Keith R. Pine

Concerns of anophthalmic patients wearing artificial eyes.

Background:  To identify the concerns of experienced artificial eye wearers and investigate whether these had changed since they lost their eye.

The response of the anophthalmic socket to prosthetic eye wear

The aim of this study was to investigate the inflammatory response of the anophthalmic socket to prosthetic eye wear.

A proposed model of the response of the anophthalmic socket to prosthetic eye wear and its application to the management of mucoid discharge

Mucoid discharge associated with prosthetic eye wear can be a distressing condition that affects the quality of life of people who have lost an eye. Discharge is the second highest concern of experienced prosthetic eye wearers after health of the companion eye and is prevalent in anophthalmic populations. Specific causes of mucoid discharge such as infections and environmental allergens are well understood, but non-specific causes are unknown and an evidence based protocol for managing non-specific discharge is lacking. Current management is based on prosthesis removal and cleaning, and professional re-polishing of the prosthesis. Tear protein deposits accumulate on prosthetic eyes. These deposits mediate the response of the socket to prosthetic eye wear and their influence (good and bad) is determined by differing cleaning regimes and standards of surface finish. This paper proposes a three-phase model that describes the response of the socket to prosthetic eye wear. The phases are: An initial period of wear of a new (or newly-polished) prosthesis when homeostasis is being established (or re-established) within the socket; a second period (equilibrium phase) where beneficial surface deposits have built up on the prosthesis and wear is safe and comfortable, and a third period (breakdown phase) where there is an increasing likelihood of harm from continued wear. The proposed model provides a rationale for a personal cleaning regime to manage non-specific mucoid discharge. Professional care of prosthetic eyes is also important for the management of discharge and evidence for effective surface finishing is reported in this study. Taken together, the proposed regimes for personal and professional care comprise a protocol for managing discharge associated with prosthetic eye wear. The protocol describes prosthetic eye cleaning methods and frequency, and suggests minimum standards for professional polishing. If confirmed, the protocol has the potential to resolve the current varied and contradictory opinions about the management of discharge, and to clarify advice given to patients about how to personally care for their prosthetic eyes.

Deposit buildup on prosthetic eye material (in vitro) and its effect on surface wettability.

Background The aim of this in-vitro study was to investigate the effect of different polishing standards on prosthetic eye material (poly(methyl methacrylate) [PMMA]) on surface wettability and the rate of protein and lipid buildup. Methods Sample disks (12 mm diameter × 1 mm thickness) of PMMA were polished to three different standards of surface finish: low, normal, and optical quality contact lens standard. The sample disks were incubated in a protein-rich artificial tear solution (ATS) for the following periods of time: 1 second, 30 minutes, 1 hour, 4 hours, 24 hours, and 14 days. Surface wettability was measured with a goniometer before and after protein deposits were removed. One-way analysis of variance and paired-samples t-test were used for the statistical analysis. Results Between 13.64 and 62.88 μg of protein adhered to the sample disks immediately upon immersion in ATS. Sample disks with the highest polish attracted less protein deposits. The sample disks polished to optical quality contact lens standard were more wettable than those less highly polished, and wettability significantly decreased following removal of protein deposits. The addition of lipids to protein-only ATS made no difference to the amount of protein deposited on the sample disks for any of the standards of surface polish tested. Conclusion The findings are consistent with the results of the in-vivo investigation reported previously by the authors. Our view that the minimum standard of polish for prosthetic eyes should be optical quality contact lens standard and that deposits on PMMA prosthetic eyes improve the lubricating properties of the socket fluids has been reinforced by the results of this study.

Deposit buildup on prosthetic eyes and implications for conjunctival inflammation and mucoid discharge

Background The aim of this study was to investigate deposit buildup on prosthetic eyes and the implications for conjunctival inflammation and discharge. Methods Forty-three prosthetic eye wearers participated in the study. Twenty-three had their prostheses polished normally before being worn continuously for 2 weeks. After this time, surface deposits were stained, photographed, and graded. The prostheses were then repolished to optical quality contact lens standard and worn for a further 2 weeks, when the deposits were again stained, photographed, and graded. Two participants had deposits on their prostheses stained, photographed, and graded on nine occasions at decreasing intervals ranging from 1 year to 1 day. Eighteen participants had the wetting angles on their prostheses measured with a goniometer before and after cleaning, after polishing normally, after polishing to optical quality contact lens standard, and after 10 minutes of wearing their optical quality contact lens polished prostheses. Concordance correlation, multiple regression, and paired t-tests were used for the statistical analysis. Results More surface deposits accumulated on prostheses polished normally than on those polished to an optical quality contact lens standard after 2 weeks of wear. The interpalpebral zone of most prostheses (observed without magnification) appeared to be clear of deposits. Removal of deposits significantly decreased surface wettability, but wettability returned after 10 minutes of wear. Optical quality contact lens polishing produced more wettable surfaces and a slower rate of deposit accumulation than normal polishing. Conclusion We recommend that an optical quality contact lens standard be the minimum standard of finish for prosthetic eyes. This standard may assist the smooth action of the lids over the interpalpebral zone of the prosthesis and the cleansing action of tears. The presence of deposits in the retropalpebral zone may improve the lubricating properties of socket fluids which, in turn, may result in less frictional irritation of the conjunctiva and less mucoid discharge.

The development of measurement tools for prosthetic eye research

Background:  The aim was to develop tools to measure the condition of ocular prostheses and the sockets response to prosthetic eyewear.

An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers

ABSTRACT We investigate prosthetic eye wearers’ initial and current concerns about mucoid discharge, visual perception, and appearance, and the reasons for their concerns. A retrospective, cross-sectional study of private practice patients was designed. Participants were 217 experienced prosthetic eye wearers, aged at least 16 years. An anonymous questionnaire was e-mailed or mailed to participants. Descriptive and inferential statistics were used to investigate differences or correlations between variables. Content analysis was used to analyze participants’ open responses. Participants were equally concerned about discharge, visual perception, and appearance during the first three months following eye loss and at least 2 years later, even though their concerns decreased. Older participants were less concerned about appearance, while females were more concerned about current discharge and appearance. The greater the frequency and volume of discharge, the greater was the concern. Participants’ initial discharge concern was due to a negative interpretation of what it meant, but later, it was due to discomfort from wiping, and how discharge looked to others. Loss of depth perception and reduced visual range were equally concerning. Initial appearance concerns related to disguisability of the prosthesis, but over time, changes to the socket and eyelids became more important. Loss of self-image is commonly considered to be the major concern of anophthalmic patients, but discharge and visual perception concerns are of equal importance. Reasons given for these concerns provide greater insight into patients’ personal experience of eye loss.

Risk of breakage of cryolite glass prosthetic eyes

Dear Editor, Despite the long history of prosthetic eye wear, there appears to be only one comparative study between prostheses made of polymethylmethacrylate (PMMA) and those made of cryolite glass [1]. This study compared the concerns of PMMA and cryolite glass prosthetic eye wearers but did not address the durability aspects of these different materials [1]. Since deformities such as scratches or breakages have also been described for PMMA prostheses, wearers of PMMA prosthetic eyes reported no concerns about durability [2] but 7% of cryolite glass eye wearers were concerned about potential breakage of their prosthesis [3]. The significance of this difference requires further investigation as not only the rates of damage but also the main reasons for breakage of glass eyes are unclear [3]. Very few reports describe rare causes of damage of glass prostheses due to abrasion, chemical attack on glass eye surfaces, or extreme temperature differences [4, 5]. High temperature differences can cause cracking of these mostly double-walled, hollow glass eyes showing a negative pressure inside the prosthesis without pressure equalization, since heating and very fast cooling down change the pressure inside the prosthesis very rapidly and contribute in addition to hydrolytic surface changes to the breakage of glass prostheses [4]. In order to address this issue, 105 unilateral anophthalmic patients of the Trester-Institute for Ocular Prosthetics and Artificial Eyes, Cologne, Germany, were asked to participate in a brief study regarding breakage of cryolite glass prosthetic eyes (Fig. 1). Of these, 101 completed an anonymous questionnaire recording the number of defects, years of wearing a prosthesis, reasons for defects, and whether a prosthetic glass eye had ever broken in the socket and if so, why. In addition, the participants were asked whether they had ever lost a prosthetic eye and if so, how it was lost. Finally, participants were asked if they had a suitable replacement prosthesis as a backup. The 101 participants had a mean prosthesis wearing time of 35.33 ± 21.57 years (range 3.08–75.67 years). The mean rate of breakage was one prosthesis per 26.63 wearing years. While breakage was a rare event, 66 patients (65%) had at least one breakage while 35 patients (35%) reported no breakages. Among the 134 breakages reported, 126 (94%) occurred during removing or cleaning the glass eye. In two cases (1.5%), the reason for breakage was manufacturing errors. Six prosthetic eyes (4.5%) broke inside the anophthalmic socket: four of these due to trauma during ball sports, one due to a slap in the face, and one due to very high temperature differences after sauna use. Six patients (6%) lost their prosthetic eye. Five lost their prosthesis during swimming, diving, or jumping into water, and one lost it during a bout of heavy drinking. Ninety-seven percent of the cryolite glass prosthetic eye wearers had at least one suitable replacement prosthesis in case of damage or loss. In summary, a majority of participants in this brief study had experienced a broken glass eye. This is naturally a legitimate concern for glass eye wearers and most keep a backup prosthesis in case of emergency. There is no sufficient possibility to polish cryolite glass prostheses because the surface of the cryolite glass is made harder and more durable via firepolishing during customized production. Edges or scratches * Alexander C. Rokohl alexander.rokohl@uk-koeln.de

Scleral Shell Prostheses and Prosthetic Contact Lenses

Where an eye has been enucleated or eviscerated, the fitting of a prosthetic eye is appropriate. However, where the eyeball has become disfigured and unsightly, a scleral shell prosthesis or a prosthetic contact lens is used to mask the defect. The development of more complex vitreoretinal surgical techniques has meant that more eyes are being saved (some with useful vision and others without sight) and that more patients are spared the potential psychological trauma of eye removal. The retained eye provides a good foundation for scleral shell prostheses or prosthetic contact lenses, and these often have excellent motility.

History of Ocular Prosthetics

This chapter provides the reader with a context for the present-day practice of ocular prosthetics. It begins with myths from ancient Egypt and draws upon a range of publications [1–10] to summarise the history of prosthetic eyes from that time to the present day. Some of the current organisations and training establishments serving ocular prosthetics emerged over the last century, and these form the foundation for the profession of ocular prosthetics going forwards.