KERATOPLASTY
[Link] Fathima
Senior resident
Dept. of Ophthalmology
Keratoplasty, also called corneal grafting or corneal transplantation, is an operation in which the
patient's diseased cornea is replaced by the healthy clear cornea.
TYPES:
A. Autokeratoplasty, which can be:
1. Rotational keratoplasty, in which patient's own cornea is trephined and rotated to transfer the
pupillary area having a small corneal opacity to the periphery.
2. Contralateral keratoplasty. It is indicated when cornea of one eye of the patient is opaque and
the other eye is blind due to posterior segment disease (e.g. optic atrophy and retinal
detachment, etc.) with clear cornea. In contralateral autokeratoplasty, cornea of the two eyes are
exchanged with each other.
B. Allografting or Allo-keratoplasty. In it, patient's diseased cornea is replaced by the
donor's healthy cornea. It can be of following types:
1. Penetrating Keratoplasty (P) (full-thickness-grafting)
2. Lamellar Keratoplasty, i.e. LK (partial-thickness grafting) which may be:
1. Anterior lamellar keratoplasty (ALK) is performed when endothelium and Descemet's
membrane are normal.
Depending upon the depth of dissection ALK can be:
• Superficial anterior lamellar keratoplasty (SALK) and
Deep anterior lamellar keratoplasty (DALK).
• Superficial anterior lamellar keratoplasty (SALK), which is
performed for superficial corneal stromal haze.
• Deep anterior lamellar keratoplasty (DALK) in which 80-90%
of the anterior stroma is replaced.
li. Posterior lamellar keratoplasty (PLK), is also known as endothelial
[Link] is performed only when endothelium is defective. It includes:
Descemet's stripping endothelial keratoplasty (DSEK), done manually.
• Descemet's stripping automated endothelial keratoplasty(DSAEK)
• Descemet's membrane endothelial keratoplasty (DMEK).
• Pre-descemets' stripping automated endothelial keratoplasty (Pre-DSAEK).
3. Small patch graft (for small defects), which may be full thickness or partial thickness.
Indications
Indications of penetrating keratoplasty
1. Optical, i.e. to improve vision. Important indications are: corneal opacity, bullous keratopathy (most
common), corneal dystrophies, advanced keratoconus.
2. Therapeutic, i.e. to replace inflamed cornea not responding to conventional therapy.
3. Tectonic graft, i.e. to restore integrity of eyeball, e.g. after corneal perforation and in marked corneal
thinning.
4. Cosmetic, i.e. to improve the appearance of the eye.
Indications of endothelial keratoplasty (EK)
• Fuchs endothelial dystrophy
• Pseudophakic corneal edema (most common)
• Posterior polymorphous dystrophy
• Aphakic corneal edema
• Iridocorneal endothelium syndrome
• Failed corneal graft.
Surgical technique of penetrating keratoplasty
1. Excision of donor corneal button. The donor corneal button should be cut 0.25 mm
larger than the recipient, taking care not to damage the endothelium. Donor cornea is
placed in a tephlon block and the button is cut with the help of a trephine from the
endothelial side (Fig. 6.35A).
2. Excision of recipient corneal button. With the help of a corneal trephine (7.5 mm to 8
mm in size) a partial thickness incision is made in the host cornea (Fig. 6.35B). Then,
anterior chamber is entered with the help of a razor blade knife and excision is completed
using corneoscleral scissors (Fig. 6.35C).
3. Suturing of corneal graft into the host bed (Fig. 6.35D) is done with either continuous
(Fig. 6.35E) or interrupted (Fig.6.35F) 10-0 nylon sutures.
Complications
1. Early complications. These include flat anterior chamber, iris prolapse, infection,
secondary glaucoma, epithelial defects and primary graft failure.
2. Late complications. These include graft rejection, recurrence of disease and
astigmatism.
