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In cases where vision is permanently lost, if there is severe pain or an aesthetically unpleasant appearance, the non-functioning parts of the eye are surgically removed and ocular prosthesis surgery is performed. The purpose of these surgeries is to achieve a cosmetic result that is indistinguishable from the healthy eye.
Ocular prosthesis surgeries involve removing the degenerated parts of non-seeing eyes and placing artificial prostheses that resemble the healthy eye aesthetically. However, it is not possible for a blind eye to regain vision through these surgeries.
The most common indications for an ocular prosthesis are eyes that have lost their function and/or integrity due to trauma, certain congenital eye diseases that cause complete loss of vision, tumors, and progressive eye diseases resulting in vision loss.
These surgeries may be performed for several reasons:
There are different techniques used in ocular prosthesis surgeries. In all cases other than tumors, the evisceration method is preferred, where the muscles and the white shell of the eye are preserved. Evisceration surgery has various sub-techniques depending on the surgeon’s experience, and the most suitable method should be chosen for each patient according to the problem and the healthy tissues.
In cases involving tumors, the enucleation method—removing the entire eyeball—is used to reduce the risk of recurrence, or in more advanced cases with extensive spread, the exenteration method—removing all tissues up to the bone—may be necessary.
Enucleation or evisceration can be performed under general anesthesia or, alternatively, with sedation (intravenous sedative injection) combined with local anesthesia.
Immediately after removing the eyeball or its internal contents, an orbital implant close in size to the natural eye is placed into the socket to restore volume and shape. The surface of this implant is surgically covered with the conjunctiva, a pink tissue that also lines the inside of the eyelids and resembles the mucous membrane inside the mouth.
Next, a thin, transparent temporary plastic plate (conformer) is inserted beneath the eyelids to maintain the space for the prosthesis. Once surgical healing is complete, a custom-made ocular prosthesis—designed to match the healthy eye—is placed in place of the conformer.
In exenteration surgery, however, all tissues surrounding the eye are removed. Since no eyelid tissue remains to cover a standard prosthesis, instead of a conventional ocular prosthesis, an epithesis is applied. This prosthesis is attached to magnets that are fixed onto magnetic screws implanted into the bone.
Ocular prosthesis surgery is a highly meticulous procedure performed to ensure that the prosthetic material—similar to a thick contact lens—can be properly fitted onto the eye surface.
This surgery has two main objectives:
If these two requirements are not fully met, the surgery may lead to lifelong dissatisfaction for the patient. Therefore, the first surgical procedure is of critical importance.
In some suitable patients, if there is a small gap between the eye surface and the eyelids, no surface irregularities exist, and the nerves on the eye surface are too damaged to transmit a sensation of irritation, a direct prosthesis application without surgery may be attempted. Whether a patient is suitable for this procedure can only be determined through an examination.
If the application is comfortable, it can be continued; however, some patients may experience irritation within a few days, making surgery necessary.
Immediately after ocular prosthesis surgery, a pressure bandage is applied over the eyelids. The purpose of the bandage is to minimize swelling of the socket tissue, and it remains in place for a few days. The bandage should not be removed during this period. Patients may find it difficult to open the other eye, which can be alarming.
Fortunately, this usually resolves spontaneously by the end of the first postoperative day. Mild to moderate discomfort is common during this period, and pain relief with paracetamol or similar medications is usually sufficient. If the eye was in severe pain before surgery, the patient will generally feel significant relief after the procedure.
After the pressure bandage is removed, some swelling and bruising of the eyelids is normal for a few days. Eye drops or ointments may be prescribed to accelerate healing.
The prosthesis cannot be fitted until the surgical site has fully healed, which typically takes about 4–6 weeks.
With your eyelids closed, there will be no visible difference. When your eyes are open, you will see the transparent plastic conformer covering the socket with the pink conjunctival tissue.
You can reposition it yourself. First, wash your hands and the conformer under running water. Gently push the conformer under the upper eyelid, then pull down the lower eyelid and blink. Usually, this will place the conformer back in position. If you are unable to do this, contact your doctor immediately to have the conformer replaced. Leaving the conformer out for an extended period can cause the socket to shrink, making prosthesis fitting impossible.
Until the socket heals, special care is required. In the early postoperative period, the closed eyelid can be gently wiped with slightly moistened cotton. Use the prescribed eye drops or ointments to protect the socket from infection. Avoid lifting heavy objects or bending forward. The healing process typically lasts 4–6 weeks.
About three weeks after surgery, you should visit an ocularist (prosthesis specialist) recommended by your ophthalmologist. The ocularist will ensure the conformer is correctly positioned and provide guidance on how the prosthesis will be made, as well as its care and maintenance.
Depending on your doctor’s follow-up schedule, the prosthesis is usually ready about 6–8 weeks after surgery. Once your doctor confirms complete healing, the ocularist will take an impression of the socket and begin fabricating the prosthesis from a custom material. The prosthesis will be shaped and painted to closely match your healthy eye, giving a very natural appearance. Its color and appearance will be designed to match your other eye.
Yes, most people have a small amount of mucus discharge. If the amount increases, or if the color or consistency changes, or if it develops an odor, you should see your doctor to rule out infection.
Yes, you can continue to drive. Your ability to drive depends on the visual acuity of your healthy eye and meeting the legal requirements for a driver’s license. If the prosthetic eye is on your left side, it is important to move your head toward that side as much as possible to expand your visual field and compensate for the missing vision.
Protecting the healthy eye cannot be emphasized enough. Regardless of age, protective measures should always be used during work, play, sports, or hobby activities. Children, in particular, should be educated on protecting their eyes and avoiding unnecessary risks.
For everyday protection, durable, impact-resistant glasses are sufficient. Polycarbonate lenses are especially recommended because of their strength. Impact-resistant glasses can also be made in stylish designs. Even if a person has no vision problems, lifelong use of protective eyewear is advised.
Although the remaining healthy eye is fully responsible for vision, it does not “overwork” or “wear out” as a result. However, regular eye check-ups by an ophthalmologist are extremely important. Examinations should be performed according to the intervals recommended by your doctor or immediately if new symptoms or problems arise.
Ocular prosthesis surgery is highly specialized and requires significant experience. The goal is to create a socket that is compatible with a prosthesis and allows natural movement in a single procedure.
If the surgery is not performed correctly, complications may include:
Correction surgeries after an improperly performed first operation can take a much longer time.
If the prosthesis does not stay in place, fails to fit, or is expelled due to the first surgery, the socket can shrink rapidly, necessitating additional surgery. When ocular prosthesis surgery is performed by an experienced oculoplastic surgeon, the likelihood of these complications is very low.
Unfortunately, these issues are common. When the initial surgery was not performed properly, or due to certain structural factors in the patient, the socket-prosthesis compatibility may be lost either immediately after surgery or over time.
If there is an opening in the socket surface, it must be corrected promptly through surgery. If insufficient volume was created during the first surgery, a very thick prosthesis may have been required, which can prevent movement and, over time, deform the eyelids due to weight. Narrowing at the junction between the eyelids and socket can also cause the prosthesis to not fit, fall, or sit improperly.
Other issues may include upper eyelid drooping, inward turning of the eyelid edges, or sagging of the eyelids. All of these problems can be corrected with socket revision and carefully planned surgeries. Different surgical techniques exist for addressing each specific problem. A detailed examination is required to determine the source of the problem and create an appropriate surgical plan.
Repeated surgeries in prosthetic eye patients can damage the vascular structure that nourishes the socket and reduce fat volume. Therefore, instead of performing multiple random procedures, the goal should be to achieve an ideal socket with the fewest possible surgeries that will not require repeated operations.
Before performing an ocular prosthesis revision, a detailed oculoplastic examination should be conducted to determine the source of the problem. In some cases, the issue may simply be related to defects in the external prosthesis or aging of the prosthesis. If, during the examination, no significant problems are found in the socket or eyelids and the patient’s complaints are solely due to the external prosthesis, creating a new prosthesis may be sufficient.
In cases where the prosthesis slips or sits improperly due to laxity or sagging of the lower eyelid, correcting the lower eyelid tension through surgery may be enough to allow for a healthy and aesthetically suitable prosthesis.
If problems with the socket surface are detected during the examination, such as openings or implant extrusion, prompt surgery to revise and restore the socket is appropriate. Depending on the condition of the socket, the surgical plan may range from simple surface-covering procedures to more complex interventions, such as removing and replacing the internal implant or transferring dermis-fat tissue harvested from the patient’s body.
In some patients, the internal implant that should have been placed during the previous surgery may be missing or smaller than necessary. In these cases, the most effective approach is to open the socket and insert a new implant or dermis-fat graft to restore proper volume. Otherwise, a very thick or heavy prosthesis on the surface may cause more serious long-term socket problems. In situations where volume loss is the primary issue and no other problems exist, another treatment option may involve placing an implant at the base of the socket to elevate it and reduce volume loss. If the patient’s anatomy and examination findings allow, a simpler alternative may be the use of a cannula to inject filler into the orbit. Additional filler can also be applied to the typical depression between the upper eyelid and eyebrow. All of these procedures should be performed by a highly experienced oculoplastic surgeon.
In some cases, the inability to fit a prosthesis is due to insufficient soft tissue covering the socket surface. Tissue grafts may be harvested from the inner lip or cheek, amniotic membrane (from the uterine lining),hard palate tissue, or fat from the abdominal wall or buttocks. The most suitable tissue type is determined through a detailed preoperative examination.
In advanced insufficiency cases, excessive shortening of the tissue covering the socket causes the eyelid edges to contract inward, the eyelashes to contact the socket surface, and drooping of the upper eyelid. In these situations, the upper and lower eyelid fornices, where the eyelids meet the globe, are often lost, preventing the prosthesis from staying in place. In such cases, the socket and fornices must be reconstructed using advanced techniques. A thorough examination is required to identify all sources of the problem, and all necessary surgeries should be individually planned, taking into account socket volume, surface tissue, fornices, eyelid edges, and eyelid positioning.
The socket refers to the space created for an ocular prosthesis. For various reasons, a patient’s socket may shrink, narrow, or become unsuitable for fitting a prosthesis. Conditions such as chemical burns, radiotherapy, certain eyelid or ocular surface diseases, multiple prior socket surgeries, wearing excessively thick or heavy prostheses for many years, or using a worn prosthesis for an extended period without replacement can lead to socket insufficiency or socket contraction syndrome.
In cases of socket volume deficiency, the most common cause is the absence of an internal implant. During the initial surgery to remove the eye contents, an implant meant to provide volume may not have been placed by the surgeon, or an inappropriately small implant may have been used. In these cases, a very thick prosthesis is required to compensate for the insufficient socket volume. This prevents prosthesis movement and, over time, the excessive weight on the eyelid tissues can cause tissue atrophy or insufficiency.
Socket insufficiency or contraction syndrome, which prevents proper prosthesis fitting, is often associated with:
Preventing socket insufficiency is easier than treating it. Therefore, it is extremely important that the first ocular prosthesis surgery is performed by an experienced surgeon to create an ideal socket.
In patients who develop socket insufficiency, a thorough examination should identify the main problem(s),and all underlying factors must be addressed.
Common surgical techniques include:
If the implant placed in the socket is too large or the tissue covering the implant is insufficient—in other words, if the tissues over the implant are inappropriate or overly tight—the surface of the implant may wear through over time. In severe cases, the implant can even extrude outside the socket. This is a significant socket problem and requires prompt intervention.
If the exposure is very small, it may occasionally be corrected with suturing, but in most cases simple stitching is insufficient. Surgical intervention is often required to cover the surface with additional tissue grafts or to relieve tension by loosening/stretching the posterior wall of the socket.
In cases of larger exposure or extrusion, the ideal solution involves removing the existing implant, placing a new appropriately sized implant, and covering the surface with surgical techniques that reduce tissue tension. In some cases, a dermis-fat graft harvested from the patient provides the optimal solution.
If an integrated implant has been used, removing it is more difficult than removing non-integrated implants such as silicone or PMMA. Very meticulous surgery is required to avoid damaging healthy tissues. The most appropriate solution depends on a detailed preoperative evaluation, careful surgical planning, and precise execution by a highly experienced surgeon.
After all prosthesis surgeries, some socket stretching may occur approximately six months postoperatively. At this stage, follow-up is essential. In cases with a healthy socket and properly fitted prosthesis, we do not recommend that the patient remove and clean the prosthesis continuously.
The more the prosthesis is left in place, the more the body adapts and accepts it as its own. During follow-up visits, usually every six months, we remove the prosthesis, examine the underlying socket, clean the prosthesis, and reinsert it. This cleaning can also be performed by your ocularist, but only your doctor can evaluate the socket, eyelids, and eye movement.
If a mismatch between the socket and prosthesis is detected, prosthesis modifications can be made. If there are reactions or allergies on the socket surface due to the prosthesis or external factors, appropriate eye drops may be prescribed.
The anterior surface of all prostheses can wear over 5–7 years, developing scratches. Therefore, prosthesis replacement every 5–10 years is recommended. This does not require surgery; a new prosthesis can be fabricated by the ocularist using a mold.
The prosthesis is like a thick contact lens placed between the eyelids. You can gently pull down your lower eyelid and press slightly on the bone to remove the prosthesis. Your doctor or ocularist can teach you this technique.
The cost of ocular prosthesis surgery varies depending on the surgical technique used. To determine an estimate, a detailed evaluation and examination are required to assess whether surgery is necessary and, if so, which method is appropriate.
Altuğ Çetinkaya, MD, FEBOOphthalmologist Turkey
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