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60 EW MEETING REPORTER January 2011 continued from page 59 volved. Corneal blindness is signifi- cant enough to be a public health issue, but is not a primary healthcare concern; unfortunately, many gov- ernments in Asia, said Ma. Dominga Padilla, M.D., Philip- pines, are hard put just to address primary care problems. Eye banks thus need to actively seek government involvement. The development of the tentatively named National Eye Bank of Sri Lanka (NEBSL)—a candidate with the potential for becoming the first category 6 eye bank, said Dr. Tan—is unfortunately something of an ex- ception, being backed from the get go by Sri Lankan president Mahinda Rajapakse. In the Philippines, Dr. Padilla and her colleagues have only re- cently gained the support of the government, and they worked hard to get it. Their strategy involved ap- proaching various sectors, not just the government per se: by gaining the support and cooperation of the medical community, the media, and the community at large, they made supporting the Eye Bank Foundation of the Philippines a win-win propo- sition for the government. Prof. Shinozaki emphasized the importance of vigilance, surveil- lance, and transparency in ensuring that the system works while avoid- ing future abuse. While a set of uni- versal standards for eye banking may eventually prove to be a utopian dream—each country having its own unique set of social, economic, and cultural challenges—a set of universal practice guidelines for quality assurance may not be too far along. As exemplified by this ACS meeting's Eye Banking Symposium, experts from eye banks around the world are actively engaged in dia- logue, exchanging information, sharing experiences, learning from each other, and basically just trying to figure out how it could all might work on a global level. Transplant or implant? Advanced keratoprosthis Many of the advances currently tak- ing place in the field of cornea sur- gery, particularly noteworthy in the Asia-Pacific region, have to do with ocular surface reconstruction. Sur- geons today now have the option of performing ocular surface transplan- tation or using keratoprosthetic de- vices such as the Boston KPro (developed at the Massachusetts Eye and Ear Infirmary, manufactured in Woburn, Mass.) and the AlphaCor (marketed in the U.S. by Addition Technology, Inc., Des Plaines, Ill.). The latter, said Michael Belin, M.D., U.S., were previously consid- ered a last resort, but have recently gained greater acceptance among both surgeons and patients. Today's keratoprostheses, he said, now offer patients who've experienced multi- ple graft failures in the past another chance at regaining vision. For ker- atoprosthetics to work, he said, pa- tients should have "wettable" corneas—i.e., intact tearing systems; lid abnormalities need to be fixed before proceeding with implanta- tion; glaucoma, if present, should be controlled. Some long-term con- cerns do remain, including the fear of excessive inflammation, the de- velopment of retroprosthetic mem- branes that require YAG membranotomy, and pressure-in- duced nerve damage. The latter is particularly worrisome, since kerato- prostheses prevent measurement of intraocular pressure. But do these concerns make oc- ular surface transplantation a better option? Not necessarily, said Ed- ward J. Holland, M.D. Each option has its own set of pros and cons. Oc- ular surface transplantation is useful even in severe disease; IOP can easily be measured after the procedure; the procedure stabilizes the surface for keratoplasty; any complications that occur will likely damage the surface without losing the eye; close follow up isn't necessary once the surface has stabilized. However, ocular sur- face transplantation is a staged pro- cedure; subsequent keratoplasty may fail; good visual acuity can only be achieved with a near-perfect surface; and immunosuppression is required. Meanwhile, keratoprostheses are im- planted in a one-stage procedure; the technique is relatively easy, and easy to learn, very much similar to regular transplantation; there is no need for immunosuppression, no risk of rejection; good visual acuity is guaranteed barring the presence of co-morbidities like glaucoma. Unfor- tunately, keratoprostheses don't allow measurement of IOP; they re- quire lifelong follow up, with life- long administration of topical antibiotics; complications—which include the potential for keratitis and endophthalmitis—can lead to loss of the eye; caution needs to be exercised in severe disease, as corneal melt is still a possibility. The question, said Dr. Holland, isn't which is better; rather, it's what is best indicated for a particular pa- tient. Over the last few years, a third alternative has caught the attention of surgeons, particularly in Asia, where severe disease is often difficult to address by conventional means. Donald Tan, M.D., has had six years experience with the rather grueling osteo-odonto-keratoprosthesis (OOKP) procedure. The procedure, he said, has been used successfully to treat patients with severe thermal or chemical burns, and is an option for patients with severe, end-stage disease "when all else has failed." Masahido Fukuda, M.D., has also had experience with OOKP, hav- ing first performed the procedure under the guidance of Giancarlo Fal- cinelli, M.D., whose modification of the procedure pioneered by Stram- pelli is now considered the gold standard. Dr. Fukuda has performed the procedure in patients with Stevens–Johnson Syndrome, ocular cicatricial pemphigoid, and chemi- cal burns. EW Editors' note: None of the doctors men- tioned declared any financial interests related to the content of their lectures. Reporting live from the 2010 Asia Cornea Society meeting, Kyoto, Japan Editors' note: This Meeting Reporter contains original reporting by the EyeWorld News Team from the 2010 ACS Meeting, Kyoto.

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