Table Of ContentM. Soledad Cortina
Jose de la Cruz
Editors
Keratoprostheses
and Artifi cial Corneas
Fundamentals and
Surgical Applications
123
Keratoprostheses and Artifi cial Corneas
M. Soledad C ortina • Jose de la Cruz
Editors
Keratoprostheses
and Artifi cial Corneas
Fundamentals and Surgical
Applications
Editors
M. Soledad Cortina Jose de la Cruz
Cornea, External Disease Cornea, External Disease
and Refractive Surgery and Refractive Surgery
Department of Ophthalmology Department of Ophthalmology
and Visual Sciences and Visual Sciences
University of Illinois Eye University of Illinois
and Ear Infi rmary Eye and Ear Infi rmary
Chicago , IL Chicago , IL
USA USA
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Foreword
Why do we need an artifi cial cornea – a keratoprosthesis – when standard
corneal transplantation (PK) is so easy to perform surgically and is so time-
tested and well established? After all we have learned over a century how to
prevent infections, suppress postoperative infl ammation, and now effectively
replace diseased corneas layer by layer.
Is that not enough? No – and the reason is related to the exaggerated notion
we often have of the long-term outcome for PK, worldwide. In the affl uent
developed world, PKs are largely performed for endothelial dysfunction in
eyes with little infl ammation, and here the 5-year outcome with clear grafts
seems to be in the range of 60–90 %, depending on where performed. In
developing countries, where 90 % of the corneal blind live, corneal damage
tends on the average to be much more severe and the eyes more infl amed.
There, outcomes after PK (when resources allow) are poorly documented but
tend to be dismal long-term. Also, worldwide, severe chemical burns and
autoimmune diseases are rarely helped by corneal allograft.
Thus, for a large portion of the world’s cornea blind, probably at least
100,000 new cases per year, a PK cannot restore vision even if repeated, and
we clearly need a simple and inexpensive back-up “rescue” procedure of
some kind. Here a keratoprosthesis should have a prominent place, but other
alternatives are also being pursued such as stem cell transplants or buccal
mucosa, followed by keratoplasty, or tissue constructs, scleral contact
lenses, etc.
T he concept of a keratoprosthesis as a defi nitive sight-restoring solution
for a severely opaque cornea is quite obvious, but throughout history it has
been very diffi cult to implement safely. Infection, tissue melt, glaucoma, reti-
nal detachment, and even total loss of eye have been frequent. Not until the
last two decades has it become justifi ed to implement keratoprosthesis sur-
gery on a routine basis in PK failures. Still, credit should go to many past
surgeons with bright minds who have patiently added building stones toward
what we have now.
T hus, keratoprosthesis implantation has now been developed into an at
least moderately safe procedure for the long-term, except in autoimmune
diseases and other heavily infl ammatory situations. It has become included
in recent ophthalmic textbooks, but it has not previously been the subject of
a single monograph. This void has now been fi lled by this elegant treatise,
ably edited by Drs. Cortina and de la Cruz, in which basic surgical and
v
vi Foreword
epidemiological aspects are covered in depth by experts. The participants
should be congratulated for producing a detailed surgical guide as well as
what should be a profound basis for the next generation’s developmental
work in this rapidly expanding fi eld. We have to realize that we have so far
reached only a few steps in this very promising area. We should encourage
coming generations of clinician-scientists to translate our present insights
into applying KPros on a massive sight-saving scale – especially in the
developing world. This monograph will serve as a great inspiration!
Claes Dohlman
Harvard Medical School
Boston , MA , USA
Pref ace
V isual rehabilitation is a major challenge in those patients whose damaged or
diseased cornea is not amenable to penetrating keratoplasty. For over two
centuries, those engaged in the fi eld of artifi cial cornea have tried to address
these important challenges. In recent years, we have seen a tremendous step
forward that makes us believe we fi nally have options to offer patients suffer-
ing from corneal blindness.
T he history of keratoprosthesis spans from the initial work of French oph-
thalmologist Guillaume Pellier de Quengsy (1751–1835), who fi rst described
the concept of an artifi cial cornea in 1789, to modern advances in integrated
and nonintegrated keratoprostheses from such luminaries as José Ignacio
Barraquer Moner, Hernando Cardona, Benedetto Strampelli, Giancarlo
Falcinelli, and Claes Dohlman. Throughout this time, different keratopros-
theses have seen their fair share of successes and failures. In the last three
decades, advances in corneal transplantation techniques, instrumentation,
identifying risk factors, and modifi cations in current keratoprosthetic devices
have helped improve the long-term outcomes for patients who would other-
wise have little to no options of visual rehabilitation.
A s improvements in keratoprosthesis surgery have occurred, a unifi ed
source of knowledge has become necessary to assist future keratoprosthesis
surgeons. Additionally, keratoprosthesis surgery is becoming a standard pro-
cedure in most academic institutions. This book is the fi rst comprehensive
textbook dedicated solely to keratoprosthesis surgery. It offers an in-depth
review of all keratoprostheses in use today. Special attention is given to the
Boston Keratoprosthesis (KPro), which has become the most commonly used
artifi cial cornea in the United States and worldwide under the stewardship of
Claes Dohlman, MD, PhD.
We are deeply grateful to all the contributors, who have so generously
shared their experiences and insight in this book, which we hope will help
other cornea surgeons in their journey through the fi eld of the artifi cial cor-
nea. Our goal was to make this book a standard reference that provides the
technical expertise acquired by years of experience, and we are very proud to
have contributions by such a distinguished group of authors.
W e would like to thank Springer for its support of this edition in what we
hope will be the main reference source of keratoprosthesis surgery.
vii
viii Preface
In closing, we would like to thank our spouses, Agustin and Sylvia, for
their continuous love and support throughout the many long hours of work,
which has allowed us to dedicate the time needed to accomplish this project,
and to our children Benjamin, Nicolas, Tobias and Francisco, and Javier and
Gabriella, to whom we dedicate this book.
Chicago, IL, USA M. Soledad Cortina
April 2014 Jose de la Cruz
Contents
Part I Introduction and History of PKP and KPRO
1 The History of Keratoplasty: A Brief Overview. . . . . . . . . . . . 3
Mark J. Mannis
2 History of the Artifi cial Cornea . . . . . . . . . . . . . . . . . . . . . . . . . 13
Samuel H. Lee, M. Soledad Cortina, and Jose de la Cruz
Part II Anatomic and Physiological Considerations
3 The Anatomy and Physiology of Cornea. . . . . . . . . . . . . . . . . . 19
Sonal Gandhi and Sandeep Jain
4 Anterior Segment Considerations in Boston
Type I Keratoprosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Kavitha R. Sivaraman and Norma Allemann
5 Overview of Relevant Clinical Disorders
and Their Relation to Keratoprosthesis. . . . . . . . . . . . . . . . . . . 35
Nadeem Fatteh and Shahzad I. Mian
Part III Boston Keratoprosthesis
6 Boston Keratoprosthesis: Design, Materials,
and Manufacturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Bilal Faiz Khan
7 Indications and Contraindications of Boston KPRO
Types I and II. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Marie-Claude Robert and Mona Harissi-Dagher
8 Imaging of Boston Keratoprosthesis Type 1 . . . . . . . . . . . . . . . 67
Joann J. Kang and M. Soledad Cortina
9 Boston Keratoprosthesis Type I: Surgical Techniques. . . . . . . 77
Lauren R. Schneider and Sadeer B. Hannush
10 Boston KPRO Type I: Outcomes . . . . . . . . . . . . . . . . . . . . . . . . 81
Alexandra A. Herzlich and James V. Aquavella
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