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New methods for retinal examination in eyes with a Boston keratoprosthesis.

New Methods for Retinal Examination in Eyes with a Boston Keratoprosthesis Corneal replacement with the Boston keratoprosthesis (KPro) is enjoying steadily increasing surgical success and ever more frequent use by corneal surgeons. Although these patients and their management are quite involved or even complex, the typical situation is quite positive and a far cry from the dismal results of earlier decades. A recent single surgeon comprehensive study (which included even the most severe categories of patients) has documented that 90% of implanted KPros are retained and that 75% of eyes achieve 20/100 or better visual acuity at 1 year, with 43% having 20/50 or better visual acuity. A slightly earlier multicenter study documented a visual acuity of 20/200 or better in 56% of patients at 1 year, with 23% achieving 20/40 or better visual acuity and a 95% retention rate. These impressive outcomes have resulted in the dissemination of KPro surgery into the hands of many more corneal surgeons, with a corresponding growth of patients presenting to the offices of all ophthalmologists for follow-up care or the management of postoperative complications. Indeed, in the typical experience of today, if a KProimplanted eye is visually limited, the visual limitation is often attributable to other aspects of the ocular complexity (e.g., advanced glaucoma, macular damage, or retinal scarring/detachment) common in eyes damaged enough to require a KPro. Preexisting optic nerve damage as a result of advanced glaucoma remains a vexing problem and argues for more careful preoperative screening. Retinal detachment is particularly troubling, as a series have shown that approximately one half to two thirds of detachments can be anatomically repaired, but visual success after late-stage detachment remains limited. The article by Sayegh and Dohlman in this issue of the journal examines an increasingly important theme, namely, the examination of the retinal periphery in patients with a Boston KPro. Fundus examination by noncontact biomicroscopy or indirect ophthalmoscopy (particularly using the small pupil feature of many ophthalmoscopes) provides an adequate view to an experienced examiner in many KPro eyes. This examination is frequently supplemented by ultrasound, which is quite helpful but fails at times to provide critical information, such as retinal vascular detail or the identification of epiretinal membranes, retinal hemorrhages, or flat retinal breaks. These authors of the current study have documented the successful examination of the retina by the use of three wide-field camera systems— Optos, RetCam, and Panoret. In their hands, useful fundus information was routinely obtained, with a modest advantage given to the Optos system. The ability to image the retina with these new camera systems does not eliminate the need for ultrasound, and it should instead be viewed as a complementary modality —with one exception which the authors identified (i.e., wide-field camera evaluation is clearly superior to the limited information obtained by ultrasound in an eye filled with silicone oil). These cameras have also been shown to improve the detection of retinal disease in eyes with normal media, and they should be hailed as a major diagnostic advance. Two other methods of retinal examination should be mentioned because they are readily available but unfortunately not routinely used. The first is simply to examine the retina during the KPro implantation surgery, while the eye is “open sky.” This can easily be done with the indirect ophthalmoscope in the conventional manner, or for those more comfortable with the microscope, by simply directing the standard vitrectomy endoilluminator toward the posterior aspect of the open globe, hovering above the vitreous body or intraocular lens, a surprisingly informative view of the retina can be obtained, and the findings will prove invaluable to the patient’s subsequent management and prognosis. Failing this intraoperative examination, all too commonly the corneal surgeon or retina consultant may ironically struggle with a limited postoperative retinal view after KPro implantation when a magnificent view was available at the time of surgery. Intraoperative viewing allows the surgeon to note the health of the optic nerve, the status of the macula, the integrity of retinal vascular perfusion, the state of retinal scarring or detachment, and many other factors that may be difficult or impossible to determine with a limited postoperative view. The author declares no conflict of interest.