What is Cornea Transplantation?

Cornea Transplantation in India: Understanding the Procedure and Treatment

Of all the tissue transplants performed in medicine, corneal transplantation is among the most successful and one of the longest established. Surgeons have been replacing diseased corneas with donor tissue for over a century, and the procedure has a track record that very few surgical interventions can match.

The cornea is the clear dome that covers the front of the eye. It contributes significantly to the eye’s focusing power and, more basically, it needs to be transparent for light to pass through to the retina at all. When disease, infection, trauma, or a genetic condition clouds or distorts the cornea, vision degrades in ways that glasses and contact lenses often cannot adequately correct. A transplant replaces the problem tissue with healthy donor cornea from someone who chose to donate their eyes after death.

What has changed most dramatically in recent decades is the surgical approach. Full-thickness transplants, where the entire corneal thickness is replaced, were once the only option. Now surgeons can selectively replace just the diseased layer while leaving the healthy layers intact.

A patient with Fuchs’ endothelial dystrophy, where only the inner cell layer fails, no longer needs a full-thickness graft. A patient with a deep stromal scar but healthy inner cells keeps their own endothelium. These selective techniques have transformed recovery times and long-term outcomes.

Corneal blindness affects an estimated 6.8 million people in India across at least one eye. The causes are somewhat different from the Western pattern: corneal scarring from herpes simplex and bacterial infections is more common here, partly reflecting the higher burden of infectious disease. Chemical injuries, trachoma (now declining but historically significant), advanced keratoconus, and surgical complications all contribute to the pool of patients needing transplantation.

The supply problem is acute. India performs roughly 40,000 corneal transplants a year, which sounds like a large number until you set it against the demand. Cultural hesitation about eye donation, limited awareness, and inconsistent retrieval systems mean that the country recovers far fewer corneas than it could. Patients wait. Some wait long enough that their condition deteriorates while they do.

Types of Cornea Transplantation Available in India

Cornea Transplantation: How the Procedure Works

In penetrating keratoplasty, the traditional approach, a circular trephine cuts through the full thickness of the diseased cornea and a matching donor button is sutured into the gap using extremely fine 10-0 nylon sutures. These sutures stay in place for a year or more while the graft heals. The central corneal surface is re-established by donor tissue from the start.

Endothelial keratoplasty, which covers DSAEK, DMEK, and PDEK, works through a small incision. The surgeon peels away the diseased inner layer of the host cornea and slides in the prepared donor disc through the incision. The disc is unfolded inside the eye and then held flat against the host cornea using an air or gas bubble injected into the anterior chamber. That bubble does the work a suture would do in PK, pressing the graft into contact while it adheres. No sutures cross the central cornea, which means less induced astigmatism and faster visual recovery.

DALK takes a different approach again. The front layers of the cornea are dissected away down to Descemet’s membrane, using air injected into the stroma to create a clean separation (the big bubble technique). Donor anterior stroma is then sutured in place, and the patient’s own endothelium is left completely untouched. Because the host endothelium is preserved, there is no risk of endothelial rejection, which is the most serious type.

When is Cornea Transplantation Necessary?

• Vision loss from corneal scarring or opacity that glasses, contact lenses, and drops cannot correct
• Advanced keratoconus where contact lens fitting is no longer possible and laser surgery is not safe
• Fuchs’ endothelial dystrophy causing persistent corneal swelling and blurred vision unresponsive to hypertonic saline drops
• Bullous keratopathy, where the inner cell layer fails and painful blisters form on the corneal surface
• Corneal ulcers or perforations that threaten the structural integrity of the eye
• Chemical or thermal burns causing irreversible corneal damage

Cornea Transplantation: Step-by-Step Procedure

1. Pre-operative workup: Corneal topography, pachymetry, specular microscopy of donor tissue, and full eye examination.
2. Donor tissue preparation: Cornea is procured from a licensed eye bank and checked for endothelial cell count and clarity.
3. Anaesthesia: Peribulbar or general anaesthesia is administered.
4. Trephination (for PK): A circular trephine removes the full-thickness diseased corneal button.
5. Donor suturing (for PK): The donor button is sutured in place with interrupted or continuous 10-0 nylon sutures.
6. Endothelial graft insertion (for DSAEK, DMEK, PDEK): The prepared donor disc is folded, inserted through a small incision, and positioned with a gas bubble.
7. Wound closure and pressure check: The eye is checked for wound integrity and appropriate intraocular pressure before the patient leaves the table.
8. Post-operative steroid drops: Initiated immediately to reduce the risk of graft rejection.

How Much Does Cornea Transplantation Cost in India?

Cornea Transplantation: Post-Surgery Care and Recovery

What to Expect After the Procedure?

Recovery after corneal transplantation tests patients’ patience more than almost any other eye surgery. After penetrating keratoplasty, vision improvement is gradual and unpredictable. The sutures distort the corneal surface while they are in place, and they need to be selectively removed over many months as the graft heals and the astigmatism pattern becomes clear. Full stabilisation can take a year or longer.

After endothelial keratoplasty, the picture is considerably better. No sutures cross the visual axis, and most patients notice meaningful improvement within two to four months. That said, the gas bubble used to hold the graft in the early post-operative period requires patients to lie face-up as much as possible in the first day or two, which is uncomfortable but important.

Graft rejection is a risk that does not disappear. It is most likely in the first two years but can occur at any time. Steroid drops are used long-term, sometimes indefinitely, to keep this risk as low as possible. The warning signs of rejection, sudden redness, pain, sensitivity to light, and a drop in vision, need to be treated as an emergency and not left until the next scheduled appointment.

Post-Operative Care Tips

• Use steroid and antibiotic drops exactly as directed and never stop without your surgeon’s explicit guidance
• Do not rub the eye, particularly in the months immediately after surgery
• Wear protective eyewear outdoors and during sleep for the period your surgeon advises
• After endothelial keratoplasty, maintain the head positioning instructions given by your surgeon to keep the gas bubble in the correct position
• Avoid heavy lifting, swimming, and strenuous activity for at least one month
• Know the signs of rejection: sudden redness, pain, light sensitivity, or any unexplained drop in vision. These need same-day attention, not a wait-and-see approach
• Attend every follow-up appointment. Rejection caught early can often be reversed with intensive steroid drops

References

Mayo Clinic. Cornea Transplant. https://www.mayoclinic.org/tests-procedures/cornea-transplant/about/pac-20385285

StatPearls, NCBI. Corneal Transplantation. https://www.ncbi.nlm.nih.gov/books/NBK539690/

Cleveland Clinic. Cornea Transplant. https://my.clevelandclinic.org/health/treatments/17714-cornea-transplant

PubMed. Outcomes of Corneal Transplantation. 2019. https://pubmed.ncbi.nlm.nih.gov/30969512/