Clinical Ocular Prosthetics

Keith R. Pine • Brian H. Sloan Robert J. Jacobs

Clinical Ocular Prosthetics Keith R. Pine Robert J. Jacobs School of Optometry and Vision Science School of Optometry and Vision Science The University of Auckland The University of Auckland Auckland Auckland New Zealand New Zealand

Brian H. Sloan New Zealand National Eye Centre The University of Auckland Auckland New Zealand

ISBN 978-3-319-19056-3 ISBN 978-3-319-19057-0 (eBook) DOI 10.1007/978-3-319-19057-0

Library of Congress Control Number: 2015944089

Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recita- tion, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www. springer.com) P r eface

Prosthetic eyes have a history that stretches back to at least 2,900 BC. Prosthetic eye materials and techniques have evolved in keeping with the times: from clay, to wood and ivory, to enamelled silver and gold, to glass and, fi nally, to (poly)methyl methacrylate (PMMA) plastic. This last step (from glass to PMMA) was accompanied by a change in the profession that supplied and fi tted prosthetic eyes. PMMA eyes could be custom-made, but this required a different skill set to the one that optometrists had used successfully with glass for the previous 500 years. The technologi- cal and professional dislocation that the change from glass eyes to PMMA eyes brought about 70 years ago possibly accounts for the almost complete absence of prosthetic eye literature today. The knowledge underpinning the modern practice of ocular prosthetics appears to be based upon clinical observations acquired from practicing ocular prosthetists (ocularists) and the analogous fi elds of dental technology and contact lenses. This book has come about because of the sincere desire of the authors to provide a more scientifi c knowledge base for the clinical practice of ocular prosthetics by bringing together information from the literature on ophthalmology, prosthetic eyes and contact lenses and from experts working in these fi elds. The genesis of this book started when Keith Pine approached the University of Auckland’s School of Optometry and Vision Science to seek advice about how best to go about writing it. He was introduced to Associate Professor Robert Jacobs who supported the concept of the book but felt that the lack of scientifi c knowledge in the fi eld was a major drawback and that more formal research should be undertaken into prosthetic eyes before a book should be contemplated. That was 6 years ago. The discussion resulted in Keith Pine enrolling in a Master of Science programme (later upgraded to a PhD) and undertaking a systematic set of individual investigations which has resulted in the publication of eight scientifi c papers to date. Associate Professor Robert Jacobs and Dr Brian Sloan supervised the research and were co- authors of the published papers. The research began with a survey of anophthalmic patients to confi rm a research focus that most refl ected their needs. The results of the survey highlighted the concerns that patients had at the time of eye loss as well as their ongoing concerns after at least 2 years of prosthetic eye wear. The health of the remaining eye was their greatest concern at both occasions in time, but second on their list of ongoing concerns was anxiety about mucoid discharge associated with their prosthesis. Frequent,

v vi Preface viscous discharge affects the quality of life of prosthetic eye wearers as it can be diffi cult to live with a continuously suppurating eye that requires constant wiping. Because of the high level of concern about discharge expressed by patients, mucoid discharge associated with prosthetic eye wear was confi rmed as a worth- while research topic; however, the scale of the problem amongst the anophthalmic population remained unknown. Also unknown were the demographics of anophthalmic patients, the aetiology of eye loss and eye loss trends in New Zealand. A second survey, larger than the fi rst, was undertaken, and 430 prosthetic eye wearers from throughout New Zealand completed a questionnaire about their experi- ences with ocular prostheses. Included with the questionnaire was an invitation to participate in further prosthetic eye research, and 330 prosthetic eye wearers agreed to do so. The results of this survey confi rmed that mucoid discharge associated with prosthetic eye wear was indeed high on patients’ list of concerns and that mucoid discharge was widespread in New Zealand even though patients had good access to prosthetic eye services. A search of the literature and of ocular prosthetists’ websites was undertaken to investigate what was known about the causes of discharge and to gain an understanding of the range of treatments for mucoid discharge associated with prosthetic eye wear. This search produced a comprehensive list of known specifi c causes of mucoid discharge, but there remained a large and under-investigated group of patients with non-specifi c discharge for which many contradictory and inconsistent causes and treatments had been postulated. A survey of members of the American Society of Ocularists in 2007 carried out by K. L. Osborn and D. Hettler also found that a standardised set of treatment protocols for managing discharge was lacking. Further analysis of the responses from the New Zealand survey provided evidence of an association between the frequency of prosthetic eye cleaning and severity of discharge. Unfortunately, the direction of cause and effect could not be established – either frequent cleaning was causing the discharge or the discharge itself was the reason patients cleaned more frequently. To resolve this issue, further research into the socket’s response to prosthetic eye wear was planned. This research involved an examination of surface deposition on prosthetic eyes (which 47 % of ocular prosthetists’ websites claimed was a main cause of mucoid discharge) and examination of the conjunctiva of the anophthalmic socket. However, surface deposits could not be investigated unless a technique was found to enable them to be seen, and neither deposits nor the conjunctiva could be examined unless measuring tools were developed for this purpose. A staining technique to make surface deposits more visible was found, and for the fi rst time it was possible to investigate changes in the amount and extent of deposition on prosthetic eyes. It was then necessary to develop and test equal interval photographic grading scales to measure these changes. At the same time, equal interval photographic grading scales were also developed to measure the severity of conjunctival infl ammation in anophthalmic sockets. The staining technique and the tools to measure surface deposition on prosthetic eyes and the severity of conjunctival infl ammation were used successfully to provide a quantitative assessment of prosthesis cleaning effectiveness and to identify Preface vii associations between deposits and discharge and deposits and conjunctival infl ammation. Again, the direction of cause and effect of these associations could not be established at that stage. Evidence was found, however, that suggested that surface deposits themselves did not infl ame the conjunctiva or cause discharge in anophthalmic sockets where the prosthesis was cleaned infrequently. The next set of experiments was designed to understand more about the characteristics of deposition and to fi nd if a causal link could be established for the association between deposits, infl ammation and discharge. The experiments involved both in vitro and in vivo tests of surface wettability and deposition rates on different prosthetic eye surface fi nishes. It was found from these experiments that rates of deposition were infl uenced by surface fi nish and that the presence of deposits caused a signifi cant improvement in surface wettability. It seemed likely that the improved surface wettability would allow prosthetic eyes to be lubricated more effectively by the socket fl uids, thereby reducing mechanical irritation of the conjunctiva. The evidence was building to suggest that the presence of at least some deposits was not only not harmful but actually benefi cial, causing reduced conjunctival infl ammation and discharge in anophthalmic sockets with prosthetic eyes. This concept was further explored in the next study. It described the build-up of deposits over time and investigated the two distinctly different areas of deposition revealed by the deposit staining process: the inter-palpebral zone where stained deposits are mostly absent and the areas in continuous contact with the conjunctiva where deposits mostly settle. The deposits in the inter-palpebral zone appeared to behave like deposits on contact lenses where they may dry out and irritate the palpebral conjunctiva, whereas the presence of deposits elsewhere on the prosthesis appeared to be benefi cial. The combined results of all the investigations culminated in a hypothesis for a three-phase model of the anophthalmic socket’s response to prosthetic eye wear and a protocol for the management of non-specifi c mucoid discharge – these topics are discussed fully in Chaps. 8 and 9 , respectively. This book, then, derives from the research described above and the successful amalgamation of a research team comprising an ocular prosthetist, an optometrist and an oculo-plastic surgeon. It contains a mix of scientifi c evidence and clinical experience and includes inferences based on material from other disciplines that are applied to the fi eld of ocular prosthetics but which are in need of corroboration. The book is written primarily for clinicians and caregivers who have contact with prosthetic eye wearers including ocular, maxillofacial and anaplastology prosthetists, ophthalmologists, ophthalmic nurses, optometrists and students of these disciplines. The book is also a useful resource for other health workers and family members who care for prosthetic eye patients and for those patients who require a deeper understanding of the issues affecting them and their prosthesis than what is currently available elsewhere. The language used in the book may be more technical for some readers than for others, but a glossary of terms is provided and over 400 illustrations add additional explanatory power to the text. It is anticipated that most readers will consult individual chapters for specifi c information or for leads to reference material on specifi c topics of interest. However, viii Preface many readers will be led down interesting byways because of the breadth of information available and the linking of different topics within the text. For example, the theory of colour is linked to iris painting; socket complications have both prosthetic and surgical solutions; the anatomy of extraocular muscles is linked to orbital implants and prosthetic eye motility. The book opens with a discussion of the biosocial and psychological aspects of eye loss and goes on to describe the anatomical and physiological features of the face and eyes that are relevant to ocular prosthetics. The causes of anophthalmia and disfi gurement of the eye and the implications of congenital anophthalmia and microphthalmia for young children are discussed, and surgical procedures for removing the eye are described. Subsequent chapters discuss techniques for evaluation of ocular prosthesis patients; techniques for making and fi tting ocular prostheses, scleral shell prostheses and prosthetic contact lenses; the response of the socket to prosthetic eyes; and the ongoing care and maintenance of prosthetic eyes. The penultimate chapter provides advice for people who wear prosthetic eyes, and the fi nal chapter summarises the history of prosthetic eyes and identifi es the various organisations that form the foundation for the ongoing professional development in ocular prosthetics. Acknowledgements

As lead author, it falls to me to fi rstly acknowledge the enormous contribution of my fellow authors. We have worked together now for 6 years and their dedication and commitment to the advancement of knowledge in the prosthetic eye fi eld has been an inspiration to me. The book has had input from many people but in particular, Michael Williams, Maxillofacial prosthetist, Maxillofacial & Dental Unit, Waikato Hospital who contributed valuable input to Chap. 5 in particular, Dr James Partridge, Chief Executive of Changing Faces (UK) who provided expert advice while we were preparing Chaps. 1 and 10 , and Neil Handley, Curator of the British Optical Association Museum who contributed both expert knowledge and photographs. Julia Drok created the better diagrams in the book and converted text and photographs to Springer’s house style. The University of Auckland has provided the scholarly environment for the cre- ation of this book but support has also come from the many optometrists and ophthalmologists who work closely with the New Zealand Artifi cial Eye Service and from the hundreds of anophthalmic patients who have given freely of their time to be either research participants or photographic subjects. Springer is also thanked for sharing the vision to bring this book to press. Finally, no project of this magnitude can be accomplished without the support of friends, partners and families, and we three authors are very grateful to ours for their forbearance and love over many years.

Keith Pine

Contents

1 The Anophthalmic Patient ...... 1 1.1 Introduction ...... 1 1.2 Epidemiology of Eye Loss ...... 2 1.2.1 Estimated Size of the Anophthalmic Population ...... 2 1.2.2 Aetiology of Eye Loss ...... 3 1.2.3 Changing Causes of Eye Loss ...... 4 1.3 Perceptual Changes Accompanying Eye Loss ...... 6 1.4 Psychosocial Issues Associated with Eye Loss ...... 7 1.4.1 Loss of Body Image ...... 8 1.4.2 Novelty Eyes ...... 9 1.4.3 The Psychological Importance of Prosthetic Eye Comfort and Convenience ...... 10 1.5 Phantom Eye Pain ...... 11 1.6 Concerns of Prosthetic Eye Wearers ...... 11 1.7 Psychological Issues for Children ...... 12 1.8 Personal Accounts of Eye Loss ...... 13 References ...... 22

2 Anatomy and Physiology ...... 25 2.1 Introduction ...... 26 2.1.1 Terminology ...... 26 2.2 Facial Architecture ...... 27 2.3 Surface Anatomy of the Eye and Eyelids ...... 28 2.4 The Skull and Orbit ...... 30 2.4.1 The Skull ...... 30 2.4.2 The Orbit ...... 31 2.5 Orbital Contents ...... 32 2.5.1 The Eye ...... 32 2.5.2 Optic Nerve ...... 34 2.5.3 The Extraocular Muscles ...... 34 2.5.4 Levator Muscle ...... 37 2.5.5 Lacrimal Gland ...... 37 2.5.6 Lacrimal Sac ...... 38

xi xii Contents

2.5.7 Orbital Fat ...... 38 2.5.8 Blood Vessels and Nerves ...... 38 2.6 Muscles of the Forehead ...... 38 2.6.1 Muscles of the Forehead ...... 38 2.7 The Eyelids ...... 40 2.8 The Conjunctiva ...... 41 2.8.1 The Palpebral Region ...... 41 2.8.2 The Bulbar Region ...... 43 2.8.3 Forniceal Region ...... 43 2.9 Sensitivity of the Conjunctiva and Cornea ...... 44 2.10 Structure of the Conjunctiva ...... 46 2.10.1 The Substantia Propria Layer of the Conjunctiva ...... 46 2.10.2 The Epithelial Layer of the Conjunctiva ...... 46 2.10.3 Goblet Cells ...... 47 2.10.4 Function of Mucus ...... 48 2.11 The Lacrimal Apparatus ...... 48 2.12 Tears ...... 50 2.12.1 Function of Tears ...... 50 2.12.2 Tear Film ...... 51 2.12.3 Tear Output ...... 52 2.12.4 Tear Distribution ...... 53 2.13 Facial Changes Due to Ageing ...... 54 2.14 Loss of the Ocular Globe ...... 55 2.14.1 Prosthetic Eye Motility ...... 57 2.14.2 Conjunctiva of the Anophthalmic Socket ...... 57 2.14.3 Tear Film with a Prosthetic Eye ...... 59 2.14.4 Tear Output with a Prosthetic Eye ...... 60 2.14.5 Tear Distribution with a Prosthetic Eye ...... 60 2.14.6 Post-enucleation Socket Syndrome (PESS) ...... 61 References ...... 64

3 Anophthalmia and Disﬁ gurement of the Eye ...... 67 3.1 Introduction ...... 67 3.2 Congenital Anophthalmia and Microphthalmia ...... 68 3.2.1 Treatment for Anophthalmia and Microphthalmia in Children ...... 70 3.3 Disﬁ gurement of the Eye ...... 71 3.3.1 Corneal Tattooing ...... 73 3.4 Surgical Removal of the Eye ...... 73 3.4.1 Enucleation Versus Evisceration ...... 73 3.4.2 Enucleation ...... 74 3.4.3 Evisceration ...... 76 3.4.4 Postsurgical Care Following Enucleation and Evisceration ...... 77 3.4.5 Postsurgical Conformer Shells ...... 80 3.4.6 Intraorbital Implants...... 81 Contents xiii

3.5 Exenteration ...... 84 References ...... 89

4 Patient Evaluation ...... 91 4.1 Introduction ...... 91 4.2 Medical History ...... 93 4.3 Psychological Assessment ...... 93 4.4 Assessment of Visual Perception ...... 94 4.5 Health of the Remaining Sighted Eye ...... 94 4.6 Assessment of an Existing Prosthetic Eye In Situ ...... 95 4.7 Assessment of Prosthetic Eye Ex Situ ...... 96 4.8 Assessment of the Anophthalmic Socket ...... 99 4.8.1 Assessment of Tears in Anophthalmic Sockets ...... 104 4.9 Assessment of Inﬂ ammation of the Anophthalmic Socket ...... 110 4.9.1 Assessment of Meibomian Gland Loss ...... 112 4.9.2 Assessment of Mucoid Discharge ...... 112 4.9.3 Assessment of Surface Papillary Texture of the Conjunctiva of the Socket ...... 113 References ...... 115

5 Making and Fitting Prosthetic Eyes ...... 117 5.1 Introduction ...... 118 5.2 Stock Versus Custom-Fit Prosthetic Eyes ...... 118 5.3 Basic Colour Theory ...... 119 5.3.1 The Colour Wheel ...... 120 5.3.2 Characteristics of Colour ...... 121 5.4 Overview of Prosthetic Eye Making and Fitting ...... 122 5.5 Creating the Iris/Corneal Unit ...... 123 5.5.1 Premanufactured Iris Discs and Corneas ...... 124 5.5.2 Alternative Methods for Creating the Iris/Corneal Unit . . . . 125 5.6 Painting the Iris ...... 128 5.6.1 The Pupil ...... 128 5.6.2 The Collarette...... 129 5.6.3 The Stroma ...... 129 5.6.4 The Limbus ...... 130 5.7 Impression Taking ...... 130 5.7.1 Ocular Tray Impression Technique ...... 131 5.7.2 Impression Mixing Gun Technique ...... 133 5.8 Casting the Impression and Preparing the Wax Pattern ...... 134 5.8.1 Alternative Method for Creating the Wax Pattern from an Impression ...... 137 5.9 Trying in the Wax Pattern and Positioning the Iris/Corneal Unit . . . 138 5.9.1 Compromises and Trade-offs at the Try in Stage ...... 139 5.9.2 Trying the Wax Pattern in the Socket and Positioning the Iris/Corneal Unit When Fitting Bilateral Prosthetic Eyes ...... 139 xiv Contents

5.10 Processing the Wax Prosthesis ...... 141 5.11 Finishing the Prosthetic Eye ...... 144 5.12 Final Clinical Session ...... 146 References ...... 147

6 Scleral Shell Prostheses and Prosthetic Contact Lenses ...... 149 6.1 Introduction ...... 149 6.2 Prosthetic Contact Lenses ...... 151 6.2.1 Aniridia ...... 151 6.2.2 Corneal Leucoma ...... 151 6.2.3 Corneal Opacities or Scars ...... 153 6.2.4 Iris Coloboma...... 154 6.2.5 Cataract Appearance ...... 155 6.2.6 Albinism ...... 155 6.2.7 Heterochromia ...... 155 6.2.8 Corneal Dystrophy ...... 157 6.2.9 In-House Tinting Systems for Soft Prosthetic Contact Lenses ...... 157 6.2.10 Hand-Painted Opaque Prosthetic Contact Lenses ...... 158 6.3 Scleral Shell Prosthesis ...... 160 6.3.1 Making and Fitting Medium or Thick Scleral Shell Prostheses (1.5 mm to 2.5 mm Thickness) ...... 161 6.3.2 Making and Fitting Thin Scleral Shell Prostheses (Less Than 1.5 mm in Thickness) ...... 163 6.3.3 Thin Scleral Shell Prosthesis Design ...... 163 6.3.4 Overview of the Making and Fitting Process ...... 163 6.3.5 Taking an Impression of the Eye ...... 165 6.3.6 Trial Shell ...... 166 6.3.7 Construction of the Final Scleral Shell ...... 169 References ...... 173

7 Socket Complications ...... 175 7.1 Introduction ...... 176 7.2 General Approach ...... 176 7.3 Socket Lesions ...... 178 7.3.1 Malignancies ...... 178 7.3.2 Granulomas ...... 178 7.3.3 Chemosis ...... 179 7.3.4 Giant Papillary Conjunctivitis ...... 180 7.4 Complications of Prosthesis Retention ...... 180 7.4.1 Inadequate Socket Lining ...... 180 7.4.2 Inadequate Fornix or Fornices ...... 184 7.4.3 Lower Eyelid Laxity ...... 185 7.4.4 Combined Surgical and Prosthetic Approach ...... 186 7.5 Complications of Prosthesis Stability ...... 190 Contents xv

7.5.1 Inadequate Prosthesis Retention ...... 190 7.5.2 Prosthesis Instability Within the Socket ...... 190 7.6 Complications of Prosthesis Motility...... 196 7.6.1 Inadequate Prosthetic Eye Motility ...... 197 7.6.2 Excessive Prosthetic Eye Motility ...... 198 7.7 Orbital Volume Deﬁ cit ...... 199 7.7.1 Orbital Volume Replacement ...... 200 7.7.2 Expanded Orbital Volume ...... 204 7.8 Superior Sulcus Deformity ...... 205 7.8.1 Prosthetic Technique ...... 205 7.8.2 Surgical Technique ...... 205 7.9 Eyelid Malposition ...... 207 7.9.1 Ectropion ...... 207 7.9.2 Entropion ...... 208 7.9.3 Ptosis ...... 209 7.9.4 Lagophthalmos ...... 212 7.10 Summary of Socket Complications and Surgical and Prosthetic Solutions ...... 215 References ...... 217

8 Deposit Build-Up on Prosthetic Eyes and a Three-Phase Model of Prosthetic Eye Wear ...... 219 8.1 Introduction ...... 219 8.2 Tear Protein Deposits ...... 220 8.2.1 Information About the Nature of Deposits from Contact Lens Research ...... 220 8.2.2 Deposit Build-Up on Prosthetic Eyes ...... 221 8.3 Effects of Prosthesis Removal, Cleaning and Reinsertion ...... 228 8.3.1 Physical Stress Associated with Removal and Reinsertion ...... 229 8.3.2 Introduction of Bacteria and Foreign Material ...... 229 8.3.3 Disturbed Socket Environment ...... 230 8.3.4 Changed Surface Characteristics of the Prosthesis ...... 231 8.4 Three-Phase Model of Prosthetic Eye Wear ...... 231 8.4.1 Establishment Phase...... 232 8.4.2 Equilibrium Phase ...... 232 8.4.3 Breakdown Phase ...... 232 8.5 Application of Model to Personal Prosthetic Eye Maintenance . . . 236 References ...... 238

9 Mucoid Discharge Associated with Prosthetic Eye Wear ...... 241 9.1 Introduction ...... 241 9.2 Speciﬁ c Causes of Discharge ...... 242 9.2.1 Viral or Bacterial Infections ...... 242 9.2.2 Eyelid-Related Pathologies ...... 243 xvi Contents

9.2.3 Environmental Allergens ...... 246 9.2.4 Environmental Irritants and Eye Stress ...... 247 9.2.5 Socket-Related Irritants ...... 247 9.2.6 Prosthesis-Related Irritants ...... 247 9.3 Non-speciﬁ c Causes of Discharge ...... 251 9.4 Contact Lens Experience with Tear Protein Deposits, Papillary Conjunctivitis and Discharge ...... 252 9.5 Personal Prosthetic Eye Cleaning Regimes and Professional Polishing ...... 253 9.6 Proposed Protocol for Managing Non-speciﬁ c Mucoid Discharge . . . 254 9.6.1 The Protocol Has Five Elements as Follows ...... 255 References ...... 257

10 Living with a Prosthetic Eye ...... 259 10.1 Introduction ...... 259 10.2 Handling Social Interactions ...... 260 10.3 Reduced Peripheral Vision and Altered Depth Perception ...... 262 10.3.1 Compensating for Reduction of Horizontal Visual Range . 262 10.3.2 Compensating for Altered Depth Perception ...... 263 10.3.3 Additional Cues to Depth Perception ...... 268 10.3.4 Utilizing Other Senses ...... 268 10.3.5 Driving with Monocular Vision ...... 268 10.4 Personal Socket Hygiene and Prosthetic Eye Care ...... 272 10.5 Caregiver Guide to Removing and Inserting a Prosthetic Eye. . . . . 273 10.6 Patient Guide to Removing and Inserting a Prosthetic Eye ...... 275 10.7 Cleaning Prosthetic Eyes ...... 276 10.8 Selecting Glasses for Protection and Camouﬂ age ...... 278 10.9 Further Resources ...... 280 References ...... 281

11 History of Ocular Prosthetics...... 283 11.1 Introduction ...... 283 11.2 Ancient Egypt ...... 283 11.3 3000 BC ...... 284 11.4 2000 BC ...... 285 11.5 Sixteenth Century ...... 287 11.6 Seventeenth Century ...... 289 11.7 Eighteenth Century ...... 290 11.8 Nineteenth Century ...... 290 11.9 Twentieth Century ...... 301 11.10 Twenty-First Century ...... 309 11.11 Contact Lenses and Scleral Shell Prostheses ...... 310 References ...... 312

Index ...... 313 List of Figures

Fig. 1.1 Eye loss as a function of age (using 10-year age bands) Fig. 1.2 Main causes of eye loss. Medical and accidental causes are shown separately Fig. 1.3 Gender mix of eye loss due to accident Fig. 1.4 Causes of eye loss in New Zealand over time Fig. 1.5 Shadow stereopsis where images of shadows are fused stereoscopically Fig. 1.6 The corneal opacity in this right eye, while less disfi guring than an enucleated eye, is still psychologically distressing for this patient Fig. 1.7 Concerns of patients when they fi rst lost their eye compared with their concerns at least 2 years later Fig. 1.8 Fashionable impact-resistant glasses Fig. 1.9 ‘Elli’ can be ordered free of charge for children with retinoblastoma via email to [email protected] Fig. 1.10 ‘When my husband Reese and I were fencing contractors, we moved around a lot and lived in tents on the properties we worked on. In 1974 we were clearing old fencing wire from a kiwifruit orchard. I cut a wire and one end sprang up and struck my right eye’. Mona Davies is a farmer (emphatically not just a ‘farmer’s wife’!). She has worked hard all her life and now lives comfortably on an 800 acre coastal farm. She and Reese run sheep and cattle as well as four beachfront cottages which they rent out to fi shing parties and families. Their two children farm their own coastal blocks on either side of Mona’s and Reece’s land, and not a day goes by when Mona does not see them or her three grandchil- dren. Mona took the loss of her eye like she does with most things in life: ‘she put up with it and moved on’. It wasn’t the damage to her appearance that concerned her so much as the diffi culty she had parking the car and reading the ground hollows when going about the farm Fig. 1.11 Natahlie is a bright and happy 3-year-old who lives on a farm. One morning a rooster fl ew at the apple Natahlie was eating but pecked at her right eye instead, resulting in Natahlie losing the eye. Natahlie was excited about getting her prosthetic eye and couldn’t wait to check it out in the mirror. In the years ahead, she will depend on her family, teachers and friends to reinforce the positive aspects of being such a unique individual

xvii xviii List of Figures

Fig. 1.12 Greg’s right eye was injured during a diffi cult birth, and while surgeons offered to operate on it at the time, his parents refused because they could not bear for him to go through any more traumas. Indeed, the experience was so painful for them that they ignored his eye’s different appearance and never spoke about it. Partly because of this lack of acknowledgment and partly because of the teasing he suffered from other children at school, Greg developed very low self-esteem and a shyness that limited his schooling and his ambitions. Even so, Greg became a quality assurance manager, but it wasn’t until a new partner (who happened to have a degree in psychology) persuaded him to seek help that he obtained life-changing scleral shell prosthesis at age 31 Fig. 1.13 Sue (aged 60) lost the sight of her right eye to endophthalmitis following a corneal transplant. For 2 years her eye became more and more unsightly, but she could not face having it removed. ‘Eyes are the win- dows of the soul. It is much harder to lose an eye than to lose other body parts because of the emotional aspects’. Sue eventually plucked up the courage to have her eye removed. ‘I should have had my eye out sooner. I wish I had not put myself through such prolonged emotional turmoil’ Fig. 1.14 Mike (aged 50) lost his left eye when he fell on a metal fence post while erecting a fence on a road construction assignment. He remembers that his major concern at the time was not damage to his appearance, but adjusting to using his right eye instead of his left for precision measuring and sighting a theodolite. Mike overcame this problem and contin- ued with his job as a roadwork supervisor where he often jokes about his prosthetic eye with his fellow workers. ‘It’s a good excuse when I make a mistake’. Mike’s open, pragmatic approach is genuine and refl ects the fact that for him, the loss of an eye was never a big issue. He is careful to look after his remaining eye however and to ensure that his prosthesis is properly maintained Fig. 1.15 Tracey was born with a microphthalmic right eye. She was teased at school to the point where she lost all self-confi dence and belief. This affected her attitude to life and her education, and she became a miser- able teenager with anorexia and bulimia. Things improved for Tracey after her eye was enucleated at age 21, and she had happier times in her 20s. Now in her 40s, Tracey is forward-looking and enthusiastic about her job as a systems manager. She has accepted that there are many more important things in her life than worrying about her eye Fig. 1.16 Diane (aged 80) has worn a prosthetic eye since her right eye was removed at age 12. Diane’s fi rst prostheses were made of glass, and she well remembers selecting her glass eyes from an assortment laid out on trays. She also remembers breaking her glass eye and the drama and stress this caused her poor mother who had to rush her to the optometrist to fi nd a replacement. Diane always left her prosthesis out at night and one morning she couldn’t fi nd it. She was very upset because nobody had ever seen her without her prosthesis, and she has vivid recollections of ripping her bedroom apart before discovering the eye List of Figures xix

mixed up in her blankets. Having only one eye has not prevented her from doing anything she would not have done otherwise – ‘it’s just felt different’ Fig. 1.17 When Raewyn’s right eye was lacerated by a piece of wire at age 40, her life took a dramatic turn for the worse. Her eye became more and more unsightly as her cornea opacifi ed, and she became very self-con- scious about her appearance. The stress contributed to the breakdown of her marriage, but after this happened she was forced to take stock of her situation. She had two children to bring up, looked awful and had no career. So what did she do? She began training as a midwife, quali- fying a few years later. Raewyn has delivered thousands of babies since then and is now a pregnancy consultant providing expert advice to young mothers. Raewyn’s disfi gured eye was fi nally eviscerated in 2007, and she was fi tted her new prosthetic eye. ‘The difference was amazing. For years I put up with a horrible looking eye and in 6 short weeks I was suddenly normal. I should have had my eye out years ago’. Raewyn is proud of overcoming the loss of her eye and going on to make a difference in her life and in the lives of others Fig. 2.1 The ‘ideal’ face divides into horizontal thirds and vertical fi fths Fig. 2.2 In the adult face, the eyes are usually separated by one horizontal palpebral width across the bridge of the nose Fig. 2.3 The eyes are a principal determinant of the appearance of facial symmetry Fig. 2.4 Gross anatomy of the eye and eyelids Fig. 2.5 The pupil is usually positioned supero-medial to the centre of the iris Fig. 2.6 The medial third of the upper eyelid angles down towards the nose Fig. 2.7 The upper eyelid crease is formed where the anterior expansions of the levator aponeurosis muscle joins the skin Fig. 2.8 The skull is made up of 21 bones immovably joined together and one moveable bone, the mandible Fig. 2.9 Transverse section of the skull showing the pyramidal shape of the orbit. Note the short length of the lateral orbital wall compared to the medial wall Fig. 2.10 Enucleated human eye Fig. 2.11 The eye Fig. 2.12 Sagittal view of the extraocular muscles Fig. 2.13 Anterior view of the extraocular muscles Fig. 2.14 The supero-nasal notches in prosthetic eyes accommodate the trochlea Fig. 2.15 Anterior view of the right eye showing the direction of movements of the eye Fig. 2.16 Eyelid characteristics differ between Asians and others Fig. 2.17 Facial muscles of the eyes and forehead Fig. 2.18 Orbicularis oculi Fig. 2.19 Anatomical features of the eyelids Fig. 2.20 The conjunctiva is a single continuous mucous membrane with three main regions xx List of Figures

Fig. 2.21 The palpebral conjunctiva may be subdivided into marginal, tarsal and orbital zones Fig. 2.22 Ducts of the meibomian glands and the punctum can be seen here in the marginal conjunctiva of a lower eyelid Fig. 2.23 The conjunctival sac of a normal eye showing the unextended depth of the fornices Fig. 2.24 The vertical lines of the meibomian glands can be seen through the transparent conjunctiva of the lower eyelid. The whitish area is the apo- neurotic expansion from the inferior rectus and inferior oblique muscles Fig. 2.25 Mean touch thresholds (in mg/mm2 ) for the conjunctiva and cornea using a hand-held 0.12 mm nylon suture Cochet-Bonnet aesthesiome- ter. The lower the threshold score, the more sensitive the area Fig. 2.26 Distribution of goblet cells in the conjunctiva of an eye with eyelids everted Fig. 2.27 Epithelium of the conjunctiva with goblet cells Fig. 2.28 Lacrimal apparatus Fig. 2.29 Tear glands Fig. 2.30 Stained tear protein deposits on the surface of a prosthetic eye Fig. 2.31 Triple-layer structure of tear fi lm Fig. 2.32 A meniscus of tear fl uid formed at the margin of the lower eyelid Fig. 2.33 Same patient wearing a left prosthetic eye at age 40 (left ) and at age 81 ( right ) Fig. 2.34 The arcus senilis (the greyish-white ring) of the cornea becomes more pronounced in old age Fig. 2.35 Following the loss of the globe, the anatomical features of the eyelids do not change Fig. 2.36 Following the loss of the globe, the eyelids lose support and collapse into the empty socket Fig. 2.37 A prosthetic eye is inserted to restore the eyelids to their original position where they look and function much as they did before eye loss Fig. 2.38 Sagittal view of an anophthalmic socket with orbital implant and prosthetic eye Fig. 2.39 Transectional view of the right anophthalmic orbit with implant and prosthetic eye. The illustrations show how the rectus muscles combine with the orbital implant to produce movement in the prosthesis Fig. 2.40 Tear fi lm with a prosthetic eye Fig. 2.41 This glass eye was made and fi tted in Germany in 2014 Fig. 2.42 The glass eye worn in Fig. 2.41 Fig. 2.43 Orbital tissue changes following enucleation Fig. 2.44 Retraction of the superior muscle complex and the inferior rectus result in a recessed socket. This photograph shows a recessed right socket with prosthesis in place Fig. 2.45 Elements of post-enucleation socket syndrome (PESS) Fig. 2.46 Right upper eyelid ptosis over a prosthetic eye List of Figures xxi

Fig. 2.47 The right prosthetic eye has tilted backwards causing it to gaze upwards and place forward and downward pressure on the lower eyelid Fig. 2.48 The left upper eyelid sulcus is much deeper due to orbital volume defi cit Fig. 2.49 Advanced left post-enucleation socket syndrome. This patient has deep upper eyelid sulcus, a contracted socket and a backward tilted prosthesis. The upper eyelashes point upwards from a retracted upper eyelid, the lower eyelid is entropic and the eyelids do not fully close over the prosthesis Fig. 3.1 Fourteen-year-old patient with untreated unilateral anophthalmia adversely affecting facial symmetry Fig. 3.2 Computed tomographic image of the skull of the young woman in Fig. 3.1 . The left orbit is considerably smaller than the right orbit Fig. 3.3 Unilateral microphthalmia Fig. 3.4 Series of custom-made conformers used to stimulate socket growth from age 1 month to when the socket is fi nally ready for a more perma- nent ocular prosthesis Fig. 3.5 Ten-month-old patient wearing clear conformers over his microphthalmic eyes. As well as stimulating orbital growth, the conformers lift the eyelids away from the pupil, enabling ongoing visual stimulation, which is vital for visual development Fig. 3.6 Disfi gured non-phthisical left eye fi tted with a prosthetic contact lens Fig. 3.7 Phthisical right eye fi tted with a scleral shell prosthesis Fig. 3.8 Collapsed remnant of the globe fi tted with a prosthetic eye Fig. 3.9 The eye is made ready for the enucleation procedure Fig. 3.10 The corneal limbus is dissected and the conjunctiva and Tenon’s capsule are drawn aside Fig. 3.11 The extraocular muscles are tagged with sutures and cut away from the globe Fig. 3.12 The optic nerve is severed Fig. 3.13 The globe is removed Fig. 3.14 The orbital cavity without the eyeball. The free ends of the extraocular muscles are held back with sutures Fig. 3.15 A hydroxyapatite orbital implant is inserted into the cavity Fig. 3.16 The conjunctiva is drawn over the wound and closed with sutures Fig. 3.17 Painful infl amed eye with corneal ulcer and hypopyon Fig. 3.18 An incision is made around the cornea and Tenon’s capsule is under- mined back to the insertions of the extra ocular muscles Fig. 3.19 The button of corneal tissue is excised Fig. 3.20 The entire ocular content is removed with an evisceration spoon Fig. 3.21 The sclera is cleaned and any residue of uveal pigment is denatured with 100 % ethanol Fig. 3.22 One or two radial slits are made inside the scleral cavity, allowing it to expand to accommodate a silicon implant Fig. 3.23 The edges of the scleral wound are about to be overlapped and secured with mattress stitches xxii List of Figures

Fig. 3.24 Tenon’s layer has been sutured and the conjunctiva closed. A postsurgical conformer is ready to be placed in the eye socket Fig. 3.25 Conformers with holes to facilitate the ﬂ ow of socket secretions. The top three are made from PMMA and the lowest one is made from silicon Fig. 3.26 Implants of various materials and designs range from a hollow glass sphere used by Mules in 1885 ( top left) to a hydroxyapatite orbital implant introduced by Dr Arthur Perry 100 years later (bottom right ). A Troutman implant ( middle left) used a magnet to hold the prosthesis while the Castroviejo (middle ) and the Allen (middle right ) implants were made of (poly) methyl methacrylate. Spheres of gold (middle top ), silicone ( middle bottom ) and acrylic (bottom left ) have also been used Fig. 3.27 Pegged hydroxyapatite implant Fig. 3.28 Chronic mucoid discharge associated with a motility peg Fig. 3.29 Total orbital exenteration Fig. 3.30 Orbital exenteration with retained eyelid skin and orbicularis muscle tissue Fig. 3.31 Orbital exenteration has extended to the removal of additional diseased bone Fig. 3.32 Orbital exenteration with full-thickness skin graft Fig. 3.33 Shallow or non-existent socket with limited room for a prosthesis Fig. 3.34 This woman had her left orbit exenterated due to adenocystic carcinoma (top photograph ). Her eyelid skin and orbicularis muscle tissue were conserved (middle photograph ) and her eye was restored with an adhesive-retained prosthesis (bottom photograph) Fig. 3.35 Implants have been placed to support a prosthetic restoration Fig. 3.36 Orbital prosthesis in mould. It incorporates magnets positioned to connect with the implants seen in Fig. 3.35 Fig. 3.37 Orbital prosthesis held in place with implants and magnets Fig. 4.1 Large variety of patients presenting for a prosthetic eye. They all have different needs and expectations Fig. 4.2 All iris colours and patterns are the result of genetics. This iris resulted from the introduction of a blue-eyed Scotsman to a family line of brown-eyed New Zealand Maori ﬁ ve generations previously Fig. 4.3 The health of the remaining sighted eye is evaluated using a slit lamp Fig. 4.4 Chart for recording measurements of prosthetic eye symmetry Fig. 4.5 The right prosthetic eye and eyelids have slumped relative to the companion eye. The top broken line indicates that the level of the upper eyelid has dropped about 6.0 mm from the horizontal. The middle broken line indicates that the iris/pupil has dropped 4.0 mm, and the lower broken line indicates that the lower eyelid has also dropped about 4.0 mm Fig. 4.6 The left prosthetic eye is recessed 4.0 mm relative to the companion eye Fig. 4.7 An entropic lower eyelid, evidence of mucoid discharge and dried tear protein deposits on the surface of this prosthetic eye are apparent in this photographic record List of Figures xxiii

Fig. 4.8 Photographic record of the extent of medial and lateral movements of a left prosthetic eye. The medial excursion is greater than the lateral excursion, which is common Fig. 4.9 Photographic record of patient looking down with one eye and involun- tarily looking up with the other prosthetic eye Fig. 4.10 The veneer has cracked at the limbus of a prosthetic eye Fig. 4.11 Cracks (highlighted by staining) have appeared between the veneer and the base material at the periphery of this prosthetic eye Fig. 4.12 A prosthetic eye being lowered into a container of dental plaque disclosing gel diluted in .85 % saline solution. The active ingredient in this staining solution is Rose Bengal Fig. 4.13 Staining has revealed tooling marks on the posterior surface of this poorly ﬁ nished prosthetic eye Fig. 4.14 A small chip is apparent on the periphery of this prosthetic eye Fig. 4.15 General wear and tear over time has resulted in micro-scratches, a dull surface and dried deposits on the surface of this prosthetic eye Fig. 4.16 Crazed clear veneer due to the use of a solvent to clean the prosthesis Fig. 4.17 Partial delamination of the PMMA veneer shows as speckles of light in the pupil of this prosthetic eye Fig. 4.18 Dried tear protein deposits can be seen on the palpebral surface of this prosthetic eye Fig. 4.19 Stained tear protein deposits on the surface of a prosthetic eye. Note the absence of deposits in the inter palpebral area Fig. 4.20 Deep right anophthalmic socket with no orbital implant Fig. 4.21 Left anophthalmic socket with pegged hydroxyapatite orbital implant Fig. 4.22 Right anophthalmic socket with epithelial tissue graft inside the lower eyelid Fig. 4.23 Right anophthalmic socket with full-thickness tissue reconstruction of the lower eyelid Fig. 4.24 Microphthalmic left eye Fig. 4.25 Remnants of a ruptured left globe Fig. 4.26 Phthisical left eye with opaque cornea Fig. 4.27 Phthisical eye with a Gunderson conjunctival ﬂ ap covering the cornea Fig. 4.28 Enucleation due to acid burns. The superotemporal fornix needs to be deepened before a prosthetic eye can be retained Fig. 4.29 The PMMA spherical implant in the anophthalmic socket has migrated forward and is covered by very thin conjunctival tissue. It is stable but needs to be monitored Fig. 4.30 The upper eyelid has been torn away, and surgery is required before a prosthetic eye can be retained Fig. 4.31 The Castroviejo implant in this socket has migrated forward and can now be seen clearly through the thin conjunctival covering Fig. 4.32 Exposure of a tantalum mesh orbital implant Fig. 4.33 White sutures can be seen clearly through the conjunctiva. These may become exposed and require removal xxiv List of Figures

Fig. 4.34 A pyogenic granuloma has formed in this left socket due to wearing a deeply vaulted stock prosthetic eye for many years Fig. 4.35 The prosthesis that caused the pyogenic granuloma in Fig. 4.34 Fig. 4.36 The contact lens seen here is analogous with prosthetic eye use in that a foreign material is in contact with the conjunctiva, and they both share similar eyelid action, bathe in the same ocular fl uids and accumulate surface deposits Fig. 4.37 A phenol red thread testing kit Fig. 4.38 The phenol red thread test for measuring tear volume Fig. 4.39 Type II ocular tear ferning pattern (tears from a prosthetic eye) Fig. 4.40 Type III ocular tear ferning pattern (tears from a prosthetic eye) Fig. 4.41 A Tearscope being used to measure tear fi lm break-up time Fig. 4.42 Equal interval photographic grading scales for measuring conjunctival infl ammation Fig. 4.43 Photographic grading scales are in common use in optometry Fig. 4.44 Two Infl ammaDry devices side by side. The display in the top device shows a single band (no infl ammation detected), while the window in the bottom device shows a double band (infl ammation detected) Fig. 4.45 Meibomian gland loss is apparent in the left anophthalmic socket of this patient compared with the right companion eye Fig. 4.46 Visual analogue scales for measuring the four characteristics of mucoid discharge Fig. 4.47 The glob of mucoid discharge seen in this socket has collected behind the prosthetic eye Fig. 4.48 Photographic record of discharge severity. Mucoid discharge is not associated with conjunctival infl ammation in this socket Fig. 4.49 A rough surface papillary texture is apparent in the lower tarsal and forniceal conjunctiva of this anophthalmic socket Fig. 4.50 Giant papillary conjunctivitis of the upper tarsal conjunctiva of an anophthalmic socket Fig. 5.1 Used stock PMMA prosthetic eye manufactured in India Fig. 5.2 Rod and cone cells in the retina of the eye Fig. 5.3 CMYK subtractive colour diagram Fig. 5.4 A basic palette might include the colours (from left to right ): ivory black, titanium white, Vandyke brown, cobalt blue, yellow ochre, raw sienna and burnt sienna Fig. 5.5 A vernier gauge for measuring the iris diameter Fig. 5.6 Assorted iris discs with matching corneal buttons Fig. 5.7 Iris disc and clear corneal button with pupil Fig. 5.8 Metal dies for making iris discs and clear corneal buttons Fig. 5.9 Sticky wax rod attached to an iris disc for easy handling during painting Fig. 5.10 A drop of water previews the fi nal appearance of iris colours when sandwiched between the corneal button and the freshly painted iris List of Figures xxv

Fig. 5.11 Custom-designed metal mould for creating iris/corneal units with four black tinted cold-cure iris blanks ready for turning on a lathe Fig. 5.12 PMMA blank is turned to the required iris diameter. The pupil is created off-centre using a squared-off drill bit Fig. 5.13 The iris disc is painted to match the patient’s iris Fig. 5.14 A clear cornea is processed over the painted iris blank and turned to the required iris diameter Fig. 5.15 It is recommended that the iris is painted under a magnifying lamp Fig. 5.16 Individual components of the iris Fig. 5.17 An arcus senilis strongly characterises the appearance of this elderly patient’s iris Fig. 5.18 Polyvinylsiloxane impression taken without an impression tray. Note the shape of the underside of the upper eyelid and the extension under the lower tarsal plate Fig. 5.19 Ocular impression tray Fig. 5.20 Disposable syringe used in conjunction with an ocular impression tray Fig. 5.21 Impression material has been injected into the socket via the hollow stem of the ocular tray Fig. 5.22 An impression mixing gun with disposable mixing tip and a cartridge containing fast set, heavy body polyvinylsiloxane impression material Fig. 5.23 The cotton thread embedded in this impression provides an excellent means by which the impression can be retrieved from the socket of a child Fig. 5.24 The impression is trimmed of excess material and fully immersed in a one- part silicon mould Fig. 5.25 The impression is removed by sectioning the mould Fig. 5.26 Preheated white ocular wax is poured into the mould Fig. 5.27 The wax pattern is cooled down and removed Fig. 5.28 The anterior surface of the wax pattern is being trimmed to approximate the shape of the anticipated prosthetic eye Fig. 5.29 The completed wax pattern is ready to be inserted into the eye socket Fig. 5.30 A backing for the wax pattern is made from shellac base plate. The backing supports the wax pattern during the try-in stage Fig. 5.31 The wax pattern is tried in the socket Fig. 5.32 A clear plastic iris/corneal blank is positioned with the rod aligned in central gaze Fig. 5.33 Matching prosthetic eyes for blind patients can be challenging. This patient’s right socket is shallow and small while her left socket is deeper and larger Fig. 5.34 The rod attaches the iris/corneal unit to the mould Fig. 5.35 The prosthesis is trial packed with white PMMA Fig. 5.36 Set up for ﬁ nal iris painting and scleral colouring Fig. 5.37 The second layer of iris colours being applied Fig. 5.38 Fine veins are teased from red embroidery thread and carefully laid on the sclera in the same manner and amount as observed in the patient’s companion eye xxvi List of Figures

Fig. 5.39 A clear veneer of PMMA is then processed over the anterior surface locking in the iris and scleral colours and restoring the cornea to its original shape Fig. 5.40 The prosthesis is buffed with a wet pumice mix using a calico mop Fig. 5.41 The fi ne marks left by the pumice are removed with a polishing compound such as tripoli Fig. 5.42 Final polishing of a concave posterior surface using a hand-piece and small polishing wheel Fig. 5.43 The use of pumice, then tripoli and then Kenda 244-Blue to polish PMMA produced surfaces that most resisted the adherence of bacteria compared with other polishing regimes Fig. 6.1 The cornea may be seen underlying thin conjunctival tissue following a Gundersen fl ap procedure Fig. 6.2 Basic prosthetic contact lens designs. (a ) Occluding pupil mask with clear iris portion. ( b) Peripheral mask with opaque black pupil. ( c ) Peripheral mask with clear pupil. (d ) Translucent tinted lens. ( e ) Translucent tinted peripheral mask with clear pupil Fig. 6.3 Iris fl aw following iridectomy. It may be masked with prosthetic contact lens with an opaque peripheral mask and clear pupil Fig. 6.4 Aniridia. It may be masked with prosthetic contact lens with a tinted or opaque peripheral mask and clear pupil Fig. 6.5 Corneal leucoma. It may be masked with a prosthetic contact lens with an opaque peripheral mask and a clear or black pupil depending on where the leucomas are located Fig. 6.6 Full-thickness, total corneal opacity. It may be masked with a prosthetic contact lens with an opaque peripheral mask and a black pupil Fig. 6.7 Iris coloboma. It may be masked with a prosthetic contact lens with an opaque peripheral mask and a clear pupil Fig. 6.8 Cataract. A clear prosthetic contact lens with a black pupil improves cosmesis when cataract surgery is not an immediate option and vision is not useful Fig. 6.9 The red appearance as well as the photophobia (both caused by light passing through the iris) may be relieved by fi tting a translucent tinted prosthetic contact lens with a clear pupil if the photophobia is moderate or an opaque prosthetic contact lens with clear pupil if the photophobia is more severe Fig. 6.10 Heterochromia. The colour discrepancy between the two eyes (the affected eye has a grey iris) may be lessened with the use of tinted prosthetic contact lenses or tinted prosthetic contact lenses with clear pupils Fig. 6.11 Corneal dystrophy. If the eyes are blind and the pupil is not discernable, clear lenses with black pupils will improve cosmesis. If the pupils are discernable and dark, translucent tinted lenses may mask the greyness of the cornea while not compromising the level of vision. Finally, opaque lenses with clear pupils may be a better option than tinted lenses if a wider range of colours is needed and the optimum level of vision is to be maintained List of Figures xxvii

Fig. 6.12 In-house colouring kit for soft contact lenses Fig. 6.13 This commercially available soft opaque lens with clear pupil does a good job of masking the iris coloboma in this patient’s left eye but has an unnatural iris texture Fig. 6.14 Two examples of soft hand-painted prosthetic contact lenses Fig. 6.15 Opaque cornea with a smaller palpebral ﬁ ssure than the companion eye Fig. 6.16 Distorted cornea following trauma Fig. 6.17 Left strabismic eye with opaque cornea is masked with a scleral shell prosthesis Fig. 6.18 Completed medium thickness scleral shell prosthesis Fig. 6.19 Premanufactured two-dimensional curved iris discs with corresponding corneas Fig. 6.20 Metal moulds for making two-dimensional curved iris discs Fig. 6.21 Thin scleral shell design showing relieved areas Fig. 6.22 Tetracaine or oxybuprocaine anaesthetic eye drops are recommended for patients with clear sensitive corneas Fig. 6.23 Polyvinylsiloxane impression taken using an ocular impression tray without stem Fig. 6.24 The two-part mould is ready to be packed with clear PMMA dough Fig. 6.25 Iris disc painted directly onto the surface of a semitranslucent shell Fig. 6.26 Iris and scleral colours drying under a lamp Fig. 6.27 A polyurethane sheet protects the painted surface when a clear PMMA veneer is trial packed Fig. 6.28 The PMMA veneer is processed according to the manufacturer’s instructions Fig. 6.29 The edges of the hole are smoothed with a cotton thread and pumice Fig. 6.30 Completed thin scleral shell prosthesis in situ Fig. 6.31 Rubber suction devices are handy for removing and inserting scleral shell prostheses Fig. 7.1 This granuloma developed in the inferior bulbar conjunctiva after the patient wore a deep vaulted stock prosthetic eye for many years Fig. 7.2 Chemosis of the conjunctiva formed under a conformer shell which was inserted following enucleation of the globe 5 weeks previously Fig. 7.3 Extreme chemosis has developed in this socket due to irritation caused by an extruding orbital implant Fig. 7.4 The GPC evident under the upper eyelid of this microphthalmic eye has persisted for many years even though the prosthesis has been well maintained and steroid drops have been used regularly to reduce mucoid discharge Fig. 7.5 Non-retentive contracted socket with a shortage of conjunctival lining and an absence of the inferior fornix Fig. 7.6 The pressure conformer is held in position by a bandage Fig. 7.7 An incision is made in the socket, and the scar tissue is released as much as possible Fig. 7.8 A full-thickness mucous membrane is harvested from the inner lower lip Fig. 7.9 Full-thickness mucous membrane tissue xxviii List of Figures

Fig. 7.10 The graft site in the lower lip is closed with sutures Fig. 7.11 The graft is sutured into the surgical defect in the socket Fig. 7.12 A patient’s old prosthesis is placed in the socket and secured with a tarsorrhaphy to stabilise the graft and resist graft contraction Fig. 7.13 Adhesions are accommodated loosely while the margins extend into the fornix on either side Fig. 7.14 Sutures hold down a bolster to deepen the inferior fornix Fig. 7.15 A ridge is added to the front of the inferior edge creating a negative curve Fig. 7.16 A second method to help resolve lower eyelid laxity is to redistribute pressure from the centre of the lower eyelid to the sides Fig. 7.17 A strip of the tarsal plate is prepared to reattach the lid to the lateral orbital rim Fig. 7.18 The sutures are placed through the periosteum of the lateral orbital rim Fig. 7.19 The tarsal strip secured to the lateral orbital rim Fig. 7.20 Left eyelid-sparing exenteration for squamous cell carcinoma of the ethmoid sinuses Fig. 7.21 Custom-made conformer Fig. 7.22 Custom-made conformer in place Fig. 7.23 Self-retentive prosthetic eye with satisfactory cosmesis Fig. 7.24 Retentiveness is enhanced by hollowing the back of the prosthesis Fig. 7.25 This patient’s orbital implant has migrated forwards displacing his right prosthetic eye Fig. 7.26 This spherical implant has migrated into a superolateral position but is stable behind very thin conjunctival tissue Fig. 7.27 A migrated but stable Castroviejo orbital implant in medial, central and lateral gaze Fig. 7.28 The posterior surface is reconﬁ gured to accommodate a migrated orbital implant Fig. 7.29 Exposed orbital implant Fig. 7.30 The patch graft procedure begins by freeing the conjunctiva from the implant in the immediate area of the defect Fig. 7.31 The edges of the detached conjunctiva are draped over the graft and sutured Fig. 7.32 This right prosthetic eye is made roughly triangular or elliptical in shape, rather than round to prevent rotation within the socket Fig. 7.33 There are three axes of movement for the prosthesis within the anophthalmic socket Fig. 7.34 The margins may be trimmed as shown to increase anterior curvature and reduce extensions into the fornices Fig. 7.35 A gap has opened medially under the prosthesis during abduction of the right prosthetic eye Fig. 7.36 PMMA material is removed from just behind the edge of the prosthesis so that the edge will settle into closer contact with the conjunctiva List of Figures xxix

Fig. 7.37 A posterior platform is added to the prosthesis. The platform is designed to prevent backward rotation of the prosthesis, to allow for a narrow lower edge to engage the inferior fornix and to reduce some of the bulk (and weight) of the prosthesis Fig. 7.38 The conical anterior surface supports and wedges the eyelids apart while minimising the overall bulk of the prosthesis Fig. 7.39 The four rectus muscles are identifi ed and the intra-conal space is defi ned Fig. 7.40 The largest spherical implant that can comfortably be accommodated by the socket is chosen Fig. 7.41 The implant is placed in the intra-conal space and the rectus muscles sutured to it Fig. 7.42 Any available remnants of Tenon’s capsule are closed in front of the implant, and then the conjunctiva is closed without tension Fig. 7.43 A temporary tarsorrhaphy is placed to control post-operative conjunctival swelling Fig. 7.44 Subperiosteal implants are designed to displace the orbital tissues upwards and forwards restoring lost orbital volume and fi lling out a deep upper eyelid sulcus Fig. 7.45 Extra bulk added anterior to the superior edge may help correct upper eyelid sulcus deformity and restore the upper eyelid crease Fig. 7.46 A second ridge in front of the inferior edge, in conjunction with thin- ning of the lower edge from the back, sets the prosthesis upright and counters the potential backward displacement of the bulkier upper edge Fig. 7.47 The prosthetic eye has improved (reduced) this patient’s right lower eyelid ectropion Fig. 7.48 The inward rotation of the eyelashes that is part of upper and lower eyelid entropion has caused an accumulation of mucous on the prosthesis Fig. 7.49 The convex curvature of the anterior surface is made concave behind the entropic eyelids Fig. 7.50 This confi guration attempts to resolve upper eyelid ptosis by fi lling the superior fornix and lifting the levator aponeurosis muscle Fig. 7.51 This patient’s ptosis on the medial side of the eyelid causes a marked contour abnormality of the upper lid, drawing attention to the prosthetic eye Fig. 7.52 A diagonal ridge is added in the location shown by the dotted line Fig. 7.53 A ptosis shelf can be seen on this prosthetic eye. It supports the upper eyelid at its correct height but prevents the eyelid from closing Fig. 7.54 Exposure of the levator and aponeurosis during ptosis repair surgery. The pink levator muscle can be seen in the middle of the wound, with the white aponeurosis below it and the yellow orbital fat above. The surgical retractors are holding open the orbital septum and orbicularis muscles Fig. 7.55 A suture is passed through the tarsal plate – usually at the apex of the desired lid contour xxx List of Figures

Fig. 7.56 The suture is then passed through the levator aponeurosis, reattaching it to the tarsal plate. The suture is seen here tied in a temporary bow, allowing the height and the shape of the lid to be checked, as the surgery is performed under local anaesthetic. Once height and contour appear satisfactory, the suture is tied Fig. 7.57 In this case, two sutures were required to obtain a satisfactory lid height and contour – they can be seen centrally and medially (to the right of the picture). The orbicularis and skin are then closed, and the operation is complete Fig. 7.58 The gap between the eyelids that remains when the prosthesis is removed is the maximum eyelid closure attainable through reducing the size of the prosthesis Fig. 8.1 Deposits on the temporal limbus area of a left prosthetic eye worn continuously for 3 months (magnifi cation 400×) Fig. 8.2 A contact lens in situ. Prosthetic eyes are analogous to contact lenses Fig. 8.3 Staining technique for measuring the intensity and extent of deposit formation on prosthetic eye surfaces Fig. 8.4 Equal interval perceptual grading scales used to measure the build-up of deposits on prosthetic eye anterior surfaces (left ) and posterior surfaces (right ) Fig. 8.5 Photographic record of how tear deposits have built up on prosthetic eyes when worn continuously by two subjects over the times indicated Fig. 8.6 Graph quantifying the build-up of deposits on the prosthetic eyes worn by the subjects in Fig. 8.5. The deposits were graded using the equal interval grading scales shown in Fig. 8.4 Fig. 8.7 Regression analysis for mean extent and intensity of stained deposits on prosthetic eyes worn continuously. Estimated mean deposit grades at 1 and 6 months are depicted by the dashed lines Fig. 8.8 Two distinct zones of deposit build-up on prosthetic eyes are apparent. The fi rst is the inter-palpebral zone where deposits are exposed to the air and the wiping action of the eyelids. The second is the retro-palpebral zone where deposits are in continuous contact with the conjunctiva Fig. 8.9 Deposit formation on the anterior and posterior surfaces of two prosthetic eyes. The prostheses were fi rst cleaned and polished normally and worn for 2 weeks. They were then cleaned and polished to optical quality contact lens standard and worn for a further 2 weeks. Prosthesis 1 was worn by a 75-year-old man. Prosthesis 2 was worn by a 77-year- old woman. The grades were measured using the equal interval photographic grading scales in Fig. 8.4 Fig. 8.10 Wettability of prosthetic eye being measured with a goniometer Fig. 8.11 The wetting angle, θ°, is the angle formed by the water droplet at the three-phase boundary where the water, air and artifi cial eye surface intersect Fig. 8.12 The wetting angle dramatically increased (the surface became much less wettable) when surface deposits were cleaned off prosthetic eyes List of Figures xxxi

Fig. 8.13 When a prosthetic eye is removed and reinserted, it is inevitable that the micro- environment of the socket is disturbed to some extent Fig. 8.14 Foreign material (a stray eyelash) fell into this anophthalmic socket when the prosthesis was removed Fig. 8.15 Slit lamp biomicroscope view of tear break-up on the surface of a recently inserted prosthetic eye. The patient’s fi ngerprint which smudged across the cornea is an example of foreign material entering the socket during reinsertion of the prosthesis Fig. 8.16 Three-phase model of prosthetic eye wear Fig. 8.17 Scanning electron microscopy showing tear deposits on a 10-year-old prosthetic eye. Note the adherent rod-shaped bacteria Fig. 8.18 Over time tear protein deposits thicken and encroach into the inter-palpebral zone of the prosthetic eye and dry out Fig. 8.19 Epitheliopathy of Marx’s line in the lower eyelid of an anophthalmic socket caused by prosthetic eye wear Fig. 8.20 GPC can be seen on the caruncle in this anophthalmic socket Fig. 8.21 This eye socket impression shows the cobblestone appearance of GPC on the tarsal conjunctiva of the upper eyelid Fig. 8.22 Excessive build-up of deposits on a prosthetic eye shown by staining. The deposits may harbour harmful bacteria and/or environmental and metabolic debris. The prosthesis was removed from the discharging socket shown Fig. 8.23 Mucoid discharge trapped in spaces behind the prosthesis Fig. 8.24 Removing and cleaning prosthetic eyes monthly resulted in less discharge than cleaning more frequently Fig. 8.25 A cold cure PMMA patch on this prosthesis can be seen to have attracted deposits, while the rest of the palpebral zone has remained clear Fig. 9.1 Anophthalmic sockets with ranges of severity (mild on the left to severe on the right) for mucoid discharge, infl ammation and papillae Fig. 9.2 Discharge resulting from a common cold Fig. 9.3 Thicker yellow / green discharge and crusting is indicative of bacterial infection Fig. 9.4 Blepharitis with typical dandruff-like crusts appearing on the eyelashes Fig. 9.5 Obstructive MGD in the upper eyelid with waxy meibum issuing from meibomian gland orifi ces, some of which are blocked Fig. 9.6 This anophthalmic socket exhibits signifi cant signs of meibomian gland dysfunction and meibomian gland dropout in both upper and lower eyelids Fig. 9.7 Eyelid margin telangiectasia (spider veins) Fig. 9.8 Lagophthalmos has impaired the normal function of the eyelids of this patient causing mucus to collect on the surface and dry out Fig. 9.9 Thinly covered implant sitting under an intact conjunctival membrane Fig. 9.10 This tantalum mesh implant has extruded through the conjunctiva Fig. 9.11 Undissolved sutures under an intact conjunctival membrane xxxii List of Figures

Fig. 9.12 Pegged hydroxyapatite implant with associated mucoid discharge Fig. 9.13 A silvery discoloration over the pupil ( seen here ) indicates delamination of the PMMA material making up the prosthesis Fig. 9.14 Scratches and dull patches on well-worn prostheses are associated with mucoid discharge Fig. 9.15 The crazed surface of this prosthesis was caused by cleaning it with a solvent Fig. 9.16 Dried, gritty deposits (stained in this photograph) in the inter-palpebral zone are a source of irritation leading to discharge Fig. 9.17 A socket containing a glob of mucoid discharge which has pooled in the space behind the deeply hollowed and poorly ﬁ nished prosthetic eye shown. Note the rough area (highlighted with stain) around the upper edge of the prosthesis and its deeply hollowed back Fig. 9.18 The duration of the effect on discharge experience of professional repolishing Fig. 9.19 Wetting angles of different PMMA surface ﬁ nishes. High wetting angles indicate that surfaces are less wettable than surfaces with low wetting angles. Bars indicate standard error Fig. 9.20 Summary of protocol for managing discharge associated with prosthetic eye wear Fig. 9.21 Cleaning deposits with a dry tissue polishes surface deposits but does not remove them Fig. 10.1 Preplanning is important at the dinner table. Place the person you are most interested in on your good side Fig. 10.2 The discrete use of mirrors, strategically positioned on your blind side, helps to overcome any problems at your workbench or desk Fig. 10.3 When near objects move across other objects in the background, the shift in their relative positions is picked up by the brain and used as a measure of distance Fig. 10.4 If you stand to one side as a ball approaches, the visual angle between you and the ball changes enabling your brain to compute its approach ( a). The angle of approach does not change when a ball comes straight at you and its distance is much harder to compute (b ) Fig. 10.5 The relative motion between the curb edge and the road surface increases when the curb is higher (B ) and decreases when it is lower (A ) Fig. 10.6 When moving your head from side to side, the background behind the nearest object moves more ( A, B ) than the background behind the fur- thermost object (C, D), thus enabling your brain to detect which object is closest Fig. 10.7 The depths between the various components of this photograph are easy to interpret with one eye using cues to depth perception. Observe the sizes of the girls’ hands for perspective and overlap and at the clar- ity of the foreground compared to the background for contrast Fig. 10.8 When pouring a cup of tea, extend the tea pot towards the cup and touch it lightly before pouring. It is easier to come at the cup front-on rather than swiping at it from the side List of Figures xxxiii

Fig. 10.9 Hearing alone will not prevent you from being run down when crossing the road, and you should get into the habit of looking carefully to each side before stepping out Fig. 10.10 The pattern of light on a wall changes as you approach and can be used as a measure of how close you are when parking Fig. 10.11 The socket may be cleansed with a syringe without removing the prosthesis Fig. 10.12 Removing a patient’s prosthetic eye. The caregiver’s forefi nger slides the lower eyelid under the prosthesis while the patient is looking upwards Fig. 10.13 Rubber suction cups make it easier to remove and insert prosthetic eyes Fig. 10.14 For orientation, the sharpest and/or pinkest point (indicated by the arrow ) is positioned towards the nose Fig. 10.15 Removing your prosthesis. Look upwards and roll the prosthesis upwards taking the top eyelid with it (Left ). The forefi nger of the free hand then slides under the prosthesis and levers it out (Right ) Fig. 10.16 Inserting your prosthesis. Look downwards and use your fi nger to hold the upper eyelid up while the prosthesis is inserted under it and held Fig. 10.17 The coatings and fi lms that build up on prosthetic eyes behave similarly to biofi lms found commonly in nature – e.g., the algal slime on the sea wall shown here Fig. 10.18 Some of the features to look for when selecting glasses Fig. 10.19 Support and information for prosthetic eye wearers is available from a number of organisations and books Fig. 11.1 The Eye of Horus was part of an ancient Egyptian system for measuring fractions Fig. 11.2 An Eye of Horus amulet. The Eye of Horus is a powerful symbol of protection in ancient Egypt Fig. 11.3 The earliest known prosthetic eye was found buried with a woman in Shahr-I Sokhta, Iran Fig. 11.4 Prosthetic eyes for the dead helped Egyptians ‘see’ when they entered the after-life Fig. 11.5 Egyptian sarcophagi often had eyes made by fi lling bronze eyelids with plaster and inserting irises of onyx Fig. 11.6 This statue of Athena, Goddess of wisdom, war and the crafts, and favourite daughter of Zeus has glass eyes Fig. 11.7 Ambroise Paré (1510–1590) illustrated this prosthesis in his 1614 book Fig. 11.8 In the sixteenth century, prosthetic eyes worn inside the socket were made from gold or silver, with coloured enamel coatings Fig. 11.9 In about 1710, William Boyse was succeeded by his son-in-law, James Smith, seen here holding a glass eye Fig. 11.10 In 1752, Dr. Heister of Nuremberg, recorded that he would prefer glass eyes to metal eyes because metal eyes repelled tear fl uid and lost their brightness xxxiv List of Figures

Fig. 11.11 Illustrations from Hazard-Mirault’s book entitled Traité pratique de l’oeil artifi cial published in 1818. Removing a prosthetic eye with an ocular hook (left ) and re-inserting it (right ) Fig. 11.12 Extracts from Chapter XV of William Mackenzie’s A practical treatise on the diseases of the eye – January 1, 1830, London (Longman, Rees, Orme, Brown, & Green. M.DCCC.XXX) Fig. 11.13 This article provides an entertaining and informative description of European ocular prosthetics in the late eighteenth to early nineteenth centuries Fig. 11.14 Auguste Boissonneau’s patent claimed the idea that separate right and left prosthetic eyes could be replaced by a prosthesis with a form that served both sides Fig. 11.15 Friedrich Philipp Ritterich established the glass eye industry in Germany Fig. 11.16 Ludwig Müller-Ur (1811–1888) developed the cryolite glass eye Fig. 11.17 This broken ‘Reform’ eye illustrates its form Fig. 11.18 Glass blowing instruments and materials laid out on a workbench Fig. 11.19 Callipers set to measure the dimensions of the prosthesis. Also glass rods of various colours Fig. 11.20 Instruments for handling glass eyes Fig. 11.21 Glass eye prescription form Fig. 11.22 The glass eye process begins by softening a pre-tinted hollow glass tube Fig. 11.23 The tube is then sealed at one end and ‘blown’ to its correct size Fig. 11.24 Coloured glass rods are melded into the body of the eye to create the iris Fig. 11.25 A partially made eye together with glass rods of various colours including black Fig. 11.26 Creating the pupil Fig. 11.27 A partially fi nished glass being compared with a completed one Fig. 11.28 The softened glass is moulded under negative pressure to create a hollow posterior surface Fig. 11.29 The fl ame is used to smooth out the posterior aspect of the eye Fig. 11.30 Preformed glass eyes are demonstrating some of the steps during manufacture Fig. 11.31 Phillip Henry Mules’ obituary appeared in the British Medical Journal in 1905 Fig. 11.32 A tray of assorted glass eyes imported from Germany by Peacock Optometrists who practised in Auckland in the early 1900s Fig. 11.33 This article comments on the glass eye industry in England early in the twentieth century Fig. 11.34 Prosthetic eyes have always been an easy target for black humour Fig. 11.35 A page from Dr. Robert Coulomb’s 1905 book entitled L’oeil artifi cial Fig. 11.36 Moveable eye article featured in the December 1948 issue of Life Magazine Fig. 11.37 Mid-twentieth-century ordering kit for plastic artifi cial eyes List of Figures xxxv

Fig. 11.38 Late twentieth-century custom-made PMMA eye Fig. 11.39 German glass eyes became unavailable at the start of World War II Fig. 11.40 Early twentieth-century stock glass eyes Fig. 11.41 Manufacturing PMMA prosthetic eyes using dental equipment and materials. Two prosthetic eyes formed with red denture wax are seen here invested in a denture fl ask Fig. 11.42 These organisations promote the professional development of ocular prosthetists by hosting conferences and disseminating information about prosthetic eyes Fig. 11.43 An optometry student at the University of Auckland adds artifi cial tears to PMMA samples to test protein adherence to prosthetic eyes Fig. 11.44 Thin glass lenses with a white body and clear corneal centres with variable optics Fig. 11.45 Adolf Fick created the fi rst scleral shell prosthesis

List of Tables

Table 1.1 Approximate number of prosthetic eye wearers in various countries Table 1.2 Ratios of men to women whose eye loss was due to accidents from 1960 to 2010 Table 5.1 Overview of prosthetic eye making and ﬁ tting Table 5.2 Trade-offs that must be resolved during the positioning of the iris/corneal unit and shaping of the wax prosthesis Table 6.1 Overview for thin scleral shell making and ﬁ tting Table 7.1 Socket complications broadly listed in descending order of importance Table 7.2 Socket complications are listed in descending order of importance

xxxvii

About the Authors

Keith R. Pine , BSc (Psych), PhD (Optom), MIMPT trained as a dental techni- cian before obtaining his advanced certiﬁ cate in maxillofacial technology through the City and Guilds of London programme and specialising in maxillofacial prosthetics. He founded a commercial dental laboratory in 1976 and over the next 27 years transformed it into Australasia’s largest private dental practice (now Lumino the Dentists) employing over 100 professional staff. After selling the practice in 2003, he established the New Zealand Artiﬁ cial Eye Service where he currently works as an ocular prosthetist. He is a research fellow with the School of Optometry and Vision Science, University of Auckland, and a member of the Institute of Maxillofacial Prosthetists and Technologists in the UK.

Robert J. Jacobs , MSc, PhD Melb. LOSc, FAAO, FACO is a fellow of the American Academy of Optometry, a fellow of the Australian College of Optometry, an honorary member of the New Zealand Association of Optometrists, an associate editor of the journal Clinical and Experimental Optometry and a director of the Optometry Council of Australia and New Zealand. He is currently the academic director of the Bachelor of Optometry programme in the Faculty of Medical and Health Sciences at the University of Auckland.

Brian H. Sloan , MB ChB, MHB (Hons), FRANZCO had his general ophthalmic training in New Zealand, followed by fellowships in the subspecialty of oculo- plastic, lacrimal and orbital surgery in Melbourne, Australia; Cincinnati, Ohio, USA; and Vancouver, Canada. He currently works in both private and public prac- tices, training ophthalmic registrars and international oculo-plastics fellows. He is an honorary senior lecturer in the University of Auckland Department of Ophthalmology, a senior inspector of training posts for the Royal Australian and NZ College of Ophthalmologists (RANZCO), president of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons, and the immediate past chairman of the RANZCO NZ branch Qualiﬁ cations and Education Committee.

xxxix

Glos sary

Abduct Movement away from the midline of the body Accommodation The act of changing the focus of the eye so that near objects can be seen clearly Acinar Of acini Acini A lobule of a gland such as the lacrimal gland Acrylic A common name for (poly) methyl methacrylate Adduct Movement towards the midline of the body Adenoid A mass of lymphatic tissue situated above the tonsils behind the nose Adnexal tissue (adnexae) The tissues around the eye and related to it. Includes the eyelids, lacrimal system, extra-ocular muscles and orbital fat Aerial perspective (atmospheric perspective) Is where distant objects appear duller and bluer than close objects and have less contrast Albinism A genetic condition that prevents the body from producing melanin which gives color to hair, skin and the iris of the eye Allergen A substance that can cause an allergic reaction Allergic reaction A reaction of the immune system to normally harmless substances in the environment Alloplastic materials Inorganic, non- biological materials Aluminium oxide paste An abrasive with specifi ed particle sizes used in polishing a variety of materials Anaplastology A branch of medicine that deals with the prosthetic rehabilitation of the face or body and includes the design and manufacture of orbital, nasal, ocular and aural prostheses Aniridia Absence of the iris Annulus of Zinn A circular band of fi brous tissue surrounding the optic nerve at the orbital apex Anophthalmia The absence of one or both eyes. Complete absence of the eyeball Anterior In front Anterior lamellar defi ciency In eyelid reconstruction, the anterior lamella is the skin and orbicularis muscle (see posterior lamellar) Antibody A protein produced by the immune system when it detects harmful substances

xli xlii Glossary

Antigen A substance that stimulates the production of an antibody as part of the immune response. Examples of antigens include bacteria, fungi, parasites, viruses and chemicals Aphakia Absence of the lens Aponeurosis Broad tendons in a layered formation Arbor band An abrasive band that fi ts over a rubber wheel attached to a dental lathe – used for grinding Arcus-senilis An opaque ring that forms around the edges of the cornea and makes the periphery of the iris appear pale Artifi cial eye A device that stimulates neural impulses to help a blind person to see. Another name for an ocular prosthesis Asepsis The absence of living pathogenic microorganisms Auricular Of the ear Autogenous tissue Derived from an individual’s own tissue Autologous bone Bone obtained for transplant from an individual’s own body Bacteriologic Of bacteriology Bacteriology A branch of microbiology which involves the study of all microorganisms including bacteria and viruses Binocular cues to depth Information about depth perception using two eyes Binocular vision Two-eyed vision Biosocial The combination and interaction of social and biological characteristics Biosocial profi le Biosocial characteristics of an individual or population Blepharitis A chronic infl ammation of the eyelid margins caused by staphylococ- cus infection or a skin condition such as seborrheic dermatitis (dandruff) Body image An emotional response to the way patients see themselves and how they appear to others when their appearance changes Bulbar Bulblike. In medicine, a rounded mass of tissue like the eyeball Bulbar conjunctiva The area of conjunctiva covering the eyeball Canthal tendons The lateral and medial canthal tendons connect the eyelids to the orbital rim Canthus Where the upper and lower eyelids meet at either side of the eye (inner and outer canthi) Capsulopalpebral fascia The fascia at the junction of the upper and lower eyelids at the medial and lateral canthi Caruncle The small fl eshy tissue at the medial (inner) corner of the eye Cataract Clouding of the crystalline lens inside the eye Chroma The purity or saturation of a colour Cicatricial Of cicatrix Cicatrix A scar left by the formation and contraction of new fi brous tissue over a fl esh wound CMYK subtractive color system A colour system in which all colours are described as a mixture of C yan, M agenta, Y ellow and B lack. CMYK is the standard colour system used in offset printing. The colours can be thought of as blocking Red, Green, Yellow and White. Cold cure PMMA A PMMA that is self curing – it does not require heat for polymerization to take place Collarette (of the iris ) The region of the iris that immediately surrounds the pupil Glossary xliii

Concha (of the nose) Shell-like turbinate bones that protrude into the nasal cavity Conformer A clear PMMA shell inserted into the socket to preserve the fornices after eye enucleation Congenital Present at birth Conjunctiva Thin, transparent tissue that covers the inside of the eyelids and the sclera Conjunctivitis I n fl ammation of the conjunctiva caused by infection or irritation Contrast sensitivity The ability to distinguish different shades of grey; distin- guishing between black from white only requires low contrast sensitivity; distin- guishing between very similar shades of grey requires high contrast sensitivity Convergence (of eyes) Where the two eyes turn in so that the lines of sight align on the same object Cornea The clear domed window covering the iris and pupil Corneal dystrophy A hereditary disorder of both eyes which appears as a greyish white or crystalline clouding of the cornea Corneal leucoma An opaque white patch present in the cornea Corneal limbus The junction between the cornea and sclera of the eye Cosmesis Physical appearance that has been either preserved, restored or enhanced Cosmetic contact lens A contact lens that alters the appearance of the iris when worn Crazing A network of hairline cracks in the surface of a material Creutzfeldt-Jakob Disease An incurable degenerative disease that progressively affects the brain. It is caused by an infectious protein Curvilinear perspective Where parallel lines become curved at the outer extremes of the visual fi eld Cyanoacrolate adhesive An instantly setting contact adhesive (also known as super glue) Cyclotorsion Rotation of an eye around its visual axis. Cyclotorsion allows binocular vision to be maintained when the head is tilted Cytological Of cells Cytoplasm The contents of a cell excluding the nucleus Dehiscence Splitting open of tissue, e.g. a wound splitting open Delamination The separation of layers Depress To pull or push something down Dermis The deeper layer of the skin below the epidermis Detached retina A serious eye condition where the retina separates from the tissue and blood vessels supporting it Diabetes A disease that causes poor control of sugar levels in the bloodstream Dry eye syndrome A chronic condition caused by inadequate moisture on the surface of the eye Ectropion Outward rotation of the eyelid margin away from the surface of the eye or prosthesis Edema Swelling due to build- up of fl uid in the tissue Ekblepharon A prosthetic eye worn outside the socket Elevate Raise Endophthalmitis I n fl ammation (usually caused by infection) of the anterior and posterior segments of the eye xliv Glossary

Enophthalmos A backward displacement of the eye Entropion Inward rotation of the eyelid margin towards the surface of the eye or prosthesis Enucleation Removal of the entire eye Eosinophil A specialised white bloodcell – part of the immune system Epidemiology The study of health and disease characteristics in defi ned populations Epidermis The superfi cial layer of skin Epiphora Spilling/overfl ow of tears onto the cheek Epithelial cells Cells that line the surfaces of the body including the skin and all internal cavities Epithelial substrate The tissue underlying the epithelium Epitheliopathy Disease that involves the epithelium Epithelium The tissue that lines the surface of the body including the skin and all internal cavities Equilibrium A state of balance Ethmoid Denoting or relating to the bone that separates the nasal cavity from the brain and the ocular orbits Ethmoid sinuses Air-fi lled cells within the ethmoid bone Aetiology Cause Everted Turned outwards Evisceration Removal of the contents of the eye, leaving only the scleral shell with or without the cornea Excyclotorsion Rotation of the 12 o’clock position of the cornea away from the midline Exenteration Removal of the eye and a variable amount of orbital and adnexal tissue Exfoliate To cast off dead skin cells Exophthalmos Forward displacement of the eyeball Ex situ Off site Extraocular muscles The six muscles that move the eye Fascia The biological fabric or connective tissue that holds the body together Fascia lata Deep fascia in the thigh and buttocks region Fenestration A hole penetrating a surface Fibromyalgia Chronic widespread pain in muscles and joints Fibrosis Excess fi brous connective tissue in an organ or tissue Fibrovascular Fibres and conducting cells together, and accompanied by a blood supply Fissure A narrow, long opening, a crack Fluorescein dye An orange solution that is taken up by damaged cells of the epithelium and that pools in irregularities on the surface of the eye. It glows green (fl uoresces) when illuminated with a blue or ultraviolet light Foramen An opening or passage (usually through bone) Forniceal Of the fornix Fornix (fornices) The area where the epithelial tissue lining inside of the eyelids joins epithelial tissue covering the globe Fossa A depression or hollow (usually in bone) Glossary xlv

Fourier-domain optical coherence tomography (FD OCT) An imaging technique that uses a broadband light source to obtain microscopic three-dimensional images of living tissue Giant papillary conjunctivitis (GPC) Conjunctivitis where associated papillae (lumps or protruberances) are larger than 1 mm diameter Glaucoma Damage to the optic nerve that causes painless loss of vision and that is treated by lowering the pressure in the eye Glycocalyx A polysaccharide or glycoprotein covering on the surface of cells Glycoproteins A molecule made up of a protein plus a carbohydrate Glycosylated Where carbohydrates are chemically attached to proteins to form glycoproteins Goblet cells Specialized epithelial cells that secrete mucus Goniometer An instrument used for measuring angles Gram-negative bacteria Bacteria that have a cell wall composed of a thin layer of peptidoglycan Granuloma An infl ammatory mass Gundersen fl ap procedure A surgical procedure that involves laying a fl ap of conjunctival tissue over the cornea Heterochromia Colour difference between the two eyes of the same individual Homeostasis The body’s tendency to seek and maintain a state of equilibrium within itself even when changes occur externally Homologous bone Bone inherited from a common ancestor, e.g. bovine bone is homologous with human bone (compare with autologous bone) Hue Colour or shade Hydrogel contact lenses Contact lenses made from material containing a propor- tion of water molecules Hydrophilic Attracting water Hydrophobic Repelling water Hydroxyapatite A coral-like material used for orbital implants Hyperkeratinisation An excess of keratin in the surface layers of the skin Hypoblepharae Prosthetic eyes worn inside the socket Image blurring Objects in focus blur at the extremes of the visual fi eld Impression A negative mould Inclusion cyst A cyst formed by the inclusion of displaced epithelial cells within connective tissue Incyclotorsion Rotation of the 12 o’clock position of the cornea towards the midline Inferior Below or lower In situ In place or in position Integrated orbital implant Implants made from hydroxyapatite or porous poly- ethylene. They allow fi brovascular ingrowth Inter-palpebral zone The area between the margins of the upper and lower eyelids when the eye is open Interposition A near object covers part of a distant object Intraconal space The cone-shaped space inside the orbit behind the eye. It is bounded by the extraocular muscles which run towards the back of the orbit to form the apex and by the back half of the globe xlvi Glossary

Intractable Not able to be treated or managed In vivo Within living tissue Involutional A decrease in size or a decline of function associated with the ageing process Ionicity Relating to ions which are atoms that have an electrical charge Iridectomy A surgical procedure to remove part of the iris Iris coloboma A congenital condition resulting in a keyhole-shaped pupil Keratin The main material making up the outer layer of human skin, hair and nails Keratoconjunctivitis sicca Dry eye syndrome Lacrimal Relating to tears Lacrimal gland A tear-producing gland Lacrimal punctum The small opening on the lid margin through which tears begin to drain from the eye Lactoferrin A protein found in tears that may have an anti-inﬂ ammatory function Lagophthalmos Inability to fully close the eyelids Lamellae Thin plate-like structures lying close together Lateral Away from the midline, outer (opposite of medial) Limbus The border between the cornea and the sclera Lipids Organic fatty molecules Lissamine green dye A yellowish green dye that highlights membrane-damaged or dead cells Lymphocytes A type of white blood cell Lymphoid Of lymphocytes, a type of white blood cell or tissue in which lymphocytes develop Lysozyme An enzyme found in tears. It provides a degree of protection against certain gram-positive bacteria Mandible Lower jaw bone Marx’s line The natural site of frictional contact between the eyelid margin and the surface of the eye Mast cells Cells found in connective tissue. They release substances such as hepa- rin and histamine in response to injury or inﬂ ammation Matrix porosity A matrix is the structure or frame surrounding empty spaces. Porosity is the fraction of space in a porous material made up by the empty spaces Maxilla Upper jaw bone Meatus Opening Medial Closer to the midline (opposite of lateral) Meibomian gland dropout The absence or loss of meibomian glands Meibomian glands Oil-secreting (sebaceous) glands found in the eyelids Meningioma A tumour that originates in the membranes (meninges) that surround the brain and spinal cord Meniscus The curve in the surface of a liquid when it is adjacent to another surface Metabolic Of metabolism Metabolism The biochemical processes that occur within a living organism Microphthalmia An underdeveloped or small eye Glossary xlvii

Microvilli Microscopic folds on the surface of some cells Morbidity A diseased state Motility Movement Motion parallax A depth cue whereby the relative movement of superimposed or overlapping visual images is used to work out which object is further away or closer and by how much Mucin Mucins are a family of proteins that is the main constituent of mucus Mucocutaneous The area of transition between mucosa (mucous membranes) and skin Mucoid discharge Mucus produced by goblet cells in response to irritation of the eye or socket Muco-purulent discharge Discharge containing mucus and pus Mucormycosis An infection caused by Mucorales fungi Mucus substrate A network of mucus formed by conjunctival goblet and epithelial cells Nasal Of the nose Nasolacrimal drainage system The system that drains tears from the eye to the nasal cavity Nasolacrimal duct The tear duct connecting the lacrimal sac with the nasal cavity Neovascularisation Where new blood vessels are formed, e.g. where conjunctival or scleral blood vessels grow into the cornea Obstructive meibomian gland dysfunction Blocked meibomian glands Occipital Of the occiput, which is the knob-like protruberance at the back of the skull Ocularist Ocular prosthetist Orbit The bony cavity that houses the eye Orbital implant An implant that is placed in the socket at the time of eye enucleation or evisceration Orbital prosthesis A facial prosthesis that restores the eye and eyelids Palatine bones The two bones forming the posterior third of the hard palate in the mouth Palpebral Relating to the eyelids Palpebral ﬁ ssure The oval aperture between the open eyelids Papilla Small nipple-like protuberance Parietal bone A bone situated at the side of the skull behind the frontal bone Patency The state of being open or unblocked Periosteum The tissue lining bone pH homeostasis The body’s tendency to maintain blood pH within a narrow range Phenol red thread test A method for measuring tear production where an impregnated thread changes colour when wetted with tears Phenol red (phenolsulfonphthalein) A pH indicator used in disclosing whether a thread has been wetted by tears Photochromic lenses Lenses that darken in sunlight and lighten in shade Photophobia Intolerence of light Phthisical Of phthisis. Shrunken xlviii Glossary

Phthisis Shrinkage of the globe and cornea Plica semilunaris The fold of conjunctiva in the inside corner of the eye Plication The act of folding a structure to shorten it (Poly) methyl methacrylate (PMMA) A plastic material used for denture bases and prosthetic eyes Polymerization Where small molecules join together to make long chains of molecules called polymers Polyvinylsiloxane A silicone elastomer used as an impression material Posterior Behind, to the rear (opposite of anterior) Posterior blepharitis Blepharitis affecting the meibomian glands and the inside of eyelid margins Posterior lamella In eyelid reconstruction, the posterior lamella is the tarsus and conjunctiva Post-traumatic stress disorder (PTSD) A state of severe depression and anxiety that may occur in people who have survived or seen a traumatic event Pre-septal In front of the orbital septum Pre-tarsal In front of the thick plate of connective tissue (tarsus) that gives shape to the eyelids Primary orbital implant An orbital implant placed at the time the eye is removed Processed acrylic Polymerized poly(methyl methacrylate) Prolapse To fall forwards and downwards Prosthesis A device that by design or function replaces a part of the body Prosthetic contact lens A contact lens that masks a disﬁ gured iris and/or improves eye comfort Prosthetic eye A prosthesis that restores the appearance of the eye and the function of the eyelids following eye loss Proteins Large, complex biological molecules that perform a wide variety of vital functions within living cells Protract To pull forwards Psychological Relating to the mind Psycho-social Pertaining to the relationship between social factors and individu- als’ behaviour and thought Ptosis An abbreviation of blepharoptosis – drooping of the upper eyelid Purulent Containing pus Recession (of eyelids) The state of being recessed or set back Rectus muscles The main four muscles controlling movements of the eye Resection The surgical removal of part or all of a biological structure Retina The layer of light-sensitive tissue that lines the back of the eye Retinal disparity Where objects are projected onto each eye at different angles Retinoblastoma A malignant tumour arising from the retina. It may be present at birth or may occur in the ﬁ rst few years of life Retract To pull back Retro-palpebral zone The part of a prosthetic eye that is in continuous contact with the conjunctiva Rigid gas permeable (RGP) contact lens A rigid contact lens that allows oxygen to permeate through it Glossary xlix

Rose Bengal A bluish red dye that highlights damaged conjunctival or corneal cells Scanning electron microscope A type of electron microscope that produces 3D images of an object by scanning it with a focused beam of electrons Schirmer tests The Schirmer tests (I and II) are used for measuring tear volume. Version II of the test is when a local anaesthetic is administered before the test Sclera The outer white casing of the eye made of collagen and elastic fi bres Scleral contact lens Contact lenses that extend over the sclera as well as the cornea Scleral shell prosthesis A prosthesis that fi ts over an existing disfi gured eye Sebaceous Secreting fat or sebum Secondary orbital implant An orbital implant that is placed at a separate operation after the removal of the eye Shade The base colour added to black Shadow stereopsis The use of shadows as a cue to steroscopic depth perception Shellac baseplate A thermoplastic material used in sheet form to support and strengthen wax shapes Sinus An air-fi lled pocket located in the skull Sjögren’s syndrome An auto-immune disorder which dries the eyes, mouth and other parts of the body Slit lamp biomicroscope A common ophthalmic instrument for examining under magnifi cation the eyelids and the anterior and posterior segments of the eye Sphenoid bone A compound bone located behind the eyes. It forms the base of the cranium Squamous cell carcinoma A form of skin cancer that develops in the squamous (fl attened) cells of the epidermis Stevens-Johnson syndrome A rare disorder of the skin and mucous membranes which may be a hypersensitive reaction to infection or medication Strabismic A condition where the direction of gaze of one eye does not align with that of the other. Sometimes termed turned eye, squint or wall eye. Stroma of the iris The fi bres that interlace throughout the upper layer of the iris Subperiosteal Located between the bone and its covering tissue (the periosteum) Subperiosteal implant An implant placed in the subperiosteal space on the fl oor of the orbit. Used to restore lost orbital volume Sulcus A groove or furrow Superior Overlying, above Superior sulcus The sulcus above the eye (upper eyelid sulcus) between the skin on the upper eyelid and the skin of the eyebrow Suppurate Fester, form pus Surfactant A substance that reduces the surface tension of water Sympathetic ophthalmia I n fl ammation in one eye caused by the immune system’s reaction to injury of the other eye Synergy An interaction that produces a whole that is better than the sum of its parts Synovial fl uid Viscous fl uid found in joints Tarso-conjunctiva The tarsus and its tightly adherent conjunctiva Tarsorrhaphy Suturing the eyelids together l Glossary

Tarsus A plate of dense connective tissue that gives shape to the eyelids Tear break-up time test (TBUT) A measurement of the time it takes for the tear fi lm to break up after blinking Tear ferning test A clinical test to measure the tear quality. A tiny drop of tear fl uid placed on a glass slide is allowed to dry, and the patterns of dried material are examined Tear meniscus The strip of tear fl uid that forms along the inner edges of the upper and lower eyelid margins. Sometimes called the tear prism Temple The name given to the arms on each side of a pair of glasses Temporal Of the temple area of the head Tenon’s capsule The fascial layer of connective tissue that encapulates the globe from the limbus to the optic nerve Texture gradient One of the cues to depth perception that does not rely on binocular vision. An example is where fi ner details can be seen more clearly on close objects Tint The base colour added to white Tone The base colour added to grey Trabeculae The strands of connective tissue that support or anchor other tissues Tripoly An abrasive impregnated wax bar commonly used for polishing dentures Trochlea of the superior oblique A u-shaped pulley made of fi bro-cartilage through which the tendon of the superior oblique muscle passes Value The lightness or darkness of a colour, is a measure of the amount of light refl ected from its surface (refl ectance). Vascular Containg vessels that carrry fl uids Veneer Outer covering Vernal keratoconjunctivitis A seasonal allergic eye disease that infl ames the conjunctiva and especially affects young males Visual analogue scale A rating scale used in questionnaires. The respondent views a line that represents the range of possible responses and where the ends of the line represent the lowest and highest responses. The respondent places a mark on the line to indicate their response. The position of the mark is measured to provide the numerical response. Visual fi eld All that can be seen at any one time without moving the eye or eyes Visual range The width or sometimes the depth of the visual fi eld Vital dye A dye used for staining living cells Vitreo-retina surgery Surgery to treat problems inside of the eye, e.g. detached retina Vomer A fl at bone that makes up part of the nasal septum Vulcanite A hard black rubber that is more durable than natural rubber. Vulcanite is produced by a chemical process called vulcanization, where natural rubber is treated under heat with large amounts of sulphur Zygomatic bone Cheek bone