The cornea is the clear tissue (window) on the surface of the eye overlying the iris (coloured part of the eye) and the pupil. Rarely disease can lead to the need to replace the cornea (a corneal graft, also referred to as a corneal transplant). This operation is usually performed to increase vision and / or make the eye more comfortable.
CONDITIONS THAT MAY REQUIRE CORNEAL TRANSPLANTS
 Keratoconus: a thinning and irregularity of the cornea
 Hereditary corneal swelling: such as Fuch’s dystrophy
 Corneal swelling after eye surgery: such as cataract surgery
 Scarring after infections or injury
 Rejection of a previous corneal transplant
When you book the operation for a corneal graft the booking officer at my rooms contacts the Lions Corneal Donation Service (Eye
Bank), a not-for-profit organisation based at the Royal Victorian Eye and Ear Hospital. Usually the time from booking till the operation is around 6 months. The cost for the graft material is about $2500, this is fully reimbursed by private health insurance.
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All cornea donors are tested for the AIDS and hepatitis viruses and are screened for risk factors for these diseases. The cornea is carefully checked for clarity and quality.
Although you will be given a time and date for your operation occasionally the Eye Bank is unable to supply a cornea on the day and the operation will need to be rescheduled. You should check with these rooms prior to going to the hospital to ensure a cornea is available.
There are two main types of corneal grafts, full-thickness and partial thickness (lamellar). For the past 50 years most grafts have been fullthickness grafts although over the past decade a major move to partial thickness grafts has occurred due to a significant improvement in the way the surgery for these types of grafts is performed. The 2 types of partial thickness grafts are DALK and DSAEK. I will explain which is appropriate for you at your consultation. The following description (except where indicated) is for all types of grafts including full-thickness grafts, with a further explanation of partial thickness grafts below.
The operation is performed with either a local anaesthetic to numb just around the eye itself (usually a mild sedative to make the patient more comfortable and sleepy during the operation is also given), or with a general anaesthetic where the patient is unconscious throughout the operation. The operation usually takes approximately
45 minutes to perform and involves the replacement of the central
80% of the cornea. If you have the full thickness or DALK graft
(partial thickness transplants, DSAEK and DALK are discussed below) the graft is sutured in place with very small sutures, usually 16 sutures are required however occasionally more may be needed.
These sutures are not usually visible to the naked eye. After the operation the patient can usually return home the same day but occasionally may spend the night in hospital but is ready to go home the next morning.
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Some patients experience a painful eye for several hours the night following the operation when the anaesthetic has worn off. Thi is usually short lived and the eye significantly more comfortable by the next morning. Follow-up visits to my rooms at 100 Victoria Pde.
East Melbourne are usually scheduled for the first day following surgery, 1 week, 3 weeks, 2, 4, 6, 9 12, and 18 months after the operation and then every 2 years for life, although commonly more or less frequent visits may be appropriate. The eye is usually red, light-sensitive, and sore for up to several weeks following surgery but is usually quite comfortable by 1 month following the operation.
Most people can return to work 3 to 4 weeks following the operation however this does vary somewhat from person to person and depends on the type of graft performed.
You will need to:
 Use the eye drops as prescribed (normally at reducing frequency for up to 2 years);
 Wear the eyeshield overnight for the first 2 weeks
 Use sunglasses for the first few weeks
 Use Panadeine or another pain killer for the first several days;
 Avoid injuring the eye, you will need protective eyewear for
contact sports for the rest of your life.
 Be careful not to rub or press on your eye while you still have sutures
 Avoid vigorous exercise or swimming for 2 to 3 weeks following the operation
 Ask Dr Loughnan when you can begin driving again. Usually if vision was poor in the eye before surgery but good in the other eye, patients can drive after a few weeks.
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If you have a graft requiring sutures they are removed from the cornea usually between 1 and 2 years following the procedure. The exact timing of removing the sutures depends on the individual circumstances of the patient. In general the older you are the longer the sutures are left. Removing the sutures is usually a straightforward, pain-free procedure and is performed during a routine follow-up appointment. All sutures are usually removed over several visits.
With a DLAK or full thickness graft if the graft is performed to improve vision it usually takes between 3 to 12 months after the operation for the vision to clear although this can occasionally be achieved earlier, sometimes by adjusting the sutures during a routine follow-up visit. Even after such a corneal graft approximately 80% of people need glasses, and 5 % need contact lenses, while 15 % need no correction to see clearly.
It usually takes 6 to 8 months following the operation for the graft to heal sufficiently for the vision to stabilise. Glasses are not usually prescribed until this has occurred.
The vision usually recovers more quickly following a DSAEK graft, within 2 to 3 months, and only low powered glasses are required.
Complications can occur with any operation and although corneal grafting is in general safe and effective problems can occur, either at or around the time of the operation or later on.
Possible serious complications include:
 Infection in the eye (endophthalmitis) – 1 in 2,000 cases
 Serious bleeding; 1 in 2,000 cases
 Retinal swelling or detachment; 0.5% of cases (2% in very short sighted people)
 Corneal graft rejection (discussed below)
 Glaucoma, which may require drops or further surgery for control
10%
 Transmission of infectious diseases from the donor tissue
(including HIV and “mad cow disease”) - extremely unlikley.
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Less serious complications include:
 A leaky wound which may need resuturing
 Infection of the graft
 A pupil which stays large (dilated) after surgery.
 Persistent eye irritation
 Double vision
This is not an exhaustive list, if you have any specific concerns please contact me to discuss them directly prior to the operation. Overall the risk of significant vision loss from complications from the operation are approximately 1 per hundred. The risk of total loss of vision or of the eye is about 1 per 500 hundred.
Free of serious complications corneal grafts can remain clear and function well for up to 20 to 30 years or more.
Graft rejection is where your body attacks and kills some of the cells in the corneal graft, this can occur at any time after the graft but usually not within the first 2 months. Graft rejection is relatively uncommon in some conditions (eg: keratoconus and Fuch’s dystrophy) and much more common when the graft is performed for some other conditions (eg: following a herpes infection of the cornea or perforated cornea). Following rejection the corneal transplant is still physically in place but becomes swollen and cloudy, decreasing vision, and occasionally causing eye irritation. Rejection can usually be stopped and the graft returned to normal with early treatment so prompt treatment is crucial. Treatment is with hourly drops for several days to a week
Rejection is much less common for DALK grafts but does occur with DSAEK and full-thickness grafts.
Symptoms of graft rejection are RSVP:
Redness of the eye
Sensitivity to light
Visual deterioration.
Pain or increased discomfort
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If these symptoms occur and are present for more than one day you should contact Dr Loughnan or another ophthalmologist, optometrist, or the hospital promptly for treatment.
If the corneal graft is rejected the corneal transplant can usually be repeated, usually with good results, but the overall rejection rates for repeated transplants are higher than for the initial corneal graft.
A recent surgical innovation is called Deep Anterior Lamellar
Keratoplasty (DALK), where only 99% of the depth of the patient’s cornea is removed. This means that the graft is less likely to be rejected. However the average sharpness of vision is a little less with this technique than with full thickness corneal grafting. It is not always technically feasible to use this technique, the main indication for this technique is keratoconus.
The graft is sutured in place the same as with a full-thickness graft as described above.
With a normal corneal graft the whole thickness of the cornea is removed and replaced with a transplant. DSAEK is a newer corneal transplant technique where the unhealthy, diseased, deep 1% (the endothelium) of a patient’s cornea is removed and replaced with healthy donor tissue obtained from the eye bank. Unlike conventional corneal transplant surgery the DSAEK procedure utilises a much smaller surgical incision and requires no corneal sutures. This usually results in more rapid visual rehabilitation and also reduces the risk of sight threatening complications that may occur with the normal corneal transplant operation such as intraoperative haemorrhage or post operative traumatic wound rupture. Another important advantage of DSAEK over a normal corneal graft is that patients can usually see well with only a slight update of their spectacles. Following a normal corneal graft patients frequently require quite thick glasses to see well and may require a contact lens for good vision.
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The downside to DSAEK is that being a newer operation we don’t yet know if the transplant will last for as many years as a normal corneal graft although t is likely it will last for at least 5 to 10 years
DSAEK is indicated for those patients who have a corneal disease
(such as Fuch’s Dystrophy) located on the deep aspect of their cornea.
Complications can occur with any operation and although corneal grafting is in general safe and effective problems can occur, either at or around the time of the operation or later on.
Possible complications include:
 Infection in the eye, called endophthalmitis (1 in 2,000 cases)
 Serious bleeding in the eye (1 in 2,000 cases)
 Dislocation of the graft requiring repositioning with further surgery (between 2 to 5%). This would usually occur within several days following surgery.
 A rise in pressure in the eye the night following the operation
 Retinal swelling or detachment (0.5% of cases)
 Corneal graft rejection (discussed below)
 Transmission of infectious diseases from the donor tissue such as
AIDS/HIV and “mad cow disease” (extremely unlikely and never been shown to occur in Australia).
This is not an exhaustive list, if you have any specific concerns please contact me to discuss them directly prior to the operation. Overall the risk of significant vision loss from complications from the operation are approximately 1 per hundred. The risk of total loss of vision or of the eye is about 1 per 500 hundred.
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The specific details of your operation including the surgery, risks and expected outcomes will be discussed with you. If any aspect of these matters is unclear or of particular concern please do not hesitate to contact me directly to discuss such matters prior to or after the operation.
DECLARATION: I have read / had read to me and
understand the above information.
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PATIENT SIGNATURE PATIENT NAME
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WITNESS NAME
DATE: / /
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WITNESS SIGNATURE
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