Background: For patients with repeated corneal grafts failures, the Boston Keratoprosthesis Type 1 (KPro) serves as one of few therapeutic arsenal for restoring vision. Because the KPro bridges the intraocular space and the ocular surface, there exists an indefinite risk of ocular infection. Lifelong antibiotic prophylaxis is therefore the current post-operative standard of care for these patients. The current regimen involves the use of a fluoroquinolone and vancomycin. The purpose of this study is twofold: to examine the effectiveness of the current post-operative antimicrobial prophylaxis for the Boston KPro and assess the impact of povidone-iodine in this regimen. 

Study Design: Systematic review. 

Methods: A search strategy using the National Library of Medicine (PubMed) database was employed to identify all articles addressing post-operative antimicrobial prophylaxis for the Boston KPro. All original articles that studied the post-operative outcomes of patients undergoing KPro transplantation and explicitly outlined post-operative antimicrobial prophylaxis were included in this review. Abstracts and full-length manuscripts were screened by two independent reviewers. 

Results: 281 articles were identified. Of these, 58 abstracts were selected for full-length analysis and 20 articles met all the aforementioned inclusion criteria. Of the included articles, 17 used a fluoroquinolone and vancomycin as their antimicrobial prophylaxis, while the remaining 3 only used a fluoroquinolone. Only 5 articles included povidone-iodine in their routine regimen. 1250 eyes were included in this literature review. The most frequent indications for KPro implantation were previous graft failure (75%), herpetic disease (15%), and cicatrizing disease (4%). There was an overall KPro retention rate of 86% during an average follow up time of 2.5 years. The retention rates were 87% and 86% for patients that did report povidone iodine use and those that did not, respectively. Endophthalmitis was reported in 4.76% of all included eyes; 10% of eyes receiving povidone iodine had a diagnosis of endophthalmitis, and 3.28% of the eyes that did not receive the antiseptic had the same diagnosis.

Conclusion: The Boston KPro is an effective alternative for eyes with severe ocular surface disease that render repeated penetrating keratoplasties unsuccessful. Herein, we compared the outcomes of KPro eyes that received povidone-iodine to those that received standard antibiotic prophylaxis. There exists a disparity in the reported rates of endophthalmitis in eyes that received povidone-iodine and
those that did not. This can be attributed to the different populations with distinct risk factors that enrolled in each respective study. Povidone-iodine and other antiseptics are understudied methods of antimicrobial prophylaxis that warrant greater attention.

Abstract: Review of current peri-operative antimicrobial prophylaxis for the Boston Keratoprosthesis Type I

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