A Brief History of the Ocular Prosthesis

Artificial eye-making has been practiced since ancient times. The first ocular prostheses were made by Roman and Egyptian priests as early as the fifth century BC. In those days artificial eyes were made of painted clay attached to cloth and worn outside the socket.

It took about twenty centuries for the first in-socket artificial eyes to be developed. At first, these were made of gold with colored enamel. Then, in the latter part of the sixteenth century, the Venetians started making artificial eyes out of glass. These early glass eyes were crude, uncomfortable to wear, and very fragile. Even so, the Venetians continued making them and kept their methods secret until the end of the eighteenth century.

After that, the center for artificial eye-making shifted to Paris for a time, but by the mid-nineteenth century, German glass blowers had developed superior techniques, and the center for glass eye-making moved to Germany. Shortly thereafter, glass eye-making was introduced in the United States.

A chain of events, since the introduction of glass eye-making in the US, have lead to the development of medical grade acrylic plastic and its use in eye-making. The popularity of this method has continued to increase over the years, and today the vast majority of patients wear ocular prostheses made of acrylic.

A Chain of Events: Plastics Creates a Profession & Two New Societies

We are proud to state that we are members of the American Society of Ocularists (ASO). Although the ASO group is small in number compared to other ancillary factions of the Academy of Ophthalmology (AAO), we are considered to be one of the smallest organized healthcare provider groups in North America, and have gained worldwide recognition.

It is interesting to follow the chain of events that paralleled the formation of the ASO and Jahrling Ocular Prosthetics, and later the formation of a oculoplastic surgical specialty group within the AAO. It can be summed up in the one magical word. PLASTIC! Please read on.

A Reason to Convert from Glass to Plastic
Plastic Replaces Glass Stock Eyes
A Reason to Convert from Empirical to Impression Fitting
Development of the Motility Implants
Formation of Two New Ophthalmic Societies

1: A Reason to Convert from Glass to Plastic

The finest material for making glass eyes was in short supply during WWII, since it had to be imported from Lauscha, Germany. Fortunately, the plastics industry had already developed a medical grade acrylic, (as reported by: Berens, C, Rothbard, S. Synthetic plastic material for implantation following enucleation. Am J Ophthalmol 1941;24:550). The time was ripe for its application as a replacement for the glass eye.

It was the Dental Corps, Army of the United States that first reported and published a 'bulletin' (Erpf S. F., Dietz V. H., Wortz M. S., et al. Prosthesis of the Eye in Synthetic Resin, A Preliminary Report. The Bulletin of the Army Medical Department, Vol. IV, No 1, July, 1945, 76-86.) on the fabrication of the impression moulded plastic eye. Needless to say, it was the material of choice when it became available to the public. The advantages of plastic over glass were numerous. There was no longer fear of breakage, it would not roughen with wear, and, if it became chipped or scratched, it could easily be repaired and polished. The curvature and thickness of the impression molded plastic prosthesis could adapt to the irregular configurations of the orbital tissue, and atonal weaknesses in the eyelids. It could improve cosmesis when there was orbital volume loss that caused superior sulcus depression of the upper lid. The moulded prosthesis could also be worn at bedtime, whereas, the glass eye with its smooth concave posterior shape, that allowed tears and secretions to accumulate behind it, had to be removed nightly to give the socket tissues a rest, and to prolong the life of the glass eye. (The glass eye would roughen and discolor caused by tears and secretions.)

2: Plastic stock eyes Replace Glass Stock Eyes

The sale of stock glass eyes was another market that flourished for the five-to-seven German families of glass eye makers in North America. Especially, if you consider 1 in every 500 people in the USA required an artificial eye, and the glass eye (if it didn't break) would have to be replaced every one to two years, because, 'tears' and 'secretions' would roughen and discolor the front surface of the glass.

The stock glass eyes were sold to those who could not afford a custom fitted glass eye. They were also fitted to younger children whose parents preferred they wore the glass stock eyes, because of expected breakage, and/or rapid tissue change (normal growth) within the cavity that required frequent replacements. And, for patients in remote areas that preferred not to travel to the big cities they provided a mail order service, where they would have the wearer do their own selecting and fitting from a sample box of two to four dozen. Besides this source of disbursement, they also sold trays of glass eyes to Oculists, Optometrists, Opticians and even jewelry stores. (These individuals were called 'glass eye fitters.')

When the public sought the plastic eye instead of glass, they were obligated to incorporate the making of both custom and stock plastic eyes in order to keep their clientele, and to attract new case referrals. At first, some of the glass eye makers embedded glass irises in the plastic prostheses, in an effort to utilize their glass blowing skills. However, due to the coefficient of expansion and contraction a delamination would occur between the two products, giving the appearance of a clouded cornea.

The increase in demand for the plastic artificial eye, and the increased amount of time it took to make meant hiring individuals who had backgrounds in art and dental laboratory skills. The dual purpose was to assist them in building up an adequate supply of stock plastic eyes to meet their own patient demand, while continuing their wholesale ancillary provider market venture. Their method of manufacture was duplication of selected preformed glass eye shapes.

3: A Reason to Convert from Empirical fitting to Impression Fitting

The initial transition from glass eyes to plastic ocular prostheses had now taken place. The inevitable was yet to happen, the manner in which a custom prosthetic eye was to be fitted. This meant conversion from the glass eye makers empirical (less time consuming) trial and error fitting method, to the more exacting impression molding technique. At the onset of this plastic era, there were few adherents for the Army Dental Corps method of impression taking.

However, those ocular prosthetists who did use the more time consuming flush fitting technique were discovering (as well as their referring ophthalmologists) that former glass eye wearers, had fewer complaints about excessive tearing and secretions. The reason for this occurrence, was that fluids could no longer pool behind its flush fitting posterior surface (which was a cause for irritation and infections of the nonconforming prostheses). The positive aspect of this conversion to impression fitting began to pay dividends for the wearer. It was no longer necessary to remove and clean the prosthesis three or more times during the day, nor was it necessary to remove it at bedtime. Despite this less attentive care, the conjunctival tissue in the cavity remained white and quiet (no sign of chronic irritation), and for some patients, they were experiencing wearing comfort for the first time.

In additional to less tearing, secretions and more wearing comfort, there was a degree of movement of the prosthesis from the underlying tissues and the (orbital volume augmented) ball implant. Of course, the extent of motility was limited, since there was no direct attachment of the eye muscles to the sphere, and in many cases the implant had migrated out of the muscle cone. This usually restricted movement to two quadrants (depending on the migration of the ball).

The next link in the chain of events was to obligate the use of impression molded fitting procedures for all plastic ocular prostheses, by introducing the dual purpose implant for "orbit volume augmentation" and "motility."

4: Development of the Motility Implants

Development of motility type implants began to transpire when a number of concerned eye surgeons experimented with medical grade plastics and other compatible materials that would not only replace lost orbital volume, but would simultaneously offer movement to an overlying eye prosthesis. It was at this stage that orbit volume augmentation became a partner with a number of non-spherical designed motility implants that were: basket (ball and socket) shaped, Saturn styled with an attached ring, pyramidal, conical, pear shaped, hemispherical with a flat anterior and even quadruple nubbins on the front surface. All of these implants were solid avascular type implants, some of which relied on imbrication of the severed recti through tunnels and posts for their attachment. Whereas, others had an external wrapping of tantalum or other non-allergic mesh material for integration of the eye muscles.

Two of the more innovative implants went another step further, one incorporated magnets in both the implant and prosthesis, while the other made a positive contact by having the anterior surface of the implant exposed with a rectangular cavity for insertion of a pegged prosthesis. This peg innovation from the late 1940's may have been the precipitant for a secondary option for the present day popular porous (coral and polyethylene) implants that integrate the rectus muscles for motility. Then, after four to six months of fibrovascularization of tissues throughout the implant, an option is available for drilling a hole for a pegged prosthetic attachment. This would increase mobile response for quick darting eye movements.

5: Formation of Two New Ophthalmic Societies

The formation of a medically affiliated Society gives indication that we are a special facet within a chosen profession. Such is the case for the two special groups that were founded more than thirty years ago. There is a coexistence created out of the need and support for one another.

The American Society of Ocularists (ASO):

ASO was founded in 1957 when a small conglomeration of stock eye fitters and several prominent glass and plastic eye makers met with a handful of young, foresighted eye research doctors and ophthalmic plastic reconstructive surgeons. A number of these providers of prosthetic services realized that the medical/surgical advances (motility implants) had passed their technical skills and it was time to become organized.

These eye specialists were located in several of the larger teaching hospitals, and were responsible for the designing of a variety of moveable orbital implants since mid to late forties. Each of which required a more completely customized impression molded prosthesis, rather than those being offered by the empirical stock eye fitters and eye makers. It was with this in mind that prompted them to seek out, initially for themselves, a limited number of skilled plastic eye prosthetists (including ocularists from the W.W.II Army Dental Corps). At the onset, it was a medical/technical team where the ocularist observed both the primary (enucleation) implant insertions with integration of the eye muscles, and the more complicated secondary procedures (acquired anophthalmos) where tissue probing was necessary to locate the four rectus muscles. This one-on-one team lead to an exchange of ideas for implant modifications for better adaptation to the mobile ocular prosthesis.

Case presentations at the AAO and articles in newspapers and magazines, also increased the demand for moveable implants, and this in turn required more ocularists knowledgeable in the proper fitting procedures. It was now their intention to help support and organize these talented and more experienced ocularists to form a society where they could disseminate their knowledge to the other artificial eye makers in the larger and smaller urban areas, in both the United States and Canada.

To form such a society was a difficult task at first. There were a limited number of new generation plastic eye technicians, and the older group of glass eye making companies (New York, Chicago, Los Angeles and San Francisco) all of whom were competitive, but splintered. There was no organization, no society meetings, and no communication whatsoever. It was with reluctance and possibly self-survival that they became involved in making the plastic eye, but then remained steadfast to adhere to their century old empirical method of trial and error fitting for both there custom and stock eyes. Initially, there was no conflict with this conversion, since the majority of general ophthalmologists were still using ball type implants at the time of enucleation, not the newer motility types.

Eventually, the impressionist and empiricist eye makers, and the stock eye fitters met on March 30th and 31st, 1957. The discussions were heated over custom fitting procedures and the use and sale of stock prostheses. In the end, the custom eye makers prevailed. There would be no future for stock eye fitting in this new age of motility implants, or within this soon to be formed society. The remaining glass artisans and plastic technicians realized they could learn more of what was needed to keep up with this new trend in plastic prosthetic eye fabrication and fitting techniques within an organized educational society. Guidelines were established, and by September of 1957, dates were being arranged for their future meetings to coincide with the American Academy of Ophthalmology, for joint sessions with the young group of eye surgeons (the future ASOPRS).

The American Society of Ophthalmic Plastic Reconstructive Surgeons (ASOPRS):

The ASOPRS were the innovators and designers of the first 'state of the art' integrated, intra-orbital moveable (plastic, tantalum and mesh) type implants. Each of these implants had the (recti) eye muscles (integrated) attached to them to allow for more responsive movement within the eye cavity. This in turn would allow the artificial eye to simulate synchronized motility with the sighted eye. This was a tremendous breakthrough from the first reported unattached embedded hollow glass ball implant (Dr. Mules sphere) that was introduced a little more than a half century earlier (1898). The sole purpose of the embedded ball was to assist the glass eye maker reduce the sunken-in appearance (enophthalmos) which was a common occurrence following the (enucleation) surgical removal of the eye.

The doctors (especially Dr. Albert D. Ruedemann, Sr.) that prompted formation of the ASO were part of the nucleus that formed their own society in 1969. It became the American Society of Ophthalmic Plastic and Reconstructive Surgeons. The formation of the ASOPRS is another group that can give credit to the magical word PLASTIC!