Ocular Fornix Reconstruction prior to Combined Boston Keratoprosthesis (KPro) and Glaucoma Drainage Impant (GDI) Surgery.

Abstract

Purpose : Glaucoma is the leading cause of vision loss in eyes with KPro. GDI have been shown to be effective in controlling glaucoma with KPro. Cicatricial conjunctival disease with forniceal shortening is a major challenge and limitation to the use of GDI. In our series, we report the success of fornix reconstruction in cicatricial ocular surface disease as a staged procedure prior to combined KPro/GDI.

Methods : Retrospective case series involving 4 eyes with severe conjunctival cicatricization. Three patients with chemical burns and one patient with Ectrodactyly Ectodermal Dysplasia-Clefting syndrome. Preoperative data, surgical interventions, and clinical outcomes were reviewed. IOP was measured by digital palpation and scleral pneumotonometery.

Results : Three males and 1 female with mean age of 42 years. All eyes had upper and lower symblepharon with shallow fornices. Two eyes were reconstructed with amniotic membrane transplantation (AMT) alone and 2 eyes with AMT and oral mucous membrane (OMM) grafting. Three eyes required one reconstructive procedure and 1 eye required 5. Three eyes had elevated IOP and 1 eye thought to be at high risk of postoperative glaucoma. Time from reconstruction to KPro/GDI surgery was 5 months in 3 eyes and 11 months in 1 eye. All eyes underwent successful implantation of KPro and GDI with vitrectomy and pars plana tube insertion with adequate conjunctival closure. None of the eyes had serious complications. One eye had transient hypotony and choroidal effusion which resolved conservatively. IOP was adequately controlled in 3 eyes, one eye needed diode laser cyclophotocoagulation as an additional procedure. All eyes were successfully fitted with contact lenses for KPro care.

Conclusions : This case series represents the first report of fornix reconstruction for combined KPro/GDI surgery. Fornix reconstruction with the aid of amniotic membrane with or without oral mucous membrane grafting is a safe and effective way to manage complex cicatricial surface disease associated with corneal scarring and glaucoma. Our series shows that ocular surface reconstruction allows for subsequent successful implantation of GDI and KPro in cases that were otherwise poor surgical candidates.

This is an abstract that was submitted for the 2018 ARVO Annual Meeting, held in Honolulu, Hawaii, April 29 - May 3, 2018.

 

A: Preoperative cicatrization. B: Reconstruction with AMT and OMM, C & D: 1 and 2months PO. E & F: 10 months PO with formed fornices. G & H: KPro and GDI.