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Corneal transplantation
Corneal transplantation, also known as corneal
grafting, is a surgical procedure where a damaged or Corneal transplantation
diseased cornea is replaced by donated corneal tissue (the
graft). When the entire cornea is replaced it is known as
penetrating keratoplasty and when only part of the
cornea is replaced it is known as lamellar keratoplasty.
Keratoplasty simply means surgery to the cornea. The
graft is taken from a recently dead individual with no
known diseases or other factors that may affect the chance
of survival of the donated tissue or the health of the
recipient.

The cornea is the transparent front part of the eye that

covers the iris, pupil and anterior chamber. The surgical Cornea transplant approximately one week
procedure is performed by ophthalmologists, physicians after surgery. Multiple light reflections
who specialize in eyes, and is often done on an outpatient indicate folds in the cornea, which were later
basis. Donors can be of any age, as is shown in the case of
resolved.
Janis Babson, who donated her eyes at age 10. The corneal
transplantation is performed when medicines, Other Corneal grafting
keratoconus conservative surgery and cross-linking names
cannot heal the cornea anymore. ICD-9-CM 11.6 (http://icd9cm.chrisendre
s.com/index.php?srchtype=pr
ocs&srchtext=11.6&Submit=S
Contents earch&action=search)

Medical uses MeSH D016039

Risks MedlinePlus 003008

Procedure
Pre-operative examination
Penetrating keratoplasty
Lamellar keratoplasty
Deep anterior lamellar keratoplasty
Endothelial keratoplasty
Synthetic corneas
Boston keratoprosthesis
AlphaCor
Osteo-Odonto-Keratoprosthesis
Prognosis
Alternatives
Contact lenses
Phototherapeutic keratectomy
Intrastromal corneal ring segments
Corneal collagen cross-linking
Epidemiology
History
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Research
High speed lasers
DSEK/DSAEK/DMEK
Stem cells
Biosynthetic corneas
Society and culture
Cost
References
External links

Medical uses
Indications include the following:

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.

Risks
The risks are similar to other intraocular procedures, but additionally include graft rejection
(lifelong), detachment or displacement of lamellar transplants and primary graft failure. Use of
immunosupressants including cyclosporine A, tacrolimus, mycophenolate mofetil, sirolimus, and
leflunomidprevent to prevent graft rejection is increasing but there is insufficient evidence to
ascertain which immunosuppressant is better.[1] In a Cochrane review which included low to
moderate quality evidence, adverse effects were found to be common with systemic mycophenolate
mofetil, but less common with topical treatments cyclosporine A and tacrolimus.

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 more slowly 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).

There is a risk of cornea rejection, which occurs in about 10% of cases.[2] 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 excessively tight stitch cheesewiring
through the sclera.

Procedure

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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
operating room, 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. In children, a metal ring is Cornea transplant one day after
stitched to the sclera which will provide support of the sclera surgery.
during the procedure.

Pre-operative examination

In most instances, the person 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 Cornea transplant after one year of
informed consent form. The doctor might also perform a physical healing, two stitches are visible
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. Within the United States, the supply of corneas is sufficient to meet the demand for surgery and
research purposes. Therefore, unlike other tissues for transplantation, delays and shortages are not
usually an issue.[3]

Penetrating keratoplasty

A trephine (a circular cutting device), which removes a circular

disc of cornea, is used by the surgeon to cut the donor cornea. A
second trephine is then used to remove a similar-sized portion of
the patient's cornea. The donor tissue is then sewn in place with
sutures.

Antibiotic eyedrops are 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 postoperative appointment. Replacement of the entire cornea

Lamellar keratoplasty

Lamellar keratoplasty encompasses several techniques which selectively replace diseased layers of the
cornea while leaving healthy layers in place. The chief advantage is improved tectonic integrity of the
eye. Disadvantages include the technically challenging nature of these procedures, which replace
portions of a structure only 500  µm thick, and reduced optical performance of the donor/recipient
interface compared to full-thickness keratoplasty.
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Deep anterior lamellar keratoplasty

In this procedure, the anterior layers of the central cornea are removed and replaced with donor
tissue. Endothelial cells and the Descemets membrane are left in place. This technique is used in cases
of anterior corneal opacifications, scars, and ectatic diseases such as keratoconus.

Endothelial keratoplasty

Endothelial keratoplasty replaces the patient's endothelium with a transplanted disc of posterior
stroma/Descemets/endothelium (DSEK) or Descemets/endothelium (DMEK).[4]

This relatively new procedure has revolutionized treatment of disorders of the innermost layer of the
cornea (endothelium). Unlike a full-thickness corneal transplant, the surgery can be performed with
one or no sutures. Patients may recover functional vision in days to weeks, as opposed to up to a year
with full thickness transplants. However, an Australian study has shown that despite its benefits, the
loss of endothelial cells that maintain transparency is much higher in DSEK compared to a full-
thickness corneal transplant. The reason may be greater tissue manipulation during surgery, the
study concluded.[5]

During surgery the patient's corneal endothelium is removed and replaced with donor tissue. With
DSEK, the donor includes a thin layer of stroma, as well as endothelium, and is commonly 100–
150  µm thick. With DMEK, only the endothelium is transplanted. In the immediate postoperative
period the donor tissue is held in position with an air bubble placed inside the eye (the anterior
chamber). The tissue self-adheres in a short period and the air is adsorbed into the surrounding
tissues.

Complications include displacement of the donor tissue requiring repositioning ("refloating"). This is
more common with DMEK than DSEK. Folds in the donor tissue may reduce the quality of vision,
requiring repair. Rejection of the donor tissue may require repeating the procedure. Gradual
reduction in endothelial cell density over time can lead to loss of clarity and require repeating the
procedure.

Patients with endothelial transplants frequently achieve best corrected vision in the 20/30 to 20/40
range, although some reach 20/20. Optical irregularity at the graft/host interface may limit vision
below 20/20.

Synthetic corneas

Boston keratoprosthesis

The Boston keratoprosthesis is the most widely used synthetic

cornea to date with over 900 procedures performed worldwide in
2008. The Boston KPro was developed at the Massachusetts Eye
and Ear Infirmary under the leadership of Claes Dohlman, MD,
PhD.[6]

AlphaCor

In cases where there have been several graft failures or the risk Boston Kpro type 1 titanium
for keratoplasty is high, synthetic corneas can substitute posterior plate
successfully for donor corneas. Such a device contains a
peripheral skirt and a transparent central region. These two parts
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are connected on a molecular level by an interpenetrating polymer network, made from poly-2-
hydroxyethyl methacrylate (pHEMA). AlphaCor is a U.S. FDA-approved type of synthetic cornea
measuring 7.0 mm in diameter and 0.5 mm in thickness. The main advantages of synthetic corneas
are that they are biocompatible, and the network between the parts and the device prevents
complications that could arise at their interface. The probability of retention in one large study was
estimated at 62% at 2 years follow-up.[7]

Osteo-Odonto-Keratoprosthesis

In a very rare and complex multi-step surgical procedure, employed to help the most disabled
patients, a lamina of the person's tooth is grafted into the eye, with an artificial lens installed in the
transplanted piece.

Prognosis
The prognosis for visual restoration and maintenance of ocular health with corneal transplants is
generally very good. Risks for failure or guarded prognoses are multifactorial. The type of transplant,
the disease state requiring the procedure, the health of the other parts of the recipient eye and even
the health of the donor tissue may all confer a more or less favorable prognosis.

The majority of corneal transplants result in significant improvement in visual function for many
years or a lifetime. In cases of rejection or transplant failure, the surgery can generally be repeated.

Alternatives

Contact lenses

Different types of contact lenses may be used to delay or eliminate the need for corneal
transplantation in corneal disorders.

Phototherapeutic keratectomy

Diseases that only affect the surface of the cornea can be treated with an operation called
phototherapeutic keratectomy (PTK). With the precision of an excimer laser and a modulating agent
coating the eye, irregularities on the surface can be removed. However, in most of the cases where
corneal transplantation is recommended, PTK would not be effective.

Intrastromal corneal ring segments

In corneal disorders where vision correction is not possible by using contact lenses, intrastromal
corneal ring segments may be used to flatten the cornea, which is intended to relieve the
nearsightedness and astigmatism. In this procedure, an ophthalmologist makes an incision in the
cornea of the eye, and inserts two crescent or semi-circular shaped ring segments between the layers
of the corneal stroma, one on each side of the pupil.[8] Intrastromal corneal rings were approved in
2004 by the Food and Drug Administration for people with keratoconus who cannot adequately
correct their vision with glasses or contact lenses. They were approved under the Humanitarian
Device Exemption,[9][10] which means the manufacturer did not have to demonstrate effectiveness.

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Corneal collagen cross-linking

Corneal collagen cross-linking may delay or eliminate the need for corneal transplantation in
keratoconus and post-LASIK ectasia, however as of 2015 it is lacking sufficient evidence to determine
if it is useful in keratoconus.[11]

Epidemiology
Corneal transplant is one of the most common transplant procedures.[12] Although approximately
100,000 procedures are performed worldwide each year, some estimates report that 10,000,000
people are affected by various disorders that would benefit from corneal transplantation.[13]

In Australia, approximately 2,000 grafts are performed each year.[12] According to the NHS Blood
and Transplant, over 2,300 corneal transplant procedures are performed each year in the United
Kingdom.[14] Between April 1, 2005 and March 31, 2006, 2,503 people received corneal transplants in
the UK.[15]

History
Spanish-born eye surgeon Ramon
Castroviejo successfully performed
keratoplasty as early as 1936.
of keratoconus, achieving significant improvement in patient's vision.[18][19]
The first cornea transplant
was performed in 1905 by
Eduard Zirm (Olomouc Eye
Clinic, now Czech Republic),
making it one of the first
types of transplant surgery
successfully performed.
Another pioneer of the
operation was Ramon
Castroviejo. Russian eye
surgeon Vladimir Filatov's
attempts at transplanting
cornea started with the first
try in 1912 and were
continued, gradually
improving until on 6 May
1931 he successfully grafted a
patient using corneal tissue Eduard Zirm
from a deceased person. [16]
He widely reported another
transplant in 1936, disclosing his technique in full detail.[17] In
1936, Castroviejo did a first transplantation in an advanced case

Tudor Thomas, a clinical teacher for the Welsh National School of Medicine, conceived the idea of a
donor system for corneal grafts and an eye bank was established in East Grinstead in 1955.[20]

Advances in operating microscopes enabled surgeons to have a more magnified view of the surgical
field, while advances in materials science enabled them to use sutures finer than a human hair.

Instrumental in the success of cornea transplants were the establishment of eye banks. These are
organizations located throughout the world to coordinate the distribution of donated corneas to
surgeons, as well as providing eyes for research. Some eye banks also distribute other anatomical
gifts.
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Research

High speed lasers

Blades are being replaced by high speed lasers in order to make surgical incisions more precise. These
improved incisions allow the cornea to heal more quickly and the sutures to be removed sooner. The
cornea heals more strongly than with standard blade operations. Not only does this dramatically
improve visual recovery and healing, it also allows the possibility for improvement in visual outcomes.

Since 2004, Amnitrans Eyebank in Rotterdam, The Netherlands, provides donor corneas pre-cut for
advanced keratoplasty procedures, such as DSEK, DSAEK, FS-DSEK and DMEK. In 2007, Seattle-
based SightLife, one of the leading corneal tissue banks in the world, introduced a process for the
preparation of donated corneal tissue using a Femtosecond Laser. This process is known as custom
corneal tissue.

DSEK/DSAEK/DMEK

Endothelial keratoplasty (EK) has been introduced by Melles et al. in 1998. Today there are three
forms of EK. Deep Lamellar Endothelial Keratoplasty (DLEK) in which the posterior part of the
recipient cornea is replaced by donor tissue. Descemet's Stripping (Automated) Endothelial
Keratoplasty (DSEK/DSAEK) in which the diseased Descemet's membrane is removed and replaced
by a healthy donor posterior transplant. The transplant tissue can be prepared by a surgeon's hand or
ordered already prepared for surgery. Ocular Systems was the first organization to deliver prepared
grafts for surgery in 2005.[21] DSEK/DSAEK uses only a small incision that is either self-sealing or
may be closed with a few sutures. The small incision offers several benefits over traditional methods
of corneal transplant such as Penetrating Keratoplasty. Because the procedure is less invasive, DSAEK
leaves the eye much stronger and less prone to injury than full-thickness transplants. New medical
devices such as the EndoSaver (patent pending) are designed to ease process of inserting endothelial
tissue into the cornea.[22] Additionally, DSAEK has a more rapid rate of visual recovery. Vision is
typically restored in one to six months rather than one to two years.

Descemet Membrane Endothelial Keratoplasty (DMEK) is the most recent EK technique in which an
isolated Descemet membrane is transplanted. The DMEK procedure is a 'like for like' replacement of
the diseased part of the cornea with visual rehabilitation to 20/40 or better in 90% of cases and 20/25
or better in 60% of cases within the first three months. Rejection rates are lower (1%) and visual
recovery is faster than any other form of corneal transplantation. In the UK (2013) DMEK is available
to patients under the National Health Service at the Royal Shrewsbury Hospital,[23] the Calderdale
and Huddersfield NHS Trust.[24] and at Worthing Hospital (Western Sussex Hospitals NHS
Foundation Trust).[25]

Not all patients with diseased corneas are candidates for endothelial keratoplasty. These procedures
correct corneal endothelial failure, but are not able to correct corneal scarring, thinning, or surface
irregularity. There is currently limited data on long-term survival of DMEK grafts however the early
indications are very positive. An upcoming systematic review will seek to compare the safety and
effectiveness of DMEK versus DSAEK in people with corneal failure from Fuchs' endothelial
dystrophy and pseudophakic bullous keratopathy.[26]

Stem cells

There is a bioengineering technique that uses stem cells to create corneas or part of corneas that can
be transplanted into the eyes. Corneal stem cells are removed from a healthy cornea. They are
collected and, through laboratory procedures, made into five to ten layers of cells that can be stitched
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into a patient's eye. The stem cells are placed into the area where the damaged cornea tissue has been
removed. This is a good alternative for those that cannot gain vision through regular cornea
transplants. A new development, announced by the University of Cincinnati Medical School in May
2007, would use bone marrow stem cells to regrow the cornea and its cells. This technique, which
proved successful in mouse trials, would be of use to those suffering from inherited genetic
degenerative conditions of the cornea, especially if other means like a transplant aren't feasible. It
works better than a transplant because these stem cells keep their ability to differentiate and replicate,
and so keep the disease from recurring, longer and better.

Biosynthetic corneas

On 25 August 2010 investigators from Canada and Sweden reported results from the first 10 people in
the world treated with the biosynthetic corneas. Two years after having the corneas implanted, six of
the 10 patients had improved vision. Nine of the 10 experienced cell and nerve regeneration, meaning
that corneal cells and nerves grew into the implant. To make the material, the researchers placed a
human gene that regulates the natural production of collagen into specially programmed yeast cells.
They then molded the resulting material into the shape of a cornea. This research shows the potential
for these bioengineered corneas but the outcomes in this study were not nearly as good as those
achieved with human donor corneas. This may become an excellent technique, but right now it is still
in the prototype stage and not ready for clinical use. The results were published in the journal Science
Translational Medicine.[27]

Society and culture

Cost

A 2013 cost-benefit analysis by the Lewin Group for Eye Bank Association of America, estimated an
average cost of $16,500 for each corneal transplant.[28]

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27. Salynn Boyles. WebMD (http://www.webmd.com/eye-health/news/20100825/first-biosynthetic-cor
neas-implanted), August 25, 2010.
28. "Cost-Benefit Analysis of Corneal Transplant" (http://restoresight.org/wp-content/uploads/2014/03/
Lewin-Study-Sept-2013.pdf) (PDF). Restoresight.org. Retrieved 2016-11-30.

External links
Facts About the Cornea and Corneal Disease (https://web.archive.org/web/20161122040846/http
s://www.nei.nih.gov/health/cornealdisease/) The National Eye Institute (NEI)

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