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Penetrating keratoplasty by pushkar dhir

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Penetrating keratoplasty by pushkar dhir

  1. 1. Venu Corneal Department
  2. 2. • Presenter Pushkar Dhir • Moderator Dr. Ashish
  3. 3. 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)
  4. 4. PKP 500µ + PLK 250µ DSEK 180μ
  5. 5. PK TYPES OPTICAL TECTONIC THERAPEUTIC COSMETIC
  6. 6. 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
  7. 7. 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.
  8. 8. Types of keratoplasty • Donor tissue Autograft Allograft Xenograft Autorotational graft
  9. 9. Advanced Dry eye Anterior staphyloma Severe cases of SJ syndrome RD
  10. 10. • Grade 4 chemical burns • Ocular cicatrical pemphigoid with no tear film • Bad ocular surface • Multiple graft failure
  11. 11. 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
  12. 12. 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)
  13. 13. 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
  14. 14. 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
  15. 15. Slit Lamp Examination  Microcystic oedema  Epithelial Abrasions  Stromal oedema  Descemet’s fold  Breaks in Descemet’s membrane What Mr.Balram trying to find out!!??
  16. 16. Procedure for PK Preoperative preparation Anesthesia Surgical preparation Trephination of Donor cornea Trephination of Recipient cornea Suturing of Donor cornea Post operative treatment
  17. 17. 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
  18. 18. • 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
  19. 19. 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
  20. 20. 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
  21. 21. ENDOTHELIAL PUNCH SYSTEM Sharp vertical cut More accurate centration Endothelial side up
  22. 22. • Hessberg Barron Vaccum trephine • Less AC collapse & distortion • Sharper, deeper & more perpendicular cut
  23. 23. 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
  24. 24. Trephination of Recipient Cornea • Trephination done either by hand held, suction & automated trephines Marking cornea
  25. 25. DIFFERENT TYPES OF FLAP WHICH CAN BE MADE Top Hat Shape •Provides large endothelial surface transplantation
  26. 26. ZIG-ZAG SHAPE Hermetic wound seal Angled edge provides smooth transition between host and donor
  27. 27. Mushroom Shape Preserves more host endothelium •
  28. 28. Recipient dissection
  29. 29. 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.
  30. 30. Interrupted corneal sutures (10/0 nylon)
  31. 31. 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
  32. 32. Single continuos sutures
  33. 33. 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
  34. 34. 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.
  35. 35. 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
  36. 36. Post op visits • Final spectacles prescribed after 24 months when sutures have been removed & refraction & corneal curvature stabilised • Contact lens fitting
  37. 37. • 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

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