Corneal Transplant Surgery
Corneal transplants have been performed for many decades; however, recent scientific advances have greatly increased the success rate of these operations and have reduced many of the discomforts and inconveniences following surgery.
We hope the following information will be helpful to you in understanding corneal transplants. Most individuals are less apprehensive when they are aware of the details concerning the proposed surgery. We feel the success rate is highly dependent upon the total cooperation of an informed patient.
In most cases, an overnight stay in a hospital is not necessary and the surgery is performed on an outpatient (ambulatory) basis. Patients living outside the metropolitan area may return to the care of their primary eye physician soon after surgery. Your physician can supervise the routine postoperative care and is prepared to recognize any problems that may occur. The members of our Transplant Team work closely together and maintain a similar relationship with the referring physician whose own skill and interest are important ingredients in the ultimate success of the surgery.
The cornea is the transparent front window portion of the eye that permits light to enter and focus on the retina. The cornea is normally clear (like a watch crystal and fairly rounded in shape like a baseball), but can become cloudy or irregular in shape, causing reduced vision or even legal blindness. The average adult cornea is less than 1 mm in thickness and consists of five layers. A diseased, injured or cloudy cornea can be replaced through transplantation, using only human donor corneal tissue.
The most common causes of corneal clouding are traumatic injury to the cornea; hereditary disorders; and corneal scars caused by infection from bacteria, fungi, or virus. Another common condition, usually in older people, is corneal edema or corneal decompensation. In this situation, fluid collects in the cornea causing it to cloud. A degeneration of the cornea called Fuch’s Endothelial Dystrophy is a common cause. In the event the cornea fails to respond to medical treatment, a corneal transplant may be the only method of treatment available to restore vision. (See “Sutureless Corneal Transplant” booklet/pamphlet).
Keratoconus is a slowly progressive corneal degeneration that can begin in the teens or early twenties. This condition results in a warped, pointed cornea causing visual distortion. This corneal weakness can initially be corrected with glasses, but eventually requires contact lenses. As Keratoconus advances, contact lenses may no longer be an effective or comfortable method of treatment and a corneal transplant may become the only alternative. Frequently, a deep, partial thickness replacement may be attempted.
Corneal transplants are considered to be the most successful of all organ transplant surgeries. Approximately 50,000 corneal transplants are performed each year in the United States alone. The success rate of this procedure has dramatically increased in the past few years as a result of recent advances in research, donor tissue preservation, and screening.
A “corneal transplant” is the replacement of the central cornea by donor corneal tissue. The success rate is over ninety percent making it by far the most successful of any organ transplant. It is important to remember, however, that vision may be restored to normal levels only if the remainder of the eye is functioning properly. In many cases it is difficult to determine the “visual potential” prior to surgery due to a hazy view of the internal structures of the eye. There are rare situations when corneal transplant surgery is advised despite poor potential for vision or to keep the eye structurally intact. Your doctor will attempt to give you as accurate an estimate (prognosis) as possible based upon the circumstances of your particular case.
The central portion of the cornea is removed with a circular blade. It is then replaced with a similar-sized donor cornea which is sutured into place with thread finer than a human hair. In most patients, the diameter of the cornea is around 12mm. Donor tissue is approximately 8-9mm in diameter and falls well within the central portion of the cornea. A corneal transplant is an extremely delicate microsurgical procedure performed with the aid of an operating microscope at magnification of ten to twenty-five times normal size.
THE EYE BANK NETWORK
The Eye Bank Network, a national network, facilitates and distributes donor tissue, usually within a few days following receipt of the donation. The Eye Bank Network is a nonprofit service organization that has been processing corneal donor tissue since 1946.
All tissue is carefully screened by the Eye Bank to insure that it is in excellent condition. The screening checks for infectious diseases such as AIDS and Hepatitis Virus. The Eye Bank obtains this tissue from individuals who have donated their eyes after death. Details about the donor are confidential and it is necessary that they remain anonymous. Letters of appreciation, if you wish to write will be forwarded appropriately. With few exceptions, corneas donated by individuals ranging in age from two to sixty-five are usually acceptable for corneal transplants.
Donations from older individuals are welcomed. Some are transplanted in this country or they may be used for recipients in some developing countries or for research purposes. Factors such as sex, race, color of the iris, or visual acuity of the donor do not influence the surgical result. Anyone who would like to be an eye donor should call Florida Lions Eye Bank in Miami, at (305) 326-6000 to request the necessary information. Another donor method requires completion of the Uniform Organ Donor Card available at the “Department of Motor Vehicles”. This alone may not be enough to qualify as legal consent. Please be sure to notify next of kin of your intentions regarding organ donation.
CORNEAL TRANSPLANT SURGERY – RISKS
As with any operation there are several risks, complications, and side effects. These include, but are not limited to, loss of the entire eye; loss of life due to abnormal reactions to anesthesia; infection; bleeding in the eye; glaucoma (high pressure within the eye); wound leakage; poor wound healing with high astigmatism and failure or rejection of the transplant. There are no guarantees with corneal transplant surgery as with any other surgical procedure. However, the incidence of complications is relatively low.
PATIENTS AWAITING CORNEAL TRANSPLANTATION
There are several factors involved in accepting tissue, including; careful background history and screening of the donor, matching donor and recipient age, and closely checking the quality of the tissue. Because of this we are not always able to obtain a cornea for transplant at the time of your scheduled surgery. If this were to happen, we would work with you to accomplish the surgery as soon thereafter as possible.
During the period prior to surgery, you must have a completed physical examination by your family doctor. A record of your examination must be forwarded to our office. If you do not have a family physician, we can help recommend one to you.
You will be instructed to begin using additional eye drop medications starting a few days prior to surgery. Usually the day before surgery, you will receive a call from the outpatient surgical center with more specific instructions regarding your surgery. DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT ON THE NIGHT BEFORE SURGERY UNLESS TOLD OTHERWISE. However, if you take heart or blood pressure medication, you may take this as usual in the morning with a sip of water. DO NOT PLAN TO DRIVE YOURSELF HOME FROM THE SURGERY CENTER. If you have no other means of transportation, call our surgical coordinator and arrangements can be made on your behalf.
WHAT TO EXPECT IN THE OUTPATIENT SURGICAL CENTER
In addition to the usual admission procedures, a blood count may be performed. An anesthesiologist will discuss with you the type of anesthesia to be administered. This may be either local, with only your eye anesthetized, or rarely, general anesthesia, in which case you will be totally asleep. Prior to entering the operating room, you will receive appropriate medications and several drops will be placed into your eye.
During the surgery your heartbeat, blood pressure, and the oxygen content of your blood will be monitored and you will receive intravenous fluids. Following surgery, a patch will be placed over the operated eye and you will go to the recovery room to be monitored for a while prior to discharge.
You will be permitted to drink, eat and talk with family or friends, and use the bathroom with assistance. When the staff determines that your vital signs are stable and you are alert, they will discharge you into the care of a family member or friend.
THE RECOVERY PERIOD
The operation alone is only the first step in a rather long process of visual rehabilitation. Your office visit will be scheduled for the following day, then another within the first week after surgery, with subsequent visits every two to six weeks, depending upon the case, and the healing progress of your eye. Office visits are usually spaced further apart as time passes. Your will perform each of the examinations.
If you live a considerable distance from our offices, your primary eye physician may share the postoperative care. Should any problems occur, please be understanding if your physician advises you to return promptly to one of our offices.
Sutures are not usually removed during this early healing period; however, they can be cut to control the amount of post-surgical astigmatism. Sutures can be removed as early as three to four months after surgery, or, if necessary, all sutures can stay in place indefinitely. Eyeglasses or a contact lens will be prescribed, and are usually necessary to obtain the best possible vision, after the eye has stabilized (approximately ten to twelve months postoperatively, sometimes longer).
You can resume most normal daily activities, with the exceptions of those activities that could cause stress to the eye or subject it to trauma, (i.e., bumping, etc.). You should not lift anything that weighs more than twenty pounds or perform any functions that could cause you to strain. At no time during the first month after surgery should you allow your head to bend lower than your waist. This activity raises the pressure in the eye, which causes stress on the newly healing corneal transplant wound.
You should protect your eye at all times with protective eyeglasses or a metal or hard plastic shield during the day. However, it is highly recommended that the shield be worn in any high-risk situation, i.e. at a public event, while in a crowd of people, on a bus, etc. The metal or hard plastic shield MUST be worn while sleeping for an extended period of time following surgery.
You may shower, shampoo, or shave but should take special care to avoid getting soap in your eye. If this should occur, immediately flush the eye with ARTIFICIAL TEARS to remove the soap. You may read and watch TV and return to work as soon as you feel capable, usually three to seven days after surgery.
PLEASE READ SPECIFIC POSTOPERATIVE INSTRUCTIONS SUMMARIZED ON PAGE 10 OF THIS BOOKLET CAREFULLY. (Note: Your wound will be at its weakest after all sutures are finally removed)
* YOU MUST BE ESPECIALLY CAUTIOUS
FOR AT LEAST ONE FULL WEEK
AFTER REMOVAL OF ANY SUTURES. *
Eye drops or ointments make your eye comfortable, decrease the amount of inflammation and help prevent infection. Mucus or dried tears accumulating on your eyelashes may be cleaned by placing a drop of artificial tears on a cotton-tipped applicator (such as a Q- Tip) and rubbing it gently on the eyelid margin at the base of your eyelashes.
USE MEDICATIONS EXACTLY AS INSTRUCTED. Do not skip doses and never use medication more frequently or for a longer period of time than prescribed. Medications should be stored at room temperature unless you are otherwise instructed by your physician or pharmacist. DO NOT LEAVE MEDICATIONS IN A HOT CAR (it breaks down the preservatives). Do not share medications with anyone or transfer medications from one bottle to another.
Avoid touching the tip of the dropper or tube to anything, especially any part of the eye. Drops or ointments can be placed in the eye at any time within an hour of the time scheduled. If you are using more than one drop, use them at least five to ten minutes apart so that one drop does not wash out or dilute the other. The milky appearing drops (suspensions) take longer to absorb or “soak” into the eye. Always use drops in the prescribed order before applying the ointment last. Keep all medication out of the reach of children.
ADMINISTRATION OF MEDICATION
You may wish to request a family member or friend to assist you when administering drops or ointment to your eye.
- Wash your hands thoroughly.
- If the bottle of medication has been refrigerated, warm it by gently rolling it between the palms of your hands.
- Shake any bottle containing a suspension (milky appearance) twenty times before each use.
- Tilt your head slightly back; it may be easier to sit or lie down.
- Look up and gently pull the lower eyelid down to form a pocket.
- Instill the medication into the pocket of the lower lid. If you are not certain that the drop of liquid medication went into the pocket, use another drop (careful, insurance co. may limit access to the next bottle). When using ointments, squeeze a strip approximately ¼ inch long into the pocket.
- Close the eyelids gently for four to five minutes. Do not squeeze the lids.
- Close the eyelids again and, if necessary, GENTLY wipe the lower lid with a clean tissue to remove any tears or excess medication. Avoid applying pressure to the eye.
CORNEAL TRANSPLANT REJECTION OR INFECTION
PLEASE READ THIS SECTION WITH EXTREME CARE. HAVE OTHER MEMBERS OF YOUR FAMILY OR FRIENDS READ IT ALSO SO YOU WILL HAVE THE BEST POSSIBLE CHANCE FOR A SUCCESSFUL TRANSPLANT. If at any time you should have any questions with respect to your surgery, or conditions you are experiencing, please call our office.
Once the healing process begins, the eye should be white, comfortable (this occurs usually within fourteen to twenty-eight days), and your vision should be slowly improving. Any sudden onset and sustained duration of a significant change; including Redness, Sensitivity to light, Vision decrease, or Pain in the eye may mean infection or rejection. IF THIS SHOULD OCCUR, PLEASE CALL OUR OFFICE IMMEDIATELY.
Corneal transplants have a high success rate and excellent chances exist for each patient. Rejection occurs when the body recognizes the new corneal tissue as foreign and attempts to fight it, which could result in a cloudy corneal transplant. Rejection episodes occur in a small percentage of cases and could happen more than once. Most episodes can be treated and reversed. A repeat corneal transplant may be performed if a rejection leads to failure and clouding of the cornea.
You may initially notice a rejection reaction as a sudden decrease in vision, often described as a cloudiness of your vision. You may also notice an acute change in the character of your discomfort. A rejection episode could occur immediately or as late as ten or more years following surgery. The most common time frame for transplant rejection is within the first six to twelve months following surgery.
After six months to one year postoperatively, the chances of rejection are less. In most cases, the rejection reaction can be reversed and stabilized with medications if diagnosed and treated early, and the graft then will remain successful and clear.
If the rejection episode is not treated in a timely manner when it begins, the chance of eventual transplant failure is much higher. It is extremely important to recognize transplant rejection and immediately report it so it can be properly treated.
Early corneal rejection is most commonly noticed as a sudden but severe decrease in vision over a period of hours or days. Four weeks following surgery, start testing your vision in the following manner: select an object on the wall of a room and back away until you can see a particular part of the object with the operated eye, keeping the un-operated eye covered. Notice how far away you are from the object so you can be consistent in measuring your vision. If your vision improves, making it easier to see the object from that distance, back farther away to establish a new distance from which you can just see the object. Please be careful not to stumble and fall. If at any time you find that your vision has SEVERELY worsened compared to the previous test, you should call our office. Daily fluctuations in vision are COMMON. Significant worsening of vision is UNCOMMON.
INCREASED REDNESS OF THE EYE
After surgery the eye will be red because of blood in the tissue. As the blood clears the eye should become whiter. If the eye becomes PROGRESSIVELY more bloodshot weeks after surgery this should be viewed as a warning signal of possibly allergy, dryness, infection, or rejection.
DISCOMFORT IN AND AROUND THE EYE
After surgery there will be some discomfort around the eye which should disappear in about one to two weeks. Because sutures are used, scratchiness, ocular irritation or a sensation of having something in the eye is not uncommon.
A “bandage contact lens” may be inserted at the time of or following surgery (see “Bandage Contact Lens” patient information sheet). This provides comfort and protection to the surface of the eye. If you feel a sudden discomfort, the lens has probably dislodged. The sensation is similar to a particle in the eye. If you find the lens, do not put it back into the eye. If you are uncomfortable, you may also use ointment up to 4 times a day and patch the eye. Call our office for further instructions. Replacing the lens is not an urgent matter!
Most eye drops and ointments are soothing to the eye. Occasionally a medication may sting temporarily, but medicines should not produce pain or increase the amount of redness or swelling around the eye. Increased pain, redness or itching could result from external irritants such as smoke or smog or could indicate an allergic reaction to one of the medications you are using. If your eye should become INCREASINGLY sore or uncomfortable in any way after it has once become comfortable, this may be a sign of infection, high pressure, or attempted corneal transplant rejection.
If you experience any of these danger signals, please call our office immediately. Remember, the success of the corneal transplant operation depends heavily upon your awareness of symptoms. No guarantee of success can be given, but we can assure you an increased chance of success if you stay alert to the danger signals.
CORRECTION AFTER SURGERY
The use of glasses, contact lenses, or intraocular lens implants will depend on your specific case. It may be possible to implant an intraocular lens at the time of corneal transplantation if a cataract operation is needed or if an intraocular lens needs to be removed. This determination will be based on your individual situation and requirements.
FEE FOR CORNEAL TRANSPLANT SURGERY
The fee for corneal transplantation includes the charges for the routine surgery and several office visits that are required during the first three months following the surgery. There are additional treatments during this time that may be indicated that incur separate expenses. If you
have a cataract extraction and/or an intraocular lens implant at the same time as the corneal transplant, the fee will reflect these additional procedures. Should you require hospitalization or a return to the surgical center at any time after the surgery, the cost will be in addition to the initial cost and will be billed as a separate admission. Spectacles, contact lenses and examinations after the initial three-month period are additional charges.
Please be aware that the Eye Bank usually charges a separate processing fee. In most cases the majority of this charge is covered by insurance. This is not a charge for the actual corneal tissue. The charge represents the extremely careful evaluation and detailed laboratory processing which require very sophisticated equipment and highly trained technicians. All patients receive tissue according to need and regardless of the ability to pay.
Finally, the operating rooms and facilities of a local Ambulatory Surgery Center are utilized for surgery; charges are significantly less than those of area hospitals. Facility charges will be billed to the patient or the insurance company. There will be an additional charge from the anesthesiologist, which may come separate or included with the bill from the Ambulatory Surgery Center.
It is important for patients to be fully aware of all charges and fees involved with the planned surgery. Patients are advised to discuss fully all insurance and financial matters with the appropriate office staff. We are prepared to assist you in every way possible.
Our office staff and corneal transplant team are prepared to answer your questions at all times. Please do not hesitate to ask concerning any aspect of your care.
Please be aware that scheduling your date for surgery and all of the coordination that goes along with it is a very intensive and time consuming effort. A separate appointment may be necessary for you to meet with our Surgical Coordinator in order to accomplish all of the paperwork necessary to schedule your surgery. Some of the effort may be completed via e-mail, fax, or US Postal Service if given enough time. Even minor changes to your scheduled surgery may require significant additional work for our staff.
- Use eye patch and metal or hard plastic shield while sleeping until you are told otherwise.
- You must protect the operated eye at all times.
- Do not bend or stoop lower than your waist line for at least one month following the
- Do not lift or push anything weighing more than twenty (20) pounds for one month
following surgery (this may be increased slowly in the following months).
- You may take a shower and your hair may be gently shampooed, but your head must be pushed back allowing the water to flow backwards off your head and not over your face. Make certain your eye shield is securely in place. (Consider going to a beauty parlor).
- Keep your bowels open and do not strain. You may require medication to soften your stool.
- You may read and watch television.
- You may take walks or short rides; however, you may NOT run or jog for at least Three (3) weeks following your surgery.
- Do not sleep on your stomach or on the side of your operation for at least three (3) months following your surgery or for two (2) weeks after any sutures are removed.
- You may not perform sexual intercourse for two (2) weeks following your surgery. (When you do begin again, please do so gently).
- You should be prepared and allow for a period of depression or agitation following your surgery, which may be caused by medication. You may also experience a period of lowered (decreased) energy lasting from days to weeks.
- Further instructions with respect to use of your medications will be given at the time of your office visit on the day after surgery or at any visit thereafter.