BlueCross BlueShield of Tennessee Medical Policy Manual

Keratoprosthesis

DESCRIPTION

Keratoprosthesis (KP) is an artificial cornea that is intended to replace the opacified corneal tissue and restore vision when severe bilateral corneal disease exists (e.g., prior failed cadaveric corneal transplant, chemical injury or certain immunological condition). Many people with corneal disease can benefit from corneal transplantation involving tissue from human (cadaveric) donors. This is the most common treatment for severe corneal opacity. However, in some cases, this treatment fails. KP has been developed for use when corneal transplant is not an option. A permanent keratoprosthesis device (i.e., Boston KPro) is implanted in the eye to allow the transmission of light through an artificial cornea.

Other keratoprosthesis devices (e.g., AlphaCor™, KereKlear™) and devices with a unique procedural approach such as the osteo-odonto-keratoprosthesis (OOKP) are available for individuals who have corneal blindness and have failed or are not candidates for human corneal transplantation. However, the clinical evidence for the other keratoprosthesis devices and the OOKP procedure is lacking and change in disease status, quality of life, and treatment-related morbidity are uncertain.

POLICY

MEDICAL APPROPRIATENESS  

IMPORTANT REMINDERS

SOURCES 

Ahmad, S., Akpek, E.K., Gehlbach, P.L., Dunlap, K., & Ramulu, P.Y. (2015). Predictors of visual outcomes following Boston type 1 keratoprosthesis implantation. American Journal of Ophthalmology, 159 (4), 739-747. Abstract retrieved July 9, 2015 from PubMed database.

Ahmad, S., Mathews, P., Lindsley, K., Alkharashi, M., Hwang, F., Ng, S., et al. (2016). Boston type 1 keratoprosthesis versus repeat donor keratoplasty for corneal graft failure. A systematic review and meta-analysis. Ophthalmology, 123, 165-177. (Level 1 evidence)

American Academy of Ophthalmology. (2018, September). Corneal edema and opacification preferred practice pattern. Retrieved March 12, 2019 from www.aao.org.

BlueCross BlueShield Association. Evidence Positioning System. (3:2018). Keratoprosthesis (9.03.01). Retrieved March 12, 20198 from https://evidencepositioningsystem. (20 articles and/or guidelines reviewed)

Goins, K. M., Kitzmann, A.S., Greiner, M. A., Kwon, Y. H., Alward, W. L., Ledolter, J., et al. (2016). Boston type 1 keratoprosthesis: visual outcomes, device retention, and complications. Cornea, 35 (9), 1165-1174. Abstract retrieved June 24, 2016 from PubMed database.

Hoffart, L., Carles, G, and Matonti, F. (2015). Lamellar corneal lenticule graft to treat keratolysis after AlphaCor keratoprosthesis implantation. European Journal of Ophthalmology, 25 (1), 1-7. Abstract retrieved April 11, 2017 from PubMed database.

Lee, W., Shtein, R., Kaufman, S., Deng, S., and Rosenblatt, M. (2015). Boston keratoprosthesis: outcomes and complications: a report by the American Academy of Ophthalmology. Ophthalmology, 122 (7), 1504-1511. (Level 1 evidence)

Rudnisky, C.J., Belin, M.W., Guo, R., Ciolino, J.B., et al. (2016). Visual acuity outcomes of the Boston keratoprosthesis type 1: multicenter study results. American Journal of Ophthalmology, 162, 89-98. Abstract retrieved March 12, 2019 from PubMed database.

Shanbhag, S.S., Saeed, H.N., Paschalis, E., & Chodosh, J. (2018). Boston keratoprosthesis type 1 for limbal stem cell deficiency after severe chemical corneal injury: a systematic review. The Ocular Surface, 16 (3), 272-281. Abstract retrieved March 12, 2019 from PubMed database.

Srikumaran, D., Munoz, B., Aldave, A.J., Aquavella, J.V., Hannush, S.B., Schultze, R., et al. (2014). Long-term outcomes of Boston type 1 keratoprosthesis implantation: a retrospective multicenter cohort. Ophthalmology, 121 (11), 2159-2164. Abstract retrieved July 10, 2015 from PubMed database.

U. S. Food and Drug Administration. (2002, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K013756 (AlphaCor™). Retrieved March 31, 2011 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2013, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K121203 (Boston KPro). Retrieved April 11, 2017 from http://www.accessdata.fda.gov.

ORIGINAL EFFECTIVE DATE:  8/1988

MOST RECENT REVIEW DATE:  4/11/2019

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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