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Sameera R. Shaik

aAssistant Professor, Department ofbAssistant Professor, Department ofcAssistant Professor, Department of

The Journal of Prosthetic

nging ocular prostheses in growing

dren: A 5-year follow-up clinical

rt

h, MDS,a Arti P. Gangurde, MDS,b andVaibhao I. Shambharkar, MDSc

Government Dental College and Hospital, Mumbai, Maharashtra,India

Eye loss in children can be caused by trauma, glaucoma, or cancer, and may result in anxiety and depression. Recovery aftereye loss involves a replacement with a custom-made eye prosthesis, but, as the patient ages, changes in the size and shape ofthe eye socket can result in a sunken appearance of the child’s prosthetic eye. This article describes the fabrication of acustom-made eye and the necessity of changing ocular prostheses for a growing child, with a 5-year follow-up. (J ProsthetDent 2014;111:346-348)

The frequency of eye injuries amongchildren is remarkably high, and thedamage often is serious.1 These injuriesmay result in enucleation of the eye. Inaddition, eye loss in children can becaused by congenital glaucoma or canbe the outcome of treatment for cancer.The loss of an eye can cause anxiety,stress, and depression at an early age,and radiation treatment can hindernormal growth processes and furtherretard development.2

In congenital deformities, the treat-ment should start within the first 4weeks of birth by placing a small ocularprosthesis (conformer) in the conjunc-tival socket.3 The replacement of an eyelost because of glaucoma, cancer, ortrauma should start as soon as possibleafter healing because an ocular pros-thesis fills the ocular cavity, enhancesfacial growth, and restores symmetry.4

The esthetic, anatomic, and physio-logic improvement of the face allows thechild to integrate into society and avoiddiscrimination.5 However, as a child’sface grows and changes, the prosthesismust frequently be modified to aid inthe normal development of the eyelidsand the soft-tissue lining the orbital

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Dentis

bone.4 The following clinical report de-scribes the treatment and 5-year follow-up of a child with the enucleation of 1eye. The procedure for fabricating theocular prosthesis also is described.

CLINICAL REPORT

A 2-year-old girl reported to thedepartment of prosthodontics with theloss of her left eye (Fig. 1). Her historyrevealed enucleation of the left eyebecause of retinoblastoma. No historyof radiation or chemotherapy wasnoted. The eye socket was thoroughlyexamined to ensure proper healing,and the absence of edema and inflam-mation was noted. The child was tobe rehabilitated with a custom-madeocular prosthesis (Fig. 2). After inser-tion of the prosthesis, weekly follow-upwas done for the first few weeks. Later,the patient was recalled every year. At7 years of age, with the growth of theocular socket, the prosthesis lookedsmall and sunken, which caused sag-ging of the lower eyelid (Fig. 3). Theprosthesis also provided inadequatesupport to the eyelid, which resultedin ptosis. Therefore, a new custom-

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made ocular prosthesis was fabricated(Fig. 4).

The first step was to make animpression of the anophthalmic eyewith a stock acrylic resin tray (DP RRCold Cure; Dental Products of India)and low viscosity elastomeric impres-sion material (Aquasil Ultra LV; Dents-ply Caulk). Material was injected intothe defect under the eyelids to com-pletely fill the socket without trappingair while the patient gazed directly for-ward at a fixed point at least 6 feetaway. This allowed an impression of thedefect site to be made with the musclescaptured in a neutral gaze position.6

The impression was poured to makea 3-piece mold. White pattern wax(Maarc; Shiva Products) was pouredinto the mold, and a wax sclera patternwas retrieved. Sharp ridges and unde-sirable irregularities were removed, andthe pattern was inserted into the defect.The pattern fit was evaluated by liftingthe eyelids and observing the extensioninto the fornices. The pattern wasevaluated to check the eye socket con-tours and eyelid configuration with thepatient’s eyes open and with bimanualpalpation with the eyes closed.6 The

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1 Preoperative view; age 2 years. 2 Postoperative view; age 2 years.

3 Patient with original prosthesis,showing sunken appearance; age 7 years.

4 Patient with replacement prosthesis;age 7 years.

April 2014 347

wax pattern was sculpted until thepalpebral tissue resembled the naturaleye. The posterior surface of the waxsclera pattern reflected the topographyof the tissue bed of the eye socket.7 Thewax pattern was then processed inwhite heat polymerizing acrylic resin(DPI Tooth Moulding Powder; DentalProducts of India) to form the scleral

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portion. The acrylic resin sclera wasthen inserted, and the contours andeyelid opening was verified again.

The patient was relaxed and askedto look straight ahead at a distantpoint. Measurements were made of thenatural eye from the center of the pupilto the medial and lateral canthus of theeye. The center of the pupil of the

prosthesis was located and marked. Byusing an architect’s compass at thecenter of the pupil, a circle was scribedon the acrylic resin sclera with thediameter approximately similar to thesize of the natural iris. This area corre-sponded to the iris position. A cylin-drical recess was made in this area toincorporate the iris. The anterior scleralcurvature of the prosthesis also wasreduced approximately 2 mm to allowfor sclera characterization and forapplication of clear heat-polymerizingacrylic resin to regain the contours ofthe finished prosthesis. The color of thenatural iris was noted, and an appro-priately matching acrylic resin stock eyeshell was selected. The scleral portionof the prefabricated eye shell was trim-med to the same size as marked on thecustom-made acrylic resin sclera(Fig. 5). The iris was sealed into itsposition with clear autopolymerizingacrylic resin (DPI-RR Cold Cure; DentalProducts of India).

Monopoly syrup was made bywarming 10 parts monomer and 1 partpolymer of autopolymerizing acrylicresin (DPI-RR Cold Cure; Dental Prod-ucts of India) to characterize the sclera.Red nylon threads were added to repre-sent veins. The prosthesis was reproc-essed with clear heat-polymerizingacrylic resin (Acralyn-H; Asian Acry-lates). The patient was taught the correctmethod of removing and inserting theprosthesis. Follow-up evaluation wasperformed at regular intervals to eval-uate the prosthesis and adjust asnecessary.

DISCUSSION

The loss of an eye, whether as a resultof surgical enucleation or evisceration, isoften followed by contraction of tissuesaround the socket, which may beaccompanied by eyelid constriction,reduced eye socket size and depth, eyelidincompetence, and decreased residualmuscle movement.8 Infants who aremissing an eye should be treated with acustom-made ocular prosthesis to mini-mize changes in the socket size andconformation, and to prevent scar tissue

5 Cylindrical recess created in acrylic resin scleral blank for iris.

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contractures from distorting the socketbed, which will help ensure symmetrywith the other eye as the child’s facialstructures change during growth. Thechild’s prosthesis is made as large aspossible to stimulate normal develop-ment.2 The parents should be informedthat a slightly exophthalmic appearancewill result but is necessary. Prostheticrehabilitation is enhanced if an implantcan be placed in the enucleated orbit toprovide an attachment for the rectusmuscles, which can impart motion co-ordinatedwith thenatural eye.4However,the placement of an ocular implant is notalways possible. In this patient, ocularimplant placement was planned aftercompletion of the growth of the child.

With increasing age, the ocularprosthesis requires replacement or mod-ification. The indications include pros-thesis rotation within the socket, loosefit, decentration of the cornea, cos-metically significant ptosis, or discolor-ation of the prosthesis.9 The size ofthe prosthesis is gradually increased tokeep pace with the child’s growth over aperiod of years until the socket is fullydeveloped. Adjunctive chemotherapyand radiation deteriorate the growthand development of the child, andfurther necessitate the modificationof the ocular prosthesis. Periodic mod-ifications of the prosthesis help to

The Journal of Prosthetic Dentis

stimulate the growth of the bones andsoft tissues of the eye socket. A pros-thesis of the correct size approximatesclosely to the tissues in the socket, whichstimulates the eyelid muscles to move,thus, exercising them.10 The socketgrows up to the age of 12 years.2 Thesoft tissues stretch during this period ofgrowth and thus enhance the develop-ment of the fornices, which gives a morenatural appearance.4 Over a period of12 years, the prosthesis needs to bechanged, depending upon the symp-toms present and in coordination withfacial growth to aid in the developmentof the soft and hard tissues of the eyesocket.

SUMMARY

Early rehabilitation of ocular defectsis necessary, especially in growing chil-dren. Custom-made ocular prostheseshelp the eye socket to grow and developappropriately and also prevent thepsychologic stress of eye loss. Regularmodifications of the ocular prosthesisare essential to allow the eye socket todevelop normally.

REFERENCES

1. Niiranen M, Raivio I. Eye injuries in children.Br J Ophthalmol 1981;65:436-8.

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2. Bartlett SO, Moore DJ. Ocular prosthesis: aphysiologic system. J Prosthet Dent 1973;29:450-9.

3. Valauri AJ. Maxillofacial prosthetics.In: McCarthy JG, editor. Plastic surgery. Vol.5, 3rd ed. Philadelphia: Saunders; 1990.p. 3537e41.

4. Cain JR. Custom ocular prosthesis. J ProsthetDent 1982;48:690-4.

5. GoiatoMC,MancusoDN, SundefeldMLMM,Gabriel MBDM, Murakawa AC, Guiotti AM.Aesthetic and functional ocular rehabilitation.Oral Oncology Extra 2005;41:162-4.

6. Haug SP, Andres CJ In: Taylor TD, editor.Clinical maxillofacial prosthetics. Chicago:Quintessence; 2000. p. 265-76.

7. Beumer J III, Zlotolow I. Restoration of facialdefects: etiology, disability, and rehabilita-tion. In: Beumer III J, Curtis TA, Firtell DN,editors. Maxillofacial rehabilitation: Pros-thodontic and surgical considerations.St Louis: Mosby; 1979. p. 311-71.

8. Sykes LM, Essop ARM, Veres EM. Use ofcustom-made conformers in the treatmentof ocular defects. J Prosthet Dent 1999;82:362-5.

9. Raizada D, Raizada K, Naik M, Murthy R,Bhaduri A, Honavar SG. Custom ocularprosthesis in children: how often is a changerequired? Orbit 2011;30:208-13.

10. Taicher S, Steinberg HM, Tubiana I, Sela M.Modified stock-eye ocular prosthesis.J Prosthet Dent 1985;54:95-8.

Corresponding author:Dr Sameera R. ShaikhDomnic Villa, 31, Ceasor Road, AmboliAndheri-West, Mumbai - 400058INDIAE-mail: shaikhsameera04@gmail.com

Copyright ª 2014 by the Editorial Council forThe Journal of Prosthetic Dentistry.

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