Transplantation of Suboptimal Corneal Donor Tissue: A Case Series

Elsie Chan, FRANZCO

Graeme Pollock, PhD

Rasik B. Vajpayee, FRANZCO

World Cornea Congress, 2015 Financial interests: nil

Introduction• Current standards for procurement and preparation of corneal donor

tissue involves:– Extensive history from next-of-kin– Slit lamp biomicroscopy of the corneo-scleral button (where the tissue

is examined in preservation medium in a bottle)– Serological and microbiological testing– Specular microscopy for endothelial cell structure and density

• There are limitations to the current screening methods, with cases of transplantation using suboptimal tissue (eg. previous refractive surgery) reported.1-3

Aim and MethodsAim• To present a series of patients who were observed to have corneal opacities in the donor

corneal tissue immediately following corneal transplantation

Study Design• Retrospective case series

Cases• 4 transplants performed using corneal buttons from 3 donors in Melbourne, Australia in

2014

Donor tissues• Prepared at a single eye bank service• No history of surgery or other pathology in any of the donor corneas was reported based

on clinical history from next-of-kin

Case 1

History• 50 year old male• History of keratoconus and previous penetrating keratoplasty• Developed post-graft ectasia• Underwent a repeat penetrating keratoplasty

Post-operative finding• Corneal opacity in mid-stroma, postulated to have been from previous

trauma

Outcome• Patient happy with visual acuity, no further intervention required

Case 1

Photograph showing mid stromal opacity in the donor button (see arrow)

History• 40 year old male• History of keratoconus • Underwent Dia-DALK4

Post-operative finding• Anterior stromal opacity

across corneal button

Outcome• Repeat Dia-DALK performed Anterior Segment OCT (Zeiss HD-OCT 4000, Carl Zeiss

Meditec, CA) image showing an anterior stromal opacity across donor tissue

Case 2a

Case 2bHistory• 20 year old male• History of advanced keratoconus • Underwent DALK (using Melles’ technique5)

Donor button• Fellow eye of donor in Case 2a

Post-operative finding• Thin donor button measuring 470µm on anterior segment OCT 1 month

post-operatively

Outcome• Patient happy with visual acuity, no further intervention required

Case 2b

Thin donor button measuring 470µm on anterior segment OCT (Visante OCT, Carl Zeiss Meditec, CA). This is the fellow eye of Case 2a

Case 3

History• 50 year old male• History of keratoconus and previous penetrating keratoplasty• Sustained blunt trauma leading to aphakia, aniridia, graft dehiscence

and graft failure• Underwent penetrating keratoplasty and insertion of aniridic IOL

Post-operative finding• 3 central corneal scars on the donor button consistent with a previous

corneal foreign body

Outcome• Patient happy with visual acuity; no further intervention required

Case 3

Photograph showing three anterior stromal opacities in the donor tissue

Discussion• Current techniques to screen donor corneal tissue for transplantation may

not be sufficient to exclude pathologies including corneal scars and previous refractive laser surgery– History taking from the next-of-kin can be inaccurate or misleading6

– Slit-lamp examination of donor corneo-scleral buttons is difficult– Subtle pathologies can be difficult to detect in donated eyes

(secondary to post-mortem stromal oedema and epithelial changes) • To decrease the number of suboptimal donor corneal tissue

– Utilisation of more advanced imaging techniques including ocular coherence tomography7, pachymetry and curvature maps8 may be advantageous

– Additional training of eye bank staff in recognising corneal pathology may also be helpful

References1Maharana P et al. Optom Vis Sci 2014; 91: e59. 2Mendez Angulo E. Refract Corneal Surg 1989; 5: 198. 3Michaeli-Cohen A et al. Cornea 2002; 21: 1114Vajpayee R et al. JCRS 2014;40:2765Melles GRJ et al. BJO 1999 83: 3276Kang SJ et al. Cornea 2010; 29: 6707Priglinger SG et al. Cornea. 2003;22:46. 8Ousley PJ and Terry MA. Cornea. 2002; 21:181.

ACKNOWLEDGEMENTSMedical Photography and Imaging Centre, Royal Victorian Eye and Ear Hospital, Melbourne, Australia and the Vision Eye Institute, Melbourne, Australia for the images used in this poster.