Corneal Transplants
Corneal transplantation is a surgical procedure that involves replacing a damaged or diseased cornea with a healthy donor cornea. The cornea is the clear, dome-shaped tissue covering the front of the eye, and when it becomes damaged or diseased, it can lead to vision problems or even blindness. Corneal transplants are performed to restore vision and improve the quality of life for individuals with corneal diseases or injuries. There are several forms of corneal transplant, the most appropriate method depends upon the condition and state of the cornea. Our subspecialist corneal surgeon, Dr Darian-Smith, is highly trained in all forms of corneal transplant.
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Corneal Transplants
Endothelial based corneal transplants: DMEK and DSEK
Descemet’s Membrane Endothelial Keratoplasty (DMEK) is an advanced technique for corneal transplantation. It involves replacing the diseased thin layer on the inner side of the cornea, called the endothelium, with a healthy donor endothelium. The endothelium is responsible for maintaining the clarity of the cornea by pumping out excess fluid. When it becomes damaged or dysfunctional, the cornea becomes swollen and cloudy, leading to vision loss. This is commonly the case in conditions such as Fuch’s endothelial dystrophy or pseudophakic bullous keratopathy.
DMEK is a technically challenging procedure that requires a high level of expertise from the surgeon. The membrane is around 5-10 micrometers thick, which is 7 times thinner than a human hair. The membrane curls up and is injected into the fluid-filled chamber of the eye. It is unfolded and held in place with an air bubble. It will usually attach over a period of 24 hours. Where appropriate, DMEK can be combined with traditional cataract surgery.
This technique offers several advantages over traditional full thickness corneal transplantation including: a faster visual recovery (usually 2-4 weeks), fewer complications, and a decreased risk of graft rejection. Moreover, DMEK provides excellent visual outcomes with minimal induced astigmatism due to smaller incisions and minimal or no sutures.
Disadvantages of the procedure include: possible non-attachment of the membrane which require either additional rebubbling in the practice post-operatively or a second operation in about 5% of cases and a rejection rate of 2% which may require repeat surgery.
Full thickness corneal transplant
Penetrating keratoplasty (PK) is the traditional method of corneal transplantation. It involves replacing the entire thickness of the cornea with a donor cornea. The central portion of the damaged cornea is removed, and a similarly sized piece of donor cornea is then stitched in its place. This is typically performed under general anesthesia and requires a longer recovery time compared to more advanced techniques.
One of the main advantages of PK is its versatility, as it can be used to treat a wide range of corneal diseases and injuries. However, there are some drawbacks to this procedure, including a higher risk of graft rejection, a longer healing process and reduced visual outcomes (50% of patients will require glasses or contacts post transplantation to manage the induced astigmatism). Despite these limitations, PK remains an important option for individuals who are not suitable candidates for other corneal transplantation techniques
Deep Anterior Lamellar Keratoplasty (DALK): Partial thickness transplant
Deep Anterior Lamellar Keratoplasty (DALK) is a corneal transplantation technique that may also offer advantages over traditional PK. DALK involves replacing the anterior layers of the cornea while preserving the healthy endothelial layer. This technique is particularly useful in cases where the endothelium is healthy but the other layers of the cornea are affected by disease or injury such as keratoconus or partial thickness corneal scars.
What corneal transplant technique is best?
All techniques aim to restore vision through corneal transplantation and all target different regions of the cornea. Therefore, the best choice of procedure depends upon the part of the cornea that is affected by your condition, as well as the overall health of the eye. No procedure is inferior to the other and all have their place in treating corneal disease.
Who is a Candidate for Corneal Transplant Surgery?
Corneal transplant surgery may be recommended for individuals with various corneal conditions.
More common reasons are:
- Corneal scars or opacities that significantly impair vision.
- Keratoconus, a progressive thinning and distortion of the cornea.
- Fuchs’ endothelial dystrophy, a condition that leads to swelling and clouding of the cornea.
- Corneal edema caused by previous eye surgery or trauma.
- Corneal dystrophies, such as lattice dystrophy or macular dystrophy.
- Corneal infections that do not respond to medical treatment.
The need for a corneal transplant depends on the particular disease affecting the cornea, overall eye health and disease severity, and visual acuity. Not all individuals with corneal diseases will require a transplant, and there may be alternative treatment options available.
The Corneal Transplant Procedure
Corneal transplants are performed as an outpatient surgery. The surgery itself can take anywhere from 15 minutes to 1.5 hours, depending on the technique being used and the complexity of the case.
The first step
The first step of the procedure involves removing the damaged or diseased cornea. The specific layers being replaced are removed using specialized surgical techniques.
Next procedure
Next, the healthy donor cornea is prepared and carefully placed into the recipient’s eye. This is secured with sutures or a gas bubble, depending on the transplant technique. Once the cornea is in place, the surgeon will ensure that it is properly aligned and that there are no leaks or complications.
After the surgery
After the surgery, the eye will be protected with a protective shield, and eye drops and medications will be prescribed to prevent infection and rejection and aid in the healing process. Endothelial corneal transplant (DMEK and DSEK) will require patient compliance with positioning for 72 hours post procedure – this is to enable transplant attachment with the gas bubble. Regular follow-up appointments will be scheduled to monitor the progress of the transplant and adjust the medication regimen if necessary.
Recovery and
Post-Operative Care
The recovery time following a corneal transplant depends on the technique used and the overall eye health. In general, it takes several weeks (DMEK, DSEK) to months (PK, DALK) for the vision to stabilize and for the eye to fully heal. It is common to experience fluctuations in vision during the healing process, but these usually stabilize over time.
Immediately after the surgery, the eye may be red, swollen, and sensitive to light. Discomfort and mild pain are common, but they can be managed with prescribed pain medications. The use of eye drops and ointments is crucial to prevent infection, rejection and promote healing. It is essential to avoid rubbing or putting pressure on the eye during the healing process. Generally, steroid eye drops are required longer term to prevent transplant rejection. There is no role for systemic steroid oral medication.
Risks and Complications of Corneal Transplant Surgery
Like any surgical procedure, corneal transplant surgery carries certain risks and potential complications. Some of these include:
Graft rejection
Graft rejection, where the recipient’s immune system recognizes the donor cornea as foreign and attacks it.
Infection
Infection, which can lead to graft failure if not promptly treated.
Increased intraocular pressure
Increased intraocular pressure, which can cause glaucoma.
Corneal graft failure
Corneal graft failure, where the transplanted cornea does not function properly.
Astigmatism
Astigmatism, resulting in distorted vision. In the majority of cases, this can be corrected with glasses or specialized contact lenses.
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Success Rates and Prognosis of Corneal Transplants
The success rates of corneal transplants have significantly improved over the years, thanks to advancements in surgical techniques and better understanding of graft management. The overall success depends on various factors, including the underlying corneal disease, the surgical technique used, and the individual’s overall eye health.
Alternative Treatments for Corneal Diseases
In some cases, corneal transplant surgery may not be the only treatment option for corneal diseases. Depending on the specific condition and its severity, alternative treatments or management may be considered. These can include:
Medications
Certain corneal diseases, such as infections or inflammatory conditions can be managed with topical or oral medications.
Custom fitted contact lenses (e.g. scleral contact lenses)
In some cases, specially designed contact lenses can help improve vision and provide relief for conditions like keratoconus.
Laser corneal treatment
PTK laser treatment can be used to treat some superficial corneal scars and conditions such as recurrent corneal erosions.
Collagen cross-linking
This procedure involves applying riboflavin eye drops and ultraviolet light to strengthen the cornea and halt the progression of keratoconus.
Amniotic membrane transplantation
This technique uses the membrane from the inner lining of the placenta to promote healing and reduce inflammation in the cornea.
Fuch’s Dystrophy
What is Fuchs Endothelial Dystrophy?
Fuchs Dystrophy, also known as Fuchs Endothelial Dystrophy, is a progressive eye disease that affects the cornea. The cornea is the clear, dome-shaped tissue at the front of the eye that helps to focus light and protect the inner structures of the eye. Fuchs Dystrophy primarily affects the innermost layer of the cornea, known as the endothelium, which is responsible for maintaining corneal clarity and hydration.
Understanding Fuchs Endothelial Dystrophy
Fuchs Endothelial Dystrophy is a hereditary condition that can run in families. It is more commonly found in women and typically begins to show symptoms in individuals over the age of 50, although it can sometimes manifest earlier. The disease progresses slowly over time, gradually causing a decline in vision.
The exact cause of Fuchs Dystrophy is not fully understood, but it is believed to be a result of abnormal genes that affect the functioning of the corneal endothelial cells. Other risk factors that may contribute to the development of Fuchs Dystrophy include aging and environmental factors such as long-term exposure to ultraviolet (UV) radiation.
In Fuchs Dystrophy, the endothelial cells whose role is to regulate fluid balance within the cornea start to deteriorate. This leads to an accumulation of excess fluid in the cornea, causing it to swell and become cloudy. At Eagle Eye Surgeons we have specialized equipment that can analyze the functioning of these endothelial cells (endothelial morphology and cell count) and monitor the resulting corneal changes (corneal topography and tomography) to appropriately guide treatment.
Symptoms and Diagnosis of Fuchs Dystrophy
The initial symptoms of Fuchs Dystrophy are often mild and may go unnoticed. As the disease progresses, however, the following symptoms may become more prominent:
- Blurred or hazy vision, particularly in the morning or after periods of rest.
- Sensitivity to light and glare.
- Poor vision in dim lighting.
- The sensation of a foreign object in the eye.
- Eye discomfort or pain.
Treatment Options for Fuchs Dystrophy
Medications for Fuchs Dystrophy
In the early stages of Fuchs Dystrophy, your doctor may prescribe eye drops or ointments to help alleviate symptoms such as dryness and discomfort. These medications can help to lubricate the eyes and reduce inflammation. However, it is important to note that these medications do not stop the progression of the disease or treat the disease and are mainly used for symptom relief.
Surgical Procedures for Fuchs Dystrophy
For more advanced cases of Fuchs Dystrophy, surgical intervention may be necessary. At Eagle Eye Surgeons, Dr. Darian-Smith offers the advancement corneal transplantation technique of Descemet’s Membrane Endothelial Keratoplasty (DMEK). During this procedure, the damaged endothelial layer of the cornea is removed and replaced with a healthy donor tissue. This can help to improve vision and reduce corneal swelling. Refer to our section on corneal transplantation for our full description on DMEK.
Eagle Eye Surgeons corneal subspecialist surgeon, Dr Darian-Smith, provides comprehensive care for patients with Fuchs Dystrophy and other corneal conditions. We are here to provide you with personalized treatment options and support to help you manage this condition effectively.
