Introduction to Corneal

Transplant
Stephen Lau
Outline
Anatomy
Histology
Indications
Techniques
Anatomy
Avascular = Transparency
Nutrients Via Diffusion
Air Tear
Aqueous Fluid
Unmyelinated Nerve Endings = Sensitivity
[V
1
]
Refractive Power
2/3 of Total Refraction Fixed
(1/3 at Lens Fine Tunes Focus)
Dimensions
Diameter
11.5mm
Thickness Thinner at Center than Periphery
0.5-0.6 mm vs. 0.6-0.8 mm

Source: wikipedia.com
Histology
Epithelium
Regenerative Capacity
Bowmans Membrane I/V Collagen
Stroma I/V Collagen
Keratocytes Repair/Maintenance
Duas Layer
Descemets Membrane IV Collagen
Endothelium
No Regenerative Capacity Hypertrophy
Function Dehydrates Cornea (Na
+
/K
+
-ATPase) = Transparency
Damage = Oedema/Clouding
Source: Sci-News.com
Source: naturephotography.info
Indications
Optical Impaired Vision
Ectasias (Bulging)
Keratoconus (Bowmans Layer )
Dystrophies
Fuchs Endothelial Dystrophy (Endothelium/DM )
Degenerations
Salzmanns Nodular Degeneration (Bowmans Layer )
Infection/Trauma Scarring
Tectonic Severe Structural Change
Thinning Prevent Perforation
Therapeutic
Chronic Corneal Infection Refractory to Abx
Cosmetic


Source: emedicine.medscape.com
Source: wikipedia.com
Techniques
Full Thickness
Penetrating Keratoplasty (PK) 1905
Partial Thickness (Lamellar)
Anterior
Deep Anterior Lamellar Keratoplasty (DALK) 1970s/80s
Posterior (Endothelial)
Deep Lamellar Endothelial Keratoplasty (DLEK) 1998
Descemet-Stripping EK (DSEK) 2005
Descemets Membrane EK (DMEK) 2008
Source: eyesite.org
Techniques
DLEK vs. DSEK vs. DMEK
DLEK
Endothelium + DM + Stroma
DSEK
Endothelium + DM Stripped
Endothelium + DM + Stroma Transplanted
DMEK
Endothelium + DM

Source: Fernandez MM and Afshari NA. Endothelial Keratoplasty: From DLEK to DMEK. Middle
East Afr J Ophthalmology. 2010; 17(1): 5-8.

Comparison
Penetrating Lamellar
Indications Any Layer Affected One Layer Affected
E.g.) Keratoconus, Fuchs Endothelial
Dystrophy
Healing Time Up to 2 Years Days-Months
Risk of
Rejection
Higher Lower (Less Foreign Antigen)

Risk of
Dehiscence
Higher Lower
PK
https://www.youtube.com/watch?v=h4P8ECq
eaJk

DALK
Corneal Trephination
Corneal Tunnel
Inject Air Anterior to DM
Remove Cornea Anterior to Bubble
Inject Viscoelastic to Bubble
Incise into Bubble
Transplant Cornea Remove DM




Source: youtube.com
DLEK
Corneal Tunnel Stromal Dissection
Remove Posterior Cornea
Scissors (Blades in Stroma + AC)
Donor Tissue Stromal Dissection
Donor Tissue Insertion
Temporary Air Bubble Tamponade
AC Irrigation + Spontaneous Unfolding
Endothelium Fluid Pump = Suction
Pull Down Edges Posterior to Transplant
Remove Air Bubble + Suture Incisions


Source: youtube.com