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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 718-722

Transforming the face of life with a customized ocular prosthesis made using digital photographic sheet


1 Department of Prosthodontics and Crown and Bridge, DY Patil Deemed to be University - School of Dentistry, Navi Mumbai, Maharashtra, India
2 Department of Prosthodontics and Crown and Bridge, Hitkarini Dental College, Jabalpur, Madhya Pradesh, India

Date of Submission02-Jan-2022
Date of Decision07-Sep-2022
Date of Acceptance19-Sep-2022
Date of Web Publication2-Nov-2022

Correspondence Address:
Dr. Maithilee Vikram Hoskalle
204, Minal Tower, Opposite Jain Nursing Home, Old Nagardas Road, Andheri East, Mumbai - 400 069, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_2_22

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  Abstract 


Anophthalmic eye has a physical, social, and psychological influence on the affected person. It is quite challenging to restore the normal look of the patient for bringing him to normality in society. An Indian female presented with the chief complaint of an ocular defect due to enucleation for choroidal melanoma, leading to an unpleasant facial appearance. Bearing in mind her psychological and economical status, a customized ocular prosthesis using a digital photographic film for the iris was planned, fabricated, inserted into the ocular defect, and was followed to assess improvement in quality of life. This case report describes the fabrication of an ocular prosthesis using a digital photographic sheet having multiple images of the iris of the patient's normal eye with slight variation in shade and size. Artistic skills, extra time needed in painting the iris, and errors happening due to incorrect sizing of the iris are avoided. The technique is advantageous for a setup where modern equipment is unavailable and a patient's economical status restricts the use of an expensive approach.

Keywords: Anophthalmic eye, customized, digital photographic sheet, enucleation, ocular prosthesis


How to cite this article:
Hoskalle MV, Bhasin AS, Mistry GS, Kini AY. Transforming the face of life with a customized ocular prosthesis made using digital photographic sheet. J Datta Meghe Inst Med Sci Univ 2022;17:718-22

How to cite this URL:
Hoskalle MV, Bhasin AS, Mistry GS, Kini AY. Transforming the face of life with a customized ocular prosthesis made using digital photographic sheet. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 8];17:718-22. Available from: http://www.journaldmims.com/text.asp?2022/17/3/718/360190




  Introduction Top


Ocular diseases, malignancies, and trauma which require enucleation result in ocular defects due to which the patient becomes visually, esthetically, and psychologically handicapped.[1] Restoring the defect restores esthetics, and the patient gains back his lost confidence and lives a normal life in society.

The eyes are windows to our soul; hence, it is a great challenge for the clinician to restore the normal look of the patient by making a lifelike artificial eye as the procedure for fabricating; it is quite exacting, arduous, and demands artistic skills.

Ambroise Pare[2] first used glass and porcelain for fabricating eye prostheses, which was a significant development in the history of ocular prostheses. Later, acrylic resin prosthesis gained popularity as it possessed greater strength and was modifiable.

An ocular prosthesis can be prefabricated or customized for a particular patient.[3] Through the present article, an attempt is made to recount a simple, less time-consuming, novel technique for fabricating a custom ocular prosthesis made utilizing a digital photographic sheet for the iris.


  Case Report Top


An Indian female patient aged 35 years presented to the department of prosthetic dentistry. She complained of an ocular defect on the right side, leading to an unpleasant appearance of the face [Figure 1]. Medical history revealed ocular enucleation done for the treatment of choroidal melanoma 2 months ago. There were no signs of inflammation in the ocular defect. Its floor and walls were healed completely. The palpebral fissure of the right eye was assessed while opening and closing the eyelids to rule out any abnormality. The internal anatomy of the right eye socket during rest and varied motions of the normal eyeball was observed. Mobility of the posterior wall of the socket was assessed.
Figure 1: Patient with right anophthalmic eye

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Considering the patient's psychological and economical status, a customized ocular prosthesis using a digital photographic film for the iris was planned. The patient was informed about the plan of action for the fabrication of the prosthesis and it was performed after taking her signature on the consent form.

Conformer

If an ocular prosthesis is not worn for a long duration of time, the anophthalmic socket sinks which affects the esthetics and eyelid support. On the contrary, if a conformer is used without delay, the socket size and shape of the conjunctival fornices are preserved, thus preventing scar-tissue contractures.[4]

An impression was made using irreversible hydrocolloid impression material (Algitex) for fabricating a conformer. It was fabricated using heat-cured, tooth-colored acrylic resin and was finished, polished, and inserted into the ocular defect. Retention was successfully achieved using natural undercuts [Figure 2]. The patient was given instructions regarding its use. The conformer gave her psychological support.
Figure 2: Patient wearing conformer

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Wax pattern fabrication and try-in

Ocular impression was made by direct impression/external impression technique[5],[6],[7] Light body vinyl polysiloxane impression material (Aquasil, Dentsply Corporation, Germany) was injected into the right anophthalmic socket utilizing a syringe and protruding it out betwixt eyelids [Figure 3]. Boxing wax was used to build a periphery around the socket. Irreversible hydrocolloid impression material (Algitex) was mixed in 5% more water than that required for intraoral impression and was poured into the boxing wax periphery [Figure 4]. After setting, the impression was removed and poured into dental stone by two-pour technique to get a two-piece cast into which modeling wax was poured and a wax pattern was obtained [Figure 5]. It was adjusted until acceptable contours of the eyelids were attained while opening and closing them [Figure 6].
Figure 3: Recording the anophthalmic socket using rubber base impression material

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Figure 4: Impression of the defect

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Figure 5: Two-piece cast

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Figure 6: Wax pattern trial in anophthalmic socket

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Fabrication of eye shell

The wax pattern was invested using dental plaster in a small crown flask followed by dewaxing to get a mold. The shade of the sclera was chosen with the help of an acrylic shade guide. Dental Product of India (DPI) Rayon thread fibrils were incorporated in acrylic to imitate vasculature, by the monomer polymer syrup method. Chosen shade of heat cure resin (DPI) was then packed in the mold with the compression molding technique. After bench curing, it was cured in acrylic for 2 h in a water bath at 74°C; the temperature was then increased to 100°C and processed for 1 h. The eye shell was recovered, finished, and polished, and was tried in anophthalmic socket [Figure 7].
Figure 7: Eye shell fabricated with rayon thread fibrils incorporated to simulate vasculature

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Placement of the iris on eye shell

The patient was requested to sit erect and stare straight ahead. A vertical midline was marked passing through the forehead crease, glabella, tip of the nose, and chin. Distance from the midline and vertical lines coinciding with the medial and distal extremities of the iris of the natural eye was measured. The distance from the midline and center of the pupil of the natural eye was measured. Measurements were taken using an electronic vernier caliper [Figure 8] Horizontal lines referring to the center and inferior and superior limits of the iris were marked. Markings were transferred to the side of the defect and were marked on the finished prosthesis. A high-resolution digital photograph of the normal eye was taken with the eyelids retracted using the digital camera, Canon EOS R (30.3 megapixels) full-frame mirrorless interchangeable-lens camera. Using graphics software, Adobe Photoshop version CC 2018 (19.0.0), different modifications of the normal iris image with slight variation in shade and size were made. A digital photographic sheet containing multiple images of the iris with minute variations in shade and size was developed on high glossy water-resistant photo paper (Kodak 200 g) [Figure 9]. Slight concavity was cut in the eye shell [Figure 10]. The iris image closest in shade and size to that of the normal iris was cut from the sheet. Professional color pencils were used to make minute color moderations. The chosen iris was incorporated into the prosthesis using cold cure acrylic resin (DPI) [Figure 11]. A very thin layer of clear cold cure acrylic resin (DPI) was adapted to it, and after setting, the added layer of resin was polished.
Figure 8: Marking of the iris and pupil position on eye shell

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Figure 9: Photographic sheet containing variations in shades and sizes of the iris of normal eye

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Figure 10: Space created in eye shell for receiving iris

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Figure 11: Iris incorporated in eye shell and covered using a thin layer of clear cold cure acrylic resin

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Insertion of ocular prosthesis

A properly finished, polished prosthesis was inserted into the socket after disinfection. Retention was achieved successfully using natural undercuts. Instructions were given to the patient regarding the use of the prosthesis. She was told to wear it day and night [Figure 12] and to remove and wash it once daily or more depending on mucus accumulation. She was told to wash it with pure soap and tap water, scouring it in the middle of her thumb and fingers and cleansing it well before insertion in the eye socket. She was warned that shaving lotion, cologne, and preparations containing alcohol can damage the prosthesis. The patient was called for a follow-up for a year. Evaluation and modification of the prosthesis were done monthly. The patient found the prosthesis comfortable and esthetically appealing and had no complaints.
Figure 12: Patient wearing finished custom ocular prosthesis

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  Discussion Top


Unavailability of modern technical resources, low-socioeconomic status, and demand for psychological satisfaction, especially pertaining to esthetics and regaining self-esteem in today's cosmetically demanding world, rehabilitation of ocular defect becomes a more challenging task for the clinician. The customized ocular prosthesis is superior to the prefabricated one concerning adaptation with tissues, mobility, comfort, esthetics, contouring, shade matching, and synchronizing movements with that of the natural eye.[3]

Over the past 30 years, there is rapid advancement in digital technologies such as milling systems, rapid prototyping, three-dimensional (3D) scanning, and 3D printing for the fabrication of maxillofacial prostheses. However, ocular prosthesis fabrication has obstacles due to confinement in a socket.[8] It was successfully designed with the use of 3D printing by Ruiters et al. They used cone-beam computed tomography (CBCT) for acquiring the image. The 3D printed impression-free mold serves as a trial working prosthesis. Human errors related to impression making are done away but the disadvantage is the X-ray exposure. Magnetic resonance imaging could be an alternative, but, is complicated and needs a longer time for procuring images.[9] The prostheses manufactured availing digital technologies are more comfortable, esthetically superior, less time-consuming with regard to fabrication, and can increase prosthesis production quantitatively. However, higher initial investments and complicated machines are mandatory. Newer technologies also call for an expert with considerable experience in software tools.[8] The ocular implant can be placed in the tissue bed to restore the lost volume and is attached to the ocular muscles to facilitate the movement of the prosthesis.[10] The patient, in this case, was neither willing for surgery nor exposure to radiation by CBCT.

Artopoulou et al. made one digital copy of the patient's normal iris but they did not use any particular specifications for defining the iris size on photographic paper.[11] Minute variation in the shade of the iris can occur while capturing its image with a camera. Furthermore, slight variation in shade and size of the iris can happen after developing the image on photographic paper. Therefore, in the present case, a digital photographic sheet with multiple images of the iris of the normal eye with slight variation in shade and size was developed. Hence, the operator had a choice to select not only the nearest matching shade but also the appropriate size of the iris corresponding to the normal eye. Artistic skills and extra time spent for painting the iris are not required and errors happening due to incorrect sizing of the iris are avoided. However, the durability of the photographic sheet for long period needs evaluation. High-resolution digital cameras and computer software for image modifications are mandatory.

To assess improvement in quality of life, the patient was judged on a subjective measurement basis. Chang et al.[12] suggested a concept of a questionnaire based on appraisal for judging patients' satisfaction with facial prostheses, especially in cancer patients. After a follow-up of a year, the present patient elucidated a fair and satisfactory response on retention, comfort, and overall appearance of the prosthesis. In addition to comfort, ease of wearing, and cleaning of the prosthesis, it revived the patient's self-regard in society and brought cheerfulness and sparkle not only to her face but also to her life.


  Conclusion Top


The technique used here is novel, simple, inexpensive, and can be performed using materials available in a setup where modern technical facilities are unavailable. The customized ocular prosthesis satisfied the patient with regard to esthetics, comfort, ease of handling, and cost. Artistic skills needed for painting the iris, extra time spent in that, and errors happening due to incorrect sizing of the iris are avoided using a digital photographic sheet having multiple images of the iris of the patient's normal eye with slight variation in shade and size. In addition to this, minute variation in the shade of the iris occuring while capturing its image with a camera, and slight variation in its shade and size happening after developing its image on photographic paper can also be avoided by this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lubkin V, Sloan S. Enucleation and psychic trauma. Adv Ophthalmic Plast Reconstr Surg 1990;8:259-62.  Back to cited text no. 1
    
2.
Manvi S. Prosthodontic rehabilitation of a patient with an orbital defect using a simplified approach. J Indian Prosthodont Soc 2008;8:116-8.  Back to cited text no. 2
  [Full text]  
3.
Deekshaitha NG, Ravichandran R, Nair VV, Janardhanan K. Prosthetic rehabilitation of a patient with an ocular defect using a simplified approach: A case report. Int J Appl Dent Sci 2020;6:233-5.  Back to cited text no. 3
    
4.
Sykes LM, Essop AR, Veres EM. Use of custom-made conformers in the treatment of ocular defects. J Prosthet Dent 1999;82:362-5.  Back to cited text no. 4
    
5.
Bartlett SO, Moore DJ. Ocular prosthesis: A physiologic system. J Prosthet Dent 1973;29:450-9.  Back to cited text no. 5
    
6.
Brown KE. Fabrication of an ocular prosthesis. J Prosthet Dent 1970;24:225-35.  Back to cited text no. 6
    
7.
Murphey PJ, Schlossberg L. Eye replacement by an acrylic maxillofacial prosthesis. US Nav Med Bull 1944;43:1085-99.  Back to cited text no. 7
    
8.
AlShaibani R, Akhtar TM, Marissa G, Chen P, Liao P. Digital applications of maxillofacial reconstruction – A systematic review. JAJD 2021;1:21-7.  Back to cited text no. 8
    
9.
Ruiters S, Sun Y, de Jong S, Politis C, Mombaerts I. Computer-aided design and three-dimensional printing in the manufacturing of an ocular prosthesis. Br J Ophthalmol 2016;100:879-81.  Back to cited text no. 9
    
10.
Rohit K, Vinay U, Versha S, Akshetya P, Shipra J. Ocular prosthesis in dentistry-a review. J Pediatr Dent Hyg 2018;1:1002.  Back to cited text no. 10
    
11.
Artopoulou II, Montgomery PC, Wesley PJ, Lemon JC. Digital imaging in the fabrication of ocular prostheses. J Prosthet Dent 2006;95:327-30.  Back to cited text no. 11
    
12.
Chang TL, Garrett N, Roumanas E, Beumer J 3rd. Treatment satisfaction with facial prostheses. J Prosthet Dent 2005;94:275-80.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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