Post-enukleation ocular prosthesis in children: case report

Sutiyo1, Vinsensia Launardo2, Muhammad Ikbal2

1
Prosthodontic Specialist Educational
2
Department of Prosthodontic
Faculty of Dentistry, Hasanuddin University
Makassar Indonesia
Corresponding author: Sutiyo, Email: sutiyo346@gmail.com

ABSTRACT
Background: Eyeball loss is a traumatic process both medically and psychologically. Cases
of losing eyeballs can cause functional, psychological, and aesthetic problems. One of the
rehabilitative treatments, in this case, is an ocular prosthesis. Objective: The purpose of
making ocular prosthesis is to accelerate physical and psychological healing and improve
aesthetics. Case: A case of child female patients aged 3 years came to Halimah Dg. Sikati
Makassar Dental Hospital with complaints of losing the right eyeball for 8 months years old
due to the second stadium of a tumor. She wants to have a false eye immediately to restore the
appearance and confidence function. Eye socket examination showed healthy conjunctiva and
no infection. The treatment plan is making non-fabricated ocular prosthesis made from acrylic
resin. Management: The treatment procedure is carried out by stages namely eye impression
with custom trays eye using a double impression silicon printing material. Making the sclera
wax model, trying the sclera wax pattern, making acrylic sclera, trying acrylic sclera,
determining the location and diameter of the iris, painting the iris and pupil, completing
ocular prosthesis, and insertion of ocular prosthesis. Control after 1 week, 1 month, and 6
months. Conclusion: An ocular prosthesis can reduce psychological trauma due to the loss of
eyeballs. By returning the appearance can increase patient confidence so that she can be
accepted in social life in the community.
Keywords: Ocular Prosthesis, Enucleation, Impression material
 .
Introduction
Eyeball loss is a traumatic
process both medically and
psychologically. The problem with
losing eyeballs from the medical
side is difficulty in vision. The
impact of psychological aspects is
feelings of inferiority (inferiority
complex) and social acceptance
that is different from before. Cases
of losing eyeballs can cause
functional, psychological, and
aesthetic problems. One of the
rehabilitative treatments is by the
ocular prosthesis. The purpose of
making ocular prosthesis is to
accelerate physical and
psychological healing and improve
aesthetics. Loss of the eyeball that
is not immediately replaced by
ocular prosthesis for a long time
will affect the function of the
surrounding tissue and the eyelids
can experience atrophy. The ocular
prosthesis functions as a cover
between the upper eyelid and the
lower eyelid. Thus, foreign objects
do not easily enter the empty eye
room.1
The advantage of making
ocular prosthesis is that it can
restore the patient's appearance to a
normal eye. By returning the
appearance can increase patient
confidence so that it can be
accepted in social life in the
community. The use of eye
prosthesis cannot restore the
patient's visual function but can
reduce psychological trauma due to
the loss of eyeballs.2
Eye loss in early childhood
will inhibit the normal growth of
orbital tissue. Replacement with
ocular prosthesis should be done as
early as possible. However,
periodically the prosthesis must be
raised along with the growth of the
child to help the normal growth of
the palpebra and orbital tissue.3
Rehabilitation due to loss of
eyeballs can be divided into 2
types, namely orbital implants and
ocular prosthesis. An ocular
prosthesis is divided into 2 namely
fabricated and nonfabricated. The
advantage of fabricated ocular
prosthesis is the minimum
manufacturing time because it does
not require manufacturing steps in
the laboratory. The Fabricated
ocular prosthesis consists of 3 types
of iris sizes and colors. The
disadvantage of this ocular
prosthesis is discomfort and
infection because of the difference
in size between the eyeball and the
socket, causing the water sac to
form where bacteria develop.
Another disadvantage is that iris
color mismatches cause aesthetic
problems.4,5
Self-made ocular prosthesis
are known as non-fabricated ocular
prosthesis. The advantage of a
nonfabricated ocular prosthesis is
the color of the ocular prosthesis
can be adjusted to the eye that is
still there, the price is more
economical and by the condition of
the patient's eye socket. The
disadvantage of nonfabricated eye
prosthesis is that making prosthesis
takes time for laboratory processes.
Indications for non-fabricated
ocular prosthesis are after
 evisceration and enucleation
surgery. Contraindications of the
nonfabricated ocular prosthesis are
patients who are allergic to acrylic
material and an eye retention
socket that is lacking in retention.4
Surgery on the eye is mostly
caused by trauma to the eye, then
phthisis bulbi, tumors, and
infections. Surgical procedures on
the eye are enucleation,
evisceration, and exenteration.
Enucleation is a surgical procedure
in the eye by removing the eyeball
a long with the sclera and the
muscles around the sclera.
Evisceration is the removal of the
contents of the eyeball, leaving the
muscles and sclera. Orbital
concentration is the act of
removing the eyeball, orbital soft
tissue, and eyelids. The most
frequently performed surgical
procedure in handling trauma is
enucleation.1,3,6,7
The indications for ocular
prosthesis are: after enucleation and
evisceration with or without
implant placement, blind eyes with
corneal scarring, congenital
anophthalmia/microphthalmia.8
Patients who experience eye defects due to
the action of enucleation of the eyeball
often experience dysfunction, aesthetic and
psychological. To overcome this,
rehabilitation efforts are carried out by
making non-fabricated ocular prosthesis.
Case Report
Female children aged 3 years old came to
Halimah Dg. Sikati Dental Hospital
Makassar with complaints of losing the
right eyeball for 8 months years old due to
a stage two tumor. Patients want to have a
false eye immediately, to restore the
appearance and confidence function.
Figure 1. Patient’s profile
On an objective examination, the eye bags
are somewhat smaller, there is no irritation,
and no infection. The eyelids stiffen due to
prolonged periods without rehabilitation.
Eyelid muscles are still good so they can
open and close. Eye bags are deep enough
to allow retention of ocular prosthesis.
Treatment Plan
1. Anamnesis and objective examination
Anamnesis and objective examination are
carried out so that a diagnosis of loss of the
oculi dextra bulbus due to a stage two
tumor is obtained. The treatment plan is
the manufacture of nonfabricated ocular
prosthesis with acrylic resin material. The
next step is making a 5x10 cm waxy
impression tray.
2. Impression with elastomer light body
material.
Before inserting the impression material,
the eyelashes and around the eyes are
smeared with petroleum jelly so it is not
sticky with the impression material when
inserted into the socket. Impression
material is injected slowly into the socket
through the tray hole. The patient is asked
to move the socket and palpebra so that the
impression material fills all aspects of the
socket. Within 1-2 minutes the impression
material forms the desired consistency and
the impression material and tray are
removed from the socket. The mold is then
filled with a cast. The hardened cast is then
used as a working model for custom tray
ocular using self-cure acrylic resin.
Figure 2. Impression process
Figure 3. Result
3. Ocular impression with custom tray
Ocular impression with custom tray using
silicon double impression material for
study and work models. The impression
method uses the mucostatic method. The
impression procedure is the area around
the eye socket smeared with vaseline,
insert the individual tray made of selfcure
slowly. Inject the elastomer light body
material slowly until the impression
material comes out of the eye socket, 1-2
minutes then the mold can be removed.
Figure 4. Eye impression with a selfcure
individual tray
Figure 5. Impression Results
Correction of the impression and eye
socket conditions. Avoid having
impression material left in the eye socket.
Then fill the impression results with stone
casts. The printout is sent to the laboratory
to make a sclera wax model.
4. Try-in the sclera wax model to patients
The patient is instructed to sit upright and
relax. The upper eyelid is raised and the
upper edge of the sclera wax model is
inserted. The lower eyelid is pulled so that
the lower edge of the night pattern can be
inserted. The sclera night pattern must be
comfortable so it doesn't cause irritation.
The opening and closing movements of the
eyelid and the shape of the sclera wax are
observed from all directions so that it
resembles the eye next to it (Figure 6).
Then sclera color was recorded using the
patient's original eye photography and
using a shade guide for making dentures
(Figure 7). The smoothed sclera night
pattern and the sclera color note are sent to
the laboratory for packing.
 Figure 6. Sclera wax model on patient
Figure 7. Determination Color
5. Try-in acrylic sclera
The patient is instructed to sit upright and
relax. The upper eyelid is removed and the
upper edge of the sclera is inserted. Then
the lower eyelid is pulled slightly so that
the lower border of the acrylic sclera can
be inserted. Acrylic sclera must be
comfortable and there are no pain
complaints. The sclera must be
symmetrical with the other eye. At this
visit the location and diameter of the iris
and the central pupil mark were made
based on the eye next to it using the Edge
PD Ruller (Pupillary Distance Ruller).
Place the Edge PD Ruller (Pupillary
Distance Ruller) at the base of the nose,
then make three reference lines at the base
of the nose, healthy pupils and missing eye
parts. Put a dot on the sclera using a
marker. The sclera is removed from the
eye socket then with a circle made
centered on the mark. Determination of the
location and diameter of the iris adjusted to
the original eye. The diameter of the iris is
confirmed by direct measurement using the
Sliding Caliper. The next step is shipping it
to the laboratory for making the iris.
Figure 8. Edge PD Ruller (Pupillary
Distance Ruller)
Figure 9. Fit on acrylic sclera in patients
(open and close eyes)
Figure 10. Determination of the pupillary
and iris points
6. Insertion of ocular prosthesis
The next visit is insertion the prosthesis
into patient. The patient is seated casually
with the back tilted. The upper and lower
eyelids are opened simultaneously to enter
the eye prosthesis. The patient is then
asked to close his eyes slowly, blink,
glance to the right and left, up and down.
The examination that needs to be done is
patient retention, stabilization, and
comfort.
7. Control
Control and evaluation of socket changes
nonfabricated use of ocular prosthesis was
performed after 24 hours, 1 week and 6
months after the insertion.
Figure 11. A. Insertion, B. Control
Discussion
Making prosthesis after enucleation or
evisceration requires planning, both before
and after surgery. Immediately after
enucleation or evisceration, the conformer
should be installed immediately. The aim
is to protect the suture line, maintain the
fornix, prevent contractures, and make
sufferers comfortable. The conformer also
keeps the eyelids in better shape and
prevents the eyelashes from entering the
socket, which can irritate.9
The choice of acrylic material
(methyl methacrylate) because it
has a good adaptation to tissue,
good aesthetics, durable, not easy
to change color, can be formed
according to the socket, economical
price, and easy to manipulate.10
Retention, stabilization, and
comfort of ocular prosthesis need
to be done during insertion. Control
and evaluation of socket changes in
the use of nonfabricated ocular
prosthesis were done 1 week after
insertion. In this patient, the
movement of the ocular prosthesis
is good because the ocular
prosthesis is made following the
contour of the eye socket. From the
aesthetic point of view, this ocular
prosthesis is better because sclera
making and iris drawing are
adjusted to the opposite eye.
Nonfabricated eye prosthesis are
more acceptable to patients because
they are more suitable with the
shape of the patient's eye socket
than fabricated eye prosthesis.1
Ocular prosthesis can last an
average of 5-7 years, depending on
the quality of accuracy, comfort
and care of the sufferer himself.
Cleanliness of the eye sockets and
hands must be considered before
installing prosthesis. Maintenance
of acrylic ocular prosthesis is easy
to do. The prosthesis can be
immersed in water, saline solution,
or contact lens fluid to remove
deposits that have formed and are
attached to the ocular prosthesis.
These deposits originate from the
production of non-infectious
mucus. The prosthesis is brushed
with a soft brush and then rinsed
with clean water to remove the
remnants of soap, then dried with a
clean cloth. For harder deposits,
wet tissue can be used to scrub the
entire surface without scratching it.
The patient must be able to
maintain the cleanliness of the
prosthesis so that the prosthesis can
last a long time.1
Education to patients and parents after
insertion:3
- The patient was instructed to remove
the eye prosthesis while sleeping,
remove it and wash with mild soap
once daily.
- To improve the movement of the
eyelids and to get shine on the surface
of the prosthesis, it is recommended to
use silicone eye fluid.
Conclusion
Eyeball loss is a traumatic process both
medically and psychologically. The
advantage of making ocular prosthesis is
that it can restore the patient's appearance
to a normal eye. Making ocular prosthesis
can reduce psychological trauma due to
loss of eyeballs. By returning the
appearance can increase patient confidence
so that it can be accepted in social life in
the community. In the treatment of this
case, a good success rate was obtained
because the movement of the ocular
prosthesis was quite good because the
ocular prosthesis was made to follow the
contours of the eye socket. And in terms of
aesthetics, this ocular prosthesis is good
because the sclera creation and iris
painting are adjusted to the other eye using
the help of the patient's eye photography.
Non-fabricated ocular prosthesis are more
acceptable to patients because they better
suit the patient's eye socket shape.

References
1. Taylor TD. Clinical Maxillofacial prosthetic. Quintessence Publishing Co, Inc; 2001.p.
265-70.
2. Adarsh N, Suresh BS, Yogesh RB, Rachana KB. Ocular Prosthesis Made Easy A Case
Report. Int J Dent Clin. 2011;3(1):105–6.
3. Dixit S, Shetty P BG. Ocular prosthesis in children – clinical report. Kathmandu Univ
Med J. 2005;3(1):81–3.
4. Aggarwal H. Rehabilitation of phthisis bulbi: a case report. JPDA. 2012;21(January
2015).
5. Cafiero-chin M, Marques C, Danz HJ, Ave T. Ocular Prosthesis : Indications to
Management. Can J Optom. 77(2):24–32.
6. Soni S, Singh PR, Singh A, Srivastava S, Shekhar A. Ocular Prosthesis : Simplified
Custom Made Technique- A Case Report. Int J Oral Heal Med Res. 2016;3(1):107–10.
7. Baino F, Perero S, Ferraris S, Miola M, Balagna C, Verne E, et al. Biomaterials for
orbital implants and ocular prostheses: Overview and future prospects. Acta
Biomaterialia. 2014;10(3):1064–87.
8. Parekh AA, Bhalerao S. Rehabilitation of ocular defects: Custom made and modified
stock eye prostheses. SRM J Res Dent Sci. 2016;7(March):6–8.
9. Stewart WB. Surgery of The Eyelid, Orbit, and Lacrymal System, vol 3. American
Academy of Ophthalmology, Oxford University; 1995. p.133–66.
10. Jamayet N, Srithavaj T, Alam MK. A Complete Procedure of Ocular Prosthesis: A Case
Report. Int Med J. 2013;Vol. 20(January 2014):1–3.