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KERATOPLASTY by arthur mohan and niko.pptx
- 1. KERATOPLASTY DR NIVETHA G SENIORRESIDENT SBMCH
- 2. INTRODUCTION Keratoplasty iscorneal transplant procedure in which diseased host corneal tissue is replaced by healthy donor cornea. Keratoplasty is considered as the most frequently performed and the most successful organ transplantation technique worldwide.
- 3. TYPES OF KERATOPLASTY Keratoplasty Partial thickness Anterior lamellar keratoplasty Posterior lamellar keratoplasty Fullthickness Penetrating keratoplasty
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- 5. OPTICAL KP Ahealthy, clear donor cornea is used to replace an opaque, cloudy, or distorted cornea in an attempt to improve vision INDICATIONS: Scar due to ulcer, trauma Degenerations and dystrophies Chemical injuries Pseudophakic bullous keratopathy Keratoconus Congenital opacities
- 6. THERAPEUTIC KP Keratoplastythat is performed to remove infected corneal tissue that has failed medical treatment. Not for only vision improvement Viral, bacterial, and fungal corneal ulcer
- 7. TECTONIC KP Torestore structural integrity of the cornea No emphasis is made here for optical outcome. Tissue addition is made in areas of corneal thinning and restoration to near normal surface contour of the cornea is carried out. Indications: Descemetocele Corneal perforation Corneal stromal thinning Post pterygium thinning
- 8. COSMETIC KP Toimprove the appearance of the patient No bearing on the visual outcome. This could also be done in a nonseeing eye. An opaque cornea with a white or blue-gray hue may be disturbing to the patient, who may request PK.
- 9. CONTRAINDICTIONS Dry eye Blepharitis Ectropion, entropion Recurrent occular infection Melting cornea due to connective tissue disorder Herpetic infection Uveitis Uncontrolled glaucoma.
- 10.
- 11. DONOR CORNEA Shouldbe removed within 6 hours of death Donor eye retreival: Enucleation/ Corneal button Donor cornea with normal endothelial cell density and morphology is suitable for transplantation regardless of age. Stored in coordinating eye banks prior to transplantation
- 12. STORAGE To maintainliving viable state for the period between donation and transplantation. Moist chamber storage : 24hrs of storage. McCarey and Kaufman medium:
- 13. CONTRAINDICATIONS Death ofunknown cause Infectious disease Infections Malignancy Neurological disorder Neurodegenerative Corneal disorder and surgery Prion disease Intrinsic eye disease
- 14. Pre operative Goodgeneral and ophthalmic history Careful examination of eyes and ocular adnexa Visual acuity and slit lamp examination IOP evaluation Dilated ophthalmoscopy Investigation : Refraction,Tear film status,pachymetry,specular microscopy,ultrasound biomicroscopy.
- 15. ANAESTHESIA Local orgeneral anesthesia Local anesthesia-Peribulbar or retrobulbar anesthesia. Long acting anesthetic agent like bupivacaine alone or combinations of bupivacaine with lidocaine should be used
- 16. PENETRATING KERATOPLASTY Transplantprocedure in which full thickness post corneal tissue is replaced with donor corneal tissue. Preoperative preparation- preoperative antibiotics,IOP control,lens management
- 17. INDICATION Keratoconus Failed graft Pseudophakic cornealedema Corneal scarring Aphakic corneal edema Herpes simplex keratopathy Trauma Infections Stromal dystrophies
- 18. SURGICAL TECHNIQUE Graftmaybe sutured with either interrupted or continuous suture technique or combination of both Painting and draping Insertion of lid speculum Placement of scleral fixation ring
- 19. Trephining of donorcornea Should always precede that of host cornea Measure the lesion size Trephined with endothelial side facing up using sharp disposable blade in a guillotine punch block apparatus Well cut, round donor button with perpendicular edges and little trauma to the endothelium Donor button is usually about 0.25 mm larger in diameter then post site.either mechanically guided manual or automated trephination is used Ideal size 7.5mm
- 21. Trephining of recipientcornea Globe is well fixed. trephine is placed vertically over the cornea Excision of corneal button using corneoscleral scissor.
- 22. Anterior chamberis filled with viscoelastic . Donor corneal tissue is gently grasped with fine toothed forceps at the junction of epithelium and stroma and transferred on to receipient bed
- 23. Suturing First foursuture known as cardinal suture are most crucial in orienting the graft evenly in bed. First suture placed at 12 o’clock followed by 6 o’ clock and then 3 o’clock and 9 o’ clock Subsequent suturing consist of placement of 12 or more interrupted suture,4 or 8 interrupted and running suture or double running suture with removal of initial four suture 10-0 NYLON suture should be used Each bite approximately 1mm long in the donor and 1.5mm long in recipient site
- 24. Suture endsare trimmed and knots are tied AC is deepened with BSS and wound margins checked for any leakage. Exposed knots are a well known source of irritation and giant papillary conjunctivitis.
- 25. INTERRUPTED SUTURE Advantages: In children Visualized cornea Cornea with uneven thickness Cornea with localized area of inflammation Less difficulty in placement or removal Disadvantages : more inflammation more vascularization
- 26. CONTINUOUS SUTURE Advantages lessinflammation Better wound healing Even tension Disadvantages Difficult technique Not removed selectively
- 28. POSTOPERATIVE MANAGEMENT Antibioticshould be given preoperatively,intraoperatively and postoperatively to prevent wound contamination and to treat microbial inoculation at the time of surgery 0.5% moxifloxacin or 0.3% gatifloxacin given. Fortified eye drops given in penetrating keratoplasty when done for uncontrolled infectious keratitis. Topical steroids(1% prednisolone acetate or 0.1% dexamethasone phosphate are used to decrease the risk of immunological graft rejection.
- 29. Immunosuppressant suchas oral azathioprine and topical and systemic ciclosporin are usually reserved for high risk patients. Cycloplegics Monitoring of IOP Removal of suture is performed when graft host junction has healed.usually done after 12-18 months.
- 30. COMPLICATION INTRAOPERATIVE : Pooranaesthesia and positive vitreous pressure Improper trephination Damaged donor button Inversion of graft Excessive bleeding
- 31. Cont.. Injury to iris– lens diaphragm Loose or Tight suture Shallow anterior chamber Wound leak Suprachoroidal haemorrhage
- 32. Lamellar Keratoplasty Anterior lamellar Superficial ALK (SALK) MidALK(MALK) Deep ALK (DALK) Posterior lamellar Deep Lamellar Endothelial Keratoplasty (DLEK) Descemet’s stripping Automated endo thelial keratoplasty (DSAEK/DSEK) Descemet’s membrane endo thelial keratoplasty (DMEK) PreDescemet’s membrane endo thelial keratoplasty (PDEK)
- 34. ANTERIOR LAMELLAR KERATOPLASTY Removaland replacement of deformed or diseased anterior corneal tissue ( epithelium, Bowman’s layer, and stroma) Sparing the host Descemet’s membrane and endothelium Indications- Opacification of the superficial one-third of the corneal stroma. Marginal corneal thinning or infiltration as in recurrent pterygium, marginal degeneration Localized thinning or descemetocele formation Keratoconus
- 35. POSTERIOR LAMELLAR KERATOPLASTY: Diseasedcorneal endothelium is replaced. Maintains structural integrity. Less Rejection 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. Indications: Pseudophakic bullous keratopathy Endothelial dystrophy
- 37. COMPLICATIONS OF KP EARLY POSTOPERATIVE COMPLICATION Shallow anterior chamber and wound leak Wound dehiscence Epithelial defect Hypaema Raised IOP and pupillary block glaucoma Endophthalmitis
- 38. LATE POSTOPERATIVECOMPLICATION Graft rejection Infectious crystalline keratopathy Urrets-Zavalia syndrome Corneal membrane Fibrous ingrowth Cataract Astigmatism Glaucoma