A closer look at the work of Vancouver’s ocularists
“Oh, this one’s close enough.”
Scary words to hear from a medial practitioner in any circumstance, but especially when it comes to fitting an artificial eye. Believe it or not, this was common practice, up until the mid-20th century when optometrists began making referrals to ocularists, rather than a drawer full of samples in their office.
Still not a booming industry by any means, Canada is now home to a small-but-mighty contingent of full-time ocularists. And, with an old-school heredity befitting of butchers, bakers and candlestick makers, many of them happen to be second or third-generation. In British Columbia, for example, there are only two families that do this type of work: the Ericksons and the Drennans, and both clans will attest that they didn’t learn the trade overnight. Learning to create custom ocular prostheses takes years of study, practice and apprenticeship, blending one’s artistic talents with a passion for anatomy, invention and, above all, helping others.
Simply put, there’s far more to this profession than meets the eye.
In an age where there’s a university program for just about everything, one might be surprised to learn that no such thing exists for ocularistry. “There’s no university that teaches how to make artificial eyes,” explained Rob Drennan, a Burnaby-based ocularist. “It’s not like you can go to BCIT or UBC because they don’t offer anything like that. It’s been handed down through generations.”
Drennan learned the trade from his wife, Marie Allen, who picked it up from her father. “He was a maxillofacial prosthetist with the BC Cancer Agency — he used to make eyes, ears, noses, fingers, toes, the whole bit,” said Drennan.
Despite her father’s warnings about the lack of demand at the time, Allen forged ahead with her training, studying at SFU and Oxford. After returning home to apprentice at the BC Cancer Agency, she became a board certified ocularist in the mid-80s.
“Sure enough, there were a couple of people who used to do it but retired and Marie got busy enough to make a go of it,” said Drennan. “It wasn’t until after we were married that I learned to do it as well.”
Recently, their daughter has joined the practice, spending one day a week at Allen’s office in Vancouver and another at Drennan’s in Burnaby. “She’s just starting so it’s going to take her at least another six years to get certified,” said Drennan.
For budding ocularists, the certification process is rigorous and expensive. Doing so involves a combination of one-on-one apprenticeship, courses, presentations and examinations conducted through the American Society of Ocularists (ASO) and the National Examining Board of Ocularists (NEBO). The ASO’s past president, Leif Erickson, happens to operate the other practice in town, and he too is passing his skills onto his children.
“If you have someone you’re apprenticing under, it is a 10,000-hour apprenticeship,” Erickson explained. “The whole concept of apprenticeship works very well for this particular type of work because so much of it is hands-on; it’s a matter of being able to actually do the work.”
Stanford University once tried its hand at training ocularists in a classroom setting, but soon realized there was no substitute for practical know-how.
“What they discovered was when people came out of the program they didn’t have enough hands-on experience to really do the work and they ended up still having to apprentice,” said Erickson. “And that was Stanford — they’re an Ivy League school and it still didn’t work. The program fell apart fairly rapidly after that.”
Erickson received his training in the United States, before heading north to set up shop in Vancouver.
“I learned from my dad and my uncle and my cousin. My dad was in Spokane, my uncle and cousin were in Seattle,” he said. “When we moved up here from Seattle in 1985 my younger son was three and the older one was five, almost six — and here they are working with me now, they’re 35 and 37.”
All, including matriarch Donna, are Capilano College alumni, having taken courses in sciences, math, bookkeeping, music and various other subjects over the years. The youngest son, Stacey, fell into the family business almost by accident in 2006, after briefly filling in for his older brother, Lars. This month, he is celebrating the final stages of his NEBO certification.
“There are a lot of medical areas where family members will indeed follow,” said Erickson. “I’m surrounded here in Vancouver. I’m over by VGH, we have a ton of opthamologists here and it’s fascinating to me how many of them have indeed been grandparent to parent to child even within opthamology … I think the parents are steeped in it at home which is what leads [the kids] to becoming doctors as well.”
Even still, there are fewer than 40 ocularists working in Canada, including apprentices.
“Essentially, a little more than one per million right now,” said Erickson. “That would hold pretty much true for the States. I think the States is actually lower than we are percentage-wise. If we had many more than where we are now we’d all need second job. It’s not a huge demand. We’re looking at about maybe one in 1,000 that needs a prosthesis.”
The exact origin of artificial eyes is widely disputed, but their first creation is typically attributed to priests in Rome and Egypt who fashioned external devices from bits of cloth and clay. “In terms of the internal ones I think you would have been looking probably at the Renaissance era where they were doing solid glass,” said Erickson. The method was first perfected in Venice, then Paris and later Germany.
Germany continued to be the leader in artificial eyes up until the Second World War, offering a blown glass variety that remains available today. A type of acrylic, known as polymethyl methacrylate (PMMA), has since become the industry standard in North America and much of the world, after being discovered somewhat by accident.
“They had been using acrylic as a dome material on the fighters and the bombers and they found that there were airman who had gotten injured where a piece of one of those domes would have been embedded in the body, like plastic shrapnel,” said Erickson, “And what they found was that the tissues around that were quiet. I mean, they did indeed take the plastic out, but the fact that the body would tolerate that really got somebody thinking, ‘You know, we could use this plastic as an implant material as well as using it for artificial eyes’ because the tissues in the body would accept it quite nicely.”
Though their methodology varies slightly, Erickson and Drennan both use PMMA for their ocular prostheses. “They’re more durable, they’re not going to break,” explained Drennan. “You know, you drop them and they’re not going to pop, and they’re not going to implode in a socket.”
“I had a patient many years ago who had a glass eye that exploded while he was wearing it,” recalled Erickson, explaining that the acidity in the man’s tears had gradually etched away at the back side of his prosthesis – its weakest point – until a crack had formed. Fluid entered, then putrefied and released gases, which reversed the vacuum effect that is a natural by-product of the glass-blowing process.
“Then you go from, in this case, a warm farmhouse where this guy was living, into a blizzard. He went out to check on the animals in the barn and he took about three or four steps outside and he heard this thing go pop.”
Snowed in, home alone and 15 miles from the nearest town, the man had to extract the shattered pieces himself and vowed that day to make the switch to acrylic. Erickson keeps the remnants of this eye in a plastic container at his office, shaking them at anyone who thinks they might like to try glass for a change.
Drennan and Erickson deal with two main types of prosthesis: one that is conventional-shaped and would fit into the socket of someone who has had their eye removed, and another called a scleral shell, which is designed to cover an unsightly or damaged eye, similar to a giant contact lens. In both cases, impressions are taken, the iris is painted by hand and great care is taken to provide optimal realism and movement.
In most cases, before the patient has even arrived in the ocularist’s office, an occuloplastic surgeon has already embedded an orbital implant within the muscle cone of their eye socket, giving something to attach the prosthesis to, and a greater potential for motility.
“At the same time that we’re doing the impression usually we’re painting the iris,” said Erickson. “It’s just like sitting for a portrait. We paint the iris and we’ll get it up to being finished other than needing to be capped with acrylic. That would all be in the first session.”
After the impression has been cast, a model is made from wax or acrylic, depending on the ocularist. “If its acrylic then that would become the base for the finished prosthesis and that’s the direction that we tend to go,” said Erickson. Others, like Drennan, use a wax pattern to start, and would then create a mold and cast it in acrylic before the next session.
Scleral shells require an extra step, where a clear shape is produced to offer a view of the cornea or remaining tissues and any clearances that must be made. After the ocularist and patient are satisfied with the fit, an opaque white version is produced and the iris is positioned.
“Then we would grind back the sides of that shape to allow for the veining to be done, the scleral tinting and then we would have the patient come back in and sit for that too so we make sure to match them as precisely as we can,” said Erickson. “Then we add a layer of clear plastic over top to seal everything in and then polish it up and try it back on them. Usually, with a few modifications, we’re done.”
In most cases, an artificial eye can be created within two to three days, with regular follow-up appointments over the ensuing months to check the fit. “We routinely see people every six months to have it polished, because they do indeed scratch, and then we’re looking at approximately three to five years for replacement,” said Erickson.
The cost of an ocular prosthesis can vary greatly according to one’s location. “Right now in Vancouver you’d be looking at about $2,500 and there’s no tax because it’s a medical appliance,” said Drennan. “In the States I know some ocularists who are billing $5,600 American for them, so they vary. It depends on where you live.”
Ocular prostheses are typically subsidized by medical coverage, according to one’s income, or paid for by insurance, depending on how the eye was lost. “If it was an ICBC case and they had insurance then ICBC covers it. If it’s Worker’s Compensation Board then they would cover it,” said Drennan, “But they’re not going to give you a new eye every year. It’s going to be every five years or so.”
People end up in an ocularist’s office for all sorts of reasons. “I’m seeing anyone from children a couple months old right up to people who are 100 years old,” said Drennan. “It’s a cross section – trauma to the eye, sports injuries, motor vehicle accidents, cancer, children born with anopthalmia (no eyes), microphthalmia (abnormally small eyes). I’ve had knife fights and things like that, beer bottles, grenades, a car hitting a moose crossing the road – we see everything.”
Although they’re largely competing for the same share of the BC-Yukon market, Drennan and Erickson consider each other to be good friends. ‘We have a wonderful relationship,” said Drennan. “We know each other through the Canadian Society of Ocularists, the American Society of Ocularists, and we’ve got that respect for each other.”
At the end of the day, it’s not about who keeps the busiest office, but rather about restoring the self-confidence of each person who comes through the door, allowing them to live their life to the fullest.
“You’re dealing with people who have lost something very dear to themselves,” said Drennan. “Try to replace an eye — you can make it look pretty nice but it’s never going to see, right? But if they can go out into the public without getting that second look… Our work is the best when no one notices.”
With normal use, a client is likely to go through several ocular prostheses in their lifetime. “Gravity takes its effect, sometimes the implant shifts in the socket after a while, and with kids you’re seeing little children and then they’re growing up to be adults,” said Drennan. “I start with them, they’re in my arms really as babies and then all of the sudden they’ve graduated and they’re taller than me, you know?”
Many ocularists develop close bonds with their clients, due to the fact that they spend so many hours with them over the course of a career.
“It’s not like going to a doctor’s appointment where you’re in and out and you’re chatting for 10 minutes before the next patient,” said Drennan. “These guys are sitting with me for hours. You get to know each other and you start to know what they do for a living, their whole character and everything else. That part of the job is pretty cool.”
Erickson agrees. “With many patients, I’ve worked with them so long that we consider each other friends. That, to me, is the real reward. I just love sitting around and talking with patients while we’re doing the work. You learn their story, they learn yours, there’s a lot of sharing that goes on. When all the other parts of this job become a bit stale, it’s the people who keep you going.”
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