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A prosthetic eye is used in cases where the function of the eye has been permanently lost, particularly if there is severe pain or an aesthetically unpleasing appearance. In these cases, the non-functional parts of the eye are removed, and a prosthetic eye surgery is performed. The aim of these surgeries is to provide a cosmetic correction that is indistinguishable from the other eye in appearance.
Prosthetic eye surgeries involve removing the decayed parts of a non-functional eye and placing artificial prosthetics that resemble the other eye aesthetically. These surgeries cannot restore vision to a non-functional eye.
Prosthetic eyes are most commonly needed in cases of eyes that have lost their function or integrity due to trauma, congenital eye diseases that cause complete loss of vision, tumors, progressive eye diseases leading to vision loss, and other similar conditions.
These surgeries are performed for various reasons:
There are different techniques used in prosthetic eye surgeries. In all cases except for tumors, the evisceration method, which preserves the muscles and the white sclera of the eye, is typically preferred. Evisceration surgery has several sub-techniques, depending on the surgeon’s experience, and the appropriate technique should be chosen for each patient based on their issue and healthy tissues.
In the case of a tumor, to reduce the likelihood of recurrence, the enucleation method, in which the entire eyeball is removed, is used. In more advanced cases with widespread involvement, the exenteration method, in which all tissues are removed down to the bone, may be applied.
Enucleation or evisceration can be performed under general anesthesia, or alternatively, under sedation (with an intravenous sedative injection) and local anesthesia.
Immediately after the removal of the eyeball or its contents, an orbital implant of a size similar to the eye is placed in the socket to fill the space and restore volume. This implant is surgically covered with a pink conjunctiva, resembling the inner mucosal tissue of the mouth, which also covers the eyelids.
Next, a thin transparent temporary plastic plate (conformer) is placed under the eyelids to create a space for the prosthesis. Once the surgical healing is complete, a prosthesis identical to the other eye will be made and placed in place of the conformer.
In exenteration surgery, all tissues surrounding the eye are removed, and since there is no longer any eyelid tissue to cover the prosthesis, instead of a standard prosthesis, an epithesis is applied that is attached to magnetic screws implanted in the bone with magnets.
Prosthetic eye surgery is a very meticulous operation performed to ensure that the prosthetic material, which can be thought of as a thick contact lens, is placed healthily on the surface of the eye. There are two key objectives in this surgery:
If these two requirements are not fully met, the patient may remain unhappy for life. Therefore, the first surgery is critical.
In some suitable patients, if there is a small space between the surface and the eyelid, no surface irregularity is present, and the nerves on the surface of the eye are damaged to the point that they cannot transmit discomfort, a direct prosthesis application to the surface may be attempted without surgery. Whether this approach is suitable for the patient can only be determined through an examination.
If the application is comfortable, it can continue, but some patients may begin to experience surface irritation within days, and surgery may become necessary.
Immediately after the prosthetic eye surgery, a pressure bandage is applied to the eyelids. The purpose of this bandage is to minimize swelling of the socket tissue, and it should remain in place for several days. The bandage must not be removed. During this period, the patient may find it difficult to open the other eye, which can be frightening.
Fortunately, this usually resolves on its own by the end of the first day post-surgery. Mild to moderate discomfort may occur during this period, and pain-relief medications such as acetaminophen usually provide relief. If there was severe pain in the eye before the surgery, the patient will feel significant relief afterward.
After the bandage is removed, it is normal for there to be some swelling and bruising around the eyelids for a few days. Eye drops or ointments may be prescribed to speed up the healing process.
The prosthesis should not be fitted until the wound has healed, which typically takes 4-6 weeks.
When your eyelids are closed, there will be no noticeable change in your appearance. When your eyelids are open, you will see the transparent plastic conformer covered with pink conjunctiva.
You can reinsert it. First, wash your hands and the conformer under running water. Push the conformer under the upper eyelid, then pull down the lower eyelid and blink. In most cases, the conformer will fit back in place. If this maneuver fails, contact your doctor immediately to have the conformer properly reinserted. Leaving the conformer out for an extended period can cause the socket prepared during surgery to narrow, making it impossible to fit the prosthesis.
The socket requires special care until it has fully healed. During the early postoperative period, the closed eyelids can be gently wiped with a damp cotton ball. Use the prescribed eye drops or ointments to protect the socket from infections. Avoid lifting heavy objects and bending forward. The healing process usually takes 4-6 weeks.
About 3 weeks after surgery, you should visit the prosthetist (ocularist) recommended by your eye doctor. The prosthetist will ensure that the conformer is in the proper position and will inform you about how the prosthesis will be made, as well as how to care for and maintain it.
Depending on your doctor's follow-up schedule, you will be ready for the prosthesis about 6-8 weeks after surgery. When your doctor confirms that healing is complete, the ocularist will take a mold of the socket and begin creating the prosthesis from a special material. This material will be shaped and painted to match the appearance of your other eye and will look very natural.
The color and appearance will be matched to the other eye to ensure compatibility.
Yes, a small amount of mucus secretion is common in most people. However, if the amount increases, or if there is a change in color, consistency, or an odor, you should see your doctor for infection control.
Yes, you can continue driving. As long as your vision sharpness in the healthy eye meets the necessary criteria for a driver's license, you can drive. If your prosthetic eye is on the left side, it is important to widen your field of vision by moving your head to the left in order to compensate for the missing vision in that area.
Protecting the healthy eye cannot be emphasized enough. Regardless of age, proper protection should always be worn during work, play, sports, or hobby activities. Especially children should be trained to protect their eyes and avoid unnecessary risks.
For daily protection, impact-resistant, durable framed glasses are sufficient. Polycarbonate lenses are particularly recommended because they are sturdy. Impact-resistant, durable-framed glasses can also be made in stylish designs. Even if a person has no vision problems, it is essential to continue wearing protective glasses for life.
Although the remaining healthy eye is fully responsible for a person's vision, it does not "work harder" or "wear out." However, regular eye check-ups by an ophthalmologist are crucial. These check-ups should be done at intervals recommended by your doctor or as soon as any new symptoms or issues arise.
Prosthetic eye surgery is a highly specialized procedure that requires experience and must use the right techniques to create a compatible, mobile socket that works well with the prosthesis.
If the surgery is not performed correctly, it can lead to difficulties in fitting the prosthesis, openings on the socket surface, implant extrusion, asymmetry, eyelid deformities, problems with opening or closing the eye, excessive crusting, and, most importantly, the use of a stationary, artificial-looking prosthesis. Incorrect surgeries may require corrective surgeries that take much longer than the original procedure.
If the prosthesis does not stay in place, is not inserted correctly, or is displaced due to the initial surgery, the socket surface can quickly shrink, requiring additional surgeries. When prosthetic eye surgery is performed by an experienced oculoplastic surgeon, the risk of encountering these issues is very low.
These questions unfortunately arise quite often. In cases where the first surgery was not performed properly, or due to the patient's structural factors, the socket-prosthesis fit may be lost either immediately after surgery or over time.
If there is an opening on the socket surface, it should be addressed quickly with surgery, and the socket should be corrected. If sufficient volume was not created during the initial surgery, a very thick prosthesis might have been used, and as a result, the heavy prosthesis may not move properly and could deform the eyelids over time due to its weight. Sometimes, narrowing at the junction of the eyelids and the socket can prevent the prosthesis from fitting, causing it to fall out.
Conditions such as drooping of the upper eyelid, inward turning of the lash line, and sagging eyelids may occur. All of these conditions can be corrected through socket revision and carefully planned surgeries. Different surgical techniques are available for addressing each problem. The source of the problem should be identified through a detailed examination, and an appropriate surgical plan should be created.
Multiple surgeries in prosthetic eye patients can damage the vascular structures that feed the socket and cause a decrease in fat volume. Therefore, instead of performing random surgeries, it is preferred to achieve the ideal socket with the least number of surgeries that will not require repeated procedures.
Before a prosthetic eye revision, a detailed oculoplastic examination must be performed to identify the source of the problem. Sometimes, the issue may arise from simple external prosthetic defects or wear and tear of the prosthesis. If the examination shows no significant issues with the socket or eyelids and the patient's complaints are solely related to the external prosthesis, preparing a new prosthesis may be sufficient.
In cases where the prosthesis has come out or appears sagging due to stretching or drooping of the lower eyelid, it may be sufficient to correct the tension of the lower eyelid through surgery to achieve a healthy and aesthetic prosthesis.
If the examination reveals problems with the surface of the socket, such as opening or implant displacement, prompt surgery to revise the socket is appropriate. Depending on the condition of the socket, the surgery may involve simple procedures to close the surface, removing the internal implant for correction, placing a new implant, or transferring dermal-fat tissue taken from the patient’s own body.
In some cases, the internal implant that should have been placed during the previous surgery may not have been implanted, or it may have been placed too small. The most effective approach in such cases is to reopen the socket and place a new implant or dermal-fat graft that provides adequate volume. Otherwise, a very thick or heavy prosthesis may lead to more severe socket problems in the long term. In cases where volume loss is prominent and there are no other significant issues, another treatment option may involve placing an implant at the bottom of the socket to elevate the socket and reduce volume loss. If the patient’s anatomical findings are suitable, a simpler alternative might be using a cannula to inject filler into the orbit. The typical sign of volume loss, such as the depression between the upper eyelid and brow, may also be treated with filler injections. All of these procedures should be performed by a highly experienced oculoplastic surgeon.
In some cases, the inability to wear a prosthesis is caused by insufficient soft tissue covering the socket. In such cases, tissue grafts taken from the inside of the lip or cheek, amniotic membrane (the inner lining of the uterus),sometimes parts taken from the hard palate, or fatty tissue taken from the abdominal wall or buttocks can be used. The most appropriate tissue to use will be determined through a detailed examination.
In advanced cases of insufficiency, the soft tissue covering the socket may shrink excessively, causing the eyelid margins to fold inward, eyelashes to touch the surface, and drooping of the upper eyelid. In such cases, the pockets (fornices) where the upper and lower eyelids meet the eyeball have usually disappeared, and the prosthesis cannot stay in place and falls out. Advanced techniques are needed to reconstruct the socket and fornices in these situations. A thorough examination must identify all sources of the problem, and surgical planning should be tailored to the individual, addressing the socket volume, surface tissue, fornices, eyelid margins, and eyelid levels.
In cases where the need for a prosthetic eye is due to orbital trauma, socket insufficiency may arise from fractures in the orbital bones that were not corrected earlier. In these cases, imaging may detect a defect in the orbital volume, and if an uncorrected bone defect is identified, the bone can be corrected with implants and volume support can be provided to allow for a better fit for the prosthesis.
The socket refers to the cavity created for the prosthetic eye. For various reasons, the socket may become narrowed, contracted, or unsuitable for a prosthesis. Chemical burns, radiation therapy, certain surface-eye-lid diseases, multiple socket surgeries, prolonged use of excessively thick or heavy prostheses, and wearing a worn prosthesis for many years without replacement can all lead to socket insufficiency or socket contraction syndrome.
In cases of socket volume insufficiency, the most common issue is the absence of an internal implant. During the first surgery where the eye contents are removed, an implant should be placed to provide volume. However, sometimes the surgeon may fail to place the implant, or an implant with an inappropriate small volume may be used. In this situation, to compensate for the insufficient volume of the socket, a very thick prosthesis is placed on the surface, which can prevent the prosthesis from moving. Additionally, over time, excessive weight on the eyelid tissues can cause tissue insufficiency due to compression and wear.
In socket insufficiency or socket contraction syndrome, which causes the inability to wear a prosthesis, the most common symptoms include drooping of the upper eyelid, inward turning of the eyelid margins, shortening of the eyelid length, contraction of the lower eyelid, inward turning of the eyelid margins and eyelashes, narrowing or loss of the fornices (the upper and lower eyelid pockets),and a marked reduction in the amount of pink tissue on the surface of the socket.
Preventing socket insufficiency is easier than treating it. Therefore, it is crucial that the initial prosthetic eye surgery is performed by experienced hands to create an ideal socket. In patients with socket insufficiency, a thorough examination should identify the primary issues, and all underlying factors must be corrected.
Common techniques used to treat socket insufficiency include extending the missing surface tissue with mucosal tissue taken from the inside of the lip or cheek, using dermal-fat tissue taken from the abdomen or buttocks to restore both volume and surface tissue deficiencies if the entire socket volume is insufficient, repairing the fornices (the pockets where the eyelid and socket surface meet) with tissue grafts and/or suturing techniques, and applying surgical techniques to turn the contracted eyelid margins outward.
All of these treatments should be tailored to the individual patient, aiming to resolve the issues with as few surgeries as possible.
If the implant placed in the socket is too large or the tissues covering the implant are insufficient, or in other words, if the tissues over the implant are closed improperly or too tightly, the surface of the implant inside the socket can wear out and open up, either early or later. In severe cases, the implant inside may be ejected. This is a significant socket problem and requires immediate intervention.
If the opening is very small, it can occasionally be corrected with suturing (stitches); however, in most cases, simple stitching is insufficient, and additional tissue pieces may be required to cover the surface or the back wall of the socket may need to be loosened/stretched surgically to reduce the tension.
In cases of larger openings or implant displacement, the ideal solution is to remove the current implant and replace it with a more suitable one, and to cover the surface with surgical techniques that reduce the tissue tension. In some cases, placing dermal-fat tissue taken from the patient into the socket may provide the most ideal solution.
If an integrated tissue implant has been used, the removal of the old implant is more difficult than removing non-integrated implants like silicone/PMMA. A very meticulous surgical approach is required to avoid damaging the healthy tissues. The most suitable solution for the patient can be achieved with a detailed pre-assessment, good surgical planning, and, most importantly, careful surgery performed by very experienced hands.
After all prosthetic surgeries, it is expected that the socket will stretch slightly around 6 months after the surgery. At this stage, a check-up is necessary. In cases where the socket and prosthetic application are healthy, we do not recommend the patient to continuously remove and clean the prosthesis.
The more we leave the prosthesis in place, the more the body will accept it as its own. We prefer to remove the prosthesis during our check-ups approximately every 6 months, assess the socket underneath, clean the prosthesis, and place it back. Your ocularist can perform this cleaning, but only your doctor can evaluate the socket, eyelid, and eye movements.
If socket-prosthesis incompatibility is detected, prosthetic modifications can be made, and if there are reactions or allergies to the prosthesis or external factors on the socket surface, appropriate eye drops may be prescribed.
All prostheses may wear out on the front surface within 5-7 years, and scratches may appear on the surface. Therefore, it is advisable to replace the prosthesis every 5-10 years. This does not require a new surgery; a new prosthesis can be produced by taking a mold by the ocularist.
The prosthesis is like a thick contact lens placed between the eyelids. You can easily remove your prosthesis by gently pulling down your lower eyelid with your finger and pressing slightly on the bone. This maneuver can be taught to you by your doctor or ocularist.
The price of prosthetic eye surgeries depends on the technique to be applied. To have an idea of the cost, a detailed evaluation and examination should be performed to determine whether surgery is necessary, and if so, which method is appropriate.
Altuğ Çetinkaya, MD, FEBOOphthalmologist Turkey