Penetrating keratoplasty by pushkar dhir
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Transcript of Penetrating keratoplasty by pushkar dhir
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