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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 128-133

Primary ocular prosthesis in patients undergoing evisceration, enucleation and socket reconstruction in north central Nigeria: A multi-center study


Department of Ophthalmology, Benue State University Teaching Hospital, Makurdi, Benue State, Nigeria

Date of Submission15-Dec-2014
Date of Acceptance02-Apr-2015
Date of Web Publication3-Sep-2015

Correspondence Address:
Keziah Nanier Malu
Department of Ophthalmology, Benue State University Teaching Hospital, PMB 102131, Makurdi, Benue State
Nigeria
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DOI: 10.4103/2384-5147.164421

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  Abstract 

Background: Facial disfigurement especially of the eye can cause a lot of psychological impact on one's life. After evisceration or enucleation, primary ocular prosthesis (POP) not only provides immediate cosmetic rehabilitation, but also helps the individual regain self-confidence to resume normal life. The aim of this study was to assess the surgical outcome of evisceration and enucleation with POP in patients with endophthalmitis/panophthalmitis and allied conditions. Materials and Methods: This was a multi-center prospective study by the authors at three centers in Makurdi of patients undergoing destructive and socket reconstructive eye surgeries who had ocular prosthesis (OP [artificial eye]) inserted as a primary procedure from January 2010 to June 2014. Results: Eighteen patients had OP fitted at the operating table. There were 13 males (72%) and 5 females, with male to female ratio of 2.6:1. The median age was 45.5 years. Half of the patients 9 (50%) were farmers. Indications for surgery were infection 10 (55.6%), corneal degeneration 4 (22.2%) and one each had trauma, tumor, anophthalmos and shallow socket. Fifteen (83.3%) patients had evisceration. There were no postoperative infections during the follow-up period. There was small degree of enophthalmos in 16 (88.9%) and slight color mismatch in17 (94.4%). The OP movement with the fellow eye was fair in all the patients. Conclusion: Insertion of POP did not cause progression of infection in patients undergoing evisceration or enucleation. Where resources are not available for an orbital implant before prosthesis, POP can be fitted without the fear of progress of infection.

Keywords: Cosmesis, enucleation, evisceration, primary ocular prosthesis


How to cite this article:
Malu KN, Gbanan DN, Ogbor E. Primary ocular prosthesis in patients undergoing evisceration, enucleation and socket reconstruction in north central Nigeria: A multi-center study . Sub-Saharan Afr J Med 2015;2:128-33

How to cite this URL:
Malu KN, Gbanan DN, Ogbor E. Primary ocular prosthesis in patients undergoing evisceration, enucleation and socket reconstruction in north central Nigeria: A multi-center study . Sub-Saharan Afr J Med [serial online] 2015 [cited 2020 Apr 9];2:128-33. Available from: http://www.ssajm.org/text.asp?2015/2/3/128/164421


  Introduction Top


An ocular prosthesis (OP) or artificial eye "(fake eye)" is worn by people to provide an improved cosmetic appearance following the loss of a natural eye. [1] The prosthetic eye does not provide vision and the users remain blind in the eye carrying the prosthesis. It is made to closely resemble the fellow natural eye. It improves cosmetic appearance and also helps in volume augmentation.

Removal of the eye is usually indicated in situations where the eye has ceased to serve as an organ of function like; end stage endophthalmitis and panophthalmitis, intraocular tumors, painful blind eyes and badly traumatized eyes.

The removal of the eye could be by enucleation, evisceration or orbital exentration.

The prosthetic eye is made to take the contour of the eye with the convex outer surface finished to match the other eye's white sclera, brown iris and dark pupil.

The OP is usually worn over an orbital implant. It can also be worn as a scleral shell over an eviscerated or phthisical eye.

There is some evidence of the use of OP dating back to 2900-2800 BC in Iran [2] and among the Romans and Egyptians. [3]

The materials for the OP evolved from gold to glass to acrylic plastics. [2] Present day ocular prostheses are made from various materials. The fabricators of OP are called ocularists. Usually, the fitting of a prosthetic eye is rested between the surgeon who does the surgery and inserts the implant and the ocularist who fabricates and fits the final prosthesis. The process is long and expensive.

In our environment where ocular implants are not readily available before the fitting of a custom made OP, the socket is left to heal for 6-8 weeks or more after removal of an eye before a removable prosthesis is fitted in. During this period, the patient goes about with one eye and a disfigured facial appearance. Some go about with dark sunshade in order to disguise the blemish or continue with an eye pad during the period of waiting for OP.

There are no ocularists in Nigeria presently to make customized prostheses. The eye prosthesis available is mostly prefabricated (stock prosthesis), not produced for a specific individual. This therefore results in mismatch of the sclera, iris and pupil colors of the natural eye of the individual.

The other challenge is the nonplacement of ball implant during the primary surgery which may lead to improper seating of the prosthesis and to its frequent dropping out as a result of shallow socket.

Psychosocial and emotional effects on the patients are other challenges. [4] The thought of not having an eye may lead to some of the patients being unwilling to consent to eye removal even when it becomes necessary or even life-threatening.

Studies with primary orbital implants in patients with endophthalmitis or panophthalmitis showed the infection rapidly resolved and the implant retained without complications preventing the need for secondary procedure. [5],[6],[7]

Based on the experience with primary orbital implants following endophthalmitis or panophthalmitis, the objective of the study was to investigate whether or not primary OP (POP) would interfere with the control of infection and how receptive it would be in patients undergoing destructive and reconstructive surgery. If it is acceptable and does not interfere with healing, it will be very useful where resources are not available for an orbital implant before prosthesis. POP can be inserted without the fear of progression of infection. Where the initial one is too small, it could also be exchanged for a bigger size in case of postoperative enophthalmos.

This type of study has not been conducted in this environment before.


  Materials and methods Top


This is a multi-center prospective study of patients undergoing destructive eye surgeries (evisceration, enucleation) and socket reconstruction where OP (artificial eye) was inserted as a primary procedure from January 2010 to June 2014. This was carried out at Federal Medical Centre, Benue State University Teaching Hospital and Adoose Specialist Hospital all in Makurdi, Benue State, Nigeria.

The ethical review committee of the Benue State University Hospital gave approval for the study. The study was carried out in accordance with Helsinki Declaration on studies involving human subjects. Consent was obtained from the patients or their guardians for surgery and for fitting of primary orbital prosthesis.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

A structured protocol, including patients' demography such as age, sex, educational background occupation, and cause and duration of eye condition, before coming to the hospital were specifically asked for. Also recorded were the patient's feelings and satisfaction following the fitting of the artificial eye. The socket was assessed for the presence of continuing infection postoperatively. The movement with the fellow eye was also noted. Patients' pre-and post-operative photographs were taken with the permission of the individual patients/carers and with the understanding that they would be used for research purposes.

The data collected were analyzed using SPSS version 17.0 software (SPSS Inc., Chicago, IL, USA). The data are presented by frequencies or cross-tabulations and Chi-square to compare variables, and wherever the observations in a cell were <5, Fisher Exact test was used. P < 0.05 was considered as significant.

Fitting the Ocular Prosthesis

The OP was fitted at surgery following evisceration, enucleation or socket reconstruction. Ball implant was not inserted in any of the sockets at surgery because they were not available. The prosthesis were immersed in a disinfectant (Chlorhexidine gluconate B.P 0.3% W/V, Cetrimide B.P 3.0% W/N) for 24 h and rinsed with normal saline prior to insertion. The orbit was infiltrated by injection with a broad spectrum antibiotic such as gentamicin 40 mg or ceftriazone 50 mg, before fitting the prosthesis. Thereafter the eye was pressure dressed and bandaged for 48 h to prevent hemorrhage. The patients were left to complete the course of preoperative systemic antibiotics they were on for the treatment of endophthalmitis or panophthalmitis. Those who did not have endophthalmitis or panophthalmitis were not placed on any systemic antibiotics.

The OP was left in place for 6-8 weeks until complete healing of the socket. During this period, the patients were placed on topical antibiotics eye medications. Follow-up visits were scheduled at 1, 2 and 6 weeks and then 3 months postoperatively. When the socket healed completely the patients were taught how to remove and reinsert the prosthesis. They were also instructed on what to do if there was any discharge from the socket at any time (such as removing the OP at night and use of topical antibiotics and reporting to the hospital). They were counseled on the importance of maintaining a healthy socket by the way they handled the prosthesis.

Marked color difference between the OP and the fellow eye was corrected by either exchanging the OP to one with color closer to the fellow eye or wearing spectacles with a slight lens tint. Size dissimilarity was handled by exchange or adding a plus lenses to the OP side until there was a match.


  Results Top


During the period under study 51 patients (51 eyes) and 2 patients (2 eyes) underwent destructive eye and socket reconstructive surgeries respectively. [Table 1] shows the centers where the eye surgeries took place. Eighteen of these were carried out by the authors and they all had OP fitted at the operating table. These 18 patients are the subjects for this report. There were 13 males (72%) and 5 females (28%) with male to female ratio of 2.6:1. This was statistically significant (Fisher's Exact test [P = 0.000]). The median age was 45.5 (range was 1-78) years. Ten of the patients were <40 years (55.6%) and nine were farmers (50%). [Table 2] shows the patients' demography.
Table 1: Centers where patients who had destructive and socket reconstructive eye surgeries were operated

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Table 2: The demography of the patients undergoing destructive eye surgery

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The ocular conditions in 10 (55.6%) were due to infection. The ocular infections included endophthalmitis/panophthalmitis seen in six patients, of which one each was a result of postcataract surgery complications and couching. The patient with ocular trauma had a ruptured globe injury. He was hit in the left eye with a golf club while practicing golf with his friend.

Most of the patients 15 (83.3%) had evisceration. Two patients had socket reconstruction for congenital anophthalmos and shallow socket respectively and one had enucleation for ocular tumor.

The recommendation for surgery was initiated by a doctor in 11 (61.1%), and seven patients requested for "just anything" that could be done to alleviate the pain or the disfigurement.

There was no postoperative infection during the follow-up period of 1-week to 3 months. The only postoperative complications of note were slight enophthalmos in the OP side 16 (88.9%) and slight color mismatch in17 (94.4%). Enophthalmos was measured by the differences in the palpebral fissure height taken in the pupillary plane of the ocular prosthetic eye and the fellow eye ("mild or slight" 2 mm, "moderate" 3 mm and "severe or marked" ≥4 mm). The OP movement with the fellow eye was acceptable in most of the cases. [Table 3] shows postoperative findings in patients with POP. [Figure 1] shows POP in a young man who sustained golf club injury with good motility of the prosthetic eye. [Figure 2] shows the balancing of the prosthetic eye with plus lenses to correct slight enophthalmos in a young man with POP following a corneal ulcer.
Figure 1: Primary ocular prosthesis in a young man who had golf club injury to the left eye 1-week postoperation: Note good ocular movement of the prosthetic eye

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Figure 2: Primary ocular prosthesis left eye in a young man with corneal ulcer. Trying plus lenses on to balance slight enophthalmos

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Table 3: History of the eye disease, duration and type of surgery carried out

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Patients willingly accepted the immediate use of OP following removal of the eye. They expressed satisfaction about the immediate disguise of their blemish by the use of OP. The 10 (55.6%) with painful blind eye from endophthalmitis/panophthalmitis were happy with the relief of pain and the OP in place of a painful eye. One of them made this comment; "I would have had the eye removed long ago if I knew my new eye would look almost like my other eye." The three patients with anterior staphyloma and one corneal ulcer preferred the new eye to the disfigured one. The parents of the 3-year-old boy with retinoblastoma were happy that at least the OP looked almost like the other eye and was hardly distinguishable from the other eye. They also expressed satisfaction that their son was rid of the cancer. [Figure 3] shows pre- and postoperative appearance in a 3-year-boy with retinoblastoma with POP. [Table 4] shows the postoperative results in patients with POP.
Figure 3: Primary ocular prosthesis right eye of a 3-year-old boy with retinoblastoma

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Table 4: Postoperative fi ndings in patients with POP

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Nine (50.0%) of the patients expressed extreme sadness over their loss of an eye, 6 (33.3%) said they were just sad and 3 (16.7%) resigned to fate and expressed it as the act of God. One was unhappy with the thought of wearing an artificial eye that could not provide vision. They however felt OP was the best option for a lost eye. [Table 5] shows the emotional postoperative assessments of the patients.
Table 5: Emotional postoperative assessment of the patient fi tted with POP

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  Discussion Top


Facial beauty is highly appreciated anywhere in the world. The facial disfigurement especially of the eye has a lot of psychological impact on one's life. POP not only provides immediate cosmetic rehabilitation following removal of an eye, but also helps the individual regain self-confidence to resume normal life. Age is no barrier for the fitting of OP and early fitting may prevent socket complications such as socket contraction. [8]

The youngest patient that had POP was a 1-year-old baby girl with congenital anophthalmos. She did well postoperatively and the parents were very appreciative; however, she presented only once (8 weeks) postoperatively for follow-up and never came again. There was slight enophthalmos in the eye with OP, but the parents did not want it changed to a bigger one, opting to wait a while.

In our environment, patients usually get lost to follow-up for various reasons.

Most of the patients 10 (55.6%) were <40 years. Four out of those who requested for surgery for cosmetic reasons were in this age group; three had anterior staphyloma and one had a corneal ulcer. The importance of facial cosmesis especially among the young cannot be over emphasized.

Farmers made up the largest group of people undergoing surgery. This could be because their occupation puts them at risks of stick injuries to the eyes at the farms and the injuries were not handled properly.

Surgery was suggested mostly by a doctor. On some occasion, a patient could opt for surgery when the pain in the eye becomes unbearable or for cosmetic reasons. The socket should immediately be fitted with an OP to cover the blemish in situations where there are no facilities for implants.

Evisceration was the most frequent surgical procedure used. This has been the procedure of choice for endophthalmitis in most developing countries. [9],[10],[11] In evisceration, the optic nerve is left intact so the subarachnoid spread and subsequent postoperative intracranial infection is minimized. Some surgeons also advocate for evisceration as a procedure of choice in endophthalmitis for the same reason of preventing postoperative bacterial meningitis. [6],[12],[13]

Orbital anatomy is also preserved for better motility and cosmesis for patients. [8],[14] Less manipulation leads to less inflammation and subsequent minimal orbital tissue scaring.

Even in places with advanced facilities, evisceration is preferred to enucleation because larger implants could be accommodated with modern sclerotomy techniques. [9],[15],[16] This helps prevent superior sulcus deformity and enophthalmos, and gives superior socket mobility for removable OP.

The common postoperative findings of note were slight enophthalmos in the OP eye in 16 (88.9%) and slight color mismatch in 17 (94.4%). These were managed by replacement with a bigger OP or by adding plus lenses to the side with OP until a balance was obtained and the latter by using a slightly tinted spectacle lenses [Figure 2]. The eye socket continues changing in shape after surgery so some adjustments and fittings may be needed after the initial placement of OP. Most of the patients were happy with their OP and did not want some of these fine adjustments.

The OP movement with the fellow eye was fair in all the cases [Figure 1]. In centers with facilities an implant is inserted before a definitive removable custom made OP is used; this provides better fitting and mobility in the absence of customized prosthesis, we depend largely on the available stock prostheses.

Patients were happy with the immediate use of OP following removal of the eye. They expressed satisfaction with the immediate disguise of their blemish by the use of OP. The patients with painful blind eye from endophthalmitis/panophthalmitis were happy with the relief of pain and the OP in place of a painful eye. The subjects with anterior staphyloma and corneal ulcer preferred the new eye to the disfigured one. Patients were happy that at least the eye with OP. was barely distinguishable from the good eye. The relatives of the child with retinoblastoma also expressed satisfaction that their child was rid of the cancer and had a new eye, which though not seeing, was better than "the cat eye." This goes without saying that people irrespective of age, sex, occupation and educational level want to look as normal and natural as possible. One of the ways we as ophthalmologists could offer this help to them is by finding ways of minimizing the period of their disfigurement by offering them POP where and whenever the occasion warrants it.


  Limitation Top


This study has a small sample size, but it is ongoing. It is hoped that as more patients are recruited and followed-up over a longer period, the usefulness of the procedure will be clearly demonstrated.

Follow-up has been a challenge. Once patients are better they stop coming probably because they do not see the need for keeping appointment again. It has therefore been difficult monitoring long term outcomes in these patients. There is the need to carry out further study comparing delayed OP with POP.


  Conclusion Top


Facial beauty is highly appreciated and disfigurement especially of the eye can cause a lot of psychological effect on one's life. POP not only provides immediate cosmetic rehabilitation, but also helps the individual regains self-confidence to resume normal life. It does not lead to any significant complication. Age is no barrier for the fitting of OP.


  Acknowledgment Top


We are most grateful to the patients who allowed us to use them for insertion of POP, a procedure that is not routine, and for allowing us to tell their story.

 
  References Top

1.
Prosthesis Eye (Ocular Prosthesis): Surgery, Care, Types. Available from: http://www.webmd.com/eye-health/prosthesis-Xeye-Ocular-prosthesis. [Last retrieved on 2014 Jun 07].  Back to cited text no. 1
    
2.
London Times (February 20, 2007). "5,000-Year-Old Artificial Eye Found on Iran-Afghan Border". Fox News. Available from: http://www.foxnews.com/story/0,2933,253221,00.html. [Last retrieved on 2014 Jun 07].  Back to cited text no. 2
    
3.
Frequently Asked Questions. American Society of Ocularists. Available from: http://www.ocularistorg/resources_faqs.asp. [Last retrieved on 2014 Jun 07].  Back to cited text no. 3
    
4.
Ayanniyi A. Emotional, psychosocial and economic aspects of anophthalmos and artificial eye use. Internet J Ophthalmol Vis Sci 2008;7.(Available at: https:/ispub.com/IJOVS/7/1/8540).  Back to cited text no. 4
    
5.
Hui JI. Outcomes of orbital implants after evisceration and enucleation in patients with endophthalmitis. Curr Opin Ophthalmol 2010;21:375-9.  Back to cited text no. 5
    
6.
Tawfik HA, Budin H. Evisceration with primary implant placement in patients with endophthalmitis. Ophthalmology 2007;114:1100-3.  Back to cited text no. 6
    
7.
Dresner SC, Karesh JW. Primary implant placement with evisceration in patients with endophthalmitis. Ophthalmology 2000;107:1661-4.  Back to cited text no. 7
    
8.
Walter WL. Update on enucleation and evisceration surgery. Ophthal Plast Reconstr Surg 1985;1:243-52.  Back to cited text no. 8
    
9.
Phan LT, Hwang TN, McCulley TJ. Evisceration in the modern age. Middle East Afr J Ophthalmol 2012;19:24-33.  Back to cited text no. 9
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Eballé AO, Dohvoma VA, Koki G, Oumarou A, Bella AL, Mvogo CE. Indications for destructive eye surgeries at the Yaounde Gynaeco-Obstetric and Paediatric Hospital. Clin Ophthalmol 2011;5:561-5.  Back to cited text no. 10
    
11.
Dada T, Ray M, Tandon R, Vajpayee RB. A study of the indications and changing trends of evisceration in north India. Clin Experiment Ophthalmol 2002;30:120-3.  Back to cited text no. 11
    
12.
Ozgur OR, Levent A, Dogan OK. Primary implant placement with evisceration in patients with endophthalmitis. Am J Ophthalmol 2007;143:902-4.  Back to cited text no. 12
    
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Birkmann LW, Bennett DR. Meningoencephalitis following enucleation for cryptococcal endophthalmitis. Ann Neurol 1978;4:476-7.  Back to cited text no. 13
[PUBMED]    
14.
Masdottir S, Sahlin S. Patient satisfaction and results after evisceration with a split-sclera technique. Orbit 2007;26:241-7.  Back to cited text no. 14
    
15.
Kaltreider SA, Lucarelli MJ. A simple algorithm for selection of implant size for enucleation and evisceration: A prospective study. Ophthal Plast Reconstr Surg 2002;18:336-41.  Back to cited text no. 15
    
16.
Smith RJ, Prazeres S, Fauquier S, Malet T. Complications of two scleral flaps evisceration technique: Analysis of 201 procedures. Ophthal Plast Reconstr Surg 2011;27:227-31.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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