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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 15-21

Custom-made caliper for pupil alignment of ocular prosthesis


1 Department of Prosthodontics and Implantology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
2 Department of Conservative Dentistry and Endodontics, Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College, Chennai, Tamil Nadu, India

Date of Submission31-Oct-2020
Date of Acceptance05-Feb-2021
Date of Web Publication30-Apr-2022

Correspondence Address:
Dr. Vasundhara Apoorva Kaligotla
Department of Prosthodontics and Implantology, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_82_20

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   Abstract 


For patients who have lost an eye as a result of trauma or carcinoma, accurate replacement with an ocular prosthesis that is symmetrical to the natural eye is essential. Rehabilitation of a missing eyeball with an ocular prosthesis is a technique that has a significant role in the field of maxillofacial prosthetics, which improve facial esthetics, physical, psychosocial, and mental well-being of the patient. An ocular prosthesis can be either prefabricated or custom made. Prefabricated ocular prostheses come in a range of standard sizes, contours, forms, and colors. A 60-year-old female reported with a chief complaint of ill-fitting eye prosthesis, which was given 10 years back. On review of the stock eye prosthesis, it was found that the iris and sclera color failed to match with the contralateral eye and improper fit. The treatment plan was decided for a replacement of old stock eye prosthesis with a custom-made ocular prosthesis. The present case report was different from the previous data on the custom-made prosthesis, which was fabricated using various techniques. This case report describes a method for recording the width and height of the original iris more accurately using the Hanau technique and transferring it to the prosthetic eye of the patient. The technique described in this case report is an easy and cost-effective method which meets the technical requirements of the clinician and results in a more esthetically pleasing and accurate prosthetic outcome.

Keywords: Enucleation, esthetics, eye, facebow, prosthesis


How to cite this article:
Kaligotla VA, Babu MS, Asritha S, Krishnaveni G, Sravani K, Teja KV. Custom-made caliper for pupil alignment of ocular prosthesis. J Interdiscip Dentistry 2022;12:15-21

How to cite this URL:
Kaligotla VA, Babu MS, Asritha S, Krishnaveni G, Sravani K, Teja KV. Custom-made caliper for pupil alignment of ocular prosthesis. J Interdiscip Dentistry [serial online] 2022 [cited 2022 May 23];12:15-21. Available from: https://www.jidonline.com/text.asp?2022/12/1/15/344466




   Clinical Relevance to Interdisciplinary Dentistry Top


  • The case report demonstrates the management of the patients with ocular defects
  • The technique helps in iris positioning and enhancing the esthetics of patient
  • The current technique for pupil alignment is a precise and effective method, which can be accurately reproducible in patients presenting with anopthalmic sockets.



   Introduction Top


The eye serves as a sense organ of sight and adds to the beauty of the face. There are several conditions such as congenital defects, irreparable trauma or tumors leading to surgical intervention, and unfortunate loss or absence of the eye.[1] Conditions as such, leading to disfigurement or loss of an eye can cause significant physical or emotional problems to an individual.[2] Multidisciplinary management and a team approach are essential in providing accurate and effective rehabilitation of the ocular defect.[3]

Several techniques have been used in the fabrication and fitting of the artificial eyes such as fitting a stock eye, modifying a stock eye by making an impression of an ocular defect, and the custom eye technique.[4],[5],[6] Literature reports using a stock eye for the replacement of ocular defect. Still, the main issue with the stock eye shell is the inability to achieve the exact color match of the iris or sclera with the adjacent eye.[5]

Custom eye prosthesis provides more esthetic blending and precise match of the sclera and iris of the contralateral eye. Although the procedure for fabricating a custom eye prosthesis is a time-consuming trial and error approach, the esthetic and functional results justify the extra effort.[7] Various techniques such as grid attached to spectacles, grid graph, pupillometer, and Benson visual judgment were used in the past for pupil alignment.[8] However, these pupil locator techniques are difficult to stabilize well and subjective.

The present article describes a case report of the patient presented with a prefabricated ocular shell with the loosening of the prosthesis with poor esthetics. Custom-made eye prosthesis was fabricated using a digital image using digital statutory liquidity ratio camera,[7] and iris positioning was done using pupil alignment technique by Shetty et al.[9] to enhance the natural esthetics and accuracy of the ocular prosthesis.


   Case Report Top


A 60-year-old female reported with a chief complaint of ill-fitting eye prosthesis, which was given 10 years back. History revealed that the patient lost the eye due to trauma 10 years ago [Figure 1] and [Figure 2]. On examination, the right eye was enucleated and was free from any infections [Figure 3]. On review of the stock eye prosthesis, it was found that the iris and sclera color failed to match with the contralateral eye and improper fit [Figure 4]. The treatment plan was decided for a replacement of old stock eye prosthesis with a custom-made ocular prosthesis. The entire treatment plan was explained to the patient, along with the limitation of the technique, and consent was obtained before the start of the procedure.
Figure 1: Frontal view of the patient eye

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Figure 2: Lateral view of the patient eye

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Figure 3: Enucleated right eye

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Figure 4: Right eye with the old prosthesis

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Before the start of the procedure, a preoperative digital image of the patient was obtained. The digital image of the patient's contralateral iris was made using a digital camera (Canon EOS Digital Rebel; Canon Inc, Tokyo, Japan,) with a macro lens (Canon Macro Lens EF 100 mm f/2.8 USM; Canon Inc) with attached ring flash (Canon Macro Ring Lite Flash MR-14EX; Canon Inc). The image was adjusted for slight differences in color, brightness, and contrast, using graphics software (Photoshop 7.0; Adobe Systems Inc, San Jose, California). Once the satisfactory image was obtained, the final image was obtained on a 20-lb white paper with brightness 87 (HP Office; Hewlett-Packard, Palo Alto, California) using a laser printer (HP Deskjet 950C; Hewlett-Packard) with a color-ink print cartridge (HP No. 78 Tri-color Inkjet Print Cartridge; Hewlett-Packard).

The primary impression of the ocular surface was made using alginate loaded in a 10 ml syringe and injected into the eye [Figure 5]a and [Figure 5]b. Once the impression material was set, it was removed, and excess was cut, and putty elastomer was adapted over impression. After the material was set, two slits were made over the putty to allow the molten wax flow into the putty and molten modeling wax was poured through the putty. After complete cooling of wax, it was removed from putty. Wax trial was done in the same appointment, where the patient was asked to move the eye in all possible directions [Figure 6],[Figure 7],[Figure 8]. Two wax trails were made to eliminate any chances of laboratory errors and prosthesis was fabricated. Among the two processed prosthesis, the patient was delivered with a comfortable final prosthesis.
Figure 5: (a) Primary impression made using alginate. (b) Impression obtained

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Figure 6: Putty adapted over the impression

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Figure 7: Horizontal and vertical slits given to allow the flow of molten wax

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Figure 8: Wax trial

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Flasking was done in a varsity flask using a two-pour technique [Figure 9], followed by dewaxing; packing was done using tooth-colored heat cure material mixed with zinc phosphate until the desired shade was obtained. Bench curing was done, followed by a long curing cycle. After deflasking and finishing of the prosthesis [Figure 10], pupil alignment was done using a Hanau Wide View Face Bow Armamentarium (Hanau Springbow; Whip Mix Corp).[9] U-shaped frame of Hanau spring was reversed such that the orbital pointer was stabilized on the left ala of the nose [Figure 11],[Figure 12],[Figure 13]. This procedure was done to stabilize and standardize the facebow. The transfer clamp assembly was attached to the reversed facebow frame.
Figure 9: Flasking of the wax trial

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Figure 10: Heat cure acrylic ocular prosthesis

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Figure 11: Metal ruler attached to edentulous bite fork of Hanau spring bow

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Figure 12: Reverse transfer rod

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Figure 13: Orbital pointer placed on the ala of the nose

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A thinner design of an edentulous facebow fork was chosen to accommodate the distance between the inner and outer canthus of the eye and attached to a transfer clamp assembly. A metal graduated scale was cut to the exact width of the facebow frame attached to the fork using double-sided tape. The width of the normal eye and the mediolateral clinical sclera was recorded. The patient was asked to look straight ahead to record the central point of the iris of the normal eye [Figure 14]a,[Figure 14]b,[Figure 14]c. The patient was asked to look straight at one constant point to maintain the position of eye opening during the measurement using a facebow. All these markings were transferred onto the scale and recorded [Figure 15]. The thumbscrew was loosened, and the facebow fork was adjusted and centered over the defective eye or wax conformer.
Figure 14: (a) Measuring the width of the iris. (b) Measuring the length of the iris. (c) Distance from the inner canthus to the center of the iris

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Figure 15: Markings located over the metal scale

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The marking obtained from the contralateral iris was aligned and checked in the patient [Figure 16]. Once the patient was satisfied with the result, the pupil digital image was cut according to the measured dimensions and placed over the prosthesis using a cellophane adhesive tape; this was done to prevent the merging with the monomer. Silk threads were placed over the acrylic to mimic the veins [Figure 17],[Figure 18],[Figure 19],[Figure 20]. The clear acrylic resin was mixed and placed in one half of the flask mold and the other half with prosthesis and packed [Figure 21]. After curing, the prosthesis was finished and polished and delivered to the patient [Figure 22]a and [Figure 22]b.
Figure 16: Marking of the iris evaluated in the patient

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Figure 17: Incorporating silk threads as veins

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Figure 18: Digital image of the iris

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Figure 19: Incorporating iris

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Figure 20: Clear acrylic packed after iris incorporation

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Figure 21: Finished and polished final ocular prosthesis

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Figure 22: (a) Old prosthesis. (b) Frontal view of customized new prosthesis

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   Discussion Top


Literature reported various artificial eyes based on the material used for fabrication and variations in the reform eye.[10] The prefabricated prosthesis should be avoided as the intimate contact between the ocular prosthesis, and the tissue bed is needed to distribute the even pressure. The voids in the prefabricated prosthesis collect the mucous and debris, which can irritate the mucosa and act as a potential infection source. These can be minimized using custom-made eye prosthesis.[11],[12] In the present case report, a custom eye prosthesis was made using acrylic resin.

The present case report was different from the previous data on the custom-made prosthesis, which was fabricated using various techniques such as paper iris disk technique,[13] using an e-max press scleral veneer,[14] transparent glass template,[15] stock impression technique by Leudde's exophthalmometer,[16] innovative impression technique using heavy bodied polyvinyl siloxane material,[17] and digital customization.[18] A recent systematic review has evaluated different methods, techniques, and concepts documented in the literature to assess the iris positioning in the fabrication of ocular prosthesis. Although the review stressed on the low-level evidence of studies included and a need for randomized controlled trials, it concluded the digital approach in iris positioning to be a superior technique as compared to the other techniques analyzed.[19]

In the present case report, the digital image technique followed was similar to the technique described by Artopoulou et al.[7] The iris color of the custom-made ocular prosthesis was selected by comparing with the color of the iris in the obtained life-size digital image of the patient's existing contralateral eye, which gave a more natural appearance and enhancement of esthetics to the ocular prosthesis. The pupil alignment followed by utilizing a facebow was similar to the report of Shetty et al.,[9] which provided the accuracy of the ocular prosthesis obtained.

The pros of the current technique are:

  1. The present technique is a mathematically correct one, which uses readily available equipment
  2. Technique was more reliable as the standard measurements can be obtained
  3. The method does not require any expensive equipment such as pupillometer, so the technique is cost-effective and reliable
  4. As the putty technique was used for obtaining the wax trails, impression and wax trail can be made on the same day, thus reducing the appointments
  5. As the same flask was used for flasking, the contour of the prosthesis can be maintained.


The cons of the current technique include:

  1. The present technique cannot be applied to the patients with the loss of an ear, because it is impossible to stabilize the facebow
  2. This technique is applicable to only patients who have a natural contralateral eye free from pathologies.


Although the technique claimed to be superior in terms of enhancing the esthetics and reciprocating the accuracy and details in the obtained prosthesis, the major drawback of the present report was the lack of long-term follow-up to prove the superiority of the technique followed.


   Conclusion Top


In the present case, we utilized a digital image of a contralateral eye to reciprocate the iris to obtain superior esthetics and life-size appearance of the ocular prosthesis. The custom-made caliper technique utilizing a facebow proved to be a simpler and reliable technique, which reciprocated the accurate details of the obtained prosthesis. From the present case report, we conclude the custom-made caliper technique utilizing a digital image of a contralateral eye for the fabrication of an ocular prosthesis to be a simpler, reliable, and cost-effective in patients with anophthalmia. However, the present technique needs a longer follow-up to prove its superiority when compared with the currently available techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Rao SB, Akki S, Kumar D, Mishra SK. A Novel method for the management of anophthalmic socket. Adv Biomed Res 2017;6:72.  Back to cited text no. 5
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Artopoulou II, Montgomery PC, Wesley PJ, Lemon JC. Digital imaging in the fabrication of ocular prostheses. J Prosthet Dent 2006;95:327-30.  Back to cited text no. 7
    
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Pai UY, Ansari NA, Gandage DS. A Technique to achieve predictable iris positioning and symmetry in ocular and orbital prostheses. J Prosthodont 2011;20:244-6.  Back to cited text no. 8
    
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Shetty PP, Chowdhary R, Yadav RK, Gangaiah M. An iris positioning device and centering approach: A technique. J Prosthet Dent 2018;119:175-7.  Back to cited text no. 9
    
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Sajjad A. Ocular prosthesis-a simulation of human anatomy: Assssssssss literature review. Cureus 2012;4:e74.  Back to cited text no. 10
    
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Da Costa GC, Aras MA, Chalakkal P, Da Costa MC. Ocular prosthesis incorporating IPS e-max press scleral veneer and a literature review on non-integrated ocular prosthesis. Int J Ophthalmol 2017;10:148.  Back to cited text no. 14
    
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John AV, Anilkumar S, Rajesh C, Raghavan SM. A novel technique of custom ocular prosthesis fabrication. J Oral Res Rev 2016;8:82.  Back to cited text no. 15
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Tripuraneni SC, Vadapalli SB, Ravikiran P, Nirupama N. An innovative impression technique for fabrication of a custom made ocular prosthesis. Indian J Ophthalmol 2015;63:545.  Back to cited text no. 17
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Sathe S, Pisulkar S, Nimonkar SV, Belkhode V, Borle A. Positioning of iris in an ocular prosthesis: A systematic review. J Ind Prosth Soc 2020;20:345.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]



 

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