1. Experience With Microbial Keratitis After Boston Type I Keratoprosthesis Implantation Cornea & Anterior Segment Services, L V Prasad Eye Institute, Hyderabad, India. Shraddha Sureka Sayan Basu Virender Sangwan

2. None of the authors have financial interests or relationships to disclose

3. Introduction Microbial keratitis after Boston type 1 keratoprosthesis (Kpro) implantation has been described in literature Indications of Kpro vary Demographic & geographic variables also influence the incidence, characteristics & outcomes of Kpro Purpose of this study: Describe incidence, characteristics, management and outcomes of Kpro in our setting Ref: 1. Kim MJ, Yu F, Aldave AJ. Microbial keratitis after Boston type I keratoprosthesis implantation: incidence, organisms, risk factors, and outcomes. Ophthalmology 2013;120:2209–16. 2. Chan CC, Holland EJ. Infectious keratitis after Boston type 1 keratoprosthesis implantation. Cornea 2012;31:1128–34.

4. Methods – Study design Retrospective, interventional case series July, 2009 to May, 2013 L V Prasad Eye Institute, Hyderabad, India Patients excluded – If patient did not have at least one follow up visit after the episode of microbial keratitis 81 Kpro - implanted in the study period Data collected: Etiological agent, predisposing factors, management strategies (medical and surgical management), anatomical retention & visual outcomes

5. Methods Standard Kpro implantation procedure was used 16-mm diameter Kontour plano CL - Changed every 3 months Tarsorrhaphy – if needed Standard post operative regimen: Prednisolone acetate 1% eye drops Moxifloxacin 0.5% eye drops Fortified vancomycin 0.5% eye drops OR Chloramphenicol 0.5% eye drops Ref: Basu S, Taneja M, Narayanan R, et al. Short-term outcome of Boston Type 1 keratoprosthesis for bilateral limbal stem cell deficiency. Indian J Ophthalmol 2012;60:151–3.

6. Methods – Microbial keratitis Corneal scraping & smear reporting Primary smear: Bacteria or no organisms – Fortified cefazolin 5% and ciprfloxacin 0.3% eye drops Fungus - 5% natamycin suspension was used every hour and ketoconazole tablet (200 mg) twice per day Treatment modified as per clinical response and culture report Non-responsive – Kpro explantation & therapeutic penetrating keratoplasty Ref: Kunimoto DY et al. Corneal ulceration in the elderly in Hyderabad, south India. Br J Ophthalmol 2000;84:54–9.

7. Results Baseline data Mean follow-up of all Kpro17.6 ± 14.3 months (Median, 13.6 months) Incidence of microbial keratitis11/81 procedures (13.5% incidence) Time from implantation to occurrence of microbial keratitis Mean time: 7.5 ± 9.6 months Median time: 4.6 months Range: 0.1-35.5 months Most common predisposing factorCicatrizing conjunctivits (6/11) Management options before therapeutic penetrating keratoplasty Tissue adhesive, amniotic membrane graft & tarsorrhaphy

8. Results: Microbial keratitis No.OrganismExtrusion/ Explantation Outcome 1 Strep Pneumoniae Explantation Failed graft 2 Staphylococcus aureus Explantation Prephthisical eye 3 Aspergillus flavus Explantation Repeat Boston Kpro 4 Fungus (Unidentified) Explantation Failed graft 5 Hemophilus influenza Explantation Failed graft 6 Streptococcus pyogens Explantation Clear graft No.OrganismExtrusion/ Explantation Outcome 7 (1) Alpha haemolytic streptococci Retained Resolved 7 (11) Streptococcus pneumoniae Retained Resolved 8 Aspergillus tereus Explantation Phthisis 9 Candida albicans Explantation Failed graft 10 Escherichia coli Explantation Failed graft 11 Hemophilus influenzae Explantation Failed graft

9. Results: Microbial keratitis No.Pre operative visual acuity Final visual acuity 1 PL, PR accCF 1.5 m 2 CF PL, PR 3 CF 0.5m20/40 4 CF HM 5 CF 20/200 6 PL, PR accHM No.Pre operative visual acuity Final visual acuity 7 (1) CF 20/100 7 (11) CF 20/100 8 HM, PR accPL 9 CF PL, PR acc 10 PL, PR accPL 11 PLHM

10. Discussion Microbial keratitis Reported rates 3.2-16.7% - Similar to our study Our indications include more cases of cicatrizing conjunctivitis due to ocular surface burns Over time the rate of microbial keratitis has reduced – Better quality of devices & post-operative regimen Favourable anatomical outcomes in end-stage corneal disease if managed efficiently Ref: 1. Kim MJ, Yu F, Aldave AJ. Microbial keratitis after Boston type I keratoprosthesis implantation: incidence, organisms, risk factors, and outcomes. Ophthalmology 2013;120:2209–16. 2. Chan CC, Holland EJ. Infectious keratitis after Boston type 1 keratoprosthesis implantation. Cornea 2012;31:1128–34.

11. Discussion Fungal keratitis 4/12 microbial keratitis 3 patients each – topical vancomycin, topical steroids & retroprosthetic membrane All 4 patients – Kpro explantation Amphotericin-B eye drops have been recommended in high-risk cases in literature: History of fungal keratitis, persistent epithelial defects in areas prone for fungal keratitis – Needs further investigation Ref: Chan CC, et al. Infectious keratitis after Boston type 1 keratoprosthesis implantation. Crnea 2012;31:1128-1134.

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