Page 36 - JOP2020

Case Study No. 1
A 46-year-old man presented with a bulging pros-
thetic eye in January 2017 (Figure 3). His prosthesis
had been made 20 years earlier by an ocularist
practice that is no longer in business and he had not
had any check-up visits during that 20-year period.
His eye socket appeared to be badly infected
(Figure 4) and he had superior and inferior eyelid
entropion and lagophthalmos. The posterior of the
prosthesis had a thick coating of protein (Figure 5).
Figure 2. This was a nice-looking prosthesis at one time, The prosthesis was placed in a medicine cup filled
but after 30 years it does not fit well. with hydrogen peroxide, which rather dramatically
fizzed and bubbled, an indication of the presence
or replaced, to accommodate changes in the eye-socket of bacteria (Figure 6). A post-enucleation–style
architecture (Figure 2). Robert A. Thomas, BCO, FASO, conformer was placed in the socket (Figure 7) and
listed six causes of anophthalmic socket contracture and he was referred to his ophthalmologist. We delivered
entropion including “extended wearing of an ill-fitting a new custom prosthesis to the patient 3 weeks later
prosthesis.” Unfortunately, not all patients receive the (Figure 8). At that time, he informed us that he had
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on-going care they need. A small population of patients been instilling ofloxacin ophthalmic solution (an
fails to have any care from an ocularist, sometimes for antibiotic) into the eye socket four times daily per
decades. The author has seen several such patients in re- his doctor’s recommendation. The appearance of
cent years who have presented with severely contracted the socket tissue was much improved by this time.
eye-socket tissue accompanied by infection and having The new prosthesis also made a big improvement
entropion of both the inferior and superior eyelids. cosmetically, but there were still issues of lagoph-
Although it is unlikely, at least in our region, that these thalmos and entropion. Due to the patient having
patients are wearing stock prostheses, the result is the poor blinking action, we recommended the use of
same as described by Raymond Jahrling, BCO, FASO: “a an oil-based prosthetic eye lubricant. At our recom-
gradual chain reaction course of events, from excessive mendation, he came in for a 6-month follow-up. At
secretions to inflammation, polyps, chronic conjuncti- that time, we observed that the patient’s eye socket
vitis or infection, fibrosis, contraction, and entropion.” looked healthy and he was managing well with his
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Some patients present with a bulging prosthetic eye that new “eye.” Approximately 14 months later, we decid-
is still being retained but barely. We typically fit these ed to make a new prosthesis because the eye-socket
patients with a temporary post-enucleation conformer. volume had increased significantly.
In other cases, patients present with their prosthesis
in hand, unable to reinsert it. Although it is likely that Discussion
the contraction of an eye socket takes place during the For a variety of reasons this patient neglected
course of months or years, it is apparent that the con- to care for his prosthetic eye for 20 years. During
traction accelerates once the socket can no longer retain that time, the ocularist practice he had gone to had
a prosthesis. For patients who are unable to retain a closed and he was unaware of other ocularists in the
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prosthesis, we begin socket restoration by placing the area. Eventually the prosthesis became an irritant
largest conformer the socket will allow, which typically is to the surrounding conjunctiva, resulting in infec-
a very small custom conformer. Another approach is to tion, contraction, entropion, and lagophthalmos.
fit a custom pressure conformer. This is followed by fit- His socket restoration took a number of months to
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ting progressively larger conformers over the next sever- achieve and although there are residual problems
al weeks as needed. We often see dramatic improvement with his eyelids, he has a relatively comfortable and
in the eye socket, but it is likely to still be smaller than good-looking prosthesis.
the original socket volume. On successful fitting with a Of note, the patient has been exceptionally good
prosthesis, these patients might have on-going issues about making and keeping his appointments with
with lagophthalmos and entropion, but they probably our office.
will be happy to be able to retain a prosthetic eye. Two
case studies are presented.

34 | LEGRAND JOURNAL OF OPHTHALMIC PROSTHETICS