Improve Your Vision With Corneal Surgery

Corneal Transplant | INTACS

EDOW offers an assortment of procedures to improve the vision and comfort of patients with corneal disorders. The doctors at EDOW are among the busiest corneal surgeons in the United States. Drs. Clinch and Kang have pioneered several surgical procedures and is regularly invited to lecture on these topics. He has also been on television and in the newspaper as an expert in this field.

Corneal Transplantation:

Explanation of the procedure:
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!

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.

Friendship Ambulatory Surgery Center

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.

Pre-operative waiting area

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.

Dr. Clinch preparing for surgery

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.

Removal of 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.

Post-operative Care:
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 and Kang, 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:

1. Pre-operative consultation by the surgeon
2. A-scan measurement
3. Facility fee at Friendship Ambulatory Surgery Center
4. Anesthesia care
5. Three months of follow-up care (pertaining to the cataract surgery) by the surgeon and staff

Please contact Maria Delgado by email or by calling 240.482.1234 for the specific details of this plan.

Please feel free to contact us with any questions or concerns.

Outcomes and Adverse Effects:

Dr. Clinch and Dr. Kang 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:

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.

INTACS - Intrastromal Corneal Ring

Intacs® are clear, thin prescription inserts. Intacs was the first "non-laser" surgical product approved by the U.S. Food and Drug Administration to correct mild amounts of nearsightedness (1 to 3 diopters). Intacs will soon be receiving a Humans Device Exemption from the U.S. FDA for use in keratoconus.

Intacs are inserted into the peripheral cornea. By increasing the volume in the peripheral cornea, there is a flattening in the central portion of the cornea.

Corneal surgeons, including Dr. Clinch and Dr. Kang, noted that the unique characteristics of Intacs make it an excellent alternative to corneal transplantation for some patients with keratoconus. Intacs can be inserted in a brief, relatively painless procedure. The convalescence is measured in weeks rather than months or years.

Unfortunately, not everyone with keratoconus will be a candidate for the Intacs procedure. Dr. Clinch and Dr. Kang evaluate patients with keratoconus on a daily basis and can make a determination as to whether you are a candidate.

Arrival and Pre-operative Testing

The Intacs procedure can be performed on an outpatient basis in our Chevy Chase office. You need to arrive at the outpatient surgical suite no later than 45 minutes prior to the procedure. Drs. Clinch and Kang, or their staff, will review the procedure and answer any questions. The procedure usually takes about 15 minutes per eye. The entire time at the facility is usually about 2 hours.

The Procedure
The procedure is performed on EDOW surgical suite. It takes approximately 15-30 minutes (see below). We recommend performing surgery on one eye to allow time for convalescence.

A small incision is made in the peripheral cornea with an ultrasonically guided diamond blade or the new Intralase. Then channels are formed in the peripheral cornea, and the Intacs segments are inserted. A micro-thin suture is then placed in the wound. It is removed within the first few weeks.

Radial incision in the cornea

Placing the channels

Inserting the segments

Eye with Intacs segments

Depending on the degree of keratoconus, the surgeon will use a variety of Intacs segments to attempt to reduce the steep irregular surface. Because the area of greatest thinning is in the lower portion of the cornea, a thicker segment may be placed in the bottom portion and a thinner segment is placed above.

Once the procedure is completed, the patient may return home. During healing, you will need medication drops in your eye.

Visits: You will return to the office on a weekly basis for 1-2 weeks. Your visit schedule will be tailored to your specific needs. A usual regimen would be as follows: post-op day 1, post-op day 7, post-op day 14-28, and then post-op month 2. After the first 1-2 months, the cornea is usually stable enough to prescribe glasses or a contact lens. It is important to understand that the prescription may need to be adjusted several times over the first year as the eye heals.

Medication: The patient is tapered off medications much more quickly than with a corneal transplant. Usually, prednisolone acetate 1.0% is prescribed 4 times per day for the first week then gradually tapered off over the next week. Antibiotic drops are used for the first week and then discontinued. Preservative free artificial tears should be used on a frequent basis (3-6 times/day) for the first several months.

Activity: Unlike with corneal transplantation, the patient may resume most activities very quickly. 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 during the first week. Most patients may return to work within 1-3 days following surgery; however, activities and vision will be limited in the operated eye until further convalescence.


Costs of Keratoconus Intacs:

The use of Intacs for the surgical correction of keratoconus has not yet received approval by the FDA. There is an abundance of medical literature supporting the use of this technology. EDOW has had success with receiving insurance authorization from several carriers (BlueCross/BlueShield, MD-IPA, etc.); however, carrier to carrier and state to state may differ on the coverage of this procedure. The staff at EDOW will assist in filing a claim for the insertion of the Intacs by doing the following:

• Prior to the surgery, we submit a letter requesting preliminary review of the procedure.
• The insurance company will usually respond within 2 to 4 weeks about the coverage of this procedure.
• If the initial response is favorable, or you wish to proceed without a final insurance approval, we can proceed and schedule your appointment.

Sometimes the response is "this procedure is considered investigational and therefore not covered under your plan." If this response is received, an appeal will be initiated. The appeal process may take 6 weeks to 1 year and will require some patience and assistance on your part. Several cases have been approved through the appeal process, but there are still several cases pending approval.

For patients who do not have insurance coverage, the fee for surgery is $4,000 per eye.

When submitting to insurance, the fee is separated into two components:

Insertion of Intacs (CPT Code 66999): $2,500

Lamellar Keratoplasty (CPT Code 65710): $1,000

Financing is available to assist with payment. Please feel free to contact us with any questions or concerns

Outcomes
The success of the procedure depends upon the underlying degree of keratoconus. Well over 95% of patients have 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; however, comfort and/or acuity is far superior. The rate of recovery is variable, usually between 1 month and 6 months, with an average of 2 months.

Complications and Risk
Since the insertion process is far less invasive than a corneal transplant, both minor side effects and complications are less common. Reported serious side effects are rare but include infection, extrusion of the intacs segments, or loss of vision. Less serious side effects include minor deposits in the cornea, lid drop (Ptosis), and visual disturbances. Dr. Clinch has not had any serious side effects with Intacs for Keratoconus. Intacs® segments can be removed or exchanged in the event of side effects.

Descemet's Stripping Endothelial Keratoplasty (DSEK)
The cornea is the optical window of the eye and must remain clear to maintain good vision. When the endothelium, the inner cell layer of the cornea, stops working, the cornea becomes cloudy. Traditionally, treatment for this condition required replacement of the whole central cornea as in a Penetrating Keratoplasty or Full Thickness cornea transplant. More recently ophthalmologists have developed an alternative known as Descemet's Stripping with Endothelial Keratoplasty (DSEK) that involves only replacing the innermost layers of the cornea.

Drs. Clinch and Kang are specially trained to perform DSEK which replaces only the damaged cell layer instead of replacing the entire thickness of the cornea. With this new technique, the cornea heals much faster and stronger and the patient's visual recovery is simpler. DSEK is Drs. Clinch and Kang's preferred method of treatment for eligible patients with Fuchs' dystrophy and pseudophakic bullous keratopathy.
The basic DSEK technique consists of gently stripping off the diseased cell layer lining the inner surface of the cornea. A donor cornea is thinly sliced and the inner portion is folded in half for insertion through a small incision made near the white part of the eye. Dr. Clinch and Kang then inject an air bubble into the eye to unfold the donor tissue and press it up into place. The natural pumping action of the donor endothelial cells quickly creates suction, which bonds the donor tissue to the recipient cornea.

This procedure has a faster recovery time than a traditional penetrating keratoplasty. Please discuss with Drs. Clinch and Kang to see if you may be a candidate.