Prosthesis Type in Altering Meibomian Gland and Thickness of

Lipid Tears Film Layer in Anophthalmia Socket

ABSTRACT
Background: Anophthalmia is a severe form of ocular malformation characterized
by the complete absence of an eye. Ocular prostheses are usually made from safe and
durable materials, but even though it’s safe, ocular prosthesis can cause problems
with the eyelids, tear film, and conjunctiva, inflammation, meibomian gland
dysfunction, and less tear fluid.
Aims: This literature review aims to investigate the effects of ocular prosthesis on
meibomian glands function and thickness of lipid tears film layer in anophthalmia
socket.
Methods: This literature review conducted 48 research publications from 2013-2023
and only 20 journals were included which cited from some reputable sources using
“ocular prosthesis”, “meibomian gland”, “anophthalmic socket”, “lipid tear film” as
keywords.
Results: The eyelids of an anophthalmic sockets have a reduced density of
meibomian glands acinar units. Several studies have found that those people with
ocular prosthesis experience a greater loss of meibomian glands compared to people
with normal eyes. Higher MMP-9 levels in patients with a longer duration of
prosthesis wear, i.e., the time since eye loss, might be a consequence of chronic
socket inflammation resulting in secondary morphological changes including atrophy
of the meibomian glands. The occurrence of meibomian dysfunction in those with
prosthetic eyes is very common and therefore causing reduction of the thickness of
the lipid layer of the tear film.
Conclusion: Meibomian gland and tear film impairment (aqueous and lipid) should
be considered in subjects with anophthalmic socket using an ocular prosthetic.
Keyword: ocular prosthesis, meibomian gland, lipid tear film, anophthalmic

INTRODUCTION
Anophthalmia is a severe form of ocular malformation characterized by the
complete absence of an eye.1 The eye is an amazing part of our life that helps us
understand the world around us. Losing an eye can have a big impact on a person's
mental, physical, and social health. It can happen for many different reasons such as,
congenital defects, severe injuries, tumors, or sympathetic ophthalmia. Ocular
prostheses offer a good solution by giving the natural look of the eye, and boosting
their confidence and overall quality of life. Ocular prostheses are usually made from
safe and durable materials, such as medical-grade acrylics or silicone elastomers that
are lightweight and resistant to moisture and bacteria. 2 Even though it’s safe, ocular
prosthesis can cause problems with the eyelids, tear film, and conjunctiva, leading to
more mucous discharge, inflammation, meibomian gland dysfunction, and less tear
fluid. When a new or recently polished ocular prosthesis is put in an anophthalmic
socket, the socket goes through a short period of adjustment, then stays stable for
about 6 months. After that, it starts to experience more deposits, mucous, and
inflammation.3

Many patients with ocular prosthesis report varying degrees of ocular

discomfort such as discharge, dryness, irritation, and sticky sensation. Infection of the
anophthalmic socket, glutinous surface deposits, and roughened prosthesis are
mechanisms that have proposed for the development of ocular discomfort in
prosthetic eye wearers.4 Moreover, Kashkouli et al. showed that prosthetic eyes had
significantly lower tear production and higher tear drainage obstruction. 5 Meibomian
gland secretion forms the lipid layer at the surface of the tear film, which prevents dry
eye by reducing ocular surface water evaporation and collapse of the tear film.
Dysfunction of meibomian glands increases the evaporation of tear fluid and results
in dry eye. Similar to contact lenses, ocular prostheses come into contact with the
conjunctiva. Mechanical trauma created by ocular prosthesis alters meibomian gland
structure and reduces number of functional meibomian glands, which leads to ocular
discomfort.6 Severe dryness of the socket because of diminished tear production
(impaired Schirmer test) may occur in up to 75% of anophthalmic sockets. It could
also be related to problems with prosthesis and altering the surrounding eye area, like
changes in the conjunctiva, issues with eyelid function, or problems with tear
production and lacrimal drainage system.5 This literature review aims to investigate
the effects of ocular prosthesis on meibomian glands function and thickness of lipid
tears film layer in anophthalmia socket.

METHODS
This literature review of meibomian glands and thickness of lipid tears film
layer alteration in ocular prosthesis was prepared via the process of searching
literature review by compiling a variety of credible sources. The keywords “ocular
prosthesis”, “meibomian gland”, “anophthalmic socket”, “lipid tear film” were used
to get a total of 48 research papers that were published between 2013 and 2023 and
only 20 journals were included. The journals cited in this literature review originate
from reliable scientific sources as following scientific sources Pubmed, Medline,
Crossref and Google Scholar. The acquired information was then examined utilizing
a critical approach to case-related issues.

RESULTS
Prosthetic Eye or Ocular Prosthesis
An ocular prosthesis is an artificial eye that is used when a person's natural
eye has been removed. This can happen due to different reasons such as surgery or
injury, etc. This special device also helps improve a patient's social and mental well-
being.7 The material used for the prosthesis is similar to what dentists use to make
molds of your teeth, and it only takes a few minutes to complete. Hydroxyapatite and
human bone are the main stuff and the natural option. This helps make the implants
stable, reduces the risk of rejection, and allows them to become a part of the body.
These prosthesis can be made from materials like porous material such as,
polyethylene, hydroxyapatite, or aluminum oxide or Non-porous materials, such as
silicon and Polymethyl Methacrylate (PMMA).8

Anophthalmic Socket Phases of Prosthetic Eye Wear

 The response of an anophthalmic socket to a prosthesis and the common
conditions that affect the socket such as mucoid discharge and papillary conjunctivitis
are important in understanding the principles of socket maintenance. A three-phase
model has been used to describe the response of the socket to prosthetic eye wear.
The establishment phase occurs when homeostasis is being established in an
anophthalmic socket with a new prosthesis or a newly polished prosthesis. This phase
can be as short as a few minutes but can last a month or more as the mucous is
distributed over the prosthesis; foreign material is cleared away; and the balance of
tear production, evaporation, and drainage is established. The equilibrium phase
occurs when the mucous is evenly distributed over the prosthesis, surface deposits
which aid in wetting of the prosthesis have built up on the prosthesis, and the
prosthesis can be comfortably worn. Bacterial homeostasis also occurs during this
phase as membrane lipid, iron, and pH all are stabilized. More gram-negative bacteria
are typically found in an anophthalmic socket compared to the companion socket, but
in the equilibrium phase they do not cause inflammation. The breakdown phase
occurs when the prosthesis cannot be worn comfortably and inflammation and
discharge increase.3

Meibomian Gland Changes in Anophthalmia Socket with Ocular Prosthesis

The eyelids of an anophthalmic sockets have a reduced density of meibomian
glands acinar units and a more inhomogeneous appearance of the periglandular
interstices and the acinar unit walls. 9 Long-term patients with an ocular prosthesis
often experience chronic eye discomfort, which is one of the most common issues
they face. Many patients with a prosthetic eye may experience chronic discharge,
which can be caused by various conditions. These conditions can be divided into two,
which is reduced tear production and blockage in tear drainage due to prosthetics or
problems with the eyelids, such as dysfunction in the meibomian glands,
lagophthalmos, and absence of the mucous membrane or skin. Several studies have
showed that there were changes in meibomian glands in people with prosthetic eyes.
These studies have found that these patients experience a greater loss of meibomian
glands compared to people with normal eyes. 6,10 Higher MMP-9 levels in patients
with a longer duration of prosthesis wear, i.e., the time since eye loss, might be a
consequence of chronic socket inflammation resulting in secondary morphological
changes including atrophy of the meibomian glands.11

Meibomian gland dysfunction (MGD) is a term used to describe a group of

problems with the meibomian glands, which are not working properly. The
International Workshop said that MGD is a long-term problem with the meibomian
glands in the eyes. It is usually caused by blockages or changes in the way the glands
produce and release oils. MGD can cause changes in the composition of the liquid
film that covers the eye, leading to problems with the surface of the eye, discomfort
in the eyes and eyelids, and dryness caused by excessive evaporation. Actually, MGD
is the main reason for evaporative dry eye.12 Eyelids of a prosthetic eye seem mostly
disposed to obstructive MGD, as result of an increased hyperkeratinization, causing
excretory duct obstruction, due to a combination of tear deficiency, deposit
accumulation, and micro-trauma. Other hypothetical pathophysiological mechanisms
of meibomian gland obstruction in the eyelid of patients with an ocular prosthesis, is
decreased and weakened eyelid blinking.13

In a study by Jang, et al. they reported a greater degree of meibomian gland

loss in patients who had used an ocular prosthesis longer than 10 years. 10 In other
study by Meduri et al, the average duration of prosthesis use was 13.6 ± 5.1 years.
For this reason, MGD could represent an undiagnosed cause of chronic ocular
discomfort in long-standing ocular prosthesis patients. 13 Depending the age and
surface of the prosthesis, the treatment may involve changing the prosthetic glass eye
or making the PMMA prostheses smoother to make it easier for tears to spread across
the surface. Cleaning too frequently can damage the natural environment that helps
the prosthesis stay wet and ensures the tears are evenly spread. Furthermore, regular
morning eyelids care can be done to get rid of crusts and help the meibomian glands
work better.14

Thickness of Lipid Tears Film Layer in Anophthalmia Socket with Ocular

Prosthesis
The tear film is an interface of about 3 μm in width between the ocular surface
epithelium and the environment. Derived from the Meibomian glands, the surface
lipid layer of the tear film functions as a smooth optical surface at the level of the air-
aqueous interface.15 While the thickness of the lipid layer is only about 100 nm, it
reduces surface tension and retards the evaporation of the tear film, which can reflect
the function of the meibomian gland.16,17 It has also been suggested that the instability
of tear film has something to do with tear film lipid layer and the meibomian gland.
Altered spreading and focal thinning of the lipid layer in Meibomian gland disease
also contribute to tear instability. In addition, the tear film quality is reported to result
in changes in the blink rate; spontaneous blinking has complex interactions with the
ocular surface.18

The occurrence of MGD in patients with prosthetic eyes is very common.

MGD presents with the reduction of the thickness of the lipid layer of the tear film. 13
Compared to the normal paired eyelids, the findings by Desouky et al, showed that
eyelids with an ocular prosthesis were substantially related with a larger degree of
meibomian gland loss. Eyelids of a prosthetic eye seem particularly prone to
obstructive MGD, which may serve as one of the mechanisms underlying prosthetic
eye-related dry eyes.1 Upper Meibomian gland loss was correlated with lower
Meibomian gland loss, and both were correlated with lipid layer thickness in
obstructive MGD.19

The three-layered pre-corneal tear film does not form over the anterior surface
of a PMMA prosthetic eye, but a confluent tear film may form for a brief time
depending on the wettability of the surface of the prosthesis. Prosthetic eyes
manufactured from PMMA are superior to glass eyes in many respects, but glass eyes
(when new) are more comfortable to wear due to their hydrophilic surfaces and
greater ability to wet and to maintain an lipid and aqueous tear film. 20 The role of the
lipid layer is to stabilize the tear film and prevent tear evaporation from the aqueous
tear film layer. However, this homeostasis may be affected by Meibomian gland
dysfunction (MGD), which is characterized by terminal duct obstruction and changes
in glandular secretion. The Meibomian gland secretes the majority of lipids that
comprises the lipid layer of the tear film and receives both parasympathetic and
sympathetic innervation to regulate tear production with the lacrimal gland.
Therefore, Meibomian gland dysfunction may affect tear film stability and tear
osmolarity.19

CONCLUSION
Meibomian glands of eyelids with a prosthetic eye are more likely to be lost
and therefore deterioration and loss of normal anatomical structures might lead to
obstructive MGD, which was strongly associated with decreased thickness of lipid
layer of the tear film. Therefore, meibomian gland and tear film impairment (aqueous
and lipid) should be considered in subjects with anophthalmic socket using an ocular
prosthetic.

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