We Pursue Eye Research
Corneal Transplant Q&A
These Ask the Doctor columns are taken from archived issues of the Foundation’s newsletter, Visionary, and the many cornea transplant questions sent by patients to Dr. Francis Price that he has responded to over the years.
The 2009 December column was co-authored with Marianne Price, Ph.D. the Executive Director of the Foundation, and overviews the process of corneal transplant donation, its journey to the recipient and the long-range impact of research on corneal conditions that the Foundation pursues.
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Ask the Doctor - December 2009
In keeping with the spirit of the December holiday season, the usual “Ask the Doctor” column was replaced with a co-authored article on “The Gift of Sight” written by Francis Price, Jr. M.D. and Executive Director, Marianne Price, Ph.D.
The Gift of Sight
During this holiday season, gifts are a recurring theme. We feel especially blessed at the Cornea Research Foundation to be intimately involved with both accepting and distributing the priceless gifts of corneas and sight. This giving and receiving is multifaceted and involves far more people and types of giving than you may have imagined.
It All Begins With a Priceless Gift
One of the most obvious gifts is given when a generous family donates a loved one’s cornea to a grateful transplant recipient. Families of transplant recipients are often moved to become organ donors themselves after experiencing, firsthand, how a transplant can transform someone’s life.
Donated corneas that are not suitable for transplantation are an equally special gift because they can be used to teach and train eye surgeons so they can help people see better with advanced transplant techniques. We have used corneas donated for research to develop new tissue-sparing endothelial keratoplasty techniques (DSEK, DSAEK, DMEK, and DMAEK). These techniques have revolutionized transplant surgery by making it safer, providing more rapid visual recovery, and avoiding loss of eyes from minor trauma after surgery. Without corneas donated for research, these techniques could not have progressed as rapidly.
The Cycle of Giving Continues
Transplant recipients perpetuate the giving by coming back for exams so we can learn more about how their donated corneas function and survive. This helps us improve the results and vision for those yet to receive a transplant. Some transplanted corneas are even donated a second time so that necessary research can be done to analyze how the donor and recipient meld together.
The Foundation has tracked over 4000 patients with full thickness grafts for up to 10 years. In addition, we are following over 1500 endothelial keratoplasty patients. With the help of our patients, we have been able to collect and share with others the longest follow up information on the largest number of EK procedures performed anywhere in the world. Our excellent graft survival rates at 5 years, and beyond, have helped assuage fears of possible early graft failure with the new endothelial keratoplasty techniques.
A sweet 2-year-old girl that we recently transplanted with DSEK was a direct beneficiary of advances made possible by families who donated corneas for research and by the patients who have pioneered these new transplant procedures. This little girl’s eyes will remain stronger and more resistant to injury for the rest of her life because she had a DSEK procedure, which only requires a small incision. In addition, her recovery was simpler and safer because DSEK doesn’t require any sutures.
Gifts of Treasure Provide Gifts of Learning
We also appreciate the monetary gifts many of you are making to the Foundation because these allow us to teach and disseminate the information we learn so that physicians and patients around the world have a better understanding of how corneal surgery can help restore vision. For example, we have trained over 500 doctors from 23 countries in endothelial keratoplasty techniques.
In addition, your gifts help support our work to grow precious cells from donated corneas in the laboratory so that one day we may be able to use a single donor cornea for 100 transplant recipients or more, to help alleviate a worldwide shortage of donor corneas.
Your support has helped us learn that…
- One third of cornea transplant recipients develop high pressure in the eye, even if they did not previously have glaucoma, and that about one fifth experience a graft rejection episode.
- Compared with Caucasians, African Americans have 5-times higher risk of developing a rejection episode.
- Surprisingly, one third of our patients who were rejecting their transplant didn’t even realize it – it was found during a routine follow up exam.
We are using these findings to educate doctors and transplant patients about the importance of having routine follow up exams. We are also evaluating new ways to prevent patients from rejecting their cornea transplant and working to optimize outcomes for patients with glaucoma who need a transplant.
The Gift of a Future in Which Transplants Are No Longer Necessary
We are trying to help as many people as possible avoid the need for a transplant in the first place. For example, we are trying to figure out what causes Fuchs’ dystrophy so that we can diagnose and treat it early before vision deteriorates. Also, we are evaluating a new non-invasive treatment for keratoconus, a visually debilitating condition that strikes teenagers and young adults. The gift of sight will become a reality for these and hundreds of others with your continued support of our mission and faith in our work.
Thank you for all you have done, and will do again in 2010, to help us share the gift of vision with others. Happy holidays to you and yours!
Ask the Doctor - June 2009
Q: “What’s the usual timeframe between transplant surgery and getting new glasses?”
A: With standard full thickness penetrating grafts, it can take a year or two to get the sutures out which hold the transplant in place. We usually do not give glasses prescriptions until the sutures are out and astigmatism is under control. With the newer forms of transplants the sutures come out sooner. With anterior lamellar grafts the sutures are usually out anywhere from 6 months to a year after surgery. With endothelial keratoplasty – DSEK, DMEK, and DMAEK – as soon as the patient’s vision clears up, he or she can have the sutures out, if needed, or have a new glasses prescription, if necessary.
Q: “I had a corneal transplant. Will I have to use FML™, Cosopt and Lumigan all of my life?”
A: The FML™ is topical corticosteroid drops used to help prevent rejection of the corneal transplant. The long term use of these medications depends on any history of rejection and the need to suppress that response from coming back. It may also be needed to control inflammation in the eye, as well, for some people.
The other drops are for glaucoma, or high pressure in the eye. Some people have glaucoma naturally and would need to be on these drops forever. If the drops are being used for eye pressure, and the increased pressure is because of a reaction to the corticosteroid drops, then they may be able to be stopped if the corticosteroid anti-rejection drops are no longer needed. There is also a new investigational drug that may block the increased intra-ocular pressure associated with corticosteroid drop use. This new drug would be used as an injection which would be given every few months and avoid the need for, or decrease the need for, anti-glaucoma drops. We are currently waiting for approval to proceed with a study to evaluate whether a single injection of an investigational drug can sufficiently lower the pressure inside the eye, so that transplant patients can continue to use their anti-rejection eye drops without developing glaucoma.
We plan to enroll up to 100 patients in this study; participants will be followed for 6 months.
Ask the Doctor - December 2008
Q: Why is DMEK better?
A: As you probably know, DSEK is already much better than a standard PK (traditional transplant) because it leaves the eye stronger and less susceptible to injury, and it has much faster visual recovery. DMEK takes this a step further - with DMEK, we only transplant a single healthy cell layer from the donor cornea. This exactly replaces the single diseased cell layer that we remove, so it is truly a disease-specific surgery.
DSEK transplants more of the donor corneal thickness and this helps provide greater strength and shape to the donor tissue, thus making it easier for the surgeon to handle. But when we just transplant a single cell layer in DMEK, we can make an even smaller incision in your eye. The smaller incision means there should be even less chance of changing the refraction, or glasses prescription, in a way we do not want.
The most common reason we have had to repeat DSEK surgery is because of folds, or wrinkles, in the donor tissue that occur when it conforms to the back of the patient’s cornea. These wrinkles are often unavoidable due to differences in the natural curvature of the donor and recipient corneas. However when we transplant just a single cell layer in DMEK, the thin membrane seems to conform without wrinkles, and this should give you much clearer vision. So far, in the initial cases of DMEK, we are finding the average vision at one month is 20/30 and that more people get 20/20 vision than in DSEK.
Better, and more predictable, results with DMEK may also allow more transplant patients to take advantage of premium intra-ocular lens implants which allow better near and distance vision without glasses after cataract surgery.
Ask Your Doctor - September 2008
Q: I have been diagnosed with cornea lattice dystrophy. My mom has had it, too, and has had multiple transplants. Every once in a while, without warning, I get a very sore eye that seems like a bad scratch on my eye and it’s very painful. Can you tell me more about this condition and what to expect as I get older?
A: Lattice dystrophy, like a number of other corneal stromal dystrophies, often starts with recurring corneal erosions that happen when the skin covering on the surface of the eye pulls off causing an abrasion, or raw spot, on the surface of the eye. It feels just like the eye has been scratched. Typically these erosions happen on first opening the eyes in the morning or in the middle of the night. In some cases the eyes feel scratchy during the day as if something is in them. Over time, abnormal deposits of material accumulate in the deeper layers of the cornea. In lattice dystrophy this material is in the form of a lattice of fine deposits in the cornea which cause the surface of the cornea to become irregular and rough and leads to decreased vision. Vision is further decreased as deposits become denser in the rest of the cornea and the cornea looses its clarity. Gradually it reaches a point where a corneal transplant is needed.
Traditionally, a full thickness corneal transplant has been done for corneal dystrophies like lattice dystrophy. More recently, anterior lamellar, or partial thickness transplants, have been done and offer these advantages:
- The eye is stronger after surgery and more resistant to traumatic wound rupture or injury
- There is minimal risk of immunological rejection of the new cornea with a lamellar graft compared to a full thickness graft.
- Because dystrophies always seem to recur in the transplanted corneas just as they did in the original cornea on average, in about 5 years, an anterior lamellar graft is much easier to replace than a standard full thickness graft. (By easier, I mean there is less damage to the host eye and less risk of immune rejection of the new graft.)
The benefits of anterior lamellar grafts can be tremendous considering that many people with corneal lattice dystrophy will require multiple grafts of each eye over a life time.
Ask Your Doctor - March 2008
Q: Can the cornea be tested before transplant surgery to determine the likelihood of success or rejection?
A: Most solid organ transplants, such as heart and liver, for example, go through tissue matching to determine the relative risk of rejection for patients. An attempt is made in those cases to get tissue types as close as possible for the recipient. The only donated organs that have no risk of being rejected are those from either the patient’s own body receiving the transplant, or from an identical twin. Corneas, however, are a relatively unique situation, and studies in this country have never shown any clear advantage for surgeries that were tissue typed compared to those that were not. Some studies outside of the U.S. have indicated that tissue typing was beneficial, but when this was checked into more closely here in the U.S., it was not shown to have similar effects.
Although we do not tissue type, corneas are screened for the viability of the corneal tissue and for possible diseases.
Ask the Doctor - December 2007
Q: I have kerataconus; what are my treatment options? Can anything actually make it better?
A: Traditionally the only treatments for keratoconus have been the use of rigid contact lenses or corneal transplants. Neither of these actually do anything to reverse or treat the underlying condition, but they allow someone to see better. In the last few years we have placed Intacts in some eyes with keratoconus to help make it easier to wear contact lenses if that has become difficult. Now, for the first time ever, there may be a new treatment that may arrest or even reverse the keratoconus. We hope to start a new study for this in the near future, so if you, or someone you know, would be interested in learning more please contact us at 317- 844- 5610. Leave your name and phone number for a call back.
In regards to corneal transplants, we have done full thickness and partial thickness corneal transplants for years. However, there are new techniques for the partial thickness transplants that will allow better visual recovery with decreased chance of rejection or long term failure of the transplants. In fact, we just conducted a course on this technique were we trained 26 corneal transplant surgeons from around the world in these new techniques.
Q: It’s flu season again and I am worried about whether or not to have a flu shot. Is it safe for me to have a shot now that I have a corneal transplant in my eye? Are there any special steps I should follow?
A: Yes, you can go ahead and have a flu shot, but you need to take Pred Forte 1% four times a day for the two days before the shot and for two weeks after the shot. The flu shot stimulates your immune system – just like having the flu – and you need to take Pred Forte to help prevent your body from recognizing the donor cornea as foreign tissue which could lead to a graft rejection. You can have a flu shot if you take these simple precautions.
Ask the Doctor - September 2007
Q: How long do you expect a DSEK corneal transplant procedure to last?
A: No one lives for ever, and neither do corneal transplants. With DSEK there appears to be more loss of the endothelial cells with the initial surgery compared to standard corneal transplants; therefore, at this point in time they may not last as long as a standard corneal transplant. However, in DSEK we also implant a larger diameter graft than with standard corneal transplants, so the DSEK graft may actually benefit from that difference. We are currently working on a number of studies looking at ways to improve the endothelial cell counts after DSEK that should prolong the life of the grafts. (Keep reading these newsletters for updates on that topic and others related to our studies.)
The importance of research and patient follow up cannot be over-emphasized because that is the only way we can improve both the technique and long term results. We currently have the largest data base on DSEK patients and are carefully tracking results to answer these questions and improve results. We previously reported on the long term results of standard corneal transplants, which to our knowledge, is the largest reported series in the United States. But since DSEK has been performed for less than 4 years, we do not yet have comparable long term results to report, such as 5 or 10 year survival rates. Overall, we do believe that DSEK (or as some call it DSAEK) has substantial advantages over standard PK in patients with Fuchs´ Dystrophy and related corneal problems.
June 2007 - Ask the Doctor
Q: My 72 year old Dad is in excellent health but he has Fuchs’ syndrome and cataracts on his eyes. He would like to have cataract surgery, but an eye specialist advised him to not have it done because it could cause him to lose his sight immediately. He would also need a corneal transplant. Have there been any new strides in the treatment of Fuchs’ syndrome with cataracts?
A: We have just finished a number of studies on Fuchs’ Dystrophy and cataracts. What I would recommend is that he go ahead with the cataract surgery and see how he does. If the vision improves enough to help him see better, then that is all he needs.
If the vision either does not improve, or gets worse, because of the Fuchs’ Dystrophy then he should have a DSEK corneal transplant surgery performed to treat the Fuchs’ Dystrophy. The only exception would be if his cornea is already turning cloudy. In that case he may want to have both surgeries done at the same time.
As we learn more about how the eye responds to the DSEK corneal transplant, we are changing some of our previous recommendations on how and when to treat people with problems like these. We will keep you informed as we learn more.
March 2007 - Ask the Doctor
Q: How long are iris implants expected to last?
A: They should last indefinitely. In some cases where the lenses are sutured, the sutures may degrade and need to be replaced in 10 to 20 years, depending on the patient’s age. At this point in time, it is difficult to determine the percentage of people with artificial irises for whom this could be an issue one day, but it is likely to be a low number.
Q: I have a damaged left Cornea, due to Herpes Simplex Keratitis. I developed the condition at about the age of 10 and have had periodic flare ups which have left a scar on my cornea. My doctor has discussed the possibility of a cornea transplant in the future should my scar get worse. My question is: at what point do you decide to do a transplant?
A: The problem with corneal scars from Herpes Simplex infections is that the infection can recur. If it does recur, then the inflammation can return, even in the new transplanted tissue, leading to immunologic graft rejection, or melting of the tissue. We do not recommend grafting corneal scars from Herpes Simplex unless there have been no recurrences for at least a year. When we do graft eyes with these scars, we also place patients on oral antiviral medications indefinitely, as this minimizes the severity and frequency of recurrent infections.
December 2006 - Ask the Doctor
Q: Is it safe for me to have the flu shot after a corneal transplant? Does it increase the risk of rejection?
A: Yes, you can have the flu shot but you should also take anti-rejection drops for at least two weeks after. I recommend that you contact your doctor and discuss these plans so that s/he can advise you as to what would be best. We usually have our patients take Pred Forte 4 times a day for 2 weeks. There have been some cases of rejections reported after flu shots – and of people who still got the flu - and this may be due to the stimulation of their immune systems.
Q: After I received a transplant and returned home to my regular doctor, the staff always wanted to test the pressure on my eyes. Is it safe to do on a transplant?
A: Yes, and it is necessary after a transplant because anti-rejection drops can increase the pressure in the eyes of some patients.
Q: If I begin to experience rejection of my transplant, what should I do to minimize the damage; for example, should I get to an emergency room?
A: I recommend that you see your local eye doctor as soon as possible. They won’t know what to do or what to look for in the ER.
March 2006 - Ask the Doctor
Q: How Has Opthalmology Changed in the Past Year?
A: The biggest advances are occurring with the aid of technology. After 25 years of little change in corneal transplants, new techniques are dramatically altering the expectations and results of transplant surgery. During 2005 we saw the growing acceptance of endothelial keratoplasty, a technique that replaces only the diseased endothelial cell layer of the cornea with thin partial-thickness posterior grafts from donor corneas. More than 50 surgeons in the U.S., and an increasing number internationally, are now routinely performing the surgery. Their innovations and modifications will rapidly improve the visual results and safety of the procedures.
The predominant type of posterior grafting surgery being performed is Descemet’s stripping with endothelial keratoplasty (DSEK) which allows patients to regain vision of 20/40 or better within 3 months of surgery. Early problems with donor tissue detachment now seem to have been solved, and some surgeons perform the procedures with only topical anesthesia.
Last year we saw the first use of femtosecond lasers, instead of metal trephines, for penetrating keratoplasty. Whatever surgical incision design we can dream up, these lasers have the capability to execute. Such incisions are stronger and can be custom-designed for each patient. We performed the first laser-assisted, contoured corneal transplant in the world here at Price Vision Group. Technology is bringing a new era of vision care and treatment possibilities. It’s an exciting time!
June 2006 - Ask the Doctor
Q: Can you tell me where I can find a doctor in my area that has trained with you in the new DSEK procedure?
A: Finding a good doctor for this new technique is an important concern. I have trained 200 doctors in DSEK from all over the world but I maintain a busy practice myself and it is beyond my capacity to make referrals. I don’t have enough time or resources to follow them after they leave my course.
Having said that, let me share some thoughts with you that come from our new book, Celebration of Light, about finding a doctor you want to work with as you undertake eye surgery.
In order for you to make a good team, it is essential that you trust your doctor, have confidence in and feel comfortable with his/her skills and style of communicating. So my first advice is to call the medical society and find a list of ophthalmologists in your area. Begin narrowing that list by calling their offices and finding out if they are doing the procedure, how long they have been doing it and what their “success” rate is. The Fuchs’ Foundation and Keratoconus Foundation can also provide additional information.
Once you have identified a potential partner, make an appointment and visit the clinic in person. Be observant: look at the equipment to see if it is modern or outdated. Observe how staff interacts with patients; are they sincerely interested and attentive to their feelings and needs? Finally, sit and talk with the doctor; does s/he look at you when talking? Does s/he seem patient with your questions, or rushed? Does the doctor inspire your confidence?
One other thing: continue to have faith in the future and be grateful for each and every day for it is a blessing. Overcoming vision challenges is as much a matter of your outlook as it is in finding the best doctor, so stay positive and maintain an attitude of gratitude.
December 2005 - Ask the Doctor
Q: Can you use a LASIK eye for a corneal transplant?
A: Currently eyes with previous laser refractive surgery are not candidates for corneal transplant surgery unless only the posterior portion of the cornea is used. These eyes can be used for some cases of DSEK if the donor is prepared by a hand dissection instead of the microkeratome. There are some studies underway to try to develop new methods so these eyes can be used. It is also important to realize that even if an eye cannot be used for a corneal transplant, it can still be invaluable for use in either teaching or research. We desperately need eyes to help train doctors in new surgical techniques. There is no substitute for a human donor eye on which to demonstrate surgery; the alternative is for doctors to learn new techniques on someone’s eye during surgery. We also need donor eyes to develop new techniques so that eyes with previous laser refractive surgery can someday be used for transplants.
March 2005 - Ask the Doctor
Q: How long do cornea transplants last and can the procedure be done again?
A: In my experience, transplants can last for at least 20 years and probably much longer. Where and why the transplant was performed are two of the most important factors that influence how long it may last. For example, studies have shown that surgeons who perform many transplants each year have higher transplant survival rates compared with surgeons who just perform a few each year. The patient’s eye condition can also influence the outcome. For example, 9 out of 10 transplants I’ve performed for keratoconus or Fuchs’ dystrophy have lasted 10 years or longer. The graft survival rates are somewhat lower in eyes with chemical burns or other complications.
A transplant can be repeated if the graft becomes cloudy. However, our studies show that the survival rate is much lower for regrafts compared to original grafts. That’s why we follow our patients very closely and do everything possible to ensure the success of the original graft.
The Cornea Research Foundation maintains the largest cornea transplant database in the Western hemisphere. We have studied the outcomes of over 4000 transplants to find out what causes grafts to fail so that we can figure out ways to help them last longer!
August 2005 - Ask the Doctor
Q: Is anyone ever too old for a cornea transplant?
A: Does anyone ever reach the point when they are too old to see? I don’t think so. Fifty years ago, it was common to expect older people to naturally become deaf, blind, and immobile as they aged. Today we expect elders to continue to enjoy excellent vision, hearing, and mobility. Cataract surgery alone has allowed many older Americans to achieve better vision after surgery than they ever had in their younger years. With improved vision, the risk of falling and fracturing a hip has been sharply reduced and enhanced the quality of life. Better vision also fosters increased communication with the world around us and keeps our minds more active.
Corneal transplants, like cataract surgery, are definitely indicated in the elderly for the reasons noted above. The only places I know of where they are discouraged from these relatively safe and effective eye surgeries are areas with either government-controlled health care, such as Canada, or large managed care plans.
In the Bible, one of the most common miracles Christ performed was to restore vision to those who were blind. The choice is to have light or darkness. Vision is key to human understanding and communication. Why would someone ever be too old for this?