Time for a corneal graft?

[Barney]

A few years ago I had a corneal graft to my left eye and, with a RGP lens, the sight in that eye is now very good, better than 6/6. (Without the lens it’s lousy.)

A couple of months ago I went for a routine check and while there asked what could be done with my right eye. Under most conditions the sight is poor with the right eye even with the lens I wear but it varies. Without the lens I can’t see much under any circumstances. On the other hand, in subdued light it’s much better and I can see better than halfway down the eyechart. The worst problem is when driving in good daylight when I can’t read the number-plate of the car in front with the poor eye if it’s more than a few feet away. I’m effectively driving with one (very good) eye with the other eye not adding anything to overall vision.

I asked the doctor I saw whether I should have a graft to the second eye. His immediate response was that I shouldn’t. I said the reason asked was that I was now 60 and with the sands of time and all that stuff it seemed to make sense that if it did need to be done I might as well have the maximum years of benefit.

He called over the consultant and said I would like to have a graft. I was a bit taken aback because what I’d really asked was whether having a graft was the sensible course for me. Without knowing all the facts available to the doctors I don’t feel in any position to judge.

The consultant had a very quick look and said there was a cataract which would also affect my sight. There was then an immediate assumption that I would now be having a graft. He asked if I wanted the cataract removed first or done at the same time as the graft. I said it wasn’t something I knew anything about and he decided that doing the two together was the best course.

He said that they would do a lamellar graft to reduce the chances of rejection but that for one in ten people that wasn’t possible and a full graft would then be required. I was surprised because I was previously told that a lamella graft would definitely not be possible for me.

What concerns me a little is that I seem to have stumbled into having the graft with the op arranged for two weeks time. I don’t really know what the options are and would have liked to have a professional judgement of what the chances of good vision are and what the risks are. At the moment I don’t feel I have any information to judge the upside or downside myself. I expected the consultation process to be a longer one after the first person I saw thought a graft wasn’t the best approach so wasn’t really ready to ask questions. I thought there might be tests to see how much the cataract was part of the problem.

Is this usually the way it happens? Seems so incredibly casual. At the same time if it is something that should be done I don’t want to lose the chance.

[GarethB]

Hi Barney,

I know in more normal situations a cataract is allowed tp 'ripen' first before the surgery is done. This is just a small incision in the cornea to remove the lens and put in an artificial one I think.

With a graft it is a case of the Penetrating Keratoplasty (PK) the full thickness of the cornea is removed.

Deep Anterior Lammela Keratoplasty (DALK) only removes the top two layers as the KC is in the middle one. So theorietically the two can be done together.

DALK seems to be more common now due to less rejection problems and that depending on the location of KC, the graft can be done closer to the extremes of the cornea where a PK graft would have a high risk of rejection.

The main times a DALK can turn into a PK is where there is deep scaring which has damaged the epethelium (inner most) layer of the cornea or if there is trouble seperating this layer from the cornea they are trying to remove.

In either case the recovery period can be some time and may well still necessitate the wearing of a lens as you do in your eye that has been grafted already.

I think Andrew here is in a similar position to you except his cataract is in the eye he has had grafted already.

I have been advised that operating on my grafted eye could cause issues that may make rejection a likely side effect. My graft is 20 years old and rejection is not something I want to go through. So this might be the case with you. The surgeon may feel that if he just did the KC now and left the cataract, the chances of complicaations may be higher when the cataract is done.

If this is the case, I think the sensible thing is to get the two done together.

At the end of the day it is your choice and you can back out at any time.

Hope this helps.

[jayuk]

Barney

Not much more to add from Gareths post aside from

a) when deciding to have a graft ALWAYS make sure you have exchausted al other options....primarily Lenses and other KC lens Designs

b) You need to decide if the current vision you have WITH both eyes corrected is acceptible in yoor every day life........

Frm a personal perspective, Id always discourage a graft (and bear in mind Ive had one with great success so far - touch wood) until all other avenues have been exhausted..as its a complex and life affecting procedure which requires a period of recovery and also needs care for the rest of your life.....

HTH

Jay

[Barney]

Thanks GarethB and Jay.

Terrible to admit but I really don't know what the options are. I wear RGPs without any problems and nothing else has ever been suggested. With the RGP I have fairly blurry vision with the right eye when driving and see some shadow images. I couldn't drive with that eye alone. Thankfully the vision in the left eye that had the graft a few years back is great with a lens.

What I don't know is what the chances are of a similar result for the right eye. I assume that surgeons keep figures for outcomes and that they could be graphed. Similarly, although I know there's a risk of "rejection" I don't know what the level of risk is or what that might mean for me. I feel that I don't have any basis to make a decision.

Can you see reasonably well with your less good eye Jay? If not, sounds as if you might be in a similar position to me so could you say why you'd prefer not to have a second graft.

I guess I'm really just trying to assess what I've got to gain and what I've got to lose.

[GarethB]

Barney,

A medical succes is often different to what the patient regards as a success.

For the surgeon it is that the cornea has healed well, the corneal thickness is good, the cornea is clear and the surface is of such a shape that sight can be corrected.

The point of a graft with KC is to provide a surface wherby vision is easier to correct.

Rejection is not that common at all, it is just something to be aware of. It has been reported that most cases of rejection can be managed with the use of medication if caught early.

Many detremine what they have to gain by assessing what impact the vision has on their lives.

I know a couple of people with KC who have taken lenses as far as they can and still avoided the graft route. ONe has a guid dog now and considers his life to be extremely satisfying and that the lack of vision has no impact on his quality of life.

When I had my grafts done, I had a promoising accadenmic carear in environmental sciences and was doing well in junior motor sport events so when lenses were not an option the impact menat I could not race or study my choosen subject. The grafts have meant that I could return to racing which I did semi-professionaly for many years with varying degrees of succes and I have a good carear in the world of science.

For me my grafts were a resounding succes from a medical perspective and personally too as I did go many years where my vision was 6/6 without correction post graft.

I still go along with what Jay says and make sure you are happy the lens route is exhausted.

There are several good posts on the subject of lenses and grafts in the Frequenty Asked Questions area of the forum they may be helpful to you.

[jayuk]

Barney

Ive been one of the lucky ones where atfer 8 weeks I got glasses and haev relied on that grafted eye every since. My other eye has Advanced KC and I havent used it (as in rely on it for vision) for around 18 months now.

I do EVERYTHING I could do when I had vision from both eyes, driving, gym, going out, building work, etc etc.....

With regards to anther graft...I was meant to have one Yesterday! My DALK....but I had no choice but to cancel and rearrange later in the year as I have just a little too much going on in my life right now.....with job, new house, traveling etc....But Yes, I will 100% have the DALK as I really have no other option in that eye.

So I am not saying dont do it, I am merely saying explore other lens types, as from what you have said it would appear noone has spoken to you aboout the vast range of lenses there are.

HTH

Jay

[Andrew MacLean]

Barney

I am 56 and will have my second eye grafted on October 27. Like you I am scheduled for a DLK, although this may change during the operation if it does not prove possible to complete the surgery.

Like you I have a cateract, although mine is growing under the graft I had done in 2003.

It sounds as if things had got to the point where you were probably ready for the graft. You suggest in your opening post that you did not have any useful sight in that eye.

All the best

Andrew

[Barney]

Hi Andrew,

It's great to hear the thoughts of others who have trodden much the same path.

I'd be wildly exaggerating to give the impression that I've no useful sight in the right eye. It's poor compared with the grafted eye but what does surprise is that it varies so much on the circumstances. I assume that's the same for everyone?

Driving in bright sunshine I can barely see a number-plate a few feet away with the right eye but in subdued light I can see reasonably well. I'm not sure what's down to the cataract, I don't think it's very developed, and what's due to corneal scarring. Certain objects such as an eyechart I can see comparatively well whereas a more complex object such as a photograph is much more difficult. I'm getting to the age where I need reading glasses and can't read the font in a newspaper with the right eye with or without correction. Life gets complicated.

You've had grafts to both eyes Gareth?

Obviously I realise that once one eye gives good vision further benefits from a second graft will be less. I am conscious of not having full binocular vision when driving so feel slightly less able to judge distances and I'm aware of effectively using one eye instead of two. For driving anything less than perfect sight is a problem and as my eye problems didn't develop until middle age I'm aware of the change - but I could certainly manage just as I am without any great hardship.

Having the first eye done about eight or so years ago was a revelation. I've had great vision and not a hint of a problem but I'm now wondering if I was lucky and might not be so lucky with the other eye. Jay, you're right that no-one has discussed any other type of lenses. I assumed they thought they wouldn't help my problems.

I'd be particularly interested in hearing the views of someone who has managed with a guide dog rather than have a graft.

Hope it all goes miraculously well for all of us.

[GarethB]

Barney,

2 grafts 1989 and 1990, start studying Environmental Microbiology registerd partially sighted and had a white stick. By 1991 I was working for the Government on an industrial placement which involved working on oil rigs, up chimmneys and down sewers! By 1992/3 my vision was good enough to get my MSA race licence back

From some research I was looking at a couiple days aga about 98% of grafts are considerd succesfull, two thirds of those success which are corrected using contact lenses, the rest with glasses and a few percent not needing any further correction.

I think questions that need asking are;

1) What are the medical benefits of having the two done together?

2) If there were no cataract, is the cornea shape such that it can be corrected useing a lens?

3) If the cataract only were to be done, would it still be possible to correct vision using a lens?

It was once the case hydrops would be induced to a KC eye and many who have had hydrops have reported vision easier to correct post hydrops, so scarring on the cornea (outside the field of vision) may well make the KC easier to correct. The flip side is that there is some research that shows trauma to the eye such an operation can make the KC to progress which might be why the surgeon would like to do the two together. This too is something that you would need to discuss with the surgeon.

Going back to the original [post, it sounds like you asked one thing, the question got twisted and the whole thing built up momentum regarding grafts and somewhat left you behind!

Hope these thoughts help too.

[Barney]

Sounds as if you had a tough time Gareth. I've probably been luckier; never really had a major problem and never thought of it as ever being any kind of handicap. Have always been able to drive and never had any problem wearing lenses.

My op is scheduled for a couple of weeks time so I'm not sure if I'll have another chance to ask any questions unless I ask for a postponement. I was a bit taken aback by how quickly the view swung from a graft not being a good idea within a couple of minutes. I heard from somewhere that I'll likely have a pre-op appointment but I'm not sure what happens during that and haven't heard anything yet with just a couple of weeks to go.