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Osteo-Odonto-Keratoprosthesis


Key Concepts

  • The osteo-odonto-keratoprosthesis (OOKP) is a form of keratoprosthesis that is indicated in cases of severe, end-stage ocular surface and corneal disease, such as Stevens-Johnson syndrome or chemical injury, where the severely compromised or dry ocular surface environment precludes long-term success in corneal or ocular surface transplantation.

  • OOKP surgery involves implantation of a polymethyl methacrylate optical cylinder cemented into an autologous tooth, coupled with replacement of the ocular surface with a full-thickness buccal mucosa graft.

  • Stage 1 involves extraction of an autologous monoradicular tooth and drilling it centrally for the placement of a cylindrical optic. The tooth–optic complex is buried in a suborbicularis pouch in the orbitozygomatic area, and a buccal mucosa graft is placed over the deepithelialized ocular surface.

  • In Stage 2, the tooth–optic complex is harvested and sutured to the cornea under the reflected buccal mucosa, with subsequent trephination of the mucosa for optic exposure.

  • Glaucoma is the most common sight-threatening complication and may be preexisting due to the underlying condition, or may develop de novo following OOKP.

  • The OOKP has excellent long-term anatomic survival rates, with reported rates of 81% at 20 years.

  • OOKP is technically challenging and requires subspecialty expertise and a multidisciplinary approach for success; however, it remains a viable long-term option for visual rehabilitation in patients with severe, end-stage ocular surface diseases.

Introduction

Surgical management of end-stage ocular surface disease remains challenging. Even with significant advances in ocular surface reconstruction and limbal stem cell transplantation, results and long-term survival remain poor for the majority of cases, especially in severe dry eye states. The main limitation of other synthetic keratoprostheses (Boston, Alphacor) lies in poor long-term survival and associated visually devastating complications, such as prosthesis extrusion and endophthalmitis for severe dry eyes. , To date, osteo-odonto-keratoprosthesis (OOKP) is the only modality that has demonstrated good long-term survival and retention rates for patients with severe, end-stage ocular surface disease.

Originally conceptualized and developed by Strampelli in the 1960s, the OOKP is an artificial cornea procedure that involves replacement of the ocular surface with a full-thickness buccal mucosa graft and implanting a polymethyl methacrylate (PMMA) optical cylinder into an autologous canine tooth that is inserted into the cornea ( Fig. 161.1 ). Key modifications to the original technique were introduced and refined by Falcinelli, Liu, and others, leading to the formation of the Modified OOKP teaching group (Falcinelli, Rome, Italy; Liu, Brighton, UK; Grabner, Salzburg, Austria; Hille, Holmberg, Germany; and others). , In 2001–2002, this group met at a consensus meeting to establish the Rome-Vienna protocol and standardize the surgical technique for modified OOKP surgery.

Fig. 161.1, Schematic representation of osteo-odonto-keratoprosthesis (OOKP) demonstrating the relationship of the buccal mucosa, OOKP lamina, and cornea.

Initiation of an OOKP surgical program requires considerable institutional commitment and resources within a tertiary ophthalmic center with subspecialty expertise and necessitates adequate training in appropriate patient selection, surgical training, and guidance in postoperative care. Today, just a few tertiary centers that offer this multidisciplinary procedure exist globally, mainly in Europe and Asia.

Preoperative Assessment

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