5.6 Transplant Rejection, Corneal

eyes.nhs.scot/
Eyecare Guidelines/
Section 5 - Corneal/
5.6 Transplant Rejection, Corneal

Date of last review:

5/9/2026

Date of next review:

5/9/2028

Date of publication:

16/9/2026

Differential diagnosis ⁽¹⁾ 

Graft failure (transplant decompensation) – typically occurs without inflammation 
Suture‑related infection 
Infective keratitis 
Anterior uveitis

Possible management by optometrist ⁽¹⁾

Advice ⁽¹⁾

Emphasise that this is a potentially sight‑threatening emergency requiring immediate assessment 
Instruct the patient to attend the local Hospital Eye Service (HES) or A&E the same day 
Contact the receiving department to:  
- Inform them of the referral 
- Ensure the patient is expected and prioritised 
Where possible, communicate directly with a clinician or appropriate healthcare professional

Treatment  ⁽¹⁾

No optometric treatment — emergency referral required

Typical dosage/duration

(Blue text = IP, black text = non-IP)

Not applicable for this condition ⁽⁷⁾

Further management options ⁽¹⁾

Emergency referral to ophthalmology – no intervention 
Immediate escalation is required to reduce the risk of graft failure and permanent visual loss

Possible management in secondary care or local/community pathways where available ⁽¹⁾

Intensive topical corticosteroid therapy
Systemic corticosteroids in more severe cases
Additional systemic and/or topical immunosuppressive agents (e.g. ciclosporin, tacrolimus)
Topical antiviral therapy if there is a history of herpes simplex infection
Hospital admission where indicated

College of Optometrists Clinical Management Guideline⁽¹⁾ 

Corneal transplant rejection - College of Optometrists  *

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

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CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

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Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

Updating the Eyecare Guidelines requires a continuous process; the date of the last review for each guideline will be clearly noted on each guideline. Users must consider these dates before using the guidance.

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