End-stage Ocular Surface Disease Research Articles

Strategic combination of cultivated oral mucosal epithelial transplantation and postoperative limbal-rigid contact lens-wear for end-stage ocular surface disease: a retrospective cohort study

PurposeTo provide the long-term outcome of patients with end-stage severe ocular surface disease (OSD) consecutively treated with cultivated oral mucosal epithelial transplantation (COMET) followed by limbal-rigid contact lens (CL)-wear therapy.DesignRetrospective...

Osteo-odonto keratoprosthesis in Egypt: a case series

Purpose The aim of this study was to evaluate the preliminary results of osteo-odonto keratoprosthesis (OOKP) performed in Alexandria Main University Hospital, Alexandria, Egypt in eyes with end-stage cicatrizing conjunctivitis.Patients and methods OOKP surgery was done in two stages. Stage 1 included preparation of the globe, buccal mucous membrane harvesting, and preparation of osteo-odonto alveolar lamina with the cemented optical cylinder. The prepared lamina was then placed in the submuscular space for 2–3 months. In stage 2, the lamina–optical cylinder complex was implanted under the buccal mucous membrane and the posterior part of the optical cylinder was placed in a central corneal opening to act as an artificial cornea, transmitting image to the retina.Results Six eyes with end-stage ocular surface disease were included in this study. Anatomical success, in the form of retention of the prosthesis, was achieved in five eyes. The procedure failed in one eye due to unhealthy canines with a small amount of bone in the lamina. Functional success, defined as restoration of vision, was achieved in four eyes. Visual improvement was not attained in one eye (in addition to the eye with anatomical failure) due to optic atrophy despite good retention of the device.Conclusion OOKP is a promising procedure to regain vision in severe cases of end-stage corneal blindness, unsuitable for cadaveric corneal grafts. Proper selection of cases is crucial to achieve the best anatomical and functional results.

The osteo-odonto-keratoprosthesis.

To describe the practice of and recent developments in the osteo-odonto-keratoprosthesis. Formal psychological assessment and support have been described. A sub-aqua system for fashioning the osteo-odonto-keratoprosthesis lamina; adoption of thicker laminae; use of bisphosphonate drugs; advances in laminar imaging; and use of bone augmentation and bone morphogenetic protein have been described for prevention, detection, and management of laminar resorption. Two systems of optical cylinders available commercially. A stepladder approach to buccal mucous membrane overgrowth onto the optical cylinder has been described, including use of mitomycin-C. Orbital decompression has been used for cosmetic improvement. Detection of glaucoma may be aided by an intraocular pressure sensor, whereas surgical treatment is mainly by way of glaucoma drainage devices, as endolaser ciliary ablation and recti muscle disinsertion and reinsertion not having prolonged and significant long-term beneficial effect. Sublingual timolol has been described. The use of endoscopy has been proposed for preoperative evaluation of the posterior segment, ciliary ablation and for vitreoretinal surgery although wide-angle viewing systems remains standard practice. The osteo-odonto-keratoprosthesis is the procedure of choice for rehabilitation of corneal blindness for end-stage ocular surface disease, serving a completely different patient group to the Boston Type 1 KPro.

Preventing complications of OOKP surgery

AbstractOsteo‐odonto‐keratoprosthesis (OOKP) is the procedure of choice for end stage ocular surface disease with severe dryness and keratinisation, and in those eyes with structural and functional lid abnormalities. The device retention rates and visual outcomes of the OOKP are far superior than any other keratoprosthesis. However, this device can have complications at every step during surgery and unto many years afterwards. Complications after the Stage 1 include: mucosal thinning and ulceration, mouth related, resorption of the implanted lamina and infections. Complications after the Stage 2 include: mucosal thinning and ulceration, mucosal overgrowth onto the optic, lid malpositions, lamina problems like resorption, tilting, infection, posterior segment complications like retinal detachment and vitreous haemorrhage. Glaucoma is a major cause of visual loss in a successful OOKP eye. Social and psychological complications can arise after visual restoration or the preexisting problems can continue. In addition, operative complications, systemic morbidity and anesthetic related problems do occur. A majority of the complications can be sight threatening if not rectified appropriately in a good time. They may be preventable or reducible with correct patient selection, improvements in preoperative and postoperative patient care and education. A sound surgical technique, reflective learning, harnessing the medical technology and multidisciplinary team approach can effectively reduce and treat the complications of OOKP surgery. Multidisciplinary team approach, having an experienced anesthetist and psychologist on board, and a continuous social support will prevent patient morbidity and optimise good outcomes.

OOKP protocol update

Abstract Purpose The OOKP remains the procedure of choice for restoring sight in patients with corneal blindness caused by end‐stage ocular surface disease not amenable to cadaveric keratoplasty. Falcinelli's modifications of Strampelli's technique of OOKP surgery remains the gold standard for its excellent visual and keratoprosthesis‐retention results. To maintain good outcomes, aid research and to maintain standards, it is important that benchmarks are maintained in patient selection and preoperative assessment, surgical technique and post‐operative care. We therefore present, for discussion, the updated protocol that is currently used in the British National OOKP Referral Centre at the Sussex Eye Hospital, Brighton. Methods Members of the OOKP Study Group met in Rome, Italy in 2001 and Vienna, Austria in 2002 to produce and up‐to‐date standard and protocol. Since then, we have continued to update our protocol on the basis of our own outcomes and findings. We present our updated protocol for discussion and for use in other OOKP centres. Results Our updated protocol includes a discussion on the indications and contraindications for surgery, criteria for patient selection, surgical technique, routine postoperative care, and the recognition and management of postoperative complications. Conclusion 5 years have passed since the standards for modified OOKP surgery were published. This paper highlights changes to this standard resulting from our practice in our national OOKP centre.

Visual rehabilitation in end-stage inflammatory ocular surface disease with the osteo-odonto-keratoprosthesis: results from the UK

Aims:To report the long-term results of osteo-odonto-keratoprosthesis (OOKP) surgery in the visual rehabilitation of patients with corneal blindness from end-stage inflammatory ocular surface disease.Methods:A non-comparative retrospective case series of 36...

UK experience and evolving strategies to improve results I ‐ clinical results

Abstract Purpose: To report the long term results of osteo‐odonto‐keratoprosthesis (OOKP) surgery in the visual rehabilitation of patients with corneal blindness from end stage inflammatory ocular surface disease. Methods: A non‐comparative retrospective interventional case series.36 consecutive patients treated at the National OOKP referral centre in Brighton, United Kingdom, between November 1996 and March 2006.Osteo‐odonto‐keratoprosthesis surgery performed in line with the Rome‐Vienna protocol.Anatomical retention, visual acuity, retention of best attained visual acuity, visual field, complications resulting in anatomical or visual failure, de novo glaucoma rate. Results: A total of 36 patients, with age ranging from 19 to 87 years (mean 51 ± 19 years), were included in the analysis. The main preoperative diagnoses were Stevens Johnson syndrome (n=16, or 44%), severe thermal or chemical burns (n=6, or 17%), and mucous membrane pemphigoid (n=5, or 14%). The remainder of the cases comprised miscellaneous causes of dry eye (n=9, or 25%), which included one each of graft versus host disease, ectodermal dysplasia, ionising radiation damage, cicatrising conjunctivitis from topical medication, trachoma, congenital trigeminal nerve hypoplasia, linear IgA disease, Sjogren’s syndrome, and nutritional deficiency. Follow‐up ranged from 6 months to nine years (mean 3.86 ± 2.45 years). Anatomical retention during the entirety of the follow‐up period was seen in 72% of patients. The main factor resulting in anatomical failure was resorption of the OOKP lamina, which occurred in seven cases (or 19%). Predicted resorption in three cases resulted in successful planned exchange of the lamina, but two cases underwent emergency removal of the OOKP, and two cases developed endophthalmitis. HLA matched allografts suffered a higher rate of laminar resorption. Out of the entire cohort, thirty patients (or 83%) had some improvement in vision, twenty eight (or 78%) achieved vision of 6/60 or better, and nineteen (or 53%) achieved 6/12 or better. The best‐achieved vision was retained throughout the follow‐up period in 61% of cases. Survival analysis suggested that the probability of retaining vision >6/60 five years after surgery was 53%±10%. Vision threatening complications occurred in 9 cases (or 25%), and included endophthalmitis, retinal detachment, and glaucoma. De novo glaucoma occurred in six patients (or 24%) but was seen overall in seventeen patients (or 47%), ten of whom required surgical treatment. Conclusions: OOKP surgery can restore useful and lasting vision in patients suffering from end stage ocular surface disease, for whom conventional corneal surgery is not possible. The main problems seen in this study were laminar resorption, particularly in allografts, and glaucoma.

Standards for Modified Osteoodontokeratoprosthesis (OOKP) Surgery According to Strampelli and Falcinelli

To establish a time-proven "gold standard" in modified osteoodontokeratoprosthesis (OOKP) surgery. The OOKP is the procedure of choice for restoring sight in patients with corneal blindness caused by end-stage ocular surface disease not amenable to penetrating keratoplasty. Members of the OOKP Study Group met in Rome, Italy in 2001 and Vienna, Austria in 2002 to discuss indications and contraindications, patient selection, surgical technique, postoperative care, and recognition and management of complications of OOKP surgery according to Strampelli and modified by Falcinelli. Falcinelli's modification of Strampelli's technique of OOKP surgery remains the gold standard as far as visual and keratoprosthesis-retention results are concerned. The agreement on indications and contraindications, patient selection, surgical technique, postoperative care, and recognition and management of complications of this technique of OOKP surgery is summarized in the text of this manuscript. This standard technique of modified OOKP surgery, where adequately performed, is capable of providing excellent anatomic and functional results even in the long term. In patients with corneal blindness untreatable by other approaches, we strongly recommend this technique for visual rehabilitation. Students of OOKP surgery should become familiar with the protocol described in this paper before subjecting the technique to further modifications.