Corneal Surgery

Understanding Corneal Transplant Surgery

In 2005 and 2006, Dr. Tim Khater performed a corneal transplant surgery on Bryan Hughes, the weatherman for Fox 34 News.  Bryan’s right eye was transplanted in 2005, and his left eye was transplanted in 2006 for a condition known as keratoconus, where the front part of the eye is misshapen.  In Bryan’s case, his eyes were bad enough where he was unable to see well enough with glasses or contacts.

Watch these videos about Bryan’s success:

After his successful right eye surgery, Bryan is seeing 20/20 with the aid of a contact lens.  Currently, Bryan is healing well in his left eye, and will be soon fitted with another contact lens for it.

Introduction

Corneal transplant surgery is quite common; some 5,000 transplants are done in the United States every year. In recent years, the chances of success of this operation have risen dramatically because of new advances such as the surgical microscope, finer, less irritating sutures, and better eye banking techniques. In fact, many patients can expect better than a 90% chance of a clear transplant. Even though this surgery is a unique and sometimes frightening experience for you as a patient, we hope that this section will help to guide you through this new experience by answering questions concerning corneal transplant surgery and your role in ensuring its success.

What is the Cornea

Corneal transplant surgery involves removing the diseased cornea surgically and replacing it with a donated cornea. To help you better understand this, let us briefly describe just what the cornea is.

In the healthy eye, the cornea is a clear, dime-sized piece of tissue that fits like a watch crystal over the blue or brown-colored part of the eye called the iris. Light passes through the cornea (just as it would through a window), through the pupil, then through the lens. The cornea and lens focus light rays on the retina in the back of the eye. The retina then transmits the image of sight along nerves to the brain.

The eye is like a camera in which the retina acts as the film and the cornea and lens act like two lenses of the camera. Cloudiness or irregularity of the cornea or of the lens of the eye results in a blurry image, just as a faulty camera lens would result in a poor photograph.
Corneal cloudiness or irregularity can result from many different kinds of diseases, such as infections, injuries, or inherited tendencies towards a cloudy cornea. In addition, the lens of the eye may become cloudy; this is called a cataract. Depending on the problem, a person might need just a new cornea or a new cornea with removal of the cataract.

 

cataract

Light is Scattered by Corneal Clouding or Irregularity

Obtaining a new cornea is what happens in corneal transplant surgery. This operation is sometimes called corneal graft surgery or penetrating keratoplasty. We will use the term corneal transplant surgery. Your eye is the recipient eye; the other person’s cornea is the donor cornea or donor tissue.

The Donor Cornea

The donor tissue for our corneal transplant surgery is provided by the Great Plains Lions Eye Bank. Eye banks have existed in this country since 1946. Through the efforts of the Lions and the Great Plains Eye Bank, thousands of Texas citizens have signed pledges indicating that, upon their death, their corneas are to be used for transplant operations. Even without the pre-arranged pledge, the nearest relative may give permission for this use of the eye tissue upon death.

The eye bank receives information regarding the availability of the eye donations, arranges for the collection and distribution of the tissue, and notifies the ophthalmologist with patients listed for surgery that the operation can be scheduled. There is no charge for the donor tissue, but the costs of operating an eye bank are quite high and patients receiving corneal transplants are asked to pay a service fee to help defray expenses.

You might be curious to know something about the donor of your corneal transplant; it is the policy of all eye banks that the donor remains anonymous. Certain general points might be of interest. Donors between the ages of 5 and 75 are considered acceptable if the tissue has been obtained promptly and passes the careful screening procedures. Sex, race, blood type, nearsightedness farsightedness, and eye color are not considered in selecting the donor because they do not affect the outcome of the corneal transplant surgery.

The donated corneas are carefully screened for transmittable disease, including AIDS and hepatitis B. Although there has never been a case of AIDS reported from a transplanted cornea, all donor tissue is screened for AIDS and rejected if positive. Indeed, if any of the known transmittable conditions are suspected by medical history or screening examination, the cornea is rejected and disposed of.

One of the most valuable recent advances is the technique for storing donor corneas in fluids for several days. This protects the donor corneas, allows for better planning and timing of surgery, and is one of several important factors that improve chances of successful surgery.

The Operation

We perform the surgery while looking through a microscope in order to do this very delicate work with great precision. A trephine, an instrument like a cookie cutter, is used to remove your cloudy cornea. A trephine cuts out the donor graft to ensure that its size and shape are right for the opening made in your cornea. Bleeding is minimal, amounting usually to only one or two drops of blood.

The new corneal transplant is placed in the opening and is sewn or sutured with a very fine thread, often finer than a human hair. This thread or suture stays in for months or even many years until your eye heals properly; in some instances the suture is left in permanently. Removing the suture is quite simple and can be easily done in the office.

Anesthesia

Corneal transplant surgery is routinely performed with either local or general anesthesia. The best method for you will be discussed with you by Dr. Khater.

If the surgery is performed under local anesthesia, you will be temporarily put into a light sleep with an intravenous medication; the local anesthesia will then be injected in the area around the eye. In most instances, patients do not feel or even remember this injection. Afterwards, your eye will be totally numb and the surgery can be performed while you are awake, but lightly sedated.

If the surgery is performed under general anesthesia, you will be put to sleep, and a plastic tube will be placed in your windpipe to breathe for you. Again no eye pain will be experienced.

Both methods of anesthesia are carefully monitored by an anesthesiologist, and both methods can be done on an outpatient basis.

After Surgery

Caring for your corneal transplant after surgery depends, in large measure, on you. We must work together well, and you must follow strictly the instructions on how to care for your precious new transplant. You will need to use eye drops for many months (or years), and we, or your referring ophthalmologist, will need to see you regularly in the office. There will be certain restrictions on your activities in the early period after your surgery. These will be explained later.

Chances of Success

In most cases the successful outcome following corneal transplant surgery depends on the type of corneal disease that was originally present. When the eye receiving a corneal transplant is perfectly healthy except for cloudiness of the central cornea, the chances of a clear transplant are greater than 90%. But to be successful, you must follow the strict schedule of drops and office visits. Failure to follow the prescribed schedule could greatly reduce the chances of successful surgery. Here are some problems that could delay or prevent the return of useful sight in your operated eye.

Primary Transplant Failure: Fortunately, this is rare. It occurs in the first week or two after surgery and is caused by a fault in the donor cornea. The only treatment is to do another transplant with a different donor cornea.

Graft Rejection: This is quite unusual. It happens when the body becomes “allergic” to the graft and can occur at any time two weeks or more after surgery. There is a good chance that this can be successfully treated if you act immediately. There are four danger signs that you must know. If any of these occur and last for more than six hours, you should immediately call us. These signs are:

  1. Red Eye: It is normal for your eye to be red in the first few weeks after surgery. If, at any time, your eye begins to get redder, then this is cause for concern and you should call your ophthalmologist. You can easily check the redness of your eye by looking into a mirror and pulling down the lower lid. Look carefully at the white part of the eye, especially in the area next to the cornea. You might even check your eye periodically even if you’re not having any problems, so that you will know what it looks like when it is normal.
  2. Decreased Vision: Even though it can take weeks or months to get good vision after you’ve had your transplant, your vision probably will be gradually improving after your surgery. Pick an object in your house that has some pattern or detail to it and get in the habit of covering your good eye and looking at this object every day. In this way you can tell how your vision is doing. If your vision seems to be getting worse, there could be a problem with your eye, and should call us.
  3. Pain: It is normal to have occasional small twinges of pain in your eye but if your eye develops constant pain for several hours, please call us.
  4. Increased sensitivity to light: Bright light might seem very irritating to your eye after surgery. This should slowly get better. If you notice that your eye seems to be getting more sensitive to light and that you feel like squinting or covering it, you should call us.

Wound Separation: This is a break in the area where the edge of the graft is sewn into the eye. There might be no symptoms at all or only a dull ache. It may be treated with a light patch or soft contact lens or it may require a trip back to the operating room so that additional suturing of the transplant can be done.

Astigmatism: This occurs when the transplanted corneas has an oblong shape similar to the surface of a football rather than the round shape of a basketball’s surface. All transplants have some amount of astigmatism and usually this can be corrected with glasses or contact lenses. If this astigmatism is severe, a refractive procedure can often correct it.

Loose Suture: This is not uncommon. Sometimes during the healing process sutures can loosen and case a foreign body feeling, especially when you blink. The loose suture can easily be removed in the office.

Macular Edema: This is a swelling from fluid that has collected in the retina in the back of the eye. It occurs most commonly if the eye has previously undergone cataract surgery. The only symptom is a painless loss of vision. This fluid cannot be surgically drained, but the condition often improves on its own or may respond to certain pills and eye drops that we prescribe.

Considerations Before Your Surgery

Outpatient vs. Inpatient Surgery

Our experience with outpatient corneal transplant surgery indicates that it is as safe for most patients as inpatient surgery, and it certainly is less stressful. Most patients can now arrive at the hospital on the morning of surgery and leaves within one hour after surgery has been completed. We do our outpatient corneal surgery in the same quality operating suites that we use for inpatients, and so you have the benefits of the highly-skilled nurses and superb facilities of The Methodist Hospital combined with the convenience of lower cost of outpatient surgery.Of course, we do admit those patients who for medical reasons require it, but we find that most of our patients can benefit from outpatient surgery.

Planning Postoperative Care

If you have a referring ophthalmologist, our staff will be happy to schedule your postoperative visits with that ophthalmologist. We are happy to provide postoperative care for as long as your referring doctor wishes.

Postoperative visits are routinely scheduled for the following intervals after your surgery: 1 day, 5-7 days, 3 weeks, and 6 weeks.  This may vary according to your particular circumstances. Subsequent visits are usually at monthly or bimonthly intervals during the first year after surgery.

If you live too far away to have follow-up care with us, and you have no referring ophthalmologist, then we will be happy to work with you to find an ophthalmologist near your home who can provide you with your postoperative care.

Your personal eye care after your surgery will mainly involve putting eye drops into the operated eye for several months or longer, beginning with 4 times a day and then at gradually decreasing intervals. We find that almost allindividuals can learn to put drops in their own eyes. If, however, this is not possible for you, please be sure to arrange for someone to help you use the eye drops at home.

General Medical Precautions

If you have medical problems that require the care of a physician, a recent written report from you physician would be helpful to us. If you doctor has a preference concerning the use of local vs. general anesthesia in your case, please let us know. In most cases we will use local anesthesia; that is, you will be awake during the operation.

Stop taking any medication containing aspirin 7-10 days before surgery. If you are taking a “blood thinner” such as Coumadin, this will need to be stopped a few days before surgery: please check with your doctor for exact instructions. Also, please consult with your doctor concerning when and if you should stop taking any other medications. Bring all medications that you are currently taking when you come for your office visit on the day before surgery.

If you experience fever or infection in any part of your body within 2-3 weeks of your scheduled date of surgery, it is likely that we will want to reschedule the surgery for a later date. In such an event, check with your general medical doctor and/or this office for a decision about rescheduling.

Your Vision After Surgery

In the months following surgery the vision in your eye will slowly improve. This improvement is variable because the healing of the corneal transplant varies from patient to patient. In general, useful vision can be obtained within two to six months. About this time, you may be given a prescription for glasses or a contact lens. As your corneal graft heals, your prescription for glasses will probably change.

The suture holding your graft in place is usually allowed to remain in the eye for a year or sometimes longer. When the suture is removed, a substantial change in your eye glasses prescription will occur. This suture can easily and painlessly be removed in the office.

Even after the suture is removed, you should always see an ophthalmologist following your corneal transplant surgery. You will need to use eye drops for a year or sometimes more depending on your particular situation.

Instructions for Patients Recovering from Corneal Transplant Surgery

Medications

  • One or more of your medications may be given to you by the nurse when you leave the SurgiCenter after your surgery. You are not to begin using the medications until seen by a doctor on the morning after surgery.
  • Use medications as instructed on the pharmacy label. All drops may be taken at about the same time, but wait five minutes between drops. DO NOT STOP ANY OF THE DROPS UNTIL DIRECTED TO DO SO.
  • The most important medication that you will be using will be cortisone like drops. These are milky colored drops in a bottle with a white cap. These drops are used for at least six months and usually longer following your operation. You should never be without this medication for longer than one day. It is therefore very important that you have an ample supply of the drops on hand at all times.
  • Tylenol or a similar type of medication (preferably one without aspirin in it) may be used to relieve pain or discomfort as needed.
  • When you get home resume taking, as directed, any medications that were prescribed by your other doctors.
  • Moisten clean cotton pads with eye irrigating solution (such as Eye Wash) and use them to gently wipe the discharge from your eyelids; we will provide you with these items prior to your leaving the hospital. Do this every morning for 1 week, then whenever necessary after that. Be extremely careful not to push on the eye itself when you clean the eyelids.

Special Eye Care Precautions

  • The white of the eye will be red for 2-3 weeks following surgery. This is normal.
  • Never try to remove any mucous from the eye with a cotton swab. Use the sterile irrigating solution.
  • For the first 4 weeks after surgery, during the daytime, wear any pair of glasses, sunglasses, or the metal eye shield for protection of the operated eye. When sleeping, tape on the metal shield. It is very important to avoid being struck in the eye.
  • Do not rub the operated eye hard at any time, now or in the future. Light rubbing, such as applying makeup to the lids, or gentle rubbing that does not compress the eyeball is ok.

Travel

  • You may travel by air or surface transportation as soon as you wish after leaving the hospital.
  • Riding in a car is fine. Please check with use before you resume driving.

Diet

  • You may resume your usual diet.

Bathing and Hair-washing

  • You may resume normal bathing and hair-washing. Avoid getting water in the eye in the first week following surgery.

Activity

  • First week after surgery – You may return to all normal, nonstrenuous activities. Avoid hard straining and resume sexual relations cautiously.
  • Six weeks after surgery – Sports such as jogging, swimming, and golf may be resumed. Sexual relations may be resumed without restrictions.
  • More vigorous activities such as racquetball sports (tennis, squash, and racquetball) and diving should be avoided for at least six months following surgery. Please check with us before resuming these activities.

Emergency Care

  • In the vast majority of patients, recovery is uneventful. Different people react differently to corneal transplant surgery. Some irritation, such as a scratchy sensation with occasional sharp pain or movement of the eye, is expected during the first week or two following surgery and is a usual accompaniment of healing. Occasionally however, a sudden change in symptoms can occur which should alert you to have your eye checked. You should contact your doctor immediately if you experience any of the following:
  1. Pain in the eye.
  2. Sudden decrease or “gray-out” of vision – Even though the vision in your operated eye is not clear at the present time, you should be familiar with its relative clarity so that you can recognize any sudden change in the vision.
  3. Thick mucous or whitish discharge – It is normal to have some extra tearing and mucous discharge during the first week or so following surgery. Any change in this pattern, particularly the development of thick yellow white discharge, should be noted and brought to our attention.
  4. Excessive redness or swelling of the lids or eye. It is normal to have a certain amount of swelling of these tissues in the first few weeks after surgery. If the swelling or redness increases significantly, please call us immediately.

Your attention to details, correct use of medications, and regular return for follow-up examinations are vital for the recovery of your eye.