Eye specialist Mr James Ball on the questions to ask
We asked James Ball, consultant ophthalmic surgeon at St James’s University Hospital Leeds, what he would want to know about corneal transplantation.
How common are corneal transplant operations?
In 2006 more than 2,500 corneal transplants were performed in the UK.
What should I ask the surgeon?
It’s a good idea to find out how many corneal transplants the surgeon performs a year. In an ideal situation, it should be 25 or more.
Are corneal transplants the same for all patients?
Fifteen years ago, all corneal transplants were ‘full thickness’ transplants. Today, due to advances in technique and knowledge, a corneal transplant has become tissue-specific for most patients. This means that only the diseased part of the cornea is replaced, and the patient keeps as much of their own cornea as possible.
Will I have to wait a long time before I have an operation?
There isn’t always a ready supply of corneas in the right condition. This can result in a delay before surgery can be performed. This is why it’s important that as many people as possible register as organ donors.
Will I have much warning before my corneal transplant?
Patients often have as much as four weeks notice before their operation is carried out. Once a cornea has been harvested from a donor, it’s sent to the National Eye Bank for three to four weeks where it’s rigorously tested to ensure that it’s healthy and suitable for transplant.
Is there a difference between a corneal transplant for older and younger patients?
No. However, the eye bank tries to match the donor corneas according to age so that younger patients receive transplants from younger donors.
Patients from different age groups tend to need corneal transplants for different reasons. The most common reason for a young person to need a corneal transplant is a condition called keratoconus. The most common reason for an elderly patient to need a corneal transplant is endothelial failure. Both of these conditions can be treated with a full thickness corneal transplant (penetrating keratoplasty).
However, many corneal surgeons would now treat keratoconus with a lamellar transplant (DALK) – a partial thickness cornea transplant, and endothelial failure with endothelial replacement (DSEK) – a new partial thickness procedure in which only the lining of the cornea is replaced.
What are the risks of corneal transplant?
- With any eye surgery there’s a small risk of infection inside the eye – although this occurs in less than 1 in 1,000 patients. If infection inside the eye does occur, there’s a risk of losing all of the sight in that eye.
- Rejection of the donor tissue is also a risk, but this is relatively common. As long as it’s caught in time, it can be stopped.
How often will I have to have a check-up following the transplant?
Follow-up after a full thickness transplant is a big commitment. After surgery, a patient needs to return for at least six follow-up visits each year for the first two years. They must be aware that there’s a lifelong risk of corneal transplant rejection. Eye drops reduce the risk of infection and rejection. They have to be applied daily for at least six to nine months and possibly longer.
A cornea transplant is an operation to remove all or part of a damaged cornea and replace it with healthy donor tissue.
A cornea transplant is often referred to as keratoplasty or a corneal graft. It can be used to improve sight, relieve pain and treat severe infection or damage.
One of the most common reasons for a cornea transplant is a condition called keratoconus, which causes the cornea to change shape.
Read more about why you might need a cornea transplant.
What is the cornea and what does it do?
The cornea is the clear outer layer at the front of the eyeball. It acts as a window to the eye. The coloured iris and the pupil (the black dot in the centre of the iris) can be seen through the cornea.
The cornea helps to focus light rays on to the retina (the light-sensitive film at the back of the eye). This “picture” is then transmitted to the brain.
When the cornea is damaged, it can become less transparent or its shape can change. This can prevent light reaching the retina and causes the picture transmitted to the brain to be distorted or unclear.
How is a transplant carried out?
The type of cornea transplant you have will depend on which part of the cornea is damaged or how much of the cornea needs replacing. The options include:
- penetrating keratoplasty (PK) – a full-thickness transplant
- deep anterior lamellar keratoplasty (DALK) – replacing or reshaping the outer and middle (front) layers of the cornea
- endothelial keratoplasty (EK) – replacing the deeper (back) layers of the cornea
A cornea transplant can be carried out under general anaesthetic (where you are unconscious) or local anaesthetic (where the area is numbed and you’re awake). The procedure usually takes less than an hour and, depending on your circumstances, you either leave hospital the same day or stay overnight.
If the procedure involves the transplantation of the outer cornea, the new outer cornea is held in place with stitches, which usually stay in for more than 12 months.
An endothelial transplant (EK) doesn’t require stitches. It’s held in place by an air bubble until a few days later, when it naturally sticks to the deep layer of the cornea.
In most cases, a cornea transplant procedure lasts less than an hour.
Read more about how cornea transplants are performed.
Are there any risks?
As with all types of surgery, there is a risk of complications resulting from a cornea transplant. These can include the new cornea being rejected by the body, infection and further vision problems.
Around 95% of full-thickness (penetrating) cornea transplants in low-risk conditions, such as keratoconus, last at least 10 years.
Read more about the risks of a cornea transplant.
After a cornea transplant
The recovery time for a cornea transplant depends on the type of transplant you have. It takes about 18 months to enjoy the final results of a full-thickness transplant, although it’s usually possible to provide glasses or a contact lens much earlier.
Recovery is usually faster after replacing just the outer and middle layers (DALK). Endothelial transplants (EK) tend to have a faster recovery time of months or even weeks.
It’s important to take good care of your eye to improve your chances of a good recovery. This means not rubbing your eye and avoiding activities such as contact sports and swimming until you’re told it’s safe.
Read more about recovering from a cornea transplant.
When cornea transplants are needed
Cornea transplants are usually performed to correct problems with your eyesight caused by certain medical conditions.
They are also sometimes used to relieve pain in a damaged or diseased eye, or to treat emergencies such as severe infection or damage.
Some of the most common reasons for requiring a cornea transplant are described below.
Keratoconus is a condition that causes the cornea to weaken, get thinner and change shape. It affects between 1 in 3,000 to 1 in 10,000 people. The exact cause of the condition is unknown. There may be a genetic link, and it’s more common in people with multiple allergic conditions, such as eczema and asthma.
Keratoconus is one of the most common reasons for corneal transplantation in younger patients. It doesn’t usually appear until the early teens, but can occasionally occur earlier.
Many cases of keratoconus are mild and can be managed by using contact lenses or glasses. But in some patients it can progress to the point where a cornea transplant is necessary.
Certain conditions may affect the eyes and cause them to slowly develop problems over time.
One example is Fuchs’ endothelial dystrophy, where the functioning of the cells lining the inner cornea (the endothelium) begins to deteriorate. This happens faster as you get older. As the cells weaken, instead of clearing excess fluid, they allow it to build up, leading to cloudy vision.
A cornea transplant may also be performed if:
- a small hole develops in the cornea as a result of damage (known as corneal perforation)
- an infection in the cornea doesn’t respond to antibiotics and keeps returning
- the cornea is scarred because of an infection or injury
Read more about how a cornea transplant is performed.
How cornea transplants are performed
The type of cornea transplant you’ll be offered will depend on the parts of the cornea that need to be replaced.
Most cornea transplant operations involve transplanting the full thickness of the cornea. However, recent advances in technology mean it’s sometimes possible to only transplant part of the cornea.
A full-thickness transplant is called a penetrating keratoplasty (PK). During this procedure, a circular piece of damaged cornea from the centre of your eye is removed and replaced with the donated cornea. In most cases, a circular cutting instrument (similar to a cookie cutter) called a trephine is used to remove the damaged cornea.
The new cornea is held in place by tiny stitches, which sometimes form a star-like pattern around the edges. You may be able to see the stitches faintly after the operation.
The operation may be done under local anaesthetic or general anaesthetic, and usually takes about 45 minutes. If local anaesthetic is used, you won’t be able to see through the eye during the operation as the anaesthetic temporarily stops the eye working.
Most people have to stay in hospital for one night after a full-thickness cornea transplant.
Recently, techniques have been developed that allow only parts of the cornea to be transplanted. These techniques aren’t suitable for everyone in need of a cornea transplant and they can take longer to perform, but they often have a faster recovery time and a lower risk of complications.
There are several different techniques your surgeon may use, depending on which layers of the cornea are transplanted. Generally, these techniques can be broken down into transplants involving the front portion of the cornea and those involving the back portion.
Most of these procedures are carried out using cutting instruments, such as a trephine, although lasers are sometimes used. These procedures can be carried out using either local or general anaesthetic, and you may be able to go home on the same day of the procedure.
Transplanting the front portion of the cornea
The main techniques for transplanting the front parts of the cornea include:
- anterior lamellar keratoplasty (ALK) – removing and replacing only the outer (front) layers of the cornea
- deep anterior lamellar keratoplasty (DALK) – removing and replacing the outer and middle layers of the cornea, leaving the inner (back) layers intact
As with a penetrating keratoplasty, stitches are used to fix the donated cornea in place during both of these procedures.
Transplanting the back portion of the cornea
The main techniques for transplanting the back parts of the cornea include:
- Descemet’s stripping endothelial keratoplasty (DSEK) – replacing the inner lining of the cornea together with about 20% of the corneal supporting tissue (corneal stroma)
- Descemet’s membrane endothelial keratoplasty (DMEK) – replacing only the inner layer of cells of the cornea
These techniques allow faster visual recovery and have a lower risk of complications.
Stitches aren’t used during either of these procedures. Instead, the donated tissue is held in place using a temporary air bubble.
Risks of a cornea transplant
As with all types of surgery, there are several risks and possible complications involved with having a cornea transplant.
Some problems are obvious soon after surgery and need emergency treatment. Others may be spotted during follow-up appointments.
Rejection happens when your immune system recognises the donated cornea as not belonging to you and attacks it. It’s quite a common problem, with symptoms of rejection occurring in about one in five full-thickness corneal transplants, although only about 5% of low-risk grafts actually fail because of this. Serious rejection is rare after deep anterior lamellar keratoplasty (DALK).
Rejection can occur a few weeks after a cornea transplant, but it’s more common after several months. The problem can often be treated effectively with steroid eye drops if treatment begins as soon as you notice symptoms.
You should seek emergency specialist advice if you notice the symptoms listed below after having a cornea transplant:
- red eye
- sensitivity to light (photophobia)
- vision problems – particularly foggy or clouded vision
- eye pain
As well as rejection, there is a risk of further problems after cornea transplant surgery. These can include:
- astigmatism – where the cornea is not a perfectly curved shape
- glaucoma – where pressure builds up in the eye as a result of trapped fluid
- uveitis – inflammation of the middle layer of the eye
- retinal detachment – where the thin lining at the back of your eye called the retina begins to pull away from the blood vessels that supply it with oxygen and nutrients
- the original eye disease (such as keratoconus) returning
- wounds from surgery reopening
- internal infection as a result of surgery wounds
After cornea transplant surgery
It’s important to take good care of your eye after a cornea transplant to help ensure a good recovery and reduce the risk of complications.
After the procedure
Most people have to stay in hospital for one night after a full-thickness cornea transplant (penetrating keratoplasty). You may be able to go home the same day if you have a partial-thickness transplant.
Your eye may be covered with an eye pad or plastic shield, which is removed the day after the procedure. When it’s taken away, you may find that your sight is blurred. This is normal.
There shouldn’t be serious pain after the operation, but there might be some swelling and discomfort.
If you’ve had an endothelial keratoplasty – a type of partial-thickness transplant that uses an air bubble to hold the donated cornea in place – you may be asked to lie on your back as much as possible in the first few days after surgery. This can help hold the transplant in the correct place. The air bubble will be absorbed after a few days.
Looking after your eye
Once you return home after the procedure, you’ll need to take good care of your eye. Some important points to remember include:
- don’t rub your eyes
- during the first weeks after surgery, avoid strenuous exercise and heavy lifting
- if you have a job that does not involve physical strain, you can return to work two to three weeks after surgery
- if your job involves manual labour, you should wait for three to four months
- avoid smoky or dusty places as this could irritate your eyes
- if your eye is sensitive to light, wearing sunglasses can help
- avoid contact sports and swimming until you’re given clear advice that it’s safe, and wear protective goggles when resuming contact sports
- bath and shower as normal, but be careful not to get water in your eye for at least a month
- don’t drive until your specialist tells you it’s possible
You’ll usually be given a patch to wear at night for the first few weeks after surgery to help protect your eye.
For all types of cornea transplant, you have to use steroid or antibiotic eye drops daily. These are normally required for several months, although some people may need to use them for more than a year. The drops reduce swelling and inflammation and help prevent infection and rejection.
At first you’ll need to attend regular follow-up appointments. These should gradually become less frequent over time.
If stitches were used to hold the transplant in place, these are initially left in place to allow the cornea to heal. They are usually removed after about a year.
The time it takes for your vision to return after a cornea transplant can range from as little as a few weeks up to a year or more. This largely depends on the specific procedure used. In some cases, your vision may fluctuate between being better or worse before it settles down.
It’s likely you’ll need corrective lenses (either glasses or contact lenses), even after your vision returns. In some cases, a small operation called arcuate keratotomy (AK) or laser treatment is used to correct vision problems after your eyes have healed.
‘It was fantastic being able to see again. It was magical’
Paul Rigg says getting his sight back after a cornea transplant was like waking up after a long sleep.
“Sight is one of the things we take for granted. It’s only when you lose it that you appreciate just how precious it is,” says Paul, from Garstang in Lancashire.
He lost the sight in his right eye after he was involved in a crash driving home from work. Paul received head, spine and stomach injuries, and shards of windscreen glass pierced his right eye. Although there was no damage to his left eye, the sight in his right eye was lost because surgeons had to remove the lens.
“With only one eye you are not able to judge distances. Walking down the street I would bump into people because I could only see from one side,” he says.
One of the biggest blows for Paul was no longer being able to play golf, and he was so upset he sold his clubs. But the possibility of a cornea transplant was raised and the operation was eventually carried out at the Royal Preston Hospital.
He had a stitch round his eye for a year, but when it was taken out he regained a degree of vision. “It was fantastic being able to see again. It really was magical,” he says.
Paul does have some double vision and is unable to read print with his right eye, but efforts are being made to improve his sight with glasses and he’s hoping to get back on the golf course soon.
‘When the stitches came out it was an absolute miracle’
Don Short, 80, from East Sussex, couldn’t read a book or newspaper and was unable to watch TV until he had a cornea graft.
“I was conscious that my eyesight was deteriorating. About five years ago I stopped driving at night,” says Don.
Despite a cataract operation, his eyesight continued to get worse. “I couldn’t read or watch TV. I could hardly recognise anyone in the street. It was a miserable time. I went to do my Christmas shopping but it was a waste of time. I couldn’t see things in the shop windows and I couldn’t read the price tags.”
Eventually Don had a cornea graft at East Grinstead’s Queen Victoria Hospital. “When the stitches came out, it was an absolute miracle. I could read and watch TV. It’s difficult to explain what a difference it made to my life because I’ve always enjoyed reading. It was tremendous.”
Don has since had a cornea graft in the other eye, which he hopes will further improve his sight. “I cannot thank the donors and their relatives enough. Their gift has given me back my sight and transformed my life.
“I’m told that many people are reluctant to allow their eyes to be used for transplantation after their death. If only they realised what a marvellous gift it is to give someone and how it can change people’s lives.”