Eye Penetration

Eye Penetration

↑ The Wills Eye Manual, 4th Edition. Kunimoto, Kanitkar, & Makar. Lippincott, 2004.

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This page was last edited on May 26, 2022, at 16:54.
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The choice of type of anesthesia for a penetrating keratoplasty depends on patient-specific factors and the surgeon's comfort levels. If a patient expresses anxiety and is likely to move around during the surgery, the surgeon may seriously consider general anesthesia. Alternatively, some ophthalmic centers routinely perform all penetrating keratoplasties with MAC and a peri- or retrobulbar block. In these cases, it is crucial to perform adequate ocular massage after the block to minimize posterior pressure. Furthermore, the surgical team may consider additional measures to minimize posterior pressure such as a reverse Trendelenburg position or IV mannitol. Pediatric cases are typically always performed under general anesthesia.

Before initiating the surgery, the surgeon should decide on the appropriate size of the corneal trephine and donor punch. Typically, a trephine is selected to encompass the entirety of the corneal pathology (e.g. in cases of microbial infections). Sometimes in the case of microbial keratitis, the infection extends beyond the limbus. In these cases, the surgeon may choose to perform a larger corneoscleral graft. In other extensive cases, such as with corneal dystrophies, corneal trephination may not include the entirety of the pathology. In these cases, a smaller graft can be used as long as it allows for the visual axis to be clear. The use a corneal button 0.25-0.50mm larger than the diameter of the host corneal opening is recommended as it can help reduce excessive postoperative corneal flattening, reduce the risk of secondary glaucoma, and enhance wound closure. In cases of keratoconus, some surgeons will opt to use a corneal button the same size as the host corneal trephination, in anticipation of potential future graft steepening.

After selecting the sizes of the trephine and punch, the following steps are performed:

Penetrating keratoplasty may be combined with cataract surgery, secondary intraocular lens implantation, glaucoma surgery, and retinal surgery. In cases of combined retinal surgery, often a temporary keratoprosthesis is sutured in place first to allow for the retina surgeon to visualize the posterior segment. After completion of the retinal surgery, the temporary keratoprosthesis is replaced with the permanent corneal graft.

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