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FIGURE 1: Highlights
THE CORNEA AND ITS HIGHLIGHTS periphery, its curvature is somewhat flatter, and the cur-
vature at the limbus reverses this. In other words,
While this most-refractive element is essential in the toward the limbus (0.8 mm to 1.0 mm thickness), the
function of vision, the corneas role in the realistic curvature of the cornea is flattened. This flattened cur-
appearance of a prosthesis is sometimes overlooked. vature is the reason reflections here widen out and
While several formulae have been offered for drawing become irregular. Thus, anatomical descriptions of the
the cornea, there is very little reference material for cornea as having a single radius are simplistic. To a gen-
ocularists.3 Ocularists will recognize that the corneas eral medical audience, this may have little meaning, but
shape is the most important element in the reflection to an ocularist or illustrator, it can make the difference
of light, and thus to its contribution to a natural between believability and error.
appearance in photographs. This aspect of the cornea Remember that the cornea (and other transparent
becomes particularly noticeable in sectional illustra- tissue) appears clear because water is actively pumped
tions (see above). out of it. When it absorbs water (or is injured), it puffs
In ocularistry, the cornea is usually made a perfect up and clouds, thus affecting the appearance of a heal-
partial-sphere primarily because of production limita- ing cornea. This condition must be considered by the
tions and convenience. This is perfectly acceptable. In ocularist when matching the appearance of a fellow eye,
actuality, the cornea is spherical only in its central which may not be healthy.
optical axis portion. Outside the central 3 mm to 6 The shape of the cornea is revealed by "highlights."
mm diameter (0.3 mm to 0.5 mm thickness) to the These highlights are the brightest reflections we see in
another persons eyes, also known as "reflexes," wet- In ocularistry, if the highlight appears "off,"
lights, or catchlights. This highlight is in the same there are two possible reasons. Perhaps the pros-
place on both the corneas, thus telling the viewer that thesis is ill-fitted, making the iris planes of the two
the eyes are looking in the same direction. Otherwise, eyes unparallel, the axes divergent. Also, the pros-
the eyes appear to diverge or converge, making the sit- thesis may have less mobility than the normal eye,
ter look cross-eyed (suboptimal at best). Highlights at thus lagging behind. The effect on appearance in
the margin of the lid tell us whether the eye is wet or both cases is negative. As predators, humans have
dry (Figure 1). evolved to be visually oriented, particularly to
identify the two rings of the eye - the pupil and THE PUPIL
iris. Evaluation of these structures in an opponent
acts as a kind of target analysis, and direct eye con- The pupil can simply be thought of as the circular
tact can be construed as a threat (Figure 3). hole in the iris, allowing light to pass through.
While a point source of light, such as a camera Though the pupil is anatomically slightly nasal and
flash, is seen as a point in the central portion of the superior in the visible iris, it is precisely in the center
cornea, it spreads in the periphery, and makes a of the anatomical iris. Its size is generally altered only
sclera-corneal reflection that is usually wider and by actions of the sphincter and dilator muscles,
less uniform because of the changing curvature of although it can be changed by medications and sur-
the cornea and conjunctiva being flattened at the gery. An average size can be estimated at 2 mm to 4
limbus. mm. Halfway to the limbus is a wide-open pupil, and
most of the active ciliary area, which is inside the iris ness is essential as in a scleral cover shell(Figure 6). An
collarette (see below). It seems to disappear in a dark- alternative to the above method would be to simply cen-
ened room because the pupil becomes larger to admit ter a punched out pupil (of thin emulsion or vinyl) of
more light (Figure 2). average diameter onto the base of the iris (button).4,5
In making the prosthesis, the circle of the pupil is
mechanically created. There are two main types of THE IRIS
pupils in corneal "buttons" or blanks. To recess the
pupil from the iris plane, one button uses a "pupil" Ranging in size from 11 mm to 13 mm, the visible
cast extending past the iris plane from the back of the shape of the iris is determined by the clarity of the
button. This pupil can be ground smaller to change clear cornea.6 Limiting factors include the position of
its diameter, if necessary (Figure 6). Another is drilled the limbus and normal senescent changes with age
into the back of the button; unfortunately, this (arcus senilis). Although the anatomical iris is round,
pupil appears to move forward as a solid and cannot the normal visible iris is slightly ovoid, being covered
be changed in size easily (Figure 6). Both are painted more on the top and bottom by the limbus. This
black. Alternatively, one method uses a flat (some- occurs more so in older eyes and is seen primarily on
times curved) gray (or brown) plastic cornea button the bottom of the cornea (Figure 3).
for both pupil and iris, especially in cases where thin- The iris is generally conical in shape, following
the lens on which it rests. This rounded conical shape, portion are caused by the action of dilator muscle
however, does affect the way light strikes the surface of cells, respectively.
the iris. The traditional upper-left hand light source Two layers of the iris are seen daily - the anterior
then will generally have more of the upper iris in light and posterior layers. In the normal eye, discontinuity
and the opposite iris in shadow. of the anterior layer shows the viewer the posterior
The iris surface is not flat, and under biomi- layer, as seen in iris crypts in the periphery and a dif-
croscopy, it displays a cloud-like 3-dimensionality, ferent texture of the iris nearest the pupil. In lighter
which is under-appreciated until one looks at it under eyes, the pupillary sphincter can be visible as a light
40x magnification 7 (Figure 4). The thickest portion is pinkish band (0.5 mm to 0.8mm wide) near the
the collarette, and the thinnest areas are the pupillary pupil, behind the posterior layer. It is actually floating
margin and the iris root. Radial folds in the central free in the posterior stroma, while the dilator cannot
pupillary portion are caused by the sphincter. be visualized; much of the stroma is colorless and
Discontinuous circumferential folds in the peripheral transparent.
While peripheral iris crypts are usually unre- smooth, velvety-brown.8 Of course, the absence of
markable because they are covered by the limbus, the pigment altogether makes the retinal reflex visible,
ciliary nature of the posterior layer is highly evident in resulting in pink eyes of the albino.
the region nearest the pupil (Figure 5). The vessels of Identifiable elements in an individual eye include
the iris are covered by a thickened lamina propria and landmarks that a computer can use better than a fin-
fibroblasts, surrounded by melanocytes and collagen gerprint. Irregularities in the anterior layer make dis-
fibrils. Occasionally a vessel will escape this matrix tinctive folds and furrows of the posterior layer evi-
and be seen as pink, but only under magnification. dent. Aggregates of melanocytes appear as brown spot
This is not a concern for ocularists. nevi, while clump cells can be seen as spherical brown
The thickness of the iris stroma is often underap- spots in the peripheral stroma and near the sphincter
preciated, as the unpigmented portions are optically muscle. While a dusting of xanthin yellow pigment
clear. Refraction within the iris vessel walls makes for can sometimes be seen on the surface of a light eye or
the variation in coloration seen in someones eye Wolffian spots, almost all the pigment in the eye is
(against the dark brown pigment of the posterior iris from brown melanin granules, becoming darker with
pigment layer). A thinly pigmented iris thus appears concentration.
blue, a thin stroma allows coloration from the brown There are several (iris) painting techniques, which
pigment of the posterior iris (green or hazel eyes), and include oil pigments, watercolors, and colored pencil,
the anterior layer of a highly pigmented iris appears a to duplicate the human iris. In back-painting directly
onto a corneal button (the LeGrand Technique), expedite coverage, and a "scrubbing" of the brush
ocularists can assemble these elements in a variety leaves complex iris "stria" or lines in the pupillary
of ways (Figure 6) Yellowing or a hazy anterior iris region.
color is laid in as a first coat. The fine detail in the Commercial, mass produced iris buttons com-
pupillary iris is assisted by scraping back the dark- plete with painted or pigmented irises have been
er background color with a blade and overpainting marketed over the years with minimal success.
with coloration variants to assume a front-most Hand-painted techniques with the patient present
position. Within the limited media available in seem to win out in the long run. I personally feel
real-time production, nevi can be painted first, or that patients appreciate seeing all of the time-
drilled out and back-filled. Painting in lacquers intensive steps that go into making the prosthesis;
with an acrylic monomer makes this one of the however, its the end result that counts.
fastest drying medium. The stem can be rotated to The collarette can be almost hazy in its atti-
tude in the lighter eye, though it is often very well- coverings (sclera, episclera, anterior Tenon's cap-
defined in the brown eye. It is scalloped mostly sule, and conjunctiva) are notable here only in that
peripherally, just like the incomplete vessel arcade the blood vessels seen over the white sclera reside
that it once was in the womb. If one thinks of how between these layers, thus causing a shadow effect
it was formed, the scallops in the collarette are on the opaque white scleral background.
pulling back from the pupil. It can be thought of This effect is conveniently handled in ocular-
as retreating, trailing strands behind it. istry by using oils and dry pigments, making ves-
This point is a bit clearer when ocularists have sels out of silk threads or tracings of red pencil
a fellow eye to match. Actually, if the fellow eye is onto a clear covering layer, then adding a clear
distorted by disease or surgery, some ocularists coating on top of them. The larger episcleral or
make the prosthesis look like it is the more normal conjunctival vessels will sometimes impress the
(although distorted in color) eye, although the external contour of the eye, thus making two high-
patient usually has a suggestion in this situation. lights possible: just on (vessel highlight) and just
Even when the fellow eye doesn't have a well- above the vessel (reflection on clear covering con-
defined collarette, inserting one anyway can soften junctiva).
the pupil. The vessels to the anterior eye are seen
The peripheral iris is mostly characterized by between the three layers of tissue over the sclera:
circumferential folds, which are never complete episclera, Tenon's capsule, and conjunctiva. These
circles. In a dark eye, pigment may be deficient in are generally transparent and fuse to the cornea
the base of the folds, seen as lighter arcs, which is near the limbus. Long posterior ciliary arteries are
a valuable detail for ocularists. usually supplied to each quadrant of the anterior
eye (visible in the conjunctiva). The straighter ves-
THE LIMBUS sels are arteriolar and can be redder; the wavy ones
are usually veins and are larger, usually deeper than
The anatomical limbus contains the drainage the same-quadrant arterioles. The arterioles should
angle, wherein resides the watery aqueous humor not cross each other in the same layer. Additional,
(produced in the ciliary body and filling the ante- extremely fine vessel arcades can be seen at the lim-
rior chamber). This is just behind (and nourish- bus, just outside the clear cornea. These details
ing) the cornea. It drains into the venous system must be considered in creating prostheses.
through the trabecular meshwork and into the Evident in the portion visible in the open eye
Canal of Schlemm. This often means the blending (Figure 8), the area of sclera usually seen is highly
of clear cornea into white sclera as seen from the vascular, and can exhibit nevi and other coloration
front. This blending must be natural or the iris variants. This is presumably caused by the fact that
looks "cut-out." Thus, one speaks of a "soft" or atmospheric pressure is less than tissue turgor, so
"hard" limbus. A soft blue tint to this area is often these substances are freer to express themselves; in
necessary for a more natural-appearing prosthesis. other words, they collect here. Dark brown eyes
Most ocularists do this mechanically as the limbus will have a smattering of brown in the sclera
is cast in acrylic, and a few paint it (Figure 7). throughout, but more so in the area of the limbus
Scattered internal reflection of light through and conjunctiva. Icterus is a faint yellow-brown
the cornea can illuminate the far side of the iris colorative element, due to deposited hepatic by-
and sclera at the limbus (as well as light reflected products. Thus, a slight yellowing of the sclera is
from the lower eyelid or nose). This is seen in the usually seen in the older eye and having clear
best portraiture and life-like illustration. eyes is a characteristic of youth. Likewise, a baby's
sclera (or in osteogenita imperfecta) often appears
THE SCLERA AND ITS COVERINGS bluer because the thinness of the young sclera.
"Pure baby-blue eyes" mean more than the iris.9 It
The normally near-white sclera extends from the is important to keep these facts in mind in order to
limbus to cover the rest of the globe. The sclera create a natural appearance in prostheses.
General, U.S. Army, Washington, D.C., The Figure 4 photograph, IRIS COLORS AND
September, 1944. UNIQUE TEXTURES was used with permis-
5. Erph SF, D.D.S., Wirtz MS D.D.S. and sion from John Daugman and Cambridge
Dietz, VH, D.D.S. Plastic Artificial Eye University.
Program, U.S. Army, American Journal of
Ophthalmology, 1946, 29: 984. CORRESPONDENCE TO:
6. Eugene Wolf s Anatomy of the Eye and Orbit,
W.B. Saunders Company, 1933. Seventh Michael O. Hughes
Edition, 1976. Artificial Eye Clinic
7. Daugman J. Biometric Decision Landscapes. 307 Maple Ave, Suite B
Technical Report No. TR482 (1999), Vienna VA 22180
University of Cambridge Computer eye226@aol.com
Laboratory.
8. Galeski JS. Galeski Laboratories Prosthetic
Eye Fitting Manual. Iris Patterns.
Richmond, Virginia, 1950.
9. Ocular Anatomy, Embryology, and Teratology,
FA Jakobiec (ed), Harper and Rowe,
Philadelphia, 1982.
ACKNOWLEDGEMENTS