Modern corneal transplantation is a safe and effective procedure with excellent results. A variety of diseases, or injury, can cause a decrease in vision secondary to corneal scarring, edema (swelling), or irregularity. More than 40,000 corneal transplants are performed each year with great success. The procedure is usually completed in less than one hour. It is performed on an outpatient basis in a surgical center. The corneas are obtained from human donors and may be stored for one to two weeks in specialized preservation media. Because the surgeons at EDOW perform a substantial number of corneal procedures each year, your procedure will be scheduled on a routine basis. Gone are the days of having a suitcase packed and waiting for the call that your cornea is available!
Arrival and Pre-Operative Testing
Prior to the procedure, you will need to receive medical clearance by your personal physician. Our coordinators will assist you with the scheduling process. This clearance is so that the anesthesiologists can provide you with the appropriate sedation and monitoring during the procedure.
Since you will be receiving human tissue, the donor cornea also undergoes a battery of tests. These tests measure the viability of the cornea as well as confirm that the donor did not have infectious diseases such as hepatitis and AIDS. It is impossible to test the corneal donor for all transmissible conditions; however, the risk of developing an infection from a corneal donor is exceedingly rare.
You need to arrive at the outpatient surgical suite no later than 45 minutes prior to the procedure. This affords the staff sufficient time to prepare you for surgery. The procedure usually takes about one hour. The entire time at the facility is usually between 2 to 2-1/2 hours.
On arrival at the surgery center, you will be given drops to constrict the eye and medications for relaxation. You will also be given some medication intravenously to reduce eye pressure.
An anesthesiologist will be present at the surgery to provide intravenous medication to help you be comfortable. An anesthetic block is performed around the eye to eliminate pain or discomfort. In this block, several local injections are given through the eyelids to numb the area of the eye and prevent eye movement during surgery. In rare instances, a patient may request or need to have general anesthesia.
Surgery is done with an operating microscope that magnifies the image of your eye, giving the surgeon the ability to remove the cloudy cornea with precision.
The eye is prepped and draped. First, the central area of the donor tissue is excised in a circular fashion. The usual size of the excision is 8.0 mm. Attention is then directed on the recipient. A device called a trephine will cut a similar size central opening into the cornea. The central cornea is excised with scissors. The donor cornea is then secured to the patient with sutures. The sutures (10-0 and 11-0 nylon) are thinner than a human hair. Depending upon the status of the eye, all interrupted sutures, a single running suture, or a combination of the two techniques is used to close the cornea.
Additional surgery may be performed at the same time as the corneal transplant. Most commonly, this will include removing a cataract or exchanging an intraocular lens that had been previously inserted. These additional procedures do not usually cause a substantial increase in the duration of surgery or convalescence.
Once the procedure is completed, the patient is taken to the recovery area. The staff will then instruct the patient and family members on the recovery process. During healing you will need medication drops in your eye. Please click here to obtain a copy of the pre-operative instructions.
You will need to wear a patch and shield for the remainder of the day. Upon awakening, you can remove the patch and shield and start your medications. Drs. Clinch, Kang, Shah or their staff will evaluate you, on the first post-operative day.
Visits: You will return to the office on a weekly basis for one to two weeks. Your visit schedule will be tailored to your specific needs. A usual regimen would be as follows: post-op day one, post-op day seven, post-op day 14-28, post-op month two, post-op month three, then quarterly for the first year. After the first two to three months, sutures will be removed or adjusted to improve the vision. Once the vision has improved to a stable point, glasses or a contact lens will be prescribed. It is important to understand that the prescription may need to be adjusted several times as the eye heals.
Medication: It is vital to the health of your new cornea for you to remain on corticosteroid drops for a long duration. Usually, prednisolone acetate 1.0% is prescribed four to six times per day for the first month and then gradually tapered over the next 3-12 months. It is unusual to have this medication discontinued prior to six months, so if you are uncertain about your treatment regimen, please contact the office.
Antibiotic drops are used for the first week and then discontinued. They will be used again each time sutures are removed; therefore, do not discard them. Preservative-free artificial tears should be used on a frequent basis (three to six times/day) for the first several months.
Activity: The cornea is held in place with micro-thin sutures during the healing process. It is important to be very careful with the eye and follow the instruction sheet carefully. It is critical to wear eye protection at all times. Most patients return to work 1-2 weeks after surgery; however, activities and vision will be limited in the operated eye until further convalescence.
Cost: Fortunately, corneal surgery is covered by most insurance plans. The surgeons at EDOW participate with many insurance plans. In the event that you do not have health insurance, or you choose not to use your insurance, EDOW has a payment plan that includes the following:
- Pre-operative consultation by the surgeon
- A-scan measurement
- Facility fee at Friendship Ambulatory Surgery Center
- Anesthesia care
- Three months of follow-up care (pertaining to the cataract surgery) by the surgeon and staff
Please contact Maria Delgado by calling 240.482.1234 for the specific details of this plan or contact us with any questions or concerns.
Outcomes and Adverse Effects
Dr. Clinch, Dr. Kang, and Dr. Shah have performed over a thousand corneal transplants. The success of the procedure depends upon the underlying corneal condition; however, for the most common conditions (Fuch’s corneal dystrophy and keratoconus), well over 95 percent of patients experience a significant improvement in their vision, some to 20/20! Most patients will still need to wear glasses or contact lenses to achieve their best visual acuity. The rate of recovery is variable, usually between two months and two years, with an average of six months.
Corneal surgery is very successful. The outlook for someone undergoing this procedure is good. It is, however, serious surgery. With all surgery, there is a risk of problems or complications, either during the operation or afterward. We make every effort to minimize the chance of problems or complications.
The most common complication is graft rejection. Graft rejection is exceedingly possible during the first month after surgery. It may, however, occur at any time thereafter, even years later. The rejection involves the patient’s body becoming sensitized to the foreign corneal tissue. The immune system attacks the donor cornea with inflammation. For common corneal conditions, the risk of an episode of graft rejection is not uncommon (20%). With early detection and prompt treatment, most rejection episodes can be reversed.
The symptoms of potential rejection can be grouped by the pneumonic RSVP:
S : Sensitivity (increase in light sensitivity)
V : Visual Loss (sudden change in vision clarity)
P : Pain (increase in eye pain)
If there is concern about a possible rejection episode, the patient should contact the surgeon immediately. The treatment of a rejection involves the use of cortisone eye drops, which is usually successful in reversing the rejection and stabilizing the cornea. However, the treatment must be instituted as soon as possible. If too much time has elapsed for the rejection episode or if the rejection is particularly severe, the cornea may become cloudy and the vision will remain blurred. If the transplant is rejected, surgery may be repeated; however, after each episode of rejection the success of a future transplant is reduced.
Corneal transplant surgery as well as the post-operative corticosteroids medication increases the risk of developing cataracts and glaucoma. Cataracts occur in all individuals with the aging process; however, corneal transplantation may hasten the process. To learn more about cataracts, please visit our cataract website.
The corticosteroid eye drops used to minimize the risk of corneal graft rejection can cause glaucoma. Reduction or elimination of these drops will usually allow the eye pressure to return to normal. The incidence of glaucoma also increases with age.
Fortunately, with careful observation and medication, glaucoma can usually be easily controlled without visual loss. To learn more about glaucoma, please visit our glaucoma website.
The ideal corneal transplant would have a smooth surface. Since the tissue is sewn into place with sutures, some irregularity will occur within the cornea. This is called irregular astigmatism. In some corneal transplants, this irregular astigmatism can diminish acuity to a point where a contact lens is required to obtain useful vision.
Other serious complications of corneal surgery include bleeding, post-operative infection, severe corneal edema, retinal detachment, and even loss of vision or the eye. Fortunately, instances of serious complications are rare. The most feared complication is an operative or post-operative hemorrhage. This is called an expulsive or suprachoroidal hemorrhage. This complication is rare (less than 1 per 350 cases); however, it can have devastating effects upon the eye. It is more common in the elderly and individuals with uncontrolled hypertension. The use of pre-operative intravenous medications to soften the edge reduces this risk. Less serious post-operative complications include drooping of the upper eyelid, transient elevation of eye pressure, transient corneal edema, and permanent irregularity or dilation of the pupil. All of these complications occur at an incidence of far less than 1 percent in patients without a pre-existing condition.
The vast majority of corneal transplant patients are pleased with the restoration of vision after surgery. Recent advances in this surgery have been one of the wonders of modern medicine and have contributed enormously to the quality of life for people.