Three-Dimensional Orientation of Iris in an Ocular Prosthesis

Using a Customized Scale

Lokendra Gupta, MDS,1 I. N. Aparna, MDS,2 B. Dhanasekar, MDS,2 Nayana Prabhu, MDS,3 Nirjalla Malla,
MDS,4 & Priyanka Agarwal, BDS5
1

Assistant Professor, Department of Prosthodontics and Crown & Bridge, Manipal College of Dental Sciences, Manipal, India
Professor, Department of Prosthodontics and Crown & Bridge, Manipal College of Dental Sciences, Manipal, India
3
Associate Professor, Department of Prosthodontics and Crown & Bridge, Manipal College of Dental Sciences, Manipal, India
4
Lecturer, Department of Prosthodontics and Crown & Bridge, Manipal College of Medical Sciences, Pokhara, Nepal
5
Postgraduate Student, Department of Pedodontics and Preventive Dentistry, Manipal College of Dental Sciences, Manipal, India
2

Keywords
Customized scale; scleral wax pattern; iris
disk; ocular prosthesis; iris orientation.
Correspondence
Lokendra Gupta, Department of
Prosthodontics and Crown & Bridge, Manipal
College of Dental Sciences, Manipal- 576104,
Karnataka, India. E-mail: lokinse@gmail.com.
The authors deny any conflicts of interest.
Accepted May 9, 2013
doi: 10.1111/jopr.12104

Abstract
The success of an ocular prosthesis depends largely on the correct orientation of the
iris disk. Various methods have been put forth to achieve this. This article emphasizes
one such simplified method, wherein a customized scale has been used to orient the
iris disk mediolaterally, superoinferiorly, and anteroposteriorly in an ocular prosthesis.
A scleral wax pattern was fabricated. The customized scale was used to measure the
dimension and orientation of the natural iris. These measurements were then transferred to the scleral wax pattern with the customized scale. An iris disk was fabricated
using black crayon on the scleral wax pattern according to the measurements. The
scleral wax pattern, including the iris disk, was then placed in the eye socket to verify
its dimension and orientation. A prefabricated iris disk was modified according to
the measured dimensions and transferred to the final scleral wax pattern. The transfer
of these dimensions to the definitive prosthesis was achieved successfully, ultimately
improving the patients social and psychological well being.

Loss of tissue, whether congenital, traumatic, or resulting from

malignancy or radical surgery, is accompanied by esthetic and
psychological effects.1,2 This loss is more pronounced when
the affected parts are the eye and the orbital contents, resulting in gross mutilation. For such patients, the primary need
is the early and satisfactory restoration of the lost tissues to
their normal anatomic form. Orbital defects with total loss of
eyelids and eyeball cannot be satisfactorily repaired by reconstructive surgery alone. Many orbital or ocular defects require
some form of surgical and prosthetic rehabilitation. Careful
preoperative surgical and prosthetic planning using a multidisciplinary approach can greatly improve prosthesis success.
Various methods3-5 have been described to position the iris portion of an ocular prosthesis accurately. Recently, Guttal et al6
and Jain et al7 suggested the use of the facial midline as a reference point to orient the iris. Previously, Roberts8 proposed
the use of a pupillometer for proper placement of the pupil,
and Joneja et al9 described the use of window light or light
reflection, viewed symmetrically in both eyes. Comparing the
positions of both irises together, as is done in various methods,
can be a major disadvantage in facial asymmetry cases. In the
current technique, this disadvantage is overcome by not considering a common reference plane for iris orientation, and hence
it can also be used in cases of facial asymmetry. The method
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proposed in this article helps place the iris disk as accurately

as possible, using a customized scale with minimum chairside
time, reducing the inconvenience of lengthy clinical sessions.

Technique
A 37-year-old male patient reported to the Department of
Prosthodontics, with the chief complaint of a missing right
eye due to an automobile injury, 2 years prior.
1. After the right eye socket was inspected (Fig 1), the
primary impression of the socket was taken with irreversible hydrocolloid impression material (Zelgan Plus
irreversible hydrocolloid; Dentsply India, Delhi, India),
a special tray was fabricated, and a final impression made
with light body addition silicone elastomeric impression
material (Reprosil vinylpolysiloxane impression material; Dentsply India).
2. After the final impression was disinfected, it was poured
with dental stone (Kalstone Laboratory Stone; Kalabhai, Mumbai, India) and the mold was prepared for wax
pattern fabrication.
3. A scleral wax pattern was made with white wax
(Hindustan Dental Products, Hyderabad, India) and tried

C 2013 by the American College of Prosthodontists

Journal of Prosthodontics 23 (2014) 252255 

Gupta et al

Figure 1 Preoperative right ocular defect.

Orientation of Iris Disk with Customized Scale

Figure 4 Verification of the measurements with black crayon iris.

Figure 2 Customized scale.

Figure 5 Definitive prosthesis after insertion.

4.

5.

6.
Figure 3 Measurement of the natural iris.

7.

in the patients eye socket for fullness, retention, and

stability.
After the try-in of the scleral wax pattern, positioning of
the iris disk began, with the help of a customized scale
(Fig 2).
The customized scale was marked from 0 to 4 cm from
left to right on top and right to left at the bottom. This customized scale can be used to place the iris mediolaterally,
superioinferiorly as well as anteroposteriorly.
The vertical line on the customized scale should coincide
with the medial canthus of the eye as a reference point.
For the measurement of the natural iris, the patient was
instructed to look at infinity. The customized scale was
then used to measure the distance from the medial outline
of the natural iris to the medial canthus of the left eye
(Fig 3) and also to measure the mediolateral dimension
of the iris.

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Journal of Prosthodontics 23 (2014) 252255 

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Orientation of Iris Disk with Customized Scale

Gupta et al

8. After placing the wax pattern in the right eye socket, the
same distance was transferred to the scleral wax pattern
of the right eye, from its medial canthus, with the help of
the customized scale.
9. An iris was fabricated manually with black crayon (Wax
Crayon Camlin; Kokuyo, Mumbai, India) on the scleral
wax pattern at the same distance transferred with the
customized scale.
10. The scleral wax pattern, including the black crayon iris,
was tried in. (Fig 4). After the final adjustment, and after
the patient was satisfied, the crayon iris was removed.
11. A stock iris disk was selected according to the shade
of the natural iris and then trimmed to the dimensions
measured. This stock iris disk was then placed in the
area from where the crayon iris was removed.
12. After final try-in of the scleral wax pattern including
the stock iris, the pattern was processed in the conventional manner. The prosthesis was then delivered, and
postoperative instructions were given to the patient for
maintenance and care of the prosthesis (Fig 5).

Discussion
A prosthetic replacement is the treatment of choice to return
the individual to his normal vocation by producing an acceptable and lifelike appearance. This can be achieved either by
relining10,11 a prefabricated or stock ocular prosthesis12 or by
fabrication of a custom-made ocular prosthesis.13 The replacement of the human eye by a prosthetic substitute presents many
problems. The most challenging of these is the alignment of
the iris in the artificial eye to achieve the correct interpupillary
distance between it and the natural eye. The accurate recording
of this measurement will influence the final esthetic effect of
the restoration. McArthur14 described methods for positioning
the artificial eye in the orbital prosthesis using an ocular locator
and fixed caliper. Benson15 suggested a method for fabricating
a custom-made acrylic resin ocular prosthesis, in which he determined the size and position of the iris by visual judgment.
Raizada and Rani also described a couple of methods for centering the iris disk and mentioned the importance of an ocularist in
fabrication of ocular prostheses.16 Recently, Pai et al proposed
the mounted graph grid for positioning the iris disk.17 The iris
positioning procedure requires more consideration, because it
is a technique-sensitive procedure. In this article, a technique
to place the stock iris disk as accurately as possible with the
customized scale has been presented.
The scale was fabricated with heat-polymerizing resin and
coated with silver paint to give an appealing effect to the customized scale. A zero-power lens was attached to the fabricated
scale so as not to affect the patients visual clarity. The scale
was marked from 0 to 4 cm from left to right as well as from
right to left, so the same scale can be used easily for both the
eyes.
The medial canthus of the eye was selected as the reference
point in this technique for iris disk placement. Various studies
justify the use of the medial canthus region as a fixed reference
point.18,19 The superioinferior visibility of the iris disk can be
checked by measuring the distance from upper eyelid to lower
eyelid with the same customized scale. The antero-posterior
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orientation can also be achieved by comparing to the natural

eye with the help of the customized scale by keeping it against
the patients face in lateral profile. The lateral canthus instead of
the medial canthus will be used as a reference point. The measurements in all three planes were verified by asking the patient
to look at infinity, to confirm the gaze orientation. This technique is more useful and advantageous than other techniques
because it can also be used for facial asymmetry cases. The inability to do this is the major drawback in most techniques. This
technique requires minimal skill and less time. This customized
scale can orient the iris disk in all three planes (mediolateral,
superioinferior, anteroposterior) accurately. Other advantages
of the customized scale are that it is very economical, easy to
fabricate, and can be used for many patients. The limitation of
the current technique is its subjective nature, due to variation
in operators perception.

Conclusion
This article introduces a customized scale that orients the iris
disk in all three planes as accurately as possible, thus simulating
the natural appearance in a very cost-effective manner.

Acknowledgment
We would like to acknowledge Dr. Lingeshwar D. and Dr.
Sunanda Sharma for manuscript preparation.

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