C O M B A T
	the Literary Expression of Battlefield Touchstones ™
	ISSN 1542-1546 Volume 01 Number 04 Fall ©Oct 2003

Speak so that I may observe you, as I want to listen even with my eyes.
paraphrase of Socrates

Because the all seeing eye is a symbol of knowledge, and blindness is often a metaphor for ignorance or irrationality, those of us who wear artificial eyes are often sensitive about the extended attribution. Myths abound and stereotypes persist, but before we can even begin educating others, we must first inform ourselves. The stigma of eradicating the ignorance on a sensitive social topic is contradicted by tasteless ostentatious displays, as when performers decorate or adorn themselves, and when musicians embellish their accouterments with numerous artificial eyes. Truth can conquer ignorance, but decadence may be immune to any form of knowledge.

One of my military instructors liked to quip that no one could tell when he was being scrutinized by the real or the artificial eye; hence he never knew what he might get away with or get caught for attempting. This instructor carried an extra prosthesis in his pocket so he could dramatically focus the class' attention by suddenly placing it on an item of interest with the wry comment to keep an eye on it. He deliberately outraged propriety and decorum by entertaining us into learning the subject.

An undoubtedly apocryphal story has made the rounds that a banker (or variously a judge or a bureaucrat) was so impressed by the quality of his prosthetic eye that he challenged anyone to identify it; until someone commented that it must be the one with the weak glint of compassion, because the other one is marble-hard and deadly cold! Alternatively, you may have heard of the jester who bet that he could bite both of his own eyes; and to win the wager, he transferred his glass-eye to his mouth for the first bite, and then removed his false teeth for biting the other eye! These anecdotes are actually more credible than the more common account of the drunk who plops his glass-eye into his drink with the convivial toast: Here's looking at you! The metaphor of Cyclops as an abnormal monster, who becomes intolerable when made aphotic, still persists.

The principal misconception about prosthetic eyes is that they're shaped like an orb or ball. A little commonsense would quickly dispel this notion, such as how to keep the simulated iris front oriented; but such reasonableness would quash too many good jokes. More than anything else, the modern artificial eye resembles a miniature brassiere cup ... a generally triangular convex shell. A prosthetic eye cannot be substituted when playing marbles or when rolling dice. It won't even float with bobbing ice-cubes in a mixed beverage. And, despite their common need for realism, a prosthesis serves a very different function from the glass-eye trophy mounts by taxidermists.

Mixed sizes and types of prosthetic eyes, with lubricants and eye-shields. Two specimens [left] are lightweight blown-glass; with one showing beaded edge, and the other showing classic temperature-moisture break.

Mankind has been losing the windows to the soul, by accident or design, since time immemorial. The technology for ocular prostheses is relatively recent, and owes much to the work of morticians, artisans, and dentists.

It's more than probable that when prehistoric man survived all the possible side-effects related to the loss of an eye, he either left the shrunken eye or empty socket exposed, or he covered it intermittently with a cosmetic patch of cloth, wood, horn, bone, or shell. Setting aside the charmingly apocryphal anecdotal history of the intrauterine device^[1], it is unlikely that primitive man experimented with small objects, such as eggs or stones, to fill the void. This behavior is consistent with preliterate tribal peoples coexisting with advanced cultures in the modern era. One of my favorite stories on this subject is set in frontier America, and aptly demonstrates the cultural contrasts and conflicts between ancient and modern values.

During the Frontier Wars, a trapper noticed an Indian with an empty eye socket. Feeling companionable, the trapper offered his extra glass-eye to the afflicted native. The Indian was at first astonished, and then delighted. He popped the glass-eye in, gazed around, and then, drawing his hatchet with a scowl, asked what this trick was all about? ... because he couldn't see any better with it than without it! The chagrined trapper replied, in defense of his life, that the defect must be due to the replacement eye being blue, instead of a matching brown!

Archaeologists have discovered that during the treatment for mummification, Egyptian priest-morticians filled the eye socket with either wax or plaster as early as the 9^th century B.C., and then affixed a gemstone to represent the iris. By the 5^th century B.C., Rome and Egypt were experimenting with cloth-wrapped clay or wax balls for use by living persons missing an eye; but no one today knows if this contrivance was worn internally or externally (as on a headband). Until the Renaissance, most (if not all) cosmetic treatments for eye loss were external; being either some form of cloth wrap or a metal headband-clamp variously painted to simulate an eye or depict a visual symbol. When I lost my eye, the fashion among us veterans was to decorate the plastic shield guarding the socket with heraldic insignia, or to paint a tortoise-shell effect ... some bon-vivants even sported haute-couture petit-point eye patches! The prevailing opinion was that we could all be intrepid mannequins for stylish Hathaway-Arrow shirts; but fashions changed, compelling all of us to find real work.

By the 16^th century A.D., some privileged persons were able to wear indwelling cosmetic shields made of glass or shell. Appearing in Italy around 1579, these shields, including one ornamental shell made from thin gold that had been enameled to resemble the eye, heralded the true beginning of ocular prosthetics. These indwelling shells were fragile and uncomfortable. They were thin and sharp-edged, they trapped secretions and lacked replacement volume, but they were a positive move in a promising direction.

After 1818, indwelling shell manufacturing was improved in Paris, until Germany introduced superior blown-glass replacements in 1850 ... which were called glass reform prostheses. The glass reform prosthesis was suitable for all applications except evisceration or atrophy. Even today, the use of a cosmetic shell over an atrophied or phthisical (wasted) orb is rare. These coverings, termed a scleral cosmetic shell, can include a contact refractive lens if the affected eye is not blind.

As science began to influence the field, shields made of glass, porcelain^[2], horn, bone, cloisonné, silver, and gold eventually gave way to prostheses made of ivory, bone, natural rubber, vulcanite, lead, aluminum, celluloid, and acrylic. The field would finally narrow to only glass and acrylic, but the competition would echo previous guild contests which embroiled international trade. After papyrus had created an exclusive market, excessive costs and trade restrictions did not coerce client compliance, but inspired the creation of parchment, which became a more popular alternative. And so likewise in the modern era, blown-glass has almost entirely lost the marketplace to acrylic prostheses.

I recently read an old Perry Mason episode^[3] in which an artificial eye was the prime evidence. Knowing the author's credentials, and his normal proclivity for factual bases, if not believable storylines, I had to do some research to satisfy my curiosity. The book states that a blown-glass eye is a ball made from glass colored to match the recipient's sclera; with the iris, pupil, and veins being specially colored glass applied to the ball; and the ball then being torch-cut to an unspecified shape (implied hemispherical). The book mentions that glass-eyes may be stock or custom, are carried or stored in a chamois leather pouch, and are secured in the wearer's eye socket by vacuum. The book is almost correct, but not quite.

Until a very recent patented development, all glass and acrylic prostheses were secured in place by a combination of eye-lid pressure and vacuum suction. This fact was graphically illustrated the first time I dived into a swimming pool wearing my new prosthesis ... excessive water pressure pulled it out of my head! Most people are initially fitted with a standard stock eye for accommodation to size and fit following the removal of the post-operative conformer, and while they are awaiting a custom-made eye. With enucleations now being performed on an out-patient basis, and custom eyes able to be finished in one sitting, the need for stock eyes is diminishing. The caricature of a bartender diligently polishing drinking glasses has nothing to do with boredom or make-work ... skin-oils will acid-etch glass, so the glass must be polished to prevent marking or fogging. This effect applies equally to optical lenses and glass-eyes. In addition to cleaning the body's own secretions off of an artificial eye, storage in a leather pouch is not recommended due to the staining and corrosive effects of the curing tannins. A better choice for that era would have been tissue-wrap in a velvet pouch, as diamonds are still sometimes carried. Today, storage in a sealed container of lens fluid, or transport in a cotton or tissue padded ring box is the preferred treatment for both glass and acrylic eyes.

Like the production of acrylic prostheses, making blown-glass eyes is a guild regulated artform. Cutting the ball into an appropriate shape may have been an early practice, similar to the earlier shields, but the specimens of the art that I've been able to locate show a highly developed skill ... one even bears a beaded edge! In making a reform prosthesis, the blown-glass ball is deliberately collapsed upon itself to form a hollow double-layer convex shell. In overall shape, the glass and acrylic eyes are very similar, so they will nestle against the surgically introduced ocular implant. The major difference between them is not their construction or their proximal realism, but is rather their effective weight. A blown-glass eye is almost as light as a feather ... being easily only one-tenth the weight of an equivalent acrylic eye.

While the glass-eye has at least one unique asset, it also has at least one significant defect. Due to its hollow design, the glass-eye is particularly vulnerable to rapid and severe temperature changes ... such as when entering a heated room directly from wintery exposure, thus producing a reaction like exploding ice-cubes in warm water. The two layers of the prosthesis are at different temperatures, and one of them often fractures in response! In addition to this problem of temperature reaction, the fragile glass-eye is very susceptible to impact ... similar to the potential with hard contact lenses. The possibility of secondary damage or reinjury due to prosthetic vulnerability is substantial enough for an active person to avoid this option.

View of various prosthetic eyes, with lubricants. Sizes vary due to age of recipient and amount of orbital damage. Two specimens [left] are lightweight blown-glass type.

Some people believe the simulated appearance of a glass-eye is more realistic, and therefore less noticeable than other imitations. These are the same people who carry an evening eye with a slightly dilated pupil, and keep a bloodshot eye for use whenever ill. The average person will not notice a prosthetic eye, unless there is accompanying facial disfigurement. When I recently replaced my old prosthesis, several people complained that I'd tricked them, because they had thought my badly damaged natural eye was the fake one! Now that my eyes match, scars and all, nobody can keep them straight! Appearance is a noteworthy consideration, but comfort and security are more important.

We enjoy a choice today, and we can make an informed decision because the international embargo imposed by war proved unsuccessful. Once Germany's craftsmen had created an undeniably superior product, they maintained control by regulating the availability of the secret-formula glass used in the manufacture of artificial eyes. A skilled ocular prosthetist could establish a service business anywhere, but would always need basic supplies from Germany. The embargo was endured during World War One, but many researchers attempted to either discover the secret-formula glass or invent a suitable replacement. When World War Two imposed the same constraints, American ingenuity^[4] found a substitute in the clear synthetic resin (acrylic methylmethacrylate) used for dentures. On the new prostheses, veins were initially scribed or inlaid silk fibers, but were later just painted along with the iris. The completed eye is finished with a polished coating of clear sealer, which can be periodically renewed.

In order to compensate for the absence of mass in the loss of an eye, a sterile implant is introduced at the back of the orbit, where the six ocular muscles are tied-off in pairs. This pairing of muscles contributes to the normal triangular shape of the convex prosthesis, so as to enable a parallel range of movement^[5] coincident with the other eye. The inner (concave) surface of the reform prosthesis nestles against the implant, in a manner similar to a ball-and-socket joint. The latest innovation in this field of medical technology has insinuated a post linking the shell and implant, in a manner similar to a mortise-and-tenon joint. Prosthetic motility response is improved by this innovation, but this adaptation usually requires professional assistance for changing, and may promote bacterial incubation due to inaccessibility. While the primary function of an implant is volume replacement (coaptation), a certain amount of form and configuration is represented by the shell. In this regard, one of the differences between glass and acrylic eyes is the empirical plasticity of the latter ... not only can't glass be recoated to extend its utility, but it can't be easily adjusted to accommodate fitting changes.

Prior to the 1890's, ocular implants were made of sponge, gelatin, metal, bone, and glass-beads; and since have been made of silicon, acrylic, coral, and, for a short time, Teflon. An integrated implant, such as bone and coral, is eventually invested by bodily tissue and connected to the body's blood supply. Because the implant could migrate or extrude during the healing process, a post-operative conformer shell, made from denture resin, and consequently colored pink, was introduced in 1906. A conformer has air and drainage holes through the shell, which are also used to flush and medicate the site. After the conformer is removed, a socket impression, using soft dental wax or a mixture of paraffin and petroleum-jelly, is taken in preparation for building an artificial eye. An impression fitted eye often involves adjustment, if for no other reason than to set the pupillary distance before painting. With the exception of the new pegged prosthesis, the usual artificial eye rests on the lower eyelid, and has a tendency to distort it if not properly adjusted. With the new pegged prosthesis, a detent must be drilled into the stable implant to accept the linking post. Another alternative is to scale a flat surface on the front of the implant to match a facing plane on the inside of the shell; so as to improve movement by increasing the contact points and friction angles. A suitable appearance is usually the first consideration of anyone recovering from eye loss, but all too often that depends upon a solid marriage of good mechanisms and talented skills.

Hygiene is always a sensitive topic, but the basic premise for wearing an artificial eye is to unapologetically present a socially acceptable appearance. The phenomenon of watery eyes, caused by scarring or aging, is usually unpleasant, but can be nauseating when combined with accumulated secretions. A nurse once told me that removal of the prosthesis was optional for periodic cleaning, but she knew of wearers who simply popped their eye into their mouth for a quick cleansing! ... she also noted that saliva was also a good natural lubricant. Although this prospect may be distasteful, it is not unlike people who clean their fingers by oral sucking after purging an ear or nostril of obstructions. Another nurse told me that one of her patients was so arrogant and imperious, if not alienated from his plight, that he refused to clean his own prosthesis; instead requiring a family or staff member to change it for him. I tactlessly wondered aloud if he brushed his own teeth; and if not, why someone didn't teach him some independent living skills, so he could join the human race. There are some people (and we've all met them) who will exploit every opportunity to exaggerate their infirmities and imperfections into dependencies; so we have a natural tendency to champion anyone who is undefeated by their handicaps.

A prosthesis is usually inserted by lifting the upper-eyelid with one hand, looking downward, and sliding the shell into the opening with the other hand until seated in the lower lid; and it is removed by reversing the process ... looking upward, pulling down the lower-eyelid and inserting a fingertip to break the suction adhesion, and then withdrawing the shell. If tactile dexterity is a problem, then a small suction-cup can be used for both insertion and extraction. Some professionals report that removing the artificial eye for cleaning is unnecessarily irritating to sensitive tissues. Others recommend removing the eye and directing the flow of a gentle shower into the empty socket. A little commonsense goes a long way ... if it hurts, then don't do it.

A prosthetic eye is subject to secretion erosion from bodily acids or salts and protein or calcium deposits. This erosion can not only prematurely^[6] deteriorate the eye, but can also create an unhealthy or breeding environment. An artificial eye should not be exposed to alcohol, ether, chloroform, caustics or solvents; and may be protected during work or recreation by goggles. The dry eye phenomenon occurs whenever anyone over-works without proper rest, or is exposed to debilitating conditions. With dry eyes, the average blink cycle^[7] is affected, and compulsive rubbing may occur. A dry artificial eye can be painful ... as the surface encrusts, the eyelids stick open, and tears leak ineffectually from the corners. As is true with performing daily ablutions, washing the affected eye will alleviate the condition, at least temporarily, but this option may not be available or convenient. An alternative treatment for an uncomfortable eye is the application of a lubricant^[8]; however an unhealthy situation can be created if mineral oil, silicone, or petroleum-jelly is used. Whenever rubbing an artificial eye, the wiping motion should always be toward the nose to avoid inadvertently turning or dislodging the shell. A routine of good hygiene will keep that unseeing eye twinkling.

The artificial eye is a triumph of resourceful human ingenuity, and a tribute to the unique enduring spirit that persists in the desire to prevail over adversity. The next time you gaze into an unseeing eye, you may be surprised to see more than a vacant perception, more than your reflected imagination, more than a projection of passionate conviction. You just might see a happy smile face painted where the iris ought to be!

When I am a veteran
With only one eye,
I shall do nothing
But look at the sky.
by W.H. Auden