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CS 107A Ocular Prosthesis

History of Artificial Eyes

The eye was a symbol of life to the ancient world, particularly in Egypt, where bronze and
precious stone eyes were placed on the deceased. The Romans decorated statues with artificial eyes
made of silver.

Ambrose Paré (1510-1590), a famous French surgeon, was the first to describe the use of
artificial eyes to fit an eye socket. These pieces were made of gold and silver, and two types can be
distinguished: ekblephara and hypoblephara, intended to be worn in front of or under the eyelids,
respectively. A hypoblephara eye was designed to be used above an atrophic eye, as enucleation was
not a common practice until the middle of the 1800s.

Enamel prostheses (1820s-1890s) were attractive but were expensive and not very durable. The
introduction of cryolite glass, made of arsenic oxide and cyolite from sodium-aluminum fluoride
(Na6A2F12), produced a grayish-white color suitable for a prosthetic eye. German craftsmen are
credited with this invention in 1835. To make these glass eyes, a tube of glass was heated on one end
until the form of a ball was obtained. Various colors of glass were used like paintbrushes to imitate the
natural color of the eye.

The glass art form flourished in France and Germany where fabricating secrets were handed
down from one generation to the next. The town of Lauscha, Germany, had a particularly rich history in
both decorative (doll eyes, Christmas ornaments) and prosthetic arts. In the 19th century, German
craftsmen (later coined "ocularists") began to tour the United States and other parts of the world,
setting up for several days at a time in one city after another where they fabricated eyes and fit them to
patients. Eyes were also fitted by mail order.

Stock eyes (or pre-made eyes) were also utilized. An "eye doctor" might keep hundreds of glass
stock eyes in cabinets, and would fit patients with the best eye right out of the drawer.

 In the United States, eyes continued to be made of glass until the onset of World War II, when
German goods were limited and German glass blowers no longer toured the United States. The United
States military, along with a few private practitioners, developed a technique of fabricating prostheses
using oil pigments and plastics. Since World War II, plastic has become the preferred material for the
artificial eye in the United States.
A Reason to Convert from Glass to Plastic

The finest material for making glass eyes was in short supply during WWII, since it had to be imported
from Lauscha, Germany. Fortunately, the plastics industry had already developed a medical grade
acrylic. The time was ripe for its application as a replacement for the glass eye.

It was the Dental Corps, Army of the United States that first reported and published a 'bulletin',
the Bulletin of the Army Medical Department, Vol. IV, No 1, July, 1945, on the fabrication of the
impression molded plastic eye. Needless to say, it was the material of choice when it became available
to the public. The advantages of plastic over glass were numerous.

There was no longer fear of breakage, it would not roughen with wear, and, if it became chipped
or scratched, it could easily be repaired and polished. The curvature and thickness of the impression
molded plastic prosthesis could adapt to the irregular configurations of the orbital tissue, and atonal
weaknesses in the eyelids. It could improve cosmetic when there was orbital volume loss that caused
superior sulcus depression of the upper lid.

The molded prosthesis could also be worn at bedtime, whereas, the glass eye with its smooth
concave posterior shape, that allowed tears and secretions to accumulate behind it, had to be removed
nightly to give the socket tissues a rest, and to prolong the life of the glass eye. (The glass eye would
roughen and discolor caused by tears and secretions.)

Stock Plastic Eyes Replace Stock Glass Eyes

The stock glass eyes were sold to those who could not afford a custom fitted glass eye. They
were also fitted to younger children whose parents preferred they wore the glass stock eyes, because of
expected breakage, and/or rapid tissue change (normal growth) within the cavity that required frequent
replacements. And, for patients in remote areas that preferred not to travel to the big cities they
provided a mail order service, A simple box of glass eyes. Where they would have the wearer do their
own selecting and fitting from a sample box of two to four dozen.

When the public sought the plastic eye instead of glass, they were obligated to incorporate the
making of both custom and stock plastic eyes in order to keep their clientele, and to attract new case
referrals.  At first, some of the glass eye makers embedded glass irises in the plastic prostheses, in an
effort to utilize their glass blowing skills.  However, due to the coefficient of expansion and contraction a
delamination would occur between the two products, giving the appearance of a clouded cornea.
 A Reason to Convert from Empirical to Impression Fitting

The initial transition from glass eyes to plastic ocular prostheses had now taken place. The
inevitable was yet to happen, the manner in which a custom prosthetic eye was to be fitted. This meant
conversion from the glass eye makers empirical (less time consuming) trial and error fitting method, to
the more exacting impression moulding technique. At the onset of this plastic era, there were few
adherents for the Army Dental Corps method of impression taking. However, those ocular prosthetists
who did use the more time consuming flush fitting technique were discovering (as well as their referring
ophthalmologists) that former glass eye wearers, had fewer complaints about excessive tearing and
secretions. The reason for this occurrence, was that fluids could no longer pool behind its flush fitting
posterior surface (which was a cause for irritation and infections of the nonconforming prostheses). The
positive aspect of this conversion to impression fitting began to pay dividends for the wearer. It was no
longer necessary to remove and clean the prosthesis three or more times during the day, nor was it
necessary to remove it at bedtime. Despite this less attentive care, the conjunctival tissue in the cavity
remained white and quiet (no sign of chronic irritation), and for some patients, they were experiencing
wearing comfort for the first time.

In additional to less tearing, secretions and more wearing comfort, there was a degree of
movement of the prosthesis from the underlying tissues and the (orbital volume augmented) ball
implant. Of course, the extent of motility was limited, since there was no direct attachment of the eye
muscles to the sphere, and in many cases the implant had migrated out of the muscle cone. This usually
restricted movement to two quadrants (depending on the migration of the ball).

The next link in the chain of events was to obligate the use of impression moulded fitting
procedures for all plastic ocular prostheses, by introducing the dual purpose implant for "orbit volume
augmentation" and "motility."

Development of the Motility Implants

Development of motility type implants began to transpire when a number of concerned eye
surgeons experimented with medical grade plastics and other compatible materials that would not only
replace lost orbital volume, but would simultaneously offer movement to an overlying eye prosthesis. It
was at this stage that orbit volume augmentation became a partner with a number of non-spherical
designed motility implants that were: basket (ball and socket) shaped, Saturn styled with an attached
ring, pyramidal, conical, pear shaped, hemispherical with a flat anterior and even quadruple nubbins on
the front surface. All of these implants were solid avascular type implants, some of which relied on
imbrication of the severed recti through tunnels and posts for their attachment. Whereas, others had
an external wrapping of tantalum or other non-allergic mesh material for integration of the eye muscles.

Two of the more innovative implants went another step further, one incorporated magnets in
both the implant and prosthesis, while the other made a positive contact by having the anterior surface
of the implant exposed with a rectangular cavity for insertion of a pegged prosthesis. This peg
innovation from the late 1940's may have been the precipitant for a secondary option for the present
day popular porous (coral and polyethylene) implants that integrate the rectus muscles for motility.
Then, after four to six months of fibrovascularization of tissues throughout the implant, an option is
available for drilling a hole for a pegged prosthetic attachment. This would increase mobile response for
quick darting eye movements.