DSEK is the procedure most often used for corneal transplantation. Dr. Gillespie performs this procedure giving much faster vision rehabilitation. The Ophthalmology Group has been offering this procedure for more than 10 years.
Ophthalmologists perform more than 40,000 corneal transplants each year in the United States. Of all transplant surgery done today—including heart, lung, and kidney—corneal transplants are the most common and successful.
What is the cornea?
The cornea is the clear front window of the eye that covers the colored iris and the round pupil. Light is focused while passing through the cornea so we can see.
How can an unhealthy cornea affect vision?
If the cornea is injured, it may become swollen or scarred, and its smoothness and clarity may be lost. Scars, swelling, or an irregular shape can cause the cornea to scatter or distort light, resulting in glare or blurred vision.
A corneal transplant is needed if:
- vision cannot be corrected satisfactorily with eyeglasses or contact lenses;
- painful swelling cannot be relieved by medications or special contact lenses.
What conditions may cause the need for a corneal transplant?
- Corneal failure after other eye surgery, such as cataract surgery;
- Keratoconus, a steep curving of the cornea;
- Hereditary corneal failure, such as Fuchs’ dystrophy
- Scarring after infections, especially after herpes;
- Rejection after a first corneal transplant;
- Scarring after injury.
What happens if you decide to have a corneal transplant?
Before Surgery Once you and your ophthalmologist decide you need a corneal transplant, your name is put on the list at the local eye bank. Usually the wait for a donor cornea is not very long. Before a cornea is released for transplant, the eye bank tests the human donor for the viruses that cause hepatitis and AIDS. The cornea is carefully checked for clarity. Your ophthalmologist may request that you have a physical examination and other special tests. If you usually take medications, ask your doctor if you should continue using them. The Day of Surgery Surgery is often done on an outpatient basis. You may be asked to skip breakfast, depending on the time of your surgery. Once you arrive for surgery, you will be given eyedrops and perhaps a sedative to help you relax. Either local or general anesthesia is used, depending on your age, medical condition, and eye disease. You will not see the surgery while it is happening. Your eye will be held open with a lid speculum or another method. The Operation The eyelids are gently opened. Your ophthalmologist will view your eye through a microscope and measure your eye for the corneal transplant. The diseased or injured cornea is carefully removed from the eye. Any necessary additional work within the eye, such as removal of a cataract, is completed. Then the clear donor cornea is sewn into place. When the operation is over, your doctor will usually place a shield over your eye. After Surgery If you are an out patient, you may go home after a short stay in the recovery area. You should plan to have someone drive you home. An examination at the doctor’s office will be scheduled for the following day. You will need to:
- use the eyedrops as prescribed,
- be careful not to rub or press on your eye,
- use over-the-counter pain medicine, if necessary,
- continue normal daily activities but avoid strenuous exercise or activities,
- wear eyeglasses or an eye shield for protection, as advised by your doctor,
- ask your doctor when you can start driving again,
- call your doctor if you have any questions about your home-care instructions.
Your ophthalmologists will decide when to remove the stitches, depending upon the health of your eye and rate of healing. Usually, it will be one year before stitches are removed, but this varies depending on the specific technique used. Often, stitches are left in place permanently.
What complications can occur?
Corneal transplants are rejected 5% to 30% of the time. The rejected comea clouds and vision deteriorates.
Most rejections, if treated promptly, can be stopped with minimal injury. Warning signs of rejection are:
- persistent discomfort,
- light sensitivity,
- change in vision.
Any of these symptoms should be reported to your ophthalmologist immediately.
Other possible complications include:
- swelling or detachment of the retina,
All of these complications can be treated. A corneal transplant can be repeated, usually with good results, but the overall rejection rates for repeated transplants are higher than for the first transplant. Irregular curvature of the transplanted cornea (astigmatism) may slow the return of vision but can also be treated. Vision may continue to improve up to a year after surgery. Even if the surgery is successful, other existing eye conditions, such as macular degeneration, glaucoma, or diabetic retinopathy, may limit vision after surgery. Even with such problems, a corneal transplant may still be worthwhile. A successful corneal transplant requires care and attention on the part of both patient and physician. However, no other surgery has so much to offer when the unhealthy cornea is deeply scarred or swollen. Corneal transplant surgery would not be possible without the thousands of generous donors and their families who have donated corneal tissue so that others may see.
DSEK – Descement’s Stripping Endothelial Keratoplasty
The cornea is a transparent dome on the front of the eye. Corneal edema (swelling) produces decreased vision due to the loss of transparency of this normally clear tissue. The swelling is due to a loss of endothelium, a thin layer of cells found on the back surface of the cornea. These cells are not capable of dividing or repairing themselves. The only treatment for visually significant corneal swelling is to replace these cells.
For the past 50 years, a full thickness corneal transplant has been the standard of care for patients with corneal endothelial disease. Other than improvements in suturing technique and tissue quality, corneal transplantation has changed very little. Corneal transplants produce anatomically clear corneas, but after the operation, it takes several months to several years to obtain your best vision. It is very difficult to predict the final curvature of the cornea; so after surgery, glasses or contact lenses are required in the vast majority of cases.
Recently a new procedure has been developed to replace the endothelial cells that do not require a full thickness corneal transplant. In the DSEK procedure, a thin piece of donor corneal tissue containing endothelial cells is placed in the eye through a small incision on the side of the eye. This tissue adheres to the back of the cornea and clears the corneal swelling.
The advantages of replacing the posterior layers of the cornea are that a smaller wound is made and fewer sutures are needed. The eye heals faster because of the smaller wound and fewer sutures that are used. Vision can return in 3-6 months instead of up to a year or more after standard corneal transplants. The eye is less susceptible to injury and rupture after DSEK compared to the standard corneal transplant. The prescription for glasses following DSEK is similar to what the prescription was prior to the surgery.
However, after standard corneal transplants, patients can end up with a large change in the prescription due to the amount of astigmatism, nearsightedness or farsightedness that is induced compared to what they had before. In the standard corneal transplant, sutures can lead to problems with infection and irritation of the eye; however, these problems are greatly reduced with DSEK. DSEK surgery is considered safer than a full thickness corneal transplant. There is less chance of a devastating hemorrhage during the surgery or an infection afterwards due to the smaller incisions used in the eye.
The potential disadvantages of DSEK are that it is a new procedure and it is not known at this time how long the surgery may be good for or how long the effect will last. If there is unusual scarring occurring between the donated cornea and the patient’s cornea, the vision might be decreased and you still may need a standard corneal transplant later to improve the vision.
Difficulties can occur during the surgery whereby the surgery would have to be converted to a standard corneal transplant. In some cases, the new portion of the donor cornea may not attach properly to the patient’s cornea. This can occur in up to 25% of the cases and this may necessitate having to return to surgery to have an air injection into the eye to push the donor cornea back into place. In some cases, the surgery itself may need to be repeated with a new donor cornea.
After the DSEK procedure, the vision clears faster than the full corneal transplant operation and the patient can return to normal activities within 2 weeks with the exception of swimming. Like full thickness corneal transplants, eye drops are required for at least a year or more to prevent graft rejection. Fortunately, graft rejections are very unusual (less than 10% of the time) and if they do occur, can be treated successfully in the majority of cases with frequent eyedrops and occasionally oral medications.
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