Venu Corneal

Department

Welcome To D World Of

Keratoplasty

• Presenter Pushkar Dhir• Moderator Dr. Ashish

KERATOPLASTYAn operation in which diseased corneal

tissue is replaced by donor corneal tissueVP Filatov – Father of Keratoplasty

Penetrating Keratoplasty Lamellar Keratoplasty

Ant.Lamellar

(DALK)

Post. Lamellar(DSEK,DS

AEK)

PKP 500µ +PKP 500µ +

PLK 250µ

PLK 250µ

DSEK 180μ

PK TYPES

INDICATIONS 1.OPTICAL

To restore vision

COMMON INDICATION

• Corneal opacity obscuring visual axis -Pseudophakic & aphakic Bullous

Keratopathy, -Fuchs endothelial dystrophy -Corneal Scars -Corneal Stromal & -Endothelial dystrophies -Failed keratoplasty

• Corneal curvature changes - Keratoconus, Keratoglobus - Corneal degeneration

2. TECTONIC / RECONSTRUCTIVE

To restore integrity of cornea

COMMON INDICATIONS

• Corneal thinning & ectasias• Corneal perforation• Pellucid marginal degeneration• Corneal melting & fistula• Post traumatic loss of corneal tissue

INDICATIONS

3.Therapeutic

To eradicate disease of cornea

COMMON INDICATION• Infective keratitis not responding to

medical Mx• Benign & malignant tumours of

cornea.

4.Cosmetic

To improve appearance of cornea

COMMON INDICATION• Cases of corneal opacities

associated with posterior segment diseases where visual improvement is not possible.

Types of keratoplasty

• Donor tissueAutograftAllograftXenograftAutorotational graft

Advanced Dry eye

Anterior staphyloma Severe cases of SJ syndrome

RD

• Grade 4 chemical burns• Ocular cicatrical pemphigoid with no tear film• Bad ocular surface• Multiple graft failure

Recruitment of Donor tissue

A. Donor tissue should be removed within six hours after death.

B. Cornea can be stored

SHORT TERM(UPTO 96 HOURS)*Whole Globe preserved in moist chamber(48hrs)*Mccarey-kaufman media

INTERMEDIATE TERM(UPTO 2 WKS)*Optisol/Dexsol/Ksol

(UPTO 35 DAYS)*By Organ culture

LONG TERM(UPTO 1 YEARS)*CRYOPRESERVATION

Corneal storage

Contra-indications for donors selection

-Death due to unknown cause.

-Certain Infectious diseases of the CNS (Jacob-Creutzfeld syndrome , Progressive Multifocal Leuko-

encephalopathy)

-Certain Systemic infections ( AIDS, Septicemia, Syphilis, Viral hepatitis)

-Leukemia and Disseminated lymphoma

-Intrinsic eye diseases (tumors, active inflammations, previous intra-ocular surgery)

Preoperative Evaluation of Recipient

• Ocular history• General history• Visual acuity• Gross ocular examination• Slit lamp biomicroscopy• Intraocular pressure• Fundus evaluation

Investigation

• Refraction • Keratometry• Gonioscopy• Pachymetry• Specular & confocal

microscopy• Laser interferometry• Videokeratography• USG

Evaluation of Donor cornea

Gross Examination

Intactness of globe Shape and size of cornea Epithelial haze or defects Any Stromal opacities Condition of anterior chamber

Slit Lamp Examination

Microcystic oedema

Epithelial Abrasions

Stromal oedema

Descemet’s fold

Breaks in Descemet’s membrane

What Mr.Balram trying to find out!!??

Procedure for PKPreoperative preparation

Anesthesia

Surgical preparation

Trephination of Donor cornea

Trephination of Recipient cornea

Suturing of Donor cornea

Post operative treatment

Anaesthesia

• Peribulbar block ,Retrobulbar block.

• General ananaesthesia :- for young , anxious patients , mentally retarded & those in which prolonged suregery is anticipated.

Preoperative preparation

Anesthesia

Surgical preparation

Trephination of Donor cornea

Trephination of Recipient

cornea

Suturing of Donor cornea

Post operative treatment

• Surgical preparation Honan ballon or ocular massage to reduce IOP . Painting (5% betadine) & draping Exposure & insertion of lid speculum Placement of scleral fixation ring – to fixate globe

• McNeill Goldman scleral & blepharostat & Flieringa ring

Preoperative preparation

Anesthesia

Surgical preparation

Trephination of Donor cornea

Trephination of Recipient

cornea

Suturing of Donor cornea

Post operative treatment

Preparation about donor cornea

-Graft size is 8.5 mm in diameter to avoid post-op

increase in intra-ocular pressure, anterior synechiae, & vascularization.

-An ideal size is 7.5 mm. -Smaller sizes (<6.5mm) would give rise to

astigmatism due to subsequent tissue tension. ->8.5m=large graft =↓astigmatism D/A:-↑rejection chances.

Preoperative preparation

Anesthesia

Surgical preparation

Trephination of Donor cornea

Trephination of Recipient

cornea

Suturing of Donor cornea

Post operative treatment

Trephination of donor cornea

• “Trephining" the Corneo-scleral button excised from the cadaver

• Whole globe(epithelial side cut) – Hand held or suction fixation trephine

• Cornea scleral button (endothelial side cut)- Hand held or endothelial punch system &

Artificial anterior chamber maintainer

Preoperative preparation

Anesthesia

Surgical preparation

Trephination of Donor cornea

Trephination of Recipient

cornea

Suturing of Donor cornea

Post operative treatment

ENDOTHELIAL PUNCH SYSTEM

Sharp vertical cut

More accurate centration

Endothelial side up

• Hessberg Barron Vaccum trephine

• Less AC collapse & distortion

• Sharper, deeper & more perpendicular cut

Hanna trephine

Donor cornea encased within an artificial anterior chamber

Corneal trephination from epithelial surface

Laser trephine Femtosecond excimer

laser

No mechanical distortion

Perpendicular congruent edges

Trephination of Recipient Cornea

• Trephination done either by hand held, suction & automated trephines

Marking cornea

DIFFERENT TYPES OF FLAP WHICH CAN BE MADE

Top Hat Shape•Provides large endothelial surface transplantation

ZIG-ZAG SHAPE

Hermetic wound seal

Angled edge provides smooth transition between host and donor

Mushroom ShapePreserves more host

endothelium •

Recipient dissection

Suturing of Donor cornea

• AC- viscoelastic• 10-O nylon (11-O) - 10-0 mersilene/ 11-0 mersilene• Cardinal sutures - 4 in number.• First suture - 12 ‘0’ C• 6’ 0’ C suture - 2nd , Critical for tissue

alignment• Suture depth - 90%• Equidistant bites• Bury knots.• Check wound leak.

Interrupted corneal sutures (10/0 nylon)

TYPE OF SUTURING CONTINOUS INTERRUPTED COMBI

NEDPICTURE

TYPES (IF ANY)

TORQUE & ANTITORQUE

INDICATION *Eyes with inflammation/vascularised corneas.*Difficult to follow up cases.

*Host bed with irregular thickness*In Infants*Vascularised/Inflammed cornea

ADVANTAGE *Incite least inflammation*Impede vascular in growth*Easy to remove*Early visualisation.

*Rapid wound healing.*Independent Suture-so easy removal in astigmatism&vascularisation cases

DISADVTGE *Slow healing*If one breaks enitre suture becomes loose*Long intervel b4 removal

*Flatenning*Fragments can b retained while removal

Single continuos sutures

Double continuos sutures

• 4 cardinal sutures• 12 bite 10-0 – 90 % depth• Second 11-0 – 50% depth• Adjustment possible

without removal• Wound apposition is good

Combined continuos

•Interrupted & single continuous sutures•Interrupted – 8/12•Continuous – 16/12•90-95% depth•Wound apposition•Earlier visual rehabilitation

INTRA OP REGIME

• Subconjunctival injections of gentamycin ( 40mg in 1 ml ) + dexamethasone ( 4 mg in 1 ml)

• Pad & bandage for 24 hrs.

POST OP REGIME

• Assess• Visual acuity• Degree of pain• SLE - Wound leak, pupil shape,

corneal epithelial status, anterior chamber, IOP, early signs of infection & endophalmitis

• Medication:- Topical antibiotics & steroids + Lubricants + cycloplegic.

COMPLICATIONSINTRAOPERATIVE EARLY POST OPERATIVE LATE POST

OPERATIVE

1.Scleral perforation

2.Damage to cornea (mechanical /contamination)

3.Retained Descemets-double AC on Day 1

4.Iris lens damage

5.AC hemorrhage

6.Suprachoroidal expulsive hemorrhage

1.Wound leakage (diagnosis by Seidel test)

2.Persisting epithelial defect.

3.Infection (kaye dots appear on donor cornea - subepithelial infiltrates seen in corneal graft rejection)

4.Elevated IOP(Urrets-zavalia pupil- Mydriasis + iris stromal atrophy + scattered pigment granules over the lens capsule and corneal endothelium, + ectropion uvea, and secondary glaucoma with multiple posterior synechiae. 5.Primary Graft Failure

1.Post-Op Astigmatism

2.Graft Rejection

Post op visits

• Final spectacles prescribed after 24 months when sutures have been removed & refraction & corneal curvature stabilised

• Contact lens fitting

• Final visual outcome• It takes two years to achieve the final

outcome. Most patients require glasses in order to see well. Often the very best vision is achieved only with a contact lens

Thank you for listening to PK