How to make an artificial eye. Keith Pine, Auckland ocular prosthetic expert explains

About 3000 New Zealanders wear an artificial eye. Many of them have been made by Dr Keith Pine, a former dental technician turned internationally renowned ocular prosthetist. Kim Knight and Michael Craig sit in on the five-hour creation process of a new eye.

You can lose your eye in the single flick of a cow’s tail.

Golf balls and bar brawls. Car accidents. Once, a rooster flew at a 3-year-old eating an apple and pecked at her eye instead. Cancer. There are a lot of eyes lost to cancer.

Keith Pine’s case history is a catalogue of worst-case scenarios. He’s the man you see when you can no longer see. At any given moment, about 3000 New Zealanders are wearing an artificial eye, and many of them will have been made by this 75-year-old from Auckland’s North Shore.

He used to be a dental technician. Former business interests include the Geddes Dental Group (now Lumino) and Pine Construction. He’s obsessed with old wooden sailing boats – part-owns one, and was involved in the restoration of another. In the 1980s, he made the Wilberforce monster prosthetics for the original Under the Mountain television series. Today, he makes eyes. Up to 15 a month, in pop-up clinics throughout the North Island.

Meet him on the doorstep of the house on the street that ends in the Waitematā. He wears shorts and a T-shirt and looks approximately 100 years younger than his passport says. Back in February, in the last weeks of pre-Covid “normal”, he travelled to the United States and delivered four hours worth of back-to-back lectures on his specialty topic. Exhilarating. Exhausting. But, “I hate ageism. I fight it. I absolutely deliberately fight the onset of old age by putting myself in uncomfortable positions. Such as now!”

Pine doesn’t do many interviews. He’s one of those New Zealanders you might be surprised you haven’t heard of – the lead author of the world’s only peer-reviewed textbook on prosthetic eyes and more than 20 academic research papers.

“I’m in the restoration business,” he says, dryly.

It’s the relative uncommonness of artificial eyes (about one in every 1440 New Zealanders) that led to the research vacuum Pine is racing to fill. Before he founded the New Zealand Prosthetic Eye Service in 2008, he says patients were “somewhat in the wilderness”.

“It’s always been a fragmented industry. People who wear prosthetic eyes are usually pretty stoic – they kind of have to be. They are very ready to kind of ignore their eye and retreat. To pretend it’s not there. It’s an imposition, but it can be put aside.”

Pine has been making eyes for most of his working life. The boy who left high school with School Certificate (and a record for the most canings in the third, fourth and “embarrassingly, also the fifth form”) is now a man with a PhD on the socket’s response to an eye prosthetic.

In the 1960s, he says, you had your pick of jobs. He’d joined St John as a volunteer cadet, and was the country’s top team leader in national competitions. When his dad suggested he consider learning dental technology at Middlemore Hospital, he thought “health – that’s a good fit”.

“It was dead luck that I got into a plastic surgery dental unit. The setting was brilliant for learning. I lapped it up.”

At Middlemore (and in the United Kingdom where he later headed for formal training) he learned how to make dentures, facial prosthetics and artificial eyes. The link between teeth and eyes is a curious quirk of history. Back in the 1930s, German-made cryolite glass eyes were the gold standard. Meanwhile, British chemists had just invented Perspex and dentists had seized on its medical-grade cousin polymethyl methacrylate or “PMMA” for denture-making. When World War II interrupted the supply of German glass eyes, dental technicians pivoted, pioneering the use of PMMA for prosthetic eyes. In the United Kingdom, the trade shifted from optometrists to dentists. And, if modern-day patients were very lucky, they might meet a technician like Pine who also had hospital-based experience in maxillofacial technology.

“I never stopped making eyes,” says Pine. “It’s the only thing I’ve done continuously, even though I was managing 110 people at Geddes, I still had private patients. When the dental practice got sold and everything settled down I had nowhere to go. I didn’t actually want to make dentures.”

Downstairs, a flat lay of conversation pieces is testament to his decades in the business. A box of old glass eyes that once belonged to a Queen St optometrist. A pair of painted sarcophagus eyes. Doll’s eye mechanisms, novelty eyeball cufflinks and – wait, is that an actual eyeball in a jar?

“It actually is,” says Pine. “Until you handle a real eye, you can’t make an artificial eye, right? A patient asked to have it, and then felt I could use it.”

Pine’s new business was born in tandem with the research projects that helped identify prospective patients. Before 1990, accidents were the main cause of eye loss in New Zealand. Improved workplace safety (and the compulsory use of seat belts) means medical conditions – tumours, glaucoma, diabetes and the like – are now the greatest contributors. About 15 per cent of all eye losses occur when people are aged between 1 and 9 years old. Pine says there’s no socioeconomic bias: “Anybody can lose an eye.” Seven months ago, he was working from Tongariro Prison – the week of these interviews, he was based out of David Haydon Optometrists in Takapuna.

He’s already under way when the New Zealand Herald arrives. It takes between four and six hours to make an eye. Among the more easily recognised tools: a dental lathe, an electric kettle, a bucket of Plaster of Paris, oil paints, sable brushes and a spool of red thread. Chemistry and craft; art and a large dollop of compassion. Mostly Pine aims to create the most natural-looking prosthetic possible, but not every patient wants that. He’s seen photographs, for example, of a Christchurch man who opted for pāua-shell eyes.

“His rationale was that he couldn’t see his eyes, and they rotated. So rather than have natural eyes that looked odd from time to time, he’d rather have these pāua-shell eyes which were consistent.”

You can’t judge or presume, says Pine. Once, he had a patient ask for a solid black eye with a red pupil.

“He’d had a [natural-looking] eye made that he wasn’t very happy with. Rather than look a bit odd, he said he’d sooner have one like this. ‘Oh, and by the way, I’m the leader of a heavy rock band.'”

Pine ended up making two prosthetics. “A good-looking eye and that was for his wife. But his kids loved the fact that they had a rock-star dad.”

Back when eyes were glass and ready-made, patients had no choice. They hoped for a good fit, a reasonable colour match and lived with the best option. The new prosthetic is bespoke – but it’s still a surprise for the uninitiated to discover it’s not perfectly round.

“Everybody knows the eyeball is round,” says Pine. “And when it’s taken out, you’re left with a spherical cavity.”

But he says you are also hopefully left with four main muscles that can be “tied” over the top of a spherical implant.

“The wound is closed, the orbital curtain is closed. So that implant and the muscles are buried at the back of the socket. Half of the sphere is now filled in. The prosthetic eye fills in the other half – and that’s the bit you can see.”

Imagine a very ornate piece of orecchiette pasta. A highly polished beach shell. “It’s hollow,” says Pine. “And it’s that shape because it’s fitting over the implant.”

You can’t “see” out of a prosthetic, but if the implant is doing its job, the prosthetic will still move. It will be capable of what Pine calls “conversational movement”. Up and down, side to side. Enough to look like a real eye.

Meet Karen. You have to stare quite hard to notice she has a prosthetic, but the 64-year-old former nurse has worn one her entire life. She has a condition called microphthalmia neonatorum or, simply, a small eye at birth. As a baby, she would have had a succession of clear shells to maintain the shape of the socket and to stimulate growth of the eyelid and orbital rim. Development is so fast, says Pine, that sometimes these shells might be replaced fortnightly. The eye stops growing around the age of 3 (babies don’t so much have big eyes as small heads) and replacement prosthetics are required less often – every two years up to the age of 6; every three years up to the age of 18 and, after that, only to keep pace with age and the natural redistribution of orbital tissue.

Karen’s prosthesis is fitted over her immature eye: “It moves. Which helps people not notice.” Her now-adult children have never seen her without it (“It’s my own anxiety, they don’t care, but I’ve never wanted to scare them.”). She’s letting us document the making of a new replacement – with some caveats around photographs and the use of her surname – because Pine asked for a volunteer. His research, she says, has changed her life.

Top concerns for single artificial eye wearers? Loss of the remaining “good” eye and mucoid discharge – a distressing problem for patients who don’t always know it’s happening. Pine’s research has turned historic protocol on its head. Once, the prosthetic would be removed and cleaned daily, but Pine has determined that practice stimulates discharge and now recommends patients sleep with their eyes in.

Karen remembers that, as a child, she was instructed to sleep with her eye under her pillow. “It’s such a security risk. I’ve lost it in sleeping bags. As a kid, it was a nightmare! So when Keith said don’t take it out at night and only clean it when you have to . . . “

Today, she’s getting a replacement prosthetic as part of Pine’s newest research, investigating the possible use of a prosthesis material that may prove more hydrophilic or “wettable” (and comfortable) than PMMA.

She’s an old hand at this. Knows where the free carparking is; has a book to read for the in-between moments. Perhaps the worst news she’ll get today is that her other eye is starting to naturally discolour with age – Pine will literally be painting matching years into her prosthesis.

“I can’t even remember when I found out I was any different,” says Karen. “I had very sensible parents. Pragmatic types who never saw it as anything that would hold me up. I think other kids only knew because of their parents’ gossip. I remember being very wounded by the name-calling, but again, my parents were ‘don’t show them that it hurts’.”

She did gymnastics. Learned to ride a bike, drive a car and waterski. It was only when she began to study nursing that she realised why she couldn’t play tennis with the rest of her family – one eye means no binocular vision.

“Anything with a bat or a racket and I’m useless!”

While she has been talking, Pine has already trimmed a plastic button to the diameter of the iris and begun the process of painting to match her natural eye. It’s time for the next step – a cartridge gun loaded with polyvinyl siloxane impression material. Pine pulls her eyelid up and speaks calmly and quietly. “Heading your way, Karen. Remember, cool and soothing . . . “

The impression material firms in under a minute. When he plops it out, like a muffin from a silicone pan, it has grabbed some of her mascara, “but no eyelashes!”. That impression will now be used to create a wax “pattern” or blank that fits Karen’s eye socket, but is malleable enough for Pine to shape and mould. He uses denture wax – a disconcerting fleshy pink but, says Pine, terrific modelling properties.

He pops the blank back into Karen’s eye socket and manipulates it slightly.

“We sit here until we get it right,” says Pine. “There’s no magic in it. You need endless patience with this job. It’s very much trial and error. But this is the most important part of eye-making. Right now, we’re determining the size of the eye, the direction of the gaze and the lid contour – all of which is more important than colour. An eye that looks cross-eyed, no matter what colour it is, is going to stand out.”

Satisfied with the shape and fit, it’s back to fit the iris and then make another Plaster of Paris mould that will eventually be filled with PMMA. We’re in a tiny room, little more than an enclosed hallway really, the shelves stacked with boxes of contact lenses and scant bench space. Pine moves quickly and efficiently. It’s second nature to him, this making of moulds from moulds, but utterly confusing for an onlooker – especially when he drops the work-in-progress into an electric jug of boiling water.

“PMMA cures under heat and pressure. So we created the pressure putting it in that clamp, and we’re creating the heat by putting it in water – 72 degrees Celsius – it’s going to be reboiled another two times.

“It does get a bit industrial. When you’re making more than one eye in a day, it’s very much like MasterChef. There are so many moving parts and bits.”

Pine bills $4600 an eye. Patients access funding from the Ministry of Health, ACC and insurance companies. If they can’t? “Nobody misses out.”

What colour are your eyes? If they’ve been made by Pine, they may contain any of the following: burnt sienna, yellow ochre, raw sienna, van dyke brown, cobalt blue, ivory black and titanium white. Karen’s eye has become a painting. A work of art?

“I can copy,” says Pine. “I’m not putting in any interpretation – so it’s not art. Artists give something of themselves.”

Burnt sienna is dry-brushed into the black of the pupil and then back out again to make the edges dissolve. There’s no red in his palette – fine veins are teased from a spool of colour-fast cotton. The prosthetic surface is matte and dull, almost chalk-like and very definitely artificial. Back to that tiny hallway. A thin PMMA veneer is applied and the flash is trimmed away.

Eventually, the surface is buffed with a dental lathe. Coarse, then fine. Karen’s eye is coming to life.It emerges clear and shiny. Just like the real thing.

“Well, I’m never happy,” says Pine. “You always see the faults. But in the context of everything else and if it’s within natural limitations, it’s okay.”

Karen: “Are they both looking the same way? Oh, great. Nice.”

Pine: “It’s a little wider than the other one . . . It’s more fitting than the other one, occupying all the nooks and crannies.”

Karen: “Feels good, looks good.”

Pine: “I think it is a better eye than the one we’ve replaced.” He smiles. “Yep. We have an eye. I’ve done something today.”

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