Corneal transplantation, also known as corneal grafting or penetrating keratoplasty, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue which has been removed from a recently deceased individual having no known diseases which might affect the viability of the donated tissue. The cornea is the clear part of eye in front of the iris and pupil. The surgical procedure is performed by ophthalmologists, medical doctors who specialize in eyes, and are often done on an outpatient basis.
Indications for corneal transplantation : -
Optical : - To improve visual acuity by replacing the opaque or distorted host tissue by clear healthy donor tissue. The most common indication in this category is pseudophakic bullous keratopathy, followed by keratoconus, corneal degeneration, keratoglobus and dystrophy, as well as scarring due to keratitis and trauma.
Tectonic/reconstructive : - To preserve corneal anatomy and integrity in patients with stromal thinning and descemetoceles, or to reconstruct the anatomy of the eye, e.g. after corneal perforation.
Therapeutic : - To remove inflamed corneal tissue unresponsive to treatment by antibiotics or anti-virals.
Cosmetic : - To improve the appearance of patients with corneal scars that have given a whitish or opaque hue to the cornea
Pre-operative examination
In most instances, the patient will meet with their ophthalmologist for an examination in the weeks or months preceding the surgery. During the exam, the ophthalmologist will examine the eye and diagnose the condition. The doctor will then discuss the condition with the patient, including the different treatment options available. The doctor will also discuss the risks and benefits of the various options. If the patient elects to proceed with the surgery, the doctor will have the patient sign an informed consent form. The doctor might also perform a physical examination and order lab tests, such as blood work, X-rays, or an EKG.
The surgery date and time will also be set, and the patient will be told where the surgery will take place.
The surgery only takes place when the best corresponding donor tissue is found. This can take weeks and months.
Steps Of Corneal Transplantation
On the day of the surgery, the patient arrives to either a hospital or an outpatient surgery center, where the procedure will be performed. The patient is given a brief physical examination by the surgical team and is taken to the operating room. In the OR, the patient lies down on an operating table and is either given general anesthesia, or local anesthesia and a sedative.
With anesthesia induced, the surgical team prepares the eye to be operated on and drapes the face around the eye. An eyelid speculum is placed to keep the lids open, and some lubrication is placed on the eye to prevent drying. A metal ring is then stitched to the sclera, which will provide a base for a trephine.
A trephine is then placed over the cornea and is used by the surgeon to cut the host cornea. The trephine is then removed and the surgeon cuts a circular graft (a "button") from the donor cornea. Once this is done, the surgeon returns to the patient's eye and removes the host cornea.
The donor cornea is then brought into the surgical field and maneuvered into place with forceps. Once in place, the surgeon will fasten the cornea to the eye with a running stitch (as used in the upper image above) or a multiple interrupted stiches (as in the lower image). The surgeon finishes up by reforming the anterior chamber with a sterile solution injected by a cannula, then testing that it's watertight by placing a dye on the wound exterior.
With the metal ring removed and antibiotic eyedrops placed, the eye is patched, and the patient is taken to a recovery area while the effects of the anesthesia wear off. The patient typically goes home following this and sees the doctor the following day for the first post operative appointment.
Risks
While the cornea is avascular, there is still a potential for loss of sight in the eye, loss of the entire eye or possible loss of life due to abnormal reactions to anesthesia. The risks are very small, but it is very important that you be aware that risks exist as with ant other surgical procedure.
Some of the possible complications that could occur are infection, bleeding, glaucoma, a wound leak, poor wound healing, and failure or rejection of the transplant. If a transplant should fail, it does not mean blindness or loss of the eye. Rather a subsequent transplant may be performed with a good chance of success.
There is also a risk of infection. Since the cornea has no blood vessels (it takes its nutrients from the aqueous humor) it heals much slower than a cut on the skin. While the wound is healing, it is possible that it might become infected by various microorganisms. This risk is minimized by antibiotic prophylaxis (using antibiotic eyedrops, even when no infection exists).
Graft failure can occur at any time after the cornea has been transplanted, even years or decades later. The causes can vary, though it is usually due to new injury or illness. Treatment can be either medical or surgical, depending on the individual case. An early, technical cause of failure, may be an overly tight stitch cheesewiring through the sclera.
Prognosis
When the primary purpose of a cornea transplant is to improve visual acuity, the prognosis is dependent upon whether the rest of the eye is healthy. If it is, then it should be possible to recover normal vision.
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