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
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.
polypropylene; fibroplasia; Seoul-type keratoprosthesis; porous polymers
The long term results of the Legeais BioKpro III keratoprosthesis are presented for seven patients with severe corneal scarring.
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.
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.
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.
keratoprosthesis; corneal blindness
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.
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.
The biocompatibility and antibacterial properties of N,N-hexyl,methyl-polyethylenimine (HMPEI) covalently attached to the Boston Keratoprosthesis (B-KPro) materials was evaluated. By means of confocal and electron microscopies, we observed that HMPEI-derivatized materials exert an inhibitory effect on biofilm formation by Staphylococcus aureus clinical isolates, as compared to the parent poly(methyl methacrylate) (PMMA) and titanium. There was no additional corneal epithelial cell cytotoxicity of HMPEI-coated PMMA compared to that of control PMMA in tissue cultures in vitro. Likewise, no toxicity or adverse reactivity was detected with HMPEI-derivatized PMMA or titanium compared to those of the control materials after intrastromal or anterior chamber implantation in rabbits in vivo.
antibacterial; polyethylenimine (PEI); keratoprosthesis; PMMA; titanium; Staphylococcus aureus; corneal cytotoxicity
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.
corneal graft failure; penetrating keratoplasty; keratoprosthesis
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.
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.
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.
Alkali Burn; Boston Keratoprosthesis; Trachoma
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.
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.
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.
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.
These results are encouraging for the potential of HAp-coated surfaces for use in keratoprostheses.
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.
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.
Boston Kpro offers a reasonably safe and effective solution for patients with corneal blindness in whom the prognosis for natural corneal grafting is poor.
Graft Rejection; Keratoprosthesis; Visual Acuity; Complications
To establish a keratoprosthesis (Kpro) surgical technique that maintains an intact superficial corneal layer.
A manual microkeratome (Moria LSK‐1) was used to create a 130 μm flap of approximately 10 mm diameter in the right eye of Japanese white rabbits. The stoma beneath the flap area was dissected before the removal of a 5.0 mm stromal disc. A 5.0 mm collagen I immobilised poly(vinyl alcohol) (COL‐PVA) disc was placed on the exposed posterior stroma close to Descemet's membrane. The flap was repositioned and fixed using 10‐0 nylon sutures, which were removed 2 days following surgery. The corneas were followed clinically by slit lamp microscopy and photographs. Rabbits were sacrificed after 6 months, and the transplanted corneas were examined histologically by haematoxylin and eosin staining and immunohistochemistry against vimentin and α‐smooth muscle actin (α‐SMA).
The transplanted COL‐PVA discs remained transparent throughout the study, with no complications related to the flap or overlying epithelium. The interface between COL‐PVA and Descemet's membrane remained clear without signs of opacification caused by scarring or cellular deposition. Pathology revealed the intact COL‐PVA polymer in the posterior stroma, with minimal cellular infiltration along the anterior and posterior interfaces. Immunohistology shows vimentin and α‐SMA staining at levels comparable to lamellar keratoplasty control.
Microkeratome assisted deep lamellar keratoprosthesis may be a safe technique for the transplantation of artificial hydrogels for therapeutic purposes.
keratoprosthesis; transplantation; microkeratome; rabbit
Despite demonstrated cost effectiveness, not all corneal disorders are amenable to type I Boston keratoprosthesis (KPro) implantation. This includes patients with autoimmune diseases, such as Stevens–Johnson syndrome/toxic epidermal necrolysis. Type II KPro is implanted through the eyelids in severe dry eye and cicatricial diseases, and its cost effectiveness was sought.
Patients and methods
In a retrospective chart review, 29 patients who underwent type II KPro surgery at the Massachusetts Eye and Ear Infirmary between the years 2000 and 2009 were identified. A total of 11 patients had 5-year follow-up data. Average cost effectiveness was determined by cost-utility analysis, comparing type II KPro surgery with no further intervention.
Using the current parameters, the cost utility of KPro from third-party insurer (Medicare) perspective was 63 196 $/quality-adjusted life year.
Efforts to refer those less likely to benefit from traditional corneal transplantation or type I KPro, for type II KPro surgery, may decrease both patient and societal costs.
decision analysis; cost utility; cost effectiveness; keratoprosthesis; autoimmune diseases
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).
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).
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.
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.
Boston type 1 Keratoprosthesis; anterior segment optical coherence tomography; Spectralis; spectral domain; Fourier domain; KPro; OCT
The implantation of the Boston Keratoprosthesis (KPro) requires a corneal button, which is usually taken from a donor. Scarcity of donor tissue has been a major limiting factor in transplant surgery. Recently, autologous recipient cornea has been reported as support for the KPro. We report the successful use of an ipsilateral failed corneal graft as the carrier tissue for a patient requiring combined pars plana vitrectomy and KPro implantation.
This study reports the short-term functional and anatomical outcome of Boston Type 1 keratoprosthesis (Boston Kpro) implantation for bilateral limbal stem cell deficiency (LCSD). Retrospective analysis was done on eight eyes of eight patients who underwent Boston Kpro implantation between July 2009 and October 2009. The best corrected visual acuity (BCVA) and slit-lamp biomicroscopy findings were assessed at 1, 3 and 6 months postoperatively. All eight eyes retained the prosthesis. BCVA of 20/40 or better was achieved in 8, 6, and 5 eyes at 1, 3, and 6 months, respectively, postoperatively. One patient each developed epithelial defect, sterile stromal melt and fungal keratitis in the late postoperative period associated with antecedent loss of the soft contact lens from the eye. Boston Kpro has good short-term visual and anatomical outcome in patients with bilateral LSCD, provided compliance with postoperative care can be ensured.
Boston keratoprosthesis; limbal stem cell deficiency
Aim: Published clinical series suggest the osteoodontokeratoprosthesis (OOKP) may have a lower extrusion rate than current synthetic keratoprostheses. The OOKP is anchored in the eye wall by autologous tooth. The authors’ aim was to compare adhesion, proliferation, and morphology for telomerase transformed keratocytes seeded on calcium hydroxyapatite (the principal mineral constituent of tooth) and materials used in the anchoring elements of commercially available synthetic keratoprostheses.
Methods: Test materials were hydroxyapatite, polytetrafluoroethylene (PTFE), polyhydroxyethyl methacrylate (HEMA), and glass (control). Cell adhesion and viability were quantified at 4 hours, 24 hours, and 1 week using a calcein-AM/EthD-1 viability/cytotoxicity assay. Focal contact expression and cytoskeletal organisation were studied at 24 hours by confocal microscopy with immunoflourescent labelling. Further studies of cell morphology were performed using light and scanning electron microscopy.
Results: Live cell counts were significantly greater on hydroxyapatite surfaces at each time point (p<0.04). Dead cell counts were significantly higher for PTFE at 7 days (p<0.002). ß1 integrin expression was highest on hydroxyapatite. Adhesion structures were well expressed in flat, spread out keratocytes on both HA and glass. Keratocytes tended to be thinner and spindle shaped on PTFE. The relatively few keratocytes visible on HEMA test surfaces were rounded and poorly adherent.
Conclusions: Keratocyte adhesion, spreading, and viability on hydroxyapatite test surfaces is superior to that seen on PTFE and HEMA. Improving the initial cell adhesion environment in the skirt element of keratoprostheses may enhance tissue integration and reduce device failure rates.
keratoprosthesis; osteoodontokeratoprosthesis; hydroxyapatite; polytetrafluoroethylene; PHEMA
PURPOSE: The purpose of this work was to develop a keratoprosthesis which utilizes a biocolonizable skirt attached to a soft, elastomeric optic for world-wide application. METHODS: Over a period of 20 years, using in vivo animal implantation studies, a series of experiments was conducted testing materials for biocompatibility and durability which resulted in the development of an improved design. A new surgical technique was developed, using porous, biocolonizable haptics embedded within the sclera and combined with the established techniques of resection of Descemet's membrane and a conjunctival flap. RESULTS: Animal implantation studies indicated that 6 haptics, equidistantly placed, was the optimal shape. Two clinical trials resulted in the selection of an aliphatic polyether-based urethane for the optic and 60 mu pore polytetrafluoroethylene for the porous ingrowth material. Heated, pressurized injection moulding proved to be the optimal bonding method between the skirt and the optic. Sclerally embedded haptics achieved excellent integration with the tissue. CONCLUSIONS: This keratoprosthesis is a significant improvement over previous models with a rigid optic in that: 1. The porous ingrowth haptic is sclerally anchored, preventing extrusion. 2. It has a soft elastomeric optic which more successfully defuses the shearing forces of the keratoprosthesis/tissue interface secondary to blinking. 3. The optic is less massive and of greater circumference at the optic/tissue interface, thereby imparting less energy per area with a given movement. 4. The optic does not project posteriorly thereby decreasing anterior chamber irritation and reducing the possibility of glaucoma, uveitis, endophthalmitis, and retinal detachment. 5. This keratoprosthesis allows a normal field of view for the patient and an effective funduscopic view for the surgeon. 6. The large optical diameter eliminates problems with decentralization of the image. 7. It has a significantly better cosmetic appearance.
Improvements in osteoconduction of implant biomaterials require focusing on the bone-implant interface, which is a complex multifactorial system. Surface topography of implants plays a crucial role at this interface. Nanostructured surfaces have been shown to promote serum protein adsorption and osteoblast adhesion when compared to microstructured surfaces for bone-implant materials. We studied the influence of the serum proteins fibronectin and vitronectin on the attachment and proliferation of osteoblasts onto nanostructured titania surfaces. Human fetal osteoblastic cells hFOB 1.19 were used as model osteoblasts and were grown on nanoporous TiO2 templates, using Ti6Al4V and commercially pure Ti substrates as controls. Results show a significant increase in cell proliferation on nanoporous TiO2 over flat substrates. Initial cell attachment data exhibited a significant effect by either fibronectin or vitronectin on cell adhesion at the surface of any of the tested materials. In addition, the extent of cell adhesion was significantly different between the nanoporous TiO2 and both Ti6Al4V and commercially pure Ti substrates, with the first showing the highest surface coverage. There was no significant difference on osteoblast attachment or proliferation between the presence of fibronectin or vitronectin using any of the material substrates. Taken together, these results suggest that the increase in osteoblast attachment and proliferation shown on the nanoporous TiO2 is due to an increase in the adsorption of fibronectin and vitronectin because of the higher surface area and to an enhanced protein unfolding, which allows access to osteoblast binding motifs within these proteins.
nanoporous TiO2; hFOB 1.19; protein adsorption; vitronectin; fibronectin
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.
Synthesis; Nanoparticles; TiO2; Aqueously soluble; Direct liquid phase precipitation; Dynamic real-time measurement
Many methods have been reported on improving the photogenerated cathodic protection of nano-TiO2 coatings for metals. In this work, nano-TiO2 coatings doped with cerium nitrate have been developed by sol–gel method for corrosion protection of 316 L stainless steel. Surface morphology, structure, and properties of the prepared coatings were investigated by X-ray diffraction, X-ray photoelectron spectroscopy, scanning electron microscopy and energy dispersive X-ray spectroscopy. The corrosion protection performance of the prepared coatings was evaluated in 3 wt% NaCl solution by using electrochemical techniques in the presence and absence of simulated sunlight illumination. The results indicated that the 1.2% Ce-TiO2 coating with three layers exhibited an excellent photogenerated cathodic protection under illumination attributed to the higher separation efficiency of electron–hole pairs and higher photoelectric conversion efficiency. The results also showed that after doping with an appropriate concentration of cerium nitrate, the anti-corrosion performance of the TiO2 coating was improved even without irradiation due to the self-healing property of cerium ions.
Nano-TiO2 coating; Cerium ion doping; Corrosion protection
AIM—The goal was to compare the biological response of the corneal stroma with three porous materials: a melt blown microfibre web of polybutylene:polypropylene (80:20); a polyester spun laced fabric (polyethylene terephthalate), and an expanded polytetrafluoroethylene. Fifty per cent of each of the materials were modified using argon radio frequency.
METHODS—Discs (6 mm in diameter) were inserted into interlamellar stromal pockets and followed for a period of 12 weeks. Clinical evaluations were performed weekly. At 6 and 12 weeks, fibroplasia and the distribution of matrix proteins and growth factors (bFGF and TGF-β) were evaluated immunohistochemically. The characterisation of glycosaminoglycans was determined after selective extraction and digestion.
RESULTS—The response to the disc resembled that of a wound with a decrease in keratan sulphate and an increase in dermatan sulphate. Pretreatment of the discs reduced corneal oedema and neovascularisation. Heparan sulphate, not normally detected in the corneal stroma, was detected in the region immediately surrounding the disc and in the discs of some materials. The presence of glycosaminoglycans and collagens in the disc indicated that cells had migrated into the disc and deposited a complex matrix in all three materials. The collagen response was not surface specific. bFGF and TGF-β were detected in the region between the disc and the stroma in the polybutylene material and became diffuse with time.
CONCLUSION—Fibroplasia occurred most rapidly into the polyester discs but was accompanied by a large number of inflammatory cells. While the distribution of collagens was not altered by the material, the expression and distribution of growth factors was material dependent. bFGF was expressed transiently and occurred before that of TGF-β. It is predicted that the transient expression of growth factors mediates the regulation of matrix proteins.
Keywords: synthetic cornea; basic fibroblast growth factor; glycosaminoglycans; wound healing; cornea
The aim of this work is to characterize a transparent tissue layer partially covering the anterior surface of the type I Boston permanent keratoprosthesis front plate in four patients.
The tissue over the front plate was easily scrolled back as a single transparent layer using a sponge. In two cases, histopathologic analysis was undertaken and immunofluorescent staining with a cytokeratin 3-specific antibody was performed. The relationship of the tissue to the keratoprosthesis device was further characterized using spectral domain high-definition optical coherence tomography (HD-OCT).
Histopathologic analysis revealed the tissue to be non-keratinized squamous epithelium. No goblet cells were seen, suggesting the cells were of corneal, and not conjunctival, epithelial origin. Immunofluorescent staining of all cells was positive for cytokeratin 3, a protein strongly associated with corneal epithelium. The tissue was easily discerned by HD-OCT and was of substantial thickness near the external junction between the keratoprosthesis device and the carrier corneal tissue. In three cases, visual acuity was unaffected by the presence or absence of this tissue. In one case, a prominent tissue margin temporarily obscured the visual axis and reduced visual acuity; this resolved with mechanical central debridement and has not recurred.
The transparent tissue layer covering the anterior surface of the type I Boston keratoprosthesis front plate was found to represent non-keratinized squamous epithelium, most likely of corneal epithelial origin. This potentially represents a further step in bio-integration of the keratoprosthesis device. In particular, epithelial coverage of the critical junction between the device and the carrier corneal tissue might serve an important barrier function and further reduce the incidence of infection and extrusion of the type I Boston permanent keratoprosthesis.
Keratoprosthesis; Corneal epithelium; Bio-integration
To evaluate outcomes of the Boston Type 1 keratoprosthesis (KPro) and associated incidence of glaucoma.
Retrospective cohort study.
All patients who underwent KPro surgery at one institution from 2003-2009 with at least 3 months follow-up.
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.
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.
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.
Boston Type 1 Keratoprosthesis; Glaucoma; Keratoplasty
A keratoprosthesis (KP), is an artificial cornea which is inserted into an opacified cornea in an attempt to restore useful vision or, less commonly, to make the eye comfortable in painful keratopathy. Results o a retrospective study of 35 patients, with 55 KP insertions, are reviewed with regard to visual acuity, length of time vision is maintained, retention time, and complication. Overall there were a number of long-term real successes, eith retention of the KP and maintenance of improved vision in eyes not amenable to conventional treatment. Careful long-term follow-up was needed, with further surgical procedures often being necessary.
In this study, TiO2 thin film photocatalyst on carbon fibers was used to synthesize ultra-long single crystalline Pt nanowires via a simple photoreduction route (thermally activated photoreduction). It also acted as a co-catalytic material with Pt. Taking advantage of the high-aspect ratio of the Pt nanostructure as well as the excellent catalytic activity of TiO2, this hybrid structure has the great potential as the active anode in direct methanol fuel cells. The electrochemical results indicate that TiO2 is capable of transforming CO-like poisoning species on the Pt surface during methanol oxidation and contributes to a high CO tolerance of this Pt nanowire/TiO2 hybrid structure.
Pt nanowires; Hybrid catalyst; Methanol oxidation; Thermally activated photoreduction