Prosthetic guidelines for ocular rehabilitation in patients with phthisis bulbi: A treatment-based classification system Himanshi Aggarwal, MDS,a Raghuwar D. Singh, MDS,b Pradeep Kumar, MDS,c Sanjiv K. Gupta, MS,d and Habib A. Alvi, MDSe King George’s Medical University UP, Lucknow, India Prosthetic rehabilitation of phthisis bulbi defects is the only treatment option for cosmetic rehabilitation of patients with such defects. Currently, there is no treatment-based classification for prosthetic rehabilitation of patients with phthisis bulbi. Phthisical ocular defects and/or prosthetic rehabilitation were evaluated in an attempt to establish prosthetic guidelines that could be organized into a classification system. Fifty patients who received rehabilitation for phthisis bulbi were reviewed. Phthisis bulbi defects were divided into 4 classes. All the patients had rehabilitation, depending upon the class to which they were assigned. The aim of this treatment-oriented classification system was to organize and define the complex nature of the restorative decision-making process for patients with phthisis bulbi. (J Prosthet Dent 2014;-:---) Eyes are sensitive structures and exhibit profound inflammatory response to noxious and irritating stimuli. Wound healing secondary to causes such as severe trauma, failed surgical procedures (cataract, glaucoma, retinal surgery), infections and inflammation (keratitis, uveitis, endophthalmitis), avitaminosis A, and intraocular malignancies (choroidal melanoma, retinoblastoma) as well as systemic cardiovascular diseases (diabetes, hypertension) may result in an ocular condition known as phthisis bulbi.1,2 The term phthisis bulbi derives from the Greek word phthiein or phthinein, meaning shrinkage or consuming, and was first used by Galen.3 Over the past 200 years, the clinical interpretation of phthisis bulbi has often been modified according to the underlying disease and structural changes; a clear distinction from ocular atrophy was often difficult and controversial.4 Hogan and Zimmerman5 in 1962 were the first ones who stated that both terms, atrophy and phthisis bulbi, refer to consecutive stages in the degeneration process of a severely damaged eye. a
Prosthetic rehabilitation over the residual eyeball is the preferred treatment of choice over surgical intervention such as enucleation or evisceration.6 Defect classification systems consider the various parameters that influence the rehabilitation process. Hogan and Zimmerman5 proposed a defect classification system that presented the various stages of phthisis bulbi based on the structural changes in the eye globe: ocular atrophy (1) without shrinkage, (2) with shrinkage, and (3) with shrinkage and disorganization. This classification has been further modified by Yanoff and Fine.7 All the previous classifications are either morphology or histology based. However, there is no treatment-based classification for prosthetic rehabilitation of patients with phthisis bulbi. There is no differentiation made for maxillofacial prosthetists and ocularists on varying the prosthetic treatmentbased on different stages of phthisis bulbi. New prosthetic guidelines that relate to various stages of phthisis bulbi seem to be mandated as a result
Senior Resident, Department of Prosthodontics. Associate Professor, Department of Prosthodontics. c Senior Resident, Department of Prosthodontics. d Associate Professor, Department of Ophthalmology. e Professor, Department of Prosthodontics. b
Aggarwal et al
of recognition of different classes of phthisis bulbi, depending upon its severity. Major factors in the prosthetic rehabilitation decision-making process include whether there is normal or disfigured sclera; no enophthalmos or mild, moderate, or severe enophthalmos and the condition of associated surrounding structures; and how these factors influence the prosthetic rehabilitation treatment process. The purpose of this treatment-oriented classification system was to organize and define the complex nature of the restorative decisionmaking process for the patient with phthisis bulbi.
CLASSIFICATION SYSTEM To assess the influence of variable presentations of phthisis bulbi on the prosthetic rehabilitation, a classification system of defects based on a selected patient population was developed. A review of 50 patients with phthisis bulbi was performed after obtaining approval from the ethics committee of the King George’s Medical
2
Volume University UP, Lucknow, India. All of the patients reviewed were prosthetically rehabilitated. The various parameters that influenced the prosthetic rehabilitation included (1) condition of cornea, (2) contour and color of sclera, (3) degree of enophthalmos, (4) presence of corneal sensitivity, and (5) condition of associated contiguous structures. Based on the evaluation of the various previously described parameters, phthisis bulbi defects were divided into 4 major classes and 2 subclasses of class I and class II as follows: Class I. Corneal opacity with no enophthalmos and normal sclera. Class II. Corneal opacity with mild enophthalmos and normal sclera. Class III. Moderate enophthalmos with disfigured sclera.
Class IV. Severe enophthalmos with disfigured sclera and loss of orbital fat. Classes I and II were further subdivided based on the presence of corneal sensitivity, into subclass “a” (without corneal sensitivity) and subclass “b” (with corneal sensitivity). All the variable presentations of phthisical eyes fall within these 4 categories. Based on the class to which the particular patient belongs, the prosthodontists and/or the ocularists can plan the treatment according to the proposed guidelines. Ocular defects that produce corneal opacity with no enophthalmos and normal sclera without corneal sensitivity were categorized as class Ia (Fig. 1). Simple prosthetic and/or cosmetic lens was sufficient to achieve the desired esthetics. Class Ib includes ocular defects that produce corneal opacity with no enophthalmos and normal sclera with
1 Class I ocular defects with corneal opacity.
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corneal sensitivity. It was required to minimize the corneal sensitivity so that the patient could be able to tolerate the prosthesis. Therefore, before proceeding with the rehabilitation, certain surgical or nonsurgical modalities, such as Gunderson flap, mucous membrane grafting, amniotic membrane grafting, use of atropine and steroid combination, and anterior stomal puncture, should be used to minimize the sensitivity. After reducing the corneal sensitivity, the same treatment could be planned as described in Class Ia. Class IIa includes ocular defects that produce corneal opacity with mild enophthalmos and normal sclera without corneal sensitivity (Fig. 2A, B). To compensate the enophthalmos, certain thicknesses of materials such as polymethyl methacrylate or silicone are needed for enhancing the bulk. Therefore, fabrication of a transparent acrylic resin or silicone sclera shell is recommended for these types of defects. Class IIb includes ocular defects that produce corneal opacity with mild enophthalmos and normal sclera with corneal sensitivity. The same procedure described in Class Ib could be applied to minimize the corneal sensitivity before fabrication of ocular prosthesis, as mentioned in Class IIa. Class III includes ocular defects that produce moderate enophthalmos with disfigured sclera (Fig. 3A, B). Prosthetic management of these types of ocular defects required an ocular prosthesis or scleral shell, with the scleral and iris shade
2 A, B, Class II ocular defects, showing corneal opacity with mild enophthalmos and normal sclera.
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3 A, B, Class III ocular defects, showing moderate enophthalmos with disfigured sclera.
4 A, B, Class IV ocular defects, showing severe enophthalmos with disfigured sclera and loss of orbital fat.
Table I.
Classification
Class
Condition
Treatment
Ia
Corneal opacity with no enophthalmos and normal sclera without corneal sensitivity
Simple prosthetic and/or cosmetic lens
Ib
Corneal opacity with no enophthalmos and normal sclera with corneal sensitivity
Simple prosthetic and/or cosmetic lens after reducing the corneal sensitivity
II a
Corneal opacity with mild enophthalmos and normal sclera without corneal sensitivity
Clear or transparent acrylic resin or silicone sclera shell
II b
Corneal opacity with mild enophthalmos and normal sclera with corneal sensitivity
Clear or transparent acrylic resin or silicone sclera shell after reducing the corneal sensitivity
III
Moderate enophthalmos with disfigured sclera
Ocular prosthesis or scleral shell
IV
Severe enophthalmos with disfigured sclera and loss of orbital fat
Ocular prosthesis or scleral shell after performing additional procedures such as dermal lid fillers or eyelid surgeries
Aggarwal et al
matched with that of the contralateral eye of the patient. Class IV includes ocular defects that produce severe enophthalmos with disfigured sclera and loss of orbital fat (Fig. 4A, B). Because there is severe enophthalmos with associated loss of orbital fat, an ocular prosthesis or scleral shell alone will not suffice for optimum esthetic outcome. In these complex situations, additional procedures such as dermal lid fillers or eyelid surgeries are mandatory to achieve optimum esthetics, before fabricating an ocular prosthesis. The proposed classification at a glance is shown in Table 1.
DISCUSSION The phthisis bulbi classification system presented was based on clinical experience, which was used to establish
4
Volume a guideline for esthetic rehabilitation of patients with pthisis bulbi. All previous classifications are either morphology or histology based. The classification system purposed by Hogan and Zimmerman for various stages of phthisis bulbi was based only on the structural changes in the eye globe. The proposed new treatment-based classification system might provide a methodology to enroll larger patient numbers from multiple institutions to study the severity of phthisis bulbi and its implication on the mode of prosthetic rehabilitation. Class I defects are the simplest type of defect, which can be easily rehabilitated to achieve the desired esthetics. From class I to class IV, the extent of severity of phthisical defect increases, thereby making the prosthetic rehabilitation more and more challenging for the ocularists and maxillofacial prosthetists. Several major factors that must be considered during prosthetic rehabilitation of phthisis bulbi have been included, but all the factors or the cause of phthisis bulbi are not addressed
by the proposed classification system. Other associated defects of eyelids and contiguous structures may affect the options related to restorative care. Similarly, a range of patient factors may influence the rehabilitation approach, such as age, comorbidities, prior surgery and/or radiation, patient motivation, and financial considerations.
SUMMARY Comprehensive treatment planning is necessary to meet multidisciplinary objectives for patients with complex reconstructive and rehabilitative needs. The defect-oriented treatment based approach of the proposed system is intended to facilitate and coordinate treatment planning among ocularists and maxillofacial prosthetists.
REFERENCES
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Issue
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2. Hadjistilianou T, Francesco S, Marconcini S, Mastrangelo D, Galluzzi P, Toti P. Phthisis bulbi and buphthalmos as presenting signs of retinoblastoma: a report of two cases and literature review. Eur J Ophthalmol 2006;16: 465-9. 3. Stefani FH. Phthisis bulbi-an intraocular fluoride proliferative reaction. Dev Ophthalmol 1985;10:78-160. 4. von Graefe A. Ueber essentielle Phthisis bulbi. Arch Ophthalmol 1883;12:256-64. 5. Hogan MJ, Zimmerman LE, eds. Ophthalmic pathology. An atlas and textbook, 2nd ed. Philadelphia: WB Saunders; 1962. p. 168-221. 6. Naveen HC, Porwal A, Nelogi S. Prosthetic rehabilitation of phthisis bulbi by digital imaging technique. A case report. Cont Lens Anterior Eye 2010;33:231-4. 7. Yanoff M, Fine BS. Ocular pathology. 5th ed. St Louis: Mosby; 2002. p. 72-3. Corresponding author: Dr Raghuwar Dayal Singh Type 4, Flat No. 9, Butler Palace Colony Lucknow - 226001 INDIA E-mail: [email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
1. Henke V, Philip W, Naumann GOH. Intraocular ossification in clinically unsuspected malignant melanoma of the uvea with phthisis bulbi. Klin Mbl Augenheilkd 1986;189:243-6.
The Journal of Prosthetic Dentistry
Aggarwal et al
Prosthetic rehabilitation over the residual eyeball is the preferred treatment of choice over surgical intervention such as enucleation or evisceration.6 Defect classification systems consider the various parameters that influence the rehabilitation process. Hogan and Zimmerman5 proposed a defect classification system that presented the various stages of phthisis bulbi based on the structural changes in the eye globe: ocular atrophy (1) without shrinkage, (2) with shrinkage, and (3) with shrinkage and disorganization. This classification has been further modified by Yanoff and Fine.7 All the previous classifications are either morphology or histology based. However, there is no treatment-based classification for prosthetic rehabilitation of patients with phthisis bulbi. There is no differentiation made for maxillofacial prosthetists and ocularists on varying the prosthetic treatmentbased on different stages of phthisis bulbi. New prosthetic guidelines that relate to various stages of phthisis bulbi seem to be mandated as a result
Senior Resident, Department of Prosthodontics. Associate Professor, Department of Prosthodontics. c Senior Resident, Department of Prosthodontics. d Associate Professor, Department of Ophthalmology. e Professor, Department of Prosthodontics. b
Aggarwal et al
of recognition of different classes of phthisis bulbi, depending upon its severity. Major factors in the prosthetic rehabilitation decision-making process include whether there is normal or disfigured sclera; no enophthalmos or mild, moderate, or severe enophthalmos and the condition of associated surrounding structures; and how these factors influence the prosthetic rehabilitation treatment process. The purpose of this treatment-oriented classification system was to organize and define the complex nature of the restorative decisionmaking process for the patient with phthisis bulbi.
CLASSIFICATION SYSTEM To assess the influence of variable presentations of phthisis bulbi on the prosthetic rehabilitation, a classification system of defects based on a selected patient population was developed. A review of 50 patients with phthisis bulbi was performed after obtaining approval from the ethics committee of the King George’s Medical
2
Volume University UP, Lucknow, India. All of the patients reviewed were prosthetically rehabilitated. The various parameters that influenced the prosthetic rehabilitation included (1) condition of cornea, (2) contour and color of sclera, (3) degree of enophthalmos, (4) presence of corneal sensitivity, and (5) condition of associated contiguous structures. Based on the evaluation of the various previously described parameters, phthisis bulbi defects were divided into 4 major classes and 2 subclasses of class I and class II as follows: Class I. Corneal opacity with no enophthalmos and normal sclera. Class II. Corneal opacity with mild enophthalmos and normal sclera. Class III. Moderate enophthalmos with disfigured sclera.
Class IV. Severe enophthalmos with disfigured sclera and loss of orbital fat. Classes I and II were further subdivided based on the presence of corneal sensitivity, into subclass “a” (without corneal sensitivity) and subclass “b” (with corneal sensitivity). All the variable presentations of phthisical eyes fall within these 4 categories. Based on the class to which the particular patient belongs, the prosthodontists and/or the ocularists can plan the treatment according to the proposed guidelines. Ocular defects that produce corneal opacity with no enophthalmos and normal sclera without corneal sensitivity were categorized as class Ia (Fig. 1). Simple prosthetic and/or cosmetic lens was sufficient to achieve the desired esthetics. Class Ib includes ocular defects that produce corneal opacity with no enophthalmos and normal sclera with
1 Class I ocular defects with corneal opacity.
-
Issue
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corneal sensitivity. It was required to minimize the corneal sensitivity so that the patient could be able to tolerate the prosthesis. Therefore, before proceeding with the rehabilitation, certain surgical or nonsurgical modalities, such as Gunderson flap, mucous membrane grafting, amniotic membrane grafting, use of atropine and steroid combination, and anterior stomal puncture, should be used to minimize the sensitivity. After reducing the corneal sensitivity, the same treatment could be planned as described in Class Ia. Class IIa includes ocular defects that produce corneal opacity with mild enophthalmos and normal sclera without corneal sensitivity (Fig. 2A, B). To compensate the enophthalmos, certain thicknesses of materials such as polymethyl methacrylate or silicone are needed for enhancing the bulk. Therefore, fabrication of a transparent acrylic resin or silicone sclera shell is recommended for these types of defects. Class IIb includes ocular defects that produce corneal opacity with mild enophthalmos and normal sclera with corneal sensitivity. The same procedure described in Class Ib could be applied to minimize the corneal sensitivity before fabrication of ocular prosthesis, as mentioned in Class IIa. Class III includes ocular defects that produce moderate enophthalmos with disfigured sclera (Fig. 3A, B). Prosthetic management of these types of ocular defects required an ocular prosthesis or scleral shell, with the scleral and iris shade
2 A, B, Class II ocular defects, showing corneal opacity with mild enophthalmos and normal sclera.
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3 A, B, Class III ocular defects, showing moderate enophthalmos with disfigured sclera.
4 A, B, Class IV ocular defects, showing severe enophthalmos with disfigured sclera and loss of orbital fat.
Table I.
Classification
Class
Condition
Treatment
Ia
Corneal opacity with no enophthalmos and normal sclera without corneal sensitivity
Simple prosthetic and/or cosmetic lens
Ib
Corneal opacity with no enophthalmos and normal sclera with corneal sensitivity
Simple prosthetic and/or cosmetic lens after reducing the corneal sensitivity
II a
Corneal opacity with mild enophthalmos and normal sclera without corneal sensitivity
Clear or transparent acrylic resin or silicone sclera shell
II b
Corneal opacity with mild enophthalmos and normal sclera with corneal sensitivity
Clear or transparent acrylic resin or silicone sclera shell after reducing the corneal sensitivity
III
Moderate enophthalmos with disfigured sclera
Ocular prosthesis or scleral shell
IV
Severe enophthalmos with disfigured sclera and loss of orbital fat
Ocular prosthesis or scleral shell after performing additional procedures such as dermal lid fillers or eyelid surgeries
Aggarwal et al
matched with that of the contralateral eye of the patient. Class IV includes ocular defects that produce severe enophthalmos with disfigured sclera and loss of orbital fat (Fig. 4A, B). Because there is severe enophthalmos with associated loss of orbital fat, an ocular prosthesis or scleral shell alone will not suffice for optimum esthetic outcome. In these complex situations, additional procedures such as dermal lid fillers or eyelid surgeries are mandatory to achieve optimum esthetics, before fabricating an ocular prosthesis. The proposed classification at a glance is shown in Table 1.
DISCUSSION The phthisis bulbi classification system presented was based on clinical experience, which was used to establish
4
Volume a guideline for esthetic rehabilitation of patients with pthisis bulbi. All previous classifications are either morphology or histology based. The classification system purposed by Hogan and Zimmerman for various stages of phthisis bulbi was based only on the structural changes in the eye globe. The proposed new treatment-based classification system might provide a methodology to enroll larger patient numbers from multiple institutions to study the severity of phthisis bulbi and its implication on the mode of prosthetic rehabilitation. Class I defects are the simplest type of defect, which can be easily rehabilitated to achieve the desired esthetics. From class I to class IV, the extent of severity of phthisical defect increases, thereby making the prosthetic rehabilitation more and more challenging for the ocularists and maxillofacial prosthetists. Several major factors that must be considered during prosthetic rehabilitation of phthisis bulbi have been included, but all the factors or the cause of phthisis bulbi are not addressed
by the proposed classification system. Other associated defects of eyelids and contiguous structures may affect the options related to restorative care. Similarly, a range of patient factors may influence the rehabilitation approach, such as age, comorbidities, prior surgery and/or radiation, patient motivation, and financial considerations.
SUMMARY Comprehensive treatment planning is necessary to meet multidisciplinary objectives for patients with complex reconstructive and rehabilitative needs. The defect-oriented treatment based approach of the proposed system is intended to facilitate and coordinate treatment planning among ocularists and maxillofacial prosthetists.
REFERENCES
-
Issue
-
2. Hadjistilianou T, Francesco S, Marconcini S, Mastrangelo D, Galluzzi P, Toti P. Phthisis bulbi and buphthalmos as presenting signs of retinoblastoma: a report of two cases and literature review. Eur J Ophthalmol 2006;16: 465-9. 3. Stefani FH. Phthisis bulbi-an intraocular fluoride proliferative reaction. Dev Ophthalmol 1985;10:78-160. 4. von Graefe A. Ueber essentielle Phthisis bulbi. Arch Ophthalmol 1883;12:256-64. 5. Hogan MJ, Zimmerman LE, eds. Ophthalmic pathology. An atlas and textbook, 2nd ed. Philadelphia: WB Saunders; 1962. p. 168-221. 6. Naveen HC, Porwal A, Nelogi S. Prosthetic rehabilitation of phthisis bulbi by digital imaging technique. A case report. Cont Lens Anterior Eye 2010;33:231-4. 7. Yanoff M, Fine BS. Ocular pathology. 5th ed. St Louis: Mosby; 2002. p. 72-3. Corresponding author: Dr Raghuwar Dayal Singh Type 4, Flat No. 9, Butler Palace Colony Lucknow - 226001 INDIA E-mail: [email protected] Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
1. Henke V, Philip W, Naumann GOH. Intraocular ossification in clinically unsuspected malignant melanoma of the uvea with phthisis bulbi. Klin Mbl Augenheilkd 1986;189:243-6.
The Journal of Prosthetic Dentistry
Aggarwal et al
