This document discusses different types of keratoplasty procedures including penetrating keratoplasty and lamellar keratoplasty. It describes the donor evaluation and surgical procedure for penetrating keratoplasty. Key steps include trephination of the donor and recipient corneas, suturing the donor cornea into place, and post-operative treatment and follow-up. Complications of the surgery are also outlined. The goal of keratoplasty is to replace diseased corneal tissue and restore vision or integrity of the cornea.

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
(DALK)
Post. Lamellar
(DSEK,DSAEK)

5. PKP
500µ +
PLK
250µ
DSEK 180μ

6. PK
TYPES
OPTICAL
TECTONIC
THERAPEUTIC
COSMETIC

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

8. INDICATIONS
3.Therapeutic
To eradicate disease of cornea
COMMON INDICATION
• Infective keratitis not responding to
medical Mx
• Benign & malignant tumours of
cornea.
4.Cosmetic
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 Severe cases of SJ syndrome
RD

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

13. Contra-indications for donors selection
-Death due to unknown cause.
-Certain Infectious diseases of the CNS
(Jacob-Creutzfeld syndrome , Progressive Multifocal Leuko-
encephalopathy)
-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
• Ocular history
• General history
• Visual acuity
• Gross ocular examination
• Slit lamp biomicroscopy
• Intraocular pressure
• Fundus evaluation
Investigation
• 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. Slit Lamp
Examination
 Microcystic
oedema
 Epithelial
Abrasions
 Stromal
oedema
 Descemet’s
fold
 Breaks in
Descemet’s
membrane
What Mr.Balram trying to find out!!??

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

20. • 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
Preoperativ
e
preparation
Anesthesia
Surgical
preparation
Trephinatio
n of Donor
cornea
Trephinatio
n of
Recipient
cornea
Suturing of
Donor
cornea
Post
operative
treatment

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

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

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
• Trephination
done either
by hand held,
suction &
automated
trephines
Marking cornea

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) - 10-0 mersilene/ 11-0 mersilene
• Cardinal sutures - 4 in number.
• First suture - 12 ‘0’ C
• 6’ 0’ C suture - 2nd , Critical for tissue
alignment
• Suture depth - 90%
• Equidistant bites
• Bury knots.
• Check wound leak.

32. Interrupted corneal sutures (10/0 nylon)

33. TYPE OF
SUTURING
CONTINOUS INTERRUPTED
COMBI
NED
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

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. INTRA OP REGIME
• Subconjunctival injections of
gentamycin ( 40mg in 1 ml )
+ dexamethasone
( 4 mg in 1 ml)
• Pad & bandage for 24 hrs.
POST OP REGIME
• 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
2.Damage to cornea
(mechanical
/contamination)
3.Retained Descemets-
double AC on Day 1
4.Iris lens damage
5.AC hemorrhage
6.Suprachoroidal
expulsive hemorrhage
1.Wound leakage
(diagnosis by Seidel test)
2.Persisting epithelial defect.
3.Infection (kaye dots appear on
donor cornea - subepithelial infiltrates
seen in corneal graft rejection)
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
1.Post-Op
Astigmatism
2.Graft Rejection

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