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Abstract This short report includes 5 eyes of 5 patients (mean age 63.2 ± 12 years) who underwent a tectonic keratoplasty [deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK)] in order to rehabilitate the eye after the extrusion of the non-perforating keratoprosthesis (Kpro) KeraKlear (KeraMed, USA). The non-perforating Kpro was extruded after a mean period of 21.4 ± 21.8 months due to melting. In two cases, the keratoplasty was performed the same day of the non-perforating Kpro removal due to a severe melting, while in the other three cases it was performed one to 3 months later. Two eyes received a DALK, but in 3 eyes a macroscopic Descemet membrane perforation forced the conversion into a PK. The mean follow-up period after the keratoplasty was 16.8 ± 6.6 months. No cases of rejection were recorded. All the 5 eyes achieved “anatomical success” (transparent graft, with no signs of infection or inflammation). Two eyes showed limited “functional success” because the achievement of the best visual potential was prevented by the development of glaucomatous optic atrophy during the follow-up period. In conclusion, this short report presents an unexpected success of a keratoplasty performed with a tectonic purpose after the extrusion of the non-perforating Kpro because the corneal graft remained transparent, without neovascularization or scarring during the follow-up period. This initial evidence shows some encouraging results regarding graft survival rate and the achievement of a useful visual rehabilitation with keratoplasty after a non-perforating Kpro failure instead of repeating the Kpro implantation.

This review explores contemporary challenges in penetrating keratoplasty (PK), focusing on technical intricacies, technological advancements, and strategies for preventing graft rejection. A systematic literature search from January 2018 to July 2023 was conducted across PubMed, Cochrane, Web of Science, Scopus, and EMBASE. The inclusion criteria comprised studies on PK and its comparison with other corneal pathologies, with emphasis on keratoconus (KC). Two independent reviewers screened studies, extracting relevant data. The review covers PK evolution, highlighting infra-red femtosecond lasers' impact on graft shapes, minimizing astigmatism, and enhancing wound healing. Graft rejection, a primary complication, is examined, detailing risk factors and preventive measures. Preoperative considerations, diagnostic techniques for rejection, and PK in KC are discussed. Postoperative care's significance, including intraocular pressure monitoring and steroid administration, is emphasized. The paper concludes with a comprehensive approach to prevent graft rejection, involving topical and systemic medications. An outlook on evolving monoclonal antibody research is presented. As the field progresses, personalized approaches and ongoing therapeutic exploration are expected to refine strategies, enhancing PK outcomes.