Improving glaucoma management for the Boston keratoprosthesis type 1: tubes versus lasers

Introduction: The Boston Keratoprosthesis (KPro) is the most used artificial cornea. It restores vision in patients with a poor prognosis with penetrating keratoplasty. Significant improvements have occurred recently in terms of implant design and postoperative care. Nonetheless, glaucoma remains the primary reason for vision loss after KPro implantation. Management of inflammation and intraocular pressure (IOP) is challenging in KPro eyes. Progressive optic nerve damage often persists in spite of medical and surgical interventions. Significant efforts are being invested to determine the best management, even when IOP is controlled. Glaucoma drainage devices (GDD) implanted during KPro surgery could offer beneficial visual outcomes. Cyclophotocoagulation (CPC) may be reserved for end-staged glaucoma. Areas covered: This review highlights glaucoma mechanisms in KPro eyes, the need to better monitor and treat glaucoma in KPro patients, and the latest innovation strategies. Recent data on current options and timing for GDD and CPC are discussed. Expert opinion: Implantation of GDD before or during KPro surgery reduces the risk of glaucoma progression compared to CPC. Future developments could offer KPro implants integrated with drainage devices and IOP sensors. Targeted control of inflammation will be the next novel strategy to reduce optic nerve damage occurring despite appropriate IOP control.