Microbial Keratitis and Endophthalmitis After the Boston Type 1 Keratoprosthesis.

PURPOSE: To determine the incidence, ocular surface disease associations, microbiological profile, and clinical course of postoperative infections after implantation of the Boston type 1 keratoprosthesis (KPro-1). METHODS: A retrospective chart review was conducted of all cases of the KPro-1 performed at a tertiary eye care center between January 1, 2008, and December 31, 2014. RESULTS: Seventy-five KPro-1 procedures were included in the analysis. Postoperative infections occurred in 13 eyes (17.3%) with an incidence of 0.064 cases per eye-year. The Kaplan-Meier probability of an infection-free graft was 0.96, 0.90, 0.88, 0.87, and 0.86 at years 1 through 5, respectively. The rate of infections was greater in eyes with ocular surface disease (26.3% vs. 8.1%, P = 0.06), especially in those with a history of chemical or thermal injury or herpes zoster keratopathy (P = 0.001). There were 8 cases (10.7%) of microbial keratitis due to either fungi (5 cases) or bacteria (3 cases). There were 7 cases (9.3%) of endophthalmitis due to bacteria (5 cases) or intraocular extension of fungal keratitis (2 cases). The incidence of microbial keratitis and endophthalmitis was 0.034 and 0.03 cases per eye-year, respectively. Therapeutic management of the infected eyes required graft and device removal in 7 eyes (53.8%). After completion of microbiologic treatment, 7 eyes (53.8%) had lost more than 2 lines of the best-corrected preinfection visual acuity, including 5 eyes with endophthalmitis that had hand motion vision or worse. CONCLUSIONS: Postoperative infections are a serious issue that compromises device retention and visual outcomes after keratoprosthesis implantation.

Boston type 1 keratoprosthesis for failed keratoplasty.

The purpose of this study was to evaluate the outcomes of the Boston type 1 keratoprosthesis (Kpro-1) in eyes with failed keratoplasty. A retrospective review was performed of every patient treated with a Kpro-1 at a tertiary eye care center between January 1, 2008 and July 1, 2013. Eyes with a failed keratoplasty originally performed for corneal edema, trauma, or keratoconus were included in the statistical analysis. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications. Twenty-four eyes met the inclusion criteria, including 13 eyes with corneal edema, 8 eyes with trauma, and 3 eyes with keratoconus. After a mean follow-up period of 28.9 months (range 7-63 months), the median best corrected visual acuity (BCVA) was 20/125. The BCVA was ≥ 20/40 in 4 (16.7 %) eyes, ≥ 20/70 in 9 (37.5 %) eyes, and ≥ 20/200 in 14 (58.3 %) eyes. Overall, the postoperative BCVA improved in 17 (70.9 %) eyes, was unchanged in 3 (12.5 %) eyes, and was worse in 4 (16.7 %) eyes. The initial Kpro-1 was retained in 22 (91.7 %) eyes, and was successfully repeated in the other 2 eyes. One or more serious prosthesis- or sight-threatening complications occurred in 8 (33.3 %) eyes. These included 1 case of wound dehiscence leading to prosthesis extrusion, 1 case of fungal keratitis leading to prosthesis extrusion, 4 cases of endophthalmitis, and 5 retinal detachments. The Boston Kpro-1 is associated with an excellent prognosis for prosthesis retention and satisfactory visual improvement in eyes with previous failed keratoplasty.

Boston type 1 keratoprosthesis for chemical and thermal injury.

PURPOSE: To evaluate the outcome of the Boston type 1 keratoprosthesis (Kpro-1) in eyes with failed interventions for chemical and thermal injury. METHODS: A retrospective review was performed of every eye with chemical or thermal injury that was treated with a Kpro-1 at a tertiary eye care center between January 1, 2008 and July 1, 2013. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications. RESULTS: Nine eyes met the inclusion criteria, including 7 eyes with alkali burns, 1 eye with an acid burn, and 1 eye with a thermal burn. After a mean follow-up of 40.7 months (range, 29-60 months), the median best-corrected visual acuity was 20/60 (range, 20/15 to no light perception). One eye was ≥20/20, 3 eyes were ≥20/40, and 6 eyes were ≥20/70. The initial Kpro-1 prosthesis was retained in 7 (77.7%) eyes and successfully replaced in the other 2 eyes. One or more serious complications occurred in 6 (66.7%) eyes. These included 2 cases of sterile corneal ulceration with prosthesis extrusion, 2 cases of microbial keratitis (1 bacterial and 1 fungal), 2 cases of bacterial endophthalmitis, and 2 cases of retinal detachments. These complications contributed to visual outcomes of hand motions in 2 eyes and no light perception in 1 eye. CONCLUSIONS: The Boston Kpro-1 is associated with highly satisfactory visual outcomes and prosthesis retention in most cases of severe chemical or thermal injury. Serious complications are common and may compromise the final outcome.

Medically reversible limbal stem cell disease: clinical features and management strategies.

PURPOSE: To describe the clinical features and management strategies in patients whose limbal stem cell (LSC) disease reversed with medical therapy. DESIGN: Retrospective case series. PARTICIPANTS: Twenty-two eyes of 15 patients seen at 3 tertiary referral centers between 2007 and 2011 with 3 months or more of follow-up. METHODS: Medical records of patients with medically reversible LSC disease were reviewed. Demographic data, causes, location and duration of disease, and medical inventions were analyzed. MAIN OUTCOME MEASURES: Primary outcomes assessed included resolution of signs of LSC disease and improvement in visual acuity. RESULTS: Causes of the LSC disease included contact lens wear only (13 eyes), contact lens wear in the setting of ocular rosacea (3 eyes), benzalkonium chloride toxicity (2 eyes), and idiopathic (4 eyes). Ophthalmologic findings included loss of limbal architecture, a whorl-like epitheliopathy, or an opaque epithelium arising from the limbus with late fluorescein staining. The superior limbus was the most common site of involvement (95%). The corneal epithelial phenotype returned to normal with only conservative measures, including lubrication and discontinuing contact lens wear in 4 patients (4 eyes), whereas in 11 patients (18 eyes), additional interventions were required after at least 3 months of conservative therapy. Medical interventions included topical corticosteroids, topical cyclosporine, topical vitamin A, oral doxycycline, punctal occlusion, or a combination thereof. All eyes achieved a stable ocular surface over a mean follow-up of 15 months (range, 4-60 months). Visual acuity improved from a mean of 20/42 to 20/26 (P < 0.0184). CONCLUSIONS: Disturbances to the LSC function, niche, or both may be reversible with medical therapy. These cases, which represent a subset of patients with LSC deficiency, may be considered to have LSC niche dysfunction.

Boston keratoprosthesis type 1 for herpes simplex and herpes zoster keratopathy.

PURPOSE: The aim of this study was to evaluate and compare the outcomes of Boston keratoprosthesis type 1 (Kpro-1) in eyes with herpes simplex virus (HSV) and herpes zoster virus (HZV) keratopathy. METHODS: A retrospective review was performed of the medical records of every patient treated with a Boston Kpro-1 at the University of Iowa Hospitals and Clinics between January 1, 2008 and July 1, 2012. Eyes with visual loss due to HSV or HZV keratopathy were included in the statistical analysis. The main outcome measures were graft retention, postoperative complications, and visual outcome. RESULTS: Nine eyes met the inclusion criteria, including 5 eyes in the HSV group and 4 eyes in the HZV group. The graft retention rate was 100% in the HSV group after a mean follow-up of 48.4 months, compared with 25% in the HZV group after 50.5 months (P = 0.048). There were 3 cases of microbial keratitis, including 2 eyes that also developed endophthalmitis, in the HZV group, compared with no cases in the HSV group (P = 0.048). There was significantly better best-corrected visual acuity at the most recent examination in the HSV group than in the HZV group (P = 0.019). All 5 HSV eyes had improved best-corrected visual acuity compared with preoperative acuity, whereas only 1 HZV eye experienced a similar result (P = 0.048). CONCLUSIONS: Kpro-1 is associated with an excellent prognosis for graft retention, acceptably low prevalence of sight-threatening complications, and highly satisfactory visual improvement in eyes with HSV keratopathy, but not in eyes with HZV keratopathy.

Conjunctival limbal autograft and allograft transplantation using fibrin glue.

BACKGROUND AND OBJECTIVE: Conjunctival limbal autograft is the surgical treatment of choice for visually significant unilateral limbal stem cell deficiency. The use of fibrin glue, which has been reported extensively in pterygium and other conjunctival surgeries, has not been fully described in limbal stem cell transplantation. PATIENTS AND METHODS: The authors reviewed 3 cases of conjunctival limbal autograft and 1 of living related conjunctival limbal allograft using only fibrin glue to secure the graft. Main outcome measures included ocular surface stability, visual acuity, and postoperative complications. RESULTS: At most recent follow-up, all 4 patients (100%) maintained a stable ocular surface. Mean epithelial healing time was 10 days. Mean visual acuity improved from 20/400 to 20/53. All grafts were successful with no postoperative dislocations or displacements. CONCLUSION: The findings demonstrate that fibrin glue can be used safely and effectively to secure conjunctival limbal grafts in limbal stem cell deficiency. This novel approach has the potential to decrease operative time, increase ease of technique, and improve patient comfort postoperatively.

Surgical and visual outcomes of the type I Boston Keratoprosthesis for the management of aniridic fibrosis syndrome in congenital aniridia.

PURPOSE: To report the clinical features and surgical management of aniridic fibrosis syndrome using the type I Boston Keratoprosthesis (KPro). DESIGN: Interventional case series. METHODS: Retrospective chart review of 9 eyes in 9 patients with congenital aniridia that developed aniridic fibrosis syndrome. RESULTS: All patients had clinical diagnosis of congenital aniridia. Previously, all patients had undergone cataract surgery with posterior chamber intraocular lens (IOL) implantation and 7 patients had existing tube shunts. In all cases, fibrosis presented as progressive retrocorneal and retrolenticular membrane formation causing displacement of the IOL and secondary corneal decompensation. Two eyes had tractional folds in the retina with posterior extension of the membrane. The management included IOL explantation in 7 of 9 cases, removal of fibrosis with pars plana vitrectomy in all 9 patients, and implantation of a type I Boston KPro in all eyes. At a mean final follow-up of 26.1 months (range 6 to 48 months), vision remained improved in all patients. No patient had recurrence of the fibrotic membrane after KPro implantation. CONCLUSION: This study represents another case series describing aniridic fibrosis syndrome and the largest study to report utilization of the type I Boston KPro in such patients. As the fibrosis can cause IOL dislocation, corneal decompensation, hypotony, and retinal detachment, monitoring for aniridic fibrosis syndrome in congenital aniridia with early surgical intervention is recommended. Type I Boston KPro may be considered in the surgical treatment of this condition.