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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 11  |  Issue : 3  |  Page : 154-158

Scleral prosthesis


Department of Prosthodontics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Date of Web Publication3-Jul-2019

Correspondence Address:
Namika Sokhal
H No. 98, Jagtar Nagar, Near D.C.W. Colony, Patiala - 147 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_23_19

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  Abstract 


The special sensory organs play a significant role in our daily lives. The disfigurement from loss of facial structure such as eye can cause psychological and social distress. Phthisis bulbi is an ocular condition caused by wound healing secondary to severe trauma, inflammation, or necrotizing tumor of the eye. Eye prosthesis is the only mode of rehabilitation for missing eye if reconstructive surgery is not possible or desired by a patient. Prefabricated eye or customized ocular prosthesis has their own advantages or disadvantages. Prosthetic rehabilitation of such patients is challenging, and multidisciplinary approach is required to provide satisfactory ocular prosthesis. This article presents a technique for fabrication of semicustomized prosthesis with stock iris and custom-made sclera.

Keywords: Customized eye, eye prosthesis, ocular prosthesis, phthisis bulbi, sclera shell prosthesis


How to cite this article:
Sokhal N, Pawah S, Gupta A, Pathak C. Scleral prosthesis. Indian J Dent Sci 2019;11:154-8

How to cite this URL:
Sokhal N, Pawah S, Gupta A, Pathak C. Scleral prosthesis. Indian J Dent Sci [serial online] 2019 [cited 2019 Jul 22];11:154-8. Available from: http://www.ijds.in/text.asp?2019/11/3/154/261943




  Introduction Top


Eyes are the organs of visual system which is sensitive to various stimuli.[1] Disfigurement of face, associated with eye, causes psychological, emotional, and esthetic distress.[2] Phthisis bulbi is a shrunken, nonfunctional eye which results from severe eye disease, inflammation, or injury. Surgical procedures such as enucleation, exenteration, or evisceration are usually not desired in a patient of phthisis bulbi because of cost and multiple postoperative visits. Hence, prosthetic rehabilitation is the preferred treatment of choice in the patient with phthisis bulbi.[1] These cases can be managed by three types of prosthesis: (1) custom eye prosthesis which includes customized sclera or iris both, (2) prefabricated eye, and (3) semicustomized prosthesis in which sclera is custom made and iris is prefabricated. Custom eye prosthesis is esthetically pleasing and has more accurate fit and comfortable to patient but is more complicated and time-consuming.[3] This case report describes prosthetic rehabilitation of the right eye of a patient with phthisis bulbi.


  Case Report Top


A 61-year-old male patient reported to the department of prosthodontics, with a chief complaint of scarred, shrunken, unaesthetic appearance, and loss of vision in the right eye. The patient had a history of blunt trauma at the age of 5 years. On ophthalmic examination, there were no signs of infection and inflammation with healthy conjunctiva showing synchronous movement [Figure 1]a. According to treatment-based classification given by Aggarwal et al., it was classified as Type 4 (severe enophthalmos with disfigured sclera and loss of orbital fat).[1] After thorough evaluation, it was decided to fabricate semicustomized prosthesis for the right eye.
Figure 1: (a) Preoperative view showing ocular defect of the right eye. (b) Stem of custom tray to which syringe is attached

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Technique

Impression procedure

A custom tray with stem was fabricated by making the impression of the closed eye with the help of irreversible hydrocolloid material (Zelgan 2002, Dentsply, India Pvt. Ltd., Gurgaon, India) which was then adjusted according to the patient's socket, and several relief holes were made for excess material to come out and also for material interlock. To this custom tray stem, a syringe was attached to act as a medium to carry the impression material into the atrophied socket of the patient. Irreversible hydrocolloid material was used (Zelgan 2002, Dentsply, India Pvt. Ltd., Gurgaon, India) for making impression of the right atrophied socket [Figure 1]b.

First, lightly lubricate the eyebrow and eyelashes with petroleum jelly and clean the socket of the right eye with saline solution. Thin mix of irreversible hydrocolloid (Zelgan 2002, Dentsply, India Pvt. Ltd., Gurgaon, India) was injected into the socket of the right eye through the syringe which was attached to custom tray to obtain the impression of the socket while impression material was setting. The patient was asked to move eye in up, down, right, and left position so as to record all the borders of the socket so that the functional impression of the defect could be obtained. The patient was asked to look at a distant spot in a forward direction till the impression material sets. After the material was set, impression was retrieved from the socket and examined for completeness, any voids, or defects [Figure 2]a and [Figure 2]b.
Figure 2: (a) Impression of socket. (b) Impression of socket with stem of custom tray to which syringe is attached

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Wax pattern fabrication

After the impressions of right socket were completed, a mold using putty consistency vinyl polysiloxane material (Aquasil, Dentsply, DeTrey GmbH, Germany) was made around the impressions into which the molten white carving wax was flowed so as to make the wax pattern [Figure 3]a. After the wax was set, it was retrieved from the putty mold, inserted into the right socket of eye, and then checked for comfort, stability, and esthetics. Necessary sculpting of wax pattern was done until the desired bulge and contour to mimic the feature of contralateral left eye [Figure 3]b and [Figure 3]c.
Figure 3: (a) Putty mold for fabrication of wax pattern. (b) Fabricated wax pattern. (c) Intaglio surface of wax pattern

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Wax pattern trial and iris orientation

The smoothened and finished pattern was tried for proper fit, contour, orientation, and adaptation. Three lines were marked on the patient's face: the first in the center of forehead between the eyebrows, the second on the outer canthus, and the third on the middle of the two lines. The same lines were marked on the contralateral side also. These lines helped to mark the middle of the pupil of the eye which helped in iris orientation. During this marking, the patient was asked to look straight. The patient was then asked to close the eyes passively, any discomfort on closing the eyelid was noted and corrected, and bilateral symmetry was checked [Figure 4]a. Iris orientation was done by attaching the iris button with a stem to wax pattern. This iris button was fabricated using the clear autopolymerizing resin (DPI-Self cure, Dental Products of India Ltd.) to which black paint was added to give it black color. Iris button was positioned on the sclera wax pattern, and the border was sealed using a hot instrument. The position of iris button is 10° medioinferiorly to the middle of the eye and in accordance with the contralateral left eye [Figure 4]b and [Figure 4]c.
Figure 4: (a) Wax pattern trial. (b) Iris orientation. (c) Close-up view of iris orientation

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Flasking and curing of wax patterns

The finished wax pattern after iris orientation with the iris buttons in place was invested in a flask using dental stone (Kalstone Type III, Kalabhai) after applying appropriate separating media between the two pours [Figure 5]a. Dewaxing was performed in usual manner as done for complete denture fabrication. After dewaxing, the heat-cured tooth-colored polymethylmethacrylate material (DPI-Heat Cure, Dental Products of India Ltd.) of appropriate shade was packed and kept for bench curing to enable complete polymerization and prevention of excess unreacted monomer. This enables minimization of porosities and gives good finish to prosthesis. Long-curing cycle 4–6 h was done to prevent any residual monomer. It prevents any untoward irritation or sensitivity to tissues and thereby rejection of the prosthesis by the patient. The eye socket is extremely sensitive, and the residual conjunctiva and related structures react to any surface roughness and irregularity.
Figure 5: (a) Flasking of wax pattern. (b) Iris placement. (c) Lateral view of the right eye showing iris placement

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Iris placement and characterization

Prefabricated eye prosthesis was selected with uniform iris color-matching contralateral eye and diameter. Iris portion was cut carefully and was adjusted over the cured shell. It was tried in the patient's eye to check for proper orientation and complete passive eyelid closure [Figure 5]b and [Figure 5]c. Custom sclera was characterized to give lifelike appearance to the prosthesis. A close-up view of the patient left eye was taken to observe the scleral pattern. It was seen that there was a slight yellowish hue present on the medial side of the natural eye, grayish hue around the iris, and few blood vessels laterally and medially [Figure 6]a. Custom sclera was painted using the soft color tones of brown, yellow, and red (Kokuyo Camlin Industrial Ltd., Mumbai, India) to match the sclera of the contralateral left eye. Then, using the red fibers from high-strength heat-cured acrylic material (Lucitone, Dentsply India Pvt. Ltd., Gurgaon, India), which mimicked the blood vessels of the eye, was retained using a thin layer of clear autopolymerizing resin monomer liquid (DPI, India) which was applied over these fibers and was left to dry [Figure 6]b. Single thickness of molding wax was adapted over the characterized shell, and flasking was done using dental plaster (Kalstone Type II, Kalabhai Dental Pvt. Ltd.) [Figure 6]c. After the plaster was set, the flask was opened and the single thickness wax was removed, and clear heat-cured acrylic polymer and monomer (DPI, India Dental Products of India Ltd.) was mixed following manufacturer's instructions and packed in dough consistency, followed by standard processing procedures. Deflasking was done, and scleral eye prosthesis was retrieved.
Figure 6: (a) Close-up view of the patient natural left eye. (b) Finished prosthesis with characterization. (c) Single thickness wax adapted for uniform thickness of clear acrylic resin. (d) Final finished prosthesis

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Finishing and polishing

Finished prosthesis requires highly polished surface [Figure 6]d. Any irregularity in eye prosthesis would lead to discomfort and can affect patient compliance. Hence, finishing and polishing were done carefully so that there was no irregularity on intaglio and polished surface. Prosthesis was inserted in the eye socket carefully, and all the contours were verified and analyzed for any adjustment [Figure 7]a and [Figure 7]b. The patient was demonstrated to insert and removal of prosthesis. The patient was able to make right, left and up, down movements without any discomfort. The patient was educated on a thorough maintenance protocol of prosthesis. A periodic recall appointment was done at 1-week, 3-week, and 1-month interval.
Figure 7: (a) Postoperative view of the patient. (b) Photograph with finished scleral prosthesis in place

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Postinsertion instructions were given to the patient regarding removal, wearing, and care of prosthesis at home:

  • Prosthesis should be handled with care and with clean hands
  • The prosthesis should be cleaned by hand with simple liquid surfactant, never use dry cloth, abrasive soap, or toothpaste
  • The prosthesis should be removed during night or once a day
  • Prosthesis should be stored in water when not in use to avoid shrinkage
  • For surface disinfection, the prosthesis should be dipped in antibacterial solution.



  Discussion Top


Eyes are the most characteristic and noticeable feature of the face. A missing eye invariably leads to physical, emotional, social, and psychological loss to the patient. Ocular defects may be congenital, associated with tumors, or acquired lesions and may affect the tissues within the orbital cavity or the surrounding facial structures. Prosthetic rehabilitation of the lost eye as soon as possible will fulfill esthetic and psychological requirement of the patient.[4] Phthisis bulbi is an end-stage ocular response to an injury of an eye. There is calcium deposition within band keratopathy, sclera, optic nerve, or retina.[5]

Prosthetic rehabilitation fulfills esthetic as well as psychological requirement of the patients.[6] Prosthetic rehabilitation of lost eye can be done with the use of prefabricated and custom-made eye prosthesis. Stock eye does not have proper fit, so it usually modified with viscoelastic tissue conditioner material according to eye socket. If unreacted monomer is present, then it causes ulceration and irritation to conjunctiva. Voids created after modification of prefabricated prosthesis can collect mucous and debris which irritate mucosa and act as potential source of infection which is minimized in custom made. Custom-made prosthesis has better contouring, color matching, and coordinated movement with contralateral eye. Intimate contact between the prosthesis and tissue bed will distribute pressure equally, which lacks in prefabricated prosthesis, so it reduces the chances of ulceration and conjunctival abrasion and provides better esthetic results.

For fabrication of artificial eye, various materials are used such as gold, silver, and silicone porcelain.[7] Acrylic and silicone elastomers are most commonly used. Acrylic resin provides adequate longevity, remarkable aging properties, low cost, and easy to process and requires minimal maintenance.[8] The rigidity of acrylic resin is seldom a problem as the tissue bed is rarely movable. Silicone materials are preferred over acrylic resin as they provide better marginal adaptation and more lifelike appearance than acrylic, but they are expensive and lack the ability of chemical/mechanical bonding.[9] Although retention of eye prosthesis can be enhanced with the use of implants, they are not always possible or feasible due to surgical and financial constraints.[4] A correctly placed prosthesis should restore the normal opening of the eye, support the eyelids, restore a degree of movement, and be adequately retained and esthetically pleasing.[7]

The custom-made ocular prosthesis involves complex technique and time-consuming but provides better esthetic results. If patients contralateral natural eye matching with the stock iris is available then to avoid complex technique semicustomized the prosthesis using stock iris and customized sclera will have advantage over customized ocular prosthesiss.[10] When configuration of eye and color contour are not satisfactorily matching with contralateral eye, then semicustomized prosthesis is usually not recommended to the patient. Moreover, the age, systemic, and financial conditions of the patient may limit their use.[5] In this current case report, successful rehabilitation of phthisis bulbi patient was done using semicustomized prosthesis.


  Conclusion Top


Success of scleral prosthesis largely depends on the precise laboratory technique and artistic skill of operator. The esthetic outcome of the custom-made prosthesis is far better than the stock ocular prosthesis. The procedure used here is simple and cost-effective. The patient cannot see by this prosthesis, but this prosthesis will help in increasing the self-confidence of the patient to face the world.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Aggarwal H, Singh RD, Kumar P, Gupta SK, Alvi HA. Prosthetic guidelines for ocular rehabilitation in patients with phthisis bulbi: A treatment-based classification system. J Prosthet Dent 2014;111:525-8.  Back to cited text no. 1
    
2.
Somkuwar K, Mathai R, Jose P. Ocular prosthesis: Patient rehabilitation. People's. J Sci Res 2009;21:21-6.  Back to cited text no. 2
    
3.
Putanikar NY, Patil AG, Shetty PK, Nagaral S, Mithaiwala HI. Prosthetic rehabilitation of a patient with ocular defect using semi-customized prosthesis: A case report. J Int Oral Health 2015;7:81-4.  Back to cited text no. 3
    
4.
Pathak C, Pawah S, Singh G, Yadav I, Kundra S. Prosthetic rehabilitation of completely blind subject with bilateral customised ocular prosthesis: A Case report. J Clin Diagn Res 2017;11:ZD06-8.  Back to cited text no. 4
    
5.
Akram W, Malabadi A, Kamble V, Desai R, Arabbi K. Prosthetic management of phthsis bulbi patient: A case report. Natl J Med Dent Res 2017;5:228-32.  Back to cited text no. 5
    
6.
Kumar P, Aggrawal H, Singh RD, Chand P, Jurel SK, Alvi HA, et al. A simplified approach for placing the iris disc on a custom made ocular prosthesis: Report of four cases. J Indian Prosthodont Soc 2014;14:124-7.  Back to cited text no. 6
    
7.
Aggarwal A, Sharma A, Singh K, Gupta A. Scleral prosthesis: An eye for an eye: A case report. Indian J Dent Sci 2013;5:63-5.  Back to cited text no. 7
    
8.
Bali N, Dhall R, Singh N. Various steps involved in fabrication of an ocular prosthesis: A case report. Int J Dent Med Res 2015;1:93-6.  Back to cited text no. 8
    
9.
Pruthi G, Jain V, Rajendiran S, Jha R. Prosthetic rehabilitation after orbital exenteration: A case series. Indian J Ophthalmol 2014;62:629-32.  Back to cited text no. 9
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10.
Kumar A, Nooji D. Custom sclera prosthesis. Int J Curr Res 2017;9:463-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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