OCULAR PROSTHESIS

Presented by: Ashima Goel JRII

Introduction

The fabrication of an extraoral prosthesis is as much an art as it is a science. The ideally constructed prosthesis must duplicate the missing facial feature so precisely that the casual observer notices nothing that would draw attention to the prosthetic reconstruction.

Ocular prosthesis

The goal of any ocular prosthetic procedure is to return the patient to society with a normal appearance and reasonable motility of the prosthetic eye. The disfigurement resulting from loss of an eye can cause significant psychological, as well as social consequences. However, with the advancement in ophthalmic surgery and ocular prosthesis, the anophthalmic patient can be rehabilitated very effectively.

Ambroise Pare, a french surgeon-dentist, is considered to be the pioneer of modern artificial eyes. In 1575, Pare fabricated artificial eyes made of glass as well as porcelain. Acrylic resins has replaced this material by the early 1940. Unlike a glass eye, an acrylic resin eye was easy to fit and adjust, unbreakable, inert to ocular fluids, esthetically good, longer lasting, and easier to fabricate.

Surgical considerations in ocular implants

The surgical procedures in the removal of an eye are classified into 3 category : Evisceration Enucleation Exenteration

Evisceration

It involves removing the contents of the globe but leaving the sclera and sometimes the cornea in place. Motility of the implanted eviscerated globe is excellent, since the extraocular muscles are intact. Disadvantages Careful selection of the size of spherical implant-to prevent extrusion and exopthalmic appearance

Fitting of the prosthesis may be difficult sensitivity of the socket Prosthesis difficult to fabricate-limited space within the fornices Advantage Light scleral shell will not depress the lower eyelid with its weight and the bulk of the material is not required to fill the sunken superior sulcus.

Enucleation

It is the surgical removal of the eyeball after the eye muscles and optic nerve have been severed. The placement of orbital implant into the enucleated socket was first described by Frost in 1886. Soll described the improved surgical method of placing the orbital implant deep within the muscle cone,and buried beneath the posterior layer of tenons capsule. The optic nerve and its associated vessels are severed and tied close to the posterior wall of the capsule. The implant is placed, and the posterior portion of Tenons capsule is closed over the implant providing the first layer of closure.

Then, the anterior portion of Tenons capsule and conjuctiva are then closed to form the second and third layers over the implant. Advantages Entire globe is available for histopathological examination Risk of spreading an ocular tumor is negated Prevention of sympathetic opthalmia Adequate space for fabricating prosthesis

It the movement of the fornix in the enucleated socket that provides the motility to the artificial eye. Utilizing the posterior wall of tenons capsule,a larger implant can be placed decreasing the incidence of implant migration,and reducing the tension on the anterior tenons capsule sutures. Reduces volume deficit in superior and inferior sulcus,preventing enopthalmos.

Exenteration

It is the removal of the entire content of the orbit including the extraocular muscles.

Materials and types of ocular implants

The first material used for orbital implants was glass. Mules introduced the hollow spherical glass implant in 1884,which is still used today and prefered by many opthalmologists. Since that time, many materials have been tried, including cartilage, fat, bone, silk, wool aluminium, cork, ivory ,vaseline, and paraffin.

Ocular implants are classified :

Integrated Semi-integrated Non-integrated

Buried Non buried

Integrated and non-buried implant

Rudermann introduced the first partially exposed,non buried, integrated implant. But these implants had limited success due to extrusion,migration and excessive infection rate. They were abandoned by the 1950.

Semi-integrated and buried implants

These implants consist of an acrylic resin implants with four protruding mounds on the anterior surface., these acrylic resin mounds on the implant protrude against the encapsulating tissue. Since this implant is buried, there is always tissue between the implant and the ocular prosthesis.

The keying effect of the protruding tissue mounds against the ocular prosthesis provide excellent support and motility. Common complication of implant was the exposure of the resins mounds with time, resulting in implant extrusion.

Non-integrated and buried implant

The buried, non integrated implant is the most common method of replacing volume loss in the socket following enucleation or evisceration.

The implant consist of hollow or a solid acrylic resin sphere (Mules sphere)10 to 22 mm in diameter. The spherical surface is easy to fit with the prosthesis and it tend to minimise pressure and friction. However, prosthesis motility was limited due to the lack of coupling of the implant to the prosthesis.

Hydroxyapatite integrated ocular implant

The first orbital implant made of hydroxyapatite was implanted in 1985, by Dr. Arthur Perry, after several years of preliminary research. The movement is automatically transferred to the artificial eye. If greater movement is desired, a titanium peg is used to connect the artificial eye to the implant. In this way, even the small, darting movements of the natural eye can be transformed directly to the artificial eye.

Allows vascular ingrowth of tissue which limits migration of implant A bone scan (Tc 99) or MRI test with contrast should be performed to confirm whether the implant had adequate vascular ingrowth
After satisfactory vascular ingrowth into HA implant (~6 months) , a hole can be drilled into the implant A surgical guide stent aids in drilling the guide hole in the proper position

healing peg is then inserted to maintain integrity of the hole while the growth develops into and around the hole Conjunctiva migrates into hole and vascular ingrowth will support a conjuntival epithelium which lines the drill hole A sterile motility peg then replaces healing peg that fits into hole in the implant

Once the peg is placed in the implant, a month of healing is suggested before the back of the artificial eye is modified to accept the head of the peg

Advantages
The peg in the implant can help hold the weight of the artificial eye, reducing the downward push on the lower eyelid. Less likely to become infected ,since it is incorporated with host blood vessel and immune defences are improved . Unlikely to extrude because it is biologically fixed .

Disadvantages

Cost of the implant The requirement and expense of the 2nd stage drilling procedure The required modifications to the artificial eye. Scans used to determine whether or not the implant is vascularised and safe to drill

Ocular impression

A thorough examination of the enucleated socket must be made to ensure proper healing and the absence of infection. .5% Tetracaine hydrochloride is used as a surface anesthetic to reduce the irritability of mucosa while taking impression.

An impression of the socket is made with an ophthalmic irreversible hydrocolloid in stock acrylic resin impression tray having a hollow handle which accommodate an impression syringe for the material to be injected directly into the socket during impression making. The patient is seated in an erect position with the head tilted backward at approx. 45 degree, while the socket is being filled with the impression material.

Once filled the head is moved back to the vertical position and the patient is directed to move their eyes both up and down. This will facilitate the flow of the impression material into all the aspects of the socket. After the material sets, the cheek, nose and eyebrow regions are massage to break the seal. While the patients gazes upward, the cheek is pulled down and the inferior portion of the impression is rotated out of the socket. Then the impression is checked for accuracy and voids.

Preparation of the cast

The impression is poured in 2 section with dental stone. The first poured stone is coated with a separating medium, such as a tin foil substitute and allowed to dry. The second half of the mold is poured with dental stone, leaving funnel shaped hole around the stem of the tray. This hole will be used as a funnel to fill the mold with molten wax. After the dental stone has set, the 2 halves of the mold are separated and the impression material is removed.

Wax pattern

Ivory inlay wax is used for wax pattern. After the wax has melted, it is poured through the funnel shaped hole into the assembled mold. After the wax has cooled, the mold is opened and the wax pattern trimmed, smoothed and polished. Then it is ready to be tried in the eye socket.

The wax pattern will feel comfortable to most patient, but in some instance, it may cause mild irritation. The wax will not move as freely as the finished acrylic resin prosthesis, but the application of an ophthalmic lubricant will aid movement. Pressure points or areas of discomfort should be noted and relieved as necessary.

The wax pattern is inserted in the socket and the patient instructed to look straight ahead at a distant point Using the companion eye for comparison ,the iris position is located on wax pattern with indelible marking pen,using the inner canthus and inner edge of the limbus as the points of reference and also in relationship to the opening of the lids.

Iris Position

Fabrication of the sclera

The wax sclera is now ready to be invested. After filling the lower portion of the flask with dental stone ,Stone is carefully vibrated onto the posterior surface of the wax pattern. The wax pattern is laid on top of the stone in the flask, taking care not to entrap air. After the stone has set, it is coated with a separating medium, such a tinfoil substitute. Then the flask is reassembled, the upper half of the flask is filled with dental stone, and the flask lid is placed on top to close the mold.

After the stone has set, the flask is separated by gently pyring it apart . The wax pattern is lifted out and the mold is checked for voids. After the mold is cleaned, a coat of tinfoil substitute is applied to both sides. Then white scleral acrylic resin is packed into the mold and processed at 150 f for 9 hrs, followed by 212 f for 2 hrs.

Selection of iris component

Ocular discs which are used in the iris painting, are available in half mm sized increments, ranging from 11mm to13mm. They come in black or clear, and either with or without pupil apertures. Clear corneal buttons are available in the same size as the disc.

Painting the iris and sclera

There are 5 basic component to painting an iris, namely, the pupil, base color, the detail, collarette and the limbus. Iris painting is usually completed in 2 stages: First the basic color of the body of the iris is selected , the base color is usually blue, gray, green, brown or a combination of these colors. Then, one or 2 coats of the monopoly syrup is applied to the painted surface of the iris disc and allowed to dry.

Adhering the painted disc to the corneal button and processing

To adhere the painted disc to the corneal button the disc is placed on a flat surface, with painted side up. 1 or 2 drops of monopoly is applied to the painted surface immediately. The corneal button is position on top of the painted disc and press down lightly until excess monopoly is forced out &the corneal button is seated firmly on the disc, the assembly is allowed to dry for about 30 mins.

Now the corneal button is ready to be inserted into the mold. The scleral polymer is mixed with monomer. Once the acrylic resin is in the dough stage it is added to the top of the button and two half of the flask press together under pressure. Then processing is done.

Scleral and second iris painting

After processing and removal, reduction of anterior curvature of the prosthesis is done to allow room for scleral and second iris painting. Reduction is approx. 1mm and is done by pear shaped bur. After smoothening of reduced surface a layer of monopoly is applied and allow to dry. Now prosthesis is ready for painting.

Spokes of the iris are painted by using either a small ooo brush or by flaring the hair of larger brush The collarette which is a circular area or star burst found around the outside border of pupil is painted with lighter or brighter color to that of the body of iris. Finally the limbus is added this is the area at the junction of the iris and sclera, it is usually a combination of grays and iris body color.

Then the next step is scleral painting, the natural sclera has veins present that are usually apparent in both the nasal and temporal corners of the eye. Red cotton fibers are used to replicate the veins ,then the fibres are separated and cut from commercially available thread. The pattern of the natural eye are copied by tacking the fibres to the sclera with a brush and monomer. The colors found in the sclera are usually yellow and blue or combination . Once completed a coat of monopoly is applied to the sclera.

Final processing

It is done by clear heat cured resin. The eye is placed into the tissue side of the molds anterior curvature facing up. The acrylic resin dough is placed on the painted surface . After processing and removal the surface is smoothed with a fine white stone and polished with flour of pumice.

Delivery of prosthesis

The prosthetic eye is washed with soap &water, a drop or two of an ophthalmic lubricant on the surface of the prosthesis will facilitate insertion. After insertion eye are examined for aesthetic appearance and the degree of movement by instructing the patient to perform the movement in various direction. Necessary adjustment were carried and the prosthesis was finished , polished and inserted.

Thank you