A very young child will not understand fully what is happening and may quickly adapt to a prosthesis as he will have known little else. However, the parents will be feeling very differently, requiring a great amount of support.
They may be suffering from acute feelings of guilt, especially if the child had an accident for which they blame themselves. Siblings and friends may also be upset, especially if they have been involved in, or caused, the accident.
All patients of any age will go through a period of loss for their eye, including feelings of anger and resentment, while coming to terms with their condition.
Teenagers may be particularly concerned about their appearance and body image, which may prevent them from socialising with their peers. All age groups and both sexes will be very aware of their changed appearance. They will be much more critical of their prosthesis, noting minute differences to their other eye. It is worth pointing out to them that no two natural eyes in the same face are exactly similar.
Some families and friends will be able to give the patient the necessary support, but others may not feel able to. Some family members may require help from the nurse to come to terms with the patient’s loss.
PROCEDURE GUIDELINE
Removal of an eye
Nursing action
1 Admit the patient to hospital.
2 Give psychological and practical help. Explain about prostheses (see below) to the patient, pointing out that these days they are very good matches and need not be removed. It may be helpful to put him in touch with a patient who already has a prosthesis. A visit by the pros- thetist before the operation will result in the patient having a better understanding of the processes involved in creating the artificial eye.
The patient needs to understand that the prosthesis will not be placed in the socket at the time of surgery but at a later stage. In addi- tion, patients should be advised that post-operatively they will have a dressing of pad and bandage, worn undisturbed for 1 week. First dressing takes place in the outpatient setting. They should be advised also that it is not unusual to suffer nausea and vomiting immediately post-operatively. They should be reassured that the nurse will give analgesia and anti-emetics as required (Waterman et al., 1998). If the patient is a child, the parents must be totally involved in his care.
3 Give pre-operative care.
4 Give post-operative care:
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Remove pressure dressing at the first dressing, clean socket and instil prescribed antibiotic ointment. Subsequently, the socket will be cleaned regularly and the ointment instilled. No further dressing is applied.r
If the socket is clean, fit a temporary shell into it.... ...
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Teach the patient or parents to remove, clean and replace the shell, and instil antibiotic ointment.5. On discharge, ensure that the patient has an appointment with the prosthetist and give him the assurance that he can return at any time to the hospital if there are any problems with the shell.
Complications
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The socket may become infected at any stage following removal of the eye. This requires cleaning of the socket and antibiotic treatment, usually ointment.r
The socket may shrink with time, causing the prosthesis to protrude and making it appear much larger than the other eye. A new prosthesis will need to be made.... ...
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Prostheses
Once the initial socket dressing has been removed following surgery and the socket is clean, a temporary shell is inserted into the socket to maintain the shape of the eyelids and to prevent them retracting. The patient is taught to remove, clean and replace this temporary shell and to make sure that the socket is clean.
At 4–6 weeks following surgery, the patient is fitted with a temporary ar- tificial eye by the prosthetist (Figure 6.6). This may be fitted earlier if the patient’s needs warrant it. Initially, a temporary prosthesis is fitted which will match as nearly as possible the patient’s other eye. Meanwhile, a permanent individualised prosthesis will be made from an impression of the socket. The colour of the sclera, the pattern of the conjunctival vessels, the colour and pattern of the iris and the position of the pupil will be painted on by hand, care- fully matching the other eye. Prosthetists are perfectionists who pay attention to the smallest of details.
Prostheses are nowadays made of an inert plastic material which can remain in the socket for up to 1 year. If there are no problems, the prosthesis is cleaned and polished annually to smooth any rough surfaces.
Figure 6.6 Artificial eye. From Olver and Cassidy (2005), Ophthalmology at a Glance, Blackwell Publishing, reproduced with permission.
A prosthesis will need to be removed if it becomes too big for the shrinking socket or if the colour of the other eye changes – as it does with age – the sclera becoming less white and the conjunctival blood vessels more pronounced. The iris may change colour and an arcus senilis may appear.
Prostheses are made to measure and, with careful matching of the other eye, it is often difficult to tell an artificial eye from a real one. Sometimes, the movement of the prosthesis is not as good as in a normal eye. Following an evisceration, movement should be nearly normal as the extra-ocular muscles are still in place and can move the prosthesis. During an enucleation, the extra- ocular muscles are cut from their insertion in the sclera and sutured together in the socket. This affords some movement of the prosthesis. Primary socket implantation can be carried out, whereby an acrylic or coralline hydroxyapatite implant is placed in the socket to which the extra-ocular muscles are attached by sutures. This affords more movement of the prosthesis. Implants can be rejected, and they tend to extrude after about 20 years, requiring replacement although the hydroxyapatite type aims to overcome this. Being a naturally derived material from coral, with a similar structure to bone, it is not rejected by the body. The body tissue actually grows into the implant. A peg can be used to attach the prosthesis to the hydroxyapatite implant to afford greater movement of the prosthesis when it is in situ. After an exenteration, it is not possible to fit a prosthesis into the socket without further plastic surgery. A prosthesis can be attached to spectacles for patients not wishing to undergo further surgery.
PROCEDURE GUIDELINE
Inserting/removing a prosthesis/shell
Nursing action: inserting a prosthesis/shell
1 Explain to the patient what you are going to do to gain informed consent.
2 Wash hands at the beginning and end of the procedure, and at any point when your hands become contaminated.
3 Pull up the upper lid and insert the prosthesis into the upper fornix.
4 Evert the lower lid and slip lower border of the prosthesis into the lower fornix.
Nursing action: removing a prosthesis/shell
1 Explain to the patient what you are going to do to gain informed consent.
2 Wash hands at the beginning and end of the procedure, and at any point when your hands become contaminated.
3 Evert the lower lid and ease the prosthesis out. A small plastic spatula may be required to assist in the removal. The prosthesis then slips out.