Complications in Cornea Transplant Surgery

Introduction

Cornea transplant surgery, or keratoplasty, is a sight-restoring procedure that involves replacing a damaged or diseased cornea with healthy donor tissue. This procedure is commonly performed to treat conditions such as keratoconus, corneal scarring, Fuchs’ dystrophy, or corneal edema. While most cornea transplants are successful and result in improved vision and eye health, like any surgical intervention, it carries potential complications. Some complications may arise shortly after surgery, while others might develop over months or even years. Being aware of these risks is crucial for patients undergoing the procedure, as early detection and treatment of complications can significantly improve outcomes. Below are some of the major complications in cornea transplant surgery.

Complications in Cornea Transplant Surgery

1. Graft rejection :- Graft rejection is one of the most common and serious complications of cornea transplant surgery. It occurs when the recipient’s immune system identifies the donor tissue as foreign and mounts an immune response against it. Rejection can happen weeks, months, or even years after the surgery. Symptoms include redness, sensitivity to light, decreased vision, and eye pain. These signs are collectively known as the “RSVP” warning symptoms. There are different types of rejection epithelial, stromal, and endothelial with endothelial rejection being the most critical because it can lead to irreversible graft failure. Prompt treatment with topical or systemic corticosteroids can often reverse the rejection if caught early, but delayed intervention increases the risk of permanent vision loss and graft failure. Patients are advised to maintain regular follow-up visits and immediately report any symptoms suggestive of rejection to their ophthalmologist.
2. Infection :- Infection is a potential complication that can occur at any stage after surgery. In the early postoperative period, infection can be caused by bacteria introduced during or after the surgical procedure. Later on, infections may result from poor hygiene, trauma, or delayed epithelial healing. Infections can involve the cornea (keratitis), the inner eye (endophthalmitis), or surrounding tissues. Symptoms include eye pain, discharge, redness, swelling, and blurry vision. Infections after a cornea transplant are serious and can compromise the integrity of the graft, potentially leading to graft failure or even loss of the eye if not treated promptly. Treatment typically involves the use of broad-spectrum antibiotics, antifungals, or antivirals depending on the type of infection. In some cases, hospitalization and intensive therapy may be necessary. Preventive measures such as strict aseptic technique, proper postoperative care, and patient education about hygiene are vital to reduce the risk.
3. Increased intraocular pressure and glaucoma :- Another complication following cornea transplant surgery is increased intraocular pressure (IOP), which can lead to glaucoma if not managed properly. Elevated IOP can result from the surgical procedure itself, the use of postoperative steroid medications, or preexisting conditions in the patient. Steroid-induced glaucoma is particularly concerning because corticosteroids are frequently used to reduce inflammation and prevent rejection. If IOP remains high for a prolonged period, it can damage the optic nerve, causing permanent vision loss. Symptoms may be subtle or absent in the early stages, so regular monitoring of eye pressure is essential after surgery. Management includes adjusting steroid dosage, using anti-glaucoma medications, or performing surgical procedures like trabeculectomy or implanting drainage devices. Uncontrolled glaucoma not only threatens the success of the transplant but also the overall health of the eye.
4. Recurrence of the original disease :- In certain cases, the condition that initially led to the need for a corneal transplant may recur in the new graft. This is particularly true for infectious conditions such as herpes simplex keratitis, where the virus remains latent in the nerves and can reactivate after surgery. Similarly, in autoimmune or inflammatory diseases, the pathological process may continue to affect the transplanted tissue. Recurrence can lead to scarring, inflammation, and a decline in visual acuity, potentially necessitating repeat surgery. Long-term management with antiviral medications or immunosuppressants is often required to reduce the risk of recurrence. Close monitoring and collaborative care between the patient and ophthalmologist can help identify early signs of disease return and allow for timely intervention to preserve graft function.
5. Astigmatism and poor visual outcome :- Even when a corneal transplant is technically successful and the graft remains clear, patients may still experience suboptimal visual results due to postoperative astigmatism. Astigmatism occurs when the cornea is irregularly shaped, causing distorted or blurred vision. After a transplant, especially penetrating keratoplasty (full-thickness graft), the sutures and healing process can alter the shape of the cornea and create uneven curvature. This may result in high degrees of astigmatism that are not easily corrected with glasses. Patients may require rigid contact lenses or further surgical procedures such as suture adjustment, laser reshaping, or additional corneal surgeries to improve visual clarity. Additionally, the new corneal tissue may not fully integrate in a way that restores perfect optics, particularly in eyes with other co-existing ocular problems like macular degeneration or optic nerve damage. Therefore, it is important to set realistic expectations about vision improvement and understand that additional corrective interventions may be needed.
6. Graft failure :- Graft failure is the most serious long-term complication following cornea transplant surgery. It occurs when the donor corneal tissue no longer functions effectively and becomes cloudy or swollen, resulting in vision loss. Graft failure may be primary where the graft never becomes clear after surgery or secondary, which happens after an initial period of clarity. Causes of secondary failure include chronic rejection, infection, trauma, or progressive endothelial cell loss. The signs of graft failure may be similar to rejection, but the response to treatment is poor or absent. Once a graft has failed, the only option for visual recovery is repeat transplantation. However, the success rate of repeat transplants is generally lower, especially if the underlying cause of the initial failure is not addressed. Managing risk factors and maintaining consistent follow-up with an eye specialist are key strategies to prolong graft survival and identify failure in its early stages.

Conclusion

Cornea transplant surgery has transformed the lives of millions of people by restoring sight and improving quality of life. However, like all surgical interventions, it carries a risk of complications that can compromise the success of the procedure. Graft rejection, infection, increased intraocular pressure, recurrence of disease, astigmatism, and graft failure are among the major concerns after transplantation. The key to minimizing these risks lies in careful patient selection, meticulous surgical technique, diligent postoperative care, and long-term follow-up. Patients must remain committed to their treatment regimen and maintain open communication with their ophthalmologist. By recognizing complications early and responding promptly, it is possible to preserve vision, extend graft survival, and ensure the long-term success of the transplant.