REVIEW

CURRENT
OPINION The osteo-odonto-keratoprosthesis
Mehran Zarei-Ghanavati a,b,, Venkata Avadhanam a,,
Alfonso Vasquez Perez a, and Christopher Liu a,c,d

Purpose of review
To describe the practice of and recent developments in the osteo-odonto-keratoprosthesis.
Recent findings
Formal psychological assessment and support have been described. A sub-aqua system for fashioning the
osteo-odonto-keratoprosthesis lamina; adoption of thicker laminae; use of bisphosphonate drugs; advances
in laminar imaging; and use of bone augmentation and bone morphogenetic protein have been described
for prevention, detection, and management of laminar resorption. Two systems of optical cylinders
available commercially. A stepladder approach to buccal mucous membrane overgrowth onto the optical
cylinder has been described, including use of mitomycin-C. Orbital decompression has been used for
cosmetic improvement. Detection of glaucoma may be aided by an intraocular pressure sensor, whereas
surgical treatment is mainly by way of glaucoma drainage devices, as endolaser ciliary ablation and recti
muscle disinsertion and reinsertion not having prolonged and significant long-term beneficial effect.
Sublingual timolol has been described. The use of endoscopy has been proposed for preoperative
evaluation of the posterior segment, ciliary ablation and for vitreoretinal surgery although wide-angle
viewing systems remains standard practice.
Summary
The osteo-odonto-keratoprosthesis is the procedure of choice for rehabilitation of corneal blindness for end-
stage ocular surface disease, serving a completely different patient group to the Boston Type 1 KPro.
Keywords
glaucoma, keratoprosthesis, KPro, laminar resorption, MOOKP, OOKP

INTRODUCTION PATIENT ASSESSMENT

The osteo-odonto-keratoprosthesis (OOKP) is
the most enduring device among all keratoprosthe-
ses to date. Its success is attributed to the biological
constitution of its components [1]. Strampelli
first described the technique of using tooth as a
keratoprosthesis (KPro) skirt and oral mucous
membrane as a cover to protect the device [2].
Faclinelli made several improvements to the
technique, which is now known as modified or
MOOKP [3].
The OOKP device is made of an alveo-dental
lamina made from a single rooted tooth usually a
canine of the patient, which harbours an optical
cylinder in its centre through which the patient can
see. The entire complex is covered with buccal
mucosa (BM) after its implantation onto the eye.
The BM is a resilient and robust membrane that
offers physical protection as well as nourishment
to the osseous part of the lamina. The OOKP is the
procedure of choice for eyes with severe dryness and
absent lid(s) or blink. Indications and contraindica-
tions for OOKP are given in Table 1.
OOKP is life-changing surgery for patients. It
requires lifelong follow up and commitment to
attend hospital visits periodically and patients
should be prepared to undertake further surgical
revisions as required. Patients referred to the OOKP
service are assessed by a multidisciplinary team
comprising of ophthalmologists, a maxillofacial sur-
geon, anaesthetists and a clinical psychologist. A
thorough assessment is carried out including ocular
examination, evaluation of visual potential, oral
health and availability of suitable teeth, general
a
Sussex Eye Hospital, Brighton, UK, bFarabi Eye Hospital, Tehran Uni-
versity of Medical Sciences, Tehran, Iran, cBrighton and Sussex Medical
School, Brighton and dTongdean Eye Clinic, Hove, UK
Correspondence to Christopher Liu, FRCOphth, Sussex Eye Hospital,
Eastern Road, Brighton, UK, BN2 5BE. Tel: +44 1273 696955;
ext: 7652; fax: +44 1273 664610; e-mail: cscliu@aol.com

Mehran Zarei-Ghanavati and Venkata Avadhanam contributed equally to
the manuscript.
Curr Opin Ophthalmol 2017, 28:397–402
DOI:10.1097/ICU.0000000000000388

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Corneal and external disorders
KEY POINTS
 Combination of careful patient selection,
multidisciplinary approach, meticulous surgical
technique and regular follow-up have provided
satisfactory visual success rate for OOKP.
 Timely management of mucosal membrane
complications can prevent more serious ones.
 Early diagnosis and treatment of glaucoma is the most
significant step to improve functional success after OOKP.
 Laminar resorption has been addressed by recent
advances in diagnosis, prevention and treatment of
this complication.
 Endophthalmitis should be ruled out and treated as an
emergency in any OOKP patient with new symptoms of
pain or decreased vision.
health condition and fitness for general anaesthesia.
The psychologist assesses patients’ mental status,
preparedness and understanding of OOKP surgery
and its sequelae. Having adequate social and family
Table 1. Indications and contraindications of OOKP
Indications:
Patient should fulfil all of the following criteria:
Severe visual loss (<6/60 in better or only eye) because of
corneal opacity (uncorrectable with scleral contact lens)
Poor prognosis of conventional keratoplasty because of high risk
of rejection or limbal stem cell deficiency
Severe dry eye and/or severe irreparable lid damage
Common indications:
Stevens–Johnson syndrome
Mucous membrane pemphigoid
Chemical injury
Thermal injury (fire, liquid aluminium, etc)
Trachoma
Contraindications:
Age under 18
Vision  6/60
No light perception in candidate eye
Advanced glaucoma or severe optic nerve damage (relative
contraindication)
Irreparable retinal detachment
Evidence of phthisis
Unrealistic expectations
Patients is not psychologically able to accept:
Severe multi-staged operations and possible further surgery
Cosmetic appearance of operated eye
Life-long follow-up
Risk of severe complications or permanent visual loss
OOKP, osteo-odonto-keratoprosthesis.
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Table 2. Preoperative assessment
Preoperative ophthalmological investigations
VA (intact light perception) Essential
Entopic phenomena Not mandatory
Electrodiagnostic tests (flash VEP, flash ERG) Not mandatory
Ultrasonography (A-scan and B-scan) Essential
Digital estimation of IOP Essential
Preoperative oral investigations
Orthopantomography Essential
X-ray of tooth Essential
Spiral CT Not mandatory
Preoperative psychological assessment Essential
Preoperative anaesthesia assessment Essential
CT, computed tomography; ERG, electroretinogram; IOP, intraocular pressure;
VEP, visual evoked potential.
support is of paramount importance. Those who are
well adjusted to blindness are best not offered the
procedure. OOKP is performed only in one eye –
usually to the eye with the best visual potential or to
an only eye. Smokers are advised to quit the habit.
Potential patients are asked to pay attention to oral
hygiene. All patients must be counselled for possible
loss of vision at any time after OOKP surgery and for
ocular emergencies such as endophthalmitis and
retinal detachment. Table 2 summarize preoperative
assessment steps.
SURGICAL TECHNIQUE
Details of OOKP surgery are fully described in
previous publications, which is generally carried
out in two stages [3,4]. In the first stage, the ocular
surface is prepared and mucous membrane grafted
onto the eye. At the same or a separate sitting, the
OOKP lamina is prepared and implanted under
orbicularis of the contralateral lower eyelid. In the
second stage, usually after 2–4 months after the
first, the lamina is retrieved, the mucosa is lifted
off the globe and lamina is inserted onto the eye.
STAGE 1
Preparation of the globe and mucous
membrane graft
A BM free graft is harvested below the parotid duct.
Muscle and excess fat are trimmed off and the graft is
soaked in an antibiotic solution usually cefuroxime.
BM is preferred over labial because the former
is thicker.
A 360-degree limbal peritomy is carried out on the
proposed eye. Superficial keratectomy is performed
to remove the epithelium and scar tissues over the
Volume 28  Number 4  July 2017
 The osteo-odonto-keratoprosthesis Zarei-Ghanavati et al.

cornea. The rectus muscles are isolated with bridle
sutures. The BM graft is trimmed to size and sutured
to the sclera and rectus insertions (for vascular supply).
A plastic conformer is applied over the mucosa, which
stays for a month to prevent adhesions.
In cases with poor oral health and mucosal
disease, severe dry eye, or where viability of BM
grafts is a concern, laminar preparation is deferred
until the mucosa is well established on the ocular
surface. Thus, stage 1 could be divided into two
separate sittings.
Preparation of the osteo-odonto-acrylic
lamina
A monoradicular tooth (usually a canine) and sur-
rounding alveolar bone is removed en bloc (Fig. 1a).
The tooth and the surrounding bone are fashioned
with a dental flywheel to an approximately 3 mm
thick rectangular lamella under constant irrigation
with balanced salt solution. An aperture is drilled
perpendicularly in its centre to accommodate the
optical cylinder (it will otherwise cause cylinder tilt)
(Fig. 1b). There are two systems of optical cylinders
available. One takes advantage of a larger posterior
diameter to increase visual field [5]. The other aims
for myopia and uses spectacle correction to mini-
mize the image to improve visual field [6]. The
current UK design of Poly(methyl methacrylate)
(PMMA) cylinder, which is based on first system,
has two sections. The anterior stem is 5.75 mm long
and 3.5 to 4 mm (small and large versions) in
diameter. It passes through the lamina and projects
a 2–3 mm beyond the alveolar side. The posterior
section, 3 mm long and 4.5 to 5.25 mm wide (small
and large versions), is closely opposed to the dentine
surface of the lamina and traverses the anterior
chamber. A PMMA cylinder of appropriate power
(based on A-scan biometry) is inserted into the
lamina and cemented, which acts as a filler rather
than an adhesive (Fig. 1c). If the periosteum has
been detached, it is reattached with fibrin glue. The
entire complex is implanted in a sub-muscular
pocket in the contralateral lower lid for fibrovascular
investment.
Edentulous patients
Patients requiring an OOKP but who do not have
suitable teeth have the option of an allograft OOKP or
tibial bone KPro. An allograft tooth can be retrieved
from living related or nonrelated donors following
human leukocyte antigen matching and screening
for blood-borne diseases. Although some authors
have reported long term success, [7] albeit not as
good retention results as autografts, our allograft
and tibial bone patients have had poor retention.
STAGE 2
First, the lamina is retrieved and soft tissues over its
osseous aspect is trimmed to reduce bulk, while the
tissue on the dentine side is totally excised (Fig. 1d).
Further surgery is only contemplated if the lamina is

FIGURE 1. (a) Upper canine tooth and surrounding jawbone extracted en bloc. (b) A hole is drilled through lamina. (c) The
optic cylinder is cemented to the hole in the lamina. (d) Removal of excess soft tissue from the retrieved lamina. (e)
Cryoextraction of lens. (f) The lamina sutured to the sclera.

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Corneal and external disorders
FIGURE 2. (a) Central mucosal membrane ulceration. (b) Implantation of Baerveldt tube. (c) Explantation of the lamina for
leakage. A channel undetectable by CT scanning had formed. CT, computed tomography.
adequate without excessive resorption. The lamina
is stored in heparinized venous blood of the patient
until the time of implantation. The BM graft is
dissected from the superior part of the globe and
lifted off to expose cornea and sclera. The centre of
the cornea is identified, marked and trephined to
match the posterior part for the optical cylinder.
Two relieving radial corneal incisions are made for
cryoextraction of lens or removal of IOL and cap-
sular bag (Fig. 1e). Iris is disinserted from its root,
and core vitrectomy is performed. The lamina is
positioned on the cornea with the posterior stem
of the cylinder passing through the corneal open-
ing. It is anchored tightly with Vicryl sutures to the
globe (Fig. 1f). Centration of the optical cylinder is
confirmed with intraoperative indirect ophthal-
moscopy. The BM graft is reflected back on the
eye to cover the lamina and ocular surface. Its
central part is trephined to allow protrusion of
the anterior optical cylinder.
FOLLOW UP CARE
OOKP patients are admitted for 1 week after each
stage and receive systemic and local antibiotic treat-
ment and oral prednisolone. Allograft patients are
started on systemic immunosuppression after stage 1.
Oral acetazolamide is required after stage 2 and it
should be continued until intraocular pressure (IOP)
is normalized. Night-time application of broad-spec-
trum antibiotic ointment has to be continued for life.
A different antibiotic ointment is used in a 3-month
alternate cycle to reduce bacterial resistance. The
optical cylinder is cleaned with juice from a fresh
cut lemon over sterile cotton tipped applicator.
OOKP patients require life-long follow up. After
surgery, they need to be seen weekly during the
first month, then monthly for 3 months, then every
3–4 months. The IOP is checked by digital palpation.
The buccal mucous must be evaluated for signs of
ischaemia, thinning, ulceration and necrosis. The
lamina should be palpated with a cotton tip for its
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bulk and mobility. The optical cylinder is checked for
stability with the wooden end of a cotton tip. Fundo-
scopy is carried out with slit lamp biomicroscopy.
Periodic visual fields and B-scanning are carried out.
OUTCOMES
OOKP is highly successful and patients can achieve a
visual acuity of up to 6/4. It is also the most durable
device with laminar retention rates of up to 80%
over two decades [1]. In Tan’s systematic review,
more than half of patients enjoy a vision better than
6/18 after OOKP [8]. In our study, the same percent-
age of patient gained visual acuity of 6/12 or better
[9]. However, a number of complications can occur
related to mucosa, lamina, IOP and retina.
BM graft problems ranging from mucous mem-
brane overgrowth occluding the optic to its ulcer-
ation and exposure of the lamina are among
the commonest complications (up to 50%) [10].
Mucosal overgrowth can be treated with trimming
and cauterization. In recurrent cases, off-label appli-
&&
cation of mitomycin C can be used [11 ]. Mucosal
ulcerations occur because of ischaemia, dryness and
infection. They need prompt treatment to prevent
laminar erosion and intraocular infection (Fig. 2a).
Mild ulcers can be treated with adequate lubrica-
tion. Small areas of laminar exposure due to mucosal
erosion can be treated with smoothening of the
lamina’s rough edges with increased lubrication.
Larger ulcers could be surgically treated with tarsal
pedicle, mucosal rotation, and bucket handle flaps
and free patch grafts. Occasionally, it is necessary
to perform a new, complete BM graft following
Stage 1. Recurrent ulceration following Stage 2 could
be treated by through the lid conversion, pulling the
upper lid down as biological cover and suturing
upper and lower lid margins after removing tarsus
and deepithelialization of the ulcerated BM
graft. Orbital decompression has been described
for retroplacement of globe to improve exposure
and cosmesis [12].
Volume 28  Number 4  July 2017

Glaucoma is an important cause of visual loss in
anatomically successful OOKP eyes. Many patients
have pre-existing glaucoma that is difficult to detect
before surgery. Falcinelli et al. reported that the overall
prevalence of pre-existing glaucoma was 36.4%
among 181 patients [1]. In our unpublished results,
the prevalence of de novo glaucoma and pre-existing
glaucoma was 15% and 40%, respectively [4]. Perform-
ing an intra-capsular lens extraction may decrease the
incidence of glaucoma. After OOKP implantation
measurement of IOP is not possible with existing
technology, hence it is estimated by digital palpation.
However, monitoring of optic disc changes can be
performed with photography, optical coherence tom-
ography and Heidelberg retina tomograph. Visual
fields can be tested with standard perimetry such as
Goldmann and Humphrey’s analysers. Falcinelli
showed that visual evoked potential is more accurate
than electroretinogram, contrast sensitivity and auto-
mated threshold perimetry for detecting glaucoma
after OOKP surgery [13]. Recent use of IOP sensor with
the Boston KPro brings hope for its similar use in
OOKP eyes that will aid in accurate measurement
and monitoring [14]. Topical antiglaucoma drops
are not usually effective after OOKP surgery because
drops are not absorbed through thick oral mucosal
graft; hence, medical treatment is mainly with oral
acetazolamide and/or sublingual timolol [15]. Patients
allergic to sulfa drugs can take an off-label oral beta-
blocker instead. Surgical procedures to reduce IOP
include cyclodiastasis, endoscopic cyclophotocoagu-
lation, disinsertion and reinsertion of recti, and tube
shunts (Ahmed and Baerveldt). Endoscopic cyclopho-
tocoagulation has a high incidence of complications
like vitreous haemorrhage and visual loss [16]. Recti
disinsertion and reinsertion can only provide limited
decrease of IOP for a limited time of several months.
Tubes are the commonly inserted after the OOKP to
reduce the IOP (Fig. 2b). Nevertheless, the results are
less efficient in OOKP eyes due to unpredictable encap-
sulation, and perhaps, because of the obliteration of
the episcleral vessels. Additionally, tube surgery is
challenging in the presence of the OOKP lamina
and thick BM graft. On the other hand, tube exposure
is much less common and tube insertion easier due to a
single chamber eye from which much vitreous had
been removed.
Although endoscopy was proposed for assess-
&&
ment of optic disc and macula before stage 1 [17 ],
it would only be useful in a limited number of can-
didates with unequivocal visual potential [18] Vitre-
ous haemorrhage and choroidal detachment are
usually self-resolving complications in early postop-
&&
erative period. Lim et al. [17 ] reported that up to one
third of their OOKP patients needed vitreoretinal
surgery for either diagnosis or treatment of retinal
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The osteo-odonto-keratoprosthesis Zarei-Ghanavati et al.
complications. Retinal detachment repair was suc-
cessful in only 20% of patients [19]. Endophthalmitis
may present with atypical signs and symptoms.
Patient education is important for early presentation
of retinal detachment and endoophthalmitis where
time is of the essence. Any acute symptom of pain or
decreased vision should be promptly evaluated to
exclude endophthalmitis. Vitreoretinal surgery can
be carried out with the aid of a temporary Ekhardt
keratoprosthesis, wide-angle viewing systems or
endoscopic vitrectomy.
Loss of laminar volume and integrity are import-
ant causes of anatomical failure of OOKP. The inci-
dence of laminar resorption is variably reported from
2% to 28% [1,7]. But, it is under reported since the
clinical detection of resorption is often a late mani-
festation. However, in the majority of the cases it is
slowly progressive and compatible with laminar sur-
vival. Detection of bone resorption is difficult
because the process is gradual and the lamella is
hidden beneath oral mucosal membrane. Resorption
can cause global or focal thinning of the lamina,
which may give telltale signs of altered refraction,
tilting of the optical cylinder, aqueous leak and
endophthalmitis.
Imaging of the lamina is usually done with
multi-detector CT (computerized tomography)
scan, which is indicated for confirmation of resorp-
tion as well as monitoring of laminar status.
Changes to linear dimensions and volumetric data
of the lamina obtained by serial CT scanning can be
compared to estimate laminar resorption [20]. Serial
surveillance of the lamina with CT scanning is not
indicated in every patient because of hazards of
radiation and clinically may not be justifiable. We
have observed that a clinically and radiologically
satisfactory lamina could still prove to be
inadequate because of undetected fracture or chan-
nels allowing ingress of infection (Fig. 2c).
Augilar et al. [21] invented autoclavable micro-
milling instrument to fashion the lamina under fluid
to eliminate thermal and desiccation damage. Bone
augmentation technique has been described to boost
the labial side of the lamina by mandibular bone graft
[22]. Although the efficacy is uncertain, bisphospho-
nate drugs can be prescribed systemically to slow down
the bone (and dentine) resorption process. In case of
severe resorption, the lamina needs to be exchanged
with a new one. Recently, Iyer performed augmenta-
tion of the bony part of the lamina by applying bone
morphogenetic protein and obtained encouraging
&&
results in cases of laminar resorption [23 ].
Fabrication of synthetic OOKP laminae reduces
oral morbidity, surgical steps and costs and may
eliminate laminar resorption. We have investigated
a hydrogel-based material as a substrate for synthetic
www.co-ophthalmology.com 401
Corneal and external disorders
lamina. In in-vitro tests, the material is found to
promote excellent cell adhesion and growth [24].
There are other studies to find biomaterial substitutes
for osteo-odonto-lamina [25–27].
CONCLUSION
Although OOKP is a demanding surgical programme
in terms of the amount of surgery, irreversibility,
requirement of oral procedure and multidisciplinary
team involvement, the long term anatomical suc-
cess is excellent even in the most challenging cases
of ocular surface disease and its functional result is
mostly limited by preoperative posterior pole dam-
age and glaucoma. Interested surgeons may consider
joining the KPro Study Group (www.kpro.org).
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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READING
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been highlighted as:
& of special interest
&& of outstanding interest
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&& overgrowth in OOKP eyes. Cornea 2014; 33:981–984.
This study showed the effective treatment of mucous membrane overgrowth and
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The vitreoretinal complications in OOKP patients need meticulous
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18. Fukuda M, Liu C. The role of intraocular video endoscopic fundal examination
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22. Iyer G, Srinivasan B, Agarwal S, et al. Bone augmentation of the osteo-odonto
alveolar lamina in MOOKP–will it delay laminar resorption? Graefes Arch Clin
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23. Iyer G, Srinivasan B, Agarwal S, et al. Structural and functional rehabilitation in
&& eyes with lamina resorption following MOOKP–can the lamina be salvaged?
Graefes Arch Clin Exp Ophthalmol 2014; 252:781–790.
This study reported the use of bone morphogenetic protein to treat significant
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24. Avadhanam V. ‘Hydrogel skirt for synthetic OOKP lamina.’ congre.co.jp. http://
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25. Sandeman SR, Jeffery H, Howell CA, et al. The in vitro corneal biocompatibility
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esis skirt. J Mech Behav Biomed Mater 2011; 4:1700–1708.
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