An eye bank is an organization which obtains,evaluates and distributes eyes from humanitarian minded citizens for use in corneal

transplantation, research and education To ensure patient safety,the donated eyes are evaluated under strict medical standards All donated eyes not suitable for corneal transplantation are used for valuable research and education

EBAA has developed extensive criteria for screening donor corneas to avoid transmissable infections and other conditions.Contraindicatons include Death of unknown cause Unknown CNS disease or certain infections (eg. Creutzfeldt-Jacob disease,SSPE,Progressive multifocal leukoencephalopathy,congenital rubella,rabies,Reye syndrome,active viral encephalitis,encephalitis of unknown origin)

Active septicemia Social ,clinical or laboratory evidence suggestive of HIV infecton,syphilis, or active viral hepatitis) Leukemias or active disseminated lymphomas Active bacterial or fungal endocarditis Active ocular or intraocular inflammation such as iritis,scleritis, conjunctivitis,choroiditis

Intrinsic malignanciessuch as malignant anterior segment tumors,adenocarcinoma in the eye of primary or metastatic origin,and retinoblastoma Congenital or acquired eye disorders that would preclude successful surgical outcome: any central donor corneal scar or pterygium involving the central 8mm clear zone(optical area of the donor button), keratoconus, keratoglobus, or Fuchs dystrophy

Prior refractive coneal surgery such as radial keratotomy(RK), PRK, LASIK, and lamellar inserts,although for use in endothelial keratoplasty such as DSAEK, refractive laser surgery may not disqualify a donor. Hepatitis B surface antigen- positive donors, hepatitis C seropositive donors.

Corneas from patients with prior intraocular surgery (cataract, IOL implants, glaucoma filtration) may be accepted if endothelial adequacy is documented by specular microscopy Other factors to be considered includes slit lamp appearance of donor tissue specular microscopic data( endothelial cell counts <2000 cells/mm2 are not used)

Death to preservation time(optimal range <12-18 hrs) Tissue storage time prior to keratoplasty Donor age Most eye banks establish a lower age limit of 24 months and an upper age limit of 70 years

The McCarey-Kaufman tissue transport medium developed in the early 1970s significantly reduced endothelial cell attrition, allowing corneal buttons to be safely transplanted after being stored for up to 4 days at 4C. Most commonly used preservative medium is Optisol-GS(Bausch & Lomb, Irvine,CA) which includes 2.5%chondroitin sulphate, 1% dextran, ascorbic acid, vitamin B 12, and the antibiotics gentamycin and streptomycin.

Corneal transplantation refers to surgical replacement of a full-thickness or lamellar portion of the host cornea with that of a donor eye. Allograft-if the donor is another person Autograft-use of donor tissue from the same or fellow eye

Complete eye examination,including a detailed social history to help determine the patients compliance postoperatively. Ocular surface problems-dry eyes,trichiasis,exposure,blepharitis,and rosacea must be recognized and treated Pre existing glaucoma or ocular inflammation should be controlled.

Active keratitis or uveitis is treated and the eye should be quiet for several months prior to surgery. FFA and OCT can be helpful in detecting retinal problems-CME and ARMD Poor prognostic factors-deep corneal vascularization,ocular surface disease, active anterior segment inflammation,peripheral corneal thinning,previous graft failures, poor compliance and increased IOP.

Indications- any stromal or endothelial corneal pathology Intraoperative complicationsdamage to the lens or iris from the trephine,scissors or other instruments irregular trephination poor graft centration on the host bed excessive bleeding-iris and the wound edge

Intra operative complicationschoroidal hemorrhage and effusion iris incarceration in the wound damage to the donor endothelium during transplantation and handling

More complex than cataract surgery Long term success of a PK depends on the quality of the postop care as much as on the performance of the operative technique Topical antibiotics,tapering topical corticosteroids.

Wound leak Flat chamber Glaucoma Endophthalmitis Persistent epithelial defect Recurrent primary disease Primary graft failure Graft rejection Corneal astigmatism

Early recognition is the key to survival of an affected corneal graft Occurs in four clinical forms Epithelial rejection Subepithelial rejection Stromal rejection Endothelial rejection Treatment-topical corticosteroidsdexamethasone 0.1% or prednisolone 1%

Full-thickness tissue eliminates interfacerelated visual problems

Difficult to determine anterior corneal curvature,leading to significant refractive error Post operative astigmatism Ocular surface disease or neurotrophic cornea leads to prolonged healing or persistent epithelial defect

2 types Superficial Anterior Lamellar Keratoplasty(SALK) Deep Anterior Lamellar Keratoplasty(DALK)

INDICATIONS- Superficial stromal dystrophies and degenerations Salzmann nodular degeneration Scars,trauma,dermoids infections Poor microkeratome dissection Corneal perforation

Postoperative complications- loss of donor lenticule Advantages- selective removal of pathologic tissue more rapid visual rehabilitation Reduced risk of graft rejection Disadvantages-irregular surface,interface vascularization

INDICATIONSKeratoconus Infections Corneal stromal dystrophies not involving endothelium Corneal ectasia secondary to LASIK

Intraoperative complicationsCorneal perforation requiring transition to PK Descemets membrane splitting Postoperative complicationsopacification and vascularization of interface, allograft rejection, inflammatory necrosis of the graft

ADVANTAGES- Tectonically stronger wound than in PK Early removal of sutures Less dependence on topical corticosteroids Minimal requirements for donor tissue DISADVANTAGES- Irregular interface

In this procedure, descemets membrane and endothelium are stripped in the host eye (descemetorhexis),producing a smooth posterior stromal bed in the host. INDICATIONS- Endothelial dystrophy Pseudophakic bullous keratopathy ICE syndrome Failed corneal grafts

Poor microkeratome dissection of donor tissue Inability to strip descemets tissue Loss of orientation of tissue Poor centration of trephination,leading to a thick edge and possible epithelial growth Intaocular hemorrhage Excessive manipulation of tissue , leading to cell loss

Pupillary block Dislocation of lenticule Primary graft failure Epithelial ingrowth

Rapid visual rehabilitation Independent of ocular surface wound healing Stable corneal curvature for triple procedures Tectonically strong Eliminates suture related problems

Significant stromal haze,subepithelial fibrosis, or epithelial irregularity may require second procedure Possible higher rate of endothelial cell loss