The purpose of this section is to provide some background on eye conditions that can lead to vision loss and eye removal. The journey that leads one to our office is often not a pleasant one. We feel quite privileged to be involved in the restoration and "return to normalcy" of our patients. We hope this information will be helpful.
- The choroid, which carries blood vessels, is the inner coat between the sclera and the retina.
- The conjunctiva is a clear membrane covering the white of the eye (sclera).
- The cornea is a clear, transparent portion of the outer coat of the eyeball through which light passes to the lens.
- The iris gives our eyes color and it functions like the aperture on a camera, enlarging in dim light and contracting in bright light. The aperture itself is known as the pupil.
- The lens helps to focus light on the retina.
- The macula is a small area in the retina that provides our most central, acute vision.
- The optic nerve conducts visual impulses to the brain from the retina.
- The pupil is the opening, or aperture, of the iris.
- The retina is the innermost coat of the back of the eye, formed of light-sensitive nerve endings that carry the visual impulse to the optic nerve. The retina may be compared to the film of a camera.
- The sclera is the white of the eye.
- The vitreous is a transparent, colorless mass of soft, gelatinous material filling the eyeball behind the lens.
THREE TYPES OF EYE REMOVAL
- EVISCERATION- removal of the inner eye contents, iris and cornea; leaving the sclera behind with the extraocular muscles still attached. Typically, an orbital implant is placed inside the sclera to replace lost eye volume. A scleral shell is fit following this eye surgery.
- ENUCLEATION- removal of the eyeball, leaving the remaining orbital contents intact; extraocular muscles are detached and typically reattached to an orbital implant or fat graft. Indications: tumors, infections, blind painful eye, severe trauma. An artificial eye is fit following this eye surgery.
- EXENTERATION- removal of the contents of the eye socket (orbit) including the eyeball, fat, muscles and other adjacent structures of the eye. The eyelids may also be removed in cases of cutaneous cancers and unrelenting infection. A maxillofacial prosthesis is typically recommended following this surgery.
Should eye removal be necessary, the surgeon will likely place an orbital
implant to recover some of the volume lost in the evisceration or
enucleation. The orbital implant is attached to the 4 rectus muscles,
providing movement of the implant with the fellow eye. Typically,
the better the movement of the implant, the better the motility
of the artificial eye or scleral shell.
Implant choices may be dictated by the conditions indicating eye removal, the surgeon's preference and your post-removal objectives. Most implants are spherical in shape, but other shapes are possible. Implants can also be coated or wrapped in donor sclera or alloderm materials. Below is a list of typical orbital implants:
- Silicone or PMMA Sphere
- Medpore (porous polyethylene)
- Bio-Eye Hydroxyapatite (HA)
- Fat Graft
While implant type is an important decision to one facing enucleation or evisceration, the most important factor is surgical technique. If you are facing the option of eye removal, we recommend that you contact your local ocularist for a recommendation of oculoplastic or ophthalmic surgeons in your area.
POSSIBLE CONDITIONS LEADING TO A SCLERAL SHELL
The following conditions can lead to the necessity of a scleral cover shell. A scleral shell fits over the existing scleral surface of the eye. A scleral shell is often worn full-time. The motility of a scleral shell is typically very good, but depends on the shape of the socket and the globe.EVISCERATION - Removal of the interior portion of the eye. The eye muscles remain attached to the sclera, so implant motility is typically better than with enucleation. An orbital implant is placed inside the sclera to help replenish volume.
PHTHSIS, PHTHSIS BULBI, PHTHSICAL EYE - A condition of the eyeball that may result from severe injury when the eye loses function and shrinks in size.
ACCIDENT OR INJURY - Trauma will often lead to a shrunken or disfigured globe, yet not necessarily require removal of the eye. In these cases, a scleral shell can be a great solution, providing comfort and a natural result.
RETINAL DETACHMENT - Separation of the thin vascular retina from it's underlying tissue, the retinal pigment epithelium. Can occur with or without trauma.
GLAUCOMA - Increased pressure inside of the eye which damages the optic nerve. It is a leading cause of blindness. In some cases, patients can be born with glaucoma.
CORNEAL DYSTROPHY - A type of eye disease in which to cornea is altered on a cellular level, resulting in loss of it's normal function. The cornea can become cloudy and inflamed, affecting vision and the health of the eye.
POSSIBLE CONDITIONS LEADING TO AN ARTIFICIAL EYE
The following conditions may lead to the necessity of a custom ocular prosthesis or artificial eye. An artificial eye is fit over an orbital implant that is attached to the existing eye muscles. A custom eye prosthesis made with an impression-fitting technique should move as well as the tissue in the socket moves, depending on the shape and edges of the prosthesis.ENUCLEATION - Removal of entire eye globe. An implant is placed in the tenons capsule to replace volume lost due to eye removal. The four extra-ocular rectus muscles are attached to the implant for motility.
BLIND, PAINFUL EYE - Condition in which eye has no light perception (NLP) and is causing pain. Enucleation is indicated to alleviate pain and avoid risk of sympathetic ophthalmia.
OCULAR MELANOMA - A type of cancer arising from the cells of melanocytes found in the eye. Melanoma is the most common type of ocular cancer.
DIABETIC RETINOPATHY - A leading cause of blindness in American adults, this disease is caused by changes in the blood vessels of the retina. The vessels either leak fluid or abnormal vessels grow on the surface of the retina. Often there are no symptoms or pain in the early stages.
TUMORS - Many types of cancers can affect the different structures of the eye. If treatment is unsuccessful in removing the tumor, enucleation is typically indicated.
TRAUMA - The most common cause of eye loss, trauma can take many forms; ruptured globe, penetrating or perforating eye injury, blunt force trauma. When risk of infection or pain is high, enucleation is typically indicated.
RUPTURED GLOBE - Full thickness wound of the eyewall caused by a blunt object or blunt force.
PENETRATING EYE INJURY - Injury to the eye that causes an entrance wound and/or an intraocular foreign body.
PEFORATING EYE INJURY - Injury to the eye that causes an entrance and exit wound as in for example a BB pellet that enters in one location and exits another.
CATARACT - A condition in which the lens of the eye becomes cloudy, diminishing vision. Cataracts are commonly associated with aging but also may be precipitated by trauma
INFECTION - Many types of infections can result in the loss of vision or the necessity to remove the eye to protect the rest of the body from infection. Shingles, uveitis, endophthalmitis, corneal ulcer, etc.
VITREOUS HEMORRHAGE - Bleeding in the vitreous cavity in front of the retina. May be caused by either disease or injury.
ENDOPHTHALMITIS - A serious intraocular bacterial infection, often the result of a penetrating eye injury.
LEADING CAUSES OF EYE LOSS IN CHILDREN
There are many reasons for a child to lose vision and require an artificial eye or a scleral shell. Some of these conditions are listed below.ANOPHTHALMIA - Congenital disorder, the absence of any eyes or ocular structures.
MICROPHTHALMIA - Congenital disorder (occurs at birth), abnormally small eyeball. Anophthalmia and Microphthalmia are both treated with progressive sized ocular conformers, which help stimulate the muscle and bone of the orbit, promoting orbital and soft tissue growth. Clear ocular conformers are custom made to fill as much of the socket as possible. These conformers are not painted to look like a normal eye because they are changed too frequently. When the conformers are in place the eye socket will look pink or cloudy. Every few weeks a child will progress to a larger size conformer until symmetry is achieved, or about 1-2 years of age. Once a child is wearing a custom prosthetic eye, the eye will be enlarged regularly to keep symmetry with the natural eye. The average child will need three to four new painted prostheses before the age of 10. The causes of these conditions may include genetic mutations, abnormal chromosomes or possible environmental factors, but often the cause is unknown.
RETINOBLASTOMA - Retinoblastoma is a type of cancer that forms in the retina. The disease usually occurs in children younger than 5 years and may be in one eye or in both eyes. In some cases the disease is inherited from a parent. It is typically discovered by a "flash of light" in the pupil, when light shines off the tumor. If treatment is unsuccessful, enucleation is indicated and a prosthetic eye will be fit about 6-8 weeks after surgery.
RETINOPATHY OF PREMATURITY (ROP) - Congenital condition that affects children born prematurely. The retina is affected by vessels that grow abnormally, resulting in a retinal detachment. ROP is a leading cause of visual impairment or blindness in children.
COLOBOMA - Congenital anomaly in which some of the structures of the eye are absent due to incomplete formation in utero.
PERSISTENT HYPERPLASTIC PRIMARY VITREOUS (PHPV) - Condition in which a vascularized membrane is present behind the lens, often resulting in microphthalmia, congenital cataracts and sometimes glaucoma. Often discovered by observation of a leukocoria ("white pupil").
TRAUMA - In children, trauma to the eye can take the form of sharp toys, BB guns, paint guns, rocks, darts, bungie cords, pencils, sport injuries or chemical burns. The use of safety glasses during any activity involving potential risk to the eyes is highly recommended.
COAT'S DISEASE - A progressive condition of the retinal capillaries, often resulting in retinal detachments. Affects kids under 10, typically males.