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Reducing Trauma from Penetrating Keratoplasty

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Reducing Trauma from Penetrating Keratoplasty
BY BEZALEL SCHENDOWICH, OD, FIACLE

Surgery is trauma to both the body and the psyche. Ocular surgery is even more so. This is not so difficult to understand when you consider that a large part of our lives centers around and depends upon our eyes and  visual sensory input.

Corneal transplant surgery (or penetrating keratoplasty [PK]) is one of the most traumatic ocular surgeries. While the procedure itself is over in a few hours, the recuperation and healing process can take years. Not to mention that essentially the graft-host boundary can never be as strong as a cornea that has not been cut.

You can ease your patients' PK surgical trauma through several stages of information gathering. Advise your patients to:

1. Acquire full and complete information about the procedure before surgery

2. Develop a good relationship with the surgeon and his staff

3. Know whom to turn to when they require more information

4. Understand how to help themselves recover from the trauma of surgery most comfortably and safely (for the graft)

What Patients Need to Know

To help PK patients gather the information they need, I have compiled a list of questions to serve as guide. These questions are designed to encourage surgeons and other hospital staff to work constructively with their patients rather than to "lose them between the benches," which is what often happens.

I have provided no answers to these questions. Many of the answers will most likely differ among institutions and even from case to case. It is the surgical candidate's responsibility to ask and investigate so he can reach a composed state of mind before entering the operating room.

The suggested questions are:

  • Who can I talk to who has undergone this surgery?
  • How can I contact other patients who have undergone this surgery for support and general advice when the doctor is not available?
  • What should I bring with me to the hospital?
  • How long will I be hospitalized?
  • How can I prepare for my hospital stay?
  • Can you give me a full description of what will take place during the surgery, barring any problematic developments?
  • Do you use local or general anesthetic?
  • Are there any possible side effects of the anesthesia?
  • How does follow-up care proceed after surgery?
  • Can you describe for me the overall road to recovery? How long will my eye remain swollen?
  • What kind of discomfort can I expect?
  • What are the possible complications of this procedure?
  • What is the procedure for removing stitches, when do you remove them and why?
  • How much vision can I expect to have directly following the operation?
  • How long will it take to gain useable vision from the operated eye?
  • What are some possible complications to watch out for, both serious and benign?
  • What should I do if I cannot contact my surgeon in an emergency?
  • What about swimming, bathing, showering or shampooing after my operation?
  • Will I need special eye protection?
  • Will I be limited in my daily activity after the operation?
  • Are there bodily motions or actions that I should refrain from for some period of time after the operation (because of possible problems for the healing of the graft or because of other ill though benign effects)?
  • Will I need assistance around the house?
  • How long until can lift heavy objects?
  • When will I be able to return to work?
  • Is it possible that I may need more surgery after the transplant?
  • What are the chances of rejection and what are the signs?
  • What are the roles of each of the medications that you will prescribe for me to use after the surgery?
  • Explain the use of steroids and suggest alternatives
  • How dangerous are the steroid drops?
  • How can I tell if the transplanted cornea is a success?

Advice for Post-graft Care

I have also collected some pearls of advice for the care and well being of the grafted cornea:

  • Make arrangements for everything beforehand: babysitters, frozen food, audio books, pain medications, etc
  • Learn how to cope with the side effects of the surgery (dizziness from the anesthesia, eye pain) and how to identify signs of possible rejection (RSVP [redness, sensitivity, vision changes, pain])
  • Too much light sensitivity (bad pain) after the transplant is not normal; excess tearing is not normal.
  • Stitches may be uncomfortable, but report any undo sensation to the surgeon.
  • Protect your eye by wearing an eye shield or clear glasses.
  • Be careful ­ in fact, be overprotective.
  • Don't get soap in your eye.
  • Don't do anything that can potentially cause the eye to get knocked.
  • Don't rub your eye.
  • Don't overdo it ­ rest when you are tired.
  • Don't overwear contact lenses on the transplanted cornea.
  • Remain vigilant and react to any possible sign of rejection.
  • Use a plastic shield when indoors and wrap-around sunglasses when you are outside.
  • Have someone look after you for at least the first three days ­ it may turn out to be unnecessary, but arrange for it beforehand anyway.
  • Watch the steroids, they do funny things to your body.
  • Don't be in a hurry to remove your stitches.
  • Talk to others who have had the surgery.
  • Prepare yourself for lifestyle changes (driving, work effectiveness).
  • Bring family members to doctor's visits so they can also ask questions, record the answers and participate in your recovery.

The National Keratoconus Foundation (NKCF) addresses many of these issues in its Corneal Transplant Surgery: A Reference Guide for Patients and their Families, which published in 2002. I recommend that practitioners distribute this guide to their pre-PK patients.

The author wishes to acknowledge members of KC-Link, which is a part of NKCF, and keratoconics@yahoogroups.com.  These currently active Internet support groups suggested many of the questions and points in this article.

 

 

Scaling System for Keratoconus

 

Many patients have serious concerns about the severity of their keratoconus. I propose the following scaling grades to help you classify keratoconus patients. I have found that in most cases this grading scale can relieve some of the psychological trauma that patients experience when they suddenly learn that their eyes are diseased.

Nearly every keratoconic patient will receive a grade of two or three out of five according to this system:

I. Spectacle correction continues to provide sufficient visual acuity

II. Eyeglasses and/or contact lenses provide adequate eyesight

III. Only contact lenses can compensate for reduced vision

IV. Pre-surgical with reduced quality of life, reduced length of continuous lens wear and significant corneal scarring.

V. Post-surgical

Dr. Schendowich is a preceptor in the Optometry Clinic at the Hadassah Academic College in Jerusalem, Israel and adjunct assistant clinical professor of Optometry of SUNY ­ Optometry based in the Optometry Clinic at the Sha'are Zedek Medical Center, Jerusalem, Israel.