Patient Regains Sight Following Artificial Cornea Implantation | Hacker News Reader

Patient Regains Sight Following Artificial Cornea Implantation

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406 pointsmuskminion75 comments

Corneal surgeon here ! (Note : I never implanted a keratoprosthesis. This is an extremely unfrequent procedure, usually performed by a handful of surgeons in a given country). Some insights about this topic. This looks like a great device (never heard before !). This is a keratoprosthesis, meaning this is a last recourse, "no-hope-except-maybe-that", procedure. However it looks infinitely more simple and respectful of the eye integrity than current keratoprosthesis, and, if it really acts like a scaffold for native corneal cells and allows a colonization and the obtention of a satisfying corneal surface, it could be a game changer. It is way too soon to know.

A significant percentage (I would say around 40-70%, depending on the country) of corneal graft indications originates from pathologies coming from the inner layer of the cornea (corneal endothelium). Posterior lamellar graft (DMEK) allows today to change only the thin cellular layer which is pathological, with an usually quick recovery. Even the best performing keratoprosthesis won't replace this procedure, because we care to preserve the eye's integrity as much as we can.

It is interesting to remember that corneal transplantation is a very special topic because the cornea is not vascularized, meaning less rejection. There still is, of course, but the outcomes as usually good. Keratoprosthesis are today indicated when previous grafts where rejected, when the other structures of the eye are healthy, and when the vision is extremely low. This allows to gain a few years of very low vision before, usually, losing the eye due to infection or high ocular pressure.

The technology presented has the potential: - to replace current keratoprosthesis and lower the threshold to decide to perform the procedure : yes, almost sure if the device is well-tolerated - to replace perforating keratoplasty (full corneal replacement, unfrequent today) where the cornea is damaged in its entirety: maybe, highly uncertain for the moment. That would be an incredible step forward, a revolution in our practice. - to replace anterior lamellar keratoplasty, where the anterior wall of the cornea is replaced : highly unlikely - to replace posterior lamellar keratoplasty, where the cornea lacks transparency because of inner layer cellular dysfunction: almost impossible.

I would also like to raise awareness on the topic of eye rubbing. The eye surgeon community progressively discovers the highly harmful consequences of vigorous and daily eye rubbing. A few teams (mine, notably) even think that it is the single trigger for keratoconus. You will find a nice illustrations of what a rubbed eye looks like in MRI I by googling "don't rub your eye" (this is me in the MRI ;-) and more explanations here : https://defeatkeratoconus.com/

I would like to second the eye rubbing awareness. I have keratoconus in both eyes, and had two (donor) corneal transplants in the 1990s, in my teens. Even with them, my sight is not great, as the distortions from the transplant scarring and residual keratoconus around the edges are only partially correctable with regular glasses lenses (I think these artificial corneas would not be better). I had bad hayfever as a kid (and still do sometimes now) and rubbed my eyes a lot. I now think it's the most likely cause.

Don't let your kids rub their eyes!

I am in a similar boat-- fairly bad animal allergies and hay fever as a child accompanied with frequent and vigorous eye rubbing and now keratoconus (though, fortunately, not so far-progressed as to need corneal transplants).

My daughter has the same characteristic long eyelashes that I do, and exhibits allergies (though much less severe than mine). My wife and I have made a very strong effort to prevent her from eye-rubbing. She's old enough now to understand why we were so adamant about it.

I'm seeing elsewhere in this thread that nocturnal eye rubbing can be a problem. I never thought about that and it's a bit disturbing. I do remember waking-up with my eyes plastered shut with hardened mucus as a child.

Interesting! How much eye rubbing are we talking about? Several times a day? Once a day? Once a week? Any tips on stopping the habit?

To start with, full disclosure : this is a controversial topic. The majority of eye surgeons are still convinced that there is a genetic predisposition to keratoconus, and that eye rubbing is an optional trigger. Other (a growing number) think that this is the sole responsible of keratoconus.

My mentor is the main proponent of the eye rubbing theory. I was a skeptic, and became convinced by learning with him how to properly interview patients on this subject, how to prevent eye rubbing, and by seeing the absence of progression after full awareness of the patients (without cross-linking. We don't do any CXL in my department, ever. KC screening and care is one of our main activity: not doing CXL is a financial loss). My mentor's website : https://www.gatinel.com/recherche-formation/keratocone-2/no-... (No conflict of interest except loyalty).

The main difficulty is that it is almost impossible to design an experiment to prove the theory (if someone has a genius idea, please don't hesitate). Usually other surgeons or students become convinced after visiting the department and spread the good practices back home : still a long way to go.

The harmful eye rubbing is made with the hard parts of the hand (knuckles). It is frequently nocturnal and almost everytime ignored. Awareness comes when the patient has been informed and told to look for this habit. At the second consultation, the eye rubbing is reported in the vast majority of cases. I count the keratoconus patients that deny eye rubbing after 2-3 consultations on one hand. We prescribe a transparent eye shell to sleep with when the patient denies eye rubbing : it allows them to realize that they rub during the night. We prescribe eye drops to ease the eye irritation which triggers rubbing, and instruct to rub the inner part of the eyelid, against the nose (no eye deformation) if necessary. Sleep position is frequently pathological too (eye vs hand or arm contact. In those cases the KC is very asymetrical).

Doctors in our team can predict the eye rubbing habit frequency and intensity by looking at a corneal topography. It is incredible that the role of this habit was ignored so long. I suppose that we doctors don't talk enough with our patients. The financial incentive of performing CXL and surgeries is so clearly detrimental the the adoption of those practices.

Hi, I am really interested in reading this conversation, as I have keratoconus and had CXL surgery about ten years ago, and am very happy with it. The CXL stopped the keratoconus progressing and I only need to wear glasses instead of the more invasive things other patients mention (contact lenses, corneal grafts and transplants, etc).

It would be good if this intervention to convince patients to cease eye rubbing was more common in keratoconus patients. There is often a delay of several months between when keratoconus is suspected or diagnosed and CXL is carried out (in my case I had to wait 6 months in one eye and 9 months in the other, during which time it got a bit worse).

About eye rubbing, yes there should be more awareness of it! In practical terms, I would recommend that everyone tries wearing an eye-mask when they’re asleep (I recently bought this one, and I'm happy with it https://www.amazon.co.uk/gp/product/B07DW32QYJ ). This is because it's more difficult to notice and prevent yourself from rubbing your eyes when you're half-asleep.

There are several reasons why I like wearing an eye mask while in bed, and some even apply to people who don’t have keratoconus: 1. It stops me rubbing my eyes when I'm in bed. 1. It might stop allergens getting into my eyes when I'm asleep, for example I notice much less rheum on my eyes when I wake up in the morning. When I’m in bed is when I notice that my allergies are worst. 3. It helps me sleep better, it's like having blackout curtains in my room. 4. If I want to get up in the middle of the night, I will be able to see better in the dark.

Are there any correlations between people who wear contacts and have keratoconus? I'm asking, because handling contacts effectively requires you to rub the eyes a little every time you take the contacts out. Or is that kind of deformation not enough?

(empirical, non scientific opinion): usually, wearing contact lenses tends to prevent vigorous eye rubbing, during the day. Also, people with sensitive, itchy eyes tend to avoid contact lenses: this is a two-way relationship. Nefarious eye rubbing is usually related to a daily, compulsory "habit", involving a vigorous pressure on the eye using the knuckles or the side of the index, also frequently present while sleeping.

I'm curious if you're familiar with the stromal stem cell research for regenerating deeper corneal tissues?

Research from University of Pittsburgh, successful on mice/rat models, was taken to India for human clinical trials with pretty great success healing severe chemical burns and scarring to the cornea. Here's video of them talking about their effort to get it FDA approved (will take 5 years), I linked it to where it shows the before and after results: https://youtu.be/q_obgXSeLaU?t=1586

This is really fantastic reply and context. Thanks for posting this!

When you see research like this, assuming all things trend positive (big if of course) what is the timeframe one expects to see it make its way to mainstream application?

If the outcomes are as great as they look, I think one could expect "mainstream adoption" (specialized centers and unfrequent indications) in 2-3 years ? This is a hard guess!

(Not remotely competing) neurosurgeon here. Vision never ceases to amaze me in its robustness. Patients with long-standing (years) visual field defect from pituitary tumour will recover their vision within minutes of it being decompressed. One of the most satisfying things I do is ask the patient in the recovery area if they can see the time on the clock opposite them, - the operation having finished 30 mins ago. Most can, - this says much more about nature, nerve compression and neuronal plasticity than the surgery.

I am a recipient of a dual cornea transplant because of a condition called: Fuch's Cornea Dystrophy.

In 5-20 years I'll need it again.

I'm not in as bad of shape as the person in TFA. I'm damn lucky, but to be honest, I'm miserable. I remember what it was like to have lazer-sharp vision. Now I can't work with electronics anymore. My soldering iron is gathering dust. I can't do 30% of my job. Hell I have to assemble PC's by feel. I can't see the writing on jumper connections, and spend a lot of time taking a picture of a thing and then magnifying the image just trying to figure out what goes where.

It's a shame I am not a mechanic, bolts are much bigger then jumpers. Working by feel is a fucking bitch.

I'm sorry to hear that. My sister has Fuch's Dystrophy as well and also had a double cornea transplant, but it seems to have mostly fixed all of her vision issues. Time will tell if I'm in the same boat, but so far have no signs of it.

I sympathize. I don't know what kind of procedure you underwent. If the blurry vision comes form an irregular anterior corneal surface, scleral lenses can be a game-changer. Also, cellular therapy could be an option in a few years, you're not condemned to another surgery with a little bit of luck. Don't hesitate to write me if you need an informal, general advice.

What is your contact information?

Sorry, I thought it was public. I updated my profile.

I just wanted to jump in and say as a sufferer of KC with pretty nasty scarring, scleral lenses were a life changer.

Keratoconus sufferer here. This looks really cool. I'm probably not going to need a corneal transplant at this point (since my condition appears to have stabilized with age) but I'm definitely going to follow this. Even with correction the acuity in one of my eyes is very bad (like, can't read 16 point font at arm's length bad). Since this method takes the tissue rejection concern out of the equation I wonder if an "elective" corneal transplant might be an option down the road.

Honestly, I think CXL then laser surgery is probably a preferable treatment to corneal transplants. You’re looking at 6 month recovery time for that.

CXL isn't useful at all since his vision has stabilized. CXL only halts the progression of the disease.

That's the assumption I've been led to believe by my doctor as well. Doing some searching does show that there's been some discussion of refractive surgery post-CXL, but I can't imagine that putting any more stress on my baggy, distended corneas would be a great idea. >smile<

I'm a little bummed I missed the possibility of CXL. I was diagnosed with KC in 2004, at age 27. I saw a couple specialists at the time, one of whom mentioned trials (in the US, where I am) for a procedure to strengthen and stabilize the cornea using UV light and riboflavin. He felt it was too new and unproven to recommend I explore it.

I was offered the CXL / laser surgery combo by my opthamologist (UK) 6 or 7 years ago, but decided to do neither. Like you, my diagnosis has stabilised with age (first diagnosed 1994) and I don’t want to potentially disturb it.

Post-CXL laser surgery is not always possible. If the cornea's thickness has already degraded too much, lasering would be very risky and lead to tearing.

Also a Keratoconus sufferer. And it also looks like the progression has at least stabilized with age (which makes treatments like CXL kinda useless). What are you using for correction? I ask because my bad eye (which can't get close to correction with glasses) now gets better than 20/20 vision with hybrid lenses. And my good eye can't get the same acuity! It's an interesting sphere of research (so much is still unknown, and there are so many changes in the material science aspects of it). I got by for a long time with "extended-range" toric soft lenses and have very different experiences depending on the material type. (For instance, Frequency 55 XR was made with 'Methafilcon B' 'High Water Ionic' and I had 'unexpectedly good vision' with them.)

Oh, contact lens material is a rabbit hole:

https://en.wikipedia.org/wiki/List_of_soft_contact_lens_mate...

I'm really pretty lucky. I can get by only using spectacles. My prescription isn't really too bad. I can get acceptable correction in my good eye and still have passable 3D vision with correction in my bad eye. On that basis I've opted to stay w/ spectacles. (I can get markedly better correction for my bad eye with some more axial tilt. I tend to easily lose convergence with that additional tilt and get massive headaches, however.)

I tried soft contact lenses, prior to my keratoconus diagnosis, when I was much younger. The foreign body sensation simply would not go away. It was a massive distraction, to the point that I couldn't really think about much else. Then I start fidgeting with my eyes and end up with swelling and tears. (Hard, balled-up fist eye rubbing from severe childhood allergies is probably the root cause of my keratoconus. The animal allergies are mostly gone now, and the hay fever is only a mild irritation. I can still, however, induce foreign body sensation and massive itchiness just by touching the skin around my eyes. There's probably a bit of obsessive compulsive disorder going on there.)

One thing that surprised me is how the whole product comes in a "kit" with instructions and tools. I never thought on those medical devices as something that would come as a lego brick, mainly something that has a huge potential as this. I thought that to perform this kind of operation a ton of material was necessary.

Tooth implants also come as "kits".

That's actually not that uncommon.

All the fancy bone reconstruction plates come in kits like this with step-by-step instruction manuals.

Often times when a surgeon is using a product for the first time, a representative from the medical device manufacture will watch the surgery and provide guidance with a laser pointer.

Most medical stuff comes as kits. In no small part because each individual manufacturer tends to have their own process for the details - it's not as interchangeable as you'd think. In part I think it's a liability thing.

It also helps a lot with sterility.

In my opinion, the problem with technology that can help the blind see is the lack of a profit incentive, which means you can only buy from a few established players and no innovation is encouraged, while prices remain astronomical. As it stands, I already pay a lot more for products I need, especially since I don’t have any government assistance. It’s what I like to call the “blind tax“. not everyone can afford to pay it. As such, it’s better to wait for general consumer devices with accessibility features like the iPhone, which is far more affordable than a braille note taker, for example. The potential market that could afford something like this, is pretty small.

I hope technology like this eventually becomes available for those of us living in developing countries.

I didn't see anything about pricing, are you referring to this specific item or in general?

Not op, but it is true in general.

The challenge is volume; with a small market, there isn't much motivation to struggle to stay in business selling at low margins. Also, since these may be considered accessibility devices but not medical devices, insurance May not cover a lot of things that ought to be considered essential.

The profit motive is everywhere in the medical sector, and that is a bad thing. Even if you believe in free markets, it's not easy to get the best care.

To stay cose to the eye as a subject, look at vitreomacular adhesion. Roughly two possible treatments: - costly and complicated eye surgery - substantially simpler ocriplasmin [0] injections

In many cases where ocriplasmin looks like it could be the perfect solution, it isn't even considered. Could that have something to do with the surgeon's incentives alignment?

[0] https://en.wikipedia.org/wiki/Ocriplasmin

An analogous problem in drugs seems to have been effectively addressed by the Orphan Drug act (https://en.m.wikipedia.org/wiki/Orphan_Drug_Act_of_1983)

Sounds like maybe there needs to be something similar for medical devices?

This is the issue with most small population medical research, or research that's worthwhile but by policy difficult to commercialize.

"Sucks to be you" tends to be every non-sufferer's response.

A good example of this is the absolutely exorbitant prices charged for low vision CCTVs and similar equipment. I assume this is because the sellers are mainly targeting state aid agencies so they can get those juicy tax funds.

I suspect it is more just volume and support costs. There really isn’t much government financial support at all for the vision impaired, outside of the Veteran’s Administration system.

A friend and I looked at doing a tech product for the vision impaired. The business case just didn’t pencil out, mainly because of TAM.

> It’s what I like to call the “blind tax“. not everyone can afford to pay it.

The other thing is that devices sold as "medical devices", unlike "general consumer devices" have (for good reasons) pretty strict regulatory schemes across the world, which means that their development and maintenance costs a lot more money.

the related term with drug development is "orphan drug". drugs designed to treat rare medical conditions that are not developed due to lack of profit incentive

Okay this is very cool. Artificial or 3D-Printed corneas seem like such an obvious target for development.

> "Unveiling this first implanted eye and being in that room, in that moment, was surreal."

Still nowhere close to an 'implanted eye'...And I don't like that that sentence is being picked up.

The 'install' kit is very interesting. Install Animation: https://www.corneat.com/kpro-animation

Pitch/Deck: https://resiconference.com/digital-resi-january-2021-agenda/...

I’m keratakonus patient who needs such surgery as well, to clarify there is also cornea transplant operations too. Which is from a donor. But that surgery requires 6-12month healing time, because it have many stiches

Realy interesting I have badly scared cornea from Sarcoidosis in one eye - I wonder if this would work for me

Amazing. In 25 years, this may be a packaged as a mod.

Paging The Expanse fans...

Or they can rebrand as Kiroshi Optics.

Awesome. Moving. Inspiring.

There are all sorts of headlines about one technology or another that seems to never get beyond the lab.

How long have we been waiting for some way to regrow the tooth after a cavity?

But then suddenly there is something like this. A PATIENT ACTUALLY REGAINED SIGHT after years of total blindness.

That cannot be said with enough awe to do it justice. It brings new faith to those at the forefront of medicine.

Anyways, for the docs in this and every other groundbreaking attempt.... Thanks! No, really, Thank you with all my heart!

It's really amazing. I don't want to be the usual cynic HNer talking stuff down, because this seems really groundbreaking.

However, corneal transplants are already a thing, and "Within the United States, the supply of corneas is sufficient to meet the demand for surgery and research purposes."

https://en.wikipedia.org/wiki/Corneal_transplantation

Of course a synthetic cornea seems like a more scalable solution, and probably reduces costs in the long term, so this is great progress.

It is true that corneal transplantation is a thing since decades. However, a corneal transplant, like any transplant, has its issues. Rejections can still occur, and the healing process takes a long time, usually not less than one year, involving constant adjustments. If a cost-effective synthetic inert material addresses these issues, this is immense progress.

But the GGP says

>>> How long have we been waiting for some way to regrow the tooth after a cavity?

An artificial cornea probably solves a lot of problem with rejections, but it is somewhat like filing the cavities in the teeth with whatever paste they are using.

I've read about people getting cataract surgery and ending up with UV sensitivity due to the material some older synthetic implants were made from, so I always assumed artificial corneas weren't uncommon.[1] I've actually kind of hoped I could get them some day.

Is the difference here that previous implants weren't total replacements, or something else?

[1] e.g. https://www.komar.org/faq/colorado-cataract-surgery-crystale...

You're not being cynical, this is exactly what one should expect in HN - combing through the deeper facts and not just the superficial information.

One thing that honestly puts me off of some HN threads is the breathless "it's full of stars" comments where people take one press release and their minds go to some near-future utopia where everything is perfect and nothing hurts.

I echo this sentiment. Here are the eligibility criteria: https://clinicaltrials.gov/ct2/show/NCT04485858. I am not an opthalmologist, however, it appears this is an option when a transplant fails or is not indicated due to infection. It's still excellent news!

Here's a good info page on corneal blindness https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2823104/ warning made me a bit queasy

Bloody marvelous!

Yeah, regrowing teeth has been in the news for decades.

Treating cataracts with eye drops is one I noticed a few years ago.

https://www.sciencemag.org/news/2015/07/eye-drops-could-diss...

I was surprised to find these start forming after age 40.

It’s great when a little science fiction finally works.

I could never find any explanation why when root is exposed and infected you can't treat it with antibiotics and seal the cavity like normal and forced to have a root canal.

If I had helped get this built, I would die a happy man. Congrats to all involved. This is inspiring!

From this article [1], there are (at least) other three business building similar things. Perhaps you can apply to work in any of them.

[1] https://eyewiki.aao.org/Boston_Keratoprosthesis_(KPro)

> In recent decades multiple synthetic corneas have been pioneered and developed, though only three are principally used in practice: the Boston Keratoprosthesis (Massachusetts Eye & Ear Infirmary, Boston, MA), the AlphaCor (Addition Technology Inc., Des Plaines, IL) and the osteo-odonto keratoprosthesis also known as the ‘OOKP’ (originally described by Strampelli, modified by Falcinelli).

Given that cornea transplants are routine operations, why was that man left blind for so long? Where there any medical factors precluding the use of a donor organ?

Don't get me wrong, this is fantastic news, but something essential has been left out of this article.

Maybe he couldn't afford the operation and the company gave it to him because they needed to try it out?

I don't think that there has to be anything exceptional going on here just because he was blind for 10 years at 78 years old.

Well that's true, or maybe he was down-prioritized for donor organs due to his age. I've got a friend who isn't allowed to drive a car because of bad corneas. He also got repeatedly rejected when trying to apply for a donor organ, because he is still far from blind, so his inability to drive is classified as a comparatively mild inconvenience. I'd just have thought that someone who actually is effectively blind would be able to get one. I'm sure my friend will be thrilled to hear about this development, he's been waiting for something like this for years, nay decades! When production ramps up he might finally be able to get his full eyesight back!

From a different article:

"He had four donor transplants to try to restore his vision, but all failed."

https://www.israel21c.org/jamal-can-see-again-thanks-to-new-...

Thanks, that sure clears things up!

I see what you did there :)

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