Transcript 192: Modified Postoperative Regimen to Increase Retention of

Modified Postoperative Regimen
to Increase Retention of
Keratoprostheses
Poster ID: 192
Juan Carlos Abad, MD
Private practice, Medellín - Colombia
Carolina Gómez Calle, MD
Universidad de Antioquia Medellín-Colombia
The authors have no financial interest in the subject matter of this poster
Purpose
• To compare the eight-year old experience with the new model
(back plate with holes) Boston Keratoprosthesis (KPro) from a
single Latin American center with published multi-diagnosis
reports using the same keratoprosthesis,1-4 and to evaluate the
effect of a modified postoperative regimen in the retention rate of
the device.
1.
Zerbe, B.L. Results from the Multicenter Boston Type 1 Keratoprosthesis Study. Ophthalmology 2006;113:1779–1784
2.
Bradley, J.C; Hernandez, E.G; Schwab, I.R; Mannis, M.J. Boston Type 1 Keratoprosthesis: The University of California Davis
Experience Cornea 2009;28:321–327
3.
4.
.Chew, H. F; Ayres, B.D. et al. Boston Keratoprosthesis Outcomes and Complications. Cornea 2009;28:989–996
Aldave, A.J et al. The Boston Type I Keratoprosthesis Improving Outcomes and Expanding Indications. Ophthalmology
2009;116:640–651
Materials and Methods
• The charts of 19 patients who had undergone type I Boston KPro
surgery from 2002 to 2009 were analyzed. Two patients required
keratoprosthesis surgery both eyes. In these cases, only the right eye
was analyzed.
• Since October 2008, we modified the postoperative regimen replacing
topical prednisolone for topical medroxyprogesterone and fourgeneration quinolones for topical aminoglycosides and adding oral
doxicycline and vitamin C for all patients based on the management
of alkali corneal burns1,2 and some studies about improved AlphaCor
retention with postoperative medroxyprogesterone.3 Compulsory
usage of the bandage contact lens (BCL) was improved by lateral
tarsorraphy and backup BCLs for all the patients.
• Topical diluted vancomycin was used before and after Oct. 2008.
1.
2.
3.
Wagoner, M.D. Chemical injuries of the eye: current concepts in pathophysiology and therapy. Survey of ophthalmology. 41(4): 275-303, 1997.
Brodovsky, S.C, McCarty C.A, Snibson, G; Loughnan, M; Sullivan, L; Daniell, M; Taylor, H.R. Management of Alkali Burns, An 11-year
Retrospective Review. Ophthalmology 2000;107:1829–1835
Hicks, C,R and Crawford G, J. Melting after Keratoprosthesis Implantation:The Effects of Medroxyprogesterone. Cornea 22(6): 497–500, 2003.
Preoperative Diagnosis
Non
inflamator
y
37%
35.00
30.00
25.00
Inflamator
y
63%
20.00
15.00
10.00
5.00
0.00
%
Repeated
graft failure
Chemical/th
ermal burns
31.58
26.32
StevensJohnson
syndrome
15.79
Atopic
Ocular
keratoconjun cicatricial
ctivitis
pemphigoid
10.53
10.53
Ocular
trauma
5.26
Results
There were 12 male and 17 female patients
Average age was 52 (±18) years old
The average of follow up was 25 months (± 21,1) (Range:2.4 to 96.7)
1. Visual Acuity
• Preoperative best-corrected visual acuity (BCVA) ranged from
20/400 to light perception
• At last follow-up, postoperative BCVA was better than 20/200 in
68.4% of patients and was greater 20/50 in 53.8% of patients. The
best visual result was observed in patients with atopic
keratoconjunctivitis and ocular trauma.
Results - BCVA
Patients %
0
5
10
15
20
25
20/20
20/25
20/30
20/40
20/50
20/80
20/100
20/200
20/400
20/800
CD
MM
PL
AV final
AV inicial
30
35
40
45
50
Results
Months of f/u
2. Kerathoprotesis Retention
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
KPRO REDO 2
KPRO REDO
KPRO
KPP
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19
Case number
Results
2. Keratoprosthesis Retention
• The estimated time of survival of the keratoprosthesis was 55,9 months
(CI 32,4 –76,3)
• Retention of the original KPro was 76,7% and of all KPros (including
redos) 94,7%.
Original KPro
1.0
Cumulative Proportion Surviving
0.8
0.6
0.4
0.2
Corneal Melt around KPro
0.0
0
10
20
30
40
50
Months
60
70
80
90
100
Results
3. Modified postoperative regimen effect
Extrusion
Yes n(%)
No
n(%)
W/o Medroxyprogesterone
5(41,7)
7(58,3)
With Medroxyprogesterone
1(14,3)
6(85,7)
P value*
OR
CI 95%
0,333
4,286
(0,386-47,625)
A modified postoperative regimen seems
to have changed the type of complications
from corneal melts to exhuberant
conjunctival growth (two cases).
Conjunctival overgrowth
Traditional vs Modified PO Regimen
Cumulative Proportion Surviving
1.0
0.8
0.6
1
2
1-censored
2-censored
0.4
0.2
0.0
0
20
40
60
Months
80
1.
2.
100
Traditional postoperative regimen
Modified posoperative regimen
Other complications
Eleven cases had glaucoma preop (57.8%) and 3 additional cases
developed it after surgery (68.4%)
Four cases of retroprosthetic membrane were encountered (21%)
Two cases had sterile vitreitis (10.5%)
There was one case of infectious keratitis and one of endophthalmitis
(P.aeruginosa) (5.3% each)
Discussion
• Postoperative BCVA was greater than 20/200 and 20/50 in 68.4% and
53,8% of patients respectively, better than Zerbe’s study1 (56% and 23%
respectively), but similar to the University of California Davis’ report2
(20/200 in 75% and 20/40 in 25% of eyes)
• In our analysis, the retention of the first KPro was 76,7%, similar to the
84 % retention rate found by Aldave.3 The overall retention in our study
was 94% like that observed by Zerbe et al.1 (95%)
• We found a lower rate of retroprosthetic membranes (21%) than the
report from Chew4 (65%)
• The modified regimen in our population shows an initial trend to diminish
corneal melt similar to the findings by Hicks et al.5
1.
2.
3.
4.
Zerbe, B.L. Results from the Multicenter Boston Type 1 Keratoprosthesis Study. Ophthalmology 2006;113:1779–1784
Bradley, J.C; Hernandez, E.G; Schwab, I.R; Mannis, M.J. Boston Type 1 Keratoprosthesis: The University of California Davis Experience
Cornea 2009;28:321–327.
Aldave, A.J et al. The Boston Type I Keratoprosthesis Improving Outcomes and Expanding Indications. Ophthalmology 2009;116:640–651
Chew, H. F; Ayres, B.D. et al. Boston Keratoprosthesis Outcomes and Complications. Cornea 2009;28:989–996
5.
Hicks, C,R and Crawford G, J. Melting after Keratoprosthesis Implantation:The Effects of Medroxyprogesterone. Cornea 22(6): 497–500, 2003.
Conclusions
• The incidence of preoperative inflammatory conditions before
keratoprosthesis surgery appears to be higher in a Third-world
setting
• The clinical results seem to be similar to multi-diagnosis KPro series
published from developed countries
• The modified postoperative regimen with medroxiprogesterone
instead of prednisolone, avoiding 4th generation quinolones and oral
doxicycline and vitamin C seems to have decreased melts or at
least their severity. Longer follow up is needed to confirm these
findings.
• Our lower retroprosthetic membrane formation rate could be related
to the fact that most patients were left aphakic during surgery.
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