ALL YOU NEED TO KNOW ABOUT CORNEA TRANSPLANT (KERATOPLASTY)

A cornea transplant, also called keratoplasty or corneal graft, is a surgery to remove a damaged cornea and replace it with healthy tissue from an organ donor. The new cornea comes from people who decided to donate this tissue when they died.

A corneal transplantation can effectively improve vision, relieve pain, treat severe infection or trauma. Usually, this surgery is considered when your cornea is damaged to a point where the vision or other symptoms can no longer be improved with glasses, contact lenses, or any medical treatment.

WHAT IS THE CORNEA?

The cornea is the clear, outermost layer at the front of our eyes. It is literally the “windshield” of our eyes. The cornea allows light rays to pass through the eyeball, focusing right to the retina, the light-sensitive layer at the back of the eye.

When the cornea is damaged, it gets cloudy or misshapen. This can prevent light from reaching the retina, causing blurred vision and even blindness.

Medically reviewed by Dr Osama Bahsas Zaky
Written by Joaquín Pineda
Updated on October 18, 2021

What is the Cornea?

Modern Techniques Currently Used.

Suitable Patients for a Cornea Transplant.

Benefits of Cornea Transplant Surgery.

Are there any Risks?

Natural Corneas and Artificial Corneas.

Cornea Transplant Surgery Process.

Corneal Graft Recovery.

Cornea Transplant Cost.

FAQ about Corneal Transplant Surgery.

WHAT TECHNIQUES ARE CURRENTLY USED IN CORNEA TRANSPLANT SURGERY?

The type of cornea transplant depends on the extent of the disease and how much of the cornea needs replacing.

Currently, there are two main techniques:

  • Penetrating keratoplasty. Also called full-thickness cornea transplant. It replaces the entire cornea.
  • Lamellar Corneal transplantation(lamellar keratoplasty). Also known as partial-thickness corneal transplant. This includes anterior lamellar keratoplasty (ALK) and endothelial keratoplasty techniques.

After a preoperative examination and depending on the condition of the patient’s cornea, your surgeon will decide on the best technique for you.

Penetrating Keratoplasty (PK)

Until recently, the most used technique was penetrating keratoplasty (PK), in which all layers of the cornea are replaced.

During the procedure, the surgeon removes a small round piece of the patient’s cornea using a circular cutting device called trephine or a femtosecond laser.

Then, a matching full-thickness section of tissue from a donor is positioned and sutured into place. The sutures (stitches) typically remain for a year or more after surgery.

Anterior Lamellar Keratoplasty (ALK)

This technique removes diseased tissue from the front corneal layers (the epithelium and the stroma) but leaves the back endothelial layer intact. The depth of cornea damage determines the best ALK type of surgery for you.

The superficial anterior lamellar keratoplasty (SALK) replaces only the upfront layers of your cornea, leaving the stroma and endothelium in place.

Conversely, a deep anterior lamellar transplant (DALK) approach is used when cornea damage extends far deeper into the stroma.

In any case, the surgeon injects air to lift off and separate the different layers of your cornea. Then, the healthy tissue from a donor is attached (grafted) to replace the removed section.

DALK transplants seem to have an even lower risk of failure. They last longer with shorter recovery times compared to PK transplants.

Endothelial Corneal Transplantation

Thanks to the latest scientific advances, it is possible to do a targeted replacement of diseased corneal layers. About half of the patients who need corneal transplants have eye conditions that affect the innermost layer of the cornea, also known as the endothelium.

There are two types of endothelial keratoplasty:

The first type, called Descemet stripping endothelial keratoplasty (DSEK), is the most common type of endothelial keratoplasty. It uses healthy donor tissue to replace about one-third of the cornea.

DESK selectively replaces the endothelium– a mere one cell thick -and a thin layer of tissue that protects the endothelium from injury, called Descemet membrane, leaving the overlying corneal tissue intact.

Then, your doctor replaces them with a donor’s endothelium and Descemet membrane still attached to the stroma (the cornea’s middle layer). This allows handling the new tissue without damaging it.

The second type, Descemet membrane endothelial keratoplasty (DMEK), uses a thinner layer of donor tissue. It transplants the endothelium and Descemet membrane without supporting stroma.

In any technique, an air bubble is used to fix the new endothelial layer into place. The microincision is self-sealing, and no sutures are required in most cases.

Endothelial keratoplasty has several advantages over penetrating keratoplasty. These include:

  • Less operating time.
  • Less aggressive.
  • Faster visual recovery with a more comfortable postoperative period.
  • No related suture complications.
  • Reduced risk of astigmatism after surgery.
  • Less chance of transplanted tissue rejection.

AMNIOTIC MEMBRANE TRANSPLANTATION

The amniotic membrane is a layer of the human placenta that contains natural substances with growth factors that help to regenerate tissues and control inflammation.

Amniotic membrane transplantation involves the placement of a fragment of amniotic membrane on the cornea, using very fine sutures. The technique is painless, does not require hospitalization, and is performed under local anesthesia.

This technique is used:

  • As a graft to fill a corneal defect.
  • As a coating to reduce inflammation of the ocular surface. It also promotes epithelial healing without leaving sequels or opacities.

WHICH PATIENTS ARE RECOMMENDED FOR A CORNEA TRANSPLANT?

A cornea transplant is recommended for patients with:

WHAT ARE THE BENEFITS OF CORNEA TRANSPLANT SURGERY?

Cornea transplantation is a very common surgical procedure. A successful surgery will provide the patient with good vision for many years. Your quality of life at the visual level will improve considerably.

However, you should keep in mind that full recovery of sight can take up to a year. And often, after the transplant, the use of glasses or contact lenses is required to improve vision.

You may be left with a degree of myopia (nearsightedness) and astigmatism due to irregularities in the curve of the new corneal tissue.

Once your cornea has healed — several weeks to several months after surgery — your eye doctor can make adjustments to improve your vision. The stitches that keep the donor cornea in place might cause dips and bumps in your cornea. So, your doctor might correct some of this by releasing some stitches and tightening others.

Also, remember that your vision will fluctuate during the first few months after surgery. So, it is advisable to wait until your vision is stable before you get a new eyeglass or contact lenses prescription.

Later on, you may be eligible to undergo laser eye surgery such as LASIK or PRK to improve your vision.

WHAT ARE THE RISKS OF CORNEAL TRANSPLANTATION?

Cornea transplants are performed routinely and have an excellent success rate. In fact, corneal grafts are the most successful of all tissue transplants, but complications may occur, such as detachment or displacement of lamellar transplants, and primary graft failure.

Other risks associated include:

The transplanted cornea is a “foreign body,” and the body can recognize it as something “strange” at any time. Rejection is the body’s defense mechanism. This can happen immediately after surgery, in months, or even after years. Rejection occurs in about 20% of corneal grafts.

However, cornea transplant rejection can be reversed in 9 out of 10 cases if detected early. Sometimes, rejection can be prevented and controlled with ophthalmic drops with steroids that you should use for six months or indefinitely.

Although it is possible to replace a failed transplant, known as a re-graft, the risk of rejection goes up each time a transplant is done.

NATURAL CORNEAS AND ARTIFICIAL CORNEAS

The cornea graft normally comes from a donor. Before the cornea is transplanted, virus tests (hepatitis, AIDS, and other potentially infectious diseases) should be performed. The donated cornea is thoroughly analyzed to verify that it is safe for surgery and that it is completely transparent.

Unlike other organs, such as the liver and kidneys, people who need a corneal graft generally do not have to endure long waits because tissue matching is not required. Human donor tissue is the first— and most successful — option for replacing a damaged cornea.

However, artificial cornea tissue is a great option for patients with a high risk of corneal transplant failure with a human donor (such as multiple failed human cornea transplants).

Artificial corneas, also known as “keratoprosthesis,” are made from a biologically inert material. Currently, the most common prostheses are osteo-keratoprostheses (tibia), odonto-keratoprostheses (dental), and Boston keratoprostheses (artificial cornea).

Keratoprosthesis surgery is used in cases where one or more cornea transplants from donors failed.

WHAT IS THE PROCESS OF CORNEA TRANSPLANT SURGERY?

The intervention lasts between 30 and 40 minutes. Although depending on the technique, it may take up to two hours to complete.

If local anesthesia is used, you will have an injection into the skin around your eye to relax the muscles that control eye movements. Also, eye drops are used to numb your eye.

You will be awake during the procedure but without pain or any discomfort. Additional sedation can make the surgery more comfortable for you. General anaesthesia is used rarely. It depends on the patient’s characteristics.

After the anaesthesia has taken effect, your surgeon uses an instrument called “lid speculum” to keep your eyelids open. He measures the diseased corneal area to determine the size of the donor tissue needed. Then, the cornea is removed and replaced according to the technique chosen.

After the surgery is done, the doctor puts antibiotic eye drops, an eye patch, and you are taken to a recovery area while the anesthesia wears off.

This surgery is an outpatient procedure, so you can go home a short while after (although you will need someone to drive you home). In case you need surgery on both eyes, they will be done separately. The second eye surgery would be planned about 6 months after the first eye heals completely.

You will remain at the hospital for two or three days, depending on your evolution.

As a foreign patient, your stay in Barcelona will be about one month to be able to perform the proper postoperative controls. It is also necessary to carry out a medical control after 3 or 6 months, depending on the patient’s postoperative course.

CORNEAL GRAFT RECOVERY

The first few days are very important to ensure a successful recovery. It is important to follow these guidelines during the postoperative period:

  • Relative rest. You should remain calm at home and refrain from straining, bending, and lifting right after the surgery.
  • It is important to sleep on your back or the opposite side of surgery.
  • When bathing, do not wet the eye patch.
  • Wear eye protection, including when you are asleep. Eyeshields or glasses protect your eye while it heals.
  • Don’t rub, scratch, or apply pressure to your eye.

Blurred vision and itchiness are normal during the first few days. They are due to inflammation and the presence of sutures. This will improve with time.

Specialists will prescribe steroid and antibiotic drops to help with the healing, prevent infection and rejection. You must take your medications as the doctor tells you to.

Most patients do not suffer from pain, although some discomfort may occur. In that case, a mild painkiller is usually enough. If it does not improve or the pain is very intense, you should call your doctor or go to the emergency room.

The doctor will remove the stitches at a control visit. Some of the sutures will be removed three to 17 months post-surgery, depending on the healing rate.

The postoperative follow-up lasts several months. Careful control by professionals is necessary to avoid long-term complications. Remember that your vision may initially be worse than before surgery until your eye is adjusted to the new cornea.

The recovery time for a cornea transplant depends on the type of transplant. It takes nearly 18 months to experience the final results of a full-thickness transplant, although it’s possible to use glasses or a contact lens much earlier.

HOW MUCH DOES A CORNEA TRANSPLANT COST?

Cornea transplant cost depends on the performed technique. Please, fill in the contact form. If you have any medical reports or examination results from other centers, we would appreciate it if you could send these tests to us by email so we can offer you the solution that best suits your needs.

You can be sure that this information will always be treated with maximum confidentiality.

FAQS ABOUT CORNEAL TRANSPLANT SURGERY

Qualified personnel is placed at your disposal, and they will advise you in your language during the hospital process. In case the doctor does not speak your language, a personal interpreter can accompany you throughout all your visits.

Visual recovery can be very slow, and medication should be taken over a period of 6 to 12 months. Total cornea transplant recovery time can be up to a year or longer.

  • Decreased vision
  • Pain
  • Red eye
  • Light sensitivity
  • Tearing

In most cases, it lasts less than one hour. The patient will remain admitted to the hospital for two to three days, depending on their evolution.

Yes, it is possible.

Across all types of cornea transplants, 75 % last at least five years, and more than 50 % last up to ten years.

BEST CORNEA TRANSPLANT SPECIALISTS IN SPAIN:

Doctor Rafael I. Barraquer

Doctor Rafael I. Barraquer

Bachelor of Medicine and Surgery (Universidad Autónoma de Barcelona, 1979). Specialist in Ophthalmology (1982). Doctorate in 1987 with the qualification of “Cum Laude”. Founder and director of the Ocular Oncology Unit. He maintains a significant teaching role as Associate Professor at the Faculty of Medicine at the Universidad Autónoma de Barcelona and in the Teaching Commission for the training of the COB MIR residents, of which he is President. He stands out for his capacity as a researcher and he is the chair holder of the “UAB Research Chair in Ophthalmology Joaquín Barraquer” since its foundation. Deputy Medical Director and Ophthalmologist at the Barraquer Ophthalmology Centre.
Languages: Spanish, Catalan, English, French.
Association number: 13.964

Doctor José Lamarca Mateu

Doctor José Lamarca Mateu

Bachelor of Medicine (University of Lleida, 1996-2002). Ophthalmology residency at the Barraquer Ophthalmology Centre. Masters in “Retinovascular Pathology, Inflammation and Intraocular Tumours”, “Corneal and Ocular Surface Pathology “,” Pathology and surgery of the Macula, Vitreous and Retina” and “Diagnosis and Treatment of Cataracts and Glaucoma” certified by the Universidad Autónoma de Barcelona (2003-2007). Coordinator of the Barraquer Institute. Tutor in the Department of Educational Surgery. Member of the executive committee of the Research Committee of the Institut Universitari Barraquer. Professor at the International University of Catalonia.
Languages: Spanish, Catalan, English
Association number: 37491

External links – Bibliography

Risk factors for graft failure after penetrating keratoplasty. Barraquer RI, Pareja-Aricò L, Gómez-Benlloch A, Michael R.Medicine (Baltimore). 2019 Apr

Comparison of long-term results between osteo-odonto-keratoprosthesis and tibial bone keratoprosthesis. Charoenrook V, Michael R, de la Paz MF, Temprano J, Barraquer RI.Ocul Surf. 2018 Apr;

Epithelial Ingrowth After Descemet Membrane Endothelial Keratoplasty. Álvarez de Toledo C, Salvador-Culla B, López JC, De la Paz MF, Barraquer RI, Álvarez de Toledo J.Cornea. 2019 Sep

Corneal graft failure: an update. Alio JL, Montesel A, El Sayyad F, Barraquer RI, Arnalich-Montiel F, Alio Del Barrio JL.Br J Ophthalmol. 2020 Aug

Osteo-odonto-, Tibial bone and Boston keratoprosthesis in clinically comparable cases of chemical injury and autoimmune disease. de la Paz MF, Salvador-Culla B, Charoenrook V, Temprano J, Álvarez de Toledo J, Grabner G, Michael R, Barraquer RI.Ocul Surf. 2019 Jul

Osteokeratoprosthesis Using Tibial Bone: Surgical Technique and Outcomes. Charoenrook V, Michael R, de la Paz MF, Ding A, Barraquer RI, Temprano J.Ocul Surf. 2016 Oct

Long-term functional and anatomical results of osteo- and osteoodonto-keratoprosthesis. Michael R, Charoenrook V, de la Paz MF, Hitzl W, Temprano J, Barraquer RI.Graefes Arch Clin Exp Ophthalmol. 2008 Aug

Prognostic factors in penetrating keratoplasty. Barraquer RI, Kargacin M.Dev Ophthalmol. 1989

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