surgeon must be prepared to perform a limited anterior vitrectomy. This can be done through the pupil or through an iridectomy and posterior to the intraocular lens. To perform a limited anterior vitrectomy, a phacoemulsiÞcation unit (InÞniti, Alcon) with an attached hand-held vitrector is placed on the ÒvitrectomyÓ setting with a cut rate of 800 m/s. The vitrector is inserted into the anterior chamber easily as the host cornea has been removed. Any visible vitreous is removed.

4.1.7.6 Anterior Chamber Hemorrhage

Anterior chamber hemorrhage may be encountered in a number of situations. In patients undergoing therapeutic PK for a medically nonresponsive infectious keratitis, intraocular inßammation is associated with engorged iris vasculature that can easily bleed as the host cornea is removed and there is an abrupt drop in the IOP. Previous intraocular inßammation from any number of causes may also have led to scarring of the iris to the host endothelium that when peeled during host cornea excision may bleed. In addition to these things, if the surgeon accidently cuts the iris as the cornea is being excised, bleeding will be encountered. And, Þnally, removal of a lens implant that is Þbrosed against the iris or in the angle will too be associated with bleeding.

Bleeding that is minor can be ignored. It will most likely stop on its own and often suturing the donor cornea into position will raise the IOP enough to tamponade the bleeding. Profuse bleeding must be stopped and there are a few different ways to do this. The surgeon may apply cautery directly to the bleeding vessel if it can be visualized but care should be taken to not cauterize too much of the iris. A bleeding scleral vessel at the edge of host cornea removal can be cauterized fairly easily. Viscoelastics may be placed in the anterior chamber to tamponade the bleeding and weck cell sponges soaked with epinephrine 1:1000 may be applied as well.

4.1.7.7 Choroidal Hemorrhage

The most dreaded complication of a cornea transplantation procedure is the expulsive choroidal hemorrhage. The incidence of expulsive hemorrhage has been reported from 0.47 to 3.3% [1]. Predisposing factors are advanced age, myopia, glaucoma, inßammation, hypotonia, or previous trauma [1]. When the

cornea surgeon attempts to repair perforated, infected, or severely traumatized eyes, he/she must be prepared to deal with expulsive choroidal hemorrhage [1].

Choroidal detachments or effusions appear as dark shadows or brown masses that can be seen in the red reßex and are often noted during the open-sky phase of the keratoplasty. This is why there should be a quick attempt on the part of the surgeon following host cornea removal to secure the donor cornea with four cardinal sutures and bring the IOP back to the normal range. Expulsive hemorrhages may occur rapidly with a sudden extrusion of intraocular contents, or there may be a more gradual hemorrhage that slowly extrudes the anterior segment structures followed by the vitreous [1]. A valsalva maneuver during the procedure can lead to an expulsive hemorrhage. For this reason, the authors prefer general anesthesia with complete paralysis of the patient when there are no systemic contraindications.

Management of an expulsive choroidal hemorrhage during the open-sky phase of the procedure requires the quick applanation of a Þnger or thumb over the wound and perhaps the placement of a posterior sclerotomy large enough for the blood to be expressed. The surgeon should quickly replace either the recipientÕs cornea or the donor cornea over the wound and secure it with interrupted sutures. These maneuvers will help direct the hemorrhage posteriorly. If the anterior intraocular contents have not been expulsed, they can be positioned in their proper places. If they have been expulsed, the surgeon should continue closing the wound and plan to have a discussion with the family before an evisceration is undertaken. We prefer not to perform a primary evisceration because having the discussion with the patient and the family Þrst may allow the patient to deal better psychologically with the situation.

4.1.8 Postoperative Management

In general, patients are followed postoperatively at day one, week one, month 1, 2, and 3, and every 3Ð4 months thereafter. If an epithelial defect is present on day one patients are seen more frequently until the epithelium heals. Visual acuity is measured using a Snellen chart at 20 feet in our clinic. UCVA is recorded at every visit, and BCVA is often attempted at the 1 month postoperative visit. The process of suture removal usually begins after three postoperative months and is guided by