OPERATION IN DETAIL: After informed consent was obtained, the patient was brought to the operating room and laid on the table in the supine position. The patient was then administered general anesthesia by the anesthesia service and was intubated. The patient was then prepped and draped in the usual sterile fashion for surgery on the right eye. A Schott lid speculum was inserted. The patient's corneal diameter was measured with a corneal caliber and found to be 12.3 mm horizontally by 11.8 mm vertically. There was significant corneal ectasia with central subepithelial and stromal scarring. Healon and a corneal shield were placed on the cornea. A scleral fixation ring was chosen and sutured with eight interrupted 5-0 Dacron sutures, with partial thickness scleral bites. The cornea was examined again, and the optical axis was marked with a sterile marking pen and the tips of a forceps. The patient's pupil was noted to be slightly nasal. The host cornea was marked by applying brief gentle pressure with an 8.0 mm trephine. The mark was repositioned until satisfactory centering was achieved. A 12-prong radial marker was marked with a sterile marker, and the cornea was marked to assist in donor-host suture symmetry and alignment. The donor cornea was trephined with an 8.0 mm trephine after being placed in a donor corneal punch that had been marked with a marker in the punch holes. The cornea was placed in the punch endothelial side up. The donor rim was sent for culture on a culture plate. The donor button was covered with Healon and OptiSeal and placed aside. Next, the host cornea was trephined with an 8.0 mm trephine until the anterior chamber was entered. Miochol was injected through the initial opening to constrict the pupil and protect the lens. The edge of the trephine recipient cornea was lifted with an ionized and 0.12 forceps and corneal scissors were used to excise the recipient button, leaving a slightly beveled edge. The cornea was noted to be extremely floppy, indicating a very thick cornea. Vannas scissors were used to trim a tag of remaining tissue superonasally. The anterior chamber, remaining recipient corneal rim and sclera out to the fixation ring were coated with Healon. The donor tissue was lifted from the corneal punch with a spatula and transferred onto the recipient bed atop the viscoelastic. The four interrupted 10-0 nylon cardinal sutures were placed first. These were left intentionally loose. Twelve additional radial interrupted 10-0 nylon sutures were placed snugly. Care was taken to pass sutures approximately 50% depth in the donor stroma and 90% depth into the host tissue. The cardinal sutures were found to be torqued, as expected, once the remaining sutures had been placed. They were cut and replaced with the proper tension. Several temporal sutures were tightened as well, as the patient's keratoconus required this adjustment. Slight override of the donor tissue was noted at the 2 o'clock position; therefore, an additional 10-0 interrupted suture was placed at that point. A plastic ring was then used to check for astigmatism, and slight against-the-rule astigmatism was detected, as the ring reflex was seen to be ovalized vertically and slightly inferonasally. Two inferonasal sutures were placed, making them tighter, and the ring was again used to check for astigmatism. This time, the reflex was nearly perfectly circular. The wound was closed with additional 10-0 nylon running suture with 90% stromal depth radial bites, with a knot buried at the 9 o'clock position on the donor side. The running suture tension was evenly distributed by adjusting the tension of each bite with tying forceps. The interrupted suture knots were buried on the donor side. The anterior chamber was reformed with BSS on a 30-gauge cannula, irrigating all of the Healon from the eye. An intracameral injection of vancomycin 10 mg/mL was given. The wound was checked with a Weck-Cel sponge and fluorescein strip for leaks. There was a micro leak at the 4 o'clock position, and an additional 10-0 nylon interrupted suture was used to close this. At the end of the procedure, the wound was Seidel negative. The donor cornea was noted to be edematous throughout the case. The entire epithelial surface was absent. The endothelial cell count, however, was good when the tissue was accepted, and it is anticipated that the edema will resolve with time. The scleral ring was removed and the lid speculum was also removed. The drapes were gently removed. Multiple drops of topical anesthetic were instilled into the eye. A drop of Alphagan and a drop of Timoptic 0.5% ophthalmic solutions were used, as well as Polysporin ophthalmic ointment. Wet and dry sponges were used to clean the eye. A piece of 1 inch Transpore tape was used to close the eyelid. Next, a light eye patch was taped in place and covered with a metal eye shield. The patient was extubated without complications and taken to the PACU in good condition.
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