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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 3  |  Page : 153-156

Expediting the prosthodontic management of a patient of phthisis bulbi


Department of Prosthodontics, Crown and Bridge, Maulana Azad Institute of Dental Sciences, New Delhi, India

Date of Submission12-Apr-2020
Date of Decision23-May-2020
Date of Acceptance19-Jun-2020
Date of Web Publication14-Aug-2020

Correspondence Address:
Abhishek Kumar Gupta
House No 177, Bahadurpur Post, Basti - 272 302, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_53_20

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  Abstract 


Eyes are generally the first feature to be noted on one's face. The loss of an eye can be socially, emotionally, and psychologically a very traumatic experience for the patient. Ocular prosthesis plays an important role in restoring the self-esteem and confidence of the patient. Enucleation results in the entire removal of orbital contents whereas, uniocular phthisis bulbi is a condition, in which the eye is shrunken and cornified. This presents a challenging condition for rehabilitation because of a lack of space for the prosthesis. This article aims to explain the challenges while making a customized scleral shell prosthesis over an existing eyeball to obtain optimum cosmetic and functional results.

Keywords: Characterization of ocular prosthesis, ocular prosthesis, phthisis bulbi, scleral shell prosthesis


How to cite this article:
Gupta AK, Kumari M, Gupta R, Gill S. Expediting the prosthodontic management of a patient of phthisis bulbi. Indian J Dent Sci 2020;12:153-6

How to cite this URL:
Gupta AK, Kumari M, Gupta R, Gill S. Expediting the prosthodontic management of a patient of phthisis bulbi. Indian J Dent Sci [serial online] 2020 [cited 2020 Sep 26];12:153-6. Available from: http://www.ijds.in/text.asp?2020/12/3/153/292278




  Introduction Top


In enucleation, entire orbital contents are removed. Initially, it was rehabilitated by providing a stock eye prosthesis.[1] The main limitations of stock eyes are their poor fit, accuracy, matching iris color, and its size.[2] Thus, customization of the ocular prosthesis became popular. Uniocular phthisis bulbi is a condition, in which the eye is shrunken, cornified, and is a challenge for rehabilitation. Scleral shell prosthesis, which is made up of a thin shell of medical-grade heat cure polymethylmethacrylate was planned, which provided satisfactory fit and retention.[3] This case report comprehensively decodes the prosthetic rehabilitation of the phthisis bulbi by modifying the impression technique.


  Case Report Top


A 24-year-old female presented to the outpatient department of prosthodontics with the chief complaint of blindness, associated with a change in color of the right eye and decreased size. The patient gave a history of traumatic injury to the right eye 7 years back. On examination, there was no pain and edema associated. After a thorough ophthalmic examination, the patient was diagnosed with a uniocular phthisis bulbi. In this condition, the eyeball was shrunken but present and hence, there was not enough space for the accommodation of conventional ocular prosthesis. Customized scleral shell prosthesis was planned for the patient. Before starting the procedure, the patient was prescribed with CIPLA (0.2% ciprofloxacin) eye drops twice a day for 1 week.

Primary impression

For the primary impression, a conformer was modified to be used as a stock tray. A hollow acrylic tube made up of self-cure acrylic resin was attached to the conformer for holding dispensing tip for impression material. Multiple perforations were made on conformer to retain the impression material [Figure 1]. After disinfection of the conformer, the extent of the conformer was checked, and the primary impression was taken using light body addition silicone. Criteria for an acceptable impression is to accurately record the position of the palpebrae in the relation of the posterior wall of the eyeball and the greatest extent of superior and inferior fornices of the palpebrae.[4] To do so, we need to make a final impression for the correct extensions. The impression was poured and a two-piece model with tissue surface in die stone and handle in dental stone was made [Figure 2].
Figure 1: Primary impression tray

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Figure 2:Two-piece model in dental stone

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Final impression

To make the final impression, 0.8 mm wax spacer was added in the cornea region on the model and over it, pink color self-cure acrylic was adapted with a small handle to be used as a custom tray. Multiple perforations were made over the special tray to retain the final impression material [Figure 3].
Figure 3: Final impression tray

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Wax spacer was removed; light body addition silicone was injected first in the inferior fornix, then all over the eyeball. The patient was instructed to make all eye movements, and the functional impression was recorded with adequate extensions [Figure 4]. Impression was verified by observing the extensions of impression, i.e., from the superior border of the eyeball to the inferior border of the eyeball, and the intimate fit of impression was verified by the circular depression in the impression which was caused because of the close contact of the cornea and impression surface.
Figure 4: Functional impression of the eye

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Fabrication of acrylic shell

The final impression was directly invested into the Hanau flask. Now, to replicate the color of the sclera, the periphery was packed with clear heat cure acrylic, and the central portion was packed with scleral color medical-grade heat cure acrylic. Processing was carried out using a long curing cycle. The polymerized shell was finished and polished up to a thickness of 1.5 mm for adequate esthetics [Figure 5].
Figure 5: Finished and polished scleral shell prosthesis

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Replicating the contour

Try in of this shell was done to assess color and extensions of the shell. To replicate the contour of the eye the diagnostic white wax was added over the shell [Figure 6]. After verifying the contour, and support of the upper and lower eyelids, it was invested in the flask to get the fixed index in the flask.
Figure 6: Try-in of the scleral shell with diagnostic wax-up

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Iris positioning

Now the iris from the stock eye was trimmed off, according to the patient's iris color and diameter. The iris positioning was done in the patient for which the patient was instructed to gaze at a far object [Figure 7]. The iris position was verified, and the whole shell with the iris was invested and polymerized. The final prosthesis obtained was a shell of peripheral clear acrylic, central white acrylic, and the iris embedded in it.
Figure 7: Try-in of the scleral shell after iris positioning

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Scleral shell characterization

To simulate the natural appearance of the eye. For that purpose, we must characterize the shell according to the patient's natural eye. For characterization, we have used red acrylic fibers and red pencil colors to duplicate the veins [Figure 8]. The red pencil was used to replicate the veins, and acrylic fibers were painted over shell using a monopoly solution. (1:10 heat-cured polymer by heat-cured monomer).
Figure 8: Characterization of the scleral shell

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Sealing of the characterized shell

After finalizing the characterized scleral shell, it was finally invested in the same flask, which was used to make the index. The main advantage of this step is that we will get the same contour, which we needed in the final shell. The external surface was added with clear heat-cured acrylic. It was polymerized, finished, and polished similarly.

Disinfection of prosthesis was done with 0.5% chlorhexidine and 70% Isopropyl alcohol for 5 min; later, it was rinsed with sterile saline and stored in the same. The final scleral shell was delivered to the patient [Figure 9]. The patient was satisfied with the esthetics and comfort of the prosthesis. Taking good care of the prosthesis is much required. The cleaning of the prosthesis is very important. The patient was instructed to gently scrub the prosthesis with fingertips using warm water. Mild soap can also be used for the same.
Figure 9: Pre- and post-rehabilitation view

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Regular follow-up was done at 2 weeks and 4 weeks interval to assess the status of the iris, eye discharge, and the fit of the prosthesis. After 2 months, recall at an interval of 3 months for the initial 1 year followed by check-up every 6 months was advised.


  Discussion Top


The custom-made scleral shell prosthesis has improved fit and esthetics.[4] The main challenge in the rehabilitation of the phthisis bulbi is the fit of the scleral shell over the blemished eye.[5] Hence, the impression technique needs to be modified accordingly. In this case, we have used conformer to take the primary impression. The main benefit was that we got the proper extensions of the conformer. For shrunken and cornified eye a careful planning and meticulous attention are needed.[2] A lot of manufacturers are there which provide readymade stock eyes, but they do not fulfill optimum esthetics and comfort. A variant of the ocular prosthesis is a scleral shell prosthesis which can be worn over a disfigured eye.[6] It covers the entire surface of an eye, giving it a natural and pleasing appearance.[7] Scleral shell prosthesis, which is made up of a thin shell of medical-grade heat cure acrylic resin, provides a better fit and retention.[3]

The main benefit was that the patient does not have to undergo enucleation for the ocular prosthesis. We were able to restore the esthetics using the scleral shell. We have first made the shell of scleral color to give the required esthetics and bulk of the shell, later the iris was attached to it. Advantages include the correct contour of the scleral shell, the color of the sclera, iris diameter, and its color. The fit of the prosthesis was improved because of an accurate impression. This was all possible because of the better retention, stability, and proper extensions of the scleral shell prosthesis. Correct impression technique and proper planning was the key to the success of the rehabilitation of the uniocular phthisis bulbi.


  Conclusion Top


The use of custom-made scleral shell prosthesis has been a boon to the patients. The esthetic and functional outcome of the prosthesis is better than the stock ocular prosthesis. It has definitely restored the patient's self-esteem. An impression fit scleral shell has provided maximum comfort, esthetics, and wearing time, which had definitely improved compliance of the patient.

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.

Acknowledgment

The author would like to thank his senior guides Dr. Rekha Gupta and Dr. Shubhra Gill constantly guiding me in completing this challenging clinical case. The author would like to thank his colleague Dr. Mamta for helping in each step of clinical and laboratory procedure till the completion of the case. The author would like to thank his parent and friends for constant support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Welden RB, Niiranen JV. Ocular prosthesis. J Prosthet Dent 1956;6:272-8.  Back to cited text no. 1
    
2.
Guerra LR, Finger IM, Echeverri J, Shipman B. Impression making, sculpting, and coloring of orbital prostheses. Adv Ophthalmic Plast Reconstr Surg 1992;9:287-96.  Back to cited text no. 2
    
3.
McArthur DR. Aids for positioning prosthetic eyes in orbital prostheses. J Prosthet Dent 1977;37:320-6.  Back to cited text no. 3
    
4.
Mathews MF, Smith RM, Sutton AJ, Hudson R. The ocular impression: A review of the literature and presentation of an alternate technique. J Prosthodont 2000;9:210-6.  Back to cited text no. 4
    
5.
Cain JR. Custom ocular prosthetics. J Prosthet Dent 1982;48:690-4.  Back to cited text no. 5
    
6.
Shafi FM. Ocular prosthesis: A case report. Ann Prosthodont Restor Dent 2016;2:92-3.  Back to cited text no. 6
    
7.
Somkuwar K, Mathai R, Jose P. Ocular prosthesis: Patient rehabilitation – A case report. People's J Sci Res 2009;2:21-6.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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