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Journal Name: Edorium Journal of Disability and Rehabilitation
Type of Article: Review Article
Title: Scoping review of the development of artificial eyes throughout the years
Authors: Holly Chinnery, Simon B N Thompson, Siamak Noroozi, Bryce Dyer
doi: To be assigned
Early view version published: September 24, 2016
How to cite the article: Chinnery H, Thompson SBN, Noroozi S, Dyer B. Scoping review
of the development of artificial eyes throughout the years. Edorium Journal of Disability
and Rehabilitation. Forthcoming 2016.
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Manuscript Accepted
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Early View Article
TYPE OF ARTICLE: Review Article
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TITLE: Scoping review of the development of artificial eyes throughout the years
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AUTHORS:
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Holly Chinnery1, Simon B N Thompson2, Siamak Noroozi3, Bryce Dyer4
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AFFILIATIONS:
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(BSc (Hons), MSc, PG Cert), Post-graduate Researcher, Psychology Research
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Centre, Faculty of Science & Technology, Bournemouth University, Poole, UK,
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[email protected]
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(BA (Hons), MPhil, PhD, PhD, PGDIS, PGCLTHE, PGCRDS, PFMBNS, MARB,
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MNYAS, FRSA, SFHEA), Associate Professor of Clinical Psychology and
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Neuropsychology, Psychology Research Centre, Faculty of Science & Technology,
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Bournemouth University, Poole, UK, [email protected]
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(MEng, PhD), Director of Design simulation Research Centre, Faculty of Science
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and Technology, Department of Design and Engineering, , Bournemouth University,
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Poole, UK, [email protected]
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(BA (Hons, MSc, PhD), Head of Research & Professional Practice and Principal
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Academic, Faculty of Science and Technology, Department of Design and
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Engineering, , Bournemouth University, Poole, UK, [email protected]
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CORRESPONDING AUTHOR DETAILS
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Holly Chinnery
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P104, Poole House, Psychology Research Centre, Faculty of Science & Technology
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Talbot Campus, Fern Barrow, Poole Dorset UK BH12 5BB
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Email: [email protected]
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Short Running Title: Development of artificial eyes
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Guarantor of Submission: The corresponding author is the guarantor of
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submission.
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SUMMARY
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Research into the development of prosthetics still focuses on factors that either
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facilitate or impede the physical adjustment of the prosthetic. Little consideration has
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been given to the continual progression of their design and the psychosocial impact
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that wearing a prosthetic has on the patient.
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enhance the outcome not only for the patient, but for practitioners as well.
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With the design, manufacturing and fitting process of artificial eyes remaining the
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same since the 1960’s, an understanding of its development in order to improve its
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current form is needed. A better designed artificial eye will not only have physical
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benefits for the wearer, but also psychological benefits where the way the wearer
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thinks about themselves and their artificial eye, as well as their perceptions of what
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others think about them, will lead to better adjustment and improved wellbeing.
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In order to assess how artificial eyes can be improved, a scoping review of the
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development of artificial eyes was undertaken. It is envisioned that this review will
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help identify future research and development in order to create better outcomes for
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practitioners and artificial eye wearers alike.
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Thirty-eight articles were included in the review, 73% of which were qualitative in
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nature.
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The scoping review found good documentation of the history and current
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manufacturing process of artificial eyes. However, research into the psychological
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impact of artificial eye wearers is sparse. Changes to the current manufacturing
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process have largely been ocularist led with various impression techniques being
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developed. Patients with artificial eyes and/or facial disfigurement have higher levels
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of anxiety and depression than the general population leading to maladaptive coping
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mechanisms and reduced emotional wellbeing.
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Explanations for the lack of development in this field include: the small population
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which can affect funding grants; technology not yet able to produce the required
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results; availability of resources and research being focused on the disease rather
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than the secondary effects.
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Understanding such factors will
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TITLE: Scoping review of the development of artificial eyes throughout the years.
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ABSTRACT
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Losing an eye following trauma can lead to profound psychosocial difficulties making
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it imperative for the wearer to be fitted with an aesthetically pleasing custom-made
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artificial eye. Despite recent technological advancements, current design and
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manufacturing processes have remained unchanged in over 55 years. With the aim
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of portraying current knowledge regarding the development of artificial eyes in order
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to aid future development, a scooping review was conducted. Six online search
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engines were used: Scopus, PubMed, MedLine Complete, Web of Science, Science
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Direct and Google Scholar.
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underwent numerical and thematic analysis with three thematic themes emerging.
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History and the current process of artificial eyes has been well documented;
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however, the impact of wearing artificial eyes is sparse. On-going research and
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development into the design and manufacturing processes of artificial eyes and the
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psychosocial impact of wearing an artificial eye is needed.
Thirty-eight articles met the inclusion criteria and
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Keywords: artificial eyes, eye loss, prosthetic eyes, psychosocial impact of
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prosthetics, historical and technological development of artificial eyes
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TITLE: Scoping review of the development of artificial eyes throughout the years.
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INTRODUCTION
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Human understanding of expressions and what they mean emerges very early on in
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life. Confronted with and revealing a whole host of emotions when we look into one
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another’s eyes gives credence to the saying ‘our eyes are the windows to our soul’.
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Our eyes act as our navigational tools: we adjust and modify our behaviour and act
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in accordance to our interpretations, whether that’s related to our physical
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surrounding, social interactions or emotional contact. With many aspects of human
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functioning relying on our eyes, a loss of one or both can have a significant impact
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on a person.
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The loss of an eye(s) can be caused by a congenital defect or be acquired.
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Examples include malignancies, intraocular and extraocular infections, trauma,
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orbital tumours and painful blind eyes [1]. Following the loss of an eye, patients are
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fitted with an artificial eye. Today’s artificial eyes are a thin hard acrylic shell that
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covers the surface of the eye, fitting over an orbital implant and under the eyelids [1].
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Research into the impact that the loss of an eye has, highlights medical,
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psychological, social, emotional and physical difficulties [1-7].
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perspective the loss of one eye results in a change from binocular vision to
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monocular vision leading to initial feelings of disorientation and clumsiness [4].
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Although adjustments by turning the head can overcome the defects in depth
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perception and field of vision some activities of daily living such as playing sports,
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driving and work requiring prolonged visual vigilance will continually be impacted.
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Psychological adjustment to the loss of an eye comes with emotional acceptance in
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all areas of one’ life including personal, professional and societal. In circumstances
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where a person has not adjusted to the loss, difficulties such as depression, anxiety,
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low self-esteem, low self-image and feelings of hopelessness may arise. This can
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lead to maladaptive coping mechanisms impacting social functioning and
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independence. Thus, in order to provide the best overall care, understanding and
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sensitivity to the loss is required [2].
From a medical
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Whilst research has documented the factors associated with the loss of an eye [3-6],
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knowledge surrounding the impact wearing artificial eyes is still in its infancy.
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Furthermore, despite its progression in related fields, such as prosthetic limbs,
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technological development regarding artificial eye design and manufacturing has
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stagnated. These two key facets are essential in identifying future research and
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development in order to create better outcomes for practitioners and artificial eye
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wearers alike.
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In order to achieve this, a strong knowledge base needs to be created. Therefore,
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the objective of the scoping review is to portray current knowledge regarding the
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development of artificial eyes in order to aid future development.
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METHOD
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This review followed the five framework stages outlined by Arksey & O’Malley’s
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(2005).
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Stage 1: Identification of the research question
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Based on two facets: development of artificial eyes remaining the same since the
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1960s, and, peoples’ needs evolving over time, led to the research question: ‘What is
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known from the existing literature about the development of artificial eyes throughout
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the years?’ It is envisioned that this review will be an aid in creating an
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understanding of where and if technology can provide the tools required by artificial
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eye wearers. To gain a rounded understanding of artificial eyes, a search strategy
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involving the historical and development of artificial eyes and what influences the
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development was deemed necessary.
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Stage 2: Identifying relevant studies
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In order to locate a wide variety of research relating to artificial eye development, no
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time span or language constraints were applied. A threefold search strategy was
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adopted: electronic databases, internet search and reference list search. The search
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was performed between August 6th and August 31st 2016 using six databases:
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PubMed; MedLine Complete; Web of Science; Science Direct and Google Scholar.
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The search strategy used terms to denote ‘artificial eyes’ (prosthetic eyes, ocular
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prosthesis) combined with a range of terms denoting its development (history,
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technology, impact, emotional wellbeing). The final stage of the search strategy was
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reference checking.
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Stage 3: Study selection
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A total of 280 references were identified from the search strategy. An inclusion and
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exclusion criteria was developed and applied to all studies that represented a best fit
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with the research question. Articles relating to the historical and technological
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development of artificial eyes; needs of and the impact upon those wearing artificial
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eyes and participants who had undergone enucleation, exenteration and evisceration
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as a result of genetics, trauma, injury, infection and disease were included in the
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review. Furthermore, due to the scarcity of publications about the psychological
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impact of wearing artificial eyes, references were sought for those associated with
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facial disfigurement only (see table 2)
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Articles regarding stock eyes, eye shells, implants and orbital prosthesis; those that
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assess the condition of and aftercare of artificial eyes and clinical/case reports were
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excluded. Reflecting time and budget constraints, the time span of articles was
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amended. With the change of material in the construction of artificial eyes occurring
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following the end of World War II, it was decided that all articles pre-dating 1950
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would be removed from the search, enabling the remaining articles to reflect current
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methods utilised in its design.
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The inclusion and exclusion criteria were applied to all 280 references using
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abstracts or the full articles where available. Of these, 121 were considered to meet
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the inclusion criteria. Full reports were obtained for 38 articles. The remaining 54
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articles consisted of those that predated the exclusion criteria (17) and those
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unavailable through library sources (66). A full list of these articles can be found in
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the appendix.
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Stage 4: Charting the data
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A data charting form was created using the database programme Excel. All 38
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articles were entered into the form that contained the following information: author(s),
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year of publication, study location; intervention type, duration of the intervention;
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study population; aim(s) of the study; methodology and key findings/results. These
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data formed the basis of the analysis.
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Stage 5: Collating, summarizing and reporting the results
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A scoping review aims to ‘map’ or identify literature in the field. This was done in two
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stages: firstly, basic numerical analysis and secondly, thematic analysis.
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RESULTS
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Numerical analysis
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Geographical distribution of articles reviewing the development of artificial eyes
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Figure 1 shows the number and proportion of research reports that looked at the
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development of artificial eyes. The majority of the articles were carried out in the
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USA (54%). In comparison a far smaller proportion of articles were derived from the
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UK (18%). New Zealand accounted for 7% of the articles and Australia accounted
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for 4% of the articles. Articles from the rest of Europe and the world accounted for
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the rest
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Categorizing the articles
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The articles were related to the historical development, current process and the
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impact upon patients with artificial eyes and facial disfigurement. In order to reflect
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this heterogeneity, studies were grouped together.
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Figure 2 shows the classification scheme used and the number of studies according
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to each intervention category. The majority of articles were narrative inquiries (39%)
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followed by historical reviews (26%) and questionnaires (22%). Literature reviews,
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interviews and interview and questionnaires made up the remaining typologies.
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Types of research methods used to understand the development of artificial eyes
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Table 3 reflects the number and proportion of studies according to type of research.
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The majority of studies (90%) used qualitative methods. Of these narrative inquiries
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compromised 39% of articles and historical reviews compromised 26% of articles.
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The remaining 35% of articles were a combination of quantitative and mixed
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methods research.
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Geographical distribution of articles of artificial eye development according to
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research method
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Table 4 shows the number and proportion of studies by country for each of the four
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typologies used.
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conducted in the USA (54%). In comparison, research in the UK has been more
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evenly spread: Narrative inquiry (60%); historical review (20%) and questionnaires
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(20%).
The majority of studies were narrative inquiries which were
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Summary of the characteristics of articles
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The 38 studies of the development of artificial eyes were included in this review. The
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data shows that:
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o The majority of articles were conducted in the USA and were qualitative in
nature.
o Narrative Inquiries were most commonly studied, followed by historical
reviews and then questionnaires.
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o UK studies encompassed both qualitative and quantitative articles reviewing
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the historical development, current methods and the impact of artificial eyes
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and facial disfigurement.
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o Articles related to specific techniques were mainly of single rather than
multiple approaches.
o Few studies assessed the needs of the artificial eye wearer.
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Thematic Analysis
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History of artificial eyes
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Anecdotal reports and relics from ancient civilizations point to the first artificial eyes
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being made by the Egyptians in the 4th Dynasty (2613 – 2392 BC) and the ancient
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cultures of Babylon and Jericho [7-14].
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The Egyptians, Greeks and Romans embellished important statues, mummies and
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animals with artificial eyes [10, 14, 15]. They were known as ‘art eyes’ and were
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made from precious stones such as earthenware, enamelled bronze, copper and
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gold. The orbit was filled with wax or plaster on top of which the precious stone was
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inserted to represent the iris of an eye [5, 9, 10, 11, 14, 16]. It is thought that these
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‘art eyes’ were used for cosmetic purposes as a symbol of light and life in their
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religious beliefs [8-9].
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From the 26th Dynasty through the Dark/Middle Ages (500 – 1500 AD), the making
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of artificial eyes was largely abandoned [10, 12].
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period (1400 – 1700 AD) that artificial eyes saw a resurgence [14].
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The 16th century saw artificial eyes being fitted in the socket and experimentation
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with materials. Ambroise Paré, a French surgeon, described two types of artificial
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eyes: the ‘Hypoblephara’, which fitted underneath the eyelid, and the ‘Ekblephara’
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which fitted externally: both of which were expensive, heavy, painful to wear and
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lacked the moist quality of a normal eye [7, 11].
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Paré was also credited with evolving the making of artificial eyes from gold and silver
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to glass [5, 8-10, 12]. Glass eyes were made of lead or soda both of which were
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durable but caused severe tissue reactions and erosion limiting their lifespan to 9-24
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months [5]. Despite these shortcomings, glass was better tolerated by the orbital
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tissue [17]. and was seen as being able to eliminate the problems associated with
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metal artificial eyes (gold and silver) such as its weight and expense [11]. The use of
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glass saw their shape change from sphere to a shell form reducing irritation to the
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socket but putting patients at risk of bruising the conjunctival bed due to not being
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able to adequately replace lost orbital volume [12, 16, 18].
It was not until the Renaissance
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In the 18th Century, the importance of a custom-fit eye to the socket to overcome the
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above problems was being realized [12]. Experimenting with new materials and
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methods for making human glass eyes, Ludwig Müller-Uri, a German glassblower
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who produced dolls eyes that had good human-like qualities, developed cryolite
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glass which was hard and light and did not irritate the conjunctiva [3-10]. By
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providing support at the anterior of the socket, creating lightness of weight, replacing
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sharp edges with rounded edges and displacing soft tissues of the orbit around the
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prosthesis to fill volume thus eliminating a sunken appearance, the shape of the
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artificial eye changed to what is now known as the Snellen Reform Eye [11-12, 19].
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Despite the Snellen Reform Eye’s vast improvements over the shell eye, they were
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uncomfortable in terms of pressure points causing irritation and discharge from large
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quantities of trapped tears and mucus partially due to being unable to achieve best fit
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due to the abstract nature of the Snellen Reform Eye and without the help of an
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impression [19].
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Fragility, surface erosion, imperfect fit, superficial staining and spontaneous
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breakage of glass eyes led to investigation into other materials such as vulcanite and
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celluloid in the 19th Century [10, 17, 20].
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With the turn of the 20th century artificial eye services were becoming more
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regulated.
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standard sizes and colours that could not be altered [21].
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secretions and rapid deterioration saw the fabrication of glass eyes using sand with a
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low oxide content being exclusively used until World War II (WWII) where it became
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unobtainable in Germany resulting in the United States temporarily relying on stock
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eyes to meet the need of the military and civilian population [8, 14, 16, 22]. In 1946
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the Veterans Administration based in America, initiated the ‘Plastic Artificial Eye
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Program’ to train ocularist to make artificial eyes for a large number of disfigured and
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disabled veterans [4].
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A polymerised form of methyl-methacrylate, acrylic resin is lightweight, easy to
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mould, fit and adjust, has good colour permanence, is resistant to rough handling,
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easily fabricated, durable and provides an aesthetic appearance, thus making it the
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most suitable material that is still used today[6-8, 12]. The few disadvantages
During this time artificial eyes were made of glass and supplied in
Vulnerability to socket
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associated with plastic artificial eyes include not being fully scratch resistant, not
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capturing iris depth and colour fading, are all related to poor restoration. With the
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right equipment and materials, these obstacles can be overcome [17]. Further
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developments in the design of artificial eyes came with the development of orbital
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implants in the 1980s.
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Current design and manufacturing process of artificial eyes
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Initially based on the shell and reform form used for glass eyes[16] acrylic artificial
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eyes also caused soreness due to ill fit, lack of mobility and lid distortion due to
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incorrect shape[9].
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Medical Schools, identified that due to the individuality of each enucleated socket,
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artificial eyes need to be custom-made[8, 12, 14, 16, 21, 22, 23].
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Although custom-made artificial eyes necessitates the work of a skilled artist making
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it a time consuming and costly process, they permit accurate colouring of the iris,
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veining and tinting of the sclera making it more cosmetically satisfactory to the
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patient [4].
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facial contours and increasing the degree of motility are achieved in custom made
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artificial eyes[4, 19, 23,], allowing even distribution of volume and weight in the
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socket reducing long-term discomfort and producing better cosmetic outcomes[9,
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14]. Furthermore, by providing close contact with the soft tissue, the artificial eye
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allows normal tear secretion, volume replacement, adequate orbital fat and absence
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of socket inflammation[7, 19, 24]. These advantages result in the artificial eye
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moving like a natural eye following almost simultaneously with the patient’s natural
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eye[9].
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In order to approximate the natural eye, accurate records of the posterior wall and its
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relation to the palpebral and the extent of the superior and inferior fornices of the
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palpebral is required in order to provide sufficient support[23].
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support, the eyebrow can fall nasal-wards, the eyelid muscles can become weaker
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leading to entropion and the edge of the eyelids can become inverted[9]. Currently,
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this is achieved by a method known as the impression technique. The fabrication of
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an artificial eye using the impression method establishes the defect contour and the
Research conducted by the United States Naval Dental and
Accurate fitting of the socket, minimising tissue distortion, improved
Without sufficient
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iris and sclera can be individually characterised offering better aesthetic and more
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precise outcomes [1, 6, 8, 19].
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The initial impression technique in the mid-1940s reported partial success in fitting
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artificial eyes [19]. However, by pressing the paste (which was often heavy) into the
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socket to fill all spaces and smoothing out the conjunctiva folds and wrinkles often
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led to overfilling [19].
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for a short period of time, thus not giving enough time for the orbicularis muscle to
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reflex from the foreign object, a good fit was not always achieved[19, 25]. These
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techniques often caused discomfort and ignited fear in the patient as a result of the
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process, materials and equipment used [25].
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Advancements in this method include the direct/external impression technique and
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the modified impression technique [6, 8, 25]. Whereas the former involves injecting
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low viscosity alginate or reversible hydrocolloid material directly into the socket, the
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latter places a stemmed tray into the eye socket for the material to be inserted into.
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Variations to the modified impression technique include attaching a solid suction rod
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to an existing prosthesis and investing it in an irreversible hydrocolloid mould before
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replacing it with clear acrylic resin (custom ocular tray impression); applying
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ophthalmic alginate to a suitable stock eye which is inserted into the socket for a
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definitive impression (stock ocular tray modified technique); trimming/polishing a
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stock eye or using alginate or soft wax which is invested and processed (ocular
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prosthesis modification technique); and adapting baseplate was around half an
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appropriately sized steel ball to create a wax blank which is tested in a socket and
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adjusted as required (wax scleral blank technique) [1, 3-5, 7, 19, 21-22, 24].
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Despite these advancements, all impression techniques are unable to design the
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front of an artificial eye, thus is unable to manipulate the eyelids to their proper
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opening and shape [25].
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Following an impression of the socket, a plaster mould is created using molten wax
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to produce a replica [5, 7]. Whilst the wax is being cured, the iris is produced. The
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iris disc is sized based on the observations of the natural eye and measuring the
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distance from the facial midline and pupillary light reflex allowing a guide for a
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centrally placed iris ensuring correct alignment [5]. Several methods such as paints,
Furthermore, by only testing the wax mould of the impression
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pigments and papers have been used: paper discs, ethyl-cellulose discs or directly
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on the acrylic resin sclera using watercolours or oil paints [3-4, 6]. Relying upon the
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artistic skills of the skilled technician led to the development of creating an iris using
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digital imaging.
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Digital imaging involves taking a digital photograph of a patient’s natural iris which is
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then compared to the natural iris. Adjustments are made to the colour, brightness,
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contrast or hue using graphics software, if required [8]. Once aesthetically pleasing,
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the image is covered with 3 light coats of water resistant spray before attaching it to
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the ocular disc and then the wax pattern [8].
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Digital imaging provides aesthetic quality as it closely replicates the natural iris with
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minimal colour adjustment and modifications needed. Furthermore, this method is
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simple and practical as well as being less time consuming than the traditional
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method [6, 8]. However, special digital photography equipment and computer
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software is needed [8, 26] and the light instability of photographic dyes results in the
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coloured iris fading quickly [4].
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Following insertion of the iris into the wax pattern, it is cast in clear acrylic resin and
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cured under compression [5].
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sclera using liquid monomer and polymer clear powder [3-4, 6]. The artificial eye is
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then coated with a layer of clear acrylic resin before being cured under heat and
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pressure, cooled and polished [3, 5-6, 21].
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The current methods used in the fabrication of artificial eyes are labour intensive and
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time consuming with the end result being heavily dependent on the experience of the
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ocularist.
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fabrication of artificial eyes a challenging task in prosthetics.
Once cooled, red cotton thread is adhered to the
The need for both functional and aesthetic consideration makes the
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Impact of artificial eyes and facial disfigurement
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Due to the search of the impact of artificial eyes producing few results, the review
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was widened to include facial disfigurements.
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Artificial eyes
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The search strategy produced eleven articles related to the impact of artificial eyes
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that met the inclusion criteria. Of these, four full articles were obtained.
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With literature primarily focusing on the before and after the loss of an eye, the long-
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term psychological impact of living with artificial eyes has received little attention[2,-
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28].
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McBain et al., (2014) reported that 40% of artificial eye wearers take an average of 2
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years to adjust to their prosthetic with clinical levels of anxiety, depression and
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appearance related distress being experienced[27-28]. Research has shown that this
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is related to older age, having children and the belief that the prosthesis influences
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social and interpersonal relationships rather than the clinical aspects such as
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duration of prosthetic wear, age of acquisition, gender, current age or type of
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prosthesis [2, 27, 29]. Satisfaction with the shape, colour, motility, comfort and
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fixation are often expressed by patients [27]. Primary concerns largely remain the
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same over time, with health of the remaining eye, ability to judge distance, receiving
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good advice and changes to appearance being at the forefront [28].
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Identification of the factors linked to artificial eye wearers wellbeing are starting to be
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investigated. Hill et al., (2011) found the visibility of the condition rather than the
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extent, type and severity of the disfigurement increases levels of distress.
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Incorporating the emotional, psychosocial and economic impact on the artificial eye
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wearer, ensures better care for the patient decreasing levels of distress and
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increasing their confidence in the care received [23-27].
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Facial disfigurement
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Twenty-nine articles regarding the psychological impact of facial disfigurements were
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found during the search strategy. Of these, twenty-four met the inclusion criteria;
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eight of which full articles were obtained for.
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The psychological care of patients with facial disfigurement is also overlooked
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despite patients having lower levels of quality of life compared to controls [30-33].
462
High levels of anxiety and depression, maladaptive behaviours and reduced
Manuscript Accepted
Early View Article
463
emotional wellbeing have been found in this population group [33] suggesting that
464
psychological adjustment to the facial disfigurement is a key indicator of overall
465
recovery[33]. Psychological adjustment has been shown to be worse for patients
466
with acquired facial disfigurement than congenital facial disfigurement with females
467
having significantly higher levels of anxiety compared with males [30, 33]. Reactions
468
of other people to the disfigurement, location and maintenance of the prosthesis,
469
impact of treatment and self-perception of their illness can affect patient’s levels of
470
adjustment leading to high levels of distress [30, 32-33].
471
Patients with facial disfigurement report difficulties in social settings when meeting
472
someone for the first time and in forming friendships leading to high levels of anxiety,
473
low self-esteem and creating expectations about life chances [32, 34]. Reasons for
474
this include focusing on information that supports their internal views. Providing
475
social support that matches the patient’s needs and challenging beliefs about the
476
disfigurement can lead to successful outcomes such as acceptance [34-35]. Self-
477
acceptance comes from finding meaning of the distress whereby the patient looks
478
beyond their physical disability. In turn, this makes them feel more accepted by
479
others and increases their level of confidence and independence, reducing social
480
distress, depression and anxiety [35-36].
481
Measuring patient’s quality of life can provide useful information regarding the health
482
needs of these patients when planning prosthetic rehabilitation [30]. By
483
understanding a patient’s distress, the stigma they face and type of social support
484
required, psychological growth can occur whereby the patient redefines themselves
485
with positive support of others [37-38].
486
487
DISCUSSION
488
The scoping review has ‘mapped’ literature documenting the development of artificial
489
eyes throughout the years. Three themes were identified in the review with the
490
current design and manufacturing process being the most referenced.
491
From their innovation in ancient Egypt, artificial eyes have undergone noteworthy
492
advancement [11]. The 16th Century saw a resurgence in the manufacturing and
493
design process where artificial eyes were being fitted in the socket and
Manuscript Accepted
Early View Article
494
experimentation with materials lead to the use of cryolite glass; changing the shape
495
from a sphere to a shell form then later to the Snellen Reform Eye[6, 9]. Despite
496
investigation with other materials, it was not until WWII that methyl-methacrylate
497
replaced glass as the main material [4, 10]. Its advantages included being
498
lightweight, easy to mould, fit and adjust, durability and having good colour
499
permanence [6, 17]. The few disadvantages associated with this material are largely
500
related to poor restoration as a result of inadequate equipment and materials20].
501
The advent of WWII also highlighted the importance of obtaining an accurate
502
impression of the socket for optimal fit. With custom-made eyes came research into
503
effective ways to fabricate an artificial eye [3, 6, 18]. Being created from dental
504
material, the process of manufacturing methyl-methacrylate artificial eyes has largely
505
followed the same procedures employed in manufacturing dentures [11]. Whilst
506
adaptions have been made, this has largely been through trial and error by ocularist
507
throughout the years [4, 13, 15].
508
509
Whilst the impression technique has gone through minimal changes, development of
510
the artificial eye has occurred through digital photography of the iris. Although this
511
method can be cost and time efficient, simple and practical [6, 21], special
512
equipment is required which is not always able to provide fine details of structures.
513
Research into the psychological impact of artificial eyes and facial disfigurement has
514
highlighted above average levels of clinical anxiety and depression, maladaptive
515
behaviours and reduced emotional wellbeing. Patients internal views about their
516
disfigurement and prosthesis affects their psychological adjustment [2], resulting in
517
reduced self-acceptance which increases distress and perceived stigma. By
518
understanding how the prosthesis affects the patient’s quality of life, adequate
519
support can be provided resulting in the patient’s psychological growth [27].
520
521
522
523
524
Manuscript Accepted
525
Early View Article
Strengths and limitations
526
527
Methodological issues
528
‘Mapping’ the literature produces a vast amount of research, thus creates difficulty in
529
deciding breadth over depth. However, the framework of a scoping review allows
530
prioritisation of certain aspects of the literature that is the best fit of the research
531
question. The development and application of the inclusion and exclusion criteria
532
after the search strategy allows for the most relevant articles to be included based on
533
familiarity with the literature.
534
Due to the nature of the scoping review, 74% of the articles were qualitative in
535
nature, providing detailed background information and processes involved that
536
quantitative studies would not be able to achieve. Most of the studies were narrative
537
inquiries or historical reviews. Whilst the majority of articles were related to the
538
current design and manufacturing of artificial eyes, there has been minimal changes
539
in the technological development of artificial eyes. Variations of the impression
540
technique have been developed through trial and error by the ocularists, rather than
541
specific research. As this specialty area grows, quantitative studies should be
542
undertaken that would further enhance our knowledge and lead us closer to
543
incorporating technological advancements into the design and manufacturing
544
process.
545
The remaining 26% of articles used mixed methods or quantitative methods, all of
546
which addressed the psychological impact of artificial eyes and facial disfigurement.
547
Articles addressed quality of life, levels of distress and stigma in both population
548
groups. Commonly used measures included the Hospital Anxiety and Depression
549
Scale, Quality of life Core Questionnaire, Perceived Stigmatization Questionnaire
550
and the Social Distress Scale; focusing more on a patient’s ability to cope rather than
551
satisfaction with their situation. As a quantitative measure, questionnaires are not
552
able to provide the whys and how of a patient’s response. Only two articles
553
administered interviews, one of which was combined with a questionnaire.
554
Whereas articles regarding the psychological impact of facial disfigurements had an
555
adequate sample size, articles related to artificial eye impact had a small sample
Manuscript Accepted
Early View Article
556
size. A possible reason for this is the small population of patients requiring artificial
557
eyes.
558
largely focused on specific techniques developed by ocularists. Thus, the results are
559
subjective in nature, have a lack or rigour, are unable to be generalised and difficult
560
to replicate.
561
By not being discriminative in the location of publication, saw various techniques
562
employed in the manufacturing and fitting process; some of which may not be
563
applicable or used in other countries or services where different levels of standards
564
exist.
565
produced to create a standard of care for all wearers within and between countries.
Articles related to the current design and manufacturing of artificial eyes
Through continuous research, recommendations and guidelines may be
566
567
Future research
568
This review has identified both positive and negative outcomes of the current form of
569
artificial eyes and the impact it has on the patient, yet there is a lack of clear
570
evidence to support any future technological development. Although the scoping
571
review suffers from some methodological weaknesses, employing a systematic
572
review would not rid it of them all, thus would not offer any more conclusive
573
evidence.
574
The overwhelming advantages associated with acrylic resin may be reason for a lack
575
of research into other materials that can be more beneficial, particularly
576
biocompatible materials. The use of biocompatible materials has been used for the
577
heart, ear, dental implants, prosthetic joints, ocular lenses, and maxillofacial
578
reconstruction. Its use in artificial eyes is yet to be investigated.
579
biomaterial;
580
polyurethanes, collagen, elastin and silk; is worthy of extensive research.
581
Future research suggestions have been made for the psychological impact artificial
582
eyes has on the wearer. By understanding the predictors, therapeutic treatment can
583
be incorporated into the rehabilitation process improving the patient’s psychological
584
adjustment. Knowledge of these predictors will come from methodologies that get to
585
the crux of the patient’s experience. Therefore, future research needs to employ
586
qualitative methods such as interviews, specifically those that are experience led.
artificial
and
natural
polymers
including
poly
One type of
(vinyl
chloride),
Manuscript Accepted
Early View Article
587
Not only can this help with the patients psychological wellbeing, it may also create
588
suggestions for the advancement of artificial eyes.
589
590
Key messages and recommendations
591
The overall aim of the scoping review is to understand the development of artificial
592
eyes and its impact on the wearers in order to improve the current process. The list
593
below sets out key messages and recommendations identified in the review.
594
595
596
Areas and questions for research
•
Qualitative studies need to be undertaken in the psychological impact of
597
artificial eye wearers, in particular, living with an artificial eye(s) and the fitting
598
of an artificial eye(s).
599
•
With the current process being ocularist experience led, a quantitative study
600
of the current design and manufacturing process is needed.
601
contribute to developing uniformity between artificial eye services.
602
•
This may
There is a need to know more about the effectiveness of support networks of
603
artificial eye wearers, such as family, friends, work collogues, peers and
604
acquaintances.
605
•
Research needs undertaking into the relationship between different
606
techniques in the design and manufacturing of artificial eyes and patient
607
satisfaction/outcomes.
608
•
Interventions need to be developed based on the psychological needs of
artificial eye wearers.
609
610
611
612
Research design
•
depth and breadth of data collected.
613
614
•
617
Longitudinal studies to examine changes of need of artificial eye wearers in
the short and long term.
615
616
A wider range of research methods needs to be employed to increase the
•
Innovative approaches to the design and manufacturing of artificial eyes
drawing on ocularists, patients and their families experience and expertise.
Manuscript Accepted
618
CONFLICT OF INTEREST
619
The authors declare no conflict of interests.
Early View Article
620
621
AUTHOR’S CONTRIBUTIONS
622
623
Holly Chinnery
624
Group 1 – Substantial contribution to the conception and design, Acquisition of data,
625
Analysis and interpretation of data
626
Group 2 - Drafting the article, revising it critically for important intellectual content.
627
Group 3 - Final approval of the version to be published
628
629
Simon B N Thompson
630
Group1 - Conception and design
631
Group 2 - Critical revision of the article
632
Group 3 - Final approval of the version to be published
633
634
Siamak Noroozi
635
Group1 - Conception and design
636
Group 2 - Critical revision of the article
637
Group 3 - Final approval of the version to be published
638
639
Bryce Dyer
640
Group1 - Conception and design
641
Group 2 - Critical revision of the article
642
Group 3 - Final approval of the version to be published
643
644
ACKNOWLEDGEMENTS
645
Author 1 is funded by the Vice Chancellor’s Open Scholarship for Postgraduate
646
Research at Bournemouth University.
647
648
Manuscript Accepted
649
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847
Nursing Studies, 37(5), 381-388.
848
•
100(5), 402-406.
849
850
•
•
•
Partner, J., & Hockney, D. (2002). Artificial eye. The Cambridge Quarterly,
31(4), 345-349.
855
856
O'Riordan, M. D. (1973). Modern ocular prosthetics. The Queens Nursing
Journal, 16(5), 107-108.
853
854
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851
852
Niiranen, J. V. (1947). The Navy's plastic ocular restoration. Military Surgery,
•
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857
with disfigurement in early adolescence. Journal of Health Psychology, 14(6),
858
731-740.
Manuscript Accepted
859
•
Early View Article
Rumsey, N., & Bull, R. (1986). The effects of facial disfigurement on social
860
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861
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862
•
Sarin, S., Gupta, R., Luthra, R. P., Sharma, V., & Ahirrao, R. (2015).
863
Fabrication of a custom resin artificial eye for rehabilitation of a bear mauled
864
patient – a case report. Journal of Advanced Medical & Dental Sciences
865
Research, 160-164.
866
•
12.
867
868
•
•
•
•
•
•
•
•
•
•
889
Thureus, S. (1949). Demonstration of eye prostheses in a new material. Acta
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887
888
Tengroth, B. (1992). [The history of the artificial eye]. Nord Medicinhist Arsb,
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885
886
Templeton, S. (1992). Facial disfigurement and stigmatization. Inforum, 13,
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883
884
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881
882
Snyder, C. (1963). Ambroise PARE and ocular prosthesis. Archives of
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879
880
Sykes, L. M. (1996). Custom made ocular prostheses: a clinical report.
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877
878
Stewart, R. E. (1947). Plastic artificial eye and restorations program, Veterans
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875
876
Seasoltz, J. F. (1947). Acrylic eye prosthesis. The Hospital Corps Quarterly,
19(7), 26.
873
874
Scott, R. B. (1956). A new type of ocular prosthesis. American Medical
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871
872
Schirmer, R. (1961). [Artificial eyes in ancient Egypt]. Klin Monbl Augenheilkd
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869
870
Sapp, N. (2003). Ocular Prosthetics. CME Journal Ophthalmology, 7(1), 11-
•
Tucker, K. R. (1980). The history of the artificial eye. Plastic Reconstructive
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Manuscript Accepted
890
•
Early View Article
Turrell, A.J. (1949). A technique for the individual fabrication of plastic eye
prostheses British Dentistry Journal, 87(4), 97-100.
891
892
•
Ursin, K.V. (1948). [Plastic artificial eyes. Duodecim, 64(2), 87-96.
893
•
Valente, S. M. (2004). Visual disfigurement and depression. Plastic Surgery
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894
895
•
Van Doorne, J. M., van Waas, M. A., & Bergsma, J. (1994). Facial
896
disfigurement after cancer resection: a problem with an extra dimension.
897
Journal of Investigative Surgery, 7(4), 321-326.
898
•
eye prosthetics]. Vestn Oftalmol, (5), 44-47.
899
900
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•
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901
(2010). Satisfaction with facial appearance and its determinants in adults with
902
severe congenital facial disfigurement: A case-referent study. Journal of
903
Plastic Reconstructive Aesthetic Surgery, 63(10), 1642-1649.
904
•
Versnel, S. L., Plomp, R. G., Passchier, J., Duivenvoorden, H. J., &
905
Mathijssen, I. M. (2012). Long-term psychological functioning of adults with
906
severe congenital facial disfigurement. Plastic Reconstructive Surgery,
907
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908
•
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909
impact of head and neck cancer and facial disfigurement on the quality of life
910
of patients and their partners. Head Neck, 25(4), 289-296.
911
•
Vroemen, A. J. (1983). [Artificial Eyes]. Tijdschr Ziekenverpl, 36(4), 109-110.
912
•
Waggoner, H. W. (1966). Ocular prosthetics. Journal of the American
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913
914
•
Wilson, N., Breen, O., & Gleeson, K. (2015). The psychological impact of
915
subjective facial disfigurement following maxillofacial injury. British Journal of
916
Oral Maxillofacial Surgery, 53(10), 74.
917
918
•
Zekman, T. N., Ladenheim, J., & Scott, R.B. (1955). Ocular prosthetics.
American Medical Association Archives Ophthalmology, 54(5), 733-737.
Manuscript Accepted
919
Early View Article
TABLES
920
921
Table 1: Number of studies of the development of artificial eyes found within different
922
sources
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
Bibliographic Source
N
%
Electronic databases
229
82
Reference checking
30
11
Internet search
21
7
Manuscript Accepted
Early View Article
946
Table 2: Publications regarding the psychological impact of wearing artificial eyes
947
and facia disfigurement
948
Eye loss
Facial disfigurement
%
N
%
N
Included
3
27
8
73
Excluded
7
24
22
76
Manuscript Accepted
949
Early View Article
Table 3: Number and proportion of studies according to type of research (N = 38)
950
N
%
o Narrative Inquiry
15
39
o Historical Review
10
26
o Literature Review
2
5
o Interviews
1
3
9
22
Qualitative methods
Quantitative
o Questionnaires
Mixed methods
o Interview
& 1
5
Questionnaire
951
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
Page 34 of 37
Manuscript Accepted
969
Early View Article
Table 4: Geographical distribution of studies according to methodology (N = 38)
970
Narrativ
Historica
Literatur
Questionnair
e Inquiry
l Review
e Review e
Intervie
Interview
&
w
questionnair
e
No
%
No
%
USA
8
53
7
70
UK
3
20
1
10
1
10
1
10
Australi
No
%
No
%
No
%
No
%
1
1
4
1
a
New
1
Zealand
Rest Of 1*
1****
Europe*
Rest of 3**
4***
World**
971
972
* Portugal (1)
973
** Brazil (1); India (2)
974
*** Nigeria (1) Turkey (1) Japan (1) Brazil (1)
975
**** Germany (1)
976
977
978
979
980
981
982
983
984
985
986
Page 35 of 37
Manuscript Accepted
987
Early View Article
FIGURE LEGENDS
988
989
Figure 1: Distribution of articles reviewing the development of artificial eyes, by
990
country (N = 38)
991
992
Figure 2: Number and proportion of studies according to typology (N = 38)
993
994
FIGURES
995
996
997
998
999
1000
1001
1002
1003
1004
1005
1006
1007
Note. * Portugal (1); Germany (1); ** Brazil (3); Nigeria (1); India (1); Turkey (1);
1008
Japan (1)
1009
1010
Figure 1: Distribution of articles reviewing the development of artificial eyes, by
1011
country (N = 38)
1012
1013
1014
1015
1016
1017
1018
Page 36 of 37
Manuscript Accepted
Early View Article
1019
1020
1021
1022
1023
1024
1025
1026
1027
1028
1029
1030
1031
Figure 2: Number and proportion of studies according to typology (N = 38)
Page 37 of 37