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Contents lists available at ScienceDirect
Contact Lens and Anterior Eye journal homepage: www.elsevier.com/locate/clae
Recommendations for post-adaption care of an ocular prosthesis: A review. Sergio Bonaque-Gonzáleza,b,* , Alfredo Amigóa , Cecilia Rodríguez-Lunaa a b
Instituto Oftalmológico Amigó, Santa Cruz de Tenerife, Spain Departamento de Física, University of La Laguna, Santa Cruz de Tenerife, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 April 2014 Received in revised form 4 May 2015 Accepted 22 June 2015
An ocular prosthesis must be maintained in a suitable state of cleanliness, fit and preservation. Otherwise its functioning may be compromised, leading to a variety of diseases. However, there is a lack of consensus on the care of such prostheses. This review assembles and attempts to update existing knowledge in this area and discusses the most appropriate care regimes. ã 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Key words: Ocular prosthesis Artificial eye Prosthetic eye Prosthesis care Prosthetic eye cleaning
Contents 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation of the ocular prosthesis . . . . . . . . . . . . . . . . . . . Longevity of the ocular prosthesis . . . . . . . . . . . . . . . . . . . Longevity of the ocular prosthesis in children . . . . 3.1. Wearing the ocular prosthesis . . . . . . . . . . . . . . . . . . . . . . . Frequency of cleaning of the ocular prosthesis . . . . . . . . . Special cases in cleaning regimes . . . . . . . . . . . . . . 5.1. Manipulating the prosthesis and cleaning agents . . . . . . . Manipulating the prosthesis . . . . . . . . . . . . . . . . . . 6.1. Cleaning agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2. Ocular prosthesis polishing . . . . . . . . . . . . . . . . . . . . . . . . . Recommended lubrication of the ocular prosthesis . . . . . . Residual monomer in the ocular prosthesis . . . . . . . . . . . . Cleaning eyelids and eyelashes . . . . . . . . . . . . . . . . . . . . . . Additional instructions to patients with ocular prostheses Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Financial disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
* Corresponding author at: Instituto Oftalmológico Amigó, C/ Bravo Murillo 10, Santa Cruz de Tenerife 38003, Islas Canarias, Spain. E-mail address: [email protected] (S. Bonaque-González).
The ocular prosthesis, also known as ‘prosthetic eye’ or ‘artificial eye’, is a device that occupies the anterior part of an anophthalmic socket and is designed to restore a lost eye due to trauma, congenital anomaly, irreparable damage, tumors or sympathetic ophthalmia, among others [1]. These aids are normally situated in the anophthalmic socket, which must be
http://dx.doi.org/10.1016/j.clae.2015.06.003 1367-0484/ ã 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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calm, healthy and dimensionally stable with any remaining sutures having been reabsorbed or fallen away. The best time for fitting an artificial eye varies from person to person, but over 8 weeks after surgery is generally accepted [2,3]. Early applications have however been reported with good results [4]. An ocular prosthesis may be available readymade (stock ocular prosthesis) or can be custom made. Stock prostheses come in standard sizes, shapes, and colors. They can be used for interim or postoperative purposes [5]. Custom-made eyes have several advantages: better mobility, more even pressure distribution (thereby reducing the incidence of ulceration), improved fit, comfort adaptation, facial contours, and enhanced aesthetics gained from the control over the size of the iris, pupil, and color of the iris and sclera [6]. Ocular prostheses meet an aesthetic or cosmetic need but are also functional in that their presence prevents possible complications like ulcers, infections, tissue retraction, severe orbital defects, and also the fallen eyebrows, eyelids and forehead that can occur in cavities without eyeballs [7–9]. They also restore lachrymal dynamics and help the tear-glands partially recover their natural position [7]. However, these alterations may occur in any case if the prosthesis is unsuitable for the size of the orbit, in poor condition, or is not custom-made from an impression of the cavity [9]. The ideal ocular prosthesis is therefore a beneficial element, which must be correctly fitted to the cavity and maintained in an excellent state of preservation [7–9]. However, there is currently no general agreement on the precise care needs for prosthetic eyes in terms of cleanliness, handling and their useful life [10]; this is reflected in the evident shortage of publications on these aspects. This review summarizes articles published in standard scientific databases up to August 2014. The intention is to provide an update of existing knowledge and propose guidelines for the most suitable care of a prosthetic eye.
issue in the scientific literature, there seems to be general agreement that the life-time of a prosthetic eye is between 2 and 6 years in an adult, depending on the patient's age, occupation, care of the prosthesis and its constituent materials [16,17]. Due to the fact that all patients are different, regular yearly checkups are very important to review the fit and condition of the prosthesis. If these are found to be unsatisfactory, there are variations in morphology or orbit volume, or the aesthetic appearance is not optimal, then replacement is the correct course of action [17–19]. 3.1. Longevity of the ocular prosthesis in children
The whole surface of the prosthesis must be free of irregularities, roughness, marks and scratches, and be perfectly polished; otherwise it may cause discomfort and be more prone to deterioration and bacterial deposits [11,12]. Jones and Collin [12] classified causes of discharge, and examined eight patients with discharge using a method based on their classification. They reported that mechanical irritation from prosthetic eyes with scratches or chips was a cause of chronic discharge with recurrent symptoms not responding to topical antibiotics. The prosthesis should therefore be examined in each visit. There may be abnormalities of the conjunctiva or cavity in general, damaged areas, deposits, irregularities or color dimming in a particular area. Where possible, repair then becomes necessary, or otherwise a new prosthesis [9,11–13]. If the artificial eye was not prepared from an impression of the cavity, the patient should be encouraged to replace it with a custom-made one, in order to avoid possible future complications [9].
Patients in early childhood are special cases. A study by Yago and Furuta [20] evaluated orbital growth after unilateral enucleation in infancy using computed X-ray tomography images. They demonstrated that socket expansion and regular replacements of the prosthesis are important for normal growth of the anophthalmic orbit in children, since it becomes progressively too small in relation to the orbit. In this context, Raizada et al. [21] analysed how many replacements were necessary in a group of 330 children. The indications for replacement in their study included enophthalmic prosthesis, rotation within the socket, loose fit, decentration of the cornea, cosmetically significant ptosis, prosthesis discoloration, lost prosthesis, replacement following implant exchange surgery and combinations of these factors. They concluded that replacement of an ocular prosthesis in children is more frequent than in adults and its useful life (months or years depending on the patient’s ophthalmological status) must be customized for each patient. It is necessary to be especially careful in children without orbital implants, as these are a major factor contributing to orbital growth [22]. In such cases, the presence of the prosthesis becomes the only element supporting growth and so it is important to ensure that successive replacements are made, as each becomes too small for the orbit [22,23]. Again in children, Ragge et al. [24] argued that if a microphthalmic eye has an axial length of less than 16 mm, such short axial-length eyes alone are unlikely to promote normal orbital growth. Therefore, it is necessary to increase the socket volume early on in life to prevent more pronounced asymmetry as the child grows. They proposed fitting a purposemade cosmetic shell (a thin ocular prosthesis) over the eye, or remnant, to promote orbital growth. Clear shapes will need to be fitted initially in the case of eyes with some residual vision [24,25]. As a conclusion, replacement of the prosthesis in children depends on the ophthalmological status and age and must be customized for each patient. If the defect is present at birth, the assessment would best be carried out in the first two weeks of life [24]. The initial socket-expansion phase involves frequent visits to hospital for sequential fitting of progressively larger acrylic shapes. Other methods such as hydrophilic expanders may also be used, with or without moulding of the socket under anaesthesia [24,26]. After the initial socket expansion, practitioners should be aware of the above indications for replacement and establish a regime of at least yearly revision over the first 5 years of life.
3. Longevity of the ocular prosthesis
4. Wearing the ocular prosthesis
Over the years, the cavity and surrounding tissues may change so that the ocular prosthesis no longer fits well; this can induce tissue hyperplasia [9]. Furthermore, the material of the prosthesis becomes more porous, encouraging bacterial growth, increased secretion, a ‘foreign-body’ sensation and discomfort. Ultimately, these factors favor the onset of chronic conjunctivitis [14–16] and so it is clear that an ocular prosthesis does not have an eternal useful life. Although there are no specific articles addressing this
The recommended use of an ocular prosthesis is 24 h a day [3]. It is generally not removed at night (except for patients with very specific problems) because this can cause the lids to fold and inflame the conjunctiva, or lachrymal fluid to accumulate at the bottom of the cavity, favoring infection [3]. If withdrawal is necessary for any reason, it can be kept in distilled water or sterile saline to avoid eye secretions drying on the surface [17]. Laiseca et al. [17] stated that the prosthesis should never be removed for
2. Evaluation of the ocular prosthesis
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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several days at a time, since the patient would then be exposed to cavity retraction, which occurs even in those who have worn an ocular prosthesis for years. It is therefore recommended that patients are provided with a prosthetic replacement in case an emergency occurs. If an infection is suspected and a specific antibiotic treatment is initiated, the prosthesis must be kept in place as a conformer, to prevent retraction of the cavity [17,27].
3
According to the model suggested by Pine et al. [28], when the prosthesis is provided for the first time or has been recently repolished, a period of adjustment to the cavity should be allowed as there may be a temporary increase in secretions that is unrelated to the cleaning regime. In these cases it is appropriate to wait a few weeks, to evaluate the prescribed cleaning regime. 6. Manipulating the prosthesis and cleaning agents
5. Frequency of cleaning of the ocular prosthesis Cleaning the prosthesis is a way to remove infective agents and to combat deposits [27]; however, this action is controversial since there is no general consensus about the cleaning regime for ocular prostheses. On the one hand, some authors maintain that many problems regarding secretion, discomfort and excessive mattering can be relieved when patients are encouraged to desist from daily cleaning [22,28–30]. This is reflected in a study by Osborn and Hettler [10] who found that the top three recommendations given by ocularists about the frequency of cleaning were: “whenever the socket felt irritated” (31.25%), followed by “removal once a month” (25%), and finally “whenever it is dirty” (21.88%). Although perhaps counter-intuitive, these infrequent cleaning regimes may gain some support from the finding of Kim et al. [31], who measured the goblet cell density and the nucleus-to-cytoplasm ratio of epithelial cells in the conjunctivae of anophthalmic sockets with prostheses. They concluded that cytological changes were not associated with any particular aspect of prosthesis care. Furthermore, Vasquez and Linberg [32] analysed microbial culture samples from the anophthalmic sockets of 40 consecutive patients using a prosthetic eye. They found that symptoms of irritation are not usually related to abnormal bacteria, arguing that such symptoms may be related with excessively frequent (weekly) cleaning regimes. On the other hand, studies of giant papillary conjunctivitis (GPC) in anophthalmic sockets with prosthetic eyes suggest that there may indeed be a relationship between poor cleaning habits, prolonged wear and papillary conjunctivitis [15,33] or conjunctival discharge [34]. Further, a study by López-Sánchez et al. [35] analysed the cavity surface of 26 prosthesis users by grouping them according to their cleaning regime (daily vs. not daily) and found that those who did not perform daily cleaning had higher levels of pathogens, perhaps implying a greater risk of infection. However, they also reported that the percentage complaining of increased secretion and discomfort while wearing the prosthesis was greater in those following a daily cleaning regime. Given these apparent contradictions in the literature, it is not possible to establish the most appropriate cleaning regime, so further studies are clearly necessary to answer this question. The closest we are to an evidence-based cleaning regime is the model provided by Pine et al. [28], which suggests that prosthetic eyes should be cleaned no more frequently than monthly and not less frequently than six-monthly. 5.1. Special cases in cleaning regimes After a case of postoperative endophthalmitis resulting from prosthesis contamination in a monocular patient, Morris et al. [36] suggested that prosthesis wearers who need surgery on the healthy eye must resort to a daily cleaning regime to prevent surgical infections. It is questionable whether wearing a prosthetic eye increases the risk of postoperative endophthalmitis in the contralateral eye, but this link should be seriously considered. Antiseptic eye-drops on the prosthetic eye before surgery have been recommended if non-ideal hygiene conditions are suspected [36,37].
6.1. Manipulating the prosthesis A study by Vasquez and Linberg [32], where culture samples were collected from the anophthalmic sockets of 40 ocular prosthesis users, showed that patients who frequently manipulated their prosthesis had a significantly higher proportion of gramnegative bacteria, suggesting that this practice or habit should be avoided. If necessary, it must obviously be done with clean hands. After cleaning, the prosthesis should be allowed to air dry, since the surface of tissues and towels could scratch and contaminate it with microbes [19]. 6.2. Cleaning agents According to Osborn and Hettler’s survey [10], the three most recommended cleaning agents among ocularists are mild soap (23.64%), baby shampoo (23.64%) and hard contact lens cleaner (12.73%). Ordinary tap water should be avoided because it is a potential source of contamination [38]. Alcohol and abrasive cleaners should not be used as they can cause permanent unrepairable surface damage, which leads to GPC and eyelid inflammation [27]. Paranhos et al. [39] assessed the levels of contamination of both the ocular prosthesis and the anophthalmic cavity, by counting the number of colony-forming units before and after use of the different cleansing solutions, i.e. neutral liquid soap, multiuse solution for contact lenses or chlorhexidine 0.12%. They found that all solutions were similarly effective in decreasing the number of aerobic microorganisms on both the prosthesis and in the anophthalmic cavity when compared to the initial condition, but multiuse solution and chlorhexidine 0.12% also decreased the number of Staphylococcus aureus. Nonspecific (e.g. household) soap should not be used for cleaning the ocular prosthesis as it often contains oils, coloring or perfumes that may irritate the conjunctiva [40]. Additionally, some authors recommend avoiding preservatives in the cleaning materials of ocular prostheses [41] because it has been reported that these can create allergic reactions in ocular tissues. Summarizing, although in general the cited cleaning agents seem to provide similar results, the use of rigid contact-lens cleaning solutions (avoiding those containing peroxides or alcohol) could be an acceptable recommendation. They have the advantage of being manufactured under stringent quality controls, are supplied in sterile packaging and are available in a wide variety of alternatives, allowing for adjustment to almost any type of patient. Nevertheless, provided the precautions mentioned above are taken, other cited cleaning methods can be used without significant problems. 7. Ocular prosthesis polishing There is general consensus among ocularists that prostheses must receive professional polishing once a year, and more frequently if certain conditions such as irritation of the eyelid rim or GPC are present [42,43]. The literature describes many polishing techniques for acrylic prostheses, however there is no specific publication evaluating these methods in the case of ocular prostheses in general. Pine et al. used in vivo [42] and in vitro [43]
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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studies to show that an optical-quality contact-lens standard of surface polishing produced a more wettable surface than a normal standard of finish and this may be particularly useful on the interpalpebral surface to assist the cleansing action of tears. 8. Recommended lubrication of the ocular prosthesis Fett et al. [44] evaluated the need for additional lubrication in 200 consecutive patients using an ocular prosthesis. From these, 46 (23%) required supplemental lubrication. This is due to a deficiency in tear production in anophthalmic sockets compared to normal eyes, which can lead to discomfort and irritation. Frequent lubrication of the prosthesis by drops is recommended if symptoms are present [45]. There are many lubrication systems available, for instance those based on silicone oil, artificial tears, rigid contact-lens liquids and specially formulated lubricants for ocular prostheses. No single general system exists, nor there is evidence that one lubricating substance is better than another. The choice of the best system for any given patient is thus a matter for individual consultation. 9. Residual monomer in the ocular prosthesis Acrylic resins have been known to cause irritation and allergic reaction in human tissues [46]. In dentistry, it has been demonstrated that the side-effects can be reduced and a patient with symptoms is able to tolerate the same denture without symptoms if the residual monomer in the prosthesis is removed [47]. Although ocular prostheses and dentures are otherwise completely different, removing residual monomer has also been proposed in the case of ocular prostheses, as a procedure to improve tolerance[13,48]. In principle, it can be achieved simply by pressure-curing at accurate timings [47,49]. In contrast, a recent article by Oliveira et al. [50] compared the residual monomer release of different resins commonly employed in ocular prostheses and concluded that the results depended more on the type of resin, rather than the polymerization cycle they were submitted to. Attempts to remove residual monomer may thus meet with variable success. Other than this, there is no scientific literature relating to ocular prostheses and residual monomers and so, no general recommendation exists. While specific studies to assess the real role of monomer in discomfort associated with ocular prostheses are necessary, literature in other fields using medical polymers supports the view that residual monomer levels are an essential factor in monitoring quality and comfort [46,47,49]. Therefore, it seems logical for ocularists to take whatever steps are available to reduce such levels in the prostheses they employ. 10. Cleaning eyelids and eyelashes It has been suggested that the presence of an ocular prosthesis may increase the likelihood of hyperkeratinization of the meibomian gland orifices, favoring obstructive dysfunction due to a combination of tear deficiency, deposit build-up, microtrauma and meibomian gland loss, when compared with normal, paired eyelids. Consequently, daily cleaning of eyelids and eyelashes is recommended in order to improve comfort [51,52]. 11. Additional instructions to patients with ocular prostheses In adults, it is necessary to follow up patients at least once a year, except when they have been recently received an operation. In that circumstance, a two-monthly check-up is needed, in
addition to the necessary postoperative visits. This enables a decision on whether an increase in prosthesis size is indicated, once any inflammation has subsided [17]. Extreme care is necessary when fitting an ocular prosthesis over a subconjunctival intraorbital implant, to avoid post-fitting issues and resultant complications [2]. A slight amount of fluid secretion from the cavity is normal and provides helpful lubrication and antibacterial action [28] . Warnings signs would be if their volume increases or color changes from yellow–white to a yellow–green or yellow–brown [27]. Lid laxity may occur, mostly due to the weight of the prosthesis and the aging process producing a descent of the lateral canthus, sagging of the tissues and skin and gravitational descent [53]. The patient must also be instructed not to pull the lids too much at the time of removal, since it has been demonstrated that, over the years, excessive eyelid manipulation may disinsert the aponeurosis of the levator palpebrae superioris muscle from the tarsus leading to ptosis [54,55]. It is therefore necessary to teach the patient to insert and remove the prosthesis correctly. On occasions when the cosmetic outcome cannot be improved, the patient can make the artificial eye less noticeable by simply avoiding extreme eye-movements and learning to move the head instead of the eyes, as occurs with progressive ophthalmic lenses. Glasses with thick frames also help divert attention and disguise the flaws in the superior sulcus. In patients for whom it has been impossible to achieve correct eyelid opening in the affected eye, a slightly positive or negative lens mounted in glasses can aid in achieving the necessary balance by virtue of its optical magnification or minification effects. Slightly tinted glasses can also help disguise the defect. It is important to prescribe special protective glasses, whatever the current status of refractive error, to prevent accidental trauma in the healthy eye and/or avoid activities that may harm it, especially in children [23].
Summary The aim of this review was to determine if a consistent set of evidence-based recommendations for postadaption care of an ocular prosthesis can be established. Study of the available literature indicates there are considerable gaps in this area as well as contradictory opinions on management protocols. Despite this, most authors agree that a close collaboration of the oculoplastic surgeon and the ocularist is necessary to ensure the best long-term rehabilitation of the patients concerned. A suboptimal prosthetic fitting could spoil the best evisceration/ enucleation surgery. There is also general agreement that all patients who wear an ocular prosthesis following removal of an eye should have a custom-made, impression-fitted ocular prosthesis, as this is the most effective way to minimize or avoid the problems highlighted in this review. ‘Off the shelf’ or stock prostheses should be discouraged. An anophthalmic socket should be checked at least once a year. Ocular prostheses are 24 h a day devices whose life varies from patient to patient but is generally between 2 and 6 years in adults. An ideal regime of extraction and cleaning has not been described in the scientific literature and currently has to be adapted for each patient. Preferred cleaning agents are rigid contact lenses cleaner, mild soap or baby shampoo. Abrasive cleaners are to be avoided. Daily cleaning of eyelids and eyelashes should be performed in all cases and professional cleaning/polishing of the prosthesis is necessary at least once a year, or more frequently if deposits are visible on the surface. When necessary, frequent lubrication of the prosthetic eye is also recommended, to improve tolerance and reduce complications.
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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Financial disclosure No author has a financial or proprietary interest in any material or method mentioned. References [1] G.R. Parr, B.M. Goldman, A.O. Rahn, Surgical considerations in the prosthetic treatment of ocular and orbital defects, J. Prosthet. Dent. 49 (1983) 379–385. [2] J.J. Zuravleff, O.H. Michael, Evisceration of the human eye with ocular prosthetic restoration, J. Ophthal. Prosthet. 3 (2011) 7–14. [3] C.S. Bailey, R.J. Buckley, Ocular prostheses and contact lenses. I-cosmetic devices, BMJ 302 (1991) 1010–1012. [4] K. Chin, C.B. Margolin, P.T. Finger, Early ocular prosthesis insertion improves quality of life after enucleation, Optometry 77 (2006) 71–75. [5] R.M. Smith, Relining an ocular prosthesis: a case report, J. Prosthodont. 4 (1995) 160–163. [6] J. Beumer, I. Zlotolow, Restoration of facial defects, in: J. Beumer (Ed.), Maxillofacial Rehabilitation—Prosthodontic and Surgical Considerations, first edition, C. V. Mosby publishers, St. Louis, 1996, pp. 350–364. [7] R.F. Kennedy, Effects of enucleation on socket anatomy, J. Ophthal. Prosthet. 2 (1997) 43–46. [8] L. Clauser, E. Sarti, V. Dallera, M. Galié, Integrated reconstructive strategies for treating the anophthalmic orbit, J. Craniomaxillofac. Surg. 32 (2004) 279–290. [9] R.C.R. Sánchez, D.R. Verdugo, I. Jankielewicz, Hiperplasia anoftálmica por prótesis ocular prefabricada mal ajustada, Caso. Clínico. Rev. Mex. Oftalmol. 82 (2008) 403–406. [10] K.L. Osborn, D. Hettler, A survey of recommendations on the care of ocular prostheses, Optometry 81 (2010) 142–145. [11] N. Kara José, J. Prado Júnior, M.W. Sampaio, Intolerância ao uso de prótese ocular pelo desenvolvimento de conjuntivite papilar gigante, Rev. Bras. Oftalmol. 39 (1980) 51–53. [12] C.A. Jones, J.R. Collin, A classification and review the causes of discharging sockets, Trans Ophthalmol. Soc. UK 103 (1983) 351–353. [13] M.C. Goiato, L.C. Bannwart, M.F. Haddad, D.M. dos Santos, A.A. Pesqueira, G.I. Miyahara, Fabrication techniques for ocular prostheses—an overview, Orbit 33 (2014) 229–233. [14] J.N. Kara, J.J.J. Prado, M.W. Sampaio, Intolerância ao uso de prótese ocular pelo desenvolvimento de conjuntivite papilar gigante, Rev. Bras. Oftalmol. 39 (1980) 51–53. [15] A. Akman, M. Irkec, M. Orhan, U. Erdener, Effect of lodoxamide on tear leukotriene levels in giant papillary conjunctivitis associated with ocular prosthesis, Ocul. Immunol. Inflamm. 6 (1998) 179–184. [16] K.R. Pine, B. Sloan, J. Stewart, R.J. Jacobs, The response of the anophthalmic socket to prosthetic eye wear, Clin. Exp. Optom. 96 (2013) 388–393. [17] J. Laiseca, D. Laiseca, A. Laiseca, J. Laiseca, Prótesis oculares y cirugía reconstructiva de cavidades, Madrid. Ed. Prensa Hispanoamericana. (1991) . [18] M.C. Goiato, D.M. dos Santos, H. Gennari-Filho, A.C. Zavanelli, S.F. Dekon, D.N. Mancuso, Influence of investment, disinfection, and storage on the microhardness of ocular resins, J. Prosthodont. 18 (2009) 32–35. [19] A.U. Fernandes, M.C. Goiato, M.A. Batista, D.M. Santos, Color alteration of the paint used for iris painting in ocular prostheses, Braz. Oral. Res. 23 (2009) 386–392. [20] K. Yago, M. Furuta, Orbital growth after unilateral enucleation in infancy without an orbital implant, Jpn. J. Ophthalmol. 45 (2001) 648–652. [21] D. Raizada, K. Raizada, M. Naik, R. Murthy, A. Bhaduri, S.G. Honavar, Custom ocular prosthesis in children: how often is a change required, Orbit 30 (2011) 208–213. [22] S.A. Kaltreider, L.R. Peake, B.T. Carter, Pediatric enucleation: analysis of volume replacement, Arch. Ophthalmol. 119 (2001) 379–384. [23] N. Peylan-Ramu, A. Bin-Nun, M. Skleir-Levy, A. Bibas, B. Koplewitz, I. Anteby, J. Pe’er, Orbital growth retardation in retinoblastoma survivors: work in progress, Med. Pediatr. Oncol. 37 (2001) 465–470. [24] N.K. Ragge, I.D. Subak-Sharpe, J.R. Collin, A practical guide to the management of anophthalmia and microphthalmia, Eye 21 (2007) 1290–1300. [25] C.J. McLean, N.K. Ragge, R.B. Jones, J.R. Collin, The management of cysts associated with congenital microphthalmos and anophthalmos, Braz. J. Ophthalmol. 87 (2003) 860–863. [26] K.K. Gundlach, R.F. Guthoff, V.H. Hingst, M.P. Schittkowski, U.C. Bier, Expansion of the socket and orbit for congenital clinical anophthalmia, Plast. Reconstr. Surg. 116 (2005) 1214–1222. [27] G.R. Parr, B.M. Goldman, A.O. Rahn, Postinsertion care of the ocular prosthesis, J. Prosthet. Dent. (1983) 220–224.
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[28] K.R. Pine, B.H. Sloan, R.J. Jacobs, A proposed model of the response of the anophthalmic socket to prosthetic eye wear and its application to the management of mucoid discharge, Med. Hypotheses. 81 (2013) 300–305. [29] K. Pine, B. Sloan, J. Stewart, R.J. Jacobs, A survey of prosthetic eye wearers to investigate mucoid discharge, Clin. Ophthalmol. 6 (2012) 707–713. [30] J.A. Legrand, Chronic exudate: an unnecessary evil, J. Ophthalmic Prosthetics 4 (1999) 33–40. [31] J.H. Kim, M.J. Lee, H.K. Choung, N.J. Kim, S. Hwang, M.S. Sung, S.I. Khwarg, Conjunctival cytologic features in anophthalmic patients wearing an ocular prosthesis, Ophthal. Plast. Reconstr. Surg. 24 (2008) 290–295. [32] R.J. Vasquez, J.V. Linberg, The anophthalmic socket and the prosthetic eye. A clinical and bacteriologic study, Ophthal. Plast. Reconstr. Surg. 5 (1989) 277–280. [33] B.D. Srinivasan, F.A. Jakobiec, T. Iwamoto, A.G. De Voe, Giant papillary conjunctivitis with ocular prostheses, Arch. Ophthalmol. 97 (1979) 892–895. [34] A.C.C. Neves, R. Rode, S.M. Rode, A.O.C. Jorge, Clinical and microbiological evaluation of the conjunctival discharge in patients with acrylic resin ocular prosthesis, Rev. Biociencias. 7 (2001) 43–49. [35] E. López-Sánchez, E. España-Grégori, V. Roda-Marzal, I. Bueno, E. FrancésMuñoz, J.L. Menezo, Conjunctival microbiological study in carriers of corneoschleral prosthesis, Arch. Soc. Esp. Oftalmol. 76 (2001) 669–672. [36] R. Morris, F.I. Camesasca, J. Byrne, G. John, Postoperative endophthalmitis resulting from prosthesis contamination in a monocular patient, Am. J. Ophthalmol. 116 (1993) 346–349. [37] S.D. Miller, R.E. Smith, D.W. Dippe, D.R. Lacey, M. Abel, Bacteriology of the socket in patients with prostheses, Can. J. Ophthalmol. 11 (1976) 126–129. [38] S. Kilvington, T. Gray, J. Dart, N. Morlet, J.R. Beeching, D.G. Frazer, M. Matheson, Acanthamoeba keratitis: the role of domestic tap water contamination in the United Kingdom, Invest. Ophthalmol. Vis. Sci. 45 (2004) 165–169. [39] R.M. Paranhos, C.H. Batalhao, M. Semprini, S.C. Regalo, I.Y. Ito, M.G. de Mattos, Evaluation of ocular prosthesis biofilm and anophthalmic cavity contamination after use of three cleansing solutions, J. Appl. Oral. Sci. 15 (2007) 33–38. [40] M.H. Friedlaender, Contact allergy and toxicity in the eye, Int. Ophthalmol. Clin. 28 (1988) 317–320. [41] M.C. Goiato, B.C. Zucolotti, D.N. Mancuso, D.M. dos Santos, E.P. Pellizzer, F.R. Verri, Care and cleaning of maxillofacial prostheses, J. Craniofac. Surg. 21 (2010) 1270–1273. [42] K.R. Pine, B. Sloan, R. Jacobs, Deposit build-up on prosthetic eyes and the implications for conjunctival inflammation and mucoid discharge, Clin. Ophthalmol. 6 (2012) 1–8. [43] K.R. Pine, B. Sloan, R.J. Jacobs, Deposit buildup on prosthetic eye material (in vitro) and its effect on surface wettability, Clinical. Ophthalmol. 7 (2013) 313–319. [44] D.R. Fett, R. Scott, A.M. Putterman, Evaluation of lubricants for the prosthetic eye wearer, Ophthal. Plast. Reconstr. Surg. 2 (1986) 29–31. [45] S.E. Kim, J.S. Yoon, S.Y. Lee, Tear measurement in prosthetic eye users with fourier-domain optical coherence tomography, Am. J. Ophthalmol. 149 (2010) 602–607. [46] H. Lygre, Prosthodontic biomaterials and adverse reactions: a critical review of the clinical and research literatura, Acta Odontol. Scand. 60 (2002) 1–9. [47] D. Koutis, S. Freeman, Allergic contact stomatitis caused by acrylic monomer in denture, Aust. J. Derm. 42 (2001) 203–206. [48] T. Sethi, M. Kheur, C. Haylock, H. Harianawala, Fabrication of a custom ocular prosthesis, Middle East Afr. J. Ophthalmol. 21 (2014) 271–274. [49] A. Dogan, B. Bek, N.N. Cevik, A. Usanmaz, The effect of preparation conditions of acrylic denture base materials on the level of residual monomer, mechanical properties and water absorption, J. Dent. 23 (1995) 313–318. [50] R. Oliveira, F. Nogueira, B. Mattos, Porosity, residual monomer and water sorption of conventional heat-cured, microwave-cured and cross-linked acrylic resins, Clin. Lab. Res. Dent. 20 (2014) 137–144. [51] S.Y. Jang, S.Y. Lee, J.S. Yoon, Meibomian gland dysfunction in longstanding prosthetic eye wearers, Br. J. Ophthalmol. 97 (2013) 398–402. [52] R. Malhotra, Ocular prostheses: not quite an eye for an eye, Br. J. Ophthalmol. 97 (2013) 383–385. [53] J.W. Moon, H.K. Choung, S.I. Khwarg, Correction of lower lid retraction combined with entropion using an ear cartilage graft in the anophthalmic socket, Korean J. Ophthalmol. 19 (2005) 161–167. [54] G. Epstein, A.M. Putterman, Acquired blepharoptosis secondary to contact-lens wear, Am. J. Ophthalmol. 91 (1981) 634–639. [55] R.C. Kersten, C. de Conciliis, D.R. Kulwin, Acquired ptosis in the young and middle-aged adult population, Ophthalmology 102 (1995) 924–928.
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Contents lists available at ScienceDirect
Contact Lens and Anterior Eye journal homepage: www.elsevier.com/locate/clae
Recommendations for post-adaption care of an ocular prosthesis: A review. Sergio Bonaque-Gonzáleza,b,* , Alfredo Amigóa , Cecilia Rodríguez-Lunaa a b
Instituto Oftalmológico Amigó, Santa Cruz de Tenerife, Spain Departamento de Física, University of La Laguna, Santa Cruz de Tenerife, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 April 2014 Received in revised form 4 May 2015 Accepted 22 June 2015
An ocular prosthesis must be maintained in a suitable state of cleanliness, fit and preservation. Otherwise its functioning may be compromised, leading to a variety of diseases. However, there is a lack of consensus on the care of such prostheses. This review assembles and attempts to update existing knowledge in this area and discusses the most appropriate care regimes. ã 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Key words: Ocular prosthesis Artificial eye Prosthetic eye Prosthesis care Prosthetic eye cleaning
Contents 1. 2. 3. 4. 5. 6.
7. 8. 9. 10. 11.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Evaluation of the ocular prosthesis . . . . . . . . . . . . . . . . . . . Longevity of the ocular prosthesis . . . . . . . . . . . . . . . . . . . Longevity of the ocular prosthesis in children . . . . 3.1. Wearing the ocular prosthesis . . . . . . . . . . . . . . . . . . . . . . . Frequency of cleaning of the ocular prosthesis . . . . . . . . . Special cases in cleaning regimes . . . . . . . . . . . . . . 5.1. Manipulating the prosthesis and cleaning agents . . . . . . . Manipulating the prosthesis . . . . . . . . . . . . . . . . . . 6.1. Cleaning agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2. Ocular prosthesis polishing . . . . . . . . . . . . . . . . . . . . . . . . . Recommended lubrication of the ocular prosthesis . . . . . . Residual monomer in the ocular prosthesis . . . . . . . . . . . . Cleaning eyelids and eyelashes . . . . . . . . . . . . . . . . . . . . . . Additional instructions to patients with ocular prostheses Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Financial disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
* Corresponding author at: Instituto Oftalmológico Amigó, C/ Bravo Murillo 10, Santa Cruz de Tenerife 38003, Islas Canarias, Spain. E-mail address: [email protected] (S. Bonaque-González).
The ocular prosthesis, also known as ‘prosthetic eye’ or ‘artificial eye’, is a device that occupies the anterior part of an anophthalmic socket and is designed to restore a lost eye due to trauma, congenital anomaly, irreparable damage, tumors or sympathetic ophthalmia, among others [1]. These aids are normally situated in the anophthalmic socket, which must be
http://dx.doi.org/10.1016/j.clae.2015.06.003 1367-0484/ ã 2015 British Contact Lens Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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calm, healthy and dimensionally stable with any remaining sutures having been reabsorbed or fallen away. The best time for fitting an artificial eye varies from person to person, but over 8 weeks after surgery is generally accepted [2,3]. Early applications have however been reported with good results [4]. An ocular prosthesis may be available readymade (stock ocular prosthesis) or can be custom made. Stock prostheses come in standard sizes, shapes, and colors. They can be used for interim or postoperative purposes [5]. Custom-made eyes have several advantages: better mobility, more even pressure distribution (thereby reducing the incidence of ulceration), improved fit, comfort adaptation, facial contours, and enhanced aesthetics gained from the control over the size of the iris, pupil, and color of the iris and sclera [6]. Ocular prostheses meet an aesthetic or cosmetic need but are also functional in that their presence prevents possible complications like ulcers, infections, tissue retraction, severe orbital defects, and also the fallen eyebrows, eyelids and forehead that can occur in cavities without eyeballs [7–9]. They also restore lachrymal dynamics and help the tear-glands partially recover their natural position [7]. However, these alterations may occur in any case if the prosthesis is unsuitable for the size of the orbit, in poor condition, or is not custom-made from an impression of the cavity [9]. The ideal ocular prosthesis is therefore a beneficial element, which must be correctly fitted to the cavity and maintained in an excellent state of preservation [7–9]. However, there is currently no general agreement on the precise care needs for prosthetic eyes in terms of cleanliness, handling and their useful life [10]; this is reflected in the evident shortage of publications on these aspects. This review summarizes articles published in standard scientific databases up to August 2014. The intention is to provide an update of existing knowledge and propose guidelines for the most suitable care of a prosthetic eye.
issue in the scientific literature, there seems to be general agreement that the life-time of a prosthetic eye is between 2 and 6 years in an adult, depending on the patient's age, occupation, care of the prosthesis and its constituent materials [16,17]. Due to the fact that all patients are different, regular yearly checkups are very important to review the fit and condition of the prosthesis. If these are found to be unsatisfactory, there are variations in morphology or orbit volume, or the aesthetic appearance is not optimal, then replacement is the correct course of action [17–19]. 3.1. Longevity of the ocular prosthesis in children
The whole surface of the prosthesis must be free of irregularities, roughness, marks and scratches, and be perfectly polished; otherwise it may cause discomfort and be more prone to deterioration and bacterial deposits [11,12]. Jones and Collin [12] classified causes of discharge, and examined eight patients with discharge using a method based on their classification. They reported that mechanical irritation from prosthetic eyes with scratches or chips was a cause of chronic discharge with recurrent symptoms not responding to topical antibiotics. The prosthesis should therefore be examined in each visit. There may be abnormalities of the conjunctiva or cavity in general, damaged areas, deposits, irregularities or color dimming in a particular area. Where possible, repair then becomes necessary, or otherwise a new prosthesis [9,11–13]. If the artificial eye was not prepared from an impression of the cavity, the patient should be encouraged to replace it with a custom-made one, in order to avoid possible future complications [9].
Patients in early childhood are special cases. A study by Yago and Furuta [20] evaluated orbital growth after unilateral enucleation in infancy using computed X-ray tomography images. They demonstrated that socket expansion and regular replacements of the prosthesis are important for normal growth of the anophthalmic orbit in children, since it becomes progressively too small in relation to the orbit. In this context, Raizada et al. [21] analysed how many replacements were necessary in a group of 330 children. The indications for replacement in their study included enophthalmic prosthesis, rotation within the socket, loose fit, decentration of the cornea, cosmetically significant ptosis, prosthesis discoloration, lost prosthesis, replacement following implant exchange surgery and combinations of these factors. They concluded that replacement of an ocular prosthesis in children is more frequent than in adults and its useful life (months or years depending on the patient’s ophthalmological status) must be customized for each patient. It is necessary to be especially careful in children without orbital implants, as these are a major factor contributing to orbital growth [22]. In such cases, the presence of the prosthesis becomes the only element supporting growth and so it is important to ensure that successive replacements are made, as each becomes too small for the orbit [22,23]. Again in children, Ragge et al. [24] argued that if a microphthalmic eye has an axial length of less than 16 mm, such short axial-length eyes alone are unlikely to promote normal orbital growth. Therefore, it is necessary to increase the socket volume early on in life to prevent more pronounced asymmetry as the child grows. They proposed fitting a purposemade cosmetic shell (a thin ocular prosthesis) over the eye, or remnant, to promote orbital growth. Clear shapes will need to be fitted initially in the case of eyes with some residual vision [24,25]. As a conclusion, replacement of the prosthesis in children depends on the ophthalmological status and age and must be customized for each patient. If the defect is present at birth, the assessment would best be carried out in the first two weeks of life [24]. The initial socket-expansion phase involves frequent visits to hospital for sequential fitting of progressively larger acrylic shapes. Other methods such as hydrophilic expanders may also be used, with or without moulding of the socket under anaesthesia [24,26]. After the initial socket expansion, practitioners should be aware of the above indications for replacement and establish a regime of at least yearly revision over the first 5 years of life.
3. Longevity of the ocular prosthesis
4. Wearing the ocular prosthesis
Over the years, the cavity and surrounding tissues may change so that the ocular prosthesis no longer fits well; this can induce tissue hyperplasia [9]. Furthermore, the material of the prosthesis becomes more porous, encouraging bacterial growth, increased secretion, a ‘foreign-body’ sensation and discomfort. Ultimately, these factors favor the onset of chronic conjunctivitis [14–16] and so it is clear that an ocular prosthesis does not have an eternal useful life. Although there are no specific articles addressing this
The recommended use of an ocular prosthesis is 24 h a day [3]. It is generally not removed at night (except for patients with very specific problems) because this can cause the lids to fold and inflame the conjunctiva, or lachrymal fluid to accumulate at the bottom of the cavity, favoring infection [3]. If withdrawal is necessary for any reason, it can be kept in distilled water or sterile saline to avoid eye secretions drying on the surface [17]. Laiseca et al. [17] stated that the prosthesis should never be removed for
2. Evaluation of the ocular prosthesis
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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several days at a time, since the patient would then be exposed to cavity retraction, which occurs even in those who have worn an ocular prosthesis for years. It is therefore recommended that patients are provided with a prosthetic replacement in case an emergency occurs. If an infection is suspected and a specific antibiotic treatment is initiated, the prosthesis must be kept in place as a conformer, to prevent retraction of the cavity [17,27].
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According to the model suggested by Pine et al. [28], when the prosthesis is provided for the first time or has been recently repolished, a period of adjustment to the cavity should be allowed as there may be a temporary increase in secretions that is unrelated to the cleaning regime. In these cases it is appropriate to wait a few weeks, to evaluate the prescribed cleaning regime. 6. Manipulating the prosthesis and cleaning agents
5. Frequency of cleaning of the ocular prosthesis Cleaning the prosthesis is a way to remove infective agents and to combat deposits [27]; however, this action is controversial since there is no general consensus about the cleaning regime for ocular prostheses. On the one hand, some authors maintain that many problems regarding secretion, discomfort and excessive mattering can be relieved when patients are encouraged to desist from daily cleaning [22,28–30]. This is reflected in a study by Osborn and Hettler [10] who found that the top three recommendations given by ocularists about the frequency of cleaning were: “whenever the socket felt irritated” (31.25%), followed by “removal once a month” (25%), and finally “whenever it is dirty” (21.88%). Although perhaps counter-intuitive, these infrequent cleaning regimes may gain some support from the finding of Kim et al. [31], who measured the goblet cell density and the nucleus-to-cytoplasm ratio of epithelial cells in the conjunctivae of anophthalmic sockets with prostheses. They concluded that cytological changes were not associated with any particular aspect of prosthesis care. Furthermore, Vasquez and Linberg [32] analysed microbial culture samples from the anophthalmic sockets of 40 consecutive patients using a prosthetic eye. They found that symptoms of irritation are not usually related to abnormal bacteria, arguing that such symptoms may be related with excessively frequent (weekly) cleaning regimes. On the other hand, studies of giant papillary conjunctivitis (GPC) in anophthalmic sockets with prosthetic eyes suggest that there may indeed be a relationship between poor cleaning habits, prolonged wear and papillary conjunctivitis [15,33] or conjunctival discharge [34]. Further, a study by López-Sánchez et al. [35] analysed the cavity surface of 26 prosthesis users by grouping them according to their cleaning regime (daily vs. not daily) and found that those who did not perform daily cleaning had higher levels of pathogens, perhaps implying a greater risk of infection. However, they also reported that the percentage complaining of increased secretion and discomfort while wearing the prosthesis was greater in those following a daily cleaning regime. Given these apparent contradictions in the literature, it is not possible to establish the most appropriate cleaning regime, so further studies are clearly necessary to answer this question. The closest we are to an evidence-based cleaning regime is the model provided by Pine et al. [28], which suggests that prosthetic eyes should be cleaned no more frequently than monthly and not less frequently than six-monthly. 5.1. Special cases in cleaning regimes After a case of postoperative endophthalmitis resulting from prosthesis contamination in a monocular patient, Morris et al. [36] suggested that prosthesis wearers who need surgery on the healthy eye must resort to a daily cleaning regime to prevent surgical infections. It is questionable whether wearing a prosthetic eye increases the risk of postoperative endophthalmitis in the contralateral eye, but this link should be seriously considered. Antiseptic eye-drops on the prosthetic eye before surgery have been recommended if non-ideal hygiene conditions are suspected [36,37].
6.1. Manipulating the prosthesis A study by Vasquez and Linberg [32], where culture samples were collected from the anophthalmic sockets of 40 ocular prosthesis users, showed that patients who frequently manipulated their prosthesis had a significantly higher proportion of gramnegative bacteria, suggesting that this practice or habit should be avoided. If necessary, it must obviously be done with clean hands. After cleaning, the prosthesis should be allowed to air dry, since the surface of tissues and towels could scratch and contaminate it with microbes [19]. 6.2. Cleaning agents According to Osborn and Hettler’s survey [10], the three most recommended cleaning agents among ocularists are mild soap (23.64%), baby shampoo (23.64%) and hard contact lens cleaner (12.73%). Ordinary tap water should be avoided because it is a potential source of contamination [38]. Alcohol and abrasive cleaners should not be used as they can cause permanent unrepairable surface damage, which leads to GPC and eyelid inflammation [27]. Paranhos et al. [39] assessed the levels of contamination of both the ocular prosthesis and the anophthalmic cavity, by counting the number of colony-forming units before and after use of the different cleansing solutions, i.e. neutral liquid soap, multiuse solution for contact lenses or chlorhexidine 0.12%. They found that all solutions were similarly effective in decreasing the number of aerobic microorganisms on both the prosthesis and in the anophthalmic cavity when compared to the initial condition, but multiuse solution and chlorhexidine 0.12% also decreased the number of Staphylococcus aureus. Nonspecific (e.g. household) soap should not be used for cleaning the ocular prosthesis as it often contains oils, coloring or perfumes that may irritate the conjunctiva [40]. Additionally, some authors recommend avoiding preservatives in the cleaning materials of ocular prostheses [41] because it has been reported that these can create allergic reactions in ocular tissues. Summarizing, although in general the cited cleaning agents seem to provide similar results, the use of rigid contact-lens cleaning solutions (avoiding those containing peroxides or alcohol) could be an acceptable recommendation. They have the advantage of being manufactured under stringent quality controls, are supplied in sterile packaging and are available in a wide variety of alternatives, allowing for adjustment to almost any type of patient. Nevertheless, provided the precautions mentioned above are taken, other cited cleaning methods can be used without significant problems. 7. Ocular prosthesis polishing There is general consensus among ocularists that prostheses must receive professional polishing once a year, and more frequently if certain conditions such as irritation of the eyelid rim or GPC are present [42,43]. The literature describes many polishing techniques for acrylic prostheses, however there is no specific publication evaluating these methods in the case of ocular prostheses in general. Pine et al. used in vivo [42] and in vitro [43]
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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studies to show that an optical-quality contact-lens standard of surface polishing produced a more wettable surface than a normal standard of finish and this may be particularly useful on the interpalpebral surface to assist the cleansing action of tears. 8. Recommended lubrication of the ocular prosthesis Fett et al. [44] evaluated the need for additional lubrication in 200 consecutive patients using an ocular prosthesis. From these, 46 (23%) required supplemental lubrication. This is due to a deficiency in tear production in anophthalmic sockets compared to normal eyes, which can lead to discomfort and irritation. Frequent lubrication of the prosthesis by drops is recommended if symptoms are present [45]. There are many lubrication systems available, for instance those based on silicone oil, artificial tears, rigid contact-lens liquids and specially formulated lubricants for ocular prostheses. No single general system exists, nor there is evidence that one lubricating substance is better than another. The choice of the best system for any given patient is thus a matter for individual consultation. 9. Residual monomer in the ocular prosthesis Acrylic resins have been known to cause irritation and allergic reaction in human tissues [46]. In dentistry, it has been demonstrated that the side-effects can be reduced and a patient with symptoms is able to tolerate the same denture without symptoms if the residual monomer in the prosthesis is removed [47]. Although ocular prostheses and dentures are otherwise completely different, removing residual monomer has also been proposed in the case of ocular prostheses, as a procedure to improve tolerance[13,48]. In principle, it can be achieved simply by pressure-curing at accurate timings [47,49]. In contrast, a recent article by Oliveira et al. [50] compared the residual monomer release of different resins commonly employed in ocular prostheses and concluded that the results depended more on the type of resin, rather than the polymerization cycle they were submitted to. Attempts to remove residual monomer may thus meet with variable success. Other than this, there is no scientific literature relating to ocular prostheses and residual monomers and so, no general recommendation exists. While specific studies to assess the real role of monomer in discomfort associated with ocular prostheses are necessary, literature in other fields using medical polymers supports the view that residual monomer levels are an essential factor in monitoring quality and comfort [46,47,49]. Therefore, it seems logical for ocularists to take whatever steps are available to reduce such levels in the prostheses they employ. 10. Cleaning eyelids and eyelashes It has been suggested that the presence of an ocular prosthesis may increase the likelihood of hyperkeratinization of the meibomian gland orifices, favoring obstructive dysfunction due to a combination of tear deficiency, deposit build-up, microtrauma and meibomian gland loss, when compared with normal, paired eyelids. Consequently, daily cleaning of eyelids and eyelashes is recommended in order to improve comfort [51,52]. 11. Additional instructions to patients with ocular prostheses In adults, it is necessary to follow up patients at least once a year, except when they have been recently received an operation. In that circumstance, a two-monthly check-up is needed, in
addition to the necessary postoperative visits. This enables a decision on whether an increase in prosthesis size is indicated, once any inflammation has subsided [17]. Extreme care is necessary when fitting an ocular prosthesis over a subconjunctival intraorbital implant, to avoid post-fitting issues and resultant complications [2]. A slight amount of fluid secretion from the cavity is normal and provides helpful lubrication and antibacterial action [28] . Warnings signs would be if their volume increases or color changes from yellow–white to a yellow–green or yellow–brown [27]. Lid laxity may occur, mostly due to the weight of the prosthesis and the aging process producing a descent of the lateral canthus, sagging of the tissues and skin and gravitational descent [53]. The patient must also be instructed not to pull the lids too much at the time of removal, since it has been demonstrated that, over the years, excessive eyelid manipulation may disinsert the aponeurosis of the levator palpebrae superioris muscle from the tarsus leading to ptosis [54,55]. It is therefore necessary to teach the patient to insert and remove the prosthesis correctly. On occasions when the cosmetic outcome cannot be improved, the patient can make the artificial eye less noticeable by simply avoiding extreme eye-movements and learning to move the head instead of the eyes, as occurs with progressive ophthalmic lenses. Glasses with thick frames also help divert attention and disguise the flaws in the superior sulcus. In patients for whom it has been impossible to achieve correct eyelid opening in the affected eye, a slightly positive or negative lens mounted in glasses can aid in achieving the necessary balance by virtue of its optical magnification or minification effects. Slightly tinted glasses can also help disguise the defect. It is important to prescribe special protective glasses, whatever the current status of refractive error, to prevent accidental trauma in the healthy eye and/or avoid activities that may harm it, especially in children [23].
Summary The aim of this review was to determine if a consistent set of evidence-based recommendations for postadaption care of an ocular prosthesis can be established. Study of the available literature indicates there are considerable gaps in this area as well as contradictory opinions on management protocols. Despite this, most authors agree that a close collaboration of the oculoplastic surgeon and the ocularist is necessary to ensure the best long-term rehabilitation of the patients concerned. A suboptimal prosthetic fitting could spoil the best evisceration/ enucleation surgery. There is also general agreement that all patients who wear an ocular prosthesis following removal of an eye should have a custom-made, impression-fitted ocular prosthesis, as this is the most effective way to minimize or avoid the problems highlighted in this review. ‘Off the shelf’ or stock prostheses should be discouraged. An anophthalmic socket should be checked at least once a year. Ocular prostheses are 24 h a day devices whose life varies from patient to patient but is generally between 2 and 6 years in adults. An ideal regime of extraction and cleaning has not been described in the scientific literature and currently has to be adapted for each patient. Preferred cleaning agents are rigid contact lenses cleaner, mild soap or baby shampoo. Abrasive cleaners are to be avoided. Daily cleaning of eyelids and eyelashes should be performed in all cases and professional cleaning/polishing of the prosthesis is necessary at least once a year, or more frequently if deposits are visible on the surface. When necessary, frequent lubrication of the prosthetic eye is also recommended, to improve tolerance and reduce complications.
Please cite this article in press as: S. Bonaque-González, et al., Recommendations for post-adaption care of an ocular prosthesis: A review., Contact Lens & Anterior Eye (2015), http://dx.doi.org/10.1016/j.clae.2015.06.003
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Financial disclosure No author has a financial or proprietary interest in any material or method mentioned. References [1] G.R. Parr, B.M. Goldman, A.O. Rahn, Surgical considerations in the prosthetic treatment of ocular and orbital defects, J. Prosthet. Dent. 49 (1983) 379–385. [2] J.J. Zuravleff, O.H. Michael, Evisceration of the human eye with ocular prosthetic restoration, J. Ophthal. Prosthet. 3 (2011) 7–14. [3] C.S. Bailey, R.J. Buckley, Ocular prostheses and contact lenses. I-cosmetic devices, BMJ 302 (1991) 1010–1012. [4] K. Chin, C.B. Margolin, P.T. Finger, Early ocular prosthesis insertion improves quality of life after enucleation, Optometry 77 (2006) 71–75. [5] R.M. Smith, Relining an ocular prosthesis: a case report, J. Prosthodont. 4 (1995) 160–163. [6] J. Beumer, I. Zlotolow, Restoration of facial defects, in: J. Beumer (Ed.), Maxillofacial Rehabilitation—Prosthodontic and Surgical Considerations, first edition, C. V. Mosby publishers, St. Louis, 1996, pp. 350–364. [7] R.F. Kennedy, Effects of enucleation on socket anatomy, J. Ophthal. Prosthet. 2 (1997) 43–46. [8] L. Clauser, E. Sarti, V. Dallera, M. Galié, Integrated reconstructive strategies for treating the anophthalmic orbit, J. Craniomaxillofac. Surg. 32 (2004) 279–290. [9] R.C.R. Sánchez, D.R. Verdugo, I. Jankielewicz, Hiperplasia anoftálmica por prótesis ocular prefabricada mal ajustada, Caso. Clínico. Rev. Mex. Oftalmol. 82 (2008) 403–406. [10] K.L. Osborn, D. Hettler, A survey of recommendations on the care of ocular prostheses, Optometry 81 (2010) 142–145. [11] N. Kara José, J. Prado Júnior, M.W. Sampaio, Intolerância ao uso de prótese ocular pelo desenvolvimento de conjuntivite papilar gigante, Rev. Bras. Oftalmol. 39 (1980) 51–53. [12] C.A. Jones, J.R. Collin, A classification and review the causes of discharging sockets, Trans Ophthalmol. Soc. UK 103 (1983) 351–353. [13] M.C. Goiato, L.C. Bannwart, M.F. Haddad, D.M. dos Santos, A.A. Pesqueira, G.I. Miyahara, Fabrication techniques for ocular prostheses—an overview, Orbit 33 (2014) 229–233. [14] J.N. Kara, J.J.J. Prado, M.W. Sampaio, Intolerância ao uso de prótese ocular pelo desenvolvimento de conjuntivite papilar gigante, Rev. Bras. Oftalmol. 39 (1980) 51–53. [15] A. Akman, M. Irkec, M. Orhan, U. Erdener, Effect of lodoxamide on tear leukotriene levels in giant papillary conjunctivitis associated with ocular prosthesis, Ocul. Immunol. Inflamm. 6 (1998) 179–184. [16] K.R. Pine, B. Sloan, J. Stewart, R.J. Jacobs, The response of the anophthalmic socket to prosthetic eye wear, Clin. Exp. Optom. 96 (2013) 388–393. [17] J. Laiseca, D. Laiseca, A. Laiseca, J. Laiseca, Prótesis oculares y cirugía reconstructiva de cavidades, Madrid. Ed. Prensa Hispanoamericana. (1991) . [18] M.C. Goiato, D.M. dos Santos, H. Gennari-Filho, A.C. Zavanelli, S.F. Dekon, D.N. Mancuso, Influence of investment, disinfection, and storage on the microhardness of ocular resins, J. Prosthodont. 18 (2009) 32–35. [19] A.U. Fernandes, M.C. Goiato, M.A. Batista, D.M. Santos, Color alteration of the paint used for iris painting in ocular prostheses, Braz. Oral. Res. 23 (2009) 386–392. [20] K. Yago, M. Furuta, Orbital growth after unilateral enucleation in infancy without an orbital implant, Jpn. J. Ophthalmol. 45 (2001) 648–652. [21] D. Raizada, K. Raizada, M. Naik, R. Murthy, A. Bhaduri, S.G. Honavar, Custom ocular prosthesis in children: how often is a change required, Orbit 30 (2011) 208–213. [22] S.A. Kaltreider, L.R. Peake, B.T. Carter, Pediatric enucleation: analysis of volume replacement, Arch. Ophthalmol. 119 (2001) 379–384. [23] N. Peylan-Ramu, A. Bin-Nun, M. Skleir-Levy, A. Bibas, B. Koplewitz, I. Anteby, J. Pe’er, Orbital growth retardation in retinoblastoma survivors: work in progress, Med. Pediatr. Oncol. 37 (2001) 465–470. [24] N.K. Ragge, I.D. Subak-Sharpe, J.R. Collin, A practical guide to the management of anophthalmia and microphthalmia, Eye 21 (2007) 1290–1300. [25] C.J. McLean, N.K. Ragge, R.B. Jones, J.R. Collin, The management of cysts associated with congenital microphthalmos and anophthalmos, Braz. J. Ophthalmol. 87 (2003) 860–863. [26] K.K. Gundlach, R.F. Guthoff, V.H. Hingst, M.P. Schittkowski, U.C. Bier, Expansion of the socket and orbit for congenital clinical anophthalmia, Plast. Reconstr. Surg. 116 (2005) 1214–1222. [27] G.R. Parr, B.M. Goldman, A.O. Rahn, Postinsertion care of the ocular prosthesis, J. Prosthet. Dent. (1983) 220–224.
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[28] K.R. Pine, B.H. Sloan, R.J. Jacobs, A proposed model of the response of the anophthalmic socket to prosthetic eye wear and its application to the management of mucoid discharge, Med. Hypotheses. 81 (2013) 300–305. [29] K. Pine, B. Sloan, J. Stewart, R.J. Jacobs, A survey of prosthetic eye wearers to investigate mucoid discharge, Clin. Ophthalmol. 6 (2012) 707–713. [30] J.A. Legrand, Chronic exudate: an unnecessary evil, J. Ophthalmic Prosthetics 4 (1999) 33–40. [31] J.H. Kim, M.J. Lee, H.K. Choung, N.J. Kim, S. Hwang, M.S. Sung, S.I. Khwarg, Conjunctival cytologic features in anophthalmic patients wearing an ocular prosthesis, Ophthal. Plast. Reconstr. Surg. 24 (2008) 290–295. [32] R.J. Vasquez, J.V. Linberg, The anophthalmic socket and the prosthetic eye. A clinical and bacteriologic study, Ophthal. Plast. Reconstr. Surg. 5 (1989) 277–280. [33] B.D. Srinivasan, F.A. Jakobiec, T. Iwamoto, A.G. De Voe, Giant papillary conjunctivitis with ocular prostheses, Arch. Ophthalmol. 97 (1979) 892–895. [34] A.C.C. Neves, R. Rode, S.M. Rode, A.O.C. Jorge, Clinical and microbiological evaluation of the conjunctival discharge in patients with acrylic resin ocular prosthesis, Rev. Biociencias. 7 (2001) 43–49. [35] E. López-Sánchez, E. España-Grégori, V. Roda-Marzal, I. Bueno, E. FrancésMuñoz, J.L. Menezo, Conjunctival microbiological study in carriers of corneoschleral prosthesis, Arch. Soc. Esp. Oftalmol. 76 (2001) 669–672. [36] R. Morris, F.I. Camesasca, J. Byrne, G. John, Postoperative endophthalmitis resulting from prosthesis contamination in a monocular patient, Am. J. Ophthalmol. 116 (1993) 346–349. [37] S.D. Miller, R.E. Smith, D.W. Dippe, D.R. Lacey, M. Abel, Bacteriology of the socket in patients with prostheses, Can. J. Ophthalmol. 11 (1976) 126–129. [38] S. Kilvington, T. Gray, J. Dart, N. Morlet, J.R. Beeching, D.G. Frazer, M. Matheson, Acanthamoeba keratitis: the role of domestic tap water contamination in the United Kingdom, Invest. Ophthalmol. Vis. Sci. 45 (2004) 165–169. [39] R.M. Paranhos, C.H. Batalhao, M. Semprini, S.C. Regalo, I.Y. Ito, M.G. de Mattos, Evaluation of ocular prosthesis biofilm and anophthalmic cavity contamination after use of three cleansing solutions, J. Appl. Oral. Sci. 15 (2007) 33–38. [40] M.H. Friedlaender, Contact allergy and toxicity in the eye, Int. Ophthalmol. Clin. 28 (1988) 317–320. [41] M.C. Goiato, B.C. Zucolotti, D.N. Mancuso, D.M. dos Santos, E.P. Pellizzer, F.R. Verri, Care and cleaning of maxillofacial prostheses, J. Craniofac. Surg. 21 (2010) 1270–1273. [42] K.R. Pine, B. Sloan, R. Jacobs, Deposit build-up on prosthetic eyes and the implications for conjunctival inflammation and mucoid discharge, Clin. Ophthalmol. 6 (2012) 1–8. [43] K.R. Pine, B. Sloan, R.J. Jacobs, Deposit buildup on prosthetic eye material (in vitro) and its effect on surface wettability, Clinical. Ophthalmol. 7 (2013) 313–319. [44] D.R. Fett, R. Scott, A.M. Putterman, Evaluation of lubricants for the prosthetic eye wearer, Ophthal. Plast. Reconstr. Surg. 2 (1986) 29–31. [45] S.E. Kim, J.S. Yoon, S.Y. Lee, Tear measurement in prosthetic eye users with fourier-domain optical coherence tomography, Am. J. Ophthalmol. 149 (2010) 602–607. [46] H. Lygre, Prosthodontic biomaterials and adverse reactions: a critical review of the clinical and research literatura, Acta Odontol. Scand. 60 (2002) 1–9. [47] D. Koutis, S. Freeman, Allergic contact stomatitis caused by acrylic monomer in denture, Aust. J. Derm. 42 (2001) 203–206. [48] T. Sethi, M. Kheur, C. Haylock, H. Harianawala, Fabrication of a custom ocular prosthesis, Middle East Afr. J. Ophthalmol. 21 (2014) 271–274. [49] A. Dogan, B. Bek, N.N. Cevik, A. Usanmaz, The effect of preparation conditions of acrylic denture base materials on the level of residual monomer, mechanical properties and water absorption, J. Dent. 23 (1995) 313–318. [50] R. Oliveira, F. Nogueira, B. Mattos, Porosity, residual monomer and water sorption of conventional heat-cured, microwave-cured and cross-linked acrylic resins, Clin. Lab. Res. Dent. 20 (2014) 137–144. [51] S.Y. Jang, S.Y. Lee, J.S. Yoon, Meibomian gland dysfunction in longstanding prosthetic eye wearers, Br. J. Ophthalmol. 97 (2013) 398–402. [52] R. Malhotra, Ocular prostheses: not quite an eye for an eye, Br. J. Ophthalmol. 97 (2013) 383–385. [53] J.W. Moon, H.K. Choung, S.I. Khwarg, Correction of lower lid retraction combined with entropion using an ear cartilage graft in the anophthalmic socket, Korean J. Ophthalmol. 19 (2005) 161–167. [54] G. Epstein, A.M. Putterman, Acquired blepharoptosis secondary to contact-lens wear, Am. J. Ophthalmol. 91 (1981) 634–639. [55] R.C. Kersten, C. de Conciliis, D.R. Kulwin, Acquired ptosis in the young and middle-aged adult population, Ophthalmology 102 (1995) 924–928.
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