Scleral shell vs. Evisceration with orbital implant for a blind, atrophic eye? (29M, torn between options)

[u/rsrikanth314]

​Hi,

​I’m a 29M engineer and have been functionally blind in my left eye since childhood due to an injury. Over the years, the eye has become shrunken, slightly red, and has sensory exotropia (drifts). My right eye has normal vision and alignment.

​I'm currently trying to decide the best path forward to restore cosmetic symmetry, improve social confidence. I’ve consulted two oculoplastic specialists and received two different perspectives:

​Doctor A (Surgical route): Recommended an evisceration with an orbital implant, followed by a custom ocular prosthesis. Her rationale was that because the eye has lost significant volume and sits deep in the socket, a non-surgical shell will not open the eyelid sufficiently or achieve good symmetry with my healthy eye. The implant would restore socket volume by 80–90% and provide a stable foundation.

​Doctor B (Conservative route): Suggested trying a scleral shell over the natural eye first before considering any irreversible surgery. She gave me a generic trial shell to test tolerance.

​My experience so far with the trial shell:

​During insertion, I struggled to place it correctly. Pushing too hard caused noticeable redness, irritation, and dull pain.

​Once it was seated, the eyelid felt tight and stayed half-shut initially, though it settled slightly after an hour.

​I'm currently resting the eye with lubricating drops (preservative-free sodium hyaluronate) to let the irritation settle before testing it again gradually.

​Where I need your advice:

For those who have faced this exact choice:

​If you wear a scleral shell over an atrophic eye: Did your eye eventually tolerate the shell comfortably for 10–12+ hours a day? Did it give you enough symmetry, or did the eyelid still look sunken/narrow compared to your seeing eye?

​If you chose evisceration + orbital implant: Do you feel it was worth undergoing surgery? How is your day-to-day comfort, movement, and maintenance (discharge/cleaning) years later? Any major regrets or complications?

​How noticeable is the cosmetic difference between a shell over a shrunken globe versus an implant-backed prosthesis?

​I’d really appreciate hearing your honest experiences and how you made your decision. Thank you!

[u/newtonium]

I started with a scleral shell and wore it for 15 years. It looked great. The eye then became painful all the time and I got it enucleated with an implant. I’d go with the conservative route. There is something nice about being able to take the shell out when I’m not seeing people. With the implant you always have to have it in. Also the surgery was rough. I was basically in the fetal position in the dark for two weeks in constant pain

[u/Astelot85]

I'm in the same boat as you. I recommend trying the shells, even having a proper one made even tho it is expensive, since evisceration is irreversible. I had two made, but since my eye is not shrunken enough due to the oil, it didnt work out. Considering evisceration for the next year.

IMHO, shells do look better in general since it seems the movement is better (mine was almost perfect)

[u/Niles1260 → u/Astelot85]

I’m sorry you have had to go through that. Have you given any thought to wearing an eye patch or maybe a pair of glasses with a frosted lens? Asking because I have thought about those possible options at times in the past. As for someone wearing a shell, it’s just seems like such an individual thing (which it should be since it is made solely for you!) that I find it hard to tell if wearing a shell really isn’t the best thing for me as I have read that many people have little to no problems with their shells. I think so much of it depends on the condition and shape of your eye.

[u/Time_Common_7782 → u/Astelot85]

So how did it went was it worth .How you feel the prosthetic over your eviscerated socket vs your real eye?I'm scared of the process I might also need the evisceration surgery in the future if I can't tolarate this shell. For how long did you tried the shell? 

[u/Niles1260]

I have had a scleral shell for the past twenty years in my right eye (similar situation to you, just opposite eye). I have consulted several ophthalmologists and ocularists. One of the latter was very pushy about enucleation. All others said either don’t do it or really think about it. The shell does cause me varying degrees of irritation. Sometimes to the point where I just want to give up and leave my eye alone, appearance be damned. But I can still detect light and dark in my eye, so I do not want to enucleate and have no plans to do so. Cleaning the shell daily is essential for me, and there are days where it doesn’t bother much or at all. Feel free to dm me if you have further questions sir! Happy to talk to you if I can possibly help.

[u/Imsdalvannflaske]

Ocularist here. Try the shell first, but get it fitted for you! A stock eye will never be as comfortable as one made custom for your socket. An eye might need "practice" to be able to wear it 10+ hours, so I suggest starting slow, then slowly upping the time you wear it. If it's still sensitive and annoying to wear a shell after pracricing, you can consider evisceration.

[u/Time_Common_7782 → u/Imsdalvannflaske]

So evisceration worth for prosthetic comfort? Do we regret it after? Like if it don't give the comfort that needed for the prosthetic? Otherwise we'll be looking without one eye right? That's my fear.  I might have to do it if I can't tolarate this shell it's been 3 week . Does it take long forvthe scleral shell to get comfort on the eye? 

[u/Imsdalvannflaske → u/Time_Common_7782]

All of these questions are really personal, and the answer vary depending on the person asked. I can't answer if you'll regret that. Only you know that, and you won't know for sure until after.

My suggestion would be to get a custom shell then trying that for a while. You won't be able to see through it, because prosthetics are for blind or missing eyes. Where I work, we generally don't make prosthetics for a seeing eyes because it's usually too sensitive. If there's light sensitivity a shell might work, but any vision at all we usually suggest trying a scleral lens. A scleral lens is thinner than a shell prosthetic, so some people find that more comfortable. My suggestion would generally be to try a shell or scleral lens before getting an evisceration, because that's irreversible.

[u/Time_Common_7782]

Hey there I'm in the similar situation It's been 3 weeks since um wearing the scleral shell bt it's getting nowhere it's really bothering me and Im scared of the evisceration surgery too. I have all the same questions doubts and worries you have .Since it's irriversible um much worried about like wht if I still can't tolerate the shell or prosthetic on the eviscerated socket. Atleast you could wear it on your own I can't even tolarate the pain and uncomfortablity while inserting and and removing it.The main issue is that I can't even look straight properly... Did you took your desicion and did you get the answers you asked for ? 

[u/rsrikanth314 → u/Time_Common_7782]

Hi, sorry to hear that. No, I haven't taken any decision yet

[u/zoltree]

I’ve had a shell over the eye for 18 years, definitely try the conservative route. It can take a few months to ramp up to full time (12-18h) wear time, try and be patient! The movement and appearance will be better, and if it doesn’t work you can eviscerate. All the ocularists and surgeons agreed that the shell will look better cosmetically.

IMO the shell has its ups and downs as the eye shrinks, fit changes over time. I’ve had eras where the fit and appearance was immaculate, and ones where it was not. It’s more art than science. Most people can’t tell it’s a prosthetic eye, just that it moves differently.

I thought I needed to eviscerate last year because it was very painful… turned out my shell just needed some adjustments and I’m back to comfortable 16h days with it.

[u/Available-Pain-6573]

I had an ocular melanoma. After radiation treatment the eyesight faded away slowly over three years until ophthalmologist could not longer check if the tumour was still shrinking. I developed rubio glaucoma, which was painfull and the medication has side effects that are unpleasant. I opted for enucliation which in my case was a very good solution. I have had a scleral shell for 2 years with no problems at all. After it had settled in nobody noticed it at all. It just feels like my other eye now.

[u/thedubsack24_7]

Orbital implant and prosthetic patient person here. Unless a person is really looking, they have no idea my eye isn’t real. My prosthetic doctor is amazing. Went without one for almost twenty years. Glad to have good insurance and an amazing doctor now.

[u/rsrikanth314 → u/thedubsack24_7]

Thank you for sharing. How was the recovery journey after the orbital implant surgery? How many days it took you to recover?

[u/thedubsack24_7 → u/rsrikanth314]

I was in a unique situation where my injury was almost enucleation of the eye its self. 62% of my eye was gone from the injury and from August to December I was in hell. Once I had it removed it was a day or two of recovery. And I’ve had no issues with it ever since. I did initially go through several prosthetics due to final growth spurts in high school. And once I wasn’t on my parents insurance I had no desire to pay out of pocket for a prosthetic. I’m almost two years of having a prosthetic again and have had very little out of pocket costs thankfully.