- Email: [email protected]
A survey of recommendations on the care of ocular prostheses
Optometry (2010) 81, 142-145
A survey of recommendations on the care of ocular prostheses Katherine L. Osborn, O.D.,a and Debbie Hettler, O.D., M.P.H.b a
Central Missouri Eyecare Associates, Jefferson City, Missouri; and bHarry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri.
KEYWORDS Ocular prosthetic; Ocularist; Care instructions; Lubrication
Abstract BACKGROUND: The purpose of this study was to determine if there is a consistent set of recommendations for patients who wear an ocular prosthesis or if each patient needs an individual plan. METHODS: A self-report questionnaire was distributed to members of the American Society of Ocularists. The survey consisted of 4 questions regarding frequency of removal and cleaning and preferred cleaning and lubrication agents. Respondents had 4 weeks to return the survey for results to be included. RESULTS: One hundred three surveys were sent; 8 were undeliverable, leaving a sample size of 95. Thirty-four percent (32 ocularists) responded. The reason with the most frequency for prosthesis removal was only when the prosthesis felt irritated (31%). Fifty-eight percent reported that the ocular prosthesis should be cleaned every time it is removed. Mild soap or baby shampoo was listed as the preferred cleaning agent with 24% each. A majority listed a silicone oil–based lubricant (29%), but responses varied based on the patient’s needs. CONCLUSIONS: An individualized treatment plan is indicated for most patients who wear an ocular prosthesis. Despite this, some commonalities in responses were noted, specifically that the ocular prosthesis needs to be cleaned with every removal, and a silicone oil lubricant is recommended. Optometry 2010;81:142-145
Many patients who require enucleation wear an ocular prosthesis. The instructions for care and handling of the artificial eye are often left up to the ocularist who created the prosthetic device. In the eye care profession, optometrists often defer to the instructions of the ocularist. However, the ocularist and the optometrist or ophthalmologist need to have the same information to provide to the patient.1 Many times, patients suffer because professionals do not communicate well enough to have a consistent care plan for the patient. Ocular prostheses were developed by dentists in the late 1940s using an acrylic resin material, similar to that used in
Corresponding author: Katherine L. Osborn, O.D., Central Missouri Eyecare Associates, 1705 Christy Drive, Suite 208, Jefferson, Missouri 65101. E-mail: [email protected]
dentures. This material cannot be cleaned with abrasive cleaners or harsh chemicals, as this may pit, cloud, or scratch the prosthesis. Artificial eyes can only be cleaned with mild soap or detergent with warm water. Tough deposits can be removed by soaking the eye in a denture cleaner or a mild solution of sodium hypochlorite (bleach) for half an hour.2 A variety of methods for cleaning the ocular prosthesis have been reported, including cleaning with hard contact lens solution, mild hand soap, or baby shampoo.3 Prosthesis lubrication has also been an area of confusion for many patients and practitioners, as some patients need extra lubrication of the artificial eye for comfort. A study by Fett et al.4 in 1986 tested 3 different products for lubrication and cleaning capacity. This group found that with proper daily hygiene, 77% of patients were comfortable with no
1529-1839/10/$ -see front matter Ó 2010 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2009.11.003
Osborn and Hettler
Clincal Care
additional lubrication. Proper hygiene was defined as forcefully flushing the socket with 5 full syringes (5 oz) of a solution consisting of one-half teaspoon of noniodized sodium chloride and one-half teaspoon of sodium bicarbonate dissolved in 1 quart of boiled water. This indicates that 23% of those who participated in the study needed additional lubrication to wear their ocular prosthesis comfortably.
Methods This is a qualitative study on preferred care and handling of ocular prostheses by the ocularists who fit and fabricate the artificial eyes. The data were collected during a 4-week period in April and May 2007. Surveys were e-mailed to members of the American Society of Ocularists who had their e-mail addresses published on a public Web site at www.ocularist.org. One hundred three surveys were sent out, and 8 were returned undeliverable, resulting in a sample size of 95 ocularists. The survey consisted of the following 4 questions: What is your recommended frequency of removing the ocular prosthetic? What is your recommended frequency for cleaning the artificial eye? What is your recommended cleaning agent? What is your recommended agent for lubricating the eye? Thirty-two ocularists completed the brief questionnaire. The survey was limited to 4 questions to encourage response. A reminder e-mail was sent approximately 2 weeks later with the survey again attached. Responses were compiled; some questions received more than one answer; therefore, the denominators in the calculations had to be changed with each question.
Results The response rate to the questionnaire was 33.68% (32 of 95 surveyed). Initially, 24 ocularists responded to the survey, with an additional 8 responding after the reminder was sent. Some responders replied with more than 1 answer per question to allow for individual needs of patients. The only question with 32 responses, the same number of respondents to the survey, related to the frequency of removing the ocular prosthesis, whereas the recommended lubricating agent yielded 70 responses, indicating some respondents gave more than 1 answer for the question.
Frequency of removing the ocular prosthesis The top 3 answers accounted for 78.13% of all responses. The most common answer was ‘‘whenever the socket felt irritated’’ with 31.25%, followed by ‘‘removal once a month’’ with 25%, and finally ‘‘whenever it is dirty’’ with 21.88%. Complete responses are shown in Table 1.
143 Table 1 Responses to frequency of removing the ocular prosthesis When to remove ocular prosthetic
Responses out of 32
Percentage
When it is irritating Monthly When it is dirty As needed Two to 3 times per year Every 6 weeks Two to 3 times per month Weekly
10 8 7 2 2 1 1 1
31.25 25.00 21.88 6.25 6.25 3.13 3.13 3.13
Frequency of cleaning the ocular prosthesis The question of how often the ocular prosthesis should be cleaned generated 40 responses, allowing for individualization of treatment to the patient. Three answers accounted for 85% of the total responses. A majority of the feedback indicated that ‘‘the prosthesis should be cleaned every time it is removed’’ (57.50%). Fifteen percent indicated that ‘‘the prosthesis should be polished by an ocularist yearly,’’ whereas 12.50% specified that ‘‘the socket should be rinsed daily with a sterile saline solution.’’ Complete results can be found in Table 2.
Recommended cleaning agents for the ocular prosthesis Fifty-five responses were given for the recommended cleaning agents for an ocular prosthesis. This varied depending on the amount of protein deposition and the comfort level of the patient. ‘‘Mild soap’’ and ‘‘baby shampoo’’ had the most responses with 23.64% each. These were followed by ‘‘hard contact lens cleaners’’ with 12.73%. If all of the soaps listed were combined (mild soap, baby shampoo, dish soap, antibacterial soap, and warm soapy water), the total proportion of responses was 60.00%. Complete results can be found in Table 3.
Table 2 Responses to the cleaning frequency of an ocular prosthesis Frequency of cleaning prosthetic
Responses out of 40 Percentage
Whenever it is removed 23 Polished once a year by an ocularist 6 Socket rinsed daily with saline 5 Polished twice a year by 3 an ocularist (adults) Once a month 1 Polished twice a year by 1 an ocularist (children) Warm compresses daily 1
57.50 15.00 12.50 7.50 2.50 2.50 2.50
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Table 3 Responses to the recommended cleaning agents for the ocular prosthesis
Table 4 Responses to the recommended lubricating agents for the ocular prosthesis
Recommended cleaning agent
Recommended lubricating agent
Responses out of 55 Percentage
Mild soap* 13 Baby shampoo* 13 Hard contact lens cleaner 7 Rinse eye socket with saline 5 Dish soap* 3 Anti-bacterial soap* 3 Enzymatic cleaner 2 Hydrogen peroxide for 5-10 minutes 2 Saline solution 2 Water 2 Denture cleaner for less than 1 30 minutes Several hours to overnight in 1 hydrogen peroxide with neutralization† Warm soapy water* 1 * All soaps combined 33
23.64 23.64 12.73 9.09 5.45 5.45 3.64 3.64 3.64 3.64 1.82 1.82
1.82 60.00
† Neutralize with 1/2 teaspoon baking soda in 1 cup cold water.
Responses out of 70 Percentage
20 Silicone oil– based drops (Sil-ophtho [Hansen Labs] or Ocu-sil [MSM Industries, LLC]) Artificial tears 14 Hard contact lens wetting drops 9 DOC (anise, eucalyptus, 5 and castor oils)* Lacrilube (Allergan) 5 Enuclene (Alcon) 4 Gel-based artificial tears 3 Preservative-free artificial tears 2 Safflower oil 2 Mineral oil 1 Natural vitamin E lube 1 Olive oil 1 Petroleum jelly at night 1 Vitamin E & aloe oil 1 Vite-lube 1
28.57
20.00 12.86 7.14 7.14 5.71 4.29 2.86 2.86 1.43 1.43 1.43 1.43 1.43 1.43
* DOC is produced by the Denver Optic Company, Englewood, Colorado.
Recommended lubricating agents for the ocular prosthesis The highest response rate was for recommended lubricating agents with a total of 70 responses. It is clear that more than one answer was given by some of the respondents for this question, as there were more responses than ocularists who responded to the survey (32) . Many respondents indicated that the level of lubrication was based on the patient’s symptoms. ‘‘Silicone oil–based drops’’ were the most popular response with 28.57% indicated. This was followed by ‘‘artificial tears’’ with 20% and ‘‘hard contact lens wetting drops’’ with 12.86%. Complete results can be found in Table 4.
Discussion The ocularists who responded to the survey indicated that patients need to develop plans that work for them based on an overview of suggestions by the ocularist and eye care practitioner. Patients must learn for themselves how often they need to remove and clean their ocular prosthetic. Some patients also need lubrication, whereas others do not. Often during the enucleation process, the lacrimal glands are left intact so, in theory, the ocular prosthesis is getting natural lubrication. Many patients experience discomfort from dryness, so many ocularists suggest a variety of lubrications depending on the needs of the patient. Many ocularists agree that frequent removal may keep the socket irritated, causing mucus production to continue. C.W. (Bill) Cox, B.C.O., FASO, MIMPT (personal
communication, May 28, 2007) hypothesized that ‘‘when [the] prosthesis becomes coated with meibomian oil, the body accepts it. Until that occurs, the body tries to reject the prosthesis. When this is impossible, it [the body] covers it [the prosthesis] with mucus. Once the prosthesis is coated with meibomian oil, the body accepts it and stops trying to cover it with mucus, usually after 4 to 5 days. If the prosthesis is removed every day or even once a week, there will always be mucus discharge.’’ A variety of methods for cleaning the ocular prosthetic exist, but most ocularists agree that alcohol should never be used to disinfect the prosthetic, as it can denature the materials used.2 Also, any abrasive cleaners like Borax or Lava soap should be avoided, as they can scratch the surface and cause the prosthetic eye to look dull. Some soft contact lens solutions have been found to damage polymethylmethacrylate artificial eyes. Many ocularists recommend daily rinsing of the socket with a sterile saline solution, which is consistent with the findings previously presented by Fett et al. in 1986.4 If the ocular prosthetic is still in the socket, it must be dabbed or wiped inward toward the medial canthus to prevent rotation or dislodging. Many ocularists (60% of responses) recommend a form of soap be used for cleaning, but Margery Schreiber, B.C.O. (personal communication, May 8, 2007) states, ‘‘we used to recommend antibacterial soap, but recent thoughts are to avoid methylparaben, which is a major component of liquid soap.’’ Interestingly, although artificial eyes are often made of polymethylmethacrylate, the same material as dentures, only one respondent recommended soaking the eye in denture cleaner and for only less than half an hour.
Osborn and Hettler
Clincal Care
Lubricating agents tended to be the area with the least consensus. Most respondents felt that lubrication was a trial and error method for each patient. Many ocularists stated that whatever can be put into the eyeball can be used on the ocular prosthetic. Many recommend starting with a liquid artificial tear and increasing the viscosity as needed. There are many lubricants made specifically for artificial eyes, including silicone oil–based drops (Sil-ophtho and Ocu-sil) and Enuclene by Alcon. Denver Optic Company (Englewood, Colorado) has developed a lubricant consisting of anise, eucalyptus, and castor oils that some ocularists recommended. Other, less-conventional eye lubricants have also been used. ‘‘I had a young man from Iraq tell me nothing worked better than this lubricant [Natural Vitamin E Lubrication] even in a sandstorm,’’ Jim Strauss, B.C.O. (personal communication, May 21, 2007). Difficulties with an open-ended survey were experienced during this study. As with any open-ended survey, responses may overlap or ideas must be assumed. For example, if a response for when the prosthesis should be cleaned is ‘‘whenever it is removed,’’ this could also encompass ‘‘when it is irritating’’ as the prosthesis is more than likely removed when it is causing pain. This overlap in responses leads to assumptions, true or false, to be made. Specific questions asked on a survey would eliminate this ambiguity. The response rate of this Web-based survey was not ideal but adequate for the purposes of this study. In a Webbased survey by Joinson and Reips,5 the response rate in college-age adults was 15.12%, less than half of the 33.68% in this study. In an attempt to maximize the responses, an option to have results sent to participants was included. At approximately the mid-point of the research, a reminder was sent to those who had not yet responded. This increased the number of replies, as 25% of the responses came after the reminder e-mail was sent to each ocularist who had not yet answered the survey. An option that was not pursued to increase the number of responses was some sort of monetary or gift reward for participation.
145
Conclusions There is no method that works for every patient who wears an ocular prosthesis. An individualized treatment plan is indicated for most patients. Some commonalities in responses were noted, specifically that the ocular prosthesis needs to be cleaned every time the patient removes the artificial eye, and most recommend a silicone oil–based lubricant if the patient is experiencing discomfort caused by dryness. Future research should focus on more direct questioning to eliminate the ambiguity of an open-ended survey. These studies need to be conducted so a consensus can be achieved by ocularists to help optometrists and ophthalmologists better serve their patients. A standardized set of treatment protocols needs to be developed.
Acknowledgement The author has no commercial or financial interest in the materials mentioned in the study. The author wishes to thank the members of the American Society of Ocularists for their assistance with the participation in this study.
References 1. Trawbujm WR. Care of ocular prosthesis. Advanced Ophthalm Plas Reconstruct Surger 1990;8:146-8. 2. Parr FG, Goldman BM, Rahn AO. Postinsertion care of the ocular prosthesis. J Prosthetic Dentistry 1983;49(2):220-4. 3. Stewart WB. Surgery of the eyelid, orbit, and lacrimal system, volume 3. San Francisco: American Academy of Ophthalmology; 1995:159-66. 4. Fett DR, Scott R, Putterman AM. Evaluation of lubricants for the prosthetic eye wearer. Ophtham Plast Reconstruct Surg 1986;2(1):29-34. 5. Joinson AN, Reips UD. Personalized salutation, power of sender and response rates to Web-based surveys. Computers in Human Behavior 2007;23:1372-83.
A survey of recommendations on the care of ocular prostheses Katherine L. Osborn, O.D.,a and Debbie Hettler, O.D., M.P.H.b a
Central Missouri Eyecare Associates, Jefferson City, Missouri; and bHarry S. Truman Memorial Veterans’ Hospital, Columbia, Missouri.
KEYWORDS Ocular prosthetic; Ocularist; Care instructions; Lubrication
Abstract BACKGROUND: The purpose of this study was to determine if there is a consistent set of recommendations for patients who wear an ocular prosthesis or if each patient needs an individual plan. METHODS: A self-report questionnaire was distributed to members of the American Society of Ocularists. The survey consisted of 4 questions regarding frequency of removal and cleaning and preferred cleaning and lubrication agents. Respondents had 4 weeks to return the survey for results to be included. RESULTS: One hundred three surveys were sent; 8 were undeliverable, leaving a sample size of 95. Thirty-four percent (32 ocularists) responded. The reason with the most frequency for prosthesis removal was only when the prosthesis felt irritated (31%). Fifty-eight percent reported that the ocular prosthesis should be cleaned every time it is removed. Mild soap or baby shampoo was listed as the preferred cleaning agent with 24% each. A majority listed a silicone oil–based lubricant (29%), but responses varied based on the patient’s needs. CONCLUSIONS: An individualized treatment plan is indicated for most patients who wear an ocular prosthesis. Despite this, some commonalities in responses were noted, specifically that the ocular prosthesis needs to be cleaned with every removal, and a silicone oil lubricant is recommended. Optometry 2010;81:142-145
Many patients who require enucleation wear an ocular prosthesis. The instructions for care and handling of the artificial eye are often left up to the ocularist who created the prosthetic device. In the eye care profession, optometrists often defer to the instructions of the ocularist. However, the ocularist and the optometrist or ophthalmologist need to have the same information to provide to the patient.1 Many times, patients suffer because professionals do not communicate well enough to have a consistent care plan for the patient. Ocular prostheses were developed by dentists in the late 1940s using an acrylic resin material, similar to that used in
Corresponding author: Katherine L. Osborn, O.D., Central Missouri Eyecare Associates, 1705 Christy Drive, Suite 208, Jefferson, Missouri 65101. E-mail: [email protected]
dentures. This material cannot be cleaned with abrasive cleaners or harsh chemicals, as this may pit, cloud, or scratch the prosthesis. Artificial eyes can only be cleaned with mild soap or detergent with warm water. Tough deposits can be removed by soaking the eye in a denture cleaner or a mild solution of sodium hypochlorite (bleach) for half an hour.2 A variety of methods for cleaning the ocular prosthesis have been reported, including cleaning with hard contact lens solution, mild hand soap, or baby shampoo.3 Prosthesis lubrication has also been an area of confusion for many patients and practitioners, as some patients need extra lubrication of the artificial eye for comfort. A study by Fett et al.4 in 1986 tested 3 different products for lubrication and cleaning capacity. This group found that with proper daily hygiene, 77% of patients were comfortable with no
1529-1839/10/$ -see front matter Ó 2010 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2009.11.003
Osborn and Hettler
Clincal Care
additional lubrication. Proper hygiene was defined as forcefully flushing the socket with 5 full syringes (5 oz) of a solution consisting of one-half teaspoon of noniodized sodium chloride and one-half teaspoon of sodium bicarbonate dissolved in 1 quart of boiled water. This indicates that 23% of those who participated in the study needed additional lubrication to wear their ocular prosthesis comfortably.
Methods This is a qualitative study on preferred care and handling of ocular prostheses by the ocularists who fit and fabricate the artificial eyes. The data were collected during a 4-week period in April and May 2007. Surveys were e-mailed to members of the American Society of Ocularists who had their e-mail addresses published on a public Web site at www.ocularist.org. One hundred three surveys were sent out, and 8 were returned undeliverable, resulting in a sample size of 95 ocularists. The survey consisted of the following 4 questions: What is your recommended frequency of removing the ocular prosthetic? What is your recommended frequency for cleaning the artificial eye? What is your recommended cleaning agent? What is your recommended agent for lubricating the eye? Thirty-two ocularists completed the brief questionnaire. The survey was limited to 4 questions to encourage response. A reminder e-mail was sent approximately 2 weeks later with the survey again attached. Responses were compiled; some questions received more than one answer; therefore, the denominators in the calculations had to be changed with each question.
Results The response rate to the questionnaire was 33.68% (32 of 95 surveyed). Initially, 24 ocularists responded to the survey, with an additional 8 responding after the reminder was sent. Some responders replied with more than 1 answer per question to allow for individual needs of patients. The only question with 32 responses, the same number of respondents to the survey, related to the frequency of removing the ocular prosthesis, whereas the recommended lubricating agent yielded 70 responses, indicating some respondents gave more than 1 answer for the question.
Frequency of removing the ocular prosthesis The top 3 answers accounted for 78.13% of all responses. The most common answer was ‘‘whenever the socket felt irritated’’ with 31.25%, followed by ‘‘removal once a month’’ with 25%, and finally ‘‘whenever it is dirty’’ with 21.88%. Complete responses are shown in Table 1.
143 Table 1 Responses to frequency of removing the ocular prosthesis When to remove ocular prosthetic
Responses out of 32
Percentage
When it is irritating Monthly When it is dirty As needed Two to 3 times per year Every 6 weeks Two to 3 times per month Weekly
10 8 7 2 2 1 1 1
31.25 25.00 21.88 6.25 6.25 3.13 3.13 3.13
Frequency of cleaning the ocular prosthesis The question of how often the ocular prosthesis should be cleaned generated 40 responses, allowing for individualization of treatment to the patient. Three answers accounted for 85% of the total responses. A majority of the feedback indicated that ‘‘the prosthesis should be cleaned every time it is removed’’ (57.50%). Fifteen percent indicated that ‘‘the prosthesis should be polished by an ocularist yearly,’’ whereas 12.50% specified that ‘‘the socket should be rinsed daily with a sterile saline solution.’’ Complete results can be found in Table 2.
Recommended cleaning agents for the ocular prosthesis Fifty-five responses were given for the recommended cleaning agents for an ocular prosthesis. This varied depending on the amount of protein deposition and the comfort level of the patient. ‘‘Mild soap’’ and ‘‘baby shampoo’’ had the most responses with 23.64% each. These were followed by ‘‘hard contact lens cleaners’’ with 12.73%. If all of the soaps listed were combined (mild soap, baby shampoo, dish soap, antibacterial soap, and warm soapy water), the total proportion of responses was 60.00%. Complete results can be found in Table 3.
Table 2 Responses to the cleaning frequency of an ocular prosthesis Frequency of cleaning prosthetic
Responses out of 40 Percentage
Whenever it is removed 23 Polished once a year by an ocularist 6 Socket rinsed daily with saline 5 Polished twice a year by 3 an ocularist (adults) Once a month 1 Polished twice a year by 1 an ocularist (children) Warm compresses daily 1
57.50 15.00 12.50 7.50 2.50 2.50 2.50
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Optometry, Vol 81, No 3, March 2010
Table 3 Responses to the recommended cleaning agents for the ocular prosthesis
Table 4 Responses to the recommended lubricating agents for the ocular prosthesis
Recommended cleaning agent
Recommended lubricating agent
Responses out of 55 Percentage
Mild soap* 13 Baby shampoo* 13 Hard contact lens cleaner 7 Rinse eye socket with saline 5 Dish soap* 3 Anti-bacterial soap* 3 Enzymatic cleaner 2 Hydrogen peroxide for 5-10 minutes 2 Saline solution 2 Water 2 Denture cleaner for less than 1 30 minutes Several hours to overnight in 1 hydrogen peroxide with neutralization† Warm soapy water* 1 * All soaps combined 33
23.64 23.64 12.73 9.09 5.45 5.45 3.64 3.64 3.64 3.64 1.82 1.82
1.82 60.00
† Neutralize with 1/2 teaspoon baking soda in 1 cup cold water.
Responses out of 70 Percentage
20 Silicone oil– based drops (Sil-ophtho [Hansen Labs] or Ocu-sil [MSM Industries, LLC]) Artificial tears 14 Hard contact lens wetting drops 9 DOC (anise, eucalyptus, 5 and castor oils)* Lacrilube (Allergan) 5 Enuclene (Alcon) 4 Gel-based artificial tears 3 Preservative-free artificial tears 2 Safflower oil 2 Mineral oil 1 Natural vitamin E lube 1 Olive oil 1 Petroleum jelly at night 1 Vitamin E & aloe oil 1 Vite-lube 1
28.57
20.00 12.86 7.14 7.14 5.71 4.29 2.86 2.86 1.43 1.43 1.43 1.43 1.43 1.43
* DOC is produced by the Denver Optic Company, Englewood, Colorado.
Recommended lubricating agents for the ocular prosthesis The highest response rate was for recommended lubricating agents with a total of 70 responses. It is clear that more than one answer was given by some of the respondents for this question, as there were more responses than ocularists who responded to the survey (32) . Many respondents indicated that the level of lubrication was based on the patient’s symptoms. ‘‘Silicone oil–based drops’’ were the most popular response with 28.57% indicated. This was followed by ‘‘artificial tears’’ with 20% and ‘‘hard contact lens wetting drops’’ with 12.86%. Complete results can be found in Table 4.
Discussion The ocularists who responded to the survey indicated that patients need to develop plans that work for them based on an overview of suggestions by the ocularist and eye care practitioner. Patients must learn for themselves how often they need to remove and clean their ocular prosthetic. Some patients also need lubrication, whereas others do not. Often during the enucleation process, the lacrimal glands are left intact so, in theory, the ocular prosthesis is getting natural lubrication. Many patients experience discomfort from dryness, so many ocularists suggest a variety of lubrications depending on the needs of the patient. Many ocularists agree that frequent removal may keep the socket irritated, causing mucus production to continue. C.W. (Bill) Cox, B.C.O., FASO, MIMPT (personal
communication, May 28, 2007) hypothesized that ‘‘when [the] prosthesis becomes coated with meibomian oil, the body accepts it. Until that occurs, the body tries to reject the prosthesis. When this is impossible, it [the body] covers it [the prosthesis] with mucus. Once the prosthesis is coated with meibomian oil, the body accepts it and stops trying to cover it with mucus, usually after 4 to 5 days. If the prosthesis is removed every day or even once a week, there will always be mucus discharge.’’ A variety of methods for cleaning the ocular prosthetic exist, but most ocularists agree that alcohol should never be used to disinfect the prosthetic, as it can denature the materials used.2 Also, any abrasive cleaners like Borax or Lava soap should be avoided, as they can scratch the surface and cause the prosthetic eye to look dull. Some soft contact lens solutions have been found to damage polymethylmethacrylate artificial eyes. Many ocularists recommend daily rinsing of the socket with a sterile saline solution, which is consistent with the findings previously presented by Fett et al. in 1986.4 If the ocular prosthetic is still in the socket, it must be dabbed or wiped inward toward the medial canthus to prevent rotation or dislodging. Many ocularists (60% of responses) recommend a form of soap be used for cleaning, but Margery Schreiber, B.C.O. (personal communication, May 8, 2007) states, ‘‘we used to recommend antibacterial soap, but recent thoughts are to avoid methylparaben, which is a major component of liquid soap.’’ Interestingly, although artificial eyes are often made of polymethylmethacrylate, the same material as dentures, only one respondent recommended soaking the eye in denture cleaner and for only less than half an hour.
Osborn and Hettler
Clincal Care
Lubricating agents tended to be the area with the least consensus. Most respondents felt that lubrication was a trial and error method for each patient. Many ocularists stated that whatever can be put into the eyeball can be used on the ocular prosthetic. Many recommend starting with a liquid artificial tear and increasing the viscosity as needed. There are many lubricants made specifically for artificial eyes, including silicone oil–based drops (Sil-ophtho and Ocu-sil) and Enuclene by Alcon. Denver Optic Company (Englewood, Colorado) has developed a lubricant consisting of anise, eucalyptus, and castor oils that some ocularists recommended. Other, less-conventional eye lubricants have also been used. ‘‘I had a young man from Iraq tell me nothing worked better than this lubricant [Natural Vitamin E Lubrication] even in a sandstorm,’’ Jim Strauss, B.C.O. (personal communication, May 21, 2007). Difficulties with an open-ended survey were experienced during this study. As with any open-ended survey, responses may overlap or ideas must be assumed. For example, if a response for when the prosthesis should be cleaned is ‘‘whenever it is removed,’’ this could also encompass ‘‘when it is irritating’’ as the prosthesis is more than likely removed when it is causing pain. This overlap in responses leads to assumptions, true or false, to be made. Specific questions asked on a survey would eliminate this ambiguity. The response rate of this Web-based survey was not ideal but adequate for the purposes of this study. In a Webbased survey by Joinson and Reips,5 the response rate in college-age adults was 15.12%, less than half of the 33.68% in this study. In an attempt to maximize the responses, an option to have results sent to participants was included. At approximately the mid-point of the research, a reminder was sent to those who had not yet responded. This increased the number of replies, as 25% of the responses came after the reminder e-mail was sent to each ocularist who had not yet answered the survey. An option that was not pursued to increase the number of responses was some sort of monetary or gift reward for participation.
145
Conclusions There is no method that works for every patient who wears an ocular prosthesis. An individualized treatment plan is indicated for most patients. Some commonalities in responses were noted, specifically that the ocular prosthesis needs to be cleaned every time the patient removes the artificial eye, and most recommend a silicone oil–based lubricant if the patient is experiencing discomfort caused by dryness. Future research should focus on more direct questioning to eliminate the ambiguity of an open-ended survey. These studies need to be conducted so a consensus can be achieved by ocularists to help optometrists and ophthalmologists better serve their patients. A standardized set of treatment protocols needs to be developed.
Acknowledgement The author has no commercial or financial interest in the materials mentioned in the study. The author wishes to thank the members of the American Society of Ocularists for their assistance with the participation in this study.
References 1. Trawbujm WR. Care of ocular prosthesis. Advanced Ophthalm Plas Reconstruct Surger 1990;8:146-8. 2. Parr FG, Goldman BM, Rahn AO. Postinsertion care of the ocular prosthesis. J Prosthetic Dentistry 1983;49(2):220-4. 3. Stewart WB. Surgery of the eyelid, orbit, and lacrimal system, volume 3. San Francisco: American Academy of Ophthalmology; 1995:159-66. 4. Fett DR, Scott R, Putterman AM. Evaluation of lubricants for the prosthetic eye wearer. Ophtham Plast Reconstruct Surg 1986;2(1):29-34. 5. Joinson AN, Reips UD. Personalized salutation, power of sender and response rates to Web-based surveys. Computers in Human Behavior 2007;23:1372-83.