Esthetic Conformers: Improving the Quality of Life of Enucleated Children

Sir,

Enucleation in a child, whether for tumors, chronic eye disease, or severe ocular trauma is extremely distressing for families. The commonest indication for enucleation in children is advanced intraocular retinoblastoma, and surgery is usually performed within a few days of diagnosis. In such cases, the distress caused by the diagnosis of such dreadful ailment is compounded by the inadequate time available for the family to prepare themselves for the postoperative appearance, which causes considerable upset to family and siblings. Of particular concern, is the cosmetic appearance of the child in the immediate postoperative period. So, allaying the anxiety of the family members during the postoperative period is of paramount importance.

Presently, most of the surgeons worldwide including India use a transparent conformer or shell postenucleation. The advantage of using transparent conformers is an easy visualization of the wound area by the clinician with minimal manipulation. But practically speaking, the ointments used to facilitate wound healing frequently conceal the wound area, making it impossible to examine the latter without removing the conformer. This transparency, however, can cause embarrassment; some patients consider visualization of the underlying socket unsightly added to which the conformer does not resemble the contralateral eye.[1] This usually forces the patients to get a final prosthesis fitted earlier than is optimal for wound healing.

The various benefits offered by the conformer such as protection of the wound, minimizing the changes in the socket size and conformation, preventing scar tissue contractures from distorting the socket bed[2] and maintaining the forniceal depth;[3] make their use indispensable following post enucleation. A commonsensical solution to overcome the cons of the transparent conformer [Figure 1a] is the utilization of the so called prosthetic or cosmetic or esthetic conformer, which is a painted conformer with an iris button attached to it in addition to the fenestrations for drainage [Figure 1b].

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Figure 1

(a) Clear conformer. (b) Esthetic conformer with fenestration indicated by arrow

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The prosthetic conformers are manufactured as stock prosthetic eyes and cost approximates that of the stock eye. The cost of clear conformers is around Rs. 150 whereas the cost of prosthetic conformers is Rs. 200. However, the various benefits offered by esthetic conformers outweigh its slightly increased cost as compared to clear conformers. As we expect that more and more ophthalmologists and surgeons will demand for esthetic conformers due to its various advantages over clear conformers, their cost will automatically come down due to its indigenous mass production by companies that supply acrylic stock eyes. An appropriately sized and color-matched conformer that will slide in easily, fill the fornices without being tight and allow lid closure can be placed in the socket at the end of surgery and kept for an average of 4-6 weeks.[4] The esthetic conformers decrease the psychological impact of enucleation, yet achieve the goals of an ideal conformer. In addition, the children are more comfortable as it avoids the use of patches and tape on the skin to cover their conformer, and helps the family to wait for an appropriate healing period of 6 weeks before the final prosthetic fitting. The role of the conformer and the cosmetic limitations of relative ptosis, enophthalmos, and slight color mismatch should be explained to the family prior to surgery.[5]

Ours is a tertiary-care centre and is registered as one of the hospital-based registry under national retinoblastoma registry project initiated by Indian Council of Medical Research. So, enucleation is routinely done for advanced retinoblastoma cases and we have found that the acceptance of esthetic conformers is much more as compared to the clear conformers, approximately 90%. The parents of children who had undergone enucleation reported that it was less traumatic for them to accept their child as appearance after enucleation when esthetic conformer was used as compared to clear conformer. As pediatric patient is the centre of attraction for both the medical team and the family, so providing them with an esthetic conformer is a highly positive approach with significant palliative effect, which improves rehabilitation and quality of life of the family and the enucleated child. Therefore, it is a humble appeal to all the concerned medical professionals to use esthetic conformers instead of clear transparent conformers in postoperative period, so as to provide a sigh of relief to the grieving patients.