Corneal Transplant: Surgery, Recovery & What to Expect

A corneal transplant (keratoplasty) is a surgical procedure that replaces damaged or diseased corneal tissue with healthy tissue from a donor. This surgery can restore vision when the cornea becomes cloudy, scarred, or misshapen due to injury, infection, or inherited conditions. With modern surgical techniques, corneal transplants have high success rates and can significantly improve quality of life for patients with corneal disease.

What Is a Corneal Transplant and Why Is It Performed?

A corneal transplant, also known as keratoplasty, is a surgical procedure that replaces all or part of a damaged cornea with healthy tissue from a deceased donor. It is performed when the cornea becomes cloudy, scarred, swollen, or irregularly shaped, causing vision loss that cannot be corrected with glasses, contact lenses, or other treatments.

The cornea is the clear, dome-shaped front surface of your eye that plays a crucial role in focusing light onto your retina. Think of it as the window of your eye—when this window becomes cloudy or distorted, your vision suffers significantly. The cornea is responsible for about two-thirds of your eye's focusing power, making its clarity and shape essential for good vision.

Corneal transplantation is one of the most common and successful tissue transplants performed worldwide. According to the Eye Bank Association of America, more than 85,000 corneal transplants are performed annually in the United States alone, and millions more worldwide. The procedure has been refined over more than a century, with the first successful human corneal transplant performed in 1905 by Dr. Eduard Zirm in Austria.

Unlike organ transplants such as kidneys or hearts, corneal transplants have unique advantages. The cornea has no blood vessels, which means it is considered an "immune-privileged" tissue. This characteristic significantly reduces the risk of rejection compared to other transplants and eliminates the need for systemic immunosuppressive medications in most cases. Additionally, corneal tissue can be obtained from donors of any age and stored for several days in eye banks, making the logistics of transplantation more manageable.

Conditions That May Require Corneal Transplant

Several conditions can damage the cornea severely enough to warrant transplantation. Understanding these conditions helps patients recognize when they might need to discuss this option with their ophthalmologist.

• Keratoconus: A progressive condition where the cornea thins and bulges into a cone shape, causing distorted vision that eventually cannot be corrected with glasses or contact lenses
• Fuchs' dystrophy: An inherited condition where cells in the innermost corneal layer (endothelium) gradually deteriorate, causing corneal swelling and cloudiness
• Corneal scarring: From infections (such as herpes simplex keratitis), injuries, or previous eye surgeries
• Bullous keratopathy: Corneal swelling from endothelial cell damage, often following cataract surgery
• Corneal dystrophies: Inherited conditions that cause material to accumulate in the cornea, affecting clarity
• Corneal ulcers: Severe infections that cause permanent scarring
• Chemical burns: That damage the corneal surface and deeper layers
• Thinning disorders: Conditions like pellucid marginal degeneration

What Are the Different Types of Corneal Transplant Surgery?

There are several types of corneal transplant procedures, ranging from full-thickness transplants (penetrating keratoplasty) that replace the entire cornea, to partial-thickness procedures (lamellar keratoplasty) that replace only the affected layers. The type chosen depends on which layer of your cornea is damaged and the underlying condition.

Modern corneal surgery has evolved dramatically over the past two decades. Rather than replacing the entire cornea in every case, surgeons can now selectively replace only the damaged layers while preserving healthy tissue. This approach, called lamellar keratoplasty, has revolutionized outcomes for many patients by reducing rejection risk and speeding visual recovery.

The cornea consists of five distinct layers: the epithelium (outermost protective layer), Bowman's layer, the stroma (makes up 90% of corneal thickness), Descemet's membrane, and the endothelium (innermost layer of pump cells). Different diseases affect different layers, and modern surgery can target the specific problem layer.

Penetrating Keratoplasty (PKP) - Full-Thickness Transplant

Penetrating keratoplasty, often called PK or PKP, is the traditional corneal transplant procedure where the surgeon removes a circular, full-thickness portion of the damaged cornea and replaces it with a matching piece of donor cornea. This technique has been performed for over a century and remains the gold standard for conditions affecting multiple corneal layers.

During PKP, the surgeon uses a circular cutting instrument called a trephine to remove the central portion of the patient's cornea, typically 7-8 millimeters in diameter. The same-sized donor cornea is then sewn into place using extremely fine sutures—thinner than a human hair. These sutures may remain in place for one to two years or longer.

PKP is typically indicated for keratoconus (when other techniques aren't suitable), full-thickness corneal scarring, corneal dystrophies affecting multiple layers, and failed previous grafts. While highly effective, full-thickness transplants have longer recovery times and higher rejection rates compared to partial-thickness procedures.

DSAEK and DSEK - Endothelial Keratoplasty

Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) and its predecessor DSEK represent a major advancement for patients with endothelial disease, such as Fuchs' dystrophy or bullous keratopathy. Rather than replacing the entire cornea, these procedures replace only the innermost layers—the endothelium and Descemet's membrane—along with a thin layer of stroma.

The procedure involves removing the patient's damaged endothelial layer through a small incision and inserting a thin disc of donor tissue. An air bubble is injected into the eye to hold the new tissue in place while it adheres to the patient's cornea. No sutures are needed on the corneal surface, which contributes to faster visual recovery.

DSAEK offers several advantages over traditional PKP: smaller incision, faster visual recovery (often within weeks to months), lower rejection rates, and a stronger eye structure post-surgery. The success rate for DSAEK exceeds 95% in appropriate candidates.

DMEK - Ultra-Thin Endothelial Keratoplasty

Descemet's Membrane Endothelial Keratoplasty (DMEK) takes endothelial keratoplasty even further by transplanting only Descemet's membrane and the endothelium—a tissue layer just 10-15 micrometers thick. This ultra-thin transplant provides the fastest visual recovery and lowest rejection rates of any corneal transplant technique.

DMEK results in visual outcomes that most closely match those of a normal eye. Studies show that approximately 60-75% of DMEK patients achieve 20/25 vision or better, compared to about 30-40% with DSAEK. However, the tissue is more delicate and technically demanding to handle, and there is a higher rate of the graft partially detaching and requiring repositioning in the first few days after surgery.

DALK - Deep Anterior Lamellar Keratoplasty

Deep Anterior Lamellar Keratoplasty (DALK) replaces the outer corneal layers (epithelium, Bowman's layer, and stroma) while preserving the patient's own endothelium. This technique is ideal for conditions like keratoconus and corneal scarring that don't affect the innermost layer.

By keeping the patient's endothelium intact, DALK eliminates the risk of endothelial rejection—the most common and serious form of corneal graft rejection. However, the surgery is technically challenging, and visual outcomes depend on achieving a smooth interface between donor and recipient tissue. Recovery times are similar to PKP, but long-term graft survival is excellent.

How Should You Prepare for Corneal Transplant Surgery?

Preparation for corneal transplant surgery involves a comprehensive eye examination, medical evaluation, discussion of anesthesia options, and coordination with an eye bank for donor tissue. Your surgeon will provide specific instructions about medications, eating, and arranging transportation and post-operative care.

Proper preparation is essential for a successful corneal transplant. The process begins weeks before your scheduled surgery date with thorough evaluations to ensure you're a good candidate for the procedure and to plan the most appropriate surgical approach for your specific condition.

Your ophthalmologist will perform detailed measurements of your eye, including corneal topography to map your cornea's shape and thickness, specular microscopy to count endothelial cells (if applicable), and assessment of your overall eye health including the retina and optic nerve. These tests help determine which type of transplant is most suitable and establish baseline measurements for comparison after surgery.

Medical Evaluation

A general medical evaluation ensures you can safely undergo surgery. Your doctor will review your medical history, current medications, and any conditions that might affect healing or increase surgical risks. Conditions like uncontrolled diabetes, autoimmune disorders, or certain medications may need to be addressed before proceeding.

If you take blood thinners (anticoagulants), your surgeon will coordinate with your prescribing physician about temporarily stopping these medications before surgery. Never stop any medication without specific instructions from your medical team.

Anesthesia Options

Corneal transplant surgery can be performed under either local or general anesthesia. Most procedures are done with local anesthesia, which numbs the eye and surrounding area while you remain awake but sedated. You won't feel pain during the surgery, though you may be aware of pressure and movement.

Local anesthesia typically involves numbing eye drops followed by an injection of anesthetic around the eye (retrobulbar or peribulbar block). Sedation is usually given through an IV to help you relax. General anesthesia may be recommended for longer procedures, patients with significant anxiety, or those who cannot lie still for an extended period.

If general anesthesia is planned, you'll meet with an anesthesiologist beforehand for evaluation. They'll review your heart and lung function to ensure safe sedation. You'll need to fast (no food or drink) for a specified period before surgery, typically starting at midnight the night before.

Day Before and Day of Surgery

The day before surgery, follow all instructions from your surgical team carefully. This may include using antibiotic eye drops, avoiding makeup and lotions around your eyes, and arranging for someone to drive you to and from the surgery center.

On surgery day, wear comfortable, loose-fitting clothing. Leave jewelry and valuables at home. Bring your glasses (if you have them) but leave contact lenses at home. Your surgical team will have you change into a hospital gown and start an IV line for medications.

How Is Corneal Transplant Surgery Performed?

During corneal transplant surgery, the surgeon uses a microscope to precisely remove the damaged corneal tissue and replace it with healthy donor tissue. The procedure typically takes 1-2 hours and is performed in an operating room with specialized microsurgical instruments. The specific technique varies depending on the type of transplant.

Corneal transplant surgery requires exceptional precision, as the surgeon works on tissue less than one millimeter thick. The entire procedure is performed under a powerful operating microscope that magnifies the surgical field, allowing for accurate tissue manipulation and suture placement.

Upon arrival in the operating room, your surgical team will position you comfortably on the operating table and administer anesthesia. Your face will be cleaned with antiseptic solution, and sterile drapes will be placed around your eye. A small device called a lid speculum gently holds your eyelids open throughout the procedure.

Full-Thickness Transplant (PKP) Procedure

For penetrating keratoplasty, the surgeon begins by marking the center of your cornea to ensure proper alignment. Using a circular cutting instrument called a trephine, the surgeon removes a disk of your damaged cornea, typically 7-8 millimeters in diameter. The donor cornea has been prepared to match this size precisely.

The donor tissue is carefully positioned in the opening and secured with extremely fine sutures—typically 16-24 individual stitches or a continuous running suture. Each suture is placed with meticulous attention to depth and tension to ensure proper healing and minimize astigmatism. The entire process requires remarkable steady-handedness, as sutures are placed with material finer than human hair.

Endothelial Keratoplasty (DSAEK/DMEK) Procedure

Endothelial procedures begin with a small incision, usually 3-5 millimeters for DSAEK or even smaller for DMEK. The surgeon removes your damaged endothelial layer by gently stripping away Descemet's membrane from the inside of your cornea.

The donor tissue—a thin disc for DSAEK or ultra-thin membrane for DMEK—is folded or rolled and inserted through the small incision. Once inside the eye, the tissue is unfolded and positioned against the back of your cornea. An air bubble is injected to press the new tissue against your cornea, where it will naturally adhere over the following hours.

After DSAEK or DMEK, you must remain lying face-up for a specified period (often several hours to overnight) to keep the air bubble pressing against the graft. This positioning is critical for proper attachment.

What Happens to the Donor Tissue?

Donor corneal tissue comes from eye banks, which carefully screen and prepare tissue from deceased donors. The donation process is carefully regulated to ensure tissue quality and safety. Eye banks test donor tissue for infectious diseases and evaluate the tissue quality, including counting endothelial cells.

Donor corneas can be stored for up to two weeks in special preservation media, allowing time for testing and coordination of surgery scheduling. Unlike organs such as kidneys, there is no need for blood type or tissue matching between donor and recipient, though some surgeons prefer to match donor and recipient age when possible.

What Is the Recovery Process After Corneal Transplant?

Recovery from corneal transplant surgery varies significantly depending on the type of procedure performed. Lamellar procedures like DSAEK and DMEK may allow visual recovery within weeks to months, while full-thickness transplants typically require 6-12 months or longer. All patients require careful follow-up and long-term use of medicated eye drops.

Understanding the recovery timeline helps set realistic expectations. Corneal healing is a slow process because the cornea has no blood vessels—the same feature that reduces rejection also means healing nutrients must diffuse from surrounding tissues. Patience is essential, as final visual outcomes may not be apparent for many months.

Immediately after surgery, your eye will be covered with a protective shield. You'll rest briefly in a recovery area before going home the same day in most cases. Some discomfort, scratchiness, or foreign body sensation is normal for the first few days. Your vision will be blurry initially, and this is expected.

First Few Days and Weeks

During the first few days, the most important tasks are protecting your eye, using prescribed medications correctly, and watching for warning signs of complications. You'll start antibiotic eye drops to prevent infection and corticosteroid drops to control inflammation and reduce rejection risk.

Keep your protective eye shield in place, especially while sleeping, for the duration your surgeon recommends (often 1-4 weeks). Avoid rubbing or pressing on your eye, as this can displace the graft. Also avoid activities that increase eye pressure, including bending over, heavy lifting, and straining.

Your first follow-up appointment is usually the day after surgery. The surgeon will examine your eye to ensure the graft is properly positioned and healing is progressing normally. After DSAEK or DMEK, this visit is particularly important to confirm the tissue has adhered properly.

Long-Term Recovery and Medications

Corticosteroid eye drops are essential for preventing rejection and may be needed for an extended period—often months to years, and sometimes indefinitely at a low dose. Your drop regimen will typically start with frequent application (4-8 times daily) and gradually taper as healing progresses.

It's crucial to follow your medication schedule precisely. Missing doses can increase rejection risk. Set reminders if needed, and always ensure you have enough medication before running out. Never stop steroid drops abruptly without your doctor's guidance, as sudden discontinuation can trigger rejection.

Regular follow-up appointments continue for life after corneal transplant. Initially, you'll be seen frequently (weekly, then monthly), with visits becoming less frequent over time. These appointments monitor for rejection, check healing progress, and adjust medications as needed.

Activities and Lifestyle During Recovery

Your surgeon will provide specific guidance on resuming activities. General recommendations include:

• Avoid swimming and hot tubs for at least one month to reduce infection risk
• Avoid dusty or dirty environments during early healing
• Protect your eye from impact—wear protective eyewear during activities with any risk of eye injury
• Wait before returning to contact sports—your surgeon will advise when it's safe
• Driving restrictions may apply until your vision meets legal requirements and your doctor clears you

Most people can return to desk work within 1-2 weeks, depending on visual demands and how they feel. More physically demanding jobs may require longer recovery periods.

What Are the Warning Signs of Corneal Transplant Rejection?

The warning signs of corneal transplant rejection can be remembered with the acronym RSVP: Redness, Sensitivity to light, Vision decrease, and Pain. If you experience any of these symptoms after your transplant, contact your ophthalmologist immediately. Early detection and treatment of rejection can often save the graft.

Rejection occurs when your immune system recognizes the donor tissue as foreign and attacks it. Despite the cornea's immune-privileged status, rejection remains a concern for all corneal transplant recipients. The risk is highest in the first year after surgery but can occur at any time—even decades later.

Understanding rejection and its warning signs empowers you to seek prompt treatment, which dramatically improves outcomes. Studies show that up to 90% of rejection episodes can be reversed if treated within the first 24 hours of symptom onset. Delays in treatment significantly reduce the chance of successful reversal.

The RSVP Warning Signs

Medical professionals use the acronym RSVP to help patients remember the key warning signs of rejection:

• R - Redness: Increasing redness of the eye, particularly around the cornea, that doesn't improve or gets worse
• S - Sensitivity to light: Increased discomfort or pain when exposed to light (photophobia)
• V - Vision decrease: Any new blurring, cloudiness, or decrease in vision quality
• P - Pain: New or increasing pain in or around the eye

These symptoms may occur individually or in combination. Any single symptom warrants immediate attention from your eye care team. Don't wait to see if symptoms improve on their own—call your ophthalmologist right away, even on nights or weekends.

Types of Rejection

Rejection can affect different layers of the cornea:

Endothelial rejection is the most common and serious form. It affects the innermost layer of cells responsible for keeping the cornea clear. Signs include corneal swelling and cloudiness. This type poses the greatest threat to graft survival.

Epithelial rejection affects the surface layer and usually appears as a line of haze moving across the cornea. It's generally less serious and responds well to increased steroid drops.

Stromal rejection affects the middle layer and may appear as patchy haze in the cornea. Like epithelial rejection, it usually responds to treatment.

Treatment of Rejection

Rejection treatment typically begins with intensive corticosteroid therapy. This usually means steroid eye drops given hourly initially, gradually tapering as the rejection resolves. In some cases, steroid injections around the eye or oral steroids may be added.

With prompt treatment, most rejection episodes can be reversed. However, each rejection episode may cause some permanent damage to the graft. Multiple rejection episodes increase the risk of eventual graft failure. This underscores the importance of both preventing rejection (with regular medication use) and catching it early when it occurs.

What Is the Success Rate for Corneal Transplant Surgery?

Corneal transplant surgery has high success rates overall. For penetrating keratoplasty, the 5-year graft survival rate is approximately 70-90% depending on the underlying condition. Newer endothelial keratoplasty techniques (DSAEK and DMEK) achieve success rates exceeding 95% in appropriate candidates. Success rates vary based on the reason for transplant and individual patient factors.

Corneal transplantation is among the most successful of all tissue transplants. The combination of the cornea's immune-privileged status, refined surgical techniques, and effective rejection prevention strategies contributes to excellent outcomes for most patients.

However, "success" in corneal transplantation encompasses multiple factors beyond simple graft survival. True success includes achieving clear corneal clarity, improved visual acuity, freedom from pain and discomfort, and enhanced quality of life. Most patients experience significant improvement in all these areas.

Factors Affecting Success

Several factors influence corneal transplant outcomes:

The underlying condition significantly affects prognosis. Transplants for keratoconus and Fuchs' dystrophy have the highest success rates, often exceeding 90% at 10 years. Conditions involving blood vessel growth in the cornea (neovascularization), previous graft failure, or significant inflammation carry higher rejection risks.

The type of transplant matters. Lamellar procedures that preserve the patient's healthy tissue generally have better outcomes than full-thickness transplants. DMEK, for example, has rejection rates as low as 1% at 5 years in some studies.

Patient compliance with medications and follow-up significantly impacts success. Patients who use their medications consistently and attend regular appointments have better outcomes than those who don't.

Surgical experience plays a role. Surgeons who perform high volumes of corneal transplants typically achieve better outcomes, particularly for technically demanding procedures like DMEK.

Graft Longevity

How long does a corneal transplant last? Many grafts function well for 10-20 years or longer. Studies show that approximately 70-80% of full-thickness grafts remain clear at 10 years. Newer techniques may have even better long-term durability, though they haven't been performed long enough to have comparable data.

If a corneal transplant eventually fails, a repeat transplant is usually possible. Second and subsequent transplants have somewhat lower success rates than first-time grafts but can still provide significant visual improvement. Some patients have had successful repeat transplants several times over their lifetime.

Frequently Asked Questions About Corneal Transplant