A scleral shell is a very thin, custom-made artificial cover that sits over a small, shrunken, or scarred eye to restore a natural look. It is different from a full artificial eye used when the eye has been removed; a shell goes over an existing eye and covers the white part and the colored part so the two eyes look alike. This type of prosthesis is fit and shaped by an ocularist to match the other eye and the person’s face. EyeWikiocularpro.com
Mal-positioning means the shell does not sit where it should. It may sit too high or too low, lean or tilt, rotate so the painted iris is off-center, push forward too much, or sink backward. Even a small mismatch can make the eye look “off,” feel uncomfortable, or irritate the eyelids and the inner pink lining (the conjunctiva). Proper fitting matters because the lids, socket, and (if present) the underlying implant have to work together to hold the device in the right spot and allow comfortable blinking. Clinical evaluation of anophthalmic sockets emphasizes checking symmetry, eyelid laxity, prosthesis position, and sulcus fullness because these features strongly influence comfort and appearance. Review of OphthalmologyNCBI
After eye removal (or when an eye is small and scarred), the socket (the tissues and space behind the lids) must be healthy, moist, and roomy enough to support a prosthesis. When the socket shrinks, scars, or loses volume, the shell or prosthesis can shift. People can develop a “post-enucleation socket syndrome” (deep upper-eyelid hollow, drooping or retracted lids, and a sunken look) that changes how a shell sits and moves. These socket changes are a common underlying reason for mal-position. United Hospitals Sussex
A scleral shell is a thin, custom-made artificial “cover” that sits over a blind, shrunken eye or an orbital implant after eye removal. It restores appearance and helps the eyelids keep their natural shape. Mal-positioning means the shell is not sitting in the right place or not fitting the socket and eyelids properly. When that happens, the shell may tilt, rotate, fall forward, sit too deep, or constantly rub the inner eyelids. This can cause discharge, redness, pain, droopy lids, or the shell popping out. In some people, repeated rubbing and inflammation can lead to socket contraction (the inner eyelid “pocket” becomes shorter and tighter), which makes it even harder to hold the shell. The core goals of care are very practical: restore a steady, comfortable fit, protect the delicate inner eyelid lining, keep the socket moist and clean, and make the eyelids look and function normally again. EyeWikiNCBI
Types of scleral shell mal-positioning
1) Vertical decentration (too high or too low).
The pupil on the shell sits higher or lower than the other eye. This can happen when the shell’s shape or volume does not match the eyelid opening, or when the upper lid is droopy or the lower lid is loose. The result is an uneven gaze and frequent “slippage” during blinking.
2) Horizontal decentration (too nasal or too temporal).
The iris is shifted inward toward the nose or outward toward the temple. This can reflect eyelid shape, canthal tendon laxity, or how the shell’s edges engage the lids.
3) Antero-posterior misplacement (too prominent or too sunken).
If the shell is too bulky or the socket is tight, it can stick out (prominence); if the socket has lost volume or the shell is too flat, it can sit too far back (enophthalmos), creating a hollowed look and reducing lid contact.
4) Tilt (top–bottom or side-to-side).
A lean or tilt makes reflections and eyelid drape look asymmetric. Tilting often indicates edge impingement in one quadrant or shallow fornices (the “pockets” under the lids).
5) Rotation (cyclorotation).
The shell slowly rotates, so the painted iris is no longer level. This is common when retention is weak (poor suction/contour), the surface is too smooth for the lids to “grip,” or the eyelids are lax. Rotational mal-position is visually very noticeable.
6) Edge impingement (digging in).
A sharp or long edge presses into the caruncle, plica, or fornix, causing soreness, redness, and discharge. Patients often report “a sore spot” or feel the shell “catches” when they blink.
7) Edge flare (lifting off).
The edge lifts from the conjunctiva. A lifted edge traps mucus and air, reducing retention and encouraging rotation.
8) Poor superior sulcus support.
A hollow above the upper lid crease (superior sulcus defect) makes the shell look sunken even when centered. This is more about volume than shape.
9) Dynamic mal-position with blink.
The shell appears centered at rest but shifts or rotates during blinking because the upper lid pushes unevenly.
10) Pupil size or centration mismatch (cosmetic mal-position).
The shell’s painted iris size/position does not match the other eye, so even a well-fit shell looks off-center.
11) Mal-position from implant issues (under a prosthesis, not a shell).
If a prior orbital implant has migrated or is exposed, it can distort the overlying tissue contour and nudge a shell into the wrong place. Cross-checking implant position is part of the evaluation. PMCWiley Online Library
12) Mal-position from contracted socket or short fornices.
Scarring shortens the inner eyelid pockets so the shell cannot sit deep and stable; it rides up, tilts, or pops out. EyeWiki
Causes
1) Inaccurate impression or contouring of the socket.
A shell starts with a mold of the socket. If the impression misses key curves and pockets, the final shape will not “lock in.” Poor contouring reduces retention and encourages rotation. PMC+1
2) Using a stock or poorly customized device.
Mass-produced devices do not match individual anatomy, so they are more likely to decenter, tilt, or rotate. Custom shells made by trained ocularists are designed to avoid these issues. American Society of Ocularists
3) Lower-lid laxity.
A loose lower lid (common with age or previous surgery) gives weak support. The shell sags or tips because the “shelf” is soft. Clinical checks specifically look for this. Review of Ophthalmology
4) Upper-lid droop (ptosis) or retraction.
A droopy lid pushes the shell down; a retracted lid lets it sit too high. Socket syndromes after surgery can worsen this imbalance. United Hospitals Sussex
5) Contracted socket or scarred fornices.
Scarring shrinks the deep pockets under the lids. Without depth, edges impinge or flare and the device cannot center. EyeWiki
6) Volume loss (superior sulcus hollow, enophthalmos).
When orbital tissue volume is low, the shell sits back and looks sunken; the upper eyelid crease looks hollow, making centering hard. United Hospitals Sussex
7) Implant problems under the surface.
If there is an orbital implant (common after removal surgery) that has shifted, is too small, or is exposed, the external fit becomes unstable. Imaging and clinical exam look for this because it changes prosthesis position and motility. Wiley Online Library
8) Edge design problems (too thin, sharp, or long).
A sharp edge digs in; a long edge binds in the corners; a thin, lifted edge flares. All cause sore spots and movement.
9) Excess shell thickness or weight.
A bulky shell may sit forward, irritate the lids, and get pushed off-center with each blink.
10) Shell too small or under-filled.
If the shell is too small, it cannot “grab” the fornices and will rotate or decenter easily.
11) Dry, inflamed socket surface.
Dryness (blepharoconjunctivitis sicca) and chronic inflammation increase mucus, reduce lubrication, and weaken adhesion between shell and tissue, so the shell wanders. ScienceDirect
12) Giant papillary conjunctivitis (GPC).
Bumpy, irritated inner eyelid lining from mechanical rubbing or deposits makes retention worse; blinking pushes the shell around and increases discharge. AAO
13) Mucus buildup and biofilm on the shell.
Excess discharge and surface deposits act like “grit,” breaking suction and promoting rotation. Regular cleaning and surface polish matter to reduce discharge. PMC
14) Infection of the socket or eyelids.
Infection increases pain, swelling, and mucus, and people often cannot keep the shell centered while inflamed. Southeastern Ocularists Inc.
15) Allergic reactions or material sensitivity.
Rarely, a person can react to polishing compounds or materials; the inflamed tissue becomes slippery or tender, and fit suffers.
16) Incorrect iris placement or size during fabrication.
If the painted iris is off from the start, the shell looks decentered even if the body is well-fit. Minor position errors become obvious in photos and in mirrors.
17) Faulty insertion technique at home.
If someone inserts the shell at a slight angle or does not seat the lower edge fully, it can sit tilted all day. Many clinics teach step-by-step insertion and removal to reduce this. HealthPartners
18) Eyelid or canthal tendon looseness.
Laxity at the outer corner (lateral canthus) lets the shell drift temporally with time; distraction tests help detect this. Review of Ophthalmology
19) Post-traumatic or radiation scarring.
Past injuries and radiation can change skin and inner lining elasticity, pulling the shell off-center as scarring matures.
20) Underlying implant vascularization or migration issues.
With certain porous implants, poor tissue ingrowth or migration alters the contour that the shell must cover; nuclear medicine or MRI sometimes helps evaluate this and guide correction. Nature
Common symptoms
1) “It doesn’t look centered.”
People usually notice the iris is too high, too low, or rotated. Friends may comment that “the eyes don’t look level,” and photos amplify the mismatch.
2) Foreign-body feeling or scratchiness.
A sharp or lifted edge rubs the inner lid. The sensation often worsens late in the day or after wind exposure.
3) Redness of the inner lids or socket.
Mechanical rubbing and dryness inflame the lining; the eye looks redder, especially after blinking or removing the shell.
4) Mucus and stringy discharge.
Discharge increases when the shell moves because the surface is irritated. People describe wiping the corner of the eye often. Mucoid discharge is common in prosthesis wearers, and it spikes with poor fit or GPC. PMC
5) Tearing (watery eye).
Reflex tearing tries to wash away the irritation; tears may spill over the lower lid.
6) Soreness or pressure pain.
An impinging edge or thick shell causes a dull ache. Pain that rapidly worsens, especially with swelling, raises concern for infection.
7) Burning or dryness.
A dry surface reduces lubrication; the shell feels “sticky” when blinking, then slips.
8) Frequent rotation.
People notice the iris “drifts” over hours and must be manually realigned in a mirror.
9) Difficulty keeping the shell in place.
The shell may “pop” forward with a sneeze or strong blink if the fornices are short or the edge flares.
10) Lid changes (droop or retraction).
A droopy lid can worsen decentration; a tight upper lid can push the shell lower.
11) Clicking sounds while blinking.
A lifted edge can click against the lid margin.
12) Skin irritation at the corners.
Mucus and rubbing can make the outer or inner corners sore and chapped.
13) Bad odor from the device.
Biofilm and retained secretions on the shell surface can smell, pointing to cleaning or polishing problems.
14) Recurrent “pink eye” episodes.
Repeat redness that gets better when the shell is out but returns when it’s in suggests mechanical or allergic irritation.
15) Headache or facial tiredness.
Constant squinting or unequal lid work can cause fatigue around the brows and temples.
Diagnostic tests
A) Physical examination (what the clinician sees and measures)
1) Face and primary-gaze symmetry check.
The clinician looks straight on to judge if the shell’s iris aligns with the other eye, if the white shows evenly above and below, and if the reflections match. Small shifts become obvious in good light and photos.
2) Eyelid position measurements (MRD1/MRD2).
These are simple ruler measurements from the pupil center to the lid edges. They tell if the upper lid droops or the lower lid sags, both of which change where the shell sits. This is part of standard socket evaluation. Review of Ophthalmology
3) Blink dynamics and lagophthalmos.
The examiner watches you blink to see if the lids close fully or if there is a gap. Incomplete closure dries and destabilizes the shell.
4) Slit-lamp inspection of the conjunctiva and lid undersurface.
A microscope light shows redness, papillae (bumps), or sore spots where the edge rubs. This helps diagnose GPC and edge impingement. AAO
5) Fornix depth and superior sulcus check.
A cotton tip gently lifts the lids to see how deep the pockets are and whether the upper hollow is too deep—signs of volume loss or scarring that promote mal-position. United Hospitals Sussex
6) Exophthalmometry / orbital fullness assessment.
A Hertel exophthalmometer or comparative palpation shows how far forward the shell sits versus the other eye and whether the orbit looks empty (enophthalmos). Prosthesis assessments commonly include this. PMC
B) Manual tests (hands-on checks in clinic)
7) Retention/suction “pull test.”
With clean gloves and a small suction cup, the clinician gently tests how easily the shell dislodges. Easy removal suggests weak contour “lock” or a lifted edge.
8) Rotation resistance test.
The shell is gently turned a few degrees to see if it snaps back or keeps turning. Free rotation implies poor fit or too smooth a surface for lid traction.
9) Edge sweep test with a moistened cotton tip.
The clinician traces the edge under each lid. Pain or blanching means the edge is digging in; a visible gap means the edge is flaring.
10) Lower-lid snap-back and distraction tests.
The lower lid is pulled down and released. Slow return or large pull-away distance means laxity, a frequent reason shells drop or tilt. Review of Ophthalmology
11) Canthal tendon evaluation.
Gentle outward traction at the eye’s corner checks tendon tone; laxity lets shells drift temporally and contributes to mal-position.
12) Trial conformer or impression trial.
A clear conformer or fresh impression material is briefly placed to simulate a new contour. If centering improves with a different shape, the problem is the current shell’s geometry. Proper impression landmarks (canthi, tarsal plate relations, folds) are important to get this right. PMC
C) Lab and pathological tests (used when inflammation or allergy is suspected)
13) Conjunctival swab for culture and sensitivity.
If there is heavy discharge, a swab checks for bacteria or yeast so treatment can be targeted. Infection often worsens fit temporarily. Southeastern Ocularists Inc.
14) Impression cytology of the tarsal conjunctiva.
A small filter paper gently touches the inner eyelid to collect cells. Microscopy can confirm allergic-type bumps or chronic surface changes seen with GPC or dryness.
15) Patch testing for contact allergy.
Dermatology-style patch tests can look for reactions to prosthetic materials or polishes when redness and itching persist after cleaning and fit changes.
D) Electrodiagnostic tests (rare, but helpful in select cases)
16) Surface EMG of orbicularis oculi (eyelid muscle).
If blinking is unusually forceful or spasmodic (blepharospasm), EMG helps confirm it. Excess squeeze can rotate or tilt a shell with each blink.
17) Blink reflex / facial nerve conduction studies.
If the lids close weakly due to nerve issues, tests can document the problem and guide whether lid-tightening surgery would stabilize the shell. These are uncommon but clarifying in complex cases.
E) Imaging tests (to understand deep structure and volume)
18) CT or MRI of the orbits.
Cross-sectional imaging shows implant position, migration, exposure, and overall orbital volume—key background causes of mal-position, especially after prior surgeries. MRI is especially informative with porous implants. Nature
19) Nuclear medicine scan (Technetium-99m MDP) for porous implants.
This test checks vascularization and health of certain implant materials (like hydroxyapatite). Poor ingrowth or implant trouble can change the external contour and destabilize the shell. Nature
20) Standardized slit-lamp photography and short video.
High-quality photos and slow-motion blink videos document decentration, tilt, and rotation in different gazes. They are invaluable for comparing before-and-after changes following refitting or eyelid procedures.
Non-pharmacological treatments (therapies & practical measures)
Each item explains what it is, why it’s done (purpose), and how it helps (mechanism)—in very simple terms.
Professional refitting by an ocularist
Purpose: Get the shell to match your socket and lids again.
Mechanism: The ocularist reshapes, relines, or remakes the shell so it sits evenly, spreads pressure gently, and stops rubbing hot spots. This is the single most important step when position is off.Regular professional polishing
Purpose: Make the surface smooth so it glides under the lids.
Mechanism: Polishing removes protein/mineral film that makes the shell rough and irritating; most clinics advise polishing about every 6 months (your schedule may vary). A smoother shell = less discharge, better comfort, better position. Memorial Sloan Kettering Cancer Centerocularpro.comSurface relining / posterior contour adjustment
Purpose: Improve “lock-in” and prevent rocking or tilting.
Mechanism: The back of the shell is modified so it hugs the socket evenly and fills dead space, reducing wobble.Edge softening and flange tweaks
Purpose: Stop lid notching or poking.
Mechanism: The ocularist rounds high edges and adjusts flanges (the rim) so the lids close smoothly over the shell.Temporary conformer therapy
Purpose: Gently reshape and maintain the eyelid fornices (the inner folds).
Mechanism: A clear “spacer” sits in the socket day and night to keep the pocket open if it started to shrink, helping the next shell fit more stably.Wear-time and handling changes
Purpose: Lower mechanical irritation.
Mechanism: Short, planned breaks; avoiding unnecessary removal; and careful insertion technique reduce rubbing and inflammation that can lead to discharge and malposition.Hygiene and cleaning routine
Purpose: Cut down mucus, odor, and infection risk.
Mechanism: Clean hands; rinse the shell with approved solution; avoid harsh chemicals; gently clean lids/lashes. A clean interface reduces friction and improves position reliability.Preservative-free lubrication during the day
Purpose: Keep the shell moving smoothly.
Mechanism: Non-medicated, preservative-free artificial tear gels/drops decrease friction between shell and conjunctiva so the shell stays centered more easily.Night-time bland ointment (non-medicated)
Purpose: Moisturize and protect when lids are closed.
Mechanism: A thin ribbon of sterile lubricating ointment reduces overnight dryness that can tighten tissues and worsen morning malposition.Allergy control in the environment
Purpose: Reduce eyelid inflammation that loosens the fit.
Mechanism: Limiting dust, smoke, pet dander, and strong winds reduces swelling and mucus that push the shell off-track.Warm compresses & lid massage (if meibomian glands are clogged)
Purpose: Improve the eyelid oil layer and comfort.
Mechanism: Heat and gentle massage melt thick oils, improving the tear film and cutting friction under the shell.Eyelid margin care (blepharitis control)
Purpose: Keep lid edges healthy so they hold the shell.
Mechanism: Daily lid wipes/scrubs decrease crust and bacteria; healthier lids grip and guide the shell better.Temporary discontinuation or reduced wear during flares
Purpose: Let the inner eyelid lining calm down.
Mechanism: Pausing wear for several days can break the cycle of rubbing → inflammation → more rubbing, especially in giant papillary conjunctivitis (GPC) triggered by prostheses. Cleveland ClinicSwitching shell materials or finish
Purpose: Improve compatibility with your tissues.
Mechanism: Some patients tolerate a different acrylic finish or design better; a change can reduce mucus and slippage.Eyelid taping at night (short-term, supervised)
Purpose: Help lids close fully if there’s lagophthalmos.
Mechanism: Gentle medical tape supports full closure so the ocular surface doesn’t dry out and pull the shell off position.Protective eyewear outdoors
Purpose: Shield from wind, dust, and sun.
Mechanism: Reducing airborne irritants lowers inflammation and secretions that destabilize the shell.Humidifier use and hydration
Purpose: Keep the socket environment moist.
Mechanism: Moist air and adequate water intake reduce dryness, friction, and morning tightness.Behavioral cues for safe handling
Purpose: Prevent trauma and accidental “popping out.”
Mechanism: Sit near a soft surface during insertion/removal; avoid forceful rubbing; use a suction cup as trained.Scheduled ocularist + ophthalmologist reviews
Purpose: Catch fit problems early.
Mechanism: Routine checks can spot early socket contraction, implant migration, or eyelid laxity before malposition becomes chronic. PMCEducation about red-flags and one-eyed safety
Purpose: Protect the healthy eye and your overall health.
Mechanism: Knowing warning signs (pain, pus, fever, implant exposure) and using protective eyewear preserves function and avoids emergencies.
Drug treatments
Medicines don’t “fix” a mis-shaped socket or a mis-fitting shell. They treat the irritated surface, allergy, infection, or inflammation that often go along with mal-positioning. Always use prescription drops only under an eye doctor’s guidance.
Preservative-free artificial tears (PFAT)
Purpose/Mechanism: Replace moisture and reduce friction; thicker gel drops can cushion the shell.
How used: 4–8×/day (or as needed).
Common side effects: Temporary blur after thicker gels.Lubricating ointment (night)
Purpose/Mechanism: Forms a moist barrier overnight to prevent dry stickiness.
How used: A pea-sized ribbon at bedtime.
Side effects: Temporary morning blur; use sparingly.Antihistamine/mast-cell stabilizer drops (e.g., olopatadine, ketotifen)
Purpose/Mechanism: Calm allergic inflammation and itch that drive GPC-like irritation in prosthesis wearers.
How used: Once or twice daily depending on brand.
Side effects: Mild sting; rare dryness. Cleveland ClinicShort course, soft steroid drops (e.g., loteprednol)
Purpose/Mechanism: Powerful inflammation control during flares.
How used: Typically QID for several days, then taper as directed.
Side effects: Possible eye-pressure rise or infection risk if overused—must be monitored by your doctor.Topical calcineurin inhibitor for chronic surface inflammation (cyclosporine 0.05–0.1%)
Purpose/Mechanism: Long-term immune “calmer” that reduces surface inflammation and improves tear quality.
How used: Usually 1 drop BID; effects build over weeks.
Side effects: Temporary burning or stinging.LFA-1 antagonist (lifitegrast 5%)
Purpose/Mechanism: Blocks inflammatory binding on the eye’s surface to ease dryness and irritation.
How used: BID; benefit often felt after several weeks.
Side effects: Transient taste change, eye irritation in some.Antibiotic ointment for blepharitis/erosions (e.g., erythromycin or bacitracin at bedtime)
Purpose/Mechanism: Decreases bacterial load on lids; protects irritated areas.
How used: Thin ribbon on lid margins for 1–2 weeks.
Side effects: Ointment blur; allergy is uncommon.Topical azithromycin 1% (where available)
Purpose/Mechanism: Anti-inflammatory and antibacterial effect for meibomian gland dysfunction (MGD) that worsens friction.
How used: Short course per local guidance.
Side effects: Mild irritation.Oral doxycycline (e.g., 40–100 mg/day) for MGD/rosacea (adults only)
Purpose/Mechanism: Reduces lid inflammation and improves oil quality.
How used: Several weeks to months under supervision.
Side effects: Sun sensitivity, stomach upset; avoid in pregnancy/children.Analgesics for short-term discomfort (e.g., acetaminophen)
Purpose/Mechanism: Pain control while other measures take effect.
How used: As directed on label or by your doctor.
Side effects: Vary by medicine; do not exceed doses.
If you develop giant papillary conjunctivitis related to a prosthesis, doctors often combine #3 and a short steroid course, plus refinish/replace the shell when needed. Cleveland Clinic
Dietary molecular supplements
These supplements do not reposition a shell. They aim to support eyelid/tear health and calm surface inflammation. Evidence quality varies; discuss with your clinician, especially if you’re pregnant, on blood thinners, or have medical conditions.
Omega-3 fatty acids (EPA/DHA; ~1000 mg/day combined)
May improve meibomian oil quality and reduce surface inflammation, which lowers friction under the shell.Omega-6 GLA (evening primrose/borage oil; 240–320 mg GLA/day)
GLA can be converted to anti-inflammatory mediators that help dry, irritated lids.Vitamin A (dietary levels only; avoid high doses)
Supports healthy surface cells and mucus production; excessive dosing is unsafe—prefer food sources.Vitamin C (250–500 mg/day)
Antioxidant support for wound healing after eyelid procedures.Vitamin E (natural mixed tocopherols, <200 IU/day)
Antioxidant partner to vitamin C; avoid high doses if on anticoagulants.Zinc (10–20 mg/day with food)
Cofactor for tissue repair enzymes; do not exceed upper limits.Lutein + Zeaxanthin (10 mg + 2 mg/day)
Carotenoids that support ocular surface oxidative balance; generally safe at dietary doses.Curcumin (turmeric extract, 500–1000 mg/day)
Anti-inflammatory properties; take with food; can interact with anticoagulants.Hyaluronic acid (oral, 120–240 mg/day)
May support tissue hydration; many people already benefit from topical hyaluronate in PF tears.Probiotics (per label, multi-strain)
May reduce systemic inflammation in some people, which can modestly help chronic surface symptoms.
Regenerative/biologic” options
There are no approved “stem-cell drugs” that treat scleral shell mal-positioning. Be cautious of clinics advertising miracle cures. What follows are adjunct biologic therapies that eye specialists sometimes use for ocular surface disease or reconstruction, not for the mechanical fit itself.
Autologous serum eye drops (ASEDs)
What: Your own blood serum, diluted into sterile drops.
Why: Contains growth factors and vitamins that may soothe severe dryness and help healing.
Evidence: Mixed—some studies show short-term improvements vs. artificial tears; benefits beyond a few weeks are uncertain. Used only under specialist protocols. PubMedLippincott Journals+1Platelet-rich plasma (PRP/PRGF) eye drops
What: Concentrated platelets from your blood release healing factors.
Why: May help persistent epithelial irritation and severe dry eye.
Evidence: Several controlled studies suggest benefit similar to or sometimes better than ASEDs in the short term. Availability and preparation standards vary. PMC+1bmjophth.bmj.comCryopreserved amniotic membrane (e.g., suture or ring device)
What: A biological “bandage” placed on the eye surface.
Why: Reduces inflammation, supports epithelial healing after abrasions, surgery, or severe surface disease.
Evidence: Reviews show amniotic membrane can aid ocular surface reconstruction; choice of fresh vs. preserved membranes shows similar outcomes in many measures. PubMed+1Biologic tear stimulators (e.g., varenicline nasal spray—prescription)
What: A nasal spray that stimulates natural tear production via nerve pathways.
Why: Improves basal tearing to reduce shell friction in very dry sockets.
Evidence: Approved for dry eye; not specific to prosthesis, but can be helpful when dryness is the main barrier to comfortable wear.Amniotic membrane + oral mucosal grafts in surgery
What: Surgeons combine biologic grafts to rebuild fornices and stabilize the shell.
Why: Restores lining and depth where scarring contracted the socket.
Evidence: Widely used in socket reconstruction algorithms. ijooo.orgCenegermin (recombinant human nerve growth factor)
What: Prescription drops for neurotrophic keratitis (not for everyone).
Why: In selected cases with corneal nerve damage, improving surface healing may indirectly improve shell tolerance.
Evidence: Approved for NK; use is specialist-directed and situation-specific.
Surgeries that correct the underlying mechanics
When fit problems come from eyelid laxity, scarred/shallow fornices, implant malposition, or lost orbital volume, surgery can restore the correct anatomy so the shell stays centered and comfortable.
Fornix deepening with mucous membrane graft (MMG)
Procedure: Tissue from the inside of the lip or cheek is grafted to the inner eyelid to rebuild the “pocket,” often with special deepening sutures.
Why: Deepens a shallow socket so the shell can seat securely and stop falling out. MMG is a common surface-expansion method in contracted sockets. ijooo.orgWebEyeOrbital volume augmentation (dermis-fat graft or implant exchange)
Procedure: Adds missing volume by transplanting the patient’s own dermis-fat or by revising/replacing the orbital implant.
Why: Corrects “sunken” appearance and helps the lids drape correctly over the shell so it doesn’t sit too deep or tilt. Outcomes are generally favorable with low complication rates in experienced hands. PMCLippincott JournalsEyeWikiLower eyelid tightening or spacer graft (e.g., hard-palate or cartilage)
Procedure: Tightens or supports a lax, sagging lower lid (ectropion) that lets the shell slip forward.
Why: A firm, well-positioned lower lid is essential to cradle the shell and prevent forward displacement.Ptosis repair (upper-lid lift)
Procedure: Strengthens or advances the upper-lid muscle/tendon.
Why: A droopy upper lid can hide or push on the shell. Repair improves lid contour and the way the shell is covered and retained.Symblepharon release and scar remodeling (± amniotic membrane)
Procedure: Cuts scar bands that tether the lid to the socket and places grafts to keep surfaces smooth.
Why: Frees the shell to move and seat properly without being dragged by scars. PubMed
Prevention tips
See your ocularist and ophthalmologist on the schedule they recommend (often every 6–12 months). Small fit problems are much easier to fix early. Memorial Sloan Kettering Cancer Center
Keep a consistent cleaning and lubrication routine; avoid alcohol-based cleaners on the shell. ocularpro.com
Don’t over-handle the shell. In/out only when needed; follow safe technique taught by your ocularist.
Use preservative-free drops to minimize sensitivity from repeated dosing.
Control allergies and blepharitis (daily lid care).
Protect the socket from wind/dust with wraparound glasses outdoors.
Sleep with humidified air if you wake up dry; consider a night ointment if advised.
Take short breaks during flare-ups instead of forcing wear (reduces GPC risk). Cleveland Clinic
Maintain general health—hydrate, don’t smoke, and manage rosacea/skin disease that worsens lid oil quality.
Learn your red-flags: pain, pus, fever, rapidly worsening redness, implant exposure, shell won’t stay in—seek care promptly. Cleveland Clinic
When to see a doctor urgently
Sudden or severe pain, swelling, or fever.
Green/yellow discharge or foul odor.
Shell won’t stay in or keeps popping out after a recent change.
You notice exposed implant, bleeding, or deep ulcer on the socket surface.
Worsening ectropion, ptosis, or new eyelid deformity.
Any injury to the socket or face.
If you have only one seeing eye: any new symptoms—protect that eye carefully. Cleveland Clinic
What to eat and what to avoid
Eat fatty fish (salmon, sardines) 2–3×/week for natural omega-3s to support healthy eyelid oils.
Eat colorful vegetables (spinach, kale, carrots, bell peppers) for vitamins A/C/E and carotenoids.
Eat nuts/seeds (walnut, chia, flax) for plant omega-3s; useful if you don’t eat fish.
Eat yogurt or fermented foods if tolerated to support overall inflammation control.
Drink enough water—steady hydration keeps tissues less sticky.
Limit ultra-processed snacks and sugary drinks that promote inflammation.
Limit excessive alcohol (dehydrates and worsens dryness).
Limit very salty foods late at night (can worsen morning dryness).
Avoid any supplement that your doctor flags as unsafe with your medications (e.g., high-dose vitamin E with anticoagulants).
Avoid “miracle” stem-cell or immunity-booster pills—there’s no proven pill that repositions a shell.
Frequently Asked Questions
1) Is mal-positioning dangerous?
It’s usually not dangerous, but it is uncomfortable and can lead to chronic irritation, mucus, and even socket scarring over time. The main risk is neglect—let your team fix it before it becomes a cycle of irritation and contraction. EyeWiki
2) Can I fix the position at home?
You can improve comfort with lubrication and careful insertion, but the underlying fit is a custom technical job for your ocularist. DIY filing or chemical cleaning can permanently damage the shell—don’t do it.
3) How often should my shell be polished?
Most patients benefit from professional polishing about every 6 months (timing is individualized). Polishing keeps the surface smooth and reduces discharge. Memorial Sloan Kettering Cancer Center
4) What is giant papillary conjunctivitis (GPC), and why does it matter?
It’s an allergic-mechanical reaction of the inner eyelid lining to rubbing from a shell (or a contact lens). It causes bumps, mucus, itching, and intolerance to wear. Treatment combines rest, anti-allergy meds, short steroid courses if needed, and often refinishing or replacing the shell. Cleveland Clinic
5) My lower lid sags and the shell slides forward—what helps?
A lax lower lid cannot cradle the shell. Lid tightening or a spacer graft can restore support so the shell sits stably again (your surgeon will assess).
6) The shell sits too deep and my upper lid droops. Why?
You may be missing orbital volume or have ptosis. Options include dermis-fat graft or implant revision for volume, and ptosis repair for the lid. PMC
7) Are there real “stem-cell drops” for this?
No approved stem-cell drug repositions a shell. Some biologic treatments (like amniotic membrane or PRP/serum drops) can comfort the surface or aid healing, but they don’t replace surgical/ocularist correction when anatomy is off. PubMedPMC
8) Can I sleep with the shell in?
Many patients do; others remove it nightly. Your ocularist will advise based on your socket and eyelids. The key is comfort, cleanliness, and safety. DMEI | Dean McGee Eye Institute
9) How long does a shell last?
With routine care and periodic refitting/polishing, many last several years. Bodies and sockets change, so expect adjustments over time.
10) Is discharge normal?
Some mucus is common. If it becomes thick, colored, or foul-smelling—or suddenly increases—see your clinician to check for infection, allergy, roughness, or poor fit. Cleveland Clinic
11) Can children wear scleral shells?
Yes, but they outgrow them and need frequent refits. Pediatric teams coordinate closely with families for safety and hygiene.
12) Can I swim or play sports?
Yes, with goggles for water sports and protective eyewear for contact sports. Avoid rubbing after exposure to chlorinated or salty water—rinse and lubricate.
13) Will my insurance cover adjustments or surgery?
Coverage varies widely. Keep all clinical documentation and photographs of problems to support claims.
14) What if my implant is exposed or shifted?
Implant issues can force the shell out of position. Surgeons may cover the implant with a graft, revise its position, or replace it. Dermis-fat grafting is a well-established option when exposure or volume loss is present. PMC
15) What’s the long-term outlook?
With the right mix of ocularist care, surface management, and, if needed, eyelid/socket surgery, most people return to stable, comfortable wear and natural-looking lids. PMC
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members
Last Updated: August 17, 2025.
