Loss of an Eye
Losing an eye to trauma, tumor or end-stage ocular disease such as glaucoma or retinal detachment is a challenging situation for any patient. It is normal for such a loss to have a major impact on one’s self-image and self-confidence. Monocular vision (single eye) may require significant adjustments in the workplace (e.g. commercial drivers, airline pilots, law enforcement, etc.)
Since eye contact is an essential part of human interaction, it is important for the artificial eye patient to maintain a natural, normal-appearing prosthetic eye. When someone loses an eye, two components are required: an orbital implant to replace the eye and help maintain the volume of the eye socket and an artificial eye (or prosthesis).
Development of Modern Orbital Implants
Over the last 100 years, a variety of synthetic (man-made) and natural materials have been used as orbital implants. Many of these materials, such as gold, silver, cartilage, bone, and cork among others, caused significant complications.
Non-porous, synthetic implants have been the mainstay of globe replacement for the past 50 or more years. These implants made of acrylic (polymethylmethacrylate, PMMA) or silicone are inert and well-tolerated by the human body. Non-porous implants typically do well for years following implantation. Because the surrounding orbital tissue does not grow into the implants (as with porous implants, see below), these standard implants occasionally may migrate (move) within the eye socket creating difficulties with fitting of a prosthesis.
Porous implant materials offer the potential advantages of host tissue ingrowth. These advantages may include long term implant stability and improved socket motility (movement). Hydroxyapatite (Bio-Eye™) is a hydrothermally altered form of sea coral that was introduced as an orbital implant more than 20 years ago. During the past two decades, porous implants have gained wide acceptance among orbital surgeons. These implants are biocompatible, non-toxic, and non-allergenic. Other synthetic porous implant materials are now commonly used including porous polyethylene (MEDPOR®, Porex Surgical Inc., Newnan, GA,USA) and most recently aluminum oxide (Al2O3) or Alumina. Alumina or Bioceramic Orbital Implants (FCI, Issy-Les-Moulineaux, Cedex, France) are made from a ceramic implant material that has been used in orthopedic surgery and dentistry for more than 30 years. Bioceramic orbital implants were approved for use in the United States by the U.S. F.D.A. in April, 2000 and currently are the most common porous orbital implant utilized in Dr. Klapper’s practice.
Dr. Klapper has conducted extensive research on porous orbital implant use in animals and humans. Dr. Klapper will discuss in greater detail the advantages and disadvantages of the available orbital implants at the time of your consultation. (Please visit Dr. Klapper’s Publications and Presentations)
Who is a candidate for orbital implant placement?
In short, anyone scheduled to have his/her eye removed:
- A blind, painful eye may result from previous trauma or ocular surgery. Removal of the painful eye is often the only way to manage the severe discomfort.
- A blind, disfigured eye may be unsightly and uncomfortable. If a shrunken eye can not be adequately covered by a scleral shell (prosthesis), then removal of the eye may be indicated.
- Intraocular tumors fortunately are quite rare; however, when a tumor inside in the eye is diagnosed removal of the eye is frequently necessary.
- Severely traumatized eye that can not be repaired at the time of injury is an infrequent indication for removal of an eye.
Also, any patient who has already had their eye removed but is experiencing any of the difficulties outlined below:
- No implant placed after initial eye removal.
- The original implant had incomplete tissue coverage and is exposed.
- The eye socket is sunken.
- The ocularist is having difficulty fitting an artificial eye (prosthesis).
- There is recurrent eye socket discomfort, redness, or other signs of chronic inflammation.
- The original implant has migrated (moved) out of position.
- Poor artificial eye movement.
There are two types of eye removal procedures, enucleation and evisceration.
Enucleation is the complete removal of the entire eye. This technique is required in all patients with known or suspected intraocular tumors. It may also be recommended if it can not be determined whether or not a tumor may be present in the back of the eye. In this technique the eye muscles are detached from the globe prior to removal of the eye, and the muscles are reattached to the orbital implant or to the material used to wrap or cover the implant.
Evisceration involves removal of the contents of the eye or globe leaving the sclera (white part of the eye) and the eye muscles in place. This technique is less disruptive to the orbit as dissection into the eye socket is minimized.
At the time of your consultation, Dr. Klapper will further discuss advantages and disadvantages of enucleation and evisceration to help you decide which technique is most appropriate for your condition.
Surgery can be performed with intravenous sedation but is typically performed with general anesthesia. The eyelids may be temporarily sewn together for 1-2 weeks to help minimize swelling and to prevent extrusion of the plastic conformer placed at the time of surgery. A patch is placed over the operated eye for a few days, then ice packs are applied. Some patients experience nausea during the first 24-48 hours following eye removal. This is generally controlled with suppositories or oral medications.
The Artificial Eye (Prosthesis)
The artificial eye covers the eye socket tissue and underlying (buried) orbital implant. Artificial eye-makers are referred to as Ocularists. Ocularists make a custom impression of a patient’s eye socket in order to obtain an ideal fit. The Ocularists hand paints the iris color to correspond to the patient’s normal eye. Fine red threads and other specialized techniques are utilized to simulate naturally appearing veins and arteries.
The artificial eye is typically fit 5-6 weeks following surgery or when the eye socket swelling has subsided.
Dr. Klapper’s office will help coordinate your care with the Ocularist. Central Indiana is fortunate to have access to some of the finest Ocularists in North America. Fitting of the prosthesis usually requires at least two visits with the ocularist. Specific instructions regarding regular prosthesis cleaning and maintenance are individualized and will be reviewed by the Ocularist and by Dr. Klapper. Annual follow-up with the Ocularist for cleaning and polishing is highly recommended. Replacement of the artificial eye may be necessary every 5 years or so.
Other Anophthalmic Socket Concerns
It is important for patients with anophthalmic sockets (eye socket that have undergone evisceration or enucleation surgery) to have regular follow-up. Upper eyelid drooping (ptosis), lower eyelid laxity (looseness), and upper eyelid hollowness (superior sulcus deformity), are common eyelid malpositions encountered even following successful enucleation or evisceration surgery. These eyelid abnormalities are corrected with out patient surgical procedures, typically with local anesthesia.