Customized ocular prosthetic rehabilitation: A case report on restoring aesthetics in patient with post traumatic eye defect

INTRODUCTION

Loss of an eye can lead to significant physical and psychological challenges, affecting a patient’s general standard of life.¹ This condition can result from a range of factors, such as cancer, congenital abnormalities, severe trauma, a painful non-functioning eye, or sympathetic ophthalmia.² Surgical management is generally tailored to the severity of the condition, with three primary approaches: evisceration, enucleation, and exenteration. These are all surgical procedures for managing severe eye conditions. Evisceration involves the removal of the eye’s internal structures while the sclera and, in some cases, the cornea are left intact. In contrast, enucleation involves the complete removal of the ocular globe, with a segment of nerve from the orbital cavity. In more severe cases, exenteration involves the total removal of all structures inside the orbit, with extraocular muscles, in a single surgical procedure.³

The psychological impact of losing an eye can be significantly reduced with the use of an ocular prosthesis that closely resembles the appearance of a natural eye. Historical evidence of eye replacement dates back to ancient Egypt, where precious stones and gold were used to create prosthetic eyes. A major innovation occurred in 1944 when the United States armed forces pioneered the use of methyl-methacrylate resin, establishing it as a successful material for ocular prosthesis fabrication.⁴

Various techniques for fitting and fabricating artificial eyes are well-documented in literature. The procedure typically involves selecting a stock eye, adjusting it based on a positive mold of the ocular defect, and then creating a custom ocular prosthesis. For custom prosthesis, both the sclera and iris are individually designed to closely resemble the patient’s natural eye, ensuring a more personalized and lifelike result.⁵ This case report delineates a method for the creation of personalized ocular prosthesis that provides both functional and aesthetic advantages.

CASE REPORT

A 22-year-old female patient presented to the Department of Prosthodontics at the Faculty of Dental Sciences, Banaras Hindu University in Varanasi, India, with the primary concern of facial deformity resulting from a defect in her left eye. She gave a history of a traumatic injury 12 years back and presented with a shrunken eye, indicating phthisis bulbi [Figure 1a]. Upon examining the anophthalmic socket, the conjunctiva was found to be in good condition, free from inflammation or infection, and showed synchronized movement. A personalized ocular prosthesis, incorporating a custom-made iris and sclera, was planned, and the treatment process was clearly communicated to the patient prior to proceeding [Figure 1b].

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Figure 1a:

Pre-operative view showing ocular defect: Patient with phthisis Bulbi.

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Figure 1b:

Close-up view of the ocular defect.

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An imprint of the anophthalmic socket was obtained using the approach described by Allen and Webster.⁶ A syringe was used to inject loose-consistency alginate into a stock ocular impression tray through its inlet. Cold water was added to increase the working time of the alginate. Adequate filling of the socket was indicated by excess alginate at the inner corner of the eye. After the impression had been made [Figure 2a], the lower eyelid was delicately retracted, and the imprint was meticulously extracted by moving it out from under the upper eyelid. A personalized tray was constructed using self-cure resin, and a master impression was made using light-body polyvinyl siloxane material [Figures 2b and 2c]. The impression was carefully examined to ensure that it accurately captured the posterior wall, the alignment of the eyelids with the wall, and the whole of the superior and inferior fornices, confirming its precision.

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Figure 2a:

Primary impression.

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Figure 2b:

Special tray.

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Figure 2c:

Master impression of left ocular defect.

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The ocular wax structure was formed by pouring hard wax into the mold, ensuring sufficient rigidity for carving and shaping. Once the wax had been set, it was carefully extracted, molded, and polished using gauze and carving tools. The final wax pattern was positioned in the patient’s eye for evaluation. Next, the patient was instructed to perform a sequence of eye motions, allowing for the assessment of aesthetics, bulk, fit, and functionality, especially concerning eyelid movement. The scleral extension of the wax pattern showed no flaws, and its support and contour were further evaluated through bimanual palpation with the patient’s eyes closed, followed by a visual comparison with the contralateral eye.

The wax pattern was embedded in dental stone using a two-pour technique and then underwent the dewaxing process. Subsequently, heat-cure acrylic resin was put into the mold and polymerized. Upon the removal of the ocular prosthesis, its outer surface was reduced by about 0.5 mm so that the layer of acrylic paint and epoxy resin can be accommodated according to the shape of the periphery of the tissue bed.

The inner surface was polished, and prosthesis try-in was done to confirm the extension, fit, and support [Figure 3]. A micropore tape was attached at the level of the eyebrow, and the facial midline was marked. Following this, the center of the iris of the non-affected eye was marked, and the distance from the center of the iris of the non-affected side to the facial midline was extrapolated on the opposite side with the help of a Vernier caliper (i.e. the defect side), having the PMMA eye-shell. Next, the outline of the iris on the eye-shell was drawn, and adequate coloration was carried out. To enhance aesthetics, acrylic paint (Camlin) was used on the cameo surface, with various shades of white, yellow ochre, and red applied to simulate veins [Figure 4a]. Once the color matching was completed with input from the patient and their family, epoxy resin was used to coat the acrylic paint so that the acrylic paint would not come into contact with the patient’s tissues. The epoxy resin (2:1 resin-to-hardener ratio) (Granotone, Hari Industries) was used to coat the prosthesis to make it appear life-like, and the thickness was kept as thin as feasible (i.e., 1-2 coats of epoxy resin using a fine tip paint brush) [Figure 4b]. After allowing the resin-coated prosthesis to cure for 24 hours, a slowly rotating hand buff was used to clean the cameo surface and borders.

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Figure 3:

Acrylized sclera try-in.

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Figure 4a:

Hand-painted acrylic conformer.

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Figure 4b:

Applying a thin layer of epoxy resin to protect the acrylic color.

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After the prosthesis was finished, it was placed inside the socket and checked for fit, aesthetics, and symmetry of movement with the other eye [Figure 5]. Following insertion, the patient was provided with detailed post-insertion instructions regarding the proper usage, limitations, and maintenance of the prosthesis.

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Figure 5:

Final ocular prosthesis in patient and camouflage with powerless spectacles.

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DISCUSSION

Creating a personalized ocular prosthesis requires patience, skill, and precision to achieve both functional and aesthetic success. The loss of an eye presents significant physical and psychological challenges, making the rehabilitation process crucial for restoring confidence and improving the patient’s quality of life. While various methods exist for fabricating ocular prosthesis, stock eyes (prefabricated stock ocular shell) often fail to provide a natural appearance and proper fit due to patient-specific anatomical variations. Custom prosthesis, on the other hand, offers superior contouring, colour matching, and movement synchronization with the natural eye.^4,7 The main drawback of a custom ocular prosthesis is the longer wait time due to the detailed fabrication and patient-specific painting process.

A well-crafted ocular prosthesis remains securely in place, allowing natural eye movements and enhancing the patient’s overall facial symmetry. The approach used in this case was simple, cost-effective, and efficient, ensuring an aesthetically pleasing outcome. By replicating the patient’s contralateral eye with acrylic paints for precise scleral shading, the prosthesis achieved a lifelike appearance while maintaining structural integrity and comfort.

Recent advancements in digital technology have significantly improved the fabrication process. The integration of sublimation transfer techniques and 3D printing allows for enhanced precision, better aesthetic results, and greater patient satisfaction.⁸ Additionally, digitally assisted, impression-free techniques such as 3D scanning and printing provide a more patient-friendly approach.⁹ This is particularly beneficial for children requiring frequent prosthesis replacements due to growth or anatomical changes.

Another aspect of ocular prosthesis rehabilitation is the use of an ocular conformer. These conformers play a vital role in shaping and maintaining the anophthalmic socket post-surgery, preventing contracture, promoting proper tissue adaptation, and ensuring a well-formed socket. By using a conformer during the healing process, the final prosthesis fits more comfortably and securely, further improving the long-term outcome for the patient.

Moreover, advancements in material science have introduced the incorporation of ceramic scleral veneers, which enhance both the aesthetics and durability of non-integrated ocular prostheses.¹⁰ This innovation contributes to a more natural appearance and greater longevity of the prosthesis, reducing the need for frequent replacements and maintenance.

CONCLUSION

This dental technique combines various methods to create a fully personalized eye prosthesis, making the procedure accessible even for less experienced clinicians. The result is a satisfactory, custom-made ocular prosthesis that is both cost-effective and resource-efficient.