Himanshi Aggarwal1, Sunit Kumar Jurel2, Pradeep Kumar3, Raghuwar Dayal Singh4, Durga Shanker Gupta5
How to CITE:
Aggarwal H, Jurel S K, Kumar P, Singh R D, Gupta D S. Rehabilitation of phthisis bulbi: a case report. J Pak dentAssoc. 2012 : 01 (02); 116 – 120
Abstract
Ocular prosthesis is an artificial replacement of the eye.After enucleation, evisceration and exenteration of the eye, the goal is to replace the missing tissues with an artificial prosthesis and restore the facial symmetry and normal appearance of the anophthalmic patient. Rehabilitating an anophthalmic patient requires a multidisciplinary approach involving the combined and timely efforts of an ophthalmologist, a plastic surgeon and a skilled maxillofacial prosthodontist. Custom made prostheses provide more esthetic and precise result when compared to stock eye prosthesis. The objective of this article is to reveal the final rehabilitation of uniocular phthisis bulbi, a clinical case treatedwith a scleral shell in a female patient.
Introduction
eauty lies in the eyes of the beholder”. Each of us have heard of this famous phrase but just imagine the pitiable condition of the patient who is sans eyes. Such a patient is not only devoid of a very essential sense organ, but he loses his ability to admire the nature’s beauty. At the same time, he loses the beauty and the charm of his face, as eyes are generally the first facial feature to be noticed andmost of the times, when wemeet other people, eyes speak earlier than thewords.
An unfortunate loss or absence of an eye due to congenital defect or an acquired defect such as trauma, tumor, painful blind eye apart from causing esthetic disfigurement of face, also significantly affects the individual physical , psychological, emotional and social well being.Majority of patients experience extreme stress due to functional disability and non-acceptance in the society. In many cultures, anophthalmic persons are considered a taboo and they are made to face negative stare looks from their own people, resulting in their segregation from the society, thereby deteriorating the patient’s quality of life.
So, replacement of the lost eye at the earliest possible is must to promote the physical, psychological and emotional healing for the patient and to improve his social life. Rehabilitating an anophthalmic patient requires a multidisciplinary approach involving the combined and timely efforts of an ophthalmologist, a plastic surgeon and a skilled maxillofacial prosthodontist. Ocular prosthesis can be stock prosthesis, or it can be customized according to the patient’s socket tissue bed and his/her individualized esthetic requirements. Prosthetic rehabilitation of a patient is enhanced to a great extent by using intraocular implants, dermal fat grafts or amniotic membrane transplants in selected patients.
A case report of a patient with uniocular phthisis bulbi, rehabilitated by a custom-made sclera shell prosthesis is presented.
Clinical Report
A 9 year-old female presented with the chief complaint of blindness associated with the decreased size of the right eye (Fig 1).
Patient gave history of trauma (rod) at the age of 8 years. Due to the poor socioeconomic status and illiteracy, no proper care was taken then, thus leading to the present clinical situation. On palpation it was found that, there was no associated pain, discomfort or residual edema. Thorough ophthalmic evaluation was done and it was diagnosed as Phthisis bulbi (Fig 2).
The appropriate treatment was planned and it was decided to fabricate a custommade scleral shell.
Clinical procedure:
After careful examination of the area of the defect and treatment planning, the procedure including its maintenance and limitations were explained to the patient/guardian to gain their co-operation. Patient/guardian consent was taken for making photographic records. The procedure was initiated by selecting and modifying a pre-fabricated (stock) eye, whose iris and pupil closely matched that of the natural eye, to comfortably and loosely fit the socket. This was duplicated with clear-heat cured PMMA (Trevalon, Dentsply India Pvt. Ltd., Gurgaon, India) and perforated for use as a tray in the impression procedure. Perforation of the tray was done to avoid any compression of the ocular tissues. The tray was placed in the socket and the patient was asked to gaze at a distant point to accurately mark the pupil as per contralateral side, on the tray.
First, petroleumjellywas applied to the eyebrows forthe easy removal of the impression when it sets.Asyringe without the needle portion(Fig: 2a) was then attached to the point of pupillary position on the custom tray to serve as a handle for the impression tray and through which the impression material can be easily injected into the defect area . Athin mixofophthalmicalginat (Opthalmicmoldite, Milton Roy Co. Sarasota Fla.) was loaded into the syringe and then, injected in the socket. The patient was asked to move his/her normal eye in all directions to allow the alginate to flow into all areas of the enucleated socket. Impression(Fig:2b) was examined for accuracy and the cast was poured in two parts with the second part being poured after applying lubricant and making orientation grooves on the partially set first half.
The thin syringe portion was maintained as a sprue to pour the wax pattern and to transfer the pupillary point onto the cast.(Fig:3)
The technique was modified here onwards by trimming out the iris portion of the stock eye and orienting it on the cast according to previously transferred pupillary mark. Carving wax mixed along with the yellow sticky wax was poured into the cast, taking care that the iris portion that was trimmed from the stock eye was maintained in its previously oriented position, in the wax pattern. This stock eye-wax pattern combination was tested in the socket(Fig:4) and modified for adequacy ofocular movements, correction of pupillary alignment, proper palpebral movements, scleral contour and convexity
The next step was to reproduce scleral shade of the normal eye. For this, shade tabs were prepared by mixing and matching different shades and proportions of toothcolored acrylic (SC 10, Pyrax, Roorkee, India) till the color of sclera of the other eye was replicated. Then the adjusted andmodified stock eye-wax pattern combination was invested, flasked and de-waxing was done.(Fig:5) Red silk fibres tomimic veinswere placed in the dough of the determined acrylic shade followed by routine curing, finishing and polishing. Finally, a thin film of the sclera was removed and replaced by a clear film of transparent heat-cured PMMA (Trevalon, Dentsply India Pvt. Ltd., Gurgaon, India) to simulate corneal translucency. The properly finished and polished prosthesis was inserted in the socket after being disinfected and lubricated with an ophthalmic lubricant (Ecotears, Intas Pharmaceuticals Ltd, Ahmedabad, India) to maintain a tear film over the prosthesis and to improve eye movements. Minor adjustments were made at the time of delivery as per the patient’s comfort and esthetics. Disinfection of prosthesis was done with 0.5% chlorhexidine and 70% isopropyl alcohol for 5 mins, later the prothesis was rinsed in sterile saline solution and inserted (Fig: 6b). Instructions were given to the patient regarding proper care and hygiene maintenance techniques in order to facilitate successful adaptation of the prosthesis and the need for regular recall appointments was emphasized. Also instructions of the use of ancillary products (e.g., lubricants, lubricant delivery systems, cleansers.) and procedures were given in order to help the patient adapt to the prosthesis.
Discussion
Fabrication of ocular prosthesis has been known to human being since times immemorial. Prosthetic rehabilitation fulfils aesthetic as well as psychological requirement of the patients. A correctly placed prosthesis should restore the normal opening of the eye, support the eyelid, restore the degree of movement and be adequately retained and aesthetically pleasing.
The ocular prostheses are either ready-made or custom-made and are produced from either glass or methyl methacrylate resin. Glass is not the material of choice as it is subject to damage and surface deterioration from contact with orbital fluids, leading to a usable life expectancy of only 18 24months.
Custom-made prosthetic eye fabrication involves complex painting procedures in various stages that are time taking and based purely on painting skills of the operator. The technique to fabricate ocular prosthesis in the present case report modifies pre-fabricated eye prosthesis to a custom-made fit and esthetics. This helped us to overcome the disadvantages of poor fit, inadequate movement and complex painting procedure and technique involved in making a custom-made ocular prosthesis. This technique of incorporating iris portion from a stock eye into the custom ocular prosthesis is relatively easy to perform, along with saving on laboratory time. The close adaptation of the custom-made ocular prosthesis to the tissue bed provides maximum comfort and restores full physiologic function to the accessory organs of the eye.
Conclusion
The custom made scleral shell fabricated for the uniocular phthsis bulbi patient presented here successfully restored the patient’s esthetics and improved her social acceptance thereby, improving her quality of life. The customized ocular prosthesis demonstrated excellent fit, mobility and comfort. Rehabilitating a patient with uniocular phthisis bulbi is relatively less challenging when it is addressed early during the treatment period, than when there has been a long delay in treatment due to detrimental effects of loss of orbital volume and disuse atrophy of residual structures.
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