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The Osteo-Odonto-Keratoprosthesis (OOKP)

Seminars in Ophthalmology,20:113 128, 2005 Copyright cTaylor & Francis : 0882-0538 DOI: ( ookp )Christopher LiuSussex Eye Hospital, Brighton,England, Aston University,Birmingham, England, and KinkiUniversity, Osaka, JapanBobby PaulSussex Eye Hospital, Brighton, EnglandRadhika TandonSussex Eye Hospital, Brighton, Englandand All India Institute of MedicalSciences, New Delhi, IndiaEdward Lee, Ken Fong, andIoannis MavrikakisSussex Eye Hospital, Brighton, EnglandJim Herold and Simon ThorpRoyal Sussex County Hospital,Brighton, EnglandPaul BrittainSussex Eye Hospital, Brighton, EnglandIan FrancisRoyal Sussex County Hospital,Brighton, EnglandColin FerrettEuropean Scanning Clinic,London, EnglandChris HullCity University, London, EnglandAndrew LloydUniversity of Brighton,Brighton, EnglandDavid Green, Valerie Franklin,and Brian TigheAston University, Birmingham.

The Osteo-Odonto-Keratoprosthesis (OOKP)

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Transcription of The Osteo-Odonto-Keratoprosthesis (OOKP)

1 Seminars in Ophthalmology,20:113 128, 2005 Copyright cTaylor & Francis : 0882-0538 DOI: ( ookp )Christopher LiuSussex Eye Hospital, Brighton,England, Aston University,Birmingham, England, and KinkiUniversity, Osaka, JapanBobby PaulSussex Eye Hospital, Brighton, EnglandRadhika TandonSussex Eye Hospital, Brighton, Englandand All India Institute of MedicalSciences, New Delhi, IndiaEdward Lee, Ken Fong, andIoannis MavrikakisSussex Eye Hospital, Brighton, EnglandJim Herold and Simon ThorpRoyal Sussex County Hospital,Brighton, EnglandPaul BrittainSussex Eye Hospital, Brighton, EnglandIan FrancisRoyal Sussex County Hospital,Brighton, EnglandColin FerrettEuropean Scanning Clinic,London, EnglandChris HullCity University, London, EnglandAndrew LloydUniversity of Brighton,Brighton, EnglandDavid Green, Valerie Franklin,and Brian TigheAston University, Birmingham.

2 EnglandMasahiko Fukuda andSuguru HamadaKinki University, Osaka, JapanABSTRACTT heosteo- odonto - keratoprosthesis ( ookp ), although describedover 40 years ago, remains the keratoprosthesis of choice for end-stage cornealblindness not amenable to penetrating keratoplasty. It is particularly resilientto a hostile environment such as the dry keratinized eye resulting from se-vere Stevens-Johnson syndrome, ocular cicatricial pemphigoid, trachoma, andchemical injury. Its rigid optical cylinder gives excellent image resolution andquality. The desirable properties of the theoretical ideal keratoprosthesis is de-scribed. The indications, contraindications, and patient assessment (eye, tooth,buccal mucosa, psychology) forOOKP surgery are described. The surgical andanaesthetic techniques are described.

3 Follow-up is life-long in order to detectand treat complications, which include oral, oculoplastic, glaucoma, vitreo-retinal complications and extrusion of the device. Resorption of the osteo - odonto -lamina is responsible for extrusion, and this is more pronounced intooth allografts. Regular imaging with spiral-CT or electron beam tomographycan help detect bone and dentine loss. The optical cylinder design is work towards the development of a syntheticOOKP analogueis described. Finally, we describe how to set up anOOKP national , ookp , surgery, dry eye, allografts, electron beam tomog-raphy, ciclosporin, opticsOsteo- odonto - keratoprosthesis ( ookp )surgery is a technique used to replacedamaged corneae in blind patients for whom cadaveric corneal transplantationis doomed to failure.

4 It was developed some 40 years ago by Strampelli and usesthe patient s own tooth root and alveolar bone to support an optical a long interval the technique is finally gaining widespread recognition bycorneal surgeons worldwide as the treatment of choice for patients with endstage inflammatory corneal disease. In the case of a dry eye, no other device willwork nearly as REVIEWK eratoprosthetics, replacing damaged and opaque corneae with an artificialimplant, dates back more than 200 years to Pellier de Quengsy, a French oph-thalmologist who proposed implanting a glass plate into an opaque Liu thanks ProfessorGianCarlo Falcinelli and Mr. MichaelRoper-Hall for their correspondence to ChristopherLiu, Sussex Eye Hospital, Eastern Road,Brighton, England BN2 5BF. Tel:+44(0)1273 606126; Fax:+44 (0)1273 693674;E-mail: surgical case in a human was performedin 1855 with a quartz crystal implant developed byNussbaum.

5 The prosthesis remained in the eye forsix months. Over the next 50 years, more attemptswere made to develop different keratoprostheses(KPros) and techniques (von Hippel 1877, Dimmer1889, and Salzer 1895). Almost all the implants wereextruded and in the early twentieth century, interestin keratoprostheses waned with the introduction ofpenetrating keratoplasty. The early pioneers in the fieldof penetrating keratoplasty included Elshnig in Prague(1914), Filatov (1924), and Tudor-Thomas, who intro-duced the technique to the United Kingdom (1936).Penetrating keratoplasty went from strength to strengthwith Stocker in the 1950s and was accompanied by theintroduction of steroids and fine needles and more diseases became suitable for penetrat-ing keratoplasty, there were still conditions where theprospect of successful grafts was hopeless and so interestwas renewed in keratoprostheses.

6 Many pioneers wereinvolved in developing new KPros (Gyorffy, Sommer,Vodovozov, Stone and Herbert, Macpherson andAnderson, Binder and Binder, Fyodorov, Puchkovska,Krasnov, Cardona, Castroviejo, de Voe, Choyce, Lund,Dohlman, Casey, Donn, Buxton, Girard, Maroz,Pintucci, Marchi, Legeais, Lacombe, Worst, Polack,Aquavella,Waring,Bertelson,Singh, Mohan,Yakimako, Caldwell and Barraquer).2 WHAT IS THE IDEALKERATOPROSTHESIS?In developing a KPro, the ideal device should be ableto surpass the natural cornea by having an improvedoptical quality, with decreased aberrations and a speci-fiable power. It should have excellent biointegration,provide resistance against infection and last the life-time of the patient. It should also replicate some of thequalities of the cornea such as drug penetration and al-lowing intraocular pressure ,4 Thetypesof KPros currently available vary in design, especially re-garding the support for the optical cylinder.

7 Most mod-els use a non-biological skirt that is often porous PMMA (Choyce, Dohlman-Doane [now known asthe Boston KPro]), Dacron (Pintucci), hydroxy-apatite(Leon-Barraquer), expanded PTFE (Legeais) and hydro-gel (AlphaCor). KPros with biological skirts were alsodeveloped, as they were thought to be closer related toTABLE 1 Comparison of Devices. Clinical Studies Reported inPubMed and KPro Study Group Bibliography Including Articles inLanguages Other Than English and Those not Indexed in IndexMedicus (Updated May 2003)DeviceClinicalPapersPatientsFollow- up(Years)Cardona12 Champagne Cork10200 Chirila (AlphaCor)25383 Choyce5107 Dohlman-Doane (Boston) (PTFE)26242 OOKP9357327 Parel-Lacombe136010 Pintucci2012819 Seoul-type272the corneal tissue so that they would intergrate betterand be more compatible, such as the Strampelli ookp using autologous tooth root and alveolar bone as a sup-port for a PMMA optical cylinder, cartilage (Casey) andtibial bone (Temprano).

8 Comparison between the various KPros can be dif-ficult as the published studies are often retrospective,are uncontrolled and have conflicting data for differentcenters. The published literature is most extensive onOOKP surgery, which was the most number of patientsand the longest follow-up (Table 1). However, it mustbe pointed out that many of the publications are not inEnglish, are not widely available, and several are not inindexed differs in several ways from othertechniques, multi-stage (usually two) surgery is re-quired, and there is surgery both in the mouth andon the eye. Complications associated with all typesof KPros are extrusion, glaucoma, retinal detachmentand retroprosthetic membrane formation. The ookp could uniquely withstand a hostile dry keratinizedocular surface.

9 Falcinelli devised stepwise modifica-tions to the original Strampelli technique, which haveled to improved visual results and retention of thedevice. A biconvex larger optic, preservation of theperiosteum, cryo-extraction of the lens and vitrec-tomy, the use of buccal as opposed to labial mucousmembrane, allograft using a non-erupted tooth, join-ing two laminae together, and a posterior drainagetube in refractory glaucoma5,6are amongst Falcinelli Liu et GUIDELINES FOROOKP SURGERYI ndicationsPatients with bilateral corneal blindness resultingfrom severe end-stage Stevens-Johnson syndrome, oc-ular cicatricial pemphigoid, chemical burns, trachoma,dry eyes or multiple corneal graft failure may be consid-ered for ookp surgery. The better, or only, eye shouldhave poor vision, such as PL, HM or at best CF.

10 One eyeonly will be rehabilitated. In suitable cases, there wouldbe no need to go through unsuccessful penetrating ker-atoplasty with or without limbal stem cells transplanta-tion and amniotic membrane grafting who are happy and managing with their levelof vision, children under the age of 17, eyes that haveno perception of light, evidence of phthisis, advancedglaucoma or irreparable retinal detachment should beexcluded. Suitable candidates have to understand thatthe surgery can be prolonged they may require mul-tiple procedures and that there is a significant risk ofserious complications including loss of the eye. The pa-tient must be able to commit to life-long follow-up,and not have unreasonable expectations of outcomeand ASSESSMENTO phthalmic AssessmentIn Brighton, patients referred for possible ookp surgery attend a joint clinic headed by an ophthal-mologist and maxillofacial surgeon.


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