Ocular surface, fornix, and eyelid rehabilitation in Boston type I keratoprosthesis patients with mucous membrane disease

Inferior Oblique Flap: An Approach for Improved Vascular Supply in Complex Ocular Surface Reconstruction

This case report describes a novel surgical technique using an inferior oblique muscle flap for a patient requiring complex ocular surface reconstruction. A 63-year-old female with Stevens-Johnson syndrome and complex ocular history including multiple penetrating keratoplasties and keratoprostheses presented with recurrent keratoprosthesis implant plate necrosis. In conjunction with revision keratoplasty, a custom inferior oblique muscle flap was designed to provide improved support and vascularity to the corneal tissue bed; at 12 months postoperation, the graft remained well attached and free of graft failure. Here, we present this technique along with operative photos, describing how this technique may provide surgeons an additional option for complex ocular surface reconstruction.

Challenges in the management of bilateral eyelid closure in Stevens-Johnson Syndrome

Purpose

Observations

Conclusion and importance

Acute and Chronic Management of Ocular Disease in Stevens Johnson Syndrome/Toxic Epidermal Necrolysis in the USA

Stevens Johnson syndrome and toxic epidermal necrolysis are on a spectrum of a severe, immune-mediated, mucocutaneous disease. Ocular involvement occurs in the vast majority of cases and severe involvement can lead to corneal blindness. Treatment in the acute phase is imperative in mitigating the severity of chronic disease. Advances in acute treatment such as amniotic membrane transplantation have shown to significantly reduce the severity of chronic disease. However, AMT is not a panacea and severe chronic ocular disease can and does still occur even with aggressive acute treatment. Management of chronic disease is equally critical as timely intervention can prevent worsening of disease and preserve vision. This mini-review describes the acute and chronic findings in SJS/TEN and discusses medical and surgical management strategies.

Treatment of Oculoplastic and Ocular Surface Disease in Eyes Implanted with a Type I Boston Keratoprosthesis in Southern China: A Retrospective Study

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.

Boston keratoprosthesis type 1 for limbal stem cell deficiency after severe chemical corneal injury: A systematic review

PURPOSE

To systematically review the published literature on outcomes of Boston keratoprosthesis type 1 for the treatment of limbal stem cell deficiency secondary to severe chemical corneal injury.

METHODS

Literature searches were conducted in MEDLINE (Ovid), Embase, Web of Science, and the Cochrane Central Register. The main outcome measures assessed were the proportion of eyes with best-corrected visual acuity (BCVA) ≥ 20/200 and the proportion retaining their original keratoprosthesis, both at the last recorded visit.

RESULTS

We identified 9 reports in which outcomes of Boston keratoprosthesis type I implantation after severe chemical injury could be determined, encompassing a total of 106 eyes of 100 patients. There were no randomized controlled studies. The median pre-operative BCVA was hand motion. Vision improved to ≥20/200 in 99/106 (93.4%) eyes after implantation. With a mean follow-up of 24.99 ± 14 months, 68/106 (64.1%) eyes retained BCVA ≥ 20/200 at the last examination. Therefore, 68/99 (68.7%) of those who improved to > 20/200 maintained at least this acuity. The originally implanted device was retained in 88/99 (88.9%) recipients for whom retention was reported. The mean time to failure was 22.36 ± 17.2 months. Glaucomatous optic neuropathy was the most common cause for BCVA <20/200 in eyes that retained the keratoprosthesis (18/27, 66.7%)..

CONCLUSIONS

Implantation of a Boston keratoprosthesis type I in eyes with corneal blindness after severe chemical ocular injury leads to functional vision in the majority of recipients. Evidence was limited by variability in outcome reporting and an absence of controlled studies..

Long-Term Outcomes of the Boston Type I Keratoprosthesis in the Management of Corneal Limbal Stem Cell Deficiency

PURPOSE

To report the long-term outcomes of the Boston type I keratoprosthesis (KPro) in the management of limbal stem cell deficiency (LSCD).

METHODS

Retrospective review of KPro procedures performed by a single surgeon from May 1, 2004, to January 1, 2015.

RESULTS

One hundred seventy-three KPro procedures were performed in 149 eyes, including 68 in 54 eyes with LSCD. Glaucoma (48% vs. 82%, P < 0.0001) and a history of ≥2 keratoplasties (39% vs. 79%, P < 0.0001) were significantly less common in eyes with LSCD. Preoperative corrected distance visual acuity was ≥20/200 in 7% of eyes with LSCD and 9% of eyes without LSCD. A significantly greater percentage of eyes with LSCD had CDVA ≥ 20/200 at each of the first 5 years after surgery. The only postoperative complication more common in eyes with LSCD compared with eyes without was persistent corneal epithelial defect (50% vs. 28%, P = 0.013), although the associated secondary complications sterile corneal necrosis (22% vs. 11%, P = 0.059) and corneal infiltrate (20% vs. 10%, P = 0.08) were twice as common in eyes with LSCD. Despite this, the retention failure rates in eyes with and without LSCD were similar (0.089/eye-yr vs. 0.071/eye-yr; P = 0.53).

CONCLUSIONS

Boston type I keratoprosthesis implantation results in a significant improvement in CDVA in the majority of eyes with LSCD through 5 years after surgery, with better visual outcomes than eyes without LSCD. Although several postoperative complications are more common in LSCD, sight-threatening complications such as endophthalmitis and retinal detachment are not. Additionally, there is no difference in the retention failure rate in eyes with and without LSCD, although a larger number of procedures with longer follow-up will be needed to determine retention outcomes more than 5 years after surgery.

Outcomes of Repeat Boston Type 1 Keratoprosthesis Implantation

PURPOSE

To describe the outcomes and prognostic characteristics of patients who had a repeat Boston type 1 keratoprosthesis (KPro) implantation.

DESIGN

Retrospective case series.

METHODS

setting: Data regarding preoperative clinical and demographic characteristics and postoperative course during initial and repeat KPro placement were collected at multiple centers across the country.

PATIENTS

Forty-eight eyes underwent explantation of KPro owing to complications between September 2003 and August 2014 at 5 participating tertiary eye care centers in the United States. Of those, 36 eyes that received a subsequent replacement device were included.

MAIN OUTCOME MEASURES

Visual acuity (VA) outcomes and postoperative complications.

RESULTS

Ocular surface disease was significantly more common in eyes that required a device explantation, compared to those that retained the device (P < .001). Sixty-seven percent of eyes (24/36) achieved VA ≥ 20/200 vision after the repeat KPro. The probability of these 24 eyes maintaining VA ≥ 20/200 after the repeat KPro was 87% at 1 year and 75% at 2 years. Predictors of the ability to maintain vision ≥ 20/200 following surgery were a better last-recorded vision before explantation (P = .0002) and better vision immediately after repeat KPro (P < .001).

CONCLUSION

Ocular surface disease and its complications were associated with more frequent device removal. In these patients, repeat KPro resulted in restoration of vision. A reasonable visual acuity prior to device removal was associated with favorable long-term postoperative visual acuity and retention.

The Usage of a Conjunctival Flap to Improve Retention of Boston Type 1 Keratoprosthesis in Severe Ocular Surface Disease

PURPOSE

The Boston keratoprostheses type 1 devices (KPro) are utilized in cases unfavorable to penetrating keratoplasty. The prognosis remains guarded in cases of ocular surface disease due to risk of tissue necrosis. We describe a novel surgical approach using a conjunctival flap with a delayed opening to improve retention.

METHODS

In three patients with advanced cicatrizing conjunctivitis, a Type 1 keratoprosthesis was stabilized using a full tarsal conjunctival flap. Three months postoperatively, an opening was created in the flap overlying the optical portion of the device.

RESULTS

All patients had no device related complications over a mean follow-up period of 17.7 months (range 15-21 months) and vision remained excellent at better than 20/200 for all patients.

CONCLUSIONS

Utilization of a tarsal flap either primarily as part of a two stage modified technique or secondarily in cases of tissue necrosis and impending device extrusion might maximize retention of the type 1 KPro.