No funding was received for this manuscript.

All procedures performed in the following protocol involving human participants were in accordance with the ethical standards of the institutional research committee of the University of Cologne and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
1. Prosthetic eye customization
<ol>
	<li>Select one of the &#34;half-done&#34; cryolite glass eyes based on the best matching iris color to the healthy fellow eye of the patient (<strong class="...

<ol>
	<li>Hintschich, C., Baldeschi, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rehabilitation+of+anophthalmic+patients.+Results+of+a+survey.">Rehabilitation of anophthalmic patients. Results of a survey.</a> Ophthalmologe. 98 (1), 74-80 (2001).</li><li>Rokohl, A. C., Mor, J. M., Trester, M., Koch, K. R., Heindl, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rehabilitation+of+Anophthalmic+Patients+with+Prosthetic+Eyes+in+Germany+Today+-+Supply+Possibilities,+Daily+Use,+Complications+and+Psychological+Aspects.">Rehabilitation of Anophthalmic Patients with Prosthetic Eyes in Germany Today - Supply Possibilities, Daily Use, Complications and Psychological Aspects.</a> Klinische Monatsbl&#228;tter Augenheilkunde. 236 (1), 54-62 (2019).</li><li>Rokohl, A. C., Koch, K. R., Trester, M., Heindl, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cryolite+glass+ocular+prostheses+and+coralline+hydroxyapatite+implants+for+eye+replacement+following+enucleation.">Cryolite glass ocular prostheses and coralline hydroxyapatite implants for eye replacement following enucleation.</a> Ophthalmologe. 115 (9), 793-794 (2018).</li><li>Rokohl, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Concerns+of+anophthalmic+patients-a+comparison+between+cryolite+glass+and+polymethyl+methacrylate+prosthetic+eye+wearers.">Concerns of anophthalmic patients-a comparison between cryolite glass and polymethyl methacrylate prosthetic eye wearers.</a> Graefe's Archive for Clinical and Experimental Ophthalmology. 256 (6), 1203-1208 (2018).</li><li>Rokohl, A. C., Trester, M., Pine, K. R., Heindl, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+of+breakage+of+cryolite+glass+prosthetic+eyes.">Risk of breakage of cryolite glass prosthetic eyes.</a> Graefe's Archive for Clinical and Experimental Ophthalmology. 257 (2), 437-438 (2019).</li><li>den Tonkelaar, I., Henkes, H. E., van Leersum, G. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Herman+Snellen+(1834-1908)+and+Muller's+'reform-auge'.+A+short+history+of+the+artificial+eye.">Herman Snellen (1834-1908) and Muller's 'reform-auge'. A short history of the artificial eye.</a> Documenta Ophthalmologica. 77 (4), 349-354 (1991).</li><li>Koch, K. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ocular+prosthetics.+Fitting,+daily+use+and+complications.">Ocular prosthetics. Fitting, daily use and complications.</a> Ophthalmologe. 113 (2), 133-142 (2016).</li><li>Pine, K. R., Sloan, B. H., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Clinical ocular prosthetics. 1st ed. , (2015).</li><li>Buckel, M., Bovet, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+eye+as+an+art+form:+the+ocular+prosthesis.">The eye as an art form: the ocular prosthesis.</a> Klinische Monatsbl&#228;tter Augenheilkunde. 200 (5), 594-595 (1992).</li><li>Rokohl, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Concerns+of+Anophthalmic+Patients+Wearing+Cryolite+Glass+Prosthetic+Eyes.">Concerns of Anophthalmic Patients Wearing Cryolite Glass Prosthetic Eyes.</a> Ophthalmic Plastic and Reconstructive Surgery. 34 (4), 369-374 (2018).</li><li>Rokohl, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cryolite+glass+prosthetic+eyes-the+response+of+the+anophthalmic+socket.">Cryolite glass prosthetic eyes-the response of the anophthalmic socket.</a> Graefe's Archive for Clinical and Experimental Ophthalmology. , (2019).</li><li>Thiesmann, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Motility+and+lid+changes+with+coralline+hydroxyapatite+orbital+implants+and+cryolite+glass+ocular+prostheses.">Motility and lid changes with coralline hydroxyapatite orbital implants and cryolite glass ocular prostheses.</a> Ophthalmologe. 115 (9), 794-796 (2018).</li><li>Thiesmann, R., Anagnostopoulos, A., Stemplewitz, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+of+the+compatibility+of+a+coralline+hydroxyapatite+implant+as+eye+replacement.">Long-term results of the compatibility of a coralline hydroxyapatite implant as eye replacement.</a> Ophthalmologe. 115 (2), 131-136 (2018).</li><li>Chin, K., Margolin, C. B., Finger, P. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+ocular+prosthesis+insertion+improves+quality+of+life+after+enucleation.">Early ocular prosthesis insertion improves quality of life after enucleation.</a> Optometry. 77 (2), 71-75 (2006).</li><li>Pine, K., Sloan, B., Stewart, J., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Concerns+of+anophthalmic+patients+wearing+artificial+eyes.">Concerns of anophthalmic patients wearing artificial eyes.</a> Clinical and Experimental Ophthalmology. 39 (1), 47-52 (2011).</li><li>Pine, K. R., Sloan, B., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biosocial+profile+of+New+Zealand+prosthetic+eye+wearers.">Biosocial profile of New Zealand prosthetic eye wearers.</a> New Zealand Medical Journal. 125 (1363), 29-38 (2012).</li><li>Pine, K. R., Sloan, B., Stewart, J., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+response+of+the+anophthalmic+socket+to+prosthetic+eye+wear.">The response of the anophthalmic socket to prosthetic eye wear.</a> Clinical and Experimental Optometry. 96 (4), 388-393 (2013).</li><li>Pine, K. R., Sloan, B. H., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+proposed+model+of+the+response+of+the+anophthalmic+socket+to+prosthetic+eye+wear+and+its+application+to+the+management+of+mucoid+discharge.">A proposed model of the response of the anophthalmic socket to prosthetic eye wear and its application to the management of mucoid discharge.</a> Medical Hypotheses. 81 (2), 300-305 (2013).</li><li>Pine, N. S., de Terte, I., Pine, K. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+investigation+into+discharge,+visual+perception,+and+appearance+concerns+of+prosthetic+eye+wearers.">An investigation into discharge, visual perception, and appearance concerns of prosthetic eye wearers.</a> Orbit. 36 (6), 401-406 (2017).</li><li>Pine, K. R., Sloan, B., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+development+of+measurement+tools+for+prosthetic+eye+research.">The development of measurement tools for prosthetic eye research.</a> Clinical and Experimental Optometry. 96 (1), 32-38 (2013).</li><li>Pine, K. R., Sloan, B., Jacobs, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Deposit+buildup+on+prosthetic+eyes+and+implications+for+conjunctival+inflammation+and+mucoid+discharge.">Deposit buildup on prosthetic eyes and implications for conjunctival inflammation and mucoid discharge.</a> Clinical Ophthalmology. 6, 1755-1762 (2012).</li><li>Pine, K., Sloan, B., Stewart, J., Jacobs, R. 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Alexander C. Rokohl, Joel M. Mor, Niklas Loreck, Konrad R. Koch, and Ludwig M. Heindl have no financial or proprietary interest in any material or method mentioned in the article. The participant in this study was recruited from the Trester-Institute for Ocular Prosthetics and Artificial Eyes in Cologne that is owned and operated by Marc Trester.&#160;

Following enucleation with an orbital implant, a conformer has to be inserted for two weeks (Figure 1) in order to prevent scarring of the conjunctival fornices and subsequent inserting of a prosthesis2,3,4,7,12,13. Because an early ocular prosthesis insertion improves quality of life after enucl...

The purpose of the present manuscript is to comprehensively demonstrate the technique of manufacturing a customized cryolite glass prosthetic that is long forgotten outside the German-speaking countries (Figure 1). This manuscript also focuses on major advantages of this technique. These include a very smooth surface of the prosthesis due to fire polishing, the light weight of the prosthesis due to the hollow design, high levels of patient satisfaction, and the need of only one appointment for manufacturing of the customized prosthesis1,2,3,4,5. This article also gives ophthalmologists better insights into ocularistic care in order to improve essential interprofessional collaboration1,2,3,4,5.
In 1832, the glassblower Ludwig Uri M&#252;ller from Thuringia, Germany, developed the cryolite glass prosthetic eye based on the class-leading models made in France4. Benefits of cryolite glass included a better look, better tolerability, easier processing, and longer durability than previous glass eyes4,6,7,8. Herman Snellen, a Dutch eye surgeon, used this cryolite glass to produce a lightweight hollow prosthetic eye in 18804,6,7,8. This lightweight prosthetic eye, the Snellen &#8216;reform eye&#8217;, increased the volume of prosthetic eyes, resulting in better fitting into larger eye sockets following the introduction of enucleation procedures made possible by the development of anesthesia and asepsis4,8. Twenty years later, cryolite glass had become the most commonly used material for prosthetic eyes. Germany developed into the manufacturing center of prosthetic eyes globally2,4,5,7,8. At the start of the second world war, German cryolite glass eyes became unavailable outside of the German-speaking area. Therefore, (poly)methyl methacrylate (PMMA) became a substitute material for prosthetic eyes4,7,8, and today PMMA is the most commonly used material for prosthetic eyes globally4,5,8. Notwithstanding, in German speaking countries, over 90% of ocularists still manufacture customized prostheses using the cryolite glass from Thuringia2,3,4,5,7,8,9,10,11,12,13. Each customized cryolite glass prosthetic eye is produced in two major steps: the first step is to produce a &#34;half-done&#34; cryolite glass eye that conforms to a white sphere with an iris and a pupil (Figure 2). The second and decisive step is to customize the &#34;half-done&#34; cryolite glass prosthetic eye for the respective patient. To that end, a &#34;half-done&#34; cryolite glass eye is selected from thousands (Figure 3) based on the best matching iris color to the patient&#39;s healthy fellow eye.
The following protocol presents customizing a selected &#34;half-done&#34; cryolite glass eye for a specific patient. This step lasts about 25&#8211;35 min.

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			<td height="21" style="height:21px;width:697px;">Bunsen burner with gas and air flow over a fire-resistant worktop made from anodised stainless steel</td>
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			<td height="21" style="height:21px;">Ocularist forceps</td>
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			<td height="21" style="height:21px;">Preheated metal container to 500 degree celsius</td>
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			<td height="21" style="height:21px;">Pre-produced &#34;half-done&#34; cryolite glass eye</td>
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			<td height="21" style="height:21px;">Transparent glass stem</td>
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			<td height="21" style="height:21px;">Various preproduced glass stems in different colors</td>
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customizing a cryolite glass prosthetic eye

In Germany, Austria, and Switzerland, over 90% of ocularists still manufacture customized prostheses using cryolite glass from Thuringia. The present manuscript demonstrates this long-forgotten technique in detail. This manuscript shows some major advantages of manufacturing prosthetic eyes using cryolite glass in comparison to poly(methyl methacrylate) (PMMA). These advantages include a lighter weight of the prosthesis, higher levels of patient satisfaction, and only one appointment necessary for the customized manufacturing. Potential risk of breakage seems not to be a critical disadvantage for glass prosthetic eye wearers. However, in some patients, manufacturing a well-fitting prosthetic eye is not possible or reasonable due to anophthalmic socket complications such as post nucleation socket syndrome, scarred fornices, or an orbital implant exposure. This article gives ophthalmologists a better insight into ocularistic care in order to improve the essential interprofessional collaboration between ocularists and ophthalmologists.

Optimal results include a new prosthetic cryolite glass eye that fits very well, is comfortable, has a good motility, and the appearance with the prosthetic eye, including the eye lid contour, is nearly symmetrical to the healthy fellow eye (Figure 12).
Suboptimal results can result if the new prosthetic cryolite glass eye fits and is comfortable, but there are concerns regarding the cosmetic results. If a prosthesis does not fit perfectly, the appearance, includi...

Watch this Scientific Journal Video about Customizing a Cryolite Glass Prosthetic Eye at JoVE.com

Customizing a Cryolite Glass Prosthetic Eye

This manuscript shows each step of customizing a cryolite glass prosthetic eye including some major advantages of the use of cryolite glass for manufacturing an eye prosthesis compared to poly(methyl methacrylate). In addition, this manuscript gives ophthalmologists better insight into the ocularistic care that could improve interprofessional collaboration.

In Germany, Austria, and Switzerland, over 90% of ocularists still manufacture customized prostheses using cryolite glass from Thuringia. The present ...

PMMA is currently the most common used material for prosthetic eyes globally. However, in Germany, Austria, and Switzerland, over 90%of the ocularists are still manufacturing customized prostheses using cryolite glass from Turnia This video will demonstrate each step of customizing a cryolite glass eye in detail, and will give ophthalmologists better insights into ocularistic care. These insights will help to improve the essential and the professional collaboration between ocularists and ophthalmologists.The major advantages of using cyrolite glass for manufacturing prosthetic eyes are the hollow and very lightweight design, the very smooth surface reducing socket inflammation, and good aesthetic outcomes with high levels of patient satisfaction. In addition, for manufacturing cryolite glass prosthetic eyes, only one appointment is needed. And after one hour, patients can leave the ocularist with a new prosthesis, while three to four appointments are required for PMMA prosthetic eyes.To begin this procedure, select one of the half-done cryolite glass eyes based on which matches the iris color best of the patient's healthy fellow eye. Examine the fitting of the current prosthetic eye by letting the patient look straight ahead. Pay special attention to the retention of the prosthesis, the viewing direction, the motility, the eyelid contours, and the size and volume of the current prosthesis.Then, remove the current prosthetic eye with the help of a contact lens suction cup for hard contact lenses. Examine the anophthalmic eye socket without the prosthesis, and pay attention to a potential inflammation of conjunctiva, the volume filling of the orbital implant, if the orbital implant is visible through the conjunctiva, and if the fornices and sulci are deep enough for a good fitting prosthesis. If there are any major concerns regarding one of these points, and examination by an ophthalmic surgeon should be performed before manufacturing a new prosthesis.Next, use ocularist forceps to pick up the selected half-done cryolite glass eye, and pick up a hollow skewer with the other hand. Using a Bunsen burner, slowly heat both the eye and the skewer to 600 degrees Celsius, making sure to continually rotate the eye and melting the skewer to the open end of the glass eye. Working with the material of glass for eye prosthesis is quite critical.A continuous heating, not over-heating, as well as a fluid work flow is important to prevent a temperature breakage in the process. After this, open the forceps and lay them down and continue heating the half-done glass eye. Use the healthy fellow eye as a model for the color, shape, and quantity of the conjunctival vessels, and draw the vessels on the white sclera of the glass eye with heated glass stems of different colors.Heat the entire half-done glass eye while continuously rotating it so that the drawn vessels merge with the white cryolite glass producing a very smooth surface. Then, modify the shape and volume of the cryolite glass prosthetic eye by suction and by blowing into the mouthpiece. Keep rotating the glass eye in the flame of the Bunsen burner occasionally.Use the old prosthesis as a template for this process, but modify the shape and the volume of the new prosthesis based on the findings of the previous examinations if necessary. Next, heat a transparent glass stem, and melt it at the pupil of the glass eye while continuously rotating the eye. While rotating the eye, melt the glass at the rear of the prosthesis, and reduce the volume of the rear by suction with the help of the mouthpiece so that the shape of the backside is nearly equal to the sample prosthesis or the desired shape.Melt the glass stem at the front side away, and heat the front of the prosthesis again to produce a very smooth surface. Use the forceps to grasp the front side of the prosthesis, and form the final shape of the back side with the help of the skewer. Then, melt the skewer away.Heat the entire prosthesis for fire polishing again, especially the back side. And make sure to rotate the prosthesis until the surface is very smooth all over. Place the smooth prosthesis into a heated metal container and let it slowly cool down.After this, insert the prosthesis and check the fitting as previously described. If necessary, modify the shape of the prosthesis again using the same process. In this study, a hollow double-walled cryolite glass prosthetic eye is customized.Optimal results include a new prosthetic cryolite glass eye that fits very well, is comfortable, has a good motility, and has an appearance, including the eyelid contour, that is nearly symmetrical to the healthy fellow eye. Here you see a sub-optimal result caused by a typical deep sulculus syndrome, which is very hard to handle. It's difficult to fill up the upper part of the orbit by the prosthesis alone since it is a combination of an orbital fat atrophy and superior muscle relaxation.The prosthesis is comfortable to wear, but in order to achieve an optimal cosmetic result in this patient a surgical intervention is necessary. Beside the knowledge how to make and fit an ocular glass prosthesis, we always have to check the eye socket of the patient to see the possible changes within the past year because we have to alterate the new prosthetic glass eye based on the changes. In summary, producing a good fitting and looking prosthetic glass eye is just a matter of practice, and also a question of experience resulting in an over six years training period for ocularists in Germany.This video gives ophthalmologists better insights into the ocularistic care of anophthalmic patients. And also shows some advantages of the use of cryolite glass for manufacturing a prosthetic eye compared to PMMA. However, some divergences have not been identified in detail yet, and especially the impact of the material should be addressed in future studies.Nevertheless, I'd like to emphasize the great importance of a good interprofessional collaboration between ocularists and ophthalmologists in the clinical care of these anophthalmic patients.

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10.4K Views.  Faculty of Medicine and University Hospital Cologne. PMMA is currently the most common used material for prosthetic eyes globally. However, in Germany, Austria, and Switzerland, over 90%of the ocularists are still manufacturing customized prostheses using cryolite glass from Turnia This video will demonstrate each step of customizing a cryolite glass eye in detail, and will give ophthalmologists better insights into ocularistic care. These insights will help to improve the essential and the professional collaboration between ocularists and opht...