Download Rehabilitation of Disfigured Eye: An Ocularist`s Overview

Oculoplasty
Rehabilitation of Disfigured Eye:
An Ocularist’s Overview
Sachin Gupta M. Opt, FAES, Shreya Gupta AIMPT
Art Eyes, Janakpuri, New Delhi
E
yes are the most important part of the facial beauty and generally the first features of the face to be noted. An
unfortunate loss or absence of an eye may be caused by a congenital defect, irreparable trauma, tumour, painful
blind eye, sympathetic ophthalmia or the need for histological confirmation of a suspected diagnosis 1. The
disfigurement associated with the loss of an eye can cause significant physical, psychological and emotional
problems2. Most patients experience significant stress, primarily due to adjusting to the functional disability caused by
the loss and to societal reactions to the facial impairment.
Replacement of the lost eye as soon as possible is necessary to promote physical and psychological healing for the
patient and to improve social acceptance3. A fundamental objective when restoring an anophthalmic socket with an
ocular prosthesis is to enable the patient to cope better with the difficult process of rehabilitation 4.
A multi-disciplinary management and team approach are essential in providing accurate and effective rehabilitation
and follow-up care for the patient. Therefore, the combined efforts of the ophthalmologist and ocularist are essential
to provide a satisfactory ocular prosthesis5.
Ocularisty is an art and science of fabrication & fitting of a customised artificial eye or ocular prosthesis to a disfigured
or lost eye. The role of an ocularist is fabricating an ocular prosthesis with acceptable aesthetics, to restore facial
symmetry and normal appearance (Figure 1).
Apart from the definite cosmetic advantages ocular prosthesis plays an important role in cases such as:
•
To help in preventing remaining soft tissue in socket from collapsing
•
To prevent eyelids and lashes from turning in
•
To help facilitate the proper circulation of tears so they can continue to do their job of cleaning and lubricating the
socket and lids.
This article is an attempt to provide the information about the different cases which need prosthetic rehabilitation and
an ocularist’s involvement in the management.
Phthisis Bulbi
Phthisis bulbi is a small, shrunken, non-functional eye. Phthisis bulbi occurs as a result of severe ocular disease, trauma,
accident, exposure to radiation, tumour, eye infection or inflammation. The severity of the disorder depends upon the
type and depth of injury. The damage to structures within the eye from any of the above mentioned causes can
eventually lead to eye atrophy.
A custom ocular prosthesis gives good outcome in case of phthisis bulbi as it helps in the augmentation of the total
volume of the eye lost due to shrinkage of the eye. (Figure 2) Custom made ocular prosthesis are made after taking
the impression of the eye socket so the weight of the prosthesis is evenly spread over the anterior surface of the
affected eye and the chances of lower lid complications are very less. Thus providing the patient with good cosmetic
result, comfort and ocular movement. Very good prosthesis movements can be achieved in case of phthisis bulbi if
volume loss (shrinkage) is not more, fornices are deep enough and anatomy of orbital tissue is undisturbed 6.
Surgically induced Anophthalmos
Surgically induced Anophthalmos is caused by Enucleation or Evisceration. Enucleation is the surgical removal of the
entire eye while Evisceration is the surgical removal of the contents of the eye, leaving the sclera and the eye muscles
intact.
Good surgical intervention enables the ocularist to deliver the best outcome in terms of aesthetic and prosthesis
motility. The adequate size of orbital implant and its centration helps in providing the best possible outcome 7 (Figure
3).
Prosthesis can be fitted after 4-6 weeks of surgery depending upon the healing.
Congenital Anophthalmos and Microphthalmos
Congenital Anophthalmos and Microphthalmos is a rare birth defect. Microphthalmos is a developmental anomaly
characterized by abnormal smallness of one or both eyes. Microphthalmos may range from mild, with a slightly small
eyeball, to severe, with a vestigial eyeball associated with hypoplastic orbits and eyelids.
The goals of treatment for Microphthalmos are:
•
To enlarge the bony orbit
•
To enlarge the conjunctival space
•
To increase fissure length and
•
To promote normal development of the lid margins and lashes.
The guiding principle is conservative therapy that is, avoiding surgery if at all possible, so that ocularisty can ultimately
provide the optimum cosmetic results6. The management of such congenital disorders is very difficult. It is always
better to start early because socket tissues are soft and fornices can be expanded easily by putting custom conformers.
Starting early also has the advantage of stimulating the growth of bony orbit and preventing the facial asymmetry.
Gradually increasing Custom conformers known as socket expanders helps in expanding the bony socket, deepen the
fornices, increasing the palpebral fissure and providing better cosmetic results (Figure 4).
Contracted Socket
Contracted socket can be caused due to various reasons. These include:
•
Etiological causes such as alkali burns, radiation therapy related, microphthalmos
•
Surgical related such as fibrosis, excess loss of conjunctiva, multiple socket surgeries, no implant in the eye,
migration or exposure of implant
•
Site related such as poor vascular supply, severe ischemic ocular diseases and
•
Prosthesis related such as not wearing conformer or prosthesis, delayed intervention, prolong use of poor fitting
prosthesis etc.
Contracted socket can be managed surgically. A good reconstruction of the socket gives the opportunity to the
ocularist for fitting a cosmetically acceptable prosthetic eye, the demand for which is ever increasing.
Mild to Moderate contracted socket with soft fonical tissues can be easily managed by custom prosthesis. Sometimes
overnight pressure therapy over such prosthesis also helps to deepen the socket and resulting good retention of the
prosthesis.
Contracted socket can also be prevented. Use of suitable type of implants and conformers and a proper technique of
enucleation with haemostasis and asepsis go a long way in preventing this problem. Another important thing to be
remembered is that early intervention followed by use of custom made ocular prosthesis can also help prevent
contraction of the socket (Figure 5).
Orbital Prosthesis
Orbital prosthesis is indicated following orbital exenteration which is a radical procedure consisting of removal of the
orbital contents, including orbital fat, conjunctival sac, globe, and a part or whole of the eyelids 8. The indication of
orbital exenteration may be due to a malignant or non malignant disease, trauma or infection.
Successful rehabilitation is dependent on good communication between surgeon and prosthetist, to ensure that a
defect that is conductive to successful prosthesis results following the definitive surgical exenteration. Ideally the
patients’ natural eyebrow should be left intact in their original position to retain realism in the post-prosthetic result.
The facial defect post exenteration is normally covered with an external orbital prosthesis (Figure 6). Orbital prostheses
are made of silicone elastomers, acrylic resin, or a combination of these two 9.
Conclusion
The major advantages of a custom made ocular prosthesis are improved fit, mobility, and aesthetics. The replacement
of the lost eye in case of congenital disorders or anophthalmos should be carried out with a custom made ocular
prosthesis as early as possible. It is important to increase the awareness of timely intervention among the patients and
their parents.
In case of infants with congenital deformities the treatment should be started within the first two months of birth by
placing a small ocular prosthesis (conformer) to prevent the cul-de-sac from shrinking and to promote development, a
conformer of a larger size must be changed as the child grows.
In cases requiring surgery, it is best to always put an implant of appropriate size to attain best possible results with the
fitting of custom ocular prosthesis. It also aids in providing best cosmetic results and good motility of ocular
prosthesis. A well fitted Custom ocular prosthesis helps the person gain back their lost confidence and helps them to
live a better life.
References
1.
Raflo GT. Enucleation and evisceration. In: Tasmun W, Jaeger E eds.Duane’s Clinical Ophthalmology, Revised edn, Vol. 5. Philadelphia: LippincottRaven, 1995: 1–25.
2.
Lubkin V, Sloan S. Enucleation and psychic trauma. Adv. Ophthalmic Plast Reconstr. Surg. 1990; 8: 259–62.
3.
Artopoulou II, Montogomery PC, Wesley PJ, et al. Digital imaging in the fabrication of ocular prostheses. J Prosthet Dent. 2006; 95: 327–30.
4.
Ow RKK, Amrith S. Ocular prosthetics: use of a tissue conditioner material to modify a stock ocular prosthesis. J Prosthet Dent. 1997; 78: 218–22.
5.
Bartlett SO, Moore DJ. Ocular prosthesis: a physiologic system. J Prosthet Dent. 1973; 29: 450–59.
6.
Dootz GL. The ocularisty management of congenital microphthalmos and anophthalmos. Adv ophthalmic Plastic Reconstr Surg. 1991; 9:41-56.
7.
Raj Anand et al. Optimal fitting of ocular prosthesis in different clinical situations. Dos times,Vol.15, No.2, Aug 2009.
8.
Perman KI, Baylis HI. Evisceration, enucleation, and exen-teration. Otolaryngol Clin North Am. 1988; 21:171-82.
9.
Kurunmaki H, Kantola R, Hatamleh MM, et al. A fiber-reinforced composite prosthesis restoring a lateral midfacial defect:A clinical report. J
Prosthet Dent. 2008; 100:348–52.