Sathish SrinivasanSathish SrinivasanUniversity Hospital AyrUniversity Hospital Ayr

Ayr, Scotland Ayr, Scotland

Past, Present, FuturePast, Present, FutureHistory of corneal History of corneal transplantationtransplantation

Track the progress of corneal Track the progress of corneal transplant surgerytransplant surgery..

Recent advancesRecent advances

Erasmus Darwin (1731Erasmus Darwin (1731--1802)1802)• Suggested removal of opaque cornea in 1760.

“Could not a small piece of cornea be cut by a kind of trephine about the size of a thick bristle and would it not heal with a transparent scar. If the scar should heal without losing transparency many blind people might be made to see.”

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1919thth Century: Experimentation and Century: Experimentation and FrustrationFrustration

• 1813: Karl Himly first suggested replacing opaque animal corneas with transparent corneas from other animals.

• It was Franz Riesinger proposed the first corneal xenograft (animal to human).

• This idea attracted several ophthalmologists around the world to perform animal trials.

None of them were achieving any success None of them were achieving any success andand 18311831 they concluded that keratoplasty they concluded that keratoplasty was simplywas simply ““an audacious fantasyan audacious fantasy””..Samuel Bigger Samuel Bigger –– Irish surgeon Irish surgeon –– interested interested in blindness from in blindness from staphylomastaphyloma. . In 1837, held captiveIn 1837, held captive-- Bedouins in Africa, Bedouins in Africa, performed the first PK in animals performed the first PK in animals –– on aon apetpet gazellegazelle with corneal scarring.with corneal scarring.

Promise of the first decade of 19Promise of the first decade of 19thth century century gave way to despair gave way to despair –– transplanted transplanted corneas invariably became infected and corneas invariably became infected and opaque.opaque.But, there was success in other branches But, there was success in other branches of surgery:of surgery: 1846 &18471846 &1847 ether and ether and chloroform was introduced and 2 decades chloroform was introduced and 2 decades laterlater-- ListerLister’’s principles of antiseptic s principles of antiseptic surgery.surgery.Both these improved the prospects of Both these improved the prospects of corneal transplantation.corneal transplantation.

Von Von HippelHippel TrephineTrephine

• Von Hippel reported the first partially successful lamellar graft in 1886.

• Did not believe in endothelium.

• Attributed the failure of xeno transplants to edema and trauma.

• Invented the circular clock work trephine – major advancement in surgery.

• The 19th century was a century of keratoplasty failure.

• Not caused by the lack of ideas of how to replace a dysfunctional cornea but due to the lack of basic science knowledge on infection, immunology, physiology and microsurgical techniques.

Keratoplasty Success and Refinement Keratoplasty Success and Refinement 19001900--19501950

On 7On 7thth Dec 1905 Dec 1905 Eduard Zirm in Eduard Zirm in Olmutz near Prague Olmutz near Prague peformed the first peformed the first successful PK in a successful PK in a human which human which remained clear.remained clear.

EloisElois GlogarGlogar45 yr old farm worker45 yr old farm workerBilateral alkali injuryBilateral alkali injuryDonor: 11yr old boyDonor: 11yr old boyTwo 5 mm donor buttons Two 5 mm donor buttons with von Hippelwith von Hippel’’trephine.trephine.Did bilateral PKDid bilateral PK’’ssOne PK survivedOne PK survivedVision of CF, J16Vision of CF, J16

FilatovFilatov 18751875--19561956Russian OphthalmologistRussian OphthalmologistPerformed thousands of Performed thousands of PKPPKP’’ssUsed an internal spatula to Used an internal spatula to protect internal contents of protect internal contents of the eyethe eyeConceived of cadavaric eye Conceived of cadavaric eye storagestorageGrandfather of eye banking.Grandfather of eye banking.

Eye BankingEye Banking

• Richard Townley Paton founded the world’s first eye bank in New York in 1944.

• Was called the Eye Bank for Sight Restoration.

Ramon Castroviejo 1904Ramon Castroviejo 1904--19871987Born in SpainBorn in SpainMoved to the US in Moved to the US in 19301930Practiced in NYCPracticed in NYCPioneered square Pioneered square PKPK’’ssAppositional suturingAppositional suturingInstrument Instrument developmentdevelopment

Edward Edward MaumeneeMaumenee 19131913--19981998

Developed Developed understanding understanding of the of the immunobiologyimmunobiologyDefined graft Defined graft

rejectionrejection

Current State of the ArtCurrent State of the ArtMicrosurgical Microsurgical techniquestechniques

Understanding of Understanding of Corneal anatomyCorneal anatomy

Ocular PharmacologyOcular Pharmacology

Ocular immunologyOcular immunology

Eye BankingEye Banking

Five Ideal Goals for Corneal Five Ideal Goals for Corneal TransplantationTransplantation

Smooth surface topography without significant Smooth surface topography without significant

change in astigmatismchange in astigmatism

Predictable corneal power Predictable corneal power

Tectonically strong globeTectonically strong globe

Healthy endotheliumHealthy endothelium

Consistently optically pure stromaConsistently optically pure stroma

PK SurgeryPK Surgery

Recipient tissue Recipient tissue removedremoved

Donor tissue sutured Donor tissue sutured into recipientinto recipient

Smooth Surface with only endothelial disease

Full thickness block of tissue removed just to get to the endothelium

Central trephine cutCentral trephine cutmademade

Sutures create anirregular surfacewith astigmatismand blurring

Five Ideal Goals for Corneal Five Ideal Goals for Corneal TransplantationTransplantation

How are we doing with PK?How are we doing with PK?Smooth surface topography without significantSmooth surface topography without significant

change in astigmatism:change in astigmatism: TerribleTerrible

Predictable corneal power:Predictable corneal power: TerribleTerrible

Tectonically Strong Globe:Tectonically Strong Globe: TerribleTerrible

Healthy endothelium:Healthy endothelium: GoodGood

Consistently optically pure stroma:Consistently optically pure stroma: GreatGreat

Current Method of Replacing the Endothelium: Full Thickness P.K.Current Method of Replacing the Endothelium: Full Thickness P.K.

Clear graft, unaided vision: HMClear graft, unaided vision: HMManifest Refraction: Manifest Refraction: --8.00+8.00X70 = 6/68.00+8.00X70 = 6/6

Severe Complications of PK

Endophthalmitis:From retained suture fragment

Expulsive Hemorrhage:Expulsive Hemorrhage:Blunt trauma 5 yrs after PKBlunt trauma 5 yrs after PK

Rebirth of Lamellar SurgeryRebirth of Lamellar Surgery

Anterior Lamellar Surgery Posterior Lamellar Surgery

Anterior Lamellar KeratoplastyAnterior Lamellar Keratoplasty

Superficial Anterior Lamellar Superficial Anterior Lamellar Keratoplasty (SALK)Keratoplasty (SALK)

Deep Anterior Lamellar Keratoplasty Deep Anterior Lamellar Keratoplasty (DALK)(DALK)

DALK

SALK Granular Granular

Lattice Lattice

Lattice

Posterior Lamellar KeratoplastyPosterior Lamellar Keratoplasty

Gerritt Melles 1998Gerritt Melles 1998Developed lamellar dissection Developed lamellar dissection techniquestechniquesIntra corneal trephinesIntra corneal trephinesSucceeded in performing PLKSucceeded in performing PLK

Indications for Post Lamellar Indications for Post Lamellar KeratoplastyKeratoplasty

Fuchs endothelial dystrophyFuchs endothelial dystrophy

Any cause for endothelial failureAny cause for endothelial failure

Failed penetrating keratoplastyFailed penetrating keratoplasty

• Between 1998 and now there has been rapid and tremendous progress in both anterior and posterior lamellar surgery.

• Several new terminologies have been coined.

Corneal SoupCorneal Soup• DALK (Deep Anterior Lamellar Keratoplasty)

• PLK (Posterior Lamellar Keratoplasty)

• DLEK (Deep Lamellar Endothelial Keratoplasty)

• DSEK (Descemet’s Stripping Endothelial Keratoplasty)

• DSAEK (Descemet’s Stripping AutomatedEndothelial Keratoplasty)

• DMEK (Descemet’s Membrane Endothelial Keratoplasty)

PLK/ DLEK SurgeryPLK/ DLEK Surgery

Donor tissue placed into recipient

Scleral incision, deepcorneal pocket, and endothelium trephined

Posterior stromal disc and endothelium removed from pocket

Endothelium replaced with no sutures, supported by air bubble in anterior chamber. Surface remains smooth with no astigmatism

During the same time, on the other side of During the same time, on the other side of the Atlantic, Mark Terry from Portland, the Atlantic, Mark Terry from Portland, Oregon Oregon –– modified and modified and popularisedpopularised the the MellesMelles technique of PLK as:technique of PLK as:

Deep Lamellar Endothelial KeratoplastyDeep Lamellar Endothelial Keratoplasty(DLEK)(DLEK)

DLEK

Video of small incision DLEKVideo of small incision DLEK Early visual rehabilitation with DLEK : Early visual rehabilitation with DLEK : 1 week1 week

MR = MR = --1.25 + 2.00 X 92 = 6/91.25 + 2.00 X 92 = 6/9--11

DLEK REDLEK RE vsvs PK LEPK LE22 months s/p DLEK:months s/p DLEK:

--0.75 + 0.25 X 89 = 6/90.75 + 0.25 X 89 = 6/999 months s/p PK:months s/p PK:

--5.25 + 3.75 X 49 = 6/95.25 + 3.75 X 49 = 6/9Same PatientSame Patient

PK RE PK RE vsvs DLEK LEDLEK LE2 years2 years s/p PK:s/p PK:

--4.25 + 4.75 X 70 = 6/124.25 + 4.75 X 70 = 6/1211 monthmonth s/p DLEK with Phaco:s/p DLEK with Phaco:

--1.00 + 1.50 X 170 = 6/121.00 + 1.50 X 170 = 6/12Same PatientSame Patient

DLEK/ PLK PitfallsDLEK/ PLK PitfallsTechnically very very difficult procedureTechnically very very difficult procedureVery few surgeons took upVery few surgeons took upNever Never ““caught oncaught on””Disc dislocationDisc dislocationEndothelial cell loss and long term survivalEndothelial cell loss and long term survivalReduced BCVA from interface hazeReduced BCVA from interface haze

MellesMelles et al: A technique to excise the et al: A technique to excise the DescemetDescemet membrane from a recipient cornea membrane from a recipient cornea ((DescemetorhexisDescemetorhexis) ) -- Cornea 2004;23:286Cornea 2004;23:286--288288

DSEK : Descemet’s Stripping Endothelial Keratoplasty.

DSAEK: Descemet’s stripping automated endothelial Keratoplasty

DLEK

DSEK/ DSAEK

Video of DSEKVideo of DSEK Moria ALTK SystemMoria ALTK System

Operating microscopeOperating microscope

Day 1

When things go well Day 1 post op – 6/60

1 week: 6/12 1 month: 6/9

Fuchs Endothelial Dystrophy with sub epithelial scarring

Day 1: 6/60 Day 1: 6/60

Day 7: 6/9 Day 7: 6/9

Top Hat PKTop Hat PK““Keratoplasty in two planesKeratoplasty in two planes”” by Jose by Jose BarraquerBarraquer 50 years ago 50 years ago

Described by Described by BusinBusin* from Italy in 2003* from Italy in 2003

Combines the visual outcomes of PKP Combines the visual outcomes of PKP with the woundwith the wound--healing advantage of healing advantage of lamellar keratoplasty.lamellar keratoplasty.

* * BusinBusin M . A new lamellar wound configuration for penetrating M . A new lamellar wound configuration for penetrating keratoplasty surgery. Arch Ophthalmol. 2003;121:260keratoplasty surgery. Arch Ophthalmol. 2003;121:260--265265

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Busin, M. Arch Ophthalmol 2003;121:260-265.

Top Hat ConfigurationTop Hat Configuration

Results : Clinical AppearanceResults : Clinical Appearance

Where are we todayWhere are we today

• PK is no more the gold standard.

• Selective lamellar transplantation – based on the level of pathology.

• Field of selective endothelial transplantation is rapidly becoming popular and is being constantly refined.

• Where next ………..

Graft Rejection Graft Rejection EndothelialEndothelial Cell LossCell Loss

The Future of corneal transplantsThe Future of corneal transplantsFemtosecond laser assisted Femtosecond laser assisted

corneal transplantation corneal transplantation

Femtosecond laserFemtosecond laser

Femtosecond laserFemtosecond laser1053 nm (near infrared)1053 nm (near infrared)

Each pulse of focused laser light lasts Each pulse of focused laser light lasts approximately 10approximately 10--1515 seconds seconds (500(500--800 800 femtoseconds)femtoseconds) • In one second, light travels 7.5

times around the globe• In 100 femtoseconds, light

travels across a human hair• Power = Energy/Time,

extremely high power attained at relatively low energy

EXITHELP MAIN MENU

FS laserFS laserSurgical effect is achieved through Surgical effect is achieved through ““PhotodisruptionPhotodisruption””

No thermal or shock wave transmission to No thermal or shock wave transmission to surrounding tissuessurrounding tissues

Pulses Pulses focused to focused to precise precise locations (locations (±± 5 5 microns) microns) Optical Optical delivery system delivery system place place pulses next to pulses next to each other creating flaps, incisions, lamellar each other creating flaps, incisions, lamellar resections, keratectomy resections, keratectomy

EXITHELP MAIN MENU

Optical Delivery SystemOptical Delivery System

Laser is set to desired Laser is set to desired depthdepth

Defined distance from Defined distance from bottom of glass applanation bottom of glass applanation surface surface

Pulses delivered in a Pulses delivered in a prescribed pattern creating a prescribed pattern creating a horizontal or vertical horizontal or vertical cleavage plane in the cornea cleavage plane in the cornea

EXITHELP MAIN MENU

PhotodisruptionPhotodisruptionPhotodisruption

A pulse of laser energy is focused to a precise location inside the cornea

A microplasma is created, vaporizing approximately 1 micron of corneal tissue

1 Micron

EXITHELP MAIN MENU

PhotodisruptionPhotodisruptionPhotodisruption

An expanding bubble of gas & water is createdseparating the corneal lamellae

5 to 12 Microns

EXITHELP MAIN MENU

PhotodisruptionPhotodisruptionPhotodisruption

The bi-products of photodisruption (CO2 & water) are absorbed by the mechanism of the endothelial

pump, leaving a resection plane in the cornea

EXITHELP MAIN MENU

PhotodisruptionPhotodisruptionPhotodisruption

Thousands of laser pulses are connected together in a raster pattern to define a resection plane

EXITHELP MAIN MENU

PhotodisruptionPhotodisruptionPhotodisruption

Gas & water are absorbed or liberated when corneal flap is lifted

A resection plane is created

EXITHELP MAIN MENU

PhotodisruptionPhotodisruptionPhotodisruption

Laser pulses can be stacked on each other to create a vertical cleavage plane

EXITHELP MAIN MENU

Control PanelControl Panel

MicroscopeMicroscope

Laser Aperture& Loading DeckLaser Aperture& Loading Deck

Display Panel & Keyboard

Display Panel & Keyboard

Emergency Shut Off

Emergency Shut Off

BeamDeliveryDevice

BeamDeliveryDevice

Power &Accessories

Power &Accessories

Key SwitchDisk DrivesKey SwitchDisk Drives

LaserConsoleLaser

Console

JoystickJoystick

Allowed Cut PatternsAllowed Cut Patterns

Lamellar Cut Posterior Side Cut

Anterior Side Cut Full

Thickness

Ring Cut

The IntraLase FS Laser has received FDA clearance to perform a wide variety of corneal cuts

Top HatTop Hat

Zig ZagZig Zag MushroomMushroom

SALK

DALK

DSAEK

Top hat PK

2007

DLEK-2002

DSEK / DSAEK-2004

Femtosecond laser assisted PK

1905

7th Dec1944, Eye Bank

PLK -1998