FAQs - Beryl Carvalho - Eyes Alive

An ocular prosthetic or artificial eye replaces a missing natural eye following an enucleation or evisceration.

It is a prosthetic eye that serves to replace the lost orbital volume when the living eye is either shrunken or surgically removed. It’s anterior (front) surface simulates the companion eye.

This is not an unusual question. Of course the answer is NO, but we have had patients tell us they can see better when the prosthesis is in the cavity. Our only explanation for this phenomenon is that you have relieved any undue tension on both upper lids when they are symmetrically aligned.

It can be any inert (avascular or porous) material, or autogenous (bone or dermis fat graft) tissue. All the implants are designed to replace orbital volume loss. Most of them are also designed to offer a range of motility by attaching the eye muscles to them. Your ophthalmologist will decide on the best implant for you.

Stock plastic eyes are mass produced ocular prostheses. Initially, they were duplications of the most common empirically fitted left and right glass eye sizes, shapes and colors.

Custom plastic eyes can be classified as being made for the individual who requires this service. The custom prosthesis can be empirically fitted from a preformed shape and modified with wax and/or acrylic prior to its fabrication, or it can be impression moulded for a more exacting fit, and then modified to accommodate any weakness in orbital tissues and/or the eyelids. This service would also include colour matching of the iris, sclera and vascular pattern of the fellow eye.

"Stock" eyes have assorted standard iris colors and whites of the eye. They are mass produced prosthetic units and do not fit anyone in particular. The "Custom" prostheses are made to adapt to the contour of the orbital tissues and eyelids, and colored to match the companion eye. They make for more a symmetrically balanced and often more comfortable result.

In general, plastic artificial eyes, unlike glass eyes, last for a long time when properly made and cared for. Most ocularists report a replacement is required every 5 to 8 years. Because of bony orbit development early in life, and/or tissue changes in a child will require an prosthesis more often...

You may refer to the Ocularists Association of Southern Africa via info@oasa.org.za for a full membership list. If you prefer to arrange for an appointment with us, you may contact us by E-mail or telephone us. Email pedro@eyesalive.co.za or call to 0861 eyes alive (0861 393725) or 0832631026 and we can answer your questions.

Patients are referred to the Ocularist by their Ophthalmologist or Optometrist or even through a friend. Appointments would then be arranged for the following procedures (initial evaluation, impression moulding, prosthetic model fitting, colour matching of the iris, sclera and vascular pattern simulation, and fitting of the completed prosthesis).

Yes, you should have routine annual visits to determine if your prosthesis needs to be polished, or if an adjustment or replacement is required.

 The Ocularist will instruct individually upon consultation but there are various products available for both cleaning and insertion of the ocular prosthesis.

Tissues from a container or 'pocket pack' are reasonably germ free, whereas, even a clean handkerchief in the pocket or purse can become contaminated.

In the sighted eye you always wipe away from the nose.  This prevents any foreign particles (eyelashes, dirt specks) from becoming embedded in the tear duct.  However, when wearing a prosthesis you would always pat or wipe toward the nose to prevent the lower eyelid from collapsing and ejecting the prosthesis.

Your meibomian and lacrimal glands, and the mucus membrane release fluid.  This combination of liquid causes a protein deposit to gradually accumulate on the prosthetic surface.  This build up can irritate the underlying tissue.  A daily hygiene routine of cleansing the lids, lashes and surface of the prosthesis (without removal) will forestall the time when it becomes necessary to remove it.

This is dependent upon your ability to completely close the eyelids, if you have any allergies, and your personal hygiene care of the prosthesis.  Some patients have to remove it daily, others once a week, a month or annually.  We will evaluate your tolerance level after the prosthesis is worn for a time period

Removal and insertion of the prosthesis is relatively simple. During your appointment, we will instruct you how to remove and re-insert the prosthesis.

Yes, if it is only the cornea that is scarred or disfigured. No if you have lost the eye.

We always mark the top by leaving it free from veins.

For patients with arthritis, rheumatism or just stiffening of the finger joints, we can provide you with a silicone prosthesis
remover, which is similar to a suction cup and only requires you to hold it and make flush contact with the prosthesis.

It is important to wear polycarbonate spectacles for protection of the remaining eye (especially for children). Spectacles can also be
prescribed for corrective cosmetic optics for modification of any asymmetrical alignment of the prosthesis and/or eyelids that cannot be
corrected surgically or by the Ocularist. This would include ("+" or "–") lenses and/or cylindrical power lenses.

When an ocular prosthesis is properly fitted, there should be no discomfort. However, on very cold or windy days you may experience dryness on
the surface of the prosthesis. This dryness causes the upper eyelid to stick to the prosthesis, especially if you do not blink too often.
This may be remedied with a wetting solution.

Any inconvenience would relate more to the loss of sight in one eye, rather than the wearing of a prosthesis.
Therefore, the problem is loss of depth perception and a percentage of your peripheral vision. We would refer
you to the Frank B. Brady’s book entitled "A Singular View."

Yes, participation in contact sports is possible only on advice of your Ophthalmologist providing you wear protective polycarbonate glasses to protect
both your eye and the prosthesis. You will have two problems to contend with however, depth perception and peripheral
vision. We have found that the younger one is when the eye loss occurs, the easier it is to adapt and compensate for these two important factors.

Yes, the hot summer heat together with any allergies (sinus, hay fever, asthma), you will experience more than the normal
amount of tearing or secretions. Always carry a pocket pack of tissues to keep the surface clean. When the pollen count is high
is a good time for your annual polish.

Yes, in the winter, the prosthesis can feel like an ice cube if you are an indoors person most of the time. Skiers will usually
wear goggles with an eye pad under the one lens, although construction workers are accustomed to cold weather and have little
complaint. However, the milder African winters make this less of a problem locally.

 There are some heavier viscosity liquids that will keep the prosthetic surface moist for a longer period of time than wetting solutions.

The anatomy has changed when there is loss of an eye.  Therefore, the tear duct in the inner canthus of the lids is not able to act as the drainage for all of the tears

Most Medical Aids cover the prosthetic eye under the non-surgical external appliance section of the fund. You can contact us and we can assist with the quotations and necessary paperwork required. Our practice aids patients in getting the relevant authorities from the various funds.

Most insurance plans cover replacement artificial eyes. Please call or email us if you have a question about coverage on your all-risks policy.

Retina Blastome Guide(PDF)

An individual skilled in the arts of fabricating, fitting, shaping and painting Ocular prostheses.
In addition to creating your prosthesis, the Ocularist will show you how to handle and care for it.
They will also see to its long-term care through periodic examinations and polishing.

It is advisable to first check the credentials of an Ocularist with the Ocularists Association of Southern Africa through info@oasa.org.za

There are stilll some Ocularists working in glass but at Eyes Alive we specialize in Acrylic prosthetic eyes.
An Acrylic eyes is durable and lasts a long time, an be added out and cut down in size an men as polished.

There are four reasons to wear an ocular prosthesis: Comfort, Cosmesis, plus continued Bony Orbital Wall and Eyelid development. The first two reasons are of immediate importance for parent and child. Comfort is gained with a properly fitted prosthesis, (by relieving the physical stress caused by eye volume loss, and drooping of the eyelid). Cosmesis is recaptured with a lifelike appearance that is once more acceptable to you, your child and peers. The other two reasons are directed toward your child's formative years. An adequate sized prosthesis is required to maintain near symmetrical bony orbital wall and eyelid development.

Yes, a moulded cover shell prosthesis can be fitted over any stage of microphthalmos. The early stage of microphthalmos may require a series of moulded clear acrylic trial shells to gradually enlarge the palpebral fissure (eyelid margins) before a final prosthesis can be fitted.

Yes and No. Each child is different in mood, personality, disposition and what they have gone through prior to this referral for an artificial eye. We can only determine this during the initial evaluation. As with all patients we want to take an impression moulding of the cavity. This is not a painful procedure, but we do require the child to be relaxed
(as possible) and not squeeze the eyelids. This impression will allow us to 'read' our duplicate copy of the socket and prepare a prosthetic model for trial fitting. If this is not possible, we would request an EUA (Examination Under Anesthesia) where your child would be anesthetized for less than 10 minutes. This is usually done on an out-patient basis at a local hospital with your Ophthalmologist: Your presence during an EUA can be discussed with your Ophthalmologist.

If this is a recent eye loss, you would be referred to an Ocularist by your paediatric Ophthalmologist, or primary care physician. Healthcare providers (medical aids) sometimes require this paper trail for approval of this service.

If this is a congenital anomaly, born without an eye(s) or a partially formed globe(s), there would be a preparatory stage of plastic conformers in incremental sizes (in order to expand the eyelid margin and create space within the socket) prior to the fitting of the artificial eye. (This process can be anywhere from three months to three years, depending on the severity of the abnormal development of the bony orbital wall and the palpebral fissure aperture (eyelids).

If on the other hand, this is an acquired eye loss due to disease or trauma, we would begin the fitting of an ocular prosthesis in four to six weeks post-operative. Our youngest patients are 2 – 3 months old.

All Ocularists have been trained to fit any and all age groups.  We are, however, well experienced in the fitting of children and babies of all ages.  Our case referrals for children under the age of 5 years is high.

The tissue sensitivity is similar to you putting a piece of hard candy into the mouth (between the teeth and cheek).

It is amazing how quickly a young child can adjust to monocular vision and the wearing of an artificial eye, as compared to the adult prosthetic eye wearer who is re-adjusting from a lifetime of having depth perception. It becomes second nature to a child, and they are quite uninhibited. We have parent and teacher stories of children removing the prosthesis during 'show and tell' in school, or when complimented by strangers about how pretty their eyes are.

Hygiene care instructions will be given upon completion of the prosthesis, plus we will demonstrate the daily maintenance and removal care.

 At our practice, we will demonstrate removal and re-insertion upon completion of the prosthesis.

Yes, during your child's teething stage, we have had reports that they may remove the prosthesis and begin to bite on it. (These small teeth marks can be polished off.) However, we also have had a few reports of children swallowing it. (If this occurs, you will have a diaper check, prior to having it disposed of or sterilized.) To date, worldwide, there has been only one report in fifty years of a child choking on it where the Heimlich maneuver was applied!

Throughout recorded history, it is evident that man has found a need to attempt to restore or replace the eyes and facial parts of those who were either unfortunate enough to have congenital deformities, or to have suffered from trauma or the disease processes of later life. Most of the evidence of the evolution of ocular and facial prosthetics until the mid 16th century is anecdotal. The record of the origin of ocular and facial prosthetics until the middle of the 16th century is more accurately an archeological record of the artistic ability and technology available to those who attempted to replace facial parts. Even so, a few examples of the artists’ attempts to deal with facial deformity have been found that give us a glimpse of the use of ocular and facial prosthetics by early civilizations and their methods of fabricating them.

Egyptologists have recovered the earliest fragments of information that we have to rely on. During the evacuation of the burial tombs of the elite in this society, it was found that the bodies had been preserved for use in their next life. Research into the methods employed in mummification has shown that an important part of the process came to be the replacement of the eyes of the person being mummified, in accordance with religious tenants. Reisburg and Habakuk state that “radiographs of mummies confirm the presence of radiopaque objects in the orbital areas that resemble eyes.”

“Mud was packed under the skin and linen cloth was placed in the mouth to restore facial contours. Artificial eyes of earthenware, precious stones, and enameled bronze, copper, and gold were placed in the shrunken sockets” (Reisburg and Habakuk 12). This postmortem replacement of the eyes and reconformation of the facial features can be argued to be the beginnings of the technology necessary to replace the lost facial features of the living.

During the same period, it is reported by Valauri that “archeological excavations of tombs pre 2,500 BC have illustrated material found in carvings and sculptures, which provide evidence of fabrication of nasal, orbital, auricular prostheses, and dental restorative treatment being carried out” (Valauri 243. The use of the same natural materials by other civilizations in later periods include the early Chinese dynasties: “historians and archeologists have reported the discovery of facial prostheses fabricated in wood, wax, and clay in the tombs of the early Chinese period” (Valauri 243) and later during the “Greek and Roman period (1,000 BC.) [there were] artificial eyes of quartz, rock crystal, and enamel made from statues (Valauri 243).

The earliest accounts of the use of facial prosthetics in living humans included those by Dyer who “related accounts where ocular prostheses were reportedly worn by individuals during life.” He referred to “Egyptian priests in 500 BC who fabricated artificial eyes from earthenware [that were] constructed so that the eye and lids were incorporated as a single unit attached to flesh colored cloth and fixed in place over the socket” (Reisburg and Habakuk 12).

It is believed that “The first well-documented account of facial prosthetics is provided by Ambroise Pare (1509-1590), a French military surgeon of great ability who made many and varied contributions to the development of surgery-no doubt the father of ‘facial prosthesis.’ ” (Valauri 244). Dr. Pare did much to standardize the indications for and materials used in facial prosthetics.

Since this time, many accounts of ocular and facial prosthetics have been recorded. Both the common and the famous have achieved notoriety as a result of their facial injuries. Their stories give us a reasonably good view of the historical progression of prosthetics from an art, to a combination of art and science. Among the more notable persons to have had a facial trauma restored by earlier prosthetic means was Tyco Brahe (1546-1601,) the famous Danish astronomer. An account of the time states that “on the 29th, at seven o’clock in the evening, in perfect darkness, [Tyco Brahe and Manderup Parbjerg] settled their dispute with swords. The result was that Tyco lost part of his nose, and in order to conceal the disfigurement, he replaced the lost piece by another made of a composition of gold and silver” (Valauri 246). Another slightly later event in 1883 brought a French private who was injured in the siege of Antwerp to the attention of the medical community. This private known as the “Gunner with the Silver Mask” had the majority of the lower portion of his face avulsed by a large shell fragment. A silver mask was fabricated to disguise the defect as well as to provide anatomical support for the tongue and for collection of secretions. The mask was described in the London Gazette as:

“Half mask, without nose or cheeks, that enclosed the whole extent of the edges of the contrivance, where they came in contact with the face, were skillfully obscured by mustachios and whiskers, and it was fortunate that these were the fashion of the day. The external aspect of the mask was painted in oils so as to correspond with his complexion, and it is said that the illusion was so strong that ‘unless forewarned, he might be steadfastly examined at a short distance without betraying his misfortune.’” (Valauri 247)

This case indicates that the importance of functionality, as well as cosmesis, was beginning to be recognized by those who were making prosthetics at the time.

In Europe, the art of fabricating artificial eyes took a great leap forward from the use of metals, ivory, and clay. This leap took place when Laurent Hiester, a German surgeon, suggested in 1752 that the “use of glass rather than metal eyes, since glass could be better tolerated by orbital tissues” (Danz Sr. 2). Glass came to become the material of choice for ocular prosthetics worldwide for the next two hundred years. The techniques for making the glass stock, as well as for the fabrication of the glass ocular prosthesis, evolved into a highly refined art limited in its approximation of the cosmesis of the eye and the anatomical relationship to the orbit only by the limitations of the material itself. The greatest of these limitations was the inability to approximate the surface irregularities of the anterior surface of the posterior orbit. Another was the fragility of the glass and its propensity to fracture in orbit.

An 1869 text entitled Diseases of the Eye, published in the United States, describes the “state of the art” with great respect. “These substitutes for one of the most expressive of the human features have been brought to a beautiful perfection” (Williams 234). It goes on to indicated the origin of the prostheses in use at the time in the U.S.. “Most of those in use are of Paris manufacture, though a few are made in this country” (Williams 234). This same period, though, saw a migration of the apprentices of Europe to the United States where in a very short period of time, a domestic capability to produce prosthetics of suitable quality was established.

The last fifty years has seen marked improvements in the field of ocular and facial prosthetics. The most significant advances have been made in materials science and integration of the prosthesis with the hard and soft tissues of the body. The impetus for these improvements came, as it often, does from the country being at war. During World War II, the specialized glass compounds that were normally imported from Western Europe were unavailable, and the closely guarded trade secrets of their manufacture made it all but impossible to recreate them of sufficient quality in the United States. As a result, the medical departments of the Army and the Navy began to do research into the use of a new material that was being introduced into the medical, and especially the dental community. It was called Poly-Methyl-Methacrylate Acrylic (PMMA) (Danz 4). This material was found to be superior to glass for use in ocular prosthetics in that it could more easily be made into the shape of an impression that was taken of the posterior section of the anophthalmic orbit. This had previously been one of the limitations of glass for ocular prosthetics. Information on the use of this new material was disseminated, and after great debate amongst the “new” plastic and “old” glass ocularist, it became evident that there was no question as to the superiority of the material. Glass prosthetics were to be used only by those who had a true allergy to acrylic. The last person in the United States who practiced the art of “glass blowing,” Earl Schribner, died in 1992, and the practice was taken over by his daughter who works only in acrylic. The art of blowing glass artificial eyes in the U.S. is now lost.

During this period, materials were also introduced which advanced the state of the art in facial prosthetics. The two improvements, which were most notable, have been elastomers, known as silastics, for the formation of the body of the prosthesis, and titanium implants placed in the bone for the retention of the prosthesis (osseointegration.) The quality of the cosmetic result and the ease of use that the magnetic attachment to the titanium implants create for the patient make this prosthesis almost perfect. Its one downfall is a lack of motility in the eye and lids.

In the 1950’s there was a greater need for prosthetics than there were qualified persons to make them. This was especially evident in medically under-served areas. As a result, several companies began to produce “stock” ocular prosthetics. A text written in 1957 alludes to the ordering of a “stock” prosthesis. It retained the limitations in fitting that were part of the “glass” tradition. The author stated that “if an artist familiar with artificial eye practice cannot be engaged, the practitioner should either use a series of artificial eyes or a specially designed set of templates for the exact cosmetic lens specifications” (Bier 122).

Other aspects of the field were also evolving at a great rate as a result of the use of PMMA. The improved technique allowed for greater transference of residual motion retained in the orbit through the interaction of specially shaped implants. “The past 30 years has witnessed the production of many types of intraorbital implants composed of varied materials. Types include spheres, buried implants, semiburied implants, magnetic implants, and two part implants, all of assorted shapes and designs” (Soll, 287). Some of these implants were to find acceptance during this period, but the majority of them suffered from complications, which precluded their use. Eventually, all of the motility implants from this generation were found to be contraindicated, primarily due to high incidences of infection due to their design. The modern implants are far more compatible with the eye socket.