As an ocularist, Jelmer is a member of the Amsterdam UMC MICA team and is involved in complex socket treatments; he focuses on research and development (3D) projects. He spoke about the close collaboration between the ocularist and the specialist.
“This collaboration has only intensified in recent years and has led to positive outcomes in patient care. When someone has to have an eye removed due to trauma or illness, it involves more than just a piece of plastic and a technical procedure. Physically, depth perception changes, the field of vision is limited, and there is a cosmetic aspect. We must also not underestimate the mental aspect.”
Each patient’s medical history is always different. For example, someone may be born with an eye abnormality, or they may have to cope with trauma or illness later in life. The loss of an eye is a kind of grieving process. During treatment, we always carefully assess how a person is coping with this. This also applies to parents of young children with retinoblastoma or microphthalmia/aphthalmia.
Steps
In a “normal” situation, (1) the patient is referred to an ocularist by the ophthalmologist who removed the eye. The ocularist fabricates the prosthesis and performs follow-up checks; beyond that, there is little need for collaboration. Complications may occasionally arise, requiring the ophthalmologist to perform a surgical procedure (2). The procedure can, in turn, affect the fit of the prosthesis, so it is important that the ocularist and ophthalmologist work together and keep each other informed about the available options. These are conventional treatment techniques.
However, there are also situations that require more intensive collaboration, such as so-called complex sockets and MICA (3). In these cases, a conventional solution is not always available, and a plan of action must be developed collaboratively. “You won’t get anywhere by limiting yourself to your own field of expertise.” Furthermore, it is important that this collaboration takes place at an academic center. Here, a wealth of knowledge is available—including in other fields—that may be relevant. Such centers also have specific facilities that would otherwise be inaccessible to an ocularist.”
3D Printing Capabilities
During the presentation, Jelmer gave several examples of how 3D techniques are used in medical applications. So-called preoperative planning is widely used, particularly in oral surgery and orthopedics. For example, missing pieces of the skull can be digitally designed based on a CT scan of the patient. This “bone” can be printed and then implanted. But Jelmer also sees opportunities to use 3D techniques specifically for the eye socket in preparing for surgery and creating a final ocular prosthesis.
Oculoplastic Surgeon
Dyonne Hartong: “At the Academic Center, we have experience with surgeries involving eye removal. As an ophthalmologist, I am happy to collaborate with the ocularist whenever necessary to provide the best possible patient care. We also collaborate on research into treatment outcomes and the publication of new developments.”
Dyonne focused on what she called the “normal” anatomy following an enucleation (removal of the eye). “To replace the lost eye volume, a small ball (or piece of buttock fat) is placed in the eye socket. Usually, both eyelids are still intact, and there is space available beneath the eyelids (fornices) where an ocular prosthesis can be fitted. Normally, there are no medical problems following an eye removal. However, it does happen that people experience symptoms, and that is what we focus on.”
Identifying Pain Symptoms
Dyonne spoke about possible pain associated with ocular prostheses: “It’s important to first try to determine the cause of the pain. However, this is by no means always clear. There are several ways to reduce the pain, or even eliminate it. First, you can have the prosthesis repolished by an ocularist; the shape of the prosthesis may need to be adjusted. An ophthalmologist can prescribe artificial tears (lubricants) or steroid eye drops, and paraffin drops have also been found to be effective. If tendon or nerve inflammation is suspected, a steroid injection may be administered. As a last resort, a dermis-fat graft procedure may sometimes offer a solution. This is a technique in which the eye socket is filled with fat harvested from the buttocks (or abdomen). In cases of chronic infections or discharge, the problem will first be assessed in collaboration with the ocularist, for example, to find a better fit and reduce irritation of the mucous membrane. We use questionnaires to evaluate the effects of the various treatments.”
Cosmetic Issues
“Minor cosmetic issues can be resolved by adjusting the prosthesis, possibly supplemented by simple surgical procedures such as correcting a drooping upper eyelid or tightening the lower eyelid.”
A loss of volume above the artificial eye is often very bothersome, as it makes the eye appear to sit very deep. These days, we fill this space with a dissolvable filler. Experience has shown that the effect of increased volume—and thus improved facial symmetry—lasts a very long time, meaning this procedure does not need to be repeated every time. Through a study, we are closely monitoring how long the effect lasts and how satisfied patients are with this simple treatment.
A complex problem arises when the prosthesis cannot stay in place because the spaces under the eyelids (the fornices) become too narrow (contracted or scarred socket). This does not occur under normal circumstances, but can happen after severe infections, multiple surgeries, radiation therapy, or chemical/firework-related trauma. A promising new technique can help in such cases. Using 3D printing technology—where the ophthalmologist and ocularist collaborate on a design—a temporary prosthesis (conformer) can be created. This slightly adjusts the shape of the eye socket. Eventually, a permanent ocular prosthesis can then be fitted. Even in cases of complex orbital problems, such as microphthalmia or anophthalmia, where the eye socket—and possibly the eyelids as well—have a completely different shape, the close collaboration between the ophthalmologist and the ocularist is evident. Using 3D imaging techniques, a customized design is created and printed in various sizes, taking into account growth and the desired shape for a future, aesthetically pleasing ocular prosthesis.”
Featured Case Study: Fireworks-Related Trauma
Jelmer and Dyonne presented eight case studies in which various techniques were applied. In this article, we’ll highlight one of them:
“Following a fireworks accident, a patient suffered severe scarring of the conjunctiva and cornea. Over the years, the patient underwent several eye surgeries, including conjunctival and corneal transplants. However, scarring continued to occur. Vision was lost, and ultimately, due to pain, it was decided to remove the eye. We decided on a collaborative approach: an implant of subcutaneous fat tissue (dermis-fat graft) combined with a specific conformer to ensure the surgical wound healed in the correct shape. Based on a facial scan, a specific conformer was designed and then 3D-printed in a biocompatible material. The ophthalmologist removed the eye and placed a dermis-fat graft. During the surgery, the custom-made conformer was inserted. After 10 weeks, the conformer could be replaced with the cosmetic prosthesis. The result was initially beautiful; however, over time, the prosthesis became loose (contracted socket). A second procedure was necessary: a buccal mucosa graft using the Dermis-fat conformer model again, which also allowed the fornices to be reconstructed. This time, we left the conformer in place for 4 months. Afterward, the conformer could be directly copied into a beautifully shaped prosthetic model. The prosthesis now stays securely in place.”
Collaboration
Jelmer concluded: “We’re pleased with the way we work together. By combining the knowledge and expertise of both fields, one plus one equals three. The use of 3D techniques offers new possibilities where conventional techniques are sometimes insufficient.”
