Corneal Transplant (Keratoplasty) - DALK & DSEK Explained

Introduction to Corneal Transplant (Keratoplasty)

A corneal transplant, medically known as keratoplasty, is a surgical procedure that replaces damaged or diseased corneal tissue with healthy donor tissue. The cornea is the clear, dome-shaped surface at the front of your eye, playing a crucial role in focusing vision. When it becomes scarred, swollen, or distorted due to injury, infection, or genetic conditions, a transplant may be necessary to restore vision.

Modern techniques like DALK (Deep Anterior Lamellar Keratoplasty) and DSEK (Descemet's Stripping Endothelial Keratoplasty) have revolutionized corneal transplants by allowing selective replacement of only the affected layers, leading to faster recovery and fewer complications. Whether you're struggling with keratoconus, Fuchs' dystrophy, or corneal scarring, understanding your options can help you make an informed decision about your eye health.

This guide will walk you through everything you need to know—from different transplant types to recovery tips—so you can approach your procedure with confidence.

Types of Corneal Transplants (DALK, DSEK, PKP, etc.)

Corneal transplants are not one-size-fits-all. Depending on which layer of your cornea is damaged, your surgeon may recommend one of these procedures:

• Penetrating Keratoplasty (PKP): The traditional full-thickness transplant, replacing all corneal layers. Used for severe scarring or advanced keratoconus.
• Deep Anterior Lamellar Keratoplasty (DALK): Replaces only the front and middle layers, preserving the healthy inner endothelium. Ideal for keratoconus or superficial scars.
• Descemet's Stripping Endothelial Keratoplasty (DSEK): Targets only the innermost layer (endothelium), common for Fuchs' dystrophy. Uses a thin donor graft inserted through a small incision.
• Descemet's Membrane Endothelial Keratoplasty (DMEK): An advanced form of DSEK using an even thinner tissue layer for faster visual recovery.

Minimally invasive techniques like DALK and DSEK reduce rejection risks and recovery time compared to PKP. Your ophthalmologist will determine the best approach based on your condition.

Who Needs a Corneal Transplant? (Indications & Symptoms)

Corneal transplants are recommended when vision impairment cannot be corrected with glasses, contacts, or medications. Common conditions include:

• Keratoconus: A thinning and bulging cornea causing distorted vision.
• Fuchs' Dystrophy: Progressive endothelial cell loss leading to corneal swelling.
• Corneal Scarring: From infections (like herpes keratitis) or injuries.
• Bullous Keratopathy: Blistering due to endothelial failure, often post-cataract surgery.

Symptoms that may signal the need for a transplant:

• Blurred vision unresponsive to corrective lenses
• Severe pain or light sensitivity
• Clouding or haziness in the cornea
• Recurrent corneal ulcers

Early evaluation by a corneal specialist is key to preventing irreversible vision loss.

Preparing for Corneal Transplant Surgery

Proper preparation ensures a smoother surgery and recovery. Here’s what to expect:

1. Pre-Operative Testing: Your surgeon will perform a thorough eye exam, including corneal topography and pachymetry, to map your cornea’s shape and thickness.

2. Donor Tissue Matching: Unlike organ transplants, corneas don’t require blood type matching. However, tissue quality and size are carefully screened.

3. Medication Adjustments: You may need to stop blood thinners or certain eye drops beforehand. Antibiotic drops might be prescribed to prevent infection.

4. Logistics: Arrange for transportation post-surgery (you won’t be able to drive). Stock up on groceries and prepare a recovery space at home.

Pro Tip: Ask your surgeon about the “visual recovery timeline”—DSEK/DALK patients often see improvement within weeks, while PKP may take months.

Step-by-Step Surgical Procedure (DALK & DSEK Explained)

While techniques vary, here’s a general overview of what happens during DALK and DSEK:

DALK Procedure:

1. Anesthesia: Local or general anesthesia is administered.
2. Partial-Thickness Removal: The surgeon peels away the diseased outer and middle layers, leaving the healthy endothelium intact.
3. Donor Graft Placement: A precisely cut donor graft is stitched or glued into place.

DSEK Procedure:

1. Small Incision: A 3–5 mm opening is made instead of a full corneal cut.
2. Endothelial Layer Removal: The damaged inner layer (Descemet’s membrane) is gently stripped away.
3. Air Bubble Insertion: The donor tissue is folded, inserted, and positioned using an air bubble to adhere it.

Both surgeries take 1–2 hours, and most patients go home the same day. Stitches (if used) are removed months later during follow-ups.

Recovery & Post-Operative Care

Recovery varies by procedure, but these guidelines apply to most patients:

First Week:

• Wear a protective eye shield at night.
• Use prescribed antibiotic and steroid drops to prevent infection/rejection.
• Avoid rubbing your eye or strenuous activities.

First Month:

• Attend all follow-ups to monitor graft attachment (especially critical for DSEK’s air bubble).
• Vision may fluctuate; DSEK patients often notice improvement within 2–4 weeks.

Long-Term:

• Full visual recovery can take 6–12 months (longer for PKP).
• Use sunglasses outdoors to protect against UV damage.

Note: DSEK/DALK patients typically resume normal activities sooner than PKP recipients.

Risks & Possible Complications

While corneal transplants have high success rates, potential risks include:

• Graft Rejection (5–30% risk): Your immune system may attack the donor tissue. Symptoms like redness, pain, or vision loss require immediate treatment.
• Infection: Rare but serious; strict hygiene with eye drops minimizes this risk.
• Astigmatism: Irregular corneal curvature may require glasses or laser correction post-surgery.
• Glaucoma: Steroid drops can increase eye pressure, needing monitoring.

Red Flags: Sudden vision decline, severe pain, or increased light sensitivity warrant an immediate call to your surgeon. Early intervention often saves the graft.

Success Rates & Long-Term Outcomes

Corneal transplants boast some of the highest success rates among organ transplants:

• PKP: 80–90% success at 5 years; may need repeat surgery if rejection occurs.
• DSEK/DMEK: 90–95% success due to selective layer replacement.
• DALK: 85–95% success for keratoconus, with lower rejection risk than PKP.

Factors Affecting Success: Underlying conditions (e.g., dry eye), adherence to post-op care, and surgeon experience play key roles. Most patients achieve significantly improved vision, though some may still need glasses/contacts for fine-tuning.

FAQs About Corneal Transplants