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Artificial corneal transplantation, commonly referred to as keratoprosthesis, represents a transformative advancement in the management of severe corneal blindness, particularly when conventional penetrating or lamellar keratoplasty is unlikely to succeed. Conditions such as multiple failed corneal grafts, severe ocular surface disease, limbal stem cell deficiency, chemical injuries, and autoimmune cicatrizing disorders often leave clinicians with limited therapeutic options. In such complex scenarios, artificial corneal transplantation offers the potential to restore vision and improve quality of life in otherwise visually debilitating conditions. This activity provides a comprehensive, clinically focused overview of artificial corneal transplantation, including indications; patient selection criteria; device types, such as the Boston Keratoprosthesis and other evolving designs; surgical principles; postoperative care; and long-term outcomes. Learners can expect a detailed discussion of preoperative evaluation, perioperative decision-making, complication prevention, and management of sight-threatening adverse events, including glaucoma, retroprosthetic membrane formation, infection, and device extrusion. Emphasis is placed on evidence-based practices and current consensus guidelines. Participation in this activity highlights the critical role of the interprofessional healthcare team, including cornea specialists, glaucoma specialists, retina surgeons, anaesthesiologists, optometrists, nurses, pharmacists, and rehabilitation professionals. Through coordinated care, shared decision-making, and vigilant long-term follow-up, the team enhances patient safety, surgical success, and visual outcomes. This activity is designed to strengthen clinical competence, promote collaborative practice, and equip healthcare professionals with the skills necessary to manage one of the most challenging areas in modern corneal surgery. Objectives: Differentiate between types of keratoprosthesis devices. Identify the indications for artificial corneal transplantation. Assess the most common adverse events associated with artificial corneal transplantation. Collaborate with multidisciplinary teams, including cornea specialists, glaucoma and retina surgeons, anesthesiologists, oral surgeons, and nurses, to optimize outcomes. Access free multiple choice questions on this topic.

Approximately 4.9 million people worldwide have bilateral blindness secondary to corneal disease, accounting for 12% of total global blindness.[1][2] Common causes include anterior corneal pathologies such as trachoma, infectious keratitis, ocular trauma, and chemical injuries, with high prevalence in developing countries.[3] Advances in corneal transplantation have dramatically improved visual rehabilitation; in non-complex eyes, primary corneal transplantation, either lamellar or penetrating keratoplasty, demonstrates excellent outcomes, with reported graft survival rates of 87% to 93% at 1 year and 72% to 73% at 5 years.[4] However, graft survival declines significantly with repeat transplantation and in complex ocular surface disease, despite refinements in surgical technique and tissue selectivity.[5][6] High-risk factors include recurrent or chronic ocular surface inflammation, glaucoma, and corneal vascularisation. Globally, the availability of donor corneal tissue can be limited by donor supply and the need for eye banking facilities. Modern lamellar corneal transplantation techniques aim to replace the non-functional or diseased part of the cornea. An artificial cornea transplant can be considered for end-stage corneal diseases such as multiple graft failures or inflammatory ocular surface disease. Bioengineered corneal endothelial therapies aim to restore native corneal physiology by replacing or regenerating dysfunctional endothelium using cell-based constructs, biomimetic scaffolds, or synthetic membranes.[7] These approaches preserve the host cornea, maintain immune privilege, and integrate with established lamellar techniques such as DMEK (descemet membrane endothelial keratoplasty), offering the potential for lower complication rates and more physiological outcomes.[8][9] In contrast, traditional keratoprostheses were developed to address end-stage corneal blindness where grafting fails, relying on rigid artificial optics that bypass biological integration. Although keratoprostheses provide vision in severe cases, they are associated with significant long-term complications, including glaucoma, infection, extrusion, and lifelong surveillance.[10][11] Overall, bioengineered endothelial strategies represent a regenerative, tissue-preserving evolution, whereas keratoprostheses remain a salvage solution for complex corneal disease.

Bioengineered corneal endothelial therapies aim to restore native corneal physiology by replacing or regenerating dysfunctional endothelium using cell-based constructs, biomimetic scaffolds, or synthetic membranes.[7] These approaches preserve the host cornea, maintain immune privilege, and integrate with established lamellar techniques such as DMEK (descemet membrane endothelial keratoplasty), offering the potential for lower complication rates and more physiological outcomes.[8][9] In contrast, traditional keratoprostheses were developed to address end-stage corneal blindness where grafting fails, relying on rigid artificial optics that bypass biological integration. Although keratoprostheses provide vision in severe cases, they are associated with significant long-term complications, including glaucoma, infection, extrusion, and lifelong surveillance.[10][11] Overall, bioengineered endothelial strategies represent a regenerative, tissue-preserving evolution, whereas keratoprostheses remain a salvage solution for complex corneal disease. Numerous artificial corneal transplant devices have been proposed, including keratoprosthesis (KPro). Pellier de Quengsy first described the initial concept in 1789.[12] These devices generally have a central, clear optic with either hard skirt plates that sandwich donor corneal tissue or a soft optic and skirt in a one-piece integrated design. The importance of a suitable skirt material with good tissue incorporation was made clear from earlier models made from rubber, milk protein, Dacron, crystal, glass, and celluloid, which resulted in device extrusion after implantation.[4] The successful introduction of cadaveric corneal transplantation resulted in decreased interest in artificial corneal transplantation. However, the discovery of polymethylmethacrylate enabled the implantation of a biocompatible device, and earlier devices have been described by Choyce and Stone.[13][14]

Numerous artificial corneal transplant devices have been proposed, including keratoprosthesis (KPro). Pellier de Quengsy first described the initial concept in 1789.[12] These devices generally have a central, clear optic with either hard skirt plates that sandwich donor corneal tissue or a soft optic and skirt in a one-piece integrated design. The importance of a suitable skirt material with good tissue incorporation was made clear from earlier models made from rubber, milk protein, Dacron, crystal, glass, and celluloid, which resulted in device extrusion after implantation.[4] The successful introduction of cadaveric corneal transplantation resulted in decreased interest in artificial corneal transplantation. However, the discovery of polymethylmethacrylate enabled the implantation of a biocompatible device, and earlier devices have been described by Choyce and Stone.[13][14] More recently, soft polymers have been used to simulate the natural cornea. Poly-2-hydroxyethyl methacrylate was used for the AlphaCor, which gained FDA approval in 2003.[15] After 1 and 2 years, retention rates were 80% and 62%, respectively, and stromal melt occurred in 27% of cases, many of which required explantation.[15] A similar design using polytetrafluoroethylene (Legeais BioKPro-III) had worse outcomes, with 86% of devices failing after implantation.[16] This review focuses on the indications and management of the most commonly used artificial cornea transplants currently in practice—the Boston KPro type 1 and the osteo-odonto-Keratoprosthesis (OOKP). Keratoprostheses

More recently, soft polymers have been used to simulate the natural cornea. Poly-2-hydroxyethyl methacrylate was used for the AlphaCor, which gained FDA approval in 2003.[15] After 1 and 2 years, retention rates were 80% and 62%, respectively, and stromal melt occurred in 27% of cases, many of which required explantation.[15] A similar design using polytetrafluoroethylene (Legeais BioKPro-III) had worse outcomes, with 86% of devices failing after implantation.[16] This review focuses on the indications and management of the most commonly used artificial cornea transplants currently in practice—the Boston KPro type 1 and the osteo-odonto-Keratoprosthesis (OOKP). Keratoprostheses Boston keratoprosthesis type I: The Boston KPro type 1 is the most widely implanted artificial cornea. First introduced by Dohlman in 1965, the device was approved by the FDA in 1992.[17] The use of Boston KPro type 1 began to increase at the beginning of the 21st century, and to date, more than 19,000 devices have been implanted worldwide. The design consists of a front plate with a central optical stem, a backplate, and a corneal donor button sandwiched in between. The front plate and optic are made from polymethylmethacrylate, and the optical power is determined by the radius of curvature. Originally, the backplate was screwed into place; this was refined with a titanium locking ring in 2003 and a threadless stem in 2007.[17] The backplate is available in polymethylmethacrylate and titanium, both of which are well-tolerated biologically. No difference in the frequency of retroprosthetic membrane formation between the 2 materials was reported at 12 months.[18]

Boston keratoprosthesis type I: The Boston KPro type 1 is the most widely implanted artificial cornea. First introduced by Dohlman in 1965, the device was approved by the FDA in 1992.[17] The use of Boston KPro type 1 began to increase at the beginning of the 21st century, and to date, more than 19,000 devices have been implanted worldwide. The design consists of a front plate with a central optical stem, a backplate, and a corneal donor button sandwiched in between. The front plate and optic are made from polymethylmethacrylate, and the optical power is determined by the radius of curvature. Originally, the backplate was screwed into place; this was refined with a titanium locking ring in 2003 and a threadless stem in 2007.[17] The backplate is available in polymethylmethacrylate and titanium, both of which are well-tolerated biologically. No difference in the frequency of retroprosthetic membrane formation between the 2 materials was reported at 12 months.[18] Osteo-odonto-keratoprosthesis: The OOKP uses an autologous tooth root-alveolar bone complex as the keratoprosthesis skirt material for better tissue integration. Originally invented by Strampelli and later modified by Falcinelli et al, the OOKP procedure involves bypassing the diseased ocular surface with a buccal mucous membrane patch and replacing the anterior segment structures with the OOKP.[19] The mucous membrane patch can tolerate dry environmental conditions and some level of inflammation. Good tissue integration ensures that OOKP can be retained for several decades.[20] Long-term anatomical retention of OOKP is favorable, with 81% reported retention rates of 81% over 5 years in 36 eyes, 98% over 20 years in 85 patients, and 80% over 18 years in 224 eyes.[19][21][22] Keratoprostheses in Development

Osteo-odonto-keratoprosthesis: The OOKP uses an autologous tooth root-alveolar bone complex as the keratoprosthesis skirt material for better tissue integration. Originally invented by Strampelli and later modified by Falcinelli et al, the OOKP procedure involves bypassing the diseased ocular surface with a buccal mucous membrane patch and replacing the anterior segment structures with the OOKP.[19] The mucous membrane patch can tolerate dry environmental conditions and some level of inflammation. Good tissue integration ensures that OOKP can be retained for several decades.[20] Long-term anatomical retention of OOKP is favorable, with 81% reported retention rates of 81% over 5 years in 36 eyes, 98% over 20 years in 85 patients, and 80% over 18 years in 224 eyes.[19][21][22] Keratoprostheses in Development Several alternative keratoprostheses are currently in development.[23][24] Studies have found that 5-year survival, both for anatomical retention and functional recovery, was higher with the Boston type 1 KPro than with the Aurolab keratoprosthesis; however, these differences were not statistically significant.[25][26] Therefore, the Aurolab keratoprosthesis can be an alternative to the Boston type 1 KPro when affordability or availability is limited. The Lucia keratoprosthesis is a modified version of the Boston Type 1 KPro to improve affordability. [27] Machinist time was reduced by changing the locking interface between the front and backplates. Photoetching was used instead of using a lathe, and the round holes in the backplate were replaced with petaloid radial slits. Anodised titanium enabled colour changes to the backplate for improved cosmesis.

Several alternative keratoprostheses are currently in development.[23][24] Studies have found that 5-year survival, both for anatomical retention and functional recovery, was higher with the Boston type 1 KPro than with the Aurolab keratoprosthesis; however, these differences were not statistically significant.[25][26] Therefore, the Aurolab keratoprosthesis can be an alternative to the Boston type 1 KPro when affordability or availability is limited. The Lucia keratoprosthesis is a modified version of the Boston Type 1 KPro to improve affordability. [27] Machinist time was reduced by changing the locking interface between the front and backplates. Photoetching was used instead of using a lathe, and the round holes in the backplate were replaced with petaloid radial slits. Anodised titanium enabled colour changes to the backplate for improved cosmesis. Several different keratoprostheses for eyes with defective blinking, dry eyes, or cicatrization are being evaluated. The Lux keratoprosthesis consists of a cone-shaped polymethylmethacrylate cylinder, a titanium sleeve, and a 7.8 mm titanium backplate. A donor cornea is double trephined, with a central trephination at 3 mm and a peripheral trephination at 7.5 mm. The polymethylmethacrylate cylinder is secured in the titanium sleeve and placed through the central 3 mm opening in the donor cornea. The backplate is secured and sutured into place in the host after the patient's cornea is removed, using interrupted nylon sutures. A mucous membrane graft is sutured over with an opening for the polymethylmethacrylate cylinder optic. Short-term results with good retention and functional outcomes have been reported.[23] Improvements in skirt materials may further enhance the development of keratoprosthesis. The OOKP is at risk of bone resorption, and a synthetic substitute comprising a hydrogel composite of nano-crystalline hydroxyapatite–coated poly(lactic-co-glycolic acid) microspheres has been evaluated in laboratory studies. A graphene oxide titania-based biomaterial has been implanted in vivo in rabbit corneas without causing an immune or inflammatory reaction, suggesting potential as a novel skirt material for keratoprostheses.[28]

Improvements in skirt materials may further enhance the development of keratoprosthesis. The OOKP is at risk of bone resorption, and a synthetic substitute comprising a hydrogel composite of nano-crystalline hydroxyapatite–coated poly(lactic-co-glycolic acid) microspheres has been evaluated in laboratory studies. A graphene oxide titania-based biomaterial has been implanted in vivo in rabbit corneas without causing an immune or inflammatory reaction, suggesting potential as a novel skirt material for keratoprostheses.[28] Eyes considered high-risk for graft failure commonly exhibit recurrent or chronic ocular surface inflammation, corneal neovascularization, glaucoma, limbal stem cell deficiency, or severe cicatrization. In addition, global donor corneal shortages and the dependence on well-developed eye banking infrastructure further limit access to conventional keratoplasty in many regions. Although modern lamellar techniques aim to selectively replace diseased corneal layers while preserving host tissue, these approaches may still fail in eyes with severe surface pathology or repeated immunologic rejection. In such end-stage corneal diseases, artificial corneal transplantation (keratoprosthesis) represents a critical alternative for visual rehabilitation.[29]

Eyes considered high-risk for graft failure commonly exhibit recurrent or chronic ocular surface inflammation, corneal neovascularization, glaucoma, limbal stem cell deficiency, or severe cicatrization. In addition, global donor corneal shortages and the dependence on well-developed eye banking infrastructure further limit access to conventional keratoplasty in many regions. Although modern lamellar techniques aim to selectively replace diseased corneal layers while preserving host tissue, these approaches may still fail in eyes with severe surface pathology or repeated immunologic rejection. In such end-stage corneal diseases, artificial corneal transplantation (keratoprosthesis) represents a critical alternative for visual rehabilitation.[29] Parallel to the development of keratoprosthesis, bioengineered corneal endothelial therapies have emerged as a regenerative strategy to restore native corneal physiology. These strategies include cell-based endothelial replacement, biomimetic scaffolds, and synthetic membranes designed to integrate with host tissue while maintaining immune privilege. When combined with lamellar approaches such as DMEK, these therapies offer the potential for lower complication rates and more physiological outcomes. However, their applicability remains limited to eyes with relatively preserved corneal architecture and ocular surface stability. In contrast, keratoprostheses were specifically designed for end-stage corneal blindness, where biological integration is no longer feasible. While they can provide dramatic visual recovery, they are associated with substantial long-term risks, including glaucoma progression, infection, extrusion, and the need for lifelong surveillance. Thus, regenerative endothelial therapies represent an evolution toward tissue preservation, whereas keratoprostheses remain a salvage solution for the most complex corneal disease.[30]

Parallel to the development of keratoprosthesis, bioengineered corneal endothelial therapies have emerged as a regenerative strategy to restore native corneal physiology. These strategies include cell-based endothelial replacement, biomimetic scaffolds, and synthetic membranes designed to integrate with host tissue while maintaining immune privilege. When combined with lamellar approaches such as DMEK, these therapies offer the potential for lower complication rates and more physiological outcomes. However, their applicability remains limited to eyes with relatively preserved corneal architecture and ocular surface stability. In contrast, keratoprostheses were specifically designed for end-stage corneal blindness, where biological integration is no longer feasible. While they can provide dramatic visual recovery, they are associated with substantial long-term risks, including glaucoma progression, infection, extrusion, and the need for lifelong surveillance. Thus, regenerative endothelial therapies represent an evolution toward tissue preservation, whereas keratoprostheses remain a salvage solution for the most complex corneal disease.[30] The concept of artificial corneal transplantation dates back to Pellier de Quengsy in 1789, marking one of the earliest attempts to replace opaque corneal tissue with a synthetic optical substitute. Most keratoprostheses consist of a central transparent optic combined with a surrounding skirt that anchors the device to host tissue, either by sandwiching donor cornea or by direct tissue integration. Early devices fabricated from materials such as rubber, glass, crystal, milk protein, Dacron, and celluloid failed due to poor biocompatibility and high extrusion rates, underscoring the importance of selecting the skirt material. With the success of cadaveric corneal transplantation, interest in artificial corneas declined temporarily until the advent of polymethylmethacrylate enabled the development of more biocompatible devices, including early designs by Choyce and Stone.[31]

The concept of artificial corneal transplantation dates back to Pellier de Quengsy in 1789, marking one of the earliest attempts to replace opaque corneal tissue with a synthetic optical substitute. Most keratoprostheses consist of a central transparent optic combined with a surrounding skirt that anchors the device to host tissue, either by sandwiching donor cornea or by direct tissue integration. Early devices fabricated from materials such as rubber, glass, crystal, milk protein, Dacron, and celluloid failed due to poor biocompatibility and high extrusion rates, underscoring the importance of selecting the skirt material. With the success of cadaveric corneal transplantation, interest in artificial corneas declined temporarily until the advent of polymethylmethacrylate enabled the development of more biocompatible devices, including early designs by Choyce and Stone.[31] Subsequent innovations explored soft polymer optics to better simulate the natural cornea. Poly-2-hydroxyethyl methacrylate, used in the AlphaCor device (approved by the Food and Drug Administration (FDA) in 2003), demonstrated retention rates of 80% at 1 year and 62% at 2 years but was limited by stromal melt in 27% of cases, often necessitating explantation. Other designs, such as the Legeais BioKPro-III using polytetrafluoroethylene, showed even poorer outcomes, with failure rates as high as 86%.[15] As a result, contemporary practice has largely converged on two established devices—the Boston KPro type I and the OOKP.[32] The Boston KPro type I, first introduced by Dohlman in 1965 and FDA approved in 1992, is currently the most widely implanted keratoprosthesis, with over 19,000 devices implanted worldwide. The modular design of Boston KPro type I—consisting of a polymethylmethacrylate front plate with optical stem, a backplate, and an intervening donor corneal button—has undergone iterative refinements, including the introduction of a titanium locking ring and a threadless stem to improve stability and reduce complications. Both polymethylmethacrylate and titanium backplates demonstrate good biocompatibility, with no significant difference in retroprosthetic membrane formation at 1 year.[7]

The Boston KPro type I, first introduced by Dohlman in 1965 and FDA approved in 1992, is currently the most widely implanted keratoprosthesis, with over 19,000 devices implanted worldwide. The modular design of Boston KPro type I—consisting of a polymethylmethacrylate front plate with optical stem, a backplate, and an intervening donor corneal button—has undergone iterative refinements, including the introduction of a titanium locking ring and a threadless stem to improve stability and reduce complications. Both polymethylmethacrylate and titanium backplates demonstrate good biocompatibility, with no significant difference in retroprosthetic membrane formation at 1 year.[7] The OOKP represents a fundamentally different approach, using an autologous tooth root-alveolar bone complex as the skirt material to achieve superior tissue integration. Originally described by Strampelli and later refined by Falcinelli, the OOKP bypasses the diseased ocular surface using a buccal mucous membrane graft and replaces the anterior segment with a biologically integrated optical system. The ability of OOKP to tolerate severe dryness and inflammation has led to exceptional long-term retention, with reported anatomical survival rates of 80% to 98% over follow-up periods up to 20 years.[30] Beyond these established devices, multiple keratoprostheses remain under development, including the Aurolab, Lucia, and Lux keratoprostheses, which aim to improve affordability, accessibility, and performance in resource-limited settings. Innovations in skirt materials, such as nano-crystalline hydroxyapatite–coated polymers and graphene oxide-titania composites, show promise in enhancing tissue integration while reducing inflammatory responses, potentially addressing longstanding limitations of keratoprosthesis design. Collectively, artificial corneal transplantation occupies a unique and indispensable role in modern corneal surgery, bridging the gap between regenerative approaches and irreversible corneal blindness. Continued refinement of device design, patient selection, and multidisciplinary postoperative care is essential to optimize outcomes in this challenging patient population.[1]

Complications can arise from failure of the KPro to biocolonise (non-epithelization) and biointegrate (corneal melt around the optic). Ongoing inflammation in the anterior chamber and the formation of retroprosthetic membranes are common complications. Corneal melt can lead to leakage and endophthalmitis, which can be repaired with corneal regrafting and autologous cartilage.[70] Higher-risk eyes are those affected by underlying autoimmune conditions. In the United States, the incidence of endophthalmitis with the Boston keratoprosthesis ranges from 1% to 12.5%, whereas internationally it can reach 17%.[71] This condition can lead to complete vision loss. After successful artificial corneal transplantation (all types), glaucoma is the most common complication and can even affect the eyes during late follow-up. High preoperative intraocular pressure and autoimmune diseases, such as mucous membrane pemphigoid and Stevens-Johnson syndrome, lead to a higher risk for glaucoma development and progression. In a recent single-center study of 140 eyes following Boston KPro type I implantation, 24% of eyes developed de novo glaucoma postoperatively.[72] Long-term monitoring for glaucoma development and progression is challenging due to the gross anatomical changes. Anterior segment optical coherence tomography can detect changes associated with glaucoma, such as angle narrowing, and, if the patient has reasonable vision, standard visual field testing can still be performed.[73][74] Several studies have shown that implanting glaucoma drainage devices before or at the time of KPro surgery reduces the risk of glaucoma progression.[75][76] Combined KPro-vitrectomy eyes show a lower incidence of retroprosthetic membrane formation and more stable long-term vision than non-vitrectomised eyes.[77] Incidents of corneal melt, endophthalmitis, and glaucoma requiring surgical intervention increase with follow-up time, and there is a paucity of published data on medium- to long-term outcomes.[78] Complete repeat KPro appears to offer a reduced risk of recurrent melt for the Boston KPro, with localized repair a temporizing measure, and is the only option in cases of device extrusion or severe infection.[79]

Combined KPro-vitrectomy eyes show a lower incidence of retroprosthetic membrane formation and more stable long-term vision than non-vitrectomised eyes.[77] Incidents of corneal melt, endophthalmitis, and glaucoma requiring surgical intervention increase with follow-up time, and there is a paucity of published data on medium- to long-term outcomes.[78] Complete repeat KPro appears to offer a reduced risk of recurrent melt for the Boston KPro, with localized repair a temporizing measure, and is the only option in cases of device extrusion or severe infection.[79] The OOKP is fully biocompatible when using the patient's tooth; however, significant complications may still occur. These complications include oral (buccal mucosa harvesting), oculoplastic, secondary glaucoma, posterior segment, and device extrusion. Vitreoretinal complications include retinal detachment, vitritis, retroprosthetic membrane, vitreous hemorrhage, choroidal detachment, and endophthalmitis.[80][81] Primary vitrectomy during OOKP surgery is sometimes performed to reduce these complications. Mucosal melt and ulceration can lead to exposure of the lamina, necessitating repair with mucosal grafting. Poor oral health and buccal mucosa scarring increase the risk of mucosal ulcers and thinning. Laminar resorption can occur in the setting of anatomical failure and is more pronounced in allografts. Detection is achieved through clinical examination and confirmed with CT imaging.[82] Patients with Stevens-Johnson syndrome are at increased risk of laminar resorption.[83] Artificial corneal transplantation, although vision-restoring in end-stage corneal disease, is associated with a distinct, often higher, complication profile compared to conventional keratoplasty. Complications may be early or late, ocular or device-related, and typically require lifelong surveillance and multidisciplinary management. Many complications are interrelated and may significantly impact long-term visual and anatomical outcomes if not detected early.

Artificial corneal transplantation, although vision-restoring in end-stage corneal disease, is associated with a distinct, often higher, complication profile compared to conventional keratoplasty. Complications may be early or late, ocular or device-related, and typically require lifelong surveillance and multidisciplinary management. Many complications are interrelated and may significantly impact long-term visual and anatomical outcomes if not detected early. The most clinically significant complications include glaucoma progression, retroprosthetic membrane formation, infectious keratitis or endophthalmitis, sterile corneal melt, and device extrusion. Artificial corneal transplantation alters normal ocular anatomy and physiology, including aqueous dynamics, ocular surface defense mechanisms, and immune privilege, predisposing patients to these events. Visual rehabilitation may also be limited by posterior segment complications such as retinal detachment, cystoid macular edema, or optic nerve damage. Long-term success of artificial corneal transplantation depends not only on surgical technique but also on strict adherence to prophylactic medications, regular follow-up, and prompt intervention when complications arise. Table Table 9. Complications of Artificial Corneal Transplantation. Key Clinical Pearls Glaucoma is the most common cause of late vision loss after artificial corneal transplantation and is often difficult to detect due to unreliable IOP measurements. Retroprosthetic membrane formation is common and should be anticipated rather than viewed as a failure. Infection risk persists lifelong, necessitating continuous topical antibiotic prophylaxis. Successful artificial corneal transplantation requires patient selection, education, and rigorous long-term follow-up.

Artificial corneal transplantation with keratoprostheses is a complex, multi-stage procedure that requires expertise, multidisciplinary teams, and resources. The ophthalmologist serves as the primary point of patient assessment, evaluating surgical suitability, identifying risk factors that may influence outcomes, and providing detailed counseling to the patient and family. When assessing suitability for OOKP, consultation with an oral and maxillofacial surgeon is essential. Clinicians can assess the patient's general systemic health. Clinical psychologists can investigate for psychological morbidity, the patient's coping mechanisms, expectations, adaptation to blindness, and the availability of social support in place. Ophthalmology specialty nurses can assist with the procedure and postoperative care. Such interprofessional team coordination contributes to improved outcomes from this procedure.[4] Artificial corneal transplantation is a complex, high-risk, vision-restorative procedure that demands robust interprofessional collaboration to optimize patient outcomes, minimize complications, and ensure long-term device retention. Effective healthcare team performance hinges on clearly defined roles, advanced clinical skills, ethical practice, structured communication, and coordinated longitudinal care. Clinician and Advanced Practitioner Roles Corneal surgeons lead patient selection, surgical execution, and long-term clinical oversight, applying evidence-based criteria to identify appropriate candidates and manage complications such as infection, glaucoma, retroprosthetic membrane formation, and device extrusion. Advanced practitioners support perioperative assessment, continuity of care, and early detection of complications, ensuring adherence to standardized follow-up protocols. Subspecialist collaboration with glaucoma and retina specialists is essential for proactive surveillance and timely intervention in posterior segment or intraocular pressure–related complications.[90] Nursing Contributions

Corneal surgeons lead patient selection, surgical execution, and long-term clinical oversight, applying evidence-based criteria to identify appropriate candidates and manage complications such as infection, glaucoma, retroprosthetic membrane formation, and device extrusion. Advanced practitioners support perioperative assessment, continuity of care, and early detection of complications, ensuring adherence to standardized follow-up protocols. Subspecialist collaboration with glaucoma and retina specialists is essential for proactive surveillance and timely intervention in posterior segment or intraocular pressure–related complications.[90] Nursing Contributions Ophthalmic nurses play a critical role in patient-centered care delivery, emphasizing medication adherence, ocular surface care, and early recognition of adverse events. Nursing responsibilities include postoperative monitoring, reinforcement of infection-prevention strategies, contact lens maintenance, and patient education regarding warning symptoms that require urgent evaluation. Nurses also facilitate communication between patients and the broader care team, improving responsiveness and safety. Pharmacist Responsibilities Clinical pharmacists enhance outcomes through medication optimization and antimicrobial stewardship, particularly in patients requiring lifelong topical antibiotics and adjunctive systemic therapy. Pharmacists assess drug interactions, counsel patients on correct administration techniques, and monitor for medication-related toxicity, thereby improving adherence and reducing preventable adverse events.[91] Allied Health and Rehabilitation Professionals Optometrists and low-vision specialists focus on functional rehabilitation, visual optimization, and quality-of-life enhancement. Their involvement ensures realistic visual expectations, appropriate visual aids, and adaptation strategies for patients with partial visual recovery. Social workers and rehabilitation counselors address psychosocial challenges, access to care, and long-term compliance with follow-up schedules. Interprofessional Communication and Ethics

Optometrists and low-vision specialists focus on functional rehabilitation, visual optimization, and quality-of-life enhancement. Their involvement ensures realistic visual expectations, appropriate visual aids, and adaptation strategies for patients with partial visual recovery. Social workers and rehabilitation counselors address psychosocial challenges, access to care, and long-term compliance with follow-up schedules. Interprofessional Communication and Ethics Structured interprofessional communication—using shared documentation, standardized protocols, and regular case reviews—reduces care fragmentation and enhances patient safety. Ethical responsibilities include informed consent, realistic counseling regarding risks and lifelong surveillance, and equitable access to advanced corneal care. Transparent communication fosters trust, shared decision-making, and sustained patient engagement. Outcome Optimization By integrating surgical expertise, vigilant nursing care, pharmacologic oversight, rehabilitative support, and ethical coordination, the interprofessional healthcare team improves anatomical retention, visual outcomes, patient satisfaction, and overall safety in artificial corneal transplantation.[92]

Artificial corneal transplantation requires coordinated, protocol-driven interventions by an interprofessional healthcare team to reduce morbidity, preserve vision, and ensure long-term device retention. Given the chronic nature of care following keratoprosthesis implantation, team-based interventions extend from the perioperative period through lifelong follow-up.[93] Nursing Interventions Ophthalmic nurses are central to perioperative care, patient education, and longitudinal monitoring. Preoperatively, nurses verify surgical readiness, reinforce ocular hygiene, ensure proper administration of preoperative antibiotics, and educate patients regarding postoperative expectations. Postoperatively, nursing interventions focus on wound assessment, contact lens positioning, medication adherence, and early detection of complications, including infection, inflammation, device instability, or increased ocular discomfort. Nurses also serve as the first point of contact for patients reporting visual changes or ocular symptoms, facilitating timely referral to the surgical team.[94] Allied Health Interventions Optometrists and vision care specialists contribute significantly to functional rehabilitation and surface maintenance. Their interventions include visual acuity monitoring, refractive assessment when applicable, therapeutic contact lens fitting, and evaluation of optic clarity. Low-vision specialists provide adaptive strategies and visual aids to enhance the quality of life, particularly in patients with limited visual recovery or bilateral disease.[62] Clinician-Led Interprofessional Interventions Corneal surgeons oversee surgical planning, postoperative management, and the mitigation of complications. Glaucoma specialists implement proactive intraocular pressure control strategies, recognizing the limitations of conventional tonometry in keratoprosthesis eyes. Retina specialists intervene early for posterior segment complications, including retinal detachment, vitreous opacities, or endophthalmitis, using B-scan ultrasonography and targeted interventions.[95] Pharmacist-Driven Interventions

Corneal surgeons oversee surgical planning, postoperative management, and the mitigation of complications. Glaucoma specialists implement proactive intraocular pressure control strategies, recognizing the limitations of conventional tonometry in keratoprosthesis eyes. Retina specialists intervene early for posterior segment complications, including retinal detachment, vitreous opacities, or endophthalmitis, using B-scan ultrasonography and targeted interventions.[95] Pharmacist-Driven Interventions Clinical pharmacists optimize medication safety and adherence, particularly for lifelong topical antibiotic prophylaxis and systemic immunosuppressive therapy when indicated. Pharmacists identify drug interactions, counsel patients on correct dosing schedules, and support antimicrobial stewardship to reduce resistance and toxicity.[96] Psychosocial and Rehabilitation Interventions Social workers and rehabilitation professionals address barriers to care, including access to medications, transportation for frequent follow-up, and psychosocial stress related to chronic ocular disease. Counseling and vision rehabilitation services support patient adaptation and adherence to long-term care plans.[92] Key Interprofessional Intervention Principle Timely, coordinated interventions across nursing, allied health, and clinician teams are essential to prevent complications, optimize visual outcomes, and ensure durable success following artificial corneal transplantation.[97]

Artificial corneal transplantation requires lifelong, structured monitoring by an interprofessional healthcare team due to the high risk of vision-threatening complications such as infection, glaucoma, retroprosthetic membrane formation, retinal detachment, and device extrusion. Effective collaboration among ophthalmologists, nurses, optometrists, pharmacists, and allied health professionals is essential to ensure patient safety, optimize outcomes, and maintain long-term device retention.[98] Nursing Monitoring and Responsibilities Ophthalmic nurses play a central role in perioperative and long-term surveillance. Preoperatively, nurses reinforce ocular hygiene, medication adherence, and patient education. Postoperatively, they monitor for early warning signs, including ocular pain, redness, discharge, contact lens displacement, or sudden visual decline. Nurses ensure correct administration of topical antibiotics, steroids, and lubricants, and assess compliance with lifelong prophylactic regimens. Prompt escalation of abnormal findings to the surgical team is critical.[31] Optometrists and Vision Care Specialists Optometrists are integral to long-term visual rehabilitation and surveillance, particularly for patients with Boston KPro type I. Their responsibilities include visual acuity monitoring, refraction when applicable, contact lens fitting and maintenance, and early detection of surface complications or device instability. Regular assessment of optic clarity and functional vision aids early identification of retroprosthetic membrane formation.[99] Glaucoma and Retina Team Monitoring Given the high incidence of glaucoma progression after artificial corneal transplantation, glaucoma specialists monitor intraocular pressure using alternative techniques, such as digital palpation and transpalpebral tonometry, and manage medical or surgical intervention as needed. Retina specialists perform serial posterior segment evaluations using B-scan ultrasonography and fundus examination when feasible to detect retinal detachment, vitreoretinal traction, or endophthalmitis.[100] Pharmacist and Medication Oversight

Given the high incidence of glaucoma progression after artificial corneal transplantation, glaucoma specialists monitor intraocular pressure using alternative techniques, such as digital palpation and transpalpebral tonometry, and manage medical or surgical intervention as needed. Retina specialists perform serial posterior segment evaluations using B-scan ultrasonography and fundus examination when feasible to detect retinal detachment, vitreoretinal traction, or endophthalmitis.[100] Pharmacist and Medication Oversight Clinical pharmacists support medication reconciliation, counsel patients on long-term antibiotic prophylaxis, identify drug interactions, particularly with systemic immunosuppressants, and reinforce adherence. Their involvement is especially valuable in complex cases requiring systemic therapy. Allied Health and Psychosocial Support Low-vision therapists, rehabilitation specialists, and counselors assist patients in adapting to visual limitations and the psychological burden of chronic ocular disease. Social workers facilitate access to medications, follow-up care, and transportation, particularly for patients requiring lifelong surveillance.[101] Table Table 10. Interprofessional Team Roles in Artificial Corneal Transplantation Monitoring. Abbreviation: IOP, intraocular pressure. Key Interprofessional Principle Early recognition of complications and seamless communication among team members are the cornerstones of long-term success following artificial corneal transplantation.