Keratoprosthesis: The Dohlman-Doane Device

doi:10.1016/j.ajo.2005.06.041

American Journal of Ophthalmology

Volume 140, Issue 6, December 2005, Pages 1032-1038.e2

https://doi.org/10.1016/j.ajo.2005.06.041 Get rights and content

Purpose

To determine the usefulness of the Dohlman-Doane type I keratoprosthesis for visual rehabilitation in cases of poor prognosis for traditional penetrating keratoplasty.

Design

A retrospective, noncomparative interventional series of 25 patients who had sustained multiple graft failure or who were otherwise deemed poor candidates for conventional keratoplasty.

Methods

Candidates were evaluated for potential acuity, intraocular pressure, inflammation, the quality of the ocular surface, and overall prognosis for penetrating keratoplasty. The keratoprosthesis was assembled and mounted on an 8.5- or 9.0-mm diameter donor corneal button and sutured into an 8.0- or 8.5-mm diameter recipient bed with 12 to 16 9–0 nylon sutures. Patients were examined on the first day and subsequently in 1 week and 1 month and then at 3-month intervals.

Results

All devices were retained without dislocation or extrusion. There were no instances of endophthalmitis or surface infection. Fundus details were visible on the first postoperative day. Patients achieved their best acuity in an average of 2 months (range, 1 to 180 days). Improvement in acuity was observed in an average of 13 days (range, 1 to 60 days). Retroprosthetic membranes occurred in three cases, with multiple recurrences in one instance. Visual acuity ranged from no light perception to 20/25.

Conclusion

We conclude that this prosthesis can be implanted routinely and maintained with minimal complications in poor prognosis keratoplasty, which presents the potential for visual rehabilitation.

Section snippets

Study Population

Characteristics of the study population are summarized in TABLE 1, TABLE 2.

All patients were evaluated before surgery by one of the authors (J.V.A.) and were determined to have sustained multiple failures of previous penetrating keratoplasty or were otherwise deemed to be poor candidates for penetrating keratoplasty. Preoperative testing included an evaluation of visual acuity and visual potential. When the posterior pole could not be visualized, B scan ultrasonography was performed. Light

Results

Visual acuity ranged from no light perception to 20/25. The visual results are summarized in TABLE 3, TABLE 4. Patients achieved their best acuity in an average of 60 days (range, 1 to 180 days). Improvement in acuity occurred in an average of 13 days (range, 1 to 60 days). Most of the refractive error of our patients ranged from +1.00 to –5.00 spheric, except one case which was –12.50. The one case of high myopia (–12.50) was the result of an aphakic power device that had been implanted

Discussion

The prognosis for this type of surgery should be evaluated in both general and specific terms. A number of reports have confirmed our opinion that a history of recurrent inflammation and an association with autoimmune disease increase the risk factors of and potential for complication.8, 14, 16, 17 Thus, there is a role for both systemic and topical anti-inflammatory agents. We have used 1% prednisolone acetate four times daily over the first few months after operation and have to date

James V. Aquavella, MD, is Professor of Ophthalmology at the University of Rochester Eye Institute and was the first fellowship trained corneal surgeon in the US. He is the author of over 300 peer-reviewed publications and has trained scores of clinical and research fellows. His primary research activity has been endothelial morphology and corneal wound healing. He has been active in the development and clinical evaluation of keratoprosthesis for over 35 years.

References (28)

C.R. Hicks et al.
Keratoprosthesisadvancing toward a true artificial cornea
Surv Ophthalmol
(1997)
H. Cardona
KeratoprosthesisAcrylic optical cylinder with supporting intralamellar plate
Am J Ophthalmol
(1962)
G.N. Rao et al.
Results of keratoprosthesis
Am J Ophthalmol
(1979)
C.H. Dohlman et al.
Prosthokeratoplasty
Am J Ophthalmol
(1974)
J.V. Aquavella et al.
Keratoprosthesisresults, complications and management
Ophthalmology
(1982)
J.J. Barnham et al.
Keratoprosthesisa long term review
Br J Ophthalmol
(1983)
D.P. Choyce
Results of keratoprosthesis in Britain
Ophthalmic Surg
(1973)
L.J. Girard
Girard keratoprosthesis with flexible skirt28 years experience
Refract Corneal Surg
(1993)
W. Stone et al.
A 15-year study of the plastic artificial cornea basic principles
K. Hille
Keratoprosthesisclinical aspects
Ophthalmologe
(2002)

A.G. DeVoe

Keratoprosthesishistory, techniques and indications

Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol

(1977)

K.J. Lindahl et al.

Complications of keratoprosthesis spontaneous unscrewing of optical cylindera case report

Cornea

(1992)

J.K. Harris et al.

Keratoprosthesistechniques and instrumentation

Ann Ophthalmol

(1984)

C.H. Dohlman et al.

Keratoprosthesisbeyond corneal graft failure

Cited by (73)

Glycosaminoglycans: Roles in wound healing, formation of corneal constructs and synthetic corneas
2023, Ocular Surface
Maintaining the clarity of the cornea is essential for vision, and is achieved through an exquisite array of collagen fibrils and proteoglycans in the corneal stroma. Alterations in the identity and modifications of the glycosaminoglycans (GAGs) are seen both throughout the normal wound healing process and in pathological conditions resulting in corneal opacity. Understanding these changes has been essential for the development of corneal prostheses and corneal reconstruction. The goal of this review article is to summarize and consolidate research in the alterations seen in glycosaminoglycans in injured and hypoxic states, address the role of proteins that can regulate glycosaminoglycans in the corneal wound healing process, and apply these findings to the context of corneal restoration through reconstruction or the insertion of synthetic devices.
Long-term Visual Outcomes and Complications of Boston Keratoprosthesis Type II Implantation
2017, Ophthalmology
To report the long-term visual outcomes and complications after Boston keratoprosthesis type II implantation in the largest single-center case series with the longest average follow-up.
Retrospective review of consecutive clinical case series.
Between January 1992 and April 2015 at the Massachusetts Eye and Ear Infirmary, 48 eyes of 44 patients had keratoprosthesis type II implanted by 2 surgeons (C.H.D. and J.C.).
For each eye, data were collected and analyzed on the preoperative characteristics, intraoperative procedures, and postoperative course.
Visual acuity outcomes, postoperative complications, and device retention.
The most common indications for surgery were Stevens–Johnson syndrome in 41.7% (20 of 48 eyes) and mucous membrane pemphigoid in 41.7% (20 of 48 eyes). Mean follow-up duration was 70.2 months (standard deviation, 61.8 months; median, 52 months; range, 6 months to 19.8 years). Almost all patients (95.8%, 46 of 48 eyes) had a preoperative visual acuity of 20/200 or worse. Postoperative visual acuity improved to 20/200 or better in 37.5% (18 of 48 eyes) and to 20/100 or better in 33.3% (16 of 48 eyes) at the last follow-up visit. The most common postoperative complication was retroprosthetic membrane formation in over half (60.4%, 29 of 48 eyes). The most pressing postoperative complication was glaucoma onset or progression in about a third. Preexisting glaucoma was present in 72.9% (35 of 48 eyes). Glaucoma progressed in 27.1% (13 of 48 eyes) and was newly diagnosed in 8.3% (4 of 48 eyes) after surgery. Other postoperative complications were tarsorrhaphy revision in 52.1% (25 of 48 eyes), retinal detachment in 18.8% (9 of 48 eyes), infectious endophthalmitis in 6.3% (3 of 48 eyes), and choroidal detachment or hemorrhage in 8.3% (4 of 48 eyes). Half of eyes retained their initial keratoprosthesis at the last follow-up (50.0%, 24 of 48 eyes).
The Boston keratoprosthesis type II is a viable option to salvage vision in patients with poor prognosis for other corneal procedures. Retroprosthetic membranes, keratoprosthesis retention, and glaucoma are major challenges in the postoperative period; however, the keratoprosthesis can still provide improved vision in a select group of patients.
Boston Type 1 Keratoprosthesis versus Repeat Donor Keratoplasty for Corneal Graft Failure: A Systematic Review and Meta-analysis
2016, Ophthalmology
To compare repeat penetrating keratoplasty (PK) with Boston type I keratoprosthesis (KPro) implantation for full-thickness donor corneal graft failure.
Previous donor graft failure is a common indication for both PK and KPro implantation. Selection of the surgical procedure is entirely dependent on the surgeon because there are no studies available for guidance. Therefore, a systematic review was undertaken to examine vision, device retention, graft clarity, and postoperative glaucoma and infection outcomes after repeat PK versus KPro implantation.
Articles with data regarding repeat PK published between 1990 and 2014 were identified in PubMed, EMBASE, the Latin American and Caribbean Health Sciences Literature Database, and the Cochrane Central Register of Controlled Trials and were reviewed. Results were compared with a retrospective review of consecutive, nonrandomized, longitudinal case series of KPro implantations performed at 5 tertiary care centers in the United States. Visual acuity at 2 years was the primary outcome measure. The proportion of clear grafts in the repeat PK group, device retention in the KPro group, and the development of postoperative glaucoma and infection were secondary outcome measures.
The search strategy identified 17 128 articles in the PK analysis. After screening, 26 studies (21 case series and 5 cohort studies) were included in the review. Pooled analysis of the 26 unique studies demonstrated a 42% (95% confidence interval [CI], 30%–56%) likelihood of maintaining 20/200 or better at 2 years after repeat PK, compared with an 80% (95% CI, 68%–88%) probability with KPro implantation. The probability of maintaining a clear graft at 5 years was 47% (95% CI, 40%–54%) after repeat PK, whereas the probability of retention of the KPro at 5 years was 75% (95% CI, 64%–84%). The rate of progression of glaucoma at 3 years was 25% (95% CI, 10%–44%) after repeat PK and 30% in the KPro cohort.
These results demonstrate favorable outcomes of KPro surgery for donor corneal graft failure with a greater likelihood of maintaining visual improvement without higher risk of postoperative glaucoma compared with repeat donor PK.
Boston keratoprosthesis - Clinical outcomes with wider geographic use and expanding indications - A systematic review
2015, Saudi Journal of Ophthalmology
Citation Excerpt :
The B-KPro is indicated for patients with refractory corneal blindness and having extremely poor prognosis for penetrating keratoplasty. A review of literature revealed that secondary keratoprosthetic implantation (KPro implantation attempted after failed corneal graft) accounted for majority of the cases, as high as 95% of the procedures in a study from Jordan, followed by 88% and 87% in two studies from the United States (Table 1).5,6,9 The two large data set multicenter studies involving up to 300 eyes also reported failed corneal graft to be the most common indication (85–86%).32,33
Over 2 decades of research, several design modifications, and improvements in post-operative management have made Boston keratoprosthesis (B-KPro) a viable option for patients with corneal blindness for whom traditional keratoplasty procedure has a very low probability of success. In this systematic review, we examined the indications, visual outcomes, complications and retention rate of the literature published in the past 10 years (2005–2014). While most of the studies report smaller datasets (typically <50 eyes), some of the recent multicenter studies have reported large datasets (up to 300 eyes). Most of the literature is published from the US; however, last few years have witnessed some papers reporting the successful use of B-Kpro from developing countries or arid climatic conditions (such as the Kingdom of Saudi Arabia). Due to differences in the causes of corneal blindness in different geographic regions, newer indications for B-Kpro are emerging (e.g. trachoma). Additionally, improving clinical outcomes and increasing surgeon confidence have also expanded indications to include cases of unilateral visual impairment and paediatric age. We observed that there is growing body of evidence of successful clinical use of B-KPro; however, financial challenges, lack of trained surgeons, shortage of donor corneas must be overcome to improve accessibility of B-KPro.
Anterior segment optical coherence tomography in the long-term follow-up and detection of glaucoma in boston type i keratoprosthesis
2015, Ophthalmology
To evaluate the role of anterior segment (AS) optical coherence tomography (OCT) as a standardized method of imaging Boston type I keratoprosthesis (KPro) after surgery, particularly in the visualization of iris and angle structures.
Prospective case series.
Twenty patients who underwent KPro implantation in 1 eye.
Patients underwent AS OCT imaging before surgery. After KPro implantation, patients were imaged using the AS single, dual, and quad scans to obtain transverse images of the eye every 15° over 360°. High-resolution, corneal quad, and anterior chamber scans were also obtained. This imaging protocol allowed juxtaposition and comparison of the same imaging coordinates obtained before surgery and 3, 6, and 12 months after surgery.
Postoperative visual acuity (VA), glaucoma progression on clinical examination and formal visual field testing, and anatomic angle changes on AS OCT defined by angle closure, peripheral anterior synechiae (PAS), iris–KPro backplate touch, and graft–host interface changes over time.
Mean follow-up was 18.8±3.2 months. The average preoperative VA was 1.9±0.5 logarithm of the minimum angle of resolution. After surgery, VA improved to 1.0±0.9 at last follow-up (P = 0.002). Fourteen of 20 patients had glaucoma before surgery. After surgery, 5 of these patients deteriorated clinically and 1 de novo diagnosis of glaucoma was made. On OCT, the average total degrees of angle closure for all patients increased from 158.5±158.9° before surgery to 205.4±154.0° after surgery (P = 0.04). The number of eyes with 360° of PAS increased from 6 of 20 before surgery to 9 of 20 after surgery. Iris–backplate touch was demonstrated in 5 of 20 patients, with an average area of involvement of 24.2±36.2°. Overall, of the 12 of 20 patients with clear signs of anatomic angle narrowing and synechiae progression on imaging, 3 had glaucoma deterioration detected by clinical examination. In the other 9 patients, angle changes on OCT were not accompanied by any detectable clinical signs of glaucomatous deterioration.
Anterior segment OCT can be used to observe anatomic changes after KPro implantation that cannot be detected otherwise. We were unable to demonstrate a correlation between anatomic features and clinical progression.
Experience with Boston keratoprosthesis type 1 in the developing world
2014, Canadian Journal of Ophthalmology
To report the experience of the Federal University of São Paulo, Brazil, in performing Boston keratoprosthesis type 1 implantation in the developing world.
We analyzed 30 eyes of 30 patients who underwent Boston type 1 keratoprosthesis surgery between 2008 and 2012 in a prospective interventional study. Preoperative, perioperative, and postoperative parameters were analyzed, including visual acuity (VA), keratoprosthesis stability, and postoperative complications.
Preoperative diagnoses were failed grafts in 16 eyes (53.33%), chemical injury in 10 eyes (33.33%) and Stevens–Johnson syndrome in 4 eyes (13.33%). Also, 16 eyes (53.33%) had preoperative glaucoma. Preoperative best corrected VA ranged from 20/400 to light perception. With an average follow-up of 32 months (range 1–55 months), postoperative vision improved to >20/200 in 24 eyes (80%). Postoperative VA was statistically improved compared with the preoperative measurement during all postoperative follow-ups (up to 36 months). During the follow-up period (32 months), retention of the initial keratoprosthesis was 93.3%. The incidence of retroprosthetic membrane was 26.66%. Progression of glaucoma occurred in 7 of 16 eyes (43%). Three patients experienced development of glaucoma after keratoprosthesis implantation. One eye experienced development of infectious keratitis, and 2 eyes had retinal detachment.
Performing Boston type 1 keratoprosthesis in a developing country is a viable option after multiple keratoplasty failures and conditions with a poor prognosis for keratoplasty. Our experience appears similar to major reports in the field from investigators in developed countries. Adjustments to postoperative management must be considered according to the particular location.
Comte rendu de l’expérience de l’Université fédérale de Sao Paulo, Brésil, concernant l’utilisation de la kératoprothèse Boston de Type 1 dans le développement mondial.
Trente yeux de 30 patients qui avaient subi une chirurgie de kératoprothèse Boston de Type 1 entre 2008 et 2012 ont été analysés dans une étude prospective d’intervention. Les paramètres préopératoires, peropératoires et postopératoires ont été colligés et analysés. Le principal résultat a porté sur l’acuité visuelle (AV), la stabilité de la kératoprothèse et les complications postopératoires.
Les diagnostics préopératoires étaient : un échec de la greffe dans 16 yeux (53,33 %); une blessure chimique (10 yeux [33,33 %]); et le syndrome Stevens Johnson (4 yeux [13,33 %]). Seize yeux (53,33 %) avaient un glaucome préopératoire. La meilleure AV corrigée préopératoire variait de 20/400 à PL. Lors d’un suivi d’une moyenne de 32 mois (allant de 1 à 55), la vision postopératoire s’était améliorée à >20/200 dans 80 % des cas. L’acuité visuelle postopératoire était statistiquement meilleure que les mesures préopératoires à tous les moments postopératoires (jusqu’à 36 mois). Dans une moyenne de 32 mois de suivi, la rétention de la kératoprothèse initiale était de 93,3 %. L’incidence de la membrane rétroprothétique était de 26,66 %. Un œil a développé une kératite infectieuse. Deux yeux ont développé un décollement de la rétine.
L’expérimentation de la kératoprothèse Boston Type 1 dans le monde en développement a démontré une option viable après plusieurs échecs de kératoplastie ou dans des conditions de faible pronostic de kératoplastie. Notre expérience ressemble aux principaux rapports dans ce domaine dans les pays développés. Des ajustements de gestion postopératoire doivent être considérés selon les particularités de chaque emplacement, spécialement dans les pays en voie de développement.

View all citing articles on Scopus

Ying Qian, MD, PhD, is a senior resident at the University of Rochester, Department of Ophthalmology. Following her PhD in experimental pathology at the University of South Carolina she was a post-doctoral fellow in Ocular and Transplantation Immunology at Schepens Eye Research Institute. Her research interests are immune modulation and gene therapy in corneal transplantation and more recently in alternative modes of therapy in poor-risk keratoplasty.

View full text

Original articleKeratoprosthesis: The Dohlman-Doane Device

Purpose

Design

Methods

Results

Conclusion

Section snippets

Study Population

Results

Discussion

Surv Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Keratoprosthesisa long term review

Br J Ophthalmol

Results of keratoprosthesis in Britain

Ophthalmic Surg

Girard keratoprosthesis with flexible skirt28 years experience

Refract Corneal Surg

A 15-year study of the plastic artificial cornea basic principles

Keratoprosthesisclinical aspects

Ophthalmologe

Keratoprosthesishistory, techniques and indications

Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol

Complications of keratoprosthesis spontaneous unscrewing of optical cylindera case report

Cornea

Keratoprosthesistechniques and instrumentation

Ann Ophthalmol

Keratoprosthesisbeyond corneal graft failure

Original article
Keratoprosthesis: The Dohlman-Doane Device