Eye removal and ocular prosthesis

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Losing sight is one thing, losing an eye is altogether another. The psychological impact of physically losing an eye is often greater than losing the vision. A lot of this apprehension comes from a poor understanding of what can be achieved cosmetically, as well as the fact that we are all squeamish about having things done to our eyes – this is just a natural protective response to help us look after one of our most important and delicate organs.

There are several situations where it may be necessary to remove the eye:

  • Malignancy – where removal may prevent the spread of a tumour and save life – this is one of the rare situations where it may be necessary to remove an eye that still has sight, although this situation is avoided wherever possible.
  • Pain – intractable pain in a blind eye.
  • Cosmetic appearance – with a blind eye.
Options

There are two

Evisceration

This involves a procedure, which removes the contents of the eyeball, but keeps the white scleral coat, which is used to wrap around a ball implant to maintain the volume.

Advantages -

  • The muscles of the eye are not detached or interfered with, leaving the eye to move in the normal way and in conjunction with the other eye.
  • Surgery is less involved and complicated with less post-operative swelling
  • There is less shrinkage of the fat in the socket, and as a result, generally the cosmetic result is more satisfactory.
  • Because there is less volume loss, you will have a thinner cosmetic shell (see later)

Disadvantages –

  • An extraordinarily rare (around 1:60,000 chance) of developing “sympathetic ophthalmia”. Whilst rare, the complication needs to be mentioned, as it can trigger inflammation and lead to sight loss in the good eye. This subject is too complicated to discuss here, and should be explained by your ophthalmologist.

Enucleation

With this procedure the whole eye is removed. An orbital implant is placed in the socket and attached to the eye muscles. Numerous types of implant can be utilised. Broadly there are those that are synthetic and made out of a polymer (porous polythene), and those that are made out of hydroxyapetite or coralline material. Both of these types of implant are called “biointegrated” which means that the material allows the blood vessels to grow in and help it heal into the tissues, making the implant more stable and less likely to extrude (push itself out).

Sometimes the implant is wrapped in donor eye tissue, which helps it integrate and heal into the tissues.

The surgery

Usually you will have a general anaesthetic. The surgery takes up to an hour. You will have a pad placed over the socket and this will remain there for at least 48hrs. You will be given post-op pain relief if required. You may be given antibiotics.

There will be a temporary shell placed over the implant behind the eyelids like a contact lens. This will remain for about six weeks. It is quite usual to have a watery red discharge for the first week or so.

What happens after surgery?

Whatever surgery you have undergone, you will need to wear a cosmetic shell over your implant. This is like a thick contact lens, which has the eye details painted on the surface.

You will be seen by an ocularist, who will take a moulding and make an implant for you. This will be designed to match your other eye in terms of appearance and size. It is often very difficult if not impossible to distinguish between the normal and the artificial eye.

Left Picture “Using an alginate gel moulding, the socket space is reproduced”
Middle Picture “The new prosthesis is painted and finished to match the fellow eye”
Right Picture “The finished product”

What can go wrong?

Early infection, necessitating removal of the implant.

Extrusion – where the soft tissues overlying the implant thin and dissolve away allowing the implant to slowly come out. This is a late complication.

In both of the above scenarios, after removal and a period of healing, a secondary implant can be attempted.

Enucleation socket syndrome is a condition usually associated with inadequate volume replacement, where the implant leaves a sunken appearance and the lid drops. This can be corrected by placing secondary implants in the socket and other corrective procedures.

Is the cosmetic shell easy to manage?

Generally so long as you take the shell out regularly and clean and polish it, it will give you years of trouble free service and comfort.

You will need to attend your ocularist from time to time.

There are some links below to help you manage this.

Caring for an ocular prosthesis

Cosmetic shell care