The Role of the Boston Keratoprosthesis in Severe Ocular Surface Disease and Autoimmune Diseases

PURPOSE: To synthesize contemporary evidence on Boston KPro outcomes in autoimmune cohorts and outline practical strategies to improve anatomic retention and visual results. METHODS: A review. RESULTS: The Boston keratoprosthesis (KPro) is the most widely implanted artificial cornea and a critical option for visual rehabilitation in patients at high risk of graft failure. Autoimmune disorders, including Stevens-Johnson syndrome (SJS), Sjögren's disease (SjD), ocular mucous membrane pemphigoid (OMMP), and ocular graft-versus-host disease (oGVHD), create highly inflammatory, cicatricial ocular surface environments characterized by severe dry eye, limbal stem cell deficiency, and corneal neovascularization, all of which undermine conventional keratoplasty. While selected patients with a relatively "wet" and medically quiet surface can benefit from Type 1 KPro, most end-stage cicatricial phenotypes are better served by Type 2 KPro or alternative mucous-membrane-covered devices. Across studies, autoimmune etiology is consistently associated with higher rates of tissue melt, infectious/sterile keratitis, retroprosthetic membrane, glaucoma, and vitreoretinal complications compared with non-autoimmune eyes. A structured perioperative bundle, systemic disease quiescence for ≥3 months, rheumatology co-management, prophylactic glaucoma drainage devices when indicated, long-term bandage contact lens wear, and intensified antibiotic ± antifungal prophylaxis appear to mitigate risk. Emerging approaches (biologics, donor-carrier crosslinking, γ-irradiated tissue, and newer KPro designs) show promise but require standardized endpoints and multicenter registries. CONCLUSION: Despite substantial challenges, the Boston KPro remains a vision-restoring option for carefully selected autoimmune patients when performed within multidisciplinary programs using rigorous preventive protocols.