Boston Keratoprosthesis Treatment of Herpes Zoster Neurotrophic Keratopathy

doi:10.1016/j.ophtha.2007.10.013

Ophthalmology

Volume 115, Issue 2, Supplement, February 2008, Pages S21-S23

https://doi.org/10.1016/j.ophtha.2007.10.013 Get rights and content

Topic

The successful use of the Boston keratoprosthesis in a severely inflamed ulcer in herpes zoster neurotrophic keratopathy.

Clinical Relevance

Approximately 10% to 20% of patients with herpes zoster will develop herpes zoster ophthalmicus (HZO). Antiviral medication forms the foundation of pharmacologic treatment for acute herpes zoster, but management of HZO is supplemented with topical and systemic antimicrobials and corticosteroid agents as well as surgical interventions. However, HZO is associated with poor healing, as evidenced by a high occurrence of ulceration, superinfection, and surgical failure.

Methods

A 95-year-old man was referred for corneal edema in the right eye. There was a history of acute herpes zoster in the right eye 10 months previously. Slit-lamp examination revealed lagophthalmos, ectropion, total corneal anesthesia, and marked inferior corneal edema. Despite surgical repair of all lid abnormalities and aggressive lubrication and management of rosacea blepharitis, the corneal surface remained unhealthy. Four months later, the patient presented with an inflamed hypopyon ulcer, culture positive for abundant Pseudomonas and Candida albicans. The ulcer progressed to descemetocele in the face of aggressive antimicrobial therapy, vision was light perception (LP), and perforation became imminent. A Boston keratoprosthesis was used to replace the severely damaged cornea, and extracapsular cataract extraction of a mature cataract was also performed.

Results

One week after surgery, the inflammation was almost entirely resolved, and cultures of the host button were negative for any organisms. Vision gradually increased from LP to 20/60 over the ensuing 4 months.

Conclusion

The Boston keratoprosthesis procedure successfully salvaged and restored vision in this high-risk herpes zoster eye in which standard keratoplasty would almost certainly have failed.

References (6)

M. Brisson et al.
Exposure to varicella boosts immunity to herpes-zoster: implications for mass vaccination against chickenpox
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Acyclovir for the prevention of recurrent herpes simplex virus eye diseaseHerpetic Eye Disease Study Group
N Engl J Med
(1998)
M.N. Oxman et al.
A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults
N Engl J Med
(2005)

There are more references available in the full text version of this article.

Cited by (41)

Toward electron-beam sterilization of a pre-assembled Boston keratoprosthesis
2021, Ocular Surface
Citation Excerpt :
Implantation of a BK, the most widely used prosthetic cornea, is a valued alternative for such patients [54–57]. Although the most common indication for BK implantation is multiple allograft failure [54], patients with chemical ocular injury [58,59], atopic keratoconjunctivitis [60] and other causes of limbal stem cell deﬁciency [61] may also beneﬁt from BK surgery, and indications for its use are expanding [62–67]. However, complications of surgery are significant, and include glaucoma, keratolysis (corneal melt), retroprosthetic membrane, sterile vitritis, infectious keratitis, and endophthalmitis [68–71], any of which can lead to loss of recovered vision.
To evaluate the effects of electron-beam (E-beam) irradiation on the human cornea and the potential for E-beam sterilization of Boston keratoprosthesis (BK) devices when pre-assembled with a donor cornea prior to sterilization.
Human donor corneas and corneas pre-assembled in BK devices were immersed in recombinant human serum albumin (rHSA) media and E-beam irradiated at 25 kGy. Mechanical (tensile strength and modulus, and compression modulus), chemical, optical, structural, and degradation properties of the corneal tissue after irradiation and after 6 months of preservation were evaluated.
The mechanical evaluation showed that E-beam irradiation enhanced the tensile and compression moduli of human donor corneas, with no impact on their tensile strength. By chemical and mechanical analysis, E-beam irradiation caused a minor degree of crosslinking between collagen fibrils. No ultrastructural changes due to E-beam irradiation were observed. E-beam irradiation slightly increased the stability of the cornea against collagenase-induced degradation and had no impact on glucose diffusion. The optical evaluation showed transparency of the cornea was maintained. E-beam irradiated corneal tissues and BK-cornea pre-assembled devices were stable for 6 months after room-temperature preservation.
E-beam irradiation generated no detrimental effects on the corneal tissues or BK-cornea pre-assembled devices and improved native properties of the corneal tissue, enabling prolonged preservation at room temperature. The pre-assembly of BK in a donor cornea, followed by E-beam irradiation, offers the potential for an off-the-shelf, ready to implant keratoprosthesis device.
Predictive factors of Boston Type I Keratoprosthesis outcomes: A long-term analysis
2020, Ocular Surface
To study the long-term visual- and device retention-related outcomes and complications of the Boston Type I Keratoprosthesis (KPro).
Single-center, retrospective cohort study of all patients undergoing KPro implantation from February 2007 to April 2014 with at least 5 years of follow-up.
68 eyes from 65 patients underwent KPro implantation during the study period. At 5 and 10 years, the probability of maintaining or improving visual acuity (VA) was 75.0% and 66.7%, respectively, and the probability of KPro retention was 89.2% and 89.2%, respectively. Initial device retention rate at 10 years was significantly lower in those with underlying ocular surface disease (46.8% [30.6–63.2] vs 75.8% [61.0–90.7], P = 0.03), while other baseline characteristics showed no significant association. Final VA was more likely to be stable or improved in patients with fewer failed grafts (2 [1–6] vs 3 [1–6], P < 0.01), and a final VA of 20/200 or better was more likely in primary KPro eyes (44.8% [26.7–62.9] vs 19.4% [6.5–32.3], P = 0.03). Combined KPro-vitrectomy eyes were more likely to have stable or improved final VA than non-vitrectomy eyes (88.5% [76.2–100.0] vs 64.1% [49.1–79.1], P = 0.04). All complications had increasing incidence beyond 5 years; in particular, corneal melt, surgical glaucoma interventions, and endophthalmitis tended to have late presentations, with 79.0%, 78.6%, and 88.9% of these complications occurring beyond one year, respectively.
KPro devices show favorable long-term visual and retention outcomes in select patients. Careful long-term, multidisciplinary follow-up is warranted to address potential complications.
Post-herpes neurotrophic keratopathy: Aetiopathogenesis, clinical signs and current therapies
2019, Archivos de la Sociedad Espanola de Oftalmologia
La queratopatía neurotrófica (QN) es una enfermedad corneal degenerativa causada por un daño en la inervación del nervio trigémino. Esta situación produce defectos epiteliales, ulceración y, eventualmente, perforación. Tanto la queratitis por herpes simple como por varicela zoster constituyen la principal causa de QN. Además, el pronóstico en este tipo de QN es pobre. Los hallazgos clínicos clásicos en la QN postherpética incluyen la rotura epitelial espontánea, defectos epiteliales ovalados y centrales de bordes suaves, queratolisis con adelgazamiento del estroma, cicatrización y neovascularización. Aunque se han descrito tratamientos médicos y quirúrgicos prometedores, actualmente no hay un tratamiento definitivo para restaurar la sensibilidad de la córnea. Por tanto, la QN sigue siendo un reto terapéutico. En esta revisión resumimos la patogenia, la clínica y el tratamiento actual de la QN postherpética. Se discute el papel del tratamiento antiviral y de las vacunas contra el virus de la varicela-zoster. Se describen nuevas terapias médicas y quirúrgicas, como los agentes regenerativos y la neurotización corneal.
Neurotrophic keratopathy (NK) is a degenerative corneal disease caused by damage of trigeminal innervation. This leads to epithelial defects, ulceration and, eventually, perforation. Both herpes simplex and varicella zoster keratitis are reported to be the main causes of NK. Furthermore, prognosis in this type of NK is poor. Classic clinical findings in post-herpes NK are spontaneous epithelial breakdown, round and central epithelial defects with smooth edges, stromal melting and thinning, scarring, and neovascularisation. Although several medical and surgical treatments have been reported, no therapies are currently available to definitely restore corneal sensitivity. Therefore, NK remains a challenging disease to treat. In this review a summary is presented of the pathogenesis, manifestations, and current management of post-herpes NK. The role of antiviral treatment and varicella-zoster vaccination is also discussed. A description is also presented on both medical and surgical novel therapies, such as regenerative drugs and corneal neurotization.
Boston keratoprosthesis type 1
2019, Journal Francais d'Ophtalmologie
La kératoplastie transfixiante est la greffe d’organe la plus pratiquée au monde. Cependant, sa réussite dépend de la santé du microenvironnement oculaire et du privilège immun intact de l’œil. En l’absence de ces derniers, les greffes cornéennes ont un taux d’échec accru et la cécité cornéenne en résulte. Depuis plus de deux cents ans, les chercheurs travaillent sur la conception de kératoprothèse pour remédier à ces cas de cécité cornéenne sévère. Malgré les difficultés antérieures, l’intérêt pour le domaine a récemment été ravivé et des progrès considérables ont été accomplis au cours des vingt dernières années jusqu’au point où la kératoprothèse est maintenant considérée comme une intervention primaire dans certaines indications, et n’est plus une chirurgie de dernier recours. Dans cette revue, on décrit l’expérience globale et personnelle avec la kératoprothèse de Boston de type 1, un traitement relativement récent de la cécité cornéenne sévère dans le contexte d’échec répété des greffes de cornée et les conditions à haut risque. Dernièrement, des modifications dans le design, la technique chirurgicale, et la prise en charge postopératoire ont augmenté le taux de succès et la notoriété de la kératoprothèse. Les complications résultantes de l’implantation de la kératoprothèse ont diminué de façon substantielle dans la dernière décennie grâce aux progrès, lui permettant de devenir une alternative efficace et sécuritaire de certaines pathologies cornéennes. Cependant, certaines complications persistent et nécessitent une prise en charge pour améliorer le pronostic visuel des patients avec cécité cornéenne.
Penetrating keratoplasty is the most commonly performed tissue transplant in the world. However, its success depends on the health of the ocular surface and the intact immune privilege of the eye. In the absence of these two conditions, corneal transplants have an increased failure rate and result in corneal blindness. For more than two hundred years, researchers have been trying to find the best design of the artificial cornea in order to address these cases of severe corneal blindness. Despite previous difficulties, interest in the field has recently been revived, and considerable progress has been made over the last 20 years, to the point where the keratoprosthesis is now considered a primary procedure for some indications and is no longer always a surgery of last resort. In this review, we describe the global and personal experience with Boston keratoprosthesis type 1. It is a relatively new treatment for severe corneal blindness in the context of multiple failed corneal transplants and high-risk conditions. In the last decade, changes in the design, surgical technique, and postoperative management have increased the success rate and popularity of the Boston keratoprosthesis and decreased its complications substantially, making it a safe and effective alternative for certain corneal pathologies. However, some complications persist and require management to improve the visual prognosis of patients with corneal blindness.
Corneal Edema and Opacification Preferred Practice Pattern®
2019, Ophthalmology
Neurotrophic keratopathy
2018, Progress in Retinal and Eye Research
Citation Excerpt :
A conjunctival flap is recommended when descemetocele or perforation recurs despite previous corneal transplantation (Vasseneix et al., 2006). The Boston keratoprosthesis implantation has emerged as an effective modality for visual rehabilitation in such patients (Katzman and Jeng, 2014; Pavan-Langston and Dohlman, 2008). Direct neurotization of the cornea using the contralateral supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve has been performed for restoring the corneal sensitivity in patients with unilateral facial palsy and anesthetic cornea.
Neurotrophic Keratopathy (NK) refers to a condition where corneal epitheliopathy leading to frank epithelial defect with or without stromal ulceration (melting) is associated with reduced or absent corneal sensations. Sensory nerves serve nociceptor and trophic functions, which can be affected independently or simultaneously. Loss of trophic function and consequent epithelial breakdown exposes the stroma making it susceptible to enzymatic degradation. Nerve pathology can range from attrition to aberrant re-generation with corresponding symptoms from anaesthesia to hyperaesthesia/allodynia. Many systemic and ocular conditions, including surgery and preserved medications can lead to NK. NK can be mild (epithelium and tear film changes), moderate (non-healing epithelial defect) or severe (stromal melting and perforation). Moderate and severe NK can profoundly affect vision and adversely impact on the quality of life. Medical management with lubricating agents from artificial tears to serum/plasma drops, anti-inflammatory agents, antibiotics and anti-proteases all provide non-specific relief, which may be temporary. Contact lenses, punctal plugs, lid closure with botulinum toxin and surgical interventions like tarsorrhaphy, conjunctival flaps and amniotic membrane provide greater success but often at the cost of obscuring sight. Corneal surgery in a dry ocular surface with reduced sensation is at high risk of failure. The recent advent of biologicals such as biopolymers mimicking heparan sulfate; coenzyme Q10 and antisense oligonucleotide that suppress connexin 43 expression, all offer promise. Recombinant nerve growth factor (cenegermin), recently approved for human use targets the nerve pathology and has the potential of addressing the underlying deficit and becoming a specific therapy for NK.

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: STATEMENT OF CONFLICT OF INTEREST: these authors have no relevant conflicts to report.

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Original articleBoston Keratoprosthesis Treatment of Herpes Zoster Neurotrophic Keratopathy

Topic

Clinical Relevance

Methods

Results

Conclusion

Vaccine

Acyclovir for the prevention of recurrent herpes simplex virus eye diseaseHerpetic Eye Disease Study Group

N Engl J Med

A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults

N Engl J Med

Original article
Boston Keratoprosthesis Treatment of Herpes Zoster Neurotrophic Keratopathy