Corneal Transplant for Keratoconus: What to Expect

For the vast majority of people with keratoconus, vision can be successfully managed with specialty contact lenses or stabilized with Corneal Cross-linking. However, in about 10% to 15% of cases, the condition may progress to a point where surgical intervention is necessary. This is where a corneal transplant (also known as a keratoplasty) comes into play.

While the idea of a transplant can be daunting, it is important to know that corneal transplants for keratoconus have some of the highest success rates of any transplant surgery in the world. Here is a guide to why they are performed, the different types of surgery, and the road to recovery.

When is a Transplant Necessary?

A transplant is generally considered a "last resort" when other management options have been exhausted. Your surgeon might recommend a transplant if:

• Corneal Scarring: The "peak" of the cone has developed significant scarring that blocks vision and cannot be bypassed with a lens.
• Extreme Thinning: The cornea has become so thin that it is at risk of perforation or can no longer support a contact lens.
• Contact Lens Intolerance: The irregular shape of the eye has become so steep that even specialized scleral lenses can no longer fit comfortably or stay on the eye.
• Hydrops: A history of acute hydrops has left the cornea with permanent, vision-obscuring cloudiness.

Types of Corneal Transplants

In years past, every transplant was a "full thickness" replacement. Today, surgeons can often replace only the specific layers of the cornea that are damaged, which can lead to faster healing and lower rejection rates.

1. Penetrating Keratoplasty (PKP)

This is the traditional "full-thickness" transplant. The surgeon removes a circular, button-sized portion of your damaged cornea and replaces it with a healthy donor cornea. This new tissue is held in place with microscopic sutures (stitches) that are often finer than a human hair.

2. Deep Anterior Lamellar Keratoplasty (DALK)

DALK is a "partial-thickness" transplant. In this procedure, the surgeon removes the outer and middle layers of the cornea (the epithelium and stroma) but leaves your own healthy inner layer (the endothelium) intact. The Benefit: Because your body’s own inner layer is preserved, the risk of your immune system rejecting the donor tissue is significantly lower compared to a PKP.

The Procedure and Recovery

The surgery is typically performed as an outpatient procedure under local or general anesthesia. While the surgery itself usually takes less than an hour, the "visual recovery" is a marathon, not a sprint.

• Immediate Aftercare: You will wear an eye patch for the first day and a protective shield while sleeping for several weeks. You will also use steroid and antibiotic eye drops to prevent infection and rejection.
• Sutures (Stitches): These remain in your eye for several months, sometimes up to a year or more. Your surgeon will gradually remove them as the cornea heals and "settles" into its new shape.
• Vision Stabilization: Your vision will fluctuate significantly in the months following surgery. It can take 6 to 12 months for the eye to heal enough to get a final prescription for glasses or contact lenses.

Important Realities: Life After Transplant

It is a common misconception that a transplant "cures" keratoconus and results in 20/20 vision without help. While the surgery provides a clear, stable window for the eye, most patients will still have astigmatism after the procedure.

Most transplant recipients will still need to wear glasses or specialty contact lenses (like scleral lenses) to achieve their best possible vision. The goal of the transplant is to provide a healthy foundation so that these lenses can finally work effectively.

Risks and Rejection

The most significant risk with any transplant is rejection, where the body's immune system recognizes the donor tissue as foreign. Symptoms of rejection include:

• Redness
• Sensitivity to light
• Vision loss
• Pain

Patients are taught the "RSVP" acronym to remember these signs. If caught early, most rejection episodes can be successfully treated with medicated eye drops.

Conclusion

A corneal transplant is a life-changing procedure that has restored sight to millions of people with advanced keratoconus. While the recovery requires patience and diligent follow-up care, the result is often a dramatic improvement in quality of life. If your specialist has mentioned a transplant, remember that you are moving toward a clearer, more stable future for your vision.