In April 2014, the 9th International Conference on Keratoprostheses was held in Salzburg, Austria, under the chairmanship of Professor Günther Grabner. At his request, contributions from Boston will be summarized here, with appropriate historical background. Participants from Boston were Drs James Chodosh, Joseph Ciolino, Kathryn Colby, Alja Črnej, Andrea Cruzat, Claes Dohlman, Larisa Gelfand, Christina Grassi, Eleftherios Paschalis, Marie-Claude Robert, Borja Salvador, Elise Taniguchi, and Michelle White.
“Artificial corneas” have been attempted in severe corneal disease for at least 230 years, with largely disappointing results until recently. ‘The Boston Keratoprosthesis’ (B-Kpro) has been part of this history on and off for a half century. Developed from several previously known concepts, it was originally made of PMMA plastics in a collar button design (Type I), to be implanted into a corneal graft carrier and then transplanted to the patients’ cornea. (A Type II with an additional stem for lid penetration is occasionally used in end-stage dry eyes.)
Management and device changes have over the years led to marked clinical improvements. Thus, postoperative infections have been drastically reduced by using low-dose prophylactic antibiotics. The corneal surface has been found to be well protected from evaporative damage by a soft contact lens or a conjunctional flap. Postoperative tissue melt around the device has been markedly reduced by improvement of nutrition from the aqueous (perforated back plates) and better anti-inflammatory strategies. Titanium alloys can be used for non-transparent parts to reduce inflammation and increase biointegration. Retroprosthesis membranes and retina complications have similarly been markedly reduced. However, post-operative glaucoma is still a stubborn problem that can cause long-term attrition of vision. Autoimmune diseases are particularly treacherous and B-KPros should not at present be used routinely. About 12,000 Boston Keratoprostheses have so far been distributed world-wide. Robust research is presently on-going to improve long-term safety, especially for the developing world.
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Behlau I, Mukherjee K, Todani A, Tisdale AS, Cade F, Wang L, Leonard EM, Zakka FR, Gilmore MS, Jakobiec FA, Dohlman CH, Klibanov AM. Biocompatibility and biofilm inhibition of N, N-hexyl,methyl-polyethylenimine bonded to Boston keratoprosthesis materials. Biomaterials. 2011;32:8783–96. PubMedCentralPubMedCrossRef
Behlau I, Martin KV, Martin JN, Naumova EN, Cadorette JJ, Sforza JT, Pineda R II, Dohlman CH. Infectious endophthalmitis in Boston keratoprosthesis: incidence and prevention. Acta Ophthalmol. 2014;92:1–10. CrossRef
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Chang HP, Luo ZK, Chodosh J, Dohlman CH, Colby KA. Primary type I Boston keratoprosthesis in non-autoimmune corneal diseases. Submitted to Cornea; 2014.
Cilolino JB, Belin MW, Todani A, Al-Arfaj K, Rudnisky CJ, Boston Keratoprosthesis Type 1 Study Group. Retention of the Boston keratoprosthesis type 1: multicenter study results. Ophthalmology. 2013;120:1195–200. CrossRef
Dohlman CH. Post operative regimen and repair of complications after keratoprosthesis surgery. Refract Corneal Surg. 1993;9:198.
Dohlman CH. Pellier de Quengsy and his keratoprosthesis. In: Mannis MJ, Mannis AA, editors. Corneal transplantation. Oostende: JP Wayenborgh; 1999. pp. 52–64.
Dohlman CH, Dohlman JG. Aqueous shunt to the ocular surface for severe dry eyes. Digit J Ophthalmol. 2005;11:2.
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Dohlman CH, Dudenhoefer EJ, Khan BF, Morneault S. Protection of the ocular surface after keratoprosthesis surgery: the role of soft contact lenses. CLAO J. 2002b;28:72–4. PubMed
Dohlman CH, Harissi-Dagher M, Graney J. The Boston keratoprosthesis: a new threadless design. Digit J Ophthalmol. 2007;13:1–2.
Dohlman JG, Foster CS, Dohlman CH. Boston keratoprosthesis in Steven-Johnson syndrome: a case of using infliximab to prevent tissue necrosis. Digit J Ophthalmol. 2009;15:1–2.
Dohlman CH, Grosskreutz CL, Chen TC, Pasquale LR, Rubin PAD, Kim EC, Durand M. Shunts to divert aqueous humor to distant epithelialized cavities after keratoprosthesis surgery. J Glaucoma. 2010;19:111–5. PubMed
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Fadlallah A, Atallah M, Cherfan G, Awwad ST, Syed ZA, Melki SA. Gamma-irradiated corneas as carriers for the Boston type 1 keratoprosthesis: advantages and outcomes in a surgical mission setting. Cornea. 2014;33:235–9. PubMed
Grassi CM, Crnej A, Paschalis EI, Colby K, Dohlman CH, Chodosh J. Idiopathic vitritis in the setting of Boston keratoprosthesis. Submitted to Cornea; 2014.
Jardeleza MS, Rheaume M-A, Chodosh J, Lane AM, Dohlman CH, Young L. Retinal detachments after Boston keratoprosthesis: incidence, predisposing factors and visual outcomes. Submitted to Retina; 2014.
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Robert MC, Spurr-Michaud S, Frenette M, Young D, Gipson IK, Dohlman CH. Stability and in vitro toxicity of an infliximab eye drop formulation. J Pharma Comp. 2014b;18:418–26.
Salvador-Culla B, Jeong KJ, Kolovou PE, Chiang HH, Chodosh J, Langer R, Dohlman CH, Kohane DS. Titanium coating of the Boston keratoprosthesis. Submitted to Biomaterials; 2014b.
Sa-ngiampornpanit T, Thiagalingam S, Dohlman CH. Boston keratoprosthesis in epithelial downgrowth. Digit J Ophthalmol. 2009;15:1–3.
White ML, Chodosh J, Jisung J, Dohlman CH. Incidence of ocular burns (thermal, chemical) and SJS spectrum: relevance for keratoprosthesis surgery. To be submitted; 2014.
World Health Organization. Visual impairment and blindness. Fact Sheet No. 282. 2014;93:563–8. (Accessed on 23 Sept).
- The Boston keratoprosthesis 2014: a step in the evolution of artificial corneas
MD, PhD Claes H. Dohlman
- Springer Vienna