KERATOPLASTY

BY: ESMAEIL HASHEMI

MC: 410a
DEPT. OF OPHTHALMOLOGY
 Anatomy of cornea

• The cornea is the refractive surface of the eye and constitutes up to

1/6 of the entire eyeball.
• It has 5 layers:
The epithelium
Bowman’s layer
The stroma
Descemet’s membrane
endothelium
Anatomy of cornea
 KERATOPLASTY
• INTRODUCTION
Keratoplasty is the corneal transplant procedure in which diseased host corneal
tissue is excised and replaced with healthy donor cornea.
• Either full thickness of the cornea or a part of it may be transplanted.
Objectives:
Establish clear corneal visual axis
Minimize refractive error
Provide tectonic support
Alleviate pain
Eliminate infection
Indication

• Optical: to improve visual acuity

Corneal scars
Corneal dystrophy/degenerations
Congenital corneal opacities
Keratoconus
 Indication

Tectonic and reconstructive

Restoration of altered corneal structure
corneal perforations/thinning

Therapeutic
Tissue substitution for corneal diseases
Non healing corneal ulcer(infectious keratitis)
Cosmetic
To improve the appearance of eye
Types of keratoplasty
1. Penetrating keratoplasty: full thickness replacement of
entire cornea
2. Lamellar keratoplasty: partial thickness replacement of
only part of the cornea
a) superficial lamellar keratoplasty
b) Deep lamellar endothelial keratoplasty
3. Endothelial keartoplaty: a variation in which only the
endothelium layer is replaced
Type of surgery chosen according to cornea’s condition
 Penetrating keratoplasty
•Full thickness replacement of diseased tissue
with healthy donor cornea
•Indications:
Pathology involving whole cornea
Full thickness scars
Perforation of cornea
Herpetic scars
Vascularized scars
keratoconus
 Penetrating keratoplasty (PK)
• Surgical indication for PK:
• Optical: a healthy, clear donor cornea is used to replace an opaque, cloudy, or
distorted cornea in an attempt to improve vision
Pseudophakic bullous keratopathy
Keratoconus
Regraft secondary to allograft rejection
Regraft unrelated to allograft rejection
Keratoglobus
Degeneretions
Dystrophies
Scars
Aphakic bullous keratopathy
Congenital opacities
Chemical injuries
• Tectonic:
Descemetocele
Corneal stromal thinning
Corneal perforation
• Therapeutic : infection may be due to bacteria, virus,
parasite,or other cause
• Cosmetic : to improve appearance of the patient
Procedure for PK
PREOPERATIVE PREPARATION

ANESTHESIA

SURGICAL PREPARATION

TREPHINATION OF DONOR
CORNEA

TREPHINATION OF RECIPIENT
CORNEA

SUTURING OF DONOR CORNEA

POSTOPERTIVE TREATMENT
 Preoperative evaluation
• Ocular history
• Visual acuity
• Detailed examination: underlying pathology
• Intraocular pressure (IOP)
• Vascularization
• Tear film status
• Presence of cataract
• Need for IOL exchange
• B-Scan
 Donor tissue preparation

• The donor cornea is trephined from endothelial or epithelial

surface. For epithelial surface trephination, an artificial
anterior chamber is required.
• 2 types of trephines are- suction less trephines and suction
trephines.
• A cutting block and artificial anterior chamber may also be
used for corneal disc preparation.
• Graft size: 7.5 mm
 Trephination of donor cornea

• Endothelial punch system

• Hessberg barron vaccum trephine: less AC collapse & distortion
• Sharper, deeper & more perpendicular cut
Hanna trephine laser trephine

• Donor cornea encased within • Femtosecond excimer laser

an artificial chamber
• No mechanical distortion
• Corneal trephination from
epithelial surface • Perpendicular congruent edges
Trephination of recipient cornea
Recipient dissection
 Suturing of donor cornea
• Placement of donor cornea on recipient
• Anterior chamber filled with viscoelastics
• Donor cornea brought into field of microscope with a graft holder
• Suturing of recipient cornea with 10-0 nylon suture -
- place 4 cardinal suture first at 900 interval
- first suture at 12 o’clock, 2nd at 6 o’clock followed at
3 o’clock and 9 o’clock
 Postoperative management
• Topical steroids : To decrease the risk of immunological
graft reaction.
• Immunosuppressants : azathioprine, cyclosporin may be
used in high risk for prevention of rejection.
• Mydriatics : if uveitis persist.
• Monitoring of IOP is performed during the early
postoperative period.
• Removal of sutures when the graft-host junction has
healed.
• Rigid contact lenses- to optimize visual acuity in eyes with
astigmatism
 Postoperative complications

• Early complications: persistent epithelial defects, irritation

by protruding sutures, wound leak, flat anterior chamber, iris
prolapse, uveitis, elevation of intraocular pressure, microbial
keratitis and endophthalmitis.

• Late : astigmatism, recurrence of intial disease process, late

wound separation, retro-corneal membrane formation,
glaucoma and cystoid macular oedema
 Lamellar keratoplasty
• Similar to PK but only a part of thickness of cornea is grafted.
1.Superficial Lamellar keratoplasty
• Partial thickness excision of the corneal epithelium and stroma.
• Endothelium and part of the deep stroma are left behind.

INDICATIONS:
• Superficial 1/3 stromal corneal opacity, granular dystrophy
• Marginal corneal thinning or infiltration as in recurrent pterygium,
marginal degeneration
• Localized thinning or descemetocele formation
 2.Deep anterior lamellar keratoplasty

• Opaque corneal tissue is removed almost to the level of Descemet

membrane
INDICATIONS:
• Disease involving the anterior 95% of corneal thickness with a normal
endothelium and absence of breaks or scars in Descemet membrane.
• Chronic inflammatory disease such as atopic keratoconjuctivitis.
• During DALK, the surgeon injects air to lift off and separate the thin
outside and thick middle layer of cornea and removal of ant. Corneal
layer( leaving the endothelium and Descemet’s membrane behind)
 Endothelial Keratoplasty

• REPLACES ONLY THE INNERMOST LAYER OF THE CORNEA (ENDOTHELIUM)

AND LEAVES THE OVERLYING HEALTHY CORNEAL TISSUE INTACT.

• THE SURGEON MAKES A TINY INCISION BY TREPHINE OR FEMTOSECOND

LASER AND PLACES A THIN DISC OF DONOR TISSUE CONTAINING A HEALTHY

• ENDOTHELIAL CELL LAYER ON THE BACK SURFACE OF THE CORNEA , AN AIR

BUBBLE IS USED TO POSITION THE NEW ENDOTHELIAL LAYER INTO PLACE ,
THE SMALL INCISION IS SELF-SEALING AND TYPICALLY NO SUTURES ARE
REQUIRED.
 DESCEMET STRIPPING ENDOTHELIAL
KERATOPLASY(DSEK)

• This technique combine stripping off endothelium and

Descemet membrane, through a corneo-scleral or corneal
incision.

• INDICATIONS:
• Pseudophakic bullous keratopathy
 DSEK

• THIS TECHNIQUE COMBINES STRIPPING OFF THE DYSFUNCTIONAL

ENDOTHELIUM FROM THE HOST CORNEA WITH MICRODISSECTION OF
THE DONOR TISSUE.
• - IN THIS TYPE PATIENT'S ENDOTHELIUM IS REPLACED WITH A
TRANSPLANTED DISC OF POSTERIOR STROMA/DESCEMET'S
MEMBRANE/ENDOTHELIUM.
• - SURGEON REMOVES THE ENDOTHELIUM ( ONE CELL THICK) AND THE
DESCEMET MEMBRANE JUST ABOVE IT. THEN HE REPLACES THEM
WITH A DONATED
• ENDOTHELIUM AND DESCEMET MEMBRANE STILL ATTACHED TO THE
STROMA .
• -THIS REDUCES OCULAR SURFACE COMPLICATIONS GENERALLY
COMPARED TO PENETRATING KERATOPLASTY.
DSEK surgical techinque
a) DLEK, b)DSEK
 DESCEMET MEMBRANE ENDOTHELIAL
KERATOPLATY (DMEK)

• DMEK is further variation on ( DSEK), in which immune- mediated

rejection is reduced by transplanting bare endothelium and
Descemet’s membrane without stroma.
• Donor tissue thin and fragile, so difficult procedure but healing is
quicker.
 Before injecting DMEK tissue into anterior chamber

• Descemetorhexis with no loose tags of Descemet membrane or

stroma
• Patent inferior peripheral iridotomy
• Main incision widened to accommodate the Straiko injector and form
a watertight seal
• Evacuation of all viscoelastic from the anterior chamber and the
injector
• Pupil smaller than 3 mm, constricted
 Complication of keratoplasty
• Early complications-
1. Persistent epithelial defect(>2 weeks in duration): symptoms are as
for corneal abrasion: pain- redness- tearing- sensitivity to light-
blurred vision- may be headache
2. Irritation by protruding sutures
3. Iris prolapse through operative wound
4. Keratitis or endophthalmitis - sight threatening complication
5. Uveitis
6. Flat anterior chamber
7. Elevated intraocular pressure
Late complications:

-Astigmatism
-Glaucoma
-Late wound separation and suture related problems
-Cystoid macular edema

Graft rejection complications:

Early graft rejection:
- Occurs by the first operative day
- There is a cloudy cornea
- this is usually due to defective donor endothelium or trauma
Cont.
• Late graft rejection
- Sign of rejection eye pain, redness, photophobia, cloudy vision.
- Occurs within the first 6 months or year
- Red eye, corneal clouding+ uveitis, a/w decreased visual acuity
- Rejection line
- Usually due to immunological graft rejection
 PROGNOSIS

• POOR PROGNOSIS IS NOTED IN PATIENTS WITH:

• 1-ADDITIONAL CORNEAL PROBLEMS SUCH AS

VASCULARISATION OR PERIPHERAL THINNING.

• 2- ASSOCIATED OCULAR DISEASE SUCH AS HERPES, ACTIVE

INFLAMMATION OR UNCONTROLLED GLAUCOMA.
POSTOPERATIVE CARE
THANK YOU