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1.  Clinical results of implantation of the Chirila keratoprosthesis in rabbits 
AIMS/BACKGROUND—An ideal keratoprosthesis (KPro) would closely resemble a donor corneal button in terms of its surgical handling, optics, and capacity to heal with host tissue in order to avoid many of the complications associated with the KPros which are currently in clinical use. This study was carried out to assess the long term clinical outcomes on implantation of the core and skirt poly(2-hydroxyethyl methacrylate) KPro in animals.
METHODS—20 KPros were made and implanted as full thickness corneal replacements into rabbits and followed for up to 21 months to date.
RESULTS—80% of the prostheses have been retained, with a low incidence of complications such as cataract, glaucoma, and retroprosthetic membrane formation which are frequently associated with KPro surgery.
CONCLUSIONS—KPros of this type may offer promise in the treatment of patients for whom penetrating keratoplasty with donor material carries a poor prognosis. Refinement of the KPro and further animal trials, including implantation into abnormal corneas, are however mandatory before human implantation could be planned.

 Keywords: complications; keratoprosthesis; optics; PHEMA
PMCID: PMC1722337  PMID: 9536874
2.  Comparative experiments for in vivo fibroplasia and biological stability of four porous polymers intended for use in the Seoul-type keratoprosthesis 
Aims: To evaluate in vivo fibroplasia and biological stability of porous polymers intended for use in the Seoul-type keratoprosthesis (S-KPro).
Methods: Four porous polymers (polypropylene, two kinds of polyethylene terephthalate (PE70 and PE50), and polyurethane) were investigated. Discs of polymers were inserted into the corneal stroma of rabbits for a 2 and 5 month period. Corneal oedema and neovascularisation were evaluated. The fibroplasia and collagen deposition were examined under light and transmission electron microscopy. S-KPros, whose skirt was made of four types of polymer, were implanted into the rabbits' eyes. The retention time and complications were evaluated.
Results: Neovascularisation and corneal oedema were found in all of the disc inserted eyes, but the corneal oedema subsided within 2 months in most of the eyes. The mean number of fibroblasts increased significantly in polypropylene and PE50 disc inserted eyes compared with polyurethane disc inserted eyes. Plentiful collagen deposition was also found in both polypropylene and PE50 disc inserted eyes. Mean retention time in the polypropylene SK-Pro implanted eyes was longer than that of the other eyes (20.7 weeks). The PE70 skirt induced corneal melting around the prosthesis.
Conclusion: Polypropylene encourages fibroblast ingrowth and shows good biological stability when used as a skirt material in S-KPro.
PMCID: PMC1771209  PMID: 12084755
polypropylene; fibroplasia; Seoul-type keratoprosthesis; porous polymers
3.  Evaluation of corneal cell growth on tissue engineering materials as artificial cornea scaffolds 
The keratoprosthesis (KPro; artificial cornea) is a special refractive device to replace human cornea by using heterogeneous forming materials for the implantation into the damaged eyes in order to obtain a certain vision. The main problems of artificial cornea are the biocompatibility and stability of the tissue particularly in penetrating keratoplasty. The current studies of tissue-engineered scaffold materials through comprising composites of natural and synthetic biopolymers together have developed a new way to artificial cornea. Although a wide agreement that the long-term stability of these devices would be greatly improved by the presence of cornea cells, modification of keratoprosthesis to support cornea cells remains elusive. Most of the studies on corneal substrate materials and surface modification of composites have tried to improve the growth and biocompatibility of cornea cells which can not only reduce the stimulus of heterogeneous materials, but also more importantly continuous and stable cornea cells can prevent the destruction of collagenase. The necrosis of stroma and spontaneous extrusion of the device, allow for maintenance of a precorneal tear layer, and play the role of ensuring a good optical surface and resisting bacterial infection. As a result, improvement in corneal cells has been the main aim of several recent investigations; some effort has focused on biomaterial for its well biological properties such as promoting the growth of cornea cells. The purpose of this review is to summary the growth status of the corneal cells after the implantation of several artificial corneas.
doi:10.3980/j.issn.2222-3959.2013.06.23
PMCID: PMC3874531  PMID: 24392340
artificial cornea; keratoprosthesis; tissue-engineered scaffold; corneal cells collagen; fibrin; amniotic membrane; biomaterial
4.  Legeais BioKpro III keratoprosthesis implantation: long term results in seven patients 
The British Journal of Ophthalmology  2006;90(9):1146-1151.
Aims
The long term results of the Legeais BioKpro III keratoprosthesis are presented for seven patients with severe corneal scarring.
Methods
The study took place at Moorfields Eye Hospital, London. Patients had either end stage ocular surface disease or corneal opacification after multiple failed graft surgery, with the potential for significant visual improvement. After insertion the device was covered with a conjunctival flap or buccal mucous membrane graft, which was later opened to expose the optic. The outcome measures were vision, complications, and retention of the device.
Results
The BioKpro III was inserted into seven patients with severe corneal scarring: ocular cicatricial pemphigoid, measles keratitis, thermal injury, Stevens‐Johnson syndrome, aniridia, chemical injury, and congenital rubella. The follow up was 18–48 months. The keratoprosthesis failed in six, because of extrusion occurring 2–28 months postoperatively. Retroprosthetic membranes occurred in three patients, and endophthalmitis in one. Vision improved from hand movements to 6/12 in the only patient who retained the KPro; however he was troubled by mucus accumulation on the optic.
Conclusions
The one success has been in a patient with thermal burns. The remaining results have been poor, with the KPro extruding in six of the seven patients.
doi:10.1136/bjo.2006.092510
PMCID: PMC1857381  PMID: 16929061
keratoprosthesis; corneal blindness
5.  Five year follow up of biocolonisable microporous fluorocarbon haptic (BIOKOP) keratoprosthesis implantation in patients with high risk of corneal graft failure 
The British Journal of Ophthalmology  2004;88(12):1585-1589.
Aim: To study the anatomical and visual performance following implantation of a model of artificial cornea and to evaluate the postoperative long term complications.
Methods: 11 eyes of 11 patients with bilateral corneal blindness considered as potentially having high risk of failure of penetrating corneal keratoplasty were implanted with biocolonisable Kpro keratoprosthesis (BIOKOP I, FCI, Rantigny, France) in the period between January 1996 and May 1998. Only one eye was implanted in all patients and followed up for a period of 60 months. The visual outcome, anatomical and functional stability, complications, and the general performance of the keratoprosthesis were evaluated.
Results: The keratoprosthesis (BIOKOP I) only 36.3% remained in position to date. In the patients’ last visit five eyes (45.4%) were blind and one (9.0%) showed a slight improvement in the best corrected visual acuity (BCVA) in comparison to preoperative tests. Six eyes (54.5%) showed improved BCVA before having postoperative complications. Four eyes underwent replacement of a BIOKOP I Kpro with a BIOKOP II as a result of extrusion. The keratoprostheses remained anatomically in situ for a mean of 25.5 months and their functional performance period was limited to a mean of 22 months.
Conclusion: Corneal keratoprosthesis (BIOKOP I, II) does not provide a stable anatomical relation with the surrounding ocular structures. Its ability to restore vision is limited to a short postoperative period in eyes implanted with severe ocular surface disease.
doi:10.1136/bjo.2004.046375
PMCID: PMC1772453  PMID: 15550368
corneal graft failure; penetrating keratoplasty; keratoprosthesis
6.  Glaucoma Associated with Boston Type 1 Keratoprosthesis 
Cornea  2012;31(2):134-139.
Purpose
To evaluate outcomes of the Boston Type 1 keratoprosthesis (KPro) and associated incidence of glaucoma.
Design
Retrospective cohort study.
Participants
All patients who underwent KPro surgery at one institution from 2003-2009 with at least 3 months follow-up.
Methods
Preoperative visual acuity, diagnosis, history of glaucoma, intraoperative and postoperative parameters were recorded. Statistical analysis was performed to identify factors that may influence increase in intraocular pressure (IOP) and glaucoma development or progression after surgery.
Main Outcome Measures
Best corrected visual acuity (BCVA), IOP, postoperative medical and surgical treatments for glaucoma, and KPro retention and complications.
Results
Thirty-six KPro procedures were performed in 30 eyes of 29 patients with mean (± SD) follow-up of 17±19 months (range 3-67 months). The main indication for KPro implantation was corneal graft failure (77%). Primary KPros were performed in 23% of eyes for limbal stem cell deficiency secondary to chemical burns and aniridia, and for herpetic disease. Median preoperative BCVA was hand motions with an overall improvement to 20/330 (range 20/20 to hand motions) at nine months postoperatively; mean BCVA was 20/600 (range 20/40 to NLP) at last follow-up. Twenty eyes (67%) had a preoperative history of glaucoma with eight of those eyes (40%) having undergone prior glaucoma surgery. Twenty-one eyes (70%) underwent concomitant glaucoma surgery. Postoperative increased IOP (22 mmHg or higher) was noted in 15 eyes (50%) while definite glaucoma development or progression was noted in 7 of those 15 eyes (23% of total eyes). Mean BCVA at last follow-up in eyes with glaucoma development or progression was 3/200 compared to 20/563 in the remaining 23 eyes. Six patients (20%) required repeat KPro implantation, and retroprosthetic membranes developed in 23 eyes (77%). No patient developed vitritis or infectious endophthalmitis.
Conclusions
The Boston Type 1 KPro is an effective option for management of eyes with poor prognosis for primary or repeat penetrating keratoplasty. Visual potential is limited by preoperative comorbidities; however, glaucoma development or progression of pre-existing glaucoma is a significant cause of postoperative visual loss. Rigorous perioperative management of elevated IOP is essential for long-term success of KPro surgery.
doi:10.1097/ICO.0b013e31820f7a32
PMCID: PMC3539166  PMID: 22134402
Boston Type 1 Keratoprosthesis; Glaucoma; Keratoplasty
7.  Hydroxyapatite for Keratoprosthesis Biointegration 
Biointegration, one of the important problems facing keratoprostheses, was addressed by coating a model material with hydroxyapatite. The coating enhanced cell viability in vitro and biointegration ex vivo and reduced inflammation in vivo.
Purpose.
Integration of keratoprosthesis with the surrounding cornea is very important in preventing bacterial invasion, which may cause ocular injury. Here the authors investigated whether hydroxyapatite (HAp) coating can improve keratoprosthesis (KPro) biointegration, using polymethyl methacrylate (PMMA)—the principal component of the Boston KPro—as a model polymer.
Methods.
HAp coatings were induced on PMMA discs after treatment with concentrated NaOH and coating with poly-dopamine (PDA) or polydopamine and then with 11-mercaptoundecanoic acid (11-MUA). Coatings were characterized chemically (Fourier transform infrared spectroscopy [FTIR], energy dispersive X-ray spectroscopy [EDX]) and morphologically (SEM) and were used as substrates for keratocyte growth in vitro. Cylinders of coated PMMA were implanted in porcine corneas ex vivo for 2 weeks, and the force required to pull them out was measured. The inflammatory reaction to coated discs was assessed in the rabbit cornea in vivo.
Results.
FTIR of the coatings showed absorption bands characteristic of phosphate groups, and EDX showed that the Ca/P ratios were close to those of HAp. By SEM, each method resulted in morphologically distinct HAp films; the 11-MUA group had the most uniform coating. The hydroxyapatite coatings caused comparable enhancement of keratocyte proliferation compared with unmodified PMMA surfaces. HAp coating significantly increased the force and work required to pull PMMA cylinders out of porcine corneas ex vivo. HAp coating of implants reduced the inflammatory response around the PMMA implants in vivo.
Conclusions.
These results are encouraging for the potential of HAp-coated surfaces for use in keratoprostheses.
doi:10.1167/iovs.11-7601
PMCID: PMC3183975  PMID: 21849419
8.  High-Resolution Spectral Domain Anterior Segment Optical Coherence Tomography in Type 1 Boston Keratoprosthesis 
Cornea  2013;32(7):951-955.
Purpose:
To report the results of imaging using high-resolution, Fourier domain anterior segment optical coherence tomography (AS-OCT) to evaluate patients with a type 1 Boston Keratoprosthesis (KPro).
Methods:
We performed a retrospective comparative study of patients in whom we implanted the Boston KPro. A total of 26 eyes of 23 patients from the Cornea Service at the University of California Davis Eye Center were included. Subjects were evaluated with the Spectralis AS-OCT (Heidelberg Engineering GmbH).
Results:
Preoperative diagnoses for KPro surgery included failed corneal transplant (69%), chemical burn (23%), and aniridia (8%). The average age of patients was 63.2 years (range, 17–88 years). Fifty-four percent of the patients were female. The mean duration between the KPro surgery and the acquisition of high-resolution AS-OCT imaging was 35.8 months (range, 2–90 months). The most commonly observed finding was retroprosthetic membrane formation, which we found in 77% of KPro eyes. In 65% of KPro eyes, we identified epithelium behind the front plate, and in 54%, we identified an epithelial lip over the anterior surface of the KPro front plate. In 31% of KPro eyes, we identified periprosthetic cysts, gaps or spaces, and thinning in the corneal carrier graft.
Conclusions:
Fourier domain AS-OCT is a useful noninvasive imaging technique in patients with a KPro and provides the ability to identify changes that are sometimes difficult to appreciate by clinical evaluation. The higher resolution Fourier domain systems may aid in the clinical diagnosis and management of pathology that might not be imaged with instruments of lower resolution. AS-OCT has the potential for monitoring the anatomic stability of an implanted KPro and may also help to monitor for complications. Moreover, high-resolution imaging may enhance our understanding of periprosthetic anatomy.
doi:10.1097/ICO.0b013e318285c8f4
PMCID: PMC3741091  PMID: 23591146
Boston type 1 Keratoprosthesis; anterior segment optical coherence tomography; Spectralis; spectral domain; Fourier domain; KPro; OCT
9.  Novel materials to enhance keratoprosthesis integration 
BACKGROUND—The successful integration of keratoprostheses (KPros) within the cornea depends in part on peripheral host keratocyte adhesion to anchor the implant in place and prevent epithelial downgrowth. The following study incorporated different acrylate co-monomers with poly(hydroxyethyl methacrylate) (p(HEMA)) and measured the suitability of these materials as potential skirt materials in terms of their ability to enhance keratocyte adhesion to p(HEMA).
METHODS—p(HEMA) hydrogels incorporating varying amounts of the acrylate co-monomers methacrylic acid (MA), 2-(dimethylamino)ethyl methacrylate (DEM), or phenoxyethyl methacrylate (PEM) were formed by free radical polymerisation. Keratocytes were seeded onto discs of each material and incubated at 37°C for 72 hours. Assays for viable cell adhesion were carried out. A viability/cytotoxicity assay using solutions of calcein-AM (0.5 mM) and ethidium homodimer-1 (EthD-1) (0.5 µM) were used to measure viable and non-viable cell adhesion, respectively. An ATP assay was also used to quantify cell adhesion in terms of the amount of ATP present following lysis of adherent cells.
RESULTS—The viability/cytotoxicity assays indicated that the incorporation of 15 mol% of the co-monomer PEM or of 20 mol% DEM increased cell adhesion to p(HEMA) by at least four times. The ATP assays confirmed the results for PEM but absorption of ATP to the DEM containing hydrogel indicated that the assay was not a suitable measure of cell adhesion to this material.
CONCLUSIONS—The properties of p(HEMA) may be moderated to enhance keratocyte adhesion by the incorporation of PEM or DEM suggesting that these may be suitable materials for use in the further development of a novel KPro skirt material.


doi:10.1136/bjo.84.6.640
PMCID: PMC1723503  PMID: 10837393
10.  Structural analysis and corrosion studies on an ISO 5832-9 biomedical alloy with TiO2 sol–gel layers 
The aim of this study was to demonstrate the relationship between the structural and corrosion properties of an ISO 5832-9 biomedical alloy modified with titanium dioxide (TiO2) layers. These layers were obtained via the sol–gel method by acid-catalyzed hydrolysis of titanium isopropoxide in isopropanol solution. To obtain TiO2 layers with different structural properties, the coated samples were annealed at temperatures of 200, 300, 400, 450, 500, 600 and 800 °C for 2 h. For all the prepared samples, accelerated corrosion measurements were performed in Tyrode’s physiological solution using electrochemical methods. The most important corrosion parameters were determined: corrosion potential, polarization resistance, corrosion rate, breakdown and repassivation potentials. Corrosion damage was analyzed using scanning electron microscopy. Structural analysis was carried out for selected TiO2 coatings annealed at 200, 400, 600 and 800 °C. In addition, the morphology, chemical composition, crystallinity, thickness and density of the deposited TiO2 layers were determined using suitable electron and X-ray measurement methods. It was shown that the structure and character of interactions between substrate and deposited TiO2 layers depended on annealing temperature. All the obtained TiO2 coatings exhibit anticorrosion properties, but these properties are related to the crystalline structure and character of substrate–layer interaction. From the point of view of corrosion, the best TiO2 sol–gel coatings for stainless steel intended for biomedical applications seem to be those obtained at 400 °C.
doi:10.1007/s10856-013-5099-7
PMCID: PMC3942627  PMID: 24271113
11.  Short-Term Visual Outcomes of Boston Keratoprosthesis Type I in Saudi Arabia 
Purpose:
To evaluate the visual outcomes, complications and retention of threadless type I Boston keratoprosthesis (KPro) in Saudi Arabia.
Materials and Methods:
Retrospective analysis of four eyes of four patients (one female and three males; age range: 48 to 72 years) who underwent Boston type I threadless KPro implantation between January and December 2009.
Results:
In the median follow-up of 11 months (range 6 to 14 months), visual outcomes were satisfactory. Preoperative diagnosis included two patients of post-trachoma dense vascularized corneal scarring, one patient of corneal alkali burn and one patient of repeated failed corneal grafts. All patients demonstrated significant improvement in vision; with pre-operative visual acuity of hand movements (HM), counting fingers and HM improved to best corrected visual acuity (BCVA) of 20/200, 20/60, 20/50 and 20/30 on their last follow-up visits respectively. None of the patients developed glaucoma as a result of the procedure. No retro-prosthetic membrane developed till the last follow-up visit. One of the four patients had a corneal melt (due to severe dryness associated with trachoma) 6 months after the KPro implantation and underwent a successful KPro revision. Despite the relatively poor prognosis expected in alkali burn eye, the patient attained the maximum BCVA (20/30) of the four eye series on the last follow-up visit at six months.
Conclusion:
In consistent with the earlier reports from other parts of the world, all the 4 eyes had a significant increase in vision after Boston type I KPro implantation. However, patients require close lifelong follow-up to manage any complications.
doi:10.4103/0974-9233.92121
PMCID: PMC3277030  PMID: 22346120
Alkali Burn; Boston Keratoprosthesis; Trachoma
12.  A Novel Murine Model for Keratoprosthesis 
Purpose.
To establish a murine model for keratoprosthesis.
Methods.
A miniature keratoprosthesis (m-KPro) device was created consisting of a poly[methyl methacrylate] front part and a titanium back plate, designed after the Boston KPro, which is in widespread clinical use. BALB/c mice were used and a 2 mm in diameter donor cornea was punched out. After 2-mm trepanation of the syngeneic recipient cornea, extracapsular crystalline lens extraction was performed. The m-KPro was assembled onto the cornea button in a similar manner to human KPro implantation. The cornea–device complex was secured to the recipient bed with eight interrupted 11-0 sutures. All mice (n = 10) were followed up for 8 weeks postoperatively.
Results.
All m-KPros were successfully implanted and retained in all 10 animals. There were no critical complications such as endophthalmitis, corneal melting, device extrusions, leakage, extensive inflammation, or weight loss in the animals. We observed mild to moderate donor and host corneal neovascularization in all cases throughout the follow-up period.
Conclusions.
We have established a novel murine model of KPro implantation that we anticipate will serve as a good experimental system for evaluating host responses after KPro surgery.
We have established a novel murine model of KPro implantation that we anticipate will serve as a good experimental system for evaluating host responses after KPro surgery.
doi:10.1167/iovs.14-14058
PMCID: PMC4059078  PMID: 24833747
keratoprosthesis; murine model
13.  Sessile macrophages forming clear endothelium-like membrane on inside of successful keratoprosthesis. 
Clinical observation and cytological study of a reasonably successful keratoprosthesis removed along with a corneal button about 20 years after its implantation in an aphakic eye revealed an acellular epithelium-like film on its outer surface, firm anchoring of its supporting skirt by stable fibrous connections to the corneal stroma, and a continuous separating membrane composed of a homogeneous proteinaceous film and fibroblast-like cells of macrophage origin on its inner surface. The significance of the successful adaptation of the plastic materials of the prosthesis to the tissues of the cornea and the fluids of the inner eye for the future of tissue engineering in the region of the eye is discussed.
Images
PMCID: PMC1298663  PMID: 6398933
14.  The Boston Keratoprosthesis: Comparing Corneal Epithelial Cell Compatibility with Titanium and PMMA 
Cornea  2009;28(7):808-811.
Purpose
To determine in vitro whether titanium is superior in corneal cell compatibility to standard polymethyl-methacrylate (PMMA) for the Boston Keratoprosthesis (KPro).
Methods
Human corneal-limbal epithelial (HCLE) cells were cultured 24, 48, 72, 96, 120, 144, or 168 hours in culture plates alone (controls) or with PMMA or titanium discs. Experiments were performed in triplicate and repeated (final n = 6). To determine if a soluble, toxic factor is emitted from materials, concurrent experiments at 48 and 144 hours were performed with discs placed in Transwell Supports, with HCLE cells plated beneath. As an additional test for soluble factors, cells were incubated 24 hours with disc-conditioned media, and number of viable cells per well was quantified at each timepoint by proliferation assay. To determine if delayed cell proliferation was attributable to cell death, HCLE cell death was measured under all conditions and quantified at each timepoint by cytotoxicity assay. The effects of material on HCLE cell proliferation over time was determined by repeated measures ANOVA. P < 0.05 was statistically significant.
Results
HCLE cell proliferation was greater in wells with titanium discs compared to PMMA. Differences between the test discs and control non-disc cocultures were statistically significant over time for both cell proliferation (P = 0.001) and death (P = 0.0025). No significant difference was found using Transwells (P = 0.9836) or disc-conditioned media (P = 0.36).
Conclusion
This in vitro HCLE cell model demonstrates significantly increased cell proliferation and decreased cell death with cell/titanium contact compared to cell/PMMA contact. Moreover, differences are unlikely attributable to a soluble factor. Prospective in vivo analysis of the two KPro biomaterials is indicated.
doi:10.1097/ICO.0b013e31819670ac
PMCID: PMC4263318  PMID: 19574903
Boston Keratoprosthesis; biomaterials; titanium; corneal cell compatibility
15.  Effect of TiO2 Nanoparticles on Tensile Strength of Dental Acrylic Resins 
Background and aims. Adding further fillers to dental resins may enhance their physical characteristics. The aim of this study was to evaluate the tensile strength of heat-curing acrylic resin reinforced by TiO2nanoparticles added into the resin matrix.
Materials and methods. Commercially available TiO2 nanoparticles were obtained and characterized using X-ray diffrac-tion (XRD) and scanning electron microscopy (SEM) to determine their crystalline structure, particle size and morphology. TiO2-acrylic resin nanocomposite was prepared by mixing 0.5, 1 and 2 (wt%) of surface modified TiO2 nanoparticles in an amalgamator providing three groups of samples. Before curing, the obtained paste was packed into steel molds. After cur-ing, the specimens were removed from the molds. The tensile strength test samples were prepared according to ISO 1567.
Results. Two crystalline phases were found in TiO2 nanoparticles including: (i) anatase as the major one, and (ii) rutile. The average particle size calculated according to the Scherrer equation was 20.4 nm, showing a normal size distribution. According to SEM images, the nanocomposite with 1wt% TiO2 nanoparticles had a better distribution compared to other groups. In addition, the group by 1wt% TiO2 exhibited higher tensile strength with a significant difference compared to other groups. ANOVA showed significant differences between the contents of TiO2 particles in acrylic resin (F = 22.19; P < 0.001).
Conclusion. A considerable increase in tensile strength was observed with titania NPs reinforcement agents in 1wt% by weight. Further increase of TiO2 nanoparticles decreased the tensile strength.
doi:10.5681/joddd.2014.036
PMCID: PMC4288908  PMID: 25587380
Acrylic resins; materials testing; metal nanoparticles; tensile strength
16.  Osteo-odonto keratoprosthesis in Stevens-Johnson syndrome: a case report 
AIM
To report a successful osteo-odonto keratoprosthesis (OOKP) procedure in a case of end stage of corneal blindness due to Stevens-Johnson syndrome (SJS).
METHODS
An interventional case report.
RESULTS
We describe a 35-year-old Indian woman, a known case of SJS with bilateral dry eyes and corneal blindness (failed corneal graft with vascularised total corneal opacity in the right eye and non-healing corneal ulcer in the left eye). Vision was hand movement only in both eyes. The corneal ulcer healed with medical treatment resulting in vascularised total corneal opacity with no improvement in vision. OOKP was performed in the right eye and the vision was improved from hand movement to 6/6. The same vision was maintained in the right eye at the last follow-up 5 years after surgery.
CONCLUSION
OOKP provides good visual rehabilitation with long-term anatomically stable prosthesis in patients with end-stage of ocular surface disorders and corneal blindness secondary to SJS.
doi:10.3980/j.issn.2222-3959.2011.02.23
PMCID: PMC3340699  PMID: 22553646
osteo-odonto keratoprosthesis; Stevens-Johnson syndrome; corneal blindness
17.  Optical Functional Properties of the Boston Keratoprosthesis 
Disability glare with keratoprosthesis can be reduced by preserving the natural iris as much as practical, or it can be significantly reduced with the use of a soft bandage contact lens with a dark iris tint. Implanting the keratoprosthesis in a patient in whom the fellow eye has normal or near normal vision does not seem to improve visual function.
Purpose.
To evaluate the optical characteristics of the Boston Keratoprosthesis (KPro), identify glare sources, evaluate possible glare control, and examine the benefit of implantation when the fellow eye has normal vision.
Methods.
Computed and optical-bench-measured point spread function (PSF) and glare sources were compared. A translucent plastic cornea was used to determine the impact of glare caused by scatter in the cornea and its control with a dark-iris tinted contact lens. The effect of glare in implanted eyes was measured with a brightness acuity test (BAT), with and without the dark-iris contact lens. Computed and measured visual fields were compared. Stereopsis was measured in patients with an intact fellow eye.
Results.
Computed and measured modulation transfer functions for the KPro were found to be very close to the diffraction limit. Both the model-eye measurements and patients' BAT glare responses identified that the hazy corneal graft surrounding the KPro is the main source of glare and can be controlled with a dark-iris contact lens. The lid effectively blocks the light that would be scattered in the hazy cornea of patients in whom the type II KPro was implanted. An intact fellow eye remains the dominant eye, with better acuity, and the KPro eye supports only minimal stereo ability and does not expand the binocular visual field.
Conclusions.
Glare can be reduced significantly with the use of a contact lens with a dark iris. Implanting the KPro in a patient whose fellow eye has normal or near normal vision does not seem to improve visual function.
doi:10.1167/iovs.09-3372
PMCID: PMC2808421  PMID: 19815733
18.  Improving cytocompatibility of Co28Cr6Mo by TiO2 coating: gene expression study in human endothelial cells 
Cobalt-based materials are widely used for coronary stents, as well as bone and joint implants. However, their use is associated with high corrosion incidence. Titanium alloys, by contrast, are more biocompatible owing to the formation of a relatively inactive titanium oxide (TiO2) layer on their surface. This study was aimed at improving Co28Cr6Mo alloy cytocompatibility via sol–gel TiO2 coating to reduce metal corrosion and metal ion release. Owing to their role in inflammation and tissue remodelling around an implant, endothelial cells present a suitable in vitro model for testing the biological response to metallic materials. Primary human endothelial cells seeded on Co28Cr6Mo showed a stress phenotype with numerous F-actin fibres absent on TiO2-coated material. To investigate this effect at the gene expression level, cDNA microarray analysis of in total 1301 genes was performed. Compared with control cells, 247 genes were expressed differentially in the cells grown on Co28Cr6Mo, among them genes involved in proliferation, oxidative stress response and inflammation. TiO2 coating reduced the effects of Co28Cr6Mo on gene expression in endothelial cells, with only 34 genes being differentially expressed. Quantitative real-time polymerase chain reaction and protein analysis confirmed microarray data for selected genes. The effect of TiO2 coating can be, in part, attributed to the reduced release of Co2+, because addition of CoCl2 resulted in similar cellular responses. TiO2 coating of cobalt-based materials, therefore, could be used in the production of cobalt-based devices for cardiovascular and skeletal applications to reduce the adverse effects of metal corrosion products and to improve the response of endothelial and other cell types.
doi:10.1098/rsif.2013.0428
PMCID: PMC3730696  PMID: 23825117
cobalt alloy; titanium oxide; endothelial cell; biocompatibility; gene expression
19.  Use of a Porous Polyethylene Lid Spacer for Management of Eyelid Retraction in Patients with Boston Type II Keratoprosthesis 
Orbit (Amsterdam, Netherlands)  2013;32(4):247-249.
Purpose:
To report a novel application of a porous polyethylene implant for lid stabilization and management of eyelid retraction in a patient with an exposed Boston Keratoprosthesis Type II.
Methods:
A 54-year-old woman with a history of mucous membrane pemphigoid and failed penetrating keratoplasty of the left eye underwent implantation of a Boston Keratoprosthesis (KPro) Type II along with permanent surgical fusion of the upper and lower lids of the left eye in January 2010. At one month follow-up, significant retraction of the lower lid around the inferior margin of the optic was noted, resulting in partial exposure of the keratoprosthesis. The patient subsequently underwent left lower eyelid reconstruction with a porous polyethylene implant to ensure coverage and stability of the KPro.
Results:
Eyelid reconstruction using a porous polyethylene implant resulted in stable retention of the KPro Type II for over 2 years.
Conclusion:
In patients with Boston KPro Type II in the setting of severe cicatrizing ocular surface disease, the use of a porous polyethylene implant during eyelid reconstruction around the KPro optic may aid in maintaining eyelid integrity and improving KPro stability and longevity.
doi:10.3109/01676830.2013.788664
PMCID: PMC4111420  PMID: 23663113
Boston keratoprosthesis; Medpor; porous polyetheylene
20.  Non-solvolytic synthesis of aqueous soluble TiO2 nanoparticles and real-time dynamic measurements of the nanoparticle formation 
Nanoscale Research Letters  2012;7(1):297.
Highly aqueously dispersible (soluble) TiO2 nanoparticles are usually synthesized by a solution-based sol–gel (solvolysis/condensation) process, and no direct precipitation of titania has been reported. This paper proposes a new approach to synthesize stable TiO2 nanoparticles by a non-solvolytic method - direct liquid phase precipitation at room temperature. Ligand-capped TiO2 nanoparticles are more readily solubilized compared to uncapped TiO2 nanoparticles, and these capped materials show distinct optical absorbance/emission behaviors. The influence of ligands, way of reactant feeding, and post-treatment on the shape, size, crystalline structure, and surface chemistry of the TiO2 nanoparticles has been thoroughly investigated by the combined use of X-ray diffraction, transmission electron microscopy, UV-visible (UV–vis) spectroscopy, and photoluminescence (PL). It is found that all above variables have significant effects on the size, shape, and dispersivity of the final TiO2 nanoparticles. For the first time, real-time UV–vis spectroscopy and PL are used to dynamically detect the formation and growth of TiO2 nanoparticles in solution. These real-time measurements show that the precipitation process begins to nucleate after an initial inhibition period of about 1 h, thereafter a particle growth occurs and reaches the maximum point after 2 h. The synthesis reaction is essentially completed after 4 h.
doi:10.1186/1556-276X-7-297
PMCID: PMC3461452  PMID: 22676412
Synthesis; Nanoparticles; TiO2; Aqueously soluble; Direct liquid phase precipitation; Dynamic real-time measurement
21.  Photocatalytic Degradation of Methylene Blue under UV Light Irradiation on Prepared Carbonaceous TiO2 
The Scientific World Journal  2014;2014:415136.
This study involves the investigation of altering the photocatalytic activity of TiO2 using composite materials. Three different forms of modified TiO2, namely, TiO2/activated carbon (AC), TiO2/carbon (C), and TiO2/PANi, were compared. The TiO2/carbon composite was obtained by pyrolysis of TiO2/PANi prepared by in situ polymerization method, while the TiO2/activated carbon (TiO2/AC) was obtained after treating TiO2/carbon with 1.0 M KOH solution, followed by calcination at a temperature of 450°C. X-ray powder diffraction (XRD), transmission electron microscopy (TEM), Fourier transform infrared (FTIR), thermogravimetric analysis (TG-DTA), Brunauer-Emmet-Teller (BET), and UV-Vis spectroscopy were used to characterize and evaluate the prepared samples. The specific surface area was determined to be in the following order: TiO2/AC > TiO2/C > TiO2/PANi > TiO2 (179 > 134 > 54 > 9 m2 g−1). The evaluation of photocatalytic performance for the degradation of methylene blue under UV light irradiation was also of the same order, with 98 > 84.7 > 69% conversion rate, which is likely to be attributed to the porosity and synergistic effect in the prepared samples.
doi:10.1155/2014/415136
PMCID: PMC4074999  PMID: 25013855
22.  Outcomes of the Boston Keratoprosthesis in Jordan 
Purpose:
To report the indications, outcomes, and complications of the Boston type I keratoprosthesis (KPro) from the first Jordanian study on the subject.
Materials and Methods:
A retrospective chart review was conducted on 20 eyes of 19 consecutive patients who had Boston type I KPro implantation at King Abdullah University Hospital. Surgeries were performed by the same surgeon (WS) from November 2007 to March 2010. Data collected included age, sex, primary indication, number of previous grafts, preoperative comorbidities, visual acuity before and after surgery, and complications.
Results:
The mean age of the participants was 51.7±19.9 years (range: 10–80 years). The mean follow-up was 18.1±9.5 months (range: 3–6 months). The most common primary corneal pathology was vascularized corneal opacity (40%). Best corrected visual acuity (BCVA) improved significantly in 85% of eyes; 65% had a BCVA of 20/200 or better and 25% had a BCVA of 20/50 or better. The most frequent complication was retroprosthesis membrane (RPM) formation, which occurred in 45% of eyes. Two eyes (10%) had implant extrusion and required further surgery.
Conclusion:
Boston Kpro offers a reasonably safe and effective solution for patients with corneal blindness in whom the prognosis for natural corneal grafting is poor.
doi:10.4103/0974-9233.92123
PMCID: PMC3277032  PMID: 22346122
Graft Rejection; Keratoprosthesis; Visual Acuity; Complications
23.  Pars plana vitrectomy through the Boston Keratoprosthesis type 1 
Eye  2013;27(6):767-769.
Purpose
To ascertain the feasibility of pars plana vitrectomy (PPV) through a permanent Boston Keratoprosthesis type 1 (KPro) without the use of a temporary KPro.
Methods
A retrospective interventional case series. Eyes implanted with Boston KPro type 1 between 2008 and 2011 requiring PPV for vitreoretinal complications were included. Feasibility of PPV through the KPro, its anatomical and functional success were studied.
Results
Five out of 70 patients required PPV for vitreoretinal complications post-KPro surgery resulting in an incidence of 7%. PPV was feasible through the Boston KPro with no deleterious effects on the corneal carrier or the KPro itself. Repeat PPV was necessary in some cases. Although anatomical repair of the vitreoretinal complications was achieved in most cases, post PPV visual acuity remained poor in the majority.
Conclusion
Our study suggests that although PPV through the Boston KPro is a viable approach for vitreoretinal disease repair, visual rehabilitation remains poor.
doi:10.1038/eye.2013.58
PMCID: PMC3682363  PMID: 23579405
pars plana vitrectomy; boston keratoprosthesis type 1; KPro outcomes; vitreoretinal complications; artificial corneal transplants
24.  The design, fabrication, and photocatalytic utility of nanostructured semiconductors: focus on TiO2-based nanostructures 
Recent advances in basic fabrication techniques of TiO2-based nanomaterials such as nanoparticles, nanowires, nanoplatelets, and both physical- and solution-based techniques have been adopted by various research groups around the world. Our research focus has been mainly on various deposition parameters used for fabricating nanostructured materials, including TiO2-organic/inorganic nanocomposite materials. Technically, TiO2 shows relatively high reactivity under ultraviolet light, the energy of which exceeds the band gap of TiO2. The development of photocatalysts exhibiting high reactivity under visible light allows the main part of the solar spectrum to be used. Visible light-activated TiO2 could be prepared by doping or sensitizing. As far as doping of TiO2 is concerned, in obtaining tailored material with improved properties, metal and nonmetal doping has been performed in the context of improved photoactivity. Nonmetal doping seems to be more promising than metal doping. TiO2 represents an effective photocatalyst for water and air purification and for self-cleaning surfaces. Additionally, it can be used as an antibacterial agent because of its strong oxidation activity and superhydrophilicity. Therefore, applications of TiO2 in terms of photocatalytic activities are discussed here. The basic mechanisms of the photoactivities of TiO2 and nanostructures are considered alongside band structure engineering and surface modification in nanostructured TiO2 in the context of doping. The article reviews the basic structural, optical, and electrical properties of TiO2, followed by detailed fabrication techniques of 0-, 1-, and quasi-2-dimensional TiO2 nanomaterials. Applications and future directions of nanostructured TiO2 are considered in the context of various photoinduced phenomena such as hydrogen production, electricity generation via dye-sensitized solar cells, photokilling and self-cleaning effect, photo-oxidation of organic pollutant, wastewater management, and organic synthesis.
doi:10.2147/NSA.S9040
PMCID: PMC3781710  PMID: 24198485
TiO2 nanostructure; fabrication techniques; doping in TiO2; TiO2-assisted photoactivity; solar hydrogen; TiO2-based dye-sensitized solar cells; TiO2 self-cleaning; organic synthesis
25.  Electrophoretic Deposition of Carbon Nanotubes over TiO2 Nanotubes: Evaluation of Surface Properties and Biocompatibility 
Titanium (Ti) is often used as an orthopedic and dental implant material due to its better mechanical properties, corrosion resistance, and excellent biocompatibility. Formation of TiO2 nanotubes (TiO2 NTs) on titanium is an interesting surface modification to achieve controlled drug delivery and to promote cell growth. Carbon nanotubes (CNTs) possess excellent chemical durability and mechanical strength. The use of CNTs in biomedical applications such as scaffolds has received considerable attention in recent years. The present study aims to modify the surface of titanium by anodizing to form TiO2 NTs and subsequently deposit CNTs over it by electrophoretic deposition (EPD). Characteristic, biocompatibility, and apatite forming ability of the surface modified samples were evaluated. The results of the study reveal that CNTs coating on TiO2 nanotubes help improve the biological activity and this type of surface modification is highly suitable for biomedical applications.
doi:10.1155/2014/236521
PMCID: PMC4100351  PMID: 25093017

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