Elsevier

The Ocular Surface

Volume 24, April 2022, Pages 129-144
The Ocular Surface

The evolution of the modified osteo-odonto-keratoprosthesis, its reliability, and long-term visual rehabilitation prognosis: An analytical review

https://doi.org/10.1016/j.jtos.2022.03.005Get rights and content

Abstract

An exhaustive search of the world's literature was performed to analyze all case reports and series on the modified osteo-odonto-keratoprosthesis (MOOKP) published up to January 2022. The demographic profile, the primary indication for surgery, surgical technique variations, postoperative medical management, long-term functional and anatomical outcomes, and intra- and postoperative complications were analyzed and compared. Additionally, some of the authors' (GI, VP, and GA) unpublished MOOKP cases were studied. An extensive literature search yielded 37 case series and case reports. Overall, 958 patients were analyzed. The most common indication for surgery was autoimmune disease (39.1%), closely followed by chemical injury (38.8%). The most common intraoperative complications (21.67%) included maxillofacial, vitreous hemorrhage/vitritis, and mucosal. The most common postoperative complications (78.4%) were lamina and oral mucosa-associated, secondary glaucoma, and choroid/retinal detachment. Follow-up periods ranged from one to 364 months (median: 36.7 months). Altogether, 78% of patients achieved a visual acuity of 20/400 or better at the end of the follow-up period, and 91.2% improved at least temporarily after MOOKP surgery. Mean anatomic success at the end-of-follow-up for all patients was 88.25% (range, 50–100%). The long-term anatomic and functional success of the MOOKP makes it a reliable option for visual rehabilitation in patients with bilateral corneal blindness and end-stage ocular surface disease. This review aims to describe the evolution of the MOOKP procedure, analyzing all published case series for its long-term reliability, visual and anatomical outcomes, complications, and future directions.

Introduction

The modified osteo-odonto-keratoprosthesis (MOOKP) is an epicorneal prosthesis with a polymethyl methacrylate (PMMA) optical cylinder supported with a biological haptic applied to patients with bilateral end-stage ocular surface disease, including Stevens-Johnson Syndrome (SJS), ocular mucous membrane pemphigoid (OMMP), and chemical injury. First designed by Strampelli [1] and later modified by Falcinelli [2], the MOOKP procedure is a heterotrophic autograft that replaces the ocular surface with a full-thickness oral mucosa graft. The latter provides vascular, physical, and microbiological sustenance to the patient's tooth and alveolar bone [2,3].

MOOKP is a complex procedure that demands technical finesse and a multidisciplinary team approach. Although an array of complications may accompany the MOOKP procedure, it has demonstrated the best long-term anatomic and functional success rates compared to all other currently available keratoprostheses (Kpros) in patients with the severe or end-stage ocular surface disease [[2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]]. Furthermore using an autograft allows better bio-integration and survival in the setting of severe sicca syndrome [5,21].

In 2001–2002, the surgeons who actively performed the MOOKP adaptation met in Rome and Vienna to discuss the surgical technique in detail and reached a consensus known as the Rome-Vienna protocol [2], and it has become the gold standard for this procedure. Today, only 14 highly specialized centers in four continents around the world offer this procedure [22].

This review aims to analyze and compare the demographic profile, surgical indications, complications, long-term functional and anatomic outcomes for all case series, case reports, and the authors' experience (VP and GI) with the MOOKP procedure.

Section snippets

Biological versus biocompatible keratoprostheses

An ideal corneal prosthesis should provide all the advantages of a corneal allograft but none of its disadvantages. Such desired features include improved optical quality, diminished optical aberrations, specifiable refractive power, bio integration and biocompatibility, resistance against infections, durability, successful drug penetration, patient affordability, and the ease to monitor intraocular pressure [[23], [24], [25], [26]].

Indications and contraindications for MOOKP

Indications for the MOOKP procedure include adult patients with bilateral corneal blindness, end-stage ocular surface disease, and severe limbal stem cell deficiency that cannot be treated within the reasonable expectation of success by any other regenerative or reconstructive method [2]. The more frequent entities treated with MOOKP are SJS, toxic epidermal necrolysis (TEN), OMMP, cicatricial trachoma, ocular surface burns, severe exposure keratopathy, and end-stage autoimmune dry eye (Fig. 1

Preoperative assessment

A multidisciplinary approach and an extensive ophthalmological and dental examination are required for adequate patient selection. An imperative requirement is the patient's commitment to a lifelong follow-up [10]. Ophthalmological assessment should include a full history and examination, emphasizing the evaluation of the retina and optic nerve function. The visual function can be assessed through the light perception and projection test, entoptic phenomena, color discrimination, and macular

Surgical technique [22,54]

Following the Rome-Vienna protocol [2], MOOKP is performed in two stages, ten to sixteen weeks apart. Recent modifications by Iyer et al. to the technique included a preliminary stage, termed Stage 1A [22,46], which is performed one month before the first stage to make the second stage safer and less time-consuming (Table 5). In addition, it allows direct intraoperative visualization of the fundus to estimate visual potential. In certain instances, with a doubtful optic nerve or retinal status,

Data analysis from MOOKP procedures

Retrieval of all published case series of MOOKP was performed in the National Library of Medicine's PubMed, SCOPUS, and Google Scholar databases. Search terms included “osteo-odonto-keratoprosthesis (OOKP)” and “modified osteo-odonto-keratoprosthesis (MOOKP).” No date or language restriction was applied. The last search on the databases was performed in January 2022. Fig. 6 summarizes the search strategy and the results. Thirty-six case series, complication reports, and case reports in English

Future directions and conclusion

Close to five million patients are estimated to have bilateral corneal blindness worldwide, and most of them are from underdeveloped countries [105]. In the US, keratoprosthesis development and adaptation have considerably increased in the past three decades. Nonetheless, KPro implantation has remained a reasonably uncommon procedure, accounting for only 0.6% of yearly corneal transplant surgeries since 2009 [106]. In our search for the literature, we could only find one institution in the US

Methods of literature search

An extensive literature search was performed in the National Library of Medicine's Pubmed, Scopus, Web of Science, and Google Scholar databases for all articles published until January 2022 in any language. The following search terms were used: keratoprosthesis, osteo-odonto-keratoprosthesis, and modified osteo-odonto-keratoprosthesis. Case reports, case series, letters to the editor, review articles, and original articles were included.

Funding

No funding or grant was received for the development of this article.

Declaration of competing interest

None of the authors hold proprietary or commercial interest in any concept or product discussed in this article.

Acknowledgments

None.

References (112)

  • G. Amescua et al.

    Modified osteo-odonto-keratoprosthesis: MOOKP. Ocular surface disease: cornea, Conjunctiva and tear film, W.B. Saunders

    (2013)
  • V. Charoenrook et al.

    Osteokeratoprosthesis using tibial bone: surgical technique and outcomes

    Ocul Surf

    (2016)
  • O.E. Cuzzani et al.

    Potential acuity meter versus scanning laser ophthalmoscope to predict visual acuity in cataract patients

    J Cataract Refract Surg

    (1998)
  • G.E. Fish et al.

    A comparison of visual function tests in eyes with maculopathy

    Ophthalmology

    (1986)
  • R.R. Reddy Pappuru et al.

    Role of diagnostic endoscopy in posterior segment evaluation for definitive Prognostication in eyes with corneal opacification

    Am J Ophthalmol

    (2017)
  • P.A. Netland et al.

    Glaucoma associated with keratoprosthesis

    Ophthalmology

    (1998)
  • A.B.G. Tay et al.

    Osteo-odonto-keratoprosthesis surgery: a combined ocular–oral procedure for ocular blindness

    Int J Oral Maxillofac Surg

    (2007)
  • S. Raman et al.

    Anesthesia Considerations in modified osteo-odonto-keratoprosthesis

    Asia Pac J Ophthalmol (Phila)

    (2019)
  • Y. Sawatari et al.

    Oral and maxillofacial surgeons' role in the first successful modified osteo-odonto-keratoprosthesis performed in the United States

    J Oral Maxillofac Surg

    (2011)
  • V. Narayanan et al.

    Osteo-odonto-keratoprosthesis – a maxillofacial perspective

    J Cranio-Maxillofacial Surg

    (2012)
  • L.S. Lim et al.

    Vitreoretinal complications and vitreoretinal surgery in osteo-odonto-keratoprosthesis surgery

    Am J Ophthalmol

    (2014)
  • P. Rishi et al.

    Vitreoretinal complications and outcomes in 92 eyes undergoing surgery for modified osteo-odonto-keratoprosthesis

    Ophthalmology

    (2018)
  • M. Zarei-Ghanavati et al.

    The Osteo-odonto-keratoprosthesis to restore vision after severe dog bite injury

    J Curr Ophthalmol

    (2019)
  • V.S. Avadhanam et al.

    Detection of laminar resorption in osteo-odonto-keratoprostheses

    Ocul Surf

    (2019)
  • V.S. Avadhanam et al.

    Clinical study of laminar resorption: Part 1 – factors affecting laminar resorption

    Ocul Surf

    (2020)
  • V.S. Avadhanam et al.

    Clinical study of laminar resorption: Part 2- outcomes, review and proposal for classification

    Ocul Surf

    (2021)
  • Strampelli B. Osteo-odontokeratoprosthesis

    Ann Ottalmol Clin. Ocul

    (1963)
  • K. Hille et al.

    Standards for modified osteoodontokeratoprosthesis (OOKP) surgery according to Strampelli and Falcinelli: the rome-vienna protocol

    Cornea

    (2005)
  • G. Falcinelli et al.

    Modified osteo-odonto-keratoprosthesis for treatment of corneal blindness: long-term anatomical and functional outcomes in 181 cases

    Arch Ophthalmol

    (2005)
  • G. Falcinelli et al.

    Osteoodontokeratoprosthesis: present experience and future prospects

    Refract Corneal Surg

    (1993)
  • V. Marchi et al.

    Osteo-odonto-keratoprosthesis. Description of surgical technique with results in 85 patients

    Cornea

    (1994)
  • K. Hille et al.

    Die osteo-odonto-Keratoprothese

    Ophthalmologe

    (2002)
  • K. Hille et al.

    Medium term results in keratoprostheses with biocompatible and biological haptic

    Graefes Arch Clin Exp Ophthalmol

    (2006)
  • M. Fukuda et al.

    Osteo-odonto-keratoprosthesis in Japan

    Cornea

    (2008)
  • C. Liu et al.

    Visual rehabilitation in end-stage inflammatory ocular surface disease with the osteo-odonto-keratoprosthesis: results from the UK

    Br J Ophthalmol

    (2008)
  • D.T.H. Tan et al.

    Keratoprosthesis surgery for end-stage corneal blindness in Asian eyes

    Ophthalmology

    (2008)
  • R. Michael et al.

    Long-term functional and anatomical results of osteo- and osteoodonto-keratoprosthesis

    Graefes Arch Clin Exp Ophthalmol

    (2008)
  • M.F. De La Paz et al.

    Impact of clinical factors on the long-term functional and anatomic outcomes of osteo-odonto-keratoprosthesis and tibial bone keratoprosthesis

    Am J Ophthalmol

    (2011)
  • G. Iyer et al.

    Modified osteo-odonto keratoprosthesis–the Indian experience–results of the first 50 cases

    Cornea

    (2010)
  • S. Basu et al.

    Mucosal complications of modified osteo-odonto keratoprosthesis in chronic Stevens-Johnson syndrome

    Am J Ophthalmol

    (2013)
  • K. Hille

    [Long-term outcome of keratoprosthesis with biological support]

    Ophthalmologe

    (2018)
  • A. Vasquez-Perez et al.

    Osteo-odonto-keratoprosthesis in severe thermal and chemical injuries

    Cornea

    (2018)
  • C. Liu et al.

    Keratoprosthesis surgery

    Surgery Dry Eye

    (2008)
  • G. Falcinelli et al.

    Modified osteo-odonto-keratoprosthesis (MOOKP): indications, contraindications, and surgical technique

    Keratoprostheses and Artificial Corneas

    (2015)
  • C. Liu et al.

    The osteo-odonto-keratoprosthesis (OOKP)

    Semin Ophthalmol

    (2005)
  • C. Liu et al.

    Striving for the perfect keratoprosthesis

    Br J Ophthalmol

    (1998)
  • J.C. Barber

    Keratoprostheses: past and present

    Int Ophthalmol Clin

    (1988)
  • J. Kaur

    Osteo-odonto keratoprosthesis: innovative dental and ophthalmic blending

    J Indian Prosthodont Soc

    (2018)
  • J.C. Barber

    Keratoprostheses: past and present

    Int Ophthalmol Clin

    (1988)
  • T.V. Chirila et al.

    The origins of the artificial cornea: Pellier de Quengsy and his contribution to the modern concept of keratoprosthesis

    Gesnerus

    (1999)
  • Cited by (0)

    View full text