0830 - Falcinelli - MIAMI 6th KPro Study Group Meeting may ... · iridodialisis, air into the bulb and patient supine in bed fo some days. The capsular residuals, pushed against the

Bascom Palmer Eye Institute 6th KPRO STUDY GROUP MEETINGSaturday, 6th May 2006

University of Miami - Florida

OSTEO-ODONTOKERATOPROSTHESISFOUNDATIONROME - ITALY

HONORARY PRESIDENT PRESIDENT

Rosario Brancato Luciano Cerulli

SCIENTIFIC DIRECTOR

Giancarlo Falcinelli



MODIFIED OSTEO-ODONTO-KERATOPROSTHESIS

(MOOKP)

OVER 30 YEARS OF EXPERIENCE

FALCINELLI G.C. – COLLIARDO P. – FALCINELLI G. – TALONI M.



FOR PERSONAL FUNDAMENTAL MODIFICATIONS TO THE ORIGINAL STRAMPELLI’S TECHNIQUE, OUR OOKP IS NAMED

FALCINELLI’S MODIFIEDOSTEO-ODONTO-KERATOPROSTHESIS

Surgical technique in two Stages separated by

3 months interval



MODIFIED OOKP: BIOLOGICAL KProsPERFORMED FROM 1973 WITH STRAMPELLI’SOSTEO-ODONTO LAMINA WHICH IS THE FIRST (1964) AND WELL ESTABLISHED BIOLOGICAL HAPTIC FOR KPros MADE OF LIVING HUMAN TISSUE



FIRST STAGE OF MODIFIED OOKPA) PREPARATION ACRYLIC OSTEO-ODONTO LAMINA (OOL)OSTEO-ODONTO ACRYLIC LAMINA IS PREPARED FROM MONO ROOTED TOOTH AND BURIED IN PALPEBRAL –ZYGOMATIC SUBCUTANEOUS POCKET FOR THREE MONTHS



B) PREPARATION OF THE OCULAR SURFACE

AFTER A SUPERFICIAL KERATECTOMY AND CONJUNCTIVA DETACHED OCULR SURFACE IS COVERED WITH BUCCAL CHEEK MUCOSA



2nd STAGE OF MODIFIED OOKP AFTER 3 MONTHS

1) REMOVAL OF BURIED LAMINA 2) DETACHMENT OF BUCCAL MUCOSA3) TREPHINING OF OPAQUE CORNEA AND 3

RADIAL CUTS

4) TOTAL REMOVAL OF THE IRIS

1

2

1

3 4



5) CRYOEXTRACTION OF THE LENS EVEN IF TRANSPARENT

6) ANTERIOR VITRECTOMY ABOUT 1,5 cc

7) IMPLANT OF PROSTHESIS

8) RECOVERING WITH BUCCAL MUCOSA

5

6 7 8



1 2

1) THE EYE AFTER OPERATION

(TEN DAYS)

2) AFTER ONE MONTH

3) WITH COSMETIC SHIELD

1

2 3



FALCINELLI’S INNOVATIONS TO STRAMPELLI’S TECHNIQUE

1) Lamellar keratectomy includingBowman’s membrane

2) Use of thicker cheek mucosa

3) Increase in diameter of opticalcylinder pondered and careful

4) Obligatory total iridoablation

5) Cryoextraction of the lenswhether transparent or not

6) Obligatory anterior vitrectomy

7) Use of biological glue to reattachthe periosteum

8) Biometric assessment ofoptical cylinder power

9) Joining of 2 osteo-odontolaminae

10) Use of impacted teeth11) Use of blood relation’s teeth in

toothless patients12) Use of Eckardt’s prothesis in

retinal detachment

13) Double thread cyclodiastasis with a single sclerotomy

14) Posterior drainage tube inrefractory glaucoma



FURTHER MODIFICATIONS TO

FALCINELLI’S TECHNIQUELamina shorter………New optical design cylinders……….Cyclocryotherapy…….. on allpatients as a preventive forglaucoma.

An. Inst. Barraquer (Barc.) 30-59-63 (2001)



NO SHORTER LAMINA TO AVOID MUCOSA DAMAGE

When the lamina is shortened, even by a few millimeters, the haptic loses a large part of the alveolar bone necessaryfor the survival of the dentine on which the optical cylinderis fixed



NO INCREASED DIAMETER OF OPTICAL CYLINDER TO ENLARGE THE VISUAL FIELD

Our optical cylinder’s diameters have beenincreased much more than Strampelli’s. A further increase requires an excessivetrephining both of the dentine with demageto the lamina and of the cornea with possibleretroprosthetic membrane, vitreous retinalcomplications or expulsion of the prosthesis.

FALCINELLI

STRAMPELLI



No CYCLOTHERAPY PERFORMED AT STAGE 1 EVEN IN NOT GLAUCOMATOUS PATIENTS AS A

PREVENTIVE MEASURE FOR GLAUCOMA :

Every ophthalmologist knows that cyclocriotherapy isnot the ideal treatment for glaucoma. Moreover in patients not suffering from this disease can create some problems to the acqueous veins which maycontribute to the onset of glaucoma.



NO EXTRACAPSULAR EXTRACTION

With the technique performed in England open-skywith posterior capsulectomy, anterior vitrectomy, total iridodialisis, air into the bulb and patient supine in bed

fo some days.The capsular residuals, pushed against the trabeculum, may increase the risk of glaucoma.Moreover possible cortical residuals may cause cyclitic or uveitic inflammations as happened in Strampelli’s original technique.



EXTRACAPSULAR LENSEXTRACTION

Apparently easier and safer, alreadyused in OOKP by Strampelli,Barraquer, Casey, Dal Fiume,Iannetti, Marchi, Tempranogives results not so good as ours



The results of British innovationscompared with those of Falcinelli’s modified OOKP

17,40%45,65%3PL-NPL

NOT IMPROVED OR BLINDNESS

34,78%

17,38%4NOT IMPROVED OR BLINDNESS

5,65%

0,00%0CF-HM

IPOVISION26,10%

26,10%6IPOVISION13,20%

13,20%76/36-6/60-1/60

4,35%13,76%26/18-6/24

30,45%739,62%216/6-6/12 USEFUL

V.A.39,15%

4,35%1USEFUL

V.A.81,12%

37,74%206/5

Cumulative%EyesCumulative%Eyes

LIU’S CONSECUTIVE CASES N° 23 presented at IOSS

INTERNATIONAL MEETING –Grosseto - ITALY 2002Follow-up 4,05 months

(range 0,05 - 5)

FALCINELLI’S CASES N° 56 published by Liu in “Indipendent

Survey of long-term results of Falcinelli’s OOKP”

Follow-up 5,11 years (range 0,2 - 16)

V.A.



MODIFIED OSTEO-ODONTOKERATO PROSTHESIS (MOOKP)

257 OPERATED EYES FROM 1973 TO 2005

FOLLOW-UP: 4 MONTHS < < 31 yrs(10.15 yrs + 6.08 yrs)



257 EYES - 232 CONSECUTIVEPATIENTS DURING 32 YEARS

58 PATIENTS DIED2 IMPLANTED IN BOTH EYES

39 PATIENTS LOST TO FOLLOW - UP1 IMPLANTED IN BOTH EYES

OOKP 1973-2005 257 EYES



OOKP 1973-2005 257 EYES

232 PATIENTS

139 MALES 93 FEMALES

207 MONOCULARS 25 BINOCULARS



OOKP 1973-2005 257 EYES

NUMBER OF YEARS OF BLINDNESSBEFORE IMPLANT

0 yr < < 59 yrs(6.97 yrs + 8.61 yrs)



OOKP 1973-2005 257 EYES

AVERAGE AGE AT TIME OFIMPLANTATION

17 yrs < < 83 yrs(53.23 yrs + 15.87 yrs)



7.0018FAILED KP, PATHOLOGY NOT INCLUDED IN THIS TABLE

7.0018CORNEAL SEQUELAE OF ANTI GLAUCOMA SURGERY

8.1721SEQUELAE OF INFECTIVE KERATITIS

35.8192BURNS (ALCALI, ACIDS, PHYSICAL INJURIES

42.02108DRY EYE SYNDROME (58 pemfigoid, 13 Sjogren, 10 trachoma, 10 Lyell,12 Stevens Johnson, 3 GVH, 2 others)

%N°BASIC PATHOLOGYOOKP 1973-2005 257 EYES



DRY EYE + BURNS

77,83% OF OUR CASES



OOKP 1973-2005 257 EYES

- 83 EYES (32,29%) OF OUR CASESHAVE HAD ONE OR MORE

PENETRATING KERATOPLASTY- 8 EYES (3,11%) WITH EPITHELIAL

STEM CELLS

FAILED BEFORE MOOKP



COMPLICATIONS DURING SURGERY(1st + 2nd stage) 22: ALL CURED

3 oro-nasal fistula3 mandibular fracture7 damaged tooth4 corneal perforation2 haemovitreous2 scleral rupture1 choroidal detachment

OOKP 1973-2005 257 EYES



OOKP 1973-2005 257 EYES

COMPLICATIONS AFTER 1st STAGEBEFORE IMPLANT 16: ALL CURED

001CHOROID DETACHMENT

1

003RETINAL DETACHMENT3

5011TOTAL16 (6.83%)

005MUCOSA ALTERATION5

300LAMINA REABSORPTION

3

202LAMINA INFECTION4

NEW LAMINANOT CUREDCURED



COMPLICATIONS AFTER IMPLANT FOR THE PROSTHESIS: 28 CURED: 26

226TOTAL28 (10.89%)

01RETROPROSTHETIC FISTULA1

11PROSTHESIS EXPULSION2

12OPTIC CYLINDER EXPULSION3

02OPTIC CYLINDER INSTABILITY2

020BUCCAL MUCOSA ALTERATION

20

NOT CUREDCURED

OOKP 1973-2005 257 EYES



COMPLICATIONS AFTER IMPLANT FOR THE EYE: 40CURED: 24

1624TOTAL40 (15.56%)

02CHOROIDAL DETACHMENT2

14UVEITIS, RETROPROSTHETIC MEMBRANE

5

111HAEMOVITREOUS12

92ENDOPHTHALMITIS11

55RETINAL DETACHMENT10

NOT CUREDCURED

OOKP 1973-2005 257 EYES



OOKP 1973-2005 257 EYES

GLAUCOMAIS THE MOST FREQUENT COMPLICATION

OF OOKP BUTWE ARE NOT SURE IF MODIFIED OOKP

MUST BE CONSIDERED THE DIRECT CAUSE OF GLAUCOMA

CERTAINLY AN INACCURATE SURGICAL PROCEDURE CAN FACILITATE THE

ONSET OF GLAUCOMA AFTER OOKP



GLAUCOMA

BEFORE OOKP 97 (37.74 %)

RE-APPEARANCE OF GLAUCOMA 53 (54.64 % of 97 eyes) EX NOVO GLAUCOMA 16

TOTAL GLAUCOMA AFTER IMPLANT 69 (26,85%)

OOKP 1973-2005 257 EYES



OOKP 1973-2005 257 EYES

SURGICAL TREATMENT OF GLAUCOMAAFTER OOKP

25 CASES, 28 OPERATIONS(3 eyes operated twice)

12 retroequatorial drainage (1 double int.) 8 STAB. - 2 Sl.W.12 double thread cyclodiastasis (2 double int.) 7 STAB. - 3 Sl.W.3 transcleral cyclophotocoagulation 1 STAB.-1 W.-1 AG1 diathermy of long ciliaries a. 1 W. 3 endo ciclo photocoagulation 1 STAB. - 1 W.



OOKP 1973-2005 257 EYES

RESULTS OF MEDICAL, SURGICAL andLASER TREATMENTS OF GLAUCOMA

69 CASES POST-IMPLANT GLAUCOMA(53 RELAPSED + 16 EX NOVO)

27 (39.12 %) STABILIZED - (Stab.)16 (23.18 %) SLIGHTLY WORSE - (Sl. W.) 23 (33.33 %) WORSENED - (W.)3 ( 4.37 %) ABSOLUTE GLAUCOMA - (A.G.)



PERCENTAGE %N. EYEVISUAL ACUITY

0.00 %0no L. P.

0.39 %1L. P.

3.50 %9H. M.

2.33 %62/50 - 1/50

4.67 %121/10 - 3/50

11.67 %304/10 - 2/10

10.51 %277/10 - 5/10

66.93 %17210/10-8/10

3.89 %3.89 %3.50 %

7.00 %

4.67 %

89.11 %

77.44 %

66.93 %

CUMULATIVE %

NOT IMPROVEDOR BLINDNESS

3.89 %

IPOVISION

7.00 %

USEFUL V.A.

89.11 %

OOKP 1973-2005 257 EYES

BEST VISUAL ACUITY



PERCENTAGE %N. EYEVISUAL ACUITY

2.72 %7no L. P.7.78 %20L. P.4.28 %11H. M.

3.50 %92/50 - 1/50

5.45 %141/10 - 3/50

10.51 %274/10 - 2/10

9.34 %247/10 - 5/10

56.42 %14510/10-8/10

14.78 %12.06 %4.28 %

8.95 %

5.45 %

76.27 %

65.76 %

56.42%

CUMULATIVE %

NOT IMPROVEDOR BLINDNESS

14.78%

IPOVISION

8.95%

USEFUL V.A.

76.27%

OOKP 1973-2005 257 EYES

FINAL VISUAL ACUITY



ANATOMICAL FAILURE11 (4.7%)

LAMINA REMOVED 10ENUCLEATED EYE 1

OOKP 1973-2005 257 EYES

ANATOMICAL SUCCESS

223 (95.3%)



F.M.: AGE 80 - 41 YEARS GOOD V.A. THANKS TO OOKP 1966 STRAMPELLI OPERATED BOTH EYES: 20/20LEFT EYE RE-OPERATED BY US IN 1993 FOR INSTABILITY OF OPTIC CYLINDER: V.A. 20/20 AT PRESENTRIGHT EYE: BLIND FOR ABSOLUTE GLAUCOMA BUT STILL AFTER 36

YEARS HAS AN ANATOMICALLY PERFECT PROSTHESIS,STUDIED BY SPIRAL VOLUMETRIC TAC (GRABNER’STECHNIQUE)



I conclude that the biological properties of Strampelli’s OOKP with the surgical innovations

introduced by us make MOOKP, if correctly performed, a surgical approach less prone to

complications and with a very good functional outcome, compared to the original OOKP technique or to the other keratoprostheses.



Thank-you for honouringwith your qualifiedattendance my great teacher, Porf. Benedetto Strampelli

Documents

0830 - Falcinelli - MIAMI 6th KPro Study Group Meeting may ... · iridodialisis, air into the bulb and patient supine in bed fo some days. The capsular residuals, pushed against the