpebral zone and become gritty [13] (Fig. 9.16).

Fig. 9.13 A silvery

discoloration over the pupil
(seen here) indicates
delamination of the PMMA
material making up the
prosthesis (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
250 9 Mucoid Discharge Associated with Prosthetic Eye Wear

Fig. 9.14 Scratches and dull

patches on well-worn
prostheses are associated with
mucoid discharge (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

Fig. 9.15 The crazed surface

of this prosthesis was caused
by cleaning it with a solvent
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 9.16 Dried, gritty

deposits (stained in this
photograph) in the inter-
palpebral zone are a source of
irritation leading to discharge
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
9.3 Non-specific Causes of Discharge 251

Fig. 9.17 A socket containing a glob of mucoid discharge which has pooled in the space behind
the deeply hollowed and poorly finished prosthetic eye shown. Note the rough area (highlighted
with stain) around the upper edge of the prosthesis and its deeply hollowed back (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

Prosthetic eyes with deeply hollowed backs may contribute towards the inci-
dence of discharge by allowing socket secretions to pool and stagnate [14]
(Fig. 9.17).

9.3 Non-specific Causes of Discharge

Many specific causes of discharge have been identified, but there remain a large
number of prosthetic eye wearers who complain about discharge for which there is
no apparent cause and for which many treatments have been postulated. A survey of
ocularists’ websites carried out in 2012 revealed that the cause of discharge had not
been settled. The largest group believed that the main cause was the build-up of
surface deposits on prosthetic eyes, but the sites contradicted this with a majority
(82 %) recommending that prosthetic eyes (with deposits) (a) never be removed and
cleaned or (b) only be removed and cleaned if causing discomfort or discharge [15].
Two studies have found that there are bacteriologic and cytologic differences
between anophthalmic and natural sockets but that these differences are not associ-
ated with symptoms of discharge [16]. Handwashing before touching the prosthesis
also appears not to be associated with symptoms of discharge [17] although it
appears that patients who frequently touch their prosthesis may have a higher pro-
portion of Gram-negative bacteria in the conjunctiva of their sockets compared to
their companion eyes [16].
In 1983, Jones and Collin classified the causes of discharging sockets. They asso-
ciated acute discharge with viral or bacterial conjunctivitis. However, chronic dis-
charge with recurrent symptoms often did not respond to topical antibiotics, so
causes other than infection were implicated. Their classification achieved its aim of
allowing more accurate diagnosis of infections but left open the question of effec-
tive treatment for ongoing discharge problems [14]. Allen et al. found that patients
with noteworthy problems had only half as much basic tear secretion in their anoph-
thalmic sockets as those without problems [18]. They suggested that aqueous or oily
prosthetic lubricants might be of value. Fett et al. evaluated the need for additional
252 9 Mucoid Discharge Associated with Prosthetic Eye Wear

lubrication in 200 anophthalmic patients and found that 23 % required supplemen-

tation [19]. However, neither Allen nor Fett directly linked low basic tear produc-
tion or the use of prosthetic lubrication with the discharge problem.

9.4 Contact Lens Experience with Tear Protein Deposits,

Papillary Conjunctivitis and Discharge

Contact lenses are analogous with prosthetic eye wear. Because of the similarities a
number of problems associated with wearing contact lenses have implications for
prosthetic eyes including tear protein deposits, papillary conjunctivitis and dis-
charge. Before the introduction of rigid gas-permeable and hydrogel (soft) lenses,
the majority of contact lenses were made from PMMA, the same material used for
manufacturing prosthetic eyes.
Contact lens-induced papillary conjunctivitis (CLPC) or giant papillary conjunc-
tivitis (GPC) associated with contact lens wear was first reported by Spring in 1974
[20]. Donshik [21] found that 85 % of reusable soft contact lenses resulted in CLPC
compared with only 15 % of RGP lenses. CLPC may develop spontaneously after
many years of successful contact lens wear and often occurs in one eye and not the
other. The symptoms of CLPC usually come before papillary conjunctivitis is
observed and there is a poor correlation between symptoms and observed enlarged
papillae. The symptoms of CLPC or GPC are excess mucus production, itching,
reduced contact lens tolerance and blurred vision due to mucus smearing and depo-
sition. The cause of CLPC is a combination of an immune response to antigenic
protein deposits and physical trauma to the conjunctiva adjacent to the surface and
edge of the lens [22]. GPC occurs more frequently in allergy sufferers and is also
seen with vernal keratoconjunctivitis in the absence of a contact lens and in ocular
prosthetic wear. CLPC will resolve once contact lenses are removed, but where this
is impractical, most cases will respond to improved contact lens hygiene and condi-
tion [21] which targets eliminating or reducing deposits and improving the physical
interface of the lens with the conjunctiva.
Tear protein deposition on contact lenses is not always associated with CLPC
[23] as disposable soft lens may cause these symptoms, while extended wear rigid
gas-permeable (RGP) lenses seldom develop CLPC [24]. Lever et al. concluded
that lens bound protein was not the primary cause of lens discomfort or intoler-
ance when they found no correlation between total protein deposited and patient
comfort [25].
Protein deposition on contact lenses is greatly affected by the material of the lens
with surface charge and water content being the main determinants of the amount of
protein deposited and/or absorbed into the lens material. One of the major tear pro-
teins that adhere to contact lens materials is lysozyme, an enzyme that acts as a mild
antiseptic. It has been shown that lysozyme serves as a natural bio-protective coat-
ing for the lens provided the quality of the protein structure in terms of molecular
conformational integrity is maintained [26].
9.5 Personal Prosthetic Eye Cleaning Regimes and Professional Polishing 253

9.5 Personal Prosthetic Eye Cleaning Regimes

and Professional Polishing

The nature of tear protein deposits on prosthetic eyes; the impact of removing,
cleaning and reinserting prosthetic eyes; and a three-phase model of prosthetic eye
wear were components of a discussion in the previous chapter that supported a per-
sonal maintenance regime for prosthetic eye wearers. The recommended prosthetic
eye cleaning regime avoids unnecessary handling of the prosthesis and preserves
surface deposits for up to 6 months at a time. This regime is critical for the manage-
ment of non-specific mucoid discharge and is probably more important than profes-
sional repolishing. In a survey of prosthetic eye wearers, 62 % reported no
improvement in discharge following professional repolishing or that any improve-
ment lasted less than 1 month. Only 5 % reported that the improvement lasted lon-
ger than 6 months [17] (Fig. 9.18). However, professional maintenance is important
for long-term prosthetic eye wearing comfort and the management of discharge.
The build-up of deposits on prosthetic eye surfaces occurs in two distinct areas:
the retro-palpebral zone where deposits are in continuous contact with the conjunc-
tiva and the inter-palpebral zone where deposits are exposed to the air and the action
of the eyelids. Deposits forming in the retro-palpebral area are important for pros-
thetic eye comfort and for minimising non-specific mucoid discharge, while

Lasting effect of re-polishing artificial eyes

100 %
90 %
80 %
70 %
Percentage of
participants

60 %
50 %
40 %
30 %
20 %
10 %
0%
t

ks

th

re
en

th

th

th
on

su
ee

on

on
em

m
w

ot
3

m
ov

N
≤2

<

6
pr

ks

ks

<

>
im

ee

ee

s
th
w
o

m
N

3
>

>

>

Lasting effect of polish improvement

Fig. 9.18 The duration of the effect on discharge experience of professional repolishing (Published
with kind permission of Dove Medical Press Ltd. Clinical Ophthalmology Journal. All rights reserved)
254 9 Mucoid Discharge Associated with Prosthetic Eye Wear

Wetting angle vs surface finish

100

90

80

70
Wetting angle

60
(degrees)

50

40

30

20

10

0
Low Normal High

Surface finish

Fig. 9.19 Wetting angles of different PMMA surface finishes. High wetting angles indicate that sur-
faces are less wettable than surfaces with low wetting angles. Bars indicate standard error (Published
with kind permission of Dove Medical Press Ltd. Clinical Ophthalmology Journal. All rights reserved)

deposits forming in the inter-palpebral zone dry out and cause problems. Professional
maintenance focuses on the inter-palpebral area where encroaching deposits dena-
ture through drying and impede the cleansing action of tears and the smooth action
of the eyelids over the prosthesis. It is important that this area is kept as clear of
deposits as possible and the best way to achieve this is to polish out micro-scratches
and restore the surface to the highest possible standard of finish. An optical quality
contact lens standard of finish has been shown to produce more wettable surfaces
than lesser standards [13] (Fig. 9.19), and prostheses polished to this high standard
are likely to attract less deposition in the inter-palpebral zone. This results in less
frictional irritation of the tarsal conjunctiva and less troublesome mucoid
discharge.

9.6 Proposed Protocol for Managing Non-specific Mucoid

Discharge

The following protocol for managing non-specific mucoid discharge associated

with prosthetic eye wear is recommended [27]. The evidence for the elements that
make up the protocol has been obtained from research results, from the three-phase
model of prosthetic eye wear described in Chap. 8 and from the above discussion
9.6 Proposed Protocol for Managing Non-specific Mucoid Discharge 255

Evidence based protocol for managing mucoid

discharge

1. Prosthetic eyes should not be removed and cleaned more

frequently than monthly

2. All patients should clean their prostheses at least 6 Personal

monthly care

3. A method for cleaning prosthetic eyes is by firmly wiping

all surfaces with a paper towel wetted with cold water

4. Prosthetic eyes should be blemish free with smooth

rounded edges and polished to optical quality contact lens
standard Professional
care
5. Prosthetic eyes should be professionally re-polished
to optical quality contact lens standard

Fig. 9.20 Summary of protocol for managing discharge associated with prosthetic eye wear

about personal prosthetic eye cleaning regimes and professional polishing stan-
dards. This evidence is summarised in the protocol presented below (Fig. 9.20).

9.6.1 The Protocol Has Five Elements as Follows

1. Prosthetic eyes should not be removed and cleaned more frequently than monthly.
Cleaning removes surface deposits, reduces the wettability of the prosthesis
and reduces the ability of socket fluids to lubricate. A certain level of surface
deposition is needed for the socket fluids to be able to lower frictional irritation
on the conjunctiva and lessen the likelihood of the mucoid discharge response.
Mechanical irritation caused by removing the prosthesis and the introduction of
foreign materials and bacteria into the socket occurs with cleaning and should be
minimised. Pine et al. demonstrated that the presence of deposits was associated
with less inflammation and discharge and that deposits do not inflame the con-
junctiva of patients who do not clean frequently. The reason for this is that the
presence of deposits improves the lubricating properties of socket fluids [17].
The improvement in discharge characteristics between ≤ weekly and monthly
cleaning reported by Pine et al. suggests that prosthetic eyes can and should be
left undisturbed for at least 1 month.
Beyond monthly, the length of time before deposits should be cleaned off may
vary for individuals with medical conditions (e.g. contact lens-induced papillary
conjunctivitis occurs more frequently in allergy sufferers [21]), or the amount of
deposition which varies between wearers and between the eyes of the same
256 9 Mucoid Discharge Associated with Prosthetic Eye Wear

wearer [28]. The length of time may also depend on the patient’s environment
and the surface finish of the prosthetic eye as this affects the rate of deposition
[17] and, potentially, the period between cleanings.
2. All patients should clean their prostheses at least 6 monthly.
Cleaning at least 6 monthly is an arbitrary time, but deposits accumulate con-
tinuously and after 6 months of wear may be thick enough to batter the conjunc-
tiva and begin encroaching on the inter-palpebral zone.
Wide variation in the amount of deposits between patients has been reported
in the contact lens literature [28]. Therefore, the ideal cleaning regime for most
individuals will be influenced by medical conditions such as allergies, the wear-
ing environment and the standard of surface finish of the prosthesis but will lie
between monthly and 6 monthly parameters.
3. A method for cleaning prosthetic eyes is by firmly wiping all surfaces with a
paper towel wetted with cold water.
This cleaning method is simple and its use ensures that all surface deposits are
removed effectively. The qualitative evidence for this cleaning method is based
on the authors’ experience of removing stained deposits from over 350 prosthetic
eyes. The effectiveness of the recommended method was able to be judged
because the deposits are visible when stained. Other methods trialled included
using wetted tissue paper (too fragile), industrial strength paper towels (degraded
the surface polish), wetted cloth (just as effective as a wetted paper towel but not
disposable after cleaning) and soap and warm water with fingers (difficult to
remove all deposits). Interestingly, rubbing with a dry paper towel or dry tissue
polished the deposits to a high gloss but did not remove them (Fig. 9.21).
4. Prosthetic eyes should be blemish-free with smooth rounded edges and polished
to optical quality contact lens standard.

Fig. 9.21 Cleaning deposits

with a dry tissue polishes
surface deposits but does not
remove them (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
References 257

A perfectly smooth surface avoids mechanical irritation of the conjunctiva

and consequent mucus production. Jones and Collin classified causes of dis-
charge and examined eight patients with discharge using a method based on their
classification. They reported that mechanical irritation from prosthetic eyes with
scratches or chips was a cause of chronic discharge with recurrent symptoms not
responding to topical antibiotics [14].
An optical quality standard of surface finish produces the best available wet-
table surface on PMMA prosthetic eyes. Le Grand recommended this standard
for polishing prosthetic eyes [29], and Pine et al. have used it in in vivo and
in vitro studies to show that an optical quality contact lens standard of surface
polish produced a more wettable surface than a normal standard of finish [11,
17]. An optical quality contact lens standard of polish may be particularly impor-
tant for the inter-palpebral surface to assist the cleansing action of tears.
5. Prosthetic eyes should be professionally repolished to optical grade contact lens
standard annually.
Annual review of anophthalmic patients is indicated to assess the prosthesis
for damage, to reassess fit and to assess the socket for signs of post-enucleation
socket syndrome including ptosis of the upper eyelid and lower eyelid laxity
[30]. Repolishing removes micro-scratches and restores the benefits of an optical
contact lens standard of finish to the prosthesis [17].

References
1. Pine KR, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing artificial
eyes. Clin Experiment Ophthalmol. 2011;39(1):47–52.
2. Clarke A. Psychosocial aspects of facial disfigurement: problems, management, and the role of
a lay-led organization. Psychol Health Med. 1999;4:127–42.
3. Benitez-del-Castillo JM. How to promote and preserve eyelid health. Clin Ophthalmol.
2012;6:1689–98.
4. Arita R, Itoh K, Inoue K, et al. Contact lens wear is associated with decrease of meibomian
glands. Ophthalmology. 2009;116:379–84.
5. Jang SY, Lee SY, Yoon JS. Meibomian gland dysfunction in long standing prosthetic eye wear-
ers. Br J Ophthalmol. 2013;97(4):398–402.
6. Kim SE, Yoon JS, Lee SY, Kim SE, Yoon JS, Lee SY. Tear measurement in prosthetic eye users
with Fourier-domain optical coherence tomography. Am J Ophthalmol. 2011;149(4):
602–7.e1.
7. Macsai MS. The role of Omega-3 dietary supplementation in blepharitis and meibomian gland
dysfunction (MGD). Trans Am Ophthalmol Soc. 2008;106:336–56.
8. Vardizer Y, Lang Y, Mourits MP, et al. Favorable effects of lacrimal plugs in patients with an
anophthalmic socket. Orbit. 2007;26:263–6.
9. Dykewicz MS, Hamilos DL. Rhinitis and sinusitis. J Allergy Clin Immunol.
2010;125:S103–15.
10. Anderson JN, Storer R. Immediate and replacement dentures. Oxford: Blackwell Scientific
Publishing; 1966.
11. Patel V, Allen D, Morley AM, et al. Features and management of an acute allergic response to
acrylic ocular prostheses. Orbit. 2009;28:339–41.
12. Smith DC, Bains MED. Residual methyl methacrylate in the denture base and its relation to
denture sore mouth. Br Dent J. 1955;98:55–8.
258 9 Mucoid Discharge Associated with Prosthetic Eye Wear

13. Pine KR, Sloan B, Jacobs RJ. Deposit buildup on prosthetic eye material (in vitro) and its
effect on surface wettability. Clin Ophthalmol. 2013;7:313–9.
14. Jones CA, Collin JR. A classification and review the causes of discharging sockets. Trans
Ophthalmol Soc UK. 1983;103(3):351–3.
15. Pine K, Sloan B, Stewart J, Jacobs RJ. A survey of prosthetic eye wearers to investigate mucoid
discharge. Clin Ophthalmol. 2012;6:707–13.
16. Vasquez RJ, Linberg JV. The anophthalmic socket and the prosthetic eye. A clinical and bac-
teriologic study. Ophthal Plast Reconstr Surg. 1989;5(4):277–80.
17. Pine KR, Sloan B, Jacobs R. Deposit build-up on prosthetic eyes and the implications for
conjunctival inflammation and mucoid discharge. Clin Ophthalmol. 2012;6:1–8.
18. Allen L, Kolder HE, Bulgarelli EM, Bulgarelli DM. Prosthetic eyes and tear measurements.
Ophthalmology. 1980;87(2):155–7.
19. Fett DR, Scott R, Putterman AM. Evaluation of lubricants for the prosthetic a. eye wearer.
Ophthal Plast Reconstr Surg. 1986;2(1):29–31.
20. Spring TF. Reaction to hydrophilic lenses. Med J Aust. 1974;1(12):449–50.
21. Donshik PC. Extended wear contact lenses. Ophthalmol Clin North Am. 2003;16(3):305–9.
22. Donshik PC. Giant papillary conjunctivitis. Trans Am Ophthalmol Soc. 1994;92:687–744.
23. Gellatly KW, Brennan NA, Efron N. Visual decrement with deposit accumulation on HEMA
contact lenses. Am J Optom Physiol Opt. 1988;65(12):937–41.
24. Grant T, Holden BA, Rechberger J. Contact lens related papillary conjunctivitis (CLPC).
Influence of protein accumulation and replacement frequency. Invest Ophthalmol Vision Sci.
1989;30(3 Suppl):166.
25. Lever OW, Groemminger SF, Allen ME. Evaluation of the relationship between total lens
protein deposition and patient-rated comfort of hydrophilic (soft) contact lenses. ICLC.
1995;22(1):5–13.
26. Subbaraman LN, Glasier M, Varikooty J, Srinivasan S, Jones L. Protein deposition and clinical
symptoms in daily wear of etafilcon lenses. Optom Vis Sci. 2012;89(10):1450–9.
27. Pine KR, Sloan B, Jacobs RJ. A proposed model of the response of the anophthalmic socket to
prosthetic eye wear and its application to the management of mucoid discharge. Med
Hypotheses. 2013;81(2):300–5.
28. Keith DJ, Christensen MT, Barry JR, Stein JM. Determination of the lysozyme deposit curve
in soft contact lenses. Eye Contact Lens. 2003;29(2):79–82.
29. LeGrand JA. Chronic exudate: an unnecessary evil. J Ophthalmic Prosthet. 1999;4(1):33–40.
30. Ophthalmology Unit, University of Malaysia Sarawak. Post enucleation socket syndrome.
http://www.sarawakeyecare.com/Atlasofophthalmology/Oculoplastic/picture26postenucle-
ationsocketsyndrome.htm. Accessed 27 Jun 2015.
Living with a Prosthetic Eye
10

Contents
10.1 Introduction ................................................................................................................... 259
10.2 Handling Social Interactions ......................................................................................... 260
10.3 Reduced Peripheral Vision and Altered Depth Perception ........................................... 262
10.3.1 Compensating for Reduction of Horizontal Visual Range ............................. 262
10.3.2 Compensating for Altered Depth Perception .................................................. 263
10.3.3 Additional Cues to Depth Perception ............................................................. 268
10.3.4 Utilizing Other Senses .................................................................................... 268
10.3.5 Driving with Monocular Vision ...................................................................... 268
10.4 Personal Socket Hygiene and Prosthetic Eye Care ....................................................... 272
10.5 Caregiver Guide to Removing and Inserting a Prosthetic Eye...................................... 273
10.6 Patient Guide to Removing and Inserting a Prosthetic Eye .......................................... 275
10.7 Cleaning Prosthetic Eyes .............................................................................................. 276
10.8 Selecting Glasses for Protection and Camouflage ........................................................ 278
10.9 Further Resources ......................................................................................................... 280
References ................................................................................................................................ 281

10.1 Introduction

This chapter contains information for patients and caregivers on a wide range of
issues that prosthetic eye wearers encounter in their daily lives. It provides guides
for handling social interactions, coping with the impact of monocular vision and
living with prosthetic eyes generally. The writing style of this chapter is different
from the rest of this book so that practitioners may reproduce the sections more
readily for their patients’ use. The chapter is mainly directed towards people who
wear a single prosthetic eye, but many of the issues also apply to people who have
lost both eyes and wear two prostheses. The chapter begins with a section on han-
dling social interactions and reflects advice given to people with disfigurements

© Springer International Publishing Switzerland 2015 259

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_10
260 10 Living with a Prosthetic Eye

provided by the “Changing Faces” organisation. It then discusses the effects of

reduced peripheral vision and altered depth perception, inserting and removing a
prosthetic eye, personal socket hygiene and prosthetic eye care and, finally, tips for
selecting glasses.

10.2 Handling Social Interactions

The psychological impact of eye loss has been discussed in Chap. 1, but this guide
approaches the subject from a more personal standpoint. This guide explains that
people communicate with their eyes and provides advice about how you might han-
dle other people’s reactions to your altered appearance.
Obviously, the primary use of the eyes is to enable us to see; however, eyes also
play an important role in non-verbal communication and self-expression. When an
eye is lost, it is not only the loss of function (reduced depth perception, less side
vision, etc.) but your self-image and communication style may be dented as well –
at least in the short term. It takes time to adjust to your new appearance as well as to
the perceptual changes that you have experienced. If you have recently lost an eye,
you may well recognise in yourself the five stages of grieving that many people go
through when they go through a similar experience of loss: denial, anger, bargain-
ing, grief and acceptance [1].
It is entirely natural to feel anxious about your appearance, especially in social
encounters with people you don’t know well. However, if your self-consciousness
has made it difficult for you to make eye contact with others, this can make you feel
even more anxious because looking at others’ eyes is how you connect with them.
It is also how they connect with you. Research shows that in terms of social interac-
tion, good communication and social skills are much more important than how you
appear [2].
During a conversation, you focus on the other person’s face and, in particular,
their eyes. You are interested to know if they are looking at you directly or looking
away distractedly. You often gain more information from their facial expressions
than by what they actually say. This non-verbal communication is the same for the
person talking with you, and it can be disconcerting for them if you do not make eye
contact in the way they expect. Worse, they may think that you are not engaging
with them, being rude, or not interested in what they are saying. Additionally if you
do make eye contact and if at first glance your eyes do not appear as expected, they
may not know how to look at you. Most people expect to make eye contact with two
identical eyes and may not know which eye to look at or how to avoid staring if one
of your eyes is slightly different. Staring is socially unacceptable of course, and if
this is their reaction, it could be interpreted wrongly by you with the result that you
both end up with high anxiety levels and not wanting to prolong the meeting [3].
The responsibility for managing social interactions mostly lies with you, and it is
up to you whether or not you put your friends, work colleagues and others at ease
when they communicate with you. In the beginning though, you may need to address
your own communication skills by practising direct eye contact. Make a list of
10.2 Handling Social Interactions 261

people you come into contact with every day and start practising normal eye contact
with those who you know and trust the best before moving on to the others [4]. It
may feel awkward at first because of your shyness, but very soon you will be able to
maintain eye contact for about 4 s when it is natural for you to look away. You will
normally look at people’s eyes for longer periods when you are listening than when
you are talking. When making eye contact, you should be able to move your focus
from one eye to the other without embarrassment as almost all prosthetic eyes have
at least this much movement. If your prosthesis is one of the few that refuses to
move, you can focus on the bridge of the other person’s nose instead. With practice,
your eye contact skills will improve, and your anxiety levels will drop accordingly.
Being proactive with others about your prosthetic eye can help them communi-
cate with you more easily, and by raising the issue yourself, you will feel more in
control. Of course, many prosthetic eyes are indistinguishable from the real thing,
and in these situations, it might be better to simply carry on as if nothing is amiss.
Sooner or later, however, somebody somewhere will ask you about your eye, and it
is important that you are ready for this and have some answers prepared in your
mind. At the very least, your immediate family and friends should be told about
your prosthetic eye as you will save yourself many anxious moments worrying
about their reaction if/when they find out. People close to you will always be sup-
portive as it is you as a complete dynamic package that they know and love – not
just your eye.
The following suggestions are designed to get you thinking about what you
might say in certain situations [4].

Situation: A small child asks directly: What is wrong with your eye?
Response: I had an accident (or operation) but the eye is ok now.

This simple answer satisfies the child’s curiosity and shuts down the
conversation.

Situation: A new partner asks: What happened to your eye?

Response: I will tell you about it sometime, but not right now because I’m a little
sensitive about it.

This answer shows that your eye is a personal issue which you are willing to
share when your relationship has become more intimate and trusting.

Situation: At a job interview your potential employer asks: What happened to your
eye?
Response: It was injured in an accident but my vision is fine and it has helped me in
my previous jobs by making me more aware of the feelings of others. Another
advantage is that people always remember me.

This answer shows that your eye does not affect your ability to work and that you
are comfortable with your appearance and about who you are.
262 10 Living with a Prosthetic Eye

Situation: A stranger is staring at you persistently.

Response: Please don’t stare at me – my eye doesn’t bother me so why should it
bother you.

This answer turns attention to the other person and shows you are able to stand
up for yourself.

10.3 Reduced Peripheral Vision and Altered Depth

Perception

Following the loss of an eye, you will discover that your peripheral vision is more
limited on one side and that you have difficulty judging distances at close range.
However, provided your remaining eye has good vision, you can carry on doing
virtually all the things you were doing previously.
While the loss of your eye will be disorientating at first, it will usually not stop
you from driving, reading, watching TV, playing sport or anything that else that you
were doing previously. Even for people whose occupations rely upon good periph-
eral vision such as police officers, airline pilots, firefighters, etc., and others who
rely upon good depth perception such as seamstresses, surgeons, waitresses, forklift
operators, etc., there are usually ways to get back on the job. All it takes is some
time to adapt and retrain the brain to compensate for the sudden change from stereo-
scopic vision to monocular vision (from two-eye vision to one-eye vision). This is
not to say that your peripheral vision and depth perception will be fully restored, but
rather that you will develop strategies and behaviours to overcome their loss.
However, it does take time to adjust. Hopefully, this guide will help.
The way you perceive most things now is still exactly the same as it was when
you had two eyes, so it is important not to overstate your limitations. This is because
the difference between you seeing with one eye and with two eyes is confined to a
reduction in your horizontal field of view by only 10–20 % and a loss of some cues
to depth perception at distances less than 7–8 m [5].

10.3.1 Compensating for Reduction of Horizontal Visual Range

Dealing with your reduced peripheral vision is achieved naturally by simply moving
your head towards the side of the lost eye and scanning in that direction a little more
frequently than you used to [6]. The purpose of this head movement is simply to
remove the bridge of your nose from obstructing the view to that side so that you
can scan in that direction with your good eye. There are some situations however
where a degree of organisation beforehand will be very helpful [4]. For example,
when walking along with friends or acquaintances, try to position them on your
sighted side as it is easier to talk with them when they are on that side. Preplanning
is also important at the dinner table to avoid being stuck with having to turn your
head excessively if the person you engage with most is on your blind side (Fig. 10.1).
10.3 Reduced Peripheral Vision and Altered Depth Perception 263

Horiz
ontal
visua
l rang
e

Fig. 10.1 Preplanning is important at the dinner table. Place the person you are most interested in
on your good side (Published with kind permission of NZ Artificial Eye Service. All rights
reserved)

Also at the dinner table, be on the lookout for the person serving you. He or she may
sneak up on your blind side with disastrous consequences if you are just about to
make wide hand gestures in conversation. You also need to develop the habit of
checking your “blind” side when you are about to change direction and move
towards that side [6]. This will save you many embarrassing bumps and apologies.
And it is not just people you bump into when changing direction without checking
but hard objects as well. Ouch!
Compensating for your restricted peripheral vision in various situations requires
time to become proficient. You may wish to start by having someone walk alongside
you switching sides a couple of times so that you can experience the difference and
can get used to moving your head naturally to compensate for your limited horizon-
tal visual range [6]. At your workbench or desk, the discrete use of mirrors, strategi-
cally positioned on your blind side, may help you overcome any problems [7]
(Fig. 10.2). Similarly, extra mirrors or special wide rear view mirrors can be fitted
to your car to enable you to cover blind spots [6].

10.3.2 Compensating for Altered Depth Perception

Your altered depth perception may take more time and effort to get used to than the
reduction in your horizontal visual range. There are many cues to depth and you
have only lost those associated with stereoscopic vision. The most useful cue that
you still retain is relative motion. Relative motion occurs when one object is moves
past another. For example, when near objects move across other objects in the back-
ground, the shift in the relative position of the objects is picked up by the brain and
used as a measure of the distance separating them (Fig. 10.3).
264 10 Living with a Prosthetic Eye

Fig. 10.2 The discrete use of

mirrors, strategically
positioned on your blind side, Mirror
helps to overcome any
problems at your workbench
or desk (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Enha
nced
vis
range ual
.

1 2 3
2

Fig. 10.3 When near objects move across other objects in the background, the shift in their rela-
tive positions is picked up by the brain and used as a measure of distance (Published with kind
permission of NZ Artificial Eye Service. All rights reserved)
10.3 Reduced Peripheral Vision and Altered Depth Perception 265

a b

Fig. 10.4 If you stand to one side as a ball approaches, the visual angle between you and the ball
changes enabling your brain to compute its approach (a). The angle of approach does not change
when a ball comes straight at you and its distance is much harder to compute (b) (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

Relative motion can be exploited by you in many situations, for example, when
catching a ball. Provided you do not stand directly in the ball’s path, the visual angle
between you and the ball changes as it approaches. Your brain computes this infor-
mation and translates it into action – you catch the ball. The angle of approach does
not change when a ball comes straight at you and its distance is much harder to
compute [6, 7] (Fig. 10.4). So the lesson is, ‘always step to one side to catch a ball’.
Another situation where you can make good use of relative motion is when you
approach steps going down such as a curb. If you watch the edge of the step or curb
as you approach and if you are observant, you will notice some relative motion
266 10 Living with a Prosthetic Eye

a
b
Low curb
High curb

Fig. 10.5 The relative motion between the curb edge and the road surface increases when the curb
is higher (B) and decreases when it is lower (A) (Published with kind permission of NZ Artificial
Eye Service. All rights reserved)

between the edge and the lower surface beyond. When the step down is greater, the
relative motion is larger [7] (Fig. 10.5). Actually, this cue to depth is also the main
one used by people with two eyes, so you will have no trouble adjusting to it. This
goes for all situations where heights or distances between horizontal surfaces are
being judged.
Relative motion can be consciously generated by you whenever you need to
determine the distance of any object closer than 7 m. You might like to demonstrate
this for yourself by sitting at a table and placing two glasses in front of you, one
placed further back than the other. Move your head from side to side or up and down
and observe the relative motion of the glasses against the background. The back-
ground behind the nearest glass moves more than the background behind the fur-
thermost glass, and thus your brain can detect which glass is closest (Fig. 10.6). The
technical name for this phenomenon is motion parallax.
With practice, you will quickly develop the skills to utilise relative motion as
your primary technique for perceiving depth when walking, running, driving, pole
vaulting, etc. And when not moving, you can still learn to perceive depth by moving
your head around.
10.3 Reduced Peripheral Vision and Altered Depth Perception 267

a b c d

Fig. 10.6 When moving your head from side to side, the background behind the nearest object
moves more (A, B) than the background behind the furthermost object (C, D), thus enabling your
brain to detect which object is closest This is called parallax. (Published with kind permission of
NZ Artificial Eye Service. All rights reserved)
268 10 Living with a Prosthetic Eye

10.3.3 Additional Cues to Depth Perception

Besides relative motion, there are a number of other cues to depth perception that
you can exploit such as perspective (distant objects appear smaller than closer
objects), contrast (distant objects are blurred and less colourful than closer objects)
and overlap (distant objects are overlapped by closer objects) (Fig. 10.7). See
Chap. 1 for more information about monocular depth perception.

10.3.4 Utilizing Other Senses

Perceiving depth does not rely solely on visual cues as other senses can also be
utilised. For example, when pouring a cup of coffee, you can extend the coffee pot
towards the cup and touch it lightly to the edge of the cup before pouring (Fig. 10.8).
This act involves your sense of touch and your sense of proprioception (knowing
where parts of your body, e.g. your hand are) as well as your sight. Note that it is
easier to reach towards the cup front-on rather than swiping at it from the side. This
is also the case in a number of other situations such as approaching a door knob, a
glass on the table or a friendly hand shake [7].
Another situation where your senses of touch and proprioception come in handy
is stepping down off the last step when descending a staircase. This is different from
approaching a curb where you can utilise relative motion. Stepping down is a hazard
for you because it is hard to differentiate the last step from the ground beyond and
below it. In this situation, it is better to err on the side of caution by firstly using a
hand rail and, secondly, by reaching for the ground with your toe before stepping
out on to it.
Your hearing is another sense that helps you compensate for your reduced visual
range. You will rely on your hearing to ‘sense’ people coming up on your blind side
and also to help keep you safe when crossing the road. Hearing alone, however, will
not prevent you from being run down, and you should get into the habit of looking
carefully to each side before stepping out (Fig. 10.9).

10.3.5 Driving with Monocular Vision

There is an infinite number of activities that will challenge you during the period of
adjustment from stereoscopic to monocular vision, but the one that likely concerns
most people is driving. Whether it is driving a motorcar, a truck, a boat or an aero-
plane, you will need to call upon all the perceptual techniques mentioned above.
And the sooner you start practising, the sooner you will regain your confidence.

10.3.5.1 Legal Requirements

You should be aware of legal requirements for getting back on the road. These vary
according to the type of vehicle you drive and the state or country that you live in.
For example, if you live in the UK, you do not need to notify the ‘Driver and Vehicle
10.3 Reduced Peripheral Vision and Altered Depth Perception 269

Fig. 10.7 The depths between the various components of this photograph are easy to interpret
with one eye using cues to depth perception. Observe the sizes of the girls’ hands for perspective
and overlap and at the clarity of the foreground compared to the background for contrast

Fig. 10.8 When pouring a

cup of tea, extend the tea pot
towards the cup and touch it
lightly before pouring. It is
easier to come at the cup
front-on rather than swiping
at it from the side

Licensing Authority’ (DVLA) to drive a car unless you cannot read a car number
plate from 20 m or your eyesight is worse than 6/12 on the Snellen scale according
to an optometrist or doctor – or you have any problem with the field of vision of
your remaining eye. If you drive a bus, coach or lorry, however, the DVLA requires
you to notify them [8].
270 10 Living with a Prosthetic Eye

Hor
izon
tal v
isua
l ran
ge

Fig. 10.9 Hearing alone will not prevent you from being run down when crossing the road, and
you should get into the habit of looking carefully to each side before stepping out (Published with
kind permission of NZ Artificial Eye Service. All rights reserved)

Other jurisdictions appear to have similar rules based on minimum visual acuity and
visual field standards. For example, in the USA, all 50 states as well as the District of
Columbia license monocular drivers provided they meet legal eyesight standards [7].

10.3.5.2 Tips for Driving

Start by practising driving in an empty parking lot when no other cars are around. It
will pay to have somebody with you as, initially, the driving experience is very dif-
ferent from what you have been used to and you can expect to be quite uncomfort-
able [9]. Once you have graduated from the car park, you should have little difficulty
handling most driving situations; however, some situations are more challenging
than others, and you should plan to tackle them in your own time rather than be
caught unawares. Negotiating narrow streets and threading your way between
parked cars is particularly difficult and made more so when driving against oncom-
ing traffic. Try to have somebody with you when you attempt this for the first few
times as they will spare you unwanted stress (and loss of paint). When possible,
follow the car in front and do what it does. If there is no car to lead you, get your
passenger to concentrate on one side while you concentrate on the other. If you have
no car to lead you and no passenger, assess the road width and drive as close to the
driver’s side of the available space as possible (with your head out the driver’s win-
dow if necessary) and trust that the other side will take care of itself. If you encoun-
ter oncoming traffic, be the first to pull over where the street is wide enough and let
it come on through [7].
10.3 Reduced Peripheral Vision and Altered Depth Perception 271

Fig. 10.10 The pattern of light on a wall changes as you approach and can be used as a measure
of how close you are when parking (Published with kind permission of NZ Artificial Eye Service.
All rights reserved)

Another area of difficulty to watch out for occurs when you are driving on a
multilane highway and another driver begins to overtake and then changes his or her
mind and continues on at the same speed as you. This is a particularly trying situa-
tion because without relative motion it is difficult for you to assess the distance
separating you and the other vehicle. The solution of course is to accelerate away or
slow down. Either way, you need to remove yourself from this situation as quickly
as possible.

10.3.5.3 Tips for Parking

Parking your car presents challenges of a different sort and requires patience and
a degree of acceptance that you may never be quite as good at this as you were
previously. However, there are a number of tricks that will help, such as placing a
mark on the wall of the garage or hanging a rope so that the free end touches your
windscreen when you arrive at your predetermined position. When parking close
up to a wall in front of you, you might try turning on the headlights and taking
note of how the pattern the light moves across the wall as you get closer. If you
place a mark on the wall corresponding to the edge of the beam when you have
reached your final parking position, you will always be able to find the spot again
(Fig. 10.10). And finally, when parking between two cars, keep as close to the
driver’s side of the space as possible and trust that the other side will take care of
itself [7].
272 10 Living with a Prosthetic Eye

10.3.5.4 Driver Safety Technology

Every year new motor vehicles deliver more and more advanced technology for the
benefit of driver safety and convenience. Much of this technology actually benefits
monocular drivers more than binocular drivers. Examples of such technology
includes: gap sensing cruise control that keeps the car a constant distance behind the
vehicle in front, automated parking programmes, sensors that detect close objects
and follow central road markings, rear vision video and wide angle driver adjusted
mirrors. New car technologies have virtually cancelled out monocular driving con-
cerns and created a level playing field for all drivers, individual differences
notwithstanding.

10.4 Personal Socket Hygiene and Prosthetic Eye Care

The protocol for managing mucoid discharge associated with prosthetic eyes sug-
gests that prosthetic eyes should not be removed and cleaned more frequently than
monthly and not less frequently than 6 monthly. There is wide variation between
individual patients and their environments, and it is up to you to experiment with
different regimes within the suggested time parameters to determine which one
reduces tearing and discharge to a minimum in your particular case. It is important
however that socket and eyelid hygiene is maintained even though your prosthesis
is not removed very often. This is achieved with daily washing and/or showering as
it is with your sighted eye. You may need to be a bit more particular with your
socket to ensure that your eyelashes are clean and clear of mucus residues, but no
special procedures are necessary as a rule.
If an episode of inflammation and/or discharge occurs, you may still cleanse
your socket without removing your prosthesis by syringing it with a tepid eye
wash solution or sterile saline (Fig. 10.11). Tilt your head (socket side downward)

Fig. 10.11 The socket may

be cleansed with a syringe
without removing the
prosthesis (Published with
kind permission of NZ
Artificial Eye Service. All
rights reserved)
10.5 Caregiver Guide to Removing and Inserting a Prosthetic Eye 273

and place the tip of a rubber bulb syringe or squeeze bottle against the inside edge
of your prosthetic eye. Support the syringe against your nose and irrigate the
socket while using your free hand to prevent the prosthesis from being flushed
out. Ensure that the liquid waste does not splash into your good eye as it may
contaminate it.
This syringing technique may also be used in conjunction with treatments rec-
ommended for meibomian gland dysfunction or other socket pathologies.

10.5 Caregiver Guide to Removing and Inserting

a Prosthetic Eye

Prosthetic eyes are worn continuously, but from time to time, they must be removed
for inspection and for cleaning. After washing your hands thoroughly with antibac-
terial soap and rinsing any residue completely away, position yourself directly in
front of the patient. Ask the patient to look upwards, place your forefinger on the
lower eyelid (over the eyelashes) and press the eyelid downwards. When the lower
edge of the prosthesis comes into view, press the eyelid inwards and then also gently
sideways away from the nose. This stretches the eyelid and causes it to slide under
the prosthesis lifting it out. If the prosthesis does not fall out by itself, hold the lower
eyelid steady, and with the thumb of your free hand, lift the upper eyelid to free the
prosthesis (Fig. 10.12).
Some prosthetic eyes are quite difficult to remove, and in these cases a smooth
instrument such as a glass rod may be carefully inserted under the lower edge of the
prosthesis and used as a lever to bring the prosthesis forwards and out. Alternatively,
a soft rubber suction cup, supplied from a number of sources online, may be used.
The suction cups have a hollow stem which when squeezed and released creates a
vacuum enabling the cup to adhere to the front of the prosthesis. Once the suction

Fig. 10.12 Removing a

patient’s prosthetic eye. The
caregiver’s forefinger slides
the lower eyelid under the
prosthesis while the patient is
looking upwards (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)
274 10 Living with a Prosthetic Eye

cup is attached, it is a relatively simple matter to manoeuvre the prosthesis out of the
socket. The cup is detached from the prosthesis by squeezing the stem and releasing
the vacuum (Fig. 10.13).
Inserting a prosthetic eye is mostly the reverse of removing it. Again, your hands
should be washed with antibacterial soap and rinsed, and you should be positioned
directly in front of the patient. Hold the prosthesis between your forefinger and
thumb and orientate it so that the inside edge (usually the sharpest corner) points
towards the nose (Fig. 10.14). Instruct the patient to look downwards and then lift
the upper eyelid with the thumb of your free hand. Insert the upper edge of the pros-
thesis into the space under the upper eyelid and transfer your thumb to the prosthe-
sis. Hold the prosthesis in place with gentle upward and inward pressure. Use the
forefinger of your freed hand to draw the lower eyelid down until the eyelashes
emerge from behind the prosthesis. Release the eyelid and allow it to spring back up
over the prosthesis.

Fig. 10.13 Rubber suction

cups make it easier to remove
and insert prosthetic eyes
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 10.14 For orientation,

the sharpest and/or pinkest
point (indicated by the arrow)
is positioned towards the nose
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)
10.6 Patient Guide to Removing and Inserting a Prosthetic Eye 275

10.6 Patient Guide to Removing and Inserting

a Prosthetic Eye

Many people are nervous about removing and inserting their prosthetic eye, but it is
important that you learn how to do this for yourself if you are able. Your ocular
prosthetist should supervise your first attempts and ensure that you can manage
your prosthesis independently before you leave the clinic for the last time.
Almost all patients manage to remove and replace their prostheses easily – you
will too with a little practice. Begin the process by washing your hands with anti-
bacterial soap. Rinse well to avoid residual soap stinging the socket and dry your
hands thoroughly so that they are not slippery. Stand in front of a mirror over a basin
covered with a towel to prevent damaging the prosthesis if you accidentally drop it.
You will need both hands to remove your prosthesis (at least in the beginning) so in
order see what is going on in the mirror, lift your arm (right arm if you wear a left
prosthesis or left arm if your prosthesis is on your right) and approach your prosthe-
sis from above with that arm. Look upwards and place the middle finger of your
uppermost hand on the surface of the prosthesis and roll it up taking your top eyelid
with it. This will lift the lower edge of your prosthesis upwards and tilt it forward.
Now place the forefinger of your free hand over the lower eyelid and press it down-
wards then inwards so that your finger nail slides under the prosthesis and pops it
out (Fig. 10.15).
Preparation for inserting a prosthetic eye is the same as when removing the pros-
thesis except that you will most likely have attended to socket and lid hygiene prior
to this step. If you have not done so already, wash, rinse and dry your hands. Stand
in front of a mirror and basin with the same precautions in case the prosthesis slips
and is dropped. Hold your prosthesis between your thumb and middle finger and
orientate it so that the sharpest corner points towards your nose (this may also be the
pink corner). Tilt your head back slightly so you are looking downwards towards the
mirror, and with the middle finger of the hand not holding the prosthesis, approach
your socket from above and lift your upper eyelid. Slide the top edge of the

Fig. 10.15 Removing your prosthesis. Look upwards and roll the prosthesis upwards taking the
top eyelid with it (Left). The forefinger of the free hand then slides under the prosthesis and levers
it out (Right) (Published with kind permission of NZ Artificial Eye Service. All rights reserved)
276 10 Living with a Prosthetic Eye

Fig. 10.16 Inserting your

prosthesis. Look downwards
and use your finger to hold
the upper eyelid up while the
prosthesis is inserted under it
and held (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

prosthesis under the upper eyelid and hold it steadily in place with the lower hand.
Now move the finger holding the top eyelid onto the prosthetic eye; keep it steady
while you use the freed up other finger from the lower hand to pull the lower eyelid
down until your lower eyelashes appear from under the prosthesis. Allow the lower
eyelid to spring back over the prosthesis and let both hands go (Fig. 10.16).
If you cannot remove and insert your prosthesis easily, the rubber suction cups
described above and shown in Fig. 10.13 will make the job easier.
After you have removed and reinserted your prosthetic eye by yourself the first
time, your confidence will increase, and you will soon adapt your method to best
suit you. You may even become expert at removing your eye with one hand although
you will probably always need two hands to insert it.

10.7 Cleaning Prosthetic Eyes

Every day, more deposits build up on prosthetic eyes. These filmy coatings con-
tain tear proteins, lipids and mucins, and while they are beneficial in the short to
medium term, over time they encroach on the front of the prosthesis where they
dry out and become rough. They also thicken and become contaminated with
microorganisms, metabolic waste and environmental debris. The object of clean-
ing a prosthetic eye is solely to remove these deposits, and the cleaning method
needs to accomplish this effectively and efficiently. The coatings and films that
build up on prosthetic eyes behave similarly to other biofilms commonly found in
nature (Fig. 10.17), but because they are too thin to be seen with the naked eye, it
is difficult to tell how they are accumulating. If you have ever come across slime-
covered rocks, you will know how hard dry material is to clean off, but once wet,
the slime comes away easily. It is the same for the coatings and films that build up
on prosthetic eyes – if dry, they are nearly impossible to remove, but once wet,
they are very easy to clean off.
10.7 Cleaning Prosthetic Eyes 277

Fig. 10.17 The coatings and

films that build up on
prosthetic eyes behave
similarly to biofilms found
commonly in nature – e.g.,
the algal slime on the sea
wall shown here

Because prosthetic eye deposits cannot be seen with the naked eye, a number of
cleaning methods in common use may appear to be effective but in reality are not.
For example, using a dry cloth or tissue to clean the prosthesis is useless, as dry
deposits stick like glue. Even though the prosthesis might look clean, it is the depos-
its themselves that become shiny. Rubbing the prosthesis between soapy fingers and
rinsing it off are also ineffective as the detergent does not dissolve the deposits and
not enough even pressure is usually applied to completely eliminate the film of
deposits covering the surface.
The best way to clean a prosthetic eye effectively is to wipe it firmly with a paper
towel wetted with cold water. Do not attempt to clean the prosthesis with a dry paper
towel as it is mildly abrasive in its dry state due to coarser wood fibres and glue used
in its manufacture (e.g. paper towels should never be used to dry spectacle lenses).
However, it is safe to use a wet paper towel on prosthetic eyes.
Wipe the front surface and then the back taking particular care to wipe out irregu-
lar hollows and grooves and then the edges. Wiping with a wet cloth is just as good
as wiping with a wet paper towel, but a cloth is not disposable and is therefore less
hygienic. Using wetted tissue paper is not recommended as it breaks up too easily
under wiping pressure.
Never clean a prosthetic eye with household cleaners or with toothpaste. The
cleaners can dissolve the plastic material, while toothpaste is mildly abrasive. Never
place the eye in hot water. If the water is hotter than you can bear, it is too hot for
the plastic your prosthesis is made from. Never dry the eye with anything but a soft
paper tissue as the surface can easily be scratched. Never let a prosthetic eye dry out.
If you need to leave the prosthesis out for any length of time, place it in a dark con-
tainer of cold water. The reason is that drying may release stresses within the plastic
that makes up the prosthesis, causing delamination.
Your prosthesis should be professionally cleaned and polished once a year. Even if
the eye looks smooth and shiny, microscopic scratches on the anterior surface attract
more deposits which are raised and can dry out and irritate the eyelids. No matter how
diligent you are with your cleaning routine, you cannot recreate a professional optical
quality contact lens finish. This once a year visit to your ocular prosthetist also enables
you to stay in touch and to have your prosthesis and socket assessed on a regular basis.
278 10 Living with a Prosthetic Eye

10.8 Selecting Glasses for Protection and Camouflage

Glasses have lost their nerdy reputation in recent years and are now fashion acces-
sories which people wear even when they have no visual impairment. The main
reason people wear glasses is of course to restore or improve their vision; however,
prosthetic eye wearers get additional benefits such as protection for their surviving
eye and potential camouflage for their prosthesis.
Protecting and enhancing the vision of your sighted eye are of critical impor-
tance to you as you totally depend on this one eye and which is quite vulnerable if
you do not wear protective glasses. Safety glasses for the workplace are mandatory
if the environment has any risks at all, but for you, everyday glasses are also essen-
tial for their protective function. For example, it is not uncommon for a small piece
of grit or dust to lodge in the eye. This is of little consequence for a person with two
eyes as they carry on using their good eye while dealing with the grit and returning
to normal function. For you however, it is a different story – you shut down com-
pletely with potentially disastrous consequences. Another more serious area where
you are vulnerable is in the garden or walking through bush or trees. Ordinary
glasses will easily protect you from protruding twigs or branches, and in this situa-
tion they will protect you from risk of eye injury and infection from the contami-
nants on the vegetation. When selecting glasses, you should look for sturdy frames
and lenses most likely made from polycarbonate which is an exceptionally strong
material used for high-impact safety glasses. You want strong frames but you also
want frames that look fashionable (you may not want to stand out by wearing old
fashioned glasses).
Aside from the main benefit of protecting your sighted eye, glasses also provide
you with an opportunity to partly or completely camouflage any problems in the
appearance of the prosthesis. Such problems may include asymmetries (e.g. move-
ment shortfalls, pupil diameter differences, eyelid recession, etc.) between your two
eyes. The lenses in a pair of glasses may completely hide your eyes if they are dark
sun glass lenses or may partially hide your eyes if the lenses change colour under
different light levels (photochromic or Transitions® lenses tints). Ordinary lenses
reflect 4–6 % of light making your eyes slightly less visible. However, modern
lenses often have an antireflection coat (sometimes in a ‘multicoat’ that protects the
lenses from scratches and makes the lenses smudge resistant) which is designed to
make your eyes more easily seen. While this is good for people taking photographs
of your eyes, you may want to avoid this option and maintain a slight camouflage
behind an ordinary reflecting lens surface (clear uncoated glasses). When using
glasses to disguise your prosthetic eye, it is important to stay within the fashion
boundaries, but note that larger lenses and wider frames cover more of your face
than smaller lenses and frames and that tinted or reflective lenses camouflage your
prosthesis more effectively than lenses with antireflective coatings. It is also possi-
ble to use the magnification effect of lenses to increase or decrease the apparent size
of your prosthetic eye relative to your good eye. Your optometrist can advise in this
situation.
10.8 Selecting Glasses for Protection and Camouflage 279

The best glasses are those that you can wear all the time. This means that they remain
safely perched on your nose and that you can always find them. This is a limitation of
sun glasses which mask your eyes and take away the glare, but are not normally used
indoors or at night. Transitions® or other photochromic lenses are a good general
choice, but their disadvantage is that they may not lighten quickly enough when walking
from a bright day into a darkened area. Separate pairs of clear prescription lenses and
tinted sun glasses are probably best as together these cover all situations.
The following is a summary of the elements you should be aware of when select-
ing glasses to protect your remaining eye and camouflage your prosthesis
(Fig. 10.18).

1. Stay within the fashion trends of the day or pick a timeless design.
2. Choose robust frames and high-impact safety lenses.
3. Discuss the pros and cons of ordinary and tinted lenses with your optometrist,
bearing in mind that the main camouflage effect of glasses is achieved through
light reflecting off the surface of the lenses. Remember that antireflection coat-
ings can be a disadvantage as they make your eyes more easily seen and that
Transitions® style lenses do not yet lighten as fast as they darken.
4. If the hollow over your upper eyelid is too deep, choose a frame shape and size
to help hide the deformity (within the boundaries of current fashions).
5. Frames with broad temples (side arms) will provide more protection and camou-
flage than those with narrow side arms – but be aware that broad temples will cut
off your side vision and can be contrary to your need for full peripheral vision.
6. Try to ensure the temples of the frame are placed high up relative to the frame to
ensure maximum vision when looking sideways.
7. Where there is no need to experiment with the magnification effect of lenses to
increase or decrease the apparent size of your prosthetic eye relative to your
good eye, use glasses with a similar prescription in each lens.

Side arms connect high up so

High impact safety lenses and they do not restrict side vision.
frames protect your natural eye

Broad arms cover

Reflective surfaces disguise more than narrow arms.
deficiencies in movement etc.

Fig. 10.18 Some of the features to look for when selecting glasses (Published with kind permis-
sion of NZ Artificial Eye Service. All rights reserved)
280 10 Living with a Prosthetic Eye

10.9 Further Resources

The following are a number of websites for patients wishing to talk to professional
advisors or fellow prosthetic eye wearers. Some books about living with a prosthetic
eye are also available (Fig. 10.19).

Changing Faces. This is a UK-based charity that provides practical and emotional
support for people who are coping with marks or scars that affect their appear-
ance. www.changingfaces.org.uk
Lost Eye: Coping with Monocular Vision After Enucleation Or Eye Loss From
Cancer Accident Or Disease by Jay Adkisson. iUniverse. 2006. This is a motiva-
tional book for people who have just lost or are about to lose an eye. The book
uses celebrities and others to educate patients by telling their own personal sto-
ries about losing an eye. The website where “Lost Eye” is found also contains a
discussion forum and links to other sites where further information can be found.
www.losteye.com
Kinder Augen Krebs Stiftung. This is a German charity whose aim is to improve
early diagnosis of retinoblastoma, to help affected children and their parents and
to support scientific research into this disease. www.kinderaugenkrebsstiftung.
de/en/the-foundation/foundation/

Fig. 10.19 Support and information for prosthetic eye wearers is available from a number of
organisations and books
References 281

Let’s Face It. This is an international support network for people with facial disfig-
urement, their families, friends and professionals. www.lets-face-it.org.uk
A Singular View by Frank Brady. Michael O. Hughes. 2005. This book is written
from the perspective of the author’s own experience of eye loss. It contains many
useful tips for living with a prosthetic eye. www.asingularview.com
Eye Was There: A Patient’s Guide to Coping with the Loss of an Eye by Slonim M.D.
and Martino M.D. AuthorHouse Publishing. 2011. This is an informative book
targeted at wearers of prosthetic eyes. http://www.amazon.com/Eye-Was-There-
Patients-Coping/dp/1456766635

References
1. Kübler-Ross E. On death and dying. New York: Simon and Schuster; 1969.
2. Clarke A. Psychosocial aspects of facial disfigurement: problems, management, and the role of
a lay-led organization. Psychol Health Med. 1999;4:127–42.
3. Langer E, Fiske S, Taylor S, Chanowitz B. Stigma, staring and discomfort: a novel-stimulus
hypothesis. J Exp Soc Psychol. 1976;2:451–63.
4. Changing Faces. Patient guides to coping with monocular vision and wearing a prosthetic eye.
2015. https://www.changingfaces.org.uk/downloads/eyeguide.pdf. Accessed 24 Jan 2015.
5. Neuro Optometric Rehabilitation Association. Implications of acquired monocular vision (loss
of one eye). 2014. https://nora.cc/for-patients-mainmenu-34/loss-of-one-eye-mainmenu-70.
html. Accessed 20 Nov 2014.
6. Ihrig C, Schaefer DP. Acquired monocular vision rehabilitation program. J Rehabil Res Dev.
2007;44:593–7.
7. Brady FB. A singular view. In: Hughes M, editor. The art of seeing with one eye. 7th ed. West
Vienna: Michael Hughes; 2011.
8. Driver and Vehicle Licensing Authority. A guide to standards of vision for driving cars and
motorcycles (Group 1). 2015. https://www.gov.uk/government/uploads/system/uploads/attach-
ment_data/file/350754/INF188X1_220814.pdf. Accessed 25 Jan 2015.
9. Slonim MD, Martino MD. Eye was there: a patient’s guide to coping with the loss of an eye.
AuthorHouse, Bloomington. Kindle edition; 2011. p. 65.
History of Ocular Prosthetics
11

Contents
11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
11.2 Ancient Egypt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
11.3 3000 BC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
11.4 2000 BC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
11.5 Sixteenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
11.6 Seventeenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
11.7 Eighteenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
11.8 Nineteenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
11.9 Twentieth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
11.10 Twenty-First Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
11.11 Contact Lenses and Scleral Shell Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312

11.1 Introduction

This chapter provides the reader with a context for the present-day practice of ocu-
lar prosthetics. It begins with myths from ancient Egypt and draws upon a range of
publications [1–10] to summarise the history of prosthetic eyes from that time to the
present day. Some of the current organisations and training establishments serving
ocular prosthetics emerged over the last century, and these form the foundation for
the profession of ocular prosthetics going forwards.

11.2 Ancient Egypt

The history of prosthetic eyes has an unlikely beginning that is shrouded in the
myths and legends of Ancient Egypt. The god Horus had many different forms but
was most notably god of the sun, war and protection. He conquered his brother Seth,

© Springer International Publishing Switzerland 2015 283

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0_11
284 11 History of Ocular Prosthetics

Fig. 11.1 The Eye of Horus was part of an ancient Egyptian system for measuring fractions

the patron of Lower Egypt when Upper Egypt conquered Lower Egypt and formed
the united kingdom of Egypt about 3000 BC. Horus was depicted in images and
statues as a falcon-headed man, who sometimes wore the crowns of Upper and
Lower Egypt. At some point in his battles, Horus’ left eye was plucked out and torn
into pieces by Seth, only to be restored by Thoth (the god of wisdom and magic and
obviously the first ocular prosthetist). Horus’ remaining right eye was said to be the
sun and his left (prosthetic) eye related to the moon which is continually torn out of
the sky and restored every lunar month piece by piece. Each piece of Horus’ eye that
Thoth pieced back together represents a fraction of descending order 1/2, 1/4, 1/8, etc.,
and together they make approximately one or ‘Wadget’ (Whole one) (Fig. 11.1).
The Wadjet was a powerful symbol of protection in ancient Egypt and is known as
the ‘Eye of Horus’ (Fig. 11.2).

11.3 3000 BC

The earliest known prosthetic eye was found buried with a woman in Shahr-I Sokhta,
Iran (Fig. 11.3). It dated back to 2900–2800 BC and was probably made of bitumen
paste which was covered with a thin layer of gold, engraved with a central iris from
which lines radiated out like the rays of the sun. Tiny holes were drilled at opposite
11.4 2000 BC 285

Fig. 11.2 An Eye of Horus

amulet. The Eye of Horus is a
powerful symbol of
protection in ancient Egypt

Fig. 11.3 The earliest

known prosthetic eye was
found buried with a woman
in Shahr-I Sokhta, Iran
(Published with kind
permission of Kaveh Farrokh.
All rights reserved)

sides near the edges of the circle and evidence of wear around the holes shows that it
was probably held in place by a gold thread and worn like a conventional eye patch.
This was not the only prosthetic eye from the ancient era as reference to a gold pros-
thesis was made in a Hebrew text (Yer. Ned. 41c; comp. Yer. Sanh. 13c).

11.4 2000 BC

Further evidence of the earliest prosthetic eyes being worn outside the socket comes
from Egyptian and Roman priests who, in the fifth century BC, were making pros-
thetic eyes from painted clay attached to a cloth or leather strip. The Greek term for
this type of prosthesis was ‘ekblepharon’. These prosthetic eyes were made for living
286 11 History of Ocular Prosthetics

Fig. 11.4 Prosthetic eyes for the dead helped Egyptians ‘see’ when they entered the after-life
(These specimens date from the late Dynastic period, circa 664–332 BCE, or later)

Fig. 11.5 Egyptian

sarcophagi often had eyes
made by filling bronze
eyelids with plaster and
inserting irises of onyx

people, but Egyptians, as early as the ninth century BC, were removing the eyes of the
dead, pouring wax into the empty orbits and putting in eye inserts made from glass
and onyx [11] (Fig. 11.4). Prosthetic eyes for the dead were to help Egyptians ‘see’
when they entered the afterlife. These specimens were made from faience (a material
made from sintered quartz ceramic displaying surface vitrification) and black onyx.
They date from the late Dynastic period, circa 664–332 BC, or later. These ‘afterlife’
eyes also adorned Egyptian sarcophagi (carved stone coffins) where they were often
made by filling bronze eyelids with plaster and inserting irises of onyx (Fig. 11.5).
Other ancient cultures, including the Aztec and Incas, used eyes of precious
stones, silver, gold and copper to adorn mummies, sarcophagi and statues, similar to
the Egyptians (Fig. 11.6).
11.5 Sixteenth Century 287

Fig. 11.6 This statue of

Athena, Goddess of wisdom,
war and the crafts, and
favourite daughter of Zeus
has glass eyes (It is on
display in the Vatican
Museum, Rome)

Unfortunately, most of the records and other evidence of prosthetic eyes

between the rise of the Roman Empire, the establishment of Christianity, the fall
of Alexandria to the Arabs in 642 AD and the ensuing dark ages have not been
found.

11.5 Sixteenth Century

In the 1500s, Frenchman Ambroise Paré (1510–1590) described a prosthetic eye

that was fastened to the end of a metal rod which bent around the back of the head
to hold the eye in place [12] (Fig. 11.7). Paré was also associated with the first pros-
thetic eyes worn inside the socket (termed ‘hypoblepharae’). These in-socket eyes
were made from gold or silver, with coloured enamel coatings (Fig. 11.8). They
were described rather than invented by Paré and may have been in existence for
some time previously although there is no evidence to substantiate this [1]. In any
event, by the late sixteenth century, Venetian glass-blowers were making more real-
istic prosthetic eyes from glass. These early glass eyes were solid shells (not hollow
like later glass eyes) but were very thin and fragile and could be uncomfortable to
wear. They were made by skilled glass-blowers and lens makers who belonged to
trade guilds. In the Venetian island of Murano (still famous for producing special-
ised glassware today), an attempt was made to monopolise glass eye manufacture
by limiting the number of artisans who could make them and by keeping the manu-
facturing technique a closely guarded trade secret. The penalty for violating this law
was death as evidenced by the records of foreign affairs on Murano showing that
two glassmakers were assassinated after being lured to Germany by Emperor
Leopold I [13].
288 11 History of Ocular Prosthetics

Fig. 11.7 Ambroise Paré

(1510–1590) illustrated this
prosthesis in his 1614 book
(Published after his death)

Fig. 11.8 In the sixteenth

century, prosthetic eyes worn
inside the socket were made
from gold or silver, with
coloured enamel coatings
11.6 Seventeenth Century 289

11.6 Seventeenth Century

Glass eyes were also produced in Augsburg near Munich which was also a historic
optical manufacturing centre until the 30 Years’ War (1618–1648) which destroyed
many German states.
During this period there were few British prosthetic eye manufacturers; however,
an advertisement for prosthetic eyes appearing in the September 1679 publication
of True Domestick Intelligence proclaimed William Boyse of London as:
the only person expert in making artificial eyes of enamel, covered after nature… which not
only fitted for socket with ease to the wearer, but turned with all the facility of the real organ
of vision.

An advertisement 2 years later in ‘Merlin’s Ephemeris’ proclaimed him

the only English operator in glass and the most expert in making artificial eyes so exact as
not to be distinguished from the natural, they are of enamel with colour mixt the same, with-
out either paint or lead, and worn with much ease, and so curious that they have the motion
of the natural eye, being exactly made to the colour or bigness of the same which renders
them very ornamental and commodious, the like was never made in England. [1] (Fig. 11.9)

Fig. 11.9 In about 1710,

William Boyse was
succeeded by his son-in-law,
James Smith, seen here
holding a glass eye
(Published with kind
permission of the British
Optical Association Museum.
All rights reserved)
290 11 History of Ocular Prosthetics

Fig. 11.10 In 1752, Dr.

Heister of Nuremberg,
recorded that he would prefer
glass eyes to metal eyes
because metal eyes repelled
tear fluid and lost their
brightness

11.7 Eighteenth Century

Dr Heister of Nuremberg, in 1752, recorded that he would prefer glass eyes to metal
eyes because metal eyes repelled tear fluid and lost their brightness (Fig. 11.10).
In the late 1700s, the centre of manufacture for artificial eyes was Paris where
prostheses were mostly made from enamel (a mixture of silicon and potash with a
little lead and tin), rather than ordinary glass.

11.8 Nineteenth Century

One of the earliest books on prosthetic eyes entitled Traité pratique de l’oeil artifi-
cial was published by Duponcet, in Paris in 1818. The author, Hazard-Mirault, pro-
moted glass as the best material to use for prosthetic eyes and described the
fabrication process. He also provided advice for prosthetic eye wearers. One of the
book’s illustrations is shown in Fig. 11.11.
11.8 Nineteenth Century 291

Fig. 11.11 Illustrations from Hazard-Mirault’s book entitled Traité pratique de l’oeil artificial
published in 1818. Removing a prosthetic eye with an ocular hook (left) and re-inserting it (right)

Frenchman Auguste Boissonneau was an ornithologist, naturalist and ocularist

who practised ocular prosthetics in London and Paris in the 1800s. The advertised
claims for the benefits of a Boissonneau enamel artificial eye (like the claims made
by William Boyse of London 175 years previously) may be contrasted with a more
sober account in a book chapter written by William McKenzie. The book was first
published in 1831 and repeated in further editions until at least 1854. Extracts from
the chapter are presented in Fig. 11.12.
A further description of European ocular prosthetics in the nineteenth century
may be found in an article (copied out in Fig. 11.13) published in New Zealand on
page 9 of the Otago Witness, Issue 930, on the 25th of September 1869. It appears
to be a reprint of an article originating in Paris.
In 1862 Auguste Boissonneau published a 32-page book translated as ‘General
observations on artificial eyes, their adaptation, employment and the means of pro-
curing them’. Four years later he filed a patent claiming the idea that separate right
and left prosthetic eyes could be replaced by a prosthesis with a form that served
both sides (Fig. 11.14). The idea was not generally adopted.
Friedrich Philipp Ritterich (1787–1866), a doctor and teacher at the University
of Leipzig, was appalled at the cost of artificial eyes from Paris and advocated for
292 11 History of Ocular Prosthetics

CHAPTER XV. ADAPTATION OF AN ARTIFICIAL EYE

‘It would appear that in former times, when the eye and eyelids had been destroyed, or removed in consequence of disease, a painted

imitation of these parts was sometimes applied over the front of the orbit, and kept in its place by means of a steel- spring going round the

temple to the opposite side of the head; but, at the present day, an artificial eye is generally meant a hollow semi -ellipse or hemi sphere of

enamel, coloured to resemble the front of the natural eye, and introduced behind the eyelids. Enamelled plates of gold were at one time used

for this purpose, but artificial eyes are now made altogether of enamel and glass.’

‘The manufacture of artificial eyes is very simple. The part imitating the sclerotica is formed of white enamel, with a tinge of yellow. The

posterior lamina of the central piece is coloured and streaked to look like the iris; on the middle of this lamina a circular patch of black

enamel is laid, to imitate the pupil; the superficial lamina is transparent glass. Threads of red enamel are spread over the surface in imitation

of blood -vessels, and are melted in before the blow-pipe.’

‘When removed, the eye is to be immediately freed from the mucus which adheres to it, by rubbing it gently with a bit of soft rag, and then
laid aside till next day. It ought not to be plunged into cold water, as this is apt to make it crack. If imperfectly annealed, art ificial eyes are apt

to crack, merely from the alternations of temperature to which they are exposed, when withdrawn in the evening, or replaced in the morning.

The patient is soon able to introduce and withdraw the eye without assistance. While withdrawing it, he leans over a bed, or ‘over a table

with a towel spread on it, in order that, if it should fall, it may not be broken.’

‘An artificial eye soon begins to suffer from the friction of the eye lids, and the effect of the tears and mucus, so that the cornea becomes dim
from the glass losing its polish. It has been supposed that it is the Meibomian secretion which is chiefly detrimental. The polish is never

completely preserved for longer than three or four months; and generally in six months the whole surface of the eye is hazy and slightly

rough. The red threads, imitating blood-vessels, sometimes dissolve entirely, leaving grooves, before the cornea or sclerotica becomes altered.

The rapidity with which this process goes on varies, depending on the peculiar qualities of the secretions of the individual. Their speedy

waste, along with their extravagant price, puts it out of the power of any but those in easy circumstances to use artificial eyes; although

many persons in indigent circumstances, finding it difficult to obtain certain kinds of employment from loss of an eye, are desirous of

wearing an artificial one. They must often submit, however, to conceal their defect behind dark-coloured glasses, or if the appearance of the

lost eye is very unsightly, to cover it with a hollow shade. They ought never to adopt the practice of covering it up closely with a patch,

which heats the parts too much, and renders them inflamed and oederatous. Enamel eyes which have, lost their polish, prove hurtful, their

roughness exciting the conjunctiva to inflammation, excoriation, and the growth of fungous excrescences. When an artificial eye, therefore, is

observed to have become dim, and to be producing irritation, it must no longer be used, any irritation already present must be calmed, and

when the parts are again perfectly free from pain or inflammation, a new artificial eye, or the old one re polished, may be applied.’

Fig. 11.12 Extracts from Chapter XV of William Mackenzie’s A practical treatise on the dis-
eases of the eye – January 1, 1830, London (Longman, Rees, Orme, Brown, & Green. M.DCCC.
XXX)

the establishment of a glass eye industry in Germany. For 30 years, he had imported
artificial eyes from Paris which he visited at least twice to negotiate the purchase of
stock. He carried 400–500 sample glass eyes in his general medical practice and
charged his patients a pittance compared to the price being charged in Paris at the
time. Ritterich encouraged German glass-blowers to make glass eyes and even
organised classes in glass-blowing technique. He also established a free glass eye
11.8 Nineteenth Century 293

ARTIFICIAL EYES.

“What do you think of this fellow?” asks the oculist of his client. “Study his features, his look, and say frankly what you think.”

“He looks well enough,” answers the other labouring usually under some little emotion.

“Well, Jean, reveal your secret to this gentleman.”

Whereupon Jean introduces a knitting -needle under his eyelid, removes his eye, and places it in the hand of the astonished spectator as

unconcernedly as though it were a mere shirt stud. How is it possible for anyone to resist such a demonstration? These gentlemen charge

from forty to fifty francs for an eye. The manufacturer of the Rue du Temple has an entirely different way of doing business. He is generally

a man pretty well informed, simple, polite, a little of an artist, a little of a workman, and a little of a tradesman. He scarcely employs either

apprentice or assistant, except when he receives a good order from some naturalist for animals’ eyes for his collection. All day long seated at

a table at one end of his workshop he works by the light of a spirit lamp. Before him are arranged, in either cakes or sticks, th e materials

used by him in his profession. He takes a little enamel, melts it, and by the aid of a blow-pipe blows it until it becomes a small ball at the end

of the instrument. This ball is destined to represent the white of the eye. He next takes some more enamel, which is coloured this time, and

lets a drop of it fall upon the summit of the cornea. Gently heating it at the flame, it spreads out in a round spot, and eventually becomes flat,

and resembles the iris. A darker drop of enamel placed in the same manner in the centre of the iris imitates the pupil. The ball is now

detached from the blow -pipe, cut to an oval shape, and smoothed at the edges, so that on introducing it beneath the eyelids it may not

wound any of the smaller nerves. These eyes cost no more than from twenty to twenty-five francs, which one can quite comprehend, as there

is neither heavy rent to pay, nor the wages of a liveried cyclops. The manufacture of artificial eyes is both difficult and tedious. It suits alike

both men and women, and many of the latter succeed well in it; it is, moreover, one of the best remunerated of art industries .

Most of the people are paid by piece-work, that is so much per eye, varying from ten to fifteen francs, and a clever workman will turn out his

eye per diem. Others receive from the large manufacturers a share of the proceeds arising from the sales of eyes manufactured by them, and

have to take back any eyes not approved of by the customers. These they put on one side to serve for their stock in trade when they

commence business on their own account. One of these collections furnishes a somewhat curious sight, Reposing p
uon wadding at the

bottom of a drawer are several score of eyes, ranged side by side, and exhibiting a singular variety of expression. Some are small, others

large; some black, others blue, hazel brown, light brown, bluish, and greenish grey; nearly all a re brilliant, all have a fixed stare – all are, in

fact, looking you through. On one side are laughing children’s eyes of young girls, the languid eyes of middle-aged women, eyes with an

amiable or sinister expression, severe official eyes; then come the old men’s eyes, slightly filmy; and in a corner are the worn-out eyes –eyes

that have been already used, and have been returned by the customers, as models to make other eyes by. The enamel eye, after being

exposed to the action of the atmosphere for some months, loses alike its colour and its lustre, and becomes opaque-looking; a thick dingy

coating of solidified humours spreads over its polished surface, and it has a glassy look, like the eye of a dead person. “Touch them, you will

do no harm,” says the oculist to visitors, just as though it was a collection of coins or minerals they were inspecting. – Once a Week.

Fig. 11.13 This article provides an entertaining and informative description of European ocular
prosthetics in the late eighteenth to early nineteenth centuries

service at the Leipzig Eye Institute where glass eyes were custom manufactured for
individual patients. This was the first time that the supply and fitting of glass eyes
was seen as a service and where glass eyes were no longer a commodity to be pur-
chased from stock [1] (Fig. 11.15).
By the mid-nineteenth century, the centre for glass eye manufacture had moved
to Germany, and in 1832 Ludwig Müller-Uri, a glass-blower who made dolls’ eyes
294 11 History of Ocular Prosthetics

Fig. 11.14 Auguste

Boissonneau’s patent claimed
the idea that separate right
and left prosthetic eyes could
be replaced by a prosthesis
with a form that served both
sides

Fig. 11.15 Friedrich Philipp

Ritterich established the glass
eye industry in Germany
11.8 Nineteenth Century 295

Fig. 11.16 Ludwig Müller-Ur (1811–1888) developed the cryolite glass eye

Fig. 11.17 This broken

‘Reform’ eye illustrates its
form (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

at the famous Lauscha Glass factory in Sonneberg, developed the cryolite glass eye
which was more durable than previous glass eyes (Fig. 11.16).
In 1880, Herman Snellen, a Dutch eye surgeon, developed the ‘Reform’ eye in
response to an increase in the number of enucleations being carried out following
the introduction of anaesthesia and asepsis. The Snellen invention was a hollow
glass eye with rounded edges (Fig. 11.17). This was more full than the earlier shell-
like glass eyes and facilitated the restoration of socket volume and improved wear-
ing comfort.
Figures 11.18, 11.19, 11.20, 11.21, 11.22, 11.23, 11.24, 11.25, 11.26, 11.27,
11.28, 11.29 and 11.30 illustrate the manufacture of the ‘Snellen Reform Eye’
which involved blowing an initial globe using pre-tinted white glass. The iris was
formed by heating thin glass rods of different colours and fusing them into the
scleral globe. These images were reproduced with the kind permission of the South
Australian Medical Heritage Society and Paul and Margaret McClarin.
296 11 History of Ocular Prosthetics

Fig. 11.18 Glass blowing instruments and materials laid out on a workbench (Published with
kind permission of the South Australian Medical Heritage Society and Paul and Margaret
McClarin. All rights reserved)

Fig. 11.19 Callipers set to measure the dimensions of the prosthesis. Also glass rods of various
colours (Published with kind permission of the South Australian Medical Heritage Society and
Paul and Margaret McClarin. All rights reserved)

In 1885, an English doctor, Phillip Henry Mules, implanted a glass sphere into
the scleral cavity of an eye following evisceration (a procedure where the vitre-
ous content of the eyeball is removed – see Chap. 3). The implant restored
lost orbital volume and gave more movement to the overlying prosthetic eye.
11.8 Nineteenth Century 297

Fig. 11.20 Instruments for handling glass eyes (Published with kind permission of the South
Australian Medical Heritage Society and Paul and Margaret McClarin. All rights reserved)

Fig. 11.21 Glass eye prescription form (Published with kind permission of the South Australian
Medical Heritage Society and Paul and Margaret McClarin. All rights reserved)

Dr Mule’s achievement was mentioned in his 1905 obituary in the British Medical
Journal (Fig. 11.31).
By the late nineteenth century, cryolite glass eyes from the Lauscha Glass
factory in Germany were being exported all over the world including to New
298 11 History of Ocular Prosthetics

Fig. 11.22 The glass eye process begins by softening a pre-tinted hollow glass tube (Published
with kind permission of the South Australian Medical Heritage Society and Paul and Margaret
McClarin. All rights reserved)

Fig. 11.23 The tube is then

sealed at one end and ‘blown’
to its correct size (Published
with kind permission of the
South Australian Medical
Heritage Society and Paul
and Margaret McClarin. All
rights reserved)

Fig. 11.24 Coloured glass rods are melded into the body of the eye to create the iris (Published
with kind permission of the South Australian Medical Heritage Society and Paul and Margaret
McClarin. All rights reserved)
11.8 Nineteenth Century 299

Fig. 11.25 A partially made eye together with glass rods of various colours including black
(Published with kind permission of the South Australian Medical Heritage Society and Paul and
Margaret McClarin. All rights reserved)

Fig. 11.26 Creating the pupil (Published with kind permission of the South Australian Medical
Heritage Society and Paul and Margaret McClarin. All rights reserved)

Zealand where optometrists such as Peacock Optometrists, who practised in

Auckland, New Zealand, at this time, were importing stocks of glass eyes from
Germany. They came in trays and clients would select the best fitting eye from
an assortment. It was unfortunate if the colour or size did not match up
(Fig. 11.32).
The two newspaper articles copied in Figs. 11.33 and 11.34 are descriptive of the
glass eye industry in the late nineteenth century.
300 11 History of Ocular Prosthetics

Fig. 11.27 A partially finished glass being compared with a completed one (Published with kind
permission of the South Australian Medical Heritage Society and Paul and Margaret McClarin. All
rights reserved)

Fig. 11.28 The softened

glass is moulded under
negative pressure to create a
hollow posterior surface
(Published with kind
permission of the South
Australian Medical Heritage
Society and Paul and
Margaret McClarin. All
rights reserved)

Fig. 11.29 The flame is used to smooth out the posterior aspect of the eye (Published with kind
permission of the South Australian Medical Heritage Society and Paul and Margaret McClarin. All
rights reserved)
11.9 Twentieth Century 301

Fig. 11.30 Preformed glass

eyes are demonstrating some
of the steps during manufac-
ture (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 11.31 Phillip Henry

Mules’ obituary appeared in
the British Medical Journal in
1905

11.9 Twentieth Century

In 1905, a book on prosthetic eyes (written in French) was published by Baillière of

Paris. The author was Dr Robert Coulomb and the 152-page book was entitled
L’oeil artificial. The content included formulae for glass and instructions for mak-
ing and fitting prosthetic eyes. One of the many illustrations from the book is shown
in Fig. 11.35.
A new material, (poly)methyl methacrylate (PMMA), was introduced by
Imperial Chemical Industries (ICI) in 1930 and marketed under various trade
302 11 History of Ocular Prosthetics

Fig. 11.32 A tray of assorted glass eyes imported from Germany by Peacock Optometrists who
practised in Auckland in the early 1900s (Published with kind permission of NZ Artificial Eye
Service. All rights reserved)

Fig. 11.33 This article

comments on the glass eye
industry in England early in
the twentieth century
11.9 Twentieth Century 303

Fig. 11.34 Prosthetic eyes

have always been an easy
target for black humour

Fig. 11.35 A page from Dr.

Robert Coulomb’s 1905 book
entitled L’oeil artificial
304 11 History of Ocular Prosthetics

names such as Plexiglas, Lucite and Perspex [14, 15]. A medical-grade PMMA
was quickly adopted by dentists as a superior alternative to vulcanite from which
denture bases were made at the time. PMMA, a thermoplastic, is a transparent
synthetic polymer of methyl methacrylate. It is well tolerated by bodily tissues
(provided it is polymerised correctly) and the techniques for moulding and curing
were similar to that used for vulcanite. When German glass eyes became unavail-
able at the start of World War II, British Royal Navy dental technicians investi-
gated the use of PMMA for prosthetic eyes. At the same time Fritz W. Jardon, a
German dental technician who immigrated to the USA in 1932, joined the
American Optical Company in Southbridge, Massachusetts, and became director
of the Monoplex eye division [16]. Fritz Jardon and the Royal Navy technicians
developed PMMA prosthetic eyes at about the same time. In Britain the Ministry
of Pensions Plastic Eye Unit was established to provide ex-servicemen with
PMMA eyes, and in the USA the American Optical Company began mass produc-
ing them for the many US veterans who lost eyes in the war [17]. PMMA proved
to be a more durable material than glass. Its working properties also enabled pros-
thetic eyes to be custom made for the first time from an impression mould of the
patient’s eye socket.
The introduction of PMMA prosthetic eyes was accompanied by a period of
experimentation that tested the boundaries of what could be achieved. For example,
Fritz Jardon and Dr William Stone Junior of the Massachusetts Eye and Ear
Infirmary in Boston coupled the prosthesis directly to a modified version of Phillip
Mules’ 1885 orbital implant. This was the world’s first pegged implant and was
featured in Life Magazine in 1948 (Fig. 11.36). Unfortunately, the implant proved
to be unstable, and the technique was abandoned until the idea was resurrected
again in 1985 by Dr Arthur Perry who used an orbital implant made of hydroxyapa-
tite, a material derived from ocean coral (see Chap. 3). Dr Perry’s pegged hydroxy-
apatite implant was very popular for a time because it provided excellent motility,
but the technique fell out of favour in most countries due to the need for additional
surgery, complications due to pegging and the fact that satisfactory prosthesis motil-
ity could be achieved without pegging [18].
In the latter half of the twentieth century, PMMA eyes (Figs. 11.37 and 11.38)
supplanted the 350-year-old glass eye industry although a small number of glass eye
manufacturers still exist in Europe (Figs. 11.39 and 11.40).
Until the introduction of PMMA, all glass prosthetic eyes and shells were fitted
by members of the optometry profession, but dental technicians were more familiar
with the new PMMA technology when it was introduced. Over the next 70 years (at
least in the UK), dental technicians increasingly dominated and extended the field
within a new discipline called maxillofacial prosthetics (Fig. 11.41).
Optometrists continued with contact lens manufacture but by the 1970s most
had retreated from the care of patients whose eyes were blind. Since World War
II, the different origins of PMMA prosthetic eyes appear to have resulted in two
main schools for manufacturing artificial eyes. The US school centred on the
American Society of Ocularists and the English school which is rooted in dental
technology.
11.9 Twentieth Century 305

Fig. 11.36 Moveable eye article featured in the December 1948 issue of Life Magazine

In the USA, the American Society of Ocularists (ASO) was established in 1957
and began certifying ocularists in 1971. Existing ocularists were automatically
certified, while newcomers were required to complete a 5-year apprenticeship
with an existing board-approved diplomate ocularist plus 750 h of related
306 11 History of Ocular Prosthetics

Fig. 11.37 Mid-twentieth-

century ordering kit for
plastic artificial eyes
(Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

Fig. 11.38 Late twentieth-

century custom-made PMMA
eye (Published with kind
permission of NZ Artificial
Eye Service. All rights
reserved)

instruction approved by the ASO. On completion of the apprenticeship, success-

ful trainees are awarded the title of Diplomate of the American Society of
Ocularists. In 1980, the National Commission of Health Certifying Agencies cre-
ated the National Examining Board of Ocularists to conduct certifying examina-
tions. Diplomates who pass a two-part written and practical examination become
board-certified ocularists. Board-certified ocularists are required to be recertified
every 6 years [19].
A second profession involved in making and fitting prosthetic eyes in the USA
and elsewhere is anaplastology. Anaplastology deals with the prosthetic rehabili-
tation of the face or body and includes the design and manufacture of facial
11.9 Twentieth Century 307

Fig. 11.39 German glass

eyes became unavailable at
the start of World War II

prostheses such as orbital, nasal and aural prostheses. Anaplastologists often

work closely with plastic surgeons, head and neck surgeons, maxillofacial sur-
geons and oculoplastic surgeons and are mostly drawn from the ranks of qualified
dental technicians. The Board for Certification in Clinical Anaplastology (BCCA)
sets strict educational requirements and provides examinations for Board
Certification in Clinical Anaplastology. Continuing professional education is
mandatory and professional and ethical guidelines are observed by certified clini-
cal anaplastologists.
In the UK, training in ocular prosthetics is carried out within the Master of
Maxillofacial Technology degree programme. This training is a post-graduate
course for those with Bachelor of Dental Technology degrees. Another way of
obtaining training is provided by the National Artificial Eye Service (NAES) which
originated in the Army Spectacle Depot during World War I. The NAES trains its
own specialised eye fitters and technicians and is managed by the Blackpool
Teaching Hospitals NHS Foundation Trust [1].
308 11 History of Ocular Prosthetics

Fig. 11.40 Early twentieth-century stock glass eyes (Published with kind permission of NZ
Artificial Eye Service. All rights reserved)

Fig. 11.41 Manufacturing PMMA prosthetic eyes using dental equipment and materials. Two
prosthetic eyes formed with red denture wax are seen here invested in a denture flask (Published
with kind permission of NZ Artificial Eye Service. All rights reserved)
11.10 Twenty-First Century 309

Fig. 11.42 These organisations promote the professional development of ocular prosthetists by
hosting conferences and disseminating information about prosthetic eyes

11.10 Twenty-First Century

During the first part of the twenty-first century, a number of new organisations for
ocularists have been established. The oldest, the American Society of Ocularists, was
set up in 1957, but since the beginning of the century, they have been joined by the
Canadian Society of Ocularists, the Association of European Ocularists, the
Ocularists Association of Australia and the Ocularists Association of Southern
Africa (Fig. 11.42). All these organisations promote the professional development of
ocular prosthetists by hosting conferences and disseminating information about
prosthetic eyes [20].
Research into prosthetic eyes being undertaken this century is beginning to
address the lack of peer-reviewed scientific literature in the field. For example, in
2010 the School of Optometry and Vision Science at the University of Auckland
began researching the response of the socket to prosthetic eye wear, bringing
together the resources of ophthalmology, optometry and ocular prosthetics in pur-
suit of further knowledge about prosthetic eyes (Fig. 11.43). A similar programme
commenced earlier at the L V Prasad Eye Institute, Hyderabad, India [21].
Interestingly, the profession that supplied glass eyes to anophthalmic patients for
350 years (optometry) appears to have surrendered its expertise in this field to other
professions, yet optometry, with its profound knowledge of contact lenses, is critical
for the future advancement of ocular prosthetics.
The history of prosthetic eyes has been influenced by the parallel histories of
orbital implants, contact lenses and scleral shell prostheses, especially since the
mid-nineteenth century when glass was used for both the first orbital implant and
the first scleral contact lens.
310 11 History of Ocular Prosthetics

Fig. 11.43 An optometry

student at the University of
Auckland adds artificial tears
to PMMA samples to test
protein adherence to
prosthetic eyes (Published
with kind permission of NZ
Artificial Eye Service. All
rights reserved)

11.11 Contact Lenses and Scleral Shell Prostheses

The history of contact lenses and scleral shell prostheses parallels the history of
prosthetic eyes from about 1845 when earlier theoretical ideas began to develop into
clinical experiments. In 1887 Friedrich Müller and Albert Müller (specialist glass-
blowers and prosthetic eye makers) created a protective shell for a patient. The
patient had skin cancer which had necessitated the removal of the right lower lid and
the temporal part of the upper lid causing the cornea to be permanently exposed.
The Müllers fitted a clear glass shell which retained fluid around the cornea, pre-
venting it from drying out. The transparent shell also maintained the vision, and 22
years later the patient wrote a letter reporting that he had worn the lens continually
for 18–24 months at a time with no apparent corneal damage [22]. The Müllers went
on to mass-produce thin glass lenses with a white body and clear corneal centres
with variable optics (Fig. 11.44).
In 1888 Adolf Fick (Fig. 11.45), a German ophthalmologist, began making
mounds of the corneas of rabbits’ eyes and constructing glass lenses. He progressed
to human cadavers using glass scleral lenses made by Professor Ernst Abbe at Zeiss
Optical and later on described six patients on whom he had tried his lenses. Fick
created the first scleral shell prosthesis for a patient with a blind, unsightly eye and
was the first to document that the cornea bulged forwards from the flatter curvature
of the sclera. About 1946, Joseph Dallos and Norman Bier, working independently,
formulated the ‘ventilated’ scleral lens, but it was the invention of PMMA which
revolutionised contact lens and scleral shell manufacture in the same way as it revo-
lutionised prosthetic eyes [22].
11.11 Contact Lenses and Scleral Shell Prostheses 311

Fig. 11.44 Thin glass lenses with a white body and clear corneal centres with variable optics
(Published with kind permission of W, Danz, Richard Danz and Sons. Inc All rights reserved)

Fig. 11.45 Adolf Fick

created the first scleral shell
prosthesis (Published with
kind permission of the British
Optical Association Museum.
All rights reserved)
312 11 History of Ocular Prosthetics

References
1. Handley N. Artificial eyes and the artificialisation of the human face. In: Timmermann C,
Anderson J, editors. Devices and designs: medical technologies in historical perspective.
Basingstoke: Palgrave; 2006. p. 97–111.
2. Conroy B, Hulterstrom A. The history and development of facial prosthetics. Dent Tech.
1978;31(3):8–15.
3. Enoch JM. History is the light on the path to (the) future: the Burnt City, and the first known
artificial eye. Hindsight. 2007;38(3):58–67.
4. Conroy BF. A brief sortie into the history of cranio-oculofacial prosthetics. Facial Plast Surg.
1993;9(2):89–115.
5. Martin O, Clodius L. The history of the artificial eye. Ann Plast Surg. 1979;3(2):168–71.
6. Reisberg DJ, Habakuk SW. A history of facial and ocular prosthetics. Adv Ophthalmic Plast
Reconstr Surg. 1990;8:11–24.
7. Roman F. The history of artificial eyes. Br J Ophthalmol. 1994;78(3):222.
8. Danz W. Ancient and contemporary history of artificial eyes. Adv Ophthalmic Plast Reconstr
Surg. 1990;8:1–10.
9. Valauri AJ. The history and development of facial prostheses. Adv Ophthalmic Plast Reconstr
Surg. 1992;9:243–60.
10. Wilson RP. Artificial eyes in ancient Egypt. Surv Ophthalmol. 1972;16(5):322–31.
11. Cerullo L, McKinstry RE. Ocular prostheses. In: McKinstry RE, editor. Fundamentals of facial
prosthetics. Arlington: ABI Professional Publications; 1995. p. 99–116.
12. Wolff E. Anatomy of the eye and orbit. 6th ed. London: H K Lewis & Co. Ltd.; 1968.
13. Ott K, Serlin DH, Mihm S. Artificial parts, practical lives: modern histories of prosthetics.
New York: University Press; 2002.
14. Kollewe J, Wearden G. ICI: from Perspex to paints. Available from: www.guardian.co.uk.
Accessed 15 May 2013.
15. Chen WP. Oculoplastic surgery. The essentials. New York/Stuttgart: Thieme; 2001.
16. Le Grand Associates. Available from: http://www.legrandeyes.net. Accessed 27 Jun 2015.
17. Science Museum. Artificial eyes. Available from: http://www.sciencemuseum.org.uk/
broughttolife/techniques/artificialeyes.aspx. Accessed 27 Jun 2015.
18. Viswanathan P, Sagoo MS, Olver JM. UK national survey of enucleation, evisceration and
orbital implant trends. Br J Ophthalmol. 2007;91:616–9.
19. Slonim MD, Martino MD. Eye was there: a patient’s guide to coping with the loss of an eye
(Kindle Locations 1080–1094). Bloomington: AuthorHouse, Bloomington; 2011. Kindle
Edition.
20. Ocularists.net. Professional associations of ocularists. Available from: http://www.Ocularists.
net. Accessed 27 Jun 2015.
21. L V Prasad Eye Institute. Available from: http://www.patientcare.lvpei.org/eye-hospital/
clinical-services/ocular-prosthesis.html. Accessed 27 Jun 2015.
22. Lamb J, Sabell A. The history of contact lenses. In: Phillips AJ, Speedwell L, editors. Contact
lenses. 5th ed. Edinburgh: Butterworth Heinemann Elsevier; 2007.
Index

A B
Additive method, 120 Bartisch, Georg, 84, 86
Ageing, 54–55 Bioeye, 82
Aniridia, 151–153, 244 Blood vessels, 38
Anophthalmia. See Congenital anophthalmia Body image, 8–9, 12, 13
Anophthalmic patient Boissonneau, Auguste, 291, 294
children, psychological issues for, 12–13 Bulbar region, 43
eye loss
aetiology of, 3–4
anophthalmic population, estimated C
size of, 2 CMYK subtractive colour, 120, 121
biosocial and psychological aspects, 1 Collarette, 129
body image loss, 8–9 Colour theory
causes, 4–6 characteristics, 121–122
novelty eyes, 9–10 rods and cones, 119–120
perceptual changes accompanying, 6–7 wheel, 120–121
personal accounts, 13–21 Cones, 119, 120
phantom eye pain, 11 Congenital anophthalmia
prosthetic eye wearers, 11–12 cases, 68
Anophthalmic socket CT image, 68, 69
conjunctiva of, 57–59 eye association, 68
forniceal region, 43–44 treatment, 70–71
GPC, 43 Congenital microphthalmia
inflammation of, 110–112 CT image, 68, 69
tears eye association, 68
distribution, 53–54 treatment, 70–71
film, 51–52 Conjunctiva
function of, 50–51 of anophthalmic socket, 57–59
glands, 49 bulbar region, 43
Jones test, 104, 106 forniceal region, 43–44
nasolacrimal drainage system, 108 palpebral region, 41–43
ocular tear ferning test, 108, 109 sensitivity of, 44–46
output, 52–53 single continuous mucous membrane with
phenol red thread test, 104 regions, 41, 42
Schirmer tests, 104 structure of
TBUT test, 109, 110 epithelial layer, 46–47
volume, 106–108 goblet cells, 47, 48
types, 99, 102–104 mucus, function of, 48
Arcus senilis, 55, 128, 130 substantia propria layer, 46

© Springer International Publishing Switzerland 2015 313

K.R. Pine et al., Clinical Ocular Prosthetics, DOI 10.1007/978-3-319-19057-0
314 Index

Conjunctiva (cont.) enucleation vs., 73–74

surface papillary texture, assessment of, postsurgical care following, 77–80
113–115 surgical removal of, 73, 76–77
Contact lens-induced papillary conjunctivitis Exenteration. See Orbital exenteration
(CLPC), 252 Existing prosthetic eye in situ assessment,
Cornea 95–96
arcus senilis, 55 Extraocular muscles, 6, 32, 34–36, 57, 74–76,
corneal unit (see Iris/corneal unit) 81, 83, 191, 197
premanufactured iris discs and, 124–125 Eyelid malposition
sclera, 33 ectropion, 207–208
sensitivity of, 44–46 entropion
tattooing, 73 cicatricial entropion, 208
Corneal opacities involutional entropion, 208
aetiologies and clinical characteristics of, 5 prosthetic technique, 209
densities and dimensions, 153, 154 surgical technique, 209
Corneal tattooing, 72, 73 ‘windscreen wiper’ effect, 208
Corrugator muscles, 39 lagophthalmos
Coulomb, Robert, 301, 303 anterior lamellar deficiency, 214–215
Cranium, bones, 30 middle lamella deficiency, 215
Custom-fit prosthetic eyes, 118–119 posterior lamellar deficiency, 215
prosthetic technique, 214, 215
ptosis
D levator function, 210
Deposit build-up prosthetic technique, 210–212
inter-palpebral zone, 222, 224 Eyelid-related pathology
rate blepharitis, 243–244
deposit formation, intensity and extent dry eye syndrome, 244
of, 221, 222 lagophthalmos, 246
equal interval perceptual grading MGD, 244–246
scales, 221, 223 Eyelids
photographic record, 221, 224 anatomical features, 28, 40–41
regression analysis, 222, 225 muscles of
retro-palpebral zone, 222, 224 corrugator, 39
surface polish effect, 222–224, 226 facial musculature of, 38, 39
wettability, 227–228 frontalis, 39
Disfigurement, 67, 71–73 orbicularis oculi, 39–40
Driver and Vehicle Licensing Authority procerus, 39
(DVLA), 268–269 pupil, 28, 29
Dry eye syndrome, 93, 108, 244 upper eyelid angles, margin of, 29
upper eyelid crease, 29, 30
Eye loss
E biosocial and psychological aspects, 1
Ectropion, 207–208 children, psychological issues for, 12–13
Elli, 13, 14 epidemiology of
Entropion aetiology of, 3–4
cicatricial entropion, 208 anophthalmic population, estimated
involutional entropion, 208 size of, 2–3
prosthetic technique, 209 causes, 4–6
surgical technique, 209 perceptual changes, 6–7
‘windscreen wiper’ effect, 208 personal accounts of, 13–21
Enucleation, 73–76 psychosocial issues
of eye, 74–76 body image loss, 8–9
vs. evisceration, 73–74 novelty eyes, 9–10
PESS, 61–64 prosthetic eye comfort and
postsurgical care following, 77–80 convenience, 10–11
Evisceration Eye of Horus, 284, 285
Index 315

F preformed glass eyes, 295, 300

Face ‘reform’ eye, 295
ageing of, 54–55 seal tube, 295, 298
architecture, 27–28 softened glass, 295, 300
skeleton of, 30 softening pre-tinted hollow glass tube,
sound appreciation of the 295, 298
characteristics of, 26 Traité pratique de l’oeil artificial,
Facial symmetry, 4, 68 290, 291
FD OCT. See Fourier domain optical William Mackenzie’s A practical
coherence tomography (FD OCT) treatise on the diseases of the eye,
Fick, Adolf, 310, 311 291, 292
Forehead, muscles of seventeenth century, 289
corrugator, 39 sixteenth century, 287–288
facial musculature of, 38, 39 3000 BC, 284, 285
frontalis, 39 twentieth century
orbicularis oculi, 39–40 Coulomb, Robert L’oeil artificial,
procerus, 39 301, 303
Forniceal region, 43–44 custom-made PMMA eye, 304, 306
Fourier domain optical coherence tomography German glass eyes, 304, 307
(FD OCT), 107–108 L’oeil artificial, 301
Frontalis muscle, 39, 210, 212 maxillofacial prosthetics, 304, 308
moveable eye article, 304, 305
plastic artificial eyes, 304, 306
G stock glass eyes, 304, 308
Giant papillary conjunctivitis (GPC), 43, twenty-first century, 309–310
113–115, 180, 234–235, 252 2000 BC, 285–287
Goblet cells, 47–49, 51, 52 Hydrogel, 70–71, 227, 252
GPC. See Giant papillary conjunctivitis (GPC) Hydroxyapatite implants, 81, 82

H I
History Impact-resistant glasses, 12, 13
ancient Egypt, 283–285 Imperial Chemical Industries (ICI), 301
contact lenses and scleral shell prostheses, Inferior oblique muscle, 35–36, 74
310–311 InflammaDry™ technology, 110, 111
eighteenth century, 290 Intraorbital implants
nineteenth century Bioeye, 82
artificial eyes, 291, 294 coral, 81
callipers, 295, 296 material, 82–83
coloured glass rods, 295, 298 orbital implant, 82
creating pupil, 295, 299 shape, 83
cryolite glass eye, 293, 295 size, 83
European ocular prosthetics, 291, 293 titanium, 82
glass blowing instruments and wrapping, 83–84
materials, 295, 296 Iris/corneal unit
glass eye industry, 291–294, 299, alternative methods, 125–127
302, 303 painting
glass eye prescription form, 295, 297 collarette, 129
glass sphere implant, 296–297, 301 individual component, 128, 129
handling glass eye instruments, limbus, 130
295, 297 magnifying lamp, 128
importing stocks of glass eyes, pupil, 128–129
299, 302 stroma, 129–130
partially eye with glass rods, 295, 299 premanufactured iris discs and corneas,
partially finished glass, 295, 300 124–125
posterior aspect of the eye, 295, 300 prosthetic eye, components, 122
316 Index

Iris/corneal unit (cont.) environmental irritants, 247

trying, wax pattern and positioning extruding implants, 247, 248
central gaze, rod aligned in, 139 eyelid-related pathology, 243–246
compromises and trade-offs, 139, 140 eye stress, 247
fitting bilateral prosthetic eyes, gritty deposits, 249, 250
139–140 mixed conjunctival membrane,
process, 138 247, 249
vernier gauge, 123 pegged hydroxyapatite implant,
247, 248
scratches and dull patches, 249, 250
J silvery discolouration, 249
Jones test, 104, 108 thinly covered implants, 247
undissolved sutures with/without
granulomas, 247, 248
K viral/bacterial infections, 242–243
Keratoconjunctivitis sicca. See Dry eye tear protein deposition, 252
syndrome wetting angle vs. surface finish, 254
Krause’s glands, 44, 46, 49, 55 Mucoid discharge assessment, 112–113
Mucus, 48
Mules, Phillip Henry, 296–297, 301
L Müller, Albert, 310
Lacrimal apparatus, 48–50 Müller, Friedrich, 310
Lacrimal gland, 37–38, 48, 49, 55, 93 Müller-Ur, Ludwig, 293, 295
Lacrimal sac, 38
Lactoferrin, 50
Lagophthalmos N
anterior lamellar deficiency, 214 Nasolacrimal drainage system, 108
middle lamella deficiency, 215
posterior lamellar deficiency, 215
prosthetic technique, 214, 215 O
Levator muscle, 37 Ocular globe, loss of
Limbus, 44, 74, 130, 210 anophthalmic socket, conjunctiva of,
Lysozyme, 50, 252 57–59
empty socket, 55, 56
PESS, 61–64
M prosthetic eye motility, 57, 58
Marginal zone, 42, 43 restore, 55, 56
Medial canthal tendon (MCT) laxity, 38, 186 superficial anatomical features, 55, 56
Meibomian gland dysfunction (MGD), tear distribution, 60–61
243–246, 273 tear film, 59, 60
Meibomian gland loss assessment, 112 tear output, 60
Methylmethacrylate and N-vinylpyrrolidone, Ocular tear ferning test, 108, 109
70–71 Ocular tray impression technique, 131–133
Mucoid discharge Optic nerve, 34
CLPC/GPC, 252 Orbicularis oculi muscle, 39–40
managing non-specific mucoid discharge, Orbit
254–257 contents of
non-specific causes, 251–252 blood vessels and nerves, 38
polish improvement, 253 extraocular muscles, 34–36
range of socket characteristics, 242 eye, 32–33
re-polishing artificial eyes, 251, 253 lacrimal sac, 38
specific causes levator muscle, 37
cleaning prosthesis with solvent, optic nerve, 34
249, 250 orbital fat, 38
environmental allergens, 246–247 floor of, 31
Index 317

lateral wall of, 31 Phenol red thread test, 53, 104, 107
medial orbital wall, 31 Phenol red thread testing kit, 107
pyramidal shape of, 31 Plaster mold casting, 137, 138
rim, 31 (Poly)methyl methacrylate (PMMA)
roof, 31 conformer shells, 80
Orbital exenteration delamination, 98, 101
additional diseased bone, removal of, 84, intraorbital implants, 81–82
86 spherical implant, 104
adhesive-retained prosthesis, 87 tear film, 59–60
Bartisch, Georg, 84, 86 wax pattern
content removal, 84, 85 alternative method, 137, 138
eyelid skin and orbicularis muscle tissue, applying, second layer of iris colours,
retaining, 84, 85 141, 142
full-thickness skin graft, 85, 86 cooled down and removed, 135, 136
indication, 84 fine veins teasing, 141, 143
inserting magnets, 87 iris painting and scleral colouring, set
in mould, 88 up for, 141, 142
prosthesis, non-existent sockets, 85, 86 mould preparation, 134, 135
Orbital fat, 38 PMMA, clear veneer of, 143
Orbital volume deficit preheated white ocular wax, 134–136
expanded orbital volume, 204–205 process completion, 135, 137
orbital volume replacement rod attaches, 141
prosthetic technique, 200–201 sectioning, 134, 135
secondary orbital implant, 201–203 shape, 135, 137
subperiosteal implant, 203–204 trial packed with white PMMA, 141,
PESS, 200 142
Orbital zone, 43 Polyvinylsiloxane, 133
Post-enucleation socket syndrome (PESS),
61–64, 200
P Postsurgical conformer shells, 80–81
Palpebral fissures, 27, 140 Procerus muscle, 39
Palpebral region, 41–43 Prosthetic eye making and fitting
Patient evaluation final clinical session, 146
anophthalmic sockets assessment impression
nasolacrimal drainage system, 108 impression mixing gun technique, 131,
ocular tear ferning test, 108, 109 133–134
TBUT test, 109, 110 ocular tray impression technique,
tear volume, 106–108 131–133
tests, 104, 106 polyvinylsiloxane, 130, 131
types, 99–104, 110–112 polishing, process for, 144–146
different patients, 91, 92 prosthetic eye making and fitting
existing prosthetic eye in situ assessment, clinical session, 122–123
95, 96 components, 122
medical history, 93 iris/corneal unit (see Iris/corneal unit)
meibomian gland loss assessment, 112 step for, 122
mucoid discharge assessment, 112–113 stock vs. custom-fit, 118–119
personal history, 91, 92 in twentieth century, 301–304
prosthetic eye ex situ assessment, 96–99 Prosthesis retention
psychological assessment, 93–94 expanded conformer and tarsorrhaphy
remaining sighted eye, health of, 94 custom-made conformer, 186, 190
surface papillary texture, assessment of, eyelid-sparing exenteration, 186, 189
113–115 self-retentive prosthetic eye, 187
visual perception assessment, 94 inadequate fornix/fornices
Personal socket hygiene, 272–273 adhesions, 184
Phantom eye pain, 11 surgical technique, 185
318 Index

Prosthesis retention (cont.) bacteria and foreign material, 230

inadequate socket lining caregiver guide, 273–274
custom-made pressure conformer, 181 disturbed socket environment, 230–231
dermis–fat graft, 184 patient guide, 275–276
mucous membrane graft, 182–183 physical stress, 229–230
non-retentive contracted socket, processes, 229
180–181 surface characteristics, 231
skin/split-thickness skin grafts, 184 resources, 280–281
lower eyelid laxity supero-nasal notches in, 35
anophthalmic socket, 185 tear distribution, 60–61
inadequate lid tension, 185 tear film, 59, 60
prosthetic technique, 186 tear output, 60
surgical technique, 186, 188 tear protein deposits
Prosthetic contact lenses analogous, 220, 221
albinism, 155, 156 contact lens research, 220–221
aniridia, 151–153 deposit build-up (see Deposit
cataract appearance, 155 build-up)
corneal dystrophy, 157 temporal limbus area, 220
corneal leucoma, 151, 153 three-phase model (see Three-phase
corneal opacities/scars, 153, 154 model)
designs, 151, 152 wearers, 2, 3, 8, 9
Gundersen flap procedure, 150 concerns of, 11–13
heterochromia, 155–156 personal accounts, 13–21
in-house colouring system, 157–158 population of, 2–3
iris coloboma, 154 Ptosis
soft hand-painted lenses, 159 levator function, 210
soft opaque lens, 158, 159 prosthetic technique, 210–212
Prosthetic eyes
altered depth perception
ball approaches, 265 R
parallax, 266, 267 Rectus muscles, 35, 57, 74
perspective, contrast and overlap Retina, 33, 120
objects, 267, 268 Rigid gas-permeable (RGP) contact lenses,
relative motion, 263–266 227
senses, 267, 268 Ritterich, Friedrich Philipp, 291–294
application, 237–238 Rods, 119, 120
cleaning prosthetic eyes, 276–277 Rosacea, 243
ex situ assessment, 96–99 Rose Bengal, 96, 99
glasses selection, 278–279
handling social interactions, 260–262
managing mucoid discharge, 272 S
monocular vision Schirmer test, 53, 106
driver safety technology, 272 Scleral shell prostheses
driving, 270–271 completed medium thickness, 161
legal requirements, 268–271 custom metal moulds, 162
parking, 271 distorted cornea, 160
motility, 57, 58 final scleral shell construction
psychological importance of, 10–11 edges polishing, 171, 172
reduced peripheral vision fitting scleral shell prosthesis, 171, 172
discrete use of mirrors, 263, 264 iris and scleral colours, 170
preplanning, 262, 263 PMMA veneer process, 171
strategically position, 263, 264 polyurethane sheet, 170–171
removal, cleaning and reinsertion pupil, collarette, stroma and limbus
prosthesis colours, 170
Index 319

remove white, clear/semitranslucent prosthetic technique, 193

shell, 169 surgical technique, 194–196
rubber suction devices, 171, 172 symptoms, 192, 194
Gundersen flap procedure, 150 orbital implant migration, 191–194
history, 310–311 rotational instability, 196
left strabismic eye, 160, 161 Stereopsis, 6
making and fitting thin scleral shell Stock prosthetic eyes, 118–119
prostheses, 163 Stroma, 129–130
manufacturing process, 163–165 Substantia propria layer, 46
opaque cornea, 160 Subtractive colour system, 120, 121
polyvinylsiloxane impression, Superior oblique muscle, 35
166, 167 Surface papillary texture assessment, 113–115
premanufactured two-dimensional curved Syringing technique, 273
iris discs, 162
thin scleral shell design, 163, 164
topical anaesthetic eye drops, 166 T
trial/test shell Tarsal zone, 43
construction of, 167 Tear Break-Up Time (TBUT) test, 109, 110
fenestration, 168–169 Tears
plaster separating solution, 167 assessment, anophthalmic socket
two-part mould, 167, 168 nasolacrimal drainage system, 108
UV and white light sources, 167 ocular tear ferning test, 108, 109
Seborrhoeic dermatitis, 243 TBUT test, 109, 110
Skull, 30 tear volume, 106–108
Socket complications, 177, 215–216 tests, 104, 106
eyelid malposition (see Eyelid distribution, 53–54
malposition) ferning test, 108, 109
lesions film, 51–52, 59, 60
chemosis, 179 function of, 50–51
GPC, 180 glands, 49
granulomas, 178–179 output, 52–53, 60
malignancy, 178 Tearscope, 109, 110
orbital volume deficit (see orbital Three-phase model
volume deficit) breakdown phase, 232
prosthesis motility epitheliopathy of Marx’s line, 234, 235
axes of movement, 197 GPC, 234–236
excessive prosthetic eye motility, over time deposits thicken and
198–199 encroach, 234
inadequate prosthetic eye motility, physiological homeostasis, 236, 237
197–198 scanning electron microscopy, 234
prosthesis retention (see Prosthesis stagnation, 236
retention) equilibrium phase, 231, 233
socket stability (see Socket stability) establishment phase, 231, 232–233
superior sulcus deformity
dermis–fat graft and fillers, 207
prosthetic technique, 205–206 V
surgical techniques, 205 Vascular choroid, 33
upper eyelid blepharoplasty, 205, 207 Visual perception assessment, 94
Socket stability
displacing prosthetic eye, 190, 192
inadequate prosthesis retention, 190, 192 W
orbital implant exposure Wax pattern, 134–139