From expertise to mentorship: Advancing keratoprosthesis surgery worldwide

The public and ophthalmologists are fascinated by keratoprosthesis surgery. Bionic eyes come to the mind when plastic, glass, crystals, and metals are used to bypass the cornea. Using biological tissues such as tooth, bone, cartilage, and even toenails to reconstruct the cornea is plain weird. When it comes to dealing with patients, their relatives and carers, and ophthalmologists, it is really important to find out what they are thinking and what they wish to achieve. This article is about educating ophthalmologists and their teams, so we will not deal with patient psychology and expectations here. In my long professional life as a keratoprosthesis surgeon, I sense there are two reasons ophthalmologists wish to enter the field of keratoprostheses. First and foremost (I hope) it is because they are interested in being able to provide hope and care to patients with desperate corneal blindness. Second, there is often a wish to be able to do something special which stands them out from the crowd. There is nothing wrong with the latter. Even altruism is not without benefit to the altruistic person. The challenge for the mentor is to show the level of challenges which the mentee or student must overcome. Let us have a look at some of the challenges. Quality of literature: Thankfully, the importance of long-term follow-up is now recognized. Papers with less than 5 years follow-up are not helpful unless they show early failure. Patients and surgeons waiting for the next best thing can wait and wait, and any new device will need 10 or 20 years to show their worth. Aside from short follow-ups, the lack of standardization and biassed (conscious or unconscious) reporting make it difficult to gauge the success of any device. Furthermore, very sadly, there is some dishonest reporting in terms of numbers and results. Afficionados know there are only two devices which have withstood the test of time. The Boston KPro Type 1 is for wet blinking eyes with no keratin bulbar or tarsal whatsoever, and the OOKP is for dry keratinized eyes even with a defective lid or blink. Glaucoma: I have received referrals and seen patients on my travels whose eyes could have been saved and their sight restored had it not been for untreated glaucoma. Some of these eyes are hard to palpation. Treatment is difficult. Eye drops alone may not be sufficient or may not penetrate due to keratinization. When the optic nerve has been damaged severely, then the eye’s visual potential has been removed. Not neglecting glaucoma especially after severe chemical or thermal injury is an important point to learn. Early care of teeth and gum: A child cannot have OOKP due to rapid laminar resorption. We need to preserve their teeth and oral hygiene, so when a child is fully grown, OOKP surgery remains possible. Dental care for the blind is difficult but possible. Avoidance of sugar, flossing, gentle brushing, and regular professional visits all help. Geographic distance: There is never a need for more than one or two keratoprosthesis centers in moderately populated countries. As such, it is often necessary to go abroad to learn or have a teacher come to teach. Geographical distance can be a hindrance as travel takes time and money and there can be large time zone differences. Teleophthalmology is not perfect as there can be no sense of touch or smell. We need to assess thickness of buccal mucous membrane with touch, and we know there is inadequate irrigation when fashioning an OOKP lamina with a drill, flywheel, or saw. Proliferation of centers is not helpful as it dilutes expertise and experience. Long surgery: This in itself is a challenge to the team, but it also makes for costly surgery. Managers will look at the number of cataract surgeries displaced. It may also be considered that restoration of sight to many is better than to a few. My view is that every person with visual impairment should be given a chance, so those requiring complex keratoprosthesis surgery should not be denied help. Multidisciplinary team: This presents a challenge with not just costs but also timetabling to assemble a team. For robustness, there should also be a double, especially when the senior surgeons are growing older or frail for succession planning. Life-long follow-up: The surgeon–patient relationship is very different from that of cataract surgery. Some say keratoprosthesis surgeons are married to their patients, or they are like family members. Nevertheless, surgeons are well advised to keep professional boundaries and not emote with patients and their families. The surgeon needs to preserve themselves to provide clear, logical care to their patients. We care about and care for our patients but must not become drained. Patients can also find regular life-long follow-up difficult be it for distance or costs. Surgeons must learn that this is not negotiable. Thankfully, most complications with the OOKP develop gradually, so there is notice. Complications: These range from extrusion, glaucoma, endophthalmitis, retroprosthetic membrane formation, oculoplastic complications, sterile vitritis, retinal detachment, and so on. There needs to be a team instantly available at each keratoprosthesis center. The lead surgeon learning to become a keratoprosthesis surgeon needs to understand the importance of having such a team 24/7/365. From my experience, vitreoretinal emergencies are some of the most challenging to manage. I have deep appreciation for the expertise and dedication of VR surgeons who handle these complex cases. That said, it is also crucial to ensure that our keratoprosthesis patients receive the extra care and consideration they might need during these situations. Length of learning: The novice may not understand it takes very long to achieve competence and even longer to achieve excellence. This is especially the case with the OOKP. There is much to learn about assessment, suitability, surgery, and recognizing and managing complications. Many keratoprosthesis surgeons will say the surgery itself is the easiest. Due to large case variation, I would say it takes 5 years of tutelage to become a competent OOKP surgeon and double that to become some sort of expert. Not everybody’s temperament is suited to become a keratoprosthesis surgeon. Attention to detail and some degree of OCD are necessary qualifications. Emotional burden: This has been mentioned above. It is a real phenomenon. Self-blame, guilt, and imposter syndrome can also come into play. Having a professional clinical psychologist as part of the team really helps with assessment and with supporting patients when their device is at risk. Professional jealousy: This can be dreadfully bad, and I need say no more. However much the keratoprosthesis surgeon acknowledges that it is teamwork, the spotlight will be on them. Success breeds jealousy. This is different with different cultures and countries. Some cultures celebrate success. Some do not!About the authorChristopher Liu OBE MD PhD FRCOphth FRCSEd FRCP FAICO(Hony) CertLRS. Professor Christopher Liu OBE is a key opinion leader in the field of keratoprostheses. His speciality is the osteo-odonto-keratoprosthesis (OOKP). He was the Lead Consultant of the National OOKP Service in the United Kingdom until September 2022, when the Service was relocated to Moorfields Eye Hospital in London. He was appointed OBE by Her Majesty Queen Elizabeth II in the 2018 New Year Honours list for Services to Ophthalmology. Professor Liu is a clinician scientist with two doctorate degrees. His MD thesis was on lens epithelial behaviour and PhD on the OOKP. He has close to 300 published papers, numerous book chapters, four books, and over a dozen inventions in his name. The latest book about to be published by Springer is a 38 chapter tome on cornea and keratoproatheses. Amongst his inventions is a synthetic OOKP analogue under development. He has been at the helm of a number of regional and national learned societies. He is the current Honorary Treasurer and Trustee of the Royal College of Ophthalmologists and examines for the CertLRS exam. He runs his private practice in Sussex, England. He provides a corneal service to the entire Scottish Highlands through monthly visits to Inverness. He has recently been appointment Lead Consultant, Ophthalmology Services of Hong Kong's Health Authority, and delivers his work through monthly visits and remote working. Outside work, Professor Liu is interested in haute cuisine, music, education, travel, and freemasonry.