Penetrating keratoplasty

1. Venu
Corneal
Department

3. • Presenter Pushkar Dhir
• Moderator Dr. Ashish

4. KERATOPLASTY
An operation in which diseased corneal tissue is
replaced by donor corneal tissue
VP Filatov – Father of Keratoplasty
Penetrating Keratoplasty
Lamellar Keratoplasty
Ant.Lamellar
Post. Lamellar
(DALK)
(DSEK,DSAEK)

5. PKP
500µ +
PLK
250µ
DSEK 180μ

6. OPTICAL
COSMETIC
PK
TYPES
THERAPEUTIC
TECTONIC

7. INDICATIONS
1.OPTICAL
2. TECTONIC / RECONSTRUCTIVE
To restore vision
To restore integrity of cornea
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
COMMON INDICATIONS
•
•
•
•
•
Corneal thinning & ectasias
Corneal perforation
Pellucid marginal degeneration
Corneal melting & fistula
Post traumatic loss of corneal tissue

8. INDICATIONS
3.Therapeutic
4.Cosmetic
To eradicate disease of cornea
•
•
COMMON INDICATION
Infective keratitis not responding to
medical Mx
Benign & malignant tumours of
cornea.
To improve appearance of cornea
•
COMMON INDICATION
Cases of corneal opacities
associated with posterior segment
diseases where visual improvement
is not possible.

9. Types of keratoplasty
• Donor tissue
Autograft
Allograft
Xenograft
Autorotational graft

10. Advanced Dry eye
Anterior staphyloma
RD
Severe cases of SJ syndrome

11. •
•
•
•
Grade 4 chemical burns
Ocular cicatrical pemphigoid with no tear film
Bad ocular surface
Multiple graft failure

12. 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)
INTERMEDIATE TERM
*Whole Globe preserved in moist
chamber(48hrs)
(UPTO 2 WKS)
*Mccarey-kaufman media
*Optisol/Dexsol/Ksol
Corneal
storage
(UPTO 35 DAYS)
*By Organ culture
LONG TERM
(UPTO 1 YEARS)
*CRYOPRESERVATION

13. Contra-indications for donors selection
-Death due to unknown cause.
-Certain Infectious diseases of the CNS
(Jacob-Creutzfeld syndrome , Progressive Multifocal Leukoencephalopathy)
-Certain Systemic infections ( AIDS, Septicemia, Syphilis, Viral hepatitis)
-Leukemia and Disseminated lymphoma
-Intrinsic eye diseases
(tumors, active inflammations, previous intra-ocular surgery)

15. Preoperative Evaluation of Recipient
Investigation
•
•
•
•
•
•
•
Ocular history
General history
Visual acuity
Gross ocular examination
Slit lamp biomicroscopy
Intraocular pressure
Fundus evaluation
•
•
•
•
•
Refraction
Keratometry
Gonioscopy
Pachymetry
Specular & confocal
microscopy
• Laser interferometry
• Videokeratography
• USG

16. 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

17. What Mr.Balram trying to find out!!??
Slit Lamp
Examination
 Microcystic
oedema
 Epithelial
Abrasions
 Stromal
oedema
 Descemet’s
fold
 Breaks in
Descemet’s
membrane

18. Procedure for PK
Preoperative preparation
Anesthesia
Surgical preparation
Trephination of Donor cornea
Trephination of Recipient cornea
Suturing of Donor cornea
Post operative treatment

19. Anaesthesia
Preoperativ
e
preparation
Anesthesia
Surgical
preparation
Trephinatio
n of Donor
cornea
Trephinatio
n of
Recipient
cornea
Suturing of
Donor
cornea
Post
operative
treatment
• Peribulbar block ,Retrobulbar block.
• General ananaesthesia :- for young , anxious
patients , mentally retarded & those in which
prolonged suregery is anticipated.

20. Preoperativ
e
preparation
Anesthesia
Surgical
preparation
Trephinatio
n of Donor
cornea
Trephinatio
n 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

21. Preparation about donor cornea
Preoperativ
e
preparation
Anesthesia
Surgical
preparation
Trephinatio
n of Donor
cornea
Trephinatio
n of
Recipient
cornea
Suturing of
Donor
cornea
Post
operative
treatment
-Graft size is 8.5 mm in diameter to avoid postop 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.

22. Trephination of donor cornea
Preoperativ
e
preparation
Anesthesia
Surgical
preparation
Trephinatio
n of Donor
cornea
Trephinatio
n of
Recipient
cornea
Suturing of
Donor
cornea
Post
operative
treatment
• “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

23. ENDOTHELIAL PUNCH SYSTEM
Sharp vertical cut
More accurate centration
Endothelial side up

24. • Hessberg Barron
Vaccum trephine
• Less AC collapse &
distortion
• Sharper, deeper &
more
perpendicular cut

25. 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

26. Trephination of Recipient Cornea
Marking cornea
• Trephination
done either
by hand held,
suction &
automated
trephines

27. DIFFERENT TYPES OF FLAP WHICH CAN
BE MADE
Top Hat Shape
•Provides large endothelial
surface transplantation

28. ZIG-ZAG SHAPE
Hermetic wound seal
Angled edge provides
smooth transition between
host and donor

29. Mushroom Shape
Preserves more host
endothelium
•

30. Recipient dissection

31. Suturing of Donor cornea
•
•
•
•
•
AC- viscoelastic
10-O nylon (11-O)
Cardinal sutures
First suture
6’ 0’ C suture
•
•
•
•
Suture depth
Equidistant bites
Bury knots.
Check wound leak.
-
10-0 mersilene/ 11-0 mersilene
4 in number.
12 ‘0’ C
2nd , Critical for tissue
alignment
- 90%

32. Interrupted corneal sutures (10/0 nylon)

33. TYPE OF
SUTURING
CONTINOUS
INTERRUPTED
PICTURE
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
COMBI
NED

34. Single continuos sutures

35. 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

36. POST OP REGIME
INTRA OP REGIME
• Subconjunctival injections of
gentamycin ( 40mg in 1 ml )
+ dexamethasone
( 4 mg in 1 ml)
• Pad & bandage for 24 hrs.
•
•
•
•
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.

37. COMPLICATIONS
INTRAOPERATIVE
EARLY POST OPERATIVE
LATE POST
OPERATIVE
1.Scleral perforation
1.Wound leakage
(diagnosis by Seidel test)
1.Post-Op
Astigmatism
2.Persisting epithelial defect.
2.Graft Rejection
2.Damage to cornea
(mechanical
/contamination)
3.Infection (kaye dots appear on
3.Retained Descemets- donor cornea - subepithelial infiltrates
double AC on Day 1
seen in corneal graft rejection)
4.Iris lens damage
5.AC hemorrhage
6.Suprachoroidal
expulsive hemorrhage
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

38. Post op visits
• Final spectacles prescribed after 24 months
when sutures have been removed & refraction
& corneal curvature stabilised
• Contact lens fitting

40. • 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