past, present, future · 2020-06-06 · history of corneal transplantation track the progretrack...
TRANSCRIPT
Sathish SrinivasanSathish SrinivasanUniversity Hospital AyrUniversity Hospital Ayr
Ayr, Scotland Ayr, Scotland
Past, Present, FuturePast, Present, FutureHistory of corneal History of corneal transplantationtransplantation
Track the progress of corneal Track the progress of corneal transplant surgerytransplant surgery..
Recent advancesRecent advances
Erasmus Darwin (1731Erasmus Darwin (1731--1802)1802)• Suggested removal of opaque cornea in 1760.
“Could not a small piece of cornea be cut by a kind of trephine about the size of a thick bristle and would it not heal with a transparent scar. If the scar should heal without losing transparency many blind people might be made to see.”
Copyright restrictions may apply.
1919thth Century: Experimentation and Century: Experimentation and FrustrationFrustration
• 1813: Karl Himly first suggested replacing opaque animal corneas with transparent corneas from other animals.
• It was Franz Riesinger proposed the first corneal xenograft (animal to human).
• This idea attracted several ophthalmologists around the world to perform animal trials.
None of them were achieving any success None of them were achieving any success andand 18311831 they concluded that keratoplasty they concluded that keratoplasty was simplywas simply ““an audacious fantasyan audacious fantasy””..Samuel Bigger Samuel Bigger –– Irish surgeon Irish surgeon –– interested interested in blindness from in blindness from staphylomastaphyloma. . In 1837, held captiveIn 1837, held captive-- Bedouins in Africa, Bedouins in Africa, performed the first PK in animals performed the first PK in animals –– on aon apetpet gazellegazelle with corneal scarring.with corneal scarring.
Promise of the first decade of 19Promise of the first decade of 19thth century century gave way to despair gave way to despair –– transplanted transplanted corneas invariably became infected and corneas invariably became infected and opaque.opaque.But, there was success in other branches But, there was success in other branches of surgery:of surgery: 1846 &18471846 &1847 ether and ether and chloroform was introduced and 2 decades chloroform was introduced and 2 decades laterlater-- ListerLister’’s principles of antiseptic s principles of antiseptic surgery.surgery.Both these improved the prospects of Both these improved the prospects of corneal transplantation.corneal transplantation.
Von Von HippelHippel TrephineTrephine
• Von Hippel reported the first partially successful lamellar graft in 1886.
• Did not believe in endothelium.
• Attributed the failure of xeno transplants to edema and trauma.
• Invented the circular clock work trephine – major advancement in surgery.
• The 19th century was a century of keratoplasty failure.
• Not caused by the lack of ideas of how to replace a dysfunctional cornea but due to the lack of basic science knowledge on infection, immunology, physiology and microsurgical techniques.
Keratoplasty Success and Refinement Keratoplasty Success and Refinement 19001900--19501950
On 7On 7thth Dec 1905 Dec 1905 Eduard Zirm in Eduard Zirm in Olmutz near Prague Olmutz near Prague peformed the first peformed the first successful PK in a successful PK in a human which human which remained clear.remained clear.
EloisElois GlogarGlogar45 yr old farm worker45 yr old farm workerBilateral alkali injuryBilateral alkali injuryDonor: 11yr old boyDonor: 11yr old boyTwo 5 mm donor buttons Two 5 mm donor buttons with von Hippelwith von Hippel’’trephine.trephine.Did bilateral PKDid bilateral PK’’ssOne PK survivedOne PK survivedVision of CF, J16Vision of CF, J16
FilatovFilatov 18751875--19561956Russian OphthalmologistRussian OphthalmologistPerformed thousands of Performed thousands of PKPPKP’’ssUsed an internal spatula to Used an internal spatula to protect internal contents of protect internal contents of the eyethe eyeConceived of cadavaric eye Conceived of cadavaric eye storagestorageGrandfather of eye banking.Grandfather of eye banking.
Eye BankingEye Banking
• Richard Townley Paton founded the world’s first eye bank in New York in 1944.
• Was called the Eye Bank for Sight Restoration.
Ramon Castroviejo 1904Ramon Castroviejo 1904--19871987Born in SpainBorn in SpainMoved to the US in Moved to the US in 19301930Practiced in NYCPracticed in NYCPioneered square Pioneered square PKPK’’ssAppositional suturingAppositional suturingInstrument Instrument developmentdevelopment
Edward Edward MaumeneeMaumenee 19131913--19981998
Developed Developed understanding understanding of the of the immunobiologyimmunobiologyDefined graft Defined graft
rejectionrejection
Current State of the ArtCurrent State of the ArtMicrosurgical Microsurgical techniquestechniques
Understanding of Understanding of Corneal anatomyCorneal anatomy
Ocular PharmacologyOcular Pharmacology
Ocular immunologyOcular immunology
Eye BankingEye Banking
Five Ideal Goals for Corneal Five Ideal Goals for Corneal TransplantationTransplantation
Smooth surface topography without significant Smooth surface topography without significant
change in astigmatismchange in astigmatism
Predictable corneal power Predictable corneal power
Tectonically strong globeTectonically strong globe
Healthy endotheliumHealthy endothelium
Consistently optically pure stromaConsistently optically pure stroma
PK SurgeryPK Surgery
Recipient tissue Recipient tissue removedremoved
Donor tissue sutured Donor tissue sutured into recipientinto recipient
Smooth Surface with only endothelial disease
Full thickness block of tissue removed just to get to the endothelium
Central trephine cutCentral trephine cutmademade
Sutures create anirregular surfacewith astigmatismand blurring
Five Ideal Goals for Corneal Five Ideal Goals for Corneal TransplantationTransplantation
How are we doing with PK?How are we doing with PK?Smooth surface topography without significantSmooth surface topography without significant
change in astigmatism:change in astigmatism: TerribleTerrible
Predictable corneal power:Predictable corneal power: TerribleTerrible
Tectonically Strong Globe:Tectonically Strong Globe: TerribleTerrible
Healthy endothelium:Healthy endothelium: GoodGood
Consistently optically pure stroma:Consistently optically pure stroma: GreatGreat
Current Method of Replacing the Endothelium: Full Thickness P.K.Current Method of Replacing the Endothelium: Full Thickness P.K.
Clear graft, unaided vision: HMClear graft, unaided vision: HMManifest Refraction: Manifest Refraction: --8.00+8.00X70 = 6/68.00+8.00X70 = 6/6
Severe Complications of PK
Endophthalmitis:From retained suture fragment
Expulsive Hemorrhage:Expulsive Hemorrhage:Blunt trauma 5 yrs after PKBlunt trauma 5 yrs after PK
Rebirth of Lamellar SurgeryRebirth of Lamellar Surgery
Anterior Lamellar Surgery Posterior Lamellar Surgery
Anterior Lamellar KeratoplastyAnterior Lamellar Keratoplasty
Superficial Anterior Lamellar Superficial Anterior Lamellar Keratoplasty (SALK)Keratoplasty (SALK)
Deep Anterior Lamellar Keratoplasty Deep Anterior Lamellar Keratoplasty (DALK)(DALK)
DALK
SALK Granular Granular
Lattice Lattice
Lattice
Posterior Lamellar KeratoplastyPosterior Lamellar Keratoplasty
Gerritt Melles 1998Gerritt Melles 1998Developed lamellar dissection Developed lamellar dissection techniquestechniquesIntra corneal trephinesIntra corneal trephinesSucceeded in performing PLKSucceeded in performing PLK
Indications for Post Lamellar Indications for Post Lamellar KeratoplastyKeratoplasty
Fuchs endothelial dystrophyFuchs endothelial dystrophy
Any cause for endothelial failureAny cause for endothelial failure
Failed penetrating keratoplastyFailed penetrating keratoplasty
• Between 1998 and now there has been rapid and tremendous progress in both anterior and posterior lamellar surgery.
• Several new terminologies have been coined.
Corneal SoupCorneal Soup• DALK (Deep Anterior Lamellar Keratoplasty)
• PLK (Posterior Lamellar Keratoplasty)
• DLEK (Deep Lamellar Endothelial Keratoplasty)
• DSEK (Descemet’s Stripping Endothelial Keratoplasty)
• DSAEK (Descemet’s Stripping AutomatedEndothelial Keratoplasty)
• DMEK (Descemet’s Membrane Endothelial Keratoplasty)
PLK/ DLEK SurgeryPLK/ DLEK Surgery
Donor tissue placed into recipient
Scleral incision, deepcorneal pocket, and endothelium trephined
Posterior stromal disc and endothelium removed from pocket
Endothelium replaced with no sutures, supported by air bubble in anterior chamber. Surface remains smooth with no astigmatism
During the same time, on the other side of During the same time, on the other side of the Atlantic, Mark Terry from Portland, the Atlantic, Mark Terry from Portland, Oregon Oregon –– modified and modified and popularisedpopularised the the MellesMelles technique of PLK as:technique of PLK as:
Deep Lamellar Endothelial KeratoplastyDeep Lamellar Endothelial Keratoplasty(DLEK)(DLEK)
DLEK
Video of small incision DLEKVideo of small incision DLEK Early visual rehabilitation with DLEK : Early visual rehabilitation with DLEK : 1 week1 week
MR = MR = --1.25 + 2.00 X 92 = 6/91.25 + 2.00 X 92 = 6/9--11
DLEK REDLEK RE vsvs PK LEPK LE22 months s/p DLEK:months s/p DLEK:
--0.75 + 0.25 X 89 = 6/90.75 + 0.25 X 89 = 6/999 months s/p PK:months s/p PK:
--5.25 + 3.75 X 49 = 6/95.25 + 3.75 X 49 = 6/9Same PatientSame Patient
PK RE PK RE vsvs DLEK LEDLEK LE2 years2 years s/p PK:s/p PK:
--4.25 + 4.75 X 70 = 6/124.25 + 4.75 X 70 = 6/1211 monthmonth s/p DLEK with Phaco:s/p DLEK with Phaco:
--1.00 + 1.50 X 170 = 6/121.00 + 1.50 X 170 = 6/12Same PatientSame Patient
DLEK/ PLK PitfallsDLEK/ PLK PitfallsTechnically very very difficult procedureTechnically very very difficult procedureVery few surgeons took upVery few surgeons took upNever Never ““caught oncaught on””Disc dislocationDisc dislocationEndothelial cell loss and long term survivalEndothelial cell loss and long term survivalReduced BCVA from interface hazeReduced BCVA from interface haze
MellesMelles et al: A technique to excise the et al: A technique to excise the DescemetDescemet membrane from a recipient cornea membrane from a recipient cornea ((DescemetorhexisDescemetorhexis) ) -- Cornea 2004;23:286Cornea 2004;23:286--288288
DSEK : Descemet’s Stripping Endothelial Keratoplasty.
DSAEK: Descemet’s stripping automated endothelial Keratoplasty
DLEK
DSEK/ DSAEK
Video of DSEKVideo of DSEK Moria ALTK SystemMoria ALTK System
Operating microscopeOperating microscope
Day 1
When things go well Day 1 post op – 6/60
1 week: 6/12 1 month: 6/9
Fuchs Endothelial Dystrophy with sub epithelial scarring
Day 1: 6/60 Day 1: 6/60
Day 7: 6/9 Day 7: 6/9
Top Hat PKTop Hat PK““Keratoplasty in two planesKeratoplasty in two planes”” by Jose by Jose BarraquerBarraquer 50 years ago 50 years ago
Described by Described by BusinBusin* from Italy in 2003* from Italy in 2003
Combines the visual outcomes of PKP Combines the visual outcomes of PKP with the woundwith the wound--healing advantage of healing advantage of lamellar keratoplasty.lamellar keratoplasty.
* * BusinBusin M . A new lamellar wound configuration for penetrating M . A new lamellar wound configuration for penetrating keratoplasty surgery. Arch Ophthalmol. 2003;121:260keratoplasty surgery. Arch Ophthalmol. 2003;121:260--265265
Copyright restrictions may apply.
Busin, M. Arch Ophthalmol 2003;121:260-265.
Top Hat ConfigurationTop Hat Configuration
Results : Clinical AppearanceResults : Clinical Appearance
Where are we todayWhere are we today
• PK is no more the gold standard.
• Selective lamellar transplantation – based on the level of pathology.
• Field of selective endothelial transplantation is rapidly becoming popular and is being constantly refined.
• Where next ………..
Graft Rejection Graft Rejection EndothelialEndothelial Cell LossCell Loss
The Future of corneal transplantsThe Future of corneal transplantsFemtosecond laser assisted Femtosecond laser assisted
corneal transplantation corneal transplantation
Femtosecond laserFemtosecond laser
Femtosecond laserFemtosecond laser1053 nm (near infrared)1053 nm (near infrared)
Each pulse of focused laser light lasts Each pulse of focused laser light lasts approximately 10approximately 10--1515 seconds seconds (500(500--800 800 femtoseconds)femtoseconds) • In one second, light travels 7.5
times around the globe• In 100 femtoseconds, light
travels across a human hair• Power = Energy/Time,
extremely high power attained at relatively low energy
EXITHELP MAIN MENU
FS laserFS laserSurgical effect is achieved through Surgical effect is achieved through ““PhotodisruptionPhotodisruption””
No thermal or shock wave transmission to No thermal or shock wave transmission to surrounding tissuessurrounding tissues
Pulses Pulses focused to focused to precise precise locations (locations (±± 5 5 microns) microns) Optical Optical delivery system delivery system place place pulses next to pulses next to each other creating flaps, incisions, lamellar each other creating flaps, incisions, lamellar resections, keratectomy resections, keratectomy
EXITHELP MAIN MENU
Optical Delivery SystemOptical Delivery System
Laser is set to desired Laser is set to desired depthdepth
Defined distance from Defined distance from bottom of glass applanation bottom of glass applanation surface surface
Pulses delivered in a Pulses delivered in a prescribed pattern creating a prescribed pattern creating a horizontal or vertical horizontal or vertical cleavage plane in the cornea cleavage plane in the cornea
EXITHELP MAIN MENU
PhotodisruptionPhotodisruptionPhotodisruption
A pulse of laser energy is focused to a precise location inside the cornea
A microplasma is created, vaporizing approximately 1 micron of corneal tissue
1 Micron
EXITHELP MAIN MENU
PhotodisruptionPhotodisruptionPhotodisruption
An expanding bubble of gas & water is createdseparating the corneal lamellae
5 to 12 Microns
EXITHELP MAIN MENU
PhotodisruptionPhotodisruptionPhotodisruption
The bi-products of photodisruption (CO2 & water) are absorbed by the mechanism of the endothelial
pump, leaving a resection plane in the cornea
EXITHELP MAIN MENU
PhotodisruptionPhotodisruptionPhotodisruption
Thousands of laser pulses are connected together in a raster pattern to define a resection plane
EXITHELP MAIN MENU
PhotodisruptionPhotodisruptionPhotodisruption
Gas & water are absorbed or liberated when corneal flap is lifted
A resection plane is created
EXITHELP MAIN MENU
PhotodisruptionPhotodisruptionPhotodisruption
Laser pulses can be stacked on each other to create a vertical cleavage plane
EXITHELP MAIN MENU
Control PanelControl Panel
MicroscopeMicroscope
Laser Aperture& Loading DeckLaser Aperture& Loading Deck
Display Panel & Keyboard
Display Panel & Keyboard
Emergency Shut Off
Emergency Shut Off
BeamDeliveryDevice
BeamDeliveryDevice
Power &Accessories
Power &Accessories
Key SwitchDisk DrivesKey SwitchDisk Drives
LaserConsoleLaser
Console
JoystickJoystick
Allowed Cut PatternsAllowed Cut Patterns
Lamellar Cut Posterior Side Cut
Anterior Side Cut Full
Thickness
Ring Cut
The IntraLase FS Laser has received FDA clearance to perform a wide variety of corneal cuts
Top HatTop Hat
Zig ZagZig Zag MushroomMushroom
SALK
DALK
DSAEK
Top hat PK
2007
DLEK-2002
DSEK / DSAEK-2004
Femtosecond laser assisted PK
1905
7th Dec1944, Eye Bank
PLK -1998