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• W4364367828 abstract "Posterior segment complications after Boston keratoprosthesis type 1 (Boston KPro, Massachusetts Eye & Ear Infirmary, Boston, Mass.) implantation alter the postoperative course and lead to severe visual loss. In patients with opaque-diseased cornea, pars plana vitrectomy (PPV) is the treatment of choice for concurrent vitreoretinal diseases. Experts have suggested that PPV should be performed at the time of Boston KPro surgery in instances of prior retinal detachment, vitreitis, macular edema, intraocular lens instability, and glaucoma valve implantation. Compared to when performed sequentially, PPV performed at the time of Boston KPro implantation can decrease rates of future glaucoma valve blockage, retinal detachment requiring repair, and other complications.1Kiang L Sippel KC Starr CE et al.Vitreoretinal surgery in the setting of permanent keratoprosthesis.Arch Ophthalmol. 2012; 130: 487-492Crossref PubMed Scopus (26) Google Scholar Perez et al.2Perez VL Leung EH Berrocal AM et al.Impact of total pars plana vitrectomy on postoperative complications in aphakic, snap-on, Type 1 Boston keratoprosthesis.Ophthalmology. 2017; 124: 1504-1509Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar report that PPV with thorough removal of the anterior hyaloid, compared with partial PPV or anterior vitrectomy, is associated with less retroprosthetic membrane (RPM) formation requiring intervention and less vision loss from glaucoma progression. Combined Boston KPro and PPV surgery also offers information about the state of the optic nerve and retina.1Kiang L Sippel KC Starr CE et al.Vitreoretinal surgery in the setting of permanent keratoprosthesis.Arch Ophthalmol. 2012; 130: 487-492Crossref PubMed Scopus (26) Google Scholar The procedure can remove potential scaffolds for inflammation such as hyaloid membranes and vitreous humor, hence limiting RPM formation.3Modjtahedi BS Eliott D. Vitreoretinal complications of the Boston keratoprosthesis.Semin Ophthalmol. 2014; 29: 338-348Crossref PubMed Scopus (18) Google Scholar Because it is associated with corneal melt in Boston KPro eyes, RPM formation and corneal melt may be decreased with combined surgery.3Modjtahedi BS Eliott D. Vitreoretinal complications of the Boston keratoprosthesis.Semin Ophthalmol. 2014; 29: 338-348Crossref PubMed Scopus (18) Google Scholar Anterior hyaloid peeling is challenging to perform surgically. Given the shortened anterior segment of Boston KPro eyes, modifications to standard PPV techniques are required to improve outcomes. Endoscopy-assisted PPV allows visualization of the vitreous base and facilitates removal of the anterior hyaloid.4Yu YZ Zou YP Zou XL. Endoscopy-assisted vitrectomy in the anterior vitreous.Int J Ophthalmol. 2018; 11: 506-511PubMed Google Scholar Nonetheless, complete PPV with anterior hyaloid peeling, assisted by endoscopy, has never been reported at the same time as Boston KPro surgery despite the potential to lower sight-threatening complication rates. In Supplementary Video 1 (available online), we present a novel technique in which Boston KPro implantation was performed together with endoscopy-assisted anterior hyaloid peeling during small-gauge PPV. To the best of our knowledge, this is the first time that endoscopy is reported with such a combined surgery in the literature. This surgical technique was approved by the Institutional Review Board of the Centre hospitalier de l'Université de Montréal (CE19.382) and adhered to the tenets of the Declaration of Helsinki. The study was registered at www.ClinicalTrials.gov (NCT04337944). Written informed consent was obtained from participants eligible for Boston KPro implantation and complete PPV. Patients with prior Boston KPro or PPV procedures were excluded. A single experienced surgeon (M.H.D.) implanted the snap-on, Boston KPro Type 1 device with a 16-hole titanium backplate (8.5 mm) and locking ring (see Supplementary Video 1, available online). Local retrobulbar anaesthesia was administered, and a Honan balloon was placed for 10 minutes on the eye. Subtenon anaesthesia with lidocaine 2% was supplemented whenever the patient experienced discomfort throughout the combined procedure. The donor cornea was trephined at 8.5 mm of diameter and its centre with a 3 mm punch. The Boston KPro was assembled with the corneal graft. The patient's opaque cornea was marked and trephined at a diameter of 8 mm. The Boston KPro–graft complex was sutured into the corneal bed with sixteen 10-0 nylon sutures (knots buried). In the same operating room, immediately after Boston KPro implantation, an experienced retina specialist (M.A.R.) performed a 3-port, 23-gauge PPV (see Supplementary Video 1, available online). Three transconjunctival oblique tunnel-like 23-gauge sclerotomies were performed 3.5 mm posterior to the limbus. The infusion cannula was inserted inferotemporally at the 5 o'clock position at the pars plana. The 2 other ports were positioned superonasally at 10 o'clock and superotemporally at 2 o'clock. Vitrectomy was performed centrally with visualization through the optical cylinder of the Boston KPro front plate. The binocular indirect ophthalmomicroscope provided an anatomic field of view beyond the equator. No Eckardt-type temporary keratoprosthesis was used. The posterior hyaloid was dissected over 360 degrees with the vitrector. Scleral depression improved visualization during the vitreous base shaving. Endoscopy was added to the PPV procedure and allowed to remove the anterior hyaloid membrane (see Supplementary Video 1, available online). Instruments were removed from the ocular cavity. The 3 cannulas were removed from the sclerotomies, sutured with 7-0 Vicryl sutures. Wounds were confirmed to be watertight and the intraocular pressure to be within normal limits. Cefazolin and dexamethasone were injected subconjunctivally. A soft contact lens was added for comfort. The patient was prescribed topical prednisolone acetate 1% and topical moxifloxacin 0.5% ophthalmic drops 4 times daily. Literature on the feasibility of PPV through an implanted Boston KPro is scarce. It is possible for patients to undergo thorough PPV, with vitreous base shaving, at the time of Boston KPro implantation to decrease potential posterior-segment complications, to accommodate pars plana glaucoma drainage implants, to remove potential scaffolds for RPMs, or to reduce possible proinflammatory material.1Kiang L Sippel KC Starr CE et al.Vitreoretinal surgery in the setting of permanent keratoprosthesis.Arch Ophthalmol. 2012; 130: 487-492Crossref PubMed Scopus (26) Google Scholar,3Modjtahedi BS Eliott D. Vitreoretinal complications of the Boston keratoprosthesis.Semin Ophthalmol. 2014; 29: 338-348Crossref PubMed Scopus (18) Google Scholar The anterior hyaloid becomes particularly relevant in glaucoma surgery, where residual anterior vitreous may block a glaucoma tube implant placed at the pars plana. Among Boston KPro patients with preexisting glaucoma, 46% will need primary or repeat glaucoma surgery.5Geoffrion D Hassanaly SI Marchand M Daoud R Agoumi Y Harissi-Dagher M. Assessment of the role and timing of glaucoma surgery in Boston Keratoprosthesis Type 1 patients.Am J Ophthalmol. 2022; 235: 249-257Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Boston KPro patients may also experience postoperative retinal detachment in up to 27.6% of cases, often necessitating surgical repair with vitrectomy and silicone oil tamponade despite difficult visualization.3Modjtahedi BS Eliott D. Vitreoretinal complications of the Boston keratoprosthesis.Semin Ophthalmol. 2014; 29: 338-348Crossref PubMed Scopus (18) Google Scholar Published reports have shown that anterior hyaloid peeling and endoscopy may both provide their own benefits in reducing sight-threatening complications. Endoscopy can rule out threats to good visual outcomes during surgery. In small-gauge vitrectomy, endoscopy allows access to poorly visualized anterior structures and repositioning between trocars to address pathologies at different locations. Furthermore, complete removal of the anterior hyaloid during PPV has shown a significant decrease in sight-threatening complications such as RPM and vision loss due to glaucoma progression and corneal melts.2Perez VL Leung EH Berrocal AM et al.Impact of total pars plana vitrectomy on postoperative complications in aphakic, snap-on, Type 1 Boston keratoprosthesis.Ophthalmology. 2017; 124: 1504-1509Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar To the best of our knowledge, the literature has not reported any case of endoscopy use during thorough PPV with anterior hyaloid peeling performed at the same time as Boston KPro implantation. We found that this novel, combined procedure is feasible in Boston KPro candidates with vitreoretinal diseases. The advantages of combining these three procedures are significant. Endoscopy offers a rare intraoperative view of intraocular structures that informs visual prognosis without being technically cumbersome intraoperatively. Anterior hyaloid peeling, usually technically challenging to perform during standard PPV, can be accomplished efficiently at the periphery with endoscopy. This has been documented to have the potential to decrease intraocular inflammation and optimize visual outcomes long term.3Modjtahedi BS Eliott D. Vitreoretinal complications of the Boston keratoprosthesis.Semin Ophthalmol. 2014; 29: 338-348Crossref PubMed Scopus (18) Google Scholar Limitations remain regarding the lack of comparison through randomized, controlled trials and formal cost analyses. Yet, we suggest that these combined procedures may prove beneficial for patients. With a single operative visit and postoperative drop regimen, Boston KPro implantation combined with PPV and added intraoperative endoscopy can be performed, hence limiting the total amount of time patients spend in the hospital. While it may be administratively challenging to recruit both cornea and retina specialists for such combined cases, as well as to use endoscopy in addition to Boston KPro and PPV, in our opinion, the cost benefits may outweigh the disadvantages. In conclusion, this combined technique, reported herein for the first time, is feasible in eligible patients and may allow total operative time to be shortened compared with the additive surgical time for each of the procedures when done sequentially. The incidence of glaucoma progression and retinal detachment may be decreased postoperatively in Boston KPro patients with earlier removal of such proinflammatory membranes.3Modjtahedi BS Eliott D. Vitreoretinal complications of the Boston keratoprosthesis.Semin Ophthalmol. 2014; 29: 338-348Crossref PubMed Scopus (18) Google Scholar Intraoperative visualization of the posterior segment characteristics may be included in the prognosis evaluation for Boston KPro candidates. The authors have no proprietary or commercial interest in any materials discussed in this correspondence. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzYTk5OWNmYWI1MDQyN2YzNzExNTc4N2YzMjExODIwZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg2MTIzMTc2fQ.VyXVVbglfvLgCKJqD4m5Llt__RpQWnntX9lGiMmCpJkkkh5fAINtrrVhaydIWHKZG4iyF14qnVmsJ4-bWkK9SCwDoyp-UoFnjG8rCn_jnu4TP9p2X72i6VJQgZN73RDN_7UcVJSw8wE9SHKYUKOLo71zVvDgnUtlJHa2y7fsjABgWQCuhWfVMvxsezb-iYERI_1SnagorPTwWe0n2IU4VlpzD2jH2gPBvWBP0TX8hqikKyWda3RxpcElDDFGrtTdKXpivTjXzpyTZL_dMnIx8UAc9BblPrTupxI6Bq08-vsh6k6EVkiXf8ApMjHsMH8VheTOffieGBPzUFRAvYJ_gw Download .mp4 (31.92 MB) Help with .mp4 files" @default.
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• W4364367828 date "2023-10-01" @default.
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• W4364367828 title "Endoscopy-assisted total pars plana vitrectomy during Boston keratoprosthesis type 1 implantation" @default.
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