Spotlight on Ophthalmic Surgery Innovations
Permanent Keratoprosthesis (K-Pro) for Corneal Repair
At the NewYork-Presbyterian/Weill Cornell Medical Center, Kimberly C. Sippel, MD, Director of the Cornea and Anterior Segment Service, and her associates Christopher E. Starr, MD, and Ana Alzaga Fernandez, MD, have developed a nationally prominent center for the implantation of permanent keratoprosthesis (K-Pro), an artificial corneal device for patients with severe corneal disease who are not candidates for standard corneal transplantation. In collaboration with Dr. D’Amico and members of the Vitreoretinal Service team, including Szilard Kiss, MD, Anton Orlin, MD, and Athanasios Papakostas, MD, the Cornea-Vitreoretinal teams offer this sight-saving procedure to many visually impaired patients for whom conventional types of corneal transplantation are prone to failure.
The team uses the Dohlman (Boston) Keratoprosthsis (K-Pro) device with which Dr. D’Amico gained extensive experience as the initial vitreoretinal surgeon who worked with his mentor, device inventor, and internationally-famous corneal surgeon Claes H. Dohlman, MD, during his earliest implantations. “Permanent K-Pro is indicated when severe bilateral corneal disease exists due to prior failed corneal transplant, chemical burns, trauma or Stevens-Johnson syndrome (SJS), a rare and serious disorder of the skin and mucous membranes that result in profound scarring, fusion of the eyelids, and dryness around the eyes,” explains Dr. D’Amico, who earned the Gertrude D. Pyron Award for his work in permanent K-Pro and complex ocular reconstruction. “Patients with SJS and severe corneal scarring are unable to see anything unless they have a permanent K-Pro. Thankfully, the use of this device has restored sight in many of our most desperate and challenging patients.”
Demonstrating the power of the K-Pro procedure, Dr. D’Amico recounts a man who became blind at age 12 due to SJS, and was left with no useful vision for 30 years. “We concluded with the patient it was reasonable to perform a K-Pro,” says Dr. D’Amico. “At surgery, we first had to expose the eye; freeing it from many years of scar tissue accumulation can be extremely difficult in these cases. We eventually exposed the remains of the original cornea and were able to insert the K-Pro and anchor it successfully. To our great surprise and joy, this gentleman regained 20/70 vision, seeing again for the first time in 30 years.”
As a major referral center for K-Pro, Weill Cornell successfully manages the formidable complications that may arise with the procedure, including the continuous risk of infection and the challenges of keeping the ocular surface lubricated. “We are now able to encourage surface tissue to grow over the ocular interface to reduce infection to a great rarity,” says Dr. D’Amico. “We are working to expand our ability to offer this miraculous device to an ever-increasing number of otherwise hopeless patients.”
Stereoscopic 3D “Heads Up” Digital Visualization System
At the David H. Koch Center, many vitreoretinal surgeries and an increasing number of anterior segment surgeries are performed with a stereoscopic (3D) “Heads Up” digital visualization system that offers superior visualization compared to the traditional operating microscope. The Koch Center is the first of its kind in New York City to have several of these devices in its eye operating rooms. The 3D system enables the surgeon to view the surgical field on a six-foot plasma screen through stereo glasses and offers tremendous magnification as well as full digital control of illumination. These features greatly increase the surgeon’s depth of field and enhance the ability to perform microscopic manipulations of delicate retinal and other ocular tissues with far greater accuracy and safety. 3D visualization also facilitates a sense of engagement for every member of the surgical team, which enhances collaboration and OR efficiency.
“We use the 3D system to perform the most delicate macular surgeries which have a ‘diamond-cutter’s’ need for precision,” says Dr. D’Amico. “For instance, to restore vision in patients with epiretinal membrane (ERM), a condition in which the membrane distorts vision, we can now remove the distorting surface membrane with the aid of 3D visualization, which provides exceptional magnification and depth of field that enhances our ability to work at such a highly precise and fine scale.”
Amniotic Membrane Application for Severe Ocular Surface Disease
Dr. Sippel and the Cornea and Anterior Segment Service team have pioneered the acute application of amniotic membrane that has revolutionized the treatment of severe ocular surface disease, such as that found in Stevens Johnson syndrome (SJS) and other related conditions, to restore vision in patients who have no other alternatives to restore sight.
In this procedure, translucent sheets of amniotic tissue are laid on top of the cornea and sutured in place, providing a highly bio-compatible, protective barrier that gradually melts away, sparing further damage to the cornea and minimizing the eventual accumulation of scar tissue.
At the NewYork-Presbyterian/Weill Cornell Medical Center William Randolph Hearst Burn Center, ophthalmologists closely collaborate with the Burn Center's surgeons, nurses, therapists, and social workers to provide multidisciplinary and comprehensive care to patients with thermal burns, chemical burns, and SJS syndrome. For many of these patients, treatment involves corneal transplantation or the application of amniotic membrane on the eye surface to prevent severe corneal scarring.
As a result of the team’s success with amniotic membrane application, it has become a standard of care in burn units around the nation.
OculoPlastics Expertise for Transorbital Neurosurgery
The Oculoplastic Surgery Service at NewYork-Presbyterian/Weill Cornell Medical Center has become the largest in the city and is proud to host the only American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS)-approved fellowship in New York City for this elegant and demanding specialty. The Oculoplastic Surgery team, comprised of Gary J. Lelli, Jr., MD, Kyle Godfrey, MD, Benjamin Levine, MD, and Kira L. Segal, MD, closely collaborates with colleagues in Neurological Surgery, ENT, and Dermatology to perform plastic and reconstructive surgery of the eyelids, orbit (eye socket), lacrimal (tear drainage) system, and face.
The dynamic collaboration between Oculoplastics and Neurological Surgery at Weil Cornell has resulted in the refinement of complex trans-orbital neurosurgical techniques that access the brain and other intracranial structures through the eye socket. “Our goal is to perform minimally invasive surgery, or diagnostic or therapeutic procedures, with smaller incisions, lower morbidity, faster recovery, and better aesthetic outcomes,” explains Dr. Godfrey, who collaborates with Theodore Schwartz, MD, Neurosurgeon at Weill Cornell. “Often, the skull base is accessed through the eye socket via small skin incisions, which can mean the difference between a small, cosmetically invisible 2 cm eyelid incision and a full craniotomy. These cases are truly multidisciplinary and require expertise from both fields.”
“For trans-orbital neurosurgery, I typically perform the approach and closure utilizing principles of ophthalmology and plastic surgery to provide adequate exposure and access to the deep orbit via cosmetically acceptable techniques,” says Dr. Godfrey. “Then, Dr. Schwartz will take over the portion involving the brain and intracranial structures beyond the orbit, typically utilizing endoscopic cameras for visualization, magnification, and illumination.”
The Oculoplastics and Neurological Surgery team has performed a number of these cases with excellent functional and aesthetic outcomes, and has thereby saved many patients from more invasive procedures with higher morbidity and mortality.
The success of the Oculoplastic Surgery Service has resulted in an exceptionally high demand for Oculoplastics expertise at Weill Cornell.
PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) for Complex Corneal Disease
NewYork-Presbyteiran/Weill Cornell Medical Center is one of a handful of ophthalmology sites in the United States that offer PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem), and has the largest PROSE lens program in New York. This innovative lens completely covers the ocular surface and restores vision in patients with complex corneal disease. The lens protects and bathes the ocular surface from the outside and restores the normal curvature of the eye.
During PROSE treatment, our ophthalmologists design, customize and fit prosthetic devices to replace or support damaged ocular functions by improving vision and reducing pain and light sensitivity. PROSE can be the ideal, and sometimes only, treatment capable of restoring vision and dramatically reducing symptoms including eye pain, severely dry eyes, blurry vision and light sensitivity.
“The PROSE lens has many powerful uses” says Dr. Jessica Ciralsky, Director of the PROSE program and corneal specialist. “It can be a permanent and restorative treatment for many patients with problems—such as severe dry eye or lid/corneal irregularities—and patients place it on their eye every day as a much more powerful type of contact lens that provides both vision and comfort. Or it can also be used as a temporary treatment for many corneal conditions that can be encouraged to heal with the protection that the device provides. Many of our patients are extremely grateful for their PROSE lenses, and there are few centers that fit PROSE lenses with the expertise that we have here at Weill Cornell.”
Viscostretch: A Novel Surgical Technique for Refractory Macular Holes
Weill Cornell Medicine ophthalmologists provide advanced evaluation and treatment for patients with retinal disorders and are actively engaged in the clinical and laboratorial investigation of new treatments for these diseases. Our retina specialists are internationally renowned for their expertise in complicated retinal detachment repair, diabetic retinopathy, the removal of macular pucker and macular hole repair.
Recently, the Vitreoretinal team has popularized a novel technique for repairing macular holes using a novel technique of subretinal viscodissection. In this technique, a standard pars plana vitrectomy with internal limiting membrane peeling (unless previously peeled) is performed, and a cohesive ophthalmic viscosurgical gel is injected through the macular hole, focally detaching and gently stretching the parafoveal retinal tissue. The gel is removed from the area of the hole at the conclusion of the procedure, and the stretched retinal tissue now has sufficient redundancy to permit hole closure with frequent improvement in postoperative vision as well. “Although there are many techniques that have been proposed to close difficult macular holes, Viscostretch has clear advantages as a minimalist approach and, in the delicate macular retina, minimal tissue manipulation is always an important goal,” says Dr. D’Amico.