A. W. Y.

 Chua et al Anaesth Intensive Care 2018 | 46:2

Review
Recent advances and anaesthetic considerations in corneal
transplantation
A. W. Y. Chua*, M. J. Chua†, P. C. A. Kam‡

Summary
Significant surgical advances have been made recently in corneal transplantation. Penetrating keratoplasty was the dominant
method from 1905, until selective lamellar keratoplasty emerged as the preferred technique over the last 20 years.
Advanced techniques such as corneal limbal stem cell transplant and keratoprosthesis are also available. The major surgical
complications of corneal transplantation are extrusion of ocular content and expulsive choroidal haemorrhage. It is essential
for an ophthalmic anaesthetist to have a good understanding of these new surgical procedures so as to provide optimal
surgical conditions. This article aims to inform anaesthetists about the recent surgical advances in corneal transplantation
and explore the anaesthetic considerations of these new techniques. General anaesthesia remains suitable for a wide range
of these procedures especially in repeat surgery, difficult, or prolonged procedures. Regional ophthalmic blocks are ideal for
endothelial keratoplasty but can be used in penetrating keratoplasty based on individual risk–benefit assessment, and as a
supplement to general anaesthesia. Topical anaesthesia provides an alternative when general anaesthesia and ophthalmic
regional blocks are less desirable but overall its use is limited.

Key Words: anaesthesia, corneal transplantation, anaesthesiology

Corneal transplantation (keratoplasty) is one of the most Search strategy

common forms of human donor transplantation1. In the last
20 years, selective keratoplasty (where only the diseased
layers of the cornea are replaced) has become more popular
than traditional penetrating keratoplasty (PK, full thickness
corneal transplant). In Australia, PK accounted for greater
than 90% of all corneal grafts performed in 2000, whereas
endothelial keratoplasty accounted for 48% of the total
corneal grafts performed and PK for less than 40% in 20132.
Advanced techniques such as corneal limbal stem cell
transplantation and artificial corneas (keratoprostheses) are
now available. Collectively, these procedures provide better
outcomes to restore vision in patients with corneal blindness.
This article aims to provide anaesthetists with a background
of the newer surgical techniques in corneal transplantation
and explore the anaesthetic considerations relevant to these
new techniques.
* MBBS FANZCA, Senior visiting anaesthetist, Department of Anaesthetics, Royal Prince
Alfred Hospital, Sydney, New South Wales
† Medical student, University of New South Wales, Sydney, New South Wales
‡ MBBS MD FANZCA FRCA FFARCSI FHKCA(Hon), Nuffield Professor of Anaesthesia,
Department of Anaesthesia, University of Sydney, Sydney, New South Wales
Address for correspondence: Alfred W. Y. Chua. Email: as_chua@bigpond.net.au
Accepted for publication on November 15, 2017
A literature search was conducted using MEDLINE
(PubMed) with the aim of identifying English language
articles published between January 1997 and May 2017. The
search words used included ‘anaesthesia’ in combination
with ‘cornea or ophthalmic’ and ‘graft or transplant’. A total
of 346 articles were retrieved. The authors examined the
articles in terms of quality and relevance to anaesthesia
for corneal transplantation. Further articles were retrieved
through their references. As a result, a total of 67 articles
concerning history, anatomy and physiology of the cornea,
surgical techniques and anaesthetic practices were included
in this review.
History
Experiments on keratoplasty using allografts and xenografts
were first performed in the 19th century3 but the lack of
anaesthesia contributed to an unfavourable outcome4.
Dr Eduard Zirm performed the first human penetrating
bilateral keratoplasty in 19055 on a patient under deep
general anaesthesia with chloroform and strict asepsis.
Unfortunately, it was successful only in the patient’s left eye4.
PK became possible with the introduction of antibiotics
and topical steroids as well as surgical improvements in the
1950s. Until recently it remained the mainstay of corneal
transplantation surgery1. Selective lamellar keratoplasty has
emerged as the preferred procedure in the last 20 years.

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Anaesth Intensive Care 2018 | 46:2
Figure 1: Normal corneal structure. The normal cornea consists of five layers.
Surgical aspects relevant to anaesthetic practice
Anatomy and physiology of the cornea
The cornea, a transparent and avascular connective tissue,
acts as the primary structural barrier of the eye. Together
with the overlying film containing tears, it also provides two-
thirds of the light-focusing ability for the eye6. The normal
cornea, about 520 microns thick, consists of five layers;
epithelium, Bowman’s membrane, stroma, Descemet’s
membrane and endothelium (Figure 1). The stroma
comprises 80% to 85% of the thickness of the cornea and
provides the main structural framework.
The main function of the corneal endothelium, a single
sheet of hexagonal cells with poor regenerative capacity, is to
transfer fluid out of the cornea. The number and morphology
of the cells of the cornea are important. At birth there are
approximately 3,500 corneal cells/mm2 and this decreases
by 0.6% per year throughout life. When this falls below 500
cells/mm2, corneal oedema may occur7. The cornea is one
of the most sensitive and densely innervated tissues in the
body. It contains sympathetic nerve fibres, as well as sensory
fibres mediated by the nasociliary branch of the ophthalmic
division of the trigeminal nerve7.
Indications for corneal transplant
The causes of corneal blindness include inherited (e.g.
aniridia), degenerative (e.g. keratoconus), dystrophic (e.g.
Fuchs’ corneal endothelial dystrophy), iatrogenic (e.g. post–
cataract surgery corneal decompensation), infective (e.g.
trachoma, river blindness), nutritional deficiency (e.g. vitamin
A), inflammatory (e.g. Stevens–Johnson syndrome), chemical
and thermal burns, and trauma. When these diseases disrupt
Anaesthesia for corneal transplantation
the curvature and impair the clarity or endothelial function of
the cornea, a corneal graft may be indicated.
Techniques of corneal transplant surgery
Penetrating keratoplasty
PK refers to a full thickness corneal graft where all five
layers of the cornea are replaced with donor cornea
(Figure 2). There are many different surgical techniques of
PK8. Common complications of PK include donor endothelial
cell loss, endothelial rejection, and glaucoma. PK is associated
with the highest risk of expulsive choroidal haemorrhage
(ECH) amongst all intraocular operations9. Visual recovery is
often slow and unpredictable. The corneal sutures remain
in situ for at least 12 months because wound healing takes
an extremely long time10. PK can be performed with either
general anaesthesia or ophthalmic regional techniques.
Selective lamellar keratoplasty
In selective lamellar keratoplasty, the current preferred
surgical procedure, only the diseased layers of the cornea
are replaced with donor tissue whilst the healthy layers are
retained. There are a variety of selective lamellar keratoplasty
techniques (Figure 2).
Anterior lamellar keratoplasty
In anterior lamellar keratoplasty, the epithelium and part of
the stroma is replaced. Deep anterior lamellar keratoplasty
is a variant of this procedure in which almost all the host
stroma is replaced. Endothelial rejection is eliminated in
both techniques because the endothelium is retained.
However, the difficulty in separating Descemet’s membrane
from the stroma makes deep anterior lamellar keratoplasty
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Figure 2: Different types of corneal transplantation.
more technically demanding. The average intraoperative
perforation rate of host Descemet’s membrane is 11.7%.
The mean conversion rate to PK is 2% but it can be as
high as 14%11. As the duration of surgery is influenced by
intraoperative issues and therefore unpredictable, general
anaesthesia is often preferred.
Endothelial keratoplasty
Endothelial keratoplasty is the preferred procedure in the
treatment of endothelial disease of the cornea. It involves
stripping Descemet’s membrane and endothelium from the
recipient stroma, and replacing it with donor tissue with the
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Anaesth Intensive Care 2018 | 46:2
aid of an air tamponade to maintain the graft in place. A
faster visual recovery is achieved compared with PK.
Variations of this technique differ in the amount of donor
tissue transplanted. In Descemet’s stripping endothelial
keratoplasty the inner 20% of the donor cornea including a
thin strip of stroma is transplanted. Descemet’s membrane
endothelial keratoplasty involves the transplantation of the
innermost 2% of the cornea without any stroma. Descemet’s
stripping endothelial keratoplasty and Descemet’s membrane
endothelial keratoplasty can also be ‘automated’ using a
microkeratome for dissecting donor tissue. Automated
procedures (Descemet’s stripping automated endothelial
Anaesth Intensive Care 2018 | 46:2
keratoplasty and Descemet’s membrane automated
endothelial keratoplasty) are associated with a lower risk of
donor tissue perforation12.
Displacement of the donor graft is the most common
complication and can be as high as 82% in Descemet’s
stripping endothelial keratoplasty and 20% in Descemet’s
membrane endothelial keratoplasty10. Endothelial
keratoplasty, which involves additional surgical manipulation
of the donor tissue, is associated with a higher endothelial
cell loss compared with PK during surgery1. To enhance the
donor–recipient graft adhesion, the patient is required to
lie still in a supine position for an hour immediately after
the surgery. Graft displacement may occur if the treated
eye is rubbed10. To minimise this potential complication,
an ophthalmic regional block is often preferred, either
as the primary technique or as a supplement to general
anaesthesia.
Advanced corneal graft techniques
Limbal epithelial stem cell transplantation
The ocular surface consists of two distinct mucosal
epithelial linings, the cornea and conjunctiva. Corneal
epithelial stem cells located at the limbus are essential
for maintaining healthy corneal epithelium. When these
cells are destroyed, the conjunctiva proliferates over the
cornea, resulting in significant visual impairment. This occurs
commonly in severe chemical or thermal burns.
When limbal epithelial stem cells are destroyed, the
traditional corneal transplantation technique cannot be
utilised because it replaces only the central part of the
cornea. A limbal epithelial stem cell graft is the appropriate
option. Donor limbal stem cells can be obtained either as
an autograft or an allograft. However, during an autograft
procedure, the healthy donor eye can be damaged as a result
of the removal of limbal tissue. In limbal allograft, the donor
cells can be cultivated in vitro from a small biopsy sample
obtained from a healthy eye and subsequently transplanted
to the diseased eye using a human amniotic membrane or
fibrin as the carrier. The overall success rate is estimated
to be 76%13. Limbal allograft survival in the diseased eye
declines over two years6. Regional or general anaesthesia can
be used for a single eye surgery whilst general anaesthesia is
preferred for bilateral procedures.
Keratoprosthesis (artificial cornea)
Keratoprosthesis is considered as the last option for
patients in whom conventional corneal transplant procedures
have failed or in patients with end-stage ocular surface
disease1. This is performed in only a few centres worldwide.
(i) Boston type I keratoprosthesis
The Boston type I keratoprosthesis is the most commonly
utilised artificial cornea when the eye is moist. It involves
Anaesthesia for corneal transplantation
the placement of two polymethylmethacrylate plates
(front and back) supported by a donor corneal transplant.
Although short-term outcomes are good, the long-term
outcome is limited by glaucoma and late endophthalmitis.
These complications occur in 12.5% of patients14,15. General
anaesthesia is the preferred option because severe corneal
scarring from existing disease or previous surgery makes
regional anaesthesia technically difficult. In addition, it is
usually a prolonged surgical procedure.
(ii) Osteo-odonto-keratoprosthesis
The osteo-odonto-keratoprosthesis, which utilises a
tooth to support an optic lens, is used if the eye is dry and
keratinised. It is a multiple stage procedure performed by a
team of corneal and oral surgeons16.
During the first stage, the entire corneal surface is removed
and replaced with a buccal mucosa autograft. A plastic
optical cylinder is fitted into a tooth together with its alveolar
bone that has been removed from the patient. Alternatively,
a tooth allograft can be utilised if the patient does not
have a suitable tooth for harvesting. The resultant tooth–
cylinder complex is implanted into the cheek so that a new
blood supply is established. The second stage is generally
performed three to four months later. The buccal mucosa
over the eye is opened and most of the inner contents of
the eye except the retina are removed. The tooth–cylinder
complex is removed from the cheek and inserted into the
eye. The airway should be reassessed carefully before the
second stage surgery as the scar from the previous buccal
mucosa harvest may limit mouth opening17.
The main risks of osteo-odonto-keratoprosthesis are
bone laminar resorption and glaucoma18. The two- and
ten-year functional survival rates are 63% and 38%
respectively19. Each surgical stage is lengthy and therefore
general anaesthesia is employed. Particular attention in the
anaesthetic management of these patients includes care of
pressure points, urinary catheter placement, maintenance of
normothermia, and thromboprophylaxis.
Descemetorhexis without transplant
Contrary to the paradigm that the corneal endothelium is
a non-regenerative monolayer of cells, various degrees of
endothelial regeneration are possible20. Descemetorhexis
refers to a special technique for excision of Descemet’s
membrane and endothelium from the recipient eye21.
Moloney et al reported two cases of successful spontaneous
corneal recovery after Descemetorhexis without transplant20.
This procedure is suitable in younger patients who have clear
and densely populated peripheral corneal endothelium22,
and is an option in selected patients with Fuchs’ endothelial
dystrophy. This procedure can be performed under topical or
regional anaesthesia.
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Table 1
Factors predisposing to expulsive choroidal haemorrhage
Systemic Ocular
Advanced age Choroid arteriolar sclerosis
Arteriosclerosis Glaucoma
Hypertension Myopia
Blood dyscrasia Recent intraocular surgery
Anticoagulation Expulsive haemorrhage in the other eye
Diabetes
Long-term steroid use
Major complications of corneal graft surgery
The major intraoperative surgical complications of corneal
graft are extrusion of ocular content and ECH. ECH, a rare but
catastrophic complication, results from a sudden decrease
in intraocular pressure (IOP) contributed to by surgical
decompression of the globe. The predisposing ophthalmic
factors are glaucoma, myopia, recent intraocular surgery,
and ECH in the other eye. Other systemic predisposing
factors include advanced age, arteriosclerosis, hypertension,
diabetes, blood dyscrasias, anticoagulation and long-term
steroid use (Table 1)9,23-25.
ECH, which results in an extremely poor visual outcome,
can occur either intraoperatively or in the postoperative
period. It is therefore essential to reduce, and maintain a low
and stable, IOP throughout the procedure. Some surgeons
utilise an infusion of mannitol as part of their routine
perioperative regimen.
The overall incidence of ECH is 0.19% in all intraocular
procedures and 0.56% during PK9. In a series of 2011
consecutive PKs, ECH occurred in 0.45% of patients.
There was no difference in the incidence between general
anaesthesia and local anaesthesia26. The authors noted
that local anaesthesia was used in shorter and simple
cases whilst general anaesthesia was preferred for longer
and more complicated operations. Bucking and movement
during general anaesthesia were attributed as the cause of
ECH in three patients. The use of neuromuscular blockade
monitoring did not eliminate this risk. The risk of ECH is
lower in endothelial keratoplasty as it is a closed surgery and
employs a smaller surgical incision10. There are no reported
cases of ECH in anterior lamellar keratoplasty1.
Scheduling of procedure
Eye banks were established in the 1940s to facilitate
the supply of corneas. Originally, tissue storage time was
limited to two to three days, and corneal transplants were
regarded as urgent procedures. Improved storage techniques
have enabled the storage time to be increased to seven to
ten days. As a consequence, corneal transplants are now
performed as elective operations, resulting in major cost
reductions and improvements in efficiency. Furthermore,
some eye banks can now provide pre-stripped donor tissue
for endothelial keratoplasty27.
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Anaesthetic considerations
Ideal anaesthetic conditions for corneal graft
Ideally, anaesthesia for corneal transplant surgery
should provide good analgesia, complete akinesia, prevent
eye squeezing, reduce and maintain a stable IOP, avoid
intraoperative coughing and movement, protect the eye (e.g.
maintain adequate perfusion, avoid iatrogenic injury or risk of
ECH), abolish the oculocardiac reflex, and avoid postoperative
nausea and vomiting (PONV).
Preoperative considerations
In patients presenting for corneal transplant surgery,
important preoperative considerations include the patient’s
age, airway, ability to lie flat, presence of tremors, use of
anticoagulants, and history of claustrophobia. Patients
should also be assessed for suitability for both general and
regional anaesthesia. Intraoperatively, even the slightest
movement (e.g. restless legs syndrome, cough) can lead to
catastrophic outcomes. Similar to cataract surgery28, the
patient’s cognitive function is an important consideration in
determining the choice of anaesthetic technique for corneal
graft surgery. The underlying corneal pathology and the
type of corneal transplantation procedure should also be
considered. As corneal pathology may be a feature of some
syndromes (e.g. keratoconus in Down syndrome, Turner’s
syndrome, Apert’s syndrome and osteogenesis imperfecta), a
thorough evaluation of any underlying syndrome is essential.
Routine preoperative investigations provide little benefit in
otherwise healthy patients29. They neither decrease adverse
events nor improve outcomes in cataract patients30-33, and a
similar approach can be applied to corneal transplantation.
The choice of anaesthetic techniques
General anaesthesia
General anaesthesia is suitable in children and a wide range
of adult patients, (including those who are unable to lie flat,
restless with tremor, or claustrophobic). Other advantages
include the absence of time constraints for surgery, and
a secured airway (Table 2). However, general anaesthesia
Table 2
Advantages and disadvantages of general anaesthesia for corneal grafts
Advantages Disadvantages
No surgical time constraint Increased postoperative nausea
Secured airway and vomiting
Motionless patient during surgery Not ideal for medically unfit
Suitable for children patients
Inability to lie flat
Tremor/Parkinson’s disease
Claustrophobia
PONV, postoperative nausea and vomiting.
Anaesth Intensive Care 2018 | 46:2 Anaesthesia for corneal transplantation

increases the risk of PONV and may not be suitable in anaesthesia has been recommended for optical PK (to
medically unfit patients. improve vision) on a cost–benefit rationale. In a prospective
To ensure a normal/low IOP, airway obstruction, coughing study comparing general anaesthesia using total intravenous
and eye squeezing must be avoided. Induction of anaesthesia anaesthesia versus peribulbar block in 141 patients
with propofol, thiopentone, opioids and volatile anaesthetic undergoing PK, Wang et al reported that general anaesthesia
agents all reduce IOP. Propofol produces a greater fall in facilitated a longer duration of surgery for the treatment of
IOP compared with thiopentone. Suxamethonium and pathology in the anterior chamber and was associated with
endotracheal intubation can raise the IOP but an additional fewer intraoperative complications in the therapeutic group
smaller dose of propofol administered immediately before but no difference in the optical group51.
intubation can lower IOP below the baseline level34.
Nitrous oxide35, midazolam36,37 and non-depolarising muscle Regional anaesthesia
relaxants have no significant effect on IOP. However, nitrous
The advantages of regional anaesthesia in corneal
oxide can cause rapid expansion of the intraocular gas
transplant surgery include good intraoperative analgesia and
spaces resulting in a marked elevation of IOP and blindness38.
akinesia, suppression of the oculocardiac reflex, reduced
Intraocular gas used during the surgical procedures for retinal
PONV, excellent postoperative analgesia, quicker recovery
detachment can persist in the eye for up to eight weeks39.
and discharge, and the avoidance of airway issues (Table
Although suxamethonium increases IOP for up to ten
3). This may be the preferred anaesthetic technique in
minutes40, it has been used in open globe injury with no
high-risk medically unwell patients. It is contraindicated in
apparent increased risk of extrusion of ocular content41. It is
patients with eye infections. Scarring arising from previous
safe to use suxamethonium where indicated provided that its
inflammation, surgery or trauma can interfere with the
effect on IOP has subsided before surgery commences.
spread of local anaesthetic solution. Furthermore, it is
Ketamine is best avoided because it can increase IOP by 2
often difficult and uncomfortable for the patient to remain
to 3 mmHg42. However, a study reported that IOP, although
motionless intraoperatively when the procedure proceeds
elevated, remained within the normal range in healthy
beyond two hours. An oculo-compression device that reduces
children undergoing non-ocular surgery43.
IOP should be used with caution because it may impair ocular
Droperidol (0.05 mg/kg intravenously) reduces the IOP and
perfusion52.
PONV when administered with general anaesthesia for PK44.
Ophthalmic regional blocks include sharp needle blocks
Its disadvantages include postoperative somnolence and, in
(retrobulbar block and peribulbar block) and sub-Tenon’s
larger doses, hypotension and extrapyramidal side-effects. It
block. Sub-Tenon’s blocks carry a lower risk of potentially
is associated with a prolonged QT interval45,46.
sight-threatening complications compared with sharp
The airway, often inaccessible to the anaesthetist, is usually
needle blocks53. The risks of sharp needle blocks in children
maintained during anaesthesia with either a laryngeal mask
are higher than in adults as a consequence of anatomical
airway (LMA) or endotracheal tube (ETT). The advantages
differences. The eye globe occupies almost 50% of the orbital
of the LMA include a smoother induction and emergence,
volume at birth and 33% at four years, whilst the adult globe
and less postoperative coughing47, but it is associated with
only fills 22% of the orbital volume54.
a higher incidence of PONV48. Since the airway is not fully
The volume of local anaesthetic solution used in these
secured by an LMA, a time limit of two hours is widely
blocks can alter IOP; the larger the volume injected, the
accepted to minimise the risk of aspiration49. If there are any
higher is the increase in IOP. IOP increases by 4 to 6 mmHg
concerns in regard to maintaining the airway with an LMA,
with retrobulbar blocks, and 5 to 22 mmHg with peribulbar
the patient’s airway should be secured with an ETT before
blocks52, whereas no significant changes in IOP are observed
surgery commences. The use of an ETT is associated with a
following sub-Tenon’s blocks55.
lower incidence of PONV, but there is an increased incidence
The ability to squeeze the eyelids is not always abolished by
of coughing at emergence leading to a marked increase in
IOP47. Insertion of an ETT can increase IOP. Table 3
Monitoring of neuromuscular blockade and depth Advantages and disadvantages of regional anaesthesia for corneal grafts
of anaesthesia can improve the safety of general
Advantages Disadvantages
anaesthesia. General anaesthesia does not eliminate the
risk of intraoperative movement. The American Society of When risks of GA are high Maximum two hours surgery
Intraoperative analgesia and akinesia Scar tissue may interfere with
Anesthesiologists’ Closed Claim Project reported 21 cases of Suppression of oculocardiac reflex LA spread
blindness allegedly associated with intraoperative movement. Excellent postoperative analgesia Not suitable for some cases
Sixteen of these cases occurred during general anaesthesia, Reduced PONV (e.g. gross infection)
Quicker recovery and discharge
whilst five occurred during monitored anaesthesia care50.
General anaesthesia is advocated for therapeutic PK GA, general anaesthesia; LA, local anaesthetic; PONV, postoperative nausea
and vomiting.
(to preserve the eye and relieve pain), whilst regional

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A. W. Y. Chua et al
an ophthalmic regional block. Closure of the eyelids increases
IOP by 5 mmHg whereas tight squeezing of the eyelids
increases it by more than 50 mmHg56 with serious adverse
complications. A supplementary eyelid block can effectively
and safely provide akinesia of the orbicularis oculi muscle
compared with facial nerve blocks (e.g. van Lint block)57.
Topical anaesthesia
Topical anaesthesia, application of topical and intracameral
local anaesthetic agents, is widely used for cataract surgery.
It has also been used for PK58, deep lamellar keratoplasty59,
endothelial keratoplasty60,61, and triple procedures (cataract
extraction, insertion of intraocular lens, and Descemet’s
stripping automated endothelial keratoplasty)62.
In short procedures (e.g. endothelial keratoplasty) that
are associated with a low risk of ECH, topical anaesthesia
provides a safe and effective option. In triple procedures,
it reduces the need for a miotic agent when the surgery
transits from cataract to the Descemet’s stripping automated
endothelial keratoplasty because the pupillary dilation
achieved with the use of 1% lignocaine is short-lived.
Pain and discomfort are common towards the end of the
operation. As such, topical anaesthesia is more suitable for
patients undergoing repeated PK as the corneal sensation is
already compromised.
Overall the use of topical anaesthesia is limited in corneal
transplants. It provides an alternative for patients in whom
general anaesthesia or ophthalmic regional blocks are less
desirable, such as patients with perforated corneal ulcers
(e.g. autoimmune diseases, herpes infection)63. These
perforations result in similar issues as those associated with
an open globe injury.
Intravenous sedation is commonly used in conjunction with
regional or topical anaesthesia to enhance patient comfort
and reduce anxiety. However, elderly patients may respond
unpredictably to sedative drugs. Sedation is not a substitute
for an inadequate block. The quality of the block should be
assessed before the surgery commences64.
Other considerations
The use of a slight head-up tilt position to reduce IOP has
to be balanced with the surgeon’s preference. If the surgeon
is positioned above the patient’s head, the patient should lie
flat.
When pharmacological agents, such as acetazolamide or
mannitol, are required to reduce IOP during the surgery, a
full bladder may cause discomfort and restlessness in an
awake patient. Placement of a urinary catheter should be
considered if mannitol is used as part of the surgical routine
during the perioperative period.
A supplementary regional block used with general
anaesthesia, especially in paediatric patients and
endothelial keratoplasty, reduces intraoperative anaesthetic
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Anaesth Intensive Care 2018 | 46:2
requirements, provides excellent postoperative analgesia, and
reduces the incidence of the oculocardiac reflex and PONV.
PONV occurs twice as frequently in children as in adults,
and increases until puberty65. It is also a side-effect of
acetazolamide. It increases the risk of graft displacement
after endothelial keratoplasty when the patient is required to
lie supine postoperatively for an hour. Retained viscoelastic
agent used during surgery may increase IOP66 and cause
intractable PONV, and this requires an urgent review by the
ophthalmologist. Prophylactic antiemetic treatment using
a combination of different classes of antiemetic drugs is
recommended for moderate- to high-risk patients65,67.
Summary
We have briefly explored the recent advances in corneal
transplantation surgery. Selective lamellar keratoplasty has
replaced PK as the preferred surgical technique. Advanced
techniques such as corneal limbal stem cell transplant and
keratoprosthesis are also available. General anaesthesia is
advocated for a wide range of these procedures especially in
repeated surgery, and in difficult and prolonged procedures.
Regional ophthalmic blockade is advocated for endothelial
keratoplasty and as a supplement to general anaesthesia but
can be used in PK. The overall use of topical anaesthesia is
limited. The choice of the anaesthetic technique is influenced
by corneal pathology, surgical procedure, patient and
surgeon’s preference as well as the anaesthetist’s skill and
preference. An unfamiliar anaesthetic technique employed
can be more harmful.
Acknowledgements
The authors wish to thank Dr Brian Harrisberg of the Royal
Prince Alfred Hospital and Dr Greg Moloney of Sydney Eye
Hospital, Sydney, for their explanation of the operative
procedures, and risks from the surgical perspective.
Authors’ contributions
Research: A.W.Y.C., M.J.C. Original draft preparation: A.W.Y.C.
Review and editing: A.W.Y.C., M.J.C., P.C.A.K. Figures: M.J.C.
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