With the increasing popularity of refractive surgery, it was just a matter of time before eye banks started to receive tissue donations from donors who have had laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK). In October 1999, it was estimated that as many as 850,000 people in the United States will have had LASIK surgery, which represents a doubling of procedures over the previous 3 years. It was estimated that laser refractive surgery had a market of 150 million Americans, but that only 0.25% had been treated to that date, partly because of a shortage in ophthalmologists trained to perform the procedure. 1 Laser refractive surgery commonly is performed in patients 20–60 years of age. This age group donated approximately 25% of the eyes received in the Eye Bank of Canada (Ontario Division) in 1999 (Eye Bank of Canada, Ontario Division, 1999 Annual report).
We report two cases of penetrating keratoplasty (PK) using both corneas from a donor who had undergone LASIK surgery.
The recipient was a 51-year-old woman with moderate (Down's syndrome) mental retardation and multiple medical problems, including a ventriculoseptal defect, mild mitral regurgitation, exertional syncope, probable Eisenmenger's syndrome with pulmonary hypertension, systemic hypertension, ischemic heart disease with angina and congestive heart failure, and hypothyroidism. She had keratoconus and cataract in both eyes, with one eye worse that the other. Her visual acuity was finger-counting vision at 40 cm OU. Because of the high risk involved with general anesthesia, it was decided to perform the surgery under local anesthesia. The patient underwent a PK with cataract extraction and posterior chamber intraocular lens (IOL) implantation. The graft was received from the eye bank rated “good,” with a remark on the tissue data sheet stating that an epithelial erosion was noted, but that the stroma was clear and compact with few folds and stress lines in the periphery. It was from a 55-year-old donor. At trephination of the corneal donor tissue, it was noticed to be somewhat “slippery” and did not handle very well with suction in the Hannah trephination system (Moria, Dollard-des-Ormeaux, Quebec, Canada). The edges of the button looked mildly irregular, but otherwise the graft looked grossly acceptable.
The patient was sedated with droperamide 15 mg, midazolam 1 mg, and fentanyl 50 mg. She also received retrobulbar and Van Lindt blocks with lidocaine and purified bovine hyaluronidase (Wydase; Wyeth-Ayerst Canada, Inc., Montreal, Quebec, Canada). After trephination, extracapsular cataract extraction was performed and a posterior chamber IOL was implanted. Provisc (sodium lyaluronate, Alcon, Mississauga, Ontario, Canada) was injected into the anterior chamber, and suturing of the corneal graft was begun. Our routine technique in these cases consists of four cardinal sutures that are removed later during surgery, and then running 10-0 and 11-0 nylon sutures. In this case, we elected to use 16 interrupted 10-0 nylon sutures and a running 11-0 nylon suture. While placing the interrupted sutures, the surgeon experienced difficulty in grasping the edge of the graft, and after nearly 5 clock hours were sutured, the graft was noticed to separate into two distinct layers. The surgeon at this point was reluctant to exchange the graft because of the fragile balance of the patient's cooperation. The surgery was continued with extra care to ensure a deep bite was taken through the two layers of the graft. The suspicion was raised that the donor had undergone prior LASIK. At the end of the surgery, the eye bank was contacted. The eye bank personnel contacted the spouse of the deceased donor, who revealed that the donor indeed had undergone LASIK surgery for mild hyperopia of +1.25+0.25 × 150 OD and +2.0 OS diopters just 2 months before her death from a cerebrovascular accident and subarachnoid hemorrhage.
Based on review of the eye bank records, it appears that the enucleating physician filled in the chart using information from the patient's medical records. There was no information about any eye surgery, so “no prior eye surgery” was recorded and the information was not verified with the spouse. The donor's husband did tell the eye bank technician over the phone that when his wife was hospitalized he volunteered the information about the eye procedure to the intensive care unit physician on call, but this apparently was not recorded in the chart.
At 3 months after surgery, all 10-0 nylon sutures were removed. Five months after surgery, the recipient of the cornea is doing well, is on steroid drops two times daily, and is happy with her new visual acuity of 20/200 SC; the graft is clear and thin; and refraction is −4.5+6 × 20° (Fig. 1).
This patient received the pair cornea of the cornea transplanted in case 1. The Eye Bank of Canada tried repeatedly to contact the Brazilian surgeon who took the cornea herself from Toronto to Brazil. By the time contact was achieved, the cornea was already transplanted in the eye of an 86-year-old woman with a history of Fuchs' dystrophy, dry eyes, and primary open-angle glaucoma. The patient underwent her first operation in 1985, at which time she had a triple procedure. The graft rejected and failed and she received another graft, which rejected several times before it failed once again. The fourth PK was performed in June 2000, with the patient having a preoperative visual acuity of 20/400. During the manual trephination, the surgeon noticed slight edema forming in the corneal graft button. As surgery proceeded and suturing took place, there was a localized area that developed increasing edema to the point of becoming opaque, but this subsided as all 24 interrupted sutures were placed. On the first day after surgery, the graft was edematous in the same area noted to be swollen during surgery. The patient was started on a regimen of steroid drops and ointment five times a day. On the last follow-up visit, 6 months after the surgery, visual acuity was 20/200, the graft was clear, and all stitches were still in place (the patient refusing to have them removed). Retinoscopy on that visit was −1+2.5 × 105°.
In this case, the surgeon did not notice or suspect during the surgery that previous LASIK surgery had been done on the graft. The graft used for this case was from the right eye of the donor and was rated by the eye bank as “very good” before surgery.
These are the first cases of post-LASIK corneas being used for PK.
Refractive surgery now is so common that in the year 2000, 750,000 North Americans were expected to undergo refractive surgery (quoted in the Toronto Star, August 8th, 2000, pages D1–D2). With this increasing number, we should endeavor to improve our screening of donor tissue. 2
Some groups have tried to use corneal topography and pachymetry maps from the Orbscan to screen for prior refractive surgery. 3–6 It may not be practical at present to screen all donations by corneal topography. However, careful questioning of family members about recent refractive surgery should be done by eye bank personnel. In addition, more specific questions directed to address this topic need to be added to the donor's history sheet for the person providing consent. Information in medical records of any department in the hospital other than Ophthalmology has to be considered incomplete, and eye banks and doctors should not rely on it for collecting prior history of donor eye problems. Our standards need to be revised in light of this effect on the donor pool.
Unfortunately, the eye bank was not able to prevent the other cornea from being used. Histopathologic testing of the other cornea would have been highly desirable. Eye banks should be aware of the need for pathologic testing of post-LASIK corneas and, should they come across a post-LASIK cornea, should report it to the medical director so it can be sent for detailed histopathologic studies.
In theory, a donor cornea that underwent LASIK before its use as a graft would be expected to affect the refraction of the transplanted eye accordingly. For example, if the donor button had a hyperopic LASIK, then the recipient eye would require a postoperative myopic correction, and vice versa. In our case, the donor button did indeed have hyperopic LASIK before being used for transplantation, but it was a mild to moderate hyperopia. The change in donor corneal curvature is another factor that affects the final refractive outcome. Axial length, astigmatism, and lens status influence the final refraction. The technical problems during surgery, trying to secure in place the two lamellar levels that formed, required putting tighter stitches, and this also could affect the final refraction. If the two lamellar sections are shifted from their proper alignment, this could produce optical aberrations and interfere with graft clarity.
When a cornea that underwent LASIK before its harvesting is to be used for transplantation, caution should be used when cutting the button. Suction might be difficult to achieve and the cornea could slip and part into the two lamellar layers. It is important to maintain proper alignment and secure both layers when suturing the graft. If the superior layer is lost during surgery, this could cause difficulty in stitching a thinner layer and lead to a postoperative epithelialization problem. The surgeon should consider replacing the graft during surgery if another graft is immediately available.
After surgery, there could be a potential problem with wound healing if the sutures do not run in a radial line and through both layers. We did not encounter this in our two reported cases. In fact, both grafts healed quite quickly. In the first case, the 10-0 nylon suture was entirely removed at 3 months after surgery, which is the routine of the surgeon who performed the operation on case 1. The policy of the surgeon who performed the surgery on case 2 is to remove stitches according to astigmatism, starting 3 months after surgery. However, in that case the sutures were left in place because of the patient's refusal to have them removed.
It is hoped that the fact that the corneas had LASIK will not affect graft survival. In theory, endothelial cell counts should be the same as if the eye had not been operated on. 7–9 Any extra manipulation of the graft during the effort to suture and secure both lamellae risks losing extra endothelial cells.
In conclusion, we report two cases of PK with tissue from a donor who had LASIK surgery. Both patients are doing well. Surgical technique was complicated by the two lamellar levels in the corneal button, and it is important to secure both layers. Potential refractive errors, healing problems, and graft failure will be confirmed only with longer follow-up. Improved eye bank screening technique is important.
1. Stats & facts. The gaining popularity of refractive laser surgery. Manag Care Interface
2. Pepose JS, Lim-Bon-Siong P, Mardelli P. Future shock: the long-term consequences of refractive surgery. Br J Ophthalmol 1997; 81: 428–9.
3. Mannis MJ, McDonough G, Howard K, et al. Screening donor corneas that have undergone PRK. Cornea 1997; 16: 683–5.
4. Lim-Bon-Siong R, Williams JM, Samapunphong S, et al. Screening of myopic photorefractive keratectomy in eye bank eyes by computerized videokeratography. Arch Ophthalnol 1998; 116: 617–23.
5. Terry MA, Ousley PJ, Rich LF, et al. Evaluation of prior photorefractive keratectomy in donor tissue. Cornea 1999; 18: 353–8.
6. Terry MA, Ousley PJ. New screening methods for donor eye-bank eyes. Cornea 1999; 18: 430–6.
7. Jones SS, Ramzy GA, Stephen MC, et al. Effects of laser in situ keratomileusis (LASIK) on the corneal endothelium. Am J Ophthalmol 1998; 125: 465–71.
8. Kent DG, Solomon KD, Peng O, et al. Effect of surface photorefractive keratectomy and laser in situ keratomileusis on the corneal endothelium. J Cataract Refract Surg 1997; 23: 386–97.
9. Perez-Santonja JJ, Sakla HF, Gobbi F, et al. Corneal endothelial changes after in situ keratomileusis. J Cataract Refract Surg 1997; 23: 177–83.
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