NEW HORIZON DENTAL COLLEGE AND RESEARCH INSTITUTE

DEPARTMENT OF PROSTHODONTICS AND CROWN & BRIDGE

SEMINAR PRESENTATION
TOPIC- OCULAR PROSTHESIS

GUIDED BY- PRESENTED BY-

Dr. SUDHEER ARUNACHALAM Dr. POOJA AGRAWAL

Dr. TUSHAR TANWANI

Dr. ANUPAM PURWAR

Dr. RUCHI GUPTA

Dr. SUDEEPTI SONI

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  CONTENT

 Introduction

 History

 Various types of artificial eyes

 Anatomy of eye

 Surgical considerations

 Ocular implants

 Patient evaluation

 Fabrication of ocular Prosthesis

 Modification of stock eye prosthesis

 Post-insertion care of ocular prosthesis

 Complications

 Recent advances

 Conclusion

 References

 INTRODUCTION

Eyes are generally the first feature of the face to be noted.

Loss of eye has a definite psychologic effect on patient.

A prosthesis should be provided as soon as possible for the psychological well-being of

patient.

 HISTORY

The eye was a symbol of life to the ancient world, particularly in Egypt.

Ambrose Pare(1510-1590), a famous french surgeon, was the first to describe the use of
artificial eyes to fit an eye socket.

Ludwig Muller-Uri (1830’s)-glass eyes.

Frohlich and Van Duyse (1884) – tried using ivory, aluminium and celluloid.

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  Various types of artificial eyes

Today three types of ocular prosthesis are used:

 Stock eyes

 Stock eyes modified by various methods

 Custom fitted eyes

A) According to material used:

i) Glass eyes.
ii) Plastic (Acrylic resin) eyes.

B) According to fabrication-
i) Stock( ready made).
ii) Custom.

 Glass eyes

Made from a combination of fusible opaque glass for scleral portion and transparent glass for
corneal portion.

INDICATION:-allergy to acrylic

DISADVANTAGES

 Becomes rough and looses its transparency.

 Easily fractured.

 More liable to get scratched.

 Poor fusion can produce cracksà ocular secretions gather insideà increased weight.

 Difficult to fit properly in relation to defect.

 Color of the iris of the glass looses its glaze and becomes dim over years.

 Acrylic resin eyes

ADVANTAGES-

 Compatible with tissues.

 Easy to work with.

 Easy color modification abilities.

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  No surface roughness due to socket secretions.

 Nonfragile.

Can be either preformed or custom made therefore can fit in a better manner in the socket.

Can be constructed with materials and equipments commonly found in dental lab.

Can be repolished to original shine and smoothness.

i) Custom.

ii) Stock( ready made).

 CUSTOM OCULAR PROSTHESIS

Close adaptation to the tissue bed:

àBetter motility

àDistributes pressure more equallyà thus reduce the incidence of ulceration

àEnhances tissue health by reducing the potential stagnation spaces at the prosthetic tissue
interface (these voids collect mucous and debris which can irritate mucosa and act as
potential source of infection).

 STOCK OCULAR PROSTHESIS

DISADVANTAGES:

 Though less time required but results are not satisfactory.

 Some discomfort always present.

 Adaptation not very good:-

Movement compromised
Collection of mucosa and debris

VARIOUS TYPES OF STOCK EYES :

Snellen conventional eyes- Most frequently used.

Horizontal diameter approximately 10% greater than vertical.

Posterior surface concave.

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Helps to keep the front surface of the eye in a cosmetically suitable position and the soft
tissue of the orbit displaces out around the prosthesis to fill the supraorbital fold which might
otherwise appear sunken.

 Conventional shell type

Similar to Snellen reform eye but is designed so that the thickness of the scleral portion is
less, therefore it is indicated in cases where orbital tissues are protrubent and leave too little
space for a prosthesis.

 Hook type

Additional hook at the top.

Indicated in eyes with a shallow lower fornix and lax lower lid which leads to a tendency for
the prosthesis to slip out from below.

Hook supports the prosthesis by resting over a stump taking away some weight being exerted
on the lower lid.

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  ANATOMY OF HUMAN EYE-

 SURGICAL CONSIDERATIONS IN PROSTHODONTIC TREATMENT OF

OCULAR DEFECTS

INDICATIONS FOR REMOVAL OF EYE-

 Irreparable trauma

 Tumor

 A blind painful eye

 Need for histologic confirmation of a suspected diagnosis. etc

Surgical procedures in the removal of eye are classified into three categories: -

 Evisceration

 Enucleation

 Exenteration

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  EVISCERATION

removing the content of globe but leaving the sclera, and some time the cornea in place.

Loss of volume is usually replaced by placing a 16 to 18 mm spherical implant.

Motility of the implanted eviscerated globe is excellent, since the extra ocular muscles are
intact.

The advantage of an eviscerated defect is that the light scleral shell will not depress the lower
eyelid with its weight, and a bulk of material is not required to fill a Sunken superior sulcus.

 ENUCLEATION

Surgical removal of the eyeball after the eye muscles and optic nerve have been severed.

The advantage of enucleation, as compared with evisceration, include the entire globe is
available for histopathological examination, the risk of spreading an ocular tumor is
neglected and adequate space is created the fabricating the ocular prosthesis.

 EXENTERATION

Removal of the entire content of the orbit,including the extraocular muscles.

This procedure is usually performed due to some form of malignant disease but may also be
due to trauma, infection, or aggressive disease processes.

 OCULAR IMPLANT

Placed in the tissue bed to facilitate construction of ocular prosthesis.

The placement of an orbital implant into an enucleated socket was Ist described by frost in
1886.

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ADVANTAGES:

 Prevents sunken appearance of orbit.

 Better movement of overlying prosthesisà muscles attached.

 In growing childrenà additional benefità restored muscle function creates

additional tension on the orbital walls and ensures normal pattern of orbital growth.

Following enucleation not all patients are candidates for placement of an ocular implant:

 Pemphigus, trachoma etc which predispose to severe scarringà implant placement

not possible.

 If there is insufficient tissue to cover the implant following surgery.

 INSERTION OF IMPLANT

 Following enucleation

 Tenon’s capsule preserved

 conjunctiva and tenon’s capsule are opened by an incision

 implant inserted (insertion clips)

 Muscles attached to implant

The mechanism of attachment of extraocular muscles to the implant can be through a loop or
screen on the implant, which allows a location for suture placement.

But more often, muscle attachment is in the form of a crossed notch on the anterior surface of
the implant into which the extraocular muscles can be placed and sutured together.

 tenon’s capsule and

 conjunctiva sutured back

 conformer placed(4-12 weeks)(decrease edema, maintain socket, stabilizes implant)

 Materials used for ocular implants

First materialà glass. Introduced by Mules(1884)

Many materials have been tried:

Bone, gold ivory, rubber, paraffin etc.

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In recent years inert resin polymers are used.

(Most of the implants are made of methyl methacrylate resin) .

Hydroxyapatite

POROUS IMPLANT- Refers to an implant with numerous interconnected pores or channels

throughout its structure that permit fibrovascular ingrowth (e.g.-Hydroxyapatite, aluminum
oxide, porous polyethylene)

NONPOROUS IMPLANT- Refers to an implant that is solid and does not allow
fibrovascular ingrowth(e.g.- Polymethylmethacrylate, Silicone)

 CLASSIFICATION OF IMPLANTS

 Buried implants: totally buried in tissues

(chance of dehisenceà exposure of overlying implant)

 Non buried: some part open. (High chance of infection and migration)

 Integrated implants

Coupled to the overlying prosthesis

PEGGING

Pegging is an option of any of the porous implants, most commonly done with
hydroxyapatite.

The thought behind pegging is that it improves motility by allowing the pegged surface to fit
into a corresponding groove in the back of the prosthesis.

But it can promote infection and lead to extrusion of implant.

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Rudermann Ist introduced 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's.

 Semi integrated
(Allen implant, Iowa implant, Quad motility implant)

Protruding mounds on implantà prosthesis will have a counter contourà excellent motility
and retention of the prosthesis.

Require excellent fit of the prosthesis

 Non integrated

Most commonly used (Mules’sphere) ( 10-22mm)Smooth surface

Motility compromised

 HYDROXYAPATITE INTEGRATED OCULAR IMPLANT

Fibrovascular growth after 4-6 months (pores of 500 micron)

Less likely to become infected since it is incorporated with host blood vessels.

Use of conformers in treatment of ocular defects

 Decrease edema

 Maintain socket contours

 Stabilizes implant

 Prevent scar tissue contractures

 Stimulates eyelid musclesà thus prevent disuse atrophy

Two types-Stock and Custom made

 PATIENT EVALUATION

Physical and psychological examination of the patient including the desires and expectations
of the patient related to proposed prosthesis.

The patient will usually present for treatment with either conformer or an existing prosthesis
in place.

 Fabrication of Ocular Prosthesis

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Indication:

 Surgical site is well healed, and dimensionally stable.

 Post surgical socket with suitable tissue bed, the socket exhibiting a healthy intact
conjunctival epithelium, deep fornix and taut eyelids.

 Physiological status of the patient.

Impression Technique:

0.5% Tetracaine hydrochloride topical solution is used as a surface anesthetic agent to reduce
the irritability of mucosa while taking the impression.

An impression of the socket is made with an ophthalmic irreversible hydrocolloid in

conjunction with a suitable impression tray (i.e. stock acrylic resin impression tray)

Techniques for making ocular impression

 Stock tray impression technique

 External tray impression technique

 Stock tray impression technique

Requirement- A disposable syringe

Stock ocular tray

Ophthalmic quality irreversible hydrocolloid

Patient Position- Upright with head supported by headrest

Checking of stock tray for extensions.

Orientation of tray-syringe assembly- Stem of tray parallel to a line perpendicular to the pupil
plane of natural eye.

Lid support- Tray should be oriented to support the lids in a similar position to the lids of the
natural eyes.

Ophthalmic quality irreversible hydrocolloid is mixed and loaded in the syringe.

Sufficient material is ejected to fill the concavity of the tray.

Tray is reinserted and reoriented in the defect; sufficient material is injected to elevate the lid
contours similar to the normal side.

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After setting, impression is removed and checked for defects.

Impression tray is inserted again in defect and checked for proper lid contour and mobility.

After an acceptable impression of eye socket has been obtained, it is reproduced in wax.

The stem of impression tray is attached an orangewood stick with sticky wax.

This assembly is suspended over a small medicine cup, and room-temperature vulcanizing
silicone mold is poured into the cup to completely cover the impression.

After silicone has set, an incision is made in the mold with a sharp scalpel extending from
the superior aspect along the stem of the impression tray through to the bottom of the mold.

The mold may be spread apart, the impression and tray removed, and the mold replaced in
medicine cup.

The resulting hole in the mold where the stem of the impression tray protruded is used as a
sprue for filling the mold with molten wax.

 External Tray impression technique

Tray can be fabricated from acrylic resin tray material on any facial cast available in office.

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 Fitting the Scleral Wax Pattern

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  CUSTOM OCULAR PROSTHESIS FABRICATION

o Paper iris disk technique

o Black iris disk technique

 PAPER IRIS DISK TECHNIQUE

1. Fabrication of scleral blank

wax pattern

flasking

scleral resin blank

Finishing and polishing

2. Determining location and size of iris

The size of iris is measured using a drafting circle template.

3. Reinvesting the scleral blank

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4. Painting the paper iris

A disk of ordinary artist’s watercolor paper is punched out using a die.

A selection should include 10 to 12 mm diameters in 0.5 mm increments.

The size selected should be 1 mm smaller than the measured size of iris.

Using artist’s acyrlic paint , the disk is painted to match the coloration of the natural iris.

Colours-

 Ultramarine blue
 Burnt sienna
 Burnt umber
 Yellow oxide
 Titanium white
 Mars black
It is important to use a thin brush and paint many brush strokes from the center of the disk
to the periphery.

Colors should be mixed and reapplied in a layering fashion to mimic the colored striations in
the patient’s iris.

 IRIS ANATOMY

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The sequence of the technique of painting the artificial eye is as follows:

 The stroma (the predominant iris color),

 The background (the colours shown at limbus),

 The collarette (the area surrounding the pupil),

 The markings (the striations on the anterior surface).

A black spot should be painted in the center of the disk to represent the pupil.

The diameter should mimic the natural pupil under indoor lighting conditions.

The paint can be dried with an ordinary hair dryer.

A drop of water applied to create the magnification of the corneal prominence, and the color
compared.

If the coloration requires modification, acrylic paint can be added and rechecked until the
desired shade match is obtained.

This step can be repeated almost limitlessly until both the patient and clinician are satisfied
with the coloration.

5. Painting on scleral blank

Using a flat end bur, a flat surface is prepared in the scleral blank for the iris painting.

An ocular button is luted to the prepared flat surface with periphery wax and the assembly
tried in.

The orientation of the surface is adjusted until the sprue points directly at the observer while
the patient looks directly into the observer’s eye.

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Ocular Buttons-

• Clear, Colored

• Flat, Curved

• With pupil, Without pupil

• Available in different sizes

• Edge cut- Thicker button

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Using a large abrasive stone, the entire anterior surface of the scleral blank is reduced at least
1 mm.

This rough surface created by the stone will facilitate painting of the scleral portion of the
prosthesis.

The flat portion of the prosthesis is painted the base color of the iris, and a black dot for the
pupil is placed.

Next, the limbus or fuzzy demarcation between the iris and sclera is painted.

The remainder of the prosthesis is then painted to match the sclera of the natural eye.

Fine threads separated from red embroidery floss are placed on the scleral painting to mimic
the blood vessels of the patient’s natural eye.

The entire scleral portion is then coated with monomer polymer syrup to keep the blood
vessel fibers in place and allowed to set.

6. Packing of scleral blank

Once the monomer-polymer syrup has set, the scleral blank is replaced into the flask, and the
iris painting is placed on the flat section.

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Clear ocular acrylic resin is mixed and placed into the mold space and the flask trial packed.

Once trial packed, the flash is removed and the location of painting verified to ensure that it
has not moved during trial packing.

The flask can then be closed and the resin processed.

Place the assembled flask in a press, and allow it to cure for 2 hours at 2120 F. starting with
cold water in the unit.

Once Polymerized, the prosthesis is trimmed and polished using pumice and acrylic resin
polish.

 BLACK IRIS DISK TECHNIQUE

1.Selection of iris disk

The patient should be comfortably seated at matching eye level.

Backing device
The natural eye is observed closely and the diameter of the iris is estimated using a
millimeter measurement guage.

An iris disk approximately 0.5 mm smaller than the actual measurement should be selected,
allowing the magnification of the iris by clear acrylic lens.

The iris disk and ocular buttons normally employed in this procedure is jet black and
available in sizes from 11 to 12.5 mm in 0.5 mm increments.

The ocular buttons are prefabricated in corresponding sizes with various size jet black pupil
disks incorporated in the center of the flat surface.

2. Painting the iris disk

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Windsor Newton oil pigments are employed in this technique but are mixed with a monomer-
polymer syrup during the painting proces.

The iris disk should be painted to match the natural eye in an environment of natural light
enhanced by diffuse fluorescent lighting.

The basic eye colour or background colour is observed along with the limbus colour and
color of collarette.

The necessary pigments are placed on a palette along with several drops of monomer-
polymer syrup.

Two dappen dish- one containing water, other containing methyl methacrylate monomer for
thinning the syrup.

The background color is applied to the disk first, using brush strokes from the center
toward the periphery.

After the background color is applied and dried , a coat of clear syrup is applied and
allowed to dry.

Characteristic striations are applied over the clear layer and allowed to dry.

A second clear layer is then applied and further characterization accomplished.

After the second layer is dried, the limbus color is matched around the periphery of the disk
and a third clear layer is applied.

The collarette colour is applied over the last clear layer and final color evaluated with the
water interface.

After a satisfactory color match has been obtained, a final clear layer is applied allowed to
stand for 15 minutes.

A single droplet of the monomer-polymer syrup is then placed in the center of the iris disk
and the lens button is gently placed and centered.

The assembly is allowed to dry for 15 to 30 minutes.

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3. Fixing the lens button to the scleral wax pattern

The object then is to fix the lens button to the scleral pattern in a manner such that the
apparent gaze of both natural and artificial eyes is on the same object, or parallel to one
another and in the same plane.

The patient should be seated comfortably in an upright position without the back or head
supported.

The operator should be positioned directly in front of and at eye level with the patient.

The patient is instructed to fix the gaze of the natural eye on an object at least 3 feet in front
of and at eye level with the natural eye.

The position of the iris pupil area of the natural eye in relation to the inner canthus and the
upper and lower lids is then transferred to the scleral pattern.

The pattern is then removed from the socket and a cylindrical portion of wax slightly larger
than the lens button and approximately 1 to 2 mm thick is removed from the marked area.

The lens button is then attached in the depression on three small cones of soft utility wax.

The patient is again instructed to fix his or her gaze on the predetermined object, the iris lens
assembly is repositioned on the soft wax cones as necessary to achieve the same iris-pupil
plane and a line of vision parallel to the natural eye.

The pattern is then carefully removed from the socket without movement of lens assembly.

Verification of the location of iris painting assembly

The lens assembly is placed in a slight depression in the scleral pattern, and a thin layer of
wax is coated over curvature of lens.

This thin layer of wax will allow the opaque white scleral resin to flow up over the edge
curvature of the lens assembly during the packing procedure, forming a very thin, translucent
layer.

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4. Investing the pattern

This finished pattern is then invested in a small two-piece brass flask.

The bottom half of the flask is filled with improved stone, and the tissue surface of the
pattern is painted with stone and placed in flask to the height of curvature of the edge of
pattern.

After a sufficient setting time has elapsed, the stem of lens assembly is covered with tin foil
and the stone is painted with a foil substitute solution.

The second half of the flask is poured.

After the stone has set, the wax is removed from the mold by boiling, the lens assembly and
the mold are cleared of all wax residue and mold is painted with foil substitute.

The mold is allowed to cool to room temperature before packing with white scleral resin.

The mold is closed and polymerized by boiling for 2 hours.

The resulting scleral blank is deflasked, trimmed and polished.

5. Modifications in processed eye

6. Painting of sclera

When a satisfactory result has been obtained, the sclera may be tinted to match the natural
eye using oil pigments and monomer-polymer syrup.

The sclera is slightly roughened using sandpaper disks in preparation for adding the
simulated vasculature.

Rayon-thread fibrils are placed onto the surface of sclera using monomer-polymer syrup.

The modifying oil pigments are mixed with monomer-polymer syrup and applied to the
sclera.

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A thin layer of processed clear acrylic resin must be applied over the surface of the painted
sclera to seal in pigment and vascular fibrils as well as to replace any wax adjustments.

Previous mold or new mold is used for packing optical grade clear methyl-methacrylate resin
and polymerized by slowly bringing to a boil and boiling for 2 hours.

The ocular prosthesis is removed from the mold and carefully trimmed of all flash using
sandpaper disk.

The surface is finely polished using pumice flour.

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Paper iris disk Black iris disk
technique technique

First Selection of
fabrication of correct size iris
scleral blank disk
Painting the Painting of iris
iris on paper disk
Painting scleral Attaching disk to
blank the scleral wax
Reinvesting pattern
keeping paper Flasking and
in place of packing with
corresponding scleral resin
iris of scleral Modifications
blank. and finishing
Finishing and polishing
polishing
 PLACEMENT OF CUSTOM OCULAR PROSTHESIS

 A feeling of fullness is natural upon placement of prosthesis.

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  Too much substractive adjustment is contraindicated for first few days.

 Patient should be instructed on how to remove and place the prosthesis.

 The patient should return in 1 day, 3 days and 1 week for follow-up.

 Once a week the prosthesis should be removed by the patient and cleaned with mild
soap and rinsed well.

 Artificial prosthesis must be protected from sunlight.

 When patient is removing it, prosthesis should be stored in a contact lens solution or
water.

 Eyeglasses should be worn.

 MODIFICATION OF STOCK EYE PROSTHESIS

A stock eye is selected with the correct iris size, color, and approximate sclera shape.

The peripheral and posterior surfaces are reduced by 2 to 3mm and retentive grooves are cut
into the posterior surfaces.

The prosthesis and impression are invested in the lower half of a flask.

After the stone has set, two small projections of autopolymerizing acrylic resin are attached
to the canthus areas of the prosthesis. These projections will hold the prosthesis in the upper
half of the flask and retain the correct relationship between the prosthesis and the mold
during the packing and processing procedures.

The packing, processing and finishing of the prosthesis are accomplished.

 COMPLICATIONS WITH OCULAR PROSTHESIS

 Superior lid dropping

 Loss of motility

 Pressure necrosis

 Inadequate space to retain the prosthesis.

Ptosis:- Superior eyelid ptosis is a frequent problem in the restoration of the an ophthalmic
patients.

Correction of persistent ptosis:

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 Steps to correct a ptosis, describe by Allen and Webster.

A-Superior aspect of prosthesis reduced for tarsal plates.

B-Material added to anterior and corneal area to steeper curve.

C-Anterior inferior surface of prosthesis reduced.

D-Material added to posterior-superior edge of prosthesis to buckle levator and lift margin of
eye.

Sagging lower eyelid:

The weight of the prosthesis and the contraction force of the upper eyelid on the prosthesis
can cause a downward displacement of the lower lid.

Degenerative disease may also weaken the lower eyelid, causing it to droop.

By removing resin from the mid inferior margin of the prosthesis, downward pressure
against the middle of the lower fornix is relieved.

Wax is added to extend the nasal and temporal aspects of the inferior margin to create
pressure in the medial and lateral areas of the lid.

Ectropion: -

Inferior displacement of the implant can lead to the loss of the inferior fornix and cause
ectropion of the lower lid.

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Patients have difficulty with retention of the prosthesis, since it has a tendency to slip down
and out over the everted lower lid.

This is rectified by extending a thin lower edge that will press downward upon the tarsus, and
rotate it into a more vertical plane, thus creating a lower fornix.

 RECENT ADVANCES IN OCULAR PROSTHESIS

In the ocularists field , the digital revolution is only just beginning.

Ocularist prefer to color the iris manually as compared to digitally by use of software.

Color is infinite and making it by software is difficult.

Still digital is future.

Dr. John Stolpe is an ocularists, who introduced a starter kit of 84 digital irises that believed
as covers the largest possible range of the population .

Ioli-Ioanna Artopoulou.Digital imaging in the fabrication of ocular prostheses.J Prosthet

Dent 2006;95:327-30.

Make a digital photograph of the patient’s iris using a digital camera.

Evaluate the photograph and compare it to the patient’s iris. Using graphics software, adjust
for slight differences in color, brightness, contrast, or hue.

Print the final image on 20-lb white paper using a laser printer with a color-ink print
cartridge.

Cover the paper iris with 3 light coats of water-resistant spray used for artwork, and attach it
to the ocular disk.

Use monopoly syrup to position the ocular button on the iris, and paint around the edges of
the button and the disk to achieve maximum seal.

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Attach the disk assembly to the wax pattern and evaluate it in the patient.

Processing is done by conventional technique.

 SUMMARY

A person without an eye undergoes too much amount of mental trauma, rehabilitation with
prosthetic eye helps in returning back to normal life.

 REFERENCES

 Taylor TD. Clinical maxillofacial prosthetics. Quintessence publication.

 Chalian VA. Maxillofacial prosthetics.
 Beumer J. Maxillofacial rehabiliation. Third edition. Quintessence publication.
 Ioli-Ioanna Artopoulou.Digital imaging in the fabrication of ocular prostheses.J
Prosthet Dent 2006;95:327-30.
 Taicher S , Steinberg HM, L. Tubiana I et al: Modified stock-eye ocular
prosthesis.1985;54(1):95-98
 Baino F et al. Biomaterials for orbital implants and ocular prostheses: Overview and
future aspects. Acta Biomaterialia 2014, 1064-1087.
 Singh KR. Ocular implants and prosthesis.. Dos times 2014:20(6)55-62.
 Bartlett S,Moore D. Ocular prosthesis: A physiologic system . J Prosthet Dent
1973;29(4):450-459.
 Shenoy KK.. Ocular impressions: An overview. J Indian Prosthodont soc 2007:7(1)5-
7.

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