Year : 1959 | Volume
: 7 | Issue : 4 | Page : 84--88
Clinical experiments in keratoplasty
Mahatma Gandhi Memorial Medical College, Indore, India
G S Wagle
Mahatma Gandhi Memorial Medical College, Indore
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Wagle G S. Clinical experiments in keratoplasty.Indian J Ophthalmol 1959;7:84-88
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Wagle G S. Clinical experiments in keratoplasty. Indian J Ophthalmol [serial online] 1959 [cited 2020 Oct 22 ];7:84-88
Available from: https://www.ijo.in/text.asp?1959/7/4/84/40694
The religious, political, and legal difficulties in obtaining donor material for corneal grafting in our country have given us only a back-seat in this branch of plastic surgery of the eye and so whatever experience one gets in his clinical practice is worth sharing. I am motivated to write my experiences from the fairly good results of my 39 cases of Keratoplasty and the relatively simple technique that I have come to adopt through these clinical experiments.
Way back in 1939 I was doing evisceration in a case of panophthalmitis. The cornea was totally opaque and yellow; the conjunctiva was suffused and oedematus and the eye was painful, The patient was unable to see any light and pleaded that his eye be removed for relief of pain. So I offered to eviscerate under local and retrobulbar anaesthesia. As I removed the opaque lens, I was surprised to find clear vitreous behind, so much so that the patient started saying that he could see the instruments I was holding. He could see the light, with its shade and pleaded that he be allowed to see things for some time more. The patient was allowed to roll his eyeballs up and down and sideways at his will for some time. He was allowed to open and close his eye lids; then he was even allowed to sit up for a few minutes. Throughout these manipulations I was agreeably surprised to find that the vitreous did not prolapse, even though it had no support, neither of the cornea nor of the lens.
This peculiar behaviour of the vitreous was encouraging and made me feel confident that the eye should be able to stand a cornea-grafting operation very well.
Experiment No. I.
With this confidence in the strange yet co-operative behaviour of the vitreous I took one case for keratoplasty in 1944 of a girl of 18 who had phthisis bulbi of the left eye and total corneal leucoma of the right eye, ever since she was three years old. She had good perception and projection of light on all sides. At this time I did not have adequate instruments for grafting. The donor eye was from a patient who had painful absolute glaucoma but clear cornea. So with the consent of the patient his cornea was utilised before enucleating that eye.
The method employed was a crude one. I removed the entire opaque cornea of the recipient - (the iris was unaffected) - along with a 5 ruin, wide conjunctival collar all round it with knife and scissors. Then by the same method I took out the entire cornea with the 5 mm. wide conjunctival collar from the donor eye and put it in the gap in the recipient's eye, stitched the conjunctival collar all round with fourteen interrupted sutures. [Figure 1] The cut edges of both the cornea were naturally irregular; as such exact apposition was not possible Somehow the graft appeared to have fitted well, at least on the table, and the girl could see moving objects for the following two weeks. She however could not recognise the objects to start with as she was blind since the age of three. She actually had to be taught to recognise objects. Unfortunately on the 15th day after the operation the cornea started slipping downwards and started getting opaque. The girl could see for a fortnight and then unfortunately drifted into her former darkness. I wonder whether it was proper in raising hopes of vision and then let her slip back into the world of the blind.
In this case too I had that peculiar kind co-operation of the vitreous and of the lens. They did not show any tendency to protrude (luring either the removal of the cornea or during the stitching manoeuvres.
Experiment No. II.
There was one male patient aged 50 years with absolute glaucoma in both the eyes. He insisted that he be operated and if he was not benefited he would not blame me. I took up this case and removed a penetrating corneal piece with a 2 mm. Elliot's trephine blade from his right and left eyes and exchanged them as mutual donors and recipients. The grafts were placed on each corneal hole, [Figure 2] keeping them pressed with the flat of the iris repositor for two minutes each without sutures. Here I noticed one very peculiar phenomenon. The grafts placed in the holes in the cornea got glued in a short space of time of about two minutes. I did not put any supporting sutures either but just covered the eyes with lids; lifting them and closing them avoiding their gliding over the edges of the graft. The grafts took very well and remained clear as was observed during the fort-night that the patient was in the hospital.
Experiment No. III.
In 1948 when I received a set of corneal grafting instruments, I started doing keratoplasty as and when the cases came my way and as and when I got donors alive or dead. For want of an organised Eye Bank and for want of co-operation from the staff of the general hospital it is difficult to report on keratoplasties in hundreds.
In my third experiment the recipient was 40 years of age whose cornea had gone irreversibly opaque due to interstitial keratitis. The donor cornea for this case was from an absolute glaucoma case with clear cornea. The patients were layed on two tables placed parallel and a 4.5 mm. piece of clear cornea of the donor was removed with a Francischetti's Trephine and layed on the recipient eve after the removal of the opaque corneal disc of the same size i.e. 4.5 mm. The opaque graft was put on the donor's eye i.e. the grafts were exchanged. The bevelled edges of the grafts help us to distinguish the endothelial from the epithelial side. [Figure 3] This was my first experiment with corneal trephine as such I took extra precautions of putting cris cross sutures [Figure 4] from the conjunctiva over the cornea. This graft also took well and remained clear for six months that the patient was followed up.
The sutures applied were found to be loose on the very next day which led me to feel that these supporting sutures were not necessary and served only as Surgeon's conscience keepers. In my subsequent cases I have dispensed with such supporting sutures. I have found consistently good results in all the cases that I have done so far, without any suturing dan with just lid support, immobilisation and bandage.
In all the corneal grafting cases than I am reporting in this paper I have neither done blood grouping nor urine examinations. However I was careful in taking the usual precautions in aseptic ocular surgery and to see that the recipient had total corneal opacity and that the perception and projection of light wore good.
Experiment No. IV.
Autogenous penetrating rotating corneal graft [Figure 5] was attempted in the case of a man aged 30 in 1948. This man had lower half of his cornea opaque and the upper half which was clear remained under cover of upper lid. A penetrating disc 5 mm. in diameter including half clear and half opaque cornea was cut through and through and rotated in such a way that the opaque part went up and the clear one came down. This also took very well although no sutures were applied. It could stay in place only with the lid support and gave fair visual result counting fingers at 6 feet. (Case No. 4)
Cases 5 to 36 in the accompanying table have been tackled with the same technique wherein either cadaveric eyes or blind eyes with clear cornea from living donors were utilised.
All my recipients unfortunately were not ideal. Amongst almost all the recipients either adherent leucomata or posterior synaechiae, lens opacities or other complications were present. The synechial irises were snipped off and the central part cleared of all the debris and then the graft placed in gave good visual results. With proper correction of error of refraction, two of my cases gave acuity of vision of 6 12 at the time of their discharge from the Hospital.
My only satisfaction at this stage is that in all 39 cases of penetrating keratoplasty that I have done up to 1957 and followed up, the grafts have taken well and have remained clear. Seven of these cases I have been able to follow up for seven years. As regards the visual results I am not quite satisfied, not because there is something wrong in the technic but because my recipients were not ideal. By ideal recipients I mean the ones who have not total corneal opacities, with good and clear anterior chamber healthy iris, clear lens and clear vitreous and who have good perception and projection of light.
Technic of Preservation of Donor Material
As soon as the House-Surgeon is informed of an unclaimed dead body, he goes and removes the eyes provided the cornea are found quite clear. The enucleated eyes are wrapped in a wet saline gauze of four layers and stored in the refrigerator. In one case I have used the preserved eye up to five days with good result. Mostly the grafting material was collected within 4 hours. In one case it was obtained 6 hours after death. Except where the grafts were autogenous, the homologus grafts were recovered from cadavers or blind glaucomatous eyes. In two cases the graft was recovered from still-born babies.
If I have a waiting recipient in the ward, I utilise the eye as early as possible; if not the one on the list of recipients is sent for and the grafting operation is done soon after his admission. In most cases the graft was utilized within 24 hours of its removal, except in one when it was removed five days later. The graft was clear and the result satisfactory.
The recipient is prepared for operation in the same way as we do in cataract cases.
The cadaveric donor eye is cleaned with normal saline at body temperature, a Kocher's forceps is applied to the optic nerve [Figure 6] and the eye ball is held in the fist as in [Figure 8] fixing it properly with firm but gentle pressure. (The eye does not slip from the fist on the other hand it has a distinct advantage; one can vary the pressure on the eye ball with fingers at the time of trephining). Now the trephine [Figure 8] is applied on the centre of the cornea and rotated till it penetrates the anterior chamber. The sign of having entered the anterior chamber is that the aqueous starts escaping. Then the trephine is removed and the graft is lifted with the corneal lifter. [Figure 9]. At this stage if any adherent tags of iris are found they are snipped off with the knife or scissors. Thus freed and lifted, the graft is placed in a watch glass containing lukewarm normal saline. This watch glass is placed in the instrument tray which is for the use of the recipient
The recipients face and eye are prepared in the same way as for a cataract operation. Instillation of 1% Anethaine and a retro-bulbar injection of about 1.5 cc. procain 2% with adrenalin is given to induce anaesthesia. The eye ball is fixed with a conjunctival forceps applied at 6 O'clock position and the Francischetti corneal trephine of 4.5 or 5 mm size (with the piston receded 4 mm.) is applied on the cornea. The size of trephine used for the donor eye and the recipient is the same. Now the trephine is rotated till it penetrates through and through the cornea as could be judged by the escape of aqueous or by feeling the loss of resistance. The corneal cut disc is lifted and while doing so if there are any adherent tags they should be snipped off . If the iris is covering the lens the best way is to lift it gently with the iris forceps and snip it off with scissors. Care has to he taken not to injure the lens capsule. If at this stage the lens is injured it will be very difficult to prevent it from veiling out. In this eventuality it is impossible to place the graft in position without sutures. That is why one should be prepared with suturing material ready at hand. If the lens is not disturbed it is easy to put the donor graft on the recipient cornea. Having placed the clear corneal graft in the hole [Figure 10] in the cornea of the recipient, it is kept in place pressed with the flat of the corneal lifter for about two minutes. One can observe that it gets glued [Figure 11] to the edges of recipient cornea during that time. Penicillin and atropine drops are put, the speculum is removed gently by lifting its arms and by asking the patient to close his eve lids. This manoeuvre should be gentle and careful. I do not allow the closing lids to glide over the edges of the graft but close the lids by lifting them over the graft. Pad and bandage are applied to both eyes.
First dressing is clone after 24 hours. Then daily dressing once a day; both eves are kept bandaged for three days. The non-operated eye remains uncovered from the fourth day onwards. The grafted eye is kept bandaged for 14 days. The progress usually is uneventful.
The homogenous grafts have all taken very well except two. The transparency of the grafts vas well maintained especially in the seven cases which have been followed for seven years. Out of the 39 cases operated, the visual results were very good in 3 good in 8, temporarily good in 4, not good in 8. The results in 16 cases are not known since they have not reported since their discharge. The visual results depend on the ideal recipient eye. In all these cases I have come to the conclusion that grafts can take well and remain transparent without sutures, the only support being obtained from the closed lids.