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Solutions for Aging Prosthetic Eyes at AAO 2024

Who says aging gracefully doesn’t involve a little fine tuning? On Day 3 of the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024), ocular prosthetic experts gathered to tackle the unique challenges of the aging anophthalmic socket, offering solutions for volume loss, lid laxity and dry eye.

As we get older, the delicate tissues around the eye don’t exactly get the memo to stay put. Throw in a prosthetic eye, and things get even more complicated. With issues like irritation and volume loss, achieving a comfortable and natural-looking prosthetic becomes a game of strategy. The experts at this symposium didn’t hold back, diving into both surgical and non-surgical fixes to keep those prosthetic eyes sitting and feeling pretty.

Surgery for volume loss

When it comes to aesthetic anophthalmic surgery for the aging population, the goal is to restore both form and function. It’s not just about appearances, though that’s a huge part of it—it’s also about giving patients back a sense of normalcy. As Dr. Robert Beaulieu (USA) pointed out, patients “have gone through significant physical as well as psychological journeys,” arriving at the clinic after prolonged battles with diseases like glaucoma and uveitis.

Volume loss, a common issue among these patients, is the key challenge. Whether it’s due to trauma, fat atrophy, or an outdated implant, the result is the same—patients are left with enophthalmos, asymmetry and discomfort. Restoring volume, Dr. Beaulieu explained, “aids in proper lid position, prevents enophthalmos and… preserves conjunctival health,” which in turn reduces irritation and improves overall quality of life.

How is this volume restored? One option is a dermis fat graft, where fat is harvested—usually from the abdomen—and placed into the socket to make up for the lost volume. 

Another approach involves updating the orbital implant to a larger one, though this can be tricky when it comes to maintaining the integrity of surrounding tissues. Alternatively, adjusting the prosthetic itself can sometimes solve the problem.

Non-surgical interventions for volume loss

One effective approach to non-surgically tackle volume deficits in anophthalmic patients is the use of fillers: polymethylmethacrylate (PMMA) and hyaluronic acid. While PMMA’s semi-permanent effects help stimulate collagen production, it’s less commonly used compared to the ever-popular hyaluronic acid. Hyaluronic acid is hydrophilic, biodegradable and—if necessary—can be reversed with hyaluronidase, making it a more flexible option.

So where exactly do we inject these fillers to restore volume? The orbit is a key area. As Dr. Amy Patel Jain (USA) explained, “Injecting posteriorly provides volume augmentation. It reduces enophthalmos and has the added benefit of potentially improving the superior sulcus, which can also translate to overall improvement of the lid position.” 

However, as with any procedure, fillers aren’t without their downsides. They’re still considered implants, which means they carry risks like inflammation, infection and even migration. There’s also the potential for patient discomfort, including orbital ache and the dreaded vasovagal response during injection. 

Despite these risks, filler remains a highly useful, non-surgical tool that can provide real improvements in orbital volume and lid positioning. And the beauty of fillers? You can always start small and build up over time—a patient-friendly approach that allows for gradual enhancement and more control over the outcome.

Lower lid laxity

The bane of prosthetic wearers, lower lid laxity comes up time and time again in the aging population. And it’s no surprise. As the years march on, gravity and a host of other factors conspire to stretch the delicate tissues around the eyelid, wreaking havoc on prosthetic fit and comfort.

The problem here is twofold. First, lower lid laxity, often caused by the stretching of the medial and lateral canthal tendons, can lead to a prosthesis that simply doesn’t stay in place. As Raymond Rudolph Rendon (USA) explained, “Lower lid laxity adversely affects prosthetic fit and function, leading to retention problems and can cause lack of balance.” 

And if that wasn’t enough, the prosthesis itself can sometimes add fuel to the fire. Heavier prostheses, especially those fit to a cavernous socket, can exacerbate lower lid laxity. So, what’s the fix? Surgery is always the preferred option when available, but not everyone is a candidate. Thankfully, ocularists are ready to step in when surgical interventions aren’t on the table. 

They’ll often begin by modifying the prosthesis itself, taking steps to relieve the pressure on the lower lid. “Removing material from the back of a prosthesis will make it lighter,” Rendon explained. The problem with this, however, is that it compromises the integrity of the impression fit.

It’s a delicate balancing act. Removing too much material might fix the lower lid laxity but at the cost of a well-fitting prosthesis. As Rendon humorously pointed out, “One-point seven grams might seem insignificant. Definitely not Ozempic-like results. But, if it alleviates discomfort, then it’s worth the effort to try it.”

Prosthetics and dry eye

Let’s face it, dry eyes are no fun. Now throw in a prosthetic eye and the stakes get even higher. As we age, tear production drops off, and for those with prosthetic eyes, it can lead to some seriously uncomfortable symptoms—think irritation, redness, excessive discharge and a lot more trips to the ocularist for a quick polish. 

The aging anophthalmic socket, already dealing with reduced volume and tissue changes, becomes even trickier when tears can’t do their job. “What we’re seeing in our aging patients is generally less tear production, or at least tears of the incorrect consistency,” noted Mitchell Mayo (USA), an ocularist from Colorado. As a result, people come in more frequently for eye polishes to relieve the gritty irritation, redness and mucus build-up. In fact, dry sockets often produce more discharge to compensate, leading to discomfort and infections.

The good news? There are several strategies to tackle the problem. Regular prosthesis polishes are a must, with the recommendation being one to two times a year. Lubrication, whether in the form of over-the-counter drops or artificial eye lubricants, also helps. “I’ve become a big fan of over-the-counter lubricants,” Mayo admitted, adding that preservative-free versions are the best option for frequent users.

Other treatments include punctal plugs to retain moisture, addressing lagophthalmos (incomplete eyelid closure), and meibomian gland expression to ensure proper tear composition. And let’s not forget the humble hot compress, a home remedy that works wonders for dry eye relief. “With a combination of any or all these things, most people can get really good results,” noted Mayo. 

Editor’s Note: Reporting for this story took place during the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024) from 18-21 October in Chicago, Illinois, USA.

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