The history of ocular prosthetics
When talking to patients, one often hears this sentence: Isn’t it good that you can get ocular prosthetics and don’t have to run around with an empty eye socket like in the old days. Artificial eyes for people who have lost their eye; how long have they been around?
The loss of an eyeball, whether through accident, war injuries or illness, leads to a severe optical changes to the face. People who suffered this kind of fate, tried to hide the facial mutilation. In order to hide this facial defect, most used bandages or eye patches. In that way it was possible to reattain minimum facial symmetry, as this has always played a large role in all cultures. Additionally, the human eye is the most important organ in the body, as without it visual perception is not possible. Therefore, it is not surprising that many ancient cultures saw the eye as a symbol for light and life. In this manner, the well-preserved and reconstructed documentations of Ancient Egyptian civilisation, unambiguously state the significance and elementary symbolic character of the eye.
Archaeologists found artificial body replacement parts, such as dental pieces, which were used for the dead. The reason behind this was in order to provide the dead with additional functions for the journey to the land of the dead, to facilitate their life in their underworld. Clay balls were found in the eyes of mummies, which were meant to prevent eyelids from falling in. The main purpose of these balls was to make sure that the dead body would remain as intact as possible. This was also the case with other body replacement parts. This contrasted to the skulls from Papua New Guinea, which were brought to Europe at the end of the 19th Century, where the family of the deceased would insert clay balls into the eye sockets, so that the deceased could watch his family and tribe’s activities from the other side.
These are two contrasting approaches which stem from mortuary practices in different cultures.
Besides these occult practices, however, exact, highly detailed reproductions of the human eye have survived from the Egyptian era. These can be found on sarcophagi or statues and are mostly made from semi-precious stones or even glass. The resulting thesis that these served as ocular prostheses, and not only for decorative purposes has not been scientifically proven. So far, there is no evidence of the manufacture of artificial eyes during the later Greek and Roman eras.
In Roman times, the terms “faber ocularius” and “medicus ocularius” were used. These were two different occupations. The “faber” produced eyes for statues of important personalities, as the specially produced artificial eyes were inserted into the figureheads. Then there was the “medicus”, the ophthalmologist. The first medical ocular prosthetics are generally related to by Ambroise Paré *) In his book about surgery, written in 1575, there are first depictions of ocular prosthetics which were worn in the eye cavity, as well as the ecblepharon, or presentation eye, worn in front of the eye cavity, which was supposed to cover the defect. The inserted eye is therefore the first proof of its existence and use in ocular prosthetic treatment and care in modern medical terms. It is this point in time, which lead to the further development of the prosthetic eye, tightly bound to those who manufactured them, the eye makers or ocularists of the present day.
Therefore it is clearly defined how long ocular prosthetics have existed. However, during the 2006 excavations in Belutschistan, Iran, in the so-called burnt city, archaeologists claim to have found the skull of a woman who died 4000 – 5000 years ago with a ball inserted in her eye socket.
In particular, the interesting thing here is statement by a scientist who participated in the excavation. According to this, the artificial eye was made of bitumen. That makes sense too. There is evidence that in Mesopotamia bitumen was extracted and used for various purposes as early as 3,000 BC. Studies have shown that bitumen is not harmful and that it can be shaped after heating. Another fact stood out: according to the description, the scientists found traces of gold in the grooves on the front side of this ball. This fact is related to a dispute between Jewish scholars and medical scholars at the end of the 19th century, whether the Jerusalem Talmud mentioned an eye of gold manufactured for a girl in biblical times.
Based on this, doctor J.Hirschberg concluded that ocular prosthetics were actually known in the early years of Judaism.*) However, the Talmud experts stated that this was a translation error. With the finding in Iran, these disputes have now received a completely new context. The bitumen comes from an area in modern Iraq today. According to Professor Lorenzo Constantini (Rome), the dead found in the “burnt city”, located on the border with Afghanistan, came from the Orient. The gold decoration could be used as evidence that the text from the Talmud may not have been a translation error; that these ocular prosthetics actually existed. The unique meaning of the find is indisputable; an artificial body-part has been discovered, which could be carefully described as an artificial eye. However, from an expert viewport, this artificial eye could not have had a medical function in the sense of today’s eye prosthetics. Drilled holes on the edges lead to the conclusion, that the eye was held in place in the cavity using bands, which excludes wearing under the eyelids. The engravings on the front surface do not depict an iris, they are much more symbolic in character. It seems as if the deceased might have used the eye defect in order to surround herself with a magic aura. Unfortunately the “eye” is not accessible, so it is not possible to receive more information. Therefore further discussion remains speculative.
In a dissertation dedicated to his teacher, Mauchard *), in 1749, Philip Adam Haug described all that was known in ocular prosthetics at the time. In his work, he mentioned a well-known ophthalmologist, John Thomas Woolhouse, 1666 – 1784, who practiced in Paris and was connected to Mauchard. Woolhouse spoke of a story from Ethiopia, which dated back to Pharaoh Ptolomeaus Philadelphus, 300 BC. This story reported that a man became very rich manufacturing artificial eyes from gold. *) At this point it is very tempting to return to the speculations that the text mentioned in the Talmud is a reference to the existence of prosthetic eyes in earlier times.
The proven existence of ocular prosthetic treatment in Europe is rooted in the 16th century. Ambroise Paré, 1510 – 1590 (Paris), described the medical possibilities at the time. Bandages, dyed to match skin tone, and eye patches painted with an eye were often used, which led to the ecblepharon described by Paré. Paré was a barber surgeon who had mainly participated in wars over Italy and as a battle medic, he was able to collect extensive experience regarding the treatment of the wounded. However, we only know little regarding what was taking place in the rest of the world, and whether they even had ocular prosthetic treatment. The collection at the Müller-Söhne Institute for Ocular Prosthetics contains some very interesting artificial eyes. For example, artificial eyes carved from ivory. Once, Christoph Müller-Uri explained that this eye had been left to him, supposedly from an Egyptologist, who believed it stemmed from ancient Egyptian times. This is however doubtful, as this eye was designed like a modern prosthetic eye. The Egyptians were fascinated by ivory. It is presumed that the eye may not be so old and possibly stems from Asia.
Besides this, there is a very interesting example of methods of covering up eye defects from Burma, which is a part of the collection of the Maxillo-Facial-Department at Queen Mary's University-Hospital, where I was able to photograph this eye covering made from a coconut shell.
*) A nose carved from ivory from the Science Museum in London could serve as evidence that it was possible to carve eyes in Asia, which would explain the origins of the ivory eye. While the use of ocular prosthetics after the removal of the eye ball was considered well-known in France, it was unknown in Germany up to the early 19th Century. The first inserted eyes were manufactured from precious metals and the sclera and iris colours were painted on the front side, and then fired. Enamel work has been known since ancient times. Enamel is ground quartz, mixed with oxides to produce a coloured powder. The powder is applied to metal surfaces and fired at approx. 500 – 600° Celsius. In the 18th Century, the German doctors, Heister und Haug mention that glass prosthetic eyes were known. These were probably eyes made in France. As with the metal eyes, the irises were first painted on using enamel colours. It was however unnecessary to fire the enamel, instead the front section of a crystal glass rod was heated until it glowed and then tapped in order to form the anterior eye chamber. The crystal rod contained a dot of black glass in the centre to form the pupil. After knocking the glass rod, it was melted in such a way that only one portion remained which was necessary to copy the cornea. The ball and crystal were fused through glass blowing in order to obtain a homogenous unity of ball and iris, which was used to produce the desired prosthetic shape. This technique was the reason why these eyes were known as enamel eyes for a long time, instead of glass prosthetic eyes.
In the early 1800s there were a number of eyemakers in Paris, the most famous of them was Hazard-Mirault.
In his book, we can find out some facts about the work and techniques used in prosthetics manufacture. But who were the Parisian eyemakers? The enamelled gold and silver shells must have been irregular orders from craftsmen. However, the glass eyes must have been made by very skilled people, mainly those who had trained in the glass industry. Besides Dr Coulombe *) he included Carré, Rho, Auzon & Gaucher, Desjardin, Carles Francois Hazard and Bernard Palissy. Ritterich *) named Noel, Chappée and Fessard who manufactured artificial eyes for him. Desjardin used opthalmoplasty as a term for ocular prosthetics, while Parisian eye maker Palissy called himself an “ocularier” . In the mid-19th Century the Boissonneau introduced the term “ocularist” for those who manufacture and fit artificial eyes. He was the first to use the term that is still valid today, and is seen as the founder of the modern day ocularist. From 1834, the technique of manufacturing artificial eyes from glass came to Lauscha in the Thuringia Forest. This had been the location of a glass works since the end of the 16th Century, which processed glass to form household and art objects. Here, glass jewellery, doll’s and animal eyes were manufactured. Due to the fact that it was only possible to buy glass artificial eyes from France, ophthalmologists Professor Adelman and Dr Ritterich tried to find talented glass blowers in Germany in order to manufacture ocular prosthetics from glass in Germany too. These were then available at much cheaper conditions than from French companies. In that way, Professor Adelman found a glassblower named Ludwig Müller in Lauscha. He showed him a French glass prosthetic eye and asked him to copy it. As Dr Ritterich wrote, after many attempts, Ludwig Müller succeeded in manufacturing glass eyes for humans. At the same time, he discovered a different method and new technique. .
This was the beginning of the success story of German ocular prosthetics. Soon afterwards, his nephew Friedrich Adolf Müller took over the idea of manufacturing eyes for humans and became the found of the F. A. Müller-Söhne Institute in Wiesbaden which still exists today. The German glass eye became world famous and up to this day, it maintains high importance in caring anophthalmus patients within and outside of Europe. Even though nearly all countries in the world produce artificial eyes from synthetic materials, this does not affect the quality of glass ocular prosthetics. On the one hand, this is due to the fact that German ocularists undergo a long and intensive education and training. On the other hand, glass has clear advantages due to its biocompatibility and associated tolerance in comparison to synthetic materials. Since 1884, manufacturers in Germany and elsewhere have attempted to produce artificial eyes from synthetic materials. This was described by Nieden und Fröhlich *). Here, celluloid and vulcanite are used, however it was not possible to manufacture the irides, and therefore it was necessary to use glass irides, which could not be integrated into the prosthetic bodies and therefore caused irritations. Prior to the Second World War, ocularists in France, England and the USA were making artificial eyes from German glass, however the war caused glass deliveries to cease. Due to the increasing demand for prosthetic eyes and the cessation of glass deliveries from Germany, it was necessary to find a replacement material in England and America. This was quickly found in the dental departments of military hospitals. This initiated the development of manufacturing plastic eyes, which continually improved in the application of materials and techniques. In Germany, Holland, Switzerland, Austria, Italy, most of Scandinavia and parts of Russia, glass prosthetic eyes continue to dominate. We remain convinced that German ocular prosthetics will continue to retain their importance in the future.