1. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience Jared D. Ament, MD, MPH, Yonas Tilahun, MD, Eiman Mudawi, MD, Roberto Pineda, MD 1 Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA; 2 Menelick II Hospital, Addis Ababa University, Addis Ababa, Ethiopia; 3 Makkah Eye Complex, Makkah Ophthalmic Technical College, Al-Rayad,Khartoum, Sudan FINANCIAL DISCLOSURE: Some of the authors of this poster have received research funding and travel expense reimbursement from Dr. Dohlman’s Keratoprosthesis research fund. Dr. Dohlman nor do any of the authors receive any financial benefit from the sale of the Boston Keratoprosthesis.

2. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience PURPOSE: To report the use of the Boston Keratoprosthesis (KPro) with ipsilateral autologous corneas in 4 eyes of 3 patients in Ethiopia and Sudan.

3. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience INTRODUCTION: Currently, surgery with the KPro is performed using an allograft donor cornea, sandwiched between two polymethlmethacrylate (PMMA) plates during assembly. Autologous corneas have been used with the Cardona “nut and bolt” prosthesis 1, but to our knowledge, no reports on its use with the Boston KPro exist. This approach is especially important in non-industrialized nations, where the availability of corneal allograft tissue, operational costs, and high corneal graft failure rates remain significant challenges. Ipsilateral autologous corneas would make the KPro more accessible in these regions. Even without a formal cost-effective analysis, the savings are markedly apparent.

4. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience METHODS: Specific patient selection criteria in non-industrialized nations are outlined in the International Boston KPro Protocol 2. Additional requirements exist when considering autologous grafts. Patients were not appropriate candidates for anterior lamellar keratoplasty due to severely scarred lids or full-thickness central corneal scars. Inclusion Criteria: -Bilateral blindness per WHO 3 -Clinically normal peripheral endothelium by specular reflection -Limited stromal thinning after trephination (<30%) Exclusion Criteria: -Uncontrolled glaucoma -Extensive anterior synechiae -Evidence of corneal perforation.

5. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience METHODS: All patients received an aphakic KPro with a 16-hole PMMA backplate and titanium- locking ring assembled around a 8.5mm trephinated ipsilateral autologous cornea. An ECCE was performed on all patients through the corneal trephination opening. Five to 20 month postoperative data is reported, including compliance, visual outcomes, complications, and results from quality of life (QOL) surveys. Disabilities in activities of daily living (ADL) were evaluated by interview, using standardized scales. 4 The Human Studies Committee at the Massachusetts Eye and Ear Infirmary granted a waiver of informed consent and HIPPA authorization for medical record review.

6. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience RESULTS: Surgery in three eyes was uneventful. In one eye, intraoperative vitreous loss was effectively managed with Wek-cel vitrectomy. Patient characteristics and follow-up data are presented in table 1. Corneal pathologies included advanced ocular trachoma and previous measles keratitis. Uncorrected visual acuity improved in 100% of the eyes. All patients adhered to the protocol, retained their contact lenses, and successfully administered their medications. Based on a culturally sensitive VF-14 survey 5, patients experienced substantial improvement in ADLs, such as regaining the ability to wash clothes and manage transportation needs.

7. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience DISCUSSION: There has been growing global interest in the use of KPro for the treatment of corneal conditions not effectively treated by penetrating keratoplasty. Despite this, and the overwhelming incidence of blindness due to corneal pathology, the use of KPro in non-industrialized countries remains equivocal and rare. The use of ipsilateral autologous cornea as the skirt in transplantation of the KPro mitigates costs and eliminates corneal allograft storage. This also avoids graft rejection and allocates available donor corneal tissue for suitable keratoplasty patients. Concerns regarding the postoperative management and complications of international KPro surgery include: inadequate follow-up, poor compliance, infection, contact lens loss, retro-prosthetic membrane formation, glaucoma, retinal detachment, and extrusion.

8. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience DISCUSSION: Nevertheless, in our small sample of ipsilateral autologous KPro recipients, retention is 100% without postoperative complications, and vision improved in all patients to ≥ 20/60. There are inherent weaknesses with this report. We discuss a small sample with limited postoperative follow-up. Many common complications, such as glaucoma and endophthalmitis, often manifest later in the postoperative period. Additional follow up will help elucidate the long term success of this procedure. In summary, the use of ipsilateral autologous corneas for assembly of the KPro in certain populations appears feasible and also practical and cost saving as shown in this small group of patients from non-industrialized countries with limited resources.

9. The Role for Ipsilateral Autologous Corneas as a Carrier for the Boston Keratoprosthesis: The Africa Experience REFERENCES: 1) Cardona H. Mushroom transcorneal keratoprosthesis (bolt and nut). Am J Ophthalmol. 1969 Oct;68(4):604-12. 2) Jared D. Ament, Roberto Pineda, Bryan Lawson, Irmgard Behlau, Claes Dohlman. The Boston Keratoprosthesis: International Protocol. Version 2: June 2009. http://www.masseyeandear.org/gedownload!/KPro%20International%20Protocol2.pd f?item_id=5816015&version_id=5816016Blindness. 3) The World Health Organization. Available at: http://www.who.int/topics/blindness/en/. Accessed on June 16, 2009. 4) Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of Illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. JAMA. 1963 Sep 21;185:914-9 5) Boisjoly H, Gresset J, Fontaine N, Charest M, Brunette I, LeFrançois M, Deschênes J, Bazin R, Laughrea PA, Dubé I.Am J Ophthalmol. The VF-14 index of functional visual impairment in candidates for a corneal graft.1999 Jul;128(1):38-44. 6) Aldave AJ, Kamal KM, Vo RC, Yu F.The Boston type I keratoprosthesis: improving outcomes and expanding indications.Ophthalmology. 2009 Apr;116(4):640-51