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EW SHOW DAILY 28 ASCRS Symposia Monday, May 9, 2016 20/200 and improved to 20/80 with a rigid gas permeable lens but no corneal edema. Among the symposium audi- ence, 81% preferred deep anterior lamellar keratoplasty (DALK) for the patient, and Dr. Hovanesian noted that the key to their choice was the presence of both stromal scarring and a healthy epithelium. "As we advance in the thinking about corneal transplants, we want to keep tissue that is healthy, so that is a reasonable choice," Dr. Hovanesian said. In comparison, Descemet's strip- ping endothelial keratoplasty does not make sense in cases of healthy tissue, and penetrating keratoplas- ty would risk the transplant of the endothelium, which could increase the risk of rejection, according to Dr. Hovanesian. EW Editors' note: Dr. Holland has finan- cial interests with Alcon (Fort Worth, Texas), Allergan (Dublin), and other companies. Dr. Farid has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Allergan, and other companies. Dr. Hovanesian has financial interests Abbott Medical Optics, Alcon, and other companies. Dr. Gupta has financial interests Abbott Medical Optics, Alcon, and other com- panies. Dr. Mah has financial interests with Abbott Medical Optics, Alcon, and Allergan, and other companies. by Rich Daly EyeWorld Contributing Writer Dr. Gupta suggested showing patients photos of the implanted device preop and the difference between options so they can know what to expect. Marjan Farid, MD, Irvine, Cal- ifornia, said the aphakic KPro recip- ients tend to have lower incidence of retroprosthetic membrane if the surgeon removes the area that can grow over the pupil. "So the aphakic ones tend to do better," Dr. Farid said. Additionally, Dr. Farid noted that primary KPros should not be used amid the highly inflamed ocular surfaces of limbal stem cell failures. "They have very high risk of failure," Dr. Farid said. In such cases—even if a KPro was appealing—Dr. Farid would first perform a limbal stem cell trans- plant, create a less-inflamed ocular environment, and then proceed. That approach "increases your odds that you can get a KPro to work," Dr. Holland said about Dr. Farid's strategy. The KPro was not the choice of the symposium audience to treat a 38-year-old male patient with a cen- tral corneal scar, who was healthy, with a history of contact lens-related infectious keratitis, whose vision was Ed Holland, MD, Cincinnati, described the Boston KPro as a "tremendous breakthrough" and said he uses many of them. "I'm very cautious about using them in a younger patient, and if I have a choice, for surface disease I'd rather do a stem cell transplant in a younger patient," Dr. Holland said. "I'd certainly choose a KPro in an older patient." In cases of multiple rejected corneas, the obvious choice is the KPro, according to Dr. Holland. All of his KPro patients are managed by his practice's glaucoma service. "We're aggressive about tube shunts, and we try to keep the pressure low but over time there's a significant number of patients with visual loss; there is this perception that we're seeing optic nerve disease, and our glaucoma people were thinking they had pretty good pres- sure control," Dr. Holland said. "So I do think that being aggressive about putting them in young patients can be a little bit worse." In terms of the KPro's retro- prosthetic membrane complication, emerging evidence provides some support for the newer titanium back plate design, according to Preeya Gupta, MD, Durham, North Caro- lina. M ost surgeons view the Boston keratoprosthesis (KPro, Massachusetts Eye and Ear Infirmary) as beneficial for certain high-risk keratoplasty cases. At a hot topics symposium on cornea and external disease, called "Pardon the Ophthalmology," 71% of attendees agreed that the Boston KPro can be used for cases of high- risk keratoplasty, especially those with multiple rejected corneas. "The Boston KPro is great for high-risk, but I would stay away from it for severe ocular surface dis- ease because the cornea melts," said Francis Mah, MD, Pittsburgh. In comparison, only 17% said the KPro can be used for all high-risk cases, including those with ocular surface disease, and 12% said they didn't know much about it. The biggest drawback Dr. Mah saw in the use of the Boston KPro was the need for chronic antibiotic prophylaxis to prevent endophthal- mitis. Other complications include glaucoma and melts. "The big one is glaucoma, chronically, for a lot of these pa- tients because you can't measure them and so many of them have glaucoma that develops," said John Hovanesian, MD, San Clemente, California. Surgeons provide latest views on the Boston KPro Dr. Gupta suggests showing photos of the implanted Boston KPro to patients so they know what to expect. Dr. Mah addresses limitations with the use of the Boston KPro.

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