Corneal Transplant Complications: Rejection, Infection, and Eye Pressure
Why Post-Transplant Complications Deserve Attention
The cornea (the clear front surface of the eye) is a living tissue that requires careful monitoring after transplant surgery. Three risks stand above the rest: rejection, infection, and elevated eye pressure. Each has distinct warning signs and a defined treatment approach, and all three are manageable when caught early.
The first year after surgery is the most critical period. Rejection risk peaks during the first six months. Infection risk is greatest in the first weeks while the surface heals. Elevated pressure can develop at any point while a patient is using steroid eye drops, which are prescribed long-term after a graft.
Risk decreases after the first year but never disappears entirely. Lifetime follow-up visits are an essential part of protecting your graft.
Steroid drops are prescribed to reduce the chance of rejection. Antibiotic drops protect the healing surface from bacterial infection in the early weeks. Pressure-lowering drops may be added if your eye pressure rises. Each medication serves a specific and important purpose.
Follow-up visits allow your Cornea Specialist to detect small changes before they become serious problems. Keeping every appointment, even when your eye feels completely normal, is one of the most important things you can do after a transplant.
The type of transplant you received affects your overall complication profile. DMEK (Descemet Membrane Endothelial Keratoplasty) and DSEK (Descemet Stripping Endothelial Keratoplasty) are partial-thickness transplants that generally carry lower rejection rates than PK (Penetrating Keratoplasty), which replaces the full thickness of the cornea. Your Cornea Specialist will explain what risks apply specifically to your graft and your health history.
Graft Rejection: What It Is and How to Respond
Graft rejection is the most discussed complication after a corneal transplant, and for good reason. It is the most common cause of late graft failure. The encouraging news is that most cases of early rejection can be reversed with prompt treatment.
Rejection occurs when the body's immune system identifies the donor tissue as foreign and sends white blood cells to attack it. This response causes swelling, reduced clarity, and potential damage to the transplanted layer. Left untreated, rejection can cause the graft to fail permanently.
It is important to understand that rejection does not automatically mean your graft is lost. Early intervention almost always improves the outcome. The primary driver of permanent graft damage is delayed treatment, not the rejection episode itself.
A simple way to remember the warning signs is the RSVP rule. Each letter stands for one key symptom to watch for after a corneal transplant.
- Redness that appears suddenly and does not resolve
- Sensitivity to light that is new or worsening
- Vision changes, including blurring or haziness
- Pain in or around the eye
Any one of these symptoms warrants a same-day call to your Cornea Specialist. Do not wait for your next scheduled appointment.
Certain factors increase the likelihood of rejection. These include blood vessel growth into the cornea (called corneal vascularization), a prior rejection episode, a history of herpes eye disease, a history of uveitis (inflammation inside the eye), and having received more than one corneal transplant. Younger patients, including children and teenagers, also face higher rejection rates than older adults.
If any of these factors apply to you, your Cornea Specialist may recommend more frequent monitoring and may discuss additional protective measures.
Treatment begins immediately with a significantly increased dose of steroid eye drops, often every waking hour in the first days. In more severe cases, your specialist may prescribe oral steroids or a steroid injection near the eye. The treatment course typically lasts weeks to months depending on the response.
Speed is everything. Rejection episodes caught within the first few days almost always respond to treatment. Episodes left untreated for weeks carry a much higher risk of permanent graft failure.
Infections After Corneal Transplant Surgery
Infection is a serious and potentially sight-threatening complication after a corneal transplant. The combination of a healing surface and immune-suppressing steroid drops creates a window of higher vulnerability, particularly in the weeks immediately following surgery.
The freshly grafted corneal surface takes days to weeks to heal fully. During this time, it is more susceptible to bacteria, fungi, and viruses. Steroid drops, which are essential for preventing rejection, also reduce the immune response that would normally fight off infection. This necessary tradeoff is why careful monitoring is so important early in recovery.
Symptoms of infection can escalate quickly. Contact your Cornea Specialist the same day if you experience any of the following.
- Increasing eye pain, especially if it comes on suddenly
- Rapid or worsening change in vision
- Thick, colored, or unusual discharge from the eye
- Significant eyelid swelling
- New or intensifying light sensitivity
Some infections, particularly bacterial ones, can spread through the eye within hours. Do not wait for a scheduled visit if you experience these signs.
People who carry the herpes simplex virus (the same virus responsible for cold sores) may have it dormant in the nerves near the eye. Steroid drops used after a transplant can reactivate this virus, leading to a painful and potentially vision-threatening corneal infection called herpetic keratitis.
If you have a history of cold sores, prior herpes eye disease, or a known herpes simplex infection, tell your Cornea Specialist before and after surgery. A long-term oral antiviral medication may be prescribed to reduce the chance of reactivation during your recovery period.
The treatment used depends entirely on the type of organism causing the infection. Bacterial infections are treated with concentrated antibiotic drops, often applied every hour in the early stages. Fungal infections require antifungal drops, which typically take longer to show results. Viral infections, including herpes simplex, are treated with antiviral medications.
In many cases, your Cornea Specialist will take a small sample from the eye surface for laboratory analysis. This allows the treatment to be matched precisely to the organism involved, which improves outcomes and reduces the risk of resistance. Treatment may last several weeks, with close follow-up throughout.
Elevated Eye Pressure After a Corneal Transplant
Elevated eye pressure, also called ocular hypertension, is a common and manageable complication after corneal transplant surgery. It is particularly important to monitor because the damage it causes to the optic nerve is often silent until it has progressed significantly.
Steroid eye drops, which are necessary after a transplant, can cause a rise in eye pressure in a subset of patients. This happens because steroids can slow the drainage of the fluid that naturally circulates inside the eye. Approximately one in three people are considered steroid responders, meaning their eyes are particularly sensitive to this effect.
The transplant surgery itself can also affect fluid drainage. Scar tissue or changes in the eye's internal anatomy may partially block the normal drainage pathways, leading to a gradual or sudden increase in pressure.
Sustained elevated pressure can damage the optic nerve, leading to glaucoma (a condition involving progressive optic nerve damage and vision loss). Because this damage often develops without obvious symptoms, patients may not notice it until it is in an advanced stage.
High pressure also accelerates the loss of endothelial cells, which are the inner cells responsible for keeping the cornea clear. Losing these cells more rapidly than normal shortens the functional lifespan of the graft.
Eye pressure is measured at every follow-up visit using a quick, painless test. If pressure is consistently elevated, additional tests such as visual field testing or optic nerve imaging may be added to assess whether the nerve has been affected.
First-line treatment involves pressure-lowering eye drops. These work either by increasing the drainage of fluid from the eye or by reducing how much fluid the eye produces. Most patients with elevated pressure can be managed successfully with one or two drops.
A small number of patients do not achieve adequate pressure control with drops alone. In these cases, a glaucoma procedure may be recommended to create or restore a drainage pathway for fluid inside the eye. This type of surgery is typically performed as a separate step after the corneal transplant has healed and stabilized.
Your Cornea Specialist will discuss a surgical option only when drops are not sufficient to bring pressure to a safe level. Many patients never require this step.
Frequently Asked Questions
The following questions address practical concerns that often come up between appointments. If you have a concern not covered here, do not hesitate to contact our team directly.
If your surgeon placed an air or gas bubble in your eye as part of the procedure, flying is not safe until that bubble has been fully absorbed. At altitude, the bubble expands and can cause a rapid rise in eye pressure that may damage both the optic nerve and the graft. Your Cornea Specialist will confirm when air travel is safe for your specific case, and this timeline varies by patient and by the type of gas used.
Slow graft failure typically shows up as a gradual increase in blurring, haziness, or glare rather than a sudden dramatic change. It often reflects a slow decline in the endothelial cell count over time. This is why your Cornea Specialist periodically measures your cell count using a specialized camera, so that changes can be tracked and decisions about the graft's future can be made before vision becomes significantly impaired.
Light walking is generally encouraged soon after surgery. Swimming, however, should be avoided for at least the first month because pool water, lake water, and hot tubs can harbor organisms that infect a healing corneal surface. When you return to swimming, well-sealed goggles provide an added layer of protection. Always confirm the appropriate timeline with your Cornea Specialist, as individual healing varies.
Most patients manage their post-transplant care with eye drops only. However, patients with a history of herpes simplex eye disease or cold sores may be prescribed an oral antiviral medication for an extended period to prevent viral reactivation. If you are in this group, continuing the antiviral even when the eye feels completely normal is important, since the goal is prevention rather than treatment of an active flare.
A failed corneal transplant can often be addressed with a repeat transplant procedure. The type of graft chosen for a second transplant depends on which layer of the cornea was affected and the reason the first graft failed. Your Cornea Specialist will review your case thoroughly before recommending a next step, and repeat transplants can be highly successful for well-selected patients.
As a general rule, any new symptom involving pain, sudden vision change, significant redness, or unusual discharge should be treated as urgent and addressed the same day. Mild, stable symptoms that are not changing may be appropriate to monitor and report at your next scheduled visit. When in doubt, contact our office and describe what you are experiencing. Our team can help you determine whether you need to be seen right away.
Expert Cornea Care at Rhode Island Eye Institute
Our Cornea Specialists at Rhode Island Eye Institute, including Dr. Jane Cook, Dr. Elliot Perlman, and Dr. Christopher Newton, bring fellowship-trained expertise and decades of combined experience to every stage of corneal transplant care, from the operating room through long-term graft monitoring. Backed by a team of in-house optometrists and the academic resources of Brown University, we are equipped to manage the full spectrum of post-transplant complications with precision and compassion. If you have concerns about your graft, notice any new symptoms, or simply want a second opinion, we encourage you to schedule a consultation with our cornea team. We are here to protect your vision for the long term.