There are three main reasons why one’s natural eye needs to be removed.
1. If the natural eye becomes blind and painful. Its removal can give the patient welcome comfort and relief. This is usually only done when most other treatments have failed
2. If the natural eye becomes blind and looks cosmetically poor. For example, the natural eye may look very scarred, start to shrink in size and the cornea (clear window at the front of the eye) may turn white.
3. If the natural eye becomes dangerous e.g. for cancer of the eye
This patient had a blind unsightly left eye which was painful and shrunken
3 months after removal of the left eye and wearing a new artificial eye, the patient is very happy with appearance and comfort
Artificial eyes are custom made in painstaking detail to give an optimum fit and appearance bespoke for that patient
The aims with all artificial eye treatment is to help the patient through the operation of eye removal and to ensure the patient is happy with its appearance, its comfort and the psychology of having an eye socket without a natural eye.
The perfect artificial eye is one which:
• Is comfortable
• Shows good movement
• Is indistinguishable to the observer
• Is easy to look after
There are essentially two types of operation for removal of the eye: Evisceration and Enucleation.
Evisceration- involves removal of the clear window at the front of the eye (cornea) & the core of the eye, leaving the outer casing of the eyeball (scleral sac).
Enucleation- involves removal of the entire eyeball.
In both types of operation, an orbital implant which is usually shaped like a ball is inserted deep into the eye socket. The aim of the orbital implant is to fill out the socket, thus replacing some of the lost volume from removed eyeball. Thus the artificial eye (prosthesis), which is later worn by the patient , can be made smaller. The outer coverings of the eyeball (conjunctiva) are then sutured together so that the cavity of the socket is shallower and lined with the pink membrane (conjunctiva). Most patients nowadays undergo an evisceration since it is quicker, thought to offer better motility and has a lower rate of long term problems. However, enucleations are still performed in certain cases such as certain types of eye cancer.
Although both operations are usually performed under general anaesthesia (patient asleep and ventilated), if the anaesthetist considers that general anaesthesia is too dangerous e.g. if the patient has severe lung or heart disease, surgery can be performed quite comfortably under local anaesthesia, often with a mild sedative to relax the patient.
Early period after surgery
A pressure dressing is applied to the socket for the 2-3 days to try to reduce the postoperative swelling. Contrary to belief, usually the patient is very comfortable immediately after surgery. A course of antibiotic tablets is usually prescribed with anti-inflammatory medication (ibruprofen or diclofenac). The patent is then reviewed usually one week after surgery and the dressing is removed. A clear plastic disc called a conformer is often inserted into the cavity of the socket at the time of surgery to help the socket attain the correct shape.
At 6 weeks to 8 weeks, the patient is then usually seen by an ocular prosthetist (sometimes called an ocularist). This is someone who is trained in making artificial eyes. A mould of the cavity of the socket is made so that a new custom made artificial eye to match the patient’s other eye can be manufactured. The manufacture of a new cosmetic shell can take a couple of months and a few visits to the ocular prosthetist since it is a highly skilled and laborious task. Each artificial eye is customised in colour, appearance, shape, thickness for each individual patient. For this reason, the final artificial eye can take up to 3 months to make. However, the patient is often given a temporary artificial from the ocular prosthetist’s supply bank until the final one is ready.
After 3 months
The patient is advised on how to look after the artificial eye and socket by the ocular prosthetist. It is usually advisable to remove the artificial eye from time to time e.g. at night or weekly and to clean it. Your ocular prosthetist will be able to advise you about this. Some patients who are uncomfortable with handling the cosmetic shell, may leave the shell in all the time.
The risk of things going wrong with artificial eye surgery is extremely low but as with any type of surgery complications and problems can occur.
Infection
With artificial eye surgery, the most serious complication which can happen early on following surgery is infection. This usually responds very well to antibiotics.
Implant extrusion/exposure
As stated above an orbital implant is usually implanted deep into the socket at the time of removing the eye. The main role of the orbital implant is compensate for the loss in volume from removing the natural eye therefore filling out the socket so that the cavity of the socket is shallower. This means the artificial eye can be thinner and lighter, thus allowing better movement and better comfort for the patient. Very, very rarely, the orbital implant may start become exposed and may even work its way out. This may require further surgery to rectify.
Imperfect appearance/comfort
The vast majority of patients are very happy with the appearance, movement & comfort of their artificial eye. However, a tiny proportion of patients request improved motility, a better appearance or greater comfort. This can often be easily achieved but may require additional surgery.
Delayed Problems of Artificial Eyes
After many, many years of wearing an artificial eye, the patient’s socket may start to alter slightly sometimes resulting in an imperfect appearance, comfort or movement of the artificial eye. For example, the artificial eye may start to look sunken, the upper lid may start to droop (ptosis) or the lower lid may start to sag . If the patient wishes, further procedures may be performed to improve matters.
Post enucleation socket syndrome gallery: After many years following eye removal surgery, the artificial eye may sink backwards due to progressive loss of fat from the socket giving the impression of hollowness. Nowadays mild forms of this may be easily treated with hyalauronic acid fillers injected into the eye socket
Post Enucleation Socket Syndrome: Before treatment with filler injections. Note how sunken the left (her left) artificial eye has become through many years of wearing an artificial eye.
Post Enucleation Socket Syndrome: Before treatment with filler injections. Note how sunken the left (her left) artificial eye has become through many years of wearing an artificial eye.
Post Enucleation Socket Syndrome: Before treatment with filler injections. Note how sunken the left (her left) artificial eye has become through many years of wearing an artificial eye.
Post Enucleation Socket Syndrome: After treatment with filler injections. Note how this lady's left artificial eye now looks more symmetrical with her right natural eye
Post Enucleation Socket Syndrome: After treatment with filler injections. Note how this lady's left artificial eye now looks more symmetrical with her right natural eye
Post Enucleation Socket Syndrome: After treatment with filler injections. Note how this lady's left artificial eye now looks more symmetrical with her right natural eye
Here is a small selection of patient testimonials kindly offered by some of Mr Cheung’s previous and current patients, which give some insight into what to expect. All the patients involved have kindly given their consent to the publication on this website. To protect patient confidentiality, any identifying elements have been removed.
"As a senior nurse, I was very discerning in my choice of surgeon , and undertook significant research before deciding to have surgery. I am delighted that I chose David Cheung. From my very first email enquiry, through to discharge, David's communication was excellent. He gave me full explanations and information. My initial consultation was friendly and thorough and by the end I felt fully informed about what to expect, I had ample opportunity to ask questions and was very involved in agreeing with David the outcome we were planning to achieve. The actual surgical experience was positive and I only experienced minimal discomfort. I am delighted with the result of the surgery which has achieved the outcome David and I agreed resulting in a more youthful but natural look."
Dame Catherine Elcoat DBE
“ Dear David, I just wanted to thank you for your extreme dedication and professionalism in coming in specially to perform expert restorative surgery on this young girl on Tuesday morning. I saw her post-op yesterday and the difference compared to pre-op was remarkable and I’m sure will make a huge difference to her in the future. The mother and the girl herself are immensely grateful for your expertise and recognise the vast improvement they can already see…."
Mr JS Barry, Consultant Ophthalmologist, Dudley Group of Hospitals NHS Trust.
" Dear David, we just wanted to say that we are incredibly happy with the final result following our surgery. It has given us so much confidence and has really made such a difference to our lives. We would have loved to see you again but hope you'll understand that we'd rather just send a selfie. Either way they look amazing and we are just so happy with them. Thank you so much for taking the time with us, making sure we were always in the loop and your intricate surgical skills. Thanks so much…."
Miss CC and SC, Glasgow. Surgery performed: Double eyelid surgery/ Oriental Blepharoplasty with medial epicanthoplasty under local anaesthetic at the BMI Edgbaston Hospital.
“ Dear Mr Cheung, Oh what a surprise! How absolutely amazing-I am sitting on cloud 9-admiring myself! On the way home last Wednesday my great friend informed me that I looked like a panda, but she did at least buy me a big bag of frozen peas on the way! I was a little anxious at the thought of looking in a mirror but anticipation too over from fear! What I saw in the mirror was absolutely incredible. I was looking at a person whom I knew very well, but had not seen for many years. This was an absolutely amazing experience. My friends and I all agree. We are absolutely thrilled with the results of my meeting with you and your surgery. We can hardly believe what we are seeing! And now I don’t know how to thank you- for words aren’t adequate. But I will say, “Thank you, thank you, thank you!”-again and again for I am over the moon! I am thrilled beyond words and am looking forward to seeing you again to say “Thank You!’”
Dr JB (retired consultant anaesthetist, Worcestershire). Surgery performed: Combined bilateral upper eyelid ptosis correction with blepharoplasty under local anaesthetic at the West Midlands Hospital, Halesowen
”Dear Sir, thank you very much indeed for the surgery you performed on me, although it was it was recommend to improve comfort it has, how can I put it, benefitted my vision…I believe that the the eyelashes were scratching the lens so following the surgery when this scratching ceased the lens allowed what sight I still have to work better. Before the operation to my right lower lid, I was down to just the left eye for clarity and that is without significant peripheral vision; the right eye was just shapes and colour- in many circumstances the right eye was detracting from the vision in the left eye and often I found it better to cover my right eye. Since the operation I can see again in my right eye. At 60 years old, my GP had told me that I would eventually go blind. Last week though my wife and I went to the photography show at the NEC and I bought a new digital camera. With the wonders of this new technology I can see the results on my new television. For the first time in a long time, I felt confident enough in the future and with my vision to buy this new camera. For the first time in a long time I have felt optimistic enough to buy something like this. Thank you so much. At the age of 87, I am living for the now and the near future, not morosely managing decline. The world is full of people who complain but few notice the good things such as your exceptional service provided…”
Mr GR. Surgery performed: Right lower lid entropion correction at the Russells Hall Hospital, Dudley
" ..Dear Paula Clark, in today’s society people are very quick at making complaints but don’t voice gratitude and acknowledge outstanding professional care. Hence the following letter: I had the privilege of being referred to Mr Cheung a few years ago following the removal of an acoustic neuroma in 1999. I have had continued problems with my left eye since that date. Although it has not probable that I have been his greatest challenge, for me it is a significant irritation when dealing with all of my other medical conditions. I feel it important to mention from the beginning I had an emergency operation in Manchester, which left me with great anxieties re: any further treatment with my eyes. I cannot state this strongly enough. My first meeting with Mr Cheung was amazing. For the very first time in many years, I met a friendly professional who LISTENED. He took my history and talked to me about my concerns and issues that arose. He remained very professional throughout examinations and explained at a level of communication that suited me, exactly what he was doing and talked to me throughout. I don’t feel he understands exactly how good he is with using his holistic skills in communication. He is open and easy to communicate with, which immediately builds a trust between patient and professional. This in turn allows a patient to build confidence and trust. He is open and transparent in his working methods, which again builds trust. I have never felt excluded from my treatment, which I have felt so many times before, which promotes a sense of mistrust. He is a shining example to so many other staff in how to relate to patients and equally I’ve seen him communicate with other professionals and teach students in such a professional and dignified manner. (I hope the students realise how privileged they are.) He is very calming and will explain at a level suitable to the recipient about what is going to happen. Mr Cheung will give useful handouts thus allowing you to take the resources home to enforce all the verbal information given in appointments. His skills in theatre again are professional, calming and promotional to a patient’s holistic needs being met. As previously stated my mistrust with any procedures was a hurdle for me to overcome beyond belief. My first meeting with Mr Cheung restored my trust and allowed me to receive treatment with confidence in his capable professional care. Obviously patients talk in waiting rooms and I can honestly say I have never heard anything but positive feedback. He treats everyone with respect, his friendly persona and open, transparent method of working builds trust.... Please pass on my thanks to Mr Cheung. I hope he is as valued by the health authority as he is valued by the patients he treats….."
Miss SD. Letter to Chief Executive of Dudley Group of Hospitals NHS Trust
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Consultant Ophthalmologist and Oculoplastic Surgeon. Expert in aesthetic and functional eyelid surgery.
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Email for Ms Elizabeth Carter PA for Mr Cheung: pa@mrdavidcheung.com
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01384 632636