Let there be light, and there was light
Picture, if you will, having irrevocably lost the sight of one eye in an industrial accident and the realisation that you will progressively loose the sight in the other eye in a few years.
You have a wife on whom you become increasingly dependent and money gets tighter. You have two baby sons, but by now your one “good” eye is so poor you can’t even distinguish one son from the other. As they grow they want to share with you their experiences, their school drawings and to be read by you. But you can’t. You are despairing; you are willing to have any treatment that offers at least some hope, but you are allergic to many things, your body reacting against all manner of agents, including the anaesthetic gases and drugs needed to perform operations, drugs to counter rejection by your body and cleaning agents used to sterilize surgical equipment and materials. Your last surgical procedure resulted in anaphylactic shock; you barely survived it. But then you are told of another somewhat bizarre operation. It involves embedding a plastic lens into one of your teeth and then the tooth into your eye – toothless patients need not apply!
The “picture” described above was reality for Ian Tibbetts, a 43 year old man from Telford. In October last year a BBC documentary entitled “The Day I Got my Sight Back” was broadcast. It described the technique known as osteo-odonto-keratoprothsesis, or OOKP, and told of Mr Tibbetts’ courageous story from the first possibility that OOKP might provide some relief through to recovered sight and how the skills of Professor Christopher Liu and his team at the Sussex Eye Hospital in Brighton that made it all possible. Along the way two other patients related their experiences and the tremendous improvements in quality of life that the technique has made to them.
OOKP was invented in Rome in the early sixties. Since then the technique has slowly spread but even now is rarely performed; in the whole of Britain only five or six patients receive it annually, all in the Sussex Eye Hospital (SEH). Compare this with, for example, the 3000 cataract transplants a year performed in SEH. OOKP is used when the eye is so damaged that a cornea transplant won’t work. The solution is to replace the cornea with a plastic lens to focus the image on the retina, which is the photo-sensitive back part of the eye that translates the light into electrical impulses for the optic nerve to transmit to the brain. However, one of the defence mechanisms that the body uses to protect us is the immune system. So how to hold the lens securely without the immune system rejecting either the plastic lens, or the “holder” needed to maintain positional stability? The answer is to not use alien material. Instead, take a canine tooth from the patient and use that as the “holder” or “frame”. Shape it, drill a hole through it to receive the lens, remove much of the internal structures from the front of the eye to make room for the lens and insert the whole onto the eye. And, to stop it falling out, remove a small “sheet” of skin from inside the patient’s mouth and place it over the cornea-replacement.
The surgery is in two stages, separated by four months. Stage One involves the removal of a tooth, with part of the jaw bone attached, from the patient's mouth. It is cut to shape, the hole drilled and the plastic lens inserted into it. This is then inserted into a pouch cut in the flesh under the non-operated eye, while a flap of skin is removed from the inside of the cheek and stitched on to the front of the eye due to receive the tooth.
When the bone material has developed a blood supply, Stage Two is carried out. Part of the cornea, the iris, the crystalline lens, and the vitreous (the gel inside the eye) are removed. The tooth and attached bone lamina is then cut out of the pouch and stitched onto the eye, where it is covered by the piece of cheek skin.
In the case of Mr Tibbetts special care had to be taken to minimize his allergic reactions. Even so he had a major reaction during the first Stage. During the four months pause further allergic tests were conducted, non-allergic products found and with their use the conduct of second Stage proved uneventful.
The technical success rate is close to 100 per cent, with about 70% seeing well for a very long time. Commonly the bandaging will be removed the morning after the second operation and the patient will see immediately. Unfortunately for Ian, there was no miraculous moment of restored sight. He recalled: "My chin just hit the floor. I went right on a downer. I was hoping to see for their [my sons’] birthday.”
But just a few weeks later, when the stitches were removed, he began to make out shapes, colours and movement. And then – finally – for the first time he could see his sons, Callum and Ryan. "I had a picture in my head of what they looked like but they were better. The image in my mind was totally different to how they were – the features. I gave them a big hug and a kiss".
But whilst there are obvious physical challenges to overcome, some of the greatest obstacles to success are mental. Potential patients, who may have seen nothing for decades, undergo psychological tests to assess whether they are robust enough to withstand the procedure and its stark cosmetic consequences. The eye looks very different; the whole eye is red with just a black dot in the centre, so dark glasses are often worn in company. In addition, the injury that caused the near-blindness may have damaged the patient's face so he or she may find it distressing to look at. Indeed other people may also have been scarred by the same incident, or have changed as a result of lifestyle or the ageing process.
Professor Liu said that the outcome is dependent on the degree of eye damage before OOKP, and that there can be future and unexpected setbacks. Yet Ian has no doubt that others in his position should have the operation. Professor Liu agreed. "It is always a joy, of course, that a patient can see," he said. However, his advice to all those he treats is the same: "Please enjoy every day you have your sight, but plan your life as if your sight will not last for ever," he adds.
OOKP was first developed in the 1960s but it, like almost all science-based developments that impact the quality of human life, are subject to increasingly rigorous testing that invariably involves comparative studies with control groups sufficient to achieve proof by statistical probability. How do you achieve approval when the numbers of patients are so low and the control group is consigned to blindness? Prof Liu overcame the conundrum when seeking to use OOKP in this country by persuasive and persistent arguments. Today the only British hospital offering OOKP surgery is the SEH, under the direction of Prof Liu. Indeed his expertise is widely sought and he travels the world delivering papers on the subject, including offering support in obtaining approval more widely. Of course he and his fellow surgeons carry out many other operations as well, the Hospital is widely considered the premier teaching hospital of the South Coast.
And the connection with Freemasonry? Prof Liu, who was born in Hong Kong, is also a Past Master of Royal Clarence Lodge No. 271, meeting just down the road from SEH. Amongst his activities in support of the Lodge, Bro Liu has proposed into the Lodge three medical students, the last of which was initiated on the 14th February this year. In conversation over the Festive Board they spoke of their exploits in Sierra Leone, providing medical assistance to the many in need.
But more of that in the next issue ….
Bro Liu has also written a book, “The Eyes Have It: A personal View”, from which much of the background material for this article was drawn. It provides interesting insights into eye surgery in the 19th century, the building of the SEH by Sussex Freemasons in 1933-5 and a good grounding in the development of ophthalmology to date. For those with an interest, copies can be purchased at list price of £14.99 from Professor Liu directly via This email address is being protected from spambots. You need JavaScript enabled to view it. .
