|Year : 2012 | Volume
| Issue : 2 | Page : 128-131
Fabrication of custom made eye prosthesis for anophthalmic paediatric patients: 2 case reports
Kaushal K Agrawal, Priyanka Mall, HA Alvi, Jitendra Rao, Kamleshwar Singh
Department of Prosthodontics & Dental Material Sciences, F.O.D.S, King George Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||4-Sep-2012|
Kaushal K Agrawal
Department of Prosthodontics & Dental Material Sciences, F.O.D.S, King George Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The loss of an eye is an emotional and psychological setback to the patient. After enucleation, evisceration or exenteration of the eye, the goal is to replace the missing tissues with an artificial prosthesis and restore the facial symmetry and normal appearance of the anophthalmic patient. In case of pediatric patients, the team approach of the ophthalmologist, the maxillofacial prosthodontist and pedodontist are required to rehabilitate the ocular defect, that improves not only the patient's comfort and cosmesis as well as maintain the near symmetrical bony orbital wall and eyelid development. This article illustrates two different cases of pediatric patients where the eye was surgically removed and ocular prosthesis was fabricated.
Clinical Relevance to Interdisciplinary Dentistry
- A few case reports are mentioned in literature for prosthetic rehabilitation of anophthalmic pediatric patients. The presented case reports stressed the use of custom made eye prosthesis than prefabricated one for pediatric patients. As patient grows, the size of eye socket changes, hence periodic enlargement of the prosthesis is necessary for a growing child to aid in the normal development of the lids and the soft tissue lining the orbital bone. The custom made prosthesis can be adjusted whether needed at recall visits.
- The presented technique is simple and less time consuming.
- This technique is least depended upon artistic ability of dentist.
Keywords: Custom made ocular prosthesis, enucleation anophthalmic socket and ophthalmic alginate
|How to cite this article:|
Agrawal KK, Mall P, Alvi H A, Rao J, Singh K. Fabrication of custom made eye prosthesis for anophthalmic paediatric patients: 2 case reports. J Interdiscip Dentistry 2012;2:128-31
|How to cite this URL:|
Agrawal KK, Mall P, Alvi H A, Rao J, Singh K. Fabrication of custom made eye prosthesis for anophthalmic paediatric patients: 2 case reports. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Dec 12];2:128-31. Available from: http://www.jidonline.com/text.asp?2012/2/2/128/100607
| Introduction|| |
The eye is a vital organ not only in terms of vision but also being an important component of facial expressionA congenital anomaly or pathology may necessitate surgical removal of eye. The surgical procedures for removal of an eye, are classified by Peyman, Saunders and Goldberg (1987) into three general categories as: Evisceration (where the contents of the globe are removed leaving the sclera intact), Enucleation (most common, where the entire eyeball is removed after severing the muscles and the optic nerve) and Exenteration (where the entire contents of the orbit including the eyelids and the surrounding tissues are removed). 
Immediate replacement of the lost eye is necessary to promote physical and psychological healing for the patient and to improve social acceptance. Unrestored anophthalmic socket exhibit growth retardation and can lead to facial disfigurement. The rehabilitation of anophthalmic socket can be especially challenging in younger, precooperative or behaviorally compromised children and requires the skills and participation of a pediatric dental specialist as part of the maxillofacial prosthetic team. The objective of the maxillofacial prosthetic team is to provide the ocular prostheses to the pediatric patient in as comfortable and atraumatic manner as possible. 
Until World War II, the glass eye was the most popular eye prosthesis. The glass eye was, however, difficult to manufacture and hazardous. The methylmethacrylate prosthesis became popular since they offered superior strength and permitted modifications of shape and size.  Flexible material such as silicone  is advantageous when the defect extends beyond the orbital area and encounters movable tissue beds.
These case reports describe a simple technique for the ocular prosthesis fabrication in pediatric patients that does not require lots of artistic ability of the operator, is easily performed and is technically less time consuming.
| Case Reports|| |
A 5-year-old female patient reported to the Department of Ophthalmology with the chief complaint of white spot on left eye accompanied by bulging and pain on movement. She was diagnosed with retinoblastoma and enucleation was done. The patient was referred to the Department of Prosthodontics for fabrication of ocular prosthesis after healing.The patient was having facial disfigurement due to the loss of left eye [Figure 1]a.
A 6-year-old female patient reported to the Department of Ophthalmology with complaints of constant headache, loss of vision, suppuration and bulging of left eye. After thorough investigations including CT scan and FNAC, the patient was diagnosed with malignant melanoma of the left eye. The eye was subsequently enucleated and on healing of the socket, the patient was referred to the Department of Prosthodontics for fabrication of ocular prosthesis [Figure 1]b.
| Clinical Procedure|| |
The anophthalmic eye socket was carefully examined. The whole treatment procedure was explained to the patient/guardian to gain their cooperation and written consent. The anterior end of the needle cover of a syringe was cut and a section of modelling wax (Hindustan Modelling Wax, The Hindustan Dental Products, Hyderabad, India), approximately of same size as the socket was attached to the anterior cut end of the needle cover with sticky wax. Autopolymerising acrylic resin (Rapid Repair, Pyrex polymer, India) was sprinkled over the modelling wax (2-mm thick). After polymerisation of acrylic resin, the modelling wax was removed and drill holes were made in acrylic resin.This tray was then checked in patient's eye socket for overextensions. The syringe was now attached with the needle cover without the needle and used for impression with thin mix of ophthalmic alginate (Opthalmic Moldite, Milton Roy Co.Sarasota Florida,USA.) [Figure 2].The tray was placed in the defect and ophthalmic alginate was extruded into defect with the help of syringe. After the material was set, the impression was removed gently [Figure 3]. The lower half of the impression was poured in dental stone. After the stone was set, key holes were cut, separating media (Cold mould seal, Dental Products of India Limited,Mumbai,India.) was applied and a second mix of stone was poured. Both halves were separated after final set, and a wax pattern was fabricated with medium hard dental wax. The wax pattern was examined for size from tissue stimulation of eye movement and eyelid coverage and necessary alterations were made. An iris button whose shape, size and color match with the contra lateral eye was selected and positioned [Figure 4].
The position of the iris was determined with the help of landmarks by making the patient look in a straight line. The horizontal position of pupil was determined by measuring the distance between midline and centre of pupil of the normal eye. The vertical position was determined by canthus relationships.
The color of the sclera portion was selected using tooth color acrylic shade guide. The corrected wax pattern was flasked and processed in appropriate colored acrylic resin. The processed prosthesis was retrieved, trimmed and highly polished. It was then placed in patient's eye socket and evaluated. All necessary adjustments are made to simulate the contra-lateral eye as closely as possible. The acrylic resin was trimmed from the outer and inner canthus, and strands of red nylon fibres were incorporated to simulate the blood vessels. The characterised prosthesis was again placed into the flask and packed with transparent heat-cured PMMA (Trevalon, Dentsply India Pvt. Ltd., Gurgaon, India) to simulate corneal translucency. The properly finished and polished prosthesis was inserted in the socket after being disinfected and lubricated with an ophthalmic lubricant (Ecotears, Intas Pharmaceuticals Ltd, Ahmedabad, India) to maintain a tear film over the prosthesis and to improve eye movements. The minor adjustments were made at the time of delivery as per the patient's comfort and aesthetics. [Figure 5] The necessary instructions for cleaning, placement and removal of the prosthesis were given and the need for regular appointment was emphasized. 
| Discussion|| |
The eye loss in early childhood hinders normal growth process and if the eye is removed due to malignancy, the radiation treatment further retards development.  In case of infants with congenital deformities the treatment should be done within the first 4 weeks of birth by placing a small ocular prosthesis (conformer) in the conjunctival socket. To prevent the cul-de-sac from shrinking and to promote development, a conformer of a larger size must replace the former as the child grows. 
The construction of a custom made ocular prosthesis for a child is the same as for an adult, but periodic enlargement of the prosthesis is necessary for a growing child to aid in the normal development of the lids and the soft tissue lining the orbital bone.  The socket is fully developed at about 12 years of age, thus teenage patients should be treated as adults. 
Ocular prosthesis may be prefabricated or custom made. Prefabricated prosthesis carries potential disadvantages of poor fit, poor esthetics and poor eye movements.  A custom ocular prosthesis is preferred for pediatric patients. It has advantage of close adaptation to the tissue bed, provides maximum comfort and restores full physiological function to the accessory organs of the eye. Voids that collect the mucus and debris, which can irritate the mucosa and act as a potential source of infection may also be minimized. 
Each child is different in mood, personality and disposition so the parent is demonstrated the proper method of removal and insertion of prosthesis and hygiene care and printed instructions also are given.
Removal is done by pulling the lower lid down, gazing overhead and engaging the lower margin of the prosthesis with one finger so that it is expelled downward in to hand.
Insertion is done by lifting the upper lid with the thumb and forefinger, sliding the prosthesis with other hand as much as possible under the upper lid and pulling the lower lid down to allow the prosthesis to slip into the socket.
The daily hygiene care begins with a warm wet face cloth with a'No More Tears' baby shampoo applied to the eyelids since they are normally crusted with secretion. This shampoo has a neutral pH and will not sting or smart the socket tissue or the fellow eye, plus it destroys bacteria. Once the lids and eyelashes are free of secretion, cleaning of the ocular prosthesis while it is in the cavity, is done with water sucked into a one ounce ear syringe. The syringe is then held in the palm of the hand, while the hand is in a'hand salute' position. The syringe is also supported by the bridge of the nose while the tip is near the inner edge of the prosthesis. The head is tipped to the side and the drainage is caught in a face cloth or hand towel.
It is suggested the prosthesis be removed once a month, and checked for protein deposits. Protein deposits will give the prosthesis a dull appearance. The prosthesis should be washed with a soft face cloth with soap.
| Conclusions|| |
The use of conventional ocular prostheses during childhood entails periodic changes with successive increases in size in order to accompany the expansion of the anophthalmic cavity, and it is the only way to aesthetically rebuild the anophthalmic socket. It is necessary to objectively determine a time-table of ocular prosthesis change along the whole period of craniofacial growth in order to minimize the possible discrepancy between the compromised and the healthy sides, thus contributing to balance and harmony of the facial development.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]