Corneal Transplants

Most individuals diagnosed with Keratoconus will not need to undergo a transplant, in fact only 15-20% of those with the disease ultimately require a corneal transplant surgery, for those who do it can be a crucial and somewhat frightening decision. In my situation it was a period of great turmoil, after months of unsuccessful fittings and nearly useless vision in my left eye, I decided I needed to move forward with that choice.

If you are faced with a similar decision or have a loved one who is going through the same thing, its important to know what to expect before, during and after surgery. That way you are better prepared and feel more in control of your personal healthcare.

In general a corneal transplant is warranted when the cornea becomes dangerously thin or when sufficient visual acuity cannot be achieved with contact lenses. This can be as a result of the steepening of the cornea, scaring from ill fitting lenses, inability to obtain a successful fit, or lens intolerance. Lens intolerance, I should note,  occurs when the steepened and irregular shaped cornea can no longer be fitted with a contact lens. The fit itself either produces too much discomfort or because of the physics required to accommodate the cornea’s conical shape cannot be achieved without the lens itself causing damage to the cornea. Either way, if your visual acuity is poor and you cannot be fit in, or tolerate lenses a Transplant becomes a viable option.

 

Once the decision has been made, you will be less anxious and feel more in control if you know what to expect – The healing process is long, there is no way around that and you will likely experience some discomfort.  Although this is a routine type of surgery for most of the professionals that perform the surgery, it can still feel a bit daunting. So, the more information you have, the more prepared you will be.

Check with your insurance company prior to scheduling surgery so you can verify that you have adequate coverage and meet any pre-authorization requirements. Ask exactly what will be covered and what will not, especially as it relates to your post operative office visits, glasses and/or contact lenses.

A few days prior to surgery a general medical examination and routine laboratory tests (such as blood count and EKG) are done to insure that you are well enough to undergo surgery. You should not use aspirin or take any blood thinners (consult with your doctor) for 2 weeks prior to surgery, since the can cause bleeding during surgery. Antibiotic drops are generally started one day before surgery to protect the eye from infection. (These drops will likely taste bad and feel a little uncomfortable for the first week or so. )

 

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The surgery is more often than not done as an outpatient procedure – you enter the hospital or surgery center a few hours prior to surgery and leave that same day- generally within just a few hours after the surgery. In the “pre-op” waiting area, you will be told about medicine and care and you will be given some sort of calming medication (valium, xanax, thing like that). The IV will be run and leads for the EKG will be attached to monitor your heart.

Local or general anesthesia can be used for this procedure. Having had intacs and relaxing incisions prior to this surgery, I did not want to endure being away… so I opted for general… But the decision is up to you and your doctor.  In the operating room, your eyelids are carefully washed and covered with a sterile plastic drape. Oxygen is occasionally provided by a plastic tube placed near the nose. Patients often doze off during the operation, and most are left with vague recollections of a short procedure, although some remember all of it.

The entire procedure is done under a microscope; using a trephine the doctor will remove a small button of your diseased cornea.  A “button” of similar size is cut from the donor cornea. This donor tissue is then sewn in place with extremely fine nylon sutures. At the conclusion of the procedure, a patch and shield are applied to protect the eye. You will then be taken to the recovery room to wait until you are fully awake before being discharged.

 

After surgery, you should rest the remainder of the day. Post surgical pain varies from person to person. I had a lot of pain, but know people that had almost none at all. Typically there is only mild discomfort and soreness for a few days which is usually relieved by Tylenol. Discuss pain management with your surgeon before the surgery and fill prescriptions to have available if needed afterwards.

The operated eye is patched until the surface epithelium (top layer of the cornea) is healed, usually 1 to 4 days. Do not remove the patch. The doctor will see you the day after surgery, remove the patch and determine if it needs to be worn longer. You will also receive detailed instructions at this visit, so bring a friend or family member who can help take notes and convey the instructions to you. Be certain that you really understand the instructions, ask questions if something is unclear.

The eye drops are very important- be sure you know exactly when you should use them. Make your next appointment, usually in three to seven days. Be sure you know how to contact the doctor if there is a problem or you have questions.

After the patch is removed, it is important to protect the eye from accidental bumps or pokes. Typically, for several months after surgery, patients wear glasses during the day and a metal or plastic shield at night to protect the eye from trauma while sleeping. I lost my metal shield as some point and spent a monthly with a Ragu spaghetti lid taped to me face… not my proudest moment, but it did help me not to rub my eyes.

Your new cornea is delicately sutured in place, as if the skin of a grape was to be sewn onto another grape… very fragile.  A direct blow to the eye must be avoided and Contact sports are discouraged after corneal transplant. Though I have played hockey for years following mine, but ALWAYS with a cage.  Within a day or two,  normal light duty activity can be resumed within a few days. After the first day, shaving, brushing teeth, bathing, light housework, bending over, walking, reading, and watching TV will not hurt the eye.

Because the cornea has no blood supply, the transplant heals relatively slowly. Sutures are left in place for three months to one year, and in some cases if the vision is good, they are left in permanently. The sutures are buried and therefore don’t cause discomfort. Occasionally, they do break and then need to be removed, and in some cases they are removed to improve vision. Suture adjustment and removal are claimed to be simple painless office procedures.

The sutures used in corneal transplants are made of a mono filament nylon and are super small (22 microns – 1/3 the thickness of a human hair). and when they pop, they make an uncomfortable prickly feeling on your eye, like a hair is stuck to you. When the doctor removes the stitch it can be uncomfortable. I have had a tremendous number of doctors and nurses say it doesn’t hurt, but when they would remove mine, it felt like a mile of rope was being pulled through. What they should have said was it doesn’t hurt for very long… Once it is removed everything goes back to being relatively comfortable.

Vision gradually improves over time, for me the biggest change was that COLOR became far brighter. I have a chronicle below of my post operative vision as it would improve. The images get more vibrant and clearer as time goes on and the new cornea heals. There is often useful vision within a few weeks. However, in some cases, it may take several months to a year for full vision to develop.

 

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To prevent rejection of the new cornea, steroid eye drops are used for several months after surgery. In some cases, low dosage steroid drops are continued indefinitely. Unlike oral steroids, steroid eye drops cause no side effects elsewhere in the body. Occasionally other eye medications are necessary.

It is important to call immediately (including weekends, evenings, and holidays) if you notice any unusual symptoms, including Redness, Sensitivity to lights, Vision loss, or Pain (“RSVP”). Flashing lights, floaters, and loss of peripheral vision should also be reported immediately.

Postoperative care is extremely important and by far the most time-consuming part of having a corneal transplant. The eye is checked the day after surgery, several times in the first two weeks, at gradually longer intervals over the first year, and usually yearly thereafter.

 

For more detailed information See the NKCF Website to learn about cutting edge corneal graft procedures.