Abstract
Introduction
This study aimed to describe the clinical features, surgical management of the eyelid and ocular surface, and outcomes of 16 patients implanted with a Boston type I keratoprosthesis (KPro).
Methods
A retrospective, single-center, consecutive case series of 16 patients with Stevens–Johnson syndrome (1), ocular chemical burns (12), and ocular thermal burns (3) implanted with KPro was studied. All subjects were men aged 27–51 years. Surgical treatment and outcomes for eyelid malposition, symblepharon, and glaucoma were assessed.
Results
From September 2010 to February 2019, 29 patients were admitted to Zhongshan Ophthalmic Center for KPro implantation, of whom 16 (55%) required eyelid or ocular surface surgeries to maintain hydration and protect the corneal tissue, which is vulnerable to epithelial defects. Forty-one adnexal surgical procedures were performed. The most common indication for surgery was symblepharon, and the most frequent procedures were symblepharon lysis with ocular mucous membrane grafts and amniotic membranes (7) and full-thickness skin grafts to the eyelids (7). Preoperative conjunctival injection and corneal staining were documented in 9 (56%) and 8 (50%) eyes, respectively, and at up to 4 months postoperative follow-up (the last adnexal surgery before KPro) were recorded in 3 (19%, p = 0.03) and 2 (12%, p = 0.02) eyes, respectively. Glaucoma drainage devices were inserted in six patients. One patient with Stevens–Johnson syndrome underwent FP7 Ahmed glaucoma valve (AGV) implantation inferotemporally and developed plate exposure 2 months postoperatively. Five patients underwent FP8 AGV implantation with tube insertion into the vitreous cavity due to the scarred conjunctiva and limited subconjunctival space. In the study period, intraocular pressure (IOP) was in the normal range, and no tube or plate exposure was observed.
Conclusion
The ocular environment is critical for successful KPro surgery. A multidisciplinary approach for any lid and ocular surface abnormality in ocular burns or Stevens–Johnson syndrome is important to improve the quality of the ocular surface and accommodate KPro and AGV, which is vital for maintaining vision after KPro surgery. FP8 AGV may be feasible for IOP control in adult KPro cases with restricted subconjunctival space.
Similar content being viewed by others
References
Nascimento E, Silva R, Shen LQ, et al. Glaucoma management in patients with aniridia and Boston type 1 heratoprosthesis. Am J Ophthalmol. 2019;207:258–67.
Brown CR, Wagoner MD, Welder JD, et al. Boston keratoprosthesis type 1 for herpes simplex and herpes zoster keratopathy. Cornea. 2014;33(8):801–5.
Kheirkhah A, Blanco G, Casas V, et al. Surgical strategies for fornix reconstruction based on symblepharon severity. Am J Ophthalmol. 2008;146(2):266–75.
Iyer G, Srinivasan B, Agarwal S, et al. Boston type 2 keratoprosthesis-midterm outcomes from a tertiary eye care centre in India. Ocul Surf. 2019;17(1):50–4.
Lee R, Khoueir Z, Tsikata E, et al. Long-term visual outcomes and complications of Boston keratoprosthesis type II implantation. Ophthalmology. 2017;124(1):27–35.
Iyer G, Srinivasan B, Agarwal S, et al. Keratoprosthesis: current global scenario and a broad Indian perspective. Indian J Ophthalmol. 2018;66(5):620–9.
Bakshi SK, Graney J, Paschalis EL, et al. Design and outcomes of a novel keratoprosthesis: addressing unmet needs in end-stage cicatricial corneal blindness. Cornea. 2020;39(4):484–90.
Harissi-Dagherr M, Beyer J, Dohlman CH. The role of soft contact lenses as an adjunct to the Boston keratoprothesis. Int Ophthalmol Clin. 2008;48(2):43–51.
Cade F, Grosskreutz CL, Tauber A, et al. Glaucoma in eyes with severe chemical burn, before and after keratoprosthesis. Cornea. 2011;30(12):1322–7.
Chen J, Wang Z, Gu J. Management of cicatricial entropion of the upper lid using acellular human dermal allograft. J Plast Reconstr Aesthet Surg. 2008;61(6):610–4.
Gu J, Zhai J, Chen J. The use of acellular human dermis composite graft for upper eyelid reconstruction in ocular injury. J Trauma Acute Care Surg. 2012;72(1):288–92.
Ma KN, Thanos A, Chodosh J, et al. A novel technique for amniotic membrane transplantation in patients with acute Stevens–Johnson syndrome. Ocul Surf. 2016;14(1):31–6.
Gu J, Zhai J, Liao G, et al. Boston type I keratoprosthesis implantation following autologous submandibular gland transplantation for end stage ocular surface disorders. Ocul Immunol Inflamm. 2018;26(3):452–5.
Hou JH, de la Cruz J, Djalilian AR. Outcomes of Boston keratoprosthesis implantation for failed keratoplasty after keratolimbal allograft. Cornea. 2012;31(12):1432–5.
Baker MS, Krakauer M, Gupta S, et al. Eyelid procedures in patients who have undergone Boston keratoprosthesis surgery. Ophthalmic Plast Reconstr Surg. 2012;28(4):286–8.
Christensen JM, Shanbhag SS, Shih GC, et al. Multidisciplinary treatment to restore vision in ocular burns. J Burn Care Res. 2019. https://doi.org/10.1093/jbcr/irz201.
Rootman DB, Kim MJ, Aldave AJ, et al. Ocular surface, fornix, and eyelid rehabilitation in Boston type I keratoprosthesis patients with mucous membrane disease. Ophthalmic Plast Reconstr Surg. 2015;31(1):43–9.
Yokoi N, Bron AJ, Tiffany JM, et al. Relationship between tear volume and tear meniscus curvature. Arch Ophthalmol. 2004;122(9):1265–9.
Koreen IV, Taich A, Elner VM. Anterior lamellar recession with buccal mucous membrane grafting for cicatricial entropion. Ophthalmic Plast Reconstr Surg. 2009;25(3):180–4.
Gu J, Wang Z, Sun M, et al. Posterior lamellar eyelid reconstruction with acellular dermis allograft in severe cicatricial entropion. Ann Plast Surg. 2009;62(3):268–74.
Paschalis EI, Zhou C, Lei F, et al. Mechanisms of retinal damage after ocular alkali burns. Am J Pathol. 2017;187(6):1327–42.
Dohlman CH, Cade F, Regatieri CV, et al. Chemical burns of the eye: the role of retinal injury and new therapeutic possibilities. Cornea. 2018;37(2):248–51.
Dohlman CH, Zhou C, Lei F, et al. Glaucoma after corneal trauma or surgery—a rapid, inflammatory, IOP-independent pathway. Cornea. 2019;38(12):1589–94.
Kumar R, Dohlman CH, Chodosh J. Oral acetazolamide after Boston keratoprosthesis in Stevens–Johnson syndrome. BMC Res Notes. 2012;30(5):205.
Byun YS, Lee NY, Park CK. Risk factors of implant exposure outside the conjunctiva after Ahmed glaucoma valve implantation. Jpn J Ophthalmol. 2009;53(2):114–9.
Akyol N, Demir T, Kükner A, et al. Effects of systemic octreotide, local mytomycine-C and local corticosteroids on wound-healing reaction after glaucoma surgery. Int Ophthalmol. 2001;24(5):235–41.
Hoan-Xuan T, Baudouin C, Creuzot-Garcher C. Inflammatory diseases of the conjunctiva. Chapter 9: systemic disease and conjunctivitis. Stuttgart: Thieme. 2001:145–160.
Pakravan M, Yazdani S, Shahabi C, et al. Superior versus inferior Ahmed glaucoma valve implantation. Ophthalmology. 2009;116(2):208–13.
Huh ES, Aref AA, Vajaranant TS, et al. Outcomes of pars plana glaucoma drainage implant in Boston type 1 keratoprosthesis surgery. J Glaucoma. 2014;23(1):e39–44.
Vajaranant TS, Blair MP, McMahon T, et al. Special considerations for pars plana tube-shunt placement in Boston type 1 keratoprosthesis. Arch Ophthalmol. 2010;128(11):1480–2.
Cortina MS, Karas FI, Bouchard C, et al. Staged ocular fornix reconstruction for glaucoma drainage device under neoconjunctiva at the time of Boston type 1 Keratoprosthesis implantation. Ocul Surf. 2019;17(2):336–40.
Kirkness CM. Penetrating keratoplasty, glaucoma and silicone drainage tubing. Dev Ophthalmol. 1987;14:161–5.
Turaga K, Rao A, Ali MH, Shastry R, et al. Safety and efficacy of paediatric silicone Ahmed glaucoma valve (AGV) in adult eyes with post-VR surgery glaucoma. Eye. 2019. https://doi.org/10.1038/s41433-019-0663-0.
Koh KM, Hwang YH, Jung JJ, et al. Comparison of the outcome of silicone Ahmed glaucoma valve implantation with a surface area between 96 and 184 mm2 in adult eyes. Korean J Ophthalmol. 2013;27(5):361–7.
Leen MM, Witkop GS, George DP. Anatomic considerations in the implantation of the Ahmed glaucoma valve. Arch Ophthalmol. 1996;114(2):223–4.
Law RW, Li RT, Lai JS, et al. Modification of an adult-sized Ahmed glaucoma valve for a small globe. Jpn J Ophthalmol. 2006;50(1):67–8.
Netland PA, Terada H, Dohlman CH. Glaucoma associated with keratoprosthesis. Ophthalmology. 1998;105(4):751–7.
Yaghouti F, Nouri M, Abad JC, et al. Keratoprosthesis: preoperative prognostic categories. Cornea. 2001;20(1):19–23.
Acknowledgements
We hereby thank all the participants of the study.
Funding
No funding or sponsorship was received for this study or publication of this article. The Rapid Service Fee was funded by the authors.
Medical Writing Assistance
Language editing and assistance for this article were provided by AJE and funded by the authors.
Authorship
All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.
Disclosures
Yuying Zhang, Zhancong Ou, Jin Zhou, Jiajie Zhai, Jianjun Gu and Jiaqi Chen have nothing to disclose.
Compliance with Ethics Guidelines
This study was conducted in accordance with the 1964 Declaration of Helsinki and its later amendments and was approved by the Ethics Committee of Zhongshan Ophthalmic Center. Informed consent for participation and publication of patient data was obtained from all individual participants included in the study. Permissions have been obtained from our patients to publish the images of patients in this article.
Data Availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Author information
Authors and Affiliations
Corresponding author
Additional information
Digital Features
To view digital features for this article go to https://doi.org/10.6084/m9.figshare.12251921.
Rights and permissions
About this article
Cite this article
Zhang, Y., Ou, Z., Zhou, J. et al. Treatment of Oculoplastic and Ocular Surface Disease in Eyes Implanted with a Type I Boston Keratoprosthesis in Southern China: A Retrospective Study. Adv Ther 37, 3206–3222 (2020). https://doi.org/10.1007/s12325-020-01381-3
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12325-020-01381-3