IMAGINE trying to unfold a section of gladwrap in a bowl of water. Now, imagine you have to unroll a piece of gladwrap about a centimetre wide in a bowl of water the size of your eyeball.
Little wonder, perhaps, that Ipswich doctor Andrew Apel is the only eye surgeon in the Ipswich area performing corneal transplants.
The cornea is the transparent, dome-shaped window covering the front of the eye that provides two-thirds of the eye's focusing power.
Dr Apel has been an eye surgeon for more than 16 years and has been working out of his Ipswich rooms since 2009.
At the Ipswich Day Hospital, he performs the majority of eye procedures in Queensland and has pioneered new surgical techniques to treat eye disease.
Corneal transplants are performed to improve vision, to preserve the eye through reconstructing the cornea or to treat the eye after disease or trauma.
Almost 450 corneal transplants are performed in Queensland each year and the success rate has risen dramatically because of technological advances such as less irritating sutures, which are often finer than a human hair, and the surgical microscope.
Corneal transplantation has been performed successfully since 1905 but over the last decade it has evolved, allowing surgeons to provide newer techniques.
Traditional corneal transplantation, known as Penetrating Keratoplasty (PK), involved replacing the full thickness of the cornea regardless of the layer that was diseased.
Descemet's Membrane Endothelial Keratoplasty (DMEK) is a new technique being pioneered in Ipswich by Dr Apel.
DMEK involves replacing only the diseased part of the cornea with similar healthy donor tissue, resulting in fewer complications and virtually no rejection.
Dr Apel has been successfully performing the DMEK procedure on patients suffering from corneal disorders such as Fuchs' dystrophy, which would result in swelling and blistering and painful loss of vision if left untreated.
"We do a number of things here but my area of training and expertise is in corneal transplantation," Dr Apel said. "Traditionally, what we've done is a full thickness transplant where you cut the whole centre out of the cornea and stitch it again.
"Now what we can offer is just taking the back layer off the cornea and putting a new back layer on. It's a significant change in the surgery time, time for visual recovery and the complexity.
"So that's kind of the new thing on the block over the last few years and I'm the only one in Ipswich who does corneal transplantation."
He spent two years in Toronto studying how to do it but it was worth it, he said, because the results were quicker and better.
"It used to be a case of 12 to 18 months to get your vision back to normal; now it's two to three months," he said.
"We can pretty much do this on anyone of any age."
The tissue used in these transplants is provided by eye banks and the Queensland Eye Bank at Princess Alexandra Hospital runs a donation service where more than 580 corneal grafts were provided this year.
"When people pass away they donate their eyes the way they donate a heart or other organ but because there are no blood vessels in the cornea the rejection rate is much lower; in a heart, lung or liver, the rejection rate is about 50 per cent," Dr Apel said.
From time of death to transplantation, you've got about 10 days so you can book an appointment rather than the middle of the night phone call type of thing.
In a normal eye, the back surface (endothelium) of the cornea acts like a pump to keep just the right amount of moisture in the cornea.
Because it is just the endothelium that is causing the swelling in Fuchs' dystrophy, it is only that part of the cornea replaced during the surgery.
The endothelium is removed and the donor endothelium is inserted on to the eye through a 2.6mm incision and held in place with an air bubble.
The air bubble holds the transplanted tissue in place until it adheres to the cornea. The procedure is obviously easier said than done.
"The cornea is about 12mm across and the tissue I'm replacing on the back of the cornea is about 50 microns in thickness (there are 1000 microns in a millimetre) so it looks like a tiny piece of gladwrap," Dr Apel said.
"Dealing with it is like if you dropped that in a tiny bowl of water and you've got to be able to manipulate it and stretch it out nice and flat and stick on the back of the eye.
It's rolled up like a newspaper and has to be placed under an incision and then manipulated flat into place.
"The beauty too is there's no stitches that need to come out after 12 months; we use an air bubble to hold it in place.
"We can combine that with all the other procedures we do, like cataract surgery, which we do a lot of."
The risk of graft failure is about one per cent. A failed graft is one that adheres after surgery, but fails to clear after several weeks. The risk of the graft dislocating is about 5% but can usually be fixed by putting another air bubble into the eye.
"The other thing I do here that other people aren't doing is correcting people's vision with a lens implant so they don't need reading glasses," he said. "The recovery time is virtually nothing; they can be back at work straight away, drive their car the next day and read the newspaper."
Dr Apel mentors young ophthalmologists to further develop their surgical skills and expertise, and regularly conducts education evenings for optometrists from Ipswich and the surrounding areas.