Brief description about each type of Keratoplasty with pictures

1. Indications of
Keratoplasty
Bindu K M
AJIMS , Mangalore

2. • Introduction to Keratoplasty
• Objectives
• Types of Keratoplasty
• Indications
• Factors affecting the prognosis

3. KERATOPLASTY
???

4. Keratoplasty
Corneal transplantation / Corneal grafting
It is an operation in which the patient's diseased cornea
is excised and replaced by the healthy clear cornea.
HISTORY – First recorded therapeutic corneal xenograft
on a human was reported in 1838 by Richard Kissam
Father of Keratoplasty – V P Filatov

6. OBJECTIVES :-
• To establish clear corneal visual axis
• To minimize refractive error
• To provide tectonic support
• To eliminate infection

9. Cornea as a transplant
✓ Absence of blood and lymphatic channel in the
graft and its bed
✓ Absence of MHC class II APCs in the graft
✓ Reduced expression of MHC coded alloantigen on
graft cells
✓ Immunosuppressive microenvironment of aqueous
humor.

10. Types :-
A. AUTOKERATOPLASTY -
1. ROTATIONAL KERATOPLASTY
2. CONTRALATERAL KERATOPLASTY
B. ALLO-KERATOPLASTY -
1. PENETRATING KERATOPLASTY
2. LAMELLAR KERATOPLASTY
3. SMALL PATCH GRAFT (for small
defects)

11. ROTATIONAL KERATOPLASTY
Patient's own cornea is trephined
rotated
Transfer of pupillary area (with small corneal opacity) to
periphery

12. Rotational Keratoplasty

13. Rotational keratoplasty

14. CONTRALATERAL KERATOPLASTY
• Cornea of one eye – opaque
• Other eye – blind due to some posterior segment
disease, but clear cornea
• Cornea of 2 eyes are exchanged with each other

15. PENETRATING KERATOPLASTY
• It is full thickness grafting
History :-
• First successful penetrating keratoplasty in humans was
done by Eduard Zirm (1905)
• Recipient – A 45 yr old farm laborer who had sustained
severe alkali burns while cleaning out chicken coop with
lime
• Donor – 11 yr old boy
• One cornea was used to provide two 5 mm donor grafts

17. INDICATIONS -
A)Optical
B)Tectonic
C)Therapeutic
D)Cosmetic

18. OPTICAL
• Keratoplasty is performed to improve vision
• Important indications -
Corneal opacity
Bullous keratopathy
Corneal dystrophies, degenerations
Advanced keratoconus
Chemical injuries

19. Pseudophakic bullous keratopathy

21. TECTONIC
• To restore integrity of eyeball
• Indications-
Marked corneal thinning
(Stromal thinning, Descemetocele)
After corneal perforation

22. THERAPEUTIC
• To replace the infected corneal
tissue which is unresponsive to
conventional antimicrobial
therapy (Non healing corneal
ulcer)
-Selected cases of viral , bacterial,
fungal , protozoal keratitis
INFECTIOUS KERATITIS

23. COSMETIC
• To improve the appearance of the eye
• Cases of corneal opacities with posterior
segment disease where Visual improvement
is not possible.
• Opaque cornea with white or blue-grey hue
may be disturbing to the patient

24. LAMELLAR KERATOPLASTY
• Partial thickness grafting
• Selective removal of diseased tissue
and replacement with donor cornea.
• It is less invasive procedure
• But it requires finer surgical skill
and more refined instrumentation

25. ALTERNATIVE TO PKP – WHY ??
1. PKP induced astigmatism in range of 3 to 7
diopter.
2. Decline in endothelial cell count leading to graft
failure
3. Allograft rejection and endothelial
decompensation were the major concerns

26. HISTORY :-
The 1st successful lamellar keratoplasty was performed
by Arthur Von Hippel (1886).
He grafted rabbit cornea into the lamellar bed of a
young woman.
He is credited with the invention of mechanical trephine
for corneal procedures.

27. LAMELLAR
KERATOPLASTY
ANTERIOR LAMELLAR
SUPERFICIAL
ANTERIOR
LAMELLAR(SALK)
DEEP ANTERIOR
LAMELLAR(DALK)
POSTERIOR LAMELLAR
DEEP LAMELLAR
ENDOTHELIAL
KERATOPLASTY(DLEK)
ENDOTHELIAL
KERATOPLASTY (EK)

28. Superficial anterior lamellar keratoplasty
• Partial thickness excision of Corneal epithelium and
stroma
• Endothelium and part of deep stroma – left behind
• INDICATIONS:-
- Opacification of superficial 1/3rd of corneal stroma
- Marginal corneal thinning/infiltration as in reccurent
pterygium, marginal degeneration
- localized thinning or descemetocele formation

30. DEEP ANTERIOR LAMELLAR KERATOPLASTY
• Opaque corneal tissue is removed almost to the level of Descemet
membrane.
• Decreased rejection risk (endothelium- major target of Rejection)
• INDICATIONS:-
- Disease involving anterior 95% of Corneal thickness (normal
endothelium, no breaks/scars in Descemet membrane)
- Chronic inflammatory disease- atopic keratoconjunctivitis which
carries increased risk of graft rejection.

31. POSTERIOR LAMELLAR KERATOPLASTY
• Performed when only endothelium is defective.
• It involves removal only of diseased endothelium along with
Descemet’s membrane, through a corneoscleral or corneal incision.
• Folded donor tissue is introduced through the same small (about 5
mm) incision.
• Maintains structural integrity. Decreases surgically induced
astigmatism.

32. Types -
1.Deep lamellar endothelial keratoplasty (DLEK)
2.Endothelial keratoplasty (EK) – This includes
- Descemet’s stripping endothelial keratoplasty (DSEK)
- Descemet’s stripping automated endothelial Keratoplasty ( DSAEK)
- Descemet’s membrane endothelial Keratoplasty (DMEK)
- Pre Descemet’s stripping automated endothelial Keratoplasty
(Pre– DSAEK)

33. • DMEK adds only a new Descemet's membrane and
endothelium.
• DSAEK also adds a new Descemet's membrane
and endothelium but with a layer of donor stroma.
Indications –
1. Fuchs endothelial dystrophy (most common)
2. Pseudophakic / Aphakic bullous keratopathy
3. Post PK endothelial graft rejection
4. Iridocorneal endothelial syndromes (ICE)

35. Host factors affecting the prognosis
1. Severe stromal vascularization , extreme thinning at
the proposed graft – host junction
2. Abnormalities of the eyelids ( Blepharitis, Ectropion,
entropion, trichiasis)
3. Recurrent conjunctival inflammations, tear film
dysfunction
4. Anterior synechiae, Uncontrolled glaucoma
5. Anterior uveitis

36. THANK YOU!