Osteo-Odonto-Keratoprosthesis (OOKP): A review ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Review Article Osteo-Odonto -Keratoprosthesis (OOKP) for patients with corneal blindness: A review Irfan Ashraf Baba 1, Chitroda Parita K 2, Kothari Shreyans P 3, Singh Ashutosh 4, Aasim Farooq Shah 5* 1Registrar, Dept. of Oral Medicine & Radiology , Govt. Dental College & Hospital, Srinagar , Jammu and Kashmir, India 2Reader, Dept of Oral Medicine & Radiology , Al-Badar Rural Dental College & Hospital , Gulbarga, Karnataka, India 3Assistant Professor, Dept. of Op hthalmology, KBN Medical College & Hospital, Gulbarga , Karnataka, India 4PG Student, Dept. of Oral Medicine & Radiology , Al-Badar Rural Dental College & Hospital , Gulbarga, Karnataka, India 5Department of Public Health Dentistry , Government Dental College and Hospital , Shrein Bagh, Srinagar, Jammu and Kashmir, India *Corresponding author email: [email protected] How to cite this article: Irfan Ashraf Baba, Chitroda Parita K, Kothari Shreyans P, Singh Ashutosh, Aasim Farooq Shah. Osteo-Odonto -Keratoprosthesis (OOKP) for patients with corneal blindness: A review. IAIM, 2015; 2(6): 240-248. Available online at www.iaimjournal.com Received on: 01-06-2015 Accepted on: 06-06-2015 Abstract Anatomically, the cornea is the outermost layer of the eye and is primarily responsible for light refraction which allows for central and peripheral vision. Corneal diseases are among the major causes of global blindness, secondary to cataracts. This paper intends to review Osteo -Odonto Keratoprosthesis (OOKP), which is a two stage procedure whereby dental and buccal tissue is auto - transplanted into eye to serve as a synthetic cornea. Our purpose is to inform readers about the relevant anatomy, two-stage pr ocedure, surgical inter-professionalism, indications, contraindications, complications, long -term functional and anatomical results and patient outcomes of OOKP. The present manuscript wa s constructed by extensive review of literature of various review art icles and case reports and the data was collected from 32 review articles and case reports. Key words Cornea, Auto-Transplant, Osteo -Odonto-Keratoprosthesis (OOKP). International Archives of Integrated Medicine, Vol. 2, Issue 6, June, 2015. Page 240 Copy right © 2015 , IAIM, All Rights Reserved. Osteo-Odonto-Keratoprosthesis (OOKP): A review ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Introduction Since then more attempts were made to The eye is considered as the “Window of our develop different keratoprosthesis and soul”; the cornea is the “Window of the eye”. techniques. Almost all the early implants Like the lens of a camera, the cornea is extruded but the interest in the keratoprosthesis transparent and has a strong focusing power waned the introduction of keratoplasty. Since that focuses light rays on the retina. then many pioneers were involved in devel oping Degeneration, trauma, chemical burn, infection, new keratoprosthesis, but it was Strampelli inflammation and allergy etc. are some of the (1963) who suggested the use of patients own common conditions that can affect the cornea, tooth and bone for replacing acrylic implant in resulting in corneal scarring and opacities which the corneal envelope. The tooth and bone would results in poor vision for the patient. form an autograft picture frame. Initially, the technique did not gain much popularity. It was In some situations, medical treatment is enough only after the refinement work of Dr. Gian Carlo to clear this cloudiness. However, in certain Falcinelli in 1980 the technique has gained fame cases where medical treatment fails, corneal and was named as Rome-Veinna protocol [4-6]. transplantation will be the next step. Yet, in some cases the damage is so severe that corneal Figure - 1: Pre-operative anterior segment transplantation will not work. Common photograph taken from patient with dry eyes examples include severe chemical burn, severe due to pemphigoid and chemical burn. dry eye with corneal opacity, severe drug al lergy (Steven-Johnson Syndrome) and repeated graft rejection, etc. (Figure - 1) To provide the patient with useful vision, not only the conventional corneal graft but a wide variety of materials has been tried earlier as artificial corneal implants includi ng metals, ceramics, glass plastics and biological tissues for anchoring skirts, plates or haptics. For the plastic prosthesis to retain in the eye, tissues from the patient’s own body are used. The tooth is ideal because it has a hard part to which the cy linder can be fixed and also it resides in the mouth where it co -exists with Patient selection criteria soft tissues, as in the eye [1-4]. Patients with bilateral corneal blindness Historical review resulting from severe end stage Stevens- Johnson syndrome, Lyell syndrome, ocular Replacing damaged and opaque cornea with an cicatricial pemphigoid, chemical or thermal artificial implant or keratoprosthesis dates back, burns, end stage trachoma, severe keratitis, dry about more than 200 year s to Pellier de eyes, multiple failed grafts and graft -versus-host Quesgsy, a French opthalmologist who proposed disease and consequences of perforating injuries implanting a glass plate into opaque cornea. may be considered for OOKP surgery. The other Nussbaum placed the first artificial corneal causes of dry eye are ectodermal dysplasia, implant in a human eye, as early as in 1855 [5]. ionizing radiation damage, c icatrizing conjunctivitis from topical medication, International Archives of Integrated Medicine, Vol. 2, Issue 6, June, 2015. Page 241 Copy right © 2015 , IAIM, All Rights Reserved. Osteo-Odonto-Keratoprosthesis (OOKP): A review ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) congenital trigeminal nerve hypoplasia, linear Overall oral hygiene is assessed; donor site IgA disease and nutritional deficiency. Only selected must be absolutely free from any those patients who are aware of their severe diseases. Buccal mucosa is examined thoroughly condition and fully understand the need for to rule out any mucosal lesions like lichen major surgical procedure , the risk of severe planus, oral submucous fibrosis etc. teeth complications and commit to lifelong follow up. selected should be free from any periapical The better eye with poor vision should be disease and must be tested for vitality. The rehabilitated [4, 7-11]. length of the teeth is estimated using panaromic and periapical radiographs. The healthiest and Contraindications best-positioned tooth with best shape, si ze and Patients who are happy and managing with their good covering of alveolar bone is selected . The level of vision, children under the age of 17 most suitable tooth for modified preparation of years, eyes that have no perception of light, the osteodental lamina is the maxillary canine evidence of phthisis, advanced glaucoma or because it has the longest and largest root with irreparable retinal detachment should be the greatest quantity of alveolar bone. excluded [10]. Contraindications for using a particular tooth include non-vitality, previous root canal therapy, Patient assessment and inadequate bone investing the root, peri - radicular pathology and close proximity of Pre-operative assessment adjacent teeth. Other single -rooted teeth can be Multi disciplinary approach is required and used in the absence of a canine. The c hoice of patient has to be scrutinized by the team of upper or lower canine depends on the proximity ophthalmologist, oral surgeons and radiologists of the maxillary sinus and the mental foramen. who form a surgical team. This evaluation In lower canine harvesting, buccal plate is should include the detailed history and etiology occasionally thin and the lingual muco - for loss of vision [4, 10]. periosteum is difficult to preserve. There is a risk of antrum perfora tion in case of upper canine. In Oral assessment the majority of patients, an autologous The oral assessment must take into account osteodental lamina is used. Occasionally when both the buccal mucosal graft donor site and a there is no suitable tooth available or in case of selection of an appropriate toot h to form a edentulous patients an allogaft is considered [4, dentine/bone lamina [8, 10]. 5, 8, 9, 10, 12, 13, 14]. Since a number of patients will need an OOKP Ophthalmic assessment due to muco-cutaneous diseases, the oral Patients are thoroughly assessed for the etiology mucosa may be damaged. The extent of damage of vision loss by in detailed history and has n ever been such to affect the harvesting of a comprehensive ocular examination [4, 10]. graft but this must be borne in mind that severe scarring of the oral mucosa may compromise Psychological a ssessment prior to OOKP the successful harvest. Those who smoke should surgery be advised to stop smoking to improve the Patients have to understand that they may chance of graft revascularizat ion. Betel nut require multiple procedures and that there is a chewing will compromise tissue quality [4, 8]. significant risk of serious complications including loss of the eye. The patient must commit to life - International Archives of Integrated Medicine, Vol. 2, Issue 6, June, 2015. Page 242 Copy right © 2015 , IAIM, All Rights Reserved. Osteo-Odonto-Keratoprosthesis (OOKP): A review ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) long followup, and not have unreasonable Step 1a: The mucous membrane graft harvesting expectations of outcome and cosmesis [10]. is done first. Step 1b: Only a fter the graft is very well Procedure established, OOKP lamina is prepared. Surgical technique Stage - 1: OOKP surgery is usually carried out in Figure - 2b : Covering of harvested wound site. two stages second surgical procedure is carried out at the time ineterval of two to four months of time. During 1 st stage a canine tooth is extracted with the entire root and a portion of the jawbone and wound sit e is covered ( Figure - 2a, 2b ). The coronal half of the tooth is sectioned and the remaining root, along with the bone and tissue are shaped into a cube that is referred to as osteo-odonto alveolar lamina. A hole is prepared in the centre of OOAL to fit a small clear plastic optical cylinder that is sealed with the help of dental cement ( Figure - 3).