James V. Aquavella

Purpose: The Boston keratoprosthesis (KPro) has been used for certain indications in pediatric patients with congenital corneal opacities. Here, we describe the use of a near-complete conjunctival flap at the time of Boston type 1 KPro surgery in pediatric patients, with the goal of improving pediatric KPro outcomes. Methods: We performed a retrospective chart review of 21 eyes from 16 patients who received their first KPro before the age of 18 years at a tertiary care center in Rochester, NY. Surgeries were performed between 2011 and 2017 (3 years before and after the incorporation of a conjunctival flap, which began in 2014 as part of the pediatric KPro procedure). Patients who had a minimum 1-year postoperative follow-up, or had corneal melts within 1 year of KPro implantation, were included in our study. The main outcome measure in this study was a comparison of the number of complications that required surgical intervention, including retroprosthetic membrane, corneal melt, retinal detachment, and endophthalmitis, in eyes that received KPro implantation without a conjunctival flap compared with eyes that received KPro implantation with a conjunctival flap. Change in the visual acuity up to 1 year postoperatively was also measured. Results: Ten eyes received KPro with no conjunctival flap, and 11 eyes received KPro with a near-complete conjunctival flap. After 1-year postoperative follow-up, eyes receiving a KPro with a conjunctival flap had fewer KPro-related complications requiring surgical intervention (5 vs. 16, P = 0.0002). Corneal melt was seen in 2 of 11 (18%) eyes in the conjunctival flap group and 5 of 10 (50%) eyes in the nonflap group (P = 0.12). No eyes developed endophthalmitis in the flap group, whereas 1 of 10 (10%) eyes developed endophthalmitis in the nonflap group. Visual acuity at 1-year follow-up improved in 9 of 11 (82%) eyes in the flap group compared with 5 of 10 (50%) eyes in the nonflap group (P = 0.3). Conclusions: Implementation of a conjunctival flap in pediatric KPro may help decrease the short-term postoperative complications requiring surgical procedures and may lead to improved visual acuity after 1 year. Further investigation, including longer-term follow-up, is needed to better understand how the described technique affects surgical outcomes in children.

Introduction: Ophthalmic antibiotics are indicated to treat bacterial ocular infections as well as to prevent devastating post-operative infectious complications. A thorough understanding of current ophthalmic antibiotics with particular attention to rising resistance can inform clinical management. Areas covered: This work reviews the current literature in order to present an in-depth discussion on ophthalmic antibiotics with particular emphasis on treatment approaches for bacterial keratitis as well as surgical prophylaxis for cataract surgery. Limitations in our ophthalmic antibiotic armamentarium are highlighted, underscoring the importance of rising antibiotic resistance. Expert commentary: Ultimately, in an era of significant antimicrobial resistance, there is a significant need for novel antibiotics in ophthalmology as well as improved drug delivery systems in order to maintain adequate treatment options to prevent vision-threatening infectious disease.

Aberrations occurring in the first trimester of pregnancy due to genetic events which disrupt anterior segment formation and the cleavage of the anterior chamber of the eye.

To describe the complex surgical management and novel medical approach for a keratoprosthesis (KPro Boston type I) in a monocular, 73-year-old patient with ectodermal dysplasia and chronic, noninfectious corneal necrosis. Best-corrected visual acuity (BCVA) was measured with Snellen letters. Surgical intervention included an amniotic membrane graft, complete replacement of the KPro, conjunctival flap graft, corneal donor tissue grafts combined with inferior rectus muscle advancement, periosteal tissue graft, tarso-conjunctival flap construction, and symblepharolysis. Infliximab was used as a medical adjunctive therapy. Initial KPro placement provided a BCVA of 20/25 and long-term stability. Subsequent chronic melting at the optic border necessitated numerous surgeries to prevent extrusion and failure. Ultimate fistulization was addressed with the formation of a surgical pocket. The addition of infliximab promoted ocular surface stability, and the patient has maintained a BCVA of 20/80. Ectodermal dysplasia can result in eyelid and corneal abnormalities, requiring a KPro for visual restoration. In the setting of chronic, sterile corneal melt, novel surgical approaches and the off-label use of infliximab allowed for visual rehabilitation.

To compare and contrast the techniques and results of keratoprosthesis (KPro) using the Cardona device (1975-1985) with those related to the use of the Dohlman-Doane type 1 device (2003-2005). We conducted a retrospective review of 31 cases of Cardona KPro implanted between 1975 and 1981 and a review of 25 cases of Dohlman-Doane type 1 KPro implanted between 2003 and 2005. Procedures were limited to eyes with a poor prognosis for traditional penetrating keratoplasty. In the Cardona cases, 39% (12/31) of patients achieved a visual acuity of 20/40 or better at some point postoperatively, degrading to 16% (5/31) at the end of the observation period. Fifty percent (15/31) required subsequent surgical revision of the KPro. Sixteen percent of cases (5/31) developed endophthalmitis, and 58% (18/31) developed retroprosthetic membranes. There were 5 dislocations of the prosthesis and an additional 3 frank extrusions (26%). Of the 25 Dohlman-Doane cases, there have been no reoperations, endophthalmitis, dislocations, or extrusions to date (8/15/05). Forty-eight percent (12/25) achieved 20/200 acuity or better, and 12% (3/25) achieved 20/40 or better. Retroprosthetic membranes formed in 3 cases. Although KPro remains a technique to be used in poor prognosis keratoplasty, improvements in the design of the device and surgical technique over the past 30 years have reduced the overall morbidity and severity of complications and improved the prognosis for visual rehabilitation.