19th and 20th century prostheses

In 1818 Hazard-Mirault wrote that many ophthalmologists were unwilling to risk the surgical enucleation necessary to prepare a socket to facilitate the insertion of an ocular prosthesis. The surgeons thought, perhaps with some cause, that they were sparing their patients misery. In the later 19th century, with anaesthesia and antisepsis, enucleation of the orbit became more common. Artificial eyes had to change because previously most ocular prostheses had been intended to cover an atrophied eye. 

 Pache and Son advertisement
The closed eye, in which the cavity was filled with wax to give it greater bulk but little additional weight was developed almost concurrently in two places. J.L. Borsch, a Philadelphia doctor, claimed to have visited Herr Müller in Wiesbaden in 1894 and commissioned from him such a prosthesis. These were subsequently tried at the de Wecker clinic in Paris and a presentation given by Borsch’s colleague, Dr Schwenk, back in Philadelphia in 1897. In 1898 Snellen presented the ‘reform-auge’ in Rotterdam. He had also called upon Müller to manufacture the item.

In 1900 Pache & Son of Birmingham were makers to the principal hospitals in the United Kingdom and could provide Snellen’s improved ‘reform eye’ a double shell that prevented a sunken appearance.

 Rose Millauro advertisement
In 1927 Rose Millauro, of London was advertising that ‘Every type of Artificial Eye embodying all modern improvements in shape, finish and aesthetic, can be supplied by the actual manufacturer. The existence of a good eye-maker should be of great interest to the Ophthalmic Surgeon; bad artificial eyes invariably spoil the result of a successful operation’.

Millauro was thus pointing out that senior surgical practitioners had a self-interest in ensuring that the work of the technician was of the highest order!
 

 G. Taylor advertisement
Also in 1927, Gustav Taylor, Artificial Eye Maker, advertised ‘The Sympathetic Artificial Eye - The Most Perfect Eye Invented’. (Mr Taylor) ‘who has made Artificial Eyes for twenty-eight years, has invented an undetectable artificial eye which moves and acts in sympathy with the natural eye. He has also invented eyes with dilating pupil. These eyes are the most lifelike and natural ever made, and a perfect likeness to the other eye. All eyes made on the premises in front of the patient within an hour by G. Taylor personally. Doctors are especially invited to see the maker at work at the above address’. Note the assumption that those all-important doctors would travel to see him. A 1935 article in The Optician by F. Kemble Williams suggests a lack of doctorly concern. He writes that no one else but the optician seems prepared to undertake this work of selling eyes. Even the eye-surgeons appeared to think that it is part of the optician’s job and always referred their patients to an optician after the enucleation. Interestingly there is no mention of artificial eyes in the exam syllabus of either profession for the period. The provision of prosthetic eyes was still regarded then as a commercial transaction rather than a medical service. Williams claims that most opticians do it occasionally but many neglect basic hygiene which is most unwise... as the patient may be dirty! He also complained that manufacturers had failed to provide an accurate method of ordering the eyes. Numbered patterns and colour charts would be useful.

One benefit of eyes supplied from stock, that still applies today, is that they can be good for children who will undergo normal growth (tissue change within the orbit) thereby wasting money spent on custom-made prostheses. Nevertheless developments in material science have made the custom-made eye the more prevalent. Changes in glass-making technology and the invention of new acrylics have been crucial in affecting the practices and training of the modern ocularist. During World War Two a shortage of German (Lauscha) glass led the British and the Americans to investigate techniques for the use of acrylic. The US Government’s involvement in partnership with manufacturing firms including one led by Paul Gougelmann, was notable. Research was carried on in parallel on both sides of the Atlantic. Royal Navy dental technicians were probably the first to use plastic in 1941. Meanwhile Fritz W. Jardon (in Southfield, MI) in conjunction with the American Optical Co and the US Army and Navy Dentist perfected Methyl-Methacrylate resin. 

 Monoplex diagram 1965
Monoplex shapes 1965 
Acrylic became the dominant material to the present day. It had durability and longevity. It was more comfortable for many patients. It did not allow fluids to build up behind the prosthesis and could be worn in bed. This led to a high public demand that eventually outweighed the preferences of many artificial eye fitters for glass, not least because their highly developed glass-blowing skills made them reluctant to make the switch. Nevertheless acrylic eyes required repolishing every 8 months to prevent infection the drug treatments for which, if needed, would damage the prosthesis. In Europe, therefore, glass eyes did continue to remain available using Cryolite glass on account of its many advantages, including its natural appearance, compatibility to match the shading of skin tones, hard surface and scratch resistance. As a hygroscopic material it retained natural eye fluids (unlike acrylic which is a water-repellent material) and could also be cleaned hygienically with just cold water.

The Monoplex eye by American Optical was a noted acrylic prosthesis of the 1950s and 1960s. Fitting sets containing 120 examples were supplied to practitioners. The use of steel dies at the factory meant that the same shapes could be produced time and time again. Three of the most common shapes are shown in the illustration: Oval, standard and three-cornered. The eye was adaptable for all types of patients. For instance hand colouring with liquid plastic pigment could take into account different racial skin colours. In 1960 the company produced a patient guide. Its advice included wearing spectacles to divert attention away from the artificial eye and turning your whole head rather than your eyes when looking at something. The same eye could have plastic added to it so that it grew with the patient and was designed to be worn continuously, day and night for prolonged periods.

In the United Kingdom the supply of artificial eyes was included within the National Health Service from 1948. A National Artificial Eye Service (NAES) with its administrative and manufacturing headquarters in Blackpool was established over the next few decades as a direct successor to the prosthetic department of the Army Spectacle Depot, the difference being that state supply was no longer restricted to serving personnel or war pensioners. The NAES developed a system whereby teams of skilled technicians took the wax models and specifications provided by Eye Fitters (Orbital Prosthetists) and turned them into a prosthesis to match the patient’s natural eye, whenever such an eye was present to copy. As of the year 2000 the NAES had 16 centres staffed by Eye Fitters and a network of 54 outreach clinics nationwide to which the Eye Fitters would travel. Artificial eyes were also manufactured for patients in Wales, Scotland, and Northern Ireland who had their own fitting services.