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Penetrating keratoplasty by pushkar dhir

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.

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Venu Corneal Department
• Presenter Pushkar Dhir • Moderator Dr. Ashish
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)
PKP 500µ + PLK 250µ DSEK 180μ
PK TYPES OPTICAL TECTONIC THERAPEUTIC COSMETIC
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
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.
Types of keratoplasty • Donor tissue Autograft Allograft Xenograft Autorotational graft
Advanced Dry eye Anterior staphyloma Severe cases of SJ syndrome RD
• Grade 4 chemical burns • Ocular cicatrical pemphigoid with no tear film • Bad ocular surface • Multiple graft failure
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
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)
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
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
Slit Lamp Examination  Microcystic oedema  Epithelial Abrasions  Stromal oedema  Descemet’s fold  Breaks in Descemet’s membrane What Mr.Balram trying to find out!!??
Procedure for PK Preoperative preparation Anesthesia Surgical preparation Trephination of Donor cornea Trephination of Recipient cornea Suturing of Donor cornea Post operative treatment
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
• 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
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
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
ENDOTHELIAL PUNCH SYSTEM Sharp vertical cut More accurate centration Endothelial side up
• Hessberg Barron Vaccum trephine • Less AC collapse & distortion • Sharper, deeper & more perpendicular cut
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
Trephination of Recipient Cornea • Trephination done either by hand held, suction & automated trephines Marking cornea
DIFFERENT TYPES OF FLAP WHICH CAN BE MADE Top Hat Shape •Provides large endothelial surface transplantation
ZIG-ZAG SHAPE Hermetic wound seal Angled edge provides smooth transition between host and donor
Mushroom Shape Preserves more host endothelium •
Recipient dissection
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.
Interrupted corneal sutures (10/0 nylon)
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
Single continuos sutures
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
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.
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
Post op visits • Final spectacles prescribed after 24 months when sutures have been removed & refraction & corneal curvature stabilised • Contact lens fitting
• 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
Penetrating keratoplasty by pushkar dhir