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DVD Contents

1. Manual lamellar keratoplasty
2. Keratoglobus — Tuck it in (Tuck in lamellar keratoplasty)
3. Automated therapeutic lamellar keratoplasty
4. Deep anterior lamellar keratoplasty: Big bubble technique
5. Deep anterior lamellar keratoplasty: Double bubble technique
6. Deep anterior lamellar keratoplasty keratoconus
7. Deep anterior lamellar keratoplasty macular dystrophy
8. Large diameter lamellar keratoplasty


9. Autorotational and autorotational keratoplasty
10. Keratoplasty — The bond strengthened (Tuck in penetrating keratoplasty)
11. Corneal debulking for corneoiridic scar


12. Corneoscleral graft for corneoscleral melting following pterygium surgery
13. Therapeutic keratoplasty in a perforated corneal ulcer following fungal keratitis
14. Patch graft for perforated corneal ulcer
15. Therapeutic penetrating keratoplasty in a case of infection following deep anterior lamellar keratoplasty


16. Descemet’s membrane endothelial keratoplasty (DMEK)
17. Descemet’s stripping automated endothelial keratoplasty (DSAEK)
18. Sutureless Descemet’s stripping automated endothelial keratoplasty (Sutureless DSAEK)
19. Descemet’s stripping automated endothelial keratoplasty: triple procedure (DSAEK: triple procedure)




Second Edition

Rasik B Vajpayee MS, FRCS (Edin), FRANZCO
Professor of Ophthalmology
Head, Cornea and Cataract Surgery
Centre for Eye Research Australia
University of Melbourne
Royal Victorian Eye and Ear Hospital
Melbourne, Australia

Associate Editors
Namrata Sharma MD, DNB, MNAMS Geoffrey C Tabin MD Hugh R Taylor AC, FRACS, FRACO, FACS
Associate Professor of Ophthalmology Professor of Ophthalmology and Visual Harold Mitchell Professor of Indigenous
Cornea and Refractive Surgery Services Sciences Eye Health
Dr Rajendra Prasad Centre for John A. Moran Eye Center Melbourne School of Population Health
Ophthalmic Sciences University of Utah University of Melbourne
All India Institute of Medical Sciences Salt Lake City Former Head Corneal Unit
New Delhi, India Utah Royal Victorian Eye and Ear Hospital
Melbourne, Australia

Claes H Dohlman
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Corneal Transplantation

© 2010, Jaypee Brothers Medical Publishers (P) Ltd

All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in
any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of
the editors and the publisher.

This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any
dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition : 2002

Second Edition : 2010

ISBN 978-81-8448-859-3

Typeset at JPBMP typesetting unit

Printed at Ajanta

To my wife Madhu and Children Mihika and Shubhankar

— Rasik B Vajpayee

To my patients
— Namrata Sharma

To my wife, Jean and children Livia, Emilia,

Allessandra, Sara and Daniel with love and thanks
— Geoffrey C Tabin

To my students who have taught me so much

and their students who will learn so much
— Hugh R Taylor

A Murchison MD Chandra Shekhar Kumar MD Gerrit RJ Melles MD

Department of Ophthalmology Fellow, Cataract, Cornea and Netherlands Institute for Innovative
University of Vermont Refractive Surgery Services Ocular Surgery
Burlington Dr Rajendra Prasad Centre for Consultancy for Research and
Vermont, USA Ophthalmic Sciences Development of Ophthalmic Surgical
All India Institute of Medical Sciences Techniques
Ahmad Kheirkhah MD New Delhi, India Rotterdam, The Netherlands
Ocular Surface Center and Ocular
Surface Research and Education Dimitri T Azar MD Graeme A Pollock BSc, MPH, PhD
Foundation BA Field Endowed Chair of Director
Miami, Florida Ophthalmologic Research Lions Eye Donation Service Melbourne
Professor and Department Head Melbourne, Australia
Amit Patel FRCOphth Department of Ophthalmology and
Villa Serena Hospital Visual Sciences Gurnarinder Singh MS
Department of Ophthalmology University of Illinois at Chicago Fellow, Cataract, Cornea and
Forli, Italy Chicago, IL 60612, USA Refractive Surgery Services
Fondazione Banca degli Occhi del Dr Rajendra Prasad Centre for
Veneto, Venice, Italy Eric Donnenfeld MD, FAAO, FACS Ophthalmic Sciences
Clinical Professor of Ophthalmology All India Institute of Medical Sciences
Ashok Kumar MD NYU Medical Center New Delhi, India
Fellow, Cataract, Cornea and Trustee Dartmouth Medical School
Refractive Surgery Services Harinder Singh Sethi MD, DNB,
Dr Rajendra Prasad Centre for Francis W Price Jr MD MNAMS, FRCS
Ophthalmic Sciences Price Vision Group, Indianapolis, USA Assistant Professor
All India Institute of Medical Sciences Department of Ophthalmology
New Delhi, India Fred Eggink OD Vardhman Mahavir Medical College
Netherlands Institute for Innovative and Safdarjung Hospital
Ben Connell BM BS, FRANZCO, MPH Ocular Surgery New Delhi, India
Corneal Unit Rotterdam, The Netherlands
Royal Victorian Eye and Ear Hospital Hossam Sheha MD, PhD
Melbourne, Australia Geetha Srinivasan MBBS, MS Ocular Surface Center and Ocular
Rajendra Prasad Centre for Surface Research and Education
Bhavna Chawla MS Ophthalmic Sciences Foundation
Assistant Professor of Ophthalmology All India Institute of Medical Sciences Miami, Florida
Dr Rajendra Prasad Centre for New Delhi, India
Ophthalmic Sciences Hugh R Taylor AC, MD, FRACS, FRACO,
All India Institute of Medical Sciences Geoffrey C Tabin MD FACS
New Delhi, India Professor of Ophthalmology and Visual Harold Mitchell Professor of
Sciences, University of Utah Indigenous Eye Health
Bilal Khan MD John A. Moran Eye Center Melbourne School of Population Health
Massachusetts Eye and Ear Infirmary Salt lake City, Utah, USA Salt Lake University of Melbourne
243 Charles Street City, Utah Former Head Corneal Unit
Boston, MA, USA Royal Victorian Eye and Ear Hospital
Gerald W Zaidman FAAO, FACS Melbourne, Australia
C Banu Cosar MD Director, Department of Ophthalmology
Associate Professor of Ophthalmology Westchester Medical Center Jacqueline Beltz MBBS (Hons), FRANZCO
Acibaden University Professor of Ophthalmology Corneal Services
Ophthalmology Clinic New York Medical College Royal Victorian Eye and Ear Hospital
Istanbul, Turkey Valhalla, NY, USA Melbourne, Australia
Jeewan S Titiyal MD Michael S Loughnan PhD, FRANZCO N Kloster MD
Professor of Ophthalmology Consultant, Cornea Clinic Department of Ophthalmology
Cataract, Cornea and Refractive Royal Victorian Eye and Ear Hospital University of Vermont
Surgery Services Melbourne, Victoria Burlington, Vermont, USA
Dr Rajendra Prasad Centre for Australia
Ophthalmic Sciences Peter R Laibson MD
All India Institute of Medical Sciences Mike Feilmeier MD Professor of Ophthalmology,
Corneal Transplantation

New Delhi, India University of Utah Thomas Jefferson University

John A Moran Eye Center School of Medicine
Jonathan G Crowston FRCOphth, Salt Lake City, Utah, USA Director Emeritus, Cornea Department
FRANZCO, PhD Wills Eye Institute
Professor of Ophthalmology Mohammad Anwar FRCS Edin, Philadelphia, Pennsylvania
Centre for Eye Research Australia FRCOphth
University of Melbourne Senior Consultant Ophthalmic Surgeon Prakash Chand Agarwal MD, FICO,
Australia Cornea and External Diseases FRCS
Magrabi Eye Hospital Fellow, Cataract, Cornea and Refractive
JW Dimming MD Dubai, UAE Surgery Services
Department of Ophthalmology Dr Rajendra Prasad Centre for
University of Vermont Mona H Dagher MD, FRCSC Ophthalmic Sciences
Burlington Fellow Cornea and Refractive Surgery All India Institute of Medical Sciences
Vermont, USA Massachusetts Eye and Ear Infirmary New Delhi, India
Harvard Medical School
Karl David Brown BSc (Hon), MPhil Boston Prashant Garg MS
Senior Research Assistant Centre MA, USA Director, Education and Dr G Chandra
for Eye Research Australia Sekhar Distinguished Chair of
32 Gisborne St. Monica Chaudhry BSc Education
East Melbourne, Australia Senior Technical Officer Consultant, Cornea and Anterior
Dr Rajendra Prasad Centre for Segment Services
Laurence Sullivan MBBS, FRANZCO Ophthalmic Sciences Medical Director, Ramayamma
Clinical Associate All India Institute of Medical Sciences International Eye Bank
Centre for Eye Research Australia New Delhi, India LV Prasad Eye Institute
Practice Principle Bayside Eye Hyderabad, India
Specialists and LaserSight Victoria M Vanathi MD
Australia Assistant Professor of Ophthalmology - Prashant Bhartiya MD, DNB, FRCS
Cornea Services Corneal Fellow, Royal Victorian Eye
Manotosh Ray MD, FRCSEd Dr Rajendra Prasad Centre for and Ear Hospital, Melbourne, Australia
Associate Consultant Ophthalmic Sciences Consultant Ophthalmologist
National University Hospital All India Institute for Medical Sciences Bombay Hospital, Indore, India
Singapore New Delhi, India
Clinical Teacher Rajesh Sinha MD,DNB, FRCS
National University of Singapore Mukesh Taneja MBBS, DO, DNB Cataract, Cornea and Refractive Surgery
Singapore Consultant, Cornea and Anterior Services
Segment Assistant Professor of Ophthalmology
Marianne O Price PhD, MBA LV Prasad Eye Institute Dr Rajendra Prasad Centre for
Cornea Research Foundation of Hyderabad, India Ophthalmic Sciences
America, Indianapolis, IN, USA All India Institute of Medical Sciences
Namrata Sharma MD, DNB, MNAMS New Delhi, India
Massimo Busin MD Associate Professor of Ophthalmology
Professor of Ophthalmology Cornea and Refractive Surgery Services Rajeev Sudan MD (AIIMS)
Director of Ophthalmology at Villa Dr Rajendra Prasad Centre for Medical Director
Serena Hospital, Forli, Italy Ophthalmic Sciences RR Eye Care and Laser Institute
University of Bonn (Germany) All India Institute of Medical Sciences CEO, Amar Eye Centre
Genova (Italy) and Catanzaro (Italy) New Delhi, India New Delhi, India

Raj Maini BSc (Hons) BM FRCOphth Scheffer CG Tseng MD, PhD Victoria Casas MD
FRCSC FRANZCO Ocular Surface Center and Ocular Ocular Surface Center and Ocular
Consultant Ophthalmologist Surface Research and Education Surface Research and Education
Moorfield’s Eye Hospital Foundation, Miami, Florida Foundation
London Miami, Florida
S Louise Moffatt BSc
Rakesh Ahuja MBBS, MD Manager Viney Gupta MD

UBC Fellowship (Canada), Harvard New Zealand National Eye Bank Associate Professor of Ophthalmology
Fellowship (Boston MA) Auckland, New Zealand Glaucoma Services
Long Island College Hospital, Dr Rajendra Prasad Centre for
Brooklyn, NY (USA) S McKeon MD Ophthalmic Sciences
Department of Ophthalmology All India Institute of Medical Sciences
Rasik B Vajpayee MS, FRCS (Edin), University of Vermont New Delhi, India
FRANZCO Burlington, Vermont, USA
Professor of Ophthalmology Virender Singh Sangwan MD
Head, Cornea and Cataract Surgery Sujata Das MS, FRCS Associate Director
Centre for Eye Research Australia Consultant, Cornea and Anterior LV Prasad Eye Institute
University of Melbourne Segment Service Head, Cornea and Anterior Segment
Royal Victorian Eye and Ear Hospital LV Prasad Eye Institute Ocular Immunology and Uveitis
Melbourne, Australia Bhubaneswar, Orissa, India Services
LV Prasad Eye Institute
Ritika Sachdev MS Sushil Vasudevan MS Hyderabad, India
Fellow, Cataract, Cornea and Refractive Senior Lecturer
Surgery Services Faculty of Medicine, University Vishal Jhanji MD
Dr Rajendra Prasad Centre for Teknologi MARA, Malaysia Assistant Professor of Ophthalmology
Ophthalmic Sciences Cornea and External Eye Diseases
All India Institute of Medical Sciences Tushar Agarwal MD Department of Ophthalmology and
New Delhi, India Assistant Professor of Ophthalmology Visual Sciences
Cataract, Cornea and Refractive Surgery The Chinese University of Hong Kong
Sameer Kaushal MD, DNB Services, Dr. Rajendra Prasad Centre 3/F Hong Kong Eye Hospital,
Associate Consultant for Ophthalmic Sciences 147K Argyle Street, Mongkok
Artemis Health Institute All India Institute of Medical Sciences Kowloon, Hong Kong
Sector 51, Gurgaon, India New Delhi, India
Vishal Gupta MD (AIIMS)
Samir A Melki MD, PhD Urmimala Ghatak MD Senior Consultant Ophthalmology
Director, Boston Eye Group and Laser Fellow, Cataract, Cornea and Refractive BCIMS
Center Surgery Services New Delhi, India
Assistant in Ophthalmology Dr Rajendra Prasad Centre for
Massachusetts Eye and Ear Infirmary Ophthalmic Sciences VK Raju MD, FRCS
Harvard Medical School All India Institute of Medical Sciences Ocular Surface Center and Ocular
New Delhi, India Surface Research and
Sandeep Jain MD Education Foundation
Assistant Professor Usha Gopinathan PhD Miami, Florida
Cornea Service Associate Executive Director
University of Illinois at Chicago LV Prasad Eye Institute Y Khalifa MD
Department of Ophthalmology and Technical and Scientific Director, RIEB University of Utah
Visual Sciences LV Prasad Eye Institute John A Moran Eye Center
Chicago, IL 60612, USA Hyderabad, India Salt Lake City, Utah, USA


It is my pleasure and an honor to be asked to write a foreword to the present text on corneal transplantation. The book presents
information that is not only updated and skillfully written, but also held in a format that should be very practical for ophthalmologists
throughout the world. With a minimum of effort, any ophthalmologist presented with a corneal problem that may need surgical
treatment should be able to rapidly find a sensible and still sufficiently detailed answer. Certainly the time is right for such a
systematic and lucid contribution. The professional standing of all the contributors certainly serves as a guarantee for success of
this timely textbook.

Claes H Dohlman MD
Professor of Ophthalmology
Harvard Medical School
Preface to the Second Edition

The first edition of “Corneal Transplantation” was published in year 2002 and techniques of corneal grafting surgery have undergone
almost revolutionary changes since then. There have been many significant and exciting developments in the technical aspects of
corneal transplantation as we have been progressively refining the relatively cumbersome use of penetrating keratoplasty to treat
all types of corneal diseases to the use of much more elegant and precise ‘Customized Component’ corneal transplantation surgery.
These customized lamellar corneal transplantation surgeries aim to replace only the diseased part of the cornea by selective
transplantation of the appropriate corresponding healthy donor lenticule. Surgical techniques like ‘Big Bubble’ DALK,
Microkeratome assisted ALTK and DSAEK have found favor with corneal surgeons over penetrating keratoplasty for corneal
disorders that affect only specific layers of cornea.
The present edition of the outstanding book has aimed to include all these developments and like the first edition, this version
too has been designed as a practical guide elucidating the many and varied aspects of modern corneal transplantation surgery. A
conscious effort has been made to keep the format very simple and easy to follow by using a straightforward ‘How to do’ kind of
This new edition includes a detailed description of all new techniques of lamellar corneal transplantation surgeries including
some very innovative techniques like “Tuck in” lamellar keratoplasty, Sutureless DSAEK Triple surgery, DMEK and “Double
Bubble” Deep Anterior lamellar keratoplasty. It also explains the various acronyms that seem to have populated modern corneal
surgery. The book carries a very wide range of and sound practical advice based on the experience of the world’s leaders in this
field who have described their surgical techniques and other aspects of corneal transplantation surgery in a lucid and well structured
A DVD of all these surgical techniques has been provided to help beginners to acquaint themselves with the state-of-the-art
techniques in corneal grafting surgery. We are indebted to all of our chapter authors for their hard work and hopes that this ‘User
Friendly’ book would be able accomplish its main objective of simplifying and spreading the knowledge of various aspects of
contemporary corneal transplantation surgery.

Rasik B Vajpayee
Namrata Sharma
Geoffrey C Tabin
Hugh R Taylor
Preface to the First Edition

Corneal Transplantation Surgery has undergone tremendous advancements over the last few decades. Innovative minds have been
contributing novel and original concepts in an ongoing pursuit, aimed towards achieving optimal long term success of this craft.
My journey in the field of corneal grafting surgery began during my residency at Gandhi Medical College, Bhopal. In those formative
years it was thrilling to observe surgeons replace diseased and scarred corneas with healthy donor tissue. After a formal training
in corneal surgery at Dr Rajendra Prasad Centre for Ophthalmic Sciences, I learnt the finer points of this craft at the Cornea
Service of Melbourne University Department of Ophthalmology in Australia. I would like to express my heartfelt gratitude to my
teachers Prof Santokh Singh, Prof MK Rathore, Dr Salil Kumar, Prof Madan Mohan, Prof VK Dada, Prof Hugh R Taylor and Prof
Peter R Laibson. These luminaries have helped me to shape my skills as an ophthalmologist and a corneal surgeon and have been
a source of inspiration in my academic endeavors including this book.
This book was conceived in Australia, when Dr Geoff Tabin and myself were working as corneal fellows with Prof Hugh
Taylor. Our interactions with him made us realize that the profile of corneal diseases and their management modalities in the
developing world differ somewhat from those of the developed nations. We felt that there was a need for a concise, user friendly
and practical book on corneal grafting surgery. The book was planned as an amalgamation of knowledge about the newer
technological advances of the developed world and the simpler alternatives appropriate and optimal for the developing countries.
Another principal purpose of this venture is to generate interest amongst ophthalmic surgeons of the developing countries in the
field of corneal grafting surgery, as corneal blindness is a major health issue here.
Bringing out a book on a subject like corneal transplantation is a kind of mammoth exercise and it is clear that work of such
enormity is the congregation of efforts of many individuals. I am grateful for the esprit de corps, collaboration, education and
altruism that my Australian, American and other International and Indian colleagues have bestowed on me over the years. Many
of them are contributing authors to this book. I am obliged to all the contributing authors for the time and effort they have put in
to share their expertise and knowledge with the readers. I am indebted to my co-editors Dr Namrata Sharma, Dr Geoff Tabin and
Prof Hugh R Taylor for their invaluable help and guidance at every step. I would also like to acknowledge my residents, and my
assistants Mr Rajkumar and Ms Meena Verma for providing useful inputs and assistance. And finally, I would like to thank my
wife Madhu and children Mihika and Shubhankar for their patience in allowing me to spend time to accomplish this work.
This book has been designed as a practical guide to the various aspects of corneal grafting surgery. It elucidates the basic
aspects in preoperative evaluation, investigations, established surgical procedures and the advanced techniques in special situations
as well as the newer technology in corneal grafting. Theoretical as well as research aspects of corneal grafting have been dealt in
a practical manner. An extensive and well-illustrated section provides up-to-date knowledge of complications in corneal
transplantation and their management. This should be of particular assistance to ophthalmologists practicing in remote areas and
involved in the postoperative care of the grafted patients.
Overall our book provides students, surgeons and practitioners a concise treatise on corneal transplantation that contains essential
information intended to help a beginner and can be consulted by the experienced corneal transplantation surgeons to acquaint
themselves with the state-of-the-art techniques in corneal grafting surgery.

—Rasik B Vajpayee
Preface to the First Edition

In the early 1990s Rasik Vajpayee and I were corneal fellows together under the guidance of Professor Hugh Taylor at the Royal
Victorian Eye and Ear Hospital in Melbourne, Australia. Dr Vajpayee had come from the busy corneal unit at the All India Institute
of Medical Sciences in Delhi and he was concerned about the difficulties of corneal surgery in the developing world. I trained at
Harvard Medical School and Brown University’s department of Ophthalmology in the United States of America and arrived with
a bias towards modern technology and no holds barred best possible care for every individual patient. Professor Taylor’s superb
corneal fellowship provided us with both a state of the art corneal fellowship experience and the opportunity to discuss wider
global issues surrounding the delivery of medical care both in the developed and developing world.
Dr Vajpayee returned to India where he quickly became one of the busiest and most influential corneal surgeons in the world.
He has an enormous surgical volume and innovative mind. He has developed numerous new techniques and has advanced the art
of corneal surgery in a myriad of areas. Along with his publications he experienced a meteoric rise through the academic ranks. Dr
Vajpayee is now a full Professor at the All India Institute of Medical Sciences and Director of Cornea services. In addition to
being involved with many aspects of cutting edge research and technology he has continued to be concerned about the difficulties
of delivering high quality corneal care in the developing world.
Dr Vajpayee and I spoke at the American Academy of Ophthalmology meeting one year ago. He felt that there was a need for
a practical book on modern corneal surgery that would transcend the boundaries of modern technology and the developing world.
He noted that there was no single book that would allow a rural surgeon in India to quickly learn what he needs to treat a specific
difficult corneal pathology that also provides in depth discussions and insights for the western fellowship trained corneal surgeon.
Professor Vajpayee’s enthusiasm was infectious. We discussed ideas and possible formats and drew up a list of topics. We then
discussed who in the world was currently at the absolute cutting edge in dealing with those specific problems. We enlisted the help
of Professor Taylor from Australia and Dr Namrata Sharma from India as co-editors and approached an all star cast of corneal
specialists from around the world.
We asked the authors to write succinct practical chapters geared towards patient care while still including sufficient academic
support for their views. In each chapter the authors delivered an excellent treatise on their topic of specific corneal expertise. We
hope this book will be a valuable resource for general ophthalmologists who are faced with a corneal crisis, residents and corneal
specialists alike. As we enter a new millennium, corneal disease and injury remains the second leading cause of blindness in the
world. We hope this book will provide a practical, yet comprehensive, guide to surgical corneal care.
I am indebted to all of our chapter authors and to my co-editors for their hard work. I am particularly grateful to Rasik B
Vajpayee for having the vision of this book and the enthusiasm to make it a reality. Happy reading!

—Geoffrey C Tabin

Preface to the First Edition

I was very pleased when Rasik B Vajpayee first raised the possibility of writing a book on corneal transplantation. Dr Vajpayee,
in addition to being an expert surgeon is also one of the most industrious and productive members of a new generation of corneal
surgeons and is rapidly becoming a world leader.
He has assembled a most distinguished group of leading corneal surgeons from around the world to contribute to this very
important and impressive book.
There have been many significant and exciting developments in the technical aspects of corneal transplantation over recent
years and these have been beautifully set out in the chapters that follow. The precision and beauty of corneal transplantation still
amazes me after thirty years. With the large numbers of cases done around the world each year and the high success rate, corneal
transplantation must be without doubt the most successful example of transplantation in the whole of medicine. Although exquisite
surgical skill and attention to detail throughout the operation are extremely important in determining the successful outcome of
corneal transplantation, they are only part of the story.
Data from the Australian Corneal Transplant Registry show that the single most important factor affecting the long-term survival
of corneal grafts is the surgeon. This does not relate to the surgical skill and dexterity as much as it relates to meticulous postoperative
management. The key to the successful postoperative management of a corneal transplant is not how many patients are seen, or
whether they are seen exactly at the time of their appointment without having to wait, or whether they are first examined by an
ophthalmic assistant, the key is the meticulous attention to detail in the postoperative management especially the recognition of
early stages of low grade rejection and its appropriate management. Attention to detail is a key to success in ophthalmology, and
in no area is this more true than the postoperative management of corneal transplantation.
One of the great strengths of this book is the wide range of experience and opinion that is presented here. This book does not
give a simplistic cookbook recipe for the management of these sometimes complex and difficult cases, rather it gives the distilled
experience of the world’s leaders in this field in which they outline their approach and their justification for the decisions they
have taken. I trust you will find this book as interesting and as informative as I have and sustain the excitement I first felt when
this book was first discussed.

—Hugh R Taylor


1. Evolution of Corneal Grafting Surgery ........................................................................................................ 1

Namrata Sharma, Chandra Shekhar Kumar
2. Indications and Outcome of Penetrating Keratoplasty ............................................................................... 4
Urmimala Ghatak, Rajesh Sinha, Namrata Sharma
3. Preoperative Evaluation ............................................................................................................................... 13
Namrata Sharma, Ritika Sachdev, Manotosh Ray, Rasik B Vajpayee
4. Eye Banking—A Practical Guide ................................................................................................................. 20
Graeme A Pollock, S Louise Moffatt
5. Medicolegal Aspects of Eye Banking ........................................................................................................... 38
M Vanathi, Gurnarinder Singh, Rakesh Ahuja
6. Setting Up Corneal Transplant Center ........................................................................................................ 43
Jacqueline Beltz, Rasik B Vajpayee
7. Setting Up an Eye Bank ................................................................................................................................ 48
Mukesh Taneja, Prashant Garg, Usha Gopinathan


8. Surgical Instruments for Penetrating Keratoplasty .................................................................................. 53

Prakash Chand Agarwal, Namrata Sharma, Vishal Gupta, Geoffrey C Tabin
9. Suture Materials and Needles ...................................................................................................................... 61
Rajeev Sudan, Sameer Kaushal
10. Technique of Penetrating Keratoplasty ....................................................................................................... 63
Namrata Sharma, Chandra Shekhar Kumar, Samir A Melki, Rasik B Vajpayee
11. Suturing Techniques in Penetrating Keratoplasty ..................................................................................... 73
C Banu Cosar, Peter R Laibson
12. Postoperative Care after Penetrating Keratoplasty ................................................................................... 78
Raj Maini, Urmimala Ghatak, Hugh R Taylor
13. Postkeratoplasty Contact Lens Fitting ........................................................................................................ 86
Rajesh Sinha, Jeewan S Titiyal


14. Complications of Penetrating Keratoplasty ............................................................................................... 95

Namrata Sharma, Urmimala Ghatak, Rasik B Vajpayee, Hugh R Taylor
15. Post Penetrating Keratoplasty Glaucoma ................................................................................................. 117
Viney Gupta, Sushil Vasudevan, Jonathan G Crowston
16. Corneal Graft Rejection ............................................................................................................................. 122
Ben Connell, Michael S Loughnan
17. Corneal Graft Astigmatism ........................................................................................................................ 128
Jacqueline Beltz, Vishal Jhanji, Laurence Sullivan, Rasik B Vajpayee


18. Surgical Instruments for Lamellar Keratoplasty ..................................................................................... 137

Namrata Sharma, Prakash Chand Agarwal, Rasik B Vajpayee
19. Epikeratoplasty ............................................................................................................................................ 140
Corneal Transplantation

Namrata Sharma, M Vanathi, Geetha Srinivasan

20. Manual Lamellar Keratoplasty .................................................................................................................. 145
Namrata Sharma, Chandra Shekhar Kumar, Rasik B Vajpayee
21. Automated Lamellar Therapeutic Keratoplasty ...................................................................................... 157
Namrata Sharma, Sameer Kaushal, Rasik B Vajpayee
22. New Lamellar Keratoplasty Techniques: Posterior Keratoplasty and
Deep Lamellar Keratoplasty ...................................................................................................................... 164
Sandeep Jain, Dimitri T Azar
23. Deep Anterior Lamellar Keratoplasty: Melles Technique ....................................................................... 170
Gerrit RJ Melles, Fred Eggink
24. Deep Anterior Lamellar Keratoplasty: Big Bubble Technique ............................................................... 185
Mohammad Anwar
25. Deep Anterior Lamellar Keratoplasty: Double Bubble Technique ........................................................ 194
Vishal Jhanji, Jacqueline Beltz, Namrata Sharma, Rasik B Vajpayee
26. “Tuck in” Lamellar Keratoplasty .............................................................................................................. 199
Jacqueline Beltz, Vishal Jhanji, Namrata Sharma, Rasik B Vajpayee


27. Descemet’s Stripping Automated Endothelial Keratoplasty ................................................................... 204

Marianne O Price, Francis W Price
28. Sutureless Descemet’s Stripping Automated Endothelial Keratoplasty ................................................ 214
Vishal Jhanji, Jacqueline Beltz, Namrata Sharma, Rasik B Vajpayee
29. Descemet’s Stripping Automated Endothelial Keratoplasty: Triple Procedure .................................... 220
Jacqueline Beltz, Vishal Jhanji, Rasik B Vajpayee
30. Descemet’s Membrane Endothelial Keratoplasty .................................................................................... 225
Amit Patel, Massimo Busin


31. Penetrating Keratoplasty and Cataract Extraction: Triple Procedure ................................................. 229
Namrata Sharma, Ashok Kumar, Manotosh Ray, Prashant Bhartiya
32. Penetrating Keratoplasty for Aphakic and Pseudophakic Bullous Keratopathy ................................. 237
Sujata Das, Vishal Gupta
33. Pediatric Keratoplasty ................................................................................................................................ 245
Gerald W Zaidman
34. Therapeutic Keratoplasty ........................................................................................................................... 252
Eric Donnenfeld
35. “Tuck in” Penetrating Keratoplasty .......................................................................................................... 262
Namrata Sharma, Rasik B Vajpayee
36. Femtosecond Laser Assisted Keratoplasty ................................................................................................ 264
Chandra Shekhar Kumar, Namrata Sharma, Rasik B Vajpayee
37. Special Techniques of Corneal Grafting Surgery ..................................................................................... 268
Namrata Sharma, Rajesh Sinha, Manotosh Ray
38. Indication Specific Corneal Grafting Techniques .................................................................................... 274
Rasik B Vajpayee, M Vanathi, Harinder S Sethi

39. Autokeratoplasty ......................................................................................................................................... 281
Tushar Agarwal, Namrata Sharma, Rasik B Vajpayee
40. Limbal Stem Cell Transplantation ............................................................................................................. 285
Geoffrey C Tabin, MR Feilmeier, Y Khalifa, N Kloster, A Murchison, JW Dimming, S McKeon
41. Ex Vivo Cultured Limbal Stem Cell Transplantation .............................................................................. 295
Chandra Shekhar Kumar, Namrata Sharma, Virender Sangwan
42. Amniotic Membrane Transplantation ....................................................................................................... 305
Ahmad Kheirkhah, Hossam Sheha, Victoria Casas, VK Raju, Scheffer CG Tseng


43. Boston Keratoprosthesis ............................................................................................................................. 317

Mona Harissi-Dagher, Bilal Khan, Claes H Dohlman
44. Phototherapeutic Keratectomy .................................................................................................................. 329
Rajesh Sinha, Namrata Sharma, Jeewan S Titiyal
45. Optical Sector Iridectomy .......................................................................................................................... 335
M Vanathi, Rasik B Vajpayee, Namrata Sharma
46. Corneal Tattooing ........................................................................................................................................ 337
Sameer Kaushal, Harinder S Sethi, Namrata Sharma
47. Prosthetic Contact Lenses........................................................................................................................... 341
Monica Chaudhry
48. Amniotic Membrane Transplantation as an Alternative to Keratoplasty ............................................. 344
Bhavna Chawla, Rasik B Vajpayee
49. Gundersen Flap ........................................................................................................................................... 350
Prakash Chand Agarwal, Namrata Sharma, Rasik B Vajpayee
50. Future Developments .................................................................................................................................. 353
Vishal Jhanji, Karl David Brown, Rasik B Vajpayee, Hugh R Taylor

Index .............................................................................................................................................................. 357

SECTION I: Evolution, Preoperative Considerations and
Eye Banking

Chapter 1: Evolution of Corneal Grafting Surgery

Evolution of Corneal Grafting Surgery
Namrata Sharma, Chandra Shekhar Kumar

Today, the keratoplasty is considered as the most frequently In the next 30 years grafting was performed using tissue from
performed and the most successful organ transplantation enucleated eyes of living donors. In 1908, Plange performed
technique worldwide. The success of this procedure has not been the first autokeratoplasty, where he replaced the scarred cornea
an overnight event. The history of today’s corneal grafting dates of a blind eye with a lamellar graft from the patient’s other eye
back to the nineteenth century when K Himly of Germany which, although blind had a normal cornea.
suggested replacing an opaque cornea of one animal with clear VP Filatov, a Russian ophthalmologist, is considered as the
cornea of another animal (1813). F Reisinger was the first to father of modern eye banking.4,5 He used an egg membrane to
suggest replacing opaque human cornea with transparent animal fixate the graft. This method was later practised widely. His work
cornea in 1824. He also coined the term ‘keratoplasty’. SLL also involved the usage of cadaver cornea as the donor material
Bigger performed the first successful penetrating allograft in and he highlighted the importance of protecting the intraocular
animals. Henry Power reported his experimental work on tissues while trephining the host tissue and advocated direct
animals and humans in 1872.1 He was the first to give importance suturing. In 1940s, corneal transplant surgery evolved
to proper graft placement, freedom from infection, usage of fresh dramatically with the availability of antibiotics and introduction
donor tissue and the minimal trauma to the endothelium. In 1886, of steroids in corneal surgery.
Von Hippel reported the first lamellar corneal grafting.2 The first In late 1950s, small fine needles were used for first time for
successful penetrating keratoplasty was performed almost a suturing. At the same time, Paufique and Charleux popularized
century ago by Edward Konrad Zirm (Fig. 1.1) on a patient lamellar corneal grafting. They also introduced limbal and
in the year 1906, who had sustained alkali burns.3 The donor eccentric grafts. Although, most of the corneal transplant surgery
was an 11-year-old boy whose eye was enucleated because of has evolved in the first-half of the 20th century, the greatest
penetrating scleral injury with retained intraocular foreign body. advances in corneal grafting have taken place in the past 30 years.
The understanding of corneal anatomy and physiology especially
with regard to the corneal endothelium, introduction of
microsurgical techniques, advances in corneal preservation, the
elucidation of the corneal immunology and the development of
usage of anti-inflammatory and immunosuppressive agents have
resulted in a high success rate of corneal grafting.
Corneal graft rejection is the greatest limiting factor in graft
survival and Edward Maumenee was the one to recognize this
clinical entity. The classic scientific description and experimental
models were elegantly designed by Khodadoust.
Ramon Castroviejo (Fig. 1.2) performed the world’s first
successful human cornea transplant. He devised numerous
instruments which were named after him, such as Castroviejo
Calipers, Forceps, Corneal Scissors, Corneoscleral Punch,
Cyclodialysis Spatula, Needle Holder, Tying Forceps, Suturing
Forceps. He was also a pioneer of various surgical techniques
in the field of keratoplasty. Castroviejo’s original suturing
technique used a continuous silk suture coursing across the
Figure 1.1: Edward Konrad Zirm external surface of a square graft, holding the graft in place using
Section I: Evolution, Preoperative Considerations and Eye Banking

Figure 1.3: Townley Paton

Figure 1.2: Ramon Castroviejo

advantages of lamellar keratoplasty such as extraocular
technique, less stringent criteria for donor tissue, less graft
intraocular pressure to support the graft against the suture. Many rejection and intraocular complications and yet offers a better
of his square grafts fared extremely well and provided good visual acuity in terms of contrast sensitivity. In 1974, Anwar
visual acuity for many years. described the use of big air bubble for deep dissection under
Richard Troutman designed a microscope and numerous direct visualization in the potential natural cleavage plane
microsurgical instruments. 6 He tackled the problem of between the Descemet’s membrane and the overlying stromal
astigmatism, invented surgical keratometer and the technique of layers.10 Archilla in 1980s, was first to use intrastromal air
wedge resection. injection and spatula dissection to facilitate access to Descemet’s
Townley Paton (Fig. 1.3) was first to set-up an eye bank in membrane without perforating it. 11 Sugita also described
New York in 1959. Later on, this led to setting up of Eye Bank hydrodelamination of the stroma from Descemet’s membrane.12
Association of America in 1961. This organization laid down Melles described the technique of deep anterior lamellar
the standards for obtaining, preservation, storage and usage of keratoplasty (DALK) in which deeper dissection was done with
donor tissue. The healthy functioning endothelium is the key to the help of viscoelastic injection through the lamellar stromal
success of a corneal graft. The specular microscope developed pocket.13 In 2002, Anwar and Teichmann described the “big
by Maurice has provided the means of studying donor and bubble” technique in which separation of Descemet’s membrane
transplanted endothelium. from the overlying stroma is achieved with injection of air.14
The preservation of donor cornea influences the outcome of Endothelial keratoplasty (EK) is an alternative to penetrating
surgery to a great extent. A preservation procedure besides keratoplasty in cases where corneal endothelium is diseased
ensuring the endothelium viability also enables safe alone. In 1998, Melles described a technique for posterior
transportation of material and increases the duration of storage, lamellar keratoplasty (PLK),15 and a year later, he successfully
so that an efficient use of donor cornea can be made. First implemented the technique for pseudophakic corneal edema. In
successful transplantation using a cryopreserved human donor 2001, Terry and Ousley reported successful results in patients
tissue was reported by East Cott in 1954. Capella and using similar procedure, which they named deep lamellar
Kaufman7,8 developed the basic method of cryopreservation in endothelial keratoplasty (DLEK).16 Price and Price made the
1965. The major break-through in corneal preservation came endothelial keratoplasty technique more popular and it was
with the introduction of MK medium by McCarey and known as Descemet’s stripping endothelial keratoplasty
Kaufman in 1974.9 This medium is quite reliable for storage of (DSEK). 17 In 2006, Gorovoy described the technique of
donor cornea for at least 3-4 days. This allowed the elective Descemet’s-stripping automated endothelial keratoplasty
planning for surgery and made corneal transplantation a (DSAEK) in which the manual stromal dissection was replaced
scheduled procedure rather than an emergency. by the microkeratome dissection.18 This method avoids all
In the last two decades, with the improvement in surgical manual lamellar dissections and has the potential to result in a
techniques and instrumentation lamellar keratoplasty has smoother interface.
undergone a revolution. The various types of lamellar In 2006, Tappin described the clinical transplantation of
keratoplasty include anterior and posterior lamellar keratoplasty 7.5 mm diameter Descemet’s membrane (DM) through an 8.0
depending on the level of pathology. With the advent of the mm scleral incision using a flat carrier device.19 In the same year
microkeratomes, automated lamellar therapeutic keratoplasty Melles described the first clinical results of DM transplantation
(ALTK) has given way to manual lamellar keratoplasty. through a self-sealing corneal incision and referred it to as
Deep lamellar keratoplasty was introduced to improve the Descemet’s membrane endothelial keratoplasty (DMEK).20
postoperative visual performance in cases with corneal pathology Further experimental studies are on to make cultured human
involving the stromal layers of the cornea. It provides all the endothelial cell transplantation successful.
Major contributions in the field of corneal transplantation
S.No. Year Name Contribution
1. 1813 K Himly Suggested replacing opaque cornea in one animal with clear cornea
from another animal.
2. 1824 F Reisinger Suggested replacing opaque human cornea with clear animal cornea
• Coined the term keratoplasty
3. 1837 SLL Bigger Successfully performed corneal allograft in animals

Chapter 1: Evolution of Corneal Grafting Surgery

4. 1872 Henry Power Experimental corneal grafting
5. 1880 Von Hippel • Introduced lamellar keratoplasty
• Invented circular trephine
6. 1906 Edward Konrad Zirm • Reported first successful penetrating keratoplasty in a
7. 1908 Plange • Autokeratoplasty
8. 1910-1950 VP Filatov • Father of keratoplasty
• Performed systematic study of keratoplasty
• Suggested using cadaver corneas as donor tissues
• Devised numerous instruments and surgical innovations
9. 1930-1950 R Castroviejo • Devised numerous instruments for microsurgery
10. 1950s Paufique and Charleux • Lamellar keratoplasty
• Limbal and Eccentric Grafts
11. 1944 RT Paton • Founded the first Eye Bank in USA
12. 1954 East Cott • Transplantation using cryopreserved cornea
13. 1960 E Maumenee • Recognition of “Graft Rejection” as a clinical entity
14. 1965 Troutman Surgical microscope and surgical keratometer
15. 1965 Capella and Kaufman • Cryopreservation
16. 1968 D Maurice • Developed Specular Microscope
17. 1974 B McCarey and H Kaufman • Developed Corneal Storage Media
18. 1985 Archila EA DALK with air assisted dissection
19. 1998 Melles GR Deep anterior lamellar keratoplasty
Posterior lamellar keratoplasty
20. 2001 Mark Terry Deep lamellar endothelial keratoplasty (DLEK)
21. 2006 Price and Gorovoy Descemet’s stripping endothelial keratoplasty (DSEK) and
Descemet’s stripping automated endothelial keratoplasty (DSAEK)
22. 2006 Melles GR Descemet’s membrane endothelial keratoplasty (DMEK)

REFERENCES 13. Melles GR, Lander F, Rietveld FJ, Remeijer L, Beekhuis WH,
Binder PS. A new surgical technique for deep stromal, anterior
1. Power H. IV International Congress of Ophthalmology. London lamellar keratoplasty. Br J Ophthalmol 1999;83(3):327-33.
1872;4:172. 14. Anwar M, Teichmann KD. Big-bubble technique to bare
2. Von Hippel A. Albrecht v. Graefes Arch Ophthalmol 1888;34:108. Descemet’s membrane in anterior lamellar keratoplasty. J Cataract
3. Zirm EK. Eine erfolgreiche totale keratoplastik. V. Graefes Arch Refract Surg 2002;28(3):398-403.
Ophthalmol 1906;64:580. 15. Melles GR, Eggink FA, Lander F, Pels E, Rietveld FJ, Beekhuis
4. Filatov VP. Transplantation of the cornea. Arch Ophthalmol WH, et al. A surgical technique for posterior lamellar keratoplasty.
1935;13:321-47. Cornea 1998;17:618-26.
5. Filatov VP, Bajenova MA. Culture of dried corneal tissue. Arch 16. Terry MA, Ousley PJ. Deep lamellar endothelial keratoplasty in
Ophthalmol and Rev Gen Ophthalmol 1937;1:385. the first United States patients: early clinical results. Cornea
6. Troutman RC. The operating microscope in ophthalmic surgery. 2001;20:239-43.
Trans Am Ophthalmol Soc 1965;63:335-48. 17. Price FW Jr, Price MO. Descemet’s stripping with endothelial
7. Capella JA, Kaufman HE, Robbine JE. Preservation of viable keratoplasty in 50 eyes: a refractive neutral corneal transplant. J
corneal tissue. Arch Ophthalmol 1965;74:669-73. Refract Surg 2005;21:339-45.
8. McCarey BE, Kaufman HE. Improved corneal storage. 18. Gorovoy MS. Descemet’s stripping and automated endothelial
Investigative Ophthalmol 1974;13:165-73. keratoplasty. Cornea 2006;25:886-89.
9. Lindstrom RL. Advances in corneal preservation. Trans Am 19. Tappin M. A method for true endothelial cell (Tencell) trans-
Ophthalmol Soc 1990;88:555-648. plantion using a custom made cannula for the treatment of
10. Anwar M. Dissection technique in lamellar keratoplasty. Br J endothelial cell failure. Eye 2007;21:775-79.
Ophthalmol 1972;56(9):711-13. 20. Melles GRJ, Ong TS, Ververs B, van der Wees J. Descemet’s
11. Archila EA. Deep lamellar keratoplasty dissection of host tissue membrane endothelial keratoplasty (DMEK). Cornea 2006;
with intrastromal air injection. Cornea 1984-1985;3(3):217-18. 25:987-90.
12. Sugita J, Kundo J. Deep anterior lamellar keratoplasty with
complete removal of pathological stroma for visual improvement.
Br J Ophthalmol 1997;81:184-88.
Section I: Evolution, Preoperative Considerations and Eye Banking

Indications and Outcome of

Penetrating Keratoplasty
Urmimala Ghatak, Rajesh Sinha, Namrata Sharma

Corneal transplantation surgery is performed for a variety of • Optical

reasons, the major being to achieve an improvement in vision. • Tectonic
Corneal transplantation is not performed just because a corneal • Therapeutic
problem exists. The transplanting surgeon must reasonably • Cosmetic
expect significant eventual improvement of the patient's
condition as a result of the surgical procedure. Improvement of Optical Keratoplasty
two or more lines in Snellen's visual acuity chart is taken as a The keratoplasty is performed with the main purpose of
significant improvement in vision after corneal grafting surgery.
improving the visual acuity. This is the most common indication
This may encompass one or more of the following:
of penetrating keratoplasty and comprises more than 90 percent
• Ability to see with acceptable optical correction of the total penetrating keratoplasties performed in majority of
• Restoration of binocularity
the countries.3 The indication for keratoplasty depends on the
• Elimination of corneal disease
visual requirement and the expected long-term benefit arising
• Improvement in function and life style out of surgery. A corneal pathology causing a reduction in visual
• Improvement in pain.
acuity to less than 6/18 is an acceptable norm for penetrating
corneal transplantation. The common indications of optical
keratoplasty include aphakic bullous keratopathy (Fig. 2.2) and
Many reports have detailed the indications of penetrating pseudophakic bullous keratopathy (Figs 2.3A and B), corneal
keratoplasty (Table 2.1). Penetrating keratoplasty is today opacities following infectious keratitis (Fig. 2.4), trauma, graft
performed for a wide variety of conditions. These may be failure (Fig. 2.5), endothelial and stromal corneal dystrophies
unilateral or bilateral (Fig. 2.1). The indications can be divided (Figs 2.6 to 2.8), corneal degenerations and congenital corneal
into four categories:1-9 opacities.4 While keratoconus (Fig. 2.9), pseudophakic bullous

Figure 2.1: Bilateral corneal opacity Figure 2.2: Aphakic bullous keratopathy
Table 2.1: Clinical indications Contd...
of penetrating keratoplasty
Vitreocorneal touch
• Pseudophakic corneal edema Recurrent stromal dystrophy
• Aphakic corneal edema Trauma/rupture
• Stromal corneal dystrophies Glaucoma
Granular dystrophy • Other causes of corneal opacification/distortion
Lattice dystrophy Uveitis

Chapter 2: Indications and Outcome of Penetrating Keratoplasty

Macular dystrophy Detached Descemet's membrane
Central crystalline dystrophy of Schnyder Failed epikeratoplasty
Central cloudy dystrophy of Francois Post laser/postrefractive surgery
• Endothelial dystrophies Silicone oil keratopathy
Fuchs' endothelial dystrophy Epithelial downgrowth
Congenital hereditary endothelial dystrophy
Posterior polymorphous dystrophy
Iridocorneal endothelial syndrome
Chandler's syndrome
• Ectasias/thinning
Anterior keratoconus
Posterior keratoconus
• Congenital opacities
Peter's anomaly
Congenital glaucoma/buphthalmos
• Viral/post-viral keratitis
Herpes simplex virus
Varicella zoster virus
Adenovirus-Epidemic keratoconjunctivitis
• Microbial/post-microbial keratitis Figure 2.3A: Pseudophakic bullous keratopathy
Infectious crystalline keratopathy
Chlamydial keratitis
Acanthamoeba keratitis
• Nutritional deficiencies
• Non-infectious ulcerative keratitis
Keratoconjunctivitis sicca
Sjögren's syndrome
Neuroparalytic/neurotrophic keratopathy
Exposure keratitis
Mooren's ulcer
• Corneal degenerations
Terrien's marginal degeneration
Calcific band keratopathy
• Chemical injuries Figure 2.3B: Penetrating keratoplasty
Alkaline with IOL exchange in PBK
• Mechanical trauma, nonsurgical
Traumatic opacity/irregular astigmatism keratopathy and Fuchs’ dystrophy are the most common
• Regraft related to allograft rejection indications for optical penetrating keratoplasty in western
• Regraft unrelated to allograft rejection world,10 in developing countries like India, corneal scarring,
Primary tissue failure caused by infection, trauma and malnutrition are the major
Pseudophakic corneal edema
indications of this surgery.11,12
With the advent of intraocular lenses, there was a rapid rise
Contd... in the numbers of cataract surgery.9 This resulted in plenty of
Section I: Evolution, Preoperative Considerations and Eye Banking

Figure 2.4: Healed keratitis Figure 2.7A: Lattice dystropy

Figure 2.5: Failed graft Figure 2.7B: Lattice dystropy (Retroillumination)

Figure 2.6: Macular dystrophy Figure 2.8: Fuchs' dystrophy with bullous keratopathy

cases of pseudophakic bullous keratopathy throughout the world. During 1970s and 1980s, when iris-fixated and rigid or semi-
Previously, regrafts, herpetic keratitis and keratoconus were the flexible, closed loop anterior chamber implants were commonly
common indications for optical penetrating keratoplasty. inserted; pseudophakic corneal edema became the leading

indication for corneal transplantation in many centers. These Tectonic/Reconstructive Keratoplasty
implants damage the corneal endothelium directly over a long
The prime purpose of tectonic/reconstructive keratoplasty is to
period. Presently, pseudophakic bullous keratopathy appears to
restore the altered corneal structure. Although improved visual
be decreasing, presumably because of improved implant design
acuity remains a relevant consideration, restoration or at least
and almost universal use of posterior chamber IOL.
preservation of ocular anatomy and physiology are the principal
indications for tectonic corneal grafts. This is required in eyes
with a thinning/ectasia in cornea, corneal perforation or loss of

Chapter 2: Indications and Outcome of Penetrating Keratoplasty

corneal tissue, keratoconus, keratoglobus (Figs 2.10A and B),
pellucid marginal degeneration (Fig. 2.11), corneal melting
associated with autoimmune disorders, corneal fistula (Fig. 2.12)
and post-traumatic loss of corneal tissue.13,14 A reconstructive
graft may also improve the patient's visual function and the
option for future optical graft remains viable.

Therapeutic Keratoplasty
Therapeutic keratoplasty is mainly indicated in cases of
infectious keratitis to eliminate the infectious load in eyes with
keratitis unresponsive to specific antimicrobial therapy15
(Fig. 2.13). These are commonly done in non-responding fungal
or Acanthamoeba keratitis. In these cases corneal transplantation
Figure 2.9: Keratoconus provides a form of surgical therapy as actively diseased tissue
is removed. Transplants that are done to preserve the globe

Figure 2.10A: Keratoglobus (diffuse illumination)

Figure 2.10B: Keratoglobus (slit) Figures 2.11A and B: Pellucid marginal degeneration
with hydrops 7
Section I: Evolution, Preoperative Considerations and Eye Banking

Figure 2.12: Corneal fistula Figure 2.14: Corneal perforation

Cosmetic Keratoplasty
The primary purpose in such cases is to restore the normal
appearance of the eye, which has limited or no visual potential
and this may be undertaken in case of unsightly corneal scars or
deposits. Patient must be cautioned that the grafts may not remain
clear in all cases and long-term medications are required as in
optical grafts. With the availability of painted soft contact lenses,
corneal tattooing, enucleation or evisceration with a skillfully
prepared prosthesis or cosmetic shields, cosmetic keratoplasty
has become a rare procedure.



The leading indications for penetrating keratoplasty in

Figure 2.13: Non-healing corneal ulcer developing countries are corneal scarring including adherent
leucoma and active infectious keratitis.11,12 In a study by Sony
therapeutically often have the added advantages of improved et al, in India, leading indications for penetrating keratoplasty
visual clarity and subsequently, improved visual acuity. Other were corneal scarring (38.03%) followed by acute infectious
therapeutic indications may be edema, scarring, and various keratitis (28.38%), regrafting (11.5%), aphakic bullous
deposits in the cornea. Pain may be a significant factor in keratopathy (7.27%), pseudophakic bullous keratopathy (6.18%),
advanced corneal swelling with bullous epithelial changes. and corneal dystrophy (3.85%). Healed infectious keratitis
Penetrating keratoplasty is effective in reducing, and usually (19.83%) was the most common subcategory among the eyes
eliminating the pain of bullous keratopathy. Sometimes, with corneal scarring followed by traumatic corneal scars
therapeutic keratoplasty is necessitated for the visualization of (16.71%). Healed (19.83%) and active keratitis (28.38%)
fundus to perform the retinal procedure, e.g. pars plana together accounted for the majority of keratoplasties (48.21%).
vitrectomy, photocoagulation or repair of complicated retinal In cataract-related corneal edema (13.45%), aphakic bullous
detachment. The use of temporary keratoprosthesis to aid in keratopathy (7.27%) was almost as frequent as compared with
vitreoretinal surgery is another new indication for therapeutic pseudophakic bullous keratopathy (6.18%).16 This is unlike
keratoplasty. developed countries where the indications such as keratoconus,
Therapeutic keratoplasty is always considered as the last pseudophakic bullous keratopathy and Fuchs' dystrophy are more
option when all other treatment modalities have failed. Therefore, common.10
alternative treatments should always be tried, wherever Some interesting trends in the clinical indications for
applicable. Conjunctival flaps can be a successful alternative in penetrating keratoplasty have been observed in the developed
non-healing corneal ulcers. Small-perforated corneal ulcers countries over the last two decades.14 Before 1980, keratoconus
(Fig. 2.14) can be treated effectively with cyanoacrylate glue and aphakic corneal edema were the most common indications
and soft bandage contact lenses. and pseudophakic corneal edema was just emerging.4,7,8,12,17
The emergence of pseudophakic corneal edema as the most Table 2.2: Expected outcomes after
common indication correlated with the overwhelming increase penetrating keratoplasty
in the number of the cataract extractions and lens implantations Category 1 (Excellent prognosis > 90% success rate)
since mid-1970. • Keratoconus
Relative number of regrafts has increased as the number of • Lattice dystrophy
keratoplasties performed in the population has increased.10 The • Granular dystrophy
combined incidence of pseudophakic and aphakic corneal edema • Early Fuchs' dystrophy

Chapter 2: Indications and Outcome of Penetrating Keratoplasty

has been decreasing with the advances and improvements in Category 2 (Very good prognosis: 80-90% success rate)
• Pseudophakic bullous keratopathy
cataract surgery and intraocular implants.
• Aphakic bullous keratopathy
Pseudophakic bullous keratopathy remains the leading • Fuchs' dystrophy
indication for corneal transplantation in the United States • Herpetic keratitis
followed by regraft.17 Cosar et al report that the percentage of • Iridocorneal endothelial syndromes
PBK cases associated with PC IOLs has increased significantly, • Interstitial keratitis
whereas the percentage associated with AC IOLs has decreased. • Macular dystrophy
Further, the frequency of regraft had also increased Category 3 (Fair prognosis: 50-80% success rate)
• Keratoglobus
• Pellucid marginal degeneration
Keratoconus is the leading indication for penetrating • Congenital hereditary endothelial dystrophy
keratoplasty in New Zealand, accounting for a higher proportion • Corneal opacities in the pediatric group
than in any other published literature.18 This suggests that • Chemical injury (mild)
keratoconus leading to transplantation may have increased • Dry eye (mild)
prevalence in New Zealand.18 • Corneal perforations
• Active keratitis

PENETRATING KERATOPLASTY Category 4 (Poor prognosis: < 50% success rate)

• Ocular pemphigoid
OF THE FELLOW EYE • Stevens-Johnson syndrome
• Congenital glaucoma
An optimal visual recovery after corneal grafting surgery usually
• Anterior chamber cleavage syndrome
does not occur until 4 to 8 months. Prior to this, vision may in • Neuroparalytic/Neurotrophic disease
fact be worse than before surgery in some of the cases. • Multiple graft failures
Considering this fact, it is wise to wait for at least 6 months after
the corneal grafting surgery in one eye before performing corneal
sensations and the microenvironment of the eyelids, as well as
transplantation in the fellow eye.19,20 Following a corneal
the tear film is healthy. Examples include keratoconus, lattice
transplant in the second eye, the risk of rejection, to both eyes,
or granular stromal dystrophies, early central Fuchs' dystrophy
has been found to be lower, longer the time between the two
or other inactive central or paracentral scars. The prognosis in
transplantation procedures, with best survival if there was no
this group is excellent with over 90 percent success. The best
rejection for three years in the first eye prior to surgery on the
reported rates of keratoplasty success are for keratoconus. Keates
and Falkenstein22 reported 100 percent graft success and 81
percent patients had 20/40 or better visual acuity. A comparison
of 50 penetrating grafts to 50 lamellar grafts for keratoconus
showed 100 percent graft clarity with a mean best-corrected
A successful outcome of a corneal grafting surgery depends on visual acuity of 20/20 in the penetrating and 20/30 in the lamellar
many variables, indication for surgery being the most important grafts.23 Kirkness et al reported 97 percent graft clarity in cases
one. There are certain indications of penetrating keratoplasty, of keratoconus at 4 years follow-up.24
which have a relatively better prognosis. The definition of
success includes the presence of a clear graft along with Category 2 (Very Good Prognosis)
improvement in vision of two or more lines on a Snellen's visual This group includes corneal lesions which involve part or whole
acuity chart. This also implies visual rehabilitation with glasses of the corneal periphery with minimal vascularization (stromal
instead of contact lenses, attainment of binocularity, decreased vascularization in not more than 2 quadrants). For example,
glare and less pain. The expected outcome of the corneal graft pseudophakic bullous keratopathy, aphakic bullous keratopathy,
surgery may be classified into four major categories based on diffuse Fuchs' dystrophy, inactive herpetic keratitis, iridocorneal
the groups described by Buxton et al (Table 2.2).2 endothelial syndromes, interstitial keratitis and macular stromal
dystrophy. The prognosis in this group is very good with 80-90
Category 1 (Excellent Prognosis)
percent success rate. Polack25 et al reported 78 percent of clear
This group consists of corneas with central corneal disease and grafts done for aphakic bullous keratopathy at 1 year and Olson26
normal peripheral architecture. The limbal anatomy, corneal reported 89 percent of clear aphakic grafts. Pineros et al reported
results in Fuchs' dystrophy with 89 percent graft clarity and visual 0.87, 0.73, 0.60, and 0.46 at 1, 5, 10, and 15 years, respectively.
acuity of 20/40 or better in 64 percent of cases at 8 years of Reasons for graft failure included irreversible rejection (34%),
follow-up.27 corneal endothelial cell failure including cases of glaucoma
(24%), and infection (14%). Variables predicting graft failure
Category 3 (Fair Prognosis) in multivariate analysis included transplant center (Centres
The corneas in this group are characterized by extremes of performing more than 20 grafts per year showed increased
survival), location and volume of surgeon's case-load, graft era,
corneal thickness, involving a large part of the recipient zone
Section I: Evolution, Preoperative Considerations and Eye Banking

indication for graft, number of previous ipsilateral grafts, lens

adjacent to the limbus and Langerhans' cells, e.g. keratoglobus,
pellucid marginal degeneration, congenital hereditary endothelial status, corneal neovascularization at transplantation, a history
of ocular inflammation or raised intraocular pressure, graft
dystrophy, keratoplasty in young children, mild chemical injury
diameter (a graft size of more than 8.5 mm in diameter or a graft
and mild dry eye. This may also include certain active infectious
or inflammatory disease, corneal perforations, peripheral disparity of greater than 0.5 mm showing poorer prognosis), and
postoperative events including graft neovascularization and
descemetoceles, and active bacterial, fungal and herpetic
rejection. Best-corrected Snellen acuity of 6/12 or better was
keratitis. Prognosis in this group is fair with a success rate
varying from 50-80 percent. Waring and Laibson28 and Stulting29 achieved by 45 percent, and of less than 6/60 by 26 percent, of
grafted eyes at last follow-up. Most penetrating grafts were
reported 60 percent success in graft for congenital opacities.
performed for visual improvement.32
Dana et al evaluated the graft survival analysis in pediatric
keratoplasty and showed that 80 percent were clear at 1 year The UK Transplant Study noted the following to be
statistically significant risk factors for graft failure: Recipient
and 67 percent at 2 years.30
diagnosis being not keratoconus or other central corneal disease,
Category 4 (Poor Prognosis) larger grafts (trephine sum = 14.5 mm) and combined running
and interrupted sutures.33
In this group, there is absence of normal limbal stem cells and In the study done by Dandona et al12 the five-year survival
normal maturation of corneal epithelium. These cases are rate was highest if the corneal transplant was done for
characterized by severe fibrovascular replacement of the cornea, keratoconus and lowest if carried out for previous transplant
conjunctival ischemia, anterior chamber obliteration, loss of failure. The relative risk of transplant failure was higher if the
corneal sensations and advanced dry eye, e.g. ocular pemphigoid, preoperative diagnosis was previous transplant failure, aphakic
Stevens Johnson syndrome, congenital glaucoma, anterior bullous keratopathy, corneal clouding due to congenital
chamber cleavage syndromes, neuroparalytic or neurotrophic conditions and glaucoma or adherent leucoma. Patients with
disease, epithelial downgrowth and multiple graft failures. The lower socioeconomic status and patients less than 10 years of
prognosis in this group is very poor with a success rate of less age also had higher risk of transplant failure. This was also
than 50 percent. A penetrating corneal grafting surgery may not associated with vascularization of the host cornea before
be the preferred therapeutic option in this group; however, transplantation and the use of fair quality donor cornea for
surgery may be undertaken with guarded prognosis when the transplantation compared with excellent, very good or good
disease is bilateral or involves the patient’s only eye. quality donor cornea.
Various studies have evaluated different risk factors for the Hassan et al attempted to determine how donor health status
graft survival after penetrating keratoplasty. In the Collaborative affects the risk of infection after corneal transplant. 34
Corneal Transplant Study, the various factors, which have Postkeratoplasty endophthalmitis was associated with recent
influenced the survival of the graft, include:31 hospitalization and fatal cancer among donors. Endophthalmitis
• The indication for the graft (keratoconus showed the best appeared more likely with tissues transplanted longer than 5 days
survival) after donation. The prevalence of concordant microbial isolates
• The graft number in the ipsilateral eye from donors and recipients was greater among fungal
• Corneal vascularization at the time of the graft endophthalmitis than among bacterial endophthalmitis. In a
• The presence of anterior synechiae during surgery separate study,35 Hassan et al tracked the relative frequency and
• The history of previous increase in intraocular pressure explored possible risk factors of fungal compared with bacterial
• The presence of aphakia or pseudophakia endophthalmitis after corneal transplantation. They noted that
• The history of previous intraocular surgery concordant cultures of the residual donor corneoscleral rim or
• Recipient age less than 40 years of age preservation medium occurred significantly more often with
• Graft size less than 8 mm fungal than bacterial endophthalmitis. After the introduction of
• Time to preservation of donor cornea of greater than six Optisol-GS, the odds of bacterial relative to fungal
hours endophthalmitis decreased by 77 percent. After adjustment for
• Blood group ABO incompatibility. the preservation method and other eye-banking variables, the
Williams et al examined graft survival and visual outcome odds of fungal endophthalmitis were 3.4 times that of bacterial
after full-thickness corneal transplantation in the Australian endophthalmitis, when donor corneal preservation was 4 days
corneal graft registry. Probability of corneal graft survival was or longer.
In poor prognostic category such as aniridia, postoperative their present level of vision and whose lifestyles are not
complications include whorl keratopathy, persistent epithelial compromised should not be operated. In developing countries
defects, central subepithelial scarring, peripheral vascularization like India, because of very high chances of graft failure, patient
with pannus, and graft rejection.36 In a study by Kremer et al, with ambulatory vision in the eye with better vision should not
glaucoma was well-controlled medically but five of nine patients have surgery. In cases of advanced dry eye, grade IV chemical
(56%) with pre-existing glaucoma needed an increase in burns (Fig. 2.15), anterior staphyloma (Fig. 2.16) and severe
medication for intraocular pressure control. Graft rejection cases of Stevens-Johnson syndrome (Fig. 2.17), ocular cicatricial

Chapter 2: Indications and Outcome of Penetrating Keratoplasty

occurred in seven of 11 eyes (64%) and three of these eyes pemphigoid (Fig. 2.18), with no tear film, and bad ocular surface
required repeat transplantation.36 may jeopardize a successful penetrating keratoplasty.
Keratoprosthesis may be a better option for these patients.37
ALTERNATIVES AND CONTRAINDICATIONS TO Multiple graft failure is a relative contraindication for penetrating
Cases of patients with inaccurate projection of rays and
While there are no absolute contraindications for penetrating underlying retinal detachment are also relative contraindications
keratoplasty except for the presence of no light perception, there for surgery. Patients with central corneal opacities and clear
are certain conditions of corneal opacification in which the paracentral areas may obtain useful ambulatory vision with
morphological and functional outcome is so poor that most optical iridectomy alone.38 Keratoplasty may also be deferred
surgeons would not prefer to perform a corneal grafting surgery in patients who have severely scarred corneas with anterior
in such cases. These eyes as such should not be operated but segment distortion due to trauma or infection in one eye and the
surgery may be undertaken especially if the disease is bilateral fellow eye has a visual acuity of 20/20. This topic is covered in
or involves patient’s only eye. Patients who are satisfied with details in section VI.

Figure 2.15: Grade IV chemical burns

Figure 2.16: Anterior staphyloma Figures 2.17A and B: Stevens-Johnson syndrome

18. Edwards M, Clover GM, Brookes N, et al. Indications for Corneal
Transplantation in New Zealand: 1991-1999. Cornea 2002;21:
19. Buxton JN, Schuman M, Pecego J. Graft reactions after unilateral
and bilateral keratoplasty for keratoconus. Ophthalmology.
20. McNeill JI. Indications and outcomes. In: Cornea. Surgery of the
cornea and conjunctiva Eds. Krachmer JH, Mannis MJ, Holland
EJ. 1997 St. Louis, Missouri, Mosby Year Book, Inc.
Section I: Evolution, Preoperative Considerations and Eye Banking

21. Tuft SJ, Gregory WM, Davison CR. Bilateral penetrating

keratoplasty for keratoconus. Ophthalmology 1995;102:462-68.
22. Keates RH, Falkenstein S. Keratoplasty in keratoconus. Am J
Ophthalmol 1972;74:442-44.
23. Richard JM, Paton D, Gasset AR. A comparison of penetrating
keratoplasty and lamellar keratoplasty in the surgical management
of keratoconus. Am J Ophthalmol 1978;86:807-11.
24. Kirkness CM, Ficker LA, Steele AD, Rice NS. The success of
Figure 2.18: Ocular cicatricial pemphigoid penetrating keratoplasty for keratoconus. Eye 1990;4:673-88.
25. Polack FM. Keratoplasty in aphakic eyes with corneal edema:
results in 100 cases with 10-year follow-up. Ophthalmic Surg.
26. Olson RJ, Mattingly TP, Waltman SR, Kaufman HE. Aphakic
1. Paytar D, Jones DB. Penetrating keratoplasty. Outcome keratoplasty: visual acuity and optical errors. Ophthalmology
monograph. Alcon monograph series 1(1), Alcon laboratories Fort 1980;87:680-86.
Worth, Texas 1976. 27. Pineros O, Cohen EJ, Rapuano CJ, Laibson PR. Long-term results
2. Buxton JN. Corneal surgery. In Collins JF, Editor: Handbook of after penetrating keratoplasty for Fuchs' endothelial dystrophy.
Clinical Ophthalmology, New York, Masson Publishers 1982. Arch Ophthalmol 1996;114:15-18.
3. Williams KA, Muehlberg SM, Lewis RF, et al. How successful 28. Waring GO 3rd, Laibson PR. Keratoplasty in infants and children.
is corneal transplantation? A report from the Australian Corneal Trans Am Acad Ophthalmol Otolaryngol 1977;83:283-96.
Graft Register. Eye 1995;9:219-27. 29. Stulting RD, Sumers KD, Cavanagh HD, Waring GO 3rd,
4. Hyman L, Wittpen J, Yang C. Indications and techniques of Gammon JA. Penetrating keratoplasty in children. Ophthalmology
penetrating keratoplasties 1985-1988. Cornea 1992;11:573. 1984;91:1222-30.
5. Mamalis N, Anderson CW, Kreisler KR, et al. Changing trends 30. Dana MR, Moyes AL, Gomes JA, Rosheim KM, Schaumberg
in the indications for penetrating keratoplasty. Arch Ophthalmol DA, Laibson PR, Holland EJ, Sugar A, Sugar J. The indications
1992;110:1409. for and outcome in pediatric keratoplasty. A multicenter study.
Ophthalmology 1995;102:1129-38.
6. The Australian Corneal Graft Registry: 1990-1992 report. Aust
31. Maguire MG, Stark WJ, Gottsch JD, Stulting RD, Sugar A, Fink
NJZ Ophthalmol 1993;21(2 suppl): 1.
NE, Schwartz A. Risk factors for corneal graft failure and rejection
7. Sharif KW, Casey TA. Changing indications for penetrating
in the collaborative corneal transplantation studies. Collaborative
keratoplasty, 1971-1990. Eye 1993;7:485.
Corneal Transplantation Studies Research Group. Ophthalmology
8. Haamann P, Jensen OM, Schimidt P. Changing indications for
penetrating keratoplasty. Acta Ophthalmol (Copenh) 1994;72:443.
32. Williams KA, Lowe M, Bartlett C, Kelly TL, Coster DJ. All
9. Robin JB, et al. An update of the indications for penetrating
Contributors. Risk factors for human corneal graft failure within
keratoplasty, 1979-1983, Arch Ohthalmol 1986;104:87-89.
the Australian corneal graft registry. Transplantation 2008;
10. Patel NP, Kim T, Rapuano CJ, Cohen EJ, Laibson PR. Indications
for an outcomes of repeat penetrating keratoplasty 1989-1995
33. Bradley BA, Vail A, Gore SM, et al. Penetrating keratoplasty in
Ophthalmology 2000;107:719-24.
the United Kingdom:an imterim analysis of the corneal transplant
11. Dada T, Sharma N, Vajpayee RB. Indications for pediatric follow-up study. In:Terasaki PI, Cecka JM, eds. Clinical Transplants.
keratoplasty in India. Cornea 1999;18:296-98. Los Angeles: UCLA Tissue Typing Laboratory 1993;293-315.
12. Dandona L, Ragu K, Janarthanan M, et al. Indications for 34. Hassan SS, Wilhelmus KR, Dahl P, Davis GC, Roberts RT, Ross
penetrating keratoplasty in India. Indian J Ophthalmol KW, Varnum BH. Medical Review Subcommittee of the Eye Bank
1997;45:163-68. Association of America Infectious disease risk factors of corneal
13. Soong HK, Farzo AA, Katz D, et al. Lamellar corneal patch grafts graft donors. Arch Ophthalmol 2008;126:235-9.
in the management of corneal melting. Cornea 2000;19:126-34. 35. Hassan SS, Wilhelmus KR. Medical Review Subcommittee of
14. Taylor DM, Stern AL. Reconstructive keratoplasty in the the Eye Bank Association of America Eye-banking risk factors
management of conditions leading to corneal destructions. for fungal endophthalmitis compared with bacterial
Ophthalmology 1980;87:892-904. endophthalmitis after corneal transplantation. Am J Ophthalmol.
15. Killingsworth DW, Stern GA, Driebe WT, et al. The results of 2005;139:685-90.
therapeutic penetrating keratoplasty. Ophthalmology 1993;100: 36. Kremer I, Rajpal RK, Rapuano CJ, Cohen EJ, Laibson PR.
534-41. Results of penetrating keratoplasty in aniridia. Am J Ophthalmol
16. Sony P, Sharma N, Sen S, Vajpayee RB. Indications of penetrating 1993;15;115:317-20.
keratoplasty in northern India. Cornea 2005;24(8):989-91. 37. Dohlman CH, Doane MG. Some factors influencing outcome after
17. Cosar CB, Sridhar MS, Cohen EJ, et al. Indications for keratoprosthesis surgery. Cornea 1994;13:214.
penetrating keratoplasty and associated procedures, 1996-2000. 38. Vajpayee RB, Sharma N, Dada T, Pushker N. Optical sector
12 Cornea 2002;21:148-51. iridectomy in corneal opacities. Cornea 1999;18:262-64.

Chapter 3: Preoperative Evaluation

Preoperative Evaluation
Namrata Sharma, Ritika Sachdev, Manotosh Ray, Rasik B Vajpayee

The principal objective of the preoperative evaluation is to History taking should also document the use of antiglaucoma
identify the underlying corneal disease, to anticipate potential medications. Poor control of intraocular pressure after
intraoperative and postoperative problems during and after the keratoplasty decreases the chance of graft survival. Chronic
surgery and to prognosticate a case of keratoplasty. It is elevation of intraocular pressure may lead to decreased
imperative that a correct etiological diagnosis of corneal endothelial cell count.4,5
pathology and associated disorder if any, is established. An Changes in the quality of vision, as the day progresses should
attempt must be made to cure all associated conditions that can also be ascertained; for example in Fuchs' dystrophy, vision is
complicate a desired result of corneal transplantation surgery. often worse immediately upon awakening with gradual
Any active corneal disease must be identified preoperatively and improvement as the day progresses. When available, old records
if required, effective measures should be taken to prevent its should be looked for. These can caution the physician to the
adverse influence on a successfully performed corneal grafting possible occurrence of intra- and postoperative problems and
surgery. A proper patient selection and comprehensive confirm important information such as prior best-corrected visual
preoperative evaluation enhance the potential for a favorable acuity, intraocular pressure control and previous intraocular lens
outcome. powers. A history should be sought about prior ophthalmic
surgical procedures such as cataract extraction, filtering
OCULAR HISTORY procedures or Nd:YAG laser for posterior capsular opacification.
A candidate for regrafting carries a high risk of rejection.
A detailed history is taken to identify the related local or systemic
conditions for the corneal blindness. Patients are carefully
screened for ocular injury, infectious keratitis, nutritional
deficiencies, history of previous surgery and for systemic The main question when obtaining the patient's history relates
diseases such as collagen vascular disease and Stevens-Johnson to the ability of the patient to undergo proposed operative
syndrome.1-3 procedure. In considering for local anesthesia, for example, the
Prognosis for successful outcome may be related to the ability of the patient to lie flat for the duration of the procedure
knowledge of the patient's preoperative history. Corneal grafts could be compromised by pulmonary or cardiac abnormalities
for herpetic scars develop recurrence of the disease and severe arthritis.6 Pre-existing medical problems such as
postoperatively and may require long-term systemic acyclovir hypertension and diabetes should be stabilized. Allergies to
therapy. medications such as antibiotics, systemic medications and
A history of good visual acuity prior to the development of anesthetics should be noted and reviewed to avoid subsequent
corneal opacity in the affected eye carries a better prognosis. A complications.
meticulous evaluation of the presence of any amblyopia related Patients taking aspirin, non-steroidal anti-inflammatory drugs
to duration of corneal opacity, anisometropia and strabismus is and other medications that interfere with blood coagulation may
mandatory. A patient with childhood onset of opacity presenting be discontinued for 48 hours before keratoplasty, especially, if
later during adulthood may signify the presence of amblyopia. the prothrombin times are in reasonably good range and the
Information should be obtained pertaining to the onset of the treatment can be resumed in the first postoperative day.
visual disturbance, whether a prior intraocular surgery or The patient's social and family support system also needs to
infection preceded it, or whether it simply deteriorated over time. be reviewed. Because consistent follow-up and proper use of
Previous retinal and macular pathology result in poor visual gain postoperative medications are required, patient rehabilitation and
despite a clear graft. compliance are important to the ultimate success of the graft.

OCULAR EXAMINATION Slit-lamp Biomicroscopy

Visual Acuity Conjunctiva and Cornea

Assessment of visual acuity is extremely important before the The tear film should be evaluated under slit-lamp for signs of
patient is taken for penetrating keratoplasty. This should include dry eye like decreased tear meniscus and floating debris.
recording of both uncorrected [UCVA] and best corrected visual Peripheral and tarsal conjunctiva are examined for the evidence
acuity [BCVA]. Standard Snellen's chart is commonly used to of scarring, symblepharon to detect the evidence of previous
Section I: Evolution, Preoperative Considerations and Eye Banking

record the visual acuity. Contact lens corrected visual acuity ocular surface disorder such as Stevens-Johnson syndrome,
should be recorded in cases of irregular astigmatism.7 ocular cicatricial pemphigoid or chemical burns. These patients
In case of poor visual acuity, it must be documented as are at increased risk of dry eyes, non-healing epithelial defects
counting fingers, hand movements or light perception. One of and postoperative infections as the normal external immune
the most important acuity factors involves the careful defense mechanism of IgA and lysozyme are compromised.
documentation of projection of rays, as this is an important Slit-lamp examination is also performed to assess the size,
indication of retinal and optic nerve function. In cases where shape, extent and severity of corneal opacity, degree and extent
there will be improvement of visual acuity after keratoplasty in of vascularization. The corneal sensation may be checked with
eyes with corneal edema, instilling topical glycerin after the fine tip of a cotton wisp 7 (Fig. 3.1).
anesthesia and waiting 20 to 30 minutes for corneal clearing may Consideration must be given to the condition of the host graft
improve acuity and facilitate retinal examinations. Pinhole visual bed, its corneal thickness or peripheral thinning in cases of
acuity, potential acuity meter and glare testing may have limited regrafts. The presence of corneal vascularization may dictate the
value in predicting best visual acuity due to severe light scattering type of suturing technique to be used in a particular case. The
from corneal pathology. In cases of small central scars, a stenopic underlying pathology and the diameter of the host cornea guide
slit visual acuity should be recorded after complete pupillary the diameter of host trephination and corresponding disparity in
dilatation. It is possible that some of these patients may the size of donor button. In cases with post-infectious scarring
significantly benefit from a simple optical iridectomy and hence with thinning and vascularization or corneal ectasias such as
a penetrating keratoplasty may be deferred.8 pellucid marginal degeneration, sizing and placement of the graft
Quantifying visual function in children is important to may require some decentring. Interrupted sutures may be
prognosticate the case. Occlusion of one eye, which is strongly preferred in corneas with excessive vascularization or in pediatric
objected by the child, can indicate a poorer acuity in the eyes due to their faster healing response seen after keratoplasty.
uncovered eye. Preferential looking test can also be performed
to assess visual acuity in children, which is based on the fact Anterior Segment and Iris
that infants prefer to fixate on the pattern rather than the The anterior chamber must be evaluated for the evidence of any
homogeneous stimuli. The infant is exposed to the stimulus and active inflammation. A transplant is best performed on an
the examiner observes the eye for fixation movements using uninflamed, quiet eye. Presence of a ciliary flush, keratic
Teller acuity cards or Cardiff acuity cards. In children > 2 years precipitates, anterior synechia and iridocorneal adhesions are
multiple picture test or Sheridan-Gardiner test can be performed signs of past or present inflammation. Iris should be examined
which is based on matching prototypes. for the presence of iridocorneal synechiae, rubeosis and also
Gross Ocular Examination fibrovascular membranes obscuring the pupil and location of

Eyes are examined with an emphasis on the external ocular

disorders. The lids are evaluated for ectropion, entropion,
lagophthalmos and trichiasis. A surgical correction of these
conditions prior to keratoplasty is advised. These conditions can
cause epithelial scarring and permanent deformity, and may
adversely affect the outcome of the corneal grafting surgery.
Because normal tear production is crucial to the graft re-
epithelization, one should note the tear film abnormalities during
the preoperative examinations. Any evidence for blepharitis
should be looked for and must be treated aggressively. The status
of the lacrimal sac and punctal positions is examined to rule out
any lacrimal system disorder. These anomalies must be corrected
before the patient is taken up for penetrating keratoplasty. If
significant dryness is present, partial or complete punctal
occlusion should be done preoperatively or at keratoplasty,
sometimes in combination with medial or lateral tarsorraphy Figure 3.1: Post-infectious corneal scarring with
14 particularly, if exposure keratitis is present. vascularization
peripheral iridectomies. Presence of extensive anterior synechiae keratoplasty despite successful graft. This may be of particular
may warrant use of special techniques like corneal debulking9 significance in cases of aphakic and pseudophakic bullous
and use of oversized grafts.10 The pupil should be examined for keratopathy with a history of intraoperative vitreous disturbances
size, shape and relative afferent pupillary defect. and postoperative iridocylitis. Knowledge of such conditions will
help to explain the prognosis to the patients. Direct and indirect
Lens ophthalmoscopy should be done under mydriasis and fundus
evaluated from the relatively clear areas, wherever possible.
The lens status must be determined for the presence of cataract,

Chapter 3: Preoperative Evaluation

aphakia and pseudophakia. Slit lamp microscopy is performed
after dilatation of pupil to detect the lenticular opacities. The
lens may have weakened zonules and exhibit phacodonesis. Refraction
Pre-existing early cataract progresses very rapidly after
penetrating keratoplasty. Moreover, coexistent cataract and An accurate refraction is mandatory under mydriasis in all cases,
corneal opacities are common, especially when the patient is wherever possible. In cases such as keratoconus, where
older than 50 years. Therefore, it may be mandatory in such cases retinoscopy is impossible, keratometry may be checked and
to remove the cataract at the time of keratoplasty, even if it is patient refracted.
minimal.11 This can avoid the risk of endothelial damage during
subsequent cataract surgery. Tear Film Status
If the eye is aphakic, the status of the anterior hyaloid face The use of fluorescein and/or rose bengal and Schirmer testing
of vitreous, presence and extent of iris coloboma and pupillary gives the ophthalmologist an indication of the extent of dryness
status must be evaluated. Such eyes may additionally require and epitheliopathy.
anterior segment reconstruction including coreoplasty, anterior
vitrectomy and an anterior chamber or scleral fixated posterior Keratometry
chamber intraocular lens implantation.
Keratometry may be warranted in cases of corneal ectasias such
If pseudophakos is present, the type of IOL should be
as keratoconus, pellucid marginal degeneration and keratoglobus.
identified. If an anterior chamber IOL is present, it must be
identified as either an open looped or closed loop lens. Iris
supported closed loop anterior chamber lenses and open-looped
anterior chamber lens should be replaced especially if any Gonioscopy may be performed to examine the iridocorneal
pseudophacodonesis is suspected. adhesions, peripheral iridectomies and to locate the position of
the lens haptics if an anterior chamber lens is present.
Intraocular Pressure
Intraocular pressure should be measured preoperatively.
Applanation tonometry may not be possible in corneas with Pachymetry should be performed to quantify corneal thickness
opacities and scarring. A MacKay Marg, pneumotonometer, using ultrasonic pachymeter or sonogauge especially in cases
scleral tonometer or Tono-pen may be required for more accurate of corneal thinning disorders such as keratoconus, keratoglobus
assessment in these patients. Raised intraocular pressure must and pellucid marginal degeneration. Not only central but also
be controlled either medically or surgically, before the patient paracentral and peripheral readings should be obtained in each
is planned for keratoplasty. Intraocular pressure should not be of the four meridians. Pachymetry is also mandatory in cases
higher than the low twenties on no more than two medications. where, automated therapeutic lamellar keratectomy is
If it is not, primary filtering or combined filtering and penetrating contemplated for proper selection of the microkeratome head
keratoplasty should be considered.4 Since, all keratoplasty to be used. Micheiletto et al have reported a very high risk of
patients require intraoperative viscoelastics to coat the perforation of the Descemet's membrane while performing the
endothelium, aid in control of bleeding and help prevent big bubble technique of deep anterior lamellar keratoplasty
synechia, therefore the eyes with pre-existing glaucoma should (DALK) in cases with preoperative pachymetry less than 250
be screened out. Further, the use of long-term topical steroids microns. 12 They hypothesized that the weakening of the
to prevent rejection may lead to steroid induced glaucoma.4,5 Descemet's membrane is related to end-stage keratoconus corneal
thinning and this ultrastructurally weakened Descemet's
Fundus Evaluation membrane is more likely to rupture during the DALK procedure.
If possible, a thorough evaluation of the retina and vitreous
Specular Microscopy and Confocal Microscopy
should be performed to ensure that the decreased vision is
secondary to corneal pathology only. Eyes with macular Specular microscopy and confocal microscopy may be
pathology, e.g. macular holes, macular degeneration and cystoid undertaken, wherever possible. Specular microscopic
macular edema are unlikely to improve after penetrating features help to diagnose early cases of Fuchs' dystrophy
(Figs 3.2A and B) and also help to differentiate various other degeneration and keratoglobus. Peripheral videokeratography
pathologies such as posterior polymorphous dystrophy and can also be done in cases of corneal opacities with cataract, which
iridocorneal syndromes. Endothelial cell counts and morphology helps to calculate the intraocular lens powers in a case of
may also be relevant in cases of superficial opacities where combined penetrating keratoplasty with cataract extraction and
lamellar grafts are contemplated and a normal endothelial reserve intraocular lens implantation.
is essential. Confocal microscopy, a more recent research tool
helps to study the status of the epithelium as well as the Slit Scanning and Scheimpflug Imaging
Section I: Evolution, Preoperative Considerations and Eye Banking

keratocytes. It non-invasively resolves the structural as well as

Slit scanning (Orbscan) and Scheimpflug (Pentacam) evaluation
functional interrelationships (Fig. 3.3). Confocal microscopy has of the anterior and posterior corneal surface as well as the corneal
been used in the detection and management of pathologic and
thickness may be useful in ectatic disorders of the cornea (Figs
infectious conditions, corneal dystrophies and ectasias and
3.5 to 3.7). Their role is however limited in opaque corneas and
assessment of the depth of corneal scarring prior to lamellar ultrasonic evaluation may be more useful in these cases.
keratoplasty procedures.
Yamaguchi T et al demonstrated that the postoperative BCVA
following DSAEK surgery correlated with irregularity of the
Laser Interferometry
anterior surface but not the posterior surface as evaluated using
More sophisticated testing with potential acuity meters and laser the Scheimpflug imaging system.13
interferometers may be helpful in evaluation of prognosis of
transplant surgery for patients with corneal opacities. Ultrasound Biomicroscopy
The original ultrasound biomicroscope (UBM) developed by
Pavlin, Sherar and Foster is based on 50 to 100 MHz transducers,
Videokeratography (Fig. 3.4) should be performed in cases of
ectatic corneal disorders such as keratoconus, pellucid marginal

Figure 3.2A: Specular microscope Figure 3.3: Confocal microscopy

Figure 3.2B: Specular microscopic features of Fuchs'

dystrophy: extensive guttae are visible Figure 3.4: Videokeratography
Chapter 3: Preoperative Evaluation
Figure 3.5: ORBSCAN Quad map of a keratoconus patient: Note posterior elevation > 50 microns, anterior elevation coinciding
with area of posterior elevation and thinnest pachymetry. Asymmetric skewed bowtie pattern seen with Placido based topography

reconstruction may be undertaken in such cases. Ultrasound

biomicroscopic evaluation can be used to determine the presence
and extent of peripheral anterior synechiae, the status of the lens
or the intraocular implant and the capsular status in aphakes.
Madhavan et al have reported its role as a useful adjunct in the
preoperative planning and prognostication of patients requiring
penetrating keratoplasty.14 Lanzl et al demonstrated the role of
UBM in surgical planning for limbal dermoids. UBM is able to
assess the depth of involvement of opaque corneal lesions such
as limbal dermoids as it distinguishes the normal cornea from
the more sonolucent lesion.15 Because planning of the surgical
approach in these cases is facilitated by preoperative knowledge
about the depth of penetration of these opaque lesions, UBM
can be regarded as useful adjunct tool in their management.
Rutnin et al evaluated the role of UBM as a method of
Figure 3.6: The Scheimpflug imaging system- Pentacam
assessing anterior chamber intraocular lens (IOL) haptics before
combined penetrating keratoplasty and IOL exchange in eyes
incorporated into the B-mode clinical scanner. Higher frequency
with poor corneal clarity resulting from pseudophakic bullous
transducers permit increased resolution, but only at the expense
keratopathy.16 They concluded that UBM can evaluate the
of decreased tissue penetration depth. The commercially
presence and extent of fibrotic encasement of the haptics in cases
available UBM is most often configured with a 50 megahertz
with an opaque cornea and the extent of fibrotic encasement was
transducer, which provides a tissue resolution of approximately
found to be predictive of the surgical difficulty in removal of
50 microns and a penetration depth of 4-5 mm. This permits
the intraocular implant.
visualization of the anterior segment. The presence of a
corneoiridic scar may necessitate an ultrasound biomicroscopy
to assess the angle and the ciliary body (Figs 3.8 and 3.9A and
B). While performing keratoplasty, the corneal debulking by A and B-scan ultrasonography should be performed in all eyes
sequential lamellar separation8 and subsequent anterior segment with corneal opacity to rule out any coexistent posterior segment
Section I: Evolution, Preoperative Considerations and Eye Banking

Figure 3.7: Scheimpflug (Pentacam) map of a keratoconic cornea

Electrophysiological Tests
The use of electrophysiologic methods is helpful to assess the
retinal functions in eyes with corneal opacities. Bright-flash
electroretinogram (ERG) will give a response despite most media
opacities. However, ERG measures only gross retinal function.
The visual evoked response (VER) is a better indicator of optic
nerve function. Pattern stimuli can give a relatively precise
measure of visual function when the media are clear, but flash
stimuli must be used when the cornea is opaque. A decreased
amplitude and prolonged latency in VER indicates poor
Once, the evaluation is over, one must establish a diagnosis
and prognosticate the case very carefully. Several factors
Figure 3.8: Ultrasound biomicroscopy including age of the patient, status of the other eye, compliance
of the patients and need of binocularity play a role in decision-
pathology such as old retinal detachment in which case the making. The procedure should be clearly explained to the patient
keratoplasty may not be undertaken due to poor prognosis. and relatives. The risks of the procedure specifically regarding
Determination of the axial length using A-scan biometry is long follow-up time, chance of rejection, long-term use of
critical in IOL power calculation while performing the triple medications should be discussed. The patient should have a
procedure. realistic expectation for visual gain after the procedure.

3. Chang, SD, Pecego JG, Zadnik K, et al. Factors influencing graft
clarity. Cornea 1996;15:577-81.
4. Charlin R, Polack FM. The effect of elevated intraocular pressure
on the endothelium of corneal grafts. Cornea 1982;1:241.
5. Sekhar GC, Vyas P, Nagarajan R, et al. Post-penetrating
keratoplasty glaucoma. Indian J Ophthalmol 1993;41:181.
6. Altman AJ, Albert DM, Fournier GA. Cocaine's use in
ophthalmology: our 100-year heritage. Surv Ophthalmol

Chapter 3: Preoperative Evaluation

7. Vail A, Gore SM, Bradley BA, et al. Clinical and surgical factors
influencing corneal graft survival, visual acuity and astigmatism.
Corneal Transplant Follow-up Collaborators. Ophthalmology
8. Vajpayee RB, Sharma N, Dada T, Pushker N. Optical sector
iridectomy in corneal opacities. Cornea 1999;18:262-64.
9. Vajpayee RB, Angra SK, Honavar S, et al. Protection of the iris
by lamellar dissection of corneal layers. A technique in penetrating
keratoplasty. Cornea 1994;13:16-9.
10. Vajpayee RB, Dada T, Ray M, Tandon R, Sethi A, Turaka K.
Oversized corneal grafts for corneal opacities with iridocorneal
adhesions. Ophthalmology 2001;108:2026-28.
11. Flowers CW, McLeod SD, McDonell PJ. Evaluation of
intraocular lens power calculation formulas in the triple
procedure. J Cataract Refract Surg 1996;22:116.
12. Michieletto P, Balestrazzi A, Balestrazzi A, Mazzotta C,
Occhipinti I, Rossi T. Factors predicting unsuccessful big bubble
deep lamellar anterior keratoplasty. Ophthalmologica.
13. Yamaguchi T, Negishi K, Yamaguchi K, Murat D, Uchino Y,
Shimmura S, Tsubota K. Effect of anterior and posterior corneal
surface irregularity on vision after Descemet’s-stripping
endothelial keratoplasty. J Catarct Refract Surg. 2009;35:688-94.
Figures 3.9A and B: Ultrasound biomicroscopy 14. Madhavan C, Basti S, Naduvilath TJ, Sangwan VS. Use of
of corneoiridic scar ultrasound biomicroscopic evaluation in preoperative planning
of penetrating keratoplasty. Cornea. 2000;19:17-21.
15. Lanzl IM, Augsburger JJ, Hertle RW, Rapuano C, Correa-Melling
Z, Santa Cruz C. Role of ultrasound biomicroscopy in surgical
1. Williams KA, Roder D, Esterman A. Factors predictive of corneal planning for limbal dermoids. Cornea. 1998;17:604-06.
graft survival. Report from Australian Corneal Graft Registry. 16. Rutnin SS, Pavlin CJ, Slomovic AR, Kwartz J, Rootman DS.
Ophthalmology 1992;99:403. Preoperative ultrasound biomicroscopy to assess ease of haptic
2. Price FW Jr, Whitson WE, John S, Gonzales JS. Risk factors for removal before penetrating keratoplasty combined with lens
corneal graft failure. J Refract Surg 1996;12:134-43. exchange. J Cataract Refract Surg 1997;23:239-43.

Section I: Evolution, Preoperative Considerations and Eye Banking

Eye Banking—A Practical Guide

Graeme A Pollock, S Louise Moffatt

The process of corneal transplantation begins with eye donation. The continued development, complexity, professionalism and
Corneal transplantation is not possible without the provision of evolution of the services provided by Eye Banks means that Eye
a viable, disease-free donor cornea. In no other area of Banking today is very different from that practiced only 10 to
ophthalmic surgery is the surgeon more dependent on a factor 20 years ago. This, coupled with increasing regulatory oversight,
over which they have little or no direct control. has consigned to history the concept of Eye Banking as a sole
An Eye Bank holds the dual responsibilities of ensuring the practitioner undertaking (often voluntary or part-time) who is
safety and efficacy of donor corneas, and ensuring fair and equipped with a only a telephone and refrigerator.
equitable distribution of transplantable corneas. In addition, Eye Such generational change has also created a new paradigm
Banks may provide other ancillary services including the supply for Eye Banks. No longer is the focus merely on the quantity of
of donated sclera for glaucoma, oculoplastic and retinal surgery, tissue provided. Instead, quality of tissue and quality of service
and more recently, human amniotic membrane for ocular surface has become a priority.
It is also important to recognize that a fully functioning and Regulation and Quality Systems
effective Eye Bank is not a simple storage and supply unit. Eye
Banking has a rich history and traces its origins back to the Eye Banking services are provided in an environment of stringent
establishment of the Eye Bank for Sight Restoration in New York quality assurance standards, often with increasing government
in 1944. Over the ensuing 60 years Eye Banks have developed regulation or oversight. In Australia since 1995, the Therapeutic
professional practices that encompass all aspects of donation. Goods Administration has mandated the licensing of Eye Banks
Thus Eye Banking involves many activities that are not only under a code of Good Manufacturing Practice.1 During 2007
directed towards providing a service to the ophthalmologist and and 2008 a newly revised code and system of regulation and
their recipients but also directed towards to the eye donor and specific tissue standards will soon extend to New Zealand under
their family. Eye Banking activities include: a new regulatory body, the Australian and New Zealand
• Hospital development and professional in-service programs Therapeutic Products Authority.2 In the United States the Food
designed to maximize the appropriate identification of and Drug Administration (FDA) has published three rules to
suitable donors and referral to the Eye Bank ensure the safety of human cell and tissue products. The most
• Provision of trained professional staff to approach families recent rule, effective from May 2005, entitled “Current Good
to offer the option of donation Tissue Practices for Human Cell, Tissue and Cellular and Tissue-
• The meticulous screening of donors to assess donor risk, Based Establishments; Inspection and Enforcement,” (cGTP) is
including evaluation of donor medical history and risk factors aimed at preventing the introduction, transmission and spread
• The donation of eye tissue according to established and of communicable diseases. The FDA also continues to issue
recognized standards and procedures guidance documents to assist with compliance to these rules.3
• Evaluation of corneas by slit-lamp, specular or light The Commission of the European Union have issued two
biomicroscopy Directives on setting standards of quality and safety for the
• Fair and equitable distribution of tissue donation, procurement, testing, processing, preservation, storage
• Donor family support which may include access to and distribution of human tissues and cells, the first of which
bereavement counseling services, information on came into effect in April 2006. In addition, these Directives are
bereavement literature and associations and facilitation of accompanied by two detailed technical annexes.4 Member States
appropriate and anonymous correspondence between have the responsibility to put in place national measures to
recipients and donor families. implement the Commission Directives.

All of these regulations have as their basis the identification of a prospective donor’s available medical records, medical
and minimization of risk so as to ensure and improve the quality history or investigation of cause of death. Any relevant
and the safety of transplanted tissue. In each instance they cover information pertaining to the donor should be recorded. Within
standards and regulations pertaining to: donor selection, donation a hospital environment this should include a review of the death
and testing; traceability; organization and management; personnel certificate and cause of death (if available), a review of progress
and training; documentation and records, facilities, equipment notes noting temperature trends, admission and history notes,
and materials; procurement and preservation; packaging and medications, laboratory reports (especially microbiology,

Chapter 4: Eye Banking—A Practical Guide

labelling; and distribution, notification and recall systems. serology and hematology reports), and noting amount and time
Formulation of standards, establishment and compliance with of any transfusions. Donor screening should also consist of a
such quality systems approaches, whether government imposed verbal review with the appropriate treating physician. This is
or self-imposed, have been a central theme for Eye Banks over especially important to accurately assess the patient’s medical
this past decade. Inevitably it has required the introduction of and social conditions during the last admission and at the time
new expertise and training to manage the quality system. In many of death. The donor’s family doctor should also be interviewed
cases it has required the recruitment of additional staff and the as well as a donor’s family member or friend who is in a position
re-development of facilities. Naturally such adjustments in scope to answer questions about the donor’s medical and lifestyle
and complexity have effects on the administrative and history. This is especially important if the donation is outside of
infrastructure support systems of the Eye Bank and ultimately a hospital environment. However, donor family interview must
result in substantial increases in operating costs. not be considered in isolation to other history as its validity and
usefulness in providing information to exclude potentially
Donor Selection infectious tissues can be questionable.8,9 Donor review may also
While the technical aspects of Eye Banking must be robust to encompass consultation with forensic pathologists and coroners/
medical examiners if appropriate. An individual who is qualified
ensure the provision of safe tissue it is in the careful selection
either by profession, education or training to perform all of the
or exclusion of potential donors that is of utmost importance in
preventing the transmission of disease to the recipient. In addition above tasks and familiar with the potential surgical uses of the
tissue should perform donor screening.
donor selection must also take into account considerations
regarding the quality, or potential efficacy for purpose, of the
Disease Transmission from Donor Corneas
Many of the standards that have been adopted by Eye Banks Fortunately, iatrogenic transmission of serious or fatal systemic
world-wide were initially developed by the Eye Bank Association disease from corneal transplantation appears to be a rare event.
of America5 who produced their first set of Medical Standards A review of the world literature reveals only 12 reports of disease
in 1980. A rigorous review process has ensured that these transmission since 1939 (excepting bacterial and fungal
Medical Standards continue to evolve as new knowledge, insights transmission).
and challenges develop. Other eye banking organizations, such Diseases that could potentially be transmitted by corneal
as the European Eye Bank Association,6 have also developed transplantation fall into three categories
minimum standards that are reviewed each year. The Eye Bank 1. Prion disease (Creutzfeldt-Jakob disease (CJD) and
Association of Australia and New Zealand (EBAANZ) have also associated variants).
produced comprehensive Medical Standards that are reviewed 2. Infections (bacterial, fungal and viral).
on a regular basis which take into account regional disease 3. Malignancies.
prevalence and risk assessment.7 However, each Eye Bank 4. Intrinsic eye disease or surgery.
jurisdiction should consider their own situation, disease
prevalence, donor profile and risk assessment, and consider their Prion Disease
contraindications accordingly.
Duffy et al.10 reported the possible transmission of CJD in 1974
and during the 1990’s two further possible cases were
Contraindications for the use of Donor Tissue
reported.11,12 However, the evidence for transmission in these
The EBAANZ contraindications for the use of Donor Tissue is later two cases is limited. In 1999, Hogan and colleagues13
reproduced in Table 4.1. These contraindications are designed reviewed known cases of transmission of CJD by tissues and
to reduce the potential for: concluded that the risk of transmission was very low. In addition,
1. Viral transmission of disease. they suggested that the review of a potential donor’s available
2. Transmission of bacterial or fungal infections. medical information for any evidence of a diagnosis or family
3. Transmission of malignant disease. history of CJD or evidence that human pituitary hormone had
4. Transplantation of corneal disorders, or of those corneas been administered was sufficient to guard against the extremely
which pose a risk to the success of the surgery. low potential risk of disease transmission.
To successfully implement these standards Eye Banks must Initial concern about the presence of variant CJD (vCJD) in
have consistent policies for the examination and documentation the United Kingdom and the theoretical possibility of
Table 4.1: Contraindications for the use of Donor Tissue for Penetrating Keratoplasty
[Eye Bank Association of Australia and New Zealand: Medical Standards 7]

1. General Exclusion: • Motor neurone disease (amyotrophic lateral sclerosis)

• Death of unknown cause • Multiple sclerosis
[May be acceptable if death certificate or autopsy report • Alzheimer’s disease
is only pending an unresolved differential cause of • Parkinson’s disease
death where all the alternatives are NOT
Section I: Evolution, Preoperative Considerations and Eye Banking

contraindications] 6. Neurodegenerative – High Risk:

• Death with neurologic disease of unknown diagnosis
2. Infectious Disease:
• Dementia or recent unexplained neurological
• AIDS or HIV seropositive symptoms, e.g. ataxia, myoclonus, memory loss
• Encephalitis – active, or of unknown origin • Recipients of human pituitary-derived growth hormone
• Endocarditis – active, or of unknown origin (PIT-HGH) from 1963 to 1985
• Hepatitis – active • Recipient of human-derived dura mater tissue at any
• HTLV-I or HTLV-II time
• Leprosy [Dementia resulting from cerebrovascular disease,
• Malaria brain tumour or trauma, or toxic- or metabolic-induced
dementia may be acceptable]
• Meningitis – active, or of unknown origin
[Recipients of synthetic growth hormone or dura mater
• Progressive multifocal leukoencephalopathy are acceptable]
• Reye’s syndrome
7. Eye Disorders, Infection and Surgery:
• Rubella – congenital
• Ocular/intraocular infection – active at time of death
• Smallpox
(e.g. endophthalmitis, keratitis, conjunctivitis, uveitis,
• Subacute sclerosing panencephalitis retinitis, choroiditis, iritis, vitreitis, scleritis)
• Syphilis – active • Malignant tumors of the eye and anterior segment (e.g.
• Tuberculosis – active retinoblastoma, melanoma, adenocarcinoma etc)
• Typhoid – active • Corneal disorders (e.g. keratoconus, keratoglobus,
[Bacterial disease may be acceptable if organ culture dystrophy)
storage is performed] • Corneal opacity, scarring, or pterygium, which involves
the central area of the corneal button
3. Infection:
• Corneal surgery e.g. radial keratotomy, refractive laser
• Septicemia (bacteremia, fungemia, viremia)
surgery (photorefractive keratectomy (PRK) or laser
[Bacteraemia may be acceptable if organ culture
in situ keratomileusis (LASIK)
storage is performed]
[Other eye disorders, e.g. cataract, glaucoma,
4. Malignancy: retinopathy acceptable]
• Hodgkin’s disease [Surgery/laser treatment for disorders other than
corneal acceptable]
• Leukemia
• Lymphoma 8. Infectious Disease – High Risk:Persons within
• Lymphomatoid granulomatosis previous 12 months who have:
• Lymphosarcoma • Performed intravenous drug use for non-medical
• Myeloma
• Been incarcerated in prison
• Myeloproliferative disease
• Engaged in prostitution or sex for money or drugs
• Polycythemia vera – primary
[Other cancers acceptable] • Tattoos or body piercings not performed in licensed
5. Neurological Disorder: • Received human-derived blood-clotting factors
• Chronic idiopathic demyelinating polyneuropathy • Close contact with persons with viral hepatitis
• Creutzfeldt-Jakob disease (CJD) of any type – in • Had sex with persons known to have HIV or hepatitis
potential donor or immediate family member • Known exposure to blood from person with HIV or
• Guillain-Barre syndrome hepatitis
• Huntington’s chorea • Men who have had sex with other men

Contraindications for Lamellar Grafts

Criteria are the same as listed for penetrating keratoplasty except that tissue with local eye disease affecting the corneal
endothelium or previous ocular surgery that does not compromise the corneal stroma is acceptable for use.
Contraindications for use of Sclera
Criteria are the same as listed for penetrating keratoplasty except that tissue with local eye disease affecting the corneal
endothelium or previous ocular surgery that does not compromise the sclera is acceptable for use.
human-to-human transmission has tempered in recent years as paralytic or dumb rabies, flaccid paralysis develops and the
the numbers of new vCJD cases continue to fall. In 2006, there exclusion criteria of “death from central nervous system disease
were five deaths attributable to definite or possible vCJD and a of unestablished diagnosis” would today exclude such potential
total of 158 deaths (to the end of 2006), since being first donors from becoming actual donors.
identified in 1995.14 However, the amount and distribution of The possibility of iatrogenic transmission of hepatitis B virus
the infectious agent in people with vCJD is greater than in other (HBV) has long been recognized. Two cases of transmission from
forms of CJD perhaps increasing its potential for transmission. 1984 and 1985 were reported by Hoft et al.26 Both these cases

Chapter 4: Eye Banking—A Practical Guide

Unfortunately, diagnostic tests on lymphorecticular tissue took place before routine serological screening of donors for
samples have not proved reliable in detecting vCJD infection.15 hepatitis B surface antigen (HbsAg).
The emergence of vCJD has led Blood Banks in parts of the Hepatitis C virus has been detected in corneas27 and in the
world to exclude from donation those people who have visited media of organ cultured corneas of seropositive donors28
or resided in the United Kingdom for a cumulative period of although at the very low concentration of virus detected it
three months or more although such decisions were based on remains arguable whether transmission via corneal
theoretical risk reduction versus potential reduction in supply transplantation is likely. In one case of a donor being anti-HCV-
rather than actual risk reduction. Internationally, Eye Banks have negative but HCV RNA-positive, HCV infection occurred in
resisted such restrictions when the very low risk versus the eight of 30 recipients of organ and tissues but not in the single
benefits is taken into consideration.16 However, 2007 guidance recipient of a corneal transplant.29
from the FDA, Guidance for Industry: Eligibility Determination Similarly, the human immunodeficiency virus (HIV) has been
for Donors of Human Cells, Tissues, and Cellular and Tissue- shown to be present in a human cornea30 but such a presence
Based Products, determine to be ineligible to donate any person may not lead to transmission of the disease by corneal
who spent three months or more cumulatively in the UK from transplantation. There are three reports in the literature of HIV-
the beginning of 1980 through the end of 1996 and any person infected donors where the corneal recipients have not
who spent 5 years or more cumulatively in Europe from 1980 seroconverted.31-33 These negative reports suggest that the
until the present. Persons who received any transfusion of blood transmission of HIV through corneal transplantation may be
or blood components in the UK or France between 1980 and difficult.
the present are also excluded.17 There is a group of diseases listed as contraindications that
Interestingly, data on CJD and vCJD suggests the disease- are diseases of possible but unproved viral etiology. This includes
related prion protein (PrPSc) may not be distributed in human – subacute sclerosing panencephalitis, progressive multifocal
eye tissue as widely as previously thought. In three cases of leukoencephalopathy, Reye’s syndrome, acute leukemia, and
sporadic (or classical) CJD no PrPSc was detected in proximal active disseminated lymphomas such as Hodgkin’s disease.
optic nerve, sclera, retina, vitreous humor, lens, aqueous humor, Hematological malignancies, with decreased immunological
iris or cornea. In the one case of vCJD investigated PrPSc in the defense mechanisms, may also mask opportunistic viral or
eye was restricted to the optic nerve and retina.18 In addition, in bacterial infections.
a widely reported case of transplantation of ocular tissues from
a donor subsequently determined to have sporadic CJD (where Infections – Bacterial and Fungal
subsequently tissues were explanted with no known Septicemia is a contraindication in a prospective corneal donor
transmission), there was no evidence of PrPSc in the cornea.19
because of the risk of pathogenic organisms being harboured in
the conjunctiva, surviving the antibiotics used throughout the
Infections – Viral
retrieval and buttoning process, and eventually leading to an
During the 50 year history of Eye Banking corneas have endophthalmitis in the recipient’s eye. The only exception to this
transmitted three types of virus – Hepatitis B, herpes simplex is if the corneas are to be placed in organ culture for preservation.
and rabies. The microbiological surveillance during organ culture allows the
Nine cases of rabies transmission from six donors result- exclusion prior to transplantation of those corneas that may be
ing in eight deaths have been documented between 1979 and harbouring organisms.6
1996.20-25 In all cases rabies was not identified in the donor until Payne34 summarized 12 enucleations reported in the literature
transmission had occurred. In only one case was rabies in the due to bacteremic or fungemic donor-induced endophthalmitis,
donor detected promptly and subsequent intensive and a number of cases have appeared in the literature since.35,36
immunotherapy for the recipient prevented their death.25 The In addition, adverse event reporting by member Eye Banks to
problem arises that diagnosis in a potential donor can be difficult the Eye Banks Association of America indicate a rate of less
if the rabies does not present with its classical picture of than 0.1% of culture positive or clinically suspected microbial
hydrophobia and hyperaesthesia (furious rabies). In the Iran case endophthalmitis among corneal recipients (unpublished data).37
the donor is described as presenting only the prodromal While the rate is very low, and may not always lead ultimately
symptoms of fever, malaise, headache and gastrointestinal to the loss of the eye, an infection of this nature is a serious and
infections prior to death. However, even in the less common dangerous complication to the transplant’s success. For this
reason, if hypothermic storage is the method of choice, any Specular microscopy of donor corneas before and after
suspicion of bacteremia or fungemia must be thoroughly transplantation adds further weight to these follow-up study
investigated and if it cannot be positively excluded, even if it findings. Endothelial cell density of the cornea after
cannot be positively proved, then that tissue should not be transplantation is related to the endothelial cell density of the
considered for distribution. donor cornea and not to the donor’s age.44 Therefore a donor
cornea with normal endothelial cell density and morphology is
Malignancies suitable for transplantation regardless of age. However, the older
Section I: Evolution, Preoperative Considerations and Eye Banking

the donor the less likely that the density and morphology is going
There are two cases reported where a malignancy has been
transmitted. In the first case a retinoblastoma was transplanted to be suitable for transplantation.45,46 Armitage and Easty
reported for organ cultured corneas of the United Kingdom Eye
from the donor eye to the recipient eye.38 There is also a report
Bank that greater than 80 percent of corneas from donors less
of transmission of a disseminated adenocarcinoma from donor
to the recipient’s iris with confirmation of tumor markers with than 40 years of age were used, but in donors older than 80 years
of age the usage rate was 45 percent.47
PCR.39 It would be incorrect however to consider malignancies
in the donor as being high risk for transmission of disease. Non-
Lower Donor Age
hematological malignancy is not an exclusion for donation, and
a substantial percentage of the hundreds of thousands of corneal There is no clearly defined lower age limit for corneal donation.
transplants performed have used corneas from donors with The Eye Bank Association of Australia and New Zealand list
malignancies, without any evidence of transmission. However, the minimum age as 2 years. Problems relate to both the technical
the two isolated cases reported above, both relating to difficulties in using infant tissue and the complication of post-
malignancies in the donor eye, do demonstrate the importance operative myopia. The extreme thinness of the infant cornea
of a careful examination, including the posterior pole of the eye, means that it is likely to fold upon itself during handling. This,
to exclude the possibility of malignancy or other pathology in combined with the small diameter of the cornea, creates problems
the donated eye. during the donation surgery, trephining, and during placement
Although leukemia and lymphoproliferative disorders pose and suturing in the host bed. Koenig provides a review of these
the greatest theoretical risk of transmission, due to a possible problems.48 The myopic shift after keratoplasty with infant donor
viral etiology, no cases of transmission have been reported. corneas has been related to the steep curvature of these corneas.49
However, these latter disorders remain as a contraindication.
Donation of Eye Tissue
Intrinsic Eye Disease or Anterior Segment Surgery
Eye Donor Coordination
Local corneal disorders or surgery may pose a risk to the success
of corneal transplant surgery. Keratoconus in its early stages or Arguably, an Eye Bank’s most important work is done during
corneal dystrophies may go undetected. Incisional surgery to consent, the interaction with bereaved family members and with
correct myopia is detected through the appearance of radial and the process of gathering of accurate medical histories. All of this
arcuate lines upon slit lamp examination but detecting past involves multiple interactions with a variety of sources such as
photorefractive surgery in a donor cornea is difficult if not relatives, medical and nursing staff, pathologists and general
impossible by current Eye Bank examinations. Modern cataract practitioners. The skill is in the collection, assimilation and
extraction by phacoemulsufication and the replacement of the analysis of all this information while ensuring that the donor
host lens by an intraocular lens is not an absolute contraindication family is cared for and is fully informed of their choices and the
to donation. However, in these cases microscopy of the processes that donation entails. All of this must be done within
endothelium is required to exclude those corneas showing low an ethical and professional framework to reduce the risk of harm
cell density or abnormal morphology. to the donor family and to the prospective recipients of donated
The form of the consent, or authority to proceed with the
Donor Age
donation, will of course vary depending on the jurisdiction’s
Clinical evidence shows that there is no influence of donor age legislation and social culture, but regardless of this the Donor
alone on corneal transplant survival.40,41 The most convincing Coordinator should ensure that all parties that need to be fully
evidence comes from the multi-centre outcome registries of the informed are fully informed. The extent of the donation (whole
United Kingdom42 and Australia.43 The United Kingdom follow- globe or just cornea, transplant and research purposes,) needs
up study followed 2,777 penetrating transplants over 4 years, to be identified and recorded. The investigations with regard to
while the 2004 Report of the Australian Corneal Graft Registry assessing medical risk or donor suitability must be conducted in
reported the outcome of 14, 649 transplants followed for periods a thorough and professional and considered manner that is
between one to 20 years. Both reported no influence of donor relative to the risk. These responsibilities extend to those
age on transplant outcome. instances where workplace partners have been primarily involved

in the consent and donor screening process (e.g. multiple tissue during the current admission. Equivalent amounts of colloid or
or organ donation); the Eye Donor Coordinator must still cross- crystalloid infused should also be considered. When blood loss
check and ensure that these processes have been suitably is known or suspected to have occurred, the potential eye donor
performed. was transfused or infused, and no adequate pre-transfusion/
infusion sample is available for infectious disease testing; then
Medical History Review an algorithm should be used to determine that there has not been
plasma dilution sufficient to affect test results. Examples of
It is important to establish the donor’s medical and lifestyle

Chapter 4: Eye Banking—A Practical Guide

appropriate algorithms are available.3,50
history prior to their death to assist in determining both the safety
and likely efficacy of the tissue. If a written Medical History of
Eye Donation Surgery
the donor’s last health care admission is readily available then
it should be thoroughly reviewed and details relevant to the Eye As with all surgery, there are many different possible approaches
Bank’s purposes recorded unambiguously. In particular the to donor surgery and donor eye preparation/dissection and
following details should be recorded – therefore this chapter will only deal with some of the salient
• Record cause of death and contributing factors points. The Procedures Manual of the Eye Bank Association of
• Record current and past medical history America does cover specific procedures written broadly enough
• Record the time of death as determined by cessation of the to provide a framework for the development of an Eye Bank’s
circulation of the blood, the important point here being a own procedures, yet specific enough to establish accepted
record of the beginning of the ischemic period baseline standards.51 In addition, an excellent introductory
• Record data to unambiguously identify the donor (as a handbook and atlas has also been published which provides good
minimum, name of patient and date of birth) illustrated step-by-step guides to Eye Bank surgical and
• In the instance of intended hypothermic storage of corneas, evaluation techniques.52
a review and interpretation of laboratory results (in particular The person performing the donor surgery must use their
blood cultures, temperature trends and white blood cell professional judgment and satisfy themselves that all reasonable
counts) must be performed to exclude or bacteremia or steps and normal surgical precautions have been taken to
fungemia in the donor at the time of death. Discussion with minimise contamination or damage to the tissue. These
the treating physician and gaining an insight into their clinical precautions should also extend to the safety of the surgeon and
impressions is often critical in making a decision on potential recipients of the tissue. Ideally the area should be one
bacteremic status. However, bacteremia can be considered of restricted access as a first step towards aseptic technique, have
suitable if normothermic (organ culture) of corneas is appropriate lighting, sharps and biohazard waste containers and
performed where significant infection of corneal tissue will generally be clean and organized. Personnel must be trained in
become evident as contamination in the storage medium. the procedures or in general surgical procedures.
In addition, as discussed in the contraindications for the use
of Donor Tissue section, it is important that the Eye Bank Preparation of the Donor
communicates with the treating doctor, the donor’s general If an enucleation is to be performed many Eye Banks may forego
practitioner, and a family member or friend in order to review
extensive donor preparation opting instead to decontaminate the
the donor’s medical and lifestyle history, and that these
globe within the Eye Bank laboratory prior to the removal of
discussions be appropriately recorded and evaluated. the cornea. This is usually performed in the laboratory by rinsing
the globe in a dilute povidone-iodine (PVP) solution (a 1 to 5%
Serology Testing
concentration resulting in 0.1 to 0.5% available iodine) for 1-2
As an absolute minimum, the donor must be serologically minutes. The PVP solution must not contain any detergents as
tested for Human Immunodeficiency Virus 1 and 2, Hepatitis this could harm the corneal epithelium, and this should be
B surface antigen and Hepatitis C virus. Depending on the checked beforehand. The PVP is then followed by a thorough
jurisdiction, additional tests (e.g. Syphilis and HTLV) may be rinse with a balanced saline solution. This is a very effective
mandated.3,4 means of decontamination53 if performed with appropriate
Plasma dilution may affect the validity of any post-infusion concentrations of PVP over a short period.54
serology so when reviewing the donor’s history it is important For those Eye Banks that perform in situ excision of corneas,
to record the amount and time of any transfusion or infusions similar solutions can be used to minimize ocular flora and reduce
(blood, colloid, crystalloid). As a rough guide a pre-transfusion/ contamination. This procedure is appropriate for donor
infusion sample should be obtained for testing if an adult donor preparation prior to both enucleation and excision. Here the
has received 4 or more units of whole blood (or equivalent) delivery of the solutions is also important as the eyes should
within 48 hours preceding cessation of circulatory function. For first be rinsed in a strong stream of balanced saline to remove
a child less than 12 years of age a pre-transfusion sample should all debris, mucus and foreign matter from the cornea and
be obtained if the child has received any blood transfusions conjunctival sack. This in itself will reduce microbial

contamination. A good stream of balanced saline is also required (other than a good medical history) to determine if there has been
after a period of PVP application to ensure good removal of the previous anterior segment surgery or if there is any pathology
PVP from the eye. The lids and the surrounding area can then of the eye not identified through the donor screening process.
be disinfected by a surgical skin preparation of PVP.
Slit-Lamp Evaluation
Enucleation, In Situ Excision and
The slit-lamp enables a more accurate observation of the cornea,
Corneoscleral Rim Sectioning revealing earlier stages of pathology that are visible grossly.
Section I: Evolution, Preoperative Considerations and Eye Banking

Enucleation or in situ excision can be performed in an operating Whole eyes can be examined by the slit-lamp within the container
theatre, a morgue, hospital room or funeral home. Prime used in retrieval, or excised corneas can be examined through
considerations are to minimize manipulation of tissues the bottom of the storage vial once the cornea and vial are
surrounding the eye in order to preserve donor appearance, to manipulated so that the cornea is endothelial side down. The
prevent touching or distortion of the cornea and thus minimize eye or cornea should be allowed to reach room temperature
any cell loss (epithelial and endothelial), and to reduce bacterial which makes the endothelium easier to visualize and more
contamination from both exogenous sources and from ocular normal in appearance.
flora. For in situ excision one must be especially aware of the The cornea should be methodically examined to ensure each
bacteriologic considerations, as no further decontamination of layer of the cornea is adequately assessed. The surrounding
the tissue is possible. limbal/scleral area should also be checked for evidence of
Corneoscleral rim excision after an enucleation is a similar surgical incisions (these may also be at the periphery of the clear
process to the in situ excision. Ideally the procedure is performed cornea) and for any sutures.
in a biological safety cabinet which provides a clean area for The epithelium is inspected for integrity and overall condition
the excision and at the same time protects the operator from specifically clarity, exposure, sloughing, defects, trauma, foreign
exposure to possible pathogens residing on the eye itself. The bodies and infiltrates. Haze is often localized and coincides with
dissection needs to be made through into and along the ante and postmortem exposure across the interpalpebral area.
suprachoroidal space. Perforation of the choroid would cause Swelling of the epithelium may cause some layers to detach
vitreous leakage, which may cause the collapse of the globe and (termed sloughing). Epithelial defects appear as clear depressed
anterior chamber, and compromise the cornea. In addition the areas within an otherwise hazy epithelium. The extent and
operator must be careful not to exert too much pressure on the position (central or peripheral) of any of these findings needs to
globe, as this will increase the potential for the scissors to cut be considered in any assessment of the suitability of the cornea
or catch on the choroid. During the procedure it is most important for transplantation.
that as little stress as possible is placed on the cornea as any The stroma is examined for overall clarity, amount of edema
stretching of the endothelial cell layer can critically damage it. and stromal folding. Major opacities are usually detected by the
preceding gross examination but using higher magnification and
Corneal Evaluation a thin slit can better identify the opacity as scarring (generally a
smooth gray appearance) or inflammatory infiltrates (generally
With the exception of tissue that would be potentially hazardous
whitish appearance with discrete borders). Stromal folding and
because of possible transmission of disease, there are no
haze are associated with corneal edema. The amount of corneal
absolutely defined criteria for the acceptance or rejection of a edema, and thus the severity and number of folds and the amount
cornea. The final decision regarding use rests with the surgeon
of haze will depend on time since donor death, temperature,
for each individual and unique case of donor to recipient
integrity of the epithelium, and the postmortem integrity and
transplantation and the transplant procedure to be undertaken. function of the endothelium. The thickest folds are a good
However, in reaching a decision on acceptance or rejection of
indicator of the overall severity of the edema. Striae, identifiable
tissue for clinical use the ophthalmologist must rely on the Eye
as fine gray/white lines, may also be in the stroma and are
Bank’s careful evaluation of the cornea. probably indicative of very localized disruptions of the stromal
Gross in situ Evaluation
Any detachment of Descemet’s membrane can be observed
Corneal evaluation begins with a gross examination of the as a separate membrane that seems to come from and be
corneas in situ. A simple penlight examination can reveal continuous with the endothelial side of the cornea. This finding
epithelial defects (drying, erosion, sloughing), corneal oedema alone is usually enough to consider the cornea unsuitable for
with associated haze and striations due to folding of Descemet’s any transplantation procedure requiring an intact endothelium.
membrane, abnormal corneal shape, blood or cloudiness in the A specular reflection of endothelial layer can be observed
anterior chamber, corneal scars or infiltrates, arcus senilis, and in a small area of the endothelial reflex. At high power
any signs of conjunctivitis and discharge. magnification an impression of cell density and the degree of
For in situ corneoscleral rim excisions a careful in situ cell uniformity in size and shape can be obtained. Guttae-like
examination is especially important. This is the only opportunity bodies (areas where no cells can be seen) may be observed in
the specular reflection. The exact nature of these areas is difficult decompensation.58 Corneal guttae have also been reported to
to determine. They may actually be guttae (bumps or reduce endothelial function.59,60 Inflammatory cells and bacteria
excrescences of Descemet’s membrane), they may be vacuolated can also be easily seen with endothelial microscopy and their
cells or they may be stress fractures (sometimes referred to as presence would lead to the exclusion of such corneas for
pseudo-guttae) due to trauma during the donation process. transplantation.
Regardless of their nature these conditions should be regarded
as a degenerative condition of the endothelium. The suitability Specular Microscopy

Chapter 4: Eye Banking—A Practical Guide

of the cornea for penetrating keratoplasty would depend on the Specular microscopy is mostly used by those Eye Banks using
relative number and location of these bodies. (Note: the term hypothermic storage of corneoscleral buttons. Plastic corneal
“pseudoguttae” is sometimes also used to refer to guttae that viewing chambers with optically clear lids (originally developed
appear at hypothermic storage temperatures but disappear at by Bourne61) are available from a number of manufacturers and
room temperature). allow for non-contact viewing of the specular image. Some Eye
Bank specular microscopes are also capable of producing
Endothelial Microscopy excellent endothelial images from corneas still contained within
The condition of the corneal endothelium is central to evaluating the storage media vial, thus further reducing handling of the
the suitability of corneal tissue for penetrating keratoplasty, as cornea. Today’s microscopes are also equipped with
it is primarily the layer responsible for the maintenance of corneal computerized morphometric analysis systems to analyze cell
turgor and transparency. Endothelial microscopy, whether it is density, average cell size and uniformity of cell shape.
through the technique of specular microscopy or transmitted A limitation with specular microscopy is that the area of
light/phase microscopy, allows for a reasonable determination the central corneal endothelium is much larger than can be
of endothelial cell density, cell pleomorphism and sampled by the specular microscope even with multiple
polymegathism and the identification of corneal guttae. These field examinations. Therefore the information gained from
changes reflect the current well being of the endothelium as well specular microscopy must be interpreted within the context of
as being indicative of its functional reserve.55 the slit-lamp evaluation.
Such objective information and has allowed the wide use of For the best observation of the corneal endothelium, the
older corneal tissue based on endothelial appearance rather than cornea must be at room temperature. Thus, the most convenient
arbitrarily excluding such tissue solely on the basis of donor age time to perform specular microscopy is after the placement of
(see section on Donor Age). In addition, endothelial microscopy the cornea in storage media, allowing sufficient time for the
has allowed for the use of corneas from donors that have had media to equilibrate with room temperature and for
anterior segment surgery. In both cases, if the corneas have deturgescence of the cornea. Corneas can also be observed after
passed the endothelial microscopy criteria and slit-lamp criteria, a period of 4ºC storage and subsequent warming to room
they should be considered for penetrating or endothelial temperature. The cycle of cooling, warming and re-cooling of a
keratoplasty (with the receiving ophthalmologist being fully donor cornea has been shown to have no adverse affects on the
informed). metabolic or morphometric status of the donor cornea.62
A low cell density may indicate that the cornea is unlikely However, it becomes more difficult to adequately visualize the
to be able to withstand the rigors of transplantation. Bourne and endothelium with specular microscopy after a period of storage.
O’Fallon56 elegantly showed that there was a loss of 23 percent Figure 4.1A shows the specular microscopic image of a
of the transplanted endothelial cells within the first week of relatively good endothelium from a 70-year-old donor. The cell
transplantation and others have demonstrated that this cell shape and size shows a small amount of variance, the cell density
loss may continue for up to at least 4 years.44 The critical at a calculated 2754 cell/mm2 is very good, and there are no
endothelial cell density below which any cornea undergoes guttae or evidence of inflammatory cells. This evidence,
decompensation is speculative although many clinicians estimate combined with a good slit-lamp appearance of the cornea,
it to be 300-500 cell/mm2. Based on the evidence of cell loss in suggests that this cornea would be suitable for use in a
the postoperative period and the estimated lower limit of a penetrating keratoplasty.
functional cell density, Eye Banks generally have a cut-off of
between 1500-2200 cells/ mm2 (depending on the Bank) below Light Microscopy
which they will no longer issue a cornea for penetrating or Eye Banks using normothermic (organ culture) storage methods
endothelial keratoplasty. In these instances the cornea may still use phase contrast microscopy and/or transmitted light
be suitable for anterior lamellar keratoplasty. microscopy often accompanied by intravital staining of the
In addition to a low cell density an abnormal endothelial endothelial layer (Figure 4.1B). This type of endothelial
appearance may indicate that the cornea is compromised or microscopy has the advantages of being able to assess the
functionally deficient. Corneas with considerable polymegathism endothelium after storage and close to the time of transplantation,
or pleomorphism have been reported to have a decreased and also enables visualization of a larger area of the central
functional reserve57 and an increased incidence of postoperative cornea compared to specular microscopy. Intravital staining,
donation and transplantation. This is the same aim as for solid
organ transplantation such as kidney transplantation. However,
while reliable kidney preservation time is still restricted to around
24 hours ischemic time, techniques developed over the past 30
years have enabled the extension of reliable corneal storage times
to approximately one month. Techniques designed to go beyond
this period of storage, such as cryopreservation, are still not
Section I: Evolution, Preoperative Considerations and Eye Banking

reliable enough for them to be routinely employed.64

Moist Chamber Storage

Filatov65 first described the use of moist chamber storage of
whole eyes. This is achieved by placing an enucleated eye in a
sealed chamber together with gauze, usually moistened by a
saline or antimicrobial solution, and then placed at 4ºC. Care
must be taken not to immerse the eye in solution as this will be
absorbed by the cornea and cause stromal edema. Although the
Figure 4.1A: Screen capture of image produced by a Konan moist chamber technique was used successfully and with
EKA-98 Eye Bank Keratoanalyzer system™ (specular confidence for over forty years (and is still employed in some
microscope and image analysis) countries), its main drawback is the limitation to around 24 hours
of storage. This is because the endothelium of a cornea stored
on the globe is subjected to the toxic build up of metabolic waste
and necrotic tissue in the stagnant aqueous humor.66 To overcome
this problem the idea evolved of removing the cornea and placing
it in a biologically defined environment.67

Hypothermic Corneal Storage

McCarey and Kaufman modified an existing tissue culture
medium, TC 199, by adding dextran as an osmotic agent to
compensate for the inactivity of the cornea’s normal water
removal mechanism at 4ºC.74 This extended reliable storage time
to 2-3 days and the media, M-K medium, quickly became the
storage system of choice for eye banks following publication of
several series of successful transplants.68,69 Over the years, the
M-K formulation has been improved by the addition of the more
stable HEPES buffer and the replacement of the penicillin-
streptomycin antibiotics to gentamicin which has a greater
Figure 4.1B: Light micrograph of endothelium of organ- spectrum against gram-negative bacteria.70 It remains a cheap,
cultured cornea. (X200 magnification) easy, simple and reliable form of corneal preservation.
In the mid-eighties, 2.5 percent chondroitin sulfate was added
to the basic M-K formulation. The resultant solution, K-Sol,
usually with trypan blue, also provides some information on successfully extended corneoscleral storage times to 7-10
number of endothelial cells still functioning. Sucrose or balanced days.71,72 However, one of the problems with media containing
salt solutions are often added which cause the intracellular space chondroitin sulfate is that the layers of the cornea can absorb
to swell, making the cell borders easier to discern for ease of some of its smaller molecular weight moieties, and the resultant
cell counting. The original technique is that described by osmotic flow of water causes the cornea to swell. An improved
Sperling.63 Such techniques can also be applied to corneas that solution, Dexsol, overcame this problem by the addition of
are hypothermically stored. dextran to the formula. Optisol, the latest commercially available
storage medium, further improves on Dexsol by maintaining
better endothelial cell morphology and thinness of the
Unlike tissues such as bone or heart valves that may be corneas.73,74
extensively processed and altered from their natural state, corneas While the original publications suggested that Optisol was
must be transplanted as a viable living tissue. Thus the aim of suitable for up to 14 days storage, in practice the maximum
all corneal storage techniques is simply to maintain this living storage time most Eye Banks feel happy within 7-10 days with
viable state while holding the cornea for the period between storage between 2 - 6ºC. The manufacturers have also published
that 48 hours room temperature storage (approximately 21ºC) Tissue swells during the culture period, becoming thickened
still provides adequate corneal preservation.81 Optisol is now and edematous (from 0.5 – 1 mm), but this is reversed during a
usually available as OptisolGS that contains both gentamicin and period of days in dextran-containing thinning medium prior to
streptomycin to give broad antimicrobial coverage75 (Figure distribution.87 Various studies have confirmed that there is a
4.2A). More recently other commercial hypothermic storage dramatically lower incidence of endothelial cell death compared
media have become available76,85 and there has been more to cold-stored corneas and that despite 10-15 percent endothelial
research on antimicrobial prophylaxis.77,78 loss during culture, the endothelium is able to eliminate dying

Chapter 4: Eye Banking—A Practical Guide

cells and repair itself.98 Cell loss is independent of donor age,
Normothermic (Organ Culture) Storage but slightly dependent on storage time and endothelial state
This alternative storage method, where corneas are incubated in before storage.94 The surface epithelial layers shed into the
nutrient medium at physiological temperature, retains active cell medium during increasing time in culture, which are quickly
metabolism and most closely resembles the corneal environment replaced by host cells postoperatively; however, fresher
in vivo. Corneas stored in this way can be reliably preserved for tissue may be indicated for patients with persistent epithelial
up to 30 days. Studies of organ-cultured corneas have defects.
demonstrated no significant difference in postsurgical endothelial Organ culture provides an in-built microbiological
cell density and graft survival when compared with surveillance system, since any culture containing microorganisms
hypothermically-stored corneas.79-81 not controlled by decontamination and antibiotics will become
Based originally on promising in vitro studies,82 the method contaminated, and the cornea not used for transplant. Such
was fully developed and extensively tested for clinical use in contamination is normally visually obvious by turbidity and
Minnesota, USA by Doughman et al, in 1974 83,84 and pH change, however, corneal cultures are quarantined until a
subsequently refined by groups in Denmark 64,85 and the sample of the medium taken at 3-7 days of storage is tested and
Netherlands,86,87 who overcame problems relating to reduction reported to show no growth of bacteria or fungi. After the
of tissue swelling, endothelial evaluation and effective antibiotic incubation period, corneas cleared for serology and microbiology
control of contamination. Organ culture storage has not been are evaluated by direct light microscopy of the endothelium
adopted in the USA, but has become the preferred storage before being transferred into ‘thinning’ medium containing 5
method in the UK,88,89 Europe90-92 and New Zealand.93 These percent dextran prior to transplantation. Prolonged presence of
reviews of organ culture provide comprehensive information on dextran in culture is thought to be toxic to the cornea, therefore
history, technique and clinical outcome. the maximum recommended time in thinning medium is 2-4
In the most common method, excised corneoscleral disks days.99,100
from decontaminated eyes are suspended in glass bottles Since endothelial evaluation is performed at the end of the
containing 100 ml of MEM medium with Earle’s salts storage period near to transplantation, the quality and likely
supplemented with 2-5 percent fetal bovine serum, L-glutamine efficacy of the tissue can be determined with greater assurance.
and the antimicrobial agents penicillin, streptomycin and This allows for reliable use of corneas from older donors and
amphotericin (Figure 4.2B). Culture bottles are closed and extended death-to-preservation time, with no significant
incubated in a dry (non-CO2) environment at a temperature impact on graft survival when compared with younger or fresher
between 31-37oC.94 Many studies have shown that corneal tissue.94
ultrastructure, endothelial cell morphology, density and viability Reported bacterial isolates101-104 are normally common
are well-maintained in organ-cultured corneas up to 48 days of ocular flora such as coagulase negative Staphylococci, Staph.
storage,47,95,96 although in practice most are distributed between aureus, Streptococcus, Pseudomonas and Corynebacterium,
10-28 days (average 16 days).97 some strains of which can be resistant to antibiotics. Fungal

Figure 4.2A: Excised cornea in hypothermic storage media Figure 4.2B: Excised cornea suspended by suture in
(Optisol GS) normothermic (organ culture) media
growth can include Candida species, Cryptococcus, Fusarium hypothermic storage and 0.7-5 percent for organ culture storage.
and Penicillium. Contamination related directly to systemic A recent single-centre study utilising both storage methods found
infection in the donor is rare, and so with this method the donor that the frequency of positive rim cultures was 9.8 percent for
pool can be expanded to include those with bacterial septicemia, hypothermic storage and 1.3 percent for organ culture storage,
a common reason for donor exclusion when hypothermic storage however, no cases of endophthalmitis resulted from either
is performed. technique.110
Compared to hypothermic storage, the organ culture
Section I: Evolution, Preoperative Considerations and Eye Banking

technique is more complex, requiring additional equipment, Current and Future Trends
testing and greater technical expertise. Although the set-up and
testing costs make it a more expensive method, efficiency Today, Eye Banking benefits from having well-established
benefits can be gained by increased certainty of cornea provision medical standards which are continually evaluated, reviewed and
and elimination of potentially unsafe tissue. It is a method best internationally promulgated, 1,2,7 improved corneal storage
suited to an established eye bank with skilled technical staff, and techniques, and comprehensive corneal evaluation through the
where donor rates are variable, or distribution required over wide combined use of slit-lamp and specular microscopy. These
geographical area. In addition to improved microbiological developments, combined with ongoing Eye Bank procurement
screening, the increased storage time allows the ability to provide programs have led to scheduled elective corneal transplant
ABO- or HLA-matched corneas for patients with high risk of surgery with safe, efficacious tissue.
rejection, and for optimizing allocation of particular corneas to The emergence of new lamellar transplant procedures such
specific patients. It more easily enables the operation of fully- as Deep Anterior Lamellar Keratoplasty (DALK) and Decemet’s
scheduled transplant booking systems, rather than those Stripping Automated Endothelial Keratoplasty (DSAEK)
organised at short notice, and enables transport over long presents some new opportunities for Eye Banking. Eye Banks
distances without the need for refrigerated conditions. need to consider and revise their acceptance criteria for eye
Regulatory concerns over the increased potential for donation and the analysis of possible anterior or posterior corneal
transmission of prion disease from the use of bovine serum have pathologies in regard to specific transplant procedures. The
to date proven unfounded, and all European Eye Banks now use reality of splitting a cornea and using the resultant lamellar tissues
serum derived from BSE-free cattle herds from Australia or New on multiple recipients111 creates new issues for the traceability
Zealand.86 Many Eye Banks compound and sterilize their own of tissue from donor to recipient and the subsequent challenges
organ culture media ‘in-house’, and although promising trials involved in reporting any adverse events that may be due to
of commercial and serum-free varieties have been reported in donor tissue. In addition, femtolaser technology is already
recent years, the long-term clinical efficacy of these is yet to be making available pre-cut corneal tissue for transplant purposes
determined.105,106 and the pre-cutting of DALK or DSAEK tissue by Eye Banks is
likely to be a natural extension of this technology.
Postoperative Infection Looking to the future, it may be possible for Eye Banks to
There is a low incidence of postoperative infection reported with enhance corneal epithelial and endothelial viability through the
any storage method, and relatively few of these cases can be manipulation of growth factors. Similar manipulation could
attributed directly to infection in the donor tissue.37 Application conceivably provide an opportunity to decontaminate the tissue
of antibiotic prophylaxis and the recipient’s ocular immune of infectious agents including bacteria, viruses and prions. Such
defense is generally effective. It can be assumed that, upon return tissue engineering techniques may also be able to modify the
to physiological temperature, the residual antibiotic effect is immune rejection and wound healing responses of donor corneas,
normally sufficient to control any organisms surviving or indeed provide the ability for in vitro “growth” of a cornea.
hypothermic storage. Confocal microscopy could provide an additional means of
Rim swabs of decontaminated eyes before storage do not evaluating the cornea prior to transplantation.
predict subsequent growth in corneal storage medium, so have Whatever the future holds, Eye Banks must continue to
been largely discontinued. Likewise, many reports have provide a service that ensures the safety and efficacy of donor
demonstrated the poor predictive value of testing the remaining tissue and ensures fair and equitable distribution of transplantable
donor rim after trephination in identifying cases of tissue. This must be achieved while at all times maintaining the
endophthalmitis due to the donor tissue.107-109 Reported figures dignity of the donor, the dignity of the donor’s family and the
of positive donor rims range widely from 12-39 percent for dignity of the prospective recipient.


SUGGESTED PREPARATION OF THE DONOR color and expiry date. Ensure that the lids can be easily
removed by simply lifting.
Prior to Preparation • Aseptically drop the disposable drape onto the instruments.
• Review the donor’s medical notes. If excising also drop two no. 15 scalpel blades onto the field.
• Establish consent and extent of donation (corneas or globes). • Aseptically put on sterile gloves. The donor is now prepared
• Complete all legal requirements. for enucleation or excision.

Chapter 4: Eye Banking—A Practical Guide

• Positively identify the donor, matching the consent with the

Clean Area Preparation

• Ensure all materials are within their “use by” date and all Follow the suggested preparation in Appendix.
sterile packs are intact.
• Unwrap a surgical gown and use the gown wrapping as a Clean Area and Draping
clean base for your work area.
• Put on the gown, surgical mask, cap and examination gloves. • Prepare two sterile containers (large enough to hold a globe)
by placing a 10 cm × 10 cm gauze swab on to the lids, and
In Situ Examination then use the Mosquito forceps to place two 5 cm × 5 cm gauze
swabs as cushioning in each container.
• Examine eyes for signs of infection, corneal damage or • Place a sterile drape onto the donor and isolate on the right
previous surgery—document if necessary eye.
• Elevate the donor’s head if deemed necessary (red, injected
(blood-shot), eyes are often an indication that the donor will
bleed during an enucleation—this can be reduced by eleva-
tion—consider having a method of cautery on standby). • Insert the Eye Speculum.
• Perform a peritomy by using a pair of Toothed forceps and
Rinse and Swab Stevens scissors to incise the conjunctiva in a circle, as close
to the limbus as possible, and then push back Tenon’s capsule
• Gently open the eyelids (right eye by habit) and irrigate
by blunt dissecting with the scissors in each of the four
vigorously with a balanced sterile saline solution (such as
quadrants (Figs 4.3A and B).
Dulbecco’s phosphate buffered saline) removing all debris,
• Using the Muscle hook, isolate the lateral rectus muscle and
mucus and foreign matter from the cornea and conjunctival
clamp with a pair of Mosquito forceps. Cut the muscle distal
sack. Repeat on the left eye.
to the clamp with Strabismus scissors (Fig.4.3D). This
Irrigation at this time may prevent damage to the cornea during
provides a “handle” to manipulate the whole eye.
the skin preparation in the event that any foreign debris is under
• In turn, locate the other three rectus muscles and sever them
the eyelids. Irrigation will also reduce microbial contamination.
with Strabismus scissors close to the insertion point. Using
• Moisten the eye with a broad-spectrum antibiotic/antifungal
the mosquito forceps “handle”, rotate the eye and locate the
solution ophthalmic solution, close the lid and place the drops
superior and inferior oblique muscles, and sever these if they
onto the eyelashes. Repeat on left eye. A solution that does
have not already been cut with the rectus muscles (Fig. 4.3C).
not require refrigeration is a convenient advantage.
• Taking a pair of Enucleation scissors, insert them behind the
Antibiotic at this time will allow maximum time for the
eye with closed blades from the medial side of the globe,
antibiotic to be effective.
while applying a gentle, lifting pressure with the handle.
• With a 10 percent povidine-iodine swab, disinfect the lids
Open the blades and locate the optic nerve with a side-to-
and surrounding area using broad single sweeps starting
side action. Cut it whilst applying an upward pressure to
centrally and working out, covering the eyebrow, bridge of
the globe (Fig. 4.3E).
the nose and areas temporal to the eyelids. Pay close attention
• Once the optic nerve is severed, gently raise the globe away
to the eyelashes. Do not repeat a stroke over the same area.
from the socket, clearing away any residual orbital
Repeat on the left eye.
attachments with the enucleation scissors. Be careful not to
• Repeat the povidine-iodine skin preparation on each eye.
cut any eyelashes at this point (Fig. 4.3F).
The eyelashes may harbor contaminants. To allow adequate
• Place the free globe onto the gauze in one of the pots without
exposure time and coverage for the povidine-iodine preparation to
the cornea touching the sides. Do not irrigate it at this point.
be effective it should be recognized that a “one wipe” technique is
• Remove the speculum and shift the sterile drape to isolate
the left eye. Repeat the above procedure.
• Remove examination gloves and place in appropriate
biohazard container.
Preparation of the Surgical Pack • Once both eyes are retrieved and in the sterile containers,
• Open the pack of sterile instruments on your work area with the sterile part of the procedure is complete, and they can
care taken to avoid reaching over the area or touching now be irrigated with enough balanced saline solution (e.g.
anything but the wrapper edges. Dulbecco’s phosphate buffered saline) to just moisten the globe
• If enucleating, place two sterile containers with loosened lids and just dampen the gauze. Place 15-20 drops of broad-
on the edges of the work area. If excising, use two containers spectrum ophthalmic antibiotic drops over each eye in their
of preservation media instead, after examining for clarity, containers to further minimize any bacterial contamination.
Section I: Evolution, Preoperative Considerations and Eye Banking

Figures 4.3A and B: Peritomy is performed close to the limbus and Tenon’s capsule is receded in each of the four quadrants

Figure 4.3C: The three recti muscles and the superior and Figure 4.3D: Lateral rectus is isolated and cut which provides
inferior oblique muscles are severed from the globe the handle to manipulate the whole eye

Figure 4.3E: Optic nerve is cut with side to side action with Figure 4.3F: The globe is raised away from the socket and
enucleation scissors by applying an upward pressure to the globe residual orbital attachments are cleared with enucleation scissors
• It is important to now restore the donor’s appearance, using • Using the fine Toothed forceps to steady the eye, take a
tight balls of cotton wool to fill the eye sockets, and a plastic no. 15 Scalpel blade and make an incision through the sclera
eye cap over this to ensure that when the upper lid is drawn 2 mm from the limbus, being careful not to penetrate the
over the lower one, the normal contour of the eye is underlying choroid (Fig. 4.4C).
maintained. Plastic eye conformers are available from funeral Perforation of the choroid would cause vitreous leakage,
director suppliers. which may cause the collapse of the globe and anterior
• Using alcohol swabs, the final part of the procedure is to wipe chamber. This can both compromise the cornea and make
off the povidone-iodine solution, ensuring that the donor is cosmetic restoration more difficult.
in a state suitable for viewing should the family have • Using Castroviejo’s corneoscleral scissors (left and right

Chapter 4: Eye Banking—A Practical Guide

requested it. In addition, the application of a moisturizer over medium blades), complete the incision around the eye,
the eyelids will improve the donor’s appearance and assist keeping the blades in the suprachoroidal space, and
keeping the eyelids comfortably shut. maintaining a 2-3 mm scleral rim (Fig 4.4D). The toothed
• A blood sample for serology can now be obtained. Suitable forceps should be used to steady and rotate the eye, and by
areas are subclavian vein, femoral vein or a cardiac puncture. using both the Left and Right scissors, difficult angles such as
• All disposable material is placed in a biohazard container that presented by the bridge of the nose can be avoided.
Trauma to the cornea during scissoring due to bending, loss of
and all sharps in a sharps container.
the anterior chamber or collapse of the globe through vitreous loss
can severely compromise its suitability for surgical use. Scleral rim
SUGGESTED CORNEAL EXCISION PROCEDURE width is important because some corneal trephines require a
minimum 2 mm rim while others require a rim not wider than 4
Preparation mm. Also cutting a rim less than 2 mm greatly increases the chance
of entering the anterior chamber during scissoring.
Follow the suggested preparation in Appendix. • Now the only attachments should be those at the scleral spur.
These adhesions are detached by using the toothed forceps
Clean Area and Draping to grasp the scleral rim, and the flat forceps to gently pull
• Prepare two preservation media containers by loosening the away the ciliary body and choroid (Figs 4.4E and F). It is
lids and placing 10 cm × 10 cm gauze swabs upon them. most important that as little stress as possible is placed on
• Place a sterile drape onto the donor and isolate on the right the cornea at this step, as any stretching of the endothelial
eye. cell layer can critically damage it. Aqueous fluid should
escape at this point.
Surgery • Lift the cap off the Corneal Preservation Media vial and place
the excised corneoscleral button into the media, endothelial
• Insert an Eye speculum.
side up.
• Perform a peritomy by using fine Toothed forceps and
• Remove the speculum, shift the eye drape to the left eye and
Stevens tenotomy scissors to incise the conjunctiva in a circle
repeat the procedure.
as close to the limbus as possible, and then push back Tenon’s
capsule by blunt dissecting with the scissors in each of the
four quadrants (Figs 4.4A and B). The exposed sclera is
carefully scraped from the limbus outward with one of the • Upon completion, insert an eyecap into each eye, carefully
scalpel blades to remove all remaining conjunctival tissue. closing the lids.
The conjunctival tissue may contain microbial contami- • The remainder of the procedure is the same as for Enucleation
nants, which should not accompany the cornea into storage media. (above).
• Isolate the instruments and scalpel used to scrape the Removal of a corneoscleral button from an enucleated
conjunctiva to use only on the other eye so as not to re- eye follows the same surgical procedure as above although
introduce microbes into the globe. the procedure is usually performed within a sterile hood.

Figures 4.4A and B: Peritomy is performed close to the limbus and Tenon’s capsule is receded in each of the four quadrants
Section I: Evolution, Preoperative Considerations and Eye Banking

Figure 4.4C: An incision is made through the sclera 2 mm Figure 4.4D: The incision is completed around the eye with a
from the limbus with a no.15 scalpel blade Castroviejo’s corneoscleral scissors maintaining a 2-3 mm scleral

Figures 4.4E and F: The adhesion from the scleral spur is detached by using toothed forceps
to grasp the scleral rim and the flat forceps to gently pull away ciliary body and choroid

REFERENCES 8. Sanchez P, Heck E, Rivera C, et al. Risk factors for infectious

disease in corneal transplant screening. Eye Contact Lens
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Chapter 4: Eye Banking—A Practical Guide

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59. Bigar F, Schimmelpfennig B, Hurlzeler R. Cornea guttata in donor 82. Summerlin WT, Miller GE, Harris JE, Good RA. The organ-
material. Arch Ophthalmol 1978;96:653-55. cultured cornea: an in vitro study. Invest Ophthalmol 1973;12:
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87. 85. Sperling S. Human corneal endothelium in organ culture. The
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64. Brunette I, Le Francois L, Tremblay M-C, Guertin MC. Corneal 86. Van der Want JJL, Pels E, Schuchard Y. Electron microscopy of
transplant tolerance of cryopreservation. Cornea 2001;20: 590- cultured human corneas: osmotic hydration and the use of a
96. dextran fraction (Dextran T500) in organ culture. Arch
65. Filatov VP. Transplantation of cornea from preserved cadaver Ophthalmol 1983;101: 1920-26.
eyes. Lancet 1937;1:1395. 87. Pels E, Schuchard Y. The effects of high molecular weight dextran
66. Bito LZ, Salvador EV. Intraocular fluid dynamics. II. Postmortem on the preservation of human corneas. Cornea 1985;3: 219-27.
changes in solute concentration. Exp Eye Res 1970;10: 273-87. 88. Armitage WJ, Moss SJ. Storage of corneas for transplantation.
67. McCarey BE, Kaufman HE. Improved corneal storage. Invest Chapter 20 in Current Ophthalmic Surgery DL Easty (Ed). Bailler
Ophthalmol 1974;13: 165-73. and Tindall, London 1990.
68. Bigar F, Kaufman HE, McCarey BE, Binder PS. Improved corneal 89. Tullo AB, Armitage WJ. Ocular tissue for transplantation – fresh,
storage for penetrating keratoplasties in man. Am J Ophthalmol chilled, warmed, frozen or pickled? (Editorial). Eye 2004;18: 865-
1975;79: 115-20. 66.
69. Aquavella JV, Van Horn DL, Haggerty CJ. Corneal preservation 90. Pels E, Schuchard Y. Organ culture preservation of human
using M-K Medium. Am J Ophthalmol 1975;80:791-99. corneas. Doc Ophthalmol 1983;56: 147-53.
70. Waltman SR, Palmberg PF. Human penetrating keratoplasty using 91. Pels E, Schuchard Y. Organ culture in the Netherlands:
modified M-K Medium. Ophthalmic Surg 1978;9: 48-50. preservation and endothelial evaluation. In Brightbill FS (Editor):
71. Kaufman HE, Varnell ED, Kaufman S, Beuerman RW, Barron Corneal Surgery, Theory, Technique and Tissue (2nd Edn).
BA. K-Sol corneal preservation. Am J Ophthalmol 1985;100: St Louis, Mosby 1993.
299-304. 92. Ehlers N. Corneal banking and grafting. The background to the
72. Keates RH, Rabin B. Extending corneal storage with 2.5 percent Danish Eye Bank System, where corneas await their patients. Acta
chondroitin sulfate (K-Sol). Ophthalmic Surg 1988;19: 817-20. Ophthalmol Scand. 2002;80: 572-78.
73. Lindstrom RL, Kaufman HE, Skelnik DL, et al. Optisol corneal 93. Patel HY, Brookes NH, Moffatt LS, Sherwin T, Ormonde S,
storage medium. Am J Ophthalmol 1992;114: 345-56. Clover GM, McGhee CNJ. The New Zealand National Eye Bank
74. Kaufman HE, Beuerman RW, Steinemann TL, Thompson HW, Study 1991-2003: A Review of the Source and Management of
Varnell ED. Optisol corneal storage medium. Arch Ophthalmol Corneal Tissue. Cornea 2005;24:576-82.
1991;109: 864-68. 94. Pels E, Houdijn Beekhuis W, Volker-Dieben HJ. Long-term tissue
75. Smith TM, Popplewell J, Nakamura T, Trousdale MD. Efficacy storage for keratoplasty. Ch 106 In Brightbill FS (Editor): Corneal
and safety of gentamicin and streptomycin in Optisol-GS, a Surgery, Theory, Technique and Tissue (2nd Edn). St Louis,
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76. Bourne WM, Nelson LR, Maguire LJ, et al. Comparison of Chen 95. Crewe JM, Armitage WJ. Integrity of epithelium and endothelium
Media and Optisol-GS for human corneal preservation at 4 in organ-cultured human corneas. Invest Ophthalmol Vis Sci
degrees C – Results of transplantation. Cornea 2001;20:683-86. 2001;42: 1757-61.
77. Ritterband DC, Shah MK, Meskin SW, et al. Efficacy and safety 96. Borderie VM Kantelip B, Delbosc B. Morphology, histology and
of moxofloxacin as an additive in Optisol-GS preservation ultrastructure of human 31oC organ-cultured corneas. Cornea
medium for corneal donor tissue. Cornea 2006;25: 1084-89. 1995;14: 300-310.
78. Jeng BH. Preserving the cornea: corneal storage media. Curr Opin 97. European Eye Bank Association Directory. 14th Edition, January
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79. Doughman DJ. Prolonged donor cornea preservation in organ 98. Doughman DJ, Van Horn DL, Rodman W, et al. Human corneal
culture: long-term clinical evaluation. Trans Am Ophthalmol Soc endothelial layer repair during organ culture. Arch Ophthalmol
1980;78: 567-628. 1976;94: 1791-96.
80. Frueh BE, Bohnke M. Prospective, randomized clinical evaluation 99. Van der Want HJL, Pels E, Schuchard Y, Oleson B, Sperling S.
of Optisol vs Organ Culture corneal storage media. Arch Electron microscopy of cultured human corneas. Osmotic
Ophthalmol 2000;118: 757-60. dehydration and the use of a dextran fraction (dextran T500) in
81. Redmond RM, Armitage WJ, Whittle J, Moss SJ, Easty DL. organ culture. Arch Ophthalmol 1983;101: 1920-26.
Long-term survival of endothelium following transplantation 100. Borderie V, Baudrimont M, Lopez M, Carvajual S, Laroche L.
of corneas stored by organ culture. Br J Ophthalmol 1992;76: Evaluation of the deswelling period in dextran-containing medium
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101. Borderie VM, Laroche L. Microbiologic study of organ-cultured 107. Wiffen SJ, Weston BC, Maguire LJ, Bourne WM. The value of
donor corneas. Transplantation 1998;66: 120-23. routine donor corneal rim cultures in penetrating keratoplasty.
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human organ-cultured corneas. Cornea 2001;20:260-63. 108. Everts RJ, Fowler WC, Chang DH, Reller LB. Corneoscleral rim
103. Hagenah M, Bohnke M, Engelmann K, Winter R. Incidence of cultures: lack of utility and implications for clinical decision-
bacterial and fungal contamination of donor corneas preserved making and infection prevention in the care of patients undergoing
by organ culture. Cornea 1995;14: 423-26. corneal transplantation. Cornea 2001;20: 586-89.
109. Rehany U, Balut G, Lefler E, Rumelt S. The prevalence and risk
104. Zanetti E, Bruni A, Mucignat G, Camposampiero D. Bacterial

Chapter 4: Eye Banking—A Practical Guide

factors for donor corneal button contamination and its association
contamination of human organ-cultured corneas. Cornea 2005;24:
with ocular infection after transplantation. Cornea 2004;23: 649-
105. Bednarz J, Doubilei V, Wollnick PCM, Engelmann K. Effect of
110. Fontana L, Errani PG, Zerbinati A, Musacchi Y, Di Pede B,
three different media on serum-free culture of donor corneas and Tassinari G. Frequency of positive donor rim cultures after
isolated human corneal endothelial cells. Br J Ophthalmol penetrating keratoplasty using hypothermic and organ-cultured
2001;85:1416-20. donor corneas. Cornea 2007;26: 552-56.
106. Stoiber J, Ruckhofer J, Lametschwandtner A, Muss W, Hitzl W, 111. Vajpayee RB, Sharma N, Jhanji V, Titiyal JS, Tandon R. One
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Section I: Evolution, Preoperative Considerations and Eye Banking

Medicolegal Aspects of Eye Banking

M Vanathi, Gurnarinder Singh, Rakesh Ahuja

Laws have been enacted to allow Eye banks to effectively • The Department of Health in consultation with organ
perform the function of collection and distribution of eyes/ procurement organizations shall:
corneas from donors to recipients. There are a number of legal — Establish guidelines regarding efficient procedures
issues associated with Eye Donation and Eye Banking. In this facilitating the delivery of anatomical gift donations.
section, we reproduce key legal acts and documents that affect — Develop guidelines to assist hospitals in selection and
eye donation, eye banking and their operations. designation of tissue procurement providers (eye bank).
In countries like the USA, where organ transplantation and The quality of medical treatment is not affected if one is a
eye banking has been long established, legislation demands a known donor. Strict laws are in existence which protect the
special role in organ collection for hospitals as part of the potential donor. Legal guidelines must be followed before death
“Required Request Law.” In addition, the “Uniform Anatomical can be certified. The physician certifying a patient’s death is not
Gift Act” and “presumed consent” are in vogue which cover involved with the eye procurement or with the transplant. Also,
human organ transplantation. it does not prohibit reimbursement for reasonable costs
Eye banks in India were formerly regulated by the Bombay associated with the removal, storage or transportation of a human
Corneal Grafting Act, 1957 and thereafter, the Eyes Act 1982 body or part thereof pursuant to an anatomical gift executed
till 1994. At present, eye banks and transplantation of other pursuant to this Act.
human organs like heart, kidney, etc. are governed by the Indian The uniform anatomical gift act was made because the
Human Organ Transplantation Act, 1994 and in the process of following key problems that hinder organ donation were
enactment of this Act, the “Eyes Act of 1982” got repealed and identified:
the provisions of the Eyes Act were not even retained, thus • Failure of persons to sign written directives.
demoting the eye banks in India to collection centers attached • Failure of police and emergency personnel to locate written
to keratoplasty units. directives at accident sites.
• Uncertainty on the part of the public about circumstances
INTERNATIONAL LAWS ON EYE BANKING and timing of organ recovery.
• Failure on the part of medical personnel to recover organs
EYE BANKING LAWS IN USA on the basis of written directives.
• Failure to systematically approach family members
Uniform Anatomical Gift Act
concerning donation.
The Uniform Anatomical Gift Act was promulgated in 1968 by • Inefficiency on the part of some organ procurement agencies
the Federal Government of the United States of America. It in obtaining referrals of donors.
covers anatomical gifts including corneas. The Uniform Gift Act, • High wastage rates on the part of some organ procurement
USA says: agencies in failing to place donated organs.
• Each acute care general hospital, with the concurrence of • Failure to communicate the pronouncement of death to next
the hospital medical staff, shall develop a method for of kin.
identifying potential organ donors (within hospital wards). • Failure to obtain adequate informed consent from family
• The acute care general hospitals shall initiate a request (to members.
relatives of the deceased) and follow the designated
procedure of the option to donate organs, tissues or eyes. Persons Who may Execute an Anatomical Gift
The person initiating the request shall be an organ
procurement organization representative or a designated • Any individual of sound mind who has attained the age of
requestor. 18 may give all or any part of his or her body for any purpose.
Such a gift may be executed in any of the ways set out in “reasonably available” which is relevant to who can make
Section 5, and shall take effect upon the individual’s death an anatomical gift of a decedent’s body or parts.
without the need to obtain the consent of any survivor. An 5. Permits an anatomical gift by any member of a class where,
anatomical gift made by an agent of an individual, as there is more than one person in the class so long as no
authorized by the individual under the Powers of Attorney objections by other class members are known and, if an
for Health Care Law, as now or hereafter amended, is deemed objection is known, permits a majority of the members of
to be a gift by that individual and takes effect without the the class who are reasonably available to make the gift

Chapter 5: Medicolegal Aspects of Eye Banking

need to obtain the consent of any other person. without having to take account of a known objection by any
• If no gift has been executed under subsection (a), any of the class member who is not reasonably available.
following persons, may give all or any part of the decedent’s 6. Creates numerous default rules for the interpretation of a
body after or immediately before death: document of gift that lacks specificity regarding either the
– the decedent’s agent under a power of attorney for health persons to receive the gift or the purposes of the gift or both.
care which provides specific direction regarding organ 7. Encourages and establishes standards for donor registries.
donation, 8. Enables procurement organizations to gain access to
– the decedent’s spouse, adult sons or daughters, either of documents of gifts in donor registries, medical records, and
the decedent’s parents, any of the decedent’s adult the records of a state motor vehicle department.
brothers or sisters, any adult grandchild of the decedent, 9. Resolves the tension between a healthcare directive
the guardian of the decedent’s estate, the decedent’s requesting the withholding or withdrawal of life support
surrogate decision maker under the Health Care systems and anatomical gifts by permitting measures
Surrogate Act, any person authorized or under obligation necessary to ensure the medical suitability of organs for
to dispose of the body. intended transplantation or therapy to be administered.
If the donor has actual notice of opposition to the gift by the 10. Clarifies and expands the rules relating to cooperation and
decedent or any person in the highest priority class in which an coordination between procurement organizations and
available person can be found, then no gift of all or any part of coroners or medical examiners.
the decedent’s body shall be accepted. 11. Recognizes anatomical gifts made under the laws of other
Revised Uniform Anatomical Gift Act, 2006 12. Updates the [act] to allow for electronic records and
This revision retains the basic policy of the 1968 and 1987 signatures.
anatomical gift acts by retaining and strengthening the “opt-in”
system that honors the free choice of an individual to donate Presumed Consent Law
the individual’s organ (a process known in the organ transplant
Presumed Consent Law allows for the harvesting of human
community as “first person consent” or “donor designation”).
organs for transplantation. This law allows, upon brain death, a
This revision also preserves the right of other persons to make person’s organs to be made available automatically to be
an anatomical gift of a decedent’s organs if the decedent had
harvested for donation, unless he or she has declared an opposite
not made a gift during life. And, it strengthens the right of an
wish in writing or otherwise. Organs and tissue may be removed
individual not to donate the individual’s organs by signing a for transplantation or scientific purposes from cadavers of
refusal that also bars others from making a gift of the individual’s
persons who did not, while living, indicate their refusal of
organs after the individual’s death. This revision:
1. Honors the choice of an individual to be or not to be a donor Organ removal may be performed only after death has been
and strengthens the language barring others from overriding
determined by two licensed physicians. The physicians in
a donor’s decision to make an anatomical gift.
question must not be associated in any way with each other, with
2. Facilitates donations by expanding the list of those who may the transplant recipient, or with the transplant procedure. In the
make an anatomical gift for another individual during that
case of the death of a minor or mentally incompetent person,
individual’s lifetime to include health care agents and, under
organ donation must be approved by the patient’s family or legal
certain circumstances, parents or guardians. representative. The removal and transplantation of organs and
3. Empowers a minor eligible under other law to apply for a
tissues may be carried out only by a physician in a hospital.
driver’s license to be a donor.
Organs, parts of organs, or any bodily tissue, may not be used
4. Facilitates donations from a deceased individual who made for financial gain.
no lifetime choice by adding to the list of persons who can
make a gift of the deceased individual’s body or parts the EYE BANKING LAWS IN AUSTRALIA
following persons: the person who was acting as the
decedent’s agent under a power of attorney for health care In Victoria, Australia the relevant Act relating to the
at the time of the decedent’s death, the decedent’s adult donation of organs and tissues is the Human Tissue Act, 1982,
grandchildren, and an adult who exhibited special care and Human Tissue (Amendment) Act, 1987 and Coroners and
concern for the decedent and defines the meaning of Human Tissue Acts (Amendment) Act 2006.
The most immediately relevant aspects of this Act (and • That the death has been documented by the medical officer.
amendments) in regards to eye/corneal donation can be • That the donor had not objected to donation prior to death.
summarized as follows: • That the senior available next-of-kin has given consent.
• When the next-of-kin cannot be located following all
Consent of Next-of-Kin reasonable attempts to contact them have been made, the
Consent can be obtained from the donor’s spouse, adult son or designated officer may also authorize the removal of tissue.
daughter, either parent, adult brother or sister, or legal guardian— • That consent from the coroner has been obtained in cases
Section I: Evolution, Preoperative Considerations and Eye Banking

in that order of priority. where a referral is necessary.

Verbal consent by the senior available next-of-kin is sufficient
for donation to proceed. There is no requirement for written Retrieval of Eyes/Corneas
consent as long as it is appropriately documented in the It is no longer a requirement that the removal of eyes/corneas
deceased’s medical notes. be carried out by a medical practitioner. The Act now states:
Any person can take consent as long as they appropriately “medical practitioner or prescribed person or class of persons
document their status (the person taking consent) and from whom to remove skin or ocular tissue or both.”
consent was obtained and the time it was obtained.
There is no legal requirement to seek the consent of the next- EYE BANKING LAWS IN UK
of-kin if the wishes of the deceased are known. However, it is
the usual practice to approach the next-of-kin to determine if The retrieval and use of tissues for transplantation in the UK
they are aware of the deceased’s intention to be a donor. This was governed by Human Tissues Act, 1961. Now it has been
may have been indicated by family discussion, sticker on a replaced with Human Tissues Act, 2004. Consent is required
drivers licence, a signed donor card or registration on the before the removal of tissues can proceed for the purposes of
Victorian Organ Donor Registry. In respect to the family unit, it transplantation, research or medical education. Either the donor
is advised to seek consent from the senior available next-of-kin, must have made his/her wishes clear prior to death or the donor’s
regardless of whether the wishes of the deceased are known or relatives must confirm to the best of their knowledge that the
not. It is very unusual for the next-of-kin to go against the known donor had not during his/her life objected to donation (In
wishes of a deceased. Conversely, donation cannot proceed if practice, a donor’s relatives are always consulted). The Human
the deceased had objected to donation prior to death. Tissue Act, 2004 and the Human Tissue (Scotland) Act, 2006
Consent should be free and comprehending. Consent for the (HT Acts) require specific consent/authorization for the donation
eyes is preferable, but it is possible for only corneas to be and storage of tissue for transplantation and other specified
donated. It should be documented if the consent was for eyes or purposes, including research, education or training, quality
only corneas. assurance and clinical audit. If a person has expressed a wish to
be an eye donor, for example through the National Organ Donor
Certification of Death Register or in a will, that consent is paramount and cannot be
overridden by relatives. In the absence of prior consent given
For the purposes of donation after circulatory arrest, it is no
by a potential donor, consent may be given by a nominated
longer necessary that the medical practitioner be of at least five
representative of the donor or by a person in a qualifying
years standing to certify death. Any medical practitioner can now
relationship/nearest relative. There are some differences between
certify circulatory arrest death (but not brain death).
the two HT Acts and it is important that consent/authorization
A formal death certificate does not have to be completed in
is obtained according to the relevant legislation.
order for eye/corneal donation to proceed. However, death
While the primary purpose of eye donation will almost
should be adequately documented in the deceased’s notes by the
always be transplantation, there is also a need for ocular tissue
medical practitioner. If time and circumstances allow it is
both for research into human eye disease and for teaching
preferable for a Death Certificate to be completed.
purposes. Relatives should therefore be asked to confirm lack
of objection to these uses as well as to transplantation.
Coroner’s Consent
Relatives should be informed that not every cornea will be
In cases where a coronal inquiry is necessary, the removal of suitable for transplantation, but that suitability cannot be
tissue cannot proceed unless the coroner gives consent. The eye determined before the eyes have been collected. Corneas and
bank will obtain this consent but next-of-kin consent is first other parts of the eye that are unsuitable for transplantation may
required. nevertheless be suitable for research or education/training. If the
tissue is not going to be used, relatives should be informed that
Designated Officer Authorization the tissue will be disposed of in a lawful manner according to
This person could be a medical practitioner (e.g. admitting the HT Acts.
officer, medical administration), hospital administrator or a nurse Consent should also be obtained for a sample of the donor’s
appointed to this position. The role of Designated Officer is to blood to be taken for testing of viral and other microbiological
ensure: markers of transmissible disease. Relatives should be told that
they will be informed of any positive results that may have cases Indian law states that no removal of organs be done without
implications for their own health. the consent of relatives. Eyes/corneas can be removed by any
When an inquest is to be held in connection with the deceased registered medical practitioner possessing an MBBS degree even
or when the Coroner, or Procurator Fiscal in Scotland, requires from dead bodies laying in peoples homes or anywhere else.
a postmortem examination of the body, permission must be Strong punishment is specified for anyone removing organs
obtained from the Coroner/Procurator Fiscal before proceeding without consent or using them for any purpose other than
with eye collection, even though consent may have already been therapeutic purposes or for buying and selling organs. All organs

Chapter 5: Medicolegal Aspects of Eye Banking

obtained from the relatives. to be donated and distributed without charge.

Corneal Tissue Act, 1986 Authority for the Removal of Human Organs
Permits suitably trained National Health Service staff, who are Any donor may, in such manner and subject to such conditions
not medically qualified, to remove eyes from donors. Training as may be prescribed, authorize the removal, before his death,
courses are run by corneal transplant service (CTS) eye banks. of any human organ of his body for therapeutic purposes.
If any donor had, in writing and in the presence of two or
Human Organ Transplant Act, 1989 more witnesses (at least one of whom is a near relative of such
It prohibits commercial dealings in human organs. The general person), unequivocally authorized at any time before his death,
standards governing eye donation and retrieval are set out in this the removal of any human organ of his body, after his death, for
act. Guidance on the retrieval of human eyes used in therapeutic purposes, the person lawfully in possession of the
transplantation and research is issued by The Royal College of dead body of the donor shall, unless he has any reason to believe
Ophthalmologists. It has been now replaced by Human Tissues that the donor had subsequently revoked the authority aforesaid,
Act 2004. grant to a registered medical practitioner all reasonable facilities
for the removal for therapeutic purposes, of that human organ
EYE BANKING LAWS IN INDIA from the dead body of the donor.
Where no authority, was made by any person before his death
The main Act governing the donation of human organs in India
but no objection was also expressed by such person to any of
is the Transplantation of Human Organs Act, 1994 and also the
his human organs being used after his death for therapeutic
Transplantation of Human Organs Rules, 1995. This Act
purposes, the person lawfully in possession of the dead body of
legislated by the Government of India provides a legal
such person may, unless he has reason to believe that any near
framework for transplant of all human organs. Eye donation
relative of the deceased person has objection to any of the
comes within its scope.
deceased person’s human organs being used for therapeutic
In a bid to increase donor cornea collection, the National
purposes, authorize the removal of any human organ of the
Program for Control of Blindness has established Eye Banks in
deceased person for its use for therapeutic purposes.
medical colleges, and now also extends support to various eye
Where any human organ is to be removed from the body of
banks run by voluntary agencies. Eye bank Association of India
a deceased person, the registered medical practitioner shall
(EBAI) is the national level body focussed on relieving Corneal
Blindness. Amongst other goals, it aims at encouraging the satisfy himself, before such removal, by a personal examination
Government to create and enforce a uniform legal framework of the body from which any human organ is to be removed, that
for eye banking in the country. It has initiated action to persuade life is extinct in such body or, where, it appears to be a case of
the Government to amend the Human Organs Transplantation brainstem death.
Act, 1994 to include eye donation and eye banks in the
framework of the Act. Authority for Removal of Human Organs in Case of
Unclaimed Bodies in Hospital or Prison
The Indian Human Organs Transplantation Act, 1994 In the case of a dead body lying in a hospital or prison and not
It is an Act to provide for the regulation of removal, storage and claimed by any of the near relatives of the deceased person within
transplantation of human organs for therapeutic purposes. It forty-eight hours from the time of the death of the concerned
regulates the following actions: person, the authority for the removal of any human organ from
All hospitals or eye banks that collects eyes or other human the dead body which so remains unclaimed may be given, in the
organs have to be registered by the government after they meet prescribed form, by the person in charge, for the time being, of
certain service and medical standards. the management or control of the hospital or prison, or by an
A procedure for obtaining written consent of relatives of employee of such hospital or prison authorized in this behalf by
deceased persons has been laid down and has to be followed the person in charge of the management or control thereof.
before eyes or other organs are removed. No authority shall be given if the person empowered to give
In India even if a person when alive ‘wills’ that his organs such authority has reason to believe that any near relative of the
can be donated after death such a will is not valid. Even in such deceased person is likely to claim the dead body even though
such near relative has not come forward to claim the body of Punishment for commercial dealings in human organs.
the deceased person within the time. Whoever —
Where, the body of a person has been sent for postmortem a. Makes or receives any payment for the supply of, or for an
examination: offer to supply, any human organ.
• For medicolegal purposes by reason of the death of such b. Seeks to find a person willing to supply for payment any
person having been caused by accident or any other unnatural human organ.
cause; or c. Offers to supply any human organ for payment.
Section I: Evolution, Preoperative Considerations and Eye Banking

• For pathological purposes. d. Initiates or negotiates any arrangement involving the making
The person competent under this Act to give authority for of any payment for the supply of, or for an offer to supply,
the removal of any human organ from such dead body may, if any human organ.
he has reason to believe that such human organ will not be e. Takes part in the management or control of a body of persons,
required for the purpose for which such body has been sent for firm or company, whose activities consist of or include the
postmortem examination, authorize the removal, for therapeutic initiation or negotiation of any arrangement referred to in
purposes, of that human organ of the deceased person provided clause (d); or
that he is satisfied that the deceased person, had not expressed, f. Publishes or distributes or causes to be published or
before his death, any objection to any of his human organs being distributed any advertisement:
used, for therapeutic purposes after his death or, where, he had
– inviting persons to supply for payment of any human
granted an authority for the use of any of his human organs for
therapeutic purposes after his death, such authority had not been
– offering to supply any human organ for payment; or
revoked by him before his death. The doctor who removes the
– indicating that the advertiser is willing to initiate or
eyes for therapeutic purposes is protected against the charges of
negotiate any arrangement
mutilating the dead body or offending religious or emotional
These shall be punishable with imprisonment for a term
sentiments which are considered offences under Section 297 of
which shall not be less than two years but which may extend to
Indian Penal Code.
seven years and shall be liable to fine which shall not be less
Restrictions on Removal and than ten thousand rupees but may extend to twenty thousand
Transplantation of Human Organs rupees.

No human organ removed from the body of a donor before his

death shall be transplanted into a recipient unless the donor is a
near relative of the recipient.
Where any donor authorizes the removal of any of his human In exercise of the powers conferred by subsection (1) of Section 24 of
organs after his death or any person competent or empowered the Transplantation or Human Organs Act, 1994 (42 of 1994), the
to give authority for the removal of any human organ from the Central Government of India made rules, the relevant ones are quoted
body of any deceased person authorizes such removal, the human as under:
organ may be removed and transplanted into the body of any A registered medical practitioner shall, before removing a human
organ from the body of a person after his death satisfy himself—
recipient who may be in need of such human organ. National
• That the donor had, in the presence of two or more witnesses (at
Human Rights Commission in its office letter no, DO No. 11/5/ least one of whom is a near relative of such person), unequivocally
2001- PRP and Pdt 29-1-2004 circulated to all States/UTs to authorized before his death, the removal of the human organ of
check illegal trade in human organs has suggested certain his body, after his death, for therapeutic purposes and there is no
measures and also mentions that cadaver transplant program reason to believe that the donor had subsequently revoked the
should be promoted. authority aforesaid;
• That the person lawfully in possession of the dead body has signed
a certificate.
Offences and Penalties
A registered medical practitioner shall, before removing a human
Punishment for removal of human organ without authority. Any organ from the body of a person in the event of his brain-stem death,
person who renders his services to or at any hospital and who, satisfy himself—
• That a certificate has been signed by all the members of the Board
for purposes of transplantation, conducts, associates with, or
of medical experts
helps in any manner in, the removal of any human organ without • That in the case of brainstem death of a person of less than eighteen
authority, shall be punishable with imprisonment for a term which years of age, a certificate has been signed by all the members of
may extend to five years and with fine which may extend to ten the Board of medical experts and an authority has been signed by
thousand rupees. either of the parents of such person.


Chapter 6: Setting Up Corneal Transplant Center

Setting Up Corneal
Transplant Center
Jacqueline Beltz, Rasik B Vajpayee


Corneal transplantation requires particular skill sets, specialized The role of an eye bank is to provide safe and viable corneal
equipment, and extensive coordination. For these reasons, tissue for transplantation. Tissue needs to be available, reliably
transplantation is only provided by top quality facilities. and safely transported, of good quality, and free of transmissible
A corneal transplant facility must offer top quality disease.
transplantation services, in all different types of corneal An onsite eye bank is most convenient, especially in
transplantation. It must employ specialized staff, right through developing countries, where same day transplantation may be
from reception staff to corneal surgeons (Fig. 6.1A). arranged once serology has cleared, without the need for
Many factors must be considered when setting up a corneal transport medium and storage. In the absence of an onsite eye
transplant facility. These include: bank, one should collaborate with as many eye banks as possible,
• Eyebank of choice and consider factors such as availability of tissue, culture medium
• Patient coordination and education used, transport issues and waiting time.
• Ward availability/staffing/education It is imperative to maintain up-to-date waiting lists, including
• Anesthetic availability all patients awaiting corneal transplantation. Priority should
• Specialty theatre nurses depend upon the need for the surgery and visual acuity in that
• Special equipment required and the other eye. The lists could be divided into the following
• Reception staff/Emergency department staff training/ categories:
education/availability • General list/Non-urgent cases
• Research • Priority list/Semi-urgent cases
• Wet Lab facilities • Top priority list/urgent cases
• Emergency list
Ideally, dates for elective, non urgent cases would be
specified at the time of booking tissue, however, emergency
cases, of course, would be organized more quickly.
If a lamellar surgical procedure, such as DSAEK or ALTK
has been planned, it is useful to cut the tissue one day prior to
the case, in order to save time in the corneal theater on the day
of surgery (Fig. 6.1B). This practice also allows for alternative
arrangements to be made should there be any technical problems
with the cutting of the tissue, and helps to avoid short notice

Patient Coordination and Education

Most corneal transplantation cases should be booked electively,
with confirmation of tissue availability 3-4 days prior to the
specified date. In more urgent cases, once a tissue is available,
Figure 6.1A: Operation theater in a corneal transplant center the patient will need to be notified of a time. They must fast for
Anesthetics Staff
Anesthetic staff involved with a corneal transplant facility should
be aware of the different types of corneal transplantation, and
their anesthetic requirements. Ideally, written guidelines would
be set by the anesthetic staff, outlining appropriate investigations
to be performed prior to each case, as this may help to avoid
delays at the time of surgery.
Section I: Evolution, Preoperative Considerations and Eye Banking

On booking a case, anesthetic preference should be

considered. If the patient is considered to be of high ansthetic
risk, preoperative assessment will be required by the anesthetist
prior to surgery. Relevant bloods and echocardiograph should
be considered. General or local anesthesia are appropriate for
most patients undergoing corneal transplantation.
It is most important to liaise with the anesthetist when
necessary, particularly for urgent cases.
Figure 6.1B: Pre-cutting tissue for DSAEK
at least 6 hours preoperatively, and be aware of instructions
requiring particular medications, particularly diabetic
Specialty Theater Nurses
Patients should receive written information, in the form of a It is important to train Ophthalmic nurses in the different types
brochure, at the time of booking the case. This information of corneal transplantation, as they will be able to assist the
should include: surgeon with each case, and ensure appropriate instruments are
• Place of arrival available. A corneal transplant facility should include relevant
• What to wear/bring equipment, and a good selection of trephines and punches, as it
• Fasting instructions may be difficult to adequately predict use prior to the case. At
• Instructions relating to any special medications, e.g. diabetic/ the time of booking a case, make sure the type of transplant to
anticoagulant be performed, as well as any special equipment is clearly
• Risks and benefits of corneal transplantation specified.
• Theoretical risk associated with transplant material Provide the nursing staff with equipment lists for all types
• Possible day/time change at late notice due to unavailability of corneal transplantation. Examples of such lists are shown in
of tissue figures 1-5. In this way, you will always have what you need
• Need for lifelong follow-up following the transplant within reach, and each surgery may run more quickly and
• Postoperative instructions, including importance of drops efficiently.
• Symptoms of rejection/infection to look out for. Lasers in Corneal Surgery

Ward/Staff Education Femtosecond laser is now being used to perform many types of
specialized corneal transplant surgeries. It is ideal to have the
A corneal transplant facility should have the capacity to laser facility and the surgical facility in the same center, in order
accommodate patients overnight, both pre- and postoperatively, to avoid transport of patients mid-procedure. Due to financial
when required. Occasionally, particularly in developing and space constraints, however, this may not be possible for
countries, patients may need to remain as inpatients whilst many transplant facilities. Even if separate locations are
awaiting transplantation, and this may amount to many days on necessary, it may well still be possible to perform these
the ward. femtosecond-assisted procedures.
Ward staff should be aware of different types of corneal
transplantation, including the possibility of posturing Special Equipment
postoperatively. They should be aware that severe pain, A corneal transplant facility must be set-up with all of the
discomfort, nausea, or vomiting must be reported to the surgeon, commonly required instruments. Less frequently used
or on-call ophthalmologist or resident. On-call staff should instruments or materials may be ordered on a case-by-case basis.
understand that there is a low threshold for contacting the corneal Equipment in the clinic would approach that usually required
surgeon should problems arise. A corneal transplant facility must for an ophthalmology clinic. Medical photographic equipment
have an on-call ophthalmologist and also, if possible, a fellow such as slit lamp mounted photographic equipment, corneal
or resident at all times, so that problems may be easily reported topography, specular microscopy, and anterior segment ocular
and patients assessed. Once assessed, a corneal fellow or corneal coherence tomography is all required. A-scan measurements,
specialist should be notified of each presentation, to ensure such as by IOL master, will be required for cataract or triple
44 management of the patient has proceeded effectively. procedures.
Ideally, a transplant facility would be set-up for all types of equipment required will differ for different surgeons. For this
corneal transplantation, including Penetrating Keratoplasty reason, these lists are a guide only, and should be regularly
(PKP), Automated Lamellar Transplantation (ALTK), Big bubble updated and stored for each surgeon. In this way, an up to date
Deep Anterior Lamellar Keratoplasty (DALK), Manual Deep list of equipment required for all different transplant procedures
Lamellar Keratoplasty (DLK), Descemet Stripping Automated
Endothelial Keratoplasty (DSAEK), Tuck-in Lamellar
Table 6.3: Equipment required for Automated Lamellar
Keratoplasty (TILK), and Femtosecond Assisted Keratoplasty. Therapeutic Keratoplasty (ALTK) or Tuck-in Lamellar

Chapter 6: Setting Up Corneal Transplant Center

Provide the nursing staff with equipment lists for all types Therapeutic Keratoplasty (TILK) in addition to that already
of corneal transplantation (Tables 6.1 to 6.5), and specify the listed for PKP
exact type of transplant planned on the booking form. Exact Instruments Consumables
Artificial anterior chamber Tegaderm × 2
Table 6.1: Equipment required for penetrating Microkeratome console and tubing Microkeratome blade × 2
keratoplasty (PKP) ALTK lens applantor set Artificial AC tubing
DRAPES CONSUMABLES ALTK suction and cutting rings IV giving set
ALTK anterior chamber bell BSS 500 Ml
Sterile Eye Drape Gloves - Size X
ALTK lens applantor
Prep tray Disposable Gown
Cutting heads 200/250/300 um DONOR TISSUE
TRAYS and INSTRUMENTS Microscope Drape
Corneal Graft Tray 15 Degree blade
• Fine tooth forceps Teflon block Table 6.4: Equipment required for cutting tissue prior
e.g. Lim/Hoskins to automated lamellar transplantation procedures
• Right and Left hand Marking pen
corneal scissors Drapes Consumables
• Universal Corneal scissors Spears Sterile sheet Sterile Gown
• Westcott scissors Sterile gauze
• Vanass scissors Disposable pot
– Straight
– Curved Fine tooth forcep x 2 IV giving set
• Needle Holder 10 Ml syringe x 1 Microkeratome console and tubing BSS 500 Ml
• Caliper 2 Ml syringe x 3 Microkeratome motor and cutting head Free standing
Trephines All types of IV pole
Viscoelastics Artificial anterior chamber and tubing 2 Ml syringe
• Eg Hessburg-Barron vacuum Nylon 10-0 suture with Cutting heads - 300 or 350 um Marking pen
trephine and punch, size sharp point needle
specified at start of case. Microkeratome blade Sterile pot
Operating microscope Tegaderm
Phaco Tray and Equipment if Subconjunctival
triple procedure Injections Pacchymeter Microscope drape
• Check present • Example, Keflin,
lignocaine Table 6.5: Equipment required for Descemet Stripping
Automated Endothelial Keratoplasty (DSAEK), In addition
EQUIPMENT BSS 18 Ml to that already listed for PKP
Microscope with attached Fluorescein 2 percent
photographic and recording minim Drapes Consumables
devices None Bipolar leads
DVD recording device Rycroft cannula × 1 3.2 mm Keratome
INSTRUMENTS Crescent Blade
Busin Glide MVR Blade
Table 6.2: Equipment required for deep anterior lamellar Busin Forceps or End gripping IV giving set, IV Pole
keratoplasty (DALK) or deep lamellar keratoplasty (DLK) forceps
in addition to that on PKP list Descemet stripper BSS 500 Ml
• Air filter Descemet scorer Anterior chamber
• 2 MI Luer Lock syringe maintainer
• 26 g needle × 2 Bipolar cautery Vision Blue
• Crescent blade Miochol
• Lamellar dissectors DONOR TISSUE 8-0 Vicryl suture
• Vision blue Pre cut, preferably 1 day prior Steristrips × 1 packet
Check list for Booking a Case
• Tissue
– Book with eye bank
– Time of arrival
– Courier if necessary
– Place of delivery
– Storage once delivered
Section I: Evolution, Preoperative Considerations and Eye Banking

– Need to pre-cut tissue for lamellar procedures

• Theatre
– Book case
– Specify particular equipment required
• Notify specialty nursing staff
• Book ward bed
• Book anesthetist, and consider need for preoperative
Figure 6.2: Example of set-up for corneal transplantation • Fast and notify patient
• Preoperative photograph
may be kept by the transplant facility for each surgeon, thus • Book follow-up
helping each surgery to run smoothly and efficiently (Fig. 6.2).
Follow-up It is essential that a corneal transplant facility will contribute to
A corneal transplant facility must have a clinic, and an emergency the progression of this rapidly expanding field. Research may
facility, in order to assess both pre- and postoperative patients. be laboratory based or clinically based. A corneal transplant
Referring practitioners would need to be aware of the presence facility should aim to publish new techniques, as well as results
of a transplant facility in their area. Services offered may be or modifications to pre-existing techniques. Make sure every
advertised to these referrers, by means of letter or pamphlet. An surgical case is recorded and catalogued for future video
example of a list of services offered by a corneal transplant production or education (Fig. 6.3).
facility may include:
• Inpatient or outpatient management of acute corneal disease Wet Lab
including: If possible, a corneal transplant facility should have a wet lab
– Infectious keratitis or skill development lab. Such a lab should have well functioning
– Neurotrophic keratitis operating microscopes, and appropriate instruments in order to
– Corneal melt practice the skills required for corneal transplant surgeries.
– Corneal perforation Residents and fellows should aim to frequently practice their
• In patient or outpatient management of chronic corneal
disease including:
– Corneal dystrophy
– Corneal ectasia
– Low vision due to previous corneal disease
• Follow-up and management of all corneal conditions
• Emergency assessment, management, and treatment of
corneal disease
Patients must be aware of the procedure to be followed
should an emergency develop, and the corneal fellow or specialist
should be contacted following on-call ophthalmologist or
resident assessment.
The major complications requiring immediate attention after
a corneal transplant are infectious keratitis and graft rejection.
A corneal transplant facility should develop management
protocols and make them available to corneal fellows for the
management of these cases.
A corneal transplant facility should aim to have photographs
of all patients preoperatively, and at each follow-up visit, to aid
in documentation of progression or improvement of disease. Figure 6.3: Recording device
skills on animal eyes prior to performing live surgeries. Suturing, identify any problems occurring. A computerized database should
in particular, must be practiced in the wet lab. Practice of the be arranged, such that data may be easily entered at the time of
various types of suturing is the best way to develop the skills of surgery or follow-up, and so additional time is not required to
intricate wrist movements and optimal hand-eye coordination that gather large quantities of data at the end of each year. It is
are required for a corneal transplant surgeon. important to specify the indication for each surgery, surgeons
Periodically, device companies may be invited to bring their involved, type of transplantation, date and time of
corneal transplant instruments and machines to the wet lab to transplantation, intra- or postoperative complications, and best

Chapter 6: Setting Up Corneal Transplant Center

encourage residents and corneal fellows to practice newer corrected visual acuities for each clinic visit. In this way, success
transplantation techniques, and to learn how to prepare donor or problems may be easily highlighted, and changes made to
tissues for such surgeries. address any issues arising.
Regular staff meetings should be held, involving all of the
Audit and Outcome Monitoring transplant facility staff, so that the facility may run effectively
An annual audit meeting should be arranged, involving all of as a single unit. In this way, any problems arising will be dealt
the corneal transplant facility staff, in order to monitor the with quickly and efficiently, in order to achieve the best possible
success of transplants performed at the facility, as well as to outcomes for as many patients as possible.

Section I: Evolution, Preoperative Considerations and Eye Banking

Setting Up an Eye Bank

Mukesh Taneja, Prashant Garg, Usha Gopinathan


From all the evidence available, direct and indirect, an annual An Eye Bank is a non-profit community organization, usually a
performance of around 100,000 corneal transplants would have society or trust registered under the Registration of Societies Act
a salutary effect on the problem of reversible corneal blindness and run by a board of directors.1 A medical director, an eye bank
in India. Going by the experience of the eye banking systems manager, eye bank technicians and grief counselors manage the
worldwide, meeting this demand would require double that day-to-day affairs of an eye bank.
number of corneas to be harvested, i.e., 200,000 annually. Each The functions of eye banks are:
Eye Bank (EB) with adequate infrastructure and trained a. Educating the public about eye donation and eye banking
manpower can comfortably process 4000 corneas per year, which b. Carrying out eye donations
translates to 50 eye banks for the entire country. In a country
c. Preserving, processing and evaluating the donor corneas
like India, where the basic infrastructure and manpower exist,
d. Carrying out serological tests of eye donor’s blood sample
this should not be a problem-theoretically.
e. Distributing donor corneas to corneal surgeons according to
Each of these eye banks should be an autonomous
the waiting list
organisation, ideally with its own Board and governance structure
representing all the stakeholders in the community. All the major f. Initiating Hospital Cornea Retrieval Programme in
functions of an eye bank should be carried out, including public neighbouring hospitals and
awareness, tissue harvesting, tissue evaluation (including g. Fund raising for defraying the capital and recurring expenses.
serology and microbiology), tissue preservation and tissue
distribution. Equitable distribution is key to long term success, Eye Donation Center (EDC)
since this builds credibility in the community with all its Eye Donation Centers are suitable for places with population
subsequent benefits. The goal is to make safe and high quality between 2–4 lakhs where the annual target may be around 25
corneal tissue accessible to everyone who needs corneal eyes. It makes sense to save on infrastructure and manpower at
transplantation in the community in an equitable manner. such locations and the eyes retrieved can be handed over to the
Essentially, this means that all those who are in need of a corneal nearest eye bank, which maintains sufficient manpower and has
transplant for visual rehabilitation, irrespective of socio- the infrastructure to process, preserve and distribute corneas.
economic status, gender, religion, or choice of surgeon and The functions of an Eye Donation Center are:
institution, should have equal access to the eyes donated to eye
a. Tissue retrieval from the donor and
banks on a first-come first-served basis.
b. Transportation of tissues to the nearest eye bank for
There should be one eye bank for every 20 million people,
processing, evaluation and distribution.
each of which should be linked to 40 Eye Donation Centres
(EDC) — eye banking units that are involved only in harvesting Feasibility Study
corneas. In addition, each eye bank should develop a Hospital
Cornea Retrieval Programme (HCRP) in 10 major hospitals in One needs to conduct a feasibility study before setting up an
the immediate community. Half (2000) of the harvesting should eye bank which should cover the following aspects:2
be achieved by the Eye Bank directly through the HCRP and a. Existing eye banks/eye donation centers in the town/city/
the other half (2000) should be through the contribution of eye suburban area
donation centers, with 50 eyes (25 donors) from each EDC. b. Population of the town/city/suburban area

c. Hospitals located in the town/city/suburban area Table 7.1: Infrastructure requirement for EB and EDC
d. Distance of the hospitals from the EB/EDC
Infrastructure Physical
e. Financial viability
Eye Bank Eye Donation Center
If an EB or an EDC functions satisfactorily in the area of
your operation, it is worthwhile to extend your cooperation to Space 500 sft 300 sft
the existing center than trying to establish another one. You can Slit-Lamp 2,00,000 –
avoid unnecessary proliferation and fragmentation of EBs which Refrigerator 25,000 25,000

Chapter 7: Setting Up an Eye Bank

may be counterproductive. Ideally, in a large city or town one Four Wheeler 3,35,000 –
or two EBs should exist with all facilities to process, evaluate Two Wheeler – 35,000
and distribute corneas. Others should function as satellites of Laminar Flow 50,000 –
the EB functioning as EDCs only. The waiting lists of all EDCs hood (Fig. 7.1)
should be collated and maintained at the central community EB. 6 sets of 10,000 10,000
Distribution should be carried out according to the central
Telephone 6000(2) 3,000 (1)
waiting list only. Exception to this may occur in cases of
Furniture 1,00,000 15,000
Serological 1,00,000 –
Some of the existing eye banks may not be functioning to
Equipment (Fig. 7.2)
the full potential that exists in their area. If the eye banks are
Autoclave 15,000 15,000
not achieving good results and exist for several years, then one
Specular 12,00,000 –
can think of setting up an EB/EDC despite their presence. Microscope (Fig. 7.3)
If no EBs/EDCs exist in your area of interest, the next aspect Total 20,41,000 1,03,000
to be examined is the population of the area.

Population and Total Potential for Eye Donation

Table 7.2: Human resource requirement for EB and EDC
According to the population of your area a decision whether an
Human Resources
EB or EDC should be established can be taken. If the population
Eye Banks Eye Donation Center
is less than 2 lakhs even an EDC may not be viable. One percent
of local death rate in the area, as an initial target for eye donation Panel of Statutory –
gives you rough figures for potential in your area. Ophthalmic
Hospital in Local Area and their Medical Director 1 Desired 1 Desired
Potential for Eye Donation Eye Bank 1 Desired 1 Desired
Information on hospitals located in your area of operation is Eye Bank 1 Statutory 1 Statutory
essential as tie-up with hospitals would ensure regular sourcing Technician
of corneas. Through such tie-ups Grief Counselors or Eye Social Worker- 1 Statutory 1 Statutory
Donation Counselors can be placed at hospital wards with cum-Health
substantial death rates. The distance of the hospitals from the
Driver-cum- 2 Statutory 1 Statutory
eye bank should be within 15 kms.

Financial Viability
Once it is concluded that there is potential for either an Eye Bank
or Eye Donation Center, the next step is to take a look at the
requirements of setting up such a centre (Table 7.1). Substantial
funds for equipment and operations, especially manpower, are
required to set up and sustain the facilities.

Location of the Center

Ideally, an Eye Bank/Eye Donation Center should be an
independent setup, serving the community irrespective of caste,
creed or religion. In India, however, the eye banks / eye donation
centres are located in a general hospital or in an eye institute
(eye care center) as this allows the EB/EDC to use some of the
facilities of the host organization like telephones, reception,
laboratory and some basic manpower (Table 7.2). The most Figure 7.1: Laminar flow hood
4. Evaluation Lab and Shipping Area (approx 12’ × 10’)
Should have a sink, slit-lamp, work station, cabinets for
storage and refrigerator.
5. Technician’s Office (approx 10’ × 10’)
Where communication and record keeping is done.
6. Manager’s Office (approx 10’ × 10’)
Should have a work desk, phone, fax and cabinets.
Section I: Evolution, Preoperative Considerations and Eye Banking

Assistance for setting up an Eye Bank

or Eye Donation Center
The National Programme for Control of Blindness of the
Ministry of Health and Family Welfare provides assistance to
organisations that want to set up an eye banks.4

Figure 7.2: Serology laboratory Criteria for Eligibility

Besides the Central/State/District/mobile units and private
charitable hospitals and nursing homes, a voluntary organisation
is eligible to become an Eye Bank if it meets the following
• The organization should be registered under the Human
Organs Transplantation Act.
• It should be non-governmental and should not be run for
profit to any individual or group of individuals.
• Its work and financial position should be satisfactory and
the payment of grant-in-aid should be recommended by a
State Government .
• It should have its own infrastructure to carry out the activities
of an Eye Bank.
• The organisation should have a good track record .
• It should be recognised/associated with the Eye Bank
Figure 7.3: Specular evaluation of donar eye Association of India (EBAI).

important advantage of such a policy is to gain credibility from Pattern of Assistance

the name of the host organization. If the host has an eye
• Non-recurring grant up to Rupees 5 lakhs for eye banks and
department, it has been the practice (though not mandatory) to
Rupees 50,000 for eye donation centers for items like
get an ophthalmologist as a medical director on honorary basis.
vehicles, refrigerator, emuclation set, containers for corneal
In such cases, the cornea retrieved by the eye bank is readily
sets, film projector with slides, etc .
utilized by the host hospital, if it specializes in corneal
• Recurring grant of Rupees 250 per eye collected for eye
transplantations. In case the host hospital cannot utilize the
donation centres and Rupees 500 per eye collected for eye
cornea, arrangements should be worked out for the distribution
banks for MK Media (Fig. 7.4), glassware and other
of the cornea to ensure timely utilization.
contingency expenditure.
Requirements for an Ideal Eye Bank Set Up
Procedure for Application
1. Instrument Cleaning Isolation Lab (approx 8’ × 10’)
An application should be submitted on the prescribed Performa
Limited access lab for authorised personnel where
through the Director, Health Services of State Governments or
instruments are washed and sterilized following corneal
be sent to the Ophthalmology Section, DGHS, Department of
Health, New Delhi.
2. Serology isolation Lab (approx 12’ × 10’)
Limited access for authorised technician only, where blood For registration under the the Human Organs Transplantation
serum samples are tested. Act, the organization should apply to the state health department.
3. Tissue Processing Isolation Lab (approx 15’ × 10’)
Legal Formalities
Where tissues are evaluated, processed and prepared for
packing and distribution. Should have space for ultraviolet Legal formalities differ from state to state. But the common
50 and laminar flow hood. procedure is the registration of the eye bank/eye donation center
with the health department of the state government under the
Transplantation of Human Organ Act 1994.3 Once the system
of accreditation of eye banks comes into practice, the eye banks
will have to go through regular inspections and file reports as
required by the accreditation system. EBAI has started the
process of accreditation system in the state of Andhra Pradesh,
which gradually will be implemented throughout India.

Chapter 7: Setting Up an Eye Bank


1. Rao GN. What is Eye Banking? Indian J Ophthalmol 1996;44:

2. Guide lines and Project Report for setting up an Eye Bank or
Eye Donation Centre, EBAI: 2003.
3. Transplantation of Human Organ Act (HOTA), 1994.
Figure 7.4: MK media preparation
4. The ministry of Health and Family Welfare Notification regarding
amendment in HOTA, 2002.

SECTION II: Penetrating Keratoplasty

Chapter 8: Surgical Instruments for Penetrating Keratoplasty

Surgical Instruments for Penetrating
Prakash Chand Agarwal, Namrata Sharma, Vishal Gupta, Geoffrey C Tabin

The basic instruments for corneal grafting surgery include eye compression. The pediatric Barraquer eye speculum is open 11
speculum, corneal trephines, needle holders, and a Pierse-Hoskin mm of blade and the blade spread is 19 mm.
forceps. However in the recent past, the number of instruments
available for corneal grafting has increased considerably. Many
of the newer instruments are variations of the earlier designs.
Instruments specific for corneal transplantation surgery
can be divided into four categories:
• Instruments designed for optimal globe exposure.
• Instruments specifically designed to cut the recipient and the
donor cornea, such as trephines, punches and blocks.
• Instruments used to secure the donor cornea and to remove
and replace lens implants such as forceps, scissors and needle
• Instruments used to assist in the maintenance and Figure 8.1: Wire speculum
reconstruction of the anterior segment such as cannulae,
spatulas and hooks. Globe Supporting Rings
• Qualitative keratometers used intraoperatively to assess the
The Flieringa ring (Fig. 8.2) is made of stainless steel and is
corneal toricity.
useful for maintaining the architecture of the globe once the host
The suitability and selection of instruments for corneal
corneal button has been removed. Although, they are available
transplantation is based primarily on specific surgical technique,
in 11 sizes from 12 to 22 mm, the most commonly used sizes
surgeon’s preference and the expertise.
are the 17 and 18 mm. Use of globe supporting Flieringa rings
has been advocated in aphakic eyes especially where vitrectomy
has been performed, pseudophakic eyes and pediatric eyes as
Eye Speculum the eyeball has a tendency to collapse in these cases after the
trephination. However, many surgeons do not choose to use these
The transplant surgeons must have several speculas available in rings as they may transmit unequal traction forces to the host
order to meet the needs of the various different anatomic cornea.1 This may distort the shape of the eyeball and cause an
configurations frequently encountered. The speculum should be oval cut during trephination and subsequent high astigmatism.
light in weight, have minimum extraneous parts and avoid undue Occasionally subconjunctival hemorrhage may also occur while
pressure over the globe which can increase intraocular pressure
or distort the cornea (which can result in increased postoperative
astigmatism). A wire lid speculum such as Barraquer eye
speculum (Fig. 8.1) or Kratz-Barraquer eye speculum is ideal
for most cases. Barraquer eye speculum has open 14 mm blades
and the blade spread is 20 mm. Eye specula used in children are
of small size and tend to offer slightly less resistance to Figure 8.2: Flieringa ring (Courtesy: Katena products)

suturing these rings to the conjunctiva. McNeill-Goldman ring CORNEAL TREPHINES
(Fig. 8.3) provides support with four stragically placed sutueres.
A trephine is a stainless, sharp, cylindrical blade, which when
The ring features medial and temporal openings for greater
used, creates a circular corneal incision (Fig. 8.4). An ideal
access to the surgical field and two lid retractors to prevent eyelid
trephine is one that produces a sharp vertical cut without causing
closure by the patient. It is available in three sizes—small,
too much damage to the corneal tissues. The most common
medium and large.
complication of corneal transplantation is postoperative
astigmatism. A poor quality trephine may contribute substantially
Section II: Penetrating Keratoplasty

to the occurrence of this problem. It is important to have an ideal

trephine that achieves the most accurate and reproducible cuts.
Some trephines are available with handles to get a firm grip while
cutting the corneal button (Fig. 8.6).

Types of Trephines
These may also be classified depending upon whether the host
cornea or the donor button has to be cut. There are various
trephines and trephination systems that are available for cutting
the recipient and donor cornea. Apart from this, the endothelial
Figure 8.3: McNeill-Goldman ring (Courtesy: Katena products)
punches are used to cut the donor cornea.
The various trephines are of following types:
• Conventional circular cutting trephines
Corneal Marking Instruments • Single point cutting trephines
Various instruments like the radial keratotomy marker and the • Combination trephines
Vajpayee corneal marker stained with gentian violet can be used • Non-contact trephines (Lasers)
to mark the donor cornea to aid in the optimal placement of the
Conventional Circular Trephines
sutures in keratoplasty (Fig. 8.4). Vajpayee corneal marker
consists of 20 radial arms which guide the placement of the single There are five types of circular trephines:
continous suture bites. Anis corneal marker (Fig. 8.5) with 8 • Hand held
marks is also commonly used to guide the initial sutures. • Mechanized
• Suction-fixation type
• Special-purpose type
• Skin biopsy punches
Hand-held trephines: Since the advent of micro-surgical
keratoplasty many modifications have occurred in the trephines
over a period of time.2-5 In the early era of corneal grafting,
trephines did not have disposable cutting edges and therefore,
required continual resharpening. This led to change in the
original circular shape over a period of time, thus distorting the
shape of the graft. Hand-held circular disposable trephines
remain the most commonly used trephines to cut both the
recipient and donor corneas, particularly in the developing
world. The hand-held trephines are available in sizes ranging
from 3 to 17 mm. The trephine is usually attached to a handle
for greater stability, leverage and control. The handle helps in
securing the trephine and confers a mechanical advantage over
Figure 8.4: Vajpayee corneal marker simply holding the trephine blade by hand. The trephine handle

Figure 8.5: Anis cornea marker (Courtesy: Katena products) Figure 8.6: Trephine Handle (Courtesy: Katena products)
may have a hollow core so as to allow observing the central mechanized trephines make the use of limbal suction ring to
cornea through the center of the trephines. In some trephines, assist in anterior chamber maintenance and protection during
there is a central obturator, which can be adjusted to select the trephination. Microkeratron (Hans Geuder, Heidelberg), a
depth of the corneal cut and hence an inadvertent entry into the commonly used mechanized trephine is used to trephine
anterior chamber can be avoided (Fig. 8.7). The handle of the recipient cornea and it permits variation of rotation speed and
obturator trephine offers a distinct advantage over the hollow has rapid braking within 0.1 second.
core in allowing a fairly accurate depth measurement. However, The disadvantages associated with motor driven trephines

Chapter 8: Surgical Instruments for Penetrating Keratoplasty

the obturator does not allow the surgeons to view the central include corkscrew edge effect in the corneal stroma. However,
cornea through the trephine during its use. This may result in less stromal disruption and a smoother interface has been
inaccurate centration during the trephination of the recipient’s reported with the use of a Microkeratron trephine (Hans Geuder,
cornea. Heidelberg) which moves at the rate of 800 rpm in comparison
The examples of hand-held trephines with obturator are the to the manual trephines.2
Castroviejo trephine and the Grieshaber-Franceschetti
Suction Fixation Corneal Trephines: These trephines have
trephine. The disadvantage of both the hollow core and the
been devised to obtain a perpendicular cut in the recipient
obturator type of handle is that each size trephine must be
cornea. These trephine systems essentially consist of an outer
matched to the handle size and hence different handles are
corneal suction ring for fixation and an inner circular cutting
required to accommodate different trephine sizes. Hence,
blade. Hessburg-Barron trephine is a prototype of this system
“Universal trephine” handle which accommodate various blade (Figs 8.8A to C). In Hessburg-Barron vacuum trephine a spring-
sizes was advocated. The advantage of this type of handle is that loaded disposable syringe creates the required negative pressure
this single instrument will secure trephine sizes used in majority and the suction fixation provides the stability and an opportunity
of cases. However, the disadvantage is that it is neither hollow to cut perpendicularly to the limbal plane and hence diminishes
for optimal visualization nor does it provide protection against the tilt of the trephine.6 The newer model of this trephine includes
inadvertent entry into the anterior chamber. the presence of a cross hair device for improved centration and
To overcome the problems of visualization associated with an outer ring of corneal marks at equal intervals to assist in suture
the obturator, certain trephine blades have been made long and placement. The Barron radial vacuum trephine is available in
can be easily grasped with the hand for a successful trephination diameters of 6.0 to 9.0 in 0.5 mm increments as well as diameter
both of the recipient cornea and the donor button. These of 7.75 mm. For each spoke (90 degrees) turned, the blade is
disposable trephines with long handle do not have provision lowered or raised approximately 0.06 mm. These trephine
for the obturator. These hand-held trephines are disposable and systems are used to trephine the host cornea. Its advantages are
made of razor blade and are see-through, easy to use and relatively low cost, consistency of the cut, control of depth,
economical. However, the cut may be uncontrolled and there may disposability and it is particularly useful for performing corneal
be difficulty in centration. Additionally, the slippage of the grafting surgery in extremely soft and perforated eyes.7 The
trephine may lead to an uneven cut. Hessburg-Barron trephine appears to improve the accuracy of
Mechanized Corneal Trephines: The cutting blade of this type the cut. However, this trephine has a tendency to undercut and
of trephine is driven by a motor present in the main body. A in the event of loss of suction during trephination, it can cause
circular trephine attached at the motor shaft end permits anterior an asymmetrical cut. The vacuum fixation ring may also lead to
chamber entry without damaging the intraocular structures. Some endothelial damage.8,9 The Barron Vacuum Punch features a
solid stainless steel blade which is permanently mounted in a
nylon housing. Four steel guide posts align with four
corresponding holes in the cutting block base, automatically
centering the blade over the donor cornea. The base of the punch
features a circular groove for aspirating the epithelial side of
the cornea, immobilizing it for cutting the button. The cutting
block well has four small holes which can be inked with a sterile
marking pen to identify the four quadrants of the cornea for
cardinal suture alignment in the recipient bed.
The Olson Calibrated Cornea Trephine System is a
precise, reproducible trephine that can be used to trephinate both
the donor and recipient corneas. The system consists of the
anterior chamber maintainer, the reusable blade holder (with
micrometer setting), and the suction ring. One revolution of the
micrometer is equivalent to 500 microns. The trephine should
Figure 8.7: Top—Obturator guided conventional circular be fully rotated at least three times to achieve a complete cut
trephine. Bottom—Conventional circular, disposable trephine for penetrating keratoplasty. If planning a partial depth incision,
select the desired depth by turning the micrometer, and tighten
the set screw. To cut the donor tissue the anterior chamber
maintainer is prepared. A small drop of viscoelastic is placed
on the endothelium of the donor tissue and the donor cornea is
centered onto the anterior chamber maintainer (epithelium-side
up). The trephine is centered on the patient’s cornea and releasing
the syringe activates the suction. While holding the suction ring,
Section II: Penetrating Keratoplasty

the top of the trephine is turned to complete the cut. Using a

different blade size, the recipient cornea can also be cut similarly.
After obtaining the donor button, it is placed in a graft
holder (Paton Spatula) (Fig. 8.9) over a viscoelastic and is kept
covered till the recipient dissection is complete. A trephine block
can be used to cut the donor cornea from endothelial side
(Fig. 8.10)
Special Purpose Trephines: These trephines are particularly
useful to perform a transplant in cases of optical zone lacerations
in the recipient cornea. This instrument helps in integrating two
Figure 8.8A: Hessburg-Barron trephine separate surgical procedures, that of initial repair and later
(Courtesy: Katena products) transplantation into one. The lacerated cornea is supported from
behind by protective plate, placed in anterior chamber and this
avoids injury to the lens and iris during trephining. An upper
plate is present above so that the cornea is securely placed
between the two plates. The trephine then descends along the
vertical shaft so that a circular cut is made without the underlying
damage to the iris or the lens.
Skin biopsy punches: The skin biopsy punches, which have
been used in dermatological practice, are especially useful in
harvesting of small patch grafts used for tectonic purposes in

Figure 8.9: Paton spatula

Figure 8.8B: Barron Punch (Courtesy: Katena products)

Figure 8.8C: Trephine Bottom view (Courtesy: Katena products) Figure 8.10: Teflon block (Courtesy: IOWA press)
cases of impending/frank perforation. These can be used for both the recipient as well as preserved donor cornea since it has an
donor and recipient corneas. The sizes of the most commonly artificial chamber maintainer system. It consists of two parts; a
used punches vary from 2.0 to 5.5 mm (Fig. 8.11). Additionally limbal suction ring system and a mechanical trephine fitted with
a Searcy chalazion trephine 2.5 or 3.0 mm in size may be used a suction ring. The suction ring helps fixating the trephine
to punch the patch grafts perpendicular to the cornea. A preset depth of cut is selected
and by rotation of the gear system, a cut of desired depth is
Single Point Cutting Corneal Trephines obtained. Once the desired depth is reached, there is no further

Chapter 8: Surgical Instruments for Penetrating Keratoplasty

descent of the blade despite continued knob rotations. The Hanna
The single point cutter trephines were designed to decrease
corneal torsion. In these trephines, fixation takes place at the vacuum trephine tends to produce less undercutting and smaller
epithelial diameter than the Hessburg-Barron trephine.6 Both the
limbus or on the sclera thereby reducing the corneal distortion.
systems produce greater final graft curvature than the hand-held
Leiberman single point cutter belongs to this class of trephines.
It is composed of two cones. The outer cone is held by the trephines although there was no significant difference in the final
keratometric results between the Hessburg-Barron trephine and
fixation hand and contains the suction ring. The inner cone
the Hanna’s trephine. Although better visual acuities were
revolves and carries a disposable razor blade knife and is capable
of making circular and oval perpendicular cuts with diameters reported in patients who underwent keratoplasty with the Hanna
trephine system compared with Hessburg-Barron trephine, the
of 2 mm to 8.5 mm. For 20º angle cuts, an interchangeable cutter
postoperative keratometric and refractive astigmatism were not
may be used for lamellar cuts. This trephine can be used only
on the eyeball for trephining donor and recipient corneas. As significantly different.10 Guided trephine system (GTS) is
another trephine system but with a different characteristic suction
compared to other available trephines, single point corneal
ring design. It uses a fixed glass obturator for corneal support
cutters do provide superior visibility under the microscope, the
least distortion and potential for reproducible controlled cutting. and the cornea is trephined in an applanated state and thus
enhances the perpendicularity of the corneal cuts.
Combination Corneal Trephines
Non-contact Trephines
Over the period of time, new trephines have come up, that
combine the best features of the previous trephines. Hanna They have got distinct advantages over other trephine systems
trephine system has got a circular razor-cutting blade and in providing complete visualization, better centration and
incorporates many of the salient features of single point cutting eliminating the corneal topographic distortion. Laser non-
trephines6 (Fig. 8.12). This assembly can be used to trephine contact trephination eliminates corneal topography distortion,
provides the visualization of the entire cornea and enhances
centration. Comparative studies between mechanical and laser
trephination with 193 nm reveal that there is no difference in
the immunologic reactions following penetrating keratoplasty.11
However, several concerns regarding endothelial injury,
mutagenicity and cost regarding use of these techniques remain.


Gauze piece fixated eyeball can be used specially in developing

Figure 8.11: Skin biopsy punches countries where preservation techniques may not be available
and the eyeball is stored in a moist chamber at 4ºC.


Tudor Thomas Stand

The Tudor Thomas stand is used to fixate the whole eye globe
prior to trephination. The whole eye globe is positioned in the
Tudor Thomas stand and the trephination can be done both for
full thickness as well as lamellar grafts.


The various cutting blocks available for corneal grafting are

Paraffin block, Teflon block and Polycarbonate and nylon
Figure 8.12: Hanna's trephine (Courtesy: IOWA press) blocks.11,12
An ideal cutting block attempts to approximate the corneal
shape and reduces the tissue distortion. Previously, early models
of blocks used to consist of different concavities of simple radius
of curvature. But now, teflon blocks with different radius of
curvature are available. The available cutting blocks are as
• The Kaufmann corneal cutting block – This is the simplest
Section II: Penetrating Keratoplasty

design which consists of a teflon block with metal cover

(Fig. 8.10).
• The Brightbill polytef cutting block – This modern,
compound curved block approximates the central, mid-
peripheral and peripheral curvature of donor. The Brightbill
polytef-cutting block uses three wells, each with a different
radius of curvature and diameter. Two concentric inlays of
colored polytef are present. The outer black polytef zone has
a chord length of 12.5 mm and corresponds to the limbus
and a second white polytef inlay with an 8 mm chord length
corresponds to the central zone of the donor cornea.
Slippage of the moist donor cornea at the time of cutting
Figure 8.13: IOWA PK Press Corneal Punch
can cause oval graft. This can be prevented by repeated drying
of the well in which the donor is placed or by using a thin, slightly
moistened layer of cotton in the well.
Rothman-Gilbard Corneal Punch
Corneal Endothelial Punches
It uses a piston which is not spring loaded. The suction block
To cut a donor button from endothelial side corneal punches are has 8 evenly spaced suction holes which anchor the corneal
also available which use disposable trephine blades. The button firmly so that there is minimal movement during
advantage of corneal punch is that they yield sharp vertical cuts trephination. The button has eight precisely placed marks and
without beveling.8 can be sutured into the host bed by suturing every mark on the
button with the marks placed on the host bed.
Cottingham Corneal Punch There are four trephine assemblies, which use artificial
anterior chamber. These include Krumeich, Hanna, Olson and
It is a metal punch with a universal style handle. Additionally, it
Lieberman systems. This involves cutting the donor corneas
also has two replaceable base plugs.
from the epithelial side rather than the endothelial side. Pressure
Troutman Corneal Punch in the artificial anterior chamber is adjusted to the intraocular
pressure with the help of attachments of the infusion tubings.
It incorporates a centered block and a piston carrier with a central
piston. The piston accommodates blades of 7 to 9 mm. This relies CUTTING INSTRUMENTS
on the surgeon’s thumb to incise the cornea.
Blade Breaker
IOWA PK Press Corneal Punch
A disposable razor blade is broken and mounted on the tip of a
It incorporates a spring-loaded piston with an expandable edge metallic pencil handle. This is one of the best instruments
to accommodate 6 to 9.5 mm trephines to harvest various sizes available for cutting tissues in straight or curved lines. Blade
the donor graft from the endothelial side. It has a unique two- breaker is used to enter the anterior chamber in a controlled
color cutting block which aids in centration of the donor tissue. manner after a deep cut has been created in the recipient’s cornea
The recessed base assumes that the block is held centrally under by a trephine. Blunt side of the blade can sometimes be used
the trephine block (Fig. 8.13). for blunt dissection of adherent iris.

Lieberman Gravity-action Punch Diamond Knife

It is a guillotine-style punch with a heavy head, which uses the This is the sharpest cutting instrument and available in various
force of gravity rather than the surgeon’s hand to punch the sizes and shapes. It is the most durable instrument and useful
cornea. for stab incisions as well as to complete the trephine cuts.

Corneal Scissors is the prototype of this variety. It can be used for suture tying
and to bury the suture knots.
Ideally, all corneal scissors should have an immobile lower blade.
Troutman microscissor (Figs 8.14A and B) is the prototype,
Forceps with Special Functions
which has blades 5 mm in length and is curved on a radius of 5
mm. The lower handle, which controls the upper blade, has a • Double corneal forceps, Colibri style – It has two 2.75 mm
flexible spring. This is a very light and fine scissors and mainly long tips separated 1 mm with 0.4 mm Pierse tips. It is 72
used to complete the cutting of the trephine incision. The blades mm long and has a serrated handle.

Chapter 8: Surgical Instruments for Penetrating Keratoplasty

should be kept vertical and must be curved to follow the • Colibri-style Polack double corneal forceps – It is used
curvature of the trephine, while cutting the host cornea. It is often for the first corneal suture. The cut edge of the graft is gently
used to remove the irregular tags from the wound margin. grasped at the junction of the epithelium and stroma with
Corneal scissors are used to complete the trephination of the host fine toothed forceps (Fig. 8.17).
cornea after creation of the circular cut following anterior
chamber entry. Curved Vannas Scissors can also be used for the HOLDING INSTRUMENTS
same (Fig 8.15).
Needle holders used in ophthalmic microsurgery consists of two
handles, which are supported between index finger and thumb.
Needle holder (Fig. 8.18), which is lightweight, with nonslip
Varieties of forceps are used for penetrating keratoplasty. curved handle and curved jaws is preferred for penetrating
However, they can be broadly classified into toothed, non- keratoplasty. The curvature of the jaw varies from a uniform
toothed or forceps used for special purposes. smooth to a hockey stick shape. The jaws should be atraumatic
to the steel needles but the grip should be firm. Barraquer’s
Toothed Forceps curved needle holder is an example.
• Pierse-Hoskin’s forceps It is a fine toothed tissue holding
forceps are used to hold the corneal tissue firmly. Pierse-
Hoskin’s forceps is the most frequently used tissue holding
forceps in corneal grafting surgery. It is a 2 × 1 fine toothed
lightweight instrument and extensively used for suture tying.
• Colibri forceps This is another example of tissue holding
forceps (Fig. 8.16).

Non-toothed Forceps Figure 8.15: Curved Vannas scissors

(Courtesy: Katena products)
The non-toothed forceps have flat edges that help in holding or
picking up structures like 10-0 nylon suture. McPherson forceps

Figure 8.16: Colibri forceps (Courtesy: Katena products)

Figure 8.14A: Right Troutman scissors
(Courtesy: Katena products)

Figure 8.14B: Left Troutman scissors

(Courtesy: Katena products) Figure 8.17: Polack forceps (Courtesy: Katena products)
observed ovality implies excessive curvature in the axis of
the shortest diameter of the oval. This is used for readjusting
and replacement of the sutures and helps to reduce
astigmatism intraoperatively and postoperatively.


• Dutch Ophthelmic Research Center, DORC Middle East,

Section II: Penetrating Keratoplasty

Figure 8.18: Titanium Needle holder Dubai, UAE

(Courtesy: Katena products)
• Katena Products, Denville, NJ, USA.

1. Vajpayee RB, Melki S. Three pearls to minimize penetrating
These are mainly used in the reconstruction of the anterior keratoplasty astigmatism. In: 101 pearls in Refractive, Cataract
chamber, the manipulation of the iris, and assistance in and Corneal Surgery 2001 Eds. Melki SA, Azar DT. SLACK Inc.,
intraocular lens placement. A double-ended iris repositer is useful Thorofare, New Jersey. Chapter 20:161-62.
for lysis of synechiae between the iris and lens capsule, dissection 2. Schanzlin DJ, Robin JB, Spence DJ. Clinical and ultrastructure
of iris from retrocorneal membranes and iris supported implants, analysis of variable speed corneal trephination. Ophthalmic Surg
lysis of broad based anterior synechiae, and sweeping the donor 1983;11:730.
tissue to undermine its edges below the host tissue. Intraocular 3. Drews RC. Corneal trephine. Trans Am Acad Ophthalmol
Otolaryngol 1974;78:223.
lens manipulators such as Sinskey and Lester hooks are very
4. Donaldson WBM, Haining WM. A new corneal trephine.
useful for placing and stabilizing an anterior chamber lens. Ophthalmic Surg 1979;10:55.
5. Smirmaul H, Casey TA. A clear view trephine and lamellar
QUALITATIVE KERATOMETERS dissector for corneal grafting. Am J Ophthalmol 1980;90:92.
6. Wiffen SJ, Maquire LJ, Bourne WM. Keratometric results of
The keratometers are very helpful to assess the degree of corneal penetrating keratoplasty with the Hessburg-Barron and Hanna
toricity at the end of the surgery. These can be of two types trephine systems using a standard double running suture
depending on whether they are attached to the microscope or technique. Cornea 1997;16:306.
they are hand-held. 7. Mader T, et al. Comparison of three corneal trephines for use in
• Keratometers with microscopic attachment – There are a theraeutic keratoplasties for large corneal perforations.
number of surgical keratometers like Smirmaul, Troutman Ophthalmic Surg 1995;26:209.
and Terry that are physically attached to the microscope and 8. Legeais JM, Parel JM, Simon G, Ren Q, Denham D. Endothelial
damage by the corneal Hessburg-Barron vacuum trephine.Refract
work by reflecting projected light off the surface of the cornea.
Corneal Surg 1993;9:255-8.
However, these are not portable and require a regular smooth 9. Denhem D, et al. Endothelial damage by the corneal hessburg-
refracting surface to reflect the image and are quite expensive. barron vacuum trephine. Refract Corneal Surg 1983;9:255.
• Handheld keratometer – Simpler, cost-effective and 10. Wilbanks GA, Cohen S, Chipman M, Rootman DS. Clinical
portable methods as Mandel intraoperative keratometer and outcomes following penetrating keratoplasty using the Barron-
Maloney keratometer are available which work by reflecting Hessburg and Hanna corneal trephination systems. Cornea
a circle from the corneal surface. Maloney keratometer is a 1996;15:589-98.
11. Seitz B, Langenbucher A, Diamantis A, Cursiefen C, Kuchle M,
titanium cone-shaped instrument, which is designed to reflect
Naumann GO. Immunological graft reactions after penetrating
the microscope light in rings on the cornea to detect
keratoplasty - A prospective randomized trial comparing corneal
astigmatism. In the absence of the expensive intraoperative excimer laser and motor trephination. Klin Monatsbl Augenheilkd
surgical keratometers, a safety pin can also be used to [German], 2001;218:710-9.
monitor the intraoperative astigmatism. The circle of the 12. Amsler M, Verry F. The removal of the graft for keratoplasty.
safety pin is reflected off the corneal surface and any Arch Ophthalmol (Paris) 8:150,1948.


Chapter 9: Suture Materials and Needles

Suture Materials and Needles
Rajeev Sudan, Sameer Kaushal

SUTURES strength that is maintained for many years. It has virtually no

tissue reaction and being the most inert material, is well accepted
Suture materials have an important bearing on anatomical and
by the tissues. Prolene resists microorganisms and tissue
functional success of penetrating keratoplasty. A judicious choice
enzymes. It is easy to remove when indicated, as it does not
of sutures, suture placement techniques and suture adjustment
adhere to the tissue. However, it is a stiff material and thus
can go a long way in reducing postoperative astigmatism.
difficult to handle. It is highly elastic and can stretch up to
Braided silk sutures were commonly used in penetrating
38 percent of its original length.5 Compared to nylon, it has a
keratoplasty before the advent of monofilament synthetic
longer life since it does not undergo hydrolytic degradation.
material. The braided silk sutures had the advantage of greater
Therefore unlike nylon, it does not produce the long term suture
tensile strength, extensibility, knot control, pliability and
relate complications due to loose or broken suture.3,4 Prolene is
resistance to shearability. However, it has been completely
rarely used as a single suture in keratoplasty but is used in
replaced by non-absorbable monofilament materials because of
combination in continuous interrupted pattern of suturing. Good
its rapid degradation and excessive tissue reactivity.
results have been reported with it because of its low tissue
reactivity, high tensile strength and non-absorbability.6 Prolene
because of non-biodegradability is used for iris repair or scleral
Nylon is the suture of choice in keratoplasty because of low tissue fixation of posterior chamber lens.
reactivity. Its monofilament character permits a smooth passage
through corneal tissue and a lesser tissue reaction. It is easy to Polyester (Mersilene)
handle and is very pliable. It maintains its tensile strength for
more than 1 year allowing adequate time for wound healing. It is biodegradable material and thus allows long-term tension
Nylon requires a greater care while adjusting tension and tying maintenance in keratoplasty incision. Polyester is stronger as
the knot because of its high elasticity. A tight appearing suture compared to Nylon with lesser elasticity. It has a stretch factor
may have an inadequate tension and vice-versa. of only 1 percent.5 This helps in better control of intraoperative
Nylon because of its gradual hydrolytic degradation can wound tension. Thus, a better control of postoperative
result in breakage of suture as well as relaxation of wound astigmatism is possible by suture adjustment without the need
tension. The broken suture tip can produce irritation, for suture removal.
vascularization, graft injection and rejection. Thus, it is The suture is however stiff with difficulty in handling and
preferable to remove the sutures at an appropriate interval.1-4 requires precise tensioning. Moreover, its pale green color is
10/0 is the most frequently used size because of its ease of difficult to differentiate from the background of the operative
placement and tensile strength, though 9/0 and 11/0 is also field. Early experience has shown that it has higher tissue
sometimes employed. 11/0 suture is rarely employed alone reactivity. Case reports of necrotizing scleritis has been reported
because of its lack of strength. It is most commonly used as a with the use of polyester suture.7 It attracts particulate material
running suture in conjunction with 10/0-interrupted suture or as and thus, requires particle free field. The rate of infiltration,
double running suture. infection, neovascularization and handling complications such
as exposed knots, loose and tight sutures and wound leaks are
Polypropylene (Prolene) higher.8 It has been shown to have a five-fold increase in handling
It is a non-absorbable suture material, which has been used as related complications and a two-fold increase in tissue related
haptic material for intraocular lenses. It has an excellent tensile complications when compared to nylon.

NEEDLES which require the surgeon to be vigilant in the presence of
edematous tissues
A good surgical needle should be–
i. Strong enough to withstand mechanical deformation. Mini Curve Needles
ii. Long enough to be passed through the wound and retrieved
without the need to hold the point. Mini curve needles have their cord length and radius of curvature
iii. Sharp cutting edge. significantly smaller than the full curve needles. These needles
iv. Atraumatic. have the advantage of making shorter and deeper bites. However,
Section II: Penetrating Keratoplasty

The composition of the needle should provide enough they are difficult to handle because of smaller size and tight radii.
strength to withstand mechanical force but should yield enough
not to get fractured. Bicurve Needles
A brief nomenclature of the needles used in keratoplasty Bicurve needles also achieve short and deep bites but are easier
is as follows: to handle. The design has an average to flat radius of curvature
• Length: It is the total distance of the needle from point to from the swage to midportion and a much steeper or tighter
swage before bending. radius from midportion to needle point. The architecture permits
• Cord length: It is a straight-line distance from point to swage an easier handling and a rapid turn out after a deep bite.
after bending.
• Curvature: It is that portion of circle to which the needle is Compound Curve Needles
It is a further modification of a bicurve design. The needle has
• Diameter: It is the diameter of the original wire from which
an initial flat curve changing to a steeper curve with a sharp
the needle is made. It is measured in thousand of an inch or
straight point. The straight portion facilitates initial entrance and
mils (1 mil = 0.001 inch).
penetration to a depth and steep curve immediately behind the
• Regular cutting: Regular cutting needle has a cross-section
point and assures a rapid turnout.
of a triangle with the base down. It can easily traverse tougher
tissues such as full thickness scleral grafts and through and
through corneal bites.
• Reverse cutting :It is a cross-section of a triangle with apex 1. Dana MR, et al. Suture erosion after penetrating keratoplasty.
down. Cornea 1995;14:243.
• Spatulated: Spatulated needle has a flattened reverse cutting 2. Sullivan LJ, Su C, Snibson G, Taylor HR. Sterile ocular
point without a third cutting edge on the bottom. Spatulated inflammatory reaction to monofilament suture material. Aust N
ZJ Ophthalmol 1994;22:175-81.
needles work better for intra-lamellar work such as lamellar
3. Landau D, Siganos CS, Mechoulam H, Solomon A, Frucht-Pery
keratoplasty, cataract incision closure, etc. J. Astigmatism after mersilene and nylon suture use for
• Tapered circular cross-section: This needle has the advantage penetrating keratoplasty. Cornea 2006;25:691-4.
of causing smaller tract in soft tissue and in conjunctiva. It 4. Bartels MC, van Rooij J, Geerards AJ, Mulder PG, Remeijer L.
is difficult to penetrate cornea and sclera with this needle. Comparison of complication rates and postoperative astigmatism
All keratoplasty needles are spatulated reverse cutting with between nylon and mersilene sutures for corneal transplants in
a smaller less traumatic point. patients with Fuchs endothelial dystrophy. Cornea 2006;25: 533-
The different needles used in keratoplasty are:
5. Alcon Laboratories: Manufacturers’ specifications, Alcon
a. Full curve needles
Laboratories, Fort Worth, Tx, 1998.
b. Mini curve needles 6. Faggioni R, deCourten C. Short and long term advantages and
c. Bicurve needles disadvantages of prolene monofilament sutures in penetrating
d. Compound curve needles keratoplasty. Klin Monatsbi Augenheilk 1992;200: 395-7.
7. Stokes J, Wright M, Ramaesh K, Smith C, Dhillon B. Necrotizing
Full Curve Needles scleritis after intraocular surgery associated with the use of
polyester nonabsorbable sutures. J Cataract Refract Surg
These are most frequently used in keratoplasty as well as in most 2003;29:1827-30.
anterior segment surgeries. Their curvature ranges from 140 to 8. Bertram BA, et al. Complications of Mersilene sutures in
180o. These needles achieve long and somewhat shallow bites, penetrating keratoplasty. Refract Corneal Surg 1992;8:296-305.


Chapter 10: Technique of Penetrating Keratoplasty

Technique of Penetrating Keratoplasty
Namrata Sharma, Chandra Shekhar Kumar, Samir A Melki, Rasik B Vajpayee

Penetrating keratoplasty is the corneal transplant procedure in • Pupillary Management: In cases of phakic keratoplasty
which the full thickness diseased host corneal tissue is excised without combined cataract surgery, two drops of 2.5 percent
and replaced with healthy donor cornea. The objectives of pilocarpine may be instilled 5 minutes apart at the time of
penetrating keratoplasty are to: Honan balloon placement to constrict the pupil and to protect
• Establish a clear corneal visual axis. the crystalline lens. If a combined cataract procedure is
• Minimize refractive error. anticipated, the pupil is dilated as for cataract surgery: 2.5
• Provide tectonic support. percent phenylephrine and 1 percent cyclopentolate drops
• Alleviate pain. every 5 minutes for three times.
• Eliminate infection. • Donor Corneal Tissue Management: The surgeon should
Penetrating Keratoplasty is a major intraocular surgery and personally supervise the donor tissue and the history of donor.
requires a meticulous surgical preparation of the patient, Defects may include infiltrates, retained glass or other foreign
operation theater, instruments, etc. and precise practice of debris, scars/lacerations or other pathology. Some donor
planned surgical technique by the surgeon. corneas may have undergone refractive surgical procedures
like photorefractive keratotomy and LASIK. To be able to
PREOPERATIVE PREPARATION exclude use of such tissue, a videokeratography of the donor
eyeball may have to be performed.
• Infection Control: Use of topical preoperative anti-biotics
may help to reduce the incidence of graft infection and ANESTHESIA
endophthalmitis. Topical instillation of 0.3 percent
Ciprofloxacin or 0.3 percent Ofloxacin eye drops four times Penetrating keratoplasty can be performed safely under local or
daily 2-3 days prior to the surgery is advisable. The common general anesthesia.3,4 The patient’s age, cooperation during
source of infection after a penetrating keratoplasty is usually surgery influences the choice of anesthesia. General anesthesia
from the patient’s ocular and periocular flora. The is indicated in pediatric cases and in uncooperative adults with
preoperative lid preparation should include treatment of mental impairment, deafness, aphasia, language barrier, etc. It
blepharitis and painting the lid margin and surface with 5 is also indicated in perforated corneas and in inflamed eyes where
percent povidone-iodine solution. local anesthesia is difficult to obtain.
• Decrease in Corneal Neovascularization: Various Local anesthesia can be given by retrobulbar or peribulbar
modalities that have been tried to decrease the corneal blocks.3 Long lasting anesthetic agent such as bupivacaine alone
neovascularization include preoperative steroids, or combinations of bupivacaine with lidocaine should be used.4
electrocautery, argon laser photocoagulation and adrenaline A complete lid and extraocular muscle akinesia is essential to
soaked sponges.1,2 However, most of these techniques have eliminate intraoperative pressure elevations associated with
not yielded desired and consistent results in moderate to muscle contraction. A good hypotony should be achieved
severe vascularization and are no longer used. preoperative by means of intravenous mannitol or digital
• Intraocular Pressure Control: The lack of positive pressure massage or Honan balloon.
appears to play a significant role in reducing endothelial and
lens complications intraoperatively. A good hypotony should SURGICAL PREPARATION
be achieved preoperatively by means of intravenous
Painting and Draping
mannitol, digital massage or a Honan balloon. Honan balloon
may be applied for 30 minutes at 30 mm Hg of pressure. It The surgical field should be cleaned and draped appropriately
decreases posterior pressure during open sky phase of surgery with the aim of providing a sterile field. The skin of the
and the risk of vitreous loss and choroidal hemorrhage. periorbital area may be painted with 5 percent povidone-iodine. 63
Ideally an adhesive drape should be placed in such a manner so has been damaged or lost during the trephining maneuvers. That
that the lid margins as well as the eyelashes are kept out of the is why it is important to first procure a good quality donor button
surgical field. before trephining the host cornea.

Exposure and Insertion of Lid-speculum Graft Host Disparity

To be able to perform all the surgical maneuvers required for The selection of the graft size depends on the planned diameter
corneal transplantation surgery a good exposure of the eyeball of the host cut. There are various factors, which determine the
Section II: Penetrating Keratoplasty

is mandatory. Also, any inadvertent pressure exerted by the graft host disparity. Barron has highlighted certain facts about
speculum should be avoided as it may raise the IOP and cause the graft host disparity.6
globe distortion that can lead to oval or irregular trephination, • If the diameter of the recipient bed is larger than 9 mm or
poor suture alignment and increased postoperative astigmatism. smaller than 7 mm, the graft should be larger than the host
We frequently use Barraquer wire speculum as it is lightweight, by 1 mm.
easy to insert and exposes the globe adequately. However, in • If the diameter of the recipient is between 7 mm and 9 mm
certain cases it can raise positive vitreous pressure and it is ideal and the eye is aphakic, the graft should be larger than the
to use separate wire specula put under each lid and taped or tied host by 0.5 mm, however, if the eye is pseudophakic or
to the drapes. Some surgeons use lid-sutures to expose the globe. phakic, the graft should be 0.25 mm larger than the host.
Superior and inferior recti may be bridled to stabilize the • With the recipient bed of 7.5 mm, a 0.5 mm oversized graft
eye. Additionally, in cases with small palpebral fissure, lateral induces myopia of 4 diopters; with an 8.0 mm recipient bed,
canthotomy may be performed to increase the area of exposure. a 0.5 mm oversized graft induces 2.5 diopters of myopia.
• With a 7.5 mm bed, a 0.25 mm oversized graft does not
Placement of Scleral Fixation Ring usually induce any refractive error.
• A graft which is the same sized or smaller than the recipient
Patients of high myopia, pediatric age group, keratoconus, etc. opening decreases the myopia but can result in a flat cornea
have low ocular rigidity and can develop scleral collapse after which may not be amenable to contact lens fitting.
the trephination of recipient cornea. The resultant displacement • Most corneal surgeons use a 0.5 mm oversized graft for their
of iris, lens and vitreous can cause extrusion of lens and vitreous routine cases. In certain situations like keratoconus, the graft
loss. Even if there is no resultant complication, the collapse of host disparity is less, i.e. 0.25 mm to compensate for the
the recipient corneal rim makes suturing very difficult. Some associated myopia.
surgeons prefer to use scleral-supporting devices in such patients. Some surgeons prefer to use a 0.5 mm oversized donor graft
These scleral support rings include McNeill-Goldman scleral and for all the cases including those with keratoconus. Irrespective
blepharostat ring and Flieringa ring. The size and the placement of the diameter of the host cut, we use 1 mm oversized grafts in
of any such ring must be such that it does not interfere and hinder cases with severe corneoiridic scars7 and pediatric eyes.8
maneuvers required to perform the procedure of penetrating The donor cornea may be cut using one of the following
keratoplasty or distort the globe. The fixation ring diameter is methods:
sized to measure slightly less than the interpalpebral opening. • Harvesting the donor graft from the whole globe stored in a
The ring should be sutured with only enough force to rest gently moist chamber using hand-held or suction fixation trephines.
on but not to press the sclera. The scleral fixation ring is sutured • Harvesting donor graft from McCarey-Kaufman preserved
with interrupted 7-0 vicryl sutures with 50 percent of the corneoscleral button using hand-held trephines or endothelial
thickness of scleral bite. These sutures should be passed from punch systems.
periphery to the limbus. Fixating the ring just peripheral to the • Harvesting the donor cornea using artificial anterior chamber
limbus gives maximum scleral support. These rings can also be maintainer.
grasped during trephination to fixate the globe.
Many surgeons have however abandoned the use of fixation Harvesting the Donor Graft from the Whole Globe
rings as these may cause distortion of the globe, especially in Stored in a Moist Chamber Using Hand-held or
pediatric and aphakic patients where the scleral rigidity is low, Suction Fixation Trephines
resulting in ovalling of the trephined opening.5
In this technique, the donor graft is cut from the epithelial side
TREPHINATION OF DONOR CORNEA and the grafts are the same sized or 0.25 mm larger than the
intended recipient opening. Many surgeons who do not have
It is recommended that the donor corneal button be cut before access to the McCarey-Kaufman preserved corneoscleral buttons,
the recipient cornea. This helps to ensure that a good quality especially in developing countries, use the whole eye globe which
and optimally prepared donor button is available prior to is fixated in the gauze piece or on a Tudor Thomas stand.
trephination of the recipient cornea. At times it has happened The globe in a moist sterile gauze piece is held in the non-
that the donor button has been cut in an irregular manner and dominant hand, taking care that the cornea is perpendicular to

the gauze piece. If the eye is tilted, the cut may be misdirected. and through trephining of the donor button. The punched cut
Through a small stab incision in the limbus one may inject corneal button either stays in the well of the teflon block or
viscoelastic into the anterior chamber prior to trephination. Then may pass up into the barrel of the blade. If the donor button
using a sharp trephine in the dominant hand, the blade is placed has been sucked inside the trephine, a viscoelastic substance
centrally on the donor eye. Using counter pressure with one hand, like 2 percent methyl cellulose is gently squirted into the
the trephine is firmly placed into the cornea and rotated with barrel to dislodge the button. In order to confirm that the
the fingers while exerting pressure downwards. A release of donor button has been cut circumferentially all around, the

Chapter 10: Technique of Penetrating Keratoplasty

pressure will be noted when the anterior chamber is entered. peripheral skirt of the corneoscleral rim may be retracted over
Trephination must then stop immediately, otherwise the the barrel of the trephine.
endothelium will come in contact with the iris. The initial cut is The button is grasped with a forceps and placed epithelial
finished with the scissors, taking care not to shelve the edge. If surface down over the graft holder. The endothelium is
minimal pressure is used, an air bubble will spontaneously fill covered by viscoelastic to prevent desiccation.
the chamber and protect the endothelium from the iris and the • Using the corneal endothelial punch systems Corneal
lens. The cut is completed with the curved corneal scissors. endothelial punch system incorporating the use of a
The donor button is then picked with the Pierse Hoskins or disposable circular trephine is an ideal technique to harvest
a Colibri forceps and is placed endothelial side up on a drop of the graft from the donor button and most surgeons prefer to
balanced salt solution on a glass Petri dish. Viscoelastic/MK use these systems. However, use of these systems is not very
medium (if available) may be placed on the endothelial surface frequent in developing countries due to the cost factor.
to prevent it from drying while the recipient cornea is being Various corneal punches that can be used to harvest donor
trephined. The Petri dish is then covered and placed at a safe graft include Cottingham punch, Barron vacuum donor
and designated place. corneal punch, IOWA PK Press corneal punch and Rothman-
Gilbard corneal punch. These punches make a sharp vertical
Harvesting the Donor Graft from cut with relatively more accurate centration. These punches
Preserved Corneoscleral Button can use trephine blades of various diameters. The basic
method of punching is similar for all the trephine systems.
It has been observed that the corneal grafts cut from the
The corneoscleral donor button is placed endothelial side
endothelial side are smaller by 0.2 mm to those cut from the
epithelial side.6-9 Since most surgeons prefer to cut the graft up on a cutting block and a barrel mounted circular trephine
is brought down through the central part of system in a single
from the endothelial side, it is advisable to oversize the graft
motion cutting the donor button.
by 0.25-0.5 mm. Principally, depending on the availability of
the types of trephines, one of the two techniques may be used to The functioning of Barron vacuum donor cornea punch
is slightly different. This punch consists of nylon cutting
punch the preserved corneoscleral donor button, i.e. the hand-
block, seating ring and a blade. The cutting block has 4 holes
held trephines and the endothelial punch systems.
• Use of hand-held trephines This technique is used in most into which the steel guidepost of the blade fit to ensure that
the blade is perpendicular. The well of the cutting block has
developing countries, where the endothelial punches may not
a diameter of 19 mm and a radius of curvature of 25.4 mm,
be available due to increased expense.
The donor button is cut over a cutting block, which may except for the central 11 mm, which has a radius of curvature
of 10 mm. The well has a central positioning hole, as well
be made of Teflon, Nylon or Paraffin and has a concave
as four additional holes and a circular trough 12 mm in
depression, or a well in which the donor cornea is placed
with epithelial surface down.10 Various trephines have been diameter that are connected by a silicone tube to a 5 ml
syringe with a spring loaded plunger. The syringe creates
developed for cutting the donor cornea but a standard
suction that holds the cornea in place as it is cut and ensures
trephine consists of a disposable circular stainless steel blade
on a handle. The blade should be properly secured on the that the corneal button remains in the well, and not in the
blade, after the cut has been made. When inked with gentian
handle and the obturator fully retracted to avoid its contact
violet, the four holes in the well mark the cornea for accurate
with the endothelium. Donor cornea should be cut by
punching rather than rotating the blade.10,11 Rotation of the placement of the cardinal sutures.
blade results in more endothelial damage. The blade should
Trephining the Donor Cornea Using Artificial
always be held perpendicular to or centered on the cutting
Anterior Chamber Maintainer
block. The slipping of blade should be guarded against, as
it can result in oblique cutting of the cornea with resultant An Olson calibrated cornea trephine system is also used to cut
irregular or oval button with beveled or ragged edge. These the donor tissue. The system consists of an anterior chamber
irregularities can distort the wound and cause significant maintainer, a re-usable blade holder (with micrometer setting),
postoperative astigmatism. and a suction ring attached to a syringe. A small drop of
A uniform pressure should be applied over the blade with viscoelastic is placed on the top of the endothelium of the donor
the thumb and an audible click signifies the complete through tissue and the tissue is centered on to the anterior chamber
maintainer (epithelial side up). Air is used to create the anterior
chamber. The suction ring is placed on the donor cornea and is
activated by releasing the syringe. Following placement of the
trephine (which consists of the blade holder with the blade) on
the suction ring, the lever of the suction ring is pressed to lower
the blade onto the donor tissue and the trephine is turned to
complete the cut.
Section II: Penetrating Keratoplasty

Non-mechanical Laser Trephination

Nonmechanical laser trephination can also be performed from
the epithelial side on the donor. This avoids the mechanical
distortion during trephination resulting in smooth almost
perpendicular edges that are congruent in the donor and thus
potentially improves the optical performance after trans-
plantation.12 Figure 10.1: Vernier calipers used
for marking the geometric center
Trephination of the donor cornea is done using a 193 nm
excimer laser. A circular round metal aperture mask consisting
of eight orientation teeth (diameter 7.6 to 8.1 mm; central
opening 3 mm for centration) are positioned on a corneoscleral
button (16 mm diameter) fixed in an artificial anterior chamber
maintainer under microscopic control.13 The pressure within the
artificial chamber maintainer is adjusted to 20 mm Hg by
attaching it to an infusion system. Using an automated rotation
device for the artificial chamber (four rotations per minute),
approximately 11,000 laser pulses are necessary to perforate the
cornea focally. After perforation, the remaining stromal lamellae
and the Descemet’s membrane are cut with a curved corneal


The centering of the graft is of utmost importance as any Figure 10.2: Geometric center of cornea marked
decentration may lead to increased risk of graft-rejection, and
high postoperative astigmatism as well as damage to the anterior
chamber angle.
The donor graft is usually centered on the host cornea or
over the pupillary axis.14 A decentered graft may be preferred
in certain situations.6 In a cornea with peripheral perforation, a
decentered graft which encompasses the area of perforation and
clears the pupil is preferred in comparison to a large, centered
If a previous decentered graft has failed, the previous
keratoplasty wound is ignored and the second graft is centered
on the geometric center of the cornea. The geometric center is
located by measuring the horizontal and vertical diameter of the
cornea with calipers (Fig. 10.1), halving each measurement and
finding the point at which the horizontal diameter line bisects
the vertical one. A centration mark is made on the anterior corneal Figure 10.3: Marks applied with suture marker using
gentian violet
surface with a surgical marking pen (Fig. 10.2).
After marking the geometric center of the cornea or the
center of the pupil, radial keratotomy markers [8 arms, 16 arms] antitorque and no torque15 The cornea should be thoroughly dried
may be used for creating impression marks guiding exact suture before putting the marker. The arms of the suture markers are
placement. We have designed a Vajpayee’s corneal marker which stained with gentian violet and the marker is pressed on the
has 20 radial arms and can be used to guide the placement of 20 corneal surface of the recipient (Fig. 10.3). While using such
bite single continuous sutures of various types such as torque, marker, care should be taken to ensure that the center of the
marker and the previously marked geometric center on the host
cornea coincide.


The size of the area on the diseased cornea to be trephined

depends upon many factors. These include diameter of the
patient’s cornea, extent of corneal disease and avoidance of use

Chapter 10: Technique of Penetrating Keratoplasty

of very small and very large grafts. The size of host cut guides
the diameter of the donor graft. Very small and very large host
cuts and corresponding diameters of donor graft may be
associated with occurrence of certain complications. While grafts
smaller than 6.5 mm can cause a high postkeratoplasty
astigmatism, a large sized host cut requiring placement of a
corresponding large donor button may carry a risk of
immunological rejection.17-19 We generally create a host cut Figure 10.4: Hand-held trephine used for trephination
ranging from 7 to 8 mm in routine cases. A larger host cut may
be needed in cases of infectious keratitis or in keratoconus. In
cases of keratoconus it is imperative that whole of the cone is
included in the host cut. Additionally, patients with poor
endothelial cell function such as Fuchs’ dystrophy or
pseudophakic or aphakic bullous keratopathy may benefit from
increased number of endothelial cells in a larger graft.
Based on the host corneal diameters and the induced myopia
after penetrating keratoplasty, the following recommendations
have been made. In patients with larger-than-average corneal
horizontal diameter (limbal white-to-white measurement ≥ 12.5
mm) an 8.25 or 8.5 mm host trephine be used and for patients
with a smaller-than-average corneal diameter (white-to-white
measurement ≤ 11.5 mm), a 7.5 or 7.75 mm trephine should be
For cutting the recipient cornea the conventional hand-held Figure 10.5: Partial thickness mark given
trephines as well as the suction and automated trephines have by hand-held trephine
been used. Uniformity of the cuts varies with the trephine type
and an ideal trephine, which provides straight cuts without tissue
be thoroughly dried before trephining. The trephine is held
distortion, is not yet available. Graft curvatures are generally perpendicular to the cornea and positioned by aligning the center
greater with suction trephines than the hand-held ones. of this blade with the centration mark on the cornea and checking
the amount of cornea surrounding the blade (Fig. 10.4). The
Trephining with Hand-held Trephines
trephine is then rotated between the thumb and the forefinger
The “standard” trephine, i.e. Castroviejo trephine consists of a maintaining a downward pressure. Care is taken to avoid
circular blade on a handle. The circular blade can be used alone. applying undue external pressure on the eye with the trephine.
The handle has an internal obturator, which limits the depth of Some surgeons prefer to trephine almost to the full thickness
the cut. The obturator, however, can distort the cornea and cause whereas others recommend a guarded entry (Fig. 10.5). In the
an irregular, non-circular cut if it comes in contact with the former, the cut is perpendicular and allows easier removal of
corneal apex before the blade touches the cornea. This can the host cornea. In the latter, a partial thickness cut up to the
happen most frequently in patients of keratoconus. A disposable pre-Descemet’s membrane is made first. A full thickness cut is
open bladed trephine may be used as it trephines the recipient generally avoided as it may cause an uneven entry into the
without distorting the cornea and simultaneously allows anterior chamber, which may lead to its collapse; further pressure
visualization of the optical centration mark. applied may lead to damage of iris or lens or extrusion of the
The optical axis of the recipient’s cornea is marked by the lens. Once a partial thickness cut is made, anterior chamber entry
surgeon, using wherever possible the central point, as described is done with a blade, most conveniently at 11 o’clock position.
earlier. The blade of the trephine should always be examined The escape of the aqueous should be carefully noted to
under microscope to check for the regularity and sharpness of ensure a full-thickness incision. If the aqueous humor is not seen,
the edge before proceeding to trephination. The cornea should it is possible that the host’s Descemet’s membrane has been

Section II: Penetrating Keratoplasty

Figure 10.6A: Corneal scissors used to cut the cornea Figure 10.6B: Corneal scissors completes the excision of the
recipient bed

detached from the posterior stroma. This occurs most likely in

patients with bullous keratopathy and CHED and if inadvertently
left, may result in double anterior chamber postoperatively.
Viscoelastic substance, such as hydroxypropylmethyl
cellulose (2%) or sodium hyalunorate (1%), is injected from the
entry site to deepen the anterior chamber. This protects the iris
and the lens against any possible trauma with the scissors blade.
Corneal scissors used to complete the cut should have a longer
posterior blade and a blunt tip to protect iris and the lens
(Fig. 10.6A). The blade of the corneal scissors should be held
perpendicular to the cornea, so as to achieve a vertical cut. The
cornea is cut full thickness along the trephine cut by closing the
scissors as an upward pressure is applied. This is done to prevent
the scissors from plunging posteriorly and damaging the iris and
the lens. Some surgeons prefer to hold the scissors slightly Figure 10.7: Posterior ledge cut with Vannas scissors
obliquely to leave a small posterior ledge along the recipient
cut (Fig. 10.6B). It helps in avoiding inadvertent cutting of the Trephining the Recipient Cornea with
iris and the presence of a posterior ledge offers better apposition Suction Trephine
while suturing. The cornea must be stabilized with the forceps
once half of it has been cut. Any iris or vitreous attachment to Suction trephines like Barron radial vacuum trephine can also
the posterior surface is severed with the scissors before lifting be used for trephining the host corneas16 (Fig. 10.8). These fixate
the corneal button. the cornea by suction during trephination and are particularly
In perforated corneas, the anterior chamber is frequently useful in perforated corneas and result in less anterior chamber
shallow and entering the anterior chamber through the cut collapse and corneal distortion.20-22 These create a sharper,
obtained by the trephine may cause damage to the underlying deeper and more perpendicular incision than free blades.
iris and the lens. In such cases, the posterior blade of the scissors The Barron radial vacuum trephine is available in diameters
may be inserted through the site of the perforation and cuts can of 6.0 to 9.0 mm, in 0.5 mm increments, as well as a diameter
be made radially towards the trephine cut like the spokes of the of 7.75 mm. This trephine consists of a body and a blade
wheel. assembly. The body contains two plastic struts for holding and
If some posterior tags of the corneal tissue are inadvertently stabilizing the trephine and a circular vacuum chamber is
left at the edges of the trephined area, these are trimmed with a recessed slightly relative to the outer wall to account for the
curved corneal or Vannas scissors (Fig. 10.7). The anterior anterior corneal curvature. The vacuum chamber is connected
chamber is filled with a viscoelastic to maintain the dome and by a silicone tube to a 5 ml syringe with a spring-loaded plunger.
the orientation of the donor button for accurate placement of The blade assembly contains a blade, cross hairs for centering
the sutures and to prevent any endothelial decompensation. the trephine, and four plastic spokes for turning the blade. The

inner wall of the body and the outer wall of the blade assembly
are threaded so they fit together in a nut and bolt fashion. The
blade is lowered or raised by turning the spokes clockwise or
counterclockwise, respectively. For each spoke turned, the blade
is lowered or raised approximately 60 mm.
Before placement on the cornea, the trephine is examined
under the microscope and the edge of the blade is aligned with

Chapter 10: Technique of Penetrating Keratoplasty

the inner wall of the vacuum chamber. This position is called
the zero position. The blade is then retracted approximately 0.18
mm by turning the spokes 270 degrees (three spokes), which
prevents the blade from hitting the cornea and interfering with
suction as the trephine is placed on the eye.
The plunger of the syringe is pushed all the way, the cross
hairs of the trephine are aligned with the centration mark on the
cornea, the trephine is pressed evenly and the plunger is released Figure 10.8: Hessberg-Barron suction trephine used to
abruptly. If suction has been obtained, the plunger stops at about trephinate the recipient bed
the 4 ml mark on the syringe. If the plunger rebounds all the
way out, suction has not been obtained and the above process is edges, thus reducing the vertical tilt.12 Trephination is performed
repeated. After suction has been obtained, the position of the using 193 nm excimer laser along metal mask (diameter
trephine on the cornea is assessed by confirming that the cross 12.9 mm; central opening 7.5 to 8 mm; 8 orientation notches
hairs and centration mark are aligned and by checking the amount 0.15 to 0.3 mm) which is placed on the recipient cornea.
of cornea surrounding the outer wall of the vacuum chamber. Manually guided excimer laser is used. For focal corneal
The trephine is stabilized by gently holding the struts, and perforation on an average 7,000 laser pulses are required. To
the cornea is cut by turning the spokes clockwise. The suction complete trephination, the remaining deep stromal lamellae and
orients the trephine perpendicular to the cornea. As the blade is Descemet’s membrane are cut with a curved corneal
lowered, the trephine is steadied but its angle to the cornea should microscissors.13
not be forcible changed. The initial 270 degree (three-spoke)
turn lowers the blade to the zero position. Because of the anterior SUTURING OF DONOR CORNEA
corneal curvature, the cornea is cut slightly when the blade is
lowered to this position. The number of spokes to turn further Placement of the Donor Cornea on the Recipient
depends on the desired depth of cut and the corneal thickness:
The anterior chamber of the host is filled with a viscoelastic,
fewer for a shallow cut or a thin cornea and more for a deep cut
which helps to maintain dome of the donor button and its
or a thick cornea. It is preferred that the cornea be cut as close
orientation for accurate suture placement and further provides
to the Descemet’s membrane as possible, without entering the
endothelial protection. Balanced salt solution or air can be used
anterior chamber. The barrel of the trephine should be watched
for anterior chamber maintenance as well, but they are not so
as the blade is lowered because if the anterior chamber is
effective during the graft placement.
inadvertently entered, aqueous humor will appear in the barrel.
The donor cornea is brought into the field of microscope on
If this occurs, the plunger of the syringe is pushed in all the way,
a graft holder (Fig. 10.9). The edge of the button is placed on
which releases the suction and the trephine is removed from the
eye. After the cut has been made up to 90 percent depth, the
trephine is removed from the eye by pushing the plunger of the
syringe in all the way, which releases the suction. The anterior
surface of the cornea is dried to reveal the 16 radial impressions
made by the trephine, and each impression is marked with a
surgical marking pen containing gentian violet. Each impression
starts 0.2 mm from the edge of the cut and is 0.5 mm in length.
Subsequently, the anterior chamber may be entered with a
diamond blade and the cut is completed with corneoscleral

Non-mechanical Trephination of the Recipient Cornea

Non-mechanical trephination of the recipient cornea is associated
with less deformation of the corneal tissue including the
distortion of the cut margins and smoother and congruent cut Figure 10.9: Paton spatula used to hold the graft
Section II: Penetrating Keratoplasty

Figure 10.10: First cardinal suture passed Figure 10.11: Second cardinal suture passed

the inferior limbus and the graft holder is slid down so that it Interrupted sutures are recommended in infants and children,
too rests on the limbus. It is then rotated slightly further so that highly vascularized corneas and in therapeutic keratoplasty. They
the anterior layers of the donor button can be grasped with a have the advantage of selective suture removal if need arises,
forceps. Alternatively, the corneal button can be flipped e.g. loose-suture, vascularized suture, suture abscess, etc.
completely over the corneal opening. Inversion of the corneal Interrupted sutures are placed in a manner similar to that used
button should be avoided by noting the orientation of the button for cardinal sutures. The needle should pass anterior to the
in the well or by the curvature of the button. The button is Descemet’s membrane. The suture length should be about 2 mm,
grasped with a “Polack” forceps and brought to the superior edge 1 mm on each side. Full-thickness suture should not be put as
of the recipient corneal opening and sutured to recipient cornea these cause more endothelial trauma and aqueous may leak
with 10-0 nylon suture on a spatulated side-cutting needle. through the suture tracts postoperatively. A total of 16 sutures
are usually placed with second four sutures equidistant between
Placement of the Cardinal Sutures the first four sutures and the second eight equidistant between
It is necessary to place four cardinal sutures first. The first suture the first eight sutures.19 More sutures may be required for larger
may be placed at 12 o’clock position followed by 6 o’clock grafts or in cases in with the recipient cornea is thin. If interrupted
suture (Fig. 10.10). The needle is passed between the two tips sutures are combined with a running suture, a total of 8,12 or
of Polack double corneal forceps exiting just anterior to 16 sutures are usually placed.
Descemet’s membrane. The needle is passed through the The knot ends are trimmed short and buried just beneath the
recipient cornea at the radial marks and should exit at 1 mm epithelium of recipient or the donor cornea. We generally prefer
from the edge. The suture is tied with a triple-throw, followed to bury the knots on the donor cornea as, if buried on the recipient
by two single throws. side, they may stimulate vascularization. However, some
The second suture is placed 180° from the first suture and is surgeons advocate that the knots should not buried on the donor
the most important suture in penetrating keratoplasty as it cornea as on removal they can create traction on the graft and
establishes equal distribution of the tissues (Fig. 10.11). Its result in dehiscence.
improper placement can cause severe postoperative astigmatism. If a single running suture technique is used a 10-0 nylon
The prior placement of radial marks can eliminate this problem. suture is placed after the cardinal sutures are in position and
The third and fourth sutures are placed through the marks 90° 20-24 bites are taken instead of 16. In double running suture
from the first two sutures. The first four sutures are known as technique, an 11-0 nylon suture may be placed between each
the cardinal sutures. The tension on the cardinal sutures should bite of a 16 bites 10-0 nylon suture. When a single running suture
be such that that a diamond-like shape appears after their is used torque, anti-torque or no torque suturing techniques can
placement. be used (Fig. 10.12). Each of these continuous suturing
techniques is amenable to suture adjustment in cases of
Placement of the Other Sutures astigmatism.

The rest of the sutures may be put as interrupted sutures, a single

Check for Wound Leakage
running suture or double running sutures. Long-term follow-up
shows no significant difference in astigmatism between the suture After the completion of the suturing, the wound is tested for water
techniques.23 tightness. This is done after drying the surface with a cellulose

may be manipulated towards the smallest diameter of the oval
so that a circular mire is obtained (Figs 10.13A and B).



A subconjunctival injection of an antibiotic (gentamicin 20 mg)

and steroid (dexamethasone 4 mg) combination is given in

Chapter 10: Technique of Penetrating Keratoplasty

inferior fornix at the end of the surgery and the patient is given
Figure 10.12: Types of continuous suturing
pad and bandage for 24 hours. We follow the following
postoperative regime in various cases of penetrating keratoplasty
sponge pressing at the limbus and observing the wound for at our center.
leakage of aqueous humor. Topical fluorescein is a better method
of evaluation for wound leakage. Here the fluorescein is instilled Antibiotics
at the wound margins. In the presence of wound leak due to
Topical antibiotics such as 0.3 percent ofloxacin or 0.3 percent
dilution of the dye, fluorescein appears to be bright green and a
ciprofloxacin are used four times a day for 1 week
track of aqueous leak can be observed. If a wound leak is present,
postoperatively or until the epithelium is healed. Prolonged use
additional sutures should be applied appropriately.
of topical aminoglycosides is toxic to the epithelium and hence
should be avoided. Topical ofloxacin may be preferred as it has
Intraoperative Adjustment for Astigmatism
better penetration than ciprofloxacin and norfloxacin and also
An intraoperative keratoscope may be helpful in reducing better activity against alpha-hemolytic streptococci.13 Fortified
postoperative astigmatism by recognizing areas of steepness or antibiotics such as fortified tobramycin 1.3 percent or cefazolin
flatter meridian. A suture adjustment may be done until regular 5 percent may be given in cases where penetrating keratoplasty
mires are obtained. Intraoperative keratoscopes available include has been performed for uncontrolled infectious keratitis varying
those with microscope attachment such as Terry’s or those which in frequency from 30 minutes to 4 hourly which (if the infection
are based on the reflection of the mires from the corneal surface, is controlled) can be tapered over a 2 to 3 weeks period,
such as Maloney’s and Mandel’s keratometer. Alternatively, the postoperatively.
round end of a safety pin may be used and the reflex of the In fungal keratitis, 5 percent Natamycin drops may be used
circular image may be evaluated to adjust the suture placement postoperatively for several weeks.6
and hence correct for astigmatism intraoperatively. If the mires Oral acyclovir may be given (400 mg 5 times/day) in herpetic
are circular, generally minimal astigmatism is present; if however keratitis and continued for 1 to 3 weeks and then decreased to
the ovalling of the mires is present, the suture should be adjusted maintenance dose (400 mg BD) for several months.22, 23
in such a manner so as to achieve circular shape of the mires. In Systemic antibiotics such as ciprofloxacin 500 to 750 mg or
cases with interrupted sutures, the tight sutures (which are present ofloxacin 200-400 mg may be given twice daily perioperatively
along the shorter diameter of the oval) may be replaced by the and for 3-5 days after the surgery in the following conditions:
sutures which have optimal tension. Similarly, if a continuos • Pre-existing external eye infection
suture is used, the loop along the largest diameter of the oval • Prosthesis use in the fellow eye

Figure 10.13A: Pre-adjustment videokeratography Figure 10.13B: Post-adjustment videokeratography

map of a patient of the torque group map of a patient of the torque group
• Penetrating trauma 2. Nirankari VS, Baer JC. Corneal argon laser photocoagulation for
• Combined procedures especially with vitrectomy or neovascularization in penetrating keratoplasty. Ophthalmology
intraocular lenses. 1986;93(10):1304-9.
3. Feibel RM. Current concepts in retrobulbar anesthesia. Surv
Ophthalmol 1985;30:102.
4. Atkinson WS. Local anesthesia in ophthalmology. Am J
Topical corticosteroids such as 1 percent prednisolone acetate Ophthalmol 1948;31:1607.
or 0.1 percent dexamethasone sodium phosphate may be used 4 5. Vajpayee RB, Melki S. Three pearls to minimize penetrating
Section II: Penetrating Keratoplasty

keratoplasty astigmatism. In: 101 pearls in Refractive, Cataract

to 6 times a day in routine keratoplasty. These are then tapered
and Corneal Surgery 2001 Eds. Melki SA, Azar DT. SLACK Inc.,
over several months. They are used more frequently, i.e. in
Thorofare, New Jersey. Chapter 20: 161-62.
1 hourly or 2 hourly dosage in cases of – 6. Barron BA. Penetrating keratoplasty In: The cornea. Eds.
• High-risk keratoplasty Kaufman HE, Barron BA, McDonald MB. Chapter 34 805-46.
• Patient develops Butterworth-Heinemann 1998, Boston.
– Increased inflammation 7. Vajpayee RB, Dada T, Ray M, et al. Oversized corneal grafts for
– Keratic precipitates on graft corneal opacities with corneo-iridic scar. Ophthalmology 108,
– Increased corneal thickness. 2001.
8. Vajpayee RB, Ramu M, Panda A, et al. Oversized grafts in
Systemic corticosteroids, i.e. Prednisolone 1 mg/kg/day is
children. Ophthalmology 1999;106:829-32.
started 1 to 2 days before surgery and tapered over 2 to 3 weeks 9. Olson RJ. Variation in corneal graft size related to trephine
in high risk keratoplasties. technique. Arch Ophthalmol 1979;97:1323-5.
10. Brightbill FS, Polack FM, Slappey T. A comparison of two
Antiglaucoma Medications methods of cutting donor corneal buttons. Am J Ophthalmol
Prophylactic antiglaucoma medication such as timolol maleate
11. Tanne E. A new donor cutting block for penetrating keratoplasty.
0.5 percent twice a day should be given in following cases: Ophthalmic Surg 1981;12:271.
• Pre-existing glaucoma 12. Seitz B, Langenbucher A, Kus MM, et al. Nonmechanical corneal
• Penetrating keratoplasty combined with trephination with the excimer laser improves outcome after
– Cataract surgery penetrating keratoplasty. Ophthalmology 1999;106:1156-64.
– Vitrectomies 13. Langenbucher A, Seitz B, Kus MM, et al. Graft decentration in
– Lysis of synechiae penetrating keratoplasty: nonmechanical trephination with the
excimer laser (193 nm) versus the motor trephine. Ophthalmic
– Use of large amounts of hyaluronate
Surg Lasers 1998;29:106-13.
– Anterior segment reconstruction 14. Uozato H, Guyton DL. Centering corneal surgical procedures.
Am J Ophthalmol 1987;103:264-75.
Cycloplegics 15. Vajpayee RB, Sharma V, Sharma N, et al. Evaluation of
techniques of single continuous suturing in penetrating
Short-acting agents such as tropicamide 1 percent or
keratoplasty. Br J Ophthalmol 2001;85:134-8.
cyclopentolate 1 percent may be given for early postoperative 16. Verdier DD. Penetrating keratoplasty. In: Cornea surgery of the
pain and inflammation control. Strong agents such as atropine cornea and conjunctiva. Vol. III Eds. Krachmer JH, Mannis MJ,
should be avoided in cases of keratoconus because of reports of Holland EJ. Chapter 130; 1581-92. Mosby, St. Louis, 1997.
permanent pupillary dilatation (Urrets-Zavalia syndrome). Wide 17. Bourne WM, Davidson JA, O’Fallon WM. The effects of oversize
dilatation of the pupil in cases of posterior chamber IOL may donor button on postoperative intraocular pressure and corneal
increase the risk of formation of synechiae to the posterior curvature in aphakic penetrating keratoplasty. Ophthalmology
capsule and capture of the edge of the lens with iris. Wide 1982;89:242.
18. Wiffen SJ, Maguire LJ, Bourne WM. Keratometric results of
dilatation should also be avoided in cases where large grafts have
penetrating keratoplasty with the Hessburg-Barron and Hannah
been used as this may cause crowding at the angle and adherence trephine systems using a standard double running suture
to the posterior edge of the wound.6 technique. Cornea 1997;16:306.
19. Waring GO III. Management of pseudophakic corneal edema with
Lubricants reconstruction of anterior ocular segment. Arch Ophthalmol
In routine keratoplasties, preservative free lubricants may be
20. Cohen SW, Benko W. Automated motorized penetrating
given at 2 hourly to 4 times daily dosage. Epitheliotoxic drugs keratoplasty. Ann Ophthalmol 1977;14:1461.
such as beta-blockers, non-steroidal anti-inflammatory drugs and 21. Weiner M, alvis BY. Transplantation of cornea by means of a
topical aminoglycosides should be used with caution. mechanically obtained bevelled edge segment. Am J Ophthalmol.
REFERENCES 22. Denham D, et al. Endothelial damage by the corneal Hessburg-
Barron vacuum trephine. Refract Corneal Surg. 1993;9:255.
1. Lim KJ, Wee WR, Lee JH. Treatment of corneal neovas- 23. Filatov V. Comparison of suture-in and suture-out post-
cularization with argon laser. Korean J Ophthalmol 1993;7:25- keratoplasty astigmatism with single running or combined and
27. interrupted sutures. Am J Ophthalmol 1996;122:696.

Chapter 11: Suturing Techniques in Penetrating Keratoplasty

Suturing Techniques in
Penetrating Keratoplasty
C Banu Cosar, Peter R Laibson

INTRODUCTION In very young pediatric keratoplasty, interrupted sutures are

used almost exclusively. For older children some surgeons
Obtaining a clear graft in penetrating keratoplasty has become
advocate a running closure providing there is no asymmetric
almost expected. For most eyes undergoing penetrating
vascularization.12,13 Single interrupted sutures are also indicated
keratoplasty, the success rate for a clear graft exceeds 90
in vascularization in the host cornea. So that, partial suture
percent.1 However, postoperative astigmatism still remains a
removal may be performed earlier in these vascularized areas
problem that can prevent the functional success of clear graft.2
in the postoperative course. Multiple previous rejections,
There are many factors contributing to astigmatism after
inflammatory conditions that may predispose to localized
penetrating keratoplasty, including pre-existing corneal thinning
vascularization, rejection, or ulceration are other indications for
and vascularization, eccentric trephination of the donor or host,
single interrupted sutures.14
oversized grafts, pre-existing keratoconus, quality of wound
Interrupted sutures are placed with 10-0 nylon. Sixteen is
healing, and astigmatism of donor eye. Tension, length, depth
the average number of interrupted sutures placed for a typical
and configuration of corneal sutures have also been implicated
8 mm diameter graft. Twenty-four or 32 sutures may be necessary
as causative factors.3
in larger grafts. An 8-blade RK marker can be used as a guide
There are mainly four types of suturing techniques in
(Fig. 11.1). The first cardinal suture is placed at 12 O’clock
penetrating keratoplasty:
position. The second cardinal suture, placed 180 degrees away
1. Interrupted sutures
at 6 O’clock, is the most critical in terms of tissue alignment
2. Combined interrupted and continuous sutures
and subsequent astigmatism. It should be placed so that an equal
3. Single continuous suture
amount of tissue is distributed on either side. Then, cardinal
4. Double continuous sutures
sutures at 3 O’clock and 9 O’clock are placed followed by other
Many authors have compared the effectiveness of these
suturing techniques in terms of astigmatism, visual outcome, and
complications.4-10 However, it is dificult to corroborate the results
of these various studies because of the differences in techniques,
indications, timing of suture adjustment and removal, and follow-
up periods. However, all suturing techniques have been used
successfully to secure the wound and create a relatively smooth
corneal contour. Therefore, specific suturing technique is mainly
dictated by the expertise and preference of the surgeon, and by
the presence or absence of localized disease (Table 11.1).


Single Interrupted Suturing Technique

Interrupted sutures are commonly used by many corneal

surgeons11 because they are easy to place and permit partial or Figure 11.1: Eight-blade RK marks on the cornea to assist in
complete suture removal in one region of the graft if necessary. suture placement. The Flieringa ring is in place

Section II: Penetrating Keratoplasty

Figure 11.3: Penetrating keratoplasty with 16 interrupted sutures

Figure 11.2: Penetrating keratoplasty with 16 interrupted sutures. which are too tight. Note guttering of fluorescein at the host-
Note the smooth contour of the host-donor junction with the slit donor junction and whorl superficial punctate keratopathy of the
illumination donor cornea

sutures. The sutures should be placed as radially and as evenly interrupted suture so that the epithelial portion of the continuous
spaced as possible, with the ideal depth of each suture bite suture lies across the wound between the interrupted sutures. If
90 percent. They should neither be too loose or too tight suture bites are made halfway between the interrupted sutures,
(Figs 11.2 and 11.3). The knots can be buried either in the host the superficial segment will lie across the interrupted sutures,
tissue or the donor tissue. We prefer to bury the knots in the providing little additional wound support. The ideal depth of the
donor tissue to induce less vascularization in the graft.15 Some suture bites is 95 percent. 11-0 mersilene suture has also been
surgeons bury the knots in the host tissue so that after the knots reported to be an effective suture material in this technique for
are cut and the suture is pulled, there is less tension on the graft- either interrupted or the running suture.17,18
host junction, reducing the chance of dehiscence if the sutures
are removed during the early stages of postoperative wound Single Continuous Suturing Technique
healing.16 There are 3 types of single continuous suturing techniques –
namely, torque, antitorque and no torque (Fig. 11.5). The torque
Combined Continuous and Interrupted pattern rotates the corneal graft counterclockwise by
Suturing (CCIS) Technique 0.7 +/- 0.1 mm at the wound or 11 degrees; the antitorque pattern
rotates the corneal graft clockwise by 0.7 +/- 0.1 mm at the
This technique is most often performed using 12 interrupted 10-0
wound or 11 degrees; the no torque pattern, the bites of which
nylon sutures and a 12 bite continuous 10-0 or 11-0 nylon
running suture with bites of the continuous suture placed between form an isosceles triangle, produces no rotational effect.19 In the
antitorque suturing technique, the distortion occurs more in the
each of the interrupted sutures (Fig. 11.4). The needle pass of
deeper layers of cornea and does not contribute much to
the continuous suture bites should be made close to the
postoperative corneal astigmatism. However, with the torque
suturing technique, the oblique overlying suture segment causes
distortion of anterior corneal surface contributing to corneal
astigmatism postoperatively. In the no torque technique, since
the intrastromal bytes and the overlying sutures are at equal
inclination, they act as a splint and cause less corneal
distortion.19,20 Vajpayee RB et al evaluated these 3 single
continuous suturing techniques in penetrating keratoplasty and
found that the torque suturing technique showed the highest
astigmatism although the difference among the three was not
A single continuous suture is technically more difficult than
interrupted sutures, because one irregular bite can impair the
integrity of the closure and cannot be removed without removing
the entire suture. The four cardinal sutures are placed in the
Figure 11.4: Combined technique, using 8 interrupted and 16- regular manner followed by a 24 bite continuous suture with 10-0
bite running 10-0 nylon sutures nylon with a 95 percent depth. The continuous suture is knotted
Chapter 11: Suturing Techniques in Penetrating Keratoplasty
Figure 11.5: Three types of single continuous suturing technique in penetrating keratoplasty

Figure 11.6: Twenty four-bite single Figure 11.7: Double continuous technique
continuous 10-0 nylon suture with 10-0 and 11-0 nylon sutures

temporarily at 12 O’clock while the four interrupted cardinal suture adjustment, early postoperative suture adjustment (< 2 wk)
sutures are carefully removed. The anterior chamber is inflated and late postoperative suture adjustment (>1 month) concluded
with BSS plus. The continuous suture is tightened and is then that early postoperative suture removal was more effective than
permanently knotted at 12 O’clock (Fig. 11.6). If the continuous late postoperative suture removal. The same study found that
suture is tightened when the eye is soft, “barrel topping” of the intraoperative suture adjustment may further reduce final
graft with a topographically flat donor cornea results.14 11-0 astigmatism and the necessity for postoperative suture
mersilene has also been reported to be an effective suture material manipulation.24 Whereas, another study compared early suture
for the single continuous suturing technique.21 removal (<18 months after surgery), late suture removal (>=18
months after surgery) and leaving the sutures in place, and
Double Continuous Suturing Technique concluded that final refractive error and net change in refractive
and keratometric astigmatism are not dependent on the timing
After the four cardinal sutures are placed, a 12 bite 10-0 nylon
of suture removal.25
suture is placed with bites at approximately 80 percent depth.
Suture adjustment or removal should be performed as early
The suture is then knotted superiorly and the knot is buried in
as possible to provide early visual rehabilitation. A previous study
the host cornea. A second continuous suture (either 10-0 or
tested the hypothesis that the cornea becomes fixed more than
11-0 nylon) is then placed. The bites should alternate between
1 year after PK, so that desirable refractive results will remain
each 10-0 bite for 360 degrees. The second 10 or 11-0 is placed
when all sutures are eventually removed. However, when the
approximately 50 to 60 percent the corneal depth (Fig. 11.7).
remaining sutures were removed 1 to 6 years after PK, corneal
astigmatism changed unpredictably and by large amounts.26
Topographical analysis using keratometry, photokeratoscopy,
The purpose of suture adjustment is to minimize postoperative or videoeratography, individually or in combination, are helpful
astigmatism. Postoperative suture adjustment is less effective in in planning suture adjustment.27 However, often there is a
reducing spherical refractive errors. Final suture removal may disagreement between the topographically determined steep axis
induce either hyperopization22 or corneal steepening.23 and sutures to be removed, and that determined by keratometry
Many studies have been performed previously to address the and refraction. Agreement between refraction, keratometry, and
ideal timing for suture removal. A study comparing intraoperative topography are associated with greater change in vector corrected
astigmatism. Disagreement between refraction, keratometry, and carefully advanced from the flat to the steep meridian,
topography is associated with less vector corrected astigmatism simultaneously flattening the steep meridian and steepening the
but patients in the disagreement group has a greater chance of flat meridian. Adjustment can be repeated more than once if
improvement than worsening following suture removal.28 desired. Acceptable astigmatism with sutures in allows the patient
Suture adjustment can take the form of removal of all sutures, to achieve early visual rehabilitation.
partial suture removal, or adjustment in the tension of a running The risk of breakage during the adjustment procedure should
suture. If corneal astigmatism is satisfactory with sutures in place, be considered seriously but is not common. Suture breakage can
Section II: Penetrating Keratoplasty

sutures should remain until there is some indication for removal, result in wound dehiscence and requires prompt repair in the
such as scarring, vascularization, suture breakage, loose operating room. Consequently, suture adjustment of the single
interrupted sutures, and pronounced inflammation, or infiltration continuous suture should not be attempted unless facilities are
around sutures.14 available to make the repair.
The suture removal or adjustment is performed at the slit
lamp with topical anesthesia guided by the computerized Double Continuous Sutures
topography, or keratometry or refraction, or by a combination
Double continuous suture technique may involve a 10-0 and an
of the three, as well as slit lamp evaluation. One drop of antibiotic 11-0 nylon suture or a double 10-0 running suture. The deeper,
is placed in the eye after removal or adjustment. The patient is
tighter 10-0 suture may be removed or adjusted. And the
given antibiotic drop four times a day and antibiotic ointment at
shallower 11-0 or 10-0 suture is left in place as a safety net.
bed time for 3 or 4 days.
The topographic changes induced by suture removal occur
immediately. However, continued shifting in corneal curvature CONCLUSION
takes place over the subsequent 4 to 6 weeks.29 Astigmatic errors All suturing techniques have been used successfully to secure
become stable, with less than 1 D of change between successive the wound and create a relatively smooth corneal contour. Suture
examinations within 6 months after suture removal.30 adjustment can be performed intraoperatively and
postoperatively. Sutures should be left in place once the suture
Single Interrupted Sutures
has been adjusted to achieve suitable topography.
The only adjustment possible with single interrupted sutures is
removal and therefore flattening. We start removing the sutures
at 1 year after the surgery unless otherwise indicated. A very
tight suture can be removed as early as 6 weeks. In the case of 1. Price FW, Whitson WE, Collins KS, Marks RG. Five-year corneal
a suture that loosens or becomes undone in the first few weeks graft survival. Arch Ophthalmol 1993;111:799-805.
after keratoplasty, if there is a wound gape this suture can be 2. Hardten DR, Lindstrom RL. Surgical correction of refractive
errors after penetrating keratoplasty. Int Ophthalmol Clin 1997;
replaced under topical anesthesia. The suture at the steepest
meridian indicated by computerized topography analysis is cut
3. Riddle HK, Parker DAS, Price FW. Management of post-
either with a razor blade fragment or a disposal 27-gauge needle. keratoplasty astigmatism. Curr Opin Ophthalmol 1998;9:15-28.
It is removed with a tying forceps or a jewelers forceps. A sudden 4. Karabatsas CH, Cook SD, Figueiredo FC, Diamond JP, Easty DL.
jerk is more effective at removing the interrupted suture than Combined interrupted and continuous versus single continuous
slower, less forceful pressure. adjustable suturing in penetrating keratoplasty: a prospective,
In pediatric keratoplasty, every other interrupted 10-0 nylon randomized study of induced astigmatism during the first
suture is removed in the early postoperative period, followed postoperative year. Ophthalmology 1998;105:1991-98.
by complete removal of sutures at a later date. All sutures in 5. Busin M, Monks T, al-Nawaiseh I. Different suturing techniques
patients less than a year are usually removed within 8 weeks. variously affect the regularity of postkeratoplasty astigmatism.
Ophthalmology 1998; 105(7):1200-05.
Combined Continuous and Interrupted Sutures 6. Murta JN, Amaro L, Tavares C, Mira JB. Astigmatism after
penetrating keratoplasty. Role of the suture technique. Doc
At approximately 2 to 3 months after PK, corneal topography is Ophthalmol 1994;87:331-36.
evaluated and a very tight interrupted suture can be removed. 7. Filatov V, Steinert RF, Talamo JH. Post-keratoplasty astigmatism
Usually this does not occur until six months from the time of with single running suture or interrupted sutures. Am J
surgery. A disadvantage of CCIS suture adjustment is that only Ophthalmol 1993;115:715-21.
the tight suture can be removed, therefore, only the steep axis 8. Assil KK, Zarnegar SR, Schanzlin DJ. Visual outcome after
can be flattened. Another disadvantage is that interrupted sutures penetrating keratoplasty with double continuous or combined
are very difficult to remove after several years. interrupted and continuous suture wound closure. Am J
Ophthalmol 1992;114:63-71.
Single Continuous Suture 9. Solano JM, Hodge DO, Bourne WM. Keratometric astigmatism
after suture removal in penetrating keratoplasty: double running
Adjustment of the single continuous suture can change corneal versus single running suture techniques. Cornea 2003;22(8):
topography and still support the wound. The suture is very 716-20.
10. Ramirez M, Hodge DO, Bourne WM. Keratometric results during 21. Touzeau O, Borderie VM, Allouch C, Scheer S, Laroche L.
the first year after keratoplasty: adjustable single running suture Effects of penetrating keratoplasty suture removal on corneal
technique versus double running suture technique. Ophthalmic topography and refraction. Cornea 1999;18:638-44.
Surg Lasers 2001;32:370-74. 22. Mathers WD, Gold JB, Kattan H, Lemp MA. Corneal steepening
11. Rapuano CJ, Luchs JI, Kim T. Anterior segment surgery and with final suture removal after penetrating keratoplasty. Cornea
complications. In: Krachmer JH, editor. Anterior segment: The 1991;10:221-23.
requisites in ophthalmology. St. Louis: Mosby, 2000;232-85. 23. Frueh BE, Brown SI, Feldman ST. 11-0 mersilene as running
12. Stulting RD. Penetrating keratoplasty in children. In: Brightbill suture for penetr ting keratoplasty. Am J Ophthalmol 1992;114:

Chapter 11: Suturing Techniques in Penetrating Keratoplasty

FS, editor. Corneal surgery: theory, technique, and tissue Mosby: 675-79.
St. Louis, 1993. 24. Shimazaki J, Shimmura S, Tsubota K. Intraoperative versus
13. Dana MR, Moyes AL, Gomes JAP, Rosheim KM, Schaumberg postoperative suture adjustment after penetrating keratoplasty.
DA, Laibson PR, Holland EJ, Sugar A, Sugar J. The indications Cornea 1998;17:590-94.
for and outcome in pediatric keratoplasty: a multicenter study. 25. Serdarevic ON, Renard GJ, Pouliquen Y. Randomized clinical
Ophthalmology 1995;102:1129-38. trial of penetrating keratoplasty. Before and after suture removal
14. Van Meter W, Katz DG. Keratoplasty suturing techniques. In: comparison of intraoperative and postoperative suture adjustment.
Krachmer JH, Mannis MJ, Holland EJ, editors. Cornea, Vol 2, Ophthalmology 1995;102:1497-503.
Surgery of the cornea and conjunctiva, ed.2. St. Louis: Mosby, 26. Davis EA, Azar DT, Jakobs FM, Stark WF. Refractive and
2005;1481-92. keratometric results after the triple procedure: experience with
15. Dana MR, Schaumberg DA, Kowal VO, Goren MB, Rapuano early and late suture removal. Ophthalmology 1998;105:624-30.
CJ, Laibson PR, Cohen EJ. Corneal neovascularization after 27. Mader TH, Yuan R, Lynn MJ, Stulting RD, Wilson LA, Waring
penetrating keratoplasty. Cornea 1995;14:604-09. GO. Changes in keratometric astigmatism after suture removal
16. Melles GRH, Binder PS. A comparison of wound healing in more than one year after penetrating keratoplasty. Ophthalmology
sutured and unsutured corneal wounds. Arch Ophthalmol 1980; 1993;100:119-26.
108:546-48. 28. Strelow S, Cohen EJ, Leavitt KG, Laibson PR. Corneal
17. Bigar F, Uffer S. The unsolved problem of transplant astigmatism. topography for selective suture removal after penetrating
Klin Montsbl Augenheilk 1992;200:401-03. keratoplasty. Am J Ophthalmol 1991;112:657-65.
18. Ramselaar JA, Beekhuis WH, Rijneveld WJ, van Andel MV, Dijk 29. Sarhan AR, Dua HS, Beach M. Effect of disagreement between
F, Jongebloed WL. Mersilene (polyester), a new suture for refractive, keratometric, and topographic determination of
penetrating keratoplasty. Doc Ophthalmol 1992;82:89-101. astigmatic axis on suture removal after penetrating keratoplasty.
19. Au YK, Mahjoub SB, Hart JC. Suture patterns and corneal graft Br J Ophthalmol 2000;84:837-41.
rotation in the cadaver eye. Ophthalmic Surg. 1990;21:472-74. 30. Goren MB, Dana MR, Rapuano CJ, Gomes JAP, Cohen EJ,
20. Vajpayee RB, Sharma V, Sharma N, Panda A, Taylor HR. Laibson PR. Corneal topography after selective suture removal
Evaluation of techniques of single continuous suturing in for astigmatism following keratoplasty. Ophthalmic Surg Lasers
penetrating keratoplasty. Br J Ophthalmol 2001;85:134-38. 1997;28:208-14.

Section II: Penetrating Keratoplasty

Postoperative Care after

Penetrating Keratoplasty
Raj Maini, Urmimala Ghatak, Hugh R Taylor

The postoperative care of a corneal graft is probably more Increased pain, irritation, redness, decreased vision and
important in determining the long-term outcome of the graft than photophobia are important symptoms. Patients should seek
the surgery itself. A lack of careful attention to prevention of, referral immediately in the event that they experience any of these
early detection and prompt treatment of rejection episodes may and should be examined within twenty-four hours of symptom
lead to graft failure in an otherwise technically perfect graft. onset.
The postoperative care in penetrating keratoplasty (PK) is It is also important the patient avoids any situation that may
far more complex than that after cataract surgery. With the advent produce trauma to the eye, such as heavy lifting, eyelid
and increasing popularity of endothelial keratoplasty and deep squeezing, contact sports, etc.
anterior lamellar keratoplasty techniques for lower risk
indications, the postoperative care for the more complex patients STANDARD POSTOPERATIVE CARE
requiring full-thickness grafts becomes even more crucial.
Routine postsurgical care involves the use of topical This section covers postoperative care in uncomplicated corneal
antibiotics until epithelial defects are healed. The use of topical grafting in nonvascularized eyes, typically with keratoconus or
steroids to minimize postoperative inflammation, reduce immune corneal dystrophy (Fig. 12.1, Table 12.1).
sensitivity and chance of rejection must be carefully tailored.
Frequent clinical assessments in the early postoperative period Early Postoperative Management
are directed at prevention and early recognition of the myriad At the completion of surgery, subconjunctival corticosteroid and
of complications that can occur after PK. This can make the antibiotic of choice are usually administered. Though
difference between surgical success and failure. intracameral antibiotic injection is gaining popularity as this has
It is very important to instruct the patient regarding symptoms been shown to be safe and efficacious in cataract surgery2 there
of rejection, but even having done this, a significant proportion is a paucity of data in this regard for PK. The eye may be patched
of episodes of clinically evident rejection are picked up during for 24 hours with antibiotic ointment. We prefer to use
routine postsurgery visits.1 fluoroquinolone ointment.

Table 12.1: Follow-up schedule

1 week 1 month 3 months 6 months 1 year
• Visual acuity • Visual acuity • Visual acuity • Visual acuity • Visual acuity
• Graft clarity • Graft clarity • Graft clarity • Graft clarity • Graft clarity
• Status of corneal • Sutures • Sutures • Sutures • Sutures
epithelium • AC depth, • AC depth, • AC depth, • AC depth,
• Sutures: tight/loose/ inflammation inflammation inflammation inflammation
broken, infiltrates • Lens status • Lens status • Lens status • Lens status
• AC depth, inflammation • Fundus • Fundus • Fundus • Fundus
• Lens status • IOP • IOP • IOP • IOP
• Fundus • Corneal topography • Corneal topography • Corneal topography • Corneal topo-
• IOP +/- suture adjustment +/- suture adjustment +/- suture adjustment graphy +/- suture
• Selective suture • Selective suture adjustment
removal removal • Suture removal
• Refractive
the leak persists for > 3 days, wound resuture should be
• Pupil shape
• Corneal epithelial status
• Extreme anterior chamber shallowing or iris incarceration
in the wound—requires immediate surgical management
• Elevated intraocular pressure-treat medically in the first

Chapter 12: Postoperative Care after Penetrating Keratoplasty

• Early signs of infection or endophthalmitis—this requires
aggressive medical and/or surgical management.
Topical medication should be commenced:
• Topical antibiotic: Fluoroquinolone eyedrops 4 times daily
until epithelium is healed—usually within 7-14 days
Figure 12.1: Routine one month postoperative appearance • Topical steroid: The use of topical corticosteroids is
of a penetrating keratoplasty universal, but the dose requirements may vary widely
between individual cases. Fluorometholone acetate 0.1
The oral carbonic anhydrase inhibitor acetazolamide may be
percent or Prednisolone acetate 1 percent are generally used
used to prevent a rise in intraocular pressure, especially if
4 to 6 times daily initially.
viscoelastic has been used. Topical carbonic anhydrase inhibitors,
Fluorometholone acetate 0.1 percent may be considered as
e.g. dorzolamide may controversially interfere with endothelial
first-line treatment because it has less epithelial toxicity than
function and should be avoided.
Prednisolone acetate 1 percent and is less likely to result in
Criteria for discharging the patient from hospital (in a
elevation of intraocular pressure. Recently Rimexolone 1 percent
daycare setting) include
• Stable vital signs has been touted as a potent topical anti-inflammatory agent
• Return to the preoperative mental state without the potential intraocular pressure problems encountered
• Absence of nausea with topical Dexamethasone. Other topical steroid preparations,
• Absence of unusual pain such as Prednisolone sodium phosphate are not potent enough
• Availability of an escort to produce adequate therapeutic effect.
• Review of postsurgical care with the patient and/or escort, In uncomplicated corneal grafts, the topical steroid medi-
including medication dosage cation may be gradually reduced as the inflammation within the
• Prearranged follow-up appointment eye diminishes. A typical regimen is outlined in Table 12.2.
• Written postoperative instructions. Intraocular pressure and the status of the lens must be
monitored carefully, for as long as the steroids are used.
First Postoperative Day
Postoperative Visits
The eye pad is removed at first dressing, but the eye should be
protected during sleep with a shield for the first 4-6 weeks and There are many postoperative care regimens; the key to them
the patient’s head should be slightly elevated (“higher than the all is a careful slit lamp examination. In addition to the signs
patient’s heart”). outlined above (day 1 assessment), the patient must be assessed
At this stage, it is mandatory to assess: for early signs of rejection: corneal stromal thickening, fine
• Visual acuity epithelial edema, aqueous flare and cell, but especially keratic
• Degree of pain precipitates (KP) (Figs 12.2 and 12.3). The presence of a few,
• Slit lamp examination fine keratic precipitates when there were none at previous visits
At slit lamp examination particular attention must be paid is indicative of early rejection and must be treated vigorously
to: with hourly topical steroid. Keratic precipitates can only be
• The presence of a wound leak-relative hypotony, unusual assumed to be ‘old pigmented KP’ if they do not resolve with
stromal swelling and a shallow anterior chamber should alert intensive treatment. If graft rejection does not improve with
you to the possibility of this. Assess the leak with the Seidel hourly topical steroids, topical cyclosporine A may be added.
test; treatment may require insertion of a therapeutic The use of pulsed high-dose systemic immunosuppression3,4 is
(bandage) contact lens or aqueous production inhibitors. If not universal.5

Table 12.2: Use of topical steroids in penetrating keratoplasty

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7

Fluorometholone acetate 0.1 percent Fluorometholone alcohol 0.1 percent

4-6 hrly 4x/day 3x/day 2x/day 4x/day 3x/day 2x/day
rosacea and blepharitis, which must be treated. Lubrication,
patching, a bandage contact lens, botulinum toxin, surgical ptosis
or tarsorraphy may be required.
Loose sutures may be secondary to poor surgical technique,
wound contraction, suture breakage or cheese wiring. They trap
mucous and can result in infection or stimulate graft rejection
or giant papillary conjunctivitis. They do not contribute to wound
Section II: Penetrating Keratoplasty

integrity and should be removed. Vascularization along suture

tracks indicates a healed wound and these sutures may also be
removed safely.
Patients who are grafted for corneal dystrophy must be
examined for recurrence of the dystrophy within the graft tissue;
fungal, viral and amebic infections may all recur within corneal
Figure 12.2: Early graft rejection manifesting an endothelial grafts and treatment should be directed towards the causative
(Khodadoust) rejection line agent.
A patient without signs or symptoms of complications should
be examined on a regular basis for 18-24 months (Table 12.3).
Progress of improvement and the course of complications should
be documented by detailed clinical drawings or anterior segment
photography at each visit.
Graft clarity and visual acuity should begin to improve in
the early postoperative period. Persistent graft edema from the
first dressing and continuing in the absence of inflammation may
indicate primary graft failure—this may be confirmed with
pachymetry and specular microscopy.
After suture removal, the patient will not require more
planned appointments. Patients should however, still be
instructed to consult an ophthalmologist promptly in the event
of any rejection symptoms. If a patient has had a rejection
episode, an argument can be made to continue long-term, low
Figure 12.3: Established graft rejection with graft thickening, dose topical steroid such as Fluorometholone alcohol 0.1 percent
keratic precipitates and neovascularization at the graft-host once or twice a day.
The prescription of spectacles or contact lenses depends on
a number of factors. The patient’s visual needs are paramount,
but the healing process, the amount of astigmatism, the presence
Deturgescence of the graft in the short to medium term can of sutures and the stability of the refractive error may all be
be monitored using pachymetry. important factors. Refraction and computerized topographic
Fundoscopy should be undertaken within the first month after mapping with suture adjustment will aid visual rehabilitation in
surgery to assess the optic nerve (glaucomatous damage, the first year. Selective suture removal may be indicated where,
atrophy), macula (age-related degeneration, scarring) and interrupted sutures have been used. Temporary spectacles may
peripheral retina (retinal tears or detachment). be prescribed within a few months of surgery to aid with the
The presence of a non-healing corneal epithelial defect for rehabilitation process.
more than 14 days increases the risk of stromal ulceration with The final spectacles are prescribed when the sutures have
subsequent corneal stromal thinning, perforation or scarring. been removed and the refraction and corneal curvature have
These patients should be carefully assessed for ocular surface stabilized. Occasionally residual or irregular astigmatism may
disease and lid malposition, in particular dry eye, exposure, require rigid gas-permeable contact lens fitting.

Table 12.3: Postoperative penetrating keratoplasty outpatient schedule

Month 1 Month 2 Months 3-12 Months 13-24

Every 2 weeks Every 4 weeks Every 6 weeks Every 6-12 weeks until
all sutures are removed

CORNEAL GRAFTING IN OCULAR antibiotic and steroid if needed. Topical Cyclosporine 0.05
SURFACE DISEASES percent emulsion has been used in the management of posterior
blepharitis and ocular rosacea. 6 The value of systemic
This section includes management of keratoplasty in
tetracyclines in the treatment of rosacea should not be forgotten.
lagophthalmos, entropion, lid scarring, dry eye, chemical burns
and ocular cicatricial pemphigoid.
Postoperative Prevention of Epithelial Problems
Overview Careful clinical examination for lash, lid abnormalities and

Chapter 12: Postoperative Care after Penetrating Keratoplasty

abnormalities of the ocular surface is mandatory.
Penetrating keratoplasty in these conditions presents a
considerable management challenge, primarily aimed at
optimizing the health of the ocular surface. Trichiasis
The integrity of the corneal epithelium after keratoplasty is Epilation is temporary as lashes normally regrow within 2 to 3
vital for graft survival. The normal intact corneal epithelium weeks. Electrolysis works well only for removing a few lashes.
provides an optical interface with the tear film and a barrier to Cryotherapy is the treatment of choice to remove ingrowing
the external environment, noxious substances, and lashes.
microorganisms. The presence of an epithelial defect interferes
with vision and increases the risk of rejection, infection, thinning Dry Eye
and perforation. Epithelial defects occur frequently on the first
postoperative day in donor corneas stored in both McCarey- Punctal occlusion may be of benefit for patients with
Kaufman (MK) medium and organ culture medium. keratoconjunctivitis sicca to prevent epithelial ulceration
Toxic topical medication and preservatives may have an postkeratoplasty. Punctal occlusion increases tear retention and
adverse effect on epithelial wound healing because of the resultant increase in the tear volume to surface area (TVSA)
inhibition of epithelial migration, epithelial mitosis, or epithelial ratio. Options include temporary punctal occlusion using punctal
attachment to the underlying basement membrane; if these plugs or permanent punctal closure with laser, cautery or
problems are encountered the patient should be switched to diathermy.
unpreserved medication or commenced on these immediately Topical Cyclosporine 0.05 percent shows beneficial effects
postoperatively. in all categories of dry eye disease.7
Abnormalities of the tear film from decreased aqueous
secretion, rapid evaporation, mucin deficiency, blepharitis, poor
lid position or movement and lagophthalmos can influence Surgical options to correct this include lateral tarsorrhaphy or
epithelial healing and wound healing. Some systemic medications lateral canthal sling procedures.
may exert an indirect effect on the corneal epithelium through The therapeutic effect of these procedures is attributable to
effects on tear secretion and epithelial cell wound healing. the decrease in exposed ocular surface area, which increases the
Local primary ocular surface disease, for example, Ocular TVSA ratio, protecting the epithelial surface and promotes
Cicatricial Pemphigoid, Stevens-Johnson syndrome or chemical spreading of the tear film.
burns may prevent normal epithelial wound healing secondary The ocular surface should be kept well lubricated with
to lid scarring, resulting in entropion and trichiasis. Disturbed artificial tears, if required more frequently than 4 to 6 times daily.
anatomy with symblepharon, ankyloblepharon and goblet cell Unpreserved solutions should be used to minimize epithelial
deficiency with resultant tear film abnormalities, or intrinsic toxicity. Unpreserved drops can be used every hour or more
epithelial abnormalities can also delay healing. frequently if needed. However, if required more than every two
Patients may present with inadvertent self-inflicted epithelial hours, punctal plugs should be considered. Carbomer gel based
damage through mechanical trauma with fingernails, mascara medication (e.g. Viscotears) and ointments without preservative
brushes, or curling irons and through the abuse of topical are retained in the conjunctival fornices for longer and may also
medication. be used four times a day and supplemented with unpreserved
It is critical for the survival of the donor corneal epithelium tears and/or punctal plugs.
that existing dry eye or local ocular surface disease, such as Patients with sensitivity to lanolin or wood should avoid
ocular pemphigoid, be recognized, treated and controlled before lanolin-containing ointment.
surgery. Topical antibiotics, antivirals, timolol and steroids may all
Aberrant lashes (trichiasis) should be eliminated either by exert a toxic effect on the epithelium and should not be used
electrolysis, or cryotherapy. Lid margin entropion or ectropion, indiscriminately.
lagophthalmos, and lid scarring should be surgically corrected Botulinum toxin ptosis is another treatment for persistent
prior to penetrating keratoplasty. epithelial defect: 7.5 units are injected into the orbital roof,
Blepharitis, whether from local or systemic disease, such as adjacent to levator palpebrae superioris. The ptosis develops in
rosacea, must be controlled with lid hygiene, topical lubrication, 2-3 days, resolves in 6-8 weeks and injections can be repeated.
Autologous serum tears containing vitamin A, epidermal Penetrating keratoplasty for non-inflammatory perforation or
growth factor and transforming growth factor-beta have been trauma requires antibiotic cover postoperatively to minimize the
shown to be of benefit in persistent epithelial defects;8 they can risk of infection and endophthalmitis.
be administered 4-6 times daily.
Corneal blindness secondary to infective keratitis is a major
One of the major causes of corneal graft failure is inadequate problem in most parts of the world. Early diagnosis, better
Section II: Penetrating Keratoplasty

control of elevated intraocular pressure (IOP). Significant understanding of pathogenesis, and the availability of potent
endothelial cell loss occurs because of acute and greatly elevated antimicrobial drugs have improved the success rate for medical
intraocular pressure. control of corneal infections, particularly those of bacterial
This is encountered secondary to severe anterior chamber origin. However, virulent and resistant forms of some bacteria,
reaction and may require treatment with topical β-blockers, such fungi and Acanthamoeba can progress inexorably, even with
as timolol maleate 0.5 percent twice daily; α-blockers (e.g. maximal medical therapy, and these may necessitate penetrating
brimonidine) in those with relative contraindications to β- keratoplasty.
blockers may be considered.
Topical prostaglandin analogues are controversial and may Bacterial Keratitis
theoretically stimulate graft rejection, although this has not been
Postkeratoplasty, in the presence of active keratitis, antimicrobial
borne out in practice and these useful drugs are in widespread
treatment is directed against the offending microbe (Fig. 12.4).
use after PK. Dorzolamide may affect the donor endothelial If an etiologic diagnosis has not been established, antibiotic
function and result in prolonged graft edema and should be
coverage with combination therapy or with a broad-spectrum
avoided postkeratoplasty.
medication should be undertaken.
Miotics are known to dilate the ocular blood vessels and Where, the sensitivities are known, the topical antibiotic with
break down the blood-aqueous barrier inducing chronic
the least toxicity, to which the organism is most sensitive, should
iridocyclitis. Miotic use in aphakic patients is associated with
be administered frequently until sterilization is achieved.
increased risk of retinal tear and subsequent retinal detachment. In cases where, the organism and\or sensitivity is unknown,
Systemic carbonic anhydrase inhibitors (e.g. acetazolamide)
combination therapy (e.g. fortified cephazolin and tobramycin)
must be used with great caution in elderly keratoplasty patients
or a broad-spectrum antibiotic (such as a fluoroquinolone) should
as they may trigger a malaise symptom complex consisting of
be given. Cycloplegics are used to alleviate discomfort and
fatigue, depression, anorexia and weight loss; the diuretic effect minimize posterior synechiae, and antiglaucoma medication used
of this drug must also be considered in patients with
as required.
cardiovascular disease.
To minimize the risk of rejection, topical corticosteroids may
If seclusio pupillae develops secondary to posterior be used judiciously. If sensitivities are known, hourly or two-
synechiae, laser iridotomy may be needed to prevent or treat
hourly Fluorometholone acetate 0.1 percent or Prednisolone
pupil block.
acetate 1 percent can be used under sufficient antibiotic cover;
Anti-inflammatory therapy can result in steroid induced in the absence of confirmed sensitivities more cautious use of
glaucoma and topical medication should be carefully tailored to
topical medication is recommended, e.g. Fluorometholone
avoid this.
acetate 0.1 percent 4 times daily.


Special precautions should be taken in cases of rheumatoid

arthritis, collagen diseases, perforation and trauma.
Postoperative care in these cases is often governed by how
well the ocular inflammation has been controlled preoperatively;
the chances of a successful outcome being inversely proportional
to the inflammatory status of the eye at surgery.
The presence of active systemic vasculitis has a bearing on
long-term outcome of grafting and should be monitored and
treated aggressively in the perioperative period; this may
necessitate the use of systemic as well as intensive topical
immunosuppression (see below—high risk keratoplasty).
Tight control of the systemic disease is necessary to
maximize graft survival and should be undertaken in conjunction
with a rheumatologist or immunologist. Figure 12.4: Microbial keratitis occurring in the graft
If perforation occurs, structural integrity can be maintained patients require frequent renal function monitoring. The HEDS
with tissue adhesive (cyanoacrylate or fibrin ‘glue’) until the study did not examine the effect of topical acyclovir as this
infection and inflammation has receded, when regrafting can be preparation is not available in the USA, it may have a role in
safely undertaken. prevention of recurrent disease in patients with a good fellow
Fungal Keratitis Valacyclovir 500 mg OD for one year has been found to have
equal efficacy as oral Acyclovir 400 mg BD in the prevention
Filamentous (Moulds) e.g. Aspergillus, Fusarium, the following

Chapter 12: Postoperative Care after Penetrating Keratoplasty

of recurrent lesions in immunocompetent individuals with ocular
regimens are currently recommended:
• Topical Natamycin 5 percent every hour initially herpes simplex virus (HSV) disease. 12 Prophylactic oral
Valacyclovir treatment is also at least as effective as oral
• Fluconazole 200-400 mg daily or topical preparation
Acyclovir in preventing recurrence in patients who underwent
1 percent
• Cyclosporine A (CsA) topically 4 times daily corneal transplantation for herpetic keratitis.13
Cyclosporine A—one drop 4 times daily may also be useful
Non-filamentous (Yeasts) e.g. Candida in controlling inflammation.
• Topical amphotericin B 0.075 – 0.15 percent every hour
• Cyclosporine A 4 times daily HIGH-RISK CORNEAL GRAFT
In patients not responding to conventional antifungal therapy,
Immunosuppression in High-risk Keratoplasty
Voriconazole (oral 200 mg BD, 2 hrly 1 percent topical eyedrops,
(Table 12.4)
intrastromal injection 50 micrograms/0.1 ml) may be used.9,10
Topical corticosteroids are used only under extremely special Two approaches can be taken to prevent immune mediated
conditions in which removal of the entire infected area has been rejection and ultimately failure (Fig. 12.5) in high-risk corneal
ensured. transplantation:
• Suppression of the host immune response.
Acanthamoeba Keratitis • Making the donor tissue less antigenic: Animal studies have
demonstrated reduced rejection rates for corneal allografts
• Topical amoebicidal drugs
after pretreatment with ultraviolet B irradiation14 and the use
• Polyhexamethyl biguanide (PHMB) 0.02 percent every 2
of anti CD4 receptor antibodies.15
These are difficult cases and should be managed in
• Propamidine isethionate (Brolene) 0.1 percent every 2 hours
conjunction with an immunologist. The role of human leukocyte
• Chlorhexidine every 2 hours
antigen class I and II matching is at present unproven in most
• Neosporin every 2 hours
• Topical corticosteroids may be given judiciously
Options for immunosuppression (these may be used as single
• Systemic steroids and itraconozole may be required
agents or in combination) include:
• Oral nonsteroidal anti-inflammatory agent
• Cycloplegic Corticosteroids
• Topical anti-acanthamebal medication is often required for
many months to eradicate the infection. Topical: Topical steroids continue to be the primary immuno-
suppressive agents in the postoperative management of high-risk
Herpes Simplex keratoplasty:

Recurrence of herpes simplex infection in the graft may lead to

or mimic a rejection episode. It is often difficult to distinguish
between the two and treating a recurrence as a rejection with
intensive topical steroid will allow uncontrolled proliferation of
the virus. Therefore treatment should be aimed at both, balancing
the epithelial toxicity of the antiviral medication with the
deleterious effect of the steroid on the virus infection.
Acyclovir given orally 200 mg 4 times daily for 4/12, then
twice daily for 4/12 may prevent recurrences of epithelial
keratitis (the Herpetic Eye Disease study—HEDS—
demonstrated this effect while treatment continued).11 It has
therefore been suggested (especially for monocular patients) that
systemic acyclovir treatment may be required on an indefinite
basis for patients at high risk of recurrent epithelial HSK. Such Figure 12.5: Graft failure secondary to profound rejection

Table 12.4: Side effects of immunosuppressive agents in high-risk penetrating keratoplasty

Topical steroid Systemic steroids Topical CsA Systemic CsA Azathioprine

Glaucoma, cataract, Weight gain, Ocular discomfort, Hypertension, Anemia,
delayed wound Hypertension, Conjunctival injection, nephrotoxic, neurotoxic, thrombocyto-
healing, infectious hyperglycemia, Punctate keratopathy hepatotoxic, hirsutism, penia, leucopenia,
keratitis peptic ulcer, growth gingival hyperplasia, bone marrow
retardation, mental reactivation of latent suppression,
Section II: Penetrating Keratoplasty

changes, cataract, infections alopecia,

osteoporosis, gastrointestinal
susceptibility to toxicity
infections, avascular
hip necrosis

Topical Fluorometholone acetate 0.1 percent or Prednisolone • Used as a ‘steroid sparing’ agent in rejection for high-risk
acetate 1 percent every 2 hours is most commonly used. keratoplasty.
Systemic: Systemic steroids can be used as an adjunct to topical Renal, hepatic and bone marrow function must be monitored.
therapy in high-risk keratoplasty to minimize risk of rejection: Reversible leucopenia may occur in up to 20 percent of patients.
Methylprednisolone 125–250 mg intravenously at the time
of surgery followed by oral Prednisolone 1 mg/kg/day slowly Mycophenolate Mofetil
tapered in 3-6 months may be useful in high-risk cases.
• 2000-3000 mg daily.
Alternatively, Prednisolone 100 mg orally for 2-3 days, then • Suppresses lymphocyte proliferation in a similar manner to
tapered over two weeks maybe used.
Severe or refractory rejection may also respond to systemic
Used successfully to treat refractory rejection in renal
immunosuppression. The role of pulsed intravenous transplantation, it has a low incidence of significant adverse
methylprednisolone for severe rejection is not proven and may
effects and is better tolerated than azathioprine.
only be of benefit if the patient presents early in the rejection
It may increasingly have a role in the management of
episode;3 some surgeons prefer to use short-term high dose oral rejection in high-risk keratoplasty.18
Prednisolone in these cases: A single intravenous dose of
Methylprednisolone 500 mg3 or oral Prednisolone 80 mg daily4 Tacrolimus
for 5-7 days may be considered.
Both are given in addition to hourly topical Fluorometholone This is a macrolide immunosuppressant that is a fungal
acetate 0.1 percent or Prednisolone acetate 1 percent. metabolite and suppresses both humoral and cellular immune
Cyclosporine A Liver transplantation studies have shown it may reduce the
need for adjunctive immunotherapy for treatment of rejection
Topical: Cyclosporine A 2 percent in castor oil or 1 percent in
episodes compared to cyclosporine based regimens.
artificial tears 4 times daily.
Renal function must be monitored and neurological adverse
At present, the penetration of this drug into the anterior effects have been documented (more so with intravenous
chamber or deeper corneal layers is not proven. Combined
treatment with Cyclosporine 2 percent and topical corticosteroids
It may surpass cyclosporine as the ‘steroid sparing’ agent of
offered better rejection free graft survival rates over use of topical choice in the future. Recent studies have confirmed its efficacy
corticosteroids alone in a study evaluating results of pediatric
in the management of high-risk keratoplasty.19,20
Topical tacrolimus 0.03 percent ointment seems to be a
Systemic: Some success has been achieved with the use of promising second-line immunosuppressant in management of
systemic cyclosporine in high-risk keratoplasty:17 high-risk grafts.21
• 4-5 mg/kg once or two divided doses daily
• Blood Cyclosporine A level should be between 100-300 REFERENCES
ng/ml. 1. Kamp MT, Finnk NE, Enger C, et al. Patient-reported symptoms
All patients using Cyclosporine A need close monitoring of associated with graft reactions in high-risk patients in the Colla-
blood pressure, renal function including serum creatinine and borative Corneal Transplantation Studies. Cornea 1995;14:43-8.
liver enzymes. 2. Barry P, Seal DV, Gettinby G, et al. ESCRS study of prophylaxis
of postoperative endophthalmitis after cataract surgery. J Cataract
Azathioprine Refract Surg 2006;32:407-10.
3. Hill JC, Maske R, Watson PG. The use of a single pulse of intra-
• 50 mg daily increasing to a maintenance dose of 75-100 mg venous methylprednisolone in the treatment of corneal graft
daily. rejection. A preliminary report. Eye 1991;5:420-24.
4. Hill JC, Maske R, Watson PG. Corticosteroids in corneal graft 13. Goldblum D, Bachmann C, Tappeiner C, Garweg J, Frueh BE.
rejection. Oral versus single pulse therapy. Ophthalmology Comparison of oral antiviral therapy with valacyclovir or
1991;98:329-33. acyclovir after penetrating keratoplasty for herpetic keratitis.Br J
5. Hudde T, Minassian DC, Larkin DFP. Randomized controlled trail Ophthalmol. 2008; 92(9):1201-05.
of corticosteroid regimens in endothelial corneal allograft 14. Niederkorn JY, Callanan D, Ross JR. Prevention of allospecific
rejection. Br J Ophthalmol 1999;83:1348-52. cytotoxic T lymphocyte and delayed-type hypersensitivity
6. Donnenfeld E, Pflugfelder SC.Topical ophthalmic cyclosporine: responses by ultraviolet irradiation of corneal allografts.
pharmacology and clinical uses. Surv Ophthalmol. 2009; Transplantation 1990;50:281-86.

Chapter 12: Postoperative Care after Penetrating Keratoplasty

54(3):321-38. 15. Pleyer U, Milani JK, Dukes A, et al. Effect of topically applied
7. Perry HD, Solomon R, Donnenfeld ED, Perry AR, Wittpenn JR, anti-CD4 monoclonal antibodies on orthotopic corneal allografts
Greenman HE, Savage HE. Evaluation of topical cyclosporine in a rat model. Invest Ophthalmol Vis Sci 1995;36:52-61.
for the treatment of dry eye disease. Arch Ophthalmol. 2008; 16. Cosar CB, Laibson PR, Cohen EJ, Rapuano CJ. Topical
126(8):1046-50. cyclosporine in pediatric keratoplasty. Eye Contact Lens.
8. Tsubota K, Goto E, Shimmura S, et al. Treatment of persistent 2003;29(2):103-37.
corneal epithelial defect by autologous serum application.
17. Hill JC. Systemic cyclosporine in high-risk keratoplasty: long
Ophthalmology 1999;106:1984-89.
term results. Eye 1995;9;422-28.
9. Lee SJ, Lee JJ, Kim SD. Topical and oral voriconazole in the
18. Reis A, Reinhard T, Voiculescu A, et al. Mycophenolate mofetil
treatment of fungal keratitis.Korean J Ophthalmol. 2009;
versus cyclosporine A in high-risk keratoplasty patients: a
prospectively randomized clinical trial. Br J Ophthalmol
10. Prakash G, Sharma N, Goel M, Titiyal JS, Vajpayee RB.
Evaluation of intrastromal injection of voriconazole as a 1999;83:1268-71.
therapeutic adjunctive for the management of deep recalcitrant 19. Sloper CM, Powell RJ, Dua HS. Tacrolimus (FK506) in the
fungal keratitis.Am J Ophthalmol. 2008;146(1):56-59. management of high-risk corneal and limbal grafts.
11. Herpetic Eye Study Group. Oral acyclovir for herpes simplex Ophthalmology 2001;108:1838-44.
virus eye disease: effect on prevention of epithelial keratitis and 20. Joseph A, Raj D, Shanmuganathan V, et al. Tacrolimus
stromal keratitis. Arch Ophthalmol 2000;118:1030-36. immunosuppression in high-risk corneal grafts. Br. J. Ophthalmol
12. Miserocchi E, Modorati G, Galli L, Rama P. Efficacy of published online 6 Sep 2006.
valacyclovir vs. acyclovir for the prevention of recurrent herpes 21. Dhaliwal JS, Mason BF, Kaufman SC. Long-term use of topical
simplex virus eye disease: a pilot study. Am J Ophthalmol. 2007; tacrolimus (FK506) in high-risk penetrating keratoplasty.Cornea.
144(4):547-51. 2008;27(4):488-93.

Section II: Penetrating Keratoplasty

Postkeratoplasty Contact Lens Fitting

Rajesh Sinha, Jeewan S Titiyal

Contact lens can be used for either visual or therapeutic purposes Short-term Indications
after a successful penetrating keratoplasty.1-3 For optimal visual
Therapeutic contact lenses may be useful in the presence of
rehabilitation, contact lenses may be required when there is
epitheliopathy following keratoplasty. Most graft epithelial
marked postoperative astigmatism, anisometropia or aphakia. On
defects heal within 48-72 hours. Certain conditions where the
the other hand, bandage soft contact lenses are used to promote
epithelial defect persists beyond 72 hours, use of a bandage
surface healing in the presence of persistent epithelial defect.
contact lens may help to promote epithelial healing. It is also
Advances in microsurgical techniques and postoperative care
indicated in the presence of a persistent punctate epitheliopathy
have made it possible to achieve a high rate of clear graft in a
in the graft. Soft (hydrogel) contact lenses are the ones that are
number of clinical conditions. Despite all these advances, many
used in such conditions.
corneal surfaces remain irregular and have high degrees of
There are certain clinical conditions where in epithelial
astigmatism following penetrating keratoplasty.4 In most of the
healing is impaired. Patients being transplanted for Stevens-
studies, postoperative astigmatism ranges between 4 to 5
Johnson syndrome, alkali burns and herpetic neurotrophic ulcers
diopters. 5-7 Excessive astigmatism decreases potential
require cover for the epithelium as early as possible after surgery
uncorrected visual acuity, reduces best-corrected spectacle acuity,
to promote and maintain epithelialization.10 Again, therapeutic
and is associated with asthenopic symptoms when patients are
lenses may play a role in patients who have lagophthalmos. It is
given spectacles. The astigmatism can be caused by factors like
also indicated in certain lid or conjunctival deformities like
the configuration of trephine incisions, donor-recipient graft
keratinized conjunctiva, irregular lid margins, cobblestone
disparity, irregular and tight suturing and differences in thickness
papillae from vernal catarrh, that do not need plastic surgery
of donor and recipient wound edges creating a step.
before grafting but that may traumatize the epithelium of the fresh
Various approaches have been tried to reduce postoperative
irregular astigmatism, which includes suture adjustment, selective
Although trichiatic lashes should be removed before corneal
suture removal and occasionally refractive surgery. The non-
surgery, lash deviation, often in association with spastic
surgical approaches to the management of postkeratoplasty
entropion, may create problems in the postoperative period.
astigmatism can be spectacles, rigid gas permeable (RGP)
A bandage contact lens may be useful temporarily in such cases.
contact lens, soft toric contact lens, contact lens and spectacle
At times, therapeutic contact lens can be used to prevent
combination, piggyback and hybrid contact lenses. RGP contact
trauma to the graft by the lids, e.g. if there is slight graft override
lenses are usually the correction of choice for such patients
(misalignment) or if the edge of the graft is elevated by edema
because of the need to correct regular and irregular astigmatism
in the suture compression zone. Such lenses will allow defects
with due consideration to improved oxygen transmission.8
on the elevated portions of the graft to heal and may also prevent
dellen formation in the adjacent concave areas where wetting
by lid may not be proper.10 Finally, it has been seen on rare
Contact lenses of various types remain an important tool in the occasion that small wound leaks can be sealed by temporary
visual rehabilitation of patients after penetrating keratoplasty. placement of a therapeutic lens.
Around 10-25% of the postkeratoplasty patients require contact
Long-term Indications
lens for visual rehabilitation.1,6,9 Therapeutic contact lenses are
used for short-term to enhance graft resurfacing.10 Long-term Optical correction is the primary aim of long-term use of contact
use of these lenses is mainly for optical purposes. lenses following penetrating keratoplasty. The primary indication

for visual rehabilitation using contact lenses is high corneal the patients of keratoconus. These patients are often excellent
toricity, irregular astigmatism, anisometropia and uniocular rigid contact lens candidates, since they have often worn rigid
aphakia. lenses for many years previously under less optimal fitting
The increasing use of triple procedure (penetrating conditions, and they are usually rigid contact lens corrected in
keratoplasty, extracapsular cataract extraction and intraocular the non-grafted eye.12 Studies indicate that such postkeratoplasty
lens implantation) in dealing with combined corneal and lens patients can be fitted in the early postoperative period even in
pathology is based on providing visual correction without the the presence of sutures, that acuity and lens tolerance are good

Chapter 13: Postkeratoplasty Contact Lens Fitting

need of contact lens use. However, contact lenses do have a role and that prekeratoplasty experience is an important factor in the
when the graft has high or an irregular astigmatism. In some such rapid rehabilitation of these patients.
cases, rigid contact lens may be a better alternative to corrective
Either rigid or soft contact lens may be employed for visual
Although lenses can be fitted when sutures are in place, rigid
purposes, depending on a variety of factors. The options from
lenses are usually fitted after suture removal, 12 to 18 months
which a physician has to decide are a rigid contact lens, a daily
postoperatively (Fig. 13.1). Prior to lens fitting, K readings and
wear or an extended wear soft contact lens, piggyback or hybrid
manifest refraction should be stable over a period of a couple
lenses. The indications for a specific lens type depend mainly
of months.
on the refractive status of the eye, the degree of corneal toricity
and the specific needs of the patient.
Prefitting Physiologic and
In an aphakic patient, with a graft of low toricity (< 2.5D),
Topographic Considerations
the physician may consider either a rigid contact lens or a soft
lens. In the presence of high corneal toricity or irregular The penetrating keratoplasty patient presents with an unusual
astigmatism, either a rigid lens or a piggyback system can be physiologic status. The patient’s donor button is entirely
employed. repopulated with host epithelium and keratocyte replacement has
In most of the phakic graft patients, contact lens correction begun by the time contact lens fitting is initiated. Unfortunately
can be achieved with rigid lenses or with daily wear soft lenses corneal innervation is permanently altered by penetrating
if corneal toricity is not excessive. If there is high toricity in the keratoplasty,13 and endothelial function may differ significantly
graft, rigid lens is the sole alternative. Most of the cases of from the preoperative status.14 Again, the impact of contact lens
keratoconus have high postoperative graft toricity and require wear on both corneal innervation,15 and endothelial function16
rigid contact lens for visual rehabilitation.9 has been well documented. For this reason, the physician has to
select a lens design that has a minimal impact on corneal
SOFT CONTACT LENSES physiology. In meeting this objective, ensuring adequate oxygen
transmissibility is a major priority. The rigid gas permeable
In the phakic or aphakic graft with low toricity, daily wear soft (RGP) lenses, owing to their high oxygen transmissibility, are
contact lenses can be used. The use of extended wear soft contact
an obvious choice (Fig. 13.2). To date, fluorosilicone-acrylates
lenses is more problematic as most studies have shown that the
are recommended because of their good oxygen transmission
corneal graft tolerates the extended wear contact lens poorly and characteristics.17
that its use in such patients is associated with corneal
vascularization. This increases the risk of graft rejection and
hence graft failure. On the contrary, some studies have shown
that extended wear contact lenses can be fitted in such patients
with long-term success.5,11 Regardless of the findings of various
studies, the indication for an extended wear lens in the graft
patients must be based not only on visual need but also on those
factors that may play a significant role in the success of the lens,
including lid function, tear quality and production, hygiene and
patient reliability. There has to be a serious commitment on part
of both patient and physician to monitor lens wear closely. Soft
contact lens especially extended wear has very limited use in
postkeratoplasty contact lens rehabilitation.


As mentioned earlier, rigid lenses play a significant role in visual

rehabilitation of phakic, aphakic and pseudophakic graft patients
with high corneal toricity.11,15-17 One such group comprises of Figure 13.1: Clear graft after suture removal

When a hydrogel lens is indicated, the physician should silicone-content lenses.17 With hydrogel lenses, high water lens
consider an extended wear variety worn on a daily basis. The options and ultrathin designs are usually contraindicated.20 The
limited oxygen profiles of hybrids and piggyback designs make use of prophylactic lid hygiene, ocular surface lubricants, and
each a less logical first choice. If these lens designs are indicated punctal occlusion should be considered if the patient remains
for other reasons, then a limited wearing time may be symptomatic. The potential for ocular surface erosion is
recommended. increased if an RGP lens is fitted on a highly irregular graft
Another factor of serious consideration in keratoplasty surface. Erosion is often the result of focal lens bearing and can
Section II: Penetrating Keratoplasty

patients is that of corneal neovascularization. be sometimes managed by altering lens design. If epithelial
If the patient’s pre-existing corneal disease is marked by erosion persists despite lens design alterations, the most prudent
severe inflammation, neovascularization may actually precede solution involves refitting into a hydrogel or piggyback design.
surgery. Often neovascularization develops as part of the In addition to these physiologic concerns of fitting the
postoperative healing phase. Aggressive corneal neovasculariza- penetrating keratoplasty patient, there are obvious topographic
tion can predispose an individual towards graft rejection.18 In considerations. Patients after penetrating keratoplasty often
contact lens patients, neovascularization has been associated with manifest a topographic profile that differs considerably from the
intracorneal hemorrhage and lipid leakage, both of which can normal cornea. This is often the result of many factors that
impair vision. Again, long-term use of contact lens itself can includes preoperative corneal pathology, donor-recipient
cause corneal vascularization. Although the exact mechanism of topographic discrepancies, surgical technique and wound healing.
contact lens induced corneal neovascularization is not known, With the corneal graft patient a significant discrepancy can exist
the importance of adequate oxygenation and minimal between the donor and recipient topographies. The resultant
inflammation is evident.19 In an effort to satisfy these needs, a cornea may manifest unusual asphericities, irregular optic zones
gas permeable lens design is often utilized. and a dramatically displaced apex. These topographic alterations
Hydrogel, hybrid and piggyback designs are less desirable result in postoperative visual disturbances which present as a
for the vascularized corneal graft, as they cover a large portion specific challenge to the contact lens fitter. Historically corneal
of the peripheral cornea. This additional coverage can result in topography measurements were limited to keratometry. In recent
a tight fit, hypoxia, and tear stagnation, inducing further years these measurements have been expanded to include
encroachment of the vessels. automated keratometry and photokeratoscopy.21 These days
Another important consideration regarding the physiologic computer assisted topographic analysis is advantageous to assess
status of the graft patient involves the corneal surface disease. the topography of regular and irregular corneas,22-29 monitor
In view of the significantly altered corneal topography, a contact lens induced corneal warpage,30 and as baseline measure-
keratoplasty patient often manifests an irregular tear film. This ments for fitting cosmetic, keratoconic and postsurgical contact
is most often observed at the graft host junction and at the site lenses.31-33 Recent software enhancements now allow the use of
of suture tracks. The compromised tear film may predispose these corneal topography to design rigid lenses.
individuals towards ocular surface disease, including keratitis
sicca, contact lens induced erosions and infectious keratitis. Contact Lens Options
No single material or design is most beneficial in managing
The aims of contact lens fitting after penetrating keratoplasty
the dry eye. While selecting an RGP lens it is wise to avoid high involve correction of residual refractive error, comfort
commensurate with a reasonable wearing time, and maintenance
of ocular health. It has long been accepted that such goals are to
be achieved by utilizing a variety of contact lens options and by
employing fitting techniques that are as much an art as a science.

Gas Permeable Lenses

Although lenses can be fitted when sutures are in place, rigid
lenses are usually fitted after suture removal, 12 to 18 months
postoperatively. Gas permeable lenses are preferable to standard
polymethylmethacrylate lenses. Enhanced oxygen trans-
missibility is desirable in the presence of a graft. Because of
astigmatism and ocular surface irregularity, it is often impossible
to achieve a perfect lens fit. Use of gas permeable materials
appears to improve the patient’s tolerance of lenses having areas
of corneal touch where the fit is fairly flat. Lens flexure and poor
wetting can be minor problems with gas permeable lenses, but
Figure 13.2: Rigid gas permeable contact lens after these can be alleviated through modifications in the lens design
penetrating keratoplasty and use of appropriate wetting agents and topical lubrication.
Goals Lens Materials
The goals in rigid contact lens fitting after keratoplasty are to Among the RGP materials fluorosilicone acrylate offers the
achieve adequate lens centration and movement, optimal visual greatest margin of safety. This material provides excellent oxygen
acuity, and good lens tolerance. Proper lens centration is difficult transmission, improved surface characteristics, and acceptable
to obtain, owing to asymmetry of the graft wound. Often there flexure resistance in comparison to other materials.
is a tendency for the lens to gravitate towards one aspect of the
wound, and lens also tends to ride high. Perfect centration is Lens Overall Diameter

Chapter 13: Postkeratoplasty Contact Lens Fitting

not necessary, but it is important to avoid decentration to the
Most clinicians agree that lenses with an overall diameter of at
extent that the lens passes over the limbus during blink-induced least 9.0 mm are indicated in graft patients.34 The earlier concept
movement. Lens contact with the limbus is usually associated
of a small (7.0 to 8.0 mm) lens fitted inside the graft-host junction
with discomfort (Fig. 13.3).
has been abandoned. Difficulties with lens position, poor
Lenses should be fit loosely enough to ensure 1 to 2 mm of comfort, and easy displacement have accounted for this designs
movement with each blink. Initially, there is often reflex tearing,
disfavor. Longer overall diameters of 9.5 to 11.0 mm are
so the lens movement must be evaluated after at least 30 minutes
necessary if the corneal apex is grossly decentered and the lens
of lens wear. Lens movement is necessary for tear exchange centration is a problem. These larger designs may also facilitate
under the lens, which in turn, is important not only for the
lid attachment. In general, flatter corneas are fit with larger lenses
delivery of oxygen that can pass through the lens but also for
and steeper corneas with smaller ones.
the removal of exfoliated material from under the lens.
Lens flexure or rocking can reduce acuity by several lines. Optic Zone
Sometimes lens flexure is diminished with a larger or thicker
lens. Lens rocking is often associated with edge lift, which can The optic zone diameter should be modified according to overall
be reduced through the use of either a steeper or a smaller lens. lens diameter. Ideally, optic zone diameter should be as large as
Lens fit as well as lens power affect visual acuity in the presence possible to facilitate lens centration and minimize glare, but not
of a graft. so large as to create harsh bearing or result in lens binding. The
The most important goal in contact lens fitting is to achieve optic zone diameter should equal the base curve when both are
good lens tolerance. The patient should be able to wear the lens expressed in millimeters. For example, a contact lens with a base
with reasonable comfort for 10 to 14 hours per day. Gas curve of 42.50D would have an optic zone of 7.95 mm.
permeable lenses with adequate centration and movement are
usually well-tolerated despite an imperfect fit over an irregular Base Curve and Peripheral Curve Systems
graft surface. Keratometry (K) provides a useful starting point for rigid lens
fitting but is of limited value in the final lens selection. After
Fitting Method keratoplasty, a wide range in curvature is present. The mires often
There are certain guidelines for selecting an initial trial lens, but are distorted making accurate measurement difficult. Routine
experience and trial and error are factors in the selection of keratometry measures only a small area of the central cornea.
subsequent trial lenses. Unfortunately, the graft topography is Because the shape of cornea near the graft-host junction is
often a challenge for the clinician who fits an RGP lens. To gain equally important in lens fitting, corneal topography, which
a better perspective on lens material and design considerations provides more information about surface topography than does
we will look at each variable. keratometry, is useful. Computerized videokeratoscopy software
programs have the capability to design initial RGP lens
parameters and simulate contact lens fluorescein patterns. Such
programs allow the physician to choose posterior lens curvature,
an overall and optic zone diameter, edge lift and power in some
Usually the first trial lens used is on or near flat K. Using
videokeratography, the average of the two flattest readings at a
point 1.5 mm superior to the visual axis can be used to select
the base curve of the initial trial lens. When astigmatism is greater
than 5 diopters, the selected initial trial lens is steeper than flat
K. The physician should modify base curve selection to facilitate
a divided support fit. In this strategy, the clinician strives for a
lens-cornea fitting relationship in which there is approximately
one-third surface area bearing and two-thirds surface area
clearance.35 Toric base curve options should be reserved for
Figure 13.3: Poorly fit contact lens patients whose grafts are highly astigmatic. Although many are
of the opinion that approximately 7D of postoperative manifest refraction expressed in minus cylinders. Sometimes, it
astigmatism is average,2 the irregular nature of this astigmatism is not possible to obtain excellent visual acuity with an over
precludes routine use of back toric designs. As aspheric lens refraction.
designs have long been recognized for their ability to Immediately after fitting a trial lens, slit lamp examination
accommodate atypical topographies, this option seems to be should be performed. A superior lens position with good lens
another logical choice. Recent work with a biaspheric back movement (1-2 mm) is the goal of fitting. A fluorescein pattern
surface design has proven beneficial for penetrating keratoplasty indicating a relatively flat fit is preferred. A tight lens fit should
Section II: Penetrating Keratoplasty

patients.36 be avoided in keratoplasty patient.

There is no clear consensus regarding the appropriate
peripheral curve system for fitting the penetrating keratoplasty Rose K Contact Lens
patient. As the central-peripheral corneal topography relationship
Rose K design of rigid gas permeable contact lens has been
is so dramatically altered in these patients, a traditional base successfully fitted in eyes with keratoconus38,39 and is now
curve-peripheral curve relationship may no longer be indicated.
becoming increasingly popular for postkeratoplasty fitting as well
There is one definite situation in which the peripheral curve
(Figs 13.4 and 13.5). The Rose K system has set optical zones
system is of paramount importance. This involves the patient to maximize vision while maintaining good corneal health.
with a plateau graft and difficulty with lens centration. In such
A separate set of post-graft trial lenses (Rose K2 post-graft) are
cases, an unusually steep peripheral curve system is indicated.
available for fitting Rose K contact lens after keratoplasty. Unlike
Such situation may require RGP design in which the secondary normal corneas, the post-graft cornea has irregularity on its
curve is steeper than the base curve.
surface and to achieve optimal alignment with the cornea, many
One recent study has reported the use of tetra-curve contact
curves are required on the back surface of the lens.
lens with an overall diameter of 12.0 mm in postkeratoplasty
patients.37 The lens was well-tolerated in all patients for more Rose K Post-graft Fitting Procedure
than 13 hours daily.
There are certain guidelines for fitting Rose K lens in
postkeratoplasty patients.
Lens Thickness

Whenever possible the thinnest design should be used to enhance Pre-fitting Examination
lens comfort, centration and optimum oxygen transmission.
A thorough history of the patients should be taken that should
Thicker lenses should be reserved for problem with flexure,
include the motivation of the patient towards using the contact
warpage, or frequent lens damage. lens. A detailed examination of the eye should be done in view
of the suitability for fitting contact lens.
Lens Power
Initial Base Curve Selection
Refraction with spheres over a trial lens of appropriate base curve
and diameter is necessary to determine which lens power to order. The initial base curve is 0.3 mm steeper than the average K
It is helpful, if a trial lens that approaches the correct power can reading. If the patient is already wearing an RGP contact lens, a
be used. Ideally, the lens power should be compatible with the base curve similar to the present lens may initially be tried.

Figures 13.4 and 13.5: Rose-K contact lens fitting over a corneal graft
Central Fit factor why it is relatively unacceptable is the potential for
neovascularization.24 Soft lenses are worn in an extended wear
Adequate time should be given for the lens to equilibrate on the
mode, the incidence of infectious keratitis can be expected to
eye and also to minimize watering in the eye. The central fit is
increase significantly.
evaluated by fluorescein pattern immediately after blink when
the lens is centered. A central pooling of 0.2-0.3 mm is acceptable Therapeutic Soft Contact Lens Fitting
in early flatter graft where the donor tissue is still flatter than
the host tissue but an alignment of 0.1 mm in older grafts is Bandage soft contact lenses are useful in management of

Chapter 13: Postkeratoplasty Contact Lens Fitting

aimed. An excessive amount of fluorescein may give a false postkeratoplasty epithelial defects and persistent superficial
picture. Similar situation can arise if there is excessive watering punctate keratitis. Patients with ocular surface diseases and
in the eye. neurotrophic keratitis prior to keratoplasty are predisposed to
nonhealing epithelial defects postoperatively. However, many
Peripheral Fit graft patients without these conditions also have significant
superficial punctate keratitis. This is caused by poor wetting due
Once a good central fit is achieved, the peripheral edge lift is to abnormal corneal topography near the wound and, in some
assessed. An even fluorescein band of 0.5-0.7 mm is aimed. cases, due to drug toxicity. When topical lubrication or patching
do not result in surface healing, bandage lenses are often
Size of the Lens beneficial. A variety of plano lenses with variable water content
The standard overall diameter in post-graft Rose K2 contact lens depending on the indication, can be used. Patients wearing
for initial trial is 10.4 mm. The purpose of using large diameter therapeutic lenses can be maintained on topical medications as
lenses is to achieve a better centration of the lens. needed for the underlying condition. Lens fit must be checked
after 1 hour, 1 day and 1 week of lens wear, and then monthly
Power to ensure that the lens moves 1-2 mm with the blink, the eye is
white and quite, and the graft is tolerating the lens.
Once the base curve has been determined, over refraction is done
to determine the correct power of the contact lens. Piggyback Lenses
When an RGP or hydrogel lens alone does not suffice, a
Soft Contact Lens Fitting
combination of the two may be indicated. The “piggyback”
Hydrogel Lenses involves using a hydrogel lens for surface smoothing and then
employing a rigid lens for visual restoration.
Soft contact lenses are fitted following keratoplasty more
frequently for therapeutic purposes to promote surface healing Materials
than for visual purposes.
The potential for oxygen debt is significant when one considers
Aphakia is one indication for corrective daily-wear and
the simultaneous use of a hydrogel and rigid contact lens.
extended-wear soft contact lens fitting. Extended wear soft
Therefore, high-oxygen transmission materials should routinely
contact lenses are used in elderly aphakic patients who are unable
be prescribed. During lens adaptation, the clinician should
to manipulate daily-wear lenses and who have only a low or
carefully monitor biomicroscopy and adjust wearing time
moderate amount of astigmatism. Another indication for hydrogel
lens is an atypical graft-recipient geometry with attending RGP
lens instability. Unfortunately, these cases may concomitantly
manifest significant amount of astigmatism and require
adjunctive spectacle correction. The two major determinations in selection of hydrogel lens are
In prescribing for a corneal graft patient a balance between corneal topography and prescription. If the patient has a flat graft,
oxygen permeability and good surface characteristics is then a mid-plus range lens design is selected. This particular
important. For myopic correction this generally involves a thin carrier lens will accommodate the anticipated need for plus
design with low water content. For moderate and high plus power correction while providing for a steeper topography on
correction, an intermediate water content design is usually which to place the rigid lens. If the patient has a steep graft,
indicated. then an ultrathin mid-minus range lens design is indicated. This
The clinician may wish to consider a toric hydrogel lens to carrier lens will lessen the amount of minus power required in
cover for the astigmatism in keratoplasty patients. However, these the rigid lens while providing a flatter topography on which to
patients manifest significant amount of irregular astigmatism on fit the rigid lens. In either of these situations, the value of
corneal topographic analysis and may cause a problem in fitting incorporating some of the refractive power into the hydrogel lens
a back toric design. allows the use of a thinner and lighter rigid lens.
The primary reason why hydrogel lenses are not fitted in a The actual fitting of a “Piggyback” lens design begins with
corneal graft patient involves poor visual outcome. Another evaluation of the underlying hydrogel lens. The lens should be
allowed to equilibrate and then evaluated for centration and lens important among patients of penetrating keratoplasty, as the graft-
movement. Optimal to slightly excessive lens movement is host junction and suture tracks are highly prone to infection and
encouraged, as once the rigid lens is placed over the hydrogel the eye may be immunocompromised as a result of long-term
its movement is almost certainly diminished. Once, a satisfactory steroid usage. The significance of epithelial erosion, loose
hydrogel lens fit is obtained, over-keratometry is performed. The sutures, improper contact lens hygiene, bacterial invasion,
result of over-keratometry serves as a starting point for rigid lens compromised host immunity and delayed treatment is obvious
selection. The average of flat and steep over- keratometric value in establishing condition for potential infectious keratitis.
Section II: Penetrating Keratoplasty

is often a reasonable starting point for rigid lens selection. Final A keratoplasty patient fitted with hydrogel lenses is prone
base curve, overall diameter, optic zone, peripheral curve, power, to develop corneal neovascularization resulting in a high chance
and thickness determinations are best accomplished by diagnostic of graft rejection. Again, optical quality of hydrogel lenses is
fitting. High molecular weight fluorescein can be utilized to not as good as RGP. Moreover, as these lenses are used for
assess optical clearance of the rigid lens relative to its hydrogel extended wear, there is always the risk of infection.
carrier. Care must be taken to avoid a tightly fitted rigid lens, as The complications that can be associated with piggyback and
this often traps interfacial debris. hybrid designs are corneal edema, neovascularization, contact
lens adherence, acute red eye episodes, infectious keratitis and
Hybrid Lenses graft rejection. Another problem with hybrid designs is difficulty
Hybrid lenses were designed to combine the comfort and in inserting and removing the lens and a high percentage of lens
centering capabilities associated with hydrogel lenses with the separation. Because of the difficulty in removing the lens and
visual acuity offered by a rigid lens. The soft perm (SBH Corp. the presence of a junction between the optical centre and
Sunny vale, CA) lens is a hybrid lens made from a single button hydrogel skirt, the lens can tear relatively easily.
containing a co-polymerized hydrophilic skirt with an RGP Many contact lens designs may be employed for the
center molecularly bonded at the transition zone. refractive management of a graft patient. These include RGP,
The overall diameter of the lens is 14.3 mm and the rigid hydrogel, hybrid and piggyback lenses. The specific design
optical zone diameter is 8 mm. A single base curve is selected selected is dependent on a number of factors, which includes
from a diagnostic set of trial lenses based upon the mean central corneal graft physiologic status, corneal topography, refractive
keratometry reading. The greater the increased corneal toricity, error, desired wearing schedule and patient handling capabilities.
the steeper the base curve selected. Because the RGP center Each of these factors must be weighed independently to ensure
diameter is 8.0 mm, one typically fits steeper than the flattest K the greatest likelihood of contact lens success.
to achieve a parallel sagittal depth in relationship to the cornea.
The final base curve must be selected by diagnostic fitting, with REFERENCES
each trial lens allowed to equilibrate for a minimum of
1. Cohen EJ, Adams CP. Postkeratoplasty fitting for visual
15 minutes. Regardless of a good visual response and positive rehabilitation, in Dabezies OH jr (Ed): Contact Lenses: The
patients acceptance, adequate lens movement is essential. Once CLAO Guide to Basic Science and Clinical Practice. New York,
an optimal fit is achieved, an over refraction is performed to Grune and Stratton 1984; Chapter 52.
determine exact lens power. Certain clinicians believe that this 2. Genvert GI, Cohen EJ, Arentsen JJ, Laibson PR. Fitting gas
lens permits a more over-refraction free from the unstable, permeable lenses following penetrating keratoplasty. Am J
inconsistent vision that can be associated with RGP lenses that Ophthalmol 1985;99:511-14.
have been fit over corneas with irregular astigmatism.40 3. McDonald M, Baldone JA. Postkeratoplasty fitting to enhance
re-epithelialisation, in Dabezies OH jr (Ed): Contact Lenses: The
Complications CLAO Guide to Basic Science and Clinical Practice. New York:
Grune and Stratton 1984; Chapter 53.
Any keratoplasty patient fitted with contact lens has to be 4. Binder PS. The effect of total suture removal on Postkeratoplasty
monitored carefully for possible complications. A corneal graft astigmatism. Am J Ophthalmol 1988;105:637-45.
fitted with contact lens is prone to develop certain specific 5. Cayanaugh HD, Leveille AS. Extended wear contact lenses in
complications owing to altered corneal surface physiology and patients with corneal grafts and aphakia. Ophthalmology
topography. There is high risk of ocular surface erosion 1980;89:643-50.
particularly if an RGP lens has been fitted on a highly irregular 6. Jensen AD, Maumenee AE. Refractive error following
graft surface. Erosion is often the result of focal lens bearing keratoplasty. Trans Am Ophthalmol Soc 1970;72:123-31.
7. Troutman RC, Gaster RN. Surgical advantages and results of
and can sometimes be managed by altering lens design. Bad
keratoconus. Am J Ophthalmol 1980;90:131.
ocular surface and compromised tear film may further aggravate
8. Bennett ES, Weissman BA. Clinical Contact Lens Practice.
the existing situation. The use of ocular surface lubricants and Philadelphia, JB Lippincott Company 1991;Chapter 47, 9-10.
lid hygiene should be considered. Infectious keratitis is the most 9. Buxton JN. Contact Lenses in keratoconus. Contact Intraoc Lens
dreaded consequence of ocular surface disease. The propensity Med J 1978;4:74.
of certain bacteria to colonize epithelial defects in contact lens 10. Casey TA, Mayer DJ. Contact lenses and keratoplasty. Corneal
users is well documented.41 This consideration is especially Grafting. Philadelphia, WB Saunders 1984;281-88.
11. Dangel ME, Kracher GP, Stark WJ, et al. Aphakic extended wear 28. Wilson SE, Friedman RS, Klyce SD. Contact lens manipulation
contact lenses after penetrating keratoplasty. Am J Ophthalmol of corneal topography after penetrating keratoplasty, A preliminary
1983;95:156-60. study. CLAO J 1992;18:177-82.
12. Mannis MJ, Zadnik K, Deutch D. Rigid contact lens wear in the 29. Strelow S, Cohen EJ, Leavitt KG, et al. Corneal topography for
corneal transplant patient. CLAO J 1986;12:39-42. selective suture removal after penetrating keratoplasty. Am J
13. Ruben M, Colebrook E. Keratoconus, keratoplasty curvatures and Ophthalmol 1991;112:657-65.
lens wear. Br J Ophthalmol 1979;63:268. 30. Wilson SE, Lin D, Klyce SD, et al. Rigid lens decentration: A
14. Brown NAP, Bron AJ. Endothelium of the corneal graft. Trans risk factor for corneal warpage. CLAO J 1990;16:177-82.

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Ophthalmol Soc UK 1974;94:863. 31. Wasserman D, Itzkowitz J, Kamenar T, et al. Corneal topographic
15. Millodot M. Effect of the length of wear of contact lenses on
data: Its use in fitting aspheric contact lenses. CLAO J
corneal sensitivity. Acta Ophthalmol 1976;54:721.
16. Holden BA, Sweeny DF, Vannas A, et al. Contact lens induced
32. Rabinowitz YS, Garbus JJ, Garbus C, et al. Contact lens selection
polymegathism. Invest Ophthalmol Vis Sci 26(suppl.): 1985;275.
for keratoconus using a computer-assisted videokeratoscope.
17. Tomlinson A. Choice of materials—a material issue. Contact Lens
CLAO J 1991;17:88-93.
Spectrum 1990;5:27.
18. Lemp MA. The effect of extended wear aphakic hydrophilic 33. Lopatynsky M, Cohen EJ, Leavitt KG, et al. Corneal topography
contact lenses after penetrating keratoplasty. Am J Ophthalmol for rigid gas permeable lens fitting after penetrating keratoplasty.
1980;90:331. CLAO J 1993;19:41-44.
19. McMonnies CW. Etiology of contact lens induced corneal 34. Zadnik K. Post-surgical contact lens alternatives. Intern Contact
vascularisation. Int Contact Lens Clinics 1984;11:287. Lens Clinics 1988;15:211.
20. Helton DO, Walton LS. Hydrogel contact lens dehydration rates 35. Shovlin J, Kame R, Weissman B, DePaolis M. How to fit an
determined by thermogravimetric analysis. CLAO J 1991;17:59. irregular cornea. Rev Optom 1987;124:88.
21. Gormley D, Gerston M, Koplin RS, Lubkin V. Corneal modeling. 36. Weiner B. Contact lens correction of the post-penetrating
Cornea 1988;7:30. keratoplasty patient. Contact Lens Update 1989;8:61.
22. Dingledein SA, Klyce SD. The topography of normal corneas. 37. Eggink FAGJ, Nuijts RMMA. A new technique for rigid gas
Arch Ophthalmol 1989;107:512-18. permeable contact lens fitting following penetrating keratoplasty.
23. Dingledein SA, Klyce SD. Imaging of the cornea. Cornea Acta Ophthalmol Scand 2001;79:245-50.
1988;7:170-82. 38. Betts AM, Mitchell GL, Zadnik K. Visual performance and
24. Wilson SE, Klyce SD. Advances in the analysis of corneal
comfort with the Rose K lens for keratoconus. Optom Vis Sci.
topography. Surv Ophthalmol 1991;36:269-77.
25. Bogan ST, Waring GO, Ibrahim OA, et al. Classification of normal
39. Jain AK, Sukhija J. Rose K contact lens for keratoconus. Indian
corneal topography based on computer assisted videokerato-
graphy. Arch Ophthalmol 1990;108:945-49. J Ophthalmol. 2007;55(2):121-25.
26. Wilson SE, Lin D, Klyce SD. Corneal topography of keratoconus. 40. Binder PS, Kopecky L. Fitting the short-term contact lens after
Cornea 1991;10:2-8. keratoplasty. CLAO J 1992;18:170-72.
27. McMohan TT, Robin JB, Scarpulla KM, et al. The spectrum of 41. Reichert R, Stern G. Quantitative adherence of bacteria to human
topography found in keratoconus. CLAO J 1991;17:198-204. corneal epithelial cells. Arch Ophthalmol 1984;102:1394.

SECTION III: Penetrating Keratoplasty:
Management of Complications


Chapter 14: Complications of Penetrating Keratoplasty

Complications of Penetrating Keratoplasty
Namrata Sharma, Urmimala Ghatak, Rasik B Vajpayee, Hugh R Taylor

Significant technological advances in last few decades have superpinkie or a similar device can reduce vitreous as well as
increased the survival rate of corneal grafts after penetrating intraocular pressure. Hypotensive drugs such as systemic
keratoplasty. Numerous noteworthy advancements have been acetazolamide may be given preoperatively. Intravenous
made in the fields of corneal preservation, surgical techniques mannitol 1-2 g/kg body weight may be given 30 minutes before
and postoperative care. However, inspite of these advancements, surgery.
complications after corneal grafting surgery have not become Further the lid speculum should be checked for the possible
rare. While some of these complications like graft infection and increase in the vitreous pressure and preferably a speculum with
graft rejection threaten the graft survival, others like high post- separate specula for upper lid and lower lid should be used.
keratoplasty astigmatism prevents achievement of optimal visual
Management: If the vitreous face is ruptured, a partial anterior
acuity even with a clear graft. This chapter reviews the possible
vitrectomy should be performed with an automated vitrectomy
problems and complications that occur during penetrating
device. Some surgeons advocate the use of pars plana vitreous
keratoplasty so that they can be prevented or treated
aspiration with an 18-gauge needle attached to a 3-ml syringe
to tap the vitreous.1
The successful management of complications associated with
any surgery requires a combination of recognition, and
Scleral Perforation during Application
knowledge of important risk factors involved. The complications of Fixation Sutures
of penetrating keratoplasty may be broadly categorized into
intraoperative or postoperative. Postoperative complications can Sclera can be perforated while applying sutures beneath the
be early and late. Early postoperative complications are those superior and inferior recti, resulting in a retinal hole and possible
occurring within the first four weeks of surgery whilst the term retinal detachment. In case of a perforation, cryotherapy should
late is applied to changes occurring after this period. be done at the suspected area and the patient is kept under close
INTRAOPERATIVE COMPLICATIONS Flieringa rings and McNeill-Goldmann blepharostat are
used by some surgeons to prevent the scleral collapse, especially
Poor Anesthesia and Positive Vitreous Pressure indicated in cases of low scleral rigidity like in children and in
aphakic or pseudophakic patients. Sutures for the globe
A properly anesthetized and immobilized eye is a prerequisite
supporting rings are usually placed anterior to the pars plana.
for keratoplasty. Prior to the entry into the anterior chamber, the
Scleral perforation during their placement leads to damage of
eye must be soft with reduced vitreous volume and decreased
the ciliary body and clinically, hemorrhage may be observed at
intraocular pressure.
the angle in this region. This is, however, self-limiting and usually
The peribulbar or retrobulbar anesthesia increases the orbital
requires no treatment.
volume. Increased vitreous pressure may be encountered
especially if adequate measures have not been taken to obtain
Improper Trephination
adequate hypotony. Increased vitreous pressure can cause
problems especially during the performance of capsulorhexis, Reversed Host and Donor Trephines
cortex aspiration and intraocular lens implantation in a case
Corneal surgeons generally use a graft host disparity of 0.5 mm
where, triple procedure is being undertaken.
in keratoplasty. In a case where the trephines for the donor and
Prevention: Positive vitreous pressure can be prevented by the recipient get inadvertently reversed, the donor button
mechanical, medical or surgical methods. Digital pressure becomes smaller than the recipient size. This results in difficulty
applied to the globe or mechanical pressure applied by in suturing and hence, a water-tight closure of the surgical wound
may not be obtained. Further, it also causes rise in intraocular due to the unequal pull caused by the sutures used to fix these
pressure due to tightened sutures, which tend to collapse the devices. Many surgeons do not prefer to use these fixation rings
trabecular meshwork.2 This also causes hyperopia.3 because of the same reason.6
Management: If the host has not been trephined or only partially
Retained Descemet’s Membrane
trephined, without entering the anterior chamber and it has been
realized that the donor button has been cut inadvertently with This problem is usually encountered by the beginners and is
the smaller trephine, a trephine 0.25 mm smaller than used on particularly common in thick and edematous cornea seen in cases
Section III: Penetrating Keratoplasty: Management of Complications

the donor cornea may be used on the host, provided it completely of congenital hereditary endothelial dystrophy and interstitial
encompasses the lesion.4 keratitis. In these situations corneal stroma may be inadvertently
If the donor has been prepared and the host anterior chamber separated from the Descemet’s membrane during the removal
entry is complete, the smaller button may be used. If an of the recipient corneal button. This may also happen when the
intraocular lens is planned, the power of the lens may be adjusted corneal scissors may be inadvertently placed anterior to the
to account for 2-3 diopters of induced hyperopia. The best Descemet’s membrane. Since the Descemet’s membrane is
alternative is to transplant another donor button of appropriate transparent, visually it may not be possible to recognize this
size, if available. complication intraoperatively. The iris architecture should be
carefully inspected after trephination of such corneas and this
Eccentric Host Trephination tissue should be gently picked up with a forceps.7 Failure to grasp
the iris is a conclusive sign of presence of retained Descemet’s
Improper centration of the graft gives rise to a high postoperative
membrane. Postoperatively, anterior segment optical coherence
astigmatism.5 The trephine should be perpendicular to the cornea
tomography (OCT) may be used to demonstrate the presence of
to prevent sliding or lamellar dissection.
a retained Descement’s membrane as well as document
Prevention and management: Use of proper centration successful management of the same.8,9
techniques can eliminate this problem of eccentric trephination.
Management: If it is recognized intraoperatively, it should be
Adequate fixation with suction fixation trephines and use of sharp
removed. Viscoelastic is placed behind the Descemet’s
trephines can avoid most trephining problems. If the eccentric
membrane so that it is elevated and removed. Postoperatively
cut is less than one third of the stromal depth, the trephine can
the membrane appears as a sheet posterior to the graft (Figs
be replaced and the initial incision maybe ignored. If the cut is
14.2A and B) and opacifies with time so that it can be confused
deeper, it may be necessary to use a slightly larger trephine, so
with the retrocorneal membranes like epithelial or fibrous
that the resultant opening encompasses the previous eccentric
ingrowth. The usual consequence of stripped Descemet’s
cut and remains central (Fig. 14.1).
membrane is graft failure. However, an attempt should be made
Irregular/Oval Trephination to salvage the graft by making an opening with Nd:Yag laser,
i.e. Nd:Yag Descemetotomy. We have used 0.1 percent Trypan
Use of blunt trephines can cause slippage and irregular cuts while blue dye to stain this membrane to improve its visualization so
trephining the cornea. It is recommended that a new, disposable that tearing of the membrane, i.e. ‘Descemetorhexis’ can be
trephine be used for each cut. Ovalling of the cut after undertaken easily (Fig. 14.3)10 A repeat graft may be required
trephination may be seen with the use of scleral fixating rings in some of the cases.

Damaged Donor Button

For a full thickness corneal transplantation, it is important to
prepare the donor cornea before trephining the host cornea so
that in the event of damage or contamination to the donor,
surgeon may be prepared if another cornea is not available.
Surgeons, should avoid distilled water on trolley so that there is
no chance of water getting onto the endothelium and destroying
it completely.
Donor corneal tissue may be damaged inadvertently peri-
operatively. This can happen particularly during the trephination
of donor tissue and placement of the first 4 cardinal sutures.
Endothelial cell loss occurs more in phakic than in aphakic grafts
and is due to endothelialiris contact during surgery.11
Prevention: Every possible effort should be made to prevent
damage to the endothelium. Viscoelastics, which protect
Figure 14.1: Eccentric graft endothelium, such as Viscoat (Chondroitin sulfate 4%, Sodium
hyaluronate 3%, Alcon Labs) should be used to enhance the
protection of the endothelium and prevent the lenticular-iris touch
with the graft. At the same time, trephine with sharp edges should
be used to cut the graft tissue since blunt trephine may not cut
the corneal button completely and attempts to repunch will lead
to damage to endothelium.
Further, the donor cornea may be inadvertently dropped

Chapter 14: Complications of Penetrating Keratoplasty

during transfer to the recipient bed, jeopardizing the endothelium
and contaminating the donor material. Hence a graft holder
should always be used to transfer the donor cornea to the
recipient bed. Cases of graft loss have occurred and if no tissue
is available, the patient’s own cornea must be replaced and the
case may be rescheduled.12 In an aphakic eye, it is possible to
loose the graft in the vitreous.7 An oversized graft reduced the
risk of this disastrous hazard.
Figure 14.2A: Retained Descemet’s membrane

Inversion of the Graft

Inversion of the corneal button can occur rarely. In one instance,
the graft has been sutured with endothelial side facing upwards.13
Prevention and management: The epithelial and the endothelial
surfaces are easily identified by the orientation of the button in
the well, the curvature of the button and marks on the epithelial
surface, if the button has been previously marked. If such an
untoward event occurs, the graft should be immediately replaced.

Excessive Bleeding
This is a common occurrence especially when the keratoplasty
is being undertaken on inflamed or perforated eyes. The bleeding
occurs most commonly due to leaking from the iris vessels.
Minimal hemorrhage usually stops after the wound closure and
restoration of normal intraocular pressure. Excessive
manipulation of the iris should be avoided especially if there
Figure 14.2B: Trypan blue assisted descemetorhexis are long-standing peripheral anterior synechiae. Severe
intraocular hemorrhage may occur when explanting closed
looped anterior chamber lenses.14 When the haptics are pulled,
it may nip the iris and cause an iridodialysis, which may lead to
severe anterior chamber bleeding.
Prevention and management: Hemorrhage may be controlled
with cautery, compression with viscoelastic or tamponade with
sponges/swab sticks soaked with epinephrine 1:1000 dilution.7
Intracameral epinephrine should be avoided in aphakic eyes as
it leads to increased risk for cystoid macular edema. Care should
be taken to prevent seepage of blood into the vitreous, especially
in aphakic patients, as this absorbs very slowly.

Injury to Iris-lens Diaphragm

In patients with corneoiridic scars, injury to Iris and lens occurs
commonly while performing trephination if special precautions
are not taken. Use of our lamellar dissection technique can
effectively save the iris from undergoing severe damage during
trephination.14a Any inadvertent iris damage and iridodialysis
Figure 14.3: Graft after surgical removal of retained should be repaired with a 10-0 polypropylene suture as far as
Descemet’s membrane in a case of CHED possible.
In young patients with keratoconus and infants with low
scleral rigidity, the iris lens diaphragm may bulge forwards as
the anterior chamber is entered. Any extraneous pressure on the
globe by lid sutures or wire speculum should be checked. If the
patient is aphakic, it may be necessary to perform a vitrectomy
to allow the iris to fall posteriorly before placing the graft on
the recipient.
Section III: Penetrating Keratoplasty: Management of Complications

Injury to the lens and iris may also occur in thinned or

perforated corneas. This can be prevented by injecting the
viscoelastic into the anterior chamber before trephination through
a paracentesis. This can also be prevented by attempting a partial
depth trephination at first, followed by anterior chamber entry
and instillation of viscoelastic. The host bed can then be cut with
a curved corneal scissors. Hirst et al have recommended
combined use of viscoelastic for reformation of anterior chamber
Figure 14.4: Broken suture
along with cyanoacrylate adhesive prior to trephination to
prevent excision of the iris in the perforated globes.15
Damage to the anterior lens capsule that occurs during suture is not being used, and the continuous suture is cut or
trephination should be recognized immediately and extracapsular broken, another suture may be used as a splice added to its length
cataract extraction should be undertaken with placement of a and the ends should be retied.
posterior chamber intraocular lens.4
Problems with Suturing Graft to the Host
Posterior Capsular Tear and Vitreous Prolapse Improper suturing can cause unequal graft tissue distribution and
During combined procedure of penetrating keratoplasty with can lead to severe postkeratoplasty astigmatism. The second
extracapsular cataract extraction, the posterior capsule may be suture is the most important. The epithelium and the stroma
torn inadvertently during the aspiration of the lens matter. The should be firmly grasped and the first suture should be placed
incidence of posterior capsular tear with vitreous loss has been directly behind the forceps, which grasps the graft to prevent
reported to vary from 0 to 16 percent.16,17 any undue torque. The depth of the suture should be almost upto
the Descemet’s membrane to ensure optimal wound closure and
Management: Small capsular tears without vitreous loss are of prevent posterior wound gaping. The donor button may be
little significance and one can place posterior chamber rotated/spun in any direction before the application of the first
intraocular lens in the bag or in the sulcus. In case where the suture. The second suture should be placed exactly opposite first,
tear is large and associated with vitreous loss, an anterior as even a slight deviation will result in the torsion of the graft
vitrectomy should be performed. In the absence of any and consequently astigmatism.
contraindication, an open loop Kelman multiflex anterior
chamber intraocular lens may be implanted. This should be Iris Incarceration
combined with a peripheral iridectomy.
The iris can be picked up with the needle and inadvertently
Suture Related Complications sutured into the wound making the pupil eccentric. Incarceration
of uveal tissue in suture may lead to inadequate healing, low-
Broken/Loose/Tight Sutures grade uveitis and can enhance chances of graft rejection.
It is possible that some of the sutures appear loose or very tight Prevention and management: This is avoided by lifting the
at the end of surgery. A final assessment of such sutures should wound edge slightly before passing the suture through the host.
be made after the reformation of anterior chamber. Also if too Air, Healon GV or BSS may also be used to push the iris away
much tension is applied to the sutures, they will break. Failure effectively. If the iris incarceration occurs and the iris has been
to bury the knots is a common problem that can be encountered inadvertently sutured in the wound, the suture should be replaced.
following the suturing of the graft.
Shallow Anterior Chamber
Management: All broken, tight and loose interrupted sutures
should be replaced. Any suture which does not bury should be A shallow anterior chamber during penetrating keratoplasty may
immediately replaced. Caution is required, especially when using occur due to the presence of floppy iris, such as in cases of
a continuous suture (Fig. 14.4) The continuous suture may be corneo-iridic scars, positive vitreous pressure, and use of small
accidentally cut while attempting to remove the cardinal sutures. graft (Fig. 14.5).
The use of double-armed suture allows suturing in a direction All previously existing synechiae should be released,
opposite the first when needed. However, if the double-armed whenever possible. In cases such as corneo-iridic scar18 and
suprachoroidal space may result in expulsion of intraocular
contents through the recipient corneal opening.
The mechanism of suprachoroidal hemorrhage is sudden and
prolonged decompression of the globe resulting in rupture of
fragile choroidal vessels due to either traction on the vitreous
or elevated transmural pressure gradient. Various risk factors
involved are pre-existing glaucoma, hypertension, high myopia,

Chapter 14: Complications of Penetrating Keratoplasty

inflammation, sudden cough, previous surgery, previous traction
and Valsalva maneuver.21,22 Injection of excessive amount of
retrobulbar local anesthetic may also predispose hemorrhage by
sharply elevating episcleral venous pressure.21
The condition can be promptly diagnosed by progressive
bulging of the vitreous anteriorly along with direct observation
of the developing detached choroid.
Prevention and management: Suprachoroidal hemorrhage can
be prevented by preoperative lowering of intraocular pressure,
Figure 14.5: Shallow anterior chamber controlling hypertension and preventing any Valsalva maneuver
during surgery. Patient’s head can be slightly elevated.
Trephination should be performed gently so that the intraocular
pediatric cases19 where, shallow anterior chamber is anticipated, pressure is not markedly elevated by downward pressure with
over sized grafts should used to prevent the occurrence of a the trephine and then rapidly reduced when the anterior chamber
shallow anterior chamber. At the end of keratoplasty, the anterior is opened.
chamber should be formed with balanced salt solution to prevent However, if the intraoperative hemorrhage occurs, the
the occurrence of posterior synechiae and endothelial damage. emergency management includes occlusion of the host corneal
Failure to reform the anterior chamber usually signifies a wound opening and sealing of the eye to provide a good tamponade.
leak from poorly apposed corneal edges or irregular suturing and The management of expulsive hemorrhage depends on the
hence should be appropriately managed. immediate recognition and prompt action.
Air has higher surface tension than water and may actually If the hemorrhage occurs immediately or shortly after
seal and thereby hide a wound leak. Therefore, when checking entering the globe, a posterior sclerotomy via a stab incision
such a leak, BSS should replace air in the anterior chamber. A through the conjunctiva and sclera is performed. The
shallow anterior chamber may also occur due to the positive inferotemporal quadrant is the most readily accessible. Multiple
vitreous pressure in the absence of wound leak. Use of pars plana sclerotomies may be required. However, if the hemorrhage
vitreous aspiration with an 18-gauze needle attached to a 3-ml occurs during the open sky phase of keratoplasty, management
syringe has been advocated in such cases.12 is more difficult. A temporary keratoprosthesis, if available, or
Floppy iris should be managed by pupilloplasty. even a finger can be used for occlusion. Intravenous mannitol
should be started immediately and one or more sclerotomies
Wound Leak
made to facilitate drainage. Donor button is then sutured in place
Following completion of the suturing of the donor to the host, with 8-0 nylon as rapidly as possible. Visual prognosis is usually
one must always check for the presence of wound leaks. poor and depends on the extent of hemorrhage, concurrent
Fluorescein dye (Seidel’s test) can be applied to the surface of involvement of retina and efficiency of intraoperative
the cornea and tight manual pressure should be applied to the management.
globe. Alternatively, the wound may be dried with one Weck
sponge and the limbus may be gently pressed with another dry POSTOPERATIVE COMPLICATIONS
sponge, so that the presence of wound leak is easily detected. If
a wound leak is noted, additional sutures may be applied. If Early Postoperative Complications
suture tract leak is present, a 10-0 prolene suture should be placed Complications in the early postoperative period vary from minor
perpendicular to the suture tract. This is especially important in to true ophthalmic emergencies resulting in the loss of the eye.
pediatric keratoplasty where, there are more chances of wound Hence a meticulous follow-up, early diagnosis and a timely
leak due the presence of a less rigid cornea. intervention is mandatory to diagnose complication occurring
after corneal transplantation.
Suprachoroidal Hemorrhage
Shallow Anterior Chamber and Wound Leak
This is a rare and the most dreaded complication of penetrating
keratoplasty.20 The incidence of suprachoroidal hemorrhage A shallow anterior chamber along with low intraocular pressure
varies from 0.47 to 3.3 percent.4 Uncontrolled bleeding into on the first postoperative day usually signifies a wound leak.
However, intraocular pressure may be normal or even high in Iris Incarceration
some eyes. The site of leak can be identified by Siedel’s test.
Iris incarceration may occur due to collapse of anterior chamber
The test is performed by placing the concentrated fluorescein
or from wound leak. This may occur in cases where, penetrating
dye on the surface of the cornea. Under the cobalt blue filter,
keratoplasty has been undertaken in inflamed eyes and the iris
the concentrated fluorescien appears black. The leakage of the
is swollen and flaccid. It may also occur due to poorly placed
wound or a suture tract results in dilution of the fluorescein and
sutures which may incarcerate the iris, especially if the lens-iris
a change in color from black to bright green.
diaphragm herniates forwards. The presence of incarcerated iris
Section III: Penetrating Keratoplasty: Management of Complications

A prolonged shallow anterior chamber may result in

may incite postoperative inflammation. It closes the anterior
occurrence of secondary glaucoma and significant endothelial
chamber angle at the site of incarceration and can cause
cell loss, as there is more chance of contact between endothelium
glaucoma and graft failure. Large adhesions at the host-graft
and iris or lens. The graft survival is dependent on early diagnosis
junction may lead to localized edema of the graft and attract
and quick reformation of the anterior chamber. The likely causes
of wound leak are as mentioned in Table 14.1.
Management: Minimum incarceration due to wound leak can
Table 14.1: Common causes of wound leak be treated conservatively and efforts should be made to seal the
leakage. Argon laser iridoplasty may be undertaken to release
• Broken, loose or misplaced suture
• Suture track leak: full thickness suture the iris. However, if conservative management fails, surgical
• Suture through thin or necrotic tissue intervention is necessary. Iris tissue is separated from all
• Excessive gap between sutures attachments and swept out of the wound with an iris repositor.
• Unequal thickness of graft and host A viscoelastic material can be injected into the anterior chamber
by making a separate stab wound entry and the iris tissue may
Prevention and management: If the anterior chamber is flat and be rotated away from the wound gently using the viscoelastic
a wound suture tract leak or iris prolapse is present, immediate cannula. In case, the iris cannot be separated from the wound,
surgical repair is mandatory. the suture may be the culprit, in which case suture must be
If the anterior chamber remains formed in the presence of a replaced.
wound leak a pressure bandage or bandage contact lens may be
given which aids in reapposition of the wound, tamponades the Wound Dehiscence
leak and decreases the trauma from the lids in the wound. A wound dehiscence in the postoperative period may occur
Additionally, acetazolamide may be prescribed to decrease the immediately or may occur several years after penetrating
aqueous production. keratoplasty. Younger patients, especially males, should be made
If the wound does not seal in 24 hours, it must be resutured. aware that their eye, after keratoplasty, will always be vulnerable
In case of interrupted sutures, any loose or broken sutures should to injury. High-risk situations should be avoided if possible.
be replaced. An additional suture can be placed in the area of Older patients at particular risk should have adequate risk
leak. In case of a continuous suture, loosening the tight area and reduction strategies, social support, and supervision, in particular
tightening the area of the leak may redistribute the tension of to minimize the risk of falls.23 A wound dehiscence in the
the wound. In case of a broken continuous suture in the early immediate postoperative period usually occurs secondary to
postoperative period, a new segment of 10-0 nylon suture must technical problems such as a thin, necrotic recipient bed. It may
be added, making several bites across the wound. It is then tied also occur due to a postoperative rise in the intraocular pressure
to both the ends of the broken suture that have been withdrawn or after suture removal. The incidence of wound dehiscence after
a loop or two on either side to provide enough suture for tying. suture removal requiring repair has been reported to be 2.424
The new suture is passed for several bites before the original and 2.9 percent.25
suture is distributed for tying. Before tying the final knot, the Causes of wound dehiscence are as mentioned in Table 14.2.
tension should be gauged and the suture should be adjusted Spontaneous wound dehiscence may occur in the elderly or in
appropriately. If this attempt does not close the leak, the suture patients of keratoconus. Generally, all traumatic wound
is cut at the knot and a second knot is tied after tightening the dehiscence following penetrating keratoplasty occur at the donor-
suture from both the sides. If the surgeon feels difficulty in the recipient interface. Eyes with traumatic wound dehiscence have
above maneuver, interrupted sutures may be placed in the area worse visual outcome than those with dehiscence after suture
of leakage. removal. Patients should be cautioned about the risks and
Suture track leak caused by full thickness sutures usually
close spontaneously. An additional mattress suture may be
Table 14.2: Causes of wound dehiscence26-29
applied perpendicular to the suture which is causing the suture
track leak. Leak caused by suturing through necrotic tissue is • Trauma
very difficult to manage, as resuturing is nearly impossible. • Infectious keratitis
• Suture failure
Corneal gluing and bandage contact lenses may be tried in such
• Spontaneous wound separation
consequences of wound dehiscence. The suture may be left in
place longer in older patients or when corneal edema is the
indication for grafting.30
A full thickness wound dehiscence must be repaired
immediately. Wound dehiscence is the leading indication for
resuturing following penetrating keratoplasty.31 If iris prolapse
is present which is less than 24 hours duration and the iris tissue

Chapter 14: Complications of Penetrating Keratoplasty

appears healthy, it should be replaced back into the anterior
chamber. If the prolapsed tissue appears necrotic or if the
duration of iris prolapse is more than 24 hours, iris tissue
abscission should be done with scissors held flush to the wound.
Additional procedures, such as lensectomy, vitrectomy, IOL
explantation may be required, and in some cases, regrafting may
be necessary.

Suture-Related Problems Figure 14.6: Loose sutures

Various suture-related complications observed in keratoplasty
patient include exposed suture knot, broken, tight or loose
sutures, unraveled suture knot, suture related infectious or
immune infiltrates and suture induced vascularization (Figs 14.6
to 14.8).
Exposed suture knots are important causal factors for foreign
body sensation, photophobia, excess mucous production, giant
papillary conjunctivitis and stimulate local corneal vasculari-
zation thereby increasing the risk of rejection. An exposed suture
also acts as a nidus for microbial infection.
In a study by Christo et al, the incidence of broken or loose
sutures needing surgical repair was found in 8.3 percent of the
cases.23 Sutures should be placed with appropriate tension since
both tight as well as loose sutures are associated with problems.
Tight suture can cause persistent epithelial defect and induce
a high amount of astigmatism. In contrast, loose suture fails to
undergo epithelization and remains exposed. It acts as a nidus Figure 14.7: Suture infiltrates
for collection of collection of mucoid and tear debris and may
become a focus for infection.
Occasionally, a suture knot may unravel, which is more
common when the suture is not squarely tied, the ends of the
suture are trimmed too close to the knot or the knot is not buried
in the cornea. Corneal deturgescence, wound remodeling, scar
contraction and biodegradation caused by enzymatic factors and
ultraviolet light exposure of the suture occur during wound
healing. As the wound healing proceeds, the suture can loosen,
become exposed and may serve as a nidus for infection.23
Suture related infections are related to suture exposure, use
of soft bandage contact lens and topical steroids. Suture
abscesses are considered poor prognostic factor for the survival
of the clear graft since even when treated aggressively, they can
result in wound dehiscence, graft failure secondary to the
Figure 14.8: Suture induced vascularization
infection, corneal scarring and endophthalmitis.
Suture related immune infiltrates occur as a result of
immunological reaction to either suture material or to talc from in contact with the margins of upper and lower eyelid. In such
the surgical gloves, which adheres to the suture material. They situations, it is seen as a hypersensitivity reaction to
must be differentiated from infectious suture infiltrates Staphylococcus albus, which colonizes the lid margins,
(Table 14.3). They are seen in relation to sutures, which come particularly in the ocular surface disorders such as blepharitis.
Table 14.3: Comparison between features of immune Epithelial Defects
and infectious suture infiltrates
During the early postoperative course of penetrating keratoplasty,
Immune suture infiltrates Infectious suture infiltrates re-epithelization and maintenance of intact epithelium is essential
Usually multiple and small Solitary for the postoperative wound healing. Epithelial defect heals by
Occur on host side only May occur on host or graft side the sliding movement of the cells towards the center over the
basement membrane until the surface is confluent and the normal
Not associated with Epithelial defect common
overlying epithelial defect thickness of cornea is restored. Survival of a corneal graft is
Section III: Penetrating Keratoplasty: Management of Complications

critically dependent on an intact epithelial barrier. A persistent

corneal epithelial defect is a full thickness loss of cells that
Management: Any tight or loose suture in the immediate fails to show the expected rate of healing. Epithelial growth
postoperative period should be replaced. In case of exposed requires careful monitoring and persistent epithelial defect is
suture knot, suture rotation should be done. If the suture rotation considered if more than 2-4 days pass without progress of
is not possible, the suture with the exposed knot should be healing. Average time for complete epithelization of a corneal
replaced and the knot buried. graft is 4-6 days.32,33
Suture abscess should be treated energetically because of its The risk factors for a persistent epithelial defect are outlined
deleterious consequences. Suture roof should be debrided with in Table 14.4.
the help of a 26-gauge needle and the material should be sent Serious consequences follow if the epithelial defect does not
for microbiological examination and culture-sensitivity plating. heal. A persistent epithelial defect (Figs 14.9 and 14.10) can give
Some surgeons even advocate the removal of the affected suture rise to graft ulceration, stromal melting, perforation and even
followed by its microbiological examination and culture- graft failure.34
sensitivity plating. If the affected suture is a running suture,
removal is based upon whether additional sutures are present Prevention and Treatment
for support. The patient should be started on broad-spectrum Preoperative: Adequate protection of cornea by proper lid closure
fortified antibiotics until organism is identified and antibiotic must be ensured before penetrating keratoplasty. Significant
sensitivity is known. ectropion, entropion, lagophthalmos or other potential causes of
The frequency of topical corticosteroids may be temporarily corneal exposure should be corrected before undertaking a
reduced in the early stages of treatment. During this period, keratoplasty. Patients with significant loss of stem cells secondary
many surgeons have used systemic corticosteroids in order to to chemical burns, thermal burns, Stevens-Johnson syndrome or
protect against possible graft rejection, although the role of other ocular surface disease should be considered for an
systemic steroids in prevention of graft rejection is not clear. Autologous limbal conjunctival transplantation, keratoepithelio-
Once the infection is controlled, dose of topical corticosteroids plasty or stem cell transplantation. Dry eye conditions can be
may be increased cautiously. improved by medical treatment or by punctal occlusion.
The immune suture infiltrates are treated in a conservative
manner. The frequency of topical corticosteroids is increased to
Table 14.4: Risk factors for persistent epithelial defect
at least every 2 hours, if the graft epithelium is intact. If the graft
epithelium is not intact, oral corticosteroids may be used on a • Ocular surface diorders
short-term basis. If the infiltrates persist for more than few days, • Lid abnormalities: Ectropion, Entropion, Lagophthalmos
one may add cyclosporin-A drops topically. • Infection and inflammation (e.g. Herpes simplex virus
Descemet’s membrane detachment: We have to include this • Neurogenic
postoperative complication. • Iatrogenic: Tight sutures, drying of the ocular surface,
poorly apposed graft-host junction
Descemet’s membrane detachment: This may be a consequence
• Epitheliotoxic drugs: Gentamicin, Timolol maleate,
of improper graft handling at the time of trephination or suturing, Ciprofloxacin, Neomycin, Diclofenac sodium, Prednisolone
or result from trauma at host-graft junction during subsequent acetate, Dorzolamide
introduction and removal of instruments. • Damaged donor epithelium
Prevention: Gentle handling of donor tissue and careful • Basement membrane disorders
instrument manipulation may minimize incidence of this • Intrinsic epithelial disorder: Stem cell deficiency secondary
to chemical and thermal burns, Stevens-Johnson
syndrome, ocular cicatricial pemphigoid
Management: Options include intra-cameral injections of air or • Trauma
viscoelastic, transcorneal suturing, and even corneal • Poor nutrition: Vitamin A deficiency, protein-calorie
transplantation for persistent cases. Intracameral injection with malnutrition
either sulfur hexafluoride (SF6) or perfluoropropane (C3F8) gas • Metabolic eye disease such as diabetes in the donor as
is being increasingly used. well as the host
increased death enucleation time are associated with higher
incidence of epithelial defects.39 Fresh corneal tissue preferably
with short death enucleation time may be used in high-risk
patients. Intraoperatively, damage to the donor epithelium should
be avoided.
Any rough areas on the Teflon block should be inspected
for and slippage of the donor cornea during the trephination

Chapter 14: Complications of Penetrating Keratoplasty

should be avoided. Cornea must be kept moist to preserve donor
epithelial cells as much as possible. However, excessive
irrigation may be detrimental to the graft and should be avoided.
Use of viscoelastic substances over the donor cornea
intraoperatively to hydrate is a useful option. Any tight sutures
must be replaced and any misalignment of graft-host junctions
should be carefully avoided by meticulous surgery. A bandage
soft contact lens or even a temporary tarsorrhaphy at the end of
Figure 14.9: Epithelial defect following penetrating surgery may be considered in high-risk cases.
Postoperative management: Eye patching for first 24 hours after
putting an antibiotic soaked collagen shield over the cornea may
help in epithelial healing. Most of the topical medications are
epitheliotoxic and therefore, their benefits must be weighed
against their possible adverse effects. Preservative free drops
such as 0.5 percent chloramphenicol minims and Predsol minims
may be used to prevent occurence of epitheliotoxicity. Use of
ointment form of Chloromphenicol is also recommended as it
provides lubrication. Frequent use of lubricants is necessary to
promote epithelial growth. In high-risk cases preservative-free
lubricants should be used.
Bandage soft contact lens is used if epithelial healing is not
complete by the first week of surgery. Bandage contact lens
protects the migrating epithelial cells underneath and hence
healing process is enhanced. Recently extended wear fluid
Figure 14.10: Fluorescein staining of epithelial defect ventilated gas-permeable scleral contact lenses have been tried.40
following penetrating keratoplasty
However, prolonged use of bandage contact lens is discouraged
because of the potential risk of infection and vascularization.
The incidence of persistent epithelial defects in herpetic
The frequency of the topical antibiotic drops should be increased
keratitis varies from 0-44 percent. In cases of penetrating
to 3 or 4 hourly when the bandage contact lens is used.
keratoplasty performed for herpes keratitis, use of perioperative
If the healing is not complete by the second postoperative
oral acyclovir (400 mg twice daily) may decrease the risk of
week, a temporary tarsorrhaphy is considered. 41 The
persistent epithelial defects associated with active herpes disease.
tarsorrhaphy should be performed in a manner that results in
In cases of persistent epithelial defects not amenable to treatment,
maximum coverage of epithelial defect. If the defect is located
the possibility of recrudescence of herpetic keratitis should
on the temporal cornea, a lateral tarsorrhaphy should be
always be considered in cases of previous herpetic scars. Surgical
performed and if it is nasal, a medial tarsorrhaphy should be
incision of the trigeminal nerve reactivates latent herpes
done. Temporary cyanoacrylate glue tarsorrhaphy has been
described but there is a risk of glue migrating into the posterior
Herpes simplex keratitis may also develop after penetrating
aspect of the lids.41 Anterior chemodenervation of the levator
keratoplasty without prior history of herpetic keratitis in the
palpebrae superioris may be performed using 10-15 units of
host.37 The incidence of newly acquired herpetic keratitis after
botulinum toxin type A (Botox) injected transcutaneously,
penetrating keratoplasty has been reported to be 1.2 per 1000
thereby creating an iatrogenic ptosis and obviating the need for
person years in one study.38 The defect usually begins at the graft-
a surgical tarsorrhaphy.42
host junction and may not resemble a typical herpetic epithelial
Autologous serum can be used to enhance the healing of
epithelial defects. The various concentrations which have been
Intraoperative: In patients in whom problems with epithelization used range from 20 to 100 percent.43-45 Epidermal growth factor
are anticipated, the use of donor tissue with good donor is present in both tears and serum and has found to be helpful in
epithelium is warranted. Prolonged donor preservation time and healing of epithelial defects, possibly due to its anti-apoptotic
properties. Further, fibronectin and vitamin A are also present
in the serum which aid epithelization.
Umbilical cord serum has demonstrated faster healing of the
persistent corneal epithelial defects refractory to all medical
management compared to autologous serum.46
Amniotic membrane transplantation can also be done for
persistent epithelial defect after penetrating keratoplasty.47 The
Section III: Penetrating Keratoplasty: Management of Complications

amniotic membrane contains a thick basement membrane and

an avascular stromal matrix. The basement membrane facilitates
migration of the epithelial cells, reinforces adhesion of basal
epithelial cells and promotes epithelial differentiation. The
basement membrane is also important in preventing epithelial
apoptosis. Collectively, these actions explain why the amniotic
membrane effectively permits rapid re-epithelization.
The use of topical agents such as recombinant epidermal
growth factor and fibronectin for enhancement of epithelial Figure 14.11: Primary graft failure
healing has not been conclusively proven.48,49 Additional clinical
trials are required to determine the use of these agents in future.
• Surgical trauma
Multifocal phototherapeutic keratectomy (PTK) has also
• Herpes simplex virus infection.
been tried for persistent epithelial defect. A focal excimer laser
Unhealthy donor endothelium, inadequate tissue preservation
PTK with a 1.0 mm diameter and 150–200 pulse ablations at
and surgical trauma are the major causes of primary graft
the edge of the epithelial defect is performed.50 The excimer laser
failure.53 Primary graft failure has also been attributed to donor
is used to remove the elevated margin surrounding the epithelial
tissue contamination with herpes simplex virus.54,55 Edema
defect zone so that the epithelial cells can migrate easily.
usually develops within the first day after surgery and is
unresponsive to hypertonic saline or steroids. However, to make
Filamentary Keratitis
the diagnosis of primary graft failure, other causes of corneal
Filaments consist of abnormal collection of mucus and corneal edema, e.g. severe hypotony and intense inflammation must be
epithelial cells. The reported incidence of filamentary keratitis excluded. Hyposecretion of aqueous humor, which is common
after penetrating keratoplasty is 27 percent in one case series.51 after penetrating keratoplasty, may result in graft edema due to
Patients complain of redness and foreign body sensation. decreased supply of metabolites to the endothelium. The
Filaments are usually seen in the early postoperative period and endothelial function improves in these eyes, once the aqueous
develop at the graft-host junction along the suture tract. They production is restored and the cornea begins to clear. The
stain brilliantly with the rose-bengal stain. incidence of primary graft failure is less than 5 percent.53
The treatment consists of treating the underlying dry eye and Prevention: Primary graft failure can be minimized by proper
specific treatments for the corneal filaments. Proposed treatments
donor selection, good preservation and by avoiding endothelial
include nonpreserved lubricants, topical steroidal and
injury during donor processing and during the surgery. A major
nonsteroidal anti-inflammatory agents, and punctal plugs for goal of corneal preservation and transplantation is to maintain
aqueous-deficient dry eye as well as mechanical removal of
high postoperative endothelial count. Long-term graft survival
filaments, hypertonic saline, mucolytic agents, and bandage
depends on postoperative endothelial cell count and quality.
contact lenses for the filaments.52 Good technique is essential when removing the corneoscleral
rim from the donor globe. All corneas should be examined
Primary Graft Failure
preoperatively with slit lamp for any possible endothelial
Corneal grafts that have gross corneal edema with large broad damage. McCarey-Kaufman medium is used in most of the eye
folds immediately after keratoplasty and which is not followed banks in India, which can preserve the donor tissue up to 96
by a period of clear cornea is called primary graft failure hours. However, if the death-to-enucleation time is prolonged,
(Fig. 14.11). It is the faulty donor tissue that results in irreversible it can preserve the donor tissue only up to 2 hours. During
graft edema in the immediate postoperative period. The possible storage, endothelial cells are lost at variable degrees. Optimum
factors responsible for primary graft failure are listed below: results are obtained if the surgery is performed at the earliest,
• Prolonged death-enucleation time minimizing the donor preservation time.
• Poor donor endothelial count During the suturing of the corneal graft, most of the damage
• Aphakic and pseudophakic donor to the endothelium occurs at the beginning when the borders of
• Elderly donor the graft rub against the host corneal rim tissue. Endothelial loss
• Inadequate preservation can be avoided by using good viscoelastics at this stage. In our

experience, Viscoat (Alcon Labs, Fort Worth, TX) which consists be required in instance of acute IOP elevation. Weak mydriatics
of 4 percent chondroitin sulfate and 3 percent sodium to prevent posterior synechiae and topical steroids to control
hyaluronate was found to be endothelio-protective. During intraocular inflammations are recommended.
surgical manipulation, distortion of the donor corneal tissue The presence of uncontrollable elevated IOP or prolonged
should be minimized, and it is imperative that no surgical persistence of hemorrhage may necessitate surgical intervention
instruments come in contact with the endothelium. Endothelial in the form of clot irrigation and aspiration through limbal
cell damage may occur from excessive irrigation of the anterior incision. The use of thrombolytic agents, e.g. streptokinase, tissue

Chapter 14: Complications of Penetrating Keratoplasty

chamber. plasminogen activator to dissolve blood clots or ε-aminocaproic
acid to prevent rebleeds have not been adequately studied in
Management: Once the diagnosis of the primary graft failure is
penetrating keratoplasty.59
made, the regrafting should be performed as early as possible.
A repeat penetrating keratoplasty is the most definite therapeutic
High Intraocular Pressure and
modality, but some grafts may clear without additional surgery.
Pupillary-block Glaucoma
A case of primary graft failure should be preferably observed
for 3-4 weeks for the signs of graft clearing before proceeding Several factors can contribute to the early elevation of intraocular
with the second surgery.56 All cases should be investigated pressure after penetrating keratoplasty.60,61 The major factors
thoroughly to determine the possible factors responsible for involved are:
primary graft failure. • Residual viscoelastics in anterior chamber
• Uveitis
Graft Rejection • Hyphema
• Crowding of anterior chamber angle
It is a specific process in which a graft, having been clear for at
• Pupillary block.
least 2 weeks, suddenly succumbs to graft edema in conjunction
• Forward movement of lens iris diaphragm
with inflammatory signs due to some immunologic process57,58
(Fig. 14.12). This will be discussed in detail in Chapter 16. Prevention and management: Viscoelastic material, which is left
inside the anterior chamber, is one of the most common causes
Hyphema of early postoperative rise of intraocular pressure. Irrigation at
the end of surgery removes most of the viscoelastics and prevents
Postoperative occurrence of hyphema is rare after penetrating
postoperative pressure rise. However, excessive irrigation can
keratoplasty. Incidence of hyphema increases with intraoperative
manipulations like extensive synechiolysis, iridoplasty or cause endothelial damage and must be avoided.
Postoperative uveitis is controlled by intensive treatment with
iridotomy. Most of the postoperative hyphema clears
topical steroids such as 1 percent prednisolone acetate or 0.1
spontaneously without treatment. It may, however, be associated
with an elevated intraocular pressure that should be treated percent dexamethasone sodium phosphate given 2 hourly.
Systemic steroids, such as T prednisolone 1-2 mg/kg body weight
may be started. Further, short acting cycloplegics, such as 1
Management: If topical β-blockers alone is not adequate to percent tropicamide may be given.
control IOP, topical apraclonidine or systemic carbonic Crowding of anterior chamber angle gives rise to both
anhydrase inhibitor should be used. Systemic osmotic agents may immediate and long-term elevation of intraocular pressure. It is
more common in aphakic keratoplasty, when trabecular
meshwork collapses due to lack of lenticular support. Relatively
small size of donor button and tight sutures are the other
important factors. Use of slightly over-sized graft in aphakic
patients and avoidance of tight sutures by maintaining anterior
chamber depth through-out the procedure may prevent
postoperative rise of IOP in these cases.
The presence of a flat or shallow anterior chamber and a
securely closed wound, confirmed by Siedel’s test, suggest the
presence of pupillary block or choroidal detachment. The
pupillary block is usually associated with high IOP whereas, a
low intraocular pressure is recorded in cases of choroidal
detachment. The presence of posterior synechiae or vitreous
protruding through the pupil confirms the diagnosis of pupillary
block. Air should not be used to form the chamber, especially in
aphakes, as this may lead to pupillary-block glaucoma.
Figure 14.12: Corneal edema due to graft rejection Sometimes a diffuse wound leak results in anterior displacement

of lens-iris diaphragm, which plugs both leak and anterior
chamber angle. This again raises the IOP.
Treatment of pupillary block includes vigorous attempt to
dilate the pupil pharmacologically and concurrent use of
antiglaucoma medications. In situations where, the pupillary
block is unresponsive to the pharmacological dilatation, a
peripheral iridectomy should be considered. This may be
Section III: Penetrating Keratoplasty: Management of Complications

undertaken with the help of laser, if the peripheral cornea is clear

or a surgical iridectomy may be done, if the peripheral cornea is

Low Intraocular Pressure

Low intraocular pressure after penetrating keratoplasty is not
uncommon. Following are the possible causative factors:
• Wound leak
• Iridocyclitis: Ciliary shock Figure 14.13: Recurrence of herpetic keratitis in a graft
• Cyclodialysis
• Choroidal detachment to distinguish the graft rejection and herpes simplex keratitis. It
• Retinal detachment. is relatively easier to diagnose herpes simplex keratitis when it
Postoperative wound leak is suspected when shallow anterior presents with classical dendritic or geographic form. However,
chamber coexists with low intraocular pressure. A positive stromal involvement which presents with graft edema and keratic
Siedel’s test confirms the diagnosis. Management of the wound precipitates, is almost impossible to distinguish from graft
leak has been discussed previously. rejection. The features which help to distinguish recrudescence
Postoperative iridocyclitis is also an important etiologic of epithelial herpetic keratitis from graft rejection include the
factor for low intraocular pressure. Iridocyclitis decreases the classical epithelial dendrite, focal involvement and propensity
aqueous humor produced by the ciliary body. Topical steroids of herpes to occur at the host-graft junction. In addition,
usually control the inflammation in 1-2 weeks and intraocular epithelium shows granular appearance. The characteristic feature
pressure returns to normal as the aqueous production resumes. of graft rejection – Khodadoust line is not seen in herpes keratitis.
A cyclodialysis is a separation of ciliary body from the scleral Management: Herpes simplex keratitis is treated with topical
spur. Inadvertent surgical manipulation can give rise to antiviral agents, e.g. acyclovir (3%) five times daily along with
cyclodialysis. Low intraocular pressure is due to excessive supportive therapy. Stromal keratitis is treated with topical
drainage of the aqueous into the supraciliary space. The condition corticosteroids along with topical antiviral agents, i.e.
is difficult to diagnose, as graft edema or hazy graft-host junction Prednisolone acetate 1 percent 2 to 4 hourly in combination with
prevents the visualization of the angle by gonioscopy. 3 percent acyclovir 5 times daily. Topical antivirals are
Fortunately, in majority of the cases resolution occurs epitheliotoxic and therefore, patients should be monitored
spontaneously. frequently.
Choroidal detachment as a cause of low IOP is suspected The recurrence of herpes simplex keratitis can be reduced
when a postoperative flat anterior chamber is associated with by prophylactic use of antivirals.62,63 Topical acyclovir (5 times
absence of wound leak. Ultrasonography B-scan confirms the daily) is given postoperatively for 2 weeks. Maintenance dose
diagnosis. Most choroidal detachments resolve spontaneously of acyclovir 400 mg BD has been shown to reduce allograft
without any sequelae. Commonly used treatment regimens for rejection and graft failure after PK in patients with herpes.
choroidal detachment include topical and systemic Vajpayee et al64 compared systemic vs topical acyclovir therapy
corticosteroids. If the anterior chamber angle is compromised for the prevention of recurrence of herpetic keratitis following
for more than 48-72 hrs and the choroidal detachment is penetrating keratoplasty (PK) and found that systemic acyclovir
persistent, surgical drainage of the suprachoroidal space with is more effective in prevention of recurrence of of herpetic
reformation of the anterior chamber is recommended. keratitis.
Valacyclovir 500 mg OD for one year has also been found
Herpes Simplex Keratitis
to be effective in the prevention of recurrent lesions in
Recurrence of herpes simplex keratitis in graft is not uncommon. immunocompetent individuals with ocular herpes simplex virus
The infection can recur any time between 1 and 15 years (HSV) disease.65 Prophylactic oral Valacyclovir treatment has
postoperatively37 (Fig. 14.13). There is a unique relationship of also been found to be as effective as oral Acyclovir in preventing
herpes simplex keratitis and graft rejection. The keratitis can recurrence in patients who undergo corneal transplantation for
incite graft rejection and vice versa. Sometimes it is very difficult herpetic keratitis.66

Microbial Keratitis and secured or knots are not buried, it can lead to loose, broken
sutures and exposed knots in the early postoperative period with
Postpenetrating keratoplasty microbial keratitis is characterized
increase risk of suture abscesses67,69 (Fig. 14.16). Corneal graft
by either infection within the graft or infection along the suture
sutures may erode through the overlying epithelium. Wound
tracts at the graft-host junction. The infections within the graft
remodeling, scar contracture and cheese-wiring of influenced
(Fig. 14.14) or at the graft-host junction can produce an
stroma may loosen and expose previously secure sutures. The
inflammatory reaction in the eye with the initiation of concurrent
superficial loop of an intrastromally embedded nylon suture tends
graft rejection and can cause graft faliure, melting of the graft

Chapter 14: Complications of Penetrating Keratoplasty

to undergo biodegradation earlier than does the deeper aspect
and even endophthalmitis with subsequent loss of vision. The
of the sutures. Loose sutures breach the epithelial surface and
incidence of microbial keratitis in corneal grafts ranges from 1.76
normal barrier and thus initiates the infection cascade providing
to 4.9 percent in western countries. In developing countries, it
a direct route for infection into the stroma. Broken and exposed
has been reported to be as high as 11.9 percent.67 Increased risk
end of a suture can accumulate mucus and foreign debris and
of graft infection is associated with preoperative herpes simplex
act as a “infectious wick”. The surgeon and the assistants should
keratitis and grafts performed for complications of previous
wash their gloves to avoid postoperative talc-related suture
infectious keratitis.67 Postoperative infectious keratitis may also
abscess. Suture fragments, cotton fibers or any debris trapped
be caused by intraoperative contamination, recurrent host disease
by the sutures must be removed meticulously as they serve as
or poorly preserved donor material (Fig. 14.15).
potential source of infection. Patients should be kept in close
Suture related problems and persistent epithelial defect are
follow-up and any loose suture must be removed as soon as
the most common risk factors predisposing to graft infection.68
possible and replaced if necessary.
It is important in reducing the risk of infection to ensure that all
Meticulous tissue processing in a sterile environment and
sutures are secure, knots are buried and sutures are nicely covered
optimum use of antibiotics in proper concentration reduce the
by epithelium postoperatively. If the sutures are not properly tied
risk factors related to faulty preservation. Any change in color
of preservative media is an indication of contamination and the
donor tissue must be discarded. Use of contact lens can incite
severe infection in the graft. The patients should be educated on
contact lens care and instructed to report early if there is pain,
irritation or foreign body sensation. Epithelial defect related
complications should be prevented. Pre-existing ocular diseases
should be treated preoperatively. Every attempt should be made
to improve ocular surface with tear substitutes, punctal
occlusions or lid surgery. Though topical corticosteroids suppress
ocular inflammation, they impair host defense mechanism and
promote bacterial super-infection. Corticosteroids are routinely
used in all keratoplasty patients to prevent graft rejection and
their risk in usage is well known. Caution must be practiced in
their use and dose should be tapered.
Figure 14.14: Graft infection following penetrating keratoplasty Management: About half of the infections occur within the first
six months of surgery, with the majority occurring within the

Figure 14.15: Infectious keratitis involving the entire graft Figure 14.16: Multiple suture abscesses in the graft