After eye loss, a fast supply with a visually appealing prosthetic eye is not just a cosmetic solution, it is the key factor for a successful social, occupational, and psychological rehabilitation. For a long time, prosthetic eye care was based on acquired experiences, and there was a significant lack of systematic studies and peer-reviewed literature on this subject. However, in recent decades, research in the field of ocular prosthetics has been driven forward by ophthalmologists, ocularists, optometrists, ophthalmoplastic surgeons, and psychologists. Many essential findings have been made for improving the care of anophthalmic patients. In this extensive review, the current state of the art regarding prosthetic eye care based on the newest scientific findings is summarized. The broad focus includes important historical aspects in ocular prosthetics, in particular the historical development that led to ocularistic care with different prosthetic materials – cryolite glass and polymethyl methacrylate. Furthermore, epidemiology and etiology of eye loss, surgical techniques of eye removal as well as types and production of prosthetic eyes are set out. Important topics with new insights include psychological issues such as living with a prosthetic eye, treatment of children with anophthalmia and microphthalmia, as well as evidence-based prosthetic eye maintenance and handling. In addition, anophthalmic socket complications and associated treatment options with a focus on the common dry anophthalmic socket and post-enucleation socket syndromes were described in detail. Finally, we will speculate how the field of prosthetic eye care will develop in the future.

PURPOSE:Research to guide scleral shell practice is sparse with minimal evidence-based information available about indications and contraindications for shell wear, or the ideal wear and maintenance regimes. New Zealand optometrists, ophthalmologists and ocular prosthetists were surveyed to gauge current understanding. METHODS:Topics queried included practitioner specialisation, judgements on the suitability and success of shells for different presentations of non-functional disfigured eyes, shell wear and maintenance protocols, and management of complications. RESULTS:Responses from 140 optometrists, 50 ophthalmologists and 8 ocular prosthetists were collected. Optometrists and ophthalmologists observed that patients with non-functional disfigured eyes had an ocular prosthesis significantly less often than anophthalmic patients (∼30 % vs >90 %). Judgements from optometrists and ophthalmologists about shell suitability for different clinical presentations were wide ranging and inconsistent. Judgements from ocular prosthetists highlighted globe volume, corneal sensitivity and corneal integrity as key factors determining shell wear success. Keratitis and discomfort with shell wear were of high concern to both optometrists and ophthalmologists. Optometrists and ocular prosthetists most frequently reported that shells should be disinfected daily with no overnight wear, while ophthalmologists provided heterogeneous recommendations. CONCLUSIONS:There are significant inconsistencies among and between ophthalmologists and optometrists in the provision, care and maintenance of scleral shells. Ocular prosthetists in New Zealand do not have the necessary scope of practice to care for patients' eye health once they have fabricated and fitted a scleral shell. The consequence of these combined factors is that people with blind disfigured eyes in New Zealand are sub-optimally managed. This survey provides a foundation for developing interdisciplinary consensus guidelines on scleral shell provision and maintenance in New Zealand.

Purpose To investigate general and electronic health literacy (HL) levels in prosthetic eye wearing patients, to define factors associated with reduced HL, and to identify a potential healthcare gap. Methods In this prospective cross-sectional study 148 prosthetic eye wearers were screened using the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16) and the 8-item electronic Health Literacy Scale (eHEALS). HLS-EU-16 and eHEALS scores were correlated to health levels, vision functioning, and sociodemographic factors. Results A total of 85 patients (57%) had adequate, 38 (26%) problematic, and 9 (6%) inadequate general HL, while 16 (11%) had no valid HLS-EU-Q16 score. General HL was positively correlated with physical health (p = 0.009) and negatively with a migration background (p = 0.023). There was a positive correlation between electronic HL and educational level (p < 0.001), social status (p = 0.048), and mental health (p = 0.013). Higher age was associated with lower electronic HL (p < 0.001). Conclusions More than 30% of the prosthetic eye wearers had problematic or even inadequate general HL, suggesting a significant health care gap. To identify patients with reduced HL, a standardized screening tool should be implemented as part of routine clinical care. Within integrated care, patients with insufficient HL should be offered barrier-free advisory services and information brochures in various languages.

Background The last definition of the post-enucleation socket syndrome (PESS) by Tyers and Collin-formulated almost 40 years ago in 1982-is predominantly based on the clinical characteristics and does not include the insights of newer studies into the pathophysiological mechanism of the PESS. Methods A systematic PubMed literature review regarding the pathophysiological mechanism of the PESS was performed, and results were comprised to give an overview of the current knowledge of the PESS including the exact pathophysiological mechanism. Results The primarily postulated pathophysiological mechanism of the PESS was the atrophy of orbital tissues, especially of fat, resulting in variable clinical findings. Newer studies using high-resolution computed tomography and magnetic resonance imaging or performing histopathological analyses found no orbital fat atrophy but rather a rotatory displacement of the orbital tissues from superior to posterior and from posterior to inferior together with the retraction of the extraocular muscles and a possible volume loss of the orbital implant by resorption if it is manufactured from hydroxyapatite. PESS results in a backward tilt of the superior fornix, a deep superior sulcus, a pseudo-ptosis, a lower eyelid elongation and laxity, a shallower inferior fornix, as well as enophthalmos and may lead to an inability of wearing ocular prostheses. Conclusions A novel and comprehensive definition of the PESS is proposed: PESS is a multifactorial and variable syndrome caused by a rotatory displacement of orbital contents together with the retraction of the extraocular muscles and possible resorption of the orbital implant if it is manufactured from hydroxyapatite.

Purpose To compare tear film osmolarity (TFO) values and matrix metalloproteinase 9 (MMP-9) levels between anophthalmic sockets and healthy fellow eyes and to assess the use of the MMP-9 and TFO as objective biomarkers for the dry anophthalmic socket syndrome (DASS). Methods In this prospective single-center study, the anophthalmic sockets and healthy fellow eyes of 98 unilateral anophthalmic patients were assessed using the ocular surface disease index (OSDI) questionnaire, InflammaDry® MMP-9 point-of-care immunoassay, TFO with TearLab™ Osmolarity System, and clinical conjunctival inflammation. MMP-9 concentration and conjunctival inflammation were graded semi-quantitatively. Differences between anophthalmic sockets and the healthy fellow eyes for OSDI scores, MMP-9, TFO values, clinical conjunctival inflammation, and eyelid abnormalities as well as the correlation between these factors and demographic data were evaluated. Results Patients had significantly higher OSDI, MMP-9, and TFO values, as well as higher conjunctival inflammation on the anophthalmic side, compared to the healthy side ( p ≤ 0.002, respectively). For anophthalmic sockets, there was a significant positive correlation between OSDI scores and TFO values ( p = 0.007), between the grade of posterior blepharitis and TFO values ( p = 0.026), and between the conjunctival inflammation and MMP-9 values ( p < 0.001), as well as between MMP-9 levels and time since eye loss ( p = 0.004). Conclusions Measuring MMP-9 and TFO may be helpful tools as efficient, quantifiable biomarkers, disease course parameters, or predictors for treatment response in the clinical management of patients with DASS or future therapy studies. Ophthalmologists should consider the updated diagnosis criteria including TFO and the definition for DASS proposed in this study.

To evaluate morphological alterations of meibomian glands (MGs) in the dry anophthalmic socket syndrome (DASS).Fifteen unilateral anophthalmic patients wearing cryolite glass prosthetic eyes were enrolled. All patients with clinical blepharitis or other significant eyelid abnormalities were excluded. In vivo laser scanning confocal microscopy (LSCM) of the MGs in the lower eyelids both on the anophthalmic side and the healthy fellow eye was performed to quantify acinar unit density, acinar unit diameter, acinar unit area, meibum secretion reflectivity, the inhomogeneous appearance of the glandular interstice, and inhomogeneous appearance of the acinar walls.The lower eyelids of the anophthalmic sockets revealed a significant reduction of the acinar unit density (p = 0.003) as well as a significantly more inhomogeneous appearance of the periglandular interstices (p = 0.018) and the acinar unit walls (p = 0.015) than the healthy fellow eyelid. However, there were no significant differences regarding the acinar unit diameter, acinar unit area, and meibum secretion reflectivity of the MGs on the anophthalmic side compared to the healthy fellow eyelid (p ≥ 0.05, respectively).The eyelids of anophthalmic sockets without clinical blepharitis demonstrate a reduced density of MG acinar units and a more inhomogeneous appearance of the periglandular interstices and the acinar unit walls. This can cause meibomian gland dysfunction contributing to DASS and suggests early treatment of these symptomatic patients, even in the clinical absence of any blepharitis signs.

Prosthetic eyes are currently manufactured using Poly(methyl methacrylate) (PMMA) which is not an ideal material because it is hydrophobic. While significant research has investigated the benefits of hydrophilic materials for contact lenses, no such research has been carried out on hydrophilic materials for prosthetic eyes until now. In this study, different derivatives of Poly(ethylene glycol) (PEG) monomer and methyl methacrylate (MMA) monomer were grafted to PMMA using copolymerisation. The resulting matrixes were evaluated by water contact angle measurement, 24 h water absorption testing, and colour-difference measurement when exposed to ultraviolet light. The contact angle and water absorption results indicated that ethylene glycol dimethacrylate (EGDMA) grafted PMMA matrix had a better hydrophilic performance than the other matrixes tested. EGDMA is already a minor constituent of the PMMA matrix currently used for manufacturing prosthetic eyes but when the proportion of EGDMA monomer to MMA monomer used in the manufacturing process was increased to 50/50 the hydrophilicity of the matrix was significantly improved.EGDMA-grafted PMMA is inexpensive and comes as a liquid monomer that is easily mixed with the PMMA monomer that ocular prosthetists are familiar with. The mixture requires no special handling beyond the normal safety precautions that apply when using PMMA monomers. In-vitro testing shows that EGDMA-grafted PMMA significantly improves the wettability of PMMA currently used for the manufacture of prosthetic eyes and has the potential to significantly improve wearing comfort and socket health.

Purpose To investigate anxiety and depression levels in prosthetic eye–wearing patients using standardized psychometric instruments, to define factors associated with these psychological diseases, and to identify a potential healthcare gap. Methods A total of 295 prosthetic eye wearers were screened using the 7-item generalized anxiety disorder scale (GAD-7) and the 9-item patient health questionnaire (PHQ-9). Scores of GAD-7 and PHQ-9 were correlated with scores of general physical and mental health functioning, vision-related quality of life, appearance-related distress, appearance-related social function, and further biosocial factors. Results Five patients (2%) had a pre-diagnosed anxiety disorder, and 20 patients (7%) had a pre-diagnosed depression. However, our screening revealed 26 patients (9%) with anxiety symptoms, 31 patients (11%) with depression symptoms, and 40 patients (14%) suffering from both anxiety and depression symptoms. This underdiagnosing for both anxiety and depression disorders was significant ( p < 0.001, respectively). Higher GAD-7 scores were significantly associated with higher PHQ-9 scores, lower appearance-related social function, lower mental health functioning, and female gender ( p ≤ 0.021, respectively). Higher PHQ-9 scores were significantly associated with lower physical and mental health functioning, higher educational degree, and non-traumatic eye loss ( p ≤ 0.038, respectively). Conclusions Anxiety and depression disorders seem to be underdiagnosed in prosthetic eye wearers and to have higher incidence compared with the general population. Therefore, a psychometric screening should be routinely implemented in the clinical care. For a successful long-term rehabilitation, integrated care by a multidisciplinary team including ophthalmic plastic surgeons, ophthalmologists, ocularists, general practitioners, and psychologists is essential.

"Prevention of Socket Complications in Anophthalmic Patients." Current Eye Research, 45(12), pp. 1625–1626

Objectives: To assess symptoms and signs of the dry anophthalmic socket syndrome (DASS) in a standardized manner. Methods: 87 unilateral anophthalmic patients were evaluated using the Ocular Surface Disease Index (OSDI), the 5-Item Dry Eye Questionnaire (DEQ-5), and a modified version of Symptom Assessment iN Dry Eye (SANDE) questionnaire separately for the anophthalmic socket and for the healthy fellow eye. Conjunctival inflammation was semi-quantitatively graded and Schirmer I test with topical anesthesia was performed bilaterally. The correlations between scores of the dry eye questionnaires and the results of the Schirmer tests, conjunctival inflammation, and demographic data were examined. Results: Patients had significantly higher OSDI, DEQ-5 and SANDE scores at the anophthalmic side compared to the healthy eye (p <= 0.019, respectively). 63% of patients complained of anophthalmic socket dryness in at least one of the three questionnaires. Patients had higher inflammation (p < 0.001) and more tear volume in the Schirmer I test with topical anesthesia (p <= 0.024) on the anophthalmic side compared to the fellow eye. Conclusions: Most anophthalmic patients have significantly more subjective dryness complaints on their anophthalmic side compared to the healthy fellow eye, even in absence of tear deficiency and clinical blepharitis. Eye care practitioners should consider the diagnosis criteria and the definition for DASS proposed in this study, when counseling anophthalmic patients. However, research should be undertaken to investigate the role and the interactions of causative etiological causes for DASS. Furthermore, there is a high priority to establish a standardized examination protocol and to develop an evidence-based treatment algorithm for DASS.

BACKGROUND:This study explores the role of appearance, mucoid discharge, visual perception and functional problems as indicators for depression, anxiety and stress amongst prosthetic eye wearers.METHODS:A total of 217 anophthalmic patients who had worn a prosthetic eye for at least two years and were older than 16 years completed an anonymous questionnaire. Descriptive and inferential statistics were used to investigate differences and correlations between variables.RESULTS:The mean scores for depression, anxiety, and stress fell within the accepted normal ranges; however, 11% of participants experienced moderate depression, while 7% experienced severe or extremely severe levels. Ten percent were moderately anxious, and 7% were severely or extremely severely anxious. Five percent of participants were moderately stressed, while 7% were severely or extremely severely stressed.CONCLUSION:Social settings are important predictors for depression, whereas anxiety and stress appear to derive more from appearance concerns and practical issues. Prosthetic eye wearers with employment, leisure and social functioning issues are at higher risk of depression, anxiety and stress, as well as appearance, anxiety and not feeling accepted by society. Older patients and those who feel accepted by society appear to suffer less anxiety and stress. It is recommended that psychologists be a part of an integrated team to address the needs of anophthalmic patients.

Clinical relevance Loss of an eye has a negative impact on the psychological health of a person. Background The aims are to: (a) identify the concerns of experienced prosthetic eye wearers in representative areas of India; (b) investigate how they change over time; (c) study how some demographic characteristics influence concerns; and (d) compare prosthetic eye concerns in India versus Germany and New Zealand. Methods This observational multi-centre study was conducted in the cities of Mumbai, Bengaluru and Delhi. Subjects aged from 18 to 65 years, with experience of at least two years of wearing a prosthetic eye fabricated from polymethyl methacrylate material, completed a validated questionnaire over the telephone. The questionnaire captured demographic data and general and prosthetic eye concerns at the time of eye loss and at the present time. Results At the time of eye loss, the five main concerns of participants were: health of the remaining eye; change in appearance; comfort; colour of the prosthesis; and movement of the prosthesis. However, after at least two years these concerns were significantly reduced (p < 0.05). The main present-day concern was watering, crusting and discharge, which was experienced by 81.1 per cent of the participants, 55.5 per cent of them on a daily basis. Compared with other demographic groups, blue-collar workers had higher odds of being concerned about the health of the remaining eye and least odds about prosthesis motility. Homemakers had higher odds of being concerned about wearing comfort and students had higher odds of being concerned about wearing comfort, appearance and health of the remaining eye. Conclusion Initial concerns significantly reduce after two years. Watering, crusting and discharge are the most important current concerns for anophthalmic participants.

To investigate mucoid discharge and the inflammatory response of anophthalmic sockets to cryolite glass prosthetic eye wear. A total of 101 cryolite glass prosthetic eye wearers used visual analog scales (0–10) to measure frequency, color, volume, and viscosity of mucoid discharge associated with their prosthesis. Standardized photographs of the conjunctiva of their anophthalmic sockets were taken and conjunctival inflammation was semi-quantitatively graded (0–4). All characteristics of discharge and conjunctival inflammation were correlated to eye loss cause, hand washing behavior, and cleaning regimes as explanatory variables. Mean mucoid discharge characteristics (0–10 scale) were frequency 5.3 ± 2.8, color 4.8 ± 3.2, volume 4.9 ± 3.0, and viscosity 5.1 ± 3.2. The mean conjunctival inflammation score (0–4 scale) was 2.1 ± 1.0. There was a positive correlation between the grade of conjunctival inflammation and the frequency (p = 0.018), color (p = 0.001), volume (p = 0.003), and the viscosity of mucoid discharge (p = 0.005). More conjunctival inflammation was associated with higher frequency of cleaning (p < 0.001) and lower frequency of hand washing before removal (p = 0.001). Higher frequency, color, volume, and viscosity of discharge were associated with higher frequency of cleaning (p ≤ 0.001). Discharge severity associated with prosthetic eye wear was positively correlated with more conjunctival inflammation, higher cleaning frequency, and less hand washing before handling. The results suggest that cryolite glass eyes should not be removed daily for cleaning and that further research should be undertaken to develop a standardized treatment protocol for managing inflammation and mucoid discharge. This protocol would advise hand washing before handling cryolite glass eyes and recommend a minimum period of wear between cleaning sessions.

Purpose To compare the concerns of experienced cryolite glass and (poly) methyl methacrylate (PMMA) prosthetic eye wearers. Methods One hundred six experienced cryolite glass and 63 experienced PMMA prosthetic eye wearers completed an anonymous questionnaire regarding general and specific prosthetic eye concerns at least 2 years after natural eye loss. From these independent anophthalmic populations, we identified 34 case-control pairs matched for the known influencing demographic variables of gender, occupation, age, and time since natural eye loss. Results The levels of concern were significantly lower in the cryolite glass group than those in the PMMA group for the following: loss of balance (p < 0.001), phantom sight vision (p < 0.001), pain (p < 0.001), receiving good advice (p = 0.001), fullness of orbit (p = 0.001), size (p = 0.007), direction of gaze relative to the healthy fellow eye (p = 0.005), eye lid contour (p = 0.037), comfort of the prosthetic eye (p < 0.001), colour relative to the healthy fellow eye (p < 0.001), and retention of the prosthetic eye (p < 0.001). Concerns about watering, crusting, discharge, visual perception, appearance, movement of the prosthetic eye, and health of the remaining eye were not significantly different between both groups. Conclusions The results of this study showed that many general and specific levels of concern were significantly lower for cryolite glass prosthetic eye wearers than for PMMA prosthetic eye wearers. The question of why there are significant differences and to what extent the material of the prosthesis (cryolite glass or PMMA) has an impact on various concerns remains unanswered and should be addressed in a prospective comparative multicentre trial.

We investigate prosthetic eye wearers' initial and current concerns about mucoid discharge, visual perception, and appearance, and the reasons for their concerns. A retrospective, cross-sectional study of private practice patients was designed. Participants were 217 experienced prosthetic eye wearers, aged at least 16 years. An anonymous questionnaire was e-mailed or mailed to participants. Descriptive and inferential statistics were used to investigate differences or correlations between variables. Content analysis was used to analyze participants' open responses. Participants were equally concerned about discharge, visual perception, and appearance during the first three months following eye loss and at least 2 years later, even though their concerns decreased. Older participants were less concerned about appearance, while females were more concerned about current discharge and appearance. The greater the frequency and volume of discharge, the greater was the concern. Participants' initial discharge concern was due to a negative interpretation of what it meant, but later, it was due to discomfort from wiping, and how discharge looked to others. Loss of depth perception and reduced visual range were equally concerning. Initial appearance concerns related to disguisability of the prosthesis, but over time, changes to the socket and eyelids became more important. Loss of self-image is commonly considered to be the major concern of anophthalmic patients, but discharge and visual perception concerns are of equal importance. Reasons given for these concerns provide greater insight into patients' personal experience of eye loss.

PURPOSE:To identify the main concerns of patients experienced in wearing cryolite glass prosthetic eyes and to investigate how these have changed over time.METHODS:One hundred six patients experienced in wearing prosthetic eyes for at least 2 years were asked to complete an anonymous questionnaire regarding prosthetic eye concerns at the time of initial eye loss and at the present time. Main outcome measures included changes in levels of concern over time.RESULTS:Initially, the participants were mainly concerned about their appearance, health of the fellow eye, and coping with monocularity. Over time, there was a significant increase of the level of concern regarding the health of the remaining eye (p < 0.001) and regarding watering, crusting, and discharge (p < 0.001). Loss of balance did not change significantly (p = 0.302). All other concerns decreased significantly over time (p < 0.001), with levels of concern about appearance decreasing the most. The current leading concern was the health of the remaining eye followed by concerns about watering, crusting, and discharge. Length of time since natural eye loss was the most important explanatory variable, with significant impact on the concerns about appearance (p = 0.013), retention of the prosthetic eye (p = 0.002), and eyelid contour (p = 0.004).CONCLUSIONS:Health of the remaining eye is the most common current concern of anophthalmic patients, acknowledging the need of good ophthalmologic follow up after losing an eye. The second most important concern is with watering, crusting, and discharge, suggesting further research for establishing an evidence-based protocol for cryolite glass prosthetic eye maintenance and supportive treatment.