Transcript Artificial eyes

ARTIFICIAL EYES
Prepared by : Dr. Khaled Awad
Presented by : T. Aisha I. Lubbad
INTRODUCTION
 An
artificial eye is a replacement for a
natural eye lost because of injury , disease
, trauma, tumor, or end stage ocular
disease such as glaucoma, or diabetes can
be devastating at any age. Although the
replacement cannot provide sight, it fills
the cavity of the eye socket and serves as
a cosmetic enhancement.
 It
may have a major impact on one’s selfimage, self-confidence, and self-esteem,
not to mention the adjustment required in
adapting to monocular (single-eye) vision.
 There may even be some job restrictions
that apply for one-eyed patients (e.g.,
commercial drivers, airline pilots,
policemen, firefighters, etc.).
 Numerous patients have been fitted with
prosthetic eyes who are currently
employed in the professions mentioned
above.
 Monocular
patients should try to return to
their work if possible and lead as normal
a life as possible.
 Although there is some loss of depth
perception and peripheral vision, they are
not as “handicapped” as many believe.
 Before
the availability of artificial eyes, a
person who lost an eye usually wore a
patch. An artificial eye can be attached to
muscles in the socket to provide eye
movement
 Today, most artificial eyes are made of
plastic, with an average life of about 10
years.
 Children require more frequent
replacement of the prosthesis due to rapid
growth changes. As many as four or five
prosthesis may be required from infancy
to adulthood.
 According
to the Society for the
Prevention of Blindness, between 10,000
and 12,000 people per year lose an eye.
 Though 50% or more of these eye losses
are caused by an accident (in one survey
more males lost their eyes to accidents
compared to females), there are a number
of inherited conditions that can cause eye
loss or require an artificial eye.
 Microphthalmia
is a birth defect where for
some unknown reason the eye does not
develop to its normal size. These eyes are
totally blind, or at best might have some
light perception .
 Some
people are also born without one or
both eyeballs. Called anophthalmia , this
presents one of the most difficult
conditions for properly fitting an artificial
eye. Sometimes the preparatory work can
take a year or more. In some cases,
surgical intervention is necessary.
 Retinoblastoma
is a congenital (existing
at birth) cancer or tumor, which is usually
inherited. If a person has this condition in
just one eye, the chances of passing it on
are one in four, or 25%. When the tumors
are in both eyes, the chances are 50%.
Other congenital conditions that cause eye
loss include cataracts and glaucoma. One
survey showed that 63% of eye loss due to
disease occurs before 50 years of age.
 There
are two key steps in replacing a
damaged or diseased eye. First, an
ophthalmologist or eye surgeon must
remove the natural eye. There are two
types of operations. The enucleation
removes the eyeball by severing the
muscles, which are connected to the
sclera (white of eyeball). The surgeon
then cuts the optic nerve and removes
the eye from the socket. An implant is
then placed into the socket to restore
lost volume and to give the artificial eye
some movement, and the wound is then
closed.
14/2/2014
 With
evisceration, the contents of the
eyeball are removed. In this operation, the
surgeon makes an incision around the iris
and then removes the contents of the
eyeball. A ball made of some inert
material such as plastic, glass, or silicone
is then placed inside the eyeball, and the
wound is closed.
 At
the conclusion of the surgery, the
surgeon will place a conformer (a plastic
disc) into the socket. The conformer
prevents shrinking of the socket and
retains adequate pockets for the
prosthesis. Conformers are made out of
silicone or hard plastic. After the surgery,
it takes the patient from four to six weeks
to heal. The artificial eye is then made
and fitted by a professional ocularist.
PRIMARY SOCKET PROCEDURE
 There
are three types of eye removal
 Evisceration - removal of the internal eye
contents, but the sclera is left behind with
the extraocular muscles still attached.
 Enucleation - removal of the eyeball, but
the adjacent structures of the eye socket
and eyelids remain. An intraocular tumor
excision requires an enucleation, not an
evisceration.
 Exenteration
- removal of the contents of
the eye socket (orbit) including the
eyeball, fat, muscles and other adjacent
structures of the eye. The eyelids may also
be removed in cases of cutaneous cancers
and unrelenting infection. Exenteration is
sometimes done together with
Maxillectomy which is removal of the
maxilla or the upper jaw bone/cheekbone
REASONS FOR EYE REMOVAL
 Cancer
of the eye (retinoblastoma,
melanomas, any other cancers of the eye
or orbit)
 Severe injury of the eye when the eye
cannot be saved or attempts to save the
eye have failed
 End stage glaucoma
 Painful, blind eye .
 In
cases of sympathetic ophthalmia
(inflammation of the eye) to prevent travel
to other eye, in which, if untreated can
cause blindness
 Congenital cystic eye
 In a deceased person, so the cornea can be
used for a living person who needs a
corneal transplant by a surgical operation
called keratoplasty.
 Constant infection in a blind, or otherwise
useless eye.
ENUCLEATION
18/2/2014
Definition
 Enucleation is the surgical removal of the
eyeball that leaves the eye muscles and
remaining orbital contents intact.
Purpose
 Enucleation is performed to remove largesized eye tumors or as a result of
traumatic injury when the eye cannot be
preserved. In the case of tumors, the
amount of radiation required to destroy a
tumor of the eye may be too intense for
the eye to bear. Within months to years,
many patients who are treated with
radiation for large ocular melanomas lose
vision, develop glaucoma, and eventually
have to undergo enucleation.
 The
two types of eye tumors that may
require enucleation are:
 Intraocular eye melanoma. This is a rare
form of cancer in which malignant cells
are found in the part of the eye called the
uvea, which contains cells called
melanocytes that house pigments. When
the melanocytes become cancerous, the
cancer is called a melanoma. If the tumor
reaches the iris and begins to grow, or if
there are symptoms, enucleation may be
indicated.
 Retinoblastoma.
Retinoblastoma is a
malignant tumor of the retina. The retina
is the thin layer of tissue that lines the
back of the eye; it senses light and forms
images. If the cancer occurs in one eye,
treatment may consist of enucleation for
large tumors when there is no expectation
that useful vision can be preserved. If
there is cancer in both eyes, treatment
may involve enucleation of the eye with
the larger tumor, and radiation therapy
for the other eye.
 The
conjunctiva (outer covering of
eye) is removed with blunt scissors
(A). The four rectus muscles are
removed from their attachments to
the eyeball (B). The optic nerve is
severed (C), and the eyeball is
removed. A synthetic globe replaces
the eyeball in the socket, and the
rectus muscles are sutured around it
(D).
ENUCLEATION
23/2/2014
Anesthesia
 The procedure may be performed under
general or local anesthesia, according to
the surgeon's preference. In either case,
the injection is given in the retrobulbar
space. An antibiotic (e.g., cefazolin) and
an anti-inflammatory (e.g.,
dexamethasone) are also given
intravenously.
 Peritomy,
Muscle Identification, and
Neurectomy
 A 360° peritomy is then performed, with
care taken to preserve as much of the
conjunctiva and Tenon's capsule as
possible. The extraorbital muscles are
then tagged with 5-0 Vicryl sutures and
are released by resection at their
attachments to the globe. A neurectomy is
then performed, according to the surgeon's
preference, and the globe is delivered.
Care should be taken to maintain
hemostasis until the implant is placed in
the orbit.
 Evaluation
and Preparation of
Tenon's capsule
 Tenon's capsule is then inspected for its
readiness to accommodate the implant. In
order to minimize the risk of implant
exposure and subsequent infections, it is
important to ensure that the tissues
overlying the implant can be closed
without tension.
 Traditionally,
the orbital implant was
placed within Tenon's capsule, as first
described by Frost (Frost 1887),
necessitating the use of a smaller implant.
This technique usually required the use of
implants with a diameter of 16 mm to 18
mm. However, due to the enophthalmos
associated with these smaller implants .
DETERMINATION OF IMPLANT SIZE
 Proper
sizing of the orbit is essential to
avoid complications and to achieve an
optimum fit of the implant to both the
orbit and the artificial eye. An undersized
implant may result in enophthalmos or a
deep superior sulcus, and may necessitate
weight-increasing modifications to the
artificial eye which, in turn, induce lower
lid sag and restricted motility.
 Conversely,
an oversized implant
increases the risks of wound dehiscence,
exposure, and infection, and may
complicate the coupling of the artificial
eye to the motility peg. An implant is of
the proper size when its volume, added to
the volume of the implant wrapping
material and the volume of the artificial
eye, equals the volume of the enucleated
globe (Perry 1983).
 Refer
to a sizing table for determining
implant size from the size of the globe. A
set of graduated sizing spheres should be
used to properly size the orbit. A sizing
sphere is of the proper size when it is the
largest sphere that allows closure of the
conjunctiva and anterior Tenon's capsule
without tension.
 The
diameter of the sizing sphere is noted
from markings on its handle, although a
calculation must be made to compensate
for the thickness of the material used to
wrap the implant. A scleral wrapping
increases the diameter of the implant by
an average of 1.5 mm. While it is known
that the average orbit will accommodate
an 18 mm or 20 mm implant wrapped in
sclera, each orbit should nevertheless be
individually sized.
WRAPPING THE IMPLANT
 There
are several benefits to wrapping the
implant. These include: increased
motility, ease of insertion, ease of muscle
attachment, and decreased risk of
exposure. The use of an unwrapped
implant allows the rough surface of the
hydroxyapatite material to snag on orbital
tissues during insertion, and may also
cause abrasion of the overlying tissues
during movement, thereby increasing the
risk of exposure.
 Prior
to wrapping, the implant is
sterilized and soaked in an antibiotic
solution (80 mg gentamicin in 100 cc
saline). The implant is placed in the
scleral shell and the shell is sutured
closed with 5-0 Vicryl sutures. The excess
tissue is trimmed and marks are made at
the attachment sites of the four rectus
muscles and at the anterior pole of the
implant

The oblique muscles can be attached,
according to the surgeon's preference.
Fornix-deepening sutures may be used at
this point, as needed, to provide space for
the artificial eye to move in concert with
this highly motile implant.
CLOSURE
 The
wound should be closed with separate
closures of Tenon's capsule and the
conjunctiva in order to minimize the risk
of exposure. Anterior Tenon's capsule is
closed with interrupted 5-0 Vicryl sutures;
the conjunctiva is closed with a running 50 Vicryl suture. Antibiotic ointment is
applied to the socket and an acrylic
conformer is placed over the conjunctiva,
with care taken to avoid undue pressure
between the conformer and the wound
closure.
DRESSINGS AND POSTOPERATIVE CARE
A
firm pressure dressing is maintained for
4 to 6 days, oral antibiotics are given for 1
week, and steroids (prednisone 20 mg,
adjusted according to patient status) are
given 3 times daily for 4 days. Oral
postoperative pain medication is also
given as needed. The socket is evaluated
after removal of the pressure dressing
and, if the edema has subsided, the
tarsorrhaphy sutures are removed.
 Topical
antibiotics are applied 4 times
daily for 4 weeks. The patient is generally
ready for fitting with an artificial eye 6 to
8 weeks postoperatively.
ENUCLEATION SURGERY
 Enucleation
25/2/2014
refers to removal of the globe
(eyeball). Surgery may be done under local
stand-by anesthesia (twilight anesthesia)
or general anesthesia (patient asleep). It
is commonly done either as an outpatient
or overnight stay patient. The surgical
procedure generally takes about 1 hour.
While under anesthesia, the lids are held
open and the external coats of the eye
(conjunctiva and Tenons) are trimmed
away from the eyeball.
 The
extraocular muscles (responsible for
moving the eye into different fields of
gaze) are also trimmed away from the eye
surface. Lastly the optic nerve is cut and
the entire eyeball is removed. Bleeding is
controlled by gentle cauterization.
 When
someone loses an eye, two
components are needed: an orbital
implant to maintain the volume of the eye
socket and an artificial eye or prosthesis.
 Thus, following removal of the eye, an
orbital implant is put into the socket and
the tissues are closed over top of it. The
extraocular muscles can be hooked up to
the implant surface to help keep the
implant from migrating and to help with
socket movement.
 Initially,
a temporary prosthetic
conformer made of clear plastic is put in
place over the orbital implant. This
conformer maintains the tissue space
behind the eyelids where the prosthetic
eye will eventually sit. In approximately
6-8 weeks, the conformer is removed and a
custom made artificial eye (prosthesis) is
made for the socket. Eye drops or
ointment are required during the first few
weeks post-op. Pain is something patients
worry about routinely with enucleation
surgery.
 There
may be some discomfort postoperatively in the first few days but how
much is variable, as everybody has a
different pain threshold. What might be a
lot of pain for one person may only be mild
to moderate in another. Whatever pain is
present (usually not severe) it subsides in
the first 3 to 5 days. Pain killers are
routinely prescribed after enucleation
surgery along with antibiotics
INDICATIONS
 There
is a long and venerable debate
about the relative merits of enucleations
and eviscerations that began with the first
medical report of an evisceration. While
this debate is by no means concluded,
some consider that an evisceration yields
the best cosmetic result because it is less
damaging to the structures of the orbit.
However, there are many cases in which
an enucleation may be indicated

These include cases in which the majority of the
contents of the eye must be removed, such as in
cases of uveal melanoma, choroidal melanoma, or
other malignant intraorbital tumors . Other
indications may include objectionable
appearance, chronic pain, atrophy bulbi,
blindness with unilateral iritis, blindness with
unilateral glaucoma, childhood hypoplasia,
prophylaxis against sympathetic ophthalmia, and
whenever a complete histological examination of
the globe is required.
CONTRAINDICATIONS
 An
enucleation is most classically
contraindicated after the onset of
sympathetic ophthalmia, and in cases of
virulent endophthalmitis. However, with
improved diagnosis and technique, and
considering the relatively rareness of
sympathetic ophthalmia, there is some
debate as to whether these diseases
necessarily contraindicated an
enucleation.
 An
enucleation is also contraindicated in
cases where it can be expected that the
patient will experience increased
psychological trauma from the thought of
losing the "entire eye". In the latter case,
an evisceration is indicated. Finally, an
enucleation is relatively contraindicated
in cases where excessive hemorrhaging is
expected.
EVISCERATION SURGERY
 Evisceration
2/3/2014
surgery refers to the removal
of the inside contents of the eye (cornea,
iris, lens, vitreous, and retina). The white
shell of the eye (sclera) is left in place. The
extraocular muscles are left attached to
the eye surface and the optic nerve is not
cut. Once the contents of the eye are
removed, an implant is placed into the
scleral shell. The sclera, Tenons, and
conjunctiva are then closed over the
implant and a temporary (clear plastic)
conformer is put in place.
 The
real artificial eye (prosthesis) is made
in about 6-8 weeks.
 Evisceration, like enucleation, can be done
under local stand-by (twilight
anaesthesia) or general anaesthesia and
may be performed as an outpatient or as
an overnight stay visit. Like enucleation,
pain is variable and dependant upon one's
pain threshold. Generally, there is some
pain but usually it is not severe. It settles
in the first 3 to 5 days .
INDICATIONS

An evisceration is indicated in the cases listed
above, where an enucleation is not specifically
indicated. Some surgeons prefer an evisceration
over an enucleation wherever possible.
Classically, the clearest indication for an
evisceration has been in cases of virulent
endophthalmitis, to reduce the risk of the
infection spreading via the optic nerve sheath. In
addition, an evisceration is often less
psychologically traumatic for the patient because
it involves the loss of what is perceived as only a
portion of the eye, as compared with the entire
eye.
CONTRAINDICATIONS
 An
evisceration is contraindicated in cases
where an intraorbital neoplasm is
suspected, in cases where acute trauma
may prevent complete removal of the
uveal tissue, and in cases where a
complete histological exam is needed.
EXENTERATION SURGERY
 Exenteration
4/3/2014
is a more radical procedure
than enucleation, evisceration or
secondary orbital implantation. It involves
removal of all the tissues within the entire
eye socket. The conjunctiva, globe,
extraocular muscles and orbital fat are all
taken out. In these situations there is no
place to put an orbital implant or artificial
eye as described above. An oculo-facial
prosthesis can be made however, to cover
the eye socket opening. Although it does
not move, it looks much better than an
empty eye socket
SECONDARY ORBITAL IMPLANT SURGERY
In some individuals who previously had an
enucleation procedure years ago, the orbital
implant may have shifted out of position,
become exposed, infected, or is simply too
small. In this situation a secondary surgery
can be performed to remove the first
implant (secondary orbital implant surgery
 Secondary
orbital implant surgery can be
more challenging than enucleation or
evisceration especially if the surgeon tries
to localize and reconnect the extraocular
muscles.

It is therefore usually done under general
anesthesia as an overnight stay patient.
The post-operative healing is similar to
enucleation and evisceration surgery.
SECONDARY IMPLANTATION :
 Anesthesia
:
The procedure may be performed under
general or local anesthesia .An antibiotic
and an anti-inflammatory are also given
intravenously.
 Removing
the implant .
 Dissection
of the muscle .
 Preparation
of the orbit :
The socket is then inspected for scarring
that may have contributed to the migration
of the primary implant, and all such scars
are remove to allow proper placement and
to prevent migration of the new implant
 Determination
of implant size :
Proper sizing of the orbit is essential to
avoid complication and to achieve an
optimum fit of the implant to both orbit and
artificial eye.
 Wrapping
the implant .
 Dressings
and postoperative care .
INDICATIONS
A
secondary implant has been traditionally
indicated in cases of chronic exposure,
migration, or extrusion of the primary
implant. In recent years, however, a
rapidly growing number of patients are
requesting secondary implants using the
Bio-eye HA orbital implant in order to
recover lost motility and to counteract lid
sag via a motility/support peg.
 In
most cases, the motility provided by the
Bio-eye HA orbital implant is equal to or
better than that provided by the primary
implant. If the rectus muscles can be
identified and attached directly to the
implant, even greater motility can be
expected. Fortunately, the rectus muscles
can usually be identified because check
ligaments attached to the fornices and
Tenon's capsule prevent them from
retracting too deeply after they are cut
from the globe.
 If
a socket containing a previously placed
implant shows no motility, then damage
to the rectus muscles or to the innervation
to the rectus muscles is expected. There is
no known implant design that will
improve the motility of either the socket
or the artificial eye in such cases.
CONTRAINDICATIONS
A secondary implant is contraindicated in
cases where there are no complications
with the primary implant and where
cosmesis and artificial eye motility is
satisfactory

GENERAL COMPLICATION
Exposure
 Early exposures :
if the exposure occurs within the first 6
months postoperatively, and if it is small
(<= 3mm). If it widens, a graft should be
considered. If the exposure does not widen
and remains stable, continue to observe it,
unless the patient complains of increased
mucous discharge.
 this is related to surgical technique and
not related to the chemical properties of
the implant.
 Late
exposure :
 If the exposure occurs later than 6 months
postoperatively, and vascularization of the
implant is confirmed, the exposure should
simply be observed, unless the exposure
widens or there is increased discharge.
Most large exposure (> 3mm) will be
accompanied by increased discharge. In
some cases, even large exposure can
remain stable for long periods of time if
the implant is well vascularized .
INDICATIONS
 Enucleation
 There
is a long and venerable debate
about the relative merits of enucleations
and eviscerations that began with the first
medical report of an evisceration. While
this debate is by no means concluded,
some consider that an evisceration yields
the best cosmetic result because it is less
damaging to the structures of the orbit.
However, there are many cases in which
an enucleation may be indicated
 These
include cases in which the majority
of the contents of the eye must be removed,
such as in cases of uveal melanoma,
choroidal melanoma, or other malignant
intraorbital tumors . Other indications may
include objectionable appearance, chronic
pain, atrophy bulbi, blindness with
unilateral iritis, blindness with unilateral
glaucoma, childhood hypoplasia,
prophylaxis against sympathetic
ophthalmia, and whenever a complete
histological examination of the globe is
required.
 Evisceration
 An
evisceration is indicated in the cases
listed above, where an enucleation is not
specifically indicated. Some surgeons
prefer an evisceration over an enucleation
wherever possible. Classically, the
clearest indication for an evisceration has
been in cases of virulent endophthalmitis,
to reduce the risk of the infection
spreading via the optic nerve sheath. In
addition, an evisceration is often less
psychologically traumatic for the patient
because it involves the loss of what is
perceived as only a portion of the eye, as
compared with the entire eye.
 Secondary
Implantation
 A secondary implant has been
traditionally indicated in cases of chronic
exposure, migration, or extrusion of the
primary implant. In recent years,
however, a rapidly growing number of
patients are requesting secondary
implants using the Bio-eye HA orbital
implant in order to recover lost motility
and to counteract lid sag via a
motility/support peg.
 In
most cases, the motility provided by the
Bio-eye HA orbital implant is equal to or
better than that provided by the primary
implant. If the rectus muscles can be
identified and attached directly to the
implant, even greater motility can be
expected. Fortunately, the rectus muscles
can usually be identified because check
ligaments attached to the fornices and
Tenon's capsule prevent them from
retracting too deeply after they are cut
from the globe.
 If
a socket containing a previously placed
implant shows no motility, then damage
to the rectus muscles or to the innervation
to the rectus muscles is expected. There is
no known implant design that will
improve the motility of either the socket
or the artificial eye in such cases.
CONTRAINDICATIONS
11/3/2014
 Enucleation
 An
enucleation is most classically
contraindicated after the onset of
sympathetic ophthalmia, and in cases of
virulent endophthalmitis. However, with
improved diagnosis and technique, and
considering the relatively rareness of
sympathetic ophthalmia, there is some
debate as to whether these diseases
necessarily contraindicated an
enucleation.
 An
enucleation is also contraindicated in
cases where it can be expected that the
patient will experience increased
psychological trauma from the thought of
losing the "entire eye". In the latter case,
an evisceration is indicated. Finally, an
enucleation is relatively contraindicated
in cases where excessive hemorrhaging is
expected.
 Evisceration
 An
evisceration is contraindicated in cases
where an intraorbital neoplasm is
suspected, in cases where acute trauma
may prevent complete removal of the
uveal tissue, and in cases where a
complete histological exam is needed.
 Secondary
Implantation
 A secondary implant is contraindicated in
cases where there are no complications
with the primary implant and where
cosmesis and artificial eye motility is
satisfactory.
ORBITAL IMPLANT
A
16/3/2014
variety of shapes and sizes have been
tried in an attempt to promote some
motility to the socket. In 1985 a new
concept in eye socket implants began to
evolve when a researcher (Dr. Arthur
Perry, San Diego, CA) began to study sea
coral as an ocular implant. Through a
patented hydrothermal process the
calcium carbonate component of sea coral
was turned into calcium phosphate and a
substance known as hydroxyapatite was
made. Hydroxyapatite has the same
chemical structure and porous structure
as human bony tissue.
 The
implant material (corralline
hydroxyapatite) is biocompatible, nontoxic and non-allergenic. The body’s tissue
recognizes the material as similar and
because of the porous nature, tissue will
grow into it. The implant becomes more
fixed and therefore resists migration. The
implant allows attachment of the
extraocular muscles which in turn leads to
improved orbital implant motility .
 The
orbital implant can also be directly
attached to the prosthesis through a peg,
protruding from the implant allowing a
wide range of prosthetic movement as well
as the darting eye movements commonly
seen when people are engaged in
conversation. The increased range and
fine darting movements allow a more lifelike quality to the prosthetic eye .
 The
hydroxyapatite implant, also known
as the Bio-Eye™ (integrated Orbital
implants, San Diego) is called a “porous
implant.” Since its introduction, a number
of other “porous implants” have been
introduced. One such implant
(popularized by Dr. D.R. Jordan University of Ottawa Eye Institute,
Ottawa, Ontario, Canada) is a synthetic
variety of hydroxyapatite (FCI3 HA
implant) that has similar qualities to the
original Bio-Eye™ but less expensive.
A
recent study has shown that HA has a
more rapid rate of fibrovascularization
than Medpor (porous polyethylene) .
 It is available in Canada and other parts
of the world but due to patent restrictions
is unavailable in the United States.
Another synthetic porous implant that
has become increasingly popular is a type
of porous plastic known as Porous
Polyethylene (Medpor™ - Porex Surgical
Inc, Cooledge Park, GA).
 This
material is a synthetic man-made
material that previously has been used in
a wide range of cranio-facial
reconstructive procedures and facial
fractures, with few problems. Its
properties demonstrate high tensile
strength, malleability, biocompatibility
and fibrovascular ingrowth.
 The porous polyethylene orbital implants
are also cheaper than the original BioEye™, and are available in spherical, egg,
conical or mounded shapes.

Aluminum oxide (Al2O3) another man-made
biomaterial that has been in use for more than 30
years as an implant in orthopedics and dentistry
has also been studied extensively (Dr. D.R.
Jordan - University of Ottawa Eye Institute,
Ottawa, Ontario, Canada) and is emerging as an
orbital implant in Canada, Europe and several
other parts of the world. The aluminum oxide
implant, also known as the Bioceramic Implant
(FCI, Issy-Les-Moulineaux, Cedex, France) looks
identical to the Bio-Eye™ hydroxyapatite with
multiple interconnected pores. Like the synthetic
HA and porous polyethylene, it is less expensive
than the Bio-Eye™.
 There
is evidence that human osteoblasts
and fibroblasts appear to grow better on
aluminum oxide than hydroxyapatite,
suggesting it may be more biocompatible
than hydroxyapatite and better tolerated
in the eye socket.
IMPLANT TYPES AND CHEMICAL
18/3/2014
CONSTRUCTION
 There
are many different types of
implants, classification ranging from
shape (spherical vs oval shaped), stock vs
custom, porous non porous, and the
presence of a peg or motility post. The
most basic simplification can be to divide
implant types into two main groups : nonintegrated (non-porous) and integrated
(porous)
NON-INTEGRATED IMPLANT
1- non-porous implants contain no unique
apparatus for attachment to the extraocular
muscles .
 2- don’t allow in-growth of organic tissue into
their inorganic substance .
 3- no direct attachment to ocular prosthesis .
 4- usually, these implants are covered with a
material that permits fixation of the extraocular
recti muscles, such as donor sclera which
improves implant motility .
 5- non-integrated implants include the acrylic
(PMMA), glass, and silicon spheres

Plymethyl methacrylate (PMMMA) :
PMMA is a transparent thermoplastic
available for use as ocular prosthesis,
replacement intraocular lens when the
original lens has been removed in the
treatment of cataract and has historically
been used as hard contact lenses.
PMMA has a good degree of compatibility
with human tissue, much more than
glasses.
INTEGRATED IMPLANT
1- the porous integrated implants allows
fibrovascular ingrowth throughout the implant.
 2- and thus also insertion of beg . Because direct
mechanical coupling (PEG) is thought to improve
artificial eye motility. Direct connected to the
artificial eye.
 3- implants that directly attached of the
prosthesis were unsuccessful because of chronic
inflammation or infection arising .
 5- integrated implants include the
hydroxyapatite, aluminum oxide and
polyethylene .

Bioceramic :
1- Bioceramic prosthetics are made of
alminum oxide (Al2O3) .
2- Low friction, durability, stability, and
inertness.
3- more biocompatible than HA .
IMPLANT SIZE
 Proper
23/3/2014
implant sizing is crucial. Implant
that provides about 65-70% of volume
replacement is ideal, the remaining 3530% being Contributed by the prosthesis.
 A smaller implant has a higher tendency
to displace or migrate
 And develop superior sulcus deformity. A
larger implant is known to improve both
cosmoses and motility. However, an
inappropriately large Implant may
produce tension on the conjunctival
wound and result in Wound gape and
implant exposure.
 Implant
sizing has mostly been Empirical
and is often decided in the operating
room.
 Generally, a 16-18 Mm implant is used in
infants, 18-20 mm in older children, and
20-22 Mm in adults. There are implant
sizers that may help gauge the
Appropriate size. A recent trend is to use
the axial length of the fellow Eye (axial
length in mm - 2 = implant diameter in
mm) to choose the Implant size.
 One
should remember to deduct an
additional 2-mm From the axial length if
the implant is traditionally wrapped but
not When the scleral cap technique is
used.
OCULAR PROSTHESIS:
 otherwise
known as an artificial eye, is a
plastic prosthesis used when an eye is
surgically removed. During surgery, a ball
implant is inserted into the eye socket to
fill the area the eye once occupied. An
ocular prosthesis is then molded to fit in
front of the implant. It occupies the space
between the eyelids and the skin
(conjunctiva) covering the implant
 The
ocular prosthesis is generally made
four to six weeks after surgery in order to
allow the socket tissues to heal
adequately. Prior to that time, a thin
plastic plate, called a conformer, is
sometimes worn in place of the prosthesis.
This prevents shrinkage of the tissue and
helps to prepare the socket for ocular
placement. Until the ocular prosthesis is
fitted, the upper eyelid can be droopy in
appearance. The prosthesis will help
support the eyelid and allow the lids to
open and close normally.
SCLERAL COVER SHELL PROSTHESIS:
 also
known as a "cover shell", is a thin,
plastic prosthesis used when an eye is
malformed as a result of a birth defect, or
becomes non-functioning due to
subsequent illness or injury. In such
cases, the non-functioning eye is left
within the eye socket. A prosthesis can
then be molded to fit between the lids and
the blind eye
 Scleral
cover shells fit directly over the
malformed eye. Sometimes a "trial shell"
is fashioned to allow the eye to grow
accustomed to the direct contact of the
prosthesis. Cover shells impart a better
cosmetic appearance by closely resembling
the remaining good eye, while leaving the
affected eye in the socket.
TYPES OF OCULAR PROSTHESIS
 1-
Artificial Eye : - patients who had one
of their eyeballs enucleated or had grossly
phthisical eyes, have been provided with
artificial eyes. These are Snellen type of
preformed eyes which vary in thickness
from 2-10 mm and in size from 12 x 14 to
28 x 30 mm, the vertical side being the
smaller one with a notch on the upper
nasal border
 2-
Moulded Eye :-In patients where a
satisfactory fitting is not possible with the
conventional type of artificial eyes
described above, a moulded eye affords
better results. Moulded eye is prepared
from an impression of the socket .
 3-
Cosmetic Contact Shell:-This is an
opaque contact lens painted for all the
anterior segment details including
conjunctiva and sclera. It requires all the
fitting techniques and procedure of a
scleral contact lens. This is given in cases
who have normal or nearly normal shape
of the eyeball having total corneal opacity
or a disfigured eye where useful vision is
not possible. These are extremely thin
shells varying in thickness from 0.50-2.50
mm depending upon the contour and
shape of the eyeball
 4-
Cosmetic Contact Lens :-This is akin
to a cosmetic shell except that the
pupillary area is left clear for visual
purposes and is suitably powered to
correct the refractive error. The scleral
portion in such cases is also transparent.
 5- Spectacle Prosthesis :-It is an ocular
prosthesis attached to a spectacle frame
and is indicated in cases whose sockets
are markedly contracted beyond
reasonable repair and cannot retain even
the smallest eye or have been subjected to
exentration
 Before
we deliver the prosthetic, we
check seven basic considerations for
assuring proper fit and life-like results:
 1) Size and lid contour.
 2) Proper posterior fit of the prosthesis
over the anterior tissues in the ocular
cavity for comfort and motility.
 3) Color of the sclera (white).
 4) Position and plane of the iris.
 5) Color of the iris and pupil size.
 6) Movement of the artificial eye.
 7) Patient comfort and a pleasing
cosmetic result.
FABRICATING OCULAR PROSTHESIS
 Prosthetic
eyes are made of an acrylic
plastic material called methyl
methacrylate. It can be formed into any
size and shape, it's durable, and is welltolerated by the surrounding eye tissues.
The prosthesis is made through the
following series of steps
 Sometimes
the process begins by taking
an impression of the eye socket to
duplicate the exact nature of the space the
prosthesis will fit into. The impression of
the eye socket is used to make a wax
model. Using the model, we determine the
correct positioning of the iris (the colored
part of the eye), the outer curvature, and
the extent to which the eyelids will open
 The iris is hand painted from direct
observation of the unaffected eye.
 The
wax model is then used to prepare a
master mold which is filled with acrylic
plastic to create a cast of the prosthesis.
 The prosthesis is further colorized and
vessels are added to simulate a natural
appearance. It is then covered with a clear
plastic protective coating and is cured
once more The prosthesis is now ready for
a polishing to give it a perfectly smooth
surface and wet-looking appearance.
 Finally,
the prosthesis is complete. Its
appearance is deceivingly real, while the
underside is an exact replica of the socket.
It fits snugly and comfortably in place .
HOW PROSTHETIC EYES ARE MADE
 1-
Clear Conformer
The first step in fitting an artificial eye or
scleral shell is to fit a clear acrylic
conformer. This conformer fits inside the
eye socket and opens the eyelids, so that
both eyes are equal in shape and in overall
appearance
 2-
Alginate Impression
The second step in the process is to take an
impression of the eye socket, allowing a
comfortable and acurate fit. The impression
allows us to match the volume and lid
contours of the fellow eye and also allows
for excellent movement in the final
prosthesis
 3-
Cast of Impression
The impression is then duplicated within a
material called castone, inside a stainless
steel cast. This cast is used for making the
white acrylic blank that will be the base of
the prosthesis. The white blank is then
processed using our specialized acrylic
processo
 4-
Iris Painting
All painting is done by hand with dry
pigments in our specially designed paint
room. The iris is painted on a flat acrylic
disc, layer by layer. We use advanced
techniques combined with careful attention
to create a realistic and accurate match.
This is one of the most important steps to
matching a prosthesis to one's existing eye
 5-
Lathe Cutting
A clear acrylic dome, similar to a cornea, is
added over the painted surface. This dome
brings up the depth and magnifies the
detail of the iris. A specially designed lathe
is used to cut a series of angles into the
clear acrylic cap, allowing for a precise
machined blend between the painted iris
and the sclera portion of the prosthesis
 6-
White Blank
This white blank is the exact size and shape
of the molded clear conformer. It will be fit
for comfort, lid size and shape, and
movement. A well fit ocular prosthesis will
move (track) right along with the orbital
implant which is attached to the ocular
muscles.
 7-
Positioning Iris
While the patient is wearing the white
blank, the iris position and plane are
marked. This step ensures that the position
of the completed prosthesis will match the
natural eye. The completed iris and
positioned blank are then prepared for
attachment
 8-
Attaching Iris
The iris is carefully attached with acrylic at
the exact plane and position illustrated.
This perfect line-up is very important for
the finished overall cosmetic result
 9-
Preparing for Veining
The excess acrylic and positioning lines are
then trimmed away, leaving a white blank
with attached iris. The prosthesis is now
prepared for the veining
 10-
Veining
The veining of the sclera (white of eye) is
done with a frayed red silk thread. This
thread is carefully applied to match the
veins on the natural eye. This step is done
in our color-corrected paint rooms
 11-
Completed Veining
Once the veining is applied, the sclera is
carefully tinted with our dry pigments to
match the surface patterns and colors of
one's existing eye. Notice how natural and
realistic the eye looks at this stage
 12-
Acrylic Capping
After the veined prosthesis is allowed to
completely dry, a final cap of clear acrylic is
applied. This final cap seals in all of the
veining and pigments and also provides the
prosthesis with its final polished surface.
The prosthesis is then ground to the correct
shape
 13-
Final Adjustments
The prosthesis is polished with pumice,
leaving a smooth durable finish for patient
comfort. Following the polish with pumice,
the prosthesis is finely polished with a
high-speed wheel to remove all scratches
and give it the final shiny finish
 14-
Completed Prosthesis
The final prosthesis is then fit, adjusted
and evaluated for size and contour, iris
color and pattern, iris position and plane,
scleral tinting and veining, movement,
patient comfort and overall pleasing
cosmetic result
 15-
Completed Prosthesis
The entire process of making a custom
ocular prosthesis takes 3-4 appointments,
which can be done over the course of 2-3
days depending on one's schedule.
ARTIFICIAL EYE CLEANING
 Cleaning
 Your
artificial eye need only be cleaned
occasionally. You may sleep with your
artificial eye in, in fact it is advisable to do
so. However, when it is removed, it should
be cleaned by using hard contact lens
cleaner, as the most common problem is
irritation and watering caused by a
protein build up.
 If
not cleaned correctly this protein will
collect upon the surface of the artificial
eye as a crystalline coating which will
eventually make the artificial eye feel
gritty. The socket lining and the inner
surface of the eyelids may become
inflamed and sore with discharge in
extreme cases
A HARD contact lens cleaner should be
used to clean the artificial eye (it is not
recommended that hand soap or washingup liquid are used as cleaners).
THE CLEANING PROCEDURE IS AS
FOLLOWS:
 Remove
artificial eye and place it on palm
of hand.
 Put a few drops of hard contact lens
solution onto the artificial eye and gently
rub over all surfaces.
 Rinse the artificial eye thoroughly in
sterile saline ensuring all the cleaner has
been removed.
 The artificial eye is now ready to be reinserted.
GENERAL POINTS
 It
is very important to wash hands
thoroughly before inserting or removing
the artificial eye for any reason.
The artificial eye should be removed and
cleaned when it becomes sticky, dry and
uncomfortable to wear. The frequency of
this may vary from a few days to a couple
of months.If dropped the artificial eye is
unlikely to break, however, to minimise
the risk of scratching or fracture great
care must be taken when inserting and
removing the artificial eye.It is
recommended that the artificial eye
should be checked and polished annually.