GLAUCOMA

INTRODUCTION

Glaucoma is a build up of pressure within the eye that causes

damage to the optic nerve.There is a small space in the front of the eye called the anterior
chamber. Clear liquid flows in and out of the anterior chamber, this fluid nourishes and
bathes nearby tissues. If a patient has glaucoma, the fluid drains too slowly out of the eye.
This leads to fluid build-up, and pressure inside the eye rises.

DEFINITION

Glaucoma is a group of eye diseases which result in damage to the optic nerve and vision
loss.

Glaucoma is a disease of the eye in which fluid pressure within the

eye rises; if left untreated, the patient may lose vision and even become blind. Glaucoma
has been called the silent thief of sight.

CAUSES

 Primary glaucoma - this means that the cause is unknown.

 Secondary glaucoma - the condition has a known cause, such as a tumor, diabetes, an
advanced cataract, or inflammation.

RISK FACTORS

According to the World Health Organization (WHO), glaucoma is the

second leading cause of blindness around the world. The risk factors for glaucoma
include:

Age
People over 60 are at increased risk of glaucoma, warns the NEI, and the risk of glaucoma
increases slightly with each year of age. If you’re African-American, your increase in risk
begins at age 40.

Ethnicity

African-Americans or people of African descent are significantly more likely to develop

glaucoma than Caucasians. People of Asian descent are at a higher risk of angle-closure
glaucoma, and people of Japanese descent have a higher risk of developing low-tension
glaucoma.

Eye Problems

Chronic eye inflammation and thin corneas can lead to increased pressure in your eyes.
Physical injury or trauma to your eye, such as being hit in your eye, can also cause your eye
pressure to increase.

Family History

Some types of glaucoma may run in families. If your parent or grandparent had open-angle
glaucoma, you’re at an increased risk of developing the condition.

Medical History

People with diabetes and those with high blood pressure and heart disease have an increased
risk of developing glaucoma.

Use of Certain Medicine

Using corticosteroids for extended periods may increase your risk of developing secondary
glaucoma.

PATHOPHYSIOLOGY
 Obstruction to outflow of aqueous humor through the trabecular meshwork into Schlemm’s
canal

raised intraocular pressure

compresses and damages the optic nerve

it fails to carry visual information to the brain

results in loss of vision.

TYPES

The two major categories of glaucoma are open-angle glaucoma (OAG) and narrow angle
glaucoma. The "angle" in both cases refers to the drainage angle inside the eye that controls
the outflow of the watery fluid (aqueous) that is continually being produced inside the eye.

If the aqueous can access the drainage angle, the glaucoma is known as open angle glaucoma.
If the drainage angle is blocked and the aqueous cannot reach it, the glaucoma is known as
narrow angle glaucoma.

Variations of OAG include: primary open angle glaucoma (POAG), normal-tension

glaucoma (NTG), pigmentary glaucoma, pseudoexfoliation glaucoma, secondary glaucoma
and congenital glaucoma.

Variations of narrow angle glaucoma include include acute angle closure glaucoma, chronic
angle closure glaucoma, and neovascular glaucoma.
 Primary open-angle glaucoma. This common type of glaucoma gradually reduces
one’s peripheral vision without other symptoms. By the time we notice it, permanent
damage already has occurred.
If the IOP remains high, the destruction caused by POAG can progress until tunnel
vision develops, and the person will be able to see only objects that are straight ahead.
Ultimately, all vision can be lost, causing blindness.

 Acute angle-closure glaucoma. Also called narrow-angle glaucoma, acute angle-

closure glaucoma produces sudden symptoms such as eye pain, headaches, halos
around lights, dilated pupils, vision loss, red eyes, nausea and vomiting.
These signs constitute a medical emergency. The attack may last for a few hours, and
then return again for another round, or it may be continuous without relief. Each
attack can cause progressively more vision loss.

 Normal-tension glaucoma. Like POAG, normal-tension glaucoma (also called

normal-pressure glaucoma, low-tension glaucoma or low-pressure glaucoma) is a type
of open-angle glaucoma that can cause visual field loss due to optic nerve damage.
But in normal-tension glaucoma, the eye's IOP remains in the normal range.
Also, pain is unlikely and permanent damage to the eye's optic nerve may not be
noticed until symptoms such as tunnel vision occur.
The cause of normal-tension glaucoma is not known. But many doctors believe it is
related to poor blood flow to the optic nerve. Normal-tension glaucoma is more
common in those who are Japanese, are female and/or have a history of vascular
disease.

 Pigmentary glaucoma. This rare form of glaucoma is caused by clogging of the

drainage angle of the eye by pigment that has broken loose from the iris, reducing the
rate of aqueous outflow from the eye. Over time, an inflammatory response to the
blocked angle damages the drainage system.
The person is unlikely to notice any symptoms with pigmentary glaucoma, though
some pain and blurry vision may occur after exercise. Pigmentary glaucoma most
frequently affects white males in their mid-30s to mid-40s.
  Secondary glaucoma. Symptoms of chronic glaucoma following an eye injury could
indicate secondary glaucoma, which also may develop with presence of eye infection,
inflammation, a tumor or enlargement of the lens due to a cataract.

 Congenital glaucoma. This inherited form of glaucoma is present at birth, with 80

percent of cases diagnosed by age one. These children are born with narrow angles or
some other defect in the drainage system of the eye.
It's difficult to spot signs of congenital glaucoma, because children are too young to
understand what is happening to them. If one notice a cloudy, white, hazy, enlarged or
protruding eye in his child, consult an eye doctor. Congenital glaucoma typically
occurs more in boys than in girls.

CLINICAL MANIFESTATIONS

The most common type of glaucoma is primary open-angle glaucoma. It shows signs or
symptoms such as:

 Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes

 Tunnel vision in the advanced stages

Acute-angle closure glaucoma, which is also known as narrow-angle glaucoma, is a medical

emergency the following symptoms will be there:

 severe eye pain

 nausea

 vomiting

 redness in your eye

 sudden vision disturbances

 seeing colored rings around lights

 sudden blurred vision

MANAGEMENT

The damage caused by glaucoma can't be reversed. But treatment and regular checkups can
help slow or prevent vision loss, especially if the disease is in its early stage.The goal of
glaucoma treatment is to lower pressure in the eye (intraocular pressure).

Eyedrops

Glaucoma treatment often starts with prescription of eyedrops. These can help decrease eye
pressure by improving how fluid drains from the eye or by decreasing the amount of fluid
the eye makes.

Prescription eyedrop medications include:

 Prostaglandins. These increase the outflow of the fluid in the eye (aqueous humor) and
reduce pressure in the eye. Examples include latanoprost (Xalatan) and bimatoprost
(Lumigan). Possible side effects include mild reddening and stinging of the eyes,
darkening of the iris, changes in the pigment of the eyelashes or eyelid skin, and
blurred vision.

 Beta blockers. These reduce the production of fluid in the eye, thereby lowering the
pressure in the eye (intraocular pressure). Examples include timolol (Betimol,
Timoptic) and betaxolol (Betoptic). Possible side effects include difficulty breathing,
slowed heart rate, lower blood pressure, impotence and fatigue.

 Alpha-adrenergic agonists. These reduce the production of aqueous humor and

increase outflow of the fluid in the eye. Examples include apraclonidine (Iopidine) and
brimonidine (Alphagan). Possible side effects include an irregular heart rate; high blood
pressure; fatigue; red, itchy or swollen eyes; and dry mouth.

 Carbonic anhydrase inhibitors. Rarely used for glaucoma, these drugs may reduce
the production of fluid in the eye. Examples include dorzolamide (Trusopt) and
brinzolamide (Azopt). Possible side effects include a metallic taste, frequent urination,
and tingling in the fingers and toes.
  Miotic or cholinergic agents. These increase the outflow of fluid from the eye. An
example is pilocarpine (Isopto Carpine). Side effects include smaller pupils, possible
blurred or dim vision, and nearsightedness.

Oral medications

If eyedrops alone don't bring the eye pressure down to the desired level, oral medication,
usually a carbonic anhydrase inhibitor is given. Possible side effects include frequent
urination, tingling in the fingers and toes, depression, stomach upset, and kidney stones.

Surgery and other therapies

Other treatment options include laser therapy and various surgical procedures. Possible
complications include pain, redness, infection, inflammation, bleeding, abnormally high or
low eye pressure, and loss of vision. Some types of eye surgery may speed the development
of cataracts.

The following techniques are intended to improve the drainage of fluid within the eye,
lowering pressure:

 Laser therapy. Laser trabeculoplasty is an option for people with open-angle

glaucoma. A laser beam is used to open clogged channels in the trabecular meshwork.
It may take a few weeks before the full effect of this procedure becomes apparent.

 Filtering surgery. With a surgical procedure called a trabeculectomy the surgeon

creates an opening in the white of the eye (sclera) and removes part of the trabecular
meshwork.

 Drainage tubes. In this procedure,the surgeon inserts a small tube in the affected eye.

 Electrocautery. It is a minimally invasive procedure to remove tissue from the

trabecular meshwork using a small electrocautery device called a Trabecutome.
PREVENTION

One may not be able to prevent glaucoma. But these self-care steps can help to detect it
early, limit vision loss or slow its progress.

 Get regular eye care. Regular comprehensive eye exams can help detect glaucoma in
its early stages before irreversible damage occurs. As a general rule, have
comprehensive eye exams every four years beginning at age 40 and every two years
from age 65. Also need more frequent screening if at high risk of glaucoma.

 Know your family's eye health history. Glaucoma tends to run in families. If at
increased risk, may need more frequent screening.

 Exercise safely. Regular, moderate exercise may help prevent glaucoma by reducing
eye pressure. Get an opinion from the physician about an appropriate exercise
program.

 Take prescribed eyedrops regularly. Glaucoma eyedrops can significantly reduce the
risk that high eye pressure will progress to glaucoma. To be effective, eyedrops
prescribed by your doctor need to be used regularly even if you have no symptoms.

 Wear eye protection. Serious eye injuries can lead to glaucoma. Wear eye protection
when using power tools or playing high-speed racket sports on enclosed courts.

NURSING MANAGEMENT

1.Disturbed sensory perception related to visual impairment as evidenced by difficulty in free

movement , difficulty in seeing objects, frequent tendency to fall.
Goal: The patient’s sensory perception will be improved.

Interventions:
Teach the client about specific safety precautions.
 Instruct the client to avoid mydriatics such as atropine, which may precipitate acute
glaucoma in a client with closed-angle glaucoma.
 Instruct the client to carry prescribed medications at all times.
  Instruct the client to carry a medical identification card or wear a bracelet stating his
type of glaucoma and need for medication.
 Instruct the client to take extra precautions at night (e.g. use of handrails, provide
extra lighting to compensate for impaired pupil dilation from miotic use).

2. Ineffective health maintenance related to knowledge deficit as evidenced by doubtful

questioning, weight loss, dehydration etc.

Goal: The patient will be able to maintain good health.

Intervention:
 Teach the client regarding adequate food intake.
 Educate the patient regarding the necessity of taking proper diet.
 Advice the patient to take more vitamin A rich food and educate him that vitamin A
improves eye sight.
 Also advice the patient to take more protein rich diet .

3. Anxiety related to possible vision loss as evidenced by frequent doubdtfull questioning.

Goal: The patient’s anxiety will be reduced.
Interventions:
 Assess the level of anxiety of the patient.
 Provide psychological support to the patient by explaining the lifestyle
modifications to be made by the patient to compensate the loss.
 Explain the choices of treatment modalities available to the patient.
 Introduce a peer recovered from the same disease to the patient.

4. Self-care deficit related to impaired vision as evidenced by difficulty in doing activities

of daily life.
Goal: The patient will improve his self care activities.
Interventions:
 Keep all the articles at proper places and easy reach of the patient.
 Allow the patient to do the self care activities alone.
 Assist the patient when ever necessary.
  Avoid over dependence of the patient.

5. Risk for injury related to impaired vision

Goal: The risk for injury will be reduced.

Interventions:
Teach the client about specific safety precautions.
a. Instruct the client to carry prescribed medications at all times.
b. Instruct the client to carry a medical identification card or wear a bracelet stating his
type of glaucoma and need for medication.
c. Instruct the client to take extra precautions at night (e.g. use of handrails, provide
extra lighting to compensate for impaired pupil dilation from miotic use).

General Nursing Management

Provide information regarding management of glaucoma

d. Discuss preoperative and postoperative teaching for immediate surgical opening of
the eye chamber.
e. Prepare to administer carbonic anhydrase inhibitors IV or IM, to restrict production
of aqueous humor.
f. Prepare to administer osmotic agents.
g. Discuss and prepare the client for surgical or laser peripheral iridectomy after the
acute episode is relieved.
Provide information about laser trabeculoplasty, if medication therapy proves
ineffective.
BIBLIOGRAPHY

Book reference:

”Lewis,Heitkemper Dirksen”,Assessment and management of clinical problems , Medical –

Surgical Nursing , 6th edition , published by MOSBY.
Joice M Black , Jane Hokanson Hawks , Medical Surgical Nursing , Clinical management of
positive outcomes, Volume 2, 7th edition \
 CATARACT
INTRODUCTION

A cataract is a dense, cloudy area that forms in the lens of the eye. A cataract
begins when proteins in the eye form clumps that prevent the lens from sending
clear images to the retina. The retina works by converting the light that comes
through the lens into signals. It sends the signals to the optic nerve, which
carries them to the brain.

DEFINITION

A cataract is a clouding of the eye's natural lens, which lies behind the iris and
the pupil .

Cataracts are the most common cause of vision loss in people over
age 40 and is the principal cause of blindness in the world.

ETIOLOGY / RISK FACTORS

Factors that increase your risk of cataracts include:

 Increasing age

 Diabetes

 Excessive exposure to sunlight

 Smoking

 Obesity

 High blood pressure

 Previous eye injury or inflammation

 Previous eye surgery

 Prolonged use of corticosteroid medications

 Drinking excessive amounts of alcohol

TYPES OF CATARACT

Cataract types include:

 Cataracts affecting the center of the lens (nuclear cataracts). A nuclear

cataract may at first cause more nearsightedness or even a temporary
improvement in your reading vision. But with time, the lens gradually
turns more densely yellow and further clouds your vision.

As the cataract slowly progresses, the lens may even turn brown.
Advanced yellowing or browning of the lens can lead to difficulty
distinguishing between shades of color.

 Cataracts that affect the edges of the lens (cortical cataracts). A

cortical cataract begins as whitish, wedge-shaped opacities or streaks on
the outer edge of the lens cortex. As it slowly progresses, the streaks
extend to the center and interfere with light passing through the center of
the lens.

 Cataracts that affect the back of the lens (posterior subcapsular

cataracts). A posterior subcapsular cataract starts as a small, opaque area
that usually forms near the back of the lens, right in the path of light. A
posterior subcapsular cataract often interferes with your reading vision,
reduces your vision in bright light, and causes glare or halos around lights
at night. These types of cataracts tend to progress faster than other types
do.

 Cataracts you're born with (congenital cataracts). Some people are

born with cataracts or develop them during childhood. These cataracts
may be genetic, or associated with an intrauterine infection or trauma.

These cataracts also may be due to certain conditions, such as myotonic

dystrophy, galactosemia, neurofibromatosis type 2 or rubella. Congenital
cataracts don't always affect vision, but if they do they're usually removed
soon after detection.
CLINICAL MANIFESTATIONS
Signs and symptoms of cataracts include:

 Clouded, blurred or dim vision

 Increasing difficulty with vision at night

 Sensitivity to light and glare

 Need for brighter light for reading and other activities

 Seeing "halos" around lights

 Frequent changes in eyeglass or contact lens prescription

 Fading or yellowing of colors

 Double vision in a single eye

At first, the cloudiness in your vision caused by a cataract may affect only a
small part of the eye's lens and you may be unaware of any vision loss. As the
cataract grows larger, it clouds more of your lens and distorts the light passing
through the lens. This may lead to more noticeable symptoms.

DIAGNOSTIC EVALUATION

The following tests help doctors diagnose eye cataracts and determine their
severity.

 Visual Acuity: A visual acuity test measures the quality of vision at

certain distances. The patient is asked to read letters of various sizes from
a chart. Each eyes will be tested individually and together to measure the
accuracy of your eyesight at different distances. A visual acuity test is an
easy, painless, and quick way to diagnosis cataracts, although more tests
will be needed to make sure cataracts are the cause of vision problems.

 Potential Acuity Test: A potential acuity test or PAM test, is a different

way to measure how good the eye will see if the cataract did not exist.
 Surgeons need to know that the cataract surgery will improve the patient's
vision. A PAM test projects a visual acuity eye chart with letters into the
eye with a laser and by-passes the cataract. The patient simply reads the
chart similar to a normal eye chart on the wall. If the best measurement
they receive is 20/40 and not 20/20, they know that if cataract surgery is
performed on a certain eye, that they will have at least 20/40 vision after
the surgery. This test becomes more important when other eye disease
exists in addition to the cataract.

 Contrast Sensitivity: Contrast sensitivity testing is similar to visual

acuity testing but places greater emphasis on how cataracts can decrease
image contrast due to light scattering and glare caused by the cataract.
Eye doctors consider contrast sensitivity testing to be a more realistic
measurement of true quality of vision.

 Slit Lamp: A slit lamp is a special type of microscope that magnifies

eyes so that the lens can be examined to determine the presence and
severity of a cataract. The chin of the patient will be told to place on the
chin rest of the slit lamp. A light will then be directed at the eyes. By
looking through the slit lamp, the doctor can examine the lens to
determine the degree to which it is clouded.

 Pupil Dilation: Pupil dilation is a common test used in diagnosing

cataracts. Clouding of the lens is not noticeable until a cataract reaches an
advanced stage. When the eye is dilated, however, the pupil increases in
size, offering a view of the entire lens. By thoroughly examining the lens,
a doctor can determine whether or not a cataract is affecting the quality of
vision.
MANAGEMENT

Surgery

 The symptoms of early cataracts may be improved with new

prescription glasses and stronger lighting. However, once cataracts
progress to the point that impaired vision reduces a person’s quality of
life and interferes with daily activities surgery is the only effective
treatment.

Cataract surgery involves removing the cataract-damaged lens and

replacing it with a clear plastic lens known as an intraocular lens
(IOL). The aim of surgery is to restore vision (particularly distance
vision) as much as possible. IOLs of differing magnifying power can
be used to help correct pre-existing short-sightedness (myopia), long-
sightedness (hyperopia) or astigmatism.

Cataract surgery is most commonly performed as a day-stay procedure

and is usually carried out under a local anaesthetic with a light
sedation.

Surgery involves making a small incision in the front of the eye,

through which the old lens is removed and a new IOL is inserted. The
incisions are usually made using a hand-held microscopic blade but, in
recent times, laser cataract surgery has allowed computer-guided,
bladeless incisions to be made. Laser cataract surgery should not be
confused with laser eye surgery (PRK and LASIK) which is used to
correct problems with the eye's ability to focus.

There are two main techniques for the surgical treatment of

cataracts: Lens replacement. There are three lens replacement
options:
 Phacoemulsification. A portion of the anterior capsule is removed,
allowing extraction of the lens nucleus and cortex while the posterior
capsule and zonular support are left intact.
o Aphakic glasses. In aphakic glasses, objects are magnified
by 25%, making them appear closer than they actually are.
 o Contact lenses. Contact lenses provide patients with almost
normal vision, but because contact lenses need to be
removed occasionally, the patient also needs a pair pf
aphakic glasses.
o IOL implants. The most common IOL is the single focus
lens or monofocal IOLthat cannot alter the visual shape;
multifocal IOLs reduce the need for eyeglasses;
accommodative IOLS mimic the accommodative response of
the youthful, phakic eye.

 Extracapsular cataract extraction (ECCE). ECCE removes the anterior

lens and cortex, leaving the posterior capsule intact. A 10-12mm incision
is made in the front of the eye and the lens is removed. The posterior
capsule is left in place to support the new IOL. Once the new lens has
been fitted the incision in the eye is closed using tiny, invisible stitches.

If cataracts affect both eyes, only one eye is operated on at a time. It is

usually recommended that the eye is well healed before the other eye is
treated. This is generally at least one month.

 Intracapsular cataract extraction. This procedure removes the entire

lens within the intact capsule.

NURSING MANAGEMENT
Pre- operative nursing assessment
The nurse should assess:

 Recent medication intake. It is a common practice to withhold any

anticoagulant therapy to reduce the risk of retrobulbar hemorrhage.
 Preoperative tests. The standard battery of preoperative tests such as
complete bloodcount, electrocardiogram, and urinalysis are prescribed
only if they are indicated by the patient’s medical history.
 Vital signs. Stable vital signs are needed before the patient is
subjected to surgery.
 Visual acuity test results. Test results from Snellen’s and other visual
acuity tests are assessed.
 Patient’s medical history. The nurse assesses the patient’s medical
history to determine the preoperative tests to be required.

NURSING DIAGNOSIS

 Disturbed visual sensory perception related to altered sensory

reception or status of sense organs as evidenced by partial or total loos
of vision on the affected eyes.

Goal: The patient will improve his visual sensory perception.

Interventions:

o Assess the patient’s visual acuity .

o Examine for severity of cataract using various diagnostic testing
available.
o Discuss with the physician what measures can be used to cure the
disease.
o Explain the surgical procedure advised if any to the patient .

 Anxiety related to threat of permanent loss of vision/independence.

Goal: The patient’s anxiety will be reduced.

Interventions:
o Assess the severity of cataract
o Explain the various methods of treatment available for curing the
disease.
o Introduce another patient who has recovered due to the same
disease to the patient.
o Provide psychological support to the patient.
 Deficient knowledge regarding ways of coping with altered abilities
related to lack of exposure or recall, misinterpretation, or cognitive
limitations.

Explain to the patient regarding the reason for occurance of the

disease and how to prevent further complications.
 Explain to the patient the treatment modalities available for the
disease.

Explain about follow up care.

Explain the measures to be taken after the surgery inorder to prevent

further complications.

 Risk for trauma related to poor vision and reduces hand-eye

coordination.

Goal : The patient will prevent the risk of occurance of trauma.

Interventions:

o Advice the patient to restrict movement until his visual acuity is

regained to an extent.
o Advice the family members to assist the patient in all his activities
at home.
o Keep all the articles necessary to the patient near to the patient bed
side for easy reach.
o Advice the patient to be cautious while doing the activities.

PREVENTION

To reduce your risk of developing cataracts:

 protect your eyes from UVB rays by wearing sunglasses outside

 have regular eye exams
 stop smoking
 eat fruits and vegetables that contain antioxidants
 maintain a healthy weight
 keep diabetes and other medical conditions in check

COMPLICATIONS
Potential complications following cataract surgery include:
  Retrobulbar hemorrhage. Retrobulbar hemorrhage can result from
retrobulbar infiltration of anesthetic agents if the short ciliary artery is
located by the injection.
 Acute bacterial endophthalmitis. Devastating complication that
occurs in about 1 in 1000 cases.
 Toxic anterior segment syndrome. Non-infection inflammation that
is a complication of anterior chamber surgery.

BIBLIOGRAPHY

Book reference:

 Brunner and Suddarths, text book on medical surgical nursing,12 th

edition,2004, Volume 1, Wolters kliever publications.
Net reference:

 https://nurseslabs.com/cataract/
 https://www.healthline.com/health/cataract
 https://www.mayoclinic.org/diseases-conditions/cataracts/symptoms-
causes/syc-20353790
EYE TRANSPLANTATION

INTRODUCTION

Eye transplantation is a misnomer. Actually till date we are just doing corneal
transplantation that is changing of diseased cornea from the eye of a donor. It is also known
as Keratoplasty or corneal grafting.

The eye is surrounded by the orbital bones and is cushioned by pads of fat within the
orbital socket. Extraocular muscles help move the eye in different directions. Nerve signals
that contain visual information are transmitted through the optic nerve to the brain.

Orbit

The orbit is the bony eye socket of the skull. The orbit is formed by the cheekbone,
the forehead, the temple, and the side of the nose. The eye is cushioned within the orbit by
pads of fat. In addition to the eyeball itself, the orbit contains the muscles that move the eye,
blood vessels, and nerves.

The orbit also contains the lacrimal gland that is located underneath the outer portion
of the upper eyelid. The lacrimal gland produces tears that help lubricate and moisten the eye,
as well as flush away any foreign matter that may enter the eye. The tears drain away from
the eye through the nasolacrimal duct, which is located at the inner corner of the eye.

Eyelids and Eyelashes

The eyelids serve to protect the eye from foreign matter, such as dust, dirt, and other debris,
as well as bright light that might damage the eye. When you blink, the eyelids also help
spread tears over the surface of your eye, keeping the eye moist and comfortable.

The eyelashes help filter out foreign matter, including dust and debris, and prevent these from
getting into the eye.
Conjunctiva

conjunctiva is a thin, transparent layer of tissues covering the front of the eye,
including the sclera and the inside of the eyelids. The conjunctiva keeps bacteria and foreign
material from getting behind the eye. The conjunctiva contains visible blood vessels that are
visible against the white background of the sclera.

Sclera

The white part of the eye that one sees when looking at oneself in the mirror is the
front part of the sclera. However, the sclera, a tough, leather-like tissue, also extends around
the eye. Just like an eggshell surrounds an egg and gives an egg its shape, the sclera
surrounds the eye and gives the eye its shape.

The extraocular muscles attach to the sclera. These muscles pull on the sclera causing the eye
to look left or right, up or down, and diagonally.

Cornea

The cornea is the transparent, clear layer at the front and center of the eye. In fact, the cornea
is so clear that one may not even realize it is there. The cornea is located just in front of
the iris, which is the colored part of the eye. The main purpose of the cornea is to help focus
light as it enters the eye. If one wears contact lenses, the contact lens rests on the cornea.

Functions of cornea

 It helps to shield the rest of the eye from germs, dust, and other harmful matter. The
cornea shares this protective task with the eyelids, the eye socket, tears, and the sclera,
or white part of the eye.

 The cornea acts as the eye's outermost lens. It functions like a window that controls
and focuses the entry of light into the eye. The cornea contributes between 65-75
percent of the eye's total focusing power.

 When light strikes the cornea, it bends -- or refracts -- the incoming light onto the
lens.
  The cornea also serves as a filter, screening out some of the most damaging ultraviolet
(UV) wavelengths in sunlight.

Anterior Chamber

The anterior chamber is the fluid-filled space immediately behind the cornea and in front of
the iris. The fluid that fills this chamber is called the aqueous humor. The aqueous humor
helps to nourish the cornea and the lens.

Iris and Pupil

The iris, which is the colored part of the eye, controls the amount of light that enters the eye.
The iris is a ring shaped tissue with a central opening, which is called the pupil.

The iris has a ring of muscle fibers around the pupil, which, when they contract, causes the
pupil to constrict (become smaller). This occurs in bright light. A second set of muscle fibers
radiate outward from the pupil. When these muscles contract, the pupil dilates (becomes
larger). This occurs under reduced illumination or in darkness.

Anterior Chamber Angle and Trabecular Meshwork

The anterior chamber angle and the trabecular meshwork are located where the cornea meets
the iris. The trabecular meshwork is important because it is the area where the aqueous humor
drains out of the eye. If the aqueous humor cannot properly drain out of the eye, the pressure
can build up inside the eye, causing optic nerve damage and eventually vision loss, a
condition known as glaucoma.

Posterior Chamber

The posterior chamber is the fluid-filled space immediately behind the iris but in front of the
lens. The fluid that fills this chamber is the aqueous humor. The aqueous humor helps to
nourish the cornea and the lens.
Lens

The lens is a clear, flexible structure that is located just behind the iris and the pupil. A ring
of muscular tissue, called the ciliary body, surrounds the lens and is connected to the lens by
fine fibers, called zonules. Together, the lens and the ciliary body help control fine focusing
of light as it passes through the eye. The lens, together with the cornea, functions to focus
light onto the retina.

Vitreous Cavity

The vitreous cavity is located behind the lens and in front of the retina. It is filled with a gel-
like fluid, called the vitreous humor. The vitreous humor helps maintain the shape of the eye.

Retina/Macula/Choroid

The retina acts like the film in a camera to create an image. When focused light strikes the
retina, chemical reactions occur within specialized layers of cells. These chemical reactions
cause electrical signals, which are transmitted through nerve cells into the optic nerve, which
carries these signals to the brain, where the electrical signals are converted into recognizable
images. Visual association areas of the brain further process the signals to make them
understandable within the correct context.

The retina has two types of cells that initiate these chemical reactions. These cells are termed
photoreceptors and the two distinct types of cells are the rods and cones. Rods are more
sensitive to light; therefore, they allow one to see in low light situations but do not allow one
to see color. Cones, on the other hand, allow people to see color, but require more light.

The macula is located in the central part of the retina and has the highest concentration of
cones. It is the area of the retina that is responsible for providing sharp central vision.

The choroid is a layer of tissue that lies between the retina and the sclera. It is mostly made
up of blood vessels. The choroid helps to nourish the retina.
Optic Nerve

The optic nerve, a bundle of over 1 million nerve fibers, is responsible for transmitting nerve
signals from the eye to the brain. These nerve signals contain information for processing by
the brain. The front surface of the optic nerve, which is visible on the retina, is called the
optic disk or optic nerve head.

Extraocular Muscles

Six extraocular muscles are attached to each eye to move the eye left and right, up and down,
and diagonally, or even around in circles when one wishes.

DEFINITION

Corneal transplantation, also known as corneal grafting, is a surgical procedure where a

damaged or diseased cornea is replaced by donated corneal tissue (the graft).

A corneal graft is the replacement of the scarred or degenerative corneal tissue by healthy
tissue.

When the entire cornea is replaced it is known as penetrating

keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty.
Keratoplasty simply means surgery to the cornea. The graft is taken from a recently dead
individual with no known diseases or other factors that may affect the chance of survival of
the donated tissue or the health of the recipient.

INDICATIONS

Corneal transplantations are done for several reasons:

 To reconstruct the cornea (eg, replacing a perforated cornea)

 To relieve intractable pain (eg, severe foreign body sensation due to recurrent
ruptured bullae in bullous keratopathy)
 To treat a disorder unresponsive to medical management (eg, severe, uncontrolled
fungal corneal ulcer) such as antivirals or antibiotics.
  To improve the optical qualities of the cornea and thus improve vision (eg, replacing a
cornea that is scarred after a corneal ulcer, is clouded because of edema as occurs in
Fuchs dystrophy or after cataract surgery, is opaque because of deposits of
nontransparent abnormal corneal stromal proteins as occurs in hereditary corneal
stromal dystrophy, or has irregular astigmatism as occurs with keratoconus)

The most common indications are the following:

 Bullous keratopathy (pseudophakic or aphakic, Fuchs endothelial dystrophy)

 Keratoconus
 Repeat graft
 Keratitis or postkeratitis (caused by viral, bacterial, fungal, or Acanthamoebainfection
or perforation)
 Corneal stromal dystrophies

OBTAINING CORNEAL TISSUE:

Corneal tissue can be obtained in 3 ways:

 Autogenous: When the patient’s other eye is blind, but has a healthy cornea , this
can be eneucleated to provide donor material.
 Live donor: when another patient has undergone eneucleation , but the cornea is
healthy, it can be used as donor material for someone requiring grafting.
 Cadaver : This is the most common and is the grafting of corneal tissue from
donated eyes following death. Donated eyes should be removed within 24 hrs of
death and can be stored in short term storsge media for 3-7 days at 40C, or for up
to 30 days in an organ culture system at 34 0C(United Kingdom Transplant Suport
Service Authority, 1995).

CONTRAINDICATIONS OF DONORS:

1. Infections such as methilline-resistant staphylococcus aureus , HIV ,Hepatitis

A,B and C.
2. Unexplained neurological disease, because of the risk of infections such as
Creutzfeldt-Jacob’s disease .
3. Leukemia, lymphoma , myeloma.
 4. Eye conditions such as uveitis , retinoblastoma, history of intraocular surgery and
malignancies of the ciliary body and iris.
5. Jaundice
6. Death due to unknown cause, although donation may takeplace after a postmortem
has been carried out.

PRE –OPERATIVE EXAMINATION

 The person will meet with their ophthalmologist for an examination in the weeks or
months preceding the surgery. During the exam, the ophthalmologist will examine the
eye and diagnose the condition.

 The doctor will then discuss the condition with the patient, including the different
treatment options available. The doctor will also discuss the risks and benefits of the
various options.

 If the patient elects to proceed with the surgery, the doctor will have the patient sign
an informed consent form. The doctor might also perform a physical examination and
order lab tests, such as blood , X-rays, or an EKG.

 The surgery date and time will also be set, and the patient will be told where the
surgery will take place.

SPECIFIC PRE-OPERATIVE PREPARATION

 Prior to preparing the patient for surgery arrangements should be made with one
of the eye banks to check availability of donor material and arrange for its
delivery.
 Surgery is usually carried out under a general anaesthetic and provided the patient
has attended for pre assessment , he will be admitted on the day of surgery, having
fasted for 4 hrs.
 Patients may need considerable psychological support as for them it may be the
last chance of achieving useful vision.
 Topical medications consists of a mitotic such as guttae pilocarp 4% every 15 min
for 1hr.This constricts the pupil , and the iris acts as a protective barrier for the
lens , so avoiding the risk of inadvertent cataract formation.
PROCEDURE

 On the day of the surgery,the patient is given a brief physical examination by the
surgical team and is taken to the operating room. In the operating room, the patient
lies down on an operating table and is either given general anesthesia, or local
anesthesia and a sedative.

 With anesthesia induced, the surgical team prepares the eye to be operated on and
drapes the face around the eye. An eyelid speculum is placed to keep the lids open,
and some lubrication is placed on the eye to prevent drying.

 In children, a metal ring is stitched to the sclera which will provide support of the
sclera during the procedure

SURGICAL PROCEDURES

1. Penetrating keratoplasty

A trephine (a circular cutting device), which removes a circular disc of cornea, is used by the
surgeon to cut the donor cornea. A second trephine is then used to remove a similar-sized
portion of the patient's cornea. The donor tissue is then sewn in place with sutures.

Antibiotic eyedrops are placed, the eye is patched, and the patient is taken to a recovery area
while the effects of the anesthesia wear off. The patient typically goes home following this
and sees the doctor the following day for the first postoperative appointment.

2. Lamellar keratoplasty

 Lamellar keratoplasty encompasses several techniques which selectively replace

diseased layers of the cornea while leaving healthy layers in place.

 The chief advantage is improved tectonic integrity of the eye.

 Disadvantages include the technically challenging nature of these procedures, which

replace portions of a structure only 500 µm thick, and reduced optical performance of
the donor/recipient interface compared to full-thickness keratoplasty.

3. Deep anterior lamellar keratoplasty

In this procedure, the anterior layers of the central cornea are removed and replaced with
donor tissue. Endothelial cells and the Descemets membrane are left in place. This technique
is used in cases of anterior corneal opacifications, scars, and ectatic diseases such as
keratoconus
 4. Endothelial keratoplasty

 Endothelial keratoplasty replaces the patient's endothelium with a transplanted disc of

posterior stroma/Descemets/endothelium (DSEK) or Descemets
(Descemet's membrane is the basement membrane that lies between the corneal
proper substance, also called stroma, and the endothelial layer of the cornea. It is
composed of different kinds of collagen )(/endothelium (DMEK- Descemet
Membrane Endothelial Keratoplasty )

 This relatively new procedure has revolutionized treatment of disorders of the

innermost layer of the cornea (endothelium).

 Unlike a full-thickness corneal transplant, the surgery can be performed with one or
no sutures. Patients may recover functional vision in days to weeks, as opposed to up
to a year with full thickness transplants.

 However, an Australian study has shown that despite its benefits, the loss of
endothelial cells that maintain transparency is much higher in DSEK compared to a
full-thickness corneal transplant. The reason may be greater tissue manipulation
during surgery, the study concluded.

 During surgery the patient's corneal endothelium is removed and replaced with donor
tissue. With DSEK, the donor includes a thin layer of stroma, as well as endothelium,
and is commonly 100–150 µm thick. With DMEK, only the endothelium is
transplanted. In the immediate postoperative period the donor tissue is held in position
with an air bubble placed inside the eye (the anterior chamber). The tissue self-
adheres in a short period and the air is adsorbed into the surrounding tissues.

 Complications include displacement of the donor tissue requiring repositioning

("refloating"). This is more common with DMEK than DSEK. Folds in the donor
tissue may reduce the quality of vision, requiring repair. Rejection of the donor tissue
may require repeating the procedure. Gradual reduction in endothelial cell density
over time can lead to loss of clarity and require repeating the procedure.

 Patients with endothelial transplants frequently achieve best corrected vision in the
20/30 to 20/40 range, although some reach 20/20. Optical irregularity at the graft/host
interface may limit vision below 20/20.

SPECIFIC POST OPERATIVE CARE

The eye may be padded for 12-24 hrs depending on the surgeon’s instruction. Dark glasses or
a plastic cartello shield may be worn for protection and to decrese photophobia. If the latter is
a problem then it may be possible to have subduded lighting in the bed area.

The eye is examined before instillation of any topical medication and following is looked for.

Position of the graft and intergrity of sutures.

Depth of anterior chambers.

Presence of red cells known as hyphaema.

Presence of white cells known as hypopyon.

Clarity of cornea.

If the condition of the eye is satisfactory , prescribed medications can be given. But if there
any cause for concern , medication should be withheld until medical opinion is sought.

Topical medication consist of;

An antibiotic Eg : guttae chloramphenicol 0.5% 3-4 times a day.

An anti-inflammatory:eg: guttae dexamenthasone 1% 3-4 times daily.

A mydriatics: eg: guttae mydrilate 1% twice a day may be given as this dialatesthe pupil and
rests the eye.

Provded the suture line is not leaking aquous , no dressing need be applied , bt the eye can
feel uncomfortable because of the presence of the sutures, although the discomfort does
decrease as the cornal epithelium regenerates over them. The level of discomfort can be
reduced by wearing dark glasses or cartello shield.

SYNTHETIC CORNEAS

1. Boston keratoprosthesis
 The Boston keratoprosthesis is the most widely used synthetic cornea to date with
over 900 procedures performed worldwide in 2008. The Boston KPro was developed
 at the Massachusetts Eye and Ear Infirmary under the leadership of Claes Dohlman,
MD, PhD
2. AlphaCor

 In cases where there have been several graft failures or the risk for keratoplasty is
high, synthetic corneas can substitute successfully for donor corneas

 AlphaCor is a U.S. FDA-approved type of synthetic cornea measuring 7.0 mm in

diameter and 0.5 mm in thickness. The main advantages of synthetic corneas are that
they are biocompatible, and the network between the parts and the device prevents
complications that could arise at their interface. The probability of retention in one
large study was estimated at 62% at 2 years follow-up.

3. Osteo-Odonto-Keratoprosthesis

 It is a very rare and complex multi-step surgical procedure, employed to help the most
disabled patients, a lamina of the person's tooth is grafted into the eye, with an
artificial lens installed in the transplanted piece.

PROGNOSIS

The prognosis for visual restoration and maintenance of ocular health with corneal transplants
is generally very good. Risks for failure or guarded prognoses are multifactorial. The type of
transplant, the disease state requiring the procedure, the health of the other parts of the
recipient eye and even the health of the donor tissue may all confer a more or less favorable
prognosis.

The majority of corneal transplants result in significant improvement in visual function for
many years or a lifetime. In cases of rejection or transplant failure, the surgery can generally
be repeated.

The chance of long-term transplant success is

 > 90% for keratoconus, traumatic corneal scars, early bullous keratopathy, or
hereditary corneal stromal dystrophies
 80 to 90% for more advanced bullous keratopathy or inactive viral keratitis
 50% for active corneal infection
 0 to 50% for chemical or radiation injury
The generally high rate of success of corneal transplantation is attributable to many factors,
including the avascularity of the cornea and the fact that the anterior chamber has venous
drainage but no lymphatic drainage. These conditions promote low-zone tolerance (an
immunologic tolerance that results from constant exposure to low doses of an antigen) and a
process termed anterior chamber–associated immune deviation, in which there is active
suppression of intraocular lymphocytes and delayed-type hypersensitivity to transplanted
intraocular antigens. Another important factor is the effectiveness of the corticosteroids used
topically, locally, and systemically to treat graft rejection.

ALTERNATIVES

1. Contact lenses

Different types of contact lenses may be used to delay or eliminate the need for corneal
transplantation in corneal disorders.

2. Phototherapeutic keratectomy

Diseases that only affect the surface of the cornea can be treated with an operation
called phototherapeutic keratectomy (PTK). With the precision of an excimer laser and a
modulating agent coating the eye, irregularities on the surface can be removed. However, in
most of the cases where corneal transplantation is recommended, PTK would not be
effective.

3. Intrastromal corneal ring segments

In corneal disorders where vision correction is not possible by using contact

lenses, intrastromal corneal ring segments may be used to flatten the cornea, which is
intended to relieve the nearsightedness and astigmatism. In this procedure,
an ophthalmologist makes an incision in the cornea of the eye, and inserts two crescent or
semi-circular shaped ring segments between the layers of the corneal stroma, one on each
side of the pupil.[6] Intrastromal corneal rings were approved in 2004 by the Food and Drug
Administrationfor people with keratoconus who cannot adequately correct their vision with
glasses or contact lenses. They were approved under the Humanitarian Device
Exemption,[7][8] which means the manufacturer did not have to demonstrate effectiveness.
 4. Corneal collagen cross-linking

Corneal collagen cross-linking may delay or eliminate the need for corneal transplantation
in keratoconus and post-LASIK ectasia, however as of 2015 it is lacking sufficient evidence
to determine if it is useful in keratoconus.

COMPLICATIONS
Complications include the following:

1. Loose sutures lead to escape of aqueous.This can be proved by Seidel’s test ,

which demonstrated the passage of fluorescein from the exterior to the interior
of the eye and also by the presence of a flat anterior chamber.
2. Damage to the lens at the time of surgery results in cataract formation.
3. Post-operative infection may occur.
4. Adhesions , known as synechiae, form between the iris and edge of the graft ,
may result in blockage of the drainage angle, leading to post-keratoplasty
glaucoma.
5. Rejection of the graft – 90% of the graft are successful and early rejection is
unusual , but the highest risk is within the first post – operative year.The
incidence increases if the eye has been grafted before.
6. Astigmatism is caused by the tension of the sutures and the size of the graf
altering the curvature of the cornea
7. Growth of new blood vessels , neovascularization , around the graft can
obscure vision if growth continues across the centre of the graft.
RECENT STUDIES

High speed lasers

Blades are being replaced by high speed lasers in order to make surgical incisions more
precise. These improved incisions allow the cornea to heal more quickly and the sutures to be
removed sooner. The cornea heals more strongly than with standard blade operations. Not
only does this dramatically improve visual recovery and healing, it also allows the possibility
for improvement in visual outcomes.

DSEK/DSAEK/DMEK

Endothelial keratoplasty (EK) has been introduced by Melles et al. in 1998. Today there are
three forms of EK. Deep Lamellar Endothelial Keratoplasty (DLEK) in which the posterior
part of the recipient cornea is replaced by donor tissue. Descemet's Stripping (Automated)
Endothelial Keratoplasty (DSEK/DSAEK) in which the diseased Descemet's membrane is
removed and replaced by a healthy donor posterior transplant. The transplant tissue can be
prepared by a surgeon's hand or ordered already prepared for surgery. Ocular Systems was
the first organization to deliver prepared grafts for surgery in 2005. DSEK/DSAEK uses only
a small incision that is either self-sealing or may be closed with a few sutures. The small
incision offers several benefits over traditional methods of corneal transplant such as
Penetrating Keratoplasty. Because the procedure is less invasive, DSAEK leaves the eye
much stronger and less prone to injury than full-thickness transplants. New medical devices
such as the EndoSaver (patent pending) are designed to ease process of inserting endothelial
tissue into the cornea.[21] Additionally, DSAEK has a more rapid rate of visual recovery.
Vision is typically restored in one to six months rather than one to two years

Stem cells

There is a bioengineering technique that uses stem cells to create corneas or part of corneas
that can be transplanted into the eyes. Corneal stem cells are removed from a healthy cornea.
They are collected and, through laboratory procedures, made into five to ten layers of cells
that can be stitched into a patient's eye. The stem cells are placed into the area where the
damaged cornea tissue has been removed. This is a good alternative for those that cannot gain
vision through regular cornea transplants. A new development, announced by the University
of Cincinnati Medical School in May 2007, would use bone marrow stem cells to regrow the
cornea and its cells. This technique, which proved successful in mouse trials, would be of use
to those suffering from inherited genetic degenerative conditions of the cornea, especially if
other means like a transplant aren't feasible. It works better than a transplant because these
stem cells keep their ability to differentiate and replicate, and so keep the disease from
recurring, longer and better.

Biosynthetic corneas

On 25 August 2010 investigators from Canada and Sweden reported results from the first 10
people in the world treated with the biosynthetic corneas. Two years after having the corneas
implanted, six of the 10 patients had improved vision. Nine of the 10 experienced cell and
nerve regeneration, meaning that corneal cells and nerves grew into the implant. To make the
material, the researchers placed a human gene that regulates the natural production of
collagen into specially programmed yeast cells. They then molded the resulting material into
the shape of a cornea. This research shows the potential for these bioengineered corneas but
the outcomes in this study were not nearly as good as those achieved with human donor
corneas. This may become an excellent technique, but right now it is still in the prototype
stage and not ready for clinical use. The results were published in the journal Science
Translational Medicine.

BIBLIOGRAPHY:

Book reference:

”Lewis,Heitkemper Dirksen”,Assessment and management of clinical problems , Medical –

Surgical Nursing , 6th edition , published by MOSBY.

Net reference

https://en.wikipedia.org/wiki/Corneal_transplantation