FEBRUARY 10, 1997Volume 9 • Number 2

our child keeps drawing increasingly intricatecrayon masterpieces, full of movementand vivid color. When you hang these

works of art on your refrigerator, youthink to yourself that one day your babymay be an:

❑ Artist❑ Architect❑ Ocularist

Ocularist? This health care profes-sion not only requires the skill to workone-on-one with patients whose illnessand treatment can be very traumatic, butalso demands the artistry to paint verydetailed reproductions of eyes, ears, noses andother facial elements.

Put simply, an Ocularist makes artificial eyesand other facial prostheses. There are only about250 – 300 ocularists in the whole of the UnitedStates - a ratio of about a million people to oneOcularist, according to Michael Hughes, theOcularist who pays a weekly visit to UVA from hisbase office in Northern Virginia.

“It’s very hard to get into this field,” saysHughes, “probably because you never hear of it. Ididn’t grow up thinking, ‘Gosh, I want to makeartificial eyes.’” In fact, Hughes went to Penn Stateto train as an illustrator. “I loved art – particularlyanatomy,” says Hughes, linking together two fieldsthat most people would consider unrelated.

After graduation, Hughes decided the life of astarving freelance artist wasn’t for him. He hadheard of a graduate program that accepted only onecandidate every two years to learn how to ocularand facial prostheses. The program was run by the

Dental Department at Temple University. Hughesapplied and was a finalist for the top slot, but lostout to an applicant from Louisiana. However, asluck would have it, that person decided to quit theprogram after only two days. “Maybe they didn’thave Cajun cooking to his liking up inPhiladelphia,” jokes Hughes. “Luckily, they calledme.”

The Temple program has since closed down and,as far as Hughes knows, there’s only one programin the country that trains ocularists – at the

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Ocularist’s Creations Wondrous

Ocularist Michael Hughes, relfected in mirror,puts his knowledge of anatomy and his skillsas an artist to work on an artificial eye.

Y

University of Chicago. SoHughes suggests that “if a youngperson wants to get into (thefield), he or she would need toapprentice with someone.

Usually, every city has oneperson (who does this work).”After working a number of yearswith an Ocularist inPhiladelphia, Hughes hung outhis own shingle in Vienna, VA.He started working at UVAwhile still in Philadelphia, andhas since added a stop inRichmond to his busy roster.

Many of Hughes’ patients arechildren or seniors. A high pro-portion of them are seeingHughes because they had oculartumors. Depending on the kindof tumor injury, a patient’s eyemight be intact, but not “normal”looking, or the eye might havebeen removed. In cases of ocularcancers, complete removal,known as enucleation, is often

recommended. Once a patient has healed

from the surgery, Hughes beginsthe process of fitting the artifi-cial eye or scleral shell (a thinnerprosthesis that fits over an exist-ing eye). The process is similarto having a mold or your teethtaken at the dentist’s office: acream paste is used to take amold of the eye socket. Hughesthen makes a cast of that mold,duplicates it in wax, and using aprocess called the lost – waxtechnique, makes a replica of theperson’s eye out of acrylic.“They’re not glass eyes any-more,” Hughes notes, adding, “Alot of my older patients have aglass –eye story to tell, but plas-tics are very nice. They can lookreal.” He gestures toward a trayof astonishingly real – lookingartificial eyes, saying “These areall hand – molded and hand –painted.”

This is artistry, indeed Hughessits down in front of a patient

and, using the intact eye as amodel, matches all the complexcolors of an iris, estimates anaverage pupil size, adds finecapillary lines and whateverother details are needed. His cre-ation will transform the life ofthe patient by making his or herloss almost unnoticeable. Forthose whose injuries are moretraumatic, Hughes is able to cre-ate facial prostheses, includingnoses, ears, and eyes with sur-rounding skin tissue.

Hughes is often impressedwith his patient’s resilience. “It’s tough enough to be in a caraccident or have a BB – guninjury,” he says. “You’d beamazed and impressed at howstrong most every patient is –especially some of those whoundergo extensive surgery . . .They are really inspiring. Onewoman is a pilot for an airlineand she’s had an artificial eyesince she was three. (She see itas) just another thing to take care

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One of the things MichaelHughes likes best aboutworking at UVa, he says, isthe chance to be a part of ateam.

Ocularist

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Ocularist

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of on the road of life.” One of the things Hughes

likes best about working at UVA,he says, is the chance to be partof a team, to have “a lot of inter-action with colleagues, differentopinions, a lot of sharing.” Herepeatedly stresses the superbskills of the physicians in theDepartment of Ophthalmologywith whose patients he mostoften works. They include Dr.Brian Conway, the departmentchair, and Drs. Sara Kaltreider,Steven Newman and JamesTiedeman.

One particularly interestingproject Hughes was drawn intoat UVA involved a patient whoseocular tumor did not qualify herfor the Collaborative OcularMelanoma Study (COMS).Coordinated by Jonni Henofer,R.N., the study has two “arms” -one for patients with largetumors, and one for those withmedium – size tumors. Of thosewith large tumors, half receivepreoperative external beam radi-ation and the other half don’t.The medium – size tumorpatients either get an I – 125radioactive plaque (which sits onthe tumor and destroys it withradiation), or are randomized tohaving an eye removed.Consequently, many of thepatients Hughes fits with eyesare participants in the study.

Describing the unusual casethat did not meet the criteria forthe COMS study. Henofer says,“One patient had a ciliary – bodytumor – anterior – right up frontin the eye near the iris. And so

we couldn’t use the I – 125plaque because it would fry thecornea. It would be a nightmare.So Dr. Conway, who is such avoracious reader, knew there hadbeen some cases in Italy wherethey had used gamma kniferadiosurgery for those ocularmelanoma.”

The gamma knife, a radiosur-gical technique pioneered atUVA by Dr. Ladislau Steinerallows for exquisite precision.The “stereotactic” technique usesthree beams of ionizing radiationto pinpoint and destroy anintracranial target without open-ing the skull (or eye, in thisinstance), and without damagingsurrounding healthy tissue.Having decided to use this tech-nique to attack the patient’stumor, the concern was thatbecause it was close to the frontof her eye, one of the radiationbeams might overexpose, or burnher eyelid.

“This,” explains Henofer, “iswhere Michael Hughes came in.“Dr. Conway said ‘Let’s getMichael to make me a scleralshell to lift her lid up, so we cango ahead and deliver the radia-tion to the melonoma and sparethe lid.’ So Dr. Conway drewthis little diagram and said,‘Make me this!”’

“Dr. Conway does this all thetime.” She notes, “if he dreamsup an instrument or wants amachine repaired.”

Henofer portrays Conway as akind of Renaissance man, burst-ing with inventive new ideas andscribbling diagrams for his col-leagues to follow. This particular

inventive idea saved the patient’seye, but not without some trialand error with the scleral shell.

After immobilizing thepatient’s eye with what are called“bridal sutures,” and getting herinto the huge contraption (a hel-met within a helmet) that com-prises part of the gamma knife,Drs. Conway and Steiner decidedthat the first scleral shell wasn’tthick enough. They had Hughesmake a second one in “a verybizarre shape,” according toHenofer. The second scleral shelllifted the patient’s eyelid out ofharm’s way, and the procedurewent out forward. After the one –day treatment, the patient’stumor receded over time (theexpected effect of the radiation),and her vision and health noware normal.

“I thought this was a blast –this creative collaboration, withConway drawing pictures,”Henofer says of the collectiveeffort to figure out how to makethe procedure work. “And I’lltell you,” she says, “that’s UVAfor you – every day you’ve gotsome magic thing going on.” ❑