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Corneal Transplants. Lecture 15 Liana Al-Labadi, O.D. Corneal Transplantation. The most common form of transplantation With over 2500 grafts in the UK & 32000 grafts undertaken in the US annually Outcomes, including failure & complications of the procedure are well known & depend on

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corneal transplants
Corneal Transplants
  • Lecture 15
  • Liana Al-Labadi, O.D.
corneal transplantation
Corneal Transplantation
  • The most common form of transplantation
    • With over 2500 grafts in the UK & 32000 grafts undertaken in the US annually
    • Outcomes, including failure & complications of the procedure are well known & depend on
      • Recipient aetiology
      • Preoperative comorbidity
      • Health of donor tissue
    • Modern-day success in transplantation is attributed to:
      • Eye banking
      • Storage techniques
      • Ocular phramacology
      • Equipment
      • Modern surgical techniques
preoperative risk factors
Preoperative Risk Factors
  • Evaluation of Preoperative Risk Factors
    • Donor factors studied include:
      • Age
      • Time from death to enucleation
      • Preservation time
      • Endothelial cell count
    • Recipient factors include:
      • Age
      • Indication for transplantation
      • Prior Grafts
      • Preoperative ocular conditions (Gluacoma, uveitis, infection, OSD)
donor tissue
Donor Tissue
  • Recruitment of donor tissue
    • Donor tissue should be removed within six hours after death
    • Viable storage period of the removed corneo-scleral button is 7-14 days
    • Grafts from donors <12months or >70 years are preferably not to be used
    • Contraindication for donor selection:
      • Death of unknown cause
      • Certain infectious diseases of the CNS
        • Jacob-Creutzfeld, SSPE, Progressive Multifocal Leuko-encephalopathy
      • Certain systemic infections (AIDS, septicemia, syphilis, viral hepatitis)
      • Leukemia & disseminated lymphoma
      • Intrinsic eye diseases (tumors, active inflammation, previous intra-ocular surgery)
recipient cornea
Recipient Cornea
  • Poor prognostic factors:
    • Absence of corneal sensations
    • Stromal vascularization
    • Corneal thinning at the expected recipient-donor margin
    • Active inflammation
preoperative instructions
Preoperative Instructions
  • Preoperative instructions to patients include:
    • If currently on anticoagulants or any blood thinning medications, continue taking it as prescribed by PCP
      • If taken for any reason other than prescribed blood thinner, please discontinue using it 7-10 day prior to surgery date
    • If taking Flomax or Cardura- must discontinue & take atropine instead for 3 days prior to surgery
    • A prescription for AB drops (Vigamox) must be used 1 day before surgery
    • Contact lenses must be removed the night prior to the surgery
    • Nothing to eat or drink or smoke 8 hours prior to surgery- small sips of water is allowed
    • Continue using systemic medications & glaucoma drops as usual
following surgery
Following Surgery
  • Immediately following the surgery:
    • Patch & shield should not be removed unless instructed by staff/doctor
    • Pain medications may be prescribed
      • OTC pain medications (Tylenol, Advil, Aspirin) may be used instead
    • Patients should continue using all prescription medications (oral & topical) as before surgery
postoperative instructions
Postoperative Instructions
  • What To Expect:
    • Explain drop & follow-up schedule
    • Explain the need to use drops for the next 3 months
      • Be certain to shake the bottle thoroughly prior to each drop
      • Allow 2-3 minutes between each drop to ensure full benefit of each drop
    • Eye may feel dry or “gritty”: that may last for several weeks
      • Use preservative free artificial tears
    • Refrain from rubbing eyes for at least 8 weeks
    • Eyelids may be mildly “droppy” or swollen: normal & will go away
    • Vision is blurred
    • Eye shield at night while sleeping for at least 6-12 weeks
postoperative instructions1
Postoperative Instructions
  • What To Expect:
    • Full time eye protection for the 1st 2-3 months & sunglasses to protect against light sensitivity
    • Can resume most activities in 1 week
    • No make up x 7 days
    • No swimming or hot tub x 14 days following surgery
    • Wear protective eyewear during any contact sports or around small children for a minimum of 3 months
    • If any symptoms of sudden onset of redness, pain, sensitivity to light, or visual decline occur
      • Must contact doctor ASAP
postoperative care
Postoperative Care
  • Careful postoperative care following PK is critical for successful outcome
    • Slit lamp findings should reveal:
      • An intact, smooth & well-hydrated corneal epithelium within 7 days
      • Sutures intact with knot buried
      • Well centered graft
      • Clean eyelids & adequate tear film to prevent onset of DES signs & symptoms
postoperative complications
Postoperative Complications
  • Graft is neurotrophic x 6months & patient will never develop absolute normal sensation - patient will be unaware of impending corneal problems
    • Graft Rejection
    • Epithelial defects
    • Ulceration & corneal infiltrates
    • Infection
    • Wound leak- Low IOP is one of the most typical early complications
    • Uncorrected sphere, cylinder, and HOA errors typically exist postoperatively
      • Consider suture adjustment as soon as able to measure K astigmatism
    • Eccentric graft
    • Tight sutures/ Broken sutures
    • Endophthalmitis
    • Glaucoma
    • Recurrence of initial disease in the donor graft
ultimate goal
Ultimate Goal
  • Ultimate Goal of PK is a clear graft
graft rejection
Graft Rejection
  • Occurs when the donor K doesn’t retain the transparency sufficient for adequate vision
    • The most common cause is endothelial cell dysfunction but other causes include:
      • Sub-optimal condition of donor tissue
      • Intraocular inflammation
      • Endothelial trauma during surgery
      • Pre-existing glaucoma
    • 50% of grafts occur within the first 6 months
      • The majority occur in the first year post-op
graft rejection1
Graft Rejection
  • Symptoms:
    • Decreased vision
    • Mild pain
    • redness
    • photophobia
    • Often asymptomatic & diagnosed on routine follow-up exam
graft rejection2
Graft Rejection
  • Critical Signs:
    • New keratic precipitates
    • Endothelial rejection line: A line of KPs on the corneal endothelium
      • aka Khodadoust line
    • Stromal edema
    • Subepithelial infiltrates
    • An irregularly elevated epithelial line (epithelial rejection line)
    • Localized stromal vascularization & infiltrates
graft rejection3
Graft Rejection
  • Other signs:
    • Conjunctival injection- circumcorneal
    • AC inflammation
    • Graft vascularization
    • Broken graft sutures
    • Usually no discharge present: tearing most likely
graft rejection4
Graft Rejection
  • Work-Up
    • Case History
      • Time since PK?
      • Current meds?
      • Recent change in steroid regimen?
      • Indication of PK (i.e. HSV)
    • Slit Lamp Exam
      • Careful inspection for the endothelial rejection line, KPs, infltrates
graft rejection5
Graft Rejection
  • Endothelial Rejection Treatment:
    • Topical Steroids
      • PF Q1H & steroid ung QHS
    • Systemic steroid & steroid injections in severe cases
    • Cyclosporine agent (Restasis BID)
      • May be helpful in the treatment & prevention of graft rejection
graft rejection6
Graft Rejection
  • Epithelial Rejection Treatment:
    • Increase steroid drops: double the current level of topical steroids or use PF QID
      • PF Q1H & steroid ung QHS
    • Cycloplegic agent
    • Topical cyclosporin