Retinal Detachment after Keratoprosthesis Placement: Incidence, Predisposing Factors, and Visual and Anatomic Outcomes

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Retinal Detachment after Keratoprosthesis
Placement Incidence, Predisposing Factors, and
Visual and Anatomic Outcomes

• M. Stephanie R. Jardeleza, M.D.
• Marc-Andre Rheaume, M.D.
• James Chodosh, M.D., MPH
• Claes H. Dohlman, M.D., Ph.D.
• Lucy Young, M.D., Ph.D.

The authors have no financial interests to
disclose.
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Introduction

• The Boston Keratoprosthesis (K-Pro) is a viable
  option after multiple failed corneal grafts or in
  patients who are poor prognostic candidates for
  primary penetrating keratoplasty
• Secondary co-morbidities such as advanced
  glaucoma and vitreo-retinal pathology often led
  to severe visual loss and failure of visual
  acuity to improve after keratoprosthesis
  implantation

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Purpose

• Knowledge of predisposing factors to retinal
  detachments in certain patient populations
  undergoing K-Pro implantation can guide surgical
  planning and patient counseling
• 2. Knowledge of timing of retinal detachments
  and surgical outcomes of retinal detachment
  repair can optimize post-operative care in
  patients undergoing K-Pro implantation

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Methods

• Research Design
• Retrospective, noncomparative, interventional
  case series
• Data Collection
• A review of 170 patients (205 eyes) who underwent
  Boston keratoprosthesis implantation at the
  Massachusetts Eye and Ear Infirmary from April
  1993 and June 2009
• Wilcoxon rank sum test and Fishers exact test
  used to determine significant differences between
  K-Pro patients who developed a retinal detachment
  and those who remained attached after surgery

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Results

• Age range 18-94 years old (mean 59.6 y.o.)
• Mean number of K-Pro implanted per eye 1.3
  (range of 1-4)
• Average follow up after first surgery 3.9 years
• Calculated incidence of RD in the entire study
  population 8.3 per 1 year

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Results

• Forty four eyes (21.5) developed a retinal
  detachment with a mean follow up of 2.6 years
  (range 1 month 9.5 years)
• Timing of retinal detachment after K-Pro
• First year 14 (32.6)
• Within 3 years 26 (60.5)
• Within 5 years 37 (86)

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Results
Category Number of Eyes With K-Pro Eyes with RD after K-Pro

Autoimmune systemic disease 65 27 (42)

Chemical burns 19 5 (26)

Non-autoimmune etiology 121 12 (10)
Mean follow up 2.6 years
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Significant predictive risk factors for Retinal
Detachment after K-Pro

• History of autoimmune or systemic disease
  (plt0.001)
• Formation of a retroprosthetic membrane (plt0.001)
• Sterile vitritis (plt0.001)
• Endophthalmitis (p0.002)
• History of K-Pro replacement in the same eye or
  multiple K-Pro implantations (p0.006)
• Post-surgical wound leak or hypotony (plt0.001)

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Surgical outcomes of RD after K-Pro
Retinal detachments (RD)
RD repaired 15 (34)
Irreparable RD 29 (66)

Total RD 44

Outcomes of repair
Attached 8 (53)
Detached/Phthisis 7 (47)

Total patients 15

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Conclusion

• Retinal detachment following K-Pro implantation
  is more frequent in patients with autoimmune
  disease (where K-Pro should be undertaken only
  after careful consideration).
• Majority of retinal detachments after K-Pro
  implantation are irreparable at the time of
  diagnosis and anatomical outcomes of surgical
  repair remain poor.
• Autoimmune systemic disease, post-operative
  endophthalmitis, sterile vitritis, formation of
  retroprosthetic membranes and hypotony predispose
  to retinal detachments in K-Pro patients.
  Patients with these risk factors should be
  co-managed with a vitreoretinal specialist.
• Retinal detachment in K-Pro patients portend a
  poor visual prognosis with majority of patients
  having final visual acuities worse than 20/400.
• 5. The next frontier will be prophylaxis
  against development of RD after K-Pro placement
  i.e. aggressive control of autoimmune disease
  and/or performing a concomitant pars plana
  vitrectomy with or without 360 degree endolaser
  or scleral buckle placement during K-Pro
  implantation.

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References

• Aldave AJ, Kamal KM, Vo RC, Yu F. The Boston
  Type I Keratoprosthesis improving outcomes and
  expanding indications.Ophthalmology. 2009 April.
  116(4)640-51.
• Dohlman, et al. Expert Rev Ophthalmol. 2006
  1(1),41-8.
• Dohlman CH and Terada H. Keratoprosthesis in
  pemphigoid and Stevens Johnson syndrome. Adv Exp
  Med Biol. 1998 4381021-5.
• Ray S, Khan BF, Dohlman CH, D'Amico DJ.
  Management of vitreoretinal complications in eyes
  with permanent keratoprosthesis. Arch Ophthalmol.
  2002 May. 120(5) 559-66.
• Zerbe BL, Belin MW, Ciolino JB, Boston Type I
  Keratoprosthesis Study Group. Results from the
  multicenter Boston Type I Keratoprosthesis Study.
  Ophthalmology. 2006 Oct. 113(10)1779.e1-7.

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Thank you
Lucy Young, M.D., Ph.D.
James Chodosh, M.D., MPH
Claes H. Dohlman, M.D., Ph.D.
M. Stephanie R. Jardeleza, M.D.
Marc-Andre Rheaume, M.D.