Published in the Waikato times feature September 2010

“GLASS eyes” conjure up ghoulish images for many people. But artificial eyes, now made from plastic, have come a long way, says Hamilton prosthetic eye wearer Steven Donnelly.

You would be hard pressed to spot the difference between his blind left eye, a cosmetic shell made of plastic, and his right; the one he was born with. The brown matches perfectly. The left even moves as he looks around the room. It’s comfortable and sturdy. “I can get a whack to the head and the eye will stay in,” says Steven, who plays goalball, a team sport in which a ball fitted with noise bells is rolled over the goal line using a bowling action. Players are blindfolded so blind, visually-impaired and sighted athletes can compete together. And things can get rough on the court, Steven laughs. “Although I’m encouraged not to wear the artificial eye when I play, I sometimes do, and I’ve never had a problem with my eye flying out.”

Steven has always had eye problems. He has only limited vision in his right eye – “kind of like on a foggy day” – and had cataracts from birth which were removed when he was 16. In 1999 his left eye developed retinal detachment, where the retina – the light-sensitive tissue lining the inner surface – peels away from its underlying layer of support tissue. Doctors tried to save it with 13 gruelling operations over two and half years. Eventually the retina “broke up into bits” and Steven lost the sight in this eye, it became discoloured and his eyeball shrunk.

After the initial shock, Steven focused on the positive. The sight in his right eye improved considerably; doctors said it had been a “lazy-eye”, letting the other one do the work. Although he could no longer work as a farmer, he visited his dad’s farm often, visited friends – “people complain I’m never home” – went for river walks assisted by his cane, went to the gym and played blind cricket and goalball. Steven was offered three guide dogs but felt they should go to people with no sight, as they are so expensive to train.

Five years after his retina loss, Waikato Hospital asked Steven if he was interested in a scleral shell prosthesis, which would fit over his left eye. Although his eye didn’t bother him too much, he wanted to look normal; blend in. “I thought it couldn’t possibly look any worse than it did, so why not?”

The artificial shell restored support to the lids, getting rid of the shrunken look. The change was remarkable. “Family and friends would say, your eye has really improved, have you got sight in it now? They didn’t realise it was artificial.” Steven had minimal problems adjusting, apart from some initial irritation. Because he still has his blind left eye, the artificial shell moves with it. For people who have their eye removed, an implant allows their artificial eye to move. Steven takes his prosthetic shell out weekly to clean it with soapy water and let it dry overnight. “I can put it in straight away, but I like to give my socket a rest.”

After five years, the first prosthesis began to rotate in the socket, sometimes unpredictably. So Steven contacted ocular prosthetist Keith Pine, who set up New Zealand Artificial Eye Service in Auckland three years ago for artificial-eye wearers to go to for information and service. Adults usually replace their artificial eyes every eight to 10 years to keep pace with socket changes, but because Steven’s was unstable, Keith suggested he make a new prosthetic shell. The results were even better than the first time. “This one is more curved. I can tell when it’s in the wrong way straight away. Before, people had to tell me; it was a bit of pot luck putting it in.”

Keith has just expanded his artificial eye service to Hamilton Eye Clinic, and Steven is thrilled he doesn’t have to travel for check-ups. With artificial eye technology having come so far, Steven, whose next goal is to find a job, looks forward to what the future will bring. “They are improving all the time.”

Who wears artificial eyes?
Keith Pine estimates about 3000 New Zealanders wear them. In New Zealand, eye loss is due to accidents (61 per cent), medical conditions like cancer or glaucoma (30 per cent) and congenital disorders (9 per cent). Men lose their eyes more frequently than women and at a younger age (median for men 22 years, women 56 years).

How are they made?
Artificial eyes are made and fitted about six weeks after eye loss to suit individual patients. It involves four one-hour treatment sessions interspersed with laboratory processing.

At the first session, an impression is taken of the socket and a plastic button trimmed to the diameter of the iris. Iris colours are matched and applied to the button using finest grade oil paints and tiny sable hair brushes.

At the second session the iris button, covered with a clear plastic cornea, is imbedded into a wax pattern made from the impression. The wax is shaped and tried in the socket until the direction of gaze, size and lid contour is established. A plaster mould is made and the wax replaced with plastic.

The third session involves colouring the plastic sclera with yellows, blues and grays and laying in fine veins teased from rayon thread. Then a clear plastic veneer is processed over the prosthesis and finished with a high polish.

The completed prosthesis is fitted in the final session and instructions given on removal, insertion and maintenance.

What are the problems?
When patients lose an eye, initial problems are mainly judging distance, reduced side vision and getting good advice, says Keith. “Patients whose jobs involve face-to-face contact are more concerned about their appearance and reduced visual range. After a few years, initial problems generally fade away and milder concerns about socket discharge (sleep in the eye) and shrinkage of the orbital tissues due to ageing take their place. The good news is that modern surgical techniques can counter shrinkage and good eye care reduces the discharge.” While adults should replace their eyes every eight to 10 years, children’s eyes are replaced every two or three to keep pace with growth.

Who pays for artificial eyes?
The cost of the initial prosthesis is covered by the hospital where the eye is removed or by ACC if caused by accident. Replacements are subsidised by the Ministry of Health and/or health insurance.

Challenging case
Keith’s most challenging case was a young woman who had an acid burn that resulted in the loss of her left eye and severe scarring and shrinkage of the socket lining. “It was impossible to retain an artificial eye at first, but with persistence, I was able to build successively larger shells to expand and soften the scar tissue to the point where an artificial eye could be retained. She was very pleased with the result.”

History of artificial eyes
For 300 years, artificial eyes were made of glass and fitted by optometrists. When plastic was invented in the 1930s, it was adopted by dental technicians as a denture-base material, then found to be better than glass for artificial eyes. This is why most artificial eyes today are made and fitted by the dental profession. Keith says he was fortunate to train as a maxillofacial prosthetist while working as a dental technician at the Plastic Surgical Dental Unit at Middlemore Hospital. “I trained for a further year at Queen Mary’s Hospital in England where New Zealanders Sir Archibald McIndoe and Sir Harold Gillies pioneered many plastic surgical techniques when treating wounded soldiers in the first and second world wars.”

Have you got an artificial eye?
Keith Pine is investigating issues affecting artificial eye wearers in New Zealand for his PhD. People interested in taking part can contact him via www.artificialeyes.co.nz.

By Danielle Heyns