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ARTICLE
Year : 1961  |  Volume : 9  |  Issue : 3  |  Page : 43-50

Keratoplasty-recent experiences


M.G.M. Medical College and M.Y. Hospital, Indore, India

Date of Web Publication7-Apr-2008

Correspondence Address:
R P Dhanda
M.G.M. Medical College and M.Y. Hospital, Indore
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Dhanda R P. Keratoplasty-recent experiences. Indian J Ophthalmol 1961;9:43-50

How to cite this URL:
Dhanda R P. Keratoplasty-recent experiences. Indian J Ophthalmol [serial online] 1961 [cited 2021 Mar 6];9:43-50. Available from: https://www.ijo.in/text.asp?1961/9/3/43/40272

Table 1

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Table 1

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One of every 200 people is pre­sumably blind in this country, and it will probably be agreed that ex­cluding cataracts, corneal diseases should account for more than half the incidence of blindness and this therefore is and has always been a national problem.

Corneal grafting had been con­ceived as a possibility long before the first successful grafting was reported by Zirm (1906). Reisinger (1824), Marcus (1841), Powers (1872), Von Hippel (1877), Fuchs (1894) were among those whose trials and newer conceptions kept corneal surgery as a live possibility through those days when surgery had not yet stood on its own legs. It 'was Elschning (1908) who first started keratoplasty and Filatov (1913) soon joined him and both laid the solid foundation to the present suc­cesses. But the credit of taking keratoplasty out of experimental stages goes to Castroviejo who among the living corneal surgeons is still improving upon techniques from time to time ever since 1931, so that corneal surgery now carries with it more success than failures. Attempts at scientific and regular corneal surgery in India have un­fortunately been too few in midst of this vast sea of blindness. Modi (1958) reported o cases of penetrat­ing keratoplasty but with unexplain­able passiveness. Practice of acro­batics in eye surgery like the graft­ing without stitches with unseen failures not only provides an amus­ing material but would in the long run dishearten even the optimists and the brave. Corneal surgery needs a positive approach and not an ostrich policy. If "taking of the graft" is the only criterion, suc­cesses of grafting will be more than 100% What has been probably lacking in such approach is the want of basic concepts and I would therefore first of all emphasise on some of these.

Nutrition of the cornea is mainly by diffusion from the Timbal vessels through lymphatics and getting into the corneal tissue through inter­lamellar spaces. If this is true, func­tional and nutritional viability of the surrounding tissue in which a graft is placed is highly important for maintaining the transparency of the graft. That is why a donor graft should be surrounded by a healthy transparent cornea at least along more than half its circumference if the graft is to receive adequate nourishment and remain healthy and transparent. If on the other hand a graft is placed in a ring of densely opaque and nutritiously dead cornea with scarring having blocked the channels of nutrition, the graft surrounded by such cor­nea may too become opaque and die of starvation. This further ex­plains the importance of direct cornea to cornea stitching of the graft because microscopic distur­bance between the edges of the recipient and donor cornea would not permit formation of adequate nutrition channels and would there­fore jeopardise the transparency of the graft.

Another important fact to appre­ciate is that the single cell posterior endothelial layer of the cornea is the most vital layer for the viability of the corneal tissue. Although not clearly understood, the endothelium of the cornea is the first tissue to die after extinction of life and that explains that graft from an eye re­moved more than 6-8 hours after death or stored more than 4-6 days even far below the ice temperature develops an endothelial oedema and is not likely to remain clear if grafted to a recipient. It also ex­plains the larger incidence of suc­cesses in lamellar keratoplasty where endothelium does not form a part of the donor material in con­trast with the penetrating kerato­plasty where the whole thickness of the corneal tissue including the endothelium is grafted as donor material.


  Donor Material Top


The present position continues that only a fresh donor material can be successfully used for pene­trating keratoplasty. But the outlook to lamellar keratoplasty has defi­nitely improved with the successes in the methods of preservation of the eyes and corneas even for 18 months to 2 years after removal.

At present there are three established methods of preserva­tions of donor materials.

1. Deep freeze refrigeration of the eye ball as a whole at-79° C temperature which can only be created in a block of Carbondioxide snow, a method being practised at the Banting Institute at Toronto.

2. Lyo-philisation and dehydra­tion of cornea in vaccum as prac­tised in Lyons by Paufique.

3. Corneas with a rim of sclera preserved in glycerine under con­ditions of perfect vaccum are being supplied from the Ocular Research Unit at Washington Hospital Centre.

The only source at present of the donor material in this country is from the unclaimed bodies. While visiting the corneal surgeons in U.S.A. and Canada last year, the one question asked by everyone was, "How will you get donor material in a country like India be­cause of the deep religious pre­judices of Indians". I am however much more luckily placed because in the first nine months of the Regional Eye-Bank at Indore, as many as 73 eyes became available as donor material. I owe it to the active co-operation of the other departments, my 22 years associa­tion with the institution and the ceaseless efforts of my colleagues. I think it should be possible every­where.

This source of donor material is however going to dwindle with economic progress, deminishing illiteracy and the growing legal psychology of the public. It is im­perative therefore that with distant future in mind a campaign for donation of eyes should be spon­sored through publicity and through the non-official agencies like the Red Cross, the Lion's club and other social organisations.


  Indications of Keratoplasty Top


To a corneal surgeon in the West, the commonest indications for keratoplasty are :­

1. Conical cornea.

2. Corneal dystrophy.

3. Interstitial keratitis.

4. Therapeutic indication like Herpetic keratitis.

But to us the problem is radically different. If an Indian Ophthal­mologist looks through the eyes of his counterpart in the West no wonder a common statement is made that in India one hardly comes across a suitable recipient. True if we adopt and not adapt. Our problem is Trachoma, its se­quelae and complications resulting in ulcers and opacities which not in­frequently cover the whole cornea, quite often have perforated and are accompanied by anterior synechia. These have always been the bug­bear to any prospective entrant in the realm of keratoplasty while the experienced ones have taken shelter under this pretext. Trachoma and anterior synechia are certainly matters for consideration but not contraindication and one of the major purposes of this talk is to con­vince you that the approach in our circumstances has to be conditioned to this altered etiology and pathology.

Out of the first 122 cases referred to this unit for suitability of corneal surgery, 60 (50%) had Trachoma. Again out of another 50 cases of corneal opacity considered suitable for keratoplasty in an Eye-Camp 34 (68%) had Trachoma. So that from whichever angle you approach the problem, you cannot escape this bugbear.

The problem of anterior synechia, the leucoma adherens, is again something which we cannot bypass if corneal surgery is to contribute towards alleviation of blindness in this country. In the series of 40 cases on which keratoplasty was actually performed, 17 had an anterior synechia, of some size vary­ing from a small tag to extensive adhesions and 19 had established Trachoma including 4 with com­plications.


  Choice of Surgery Top


Having to start corneal surgery in 1960 and specially after a visit to most of the important corneal surgeons in United States and Canada, with encouragement in the matter of bate surgical necessities and an. enthusiastic colleague, we adopted the technique of present day surgery of direct cornea to cornea stitching. Of the 52 cases of corneal operations we have performed, 29 penetrating keratoplasties varying from 6.5-9 mm. in size and 14 lameilars from 7-11 mm. in diameter, and 8 keratectomies. The suturing materi­al used was 7-0 silk and depend­ing upon the size of the graft we applied from 14--22 interrupted stitches in cases of penetrating and 12-16 in cases of lamellars. The whole purpose of direct stitching in present day corneal surgery and probably the only sound way to successful keratoplasty is to make the anterior chamber a tight com­partment. In spite of this close stitching it was not always easy to inject and retain enough air in anterior chamber. In three cases penetrating keratoplasty was done twice on. the same eye and of these two did very well indeed. In one case I faced an interesting situa­tion. When doing a keratectomy with no donor eye at hand, the cornea was inadvertantly perforat­ed. A penetrating keratoplasty with preserved cornea I had bro­ught from Washington, was com­pleted. Even though this preserv­ed cornea showed definite signs of clearance at first dressing, the graft was replaced by a fresh one 24 hours after the first surgery and this case did very well indeed.

Of the 14 lamellars, three were preparatory to penetrating surgery, three were therapeutic lamellar for trachomatous panes and the other eight being the regular lamellars. Eight pro-operative and two post-operative peritomies were done in cases of marked vascularisation of the cornea either before or at the time of surgery.

The following table is a summary of the results of the first 47 cases of corneal surgery.

Our best visual result in penetrat­ing was with correction, 6/9p 6/6p in a girl aged 11 years and in lamellar 6/24 in a case of complicat­ed Trachoma

Although it is suggested that keratoplasty should not be under­taken under the age of 14 years (Paton), we have operated on nine children below this age, the young­est being a girl of 4 years, and among our best results are in these.


  Post-Operative Complications Top


During this early phase of our corneal surgery life we have faced complications as every corneal surgeon would even after long ex­periences. The uncertain elements in this surgery might dampen the enthusiasm but should not lead to dejection. Unlike our counter parts in West our cases were not and could not be ideal from their point of view.

1. Anterior synechia and iris prolapse. With the direct con neo-corneal stitching one mm. apart, chances of iris prolapse are very few. We had to excise iris knobs in two cases in the early stages but with improvements in stitching technique we did not face this complication any longer. How­ever isolated anterior synechia with the posterior corneo-corneal groove are more frequent in cases where keratoplasty was performed in leucoma with extensive anterior s7nechias and this was responsible for loss of one eye due to second­ary glaucoma and resulted in opacification of graft in another three cases.

2. Falling off of stitches. Too small a bite of corneal tissue while stitching and restlessness on the part of the patient would be responsible for this and in our early series there were cases when betwe­en the 14th to 21st day after sur­gery there were hardly any stitch­es to be removed. Since we have started keeping both eyes bandag­ed for one week after surgery we have a pleasent experience that most of the stitches are in place even up to the 21st day and they are removed any time during the week after this. Slight displace­ment of the graft forward due to early falling out of stitches in 3 cases could be controlled by tight pressure bandage.

3. Vascularisation of graft. In view of the extensive association of Trachoma with corneal disease in this country, it is surprising how few of our grafts were invaded by neo-vascularisation. Most of the blood vessels come up to the graft margin and stop short at that. How­ever in a case of chemical burns due to ammonia, the vascularisation of the graft was so extensive as to result in complete opacification. It is reported that a case of ammonia burn is yet to have a successful keratoplasty.

4. Ulceration. Superficial epithe­lial ulceration of the graft was faced in four cases, two penetrating and two lamellar. The ulcers are extremely resistant to treatment pro­bably because the sensory nerve supply of the graft does not regene­rate for months after surgery or due to some trophic tissue changes. Ulceration was responsible for opa­cification of grafts in all the four cases and in one case of lamellar keratoplasty even a re-grafting was followed by ulceration and opacifi­cation.

5. Oedema and opacification. Uncertainties of the yet un­recognised immunological reac­tions even in cases of grafts placed under most suitable circumstances and ideal surgery done is as much a problem in the West as it will be in the East. A co-ordinated and active basic research work more so in a country like India where pro­blem of corneal disease is made so different by Trachoma could alone provide some answer. A three hourly instillation of hydrocorti sone drops and if necessary a systemic administration helped us overcome this complication quite often. We were prepared to use hydrocortisone any time after the seventh post-operative day.

6. Subluxation of Lens. One thing which at times makes the surgeon and the assist­ant perspire is when the button from the recipient eye has been removed and large tags of iris ­remains from leucoma adherens have to be excised, the lens starts moving forward through this wide gap. One can only attempt to slow its passage forwards till one is able to put in four vital quadrant stitch­es. The partially dislocated lens has to be removed better ex­tracapsularly than intracapsularly. We faced this situation in 5 cases of leucoma with extensive adhe­sions, and only in one of these cas­es, the graft remained clear. In another two the graft was clear for about a month and then started be­coming hazy.

The paper was followed by a movie showing the surgical techni­que used.


  Summary Top


Difficulties in securing donors and suitable recepient eyes in India are emphasised.

Results of 25 cases of penetrat­ing keratoplasty, 13 cases of lamil­lar keraplasty and 9 cases of kera­tectomy are tabulated and discus­sed.

The complications are described and the means adopted to minimise the same are stated.


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9]
 
 
    Tables

  [Table - 1]



 

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Donor Material
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