Corneal Corneal TransplantationTransplantation

11PHRM-520,L.S.No-5.1PHRM-520,L.S.No-5.1

Review of Corneal Review of Corneal AnatomyAnatomy

1.1. EpitheliumEpithelium

2.2. BowmanBowman’’s layers layer

3.3. StromaStroma

4.4. DescemetsDescemets

5.5. Endothelial Endothelial layerlayer

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Endothelial layerEndothelial layer Born with approx 4200 cells/mmBorn with approx 4200 cells/mm22

Cells have a pump mechanism for Cells have a pump mechanism for removing fluid from the cornearemoving fluid from the cornea

No ability to replicateNo ability to replicate Cell death throughout lifeCell death throughout life Cells are easily injuredCells are easily injured Normal adult count 2800 c/mmNormal adult count 2800 c/mm22

Gross corneal edema with vision Gross corneal edema with vision change if <800 cells/mmchange if <800 cells/mm22

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Indications for Corneal Indications for Corneal TransplantationTransplantation

Lack of corneal clarity (scar)Lack of corneal clarity (scar) Corneal curvature abnormalities Corneal curvature abnormalities

(ectasia)(ectasia) Corneal edemaCorneal edema Lack of corneal integrity Lack of corneal integrity

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Why Corneal Grafting? Why Corneal Grafting?

Corneal OpacityCorneal Opacity Corneal CloudingCorneal Clouding Corneal EctasiasCorneal Ectasias Corneal EdemaCorneal Edema Fuchs Endothelial DystrophyFuchs Endothelial Dystrophy

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Corneal OpacityCorneal Opacity

Corneal scarring from firework accident

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Corneal CloudingCorneal Clouding

Granular stromal dystrophy

Fungal keratitis

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Corneal CloudingCorneal Clouding

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Corneal EctasiasCorneal Ectasias Keratoconus- progressive corneal Keratoconus- progressive corneal

thinning and steepening. Presents in thinning and steepening. Presents in late teens and causes late teens and causes astigmatismastigmatism that may not be correctable with that may not be correctable with glasses or rigid contact lensesglasses or rigid contact lenses

Pellucid marginal degenerationPellucid marginal degeneration

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Corneal EdemaCorneal Edema

Pseudophakic bullous keratopathy Pseudophakic bullous keratopathy (PBK) – swelling related to endothelial (PBK) – swelling related to endothelial dysfunction. Common problem with dysfunction. Common problem with early lens implants.early lens implants.

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Fuchs Endothelial DystrophyFuchs Endothelial Dystrophy Inherited condition- AD w/ variable Inherited condition- AD w/ variable

penetrance. Endothelial cells die at a faster penetrance. Endothelial cells die at a faster rate due to corneal guttata. rate due to corneal guttata. Poor vision due to Poor vision due to edema, or to glare caused by the guttata.edema, or to glare caused by the guttata.

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FuchsFuchs

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Loss of corneal IntegrityLoss of corneal Integrity Corneal perforation or melt Corneal perforation or melt

(infectious or rheumatologic)(infectious or rheumatologic)

Infectious melt due to wire injury

One month post-op PK

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HistoryHistory

1906 – Dr. Eduard Konrad Zirm in 1906 – Dr. Eduard Konrad Zirm in Moravia performed the first successful Moravia performed the first successful penetrating keratoplasty (PK) on a penetrating keratoplasty (PK) on a farmer in Prague who sustained farmer in Prague who sustained bilateral alkali burns after cleaning his bilateral alkali burns after cleaning his chicken coop with lime. Bilateral 5 mm chicken coop with lime. Bilateral 5 mm grafts from a single donor (11 yo boy grafts from a single donor (11 yo boy who required enucleation)who required enucleation)

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HistoryHistory

Essential Principles (still in use)Essential Principles (still in use)

1. Donor must be human1. Donor must be human

2. Aseptic technique2. Aseptic technique

3. No antiseptic agents should go on 3. No antiseptic agents should go on corneacornea

4. Protect graft w/ saline moistened 4. Protect graft w/ saline moistened gauzegauze

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LimitationsLimitations good understanding of corneal good understanding of corneal

physiology or immunologyphysiology or immunology fine sutures or operating microscopefine sutures or operating microscope pharmacologic ability to treat or pharmacologic ability to treat or

prevent rejectionprevent rejection

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HistoryHistory Elschnig (Prague) 1920 Elschnig (Prague) 1920

report first clinical series report first clinical series of corneal transplantsof corneal transplants

Reported another series of Reported another series of 174- confirmed partial PK 174- confirmed partial PK better then total. 22% better then total. 22% success rate (graft clarity)success rate (graft clarity)

Filatov (Odessa) reported Filatov (Odessa) reported 800 grafts from 1922-800 grafts from 1922-1945, started to use 1945, started to use cadaver corneascadaver corneas

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HistoryHistory Ramon Castroviejo Ramon Castroviejo

(New York) 1930(New York) 1930’’s s designed a square designed a square graft graft ““watermelon watermelon plugplug”” to have better to have better wound coaptation. wound coaptation. Improved suturing Improved suturing and and instrumentation.instrumentation.

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von Hippel clockwork trephine

(trephine: a surgical instrument for cutting out circular sections)

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HistoryHistory 1945 R. Townley Paton started the first Eye 1945 R. Townley Paton started the first Eye

Bank in NYC. Bank in NYC. Early tissue was acquired from Early tissue was acquired from prisoners executed at Sing-Sing prisonprisoners executed at Sing-Sing prison

A. Edward Maumenee at Wilmer Eye Hospital A. Edward Maumenee at Wilmer Eye Hospital advanced the field with his work in corneal advanced the field with his work in corneal physiology and immunology. physiology and immunology.

Coincided w/ the advent of topical Coincided w/ the advent of topical corticosteroids which had a profound effect on corticosteroids which had a profound effect on modern corneal transplantationmodern corneal transplantation

Surgical success was followed by optical Surgical success was followed by optical successsuccess

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1950 to present1950 to present Operating microscopeOperating microscope New trephines and laser trephination New trephines and laser trephination New suture needlesNew suture needles ViscoelasticsViscoelastics Steroids and other immunomodulatorsSteroids and other immunomodulators Better antibioticsBetter antibiotics Eye Bank Association of America (1961) Eye Bank Association of America (1961) Improved storage medium for donor Improved storage medium for donor

corneascorneas

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Eye Bank Association of America Eye Bank Association of America contraindications for donor contraindications for donor

corneascorneas Death of unknown causeDeath of unknown cause Unknown central nervous system disease Unknown central nervous system disease Infections including HIV or hepatitisInfections including HIV or hepatitis Active ocular inflammationActive ocular inflammation Leukemia or lymphomaLeukemia or lymphoma Cancer in the eyeCancer in the eye Congenital corneal dystrophies or ectasias Congenital corneal dystrophies or ectasias

(e.g. keratoconus)(e.g. keratoconus) Prior refractive surgery (e.g. LASIK)Prior refractive surgery (e.g. LASIK)

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Storage MediaStorage Media Optisol GS allows for Optisol GS allows for

storage up to 10 storage up to 10 days. Allows surgery days. Allows surgery to be scheduled to be scheduled electivelyelectively

D to P (death to D to P (death to preservation) preservation) preferably less than preferably less than 12 hours12 hours

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Types of Corneal Types of Corneal TransplantsTransplants

Penetrating keratoplasty Penetrating keratoplasty (PK)(PK) Lamellar keratoplasty Lamellar keratoplasty (LK)(LK)

Anterior lamellar keratoplasty Anterior lamellar keratoplasty (ALK)(ALK) Deep anterior lamellar keratoplasty Deep anterior lamellar keratoplasty (DALK)(DALK)

Posterior lamellar keratoplasty Posterior lamellar keratoplasty (PLK)(PLK) Endothelial keratoplasty Endothelial keratoplasty (EK)(EK)

Deep lamellar endothelial Deep lamellar endothelial keratoplasty keratoplasty (DLEK)(DLEK)

DescemetDescemet’’s stripping endothelial s stripping endothelial keratoplasty keratoplasty (DSEK)(DSEK)

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PK Surgery: Full Thickness PK Surgery: Full Thickness SurgerySurgery

Recipient tissue Recipient tissue removedremoved

Donor tissue Donor tissue sutured into sutured into recipientrecipient

Smooth Surface with only endothelial disease

Full thickness block of tissue removed just to get to the endothelium

Central trephine cutCentral trephine cut mademade

Sutures create anirregular surfacewith astigmatismand blurring

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PK instrumentsPK instruments

Trephine with suction for host cornea

Donor cornea punch

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Penetrating keratoplasty for keratoconus

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Penetrating keratoplasty

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Indications for corneal Indications for corneal transplanttransplant

IndicationIndication 1970s (%)1970s (%) 1980s (%)1980s (%)1990(%)1990(%)

PBKPBK 1.7 1.7 18.9 18.9 21.121.1ABKABK 9.2 9.2 8.4 8.4 4.04.0FuchsFuchs 6.4 6.4 10.6 10.6 13.413.4KeratoconusKeratoconus 16.5 16.5 16.0 16.0 13.413.4RegraftsRegrafts 26.2 26.2 18.9 18.9 11.811.8ScarsScars 4.2 4.2 7.3 7.3 0.40.4UlcersUlcers 2.7 2.7 3.0 3.0 4.64.6Corneal dystrophyCorneal dystrophy 4.7 4.7 2.5 2.5 2.82.8Chemical BurnChemical Burn 3.2 3.2 0.6 0.6 0.40.4TraumaTrauma 3.7 3.7 2.1 2.1 2.02.0Interstitial keratitisInterstitial keratitis 5.8 5.8 2.22.2 0.3 0.3CongenitalCongenital 0.4 0.4 0.6 0.6 1.31.3VirusVirus 12.1 12.1 5.5 5.5 1.41.4OtherOther 3.0 3.0 3.3 3.3 23.123.1

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Problems with PK:Problems with PK:

Unpredictable astigmatism and Unpredictable astigmatism and corneal powercorneal power

InfectionInfection UlcerationUlceration VascularizationVascularization RejectionRejection Poor Wound Healing: Risk of RupturePoor Wound Healing: Risk of Rupture

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Severe Complications of Penetrating Keratoplasty: Severe Complications of Penetrating Keratoplasty: Suture Problems and Wound Healing ProblemsSuture Problems and Wound Healing Problems

Endophthalmitis:Endophthalmitis:From retained suture From retained suture

fragmentfragment

Expulsive Hemorrhage:Expulsive Hemorrhage:From mild blunt trauma From mild blunt trauma five years after PKfive years after PK

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Deep Lamellar Endothelial Deep Lamellar Endothelial KeratoplastyKeratoplasty

First described by Dr. Gerrit Melles- 1998First described by Dr. Gerrit Melles- 1998 First done in the US by Mark Terry, M.D.First done in the US by Mark Terry, M.D. Terry has done> 250 between 2000-05Terry has done> 250 between 2000-05 Terry has trained> 100 cornea specialists Terry has trained> 100 cornea specialists

to perform DLEK, and formed EKG to perform DLEK, and formed EKG (Endothelial Keratoplasty Group)(Endothelial Keratoplasty Group)

Initially all procedures done under IRBInitially all procedures done under IRB

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DLEK Surgery: Split Thickness DLEK Surgery: Split Thickness Surgery to replace only the Surgery to replace only the

diseased tissuediseased tissue Recipient tissue removed

Donor tissue placed into recipient

Scleral incision, deepcorneal pocket, and endothelium trephinedwith Terry Trephine

Just endothelium on posteriorstromal disc removed from pocket

Endothelium replaced with no sutures, supported by air bubble in anterior chamber. Surface remains smooth with no astigmatism

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EKEK Large air bubble is left in Large air bubble is left in

the eye at the end of the eye at the end of surgery to help support surgery to help support the graft while adhering. the graft while adhering. Patient is to be supine Patient is to be supine the rest of the day and the rest of the day and nightnight

If the bubble is too big, If the bubble is too big, pupillary block glaucoma pupillary block glaucoma can occur can occur

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Advantages of EK over PKAdvantages of EK over PK

Faster visual recovery Faster visual recovery Less postoperative astigmatism (confirmed by corneal Less postoperative astigmatism (confirmed by corneal

topography)topography) Stronger globe integrity due to lack of full-thickness Stronger globe integrity due to lack of full-thickness

corneal incision corneal incision No suture related infections No suture related infections

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Disadvantages of DLEKDisadvantages of DLEK

More time consuming and difficult procedure due More time consuming and difficult procedure due to lamellar dissectionto lamellar dissection

Graft dislocation- 5-20% on post-op day 1Graft dislocation- 5-20% on post-op day 1 Not as many patients get to 20/20 as with PK; Not as many patients get to 20/20 as with PK;

may be interface problemmay be interface problem

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DSEK- Descemets Stripping DSEK- Descemets Stripping Endothelial KeratoplastyEndothelial Keratoplasty

2005 Price, Gorovoy- eliminated the 2005 Price, Gorovoy- eliminated the recipient dissection by just removing recipient dissection by just removing descemets membrane and the descemets membrane and the endotheliumendothelium

Surgeon still had to perform the lamellar Surgeon still had to perform the lamellar dissection on the donor. If it went badly, dissection on the donor. If it went badly, the tissue was wasted.the tissue was wasted.

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DSAEKDSAEK Replaced donor dissection with a cut made Replaced donor dissection with a cut made

by an automated lamellar keratome (used for by an automated lamellar keratome (used for LASIK refractive surgery)LASIK refractive surgery)

Cut can be made by the surgeon or at the Cut can be made by the surgeon or at the eye bankeye bank

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DSAEK at UVADSAEK at UVA

We undertook an IRB approved We undertook an IRB approved prospective study to look at the DSAEK prospective study to look at the DSAEK procedure as described by Terry procedure as described by Terry (Ophthalmology 2008; 115:1179-1186)(Ophthalmology 2008; 115:1179-1186)

Dr. Paul Phillips (previous resident at UVA Dr. Paul Phillips (previous resident at UVA and Terry fellow 2007-2008) performed and Terry fellow 2007-2008) performed initial procedures and taught LAOinitial procedures and taught LAO

Strictly followed the procedureStrictly followed the procedure First case performed 9/16/09First case performed 9/16/09 All tissue was pre-cut at Portland Eye BankAll tissue was pre-cut at Portland Eye Bank

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DSAEK: ComplicationsDSAEK: Complications

DislocationDislocation Primary Graft Primary Graft FailureFailure

PricePrice

(n=200)(n=200)8%8% 2% 2%

MearzaMearza

(n=11)(n=11)83%83% 9%9%

KoenigKoenig

(n=34)(n=34)27%27% 9%9%

TerryTerry

(n=200)(n=200)1.5%1.5% 0%0%

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Cases – J.SCases – J.S

62 yo F w/ Fuchs62 yo F w/ Fuchs LAO did PK OD 8/03 – did LAO did PK OD 8/03 – did ““wellwell”” 20/40 -3.25+4.75x025 (unable to 20/40 -3.25+4.75x025 (unable to

tolerate RGP) tolerate RGP) 9/16/09 TCC Phaco/IOL and 8.0mm 9/16/09 TCC Phaco/IOL and 8.0mm

DSAEK – PPDSAEK – PP 20/25 Va unaided at 1 month post-op20/25 Va unaided at 1 month post-op VERY HAPPY patientVERY HAPPY patient

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P.R.P.R.

58 yo F w/ Fuchs58 yo F w/ Fuchs LAO did PK OS 5/05 – did LAO did PK OS 5/05 – did ““wellwell”” 20/30 +4.50+1.25x05520/30 +4.50+1.25x055 5/19/09 TCC Phaco/IOL and 8.0mm 5/19/09 TCC Phaco/IOL and 8.0mm

DSAEK – LAODSAEK – LAO 20/20-1 unaided 1 month post-op20/20-1 unaided 1 month post-op VERY HAPPY patientVERY HAPPY patient

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SummarySummary

Corneal transplantation has evolved Corneal transplantation has evolved dramatically over the past century.dramatically over the past century.

The most recent advances have The most recent advances have allowed the procedure to become allowed the procedure to become less invasive and more optically less invasive and more optically successful for the recipient, but more successful for the recipient, but more challenging for the surgeon.challenging for the surgeon.

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Thank YouThank You

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