|Year : 2015 | Volume
| Issue : 1 | Page : 37-41
Evaluation of the use of blind disfiguring eye as a natural implant for artificial eyes
Mohammed Iqbal Hafez
Department of Ophthalmology, Sohag University Hospital, Sohag University, Sohag, Egypt
|Date of Submission||09-May-2014|
|Date of Acceptance||06-Aug-2014|
|Date of Web Publication||29-May-2015|
Mohammed Iqbal Hafez
Department of Ophthalmology, Sohag University Hospital, Sohag University, 82425, Sohag
Source of Support: None, Conflict of Interest: None
The aim of this study was to evaluate the use of the blind disfiguring eye as a natural implant for artificial eyes instead of evisceration or enucleation with synthetic implants.
Patients and methods
Ten eyes, which were painless and blind with disfiguring appearance, were included in this study. All eyes were subjected to a new simple surgical technique by simply converting the eye into a natural implant. The main outcome measure was the cosmetic appearance, patient satisfaction, and psychological impact. All patients were followed up at 1 and 2 weeks and 1, 3, and 6 months postoperatively.
Ten eyes of 10 patients were included in this study with a male-to-female ratio of 1 : 4. Two (20%) eyes developed lid edema and ecchymosis, one (10%) eye complicated with conjunctival hematoma, and another eye (10%) had postoperative shallow fornices. Seven (70%) patients had good postoperative cosmetic appearance with good prosthesis motility and patient satisfaction. Two (20%) patients were not satisfied, as they had poor cosmetic appearance with restricted prosthesis motility. One (10%) patient had failed surgery.
The use of the painless blind disfiguring eye as a natural implant for artificial eye proved to be an efficient and cheap procedure with excellent cosmesis. Great patient satisfaction was noted as regards the prosthesis movements and final new look.
Keywords: artificial eyes, cosmesis, disfiguring eye, implants, patient satisfaction, RPSTC
|How to cite this article:|
Hafez MI. Evaluation of the use of blind disfiguring eye as a natural implant for artificial eyes. Delta J Ophthalmol 2015;16:37-41
|How to cite this URL:|
Hafez MI. Evaluation of the use of blind disfiguring eye as a natural implant for artificial eyes. Delta J Ophthalmol [serial online] 2015 [cited 2017 Aug 24];16:37-41. Available from: http://www.djo.eg.net/text.asp?2015/16/1/37/157790
| Introduction|| |
Since 1885 when Mules placed the first orbital implant consisting of a blown glass sphere, various types of materials have been placed in the orbit following removal of an eye  . Glass, rubber, steel, gold, silver, silicone, acrylic, titanium mesh, and polymethylmethacrylate spheres have been used. Many of these materials are well tolerated by the host and provide adequate orbital volume  .
The disfigurement associated with the loss of an eye can cause significant physical and emotional problems  . The rehabilitation of a patient who has suffered the psychological trauma of an ocular loss requires a prosthesis that will provide the optimum cosmetic and functional result. An ocular prosthetic does not provide vision  .
Evisceration is the surgical procedure in which the entire intraocular contents are removed, leaving the sclera and orbit intact (with or, more often, without the cornea)  . Ocularistry, the science of making ocular prosthesis, has undergone phenomenal growth in recent times. An ocularist is an individual skilled in fabricating the ocular prosthesis  .
The idea of this research was quite simple. Most patients indicated for evisceration or enucleation with synthetic implants are usually psychologically greatly depressed. Many of them ask for an alternative cosmetic procedure that allows them to preserve their original eyeballs, without evisceration or enucleation. Furthermore, almost all patients are psychologically harmed postoperatively when they remove their prostheses to look at the mirror and suddenly discover the disappearance of their pupils from the eye. This is annoying to most of the patients.
From this point of view, the idea of using the blind disfiguring eye as a natural implant was born. This simple technique includes five simple steps that convert the eye to an implant and make the conjunctival socket ready for the prosthesis. These five simple steps are simply named as RPSTC. Each letter of the word RPSTC represents the first letter in each of the five steps.
| Patients and methods|| |
This study was designed as a prospective noncomparative clinical trial that was performed in Sohag University Hospital (Egypt) after the approval of the ethical committee. Written consent was obtained from the patients after explanation of the new procedure for correction of their cosmetic appearance.
This study included 10 eyes of 10 patients (eight female and two male patients). Inclusion criteria were as follows: patients who were blind (no perception of light), presence of disfiguring, atrophic, and painless eyes. Exclusion criteria were presence of painful eyes, active inflammation (uveitis), progressive phthisis bulbi, contracted socket, proptosis, normal-sized globe, and absolute glaucoma.
All eyes were subjected to the new surgical procedure RPSTC, which included the following five steps:
- Removal of corneal epithelium, Bowman's membrane, and superficial part of the corneal stroma.
- Periotomy with generalized conjunctival dissection.
- Separation of Tenon's capsule from the conjunctiva.
- Tenon's capsule closure over the cornea as a separate layer.
- Conjunctival closure over the Tenon's capsule as a second separate layer.
At the end of the surgery, the conformer was placed into the conjunctival socket, to be removed later on when the prosthesis was placed. [Figure 1] shows the detailed steps of RPSTC. Eye drops were instilled at the end of surgery in the form of antibiotic eye drops (gatifloxacin 0.3%), steroid eye drops (prednisolone acetate 1%), and topical gel. Finally, the eye was covered by eye patching followed by a tight bandage.
|Figure 1: The operative procedure (RPSTC): (a) the preoperative view of a painless blind disfi guring eye; (b) removal of corneal epithelium; (c) the intraoperative view after removal of corneal epithelium and Bowman's membrane; (d) peritomy with generalized conjunctival dissection; (e) separation of Tenon's capsule from the conjunctiva; (f) Tenon's capsule closure over the cornea as a separate layer; (g) conjunctival closure over the Tenon's capsule as a second separate layer; (h) introducing the conformer into the conjunctival socket.|
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The key to success of the surgery was the meticulous removal of corneal epithelial and Bowman's membrane to allow fibrosis between the Tenon's capsule layer and corneal stroma, thus preventing any future trouble from the corneal epithelium, such as ulceration and pain. Another key to success was the use of a tight eye bandage for 24 h, thus avoiding many postoperative complications such as secondary hemorrhage, echymosis, and edema.
Postoperatively, the bandage was removed after 24 h, but eye patching continued until the prosthesis was fitted. Postoperative antibiotic eye drops (gatifloxacin 0.3%) and steroid eye drops (prednisolone acetate 1%) were used four times daily. Topical gel was used twice daily. Systemic antibiotics and analgesics were used twice daily. The treatment usually lasted for 7-10 days postoperatively.
In all eyes, the prosthesis was placed 2 weeks postoperatively. The prosthesis was fabricated and fitted by an ocularist after complete healing of the conjunctival socket. All patients were given instructions on how to wear and how to take care of the prosthesis. They were also instructed that the prosthesis should be handled with care and with clean hands, and that the acrylic prosthesis should be removed at night to clean it with an antiseptic solution or simply soap and water, to wear it next morning. The prosthesis should be changed every year.
All patients were followed up at 1 and 2 weeks, and 1, 3, and 6 months postoperatively. The main outcome measures were the cosmetic appearance of the operated eye in comparison with the sound eye, the prosthesis movements, and the patient satisfaction about the cosmetic appearance and the new look.
| Results|| |
This study included 10 eyes of 10 patients. There were two (20%) male and eight (80%) female patients, with a male-to-female ratio of 1 : 4. The ages of the patients ranged from 14 to 38 years. All eyes presented with blind disfiguring painless eyes and were subjected to the RPSTC procedure. All patients were postoperatively followed up for 6 months.
The parameters of results were classified into three types. Good results were recorded in seven (70%) eyes and were characterized by good cosmetic appearance, good prosthesis motility, almost no postoperative complications, and good patient satisfaction. Poor results were recorded in two (20%) eyes and were characterized by poor cosmetic appearance, restricted eye movements, postoperative complications, and poor patient satisfaction. Failed results were recorded in one (10%) patient, as her eye was complicated with postoperative shallow fornices that allowed only the use of small sized prosthesis, resulting in asymmetry in size between the two eyes. Furthermore, there was no prosthesis motility in this eye. Postoperative results are shown in [Figure 2] and [Figure 3].
|Figure 2: Postoperative view of a female patient: the conjunctival socket after healing (above); a view showing prosthesis motility when the patient was looking to the right side (below).|
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|Figure 3: Postoperative view of a male patient: appearance of the pupil shadow (above); postoperative view in the primary position (below).|
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As regards postoperative complications, two (20%) eyes had lid edema and ecchymosis, one (10%) eye had conjunctival hematoma and chemosis, and one (10%) eye had postoperative shallow fornices. [Table 1] shows summary of the postoperative complications.
Postoperative pain was recorded in four (40%) eyes. The pain ranged from mild to moderate in most patients, which was controlled with oral analgesics. However, severe postoperative pain was the main complain of one (10%) patient, who required strong systemic analgesics (oral and injections). In these eyes, it was noticed that there was marked lid edema and ecchymosis. In all eyes, postoperative pain disappeared within 2-5 days postoperatively. Meanwhile, the lid edema and conjuctival chemosis resolved within 7-10 days postoperatively.
| Discussion|| |
To my knowledge, this new surgical procedure, named RPSTC, is the first of its kind and no previous studies have been performed or published on this issue.
In this study, the blind disfiguring eyes were used for cosmesis as a natural implant to be an alternative to synthetic implants. The idea of RPSTC was formulated for their cheap cost and availability, taking into consideration the fact that most patients could not afford the cost of expensive implants such as hydroxyapatite and Medpor implants.
Furthermore, the use of inexpensive implants such as acrylic implants is associated with the risk of infection, extrusion, and other complications. This makes the simple idea of RPSTC more close to be performed with no risk of implant extrusion.
In addition, this new procedure had many advantages such as simplicity, cheap cost, good cosmesis, and avoidance of most of the complications of synthetic implants. One great advantage was the psychological relief of the patient, as the eye was not eviscerated or enucleated. Furthermore, all patients expressed their happiness with the pupil preservation, as they could see the shadow of their pupil when they looked at the mirror without prosthesis. RPSTC succeeded to fulfil the patients' cosmetic needs and expectations. This new look with pupil preservation was the basic success of RPSTC.
Another unexpected advantage of RPSTC that showed up in this study was that it helped the surgeons in easy decision-making in cases presenting with up to 50% or more reduction in eyeball size in nonprogressive atrophic eyes in which evisceration was not a possibility and enucleation was not a simple decision to make.
Raizada and Rani  reported that loss of an eye or a disfigured eye has a far-reaching psychological impact on an individual. In addition, it affects one's social and professional life. Cosmetic rehabilitation with custom-made prosthetic devices gives such individuals professional and social acceptance and alleviates problems.
The results of this study showed that seven (70%) eyes had good cosmetic results, two (20%) eyes had fair results, whereas only one (10%) eye had failed surgery because of postoperative shallow fornices.
The postoperative complications recorded in this study were mild, limited, and easily managed. Two (20%) eyes had lid edema and ecchymosis, one (10%) eye had conjunctival hematoma and chemosis, and one (10%) eye had postoperative shallow fornices that required further surgical intervention.
Today, a vast majority of patients all around the world wear ocular prosthesis made of acrylic  . Rachdan et al.  reported that acrylic implants are safe and cost-effective for restoring orbital volume after evisceration. Furthermore, Zuravleff and Hugbes  reported that a good target ratio for the implant/sclera prosthesis total is 65-70% of the volume of the affected eye to 30-35% supplied by the ocular prosthesis. The ocularist can then choose whatever build is required, as the fornices of an eviscerated socket are usually well-formed and require few alternatives. The prosthesis can often be shallower, thinner, and, thus lighter, approaching a scleral shell.
Lui  reported a higher rate of acrylic implant extrusion, which occurred in 54 (28.1%) of the 192 patients. Implant extrusion was likely due to infection, edema, hemorrhage, or faulty surgical technique. The extrusion rate was 28.1%.
In contrast to these studies, RPSTC requires no synthetic implants and had no recorded cases of infection.
In this study, the conformers were placed to prevent contraction of the socket and prevent shallowing of the fornices until the prostheses were placed. Conformers are transparent and fenestrated with multiple holes. They had many advantages such as easy delivery of the eye drops into the socket, allow appearance of any abnormalities such as blood or discharge, and also keep well-formed fornices until the prosthesis was fitted.
As regards postoperative pain in this study, it was recorded in four (40%) eyes and ranged from mild to moderate pain in most eyes, with only one (10%) patient complaining of severe postoperative pain and complicated with marked lid edema and ecchymosis. In all patients, the pain was controlled with systemic analgesics.
Lui  reported that the postoperative pain scores over the entire 96-h period showed that pain intensity decreased following immediate implant. This is not surprising, because postoperative pain tends to decrease with time. In terms of total dose and frequency of pain medication used during the entire hospital stay, patients in the delayed implant group used 30-80% more pain medication than those in the immediate implant group.
In this study, the motility of the prosthesis reached up to 50% or more for the sound eye in seven (70%) eyes, which was satisfactory to these patients. Limited motility of the prosthesis was recorded in two (20%) eyes, with absent motility in one (10%) eye.
In addition, Zuravleff and Hugbes  reported that evisceration has several advantages for motility in the prosthesis and that as it has been gaining popularity, more patients may be seen asking about evisceration. In contrast, the patients in this study were asking for cosmetic surgery without evisceration or enucleation of their eyes. However, RPSTC succeeded to gain good prosthesis similar to their study.
Hatamleh et al.  reported that restoring unilaterally missing ocular and orbital tissues is a challenging task, which requires great skill from the clinician (anaplastologist), to accurately mimic the opposing natural tissues, thus enhancing patients' self-esteem and reintegration into social life. Clinical challenges include impression taking, prosthesis fabrication, identification of the correct orientation into the socket, communication with the patient, and satisfaction of patient expectations. This coincided with the results of this study in which fabricating and fitting the acrylic prosthesis with good motility was a cornerstone in achieving the patients' expectations and self confidence in their new look.
| Conclusion|| |
The use of the painless blind disfiguring eye as a natural implant for artificial eye proved to be an efficient and cheap procedure with excellent cosmesis and avoidance of complications of synthetic implants. The procedure is simple, with an easy learning curve to oculoplasty surgeons. Great patient satisfaction was noted as regards the prosthesis movements and final new look.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Mules PH. Evisceration of the eye and its relation to the bacterial theory of origin of sympathetic disease. Trans Ophthalmol Soc UK 1885; 5:200-205.
Perry AC. Integrated orbital implants. Adv Ophthalmic Plast Reconstr Surg 1990; 8:75-79.
Lubkin V, Sloan S. Enucleation and psychic trauma. Adv Ophthalmic Plast Reconstr Surg 1990; 8:259-262.
Cain JR. Custom ocular prosthetic. J Prosthet Dent 1982; 48:690-694.
Zuravleff J, Hugbes M. Evisceration of the human eye with ocular prosthetic restoration. J Ophthal Prosthet 2013; 2:7-14.
Raizada K, Rani D. Ocular prosthesis. Cont Lens Anterior Eye 2007; 3:152-162.
Patil SB, Meshramkar R, Naveen BH, Patil NP Ocular prosthesis: a brief review and fabrication of an ocular prosthesis for a geriatric patient. Gerodontology 2008; 25:57-62.
Rachdan D, Shafi F, Ford R, et al.
Outcomes and complication rate of acrylic orbital implantation after evisceration and enucleation. Plast Surg Soc 2012; 9:752-759.
Lui D. A comparison of implant extrusion rates and postoperative pain after evisceration with immediate or delayed implants and after enucleation with implants. Trans Am Ophthalmol Soc 2012; 103:568-591.
Hatamleh M, Haylock C, Hollows P, et al.
Prosthetic eye rehabilitation and management of completely blind patients. Int J Prosthodont 2012; 6:631-635.
[Figure 1], [Figure 2], [Figure 3]