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Cornea Transplant Surgery: Procedure, Recovery, Rejection

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Cornea transplant is a procedure that replaces your cornea, the clear front layer of your eye. During this procedure, your surgeon removes damaged or diseased corneal tissue. Healthy corneal tissue from the eye of a deceased human donor replaces the damaged cornea. For many people, cornea transplant surgery restores clear vision and improves their quality of life.

Cornea Transplant

What does the cornea do?

The clear, dome-shaped cornea protects the eyes against dirt, germs, other particles, and damaging UV light. The cornea, working together with the lens of the eye, focus light that enters the eye so that vision can be clear.

The cornea is made up of three main layers of tissue, with two thinner layers of membrane between them.

What symptoms may indicate I need a cornea transplant?

If you have a damaged cornea, you may experience symptoms including:

  • Eye pain
  • Blurred vision
  • Cloudy vision

Your ophthalmologist will determine the cause and other possible treatments that may resolve these symptoms. If your cornea cannot be repaired using other methods, your surgeon may recommend a cornea transplant.

How often are cornea transplants performed?

Currently, ophthalmologists perform more than 47,000 corneal transplants in the U.S. every year. This is expected to increase as the population ages.

What types of diagnoses indicate I could need a cornea transplant?

Conditions that damage your corneas and impair your ability to see clearly may require a corneal transplant. These conditions include:

  • Fuchs’ dystrophy, a condition in which the inner layer (endothelial) cells of the cornea die, causing the cornea to swell and thicken and vision to become blurred
  • Keratoconus, a condition that causes the cornea to be cone-shaped instead of dome-shaped
  • Infections, which cause permanent damage to the cornea
  • Traumatic injuries that penetrate or scar the cornea
  • Previous eye surgeries that damaged the cornea
  • Bullous keratopathy, a blister-like swelling of the cornea that causes eye discomfort, pain, and blurred vision
  • Keratitis, an inflammation of the cornea caused by viruses, bacteria, fungi, or parasites

How is a cornea transplant performed?

Your surgeon will recommend one of three surgical options for cornea transplant. The method your surgeon chooses depends on the cause of the damage to the cornea, the condition of your cornea, and your unique needs. In some cases, a corneal transplant may not improve your vision, and your surgeon may recommend against surgery.

Regardless of the type of transplant you receive, your new cornea will come from a deceased human organ donor. Every donor cornea undergoes thorough testing to make sure it is safe for transplant. The cornea is made up of three layers of tissue. Each surgical option focuses on a specific layer or layers.

Penetrating keratoplasty

Penetrating keratoplasty is also called a full thickness cornea transplantation. Developed over 100 years ago, the modern version of this surgery continues to help thousands of people each year. In this procedure, your surgeon uses a small circular blade to remove the entire center part of the damaged cornea and replaces it with a healthy same-shaped piece of donor cornea.

Deep anterior lamellar keratoplasty

If the innermost layer of your cornea is healthy, but the middle and outer layers are damaged, your surgeon may perform a partial thickness cornea transplant. This procedure is also known as deep anterior lamellar keratoplasty. During this surgery, your surgeon removes the middle and outer layers of your cornea and replaces them with healthy corneal tissue.

Endothelial keratoplasty

This procedure may help if the innermost layer of your cornea, the endothelium, is damaged. This thin layer of endothelial tissue is called Descemet’s membrane. Surgeons perform two types of endothelial keratoplasty surgeries:

  • Descemet stripping automated endothelial keratoplasty (DSAEK)
  • Descemet membrane endothelial keratoplasty (DMEK)

Each procedure removes damaged endothelial tissue and replaces it with healthy donor tissue. Unlike the other keratoplasty procedures, fewer or no stitches are needed with the endothelial keratoplasty procedures. Instead, an air bubble is used to keep the donor cornea in position. To increase the chance of success, you will need to position yourself face-up for a few days after the surgery so the bubble can keep the corneal tissue in place. The difference between DSAEK and DMEK is the thickness of the donor cornea – DSAEK is thicker, while DMEK is thinner. Your surgeon will decide which type of transplant is best suited for your specific eye condition.

What typically happens before cornea transplant surgery?

Your doctor and the anesthesia team will review your medical history, answer your questions and confirm the surgical plan. The anesthesia team will administer either sedation or general anesthesia (making you unconscious), depending on your medical condition and what you and your doctor have discussed. Numbing medication will be applied to the eye.

The surgery itself is an outpatient procedure (you will not be staying at the hospital or eye center). The surgery typically takes less than 2 hours to perform.

What should I expect after my cornea transplant?

For the first few days after surgery, expect your eye to be red, irritated, and sensitive to light. Typically, pain can be controlled with over-the-counter pain relievers that your surgeon can recommend. Your eye will be covered with an eye patch after your surgery. The eye patch must be worn when you shower and sleep. Your surgeon will also talk about activities you will need to avoid, especially any activities that could result in a direct hit to your eye. For endothelial transplants, you will need to position with your face up (on your back) for a few days after surgery.

You will have a follow-up visit with your surgeon, usually within 24 to 48 hours of your surgery. He or she will remove your eye patch and check on how well your eye is healing. Also, eye drops and ointments will be prescribed to help your eye heal. Eye drops and ointments usually prescribed are both antibiotics (to prevent infection) and corticosteroids (to reduce swelling, inflammation, and to prevent rejection).

Stitches may need to be removed depending on the type of stitches and surgical technique used. If stitches do need to be removed, they may not be removed for several months.

Your surgeon will recommend that you wear glasses or other protective eyewear for a period of time to help protect your eyes. While recovering, you should not rub or press on your eyes. Rubbing can cause damage and interfere with healing.

What complications are associated with cornea transplant?

One of the most concerning complications of cornea transplant is organ (cornea) rejection. Rejection means your body’s immune system identifies the donated cornea as foreign and tries to fight off the transplant. You will take eye drops for at least a year following surgery to reduce the risk of rejection.

Risk of rejection varies based on the surgical technique used and on the condition of your eye. Conditions like dry eye, blood vessels growing in the cornea, and eye infections increase the chance of rejection. In some eyes, a transplant will have a very high risk of rejection and your surgeon may recommend against surgery. Ask your doctor how the condition of your eye affects the chances of rejection.

Other complications of cornea transplant surgery include:

  • Infection – in the cornea or inside the eye
  • Bleeding
  • Glaucoma (increased pressure inside your eye)
  • Fluid leakage from your cornea
  • Detached retina (tissue lining the back of the eye pulls away from the eye)
  • Visual acuity problems (sharpness of the vision) caused by an irregular curve in the shape of the cornea
  • Detachment of the corneal transplant (for the endothelial transplant which is held in place by an air bubble)

For most people, cornea transplant is very successful in the long-term. Your surgeon can help you decide if cornea transplant is right for you.

Can a cornea transplant be avoided?

The key to avoiding a cornea transplant is to prevent damage or injury to your cornea. If a damaged cornea will not heal using other methods, a cornea transplant may be unavoidable to keep your vision.

What is the prognosis (outlook) for people who have a cornea transplant?

The degree of long-term success depends on a number of factors including the underlying cause of the cornea damage, surgical technique used, expertise of the surgeon, patient’s immune system acceptance of the donor transplant (organ rejection) and other factors. Because the rates vary so greatly, you should ask your doctor about the rate of success in your eye. It is important to keep in mind that vision is usually blurred after surgery and will gradually improve over time. The length of time it takes to return to good vision depends on several factors, including the type of surgery performed. It may take up to 12 months for full vision to be achieved in patients who undergo full thickness tissue transplant. For endothelial transplants (DMEK and DSAEK), good vision is typically achieved within 3 months.

Will I need to wear glasses or contacts after cornea transplant?

An irregular cornea surface is expected following full thickness corneal transplant surgery. This imperfection in the curve of the cornea, called astigmatism, results in distorted vision. Correction with glasses, contact lenses, or additional surgery is often needed. Special types of contact lenses (rigid gas permeable or scleral lenses [a larger lens that lays on the white part of the eye]) are not typically needed following endothelial transplants, but may be needed after penetrating keratoplasty or deep anterior lamellar keratoplasty surgery. Your surgeon will discuss the best options to meet your vision needs.

How soon can I drive after a cornea transplant?

You must not drive on the day of your cornea transplant. Someone must drive you home after surgery and bring you back for your follow-up visit.

If you have good vision in the non-transplant eye, you can legally drive 24 hours after surgery. However, your surgeon may recommend waiting longer before driving.

When can I return to work after a cornea transplant?

It may take a few days to a few weeks before you can return to work. It depends on your level of discomfort, your vision and what activities you perform at work. Jobs that require strenuous activity such as lifting may need more time off from work.

When should I call my surgeon?

Contact your surgeon immediately if you experience any signs of cornea rejection, including:

  • Eye pain
  • Eye redness
  • Hazy or cloudy vision
  • Sensitivity to light
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