Penetrating Keratoplasty

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Assigned status Up to Date on March 11, 2015.


  • Keratoconus and ectasias
  • Corneal degenerations
  • Corneal dystrophies including Fuchs endothelial dystrophy
  • Noninfectious ulcerative keratitis
  • Microbial keratits including Fungal and Bacterial keratitis
  • Viral keratitis
  • Post infectious keratitis
  • Congenital opacities
  • Chemical injuries
  • Mechanical trauma
  • Refractive indications
  • Regraft related to allograft rejection
  • Regraft unrelated to allograft rejection

Surgical Procedure

The initial step in penetrating keratoplasty should be the preparation of the donor tissue. The use a corneal button 0.25-0.50mm larger than the diameter of the host corneal openning is recommneded as it can help reduce excessive postoperative corneal flattening, reduce the risk of secondary glaucoma and enhance wound closure.

Penetrating Keratoplasty with interrupted and running sutures, 1st postoperative day

The host cornea is trephined, the anterior chamber is filled with viscoelastic and the the donor tissue is placed endothellial side down on the recipient's eye. The cornea is then sutured in place with either interrupted or continuous sutures. Interrupted sutures are preferred in vascularized, inflammed or thinned corneas as well as in pediatric cases.

Penetrating keratoplasty may be combined with cataract surgery, secondary intraocular lens implantation, glaucoma surgery and retinal surgery.

Intraoperative Complications

  • Poor graft centration
  • Irregular trephination
  • Damage to the lens
  • Damage to the donor tissue
  • Choroidal hemorrhage and effusion
  • Incarceration of iris tissue in the wound
  • Vitreous in the anterior chamber

Postoperative Complications

Corneal Graft Rejection


  • Decreased vision, pain, redness and photophobia after a corneal transplant


  • Keratic precipitates or a white line on the corneal endothelium
  • Stromal edema or infiltrates
  • Subepithelial or epithelial edema
  • Conjunctival injection
  • Anterior chamber cells or flare
  • Neovascularization

Differential Diagnosis

  • Increased intraocular pressure
  • Uveitis
  • Suture abscess
  • Corneal infection
  • Recurrent disease in the graft (Herpetic or corneal dystrophy)


  • Start a topical steroid, such as prednisolone acetate 1% q 1hr immediately. Use a cycloplegic agent. Systemic steroids (prednisone 40-80 mg daily) should be considered in cases that do not respond to topical steroids and in recurrent rejection episodes. [1]

Additional Resources


  1. The Wills Eye Manual, 4th Edition. Kunimoto, Kanitkar, & Makar. Lippincott, 2004.
  1. H.E., Barron, L., McDonald, M.B., eds., The Cornea, 2d ed., 1996
  2. External Disease and Cornea, Section 8. Basic and Clinical Science Course, AAO, 2006.