trials and tribulationstrials and tribulations chairs: konrad hille, masahiko fukuda, christopher...

10th KPro Study Group MeetingApril 22 (Fri) ‒23(Sat), 2016 Kyoto

Trials and tribulationsChairs: Konrad Hille, Masahiko Fukuda, Christopher Liu

1-1 KeynoteTitle: Trials and tribulationsHistory of KProsThe demise of Cardona, Choyce, Legeais

and AlphaCor devices

Author: Konrad Hille

Affiliation: Ortenauklinikum Offenburg, Germany

ThefirstsuggestiontoreplaceanopaquecorneabyalloplasticmaterialwasdonebyPellierdeQuengsyin1789.SincethentherehadbeenmanyeffortssearchingforapermanentfixationofsuchanartificialcorneaorKeratoprosthesis(KPro).DifferentdesignsofKProweredevelopedwithanintra-stromal,trans-corneal(nutandbold)or epi-stromalfixationandinthelastdecadealamellarapproach.Manydifferentmaterialshadbeenusedfortheopticandthesupport.OutofthehugenumberofdevicesthefocuswillbeonthosemorewidelyusedandwithahigherimpactinparticularthedeviceofCardona,Choyce,Pintucci,LegeaisandAlphaCor.

Inthesedevicesthemajorityofreasonsoffailureismeltingofcornealstromainfrontoftheprostheses(Cardona,Choyce,AlphaCor)andlackof"biointegration"(PMMA)ordisintegrationbychangeofabiointegrablesurface(Legeais,Pintucci)followedbyepithelialingrowthandleakageofaqueoushumor.NeverthelesstheknowledgeaboutsuccessandpitfallsofthosepioneersinKProisimportantunderstandingthematteranddevelopingbetterideasforanartificialKPro.

Study supported by: None

Conflictofinterest: None



1-2Title: The History of Research on Artificial Cornea in Japan

Authors: HiroshiEguchi1; Hiroshi Shiota2; Masahiko Fukuda3; Yoshikazu Shimomura3

Affiliations: 1DepartmentofOphthalmology,SakaiHospital,KindaiUniversity,Japan;2DepartmentofOphthalmology,KaiseiHospital,Japan;3DepartmentofOphthalmology;KindaiUniversity,Japan

Objective: LittleisknownabouttheformerhistoryofartificialcorneainJapan.Since2003,afterOOKP,AlphCor,andBostonKProwereclinicallyintroduced,severalarticleshavebeenpublished.

Methods: WetracedthehistoryofresearchonartificialcorneainJapanfromitsoriginwithreferringboththearticlereviewedbyDr.ChirilainJapaneseJournalofOphthalmologyandarticlespublishedbyJapanesereserchersinHeiseiera.

Results: Dr.KoshunTakahashihasbeenreportedastheJapaneseophthalmologistwhoimplantedartificialcorneaintohumaneyeatthefirsttimeintheMeijiera.Althoughvariousshapesofartificialcorneausingseveralmaterialsweredevelopedinthe1980s,theresearchonartificialcorneainJapanbecamesubsidedbecausepenetratingkeratoplastyusinghumaneyehasspread.Since2003,theresearchcametoattractattentionagainafterOOKP,AlphCor,andBostonKProwereclinicallyintroduced.However,itlooksremainingstaticinrecentyears.

Conclusions: TheresearchonartificialcorneainJapanhasaccomplishedcertainresultsintheHeiseierabyclinicalintroductionofthreeKPros.Foritsfurtherdevelopment,problemsthatmustovercomeareexisted.




1-3Title: Medium and longterm results in Keratoprostheses with biological and Dacron?

support



Objective: TodemonstratethemediumtolongtermoutcomeofKeratoprostheseswithbiologicalandbiocompatiblesupport.

Methods: Inthelast21yearsweimplanted93KPro,in56patientswepreparedanOsteo-odonto-Keratoprotsthesis(OOKP)supportedbytheowntoothandsurroundingmaxillarbone,in30aTibia-Keratoprotstheisis(TKPro)supportedbyalaminaoftibiacorticalisandin7aPintucci-KPro(PKPro)supportedbyaDacron-shirt.

Results: Themediumfollowupwas7/6years/months(max.20/0,min0/1)inOOKP,4/11(max.12/10,min0/7)inTKProand4/3(max.13/9,min0/5)inPKProrespectively.OOKP-patientsgainedavisualacuityof≥0,8in32%,of≥0,5in52%,of≥0,2in72%andsignificantimprovementin87%,inTKPro6,9%,28%,70%and76%andinPKPro14%,42%,71%and86%respectively.Wefoundasignificantdeteriorationofvisualacuitymorethan2linesinOOKPin24%,TKPro23%andPKPro85%.Therewasananatomiclossin4OOKP(7%),4TKPro(13%)and5PKPro(71%).TheKaplan-Meieranalysisshowsananatomicalsurvivalof92%inOOKPupto20years,83%inTKProupto12/10 (y/m)and21%inPKProupto13/9(y/m).

Conclusions: InKProwithbiologicalsupportwecanexpectasatisfyingmediumandlongtermrehabilitationofvisionmuchlongerthaninotherKPros.Complicationscanbemanagedinmostcases,onlyinafewtheymayleadtoalossoftheprosthesis.





Providing a serviceChairs:YoshikoTakesue,BernardDuchesne

2-1 KeynoteTitle: Providing a Service

Author: Christopher Liu

Affiliation: SussexEyeHospital,U.K.

Thesettingupofanartificialcornealservicestartswithlearninghowtoperformthesurgery,alongwithpatientselection,andrecognitionandmanagementofcomplicationsfromthepublishedliteratureandcompetentpractisingteacherswhocanremainmentors.Asystemoflearningcouldbevisitingatleastoneteachingcentre,reviewingtheirpatientsandrecords,andcommencingtheserviceathandwiththesupportofthementor.Thenoviceshouldstartwithroutinecasesandnotonpatientswithrelativecontraindications.

Amultidisciplinaryteamneedstobeassembledtoincludetheleadsurgeon,anassistantsurgeon,oculoplastic,glaucomaandvitreoretinalsurgeons,alongwithanaesthetistsandradiologists.Theatre,ward,andoutpatientsshouldalsohavenamedtrainednurses.Acoordinatorfortheserviceisessentialtogetherwithaclinicalpsychologisttohelpassessandsupportpatientsgoingthroughsurgeryorfacingcomplicationsandthreatenedoractualrepeatsightloss.

Theinstitutionshouldhaveabedbase,andITU,GAfacilitiesandphysiciancolleagueswhocanhelpwithcomplexhealthproblemsoftenassociatedwithpatientsrequiringanOOKP.Financesshouldbesortedoutpriortorollingoutoftheservice.Ideally,theserviceshouldbecentrallyfundedasthemajorityofblindpatientscannotaffordtopayforcomplexlife-longtreatment.

Thereferralcentreshouldalsohavethesupportofcolleaguesintheregionorevennationwidedependingonthesizeofthecountry.

TheSussexEyeHospitalinBrighton,Englandwillbeusedasanexample.


The OOKPⅠChairs:ChristopherLiu,GiovanniFalcinelli

3-1 KeynoteTitle: The OOKP

Author: GiovanniFalcinelli

Affiliation: OPHTHALMOLOGIST.O.O.K.P.FOUNDATION,ROME,ITALY

MOOKP(MODIFIEDOSTEOODONTOKERATOPROSTHESIS)istheonlyKprowhichusesabiologicalhaptic(anosteodentallamina),takenfromthepatientwithcornealblindness.Insomecases(toothlesspatientsorwithverydamagedteeth)itisnotpossibletoobtainanosteodentallaminasuitableforMOOKP.Intheserarecasesweusedanosteodentallaminatakenfromanhistocompatiblebloodrelation,withgoodanatomicalandfunctionalresults.Asanalternativethelaminawasmadeoutfrom2joinedteeth(incisorsand/ormolars).Inaveryexceptionalcaseanimpactedtoothwasused.Whennoneoftheseispossible,weprefertoperformaBostonKpro.



3-2Title: A case of severe facial thermal burn treated with MOOKP

Authors: Masahiko Fukuda1; Keizo Watanabe1;KojiSugioka1; Yoshikazu Shimomura1; Suguru Hamada2; Christopher Liu3

Affiliations: 1DepartmentofOphthalmology,KindaiUniversityFacultyofMedicine;2DepartmentofOralSurgery,KindaiUniversityFacultyofMedicine;3SussexEyeHospital

Objective: WereportacaseofseverefacialthermalburntreatedwithMOOKP.

Methods: Thepatientwas32-year-oldmalewhosufferedfromseverefacialandupperbodythermalburnofgrade3byatrafficaccidentin2004atage23.Hewastreatedextensivelybyskingraftingincludingthefacialpart.Hisrighteyewastotallycoveredbyskingraftandlefteyewasconfirmedunderthickmucoustissueswithoutanypalpebraltissues.ThecorrectedvisualacuitywasLP(OD)andHM(OS).WeconfirmednormaleyeballshapebyultrasoundandgoodERGandVEPresponse(OS).So,weperformedMOOKPStage1tohislefteyeon12/8/2014withoutanycomplications.On3/9/2015,weperformedMOOKPStage2.However,duringthesurgery,wefounddetachmentoftheopticalcylinderandosteo-odontolaminaduetomeltingofthedentinetissue.Wewereabletomanagethisproblembydebridementofthetissuearoundtheopticalcylinderandlaminaholefollowedbyfixationbydentalcement.WeputtheMOOKPlaminabacktomuscletissuesandplannedthethirdsurgeryintwoweeks.On3/23/2015,weperformedsuccessfullyMOOKPStage2again.Wefoundirisadhesionunderthecorneaandafewwhitemassparticleswereextracted.Wethencuttheproliferativemembraneandalsoperformedvitrectomy.ThesuturingoftheMOOKPlaminatothecorneaandsclerawasdonesmoothly.However,thevisualacuitydidnotrecoverfromHM,becauseofopticnerveatrophyandretinaldegeneration.

Conclusions: TheERGandVEPtestingbeforesurgerydidnotreflectwellthevisualprognosisofthiscase.


3-3Title: Starting Osteo-odonto-keratoprosthesis in Egypt

Authors: MohamedBahgatGoweida;IslamKassem

Affiliation: FacultyofMedicine,AlexandriaUniversity,Egypt

Objective: toassesstheresultsofthefirst3casesofOOKPdoneinEgypt.

Methods: modifiedOOKPwasdonein3cases,assessmentofvisualandanatomicalsuccesswasdone 3 months after stage 2.

Results: Retentionofthedeviceinallcasesafter3months.Boneexposureinonecaserequiredreintervention,buccalmucousmembranenecrosisafterstage1inonecasesrequiringreplacement.Improvementofvisionin2casesreaching0.2and0.3after3months.onecasedidnotshowanyimprovementaftersurgeryandlostthelightperceptionafter3months of surgery.

Conclusions: preliminaryresultsshowedthatOOKPisvaluableinrestoringvisioninpatientswithendstagecornealblindness

Conflictofinterest: nofinancialinterest



3-4Title: Osteo-odontokeratoprosthesis using living-related donors in cases of edentulia or

immature dentition.

Author: MariaFidelizD.DeLaPaz

Affiliation: CentrodeOftalmologíaBarraquerandInstitutUniversitariBarraquer,Spain

Purpose: toreport3casesofosteo-odontokeratoprosthesisusingliving-relateddonorsincasesofcompromiseddentalconditions.

Setting: CentrodeOftalmologíaBarraquer,BarcelonaSpain

Methods: threecasesarereportedwithameanfollowuptimeof22years(range:10-29years).

Results: threecasesofseverealkaliburnswithextensivesymblepharonandcornealneovascularizationrequiredOOKP.Ageswere41,8and4.5yearsold.

Thefirstcaseisanedentulous41year-oldfemalewithBCVAof0.002inheronlyeye.OOKPwasperformedusinghertwinsister´scanine.Theimplantremainedinexcellentconditionsduring26years,reachingBCVAof0.9.Finally,late-onsetglaucomacompromisedhervisualfield. Thesecondandthirdcaseshadimmaturedentition,andreceivedanOOKPusingtheirbiologicalfather'scanineteeth. The8year-oldboyreachedBCVAof0.7and0.85inODandOS,respectively,butbothhomograftswereexpulsedaftertwoyears.Later,thepatient´sowncanineteethwereimplantedinanotherOOKPinOUbuthadpoorvisualimprovement.Atotalretinaldetachmentoccuredinbotheyesafter6years. The4.5year-oldboyreceivedanOOKPinODtwice,bothwereexpulsedinlessthan2years.SubsequentkeratoprosthesisusingtibialboneinODwasperformedbutendedupinphthisisbulbi.InOS,theOOKPusingtibiawasexpulsedafter8years,beforedevelopingglaucoma.BCVAwas0.45and0.2inODandOS,respectively,probablyhelpingavoidprofoundamblyopia.

Conclusions: OOKPusingliving-relateddonorsmaybeanalternativeinedentulouscasesorthosewithimmaturedentition.HLA-matcheddonorsfarebetterthanthosethatarenotmatchedprobablyduetohighimmunologicalcompatibilityandlow/absentimmunerejection.




3-5Title: TYPE 2 KPROS IN CHEMICAL INJURY

Author: BhaskarSrinivasan

Affiliation: CMER-Dennislameyehospitalchina,China

AIM: Toreporttheoutcomes,anatomicalandfunctional,ofdifferenttypesoftype2Kprosforsevereocularchemicalinjuries.

Methods : RetrospectiveChartReviewofpatientswithocularchemicalinjurieswhounderwenttheMOOKP(36eyes),LuciaType2(12eyes),OsteoKpro(3eyes)andtheBostonType2Kpro(1eye)betweenApril2005andDecember2015wasdone.

Results : BCVA>6/60wasachievedin30(83.34%)andmaintainedin26(72.23%)eyesoftheMOOKPoverameanfollowupperiodof57.63months,in7(58.3%),3and1eyesfollowingtheotherKprosoverameanfollowupof23.4,6and36monthsrespectively.Preexistingglaucomawasnotedtobethemostcommonco-morbidityin14(38.9%)eyesand4(33.3%)eyes;retroprostheticmembraneoccurredin1eye(2.7%)and8(66.67%)eyes;endophthalmitisin4(11.11%)eyesand1(8.33%)eye;retinaldetachmentin1eyeeach;followingtheMOOKPandLuciaType2Kprosrespectively.Mucosalrevisionswererequiredin8(22.2%)and6(50%)eyes;andresorptionofthelaminarequiringreplacementorremovalwasrequiredin5(13.8%)eyesfollowingMOOKPandperiopticmeltnecessitatingKproreplacementwasnotedin1eye(8.3%)followingtheLuciaType2Kpro.RepeatedskinovergrowthrequiringexcisionwasnotedintheBostonType2Kpro.SterileVitritisoccurredin1eyeandRPMin1eyeaftertheosteokpro.

Conclusion: EyeswhereintheMOOKPwasnotimplantableduetovariousreasons,theothertype2Kproswerechosenbasedontheadnexalandothereligibilitycriteria.LongertermoutcomesarerequiredfortheKprosotherthantheMOOKP,thoughtheocularcomplications,inparticularRPM,werenotedtobehighamongeyeswiththeLuciaType2 Kpro.



Special Lecture: Ocular Surface Reconstruction by Prof. Shigeru Kinoshita

Chair: Masahiko Fukuda

4SHIGERU KINOSHITA MD, PhDProfessor and Chair DepartmentofFrontierMedicalScienceandTechnologyforOphthalmology KyotoPrefecturalUniversityofMedicine,

1974 MD,OsakaUniversityMedicalSchool

1979 ResearchFellow,HarvardMedicalSchooland MassachusettsEyeandEarInfirmary.

1983 PhD,OsakaUniversity(Thesis:Limbalepitheliuminocularsurfacewoundhealing)

1988 AssociateProfessorofOphthalmology,OsakaUniversityMedicalSchool

1992 ProfessorandChairofOphthalmology,KyotoPrefecturalUniversityofMedicine

2003 AdjunctClinicalSeniorScientist,TheSchepensEyeResearchInstitute,Boston,USA

2008 HonoryDistinguishedProfessor,CardiffUniversity,Cardiff,UnitedKingdom

2011 VicePresident,KyotoPrefecturalUniversityofMedicine

2015 ProfessorandChairofFrontierMedicalScienceandTechnologyforOphthalmology, KyotoPrefecturalUniversityofMedicine

HONORSANDAWARDS

International TheDohlmanLecture,20thBostonCorneaResearch,USA,1997 AlconResearchInstituteAward,USA,1999 AchievementAward,AmericanAcademyofOphthalmology,2000 Daiwa-EdrianPrize,UK,2004 DavidEastyLecturer,UK,2007 TheCastroviejoMedalLecturer,USA,2008 ARVOGoldFellow,USA,2009 ClaesH.DohlmanConferenceAddress,TFOS,Florence,2010 MeibomLecturer,Germany,2010 TheDoyneMemorialLecturer,OxfordOphthalmologicalCongress,UK,2011 ElsemayBjornLecture,Finland,2011 SchepensEyeResearchInstituteAlmunusAwardee2011,USA,2011 PeterHerbergLecture,IMCLC,WOC2012,AbuDhabi,2012 RichardLindstromLecture,CLAO,ASCRS2014 CharlesD.KelmanInovatorAward,ASCRS2015 FriedenwaldLecture,ARVO2016(tobescheduled)


4Title: Translational Research Opens New Horizons for the Devastating Ocular Surface

Diseases

Author: Shigeru Kinoshita

Affiliation: DepartmentofFrontierMedicalScienceandTechnologyforOphthalmology, KyotoPrefecturalUniversityofMedicine,Kyoto,Japan

Abstract: Thereareseveraldevastatingocular-surface-relateddisorders,suchasStevens-Johnsonsyndrome,chemicalinjury,andFuchsendothelialcornealdystrophy,aseverecornealendothelialdysfunction,thataredifficulttotreatproperly.Today,thankstostate-of-the-artregenerativemedicineandthelatestadvancementsinocularsurfacebiology,severaltypesoftransplantablecultivatedmucosalepithelialsheetsarenowavailableforthereconstructionofadevastatedocularsurface.Oneistheallogeneic/autologouscornealepithelialstem-cellsheet,andtheotheristheautologousoralmucosalepithelialsheet.Althoughocularsurfacereconstructionusingthesesheetsissometimesaccompaniedbyvaryingdegreesofbiologicaland/orimmunologicalpostoperativecomplications,studieshaveshownthatingeneral,theocularsurfacecanbewellrestored. Asimilartypeofregenerativemedicinecanbeappliedforthetreatmentofcornealendothelialdysfunction.Forexample,asurgicalmodalitysimilartothatoftheDescemet’sMembraneEndothelialKeratoplastyprocedureusinganovel‘cell-injectiontherapy’,involvestheinjectionofculturedhumancornealendothelialcellsintotheanteriorchamber,hasnowshownpromiseinourclinicalresearch.Anotheraspectofourcutting-edgetranslationalresearchisfocusedondevelopinganovelmedicaltreatmentforearly-phasecornealendothelialdisease.Tothatend,theuseofRho-associatedproteinkinase(ROCK)-inhibitoreyedropshasprovedtobeeffectivefortreatingpartialendothelialdysfunction. Itisourgreathopethatophthalmology-relatedtranslationalresearch,suchasthatdescribedabove,willreceiveofficialgovernmentalapprovalbasedontheaccumulateddataofthesafetyandefficacyaspectsoftheprocedures,thusultimatelyresultingintheworldwidepreventionofblindness.



Ocular surface reconstructionChairs:ShigeruKinoshita,JunShimazaki

5-1 KeynoteTitle: Development of stem cell-based therapy for corneal diseases-from tissue stem cell

to iPS cell

Author: KohjiNishida

Affiliation: DepartmentofOphthalmology,OsakaUniversityMedicalSchool,Japan

Cornealepithelialstemcellsareknowntobelocalizedtothebasallayerofthelimbalepithelium.Thiscornealstemcellconcepthasbeenfirstreportedin1980s,basedonthefindingsthatlabel-retainingcellsarelocatedinthelimbalbasalepithelium.Sincethen,severalinvestigatorsreportedthespecificcharacteristicsforcornealepithelialstem/progenitorcells,includinghighcolony-formingpotential,p63positiveandsoon.Wehaverecentlydemonstratedthatcornealepithelialstem/progenitorcellscanbeenrichedinintegrinα6bri/CD71dimfractionbyFACS. Completelossofcornealepithelialstemcellsbecauseofseveretraumaeyediseaseleadstocornealvascularizationandopacificationwithseverevisualloss.Forcornealreconstructioninpatientswithsuchlimbalstemcelldeficiencies,wepreviouslydevelopedauniquemethodusingtissue-engineeredepithelialcellsheetscomprisingonlythepatient’sautologousoralmucosalepithelium.Wearecurrentlystudyingthepotentialofpluripotentstemcellsforthetreatmentofcornealdiseases.Inthispresentation,Iwilltalkabouttherecentprogressofstemcelltherapyforcornealdiseases.




5-2Title: Strategies for Visual Improvement in chronic SJS/TEN

Authors: Chie Sotozono1; Tsutomu Inatomi1;MayumiUeta1,2;TakahiroNakamura1,2; Shigeru Kinoshita1,2

Affiliations: 1DepartmentofOphthalmology,KyotoPrefecturalUniversityofMedicine,Kyoto,Japan;2DepartmentofFrontierMedicalScienceandTechnologyforOphthalmology,KyotoPrefecturalUniversityofMedicine,Kyoto,Japan

Objective: VisionlossresultingfromStevens-Johnsonsyndrome/ToxicEpidermalNecrolysis(SJS/TEN)isoftenextremelyseriousandlastlifelong.TheoutcomeofconventionalcornealtransplantationforSJS/TENispoor.WereportedtheefficacyofCultivatedOralMucosalEpithelialTransplantation(COMET)forsevereocularsurfacediseases.Asanothertreatmentmethod,wedevelopedanewtypeofrigidcontactlens(CL)witha13.0-or14.0-mmdiametersize,named“LimbalRigidContactLens(LimbalCL)”Wecomparedboth treatment methods.

Methods: All21COMEToperationsforSJS/TENperformedbetweenJune2002andDecember2008,and53eyesof42SJS/TENcasesenrolledclinicalresearchforlimbalCLwerecomparedtheefficacyforvisualimprovement.

Results: COMETsignificantlyimprovedbestcollectedvisualacuity(BCVA)inpatientswithend-stageSJS/TEN.Inmorethan50%oftheeyes,preoperativeBCVAwasunder20/2000,limitedtocountingfingersorhandmotion.LogMARimprovedfrom2.35to1.93at24-weekspostoperative.InclinicalresearchforlimbalCL,BCVAwasunder20/2000in 11eyes(21%)outof53eyes.LogMARimprovedfrom1.61to0.86at3-monthspost-fittingCLuse.NinecasesusedlimbalCLafterCOMET,andobtainedvisualimprovement.

Conclusions: SJS/TENpatientswithocularsequelaecanobtainvisualimprovementbyuseoftheLimbalCLalone,COMETalone,orthecombinationofboth.

Study supported by: aGrant-in-AidforScientificResearchfromtheJapaneseMinistryofHealth,LaborandWelfare,andJapanAgencyforMedicalResearchandDevelopment




5-3Title: SLET: The new revolution in limbal stem cell therapy

Author: Sayan Basu

Affiliation: L V Prasad Eye Institute, India

Abstract: SLETorsimplelimbalepithelialtransplantationisaneffective, reliableandreplicabletechniqueforlong-lastingcornealregeneration andvisionrestorationineyeswithlimbalstemcelldeficiency.This talkwillbrieflyreviewthesurgicaltechnique,typicalpost-operative outcomesandsuccessratesofSLETindifferentindications.The mechanismofcornealwoundhealingandstemcellrestorationfollowing SLETwillalsobedescribedusingultra-highresolutionoptical coherencetomographyimaging.FinallythereasonswhySLETcouldbe preferabletoothertechniquesoflimbalstemcelltransplantationwill bediscussed.


PosterP1

Title: Clinical backgrounds of postoperative keratoplasty patients with spontaneous wound dehiscence of gaps after suture removal

Authors: ShotaFujii;YoshiyukiIchihashi;TetsuyaKawakita;ShigetoShimmura;KazuoTsubota

Affiliation: DepartmentofOphthalmology,KeioUniversitySchoolofMedicine,Japan

Objective: Toreportthatspontaneouspostkeratoplastywounddehiscenceorgapscausedbysutureremovalmayoccuryearsafterpenetratinganddeeplamellarkeratoplasty.

Methods: Weretrospectivelyreviewedthemedicalrecordsof667keratoplastypatients(890eyes).Thisstudyincluded8eyesof8patients(3menand5women)aged64to86yearswhosufferedfromspontaneouswounddehiscenceorgapscausedbysutureremoval.Weexaminedtheirclinicalbackgroundssuchassurgicalprocedure,reasonforsutureremoval,andtimeintervalbetweenkeratoplastyandsutureremoval.

Results: Thesurgicalproceduresincluded6penetratingkeratoplastiesand2deepanteriorlamellarkeratoplasties.Themostcommonreasonforsutureremovalwashighcornealastigmatism.Timeintervalbetweenkeratoplastyandsutureremovalwas15.9± 7.7 months(7-26months).Threepatientsunderwentsutureremovalfrom6monthsto1yearafter keratoplasty, 3 patients from 1 to 2 years, and 2 patients after more than 2 years.

Conclusions: Wheneverpostoperativekeratoplastysutureisremoved,itisimportanttoconsiderthatwounddehiscenceorgapsmayoccurwithoutincidenceoftrauma.





P2Title: Outcome of Keratoplasty at Ehime University

Authors: Atsushi Shiraishi1; Yuri Sakane1; Yuko Hara1; Takashi Suzuki1; Xiaodong Zheng 1; Yasuhito Hayashi1;ToshihikoUno2;MasahikoYamaguchi3;YuichiOhashi1

Affiliations: 1EhimeUniversitySchoolofMedicine,Japan;2ShiraiHospital,Japan;3EhimePrefecturalCentralHospital,Japan

Objective: Toreview11-yeartrendsandoutcomesofcornealtransplantationatEhimeUniversityHospital.

Methods: Threehundredandthirtyoneeyesof302cases(129menand202womenaged8to95years,meanage:69.1±14.4years)whounderwentcornealtransplantationinEhimeUniversityHospitalfromJuly2003toDecember2014wereincludedinthisstudy.Causativediseases,surgicalproceduresandcomplicationswerereviewedretrospectively.

Results: Thecausativediseaseswerebullouskeratopathy(BK;188eyes56.8%),cornealopacity(CO;67eyes20.2%),keratoconus(KC;20eyes6.0%),cornealdystrophy(CD;19eyes5.7%),marginalulcer(MU;16eyes4.8%),cornealinfection(CI;11eyes3.3%),dermoid(DE;5eyes1.5%),andlimbaldeficiency(LD;5eyes1.5%).Thesurgicalprocedureperformedwerepropenetratingkeratoplasty(PKP)on199eyes(60.1%)forBK(120eyes),CO(52eyes),KC(14eye),etc,endothelialtransplantation(EK)on68eyes(20.6%)forBK,lamellarkeratoplasty(LKP)on58eyes(17.5%)forCO(15eyes),CD(14eyes),MU(17eye),KC(6eye),etc,andlimbaltransplantation(LT)on6eyes(1.8%).Postoperativecomplicationsweredetectedin98cases(29.6%),includingrejection(33eyes),secondaryglaucoma(17eyes),cornealinfection(16eyes).TheincidenceofrejectionandsecondaryglaucomawasdetectedmostfrequentlyinPKPgroup.

Conclusions: BKwasthereadingcausativediseasesrequiringcornealtransplantation.ThetrendofsurgicalprocedureforBKhasbeenchangingfromPKPtoDSAEK.FurtherinvestigationwillbenecessaryfortheoutcomesofsurgicalprocedureforBK.


P3Title: Pseudoexfoliation Syndrome Endotheliopathy and its Prevalence in Bullous

Keratopathy

Authors: XiaodongZheng;AtsushiShiraishi;YuichiOhashi

Affiliation: EhimeUniversitySchoolofMedicine,Japan

Objective: Tostudythemorphologicalchangesofthecorneainpseudoexfoliationsyndrome(PEX)andtoreportanationalsurveyonitsprevalenceinbullouskeratopathythatnecessitatekeratoplasty.

Methods: Thefirstpartofthisstudywasaclinicalsettingtoinvestigatethemorphologicalchangesofcornealcellsandnervesin20patients(78.3± 8.5yrs.)diagnosedwithunilateralPEX.Genderandage-matched20normalsubjectswerealsoincludedascontrols.Invivoconfocalmicroscopy(IVCM)wasusedtoexaminethecelldensityandthedensityandtortuosityofthesubbasalcellnerveplexus.ThesensationofthecorneawasmeasuredusingCochet-Bonnetnylonthreadesthesiometer.FindingswerecomparedbetweenthePEXeyes,theircontralateraleyesandnormalcontrols.ThesecondpartofthisstudywastoconveyaJapanesenationalsurveyontheetiologyofbullouskeratopathy(BK)thatrequiredkeratoplastyfromtheyear2008to2011.SevenfacilitiesoftheMinistryofHealthStudyGroupforIntractableDiseasewereincluded.TheetiologyofBKwereretrospectivelyinvestigatedandthetrendwasanalyzedusingCochran-Armitageanalysis.

Results: PEXeyeshadsignificantlylowercelldensitiesinthebasalepithelium(P=0.003),stroma(P=0.007)andendothelium(P < 0.0001)thaninthecorrespondinglayersofnormaleyes.PEXeyesalsohadlowersubbasalnervedensitiesandgreatertortuosityofthenerves.CornealsensitivitywassignificantlydecreasedinPEXeyes,andthiswassignificantlycorrelatedwiththedecreaseofbasalepithelialcellandsubbasalnerve(bothP<0.0001).PEXFelloweyeshadsimilarfindingsasPEXeyes.IntraocularsurgeryrankedfirstforthecauseofBK,itfollowedbylaseriridectomy.BKofunknownoriginsignificantlyincreasedfrom8.8%to14.4%(P=0.036,Cochran-Armitage)duringthethreeyearinvestigated.PEXendotheliopathyaccountedfor36.4%casesin2008andthisnumbersignificantlyincreasedto58.8%in2010(P=0.027).

Conclusions: PEXcausesmorphologicalchangesinallcorneallayers.PEXendotheliopathyisbecominganincreasinglyimportantetiologyforBKof“unknownorigin”




P4Title: Multilayered compressed collagen scaffolds as a novel carrier for the Boston KPro

Authors: MGonzalez-Andrades1,2; R Weerasena2;NSTan2;CHDohlman1;RABrown2

Affiliations: 1SchepensEyeResearchInstituteandMassachusettsEyeandEar,DepartmentofOphthalmology,HarvardMedicalSchool,Boston,Massachusetts,USA;2UniversityCollegeLondon,UCLTissueRepair&EngineeringCentre,StanmoreCampus,London,UK

Objective: TogenerateanewBostonKProcarrierbasedonmultilayeredplasticcompressedcollagenscaffolds(MPCCS)withthepurposeofsubstitutingthehumandonorcorneaastheactualcarrier.

Methods: MPCCScomposedofdifferentnumberoflayersofcollagen(1to12layers)weregeneratedfollowingthemethodpreviouslydescribedbyHadjipanayietal.,2011.Briefly,collagengelswerepreparedbysodiumhydroxideneutralizationofsterileNutragen® collagensolutionmixedwithculturemedium.Gelswerecastin22mmdiametercircularmoldsof380mm2.Differentcollagensolutionvolumeswereaddedpermold:1ml,2mlor3ml.Afterwards,themixturewasplacedat37℃inatemperatureincubatorfor25mintopromotefibrillogenesis.Then,theplasticcompressionwasperformedplacingtwodiscsoffilterpaperoverthecollagengel,andoverthesediscs,atightrollofchromatographypaperwasplacedontoptoabsorbfluidfromthegelbyanunconfinedcompression.Thosecollagenscaffoldscomposedbyonlyonelayer,wereanalyzedafterthattime.Themultilayeringcollagenscaffoldscomposedbyseveralcollagenlayerswerecomposedaddingnewcollagensolutiontothescaffoldobtainedapplyingthesameprocessdescribedabove,alwaysusingthesamevolumeofcollagenusedinthefirstcollagenlayerobtained.MPCCSwerehistologicallyevaluatedwithPicro-Siriousredstain.ThetransparencyandtheblurrinessoftheMPCCSweremeasuredanalyzingphotographicimages of a standardized band pattern taken through the different samples, applying our previouslydescribedmethod(Gonzalez-Andradesetal.,2015).Afterwards,weevaluatedtheeffectofcompressionandrelaxationoftheMPCCSusingsurfaceinterfacerefractivepositioning.

Results: Analysisoftransmissionandblurringcoefficientclearlydemonstratedthatforthesametotalcollagencontent,alargernumberofthinnerlayerssignificantlyimprovedopticalperformance.Histologysectionsshowedawell-developedlamellacollagenstructurewherecollagenlayerswerewellintegrated,oneabovetheother.Compressionandrelaxationevaluationidentifiedadegreeofre-swellingfollowingcompression,whichwasgreatestinthickerlayers.Furthermore,wherecompressionwasrepeated,thethinlayersstoppedre-swelling,suggestingthatcollagenfibrilbondinghadoccurredtostabilizethepackeddensity.

Conclusions: Compressedcollagenmultilayersnotonlyproducedstructurallypromisingcornealconstructsbut,criticallyalsoshowedthatincreasingnumbersofthinnercollagenlayersimprovesopticalperformance.Thus,MPCCScouldemergeasapromisingBostonKProcarrierthataddressestheneedofhumandonorcorneas.


P5Title: Keratitis in Boston keratoprosthesis grafts that were suspected of fungal infection

Authors: YosaiMori;TakashiOno;RyoheiNejima;KeiichiroMinami;KazunoriMiyata

Affiliation: MiyataEyeHospital,Japan

Objective: After10implantationsofBostonkeratoprosthesis(KPro),weobserved3eyeswithinfectiouskeratitisforwhichanti-fungalregimenswereeffective.

Methods: Case1:Therighteyeofa57-year-oldmanundercontinuousadministrationoftopicalantibioticsandcorticosteroidsafterKProimplantation.Slit-lampexamination6monthspostoperativelyrevealedthickerinfiltrationwithfuzzymarginsatthejunctionofKProanddonorgraft.ScrapingcytologyofcorneallesionrevealedGram-positivecocci.Althoughtreatmentwithtopicalandoralantibioticswasprovided,therapeutickeratoplastywasperformedduetorapidcornealliquefactionandendophthalmitis.Microscopicanalysisoftheexcisedgraftdemonstratedthepresenceofmolds(filamentousfungi).Endophthalmitiswasimprovedbytreatmentwithtopicalandoralvoriconazole(VRCZ).PCRanalysisofthegraftrevealedthesequenceofAspergillus. Cases2and3:Therighteyeofan85-year-oldwoman(Case2)andthelefteyeofa35-year-oldman(Case3)sufferedfrominfectiouskeratitisat24monthsand13monthspostoperatively,respectively.BothcasesalsoexhibitedinfiltrationsatthesameportionsasCase1.MicrobiologicalstudydisclosedPropionibacteriumacnesinCase2andStaphylococcusaureusinCase3.TopicalandoralVRCZwereadministeredtogetherwithtopicalmoxifroxacinandvancomycin.IntrastromalinjectionofVRCZwasconductedinCase3afterPCRwasusedtodetectfungal28srDNAsequenceinthetearsofCase3.Theinfectiouskeratitisesofbothcaseswereresolvedwithoutliquefactions.

Conclusions: InfectiouskeratitisesinthreeeyeswithKProwereattributedtofungalinfection.TheriskoffungalinfectionofthegraftmightbeincreasedbycontinuouscorticosteroideyedropsandcontactlenswearingintherecipientsafterKPro.Fungalinfectionmustbesuspectedwheninfiltrationwasobservedaroundthejunctionofartificialcorneaanddonorgraft.





P6Title: LONG TERM OCULAR COLONIZATION OF METHICILLIN RESISTENT

STAPHYLOCOCCUS AUREUS IN PATIENTS WITH OCULAR SURFACE DISORDERS.

Authors: HiroshiTanaka;MayumiUeta;TsutomuInatomi;ShigeruKinoshita;ChieSotozono

Affiliation: KyotoPrefecturalUniversityofMedicine,Japan

Objective: Methicillin-resistantStaphylococcusaureus(MRSA)isoneofthetypicalresistantbacteriaandoccursintractableocularinfections.Especiallyinocularsurfacedisorder(OSDs),weshouldknowwhetherpatientshaveMRSAcolonizationornotbecauseMRSAcolonizationmayleadinflammationandinfectionduringthereconstructivesurgery.ThepurposeistoinvestigatewhatkindofdisordershaslongtermcolonizationofMRSA.

Methods: Adatabaseofthebacterialculturewasretrospectivelyreviewedover10yearsbetweenJanuary2000andDecember2009,weidentifiedMRSApositiveamongconsecutive9845culturespecimensfrominpatientandoutpatientclinicsofthedepartmentofophthalmology,KyotoPrefectureUniversityofMedicine,inJapan.WeinvestigatedtheprofileofthediagnosisandthedurationofMRSAdetection.

Results: MRSAwasdetectedfrom208eyesatleastonceandfrom54eyesforthelongterm,morethan6months.Among54eyeswithlong-termdetectionofMRSA,46eyeswerediagnosedasOSDs.InOSDs,28eyes(60.9%)wereStevens-Johnsonsyndrome,13eyes(28.3%)wereocularcicatricialpemphigoid,4eyes(8.7%)weregraftversushostdisease,1eyewasrelatedtoatopicdermatitis.NoMRSAwasdetectedfrompatientswiththermalandchemicalburn.

Conclusions: PatientswithsevereOSDs,especiallySJS,canbelong-termcarrierofMRSA.Weshouldtakecaretopreventinfectionaftercornealreconstructivesurgeryorkeratoprosthesisforpatientswiththesedisorders.




P7Title: Attempt for better OOKP lamina preparation and novel wound management

Authors: Suguru Hamada1; Masahiko Fukuda2; Akifumi Enomoto1; Kazuhide Matsunaga1; Takao Mukai1;TakayukiUchihashi1;HajimeTamitsu1; Christopher Liu3;JimHerold3; Yoshikazu Shimomura2

Affiliations: 1DepartmentofOralandMaxillofacialSurgery,KindaiUniversityFacultyofMedicine,Osaka,Japan;2DepartmentofOphthalmology,KindaiUniversityFacultyofMedicine,Osaka,Japan;3SussexEyeHospital,Brighton,UK

Objective: TodevelopnewdeviseforbetterOOKPlaminapreparationandnewmanipulationmethodsforbetterwoundhealing.

Methods: Wecarriedout8casesofOOKPstage1surgeryandappliedourimprovedmethodtolater6cases.Ourmodificationsarefollows. 1.Weusedresinstickduringprocessingcaninetoothrootbyfixingthecrownbycement　to help better handling the OOKP lamina. 2.ThecleftafterremovingcaninetoothandalveoluswasburiedbyTeruplug®(collagen-　basedmaterialforextractionsockets)tohelpwoundhealing. 3.Preventionoftrismusbythescarformationaftertakingbuccalmucosausing 　Terudermis®(collagen-basedartificialdermis)fixedbysiliconstent.

Results: Resinstickfixationwithcaninecrownworkedmoreefficientlythanforcepsgraspingduringprocessingthetoothroot.Teruplug ｮprovidedgoodhealingofalveolusandslightregenerationofalveolus.Terudermis ｮalsoprovidedgoodhealingofbuccalmucosaandnodisturbanceofmouthopening.

Conclusions: OurattemptsforlaminapreparationandwoundmanagementatOOKPstage1surgerycontributedthesafetyandstableresults.

Conflictofinterest: NopotentialCOItodisclose.



The OOKPⅡChairs:ChristopherLiu,GiovanniFalcinelli

6-1 KeynoteTitle: MOOKP – THE INDIAN EXPERIENCE OVER 13 YEARS

Author: Geetha Iyer

Affiliation: Corneaservices,SankaraNethralaya,India

AIM: Toreporttheoutcomes,anatomicalandfunctional,oftheMOOKP,overa13yearperiodinthetwoprimarygroups-namelySJSandchemicalinjuries.

Methods: RetrospectiveChartReviewofpatientswhounderwenttheMOOKPbetweenMarch2003andDecember2015wasdone.

Results: MOOKPwasperformedin94eyesof91patients,ofwhich36eyesbelongedtothechemicalinjurygroupand56eyestotheSJSgroup.BCVA>6/60wasachievedandmaintainedin30(83.3%)and26(72.2%)eyesrespectivelyinthechemicalinjurygroup;andin54(96.4%)and36(64.3%)eyesrespectivelyintheSJSgroup.Anatomicalsuccessdefinedasretentionofthelaminawasnotedin26(72.2%)and33(58.9%)eyesrespectivelyinthechemicalinjuryandSJSgroups.Ocularcomplicationsincludingendophthalmitisin4(11.1%)and6(10.7%)eyes;RDin1(2.7%)and2(3.6%)eyes,preexistingglaucomain14(38.8%)and5(8.9%)eyesandsterileVitritisin3(8.33%)and19(33.9%)eyes,werenotedinthechemicalinjuryandSJSgroupsrespectively.KprorelatedcomplicationsincludingMMGrevisionsforlaminaexposurein9(25%)and17(30.3%)eyes;andlaminarresorptionin6(16.6%)and17(30.35%)eyeswerenotedinthe2groupsrespectively.Themeandurationoffollow-upwas60.45months.

Conclusion: Functionalvisualsuccess(>6/60)in58.5%eyesandananatomicalsuccessof64.1%wasnotedinourseries.Betweenthetwogroups,theincidenceoflaminarresorptionwasnotedtobehighamongtheSJSgroupandpreexistingglaucomawashighamongthechemicalinjurygroup.MOOKPisaviableoptionwithgoodlongtermresultsforsevereocularsurfacedisorders.


6-2Title: Surgical management of aqueous leakage due to lamina resorption in OOKP.

Authors: AlfonsoVasquezPerez;ChristopherLiuFRCOphth

Affiliations: SussexEyeHospital.BrightonandSussexUniversityHospitals.NHSFoundationTrust.UnitedKingdom

Purpose: TopresentourexperienceinthemanagementocularhypotonyandaqueousleakageduetolaminaresoptioninOsteo-Odonto-Kerato-Prosthesis.

Methods: WedescribetwosurgicalapproachesforthemanagementofhypotonyduetoaqueousleakageinacaseofOOKPwithlaminaresorption.

Management: AnOOKPpatientwithpreviousBCVAof6/9presentedwithocularhypotonyandchoroidalfoldsduetospontaneousaqueousleakingaroundtheacryliccylinder.CTshowedsignsofresorptionofthelamina.Heunderwenturgentsurgicalexplorationandinitiallyweperformedare-suturingofthelaminaontothescleraachievingatightandstableposition.Hisvisionimprovedto6/12andinitiallytherewerenosignsofleakagepostoperatory. Unfortunatelythreemonthslaterhehadrecurrenceofaqueousleakagewithocularhypotonyandwedecidedtoremovethelaminaandacornealgraftwasplacedtocoverthecornealgap.Detailedexaminationofthelaminarevealedsignificantresorption,boneerosionsandbonefracture.

Conclusion: AqueousleakinginOOKPrequiresurgentsurgicalexploration.Re-suturingofthelaminacouldbeinitiallyeffectivehoweverifsignificantresorptionisevidenced,laminaremovalisnecessaryinordertoavoidfurthercomplications.



6-3Title: Clinical and radiological assessment of Lamina

Authors: VenkataAvadhanam

Affiliations: SussexEyeHospital,Brighton,UKBrightonandSussexMedicalSchool,Brighton,UK

Purpose: Resorptionofthelaminainosteo-odontokeratoprosthesis(OOKP)andOsteo(tibial)keratoprosthesis(OKP)canleadtoseriouscomplicationslikedevicefailure,retinaldetachmentandendophthalmitis.Thesepatientsrequirelife-longfollowuptomonitorthelaminafortimelyinstitutionofprophylacticmeasures.Periodicclinicalexaminationandserialimagingofthelaminawithcomputerisedtomography(CT)scanningarethestandardmethodstosurveythelamina.Thisstudyaimstocomparetheefficacyofclinicalandradiologicalmethodsinthedetectionoflaminarresorption.

Methods: Forty-onepatientsfromtheUKcohortwitheitherOOKPorOKPwereevaluated.Atotalof48laminaewerestudied.Patients’notesweresystematicallyreviewedtoidentifytheclinicalsignsandonsetoflaminarresorptionduringtheirfollow-ups.AlltheCTscanimageswereevaluatedtoobtainobjective2Dlinearmeasurementsandclinician’ssubjectiveassessment.Thedegreeoflaminarresorptionwasgradedasaprogressiveincrementform0to3basedon2Dmeasurements.Significantresorptionwasconsideredtobepresentifgrade≥1.Radiologicalfindingswerecomparedagainsttheclinicalfindingstemporallyandspatially.

Results: Atthetimeofwriting,temporaldetectionofresorptioncouldbecomparedin25laminae.Withthe2Dmeasurementgradingscale:3laminaeshowedresorptiononclinicaldetectionalone(12%),8laminaeshowedresorptiondetectedclinicallylaterconfirmedradiologically(32%),8laminaeshowedresorptiondetectedfirstonCTscans(32%)and3laminaehadshownresorptionidentifiedonlyonCTimages(12%).Spatiallocationofresorptionwasevaluatedin22laminae.In6laminaethesiteofresorptiondidnotmatchbetweentheCTandclinicalfindings(27%),in10laminaeitwaspartiallymatched(45%)andin6casesitwasfullymatched(27%).

Conclusions: Bytheuseof2Dmeasurementanalysis,CTscanningcandetectlaminarresorptionearlierthantheclinicalexamination.CTscanningalsohasabetteraccuracyinthedetectionoflaminarresorption.


6-4Title: Clinical dimensions of laminar resorption



Purpose: Todeterminetheincidence,aetiology,clinicalfeaturesandoutcomesoflaminarresorptioninosteo-odonto(OOKP)andosteokeratoprosthesis(OKP).

Methods: AretrospectivereviewofthecasesfromUKnationalcohortofkeratoprosthesiswasconducted.Atotalof64patients,whounderwenteitherOOKPorOKP,wereidentified.Patientdataincluding:demography,diagnosis,surgicaldetailsandpostoperativeoutcomesrelatedtolaminarresorptionwascollectedandanalysed.

Results: Atotalof74laminaewereimplantedintotheeyesof64patients.Outofwhich60wereOOKPautografts,11wereOOKPallograftsand3weretibialbonegrafts.Stevens-Johnsonsyndrome(SJS)accountedforthemajorityoftheindicationsforkeratoprosthesisimplantation(42%)followedbyocularsurfaceinflammatorydiseases(30%),ocularinjuries(19%),congenitaldisorders(6%)andmiscellaneouscauses(3%).Noneoftheallograftsortibialgraftssurvivedformorethan5years.Resorptionwasnotedin65%oftheautografts.ResorptionwasmostfrequentinSJS(81%)cases.Fourlaminaewereexchangedprophylacticallyduetoresorptionandtwowereexplantedduetothecomplicationsofresorption.

Conclusions: LaminarresorptionisacommoncomplicationoftheOOKPandOKP.Allograftsandtibialbonegraftsareproneforsevereresorption.InmostoftheOOKPautograftsresorptioniscompatiblewithlaminarsurvival.



6-5Title: Results of biological keratoprostheses from the UK



Biologicalkeratoprosthesesemploytheskirtsmadeofbiologicalmaterialssuchasalveo-dentaltissuecomplexandcorticalboneoftibia.Theyusuallycontainacentralcore,whichservesasanopticalsegmentmadeofpolymethylmethacrylate.Apatchofbuccalmucosalmembranenormallyprovidesasabiologicalcoveringforthesedevices.Theadvantageofthebiologicalskirtmaterialsisthattheyintegratewellwiththeoculartissuesandthereisalittlechanceforthedeviceextrusion.However,theyaresubjectedtobiologicalinfluencessuchashealing,repairandregeneration.Wewillpresenttheresultsofosteo-odontoandosteokeratoprostheses(OOKPandOKP)fromtheUK.


Dealing with complicationsChairs: Soledad Cortina, Sayan Basu, Maria Fideliz de la Paz

7-1 KeynoteTitle: Oculoplastic: Lid malposition and fornix reconstruction, mucous membrane

alterations and overgrowth, cosmesis and orbital decompression Retinal detachment, VR surgery, Hypotony

Authors: MariaFidelizDelaPaz;VictorCharoenrook;GorkaMartinezGrau;JeroniNadal; JoseTemprano

Affiliation: CentroOftalmologicoBarraquerandInstitutUniversitariBarraquer,Spain

GoodlidappositioniscrucialforthesuccessoftheBostonKProType1aspoorlidmalpositionwouldleadtopoorbandagecontactlensfitandcausesubsequenterosionsonthecornea,leadingtonecrosis,andeventualextrusion.Thisismanagedbytheoculoplasticsurgeonbydoinganteriororposteriorlamellarreconstruction,lateraltarsalstriporlateraltarsorraphy.FornixreconstructionusingoralmucosaisagoodalternativetoreconstructthefornixwhetherusingscissorsorusingtheCastroviejoelectro-keratome.Amnioticmembraneisapoormaterialforthispurposeasitgetsreabsorbedafterseveralweeks.MucousmembranenecrosisincasesofOOKPorTibiaKPromustbecloselywatchedasitmayleadtoextrusionoftheprosthesis.Managementmaybeconservativeusingmedicaltreatmentorsurgicalusingoralmucosaimplant.MucousmembraneovergrowthinOOKP/TibiaKPRoispreventedbyperformingatrephinationoftheoverlyingmucosasmallerthanthediameteroftheopticalcylindertoassureaverytightfit.Shouldovergrowthoccur,excisionofoverlyingmucosaisperformed,preferablywithelectriccauterycutting.CosmesiswiththeBostonKProType1maybeachievedusingcustom-madetintedbandagecontactlensandasforOOKP,alsoacustom-madeprostheticshellisused.Orbitaldecompressionsurgeryisperformedbyexperiencedsurgeonsonlyifthereiscompromiseoftheopticnerve.Inourexperience,ifthereisexophthalmoswithextrusionoftheOOKP/TibiaKPro,weconsidertransformingtheprosthesisintoatranspalpebraltype.Retinaldetachmentandvitreo-retinalsurgeryareperformedinanormalfashionincasesofBostonKProType1.AsforOOKP/TibiaKProcases,aspeciallens(Nadal-Barraquerlens)isadaptedontheocularsurfaceandopticalcylinderusingoverlyinghighdensityviscoelastictoperformbimanualmaneouvers.LimitationsincluderestrictedviewoftheperipheryduetothediameteroftheopticalcylinderbothinBostonKProType1andOOKP/TibiaKPro.Hypotonyismanagedusingaggressivepotenttopicalsteroidsorintravitrealinjectionofdepotsteroids.Inextremecases,siliconeoilisappliedtopreventphthisisbulbi.Severalvideosarepresented.


Conflictofinterest: NOFINANCIALINTERESTSTODISCLOSE



7-2Title: Post - operative Scleral Contact Lens Use to Stabilize the Ocular Surface in Cases

of High Risk Type 1 Boston Keratoprosthesis

Authors: SarahMNehls;AmyWalkerOD;EvanWarneMD

Affiliation: UniversityofWisconsinDeptofOphthalmology&VisualSciences,USA

Objective: PatientswithahistoryofocularsurfacescarringduetoautoimmunediseaseareathighriskofcornealmeltingandpossibleextrusionofaBostonkeratoprosthesis.ScleralcontactlensesareoftenusedtherapeuticallytoprovideocularsurfaceprotectionandlubricationintheseautoimmuneocularsurfacediseasesbuttheroleofscleralcontactlenseshasnotbeendescribedfollowingBostonkeratoprosthesissurgery.

Methods: Retrospectivecasereview

Results: ThreepatientswereidentifiedascandidatesforBostonkeratoprosthesissurgerycombinedwithplannedpost-operativescleralcontactlenswear.AllpatientshadahistoryofseverekeratoconjunctivitissiccaandocularsurfacescarringfromStevensJohnsonsyndrome(case1),ocularcicatricialpemphigoid(case2)andgraftversushostdiseasewithapriorsterilecornealmelt(case3).Thepatientswereassessedpre-operativelyfortheabilitytosuccessfullyfitascleralcontactlens.Followingthetype1Bostonkeratoprothesissurgery,twopatientsbeganfulltimeuseofscleralcontactlenswearwithinthefirstpostoperativemonth.Case1hadastableocularsurfaceusingthesclerallensfor9monthsandthenunderwentemergencyglaucomavalvesurgery.Cornealmeltingoccurredwithintwomonthsfollowingthissurgeryduetoconjunctivalswellingandtheinabilitytowearthesclerallens.Theocularsurfacestabilizedfollowingrepeattype1Bostonkeratoprosthesissurgerywithre-initiationofscleralcontactlensuse.Case2wasstablewithinitiationofscleralcontactlenswearwithinthefirstpost-operativemonth.Case3wasabletowearthesclerallensbutpreferredtheuseofalargediametersoftbandagecontactlenswithnocomplicationofcornealmelt.

Conclusions: EyesundergoingBostonkeratoprosthesisinthesettingofhighriskautoimmuneocularsurfacediseasemaybesuccessfullymanagedinthepost-operativeperiodwithscleralcontactlenswear.

Study supported by: ResearchtoPreventBlindness



7-3Title: Keratoprosthesis complications: the daily duty

Authors: BernardDuchesne1; Pierre Sohngen1;YvesGillon2;GaëlXhauflaire1

Affiliations: 1DepartmentofOphthalmology;2DepartmentofOro-Facialsurgery,UniversityofLiège,Belgium

Abstract: Toshareourexperienceinmanagingcomplicationsduringand/orfollowingKProsurgeries.Overtime,ourcomplicationsrateremainsstable.Inordertomanagesuchend-stageprocedure,wehavetobepreparedtodealwithcomplicationssuchasglaucoma,valveimplantation,boneexposure,buccalmucosaovergrowth,retroprostheticmembrane,chronicinflammation,macularedema,cornealmelting,boneinfection,cornealinfection,retinaldetachment,epithelialdowngrowth,phtyisibulbi,endophthalmitisandopticaldecentration.Theseareexamplesofthedailyclinicalchallengewehavetoface. ThecomplicationrateishighafterKProsurgeryandisnotcorrelatedtoalearningcurveperiod. Pre-existingpathology/surgeryandseverityatpresentationaretwoimportantfactors.DrynessassessmenttodecidewhattypeofKProhastobeused,earlydetectionofglaucoma,closefollow-uparesomekeypointsforthepatienttomaintainsightforalongperiod.Ifpossiblethefollow-uphastobedonebythesurgeon’steamandnotbyageneral ophthalmologist. Thisdrivesustodeclineseveralpatientsunabletoattendtheirfollow-up.


Conflictofinterest(ifany): None



7-4Title: Baerveldt device implantation in OOKP

Authors: AlfonsoVasquezPerez;ChristopherLiu

Affiliations: SussexEyeHospital.BrightonandSussexUniversityHospitals.NHSFoundationTrust.UnitedKingdom

Purpose: TopresentourexperienceusingtheBarveldtglaucomaimplantinapatientwithOOKPandprogressiveglaucomadespitepreviousAhmedvalveimplant.

Clinicalcase: Casereport.A47-year-old-ladywithpreviousOOKPhaduncontrolledglaucomadespitesystemicacetazolamideandpreviousAhmedvalve.SheunderwentanimplantationofBAERVELDT®250mm2(BG103-250)intheínferonasalquadrant.Topreventearlyhypotonyatubeligaturewith7/0vycrilwasdoneinadditiontoapartialtubelumenocclusionusinga3/0Supramidsuture.Supramidsuturewasleftinasuperficialpocketinthebuccalmucosaandsixweekslateritwasremoved.

Results: Thedigitalpressureoftheeyeimprovedtonormalandoralacetazolamidewasthendiscontinued.

Conclusion: BaerveldtglaucomaimplantisaneffectiveoptioninOOKPwithuncontrolledglaucomaandcouldbeconsideredasfirstlinetreatmentasithasshowntohavelowerpressuresreductionthanAhmedvalve.


7-5Title: Oculoplastic complications of OOKP and Tibial KPro



Purpose: Todescribetheclinicalfeaturesandoutcomesofoculoplasticcomplicationsinosteo-odonto(OOKP)andosteokeratoprosthesis(OKP).

Methods: AretrospectivereviewofthecasesfromUKnationalcohortofkeratoprosthesiswasconducted.Atotalof64patients,whounderwenteitherOOKPorOKP,wereidentified.Patientdataincluding:demography,diagnosis,surgicaldetailsandpostoperativeoutcomesrelatedtooculoplasticcomplicationswascollectedandanalysed.

Results: Mucosalthinningandulcerationwerethemostcommoncomplications,seenin45%ofthecasesafterthestage-1operation.Fourteenoutof30patientsrequiredmucosalgraftsandlidprocedurestocorrectthemucosalandlidanomaliesafterthestage-1.Mucosalovergrowthwasobservedin22cases,outwhich,4hadrespondedtoconservativemanagement.Mucosalulcerationwasnotedin14casesafterthestage-2.Laminartiltingwasobservedin3cases.Majorityoftheulcerationsafterthestage-1(14outof30)respondedtoconservativetreatment,whereasonly4outof14casesofulcerationafterthestage-2hadrespondedtoconservativetreatment.Twenty-fivecaseshadassociatedlidabnormalitiesoutofwhich15requiredsurgicalcorrections.

Conclusions: Mucosalcomplicationsaremostcommonafterbothstages1and2oftheOOKP(andOKP).Ulcerationisthemostcommonproblemafterthestage-1,whereasmucosalovergrowthwasthemostcommonproblemafterthestage-2.Asignificantnumberofcasesrequiredsurgicaltreatmentsfortheoculoplasticcomplications



7-6Title: OUTCOMES OF MEANS TO ADDRESS LAMINAR RESORPTION IN MOOKP

Author: Geetha Iyer


AIM: Toreportthetechniqueandoutcomes,ofBMPandboneaugmentation,asmeasurestoaddressandpreventordelay,laminarresorptioninMOOKPeyes.

Methods: RetrospectiveChartReviewofMOOKPpatientswhounderwenttheBMP(15eyes)andboneaugmentation(30eyes)betweenApril2012andJan2016wereincluded.BMPinvolvesplacementoftheproteinbeneaththefibrovasculartissuecoveringthelamina.Boneaugmentationinvolvesbonegraftingofthecaninetoothpriortoharvestingthelaminatoincreasethegirthoftheboneonthelabialaspect,notedtobemostpronetolaminar resorption.

Results: BoneMorphogenicProtein(BMP):BMPwasusedin4and11eyes,withlaminarresorptionnotedatameanfollowupof153(median79)and56.8months,belongingtothechemicalinjuryandSJSgroupsrespectively.7eyeshaveremainedstableoverafollowupof18-40months,while8eyesrequiredareKproprocedurewithin2-8monthsfollowingtheBMP. Bone Augmentation Thisprocedurehasbeenperformedin30patientsofwhich15haveundergoneallstagesoftheMOOKPwithameanfollowupof16.73monthsfollowingStage2.Ofthese,5eyesrequiredmucosalrevisionproceduresimmediatelyafterStage2forlaminarexposure.Thelaminardimensionswerenotedtobelargerfollowingboneaugmentation.Oftheremaining15,1graftunderwentnecrosisduetoexposureinthemouth,1hadaninfectioninthesubcutaneouspouchand1hadafractureofthetoothunrelatedtotheaugmentationduringtoothharvesting.Forthelatter2,asecondboneaugmentationhasbeen performed.

Conclusion: BMPhelpedstabilizetheresorptionin46.67%ofeyesandthereforehasaroleineyeswithmildtomoderategradesoflaminarresorption.BoneAugmentationmighthavearoleinpreventingordelayingtheonsetofresorptioninMOOKPeyes.Howeveralongtermfollowupisrequiredtoestablishtheroleofthesame.Initialresultshoweverdoappeartobe promising.


7-7Title: The use Bone-Morphogenic-Protein to avoid loss of a biological support in KPro,

first experience



Objective: Inkeratoprostheses(KPro)withbiologicalsupportlikeOsteo-Odonto-Keratoprosthesis(OOKP)andTibiabone-Keratoprotsthesis(TKPro)thereisariskofboneabsorptionoccasionallyleadingtoalossoftheKPro.TheIndianstudygrouparoundGeethaIyersuggestedusingacollagenspongesuckedwithBone-Morphogenic-Protein(BMP)torebuildtheboneandtosavetheKPro.

Methods: WeusedBMPin2Patients:oneOOKPandoneTKProwithsevereabsorptionofthebone.IntheOOKPhalfofthedentinewasexposedbutstillcoveredbyalayerofmucosa.WeremovedthemucosaandcoveredtheareabyaspongesuckedwithBMP,spongiosaofthepatientandthevitalmucosaagain.IntheTKProweremovedallofthemucosa,coveredtherestofbonewitha15mmwideringofspongesuckedwithBMPandcoveredthisbyacorticalbonelaminafromthetibiawithacentralholepositioningthevitalmucosabackontheimplant.

Results: IntheOOKPpatientwedidnotfoundanysignificantgrowthofboneincomputedtomographysothatwewillexchangetheprosthesisinthenearfuture.IntheTKProtherewasagenerationofnewboneinthegapbetweentheoldsupportandthenewcorticallamina.Untilnowtheprosthesisisstable.

Conclusions: BMP seems to be a promising tool in repairing a bone support in OOKP and TKPro. Coveringtheoldlaminabyalaminaoftibia-corticalisisanewideaandmaybemoresuccessfulthanonlycoveringtheBMP-spongebyspongiosatoinduceboneregeneration.Furtherinvestigationsareneeded.





The Boston devicesChairs:JamesChodosh,ShiroAmano

8-1 KeynoteTitle: Boston Keratoprosthesis Type I: The Outer Limits

Author: JamesChodosh

Affiliation: MassachusettsEyeandEar-HarvardMedicalSchool,Boston,Massachusetts,USA

TheBostonkeratoprosthesistypeIwasapprovedformarketingbytheUSFood&DrugAdministrationin1992.Over12,000deviceshavebeenimplantedsincethen.Thedeviceisusedmostcommonlyinpatientswithrepeatedcornealallograftrejectionsorinthesettingofheavilyvascularizedcornealscars,whenanother(orfirst)cornealtransplantislikelytofail.Suchpatientsalsoexperiencethebestlong-termoutcomeswithaBostonkeratoprosthesistypeI.Incontrast,cornea-blindeyesafterseverechemicalburnorinthesettingofautoimmunedisorderssuchasmucousmembranepemphigoidorStevens-Johnsonsyndromedolesswell,andtheseconditionsremainrelativecontraindicationstouseofthedevice.However,patientsblindedbytheselatterdisordersarealsothosemostlikelytoexperienceprofoundimprovementstotheirqualityoflifewhenimplantationofthedevicesuccessfullyrestoresvision.ThispresentationwillreviewuseoftheBostonkeratoprosthesisdeviceinchallengingmedicalconditions,alongwithmodificationsofthedevicetoaccommodatespecialcircumstancesaffectingthecorneaandocularsurface.


Conflictofinterest: Dr.ChodoshisanemployeeoftheMass.Eye&Ear,anonprofitinstitutionwhichdistributes the Boston keratoprosthesis.


8-2Title: Long-Term Outcomes of Boston type I Keratoprosthesis as Primary Penetrating

Corneal Procedure

Authors: CarolinaAravena;TahirKansuBozkurt;FeiYu;AnthonyJ.Aldave

Affiliation: TheJulesSteinEyeInstitute,UCLA,USA

Objective: Reportthelong-termoutcomesoftheBostontypeIkeratoprosthesis(Kpro)astheprimarypenetratingcornealprocedureinpatientswithhighriskofpenetratingkeratoplasty(PK)failure.

Methods: RetrospectivereviewofallKproproceduresperformedbyasinglesurgeonbetween5/1/04and1/1/15.Postoperativeoutcomes(correcteddistancevisualacuity(CDVA),retentionandcomplications)werecomparedbetweenKproproceduresperformedineyesasprimarypenetratingcornealprocedure(nopriorPK)andeyeswithpriorPK.

Results: 173Kproprocedureswereperformedin149eyesof139patients;31oftheprocedureswereperformedin24eyesof21patientswithnopriorPK.ThemostcommonindicationsineyeswithnopriorPKweresignificantcornealscarringand/orvascularization(10eyes,42%),Stevens-Johnsonsyndrome(4eyes,17%),chemicalinjury(4eyes,17%)andaniridia(3eyes,13%).ComparingeyeswithnopriorPKtoeyeswithpriorPK,preoperativeglaucomawassignificantlylesscommon(13%vs.64%,p<0.001)andthepostoperativefollow-upwassimilar(49.3+29.9movs.39.8+29.3mo;p=0.13).TherewasnosignificantdifferenceinthepercentageofeyesineachgroupwithCDVA=20/200priortoKproimplantation(nopriorPK,8%)orupto7yearsaftersurgery(nopriorPK,range69-100%).Retroprostheticmembrane(RPM)formationwassignificantlylesscommonineyeswithnopriorPK(29%vs.52%;p=0.047).Persistentcornealepithelialdefect(PED)formationwastheonlypostoperativecomplicationsthatwassignificantlymorecommonineyeswithnopriorPK(63%vs.31%,p=0.005),althoughtheassociatedsecondarycomplicationssterilecornealstromalnecrosis(25%vs.13%)andcornealinfiltrate(25%vs.11%)weretwiceascommonineyeswithnopriorPK.Despitethis,therewasnosignificantdifferenceintheretentionfailureratesinthetwogroups(8.1per100eye-yearvs.7.7per100eye-year;p=0.94).

Conclusions: BostontypeIkeratoprosthesisimplantationastheprimarypenetratingcornealprocedureresultsinasignificantimprovementinCDVAinthemajorityofeyesthrough7yearsaftersurgery.Theincidenceofthemostcommonpostoperativecomplication,RPMformation,wassignificantlylowerineyeswithnopriorPK,andtherewasnosignificantdifferenceintheretentionfailureratecomparedwitheyeswithpriorPK.





8-3Title: Interface Gap in Infectious Keratitis after Boston Keratoprosthesis Detected by

Anterior Segment Optical Coherence Tomography

Authors: EmiKashizuka;TakafumiYamaguchi;YumikoHirayama;YoshiyukiSatake;JunShimazaki

Affiliation: DepartmentofOphthalmology,TokyoDentalCollege,Japan

Objective: Bostonkeratoprosthesis(Kpro)isanalternativedevicetoimprovevisioninpatientswithmultiplepastgraftfailuresfromimmunologicrejection.However,infectiouskeratitis(IK)isknowntooccurfrequentlyinpatientswithKpros.Inthisstudy,wereporttheincidenceofinterfacegapinIKafterKpro,detectedbyanteriorsegmentopticalcoherencetomography(AS-OCT).

Methods: IKoccurredin3eyesoutof12patients(25%)whounderwentKproproceduresinTokyoDentalCollegefrom2010to2015.WeevaluatedtheAS-OCTfindings,suchasinterfacegapbetweenKproandthegraftcornea,andtheincidenceinthese3eyeswithIK,comparingwiththe9othereyeswitoutIK.

Results: Sixtysix-year-oldfemale(Case1),38-year-oldfemale(Case2),82-year-oldmale(Case3)developedIKat28-month,28-month,and8-monthafterKproimplantation.Theslit-lampexaminationshowedsimilarcharactersinthreecases;thickwhitishinfiltratesatthejunctionbetweenKproandgraftcorneawithepithelialdefects.ThesmearofthreecasesdisclosedCandidaalbicans,MRSA,andGrampositivemicroorganism,respectively.In2eyeswithMRSAandGrampositivemicroorganism,IKimprovedclinicallywitharapidresponsetoantibacterialtherapy.OneeyeswithCandidainfectiondevelopedendophthalmitisdespitetheaggressiveantifungaltreatmentandvitreoretinalsurgery,leadingtophthisis.RegardingtheassociationofAS-OCTfindingswiththedevelopmentofIK,aKpro-corneainterfacegapwasdetectedinfourpatients(4/12eyes;33%).LackofepithelialcoverageovertheKproedgewasobservedin3patients(3/12eyes;25%),andepithelialcystsin8patients(8/12eyes;67%).Fivepatients(5/12eyes;42%)including3eyeswithIKhadmorethantwoofthesefindings,detectedbyAS-OCT.

Conclusions: ThepresenceofagapintheinterfacebetweenKproandgraftcornea,epithelialcystorlackofepithelialcoveragemightbeassociatedwiththedevelopmentofIK,detectedbyAS-OCT.




8-4Title: “Blind for second time” Psychological and social impact of blindness in patients

with Boston Keratoprosthesis.

Authors: Arturo E. Grau1; Andrea Cruzat2;DanielaKhaliliyeh1

Affiliations: 1DepartmentofOphthalmology,PontificiaUniversidadCatolicadeChile;2MassachusettsEye&EarInfirmary,DepartmentofOphthalmology,HarvardMedicalSchool

Objective: Toassesstheimpactofbecomingblindforthesecondtimeinpatientsthatwerebilaterallyblind,underwentakeratoprosthesisimplantationandsufferedacomplicationlosing sight again.

Methods: Westudiedpatientswhohavebeenlegallyblind,thenrecoveredtheirsightafterakeratoprosthesisimplantation,andthenbecameblindagainafteracomplication.Weimplementedquestionnairesandinterviewedthepatientstomeasuredifferentaspectsofsight loss.

Results: Weexaminedthesocialandemotionalimpactofsightlossonasampleof4blindKPropatients.Patientsdescribedtheirfeelings,symptomsandfears.Wealsoscreenedforsuicidalthoughtsanddepression,andexaminedfamilyinteractionsandsocialnetworks.Theimpactofsightlossrevealedthatpatientsmayfallintoamildtoseveredepressionafterlosingsightforthesecondtime.

Conclusions: Whilethesampleofthisstudyistoosmalltoresultinanysignificantconclusion,theoutcomesofthestudyraiseanimportantquestion- whetheritisbettertoperformakerataprosthesisornot,intermsofthementalhealthandwellbeingofthepatient.Withalargergroupofpatientswemaybeabletoperformafurtheranalysisofthepsycologicalimpactofbecomingblindforthesecondtimeandgiverecommendationsfortheintegralmanagement of these patients.




8-5Title: TYPE 1 KPROS IN CHEMICAL INJURY

Author: BhaskarSrinivasan

Affiliation: CMER-Dennislameyehospitalchina,China

AIM: Toreporttheoutcomes,anatomicalandfunctional,ofthetype1Kproinocularchemicalinjuries.

Methods: RetrospectiveChartReviewofpatientswithocularchemicalinjurieswhounderwenttheBostonType1Kpro(16eyes)andtheLuciaType1Kpro(7eyes)betweenApril2008andDecember2015wasdone.

Results: BCVA>6/60wasachievedin15(93.75%)and6(85.7%)eyes;andmaintainedin8 (50%)and5(71.4%)eyesoftheBostonandLuciaType1Kprosoverameanfollowupperiodof31.43and16.42monthsrespectively.Preexistingglaucomawasnotedtobethemostcommonco-morbidityin9(56.25%)and3(42.85%)(1denovo)eyes;retroprostheticmembraneoccurredin3(18.75%)andnileyes;endophthalmitisin5eyes(31.25%)(4withanAhmedGlaucomavalveimplant)and1eye(14.3%)(withanAGVimplant);followingtheBostonType1andLuciaType1Kprosrespectively.Periopticmeltwasnotedin3(18.75%)and2(28.6%)eyesandarekprowasperformedin7(43.75%)and2(28.57%)eyesfollowingtheBostonType1andLuciaType1Kprorespectively.

Conclusion: TheLuciaType1Kprowithatitaniumbackplateisaneconomical,singleaxiallengthKpro,similarotherwisetotheBostonType1Kpro.NoRPMwasnotedineyeswiththeLuciaType1Kproprobablyduetothetitaniumbackplate.TheothercomplicationsnotedweresimilartotheBostonType1Kpro.EndophthalmitiswasnotedtooccurmorefrequentlyineyeswiththeAGVandwereallfungalinetiology.


8-6Title: Tissue carriers for the Boston Keratoprosthesis

Authors: Andrea Cruzat; Miguel González;DohlmanClaes

Affiliation: MassachusettsEyeandEar,HarvardMedicalSchool,USA

Objective: TheBostonkeratoprosthesis(B-KPro),presentlyneedsacornealgraftasatissuecarrier.Althoughcornealallografttissueisreadilyavailableandaffordableindevelopedcountrieswithestablishedeyebanks,theworldwideneedvastlyexceedssupply.Therefore,asimple,safe,andinexpensivealternativetocornealallograftsisdesirableforthedevelopingworld.WereviewreasonablealternativeoptionsforB-KProcarrierssuchascornealautografts,xenografts,non-cornealautologoustissues,andlaboratory-madeconstructs.Weareparticularlyinterestedinxenografts.Westudiedmethodsforreducingxenograftantigenicitybydecellularizationandforsterilizationpurposes.Preliminaryresultsofmodifiedpigcorneasandtransplantationintorabbitswillalsobepresented.

Study supported by: BostonKeratoprosthesis,MassEye&Ear




8-7Title: Boston Keratoprosthesis Type I in Elderly Patients

Authors: JamesChodosh,MD,MPH;GelarehHomayounfar,MD;ChristinaM.Grassi,MD; AhmadAl-Moujahed,MD;KathrynA.Colby,MD;PhD,ClaesH.Dohlman,MD,PhD

Affiliation: MassachusettsEyeandEar-HarvardMedicalSchool,Boston,Massachusetts,USA

TheBostonkeratoprosthesistypeIisanacceptedalternativeforcornea-blindpatientswhenstandardcornealtransplantationisunlikelytosucceed.Recipientscanexperiencedramaticvisualrecoverybutarealsosusceptibletocomplications.WesoughttodeterminetheoutcomesandcomplicationsofBostontypeIkeratoprosthesisimplantedinelderlypatients.Aretrospectivecaseserieswasperformedonpatientsatleast75yearsoldwhoreceivedtheBostontypeIkeratoprosthesisbetweenJanuary1,2007andDecember31,2012.Preoperativediagnosis,intervalvisualacuity,keratoprosthesisretention,andpostoperativecomplicationswererecordedforeachpatient.Overthistimeperiod,44BostontypeIkeratoprostheseswereimplantedin44eyesof43patients.Themostcommonindicationforsurgerywascornealgraftfailure(n=23;52.3%)followedbycornealscar(n=8;18.2%),andlimbalstemcelldysfunction(n=8;18.2%).Allpatientshadpreoperativevisualacuityof≤20/200.Thirty-sixof44(82%)patientsachievedvisualacuityof20/200orbetterpostoperatively,and20ofthose(55.6%)maintained20/200orbetterfor1yearaftersurgery.Themedianlengthoffollowupwas825days(range:27–2193days),andatthelastfollow-upvisit,20of44(45.5%)had20/200orbettervision.Themedianbest-correctedvisualacuity(logMAR)improvedfrom2.6preoperativelyto1.0atoneyearpostoperative(p


Case presentation and future KProsChairs:HiroshiEguchi,VenkataAvadhanam,GeethaIyer

9-1 KeynoteTitle: CHOOSING THE RIGHT KPRO FOR PATIENTS NOT PATIENT FOR KPRO IN SEVERE

CHEMICAL INJURIES –

Author: Geetha Iyer


Aim: Toreportthechoice,techniqueandoutcomesof4differenttypesofKprosin4patientswithseverechemicalinjuries.

Methods: 4patientswhounderwenttheBostonType2/LuciaType2/LuciaType1andtheosteoKprounderchallengingcircumstancesisreported.

Results: Patient1:Oneeyedpatientwhopresentedwithaself-sealedcornealperforation(AL-13mm)amonthafterchemicalinjury,underwenttheLuciaType1Kproaftermultiplesurgeriesforfornixreconstruction.Hedevelopedaretinaldetachmentonday5,whichwassettled.Intraocularpressurewasnotedtobehigh5monthslaterthatrequiredSORandAGVsubsequently.2yearslater,withBCVAof6/24-hepresentedwithagraftmeltforwhichalamellarpatchgraftwasdoneandmaintainsanatomicandfunctionalintegrity4yearssincepresentation. Patient2:Oneeyedpatientwithperceivedglobemovements(AL-20MM)beneathaskingraftunderwenttheLuciaType2Kproandmaintainsavisionof6/36at2yearsoffollowupwithaneedformucosalrevisionsforovergrowth. Patient3:OneeyedpatientwithalongstandingnasalRDwitheyelidskinscarring,underwentRDsurgery,BostonType2Kpro,multipleskinrevisionsurgeries,andmaintains6/24at3yearfollowupwithexcisionforskinovergrowththatoccursover4-6months. Patient4:PatientwihanALof13mmwithRD,inwhomretinawasattachedfollowingplacementoftemporaryKproina6mmcornea.Thiswasfollowedbymucosalgraft/osteoKprowithrecoveryofvisionto6/60.

Conclusion: Theoutcomeofdifficultandchallengingchemicalinjurieshasbeenreported.Thepracticaldifficultiesincludingadministrationofanesthesia,decisionofthetypeofKprotobeimplantedandassociatedposteriorsegmentcomplicationshasbeendescribed.Howeverthegoodresultsobtainedareencouragingtoattemptsuchsurgeriesintheseotherwisechallengingsituations.



9-2Title: Staged procedure using temporary keratoprosthesis to repair severe ocular

trauma: case report

Authors: HideakiYokogawa;AkiraKobayashi;NatsukoMori;TetsuhikoOkuda;KazuhisaSugiyama

Affiliation: DepartmentofOphthalmology,KanazawaUniversityGraduateSchoolof MedicalScience,Japan

Objective: ToreportstagedprocedureusingEckardttemporarykeratoprosthesis(kpro)torepairsevereoculartrauma.

Methods: A54-year-oldmanwasreferredtousformultiplecorneallacerationsandmultipleintravitreousforeignbodiescausedbychemicalexplosionaccident.Atfirstsurgery,penetratingkeratoplastycombinedwithparsplanavitrectomywasperformed.Thedamagedrecipientcorneawastrephined,andkprowassuturedonthetrephineopening.Goodvisualizationofintraocularstructurethroughkprowithclosed-systemenabledsafemaneuverincludingforeignbodyextraction.Then,siliconeoilwasinjected,andthekprowasexchangedbycryopreserveddonorcornea.Twomonthsafterthefirstoperation,penetratingkeratoplastycombinedwithtransscleralfixationofintraocularlenswasperformed.Thesiliconeoilwasremovedthroughreopenedcornea,andkprowassutured.Intraocularlenswasimplantedwithclosed-system.Then,kprowasexchangedbyfreshdonorcornea.Finalbestcorrectedvisualacuitywas20/130,althoughBaerveldtglaucomatubeimplantationwasrequired.

Conclusions: Stagedprocedurewithuseofkproisusefultorepairsevereoculartrauma.

Conflictofinterest: HideakiYokogawa,recpient:AlconJapanLtd.


9-3Title: Novel Artificial Cornea KeraKlear Keratoprosthesis for 4 Cases with Severe Corneal

Disorders

Authors: Masaki Fukui1,2,3; Takeshi Ide1;YoshiyukiIchihashi1,3; Emiko Miki1;TetsuyaKawakita1,3; TerukiFukumoto1,4; Kazuo Tsubota1,3 ;Ikuko Toda1

Affiliations: 1MinamiaoyamaEyeClinic,Japan;2NationalHospitalOrganizationTokyoMedicalCenter,Japan;3DepartmentofOphthalmology,KeioUniversitySchoolofMedicine,Japan;4KikugawaEyeClinic,Japan

Objective: KeraKlearKeratoprosthesis(K3)isafoldable,non-penetratingartificialcorneathatisinsertedinthefemtosecondlaser(FSL)-createdpocket.Herein,wereportourearlyexperiencewithK3transplantations.

Methods: A4-caseseries. Case1:A53-year-oldmanwithseveregelatinousdrop-likedystrophyhadundergonephototherapeutickeratectomy(PTK)twice.Thethicknessofhiscorneawas337μm. His bestcorrectedvisualacuity(BCVA)beforeK3insertionwas20/320. Case2:An18-year-oldmanhadaprogressivekeratoconusandatopicdermatitis.Thethicknessofhiscorneawas349μm,andhispreoperativeBCVAwas20/200. Case3:A48-year-oldwomanhadarecurrentAvellinocornealdystrophy.Shehadlamellarkeratoplastyandpenetratingkeratoplasty(PKP),andhadundergonePTKthreetimes.HerpreoperativeBCVAwas20/100. Case4:A44-year-oldmanhadaprogressivekeratoconus.Hepreviouslyhadintracornealring(ICR)insertion.WeremovedtheICRs4monthsbeforeK3surgery.HisBCVAwas20/100.

Results: Case1:K3transplantationwasperformedinFebruary2014.CornealperforationwasobservedwhenthepocketwasmadebyusingFSL.SubluxationofK3wasfoundatthethirdpostoperativeday,andK3repositioningandanchoringsuturewereperformed.HispostoperativeBCVAimprovedto20/32. Case2:TransplantationwasperformedonApril12,2014,withoutanyintraoperativeandpostoperativecomplications.HisBCVAimprovedto20/40. Case3:TheoperationwasperformedinOctober2014,withoutanyintraoperativeandpostoperativecomplications.HerBCVAimprovedto20/25. Case4:TheoperationinApril2015wentwell.HisimmediatepostoperativeBCVAdecreasedto20/200,andhehadanintolerablepain.TwomonthsafterK3insertion,PKPwasperformed.Hedidnothaveanintolerablepain,andhisBCVAimprovedto20/32.

Conclusions: Conventionalcornealtransplantationsareassociatedwithproblemssuchasshortsupplyofdonorcornea,graftrejection,andproceduralcomplexity.ThenewKeraKlearKeratoprosthesismayovercometheseissuesandcanbeappliedclinicallymorevariousdiseases.Inthisstudy,K3wassafeandshowedquickimprovementinvisualacuity.K3providesanovelconceptofartificialcornealtransplantationandcanbeusedasanalternativetoconventionaldonorcornea.





9-4Title: Chondro-keratoprosthesis: an alternative to OOKP ?

Authors: Hoffart Louis1,2,3; Guyot Laurent1,2,4

Affiliations: 1Aix-MarseilleUniversity,France;2AssistancePubliqueHopitauxdeMarseille;3OphthalmologyDepartment;4OralandMaxillofacialSurgeryDepartment

Objective: Toevaluatetheuseofcartilageasapotentialgraftmaterialinordertoexploreanewapproachtowardosteo-odontaltissuereplacementinkeratoprosthesissurgery.

Methods: Wedescribeamodificationoftheosteo-odonto-keratoprosthesissurgerythatinvolvestheuseofautogenousauricularconchalcartilagegraft(ACCG)in2patients.Instage1,autogenousconchalcartilagewasharvestedviaaposteriorapproach.Then,anopticalpolymethyl-methacrylatecylinderwasembeddedintoadouble-layeredfragmentoftheconchalcartilageandsecuredbycyanoacrylateglue.Theopticalcylinderandcartilagecomplexwerethenimplantedintothecheek.Duringthesameprocedure,theocularsurfacewasdenudedandreplacedwithfull-thicknessbuccalmucosagraft.Thestage2,performed2to4monthslater,involvedretrievalofthecomplexandimplantationintothecornea,afterreflectionofthebuccalmucosalflap,cornealtrephination,irisandlensremoval,andanteriorvitrectomy.Cartilagespecimenswerethenprocessedforhistologicalevaluationafterretrieval.

Results: Wereporttwocasesofchondro-keratoprosthesis(CKPRO)whounderwentsurgerywitha6monthsfollow-upfollowingabilaterallimbalstemcelldeficiencyassociatedwithseverecornealchanges.Bothpatientsexperiencedmultiplefailedpenetratingkeratoplastyrelatedtocongenitalaniridia(patient1)andphysicalinjury(patient2)respectively.Visionwaslimitedtolightperception(LP)onlyinbothcases.Afterretrievalofopticalcylinderandcartilagecomplex,connectivetissueservedtobindthehostcorneatothecartilage.Afragmentwassentforhistologicalstudiesthatdidnotshownanyinfiltrationorinflammationandthecartilageremainedavascular.Onpatient1,CKPROwasperformedinthelefteyeandthevisionwasimprovedto20/100J6duringthefollow-up.Onpatient2,CKPROwasperformedintherighteyeandthepostoperativevisualacuitystaylimitedtoLPrelatedtopreoperativeretinallesions.Duringthefollow-up,anypostoperativecomplicationasextrusion,epithelialdowngrowth,retrocornealmembraneorendophtalmiawasobserved.

Conclusions: ACCGcouldbeagoodalternativetoreplaceosteo-odontalgraftinkeratoprosthesissurgeryespeciallyinyoungpatientswithhealthyteeth.ACCGhasalreadybeenwidelyusedforreconstructivesurgeryandprovidessafeandstablesupporttotheopticalcylinder.Hiddenskinscaristheonlyconsequenceatthedonorsite.However,furthercomprehensivestudieswithlargersamplesizeandlongfollow-uparerequiredtoelucidateanydifferencebetweenthesetwotechniques.




9-5Title: Micro pressure sensor integrated into the Boston keratoprosthesis

Authors: EleftheriosI.Paschalis;JamesChodosh;ClaesH.Dohlman

Affiliation: MEEI/SERI,USA

Objective: Elevatedintraocularpressure(IOP)leadstoglaucoma,themostseverecomplicationfollowingBostonkeratoprosthesis(BKPro)surgery.StandardtonometersarenotsuitableforKPropatients,andfingerpalpationisofteninaccurate.Wehavedevelopedamicro-opto-mechanicalpressuresystem(MOMS)thatisintegratedintotheopticalstemoftheBKProdeviceandcanprovideno-contactIOPmeasurementswithhighaccuracy.

Methods: Aminiaturizedfiberopticpressuresensor(300μmindiameter)basedonMOMStechnologywasintegratedintotheperipheryoftheBKProopticalstemthrougha305μm holemadeintheperipheryofthestem.Theopticalfiberwaslasercleavedintotwopartstoformaconvexlenssystem,suitablefornon-contactcouplingoflight.Thecouplingefficiencyofthesensorandcleavedopticalfiberwasevaluatedbycomputercontrolledopticalanalyzerconnectedtothefiberandwasassessedinregardstodistanceandangularmisalignmentinvitro.Thereliabilityofthesensorwasassessedinvitrofor9monthsusingcontinuouspressuremeasurementsoftwoidenticalcalibratedsensorsinthesamehydrostaticcolumn.

Results: Measurementsfromthetwosensorswereperformedcontinuouslyfor9monthswithpressurerangingfrom-7.5to+40mmHg.Thetwosensorsexhibitednegligibledifferencesinmeasuringpressure(difference<0.8mmHg)andexcellentaccuracyinmeasuringabsolutepressure(accuracy±0.2mmHg).Withinthe9monthsofevaluation,nopressuredriftwasnotedbythetwosensors.Non-contactmeasurementswereperformedusingairorwaterinterfacebetweenthetwofiberends.Optimalsignaltonoiseratiowasachievedataseparationdistanceof300μminairand1000μminwaterandwithangularmisalignmentupto20degrees.Oncethefiberswerecoupled,apressuremeasurementwasachievedwithin60milliseconds.

Conclusions: UsingopticalMOMStechnologywewereabletodesignanultra-miniaturizedmicropressuresensor,suitableforintegrationintotheBKProstem.ThefactthatthesensoroperatesintheopticalspectrumallowsthescalingdownoftransducerdimensionsandMOMScomponents,therebyminimizingdriftandmaximizingaccuracyanddetectionresolution.Theshapingofthefiberendtoanintegratedopticalcouplerallowsnon-contactmeasurementstobeperformedattheslitlamp.TheimplementationofthistechnologyinKProdevicesmayprovideanintegratedall-in-onesolutionforIOPmeasurement,andimprovedetectionandmanagementofglaucoma.





9-6Title: Hydrogel skirt for synthetic OOKP lamina

Authors: VenkatAvadhanam

Affiliation: SussexEyeHospital,Brighton,UKBrightonandSussexMedicalSchool,Brighton,UK

Purpose: Toreportthestudyofahydrogelpolymericinterpenetratingnetwork(IPN)compositemadeofagaroseandpoly-ethyleneglycol-diacrylate(PEGDA)asasubstituteforosteo-odonto-keratoprosthesis(OOKP)lamina.

Methods: Inanin-vitrostudy,acompositeofagaroseandPEGDAwasprepared,whichhasatuneablemechanicalstiffness.ThesehydrogelmaterailswereIncorporationwithhydroxyapatite(HA)coatedpoly(lactic-co-glycolicacid)(PLGA)microspherestoimprovecellularresponseandmimicbonemicro-environmentasinOOKPlamina.Materialcharacterisationwasstudiedwith:mechanicalresistancetostress,swellability,andporosityassessmentwithscanningelectronmicroscopy.MultipleIPNdiscsofvaryingconcentrationofitsconstituents(2to5%agarose,10to40%PEGDA)werepreparedandseededwith3T3fibroblastsandkeratocytes.Cellgrowthstudiedwithlive-deadassays.

Results: HighconcentrationsofthePEGDAandagaroseprovidedhighermechanicalstrength.Additionally,IPNscontaining6000molecularweightPEGDAand5%agaroseincorporatedwithHAcoatedmicrospheres(5-40IPN+HA)hadahigherelasticmodulusthantheIPNcontaining2%agarosewith40%PEGDA(2-40%IPN)and5%agarosewith40%PEGDA(5-40%IPN).HAincorporationenhancedcellviabilityandmigrationintothematerial.

Conclusions: WesuccessfullysynthesizedapromisingIPNhydrogelmaterialwithauniquecombinationofhighmechanicalstrengthandcyto-compatibility.TuneablemechanicalstrengthandenhancedcellviabilitywithHArichmicroenvironmentarethedesirableattributesofthishybridmaterialsystem,whenusedasapotentialskirtmaterialinOOKP.


9-7Title: TRAUMA FOLLOWING MOOKP

Author: Geetha Iyer


Aim: ToreporttheoutcomeinacaseoftraumafollowingtheMOOKPprocedure

Methods: Aninterventionalcasereport

Results: Aoneeyedyoungladyof38yearswithSJSunderwentanuneventfulMOOKPprocedurein2006withavisualrecoveryof6/6.Shemaintainedthesametill2011,whensheusedachemicalofunknowncompositionintheeyethatledtomucosalnecrosisandthesamewasattemptedtobesuturedelsewhere.ShepresentedwithadropinvisiontoPL,severehypotonyandclinicalfeaturesofalargeareaofmucosalnecrosisinferiorlywithcornealperforationbeneaththelamina.Anexplorativesurgeryrevealedanintactlaminawhichwasplacedinthecontralateralsubcutaneouspouch,atectonicpenetratingkeratoplastywasperformed,thesuperiorintactmucosawasleftaswasandatotaltarsorrhaphywasperformed.2monthslaterfollowingsubsidenceofthechoroidaldetachment,amucosalrevisionsurgerywasperformed.Amonthlaterthelaminawasplacedbackintheeyewithavisualrecoveryof6/6.Laminarexposuremediallywasaddressedbyatarsoconjunctivalflap.Shemaintainedavisionof6/6till2015,whenfollowingatrauma2monthsbackshepresentedwithanirreparableRD.Laminawasnotedtobeintact.

Conclusion: Thiscasehighlightsthetenacityofthelamina,theneedtopresentimmediatelyfollowingtraumaandthepossibilitytorestoreanatomicandfunctionalintegrityifaddressedappropriately.Thoughshemaintainedavisionof6/6over9years,theeyewaslosttoa2nduntowardevent.



9-8Title: Evaluation of effectiveness of real-time PCR for clinical diagnosis of herpes

simplex virus keratits

Authors: DaisukeShimizu;DaiMiyazaki;InataKoudai;RyuUotani;KeikoYakura;TomokoHaruki;Yoshitsugu Inoue

Affiliation: OphthalmologyandVisualScience,FacultyofMedicine,TottoriUniversity,Japan

Objective: ToevaluatetheeffectivenessofmeasurementofHSVDNAamountbyreal-timePCRforclinicaldiagnosisofherpessimplexvirus(HSV)keratitis.

Methods: Threehundredandfifty-onecasesmeasuredforHSVDNAcopynumbersincornealscrapingsortearfluidsforthesuspicionorexclusionofHSVkeratitis,wereretrospectivelyanalyzed.DiagnosticefficacyofHSVDNAcopynumbers,clinicalfindingsofdendriticlesions,cornealulcerandcornealinfiltrateswereevaluatedbyreceiveroperatingcharacteristic(ROC)analyses.

Results: OnehundredeyeswerefinallydiagnosedasHSVkeratitis(epithelialkeratitis:72eyes,stromalkeratitis26eyes,endothelialkeratitis2eyes).IntheHSVkeratitiseyes,positiverateofPCR,dendriticlesions,cornealulceranddisciformlesionswas66%,30%,56%,24%,respectively.Inthenon-HSVkeratitiseyes,thepositiveratewas12%5.2%,57%,1.2%,respectively.Areaunderthecurve(AUC)wascalculatedtoshowdiagnosticefficacybasedonROCanalyses.TheAUCforepithelialHSVkeratitiscalculatedbyusingHSVDNAcopynumbersobtainedfromcornealscrapingswas0.87(dendriticlesions:0.72,cornealulcer:0.56,disciformlesions:0.48).Byusingtearfluids,theAUCfortheepithelialHSVkeratitiswas0.74(dendriticlesions:0.65,cornealulcer:0.47,disciformlesions:0.47).Inasimilarway,theAUCforstromalHSVkeratitiscalculatedbyusingHSVDNAcopynumbersobtainedfromtearfluidswas0.58.

Conclusions: HSVDNAcopynumbersobtainedfromcornealscrapingsbyreal-timePCRmethodwashighlyefficacioustodefinitivelydiagnoseepithelialHSVkeratitisandmoreusefulthanclinicalcornealfindings.


Endothelial keratoplasty (DSAEK vs DMEK)Chairs:JunShimazaki,SatoruYamagami

10-1 KeynoteTitle: DSAEK

Author: Akira Kobayashi

Affiliation: DepartmentofOphthalmology,KanazawaUniversityHospital,Japan

Overthepastdecade,newsurgicaltechniqueshavebeenreportedfortreatmentofbullouskeratopathythatreplaceonlythedysfunctionalposteriorportionofthecorneathroughascleralpocketincision.Mostnotably,thesetechniquescompletelyeliminatesurfacecornealincisionsorsutures,maintainmuchofthecornea’sstructuralintegrityandinduceminimalrefractivechange,suggestingdistinctadvantagesoverstandardpenetratingkeratoplasty.In2006,preparationofdonortissueinendothelialkeratoplastyhasbeenmadeeasierwiththeutilizationofanautomatedmicrokeratome,andtheadditionofthiscomponenttothesurgicalprocedurehasbeenpopularizedasDescemetStrippingAutomatedEndothelialKeratoplasty(DSAEK). InJapan,bullouskeratopathiessecondarytoargonlaseriridotomyarequitecommon.Theyhaveshallowanteriorchamberwithhighvitreouspressure,whichmakestaco-foldingdonorinsertionquitedifficult;sometimesthedonorendotheliallamellapopsoutafterinsertion,resultinginrepeatedgraftfoldingandinsertion.In2006,weintroduceddonorpull-throughtechnique,anddevelopeddouble-glidetechniqueusingbothBusinglideandIOLsheetsglide.Also,toavoidanothercomplicationsinDSAEK,severaltechniquesusingnewdevicesandviscoelasticshasbeendeveloped. Now,weconfirmedDSAEKissimple,reproducible,safeandeffectiveprocedureformostAsianpatientswithcornealendothelialdysfunction.





10-2 KeynoteTitle: DMEK - the method of choice for endothelial replacement

Author: FriedrichE.Kruse

Affiliation: DepartmentofOphthalmology,UniversityHospitalErlangen,Erlangen,Germany

Keratoplastyhasbeenrevolutionizedbytheintroductionoflamellartechniquesthatallowforselectivereplacementofdiseasedcornealstructures.InEuropeabout40%ofallgraftsareperformedfordiseasesofthecornealendotheliumnamelyFuchsendothelialdystrophy.HereDescemetstrippingendothelialkeratopasty(DSEK)hasgreatlyimprovedboththespeedoffunctionalrecoveryaswellasvisualoutcomesascomparedtopenetratingkeratoplasty(PK).

Previouslytherewasdebateastowhattechniquesreachbestoutcomes:Descemetstrippingautomatedendothelialkeratoplasty(DSAEK)isastandardizedmethodutilizingthin(150µ)graftswhichcanbesuppliedbyeyebanks(precuttissue)andinsertedbyinsertedbydevices(e.g.Businglide,TanEndoglide)whicharecommerciallyavailable.IncontrastDescemetmembraneendothelialkeratoplasty(DMEK)isinvolvesmanualpreparationofultrathin(10µ)graftsandahighlydemanding,non-standardizedimplantationprocedurewhichlackscommerciallyavailabledevicesforinsertion.

SeveralstudieshaveclearlyshownthatDMEKrendersbetterfunctionalresultsthanDSAEKwhichisnotonlyduetorestaurationoftheanatomyintheinterfacebutalsoduetoasuperiorqualityoftheposteriorcornealsurfacewithsignificantlylesshigherorderaberrations.

UptonowthemajorlimitationofDMEKisthelackofstandardizationaswellasproblemswithgraftadhesion.Wehavedevelopedaseriesofstepswhichhelptostandardizebothtissuepreparationaswellastissueinsertionandmanipulationintheanteriorchamber:ThesestepsincludestandardizedremovalofthehostDM,individualizedassignmentofgraftsaccordingtothepatientsanteriorchamberdepthandthebubbleintherolltechniqueusingaspecialcartridgefordeliveryofthetransplant.

MajoradvantagesofDMEKrelatenotonlytosuperiorvisualfunctionandfastvisualrecoverybutalsotoasignificantlyreducedrateofimmunologicalgraftrefectionwhichisseverallogunitsbelowthatofDSAEKandPK.


10-3Title: Descemet membrane endothelial keratoplasty: challenges in the first 100 cases in

Egypt

Author: MohamedBahgatGoweida

trials and tribulationstrials and tribulations chairs: konrad hille, masahiko fukuda, christopher...

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