Management of glaucoma with Boston type 1 keratoprosthesis

Patients who underwent keratoprosthesis surgery between June 2010 and January 2020 were retrospectively evaluated for glaucoma association and prognoses.

Results:

Among 17 patients who underwent keratoprosthesis surgery, 9 (52.9%) were associated with underlying or keratoprosthesis-induced glaucoma. Five eyes (29.4%) had underlying glaucoma and underwent a glaucoma drainage device implantation at least 6 months before keratoprosthesis surgery. One eye (5.9%) with normal intraocular pressure had glaucoma drainage device implantation at the same session with keratoprosthesis surgery due to high-risk characteristics of anterior segment structures. Four eyes with preexisting glaucoma showed progression after keratoprosthesis surgery. Additional antiglaucomatous treatment was commenced in two eyes whereas implantation of 2^nd glaucoma drainage device was performed in two eyes. Postoperative complications in three eyes (100%) with glaucoma drainage device implanted 6 months before or at the same session with aphakic type keratoprosthesis surgery with partial vitrectomy included rhegmatogenous retinal detachment in two eyes and bacterial endophthalmitis in one eye. Migration of silicone oil through the tube to the subconjunctival area was seen after pars plana vitrectomy in one eye. None of the three eyes (0%) that underwent glaucoma drainage device implantation years before keratoprosthesis surgery experienced a posterior segment complication other than glaucomatous progression. Out of 11 eyes with no previous history of glaucoma, 3 (27.3%) showed high intraocular pressure and glaucomatous disc changes after keratoprosthesis surgery, which could be pharmacologically controlled.

Conclusions:

In this cohort, eyes with preexisting glaucoma were more difficult to manage compared to eyes with de novo glaucoma after keratoprosthesis surgery. Retinal complications appeared more often when glaucoma drainage device implantation was performed no more than 6 months before aphakic type keratoprosthesis surgery with partial vitrectomy.

Keywords:
Glaucoma/surgery; Intraocular pressure; Postoperative complication; Prosthesis implantation; Glaucoma drainage implant

Patient #	Gender	Age	Etiology	Pre-Kpro corneal graft #	Follow-up after Kpro surgery	Initial BCVA	Final BCVA	Best-ever BCVA	Final exam notes
1	F	41	KCN, multiple graft failure, decentralized PCIOL	4	3 years	10 cmcf	0.5	1.0	Kpro intact, aphakic, subconjunctival SO, retina flat after PPV for RRD and SO removal, thin ERM, c/d 0.4, 2 GDDs
2	M	59	Bullous keratopathy, multiple graft failure, decentralized PCIOL Multiple graft failure,aphakic	2	4.5 years	HM	LP	0.6	Kpro intact, aphakic, closed tunnel retinal detachment due to endophthalmitis Kpro intact, aphakic,c/d 0.9, 2 GDDs
3	F	42	Multiple graft failure,aphakic	3	3 years	HM	0.5	0.5	Kpro intact, aphakic,c/d 0.9, 2 GDDs
4	M	78	Trachoma, multiple graft failure, decentralized PCIOL	2	3 years	LP	0.05	0.3	Kpro intact, aphakic, retina flat after PPV for RRD, c/d 0.3
5	M	64	KCN, multiple graft failure, PCIOL	2	3.5 years	1 mcf	0.4	0.6	Kpro intact, pseudophakic, c/d 0.7 Severely constricted VF
6	M	69	Severe LSCD due to topical antiglaucomatious drugs use, PCIOL	0	2.5 years	HM	0.1	0.3	Kpro intact, pseudophakic, c/d 0.9–1.0
7	M	47	Chemical burn, graft failure, decentralized PCIOL	2	3.5 years	HM	0.7	0.7	Kpro intact, aphakic, c/d 0.9,Severely constricted VF
8	M	47	VKC, KCN, multiple graft failure, PCIOL	3	3 years	HM	0.7	1.0	Kpro intact, pseudophakic, c/d 0.4, Severely constricted VF
9	F	51	Severe AKC, multiple graft failure, nuclear cataract	4	1 year	10 cmcf	0.1	0.4	Kpro intact, aphakic, c/d 0.5

Patient #	History of glaucoma before Kpro	Time for GDD implantation with respect to Kpro	Pre-Kpro IOP (mmHg)	Pre-GDD IOP* (mmHg)	Post-GDD final IOP* (mmHg)	Final antiglaucomatous medication	Other comments
1	Yes	Six months before and three years after	18	20	12	None	Postoperative RRD, treated with PPV. Silicone oil occluded the GDD. 2^nd GDD implanted
2	Yes	Six months before	12	28	10	None	No further IOP elevation
3	Yes	1.5 year before and six months after	15	24	12	dorzolamide 2% + timolol 0.5% brimonidine 0.15 % travoprost 0.004 %	A session of transscleral CPC performed for IOP elevation; but no permanent effect. 2^nd GDD implanted.
4	No	At the same session with Kpro implantation	20	20	9	None	Postoperative RRD, treated with PPV. Remained hypotonic thereafter.
6	Yes	Two years before	14	Unknown	22	brinzolamide 1% + timolol 0.5% brimonidine 0.15 % travoprost 0.004 %	Additional topical antiglaucomatous treatment for IOP control
7	Yes	Seven years before	12	Unknown	15	brinzolamide 1% + timolol 0.5 %acetazolamide 250 mg (qd)	GDD surgery was recommended but denied due to “high risk” characteristics of ocular surface disease

Patient #	History of glaucoma before Kpro	Time for GDD implantation with respect to Kpro	Follow-up after Kpro surgery	Pre-Kpro IOP (mmHg)	Final IOP ^* * Final IOPs were measured through the temporal sclera by TonoPen® as described in the text. (mmHg)	Final antiglaucomatous medication
5	No	None	3.5 years	17	11	dorzolamide 2% + timolol 0.5%brimonidine 0.15% latanaprost 0.005%
8	No	None	3 years	12	14	dorzolamide 2% + timolol 0.5%brimonidine 0.15%
9	No	None	1 year	12	17	brinzolamide 1% + timolol 0.5%brimonidine 0.15% High IOP attacks were managed with I.V. mannitol and P.O. acetazolamide

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[1] Corresponding author: Canan Asli Utine. E-mail: cananutine@gmail.com