Not yet 1, cancer survivor receives an artificial eye

With his remaining eye, Tyler Sanzone could see everything just fine: Cheerios, toys, bunnies in his backyard in Old Bridge, N.J., people who made him smile.

Almost everyone, including white-coated doctors, got a smile from the 11-month-old.

So at a doctor's visit last week, his parents, Emily and Mike, and his grandmother, Diana Gabardi, were happy. Tyler was free of retinoblastoma, the rare eye cancer that had cost him his right eye. And he was about to get an "ocular prosthesis" - an artificial eye.

To be sure, it wasn't quite the outcome that they and Tyler's doctors at Wills Eye Institute had hoped for.

In March, when the classic sign of retinoblastoma, cloudiness in the eye, led to his diagnosis, they hoped cutting-edge treatment would salvage the globe, possibly even with some vision.

Tyler underwent the treatment, three monthly infusions of chemotherapy directly into the eye's blood vessels. Although it killed the grape-sized tumor, destroying such a large malignancy also ruined the vital blood supply that the eye shared with the cancer. The eyeball literally shriveled, a condition called phthisis bulbi.

In August, the eye was removed by Carol Shields, the renowned ocular oncologist who directed Tyler's care at Wills in Center City. She placed an "orbital implant" in the socket, then attached the eye muscles to it.

The implant would serve as a foundation for the artificial eye, a round cap that forms the visible part of the replacement eye.

"I know this has been wrenching to your hearts, but you've done well," Shields told the family after examining the baby Tuesday. "Tyler has healed beautifully."

On the verge of walking, he had no apparent problem with his lack of stereo vision. Nor did he seem aware that his right upper eyelid drooped because of the hollow behind it, giving him a lopsided squint like Popeye or the late actor Peter Falk (who was also a retinoblastoma survivor).

By day's end, that Columbo squint would be gone. Eight blocks from Wills, Susan Frost Shore of LeGrand Associates Ocularists was set to fashion and fit Tyler's new eye - right before his parents' eyes.

In 1953, when Joseph A. LeGrand Sr. founded his eye-making business, the field was in flux.

Surgical implants were improving, which made even mediocre prostheses move better. The glass eye, long a specialty of German glassblowers, was becoming obsolete, a result of the postwar advent of American prosthetics made with acrylic plastic.

But "ocularistry" had not become a recognized profession, said one LeGrand colleague - his son Joseph Jr.

"There was little in the way of education and training," LeGrand Jr. wrote in a 2006 journal article on his father's career. "Many patients had only stock [ready-made] prosthetic eyes available to them. Often these eyes left much to be desired in terms of fit and appearance."

LeGrand Sr. and a Philadelphia competitor, John Kelley, were among those who changed the status quo. (Kelley, too, had a son who has carried on the business.)

Today, there are still no schools that teach ocularistry. But the American Society of Ocularists, founded in 1957, has a rigorous training and certification program that requires a five-year, 10,000-hour apprenticeship.

The elder LeGrand, who became interested in artificial eyes after a high school basketball injury cost him an eye, was known for mentoring apprentices, and for innovations.

"That's the legacy," a West Virginia colleague wrote in that 2006 article. "Joe LeGrand Sr. developed a method to make a . . . fitted plastic ocular prosthesis in 31/2 to 4 hours."

Today, the method is much the same. A wax impression of the eye socket is used to make a plaster mold. The white part of the eye, or sclera, the colored iris, and the black pupil are embedded in the mold, which is covered with a layer of clear plastic. The plastic is cured in a steam bath, then polished to a smooth luster.

It is part technology, part art.

Tyler did not like one of LeGrand Sr.'s biggest innovations: a fast way to take an accurate impression of the inside of the eye socket.

LeGrand calculated the size and shape of the average prosthesis, then made a wax version. This generic wax prosthesis, which looks like a little tortoise shell, is tried in the socket, then removed and customized by carving the edges or adding wax to build up certain spots.

With each try, the patient finds the fit more comfortable.

Unless the patient is a baby.

"Hold him tight," Shore told Mike and Emily as she put the wax model into the socket of their terrified son.

Shore, a 1978 graduate of Temple University's Tyler School of Art, was a textile designer and geriatric art therapist before her apprenticeship at LeGrand Associates beginning in 1984.

"I thought it would be a good way to use art to help people," she said.

Gradually, babies became her specialty. Because their eye sockets are growing, she sees them every six months, enlarging their prostheses as needed. After two or three such adjustments, a new $2,700 device must be made to ensure a good fit.

"The younger they are, the more often they need a replacement," she said, estimating that Tyler might need a new one in about two years.

While having wax stuck in his eye was the most unpleasant part of the day for Tyler, the subsequent painting of the prosthetic iris and sclera was the most exhausting.

The iris is painted on a curved plastic lens to which a black dot, the simulated pupil, is attached. To make sure the right and left eyes match, Shore had to constantly compare her work-in-progress with the real thing.

"Ty! Look here! Look up here!" his father called, waving a musical toy.

Tyler, sitting on Emily's lap, lifted his gaze, giving Shore the moment she needed to hold the fake iris next to his eye.

Then Shore dipped a fine-tipped brush into pots of acrylic paint, mixed spots of color on a glass palette, and added to the iris. Layer after layer. Brown and gray. Hints of yellow, red, even blue. Subtle striations that only her trained eyes could see were missing.

"We're getting there, folks," Shore said after more than an hour.

Tyler, up since 6 a.m. without a nap, laid his head on his mother's shoulder and closed his non-droopy lid.

"Ty! Ty! Look at the teddy bear," his grandmother called as Shore checked the blue hue she had just added to the sclera.

By 1:30, the eye was ready.

Shore slipped it in Tyler's socket. He protested, but only until it was in place.

Suddenly, it was as if he had never been a cancer patient, never lost a precious organ. He was simply a cherub-cheeked tot with soft curls and two big brown peepers.

"The eye moves so naturally," Emily said.

"You can't even tell the difference," Mike marveled.

Shore gave them a sheet of instructions and little suction cups in case they needed to remove the prosthesis.

"It could accidentally come out," she said. "That would be unusual, but if it does, just wash it with regular soap and water."

After a round of hugs, the family packed up the toys, sippy cup, diapers, and other necessities of babyhood.

Tyler, sizing up the situation, saw what he should do.

He waved goodbye.