An ocular prosthesis is an artificial eye fitted into the socket after enucleation or evisceration. It helps restore appearance and also serves functional roles such as maintaining eyelid closure, preserving the conjunctival sac, and promoting orbital bone growth in children.
Ocular prostheses have a long history, with use recorded as far back as ancient Egypt and Rome. In modern times, materials changed from metal and glass to acrylic (polymethyl methacrylate: PMMA), and acrylic custom-made prostheses are now standard.
Ocular prostheses are made and adjusted at prosthetic eye clinics where an ocularist (an eye-care support specialist) is on staff. In cooperation between the ophthalmologist and the ocularist, prosthesis management is provided from the early postoperative period through long-term follow-up. Wearing a prosthesis greatly improves the patient’s social and psychological quality of life.
After enucleation, the orbital volume deficit reaches 7.0–9.0 ml (average 7.9 ml) 1). Replacing this volume with an orbital implant and ocular prosthesis is the basic principle of cosmetic restoration. The volume of a prosthesis alone is generally estimated at 2.5–3.5 ml (maximum thickness about 4.2 mm) 1).
Main candidates are patients who have undergone enucleation or evisceration. It may also be worn for cosmetic purposes in congenital anophthalmia, microphthalmia, and severe phthisis bulbi (eyeball atrophy). The prosthesis plays an important role not only in appearance but also in maintaining eyelid closure, preserving the conjunctival sac, and promoting orbital development in children.
Ocular prostheses are broadly classified by material and manufacturing method. In current clinical practice, custom-made prostheses fitted to each person’s socket are standard, and the ocularist handles everything from taking the mold to the final finish.
Type
Features
Current role
Temporary ocular prosthesis (prefabricated)
Used temporarily before fitting adjustment. Used to maintain the conjunctival sac immediately after surgery
Early introduction, temporary use
Custom ocular prosthesis (made to order)
Made by an ocularist to match the shape of the socket
Standard (final prosthesis)
Glass ocular prosthesis
Made by a skilled ocularist. Good gloss and a natural appearance. Heavy and easy to break
Limited use
Acrylic (PMMA) ocular prosthesis
Lightweight, less likely to break, easy to adjust and modify
Immediately after surgery, a temporary prosthesis or a transparent plastic conformer is fitted to maintain the shape of the conjunctival sac. The conformer plays an important role in preventing contraction and adhesion of the conjunctival sac and making later ocular prosthesis fitting easier.
QWhich is better, a glass ocular prosthesis or an acrylic ocular prosthesis?
A
Acrylic (PMMA) prosthetic eyes are currently the mainstream option. They are lightweight, less likely to break, and easy to adjust. Glass prosthetic eyes have a good shine and a natural appearance, but they are heavy and break easily. In either case, the standard is a custom-made prosthesis created by a specialist in eye prosthetics to fit the individual’s socket. Selection is based on the condition of the socket, the patient’s preferences, and financial circumstances.
All patients after enucleation or evisceration are candidates for prosthetic eye use. Ocular trauma is one of the main causes of prosthetic eye use, and it has been reported that more than 55 million eye injuries occur worldwide each year2). In severe cases of trauma-related ocular damage, enucleation may be required2).
In one institution, 345 enucleations were performed from 1996 to 2003, with ocular trauma, ocular tumors, and painful phthisis bulbi as the main indications3).
In children, the main causes of prosthetic eye use are congenital anophthalmia, after retinoblastoma removal, and after trauma. Prostheses for microphthalmia are generally not covered by insurance, and this can place a heavy financial burden on families.
The orbital volume grows rapidly from birth, reaches about 80% of adult size by age 5, and becomes comparable to adult size at 14 to 15 years of age1). For this reason, prosthetic eye management in childhood is especially important from the standpoint of orbital growth.
4. Evaluation and examination of difficult prosthetic eye fitting
Prosthetic socket shape and depth: confirm the presence, type, and position of the prosthetic base
Size of the conjunctival sac: assess the horizontal and vertical width and the depth of the upper and lower fornices
Orbital volume assessment: the total orbital volume has been reported as about 24 mL by CT measurement1), and the post-enucleation volume deficit reaches an average of 7.9 mL1)
Hertel exophthalmometer: quantify the amount of enophthalmos by comparing with the healthy eye
Orbital CT: assess the position and condition of the prosthetic base and the bony structure
Presence of prosthetic base exposure: consider secondary reconstruction if exposure or displacement is present
5. Fabrication, fitting, and daily care of the ocular prosthesis
Immediately after surgery: wear a conformer or temporary prosthesis to maintain the shape of the conjunctival sac.
2–4 weeks after surgery: confirm that pain and inflammation have subsided.
6–8 weeks after surgery: Visit the ocularist (artificial eye clinic). Start fitting adjustments for the temporary prosthesis.
After the conjunctival sac has stabilized: Make and complete a custom-made personal prosthesis.
From then on: Continue repolishing and regular adjustments at least once a year.
Introducing ocular prostheses in children
Once the conjunctival sac has expanded enough: Refer to the ocularist and start fitting and adjusting the temporary prosthesis.
Number and period of adjustments: Three or more adjustments, and often an adjustment period of six months or longer, are needed.
Importance of early wear: Wearing the prosthesis as early as possible helps promote the development of the eyelids and orbital bones. This is especially important in children under 5 years old.
Ongoing remaking: Regularly increase the size of the prosthesis to match growth, and continue until 14–15 years of age.
Process for introducing an ocular prosthesis (by stage)
Proper care of the ocular prosthesis helps maintain the health of the conjunctiva and preserve good appearance and function over the long term.
Daily wiping:
With the ocular prosthesis in place, gently wipe away any discharge on the eye surface with soft cotton or clean gauze
It is also helpful to moisten the surface with eye drops such as artificial tears
Regular cleaning (once or twice a week):
Remove the ocular prosthesis and carefully clean it with lukewarm water or a special cleaning solution for ocular prostheses
Avoid using soap, alcohol, or hot water, as these may damage the material of the ocular prosthesis
After cleaning, wipe off the moisture with a clean cotton pad and reinsert it
Regular maintenance by an ocular prosthetist (at least once a year):
Repolish the surface of the ocular prosthesis to restore its shine and smoothness
Readjust the shape of the ocular prosthesis to match changes in the socket
If the ocular prosthesis has significant discoloration or shape changes, consider making a new one
Ongoing care of the conjunctival sac:
Even after conjunctival sac expansion surgery, contraction and atrophy can occur within 3 to 6 months. It is important to keep wearing the ocular prosthesis while keeping it clean to help prevent contraction of the conjunctival sac.
An ocular prosthesis usually lasts 5 to 10 years. Because it gradually discolors and changes shape, it should be replaced at the appropriate time. In children, it needs to be remade regularly as they grow and the orbit develops.
The cost of an ocular prosthesis varies depending on the type and method of fabrication. A custom-made individual ocular prosthesis is generally around 80,000 to 100,000 yen. The following systems may apply.
Medical expense reimbursement (health insurance): An ocular prosthesis after eye removal may be eligible for reimbursement under insurance
Assistive device cost subsidy system: If you have a Physical Disability Certificate (visual impairment), an ocular prosthesis may be eligible as an assistive device
Ocular prosthesis for microphthalmia: As a rule, it is not covered by insurance benefits, and the financial burden on the family is large
QHow often should an ocular prosthesis be cleaned?
A
Remove the prosthesis once or twice a week and clean it with lukewarm water or a dedicated cleaning solution. In daily life, while wearing the prosthesis, wipe away secretions from the eye surface with soft cotton. It is recommended to have it repolished and readjusted by an ocularist at least once a year. Keeping the prosthesis clean helps maintain conjunctival health and keeps it comfortable to wear over the long term.
6. Problems with the prosthetic socket and how to manage them
If depression of the prosthetic socket is progressing, surgical augmentation is needed. The choice of material is determined by the degree and location of the depression and the patient’s general condition.
Material
Features
Indications
Dermal fat graft (DFG)
Soft and easy to fit with the prosthesis. Can be regrafted if it atrophies again. Low risk of exposure
First choice. Moderate depression
Bone (iliac bone)
Suitable for orbital bony atrophy. Strong and less likely to be resorbed
Severe bony depression
Cartilage
Autologous tissue. Easy to shape
Local filling
Silicone block
Inexpensive and easy to process. Deep insertion is important
When soft tissue is sufficient
Hydroxyapatite (HA)
Highly osteoconductive and stable
Use deep to avoid surface exposure
If the indentation is not very severe, a dermis-fat graft is relatively easy to harvest and the socket is also soft, so it is a good option.
DFG is an autologous tissue graft in which dermis and fat are taken from areas such as the buttock or inner thigh and transplanted into the orbit. It does not cause a foreign-body reaction, and the risk of implant exposure is low4). Epithelialization of the conjunctival sac is completed 4 to 6 weeks after surgery, after which prosthesis fitting is started4).
In primary DFG (performed at the same time as eye removal), good eyelid position reaches 83.3%, whereas in secondary DFG (secondary reconstruction), it has been reported to be only 37.5%4).
Advantages of DFG include formation of a deep fornix, good prosthesis mobility, low cost, and no risk of exposure4). In children, DFG may enlarge as they grow, and debulking may sometimes be needed4).
If the conjunctival sac has contracted and the prosthesis no longer fits, conjunctival sac expansion surgery using a full-thickness skin graft is indicated. A full-thickness skin graft taken from the groin or lower abdomen is wrapped inside out around a thin prosthesis and inserted, with the prosthesis left in place within the conjunctival sac. It is important to fix the lower fornix of the conjunctival sac deeply to the periosteum of the inferior orbital rim; if fixation is inadequate, the prosthesis is more likely to dislodge.
Management when the implant is exposed is as follows.
Conservative treatment: For mild exposure, observation and antibiotic eye drops are used
Surgical treatment: Secondary reconstruction with DFG or implant exchange is performed. DFG is an effective salvage option for implant exposure4)
QWhat should I do if my prosthetic eye no longer fits well?
A
It is often caused by atrophy of the anophthalmic socket and contraction of the conjunctival sac. If it is mild, the prosthesis can often be readjusted by an ocularist. If the socket hollowing is progressing, surgical treatment such as a dermis-fat graft may be needed. Regular follow-up with both the ophthalmologist and the ocularist is important.
After eye removal, the orbital fat tissue gradually shrinks, and scarring from connective tissue progresses. Natural age-related reduction in orbital fat also adds to the effect, causing the entire anophthalmic socket to become more sunken over time. After radiation therapy, fibrosis and vascular damage in the orbital tissues accelerate atrophy.
Orbital development in children and prosthesis management
The eyeball acts as a spacer that provides mechanical stimulation for the growth of the orbital bones. After eye removal, this stimulation is lost, delaying orbital bone growth and causing facial asymmetry. The orbital volume reaches about 80% of adult size by age 5 and becomes equal to adult size by ages 14 to 151), so proper sizing of the prosthesis and implant during this growth period is important. Early fitting of a prosthetic eye can preserve mechanical stimulation to the orbit and promote normal orbital bone development.
Eye volume is said to increase to about three times its size from birth to puberty1), which is why regular remaking of pediatric prostheses is essential.
After eye removal, orbital fat may redistribute, leading to a combination of changes such as ptosis, deepening of the upper eyelid sulcus, lower eyelid malposition, and lagophthalmos1). This is called Anophthalmic Socket Syndrome. Adequate volume replacement with an orbital implant and prosthesis is the basic prevention.
Even after enlargement procedures, the conjunctival sac may contract and atrophy again within 3 to 6 months. Continuing to wear the prosthetic eye adds mechanical stretching within the conjunctival sac and can help prevent recurrence of the contracture. Keeping the prosthesis clean and wearing it continuously support long-term stability of the conjunctival sac.
Long-term results of DFG: Primary DFG showed better eyelid position than secondary DFG (83.3% vs 37.5%), indicating the advantage of early performance4). Most complications were mild and resolved on their own4).
Expandable hydrogel implant (HEMA): The use of gradually expandable HEMA implants is being studied to promote orbital growth in children1). It is expected that orbital volume can be controlled according to the growth stage.
3D-printed ocular prosthesis: Efforts to create ocular prostheses using digital design and 3D printing are advancing. By obtaining precise shape data of the ocular socket, it is expected that custom ocular prostheses can be made in less time and at lower cost.
AI-assisted iris matching: Technology is being developed that uses AI to analyze the iris pattern of the healthy eye and match the color and pattern of the ocular prosthesis with high precision. It is expected to improve cosmetic naturalness.
Psychosocial support for ocular prosthesis wearers: Wearing an ocular prosthesis affects not only cosmetic restoration but also psychological and social quality of life. The importance of comprehensive support from a multidisciplinary team (ophthalmologists, ocularists, clinical psychologists, and social workers) is increasingly recognized.
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Narang U, Maubon L, Shah V, Wagh V. Ocular trauma or Oedipism: completing the evisceration. GMS Ophthalmol Cases. 2021;11:Doc13. doi:10.3205/oc000186. PMID:34540525; PMCID:PMC8422941.
Rasmussen MLR, Prause JU, Johnson M, Kamper-Jørgensen F, Toft PB. Review of 345 eye amputations carried out in the period 1996-2003, at Rigshospitalet, Denmark. Acta Ophthalmol. 2010;88:218-221.
Aryasit O, Preechawai P. Clinical outcomes of primary versus secondary dermis fat graft in anophthalmic socket reconstruction. Eye. 2015;29:1496-1502.
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