M. El-Dakkak, BChD, HDD, MS
Department of Prosthetic Dental Sciences, King Saud University, College of Dentistry, P.O. Box 60169, Riyadh 11545, Saudi Arabia

This study was conducted on twelve subject who had undergone surgical enucleation of the eye as a result of accidents, Their cosmetic problem was corrected by serial construction of cone formers with bigger sizes and lining modification of stock eye prostheses. The method resulted in sufficient room for the retention of the eye prosthesis and gradually improved the cosmetic problem developed from narrow palpebral fis­ sures.

Eye defects are congenital results of an underde­ veloped bulb that is not functional, or due to enucleation of the eye ball. Such defects can be corrected by ocular prostheses.1,2,3,4 This ocular prosthesis gives special attention to the accurate duplication of the natural color, contour, size and ocular orientation, and should provide realism and symmetry for patients who need it.4,5 While an ocular prosthesis is a means for esthetic improve­ ment, correction of either congenital or acquired defects may cause the patient a new set of prob­ lems.2

When the opening between the eyelids is too narrow, a cosmetic problem will develop resulting from asymmetrical size, form, and contour of the artificial eye relative to the natural eye. As of the moment, very few studies have been conducted to manage cases with narrow openings. The goal of this study is to introduce a clinical procedure for managing narrow ocular openings.5

The current study comprises a total of twelve sub­ jects with enucleated eyes as a result of accidents.

The ages ranged from 26 to 32 years with a mean of 28 years. All patients had the additional problem of narrow palpebral fissures. None of them received implant, cone formers, or previous ocular prostheses [Figs. 1 a & b].The existing muscle movement of the anophthal-mic socket of each subject was examined by asking the subject to look in various directions while the eyelids were opened by the operator's fingers. The depth of the socket as well as the tonus of the eyelids were evaluated at the time of the examina­ tion.

Serial Construction of Cone Formers:

After thorough examination of the enucleated socket, an impression of the socket was made with eye irreversible hydrocolloid (Caulk Eye Impres­ sion, Caulk Company, Milford, DE, USA) using an adjusted ocular tray [Fig. 2].

Each subject was seated erect and was requested to stare at a distant spot while holding out his gaze in a straightforward position with the eyes open while the impression was being made. This proce­ dure ensured that the posterior aspect of the enuc­ leated socket and its rectus muscles were in the same relative position as those of the remaining eye.

The impression material was mixed and placed into a large syringe. The ocular tray was inserted in the eye socket with the eyelid open. The impres­sion material was injected carefully into the socket through the channel of the ocular tray and was allowed to set. The patient was instructed to open his eyes widely and the tray, with its impression, was gently removed. The impression was inspected and the socket was checked for any residual impression material. The tissue surface of the impression was invested in the first half of a flask

using dental stone. At least two keys were cut into the surface of the first pour which was then lubri­ cated with a separating medium. A box was formed around the first half with a three-inch masking tape and the second half of the cast was poured [Fig.3].

After setting of the stone mix, both halves of the cast were separated from each other. The tray and the impression was then removed and replaced with molten base plate wax. The wax took the shape of the impression for constructing the wax cone former. The wax cone former was checked inside the socket of the missing eye and was then invested in a small flask to produce an acrylic cone former [Fig. 4j. The cone former was finished and highly polished and inserted inside the eye socket [Fig. 5].

Larger cone formers were made using the same procedure except that in each sequential former, the size was increased in increments suitable for the particular patient. The cone former was changed into a bigger one every week for six consecutive weeks to achieve sufficient increase in the eye socket receiving a prosthesis.

Systematic Modification of the Stock Eye:

A stock eye was selected (Monoplex Eye, Amer­ ican Optical, California, USA) for each subject to simulate the remaining eye in its color, corneal contour and pupil size. The stock eye was checked and adjusted to make sure its size was suitable to the socket of the missing eye. The stock eye's fitting surface was scraped with acrylic stone to create a space between it and the posterior aspect of the socket. Korecta Wax No. 4 (Block Drug Company, Inc. Jersey City, NJ 07302, USA) was added to the fitting surface and borders of the artificial eye. The patient was asked to gaze in a straightforward position and then the artificial eye was inserted. New wax was added where blending the surface of the eye with the newly established level of the corneal surface was needed. The modified eye was tested in the socket as often as necessary to achieve an acceptable opening. The waxed artificial eye was worn for several minutes, and for some very sensi­ tive persons as long as 15 or 20 minutes before the eyelid opening was considered acceptable. After the plastic eye was finished and worn for 20 minutes, it was occasionally necessary to remove small amounts of plastic and repolish the area to let the eyelids close in the correct manner IFig. 6J.

The finished eye was inserted in place and checked with regards to its size, movements, position of the pupil, and the opening of the eyelids [Fig. 7]. The eye was used and checked every two weeks for a total period of six months. A larger final form was then needed to open the eyelids to the correct amount which simulates the remaining eye. The increase in eye size was achieved by adding more wax in the fitting surface of the artificial eye where it was needed to obtain the correct opening; then, the previous procedure was repeated. Finally, the wax was replaced with sclera acrylic resin material and the eye was reinserted in its final size and form [Fig.8],

The results of the procedure and its clinical suc­cess can be observed by examining Figures 7 and 8. Relative successes of different eye prostheses are based upon subjective impression. However, with this fact in mind, the technique used in the present study was favorably received by all patients, refer­ ring physicians, families and friends. These opin­ ions can be considered as a good evidence in favor of the technique used.

This technique helped in better retention of the eye prostheses and improved the appearance of the patients than with the rapid and immediate restoration of the corneal form technique. Patients reported more comfort and were satisfied with their cosmoses at termination of treatment.