Corneal transplant

This page contains a summary of our information on corneal transplant. To read our full information, download our factsheet:

If your cornea is scarred, damaged, or distorted to a point where the vision can no longer be improved with glasses or contact lenses, you may need a corneal transplant to provide clear vision once more. A corneal transplant can also be used to relieve any pain or discomfort caused by severe infection or injury that is no longer being managed effectively with treatment.

Your ophthalmologist (hospital eye doctor) will discuss with you how a corneal transplant will help, and they should help you make the decision on whether and when to have your transplant.

Surgery for a corneal transplant usually takes around an hour, although depending on the type you are having, it may take up to two hours to complete. Transplant surgery can be done under either under local anaesthetic, where you are awake, or general anaesthetic, where you are unconscious and unaware.

If you have a local anaesthetic, you will usually have an injection into the soft tissue around your eye, not into your eye itself. You will also be given eye drops to numb the front of the eye.

The injection stops you feeling pain from your eye, reduces what you can see and stops your eye from moving around. You will need to be able to lie still for the whole operation to be suitable for local anaesthetic.

If you have local anaesthetic, you might be offered sedation, medication which makes you feel sleepy and relaxed during the surgery. Sedation can make the surgery less stressful and more comfortable for you. Your doctor would be able to explore whether sedation would be right for you.

What can I expect after all types of surgery?

Your eye should not be too painful following the surgery, but if there is any discomfort you may be given painkillers such as paracetamol. The sutures in your eye may make your eye feel gritty, but these should not be uncomfortable or painful. If they are, it would be important to contact the hospital about this.

Following surgery your eye will be patched. You can usually go home either the same day or next day but will have to go back within the first week to have your eye checked by your ophthalmologist. During this time, you may need to wear a plastic shield at night to protect your eye while you are asleep.

You will need to use steroid eye drops for at least one year and in some cases, life-long to prevent your immune system from rejecting the new donor corneal layers. You might need to take other medicines to suppress your immune system if your ophthalmologist feels that there is a high risk of rejection.

After surgery you’ll been given antimicrobial eye drops for a few weeks to prevent infection. You ophthalmologist will advise you how often you will need to use all these medicines and for how long.

After the first week’s check-up, you would typically be seen again within a month and then every three months for the first year. Depending on the type of transplant you have, after the first one to two years, further appointments may not be needed. Some people who have had a corneal transplant will need life-long check-ups.

There are three types of corneal transplant.

• EK – Endothelial Keratoplasty which removes and replaces the innermost layers of the cornea
• DALK – Deep Anterior Lamellar Keratoplasty which removes and replaces part of the front layers of the cornea
• PK – Penetrating Keratoplasty which removes and replaces all the layers of your cornea.

The type of transplant you will be offered depends on the layers of your cornea that are affected.

Endothelial keratoplasty (EK)

EK replaces only the innermost layers of the cornea, making it suitable for corneal dystrophies and conditions solely affecting the endothelial layer of the cornea, such as Fuchs endothelial dystrophy. EK surgery is usually carried out under both local and general anaesthesia and takes about an hour.

There are two main types of EK transplants, which require different preparation:

• Descemet's stripping endothelial keratoplasty (DSEK), also known as a 'DSAEK' where the 'A' stands for automated

In DSEK you receive a replacement endothelium and Descemet's membrane, as well as some of the stroma from a donor cornea.

• Descemet's membrane endothelial keratoplasty (DMEK)

In DMEK you receive only the endothelium and Descemet's membrane from a donor cornea.

Descemet stripping automated endothelial keratoplasty (DSAEK) is most widely used.

Deep anterior lamellar keratoplasty (DALK)

In DALK surgery, the surgeon removes the corneal epithelium, Bowman’s membrane, and stromal layers from the centre of your cornea, leaving in place Descemet’s membrane and the innermost endothelial layer.

Your ophthalmologist then places a specially prepared donor cornea ("button") containing stroma and epithelium onto your cornea. The donor button is cut so that it fits precisely into the area of your cornea which was removed. This donor cornea position is secured by tiny sutures until it heals in place.

DALK usually takes about a year to heal. Some stitches may be removed before this, but usually not before the first six months.

Penetrating keratoplasty (PK)

PK is a "full thickness" transplant. PK is more likely to be offered if the stroma and endothelium of your cornea are damaged, for example in keratoconus. During PK your whole cornea is replaced by a donor cornea which is held in place with sutures. Corneal transplant sutures are made of nylon which is non-absorbable and provides long lasting good tensile strength in tissues. Sutures are usually left in place for a year or more following surgery.

EK is "keyhole" surgery, which is quick to heal. By transplanting a thinner layer of tissue in DMEK, recovery times are faster than for DSAEK, the visual results are better, and the rejection risk is lower at only one per cent for DMEK, compared to seven to eight percent for DSAEK and 13 percent for a full thickness ‘penetrating keratoplasty’ (PK) transplant. Your ophthalmologist would be able to explain whether a DSAEK or DMEK transplant would be right for you. Sometimes, the donor layer can detach from the back of the cornea. This usually happens in the first days following an EK transplant. If this happens, you will need to have a small procedure to inject a further air bubble into the eye to help the transplanted tissue to reattach. This is known as "rebubbling".

Both DALK and PK transplants work well. About 90 per cent of DALK and PK transplants carried out for keratoconus are functioning well after five years. Newer DALK transplants also seem to have an even lower risk of failure, to last for longer and to have shorter recovery times compared to PK transplants.

Although PK transplants are an effective treatment, 50 per cent are no longer working at 20 years. This means that if you’re younger you might be advised to wait longer before having a corneal transplant, as you are more likely to require a number of transplants in your lifetime.

The risks of failure of both PK and DALK are low for most corneal conditions, but after both types of surgery it can take a long time for vision to recover. You will need to wear glasses and sometimes contact lenses after the transplant to get the best possible vision.

Following a transplant, you will need to use steroid eye drops for at least one year, and in some cases indefinitely, to prevent rejection of the transplanted donor cornea.

Transplants also carry the risk of cataracts, the clouding of the lens in your eye, and glaucoma, a condition where pressure at the front of your eye damages the optic nerve at the back of your eye. These risks are partly due to the need for steroids following the surgery.

Corneal transplants are an effective treatment, but sometimes following surgery, your body’s immune system recognises the transplanted donor tissue as foreign tissue and starts to react against it. This is known as corneal transplant rejection. Corneal transplant rejection can usually be reversed if it is diagnosed, and treatment commences early enough.

It is usually possible to treat corneal transplant rejection with anti-inflammatory eye drops, usually corticosteroids. Corticosteroids work by reducing the activity of your immune system so that it no longer releases the chemicals which cause inflammation. You may require steroids both topically and by injection to treat the rejection.

How common is corneal transplant rejection?

The risk of corneal transplant rejection varies according to the type of transplant and the presence of risk factors. This risk can be assessed by your ophthalmologist who will be familiar with your condition. Repeated problems with rejection can lead to the transplant failing and the need for repeat surgery.

Being diagnosed with an eye condition can be very upsetting. You may find that you are worried about the future and how you will manage with a change in your vision. We’re here to support you every step of the way, and to answer any questions you may have – just get in touch with our Sight Loss Advice Service.