Corneal Surgery Melbourne
Subspecialty corneal surgery including the full range of corneal transplantation techniques, combined cataract and corneal surgery, and pterygium removal. Dr Ross MacIntyre MD FRANZCO brings fellowship training from the Wilmer Eye Institute at Johns Hopkins to his Melbourne practice.
What Is Corneal Surgery?
The cornea is the clear front window of the eye — a dome-shaped, transparent tissue approximately 12 mm in diameter that provides around two-thirds of the eye's total focusing power. Its clarity depends on a precise architecture: five distinct layers, each with a specific role, and an innermost cell layer (the endothelium) that continuously pumps fluid out to keep the cornea in the slightly dehydrated state that allows it to remain transparent.
When the cornea is damaged by disease, infection, or structural change, vision deteriorates in ways that cannot always be corrected with glasses or contact lenses. Corneal surgery encompasses a range of procedures aimed at restoring clarity and structural integrity — from replacing specific diseased layers of the cornea with donor tissue, to removing conjunctival growths from the corneal surface. The appropriate procedure depends on which layer is affected and the nature of the underlying condition.
Modern corneal surgery has evolved significantly over the past two decades. Where once the only option was a full-thickness corneal graft requiring sutures and an eighteen-month visual recovery, today targeted lamellar techniques replace only the diseased layer — with faster recovery, better visual outcomes, and significantly lower rejection rates. Patient selection and matching the correct technique to the correct indication are central to achieving good results.
Corneal Transplantation
Corneal transplantation — keratoplasty — involves replacing diseased corneal tissue with healthy donor tissue sourced through the Lions Eye Donation Service. The key principle guiding modern technique selection is to replace only the layer that is diseased, preserving healthy tissue. The appropriate technique depends on which layer is affected.
DMEK — Descemet Membrane Endothelial Keratoplasty
DMEK is the most advanced and most commonly performed endothelial keratoplasty technique, and is the preferred surgical treatment for most patients with Fuchs endothelial dystrophy and bullous keratopathy. The procedure replaces only the Descemet membrane and endothelium — the innermost 10 to 15 microns of the cornea — leaving all of the patient's healthy anterior tissue intact. Donor tissue is carefully prepared, rolled into a scroll, and inserted into the anterior chamber through a small incision, then unrolled and positioned against the recipient cornea using an air bubble.
Because the graft contains no donor stroma, the optical interface is nearly perfect — producing better visual outcomes and a lower rejection rate than any other transplant technique. Most patients achieve functional vision within four to six weeks. In the first 48 hours after surgery, patients are asked to maintain a face-up (supine) position for 45 minutes per hour to allow the air bubble to hold the graft in contact with the cornea while it adheres. DMEK is technically demanding and requires specific surgical training and ongoing high procedural volume. For a detailed guide to the procedure, see Dr MacIntyre's DMEK guide at drmacintyre.com.
DSAEK — Descemet Stripping Automated Endothelial Keratoplasty
DSAEK also replaces the inner layer of the cornea but includes a thin layer of donor stroma in addition to the Descemet membrane and endothelium — a graft approximately 100 to 150 microns thick. This makes the donor tissue easier to handle and unfold within the eye compared to DMEK. DSAEK produces excellent outcomes and remains an important technique in cases where DMEK is technically difficult — for example, in eyes with abnormal anterior chamber anatomy, previous glaucoma surgery, or failed DMEK grafts. Recovery is slightly slower than DMEK, with most visual improvement occurring over three to six months.
DALK — Deep Anterior Lamellar Keratoplasty
DALK replaces the epithelium and stroma — the anterior portion of the cornea — while preserving the patient's own Descemet membrane and endothelium. It is the preferred technique for keratoconus, anterior corneal scarring, and corneal dystrophies affecting the stroma where the endothelium remains healthy. Because no donor endothelium is transplanted, the risk of endothelial rejection is eliminated entirely, and the long-term graft survival of DALK is significantly better than full-thickness PKP for these indications. DALK is technically demanding — the critical step is separating the stroma from Descemet membrane at a precise plane — but in experienced hands the technique achieves excellent visual outcomes. Visual recovery takes longer than endothelial keratoplasty, typically twelve to eighteen months, as sutures remain in place for an extended period.
PKP — Penetrating Keratoplasty (Full-Thickness Transplant)
PKP replaces the full thickness of the central cornea with a circular disc of donor tissue and remains the appropriate technique when multiple corneal layers are diseased, when there is significant deep stromal scarring, or when anatomy prevents lamellar techniques. The donor disc is sutured in place using very fine interrupted or running sutures that typically remain for twelve to eighteen months. Visual recovery is the slowest of all transplant techniques — final acuity often takes twelve to eighteen months to stabilise — and the wound remains a structural weak point indefinitely. PKP also carries a higher rejection risk than lamellar techniques and requires careful long-term follow-up. Despite these limitations, PKP produces excellent results in appropriately selected patients and remains an important part of the surgical repertoire.
Combined Cataract and Corneal Transplant Surgery
Many patients with Fuchs endothelial dystrophy also develop a visually significant cataract as part of normal ageing — and the combination presents a specific management challenge. Standard cataract surgery uses ultrasound energy (phacoemulsification) to remove the cloudy lens, and this energy further stresses the already-compromised endothelial cells. In an eye with borderline endothelial reserve, cataract surgery alone can precipitate corneal decompensation that then requires a subsequent corneal transplant. Conversely, performing the corneal transplant first and addressing the cataract later means two separate surgical procedures and a prolonged overall visual rehabilitation timeline.
For carefully selected patients, combined DMEK and cataract surgery allows both conditions to be addressed in a single anaesthetic. The cataract is removed and an intraocular lens implanted, then the DMEK graft is inserted in the same procedure. This approach eliminates the need for a second surgery, removes the risk of cataract surgery causing endothelial decompensation, and shortens the overall treatment pathway considerably — with a single rehabilitation period rather than two sequential recoveries.
Combined surgery does require more complex pre-operative planning. Calculating the correct intraocular lens power is more challenging in a cornea that is oedematous, and decisions about premium lens selection must account for the fact that the corneal shape will change after the transplant. Not all patients are candidates — those with very mild Fuchs changes may be better served by cataract surgery alone with close monitoring. The decision requires experienced judgement. For further detail, see Dr MacIntyre's article on combined cataract and corneal surgery.
Pterygium Surgery
A pterygium is a fleshy, wedge-shaped overgrowth of vascularised conjunctival tissue that extends from the white of the eye (conjunctiva) onto the clear cornea, typically from the nasal side. It is associated with chronic UV exposure and is more common in patients who work or spend significant time outdoors. Pterygia are frequently seen in sunny, dry climates and tend to grow more rapidly in these environments.
Many pterygia are initially small and cause only mild irritation or redness. Lubricating eye drops and UV-protecting sunglasses are appropriate for managing symptoms in early cases. Surgical removal is recommended when the pterygium is actively growing towards the visual axis, inducing clinically significant astigmatism (which can cause blurring or distortion), or causing persistent irritation and redness that affects daily life. In advanced cases, a pterygium can encroach on the pupil and directly obstruct vision.
The preferred surgical technique is excision with conjunctival autograft. After the pterygium is carefully dissected and removed, a small piece of healthy conjunctiva is harvested from the patient's own eye — typically from under the upper eyelid — and transplanted to cover the bare area where the pterygium was removed. Using the patient's own tissue as a graft dramatically reduces the risk of recurrence compared to older techniques that left bare sclera or used synthetic materials. The recurrence rate with conjunctival autograft is under five percent compared to over thirty percent with bare sclera excision.
Recovery from pterygium surgery typically involves a few days of redness and mild discomfort, with most patients returning to normal activities within a week. Anti-inflammatory eye drops are used for several weeks post-operatively. Long-term, protecting the eyes from UV light with wrap-around sunglasses and a hat is the most important step in preventing recurrence or formation of a new pterygium.
Corneal Conditions Treated
Fuchs Endothelial Dystrophy
Fuchs dystrophy is a hereditary condition causing progressive loss and dysfunction of the corneal endothelial cells. As cell density falls, the cornea swells and vision becomes hazy — typically worse in the morning and improving through the day. In mild cases, hypertonic saline drops can reduce morning oedema. When vision is significantly affected or endothelial cell counts indicate the cornea cannot safely tolerate cataract surgery, DMEK is the treatment of choice.
Keratoconus
Keratoconus is a progressive condition in which the cornea thins and bulges forward into a cone shape, causing distorted and blurred vision that worsens over time. Management ranges from speciality contact lenses and corneal cross-linking to halt progression, through to DALK when the cone is advanced and cannot be corrected with lenses. For a comprehensive overview, see the keratoconus page.
Corneal Scarring
Corneal scarring can result from bacterial or fungal infection (keratitis), viral disease (herpes simplex, herpes zoster), trauma, or chemical injury. Scarring within the visual axis reduces clarity and cannot be corrected with glasses alone. Depending on the depth and extent of the scar, treatment options range from phototherapeutic keratectomy (PTK) using an excimer laser, to lamellar transplantation (DALK) for anterior scars, or PKP for deeper or full-thickness involvement.
Bullous Keratopathy
Bullous keratopathy occurs when the corneal endothelium fails — most commonly following cataract surgery, other intraocular surgery, or trauma — causing the cornea to swell with fluid and form painful surface blisters (bullae). When conservative management with hypertonic drops no longer provides adequate comfort and vision, DMEK is the treatment of choice, replacing the failed endothelium with healthy donor cells.
What to Expect
Corneal surgery is a carefully staged process involving assessment, surgical planning, and a variable recovery period depending on the technique. Here is what the journey typically involves:
Surgeon Training and Experience
Dr Ross MacIntyre MD FRANZCO undertook a subspecialty fellowship in cornea, complex cataract, and refractive surgery at the Wilmer Eye Institute at Johns Hopkins University in Baltimore — one of the world's most highly regarded ophthalmic referral centres. Fellowship training at Wilmer provides concentrated exposure to advanced corneal disease and the full range of keratoplasty techniques, including a surgical volume of complex and referred cases that would take many years to accumulate in a standard practice setting.
Following his Wilmer fellowship, Dr MacIntyre completed a corneal fellowship at the Royal Victorian Eye and Ear Hospital in Melbourne — the national referral centre for corneal disease in Australia. He continues as a Staff Specialist on the RVEEH Cornea Unit, which keeps him connected to a public referral caseload of advanced and unusual presentations. He performs corneal transplantation at Northpark Private Hospital in Bundoora and at the RVEEH. For further detail on his training and credentials, see drmacintyre.com.
- Subspecialty fellowship: cornea, complex cataract, and refractive surgery — Wilmer Eye Institute, Johns Hopkins University
- Corneal fellowship — Royal Victorian Eye and Ear Hospital, Melbourne
- Staff Specialist, RVEEH Cornea Unit (ongoing public appointment)
- FRANZCO — Fellow, Royal Australian and New Zealand College of Ophthalmologists
- Diplomate, American Board of Ophthalmology
- Consulting at Northpark Private Hospital, Bundoora and Bass Coast Eye Centre, Wonthaggi
Corneal Surgery Melbourne — FAQ
Concerned About Your Cornea?
A referral from your GP or optometrist is required to see Dr MacIntyre. Once you have a referral, appointments can be booked through Northern Eye Consultants.
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