Corneal transplantation: Restoring sight to the blind

Corneal blindness is one of the leading causes of vision loss worldwide. Transplantation of the cornea can restore vision and make blind patients see again. Corneal transplant surgery has undergone major evolution in recent decades with the advent of minimally invasive lamellar surgical approaches such as DMEK and DALK. Nonetheless, on a global scale, penetrating keratoplasty, especially in so-called high-risk settings, remains a commonly performed surgery. As pathologic blood and clinically invisible lymphatic vessels have been identified as key risk factors for immune reactions after high-risk transplantation, we present current evidence for temporary pre-transplant lymphangioregression in the cornea as a novel concept to promote graft survival after subsequent transplantation. Here, UVA-based crosslinking can be used as a novel method to regress pathologic corneal vessels. Also, performing DMEK in high-risk eyes and the use of artificial endothelial transplants can prevent immune reactions in these patients. Finally, novel developments in the area of DMEK, DSO and endothelial cell transplantation are discussed. We are experiencing (r)evolutionary improvements not only in modern lamellar but also in penetrating corneal transplantation to make patients with corneal blindness see again.