Professional Statements and Societal Positions Guidelines
American Academy of Opthalmology-2018
The 2018 Preferred Practice Parameter on ocular edema and opacification by the American Academy of Ophthalmology did not provide specific recommendations on the keratoprosthesis, but discussed the technology and its current use:
"Significant improvements in the design and postoperative management of the Boston type 1 keratoprosthesis has resulted in a steady rise in the number of these procedures performed both in the United States and abroad. Reduced incidence of postoperative stromal necrosis and bacterial endophthalmitis due to the chronic use of protective soft contact lenses and topical antibiotics has resulted in improved retention and visual outcomes and has had a positive impact on surgeons' perceptions of when to recommend keratoprosthesis. Once considered a procedure of last resort in patients with severe bilateral visual impairment, it is now being used for a variety of unilateral and bilateral indications, such as ocular trauma, herpetic keratitis, aniridia, and Stevens-Johnson syndrome. More recently, as corneal surgeons have gained a greater appreciation of the failure rate of repeat corneal transplantation, a role for a keratoprosthetic in cases of multiple graft failure has become clearer. Despite earlier suggestions, keratoprosthetics are not considered ideal for pediatric cases, particularly as primary treatment....
"Individuals with severe dry eye and autoimmune ocular surface diseases...remain a difficult management group despite the other successes of the Boston type 1 keratoprosthetic. Primary placement of the Boston keratoprosthesis in this group of individuals results in a higher rate of epithelial defects, scleral and corneal necrosis, extrusion, and endophthalmitis. Some surgeons advocate ocular surface reconstruction with combined keratolimbal allografts or living related allografts prior to placement of the keratoprosthesis. This can potentially lead to improved outcomes in this group. The Boston type 2 keratoprosthetic designed to be used through the eyelid and the osteo-odonto-keratoprosthesis have been implanted with some success in this group of individuals."
American Academy of Ophthalmology-2009
In 2009, the American Academy of Ophthalmology (AAO) published a position paper on endothelial keratoplasty, stating that the optical advantages, speed of visual rehabilitation, and lower risk of catastrophic wound failure have driven the adoption of endothelial keratoplasty as the standard of care for individuals with endothelial failure and otherwise healthy corneas. The 2009 AAO position paper was based in large part on an AAO comprehensive review of the literature on Descemet stripping automated endothelial keratoplasty. AAO concluded that "the evidence reviewed suggests Descemet stripping automated endothelial keratoplasty appears safe and efficacious for the treatment of endothelial diseases of the cornea. Evidence from retrospective and prospective Descemet stripping automated endothelial keratoplasty reports described a variety of complications from the procedure, but these complications do not appear to be permanently sight threatening or detrimental to the ultimate vision recovery in the majority of cases. Long-term data on endothelial cell survival and the risk of late endothelial rejection cannot be determined with this review." "Descemet stripping automated endothelial keratoplasty should not be used in lieu of penetrating keratoplasty for conditions with concurrent endothelial disease and anterior corneal disease. These situations would include concurrent anterior corneal dystrophies, anterior corneal scars from trauma or prior infection, and ectasia after previous laser vision correction surgery."
