Corneal Transplantation at the Moran Eye Center

The Moran Eye Center Performed the First Laser Based Cornea Transplant in Utah

Specialists in Corneal Disease & Refractive Surgery at the Moran Eye Center include: Mark D. Mifflin, M.D., Geoffrey Tabin, M.D. and Majid Moshirfar, M.D., F.A.C.S. Research into Glaucoma is also being done at the Moran Eye Center in the Zhang Laboratory, by Kang Zhang, M.D., Ph.D.

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What is the cornea?

The cornea is the eye's outermost layer. It is the clear, dome-shaped surface that covers the front of the eye and allows light to pass through to the retina unobstructed. The curvature of the cornea bends the light rays to focus them on the retina producing clear images and normal vision.

What is corneal transplantation?

Several diseases and sometimes trauma to the cornea can alter its structure in a way which produces visual loss. Changes in corneal shape, thickness, or clarity that result in poor vision can often be corrected with transplants. A corneal transplant involves replacing a diseased or scarred cornea with a new one. When the cornea becomes cloudy, light cannot penetrate the eye to reach the light-sensitive retina. Poor vision or blindness may result.

In corneal transplant surgery, the surgeon removes the central portion of the cloudy cornea and replaces it with a clear cornea, usually donated through an eye bank. The standard procedure has been to use A trephine, an instrument like a cookie cutter, is used to remove the cloudy cornea. The surgeon places the new cornea in the opening and sews it with a very fine thread. The thread stays in for months or even years until the eye heals properly (removing the thread is quite simple and can easily be done in an ophthalmologist's office). Following surgery, eye drops to help promote healing will be needed for several months.

Corneal transplants are very common in the United States; about 40,000 are performed each year. Corneal transplantation has restored sight to many, who a generation ago would have been blinded permanently by corneal injury, infection, or inherited corneal disease or degeneration.

Typical Cornea Transplant Surgery

When the cornea becomes cloudy, light cannot penetrate the eye to reach the light-sensitive retina. Poor vision or even blindness may result. In corneal transplant surgery, the surgeon removes the central portion of the cloudy cornea and replaces it with a clear cornea, usually donated through an eye bank. Corneal transplantation has restored sight to hundreds of thousands of individuals who otherwise would be blind due to corneal injury, infection, or inherited corneal disease or degeneration. In 2004, 46,841 corneal grafts were supplied by over 42,000 donors through US eye banks; 32,106 corneal transplants were performed in the US.

Cornea transplant surgery is typically done with a Trephine Corneal Cutter, a hand-held bladed “cookie cutter” that stamps onto the cornea to make a circular incision with straight vertical edges. This technique requires suturing around the circumference of the tissue graft to maintain the position of the new cornea. Sutures stay in the eye for at least one year, possibly longer and patients generally don’t achieve full visual recovery for at least one year. After traditional corneal transplantation, very little pressure is required to displace the donor tissue from the patient’s eye.

Moran Eye Center State-of-the-art Corneal Transplantation

IntraLase-Enabled Keratoplasty™ (IEK™)

The John A. Moran Eye Center has a tradition of pioneering research and innovative firsts in surgical techniques. For example, cornea disease and refractive surgery specialist, Majid Moshirfar, M.D., F.A.C.S., of the John A. Moran Eye Center at the University of Utah performed the first ever laser-based cornea transplant in Utah on April 20, 2007. The procedure is called IntraLase-Enabled Keratoplasty™ (IEK™). Moran was also the first eye center in Utah to: use implantable contact lenses, perform custom LASIK, implant artificial corneas, treat vision correction with LASEK and more.

At the Moran Eye Center we use the Intralase IEK procedure, which allows the surgeon to use a computer-guided ultra-fast femtosecond laser to create precisely shaped incisions. Fitting together like a puzzle, these shaped incisions may result in a more stable graft and faster healing, and require fewer sutures to keep the graft in place. Sutures may also be removed much earlier (before six months in initial cases). Another potential advantage is better corrected vision with less irregularity and less astigmatism so also potentially better uncorrected vision.

Past experience with exacting laser techniques indicates that this method will provide a more stable graft that speed patient healing and visual recovery. Risk for displacement is greatly reduced as shaped incisions have demonstrated a seven-fold increase in strength. These are all clinical benefits that have not been possible with the manual trephine corneal cutter.

Phototherapeutic keratectomy (PTK)

PTK is one of an option for the treatment of corneal dystrophies, corneal scars, and certain corneal infections. Only a short time ago, people with these disorders would most likely have needed a corneal transplant. By combining the precision of the Excimer laser with the control of a computer, doctors can vaporize microscopically thin layers of diseased corneal tissue and etch away the surface irregularities associated with many corneal dystrophies and scars. Surrounding areas suffer relatively little trauma. New tissue can then grow over the now-smooth surface. Recovery from the procedure takes a matter of days, rather than months as with a transplant. The return of vision can occur rapidly, especially if the cause of the problem is confined to the top layer of the cornea. Studies have shown close to an 85 percent success rate in corneal repair using PTK for well-selected patients.

DSEK Procedure

More than half of cornea transplant patients need surgery because of eye diseases or conditions that lend themselves to a new, less invasive technique that doesn't require stitches, speeds healing and preserves the cornea's strength.

Once again Dr. Majid Moshirfar at the Moran Eye Center performed the first Utah surgery using a switchless technique called DSEK. The procedure is faster than traditional cornea transplants and afterward patients don't usually need a rigid gas permeable contact, a staple of traditional surgery because of the changes that result from the stitches.

The cornea is not removed and a new one sewn in, so healing is faster. Without stitches, discomfort is lessened greatly. And it takes days or weeks, rather than months, to see the improvement in vision.

About 55 percent of cornea transplant patients have endothelial diseases, and it is those patients who are candidates for the newer sutureless surgery. Babies are born with about 4,000 endothelial cells in the back of their corneas, and that layer is responsible for the clarity of the cornea, the pristine luster. With age, as many as half those cells are lost. People with endothelial diseases lose even more. And the condition can't be corrected with glasses or contacts. The cornea has to be replaced.

With DSEK, the surgeon only removes the endothelial layer of the cornea. Through a tiny 2 millimeter incision, he removed the endothelium, preserving the rest of the cornea. Then an endothelial layer of the donor cornea is folded in half and slipped through the incision, where a very small air bubble is added. The bubble acts as a spacer that helps the new layer unfold and attach to the patient's cornea, then dissipates within a few days.

Two main plusses from having this treatment are that there are no stitches after the procedure and, because of the lack of stitches, fewer follow up exams are needed. Like many procedures, DSEK may not be appropriate for some people with particular corneal diseases. The knowledgeable staff at the Moran Eye Center can help decide if DSEK is appropriate for you.

Pioneering Artificial Cornea Transplantation at the Moran Eye Center

With extensive cornea damage caused by a chemical accident, John Taylor could only perceive blurry light in his left eye. Even with a standard cornea transplant, he was expected to see only 20/400 – an improvement, but still legally blind. Today, following a first-of-its-kind surgical technique, developed and performed by Dr. Majid Moshirfar at the John A. Moran Eye Center, John has 20/30 vision. He has regained a skill he thought he had lost for the rest of his life following the accident, he can drive.

Dr. Moshirfar, a corneal specialist at the Moran Eye Center, determined that a synthetic cornea called the Boston Keratoprosthesis was indicated for John’s complex injury. Artificial corneas are not new, but the surgical technique performed on February 19, 2010 by Dr. Moshirfar was. He used an Intralase iFS Femtosecond laser to implant the Boston Keratoprosthesis for the first time. John’s incredible outcome holds promise for more precise and successful artificial cornea transplants in the future.

The Boston Keratoprosthesis synthetic cornea is used in difficult corneal transplants where standard donor tissue transplants are unlikely to succeed or have failed in the past. The common procedure is to use a trephine (a circular cutting device) to cut circular grafts in the patient’s cornea and donor tissue. Instead of the trephinie, Dr. Moshirfar used the Intralase iFS laser, which allowed for more precise concentric circles and a better fit than traditional blade surgery.

Shortly after the surgery John read line after line below the “big E” on the eye chart--much to the surprise of Dr. Moshirfar and John’s wife, Wendy Taylor. Wendy describes their experience in post surgery. “The doctor’s surgical assistant took off the bandages and everything looked great. Dr. Moshirfar asked John if he could see anything and he said, yes, he could see me. Then, with each line John read, more tears ran down my face. “

Dr. Randall Olson, Chairman of the Department of Ophthalmology at the University of Utah and CEO John A. Moran Eye Center had this to say about the case, “To my knowledge, Dr. Moshirfar is the first surgeon to use the Intralase iFS laser and the Boston Keratoprosthesis together to restore vision. This is no surprise to me considering the many pioneering procedures Dr. Moshirfar has skillfully researched and carried out in his career.”

The integration of these technologies is another indication that the Moran Eye Center is a leader in the use of laser technologies in cornea and refractive surgery. The Moran Eye Center is also conducting clinical trials evaluating the iFS Intralase laser in LASIK surgery to determine the benefits of this advanced technology.

The Moran Eye Center is one of the top ophthalmic surgical and training centers in North America. Moran surgeons perform more than 7,000 surgical procedures each year. Located on the campus of the University of Utah, it is part of the University Health Care system. The Moran Eye Center has more than 50 faculty members and over 50 Ph.D. researchers, including one of the top retinal research teams in the world.