Infant Corneal Transplant: New Light on Baby’s Eyesight
Within hours after Brent Nolan was born on July 30 at Placentia-Linda Community Hospital in Orange County, nurse Danette Duggan noticed a slight clouding in the baby’s left eye.
Six days later, Brent became what doctors believe may be the nation’s youngest recipient of a cornea transplant when Stuart I. Brown, a San Diego doctor, performed the delicate surgery.
Lives Turned Upside Down
During the five months since Brent’s birth, his parents, Bob and Penny Nolan of Mission Viejo, have watched as their once well-ordered lives were turned upside down, first by countless trips to San Diego and around-the-clock monitoring of Brent’s progress, then by a second transplant operation in October when Brent’s tiny body rejected the new cornea.
The second transplant has been labeled a success by Brown, who performed the surgery at UC San Diego Medical Center. Brown, an acknowledged pioneer in the field of infant corneal transplants, is professor and chairman of the ophthalmology department at UC San Diego School of Medicine and director of the San Diego Eye Bank.
“This is the youngest one that we have ever done,” said Brown, one of the few physicians in the country who performs such delicate surgery on infants.
“We just feel we were so lucky,” said Penny Nolan, 33, an elementary school teacher in the Ocean View School District in Huntington Beach.
The Nolans count themselves lucky because Brent’s problem was discovered so soon after his birth. If a newborn does not achieve sight in the affected eye during the first six weeks of life, the brain may not accept the images if sight is restored later, Brown said.
“The longer we wait, the less chance (there is) of success,” he said.
But often there are delays in referring such infants to a specialist, Brown said. “And the delays are tragic. In general, we do not see the babies until after the first six weeks. If we can perform the surgery early, then we can achieve substantial sight.”
(In Brent’s case, the Nolans said, the baby was recently tested and the lens and retina appear normal in his left eye.)
Defect Not Obvious
The Nolans were referred to Brown by Brent’s pediatrician, Dr. Donald Crocker of Yorba Linda.
“When I saw Brent after he was born I had no idea anything was wrong,” Penny Nolan said. “But they said something was wrong with his left eye. It was completely clouded.”
The Nolans, whose 5-year-old daughter, Kellie, has normal vision, took Brent to see Brown and received some devastating news. “We were told that it (the clouding) would not clear up, that Brent would have no sight in that eye,” said Bob Nolan, 34, a safety engineer for a company in Irvine.
The congenital condition from which Brent suffered is called Peters anomaly, which Brown described as “not a very common affliction, but not rare.”
“About 15 years ago I developed a (surgical) procedure for this condition, and over the years it has been improved so that we get a fairly good success rate,” said Brown, who is described by Bartly Mondino, professor of ophthalmology at Jules Stein Eye Institute at UCLA, as “the world’s authority on infant corneal transplants.”
Such surgery on infants has been “more difficult, rarer and less successful than similar surgery performed on adults,” according to Don Ward, executive director of the Lions Doheny Eye Bank in Los Angeles, the world’s largest provider of corneas.
“We do not see a lot of infant corneal transplants,” observed Robert Fenzl, a Garden Grove ophthalmologist and former director of the Medical Eye Bank of Orange County in Santa Ana. Although Fenzl performs 45 to 50 corneal transplants each year--mostly on adults--he has never done one on a child as young as Brent. Fenzl’s youngest transplant patient was 10 months old.
Exact statistics on infant corneal transplants are not available, but Brown estimated that in the past two or three years he has done 30 to 40 such surgeries.
The only other place in the country where they are being performed in such large numbers is at Emory Eye Center at Emory University in Atlanta, where Dr. Doyle Stulting estimates that 200 to 250 such operations have been performed in the past seven years.
Stulting said his youngest patients have been about 3 to 4 weeks old. “We routinely do them at under a month of age,” he said. “But nobody keeps statistics on the numbers of such surgeries performed or the youngest patient. It is a rarer procedure (than adult cornea transplants). It is more difficult. But Brown is a pioneer in this area. For a while, people didn’t think it was possible to perform them successfully on young children. But in the past 15 years, people have begun to operate on children, and their prognosis is as good as in an adult.”
Network of Eye Banks
Brent received both his corneas through the San Diego Eye Bank, one of four eye banks in Southern California and one of 100 in the United States.
“We all belong to a large network,” Don Ward of the Lions Doheny Eye Bank said. As the public’s awareness of transplant operations has grown, so has the availability of corneas, Ward said.
A Shorter Wait
“It used to be that we had a six-months-to-a-year wait for a cornea. Now there is only a two- or three-week wait,” said Ward, who estimated that 23,000 corneal transplants are performed annually nationwide.
Ward is expecting an even larger increase in the number of available corneas as a result of Assembly Bill 631, known as “the required request law,” that went into effect Jan. 1.
“The new law requires hospitals to offer families the opportunity to donate organs and tissues at the time of death,” Ward said. “We had found in the past that the reason a lot of people didn’t donate was because they were not asked to. This law requires that they be asked.”
In general, corneas make easy donor-to-recipient matches, noted Ward. “Corneas do not need to be matched as to blood type and age,” he said. “Any healthy recipient generally makes a good match.”
The only exception, according to Ward, is that doctors performing transplants on infants or children will try to obtain a cornea from someone under 20. “It is thought that is better because if you have a cornea from a 65-year-old in a baby, when that baby is 65, the cornea will be 130,” he said.
Both corneas transplanted in Brent Nolan were from young adults, Brown said. “We don’t want it (the cornea) from another infant because it is very difficult to work with,” he said.
Although the surgery on Brent was performed on an outpatient basis, the Nolans had to drive back and forth to San Diego daily for the first week for checkups.
“When we brought Brent home his arms were splinted,” Penny Nolan recalled, “so that he couldn’t touch his eye. But he kept swinging his arms around even with the splints. We spent all night up with him to keep his hands away from his eye.”
Hourly Medication
“And we were up every hour putting medication in his eye for three days,” Bob Nolan said. “Now we still have to put drops in every four hours.”
The low point for the Nolans came when Brent’s new cornea became cloudy as his body rejected the first transplant, prompting Brown to perform the second operation. A critical factor in both operations, he said, was the dedication of the parents.
“Nowadays when both the mother and the father work, it requires a donation of time. They really have to be able to drop what they are doing,” he said. “It is an enormous emotional drain on marriages. The Nolans are very special people. They always had a smile and a sense of cooperation and devotion. That child has got a lot of love.”
Fenzl agrees that the family plays a crucial role in such an operation. “If they are dedicated to it, you can accomplish almost anything,” he said.
A Difficult Situation
“Oh, we have gone through a lot of ‘Why me?’ ” Penny Nolan said. “It has been difficult. And the appearance of his left eye will always be a little different. Being a teacher, I know that kids can be horribly cruel, and I worry about that.”
Nor is the work over for the family. In order to force Brent to use his new left eye, the Nolans must patch the baby’s right eye three days a week. “His left eye is like a newborn’s eye,” his mother said. “And we have to teach him to use it.”
Although the going has been rough, the Nolans have no regrets about opting for the transplant surgery. “There was no question in our minds as long as there was a chance he might see with that eye,” Bob Nolan said. “As for us, we are now both staunch advocates of organ donations.”
