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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 1  |  Page : 41-44

Rehabilitation of ocular defects: Custom made and modified stock eye prostheses


Department of Prosthodontics, Government Dental College, Aurangabad, Maharashtra, India

Date of Web Publication16-Feb-2016

Correspondence Address:
Amaey A Parekh
A/1001, Pranay Vidya Bldg, Off Borsa Pada Road, Kandivali West, Mumbai - 400 067, Maharashtra
India
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DOI: 10.4103/0976-433X.176483

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  Abstract 

Physical defects that compromise appearance or function prevent an individual from leading a normal life. The loss of eye is a visible facial defect and often undermines the patient's confidence. Prosthetic rehabilitation of ocular defect should be done as soon as possible for physical as well as psychological healing. This paper describes two case reports detailing alternative procedures for prosthetic rehabilitation of ocular defects. The article also discusses the most economical and effective esthetic treatment available for ocular defects as applicable in the Indian scenario. It describes the fabrication of a custom ocular prosthesis and modified stock ocular prosthesis and the differences in methods of fabrication and outcomes. In addition, use of Leudde's exopthalmometer for easier measurements is explained.

Keywords: Defects, eye, ocular, prostheses, scleral shell, stock


How to cite this article:
Parekh AA, Bhalerao S. Rehabilitation of ocular defects: Custom made and modified stock eye prostheses. SRM J Res Dent Sci 2016;7:41-4

How to cite this URL:
Parekh AA, Bhalerao S. Rehabilitation of ocular defects: Custom made and modified stock eye prostheses. SRM J Res Dent Sci [serial online] 2016 [cited 2020 Aug 13];7:41-4. Available from: http://www.srmjrds.in/text.asp?2016/7/1/41/176483


  Introduction Top


The loss of an eye impairs the patient's visual function and also results in a noticeable deformity. Orbital defects may be associated with congenital deformities, tumors, or acquired traumatic lesions. The minimal surgical procedure is “Evisceration” is the removal of the contents of the globe, leaving the sclera and/or cornea intact. “Enucleation” is the removal of the entire eyeball and “Exenteration” is the removal of the entire contents of the orbit.[1]

The rehabilitation of a patient who has suffered the psychological trauma of an ocular loss requires a prosthesis that will provide the optimum cosmetic and functional results.[2] Patients with evisceration defects or ocular atrophy can be treated with custom-made ocular prostheses or modified stock eyes.[3],[4],[5] The shell prosthesis covers the entire surface of the eye, restoring it to a natural appearance. The prosthesis is commonly made of polymethyl methacrylate resin which is superior to other ocular prosthetic materials in terms of tissue compatibility, esthetic capabilities, durability, and color permanence, adaptability of form, cost, and availability.[6] In the Indian scenario, patients may not be able to afford surgical reconstruction or major cosmetic treatments. However, the scleral shell prosthesis as described below gives the patient a much more cost-effective treatment whilst achieving satisfactory esthetics.[7],[8] Presented below are two case reports describing fabrication of a custom ocular prosthesis and modified stock ocular prosthesis and the differences in their methods of fabrication and outcomes.

Indications for ocular prosthesis

  • After enucleation and evisceration with or without implant.
  • Over phthisical eyes.
  • Blind eye with scarred corneas.
  • Congenital anophthalmia/microphthalmia. [2],[3],[6],[7],[8]



  Case Reports Top


Case 1

A 23-year-old male reported to the department of Prosthodontics, Nair Hospital Dental College with loss of the right eye 8 years back in an accident [Figure 1]a. The right eye bed with a part of the sclera was able to perform and co-ordinate all movements in unison with the left eye bed. It was decided to fabricate a custom ocular prosthesis with the iris obtained from a prefabricated ocular shell.
Figure 1: (a) Pretreatment (b) modified conformer (c) impression of the eye bed (d) dental stone mold

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Impression technique

Petroleum jelly was applied to the eyebrows. A prefabricated conformer was selected according to the size of the defect and modified by attaching a hollow plastic stem [Figure 1]b serving as in inlet for Irreversible hydrocolloid impression material (Neocolloid), which was injected into the socket through the attached hollow stem with the patient instructed to make various eye movements to get functional impression [Figure 1]c. A dental stone (Denstone grade 3) mold was obtained. After the stone had set, markings were made for reorientation; separating media was applied, and a second layer was poured [Figure 1]d.

Evaluation of the bulge of normal eye and ocular defect

A Leudde's exopthalmometer is a simple oplthalmologic instrument that acts as a ruler for precise measurement of the degree of exopthalmos.[9] It aids in avoiding any excessive instrumentation or making a template to assess the position of the future prosthetic iris and pupil. It was used to assess the bulge of both the eyes with the base of the transparent ruler placed against the external orbital canthus and patient looking forward [Figure 2]a. The difference in the bulge between the normal eye and that of the right eye bed was 3 mm which was decided to be used as the thickness of the wax pattern fabricated.
Figure 2: (a) Leudde's exopthalmometer (b) try-in of the wax pattern (c) final prosthesis in-situ

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Fabrication of prosthesis

The wax pattern was fabricated by pouring the molten wax into the mold that on cooling was retrieved and adjusted to 3 mm thickness. Try-in of the wax conformer was done after topical anesthetic application. An iris button was obtained from prefabricated ocular shell prosthesis, and its position was determined with the help of anatomical landmarks making the patient look straight. Final try-in was done keeping the iris in its defined position [Figure 2]b. A 10 min waiting period was kept to adapt to any protective blepharospasm. The shade of the scleral portion was selected by using a customized shade guide made by processing heat cured acrylic (Acralyn-H) buttons of different shades. Flasking was done securing the iris to the counter flask. The first packing was done with the selected heat cured tooth colored acrylic. The prosthesis was cured and finished. The prosthesis was evaluated in the patient. After the necessary adjustments, a final layer was added to the prosthesis along with small red color silk threads, simulating the blood vessels. The prosthesis was again cured, finished, and polished. The final prosthesis was then inserted in patient's eye [Figure 2]c. The patient was recalled after 24 h and weekly for a month with no discomfort reported.

Case 2

A 48-year-old male patient was referred to the department of Prosthodontics with a history of trauma to the right eye over 12 years back. On examination, part of sclera was seen [Figure 3]a. The right eye bed was able to perform and coordinate all movements in unison with the left eye bed. It was decided to modify stock ocular shell prosthesis for rehabilitation of the defect.
Figure 3: (a) Pretreatment (b) prefabricated conformer (c) custom made conformer (d) final impression (e) wax pattern (f) final prosthesis in-situ

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A primary impression was made in irreversible hydrocolloid with a prefabricated conformer and poured [Figure 3]b. Following retrieval of the cast, a custom tray was fabricated using clear self-cure resin (DPI-RR Cold cure). Five holes were made in the periphery for escape of the impression material [Figure 3]c. A larger hole was made in the center to serve as an inlet for light body impression material (Silagum). The tray was tried in the patient's socket, and minor adjustments were made. The patient was instructed to sit straight, looking in front at the level of the eyes. Light body was then injected into the try through the inlet [Figure 3]d. After obtaining the impression; a die stone (Kalrock) mold was poured as described earlier to obtain a final cast.{Figure 3}

The wax pattern was fabricated by pouring the molten wax into mold and bulge of both eyes assessed as described earlier. The difference in bulge between both the eyes was 4 mm. An appropriate stock eye shell was selected and positioned over the wax pattern [Figure 3]e and tried on the patient for further adjustments. Processing was done with clear heat cure acrylic resin after shade matching and processed as described earlier. The final prosthesis was inserted in patient's eye [Figure 3]f with no discomfort reported on delivery and recall.

After care

  1. The patient was instructed to wear the prosthesis day and night, which must be removed and washed with mild soap once every 1 or 2 weeks.
  2. Ophthalmic irrigation solution is used daily as eye drops to clean the anterior surface of the prosthesis as well as soft tissues of the socket. The presence of an infection that does not respond to simple irrigation should be referred to an ophthalmologist.
  3. The surface of the prosthesis may become scratched or pitted with time and must be re-polished immediately as well as periodically during routine follow-up examinations at least once a year. The ocularist/prosthodontist should evaluate if the scleral shell prosthesis is acceptable or needs to be replaced.
  4. Prognosis of the prosthesis has been suggested up to 4.8 years. However, it depends on maintenance by the patient and evaluation by the ocularist periodically. [10],[11]



  Discussion Top


The challenge in restoring an ocular defect is replacing a mobile sense organ with a static prosthesis. An ocular prosthesis should maintain its orientation when the patient is looking straight ahead. It should restore the normal opening of the eye, support the eyelids, restore a degree of movement, must be adequately retained and esthetically pleasing.[2],[10] The use of a stock prosthesis is usually advocated when time is limited, and cost is a consideration. Fabrication of a custom ocular prosthesis allows several variations during construction. The close adaptation to tissue bed uses the full potential to produce movement.[12] Voids that collect mucus and debris and irritate mucosa and act as a potential source of infection are minimized. Optimum cosmetic and functional results enhance the patient's rehabilitation to a normal lifestyle.

A properly fitted and acceptable custom ocular prosthesis has the following characteristics:[6]

  • Retains the shape of the residual socket.
  • Prevents collapse or loss of shape of the lids.
  • Provides proper muscular action of the lids.
  • Prevents the accumulation of fluid in the cavity.
  • Maintains palpebral opening similar to the natural eye.
  • Mimics the colorations and proportions of the natural eye.
  • Has a gaze similar to the natural eye.


The prosthesis has been tried in patients of all ages, ranging from children to geriatric patients.[7],[8] Age is not a contra-indication for this treatment as it is a purely cosmetic and noninvasive treatment. The dictating factor for the design of the prosthesis is based on the defect size, the fornices, condition of the eyeball, as well as the lining.

Even though custom-made, limitations are always there. In a few cases, we can camouflage the deficiency by giving,

  • Larger spectacle frames.
  • Using dark tinted glasses.
  • Plus or minus spheres or cylinders.
  • Prisms.


Lastly and most importantly, this is only an esthetic rehabilitation. The patient does not regain vision with the procedure.


  Conclusion Top


The treatment of two patients described is done considering the economical restraints with flexible treatment modalities that improve old, accepted practices. Rehabilitation of ocular defects indeed results in a significant improvement in esthetics contributing immensely to the physical and mental well-being of the patient. The article describes how both stock and modified shell prosthesis may aid in the cosmetic rehabilitation of the patients in the Indian scenario.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

 
  References Top

1.
Perman KI, Baylis HI. Evisceration, enucleation, and exenteration. Otolaryngol Clin North Am 1988;21:171-82.  Back to cited text no. 1
    
2.
Taylor TD. Clinical Maxillofacial Prosthetics. 3rd ed. Chicago: Quintessence Publishing Co. Inc.; 2000. p. 265-76.  Back to cited text no. 2
    
3.
Cain JR. Custom ocular prosthetics. J Prosthet Dent 1982;48:690-4.  Back to cited text no. 3
    
4.
Taicher S, Steinberg HM, Tubiana I, Sela M. Modified stock-eye ocular prosthesis. J Prosthet Dent 1985;54:95-8.  Back to cited text no. 4
    
5.
Sykes LM. Custom made ocular prostheses: A clinical report. J Prosthet Dent 1996;75:1-3.  Back to cited text no. 5
    
6.
Gupta RK, Padmanabhan TV. Prosthetic rehabilitation of a post evisceration patient with custom made ocular prosthesis: A case report. J Indian Prosthodont Soc 2012;12:108-12.  Back to cited text no. 6
    
7.
Doshi P, Aruna B. Prosthetic management of patient with ocular defect. J Indian Prosthodont Soc 2005;5:37-8.  Back to cited text no. 7
  Medknow Journal  
8.
Somkumar K, Mathai R, Jose M. Ocular prosthesis: Patient rehabilitation — A case report. Peoples J Sci Res 2009;2:21-6.  Back to cited text no. 8
    
9.
Chang AA, Bank A, Francis IC, Kappagoda MB. Clinical exophthalmometry: A comparative study of the Luedde and Hertel exophthalmometers. Aust N Z J Ophthalmol 1995;23:315-8.  Back to cited text no. 9
    
10.
Raizada K, Rani D. Ocular prosthesis. Cont Lens Anterior Eye 2007;30:152-62.  Back to cited text no. 10
    
11.
Trawnik JR. Dallas Eye Prosthetics. Available from: . [Last accessed on 2014 Nov 27].  Back to cited text no. 11
    
12.
Shenoy KK, Ratna NP. Ocular impression: An overview. J Indian Prosthodont Soc 2007;7:5-7.  Back to cited text no. 12
  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Case Reports
Discussion
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