Aaron James still finds it hard to comprehend that he received the first successful full-eye transplant in history. “It’s just overwhelming to be a part of something so big,” said the 47-year-old father from Hot Springs, Arkansas.

In 2021, James was injured in an electrical accident while working as a high voltage technician. He lost his dominant left arm, his left eye, his chin and his nose. For two years he was unable to eat solid food, taste, smell or speak normally.

In May 2023, he received the first full eye and face transplant at New York University (NYU) Langone Health in New York City. More than a year after the operation, his transplanted eye remains healthy – the retina even reacts to light - but James can't see out of it.

“It's a technically brilliant operation,” says surgeon Bohdan Pomahač of the Yale School of Medicine in New Haven, Connecticut, who performed the first full face transplant in the United States in 2011 but was not involved in James' case. “The authors have pushed the boundaries of innovation.” The operation will take place todayJAMA 1described.

Marathon surgery

A large medical team transplanted the entire left eye, the bony eye socket, the nose, a piece of the chin bone, and associated muscles, nerves and blood vessels from a donor whose brain showed no functional activity. The operation lasted approximately 21 hours.

Doctors never expected that James would be able to regain vision in the transplanted eye, says Daniel Ceradini, a surgeon at NYU Langone Health and lead author of the study. The reason for this is that there was no evidence that the Donor optic nerve could successfully reconnect with James’ brain. The optic nerve, which sends information from the retina to the brain, is part of the central nervous system, and how to regenerate this system remains a mystery. But the surgery brings researchers one step closer to an eye transplant that could one day restore vision, which Ceradini said is considered the "holy grail."

James needed a face transplant and was willing to take the additional risk of an eye transplant to help future organ recipients. “I would take immunosuppressants for the face transplant anyway,” he says. “All we could do was win something.”

Practice, practice

Surgical dissection of the eye is so complex that the team practiced on cadavers at least 15 times, Ceradini says.

Many scientific advances came together to make the operation possible. The team “essentially developed a new operation based on existing principles,” says Pomahač. The blood supply to the eyes comes from a different artery than the one that supplies the rest of the face. To ensure that the donated eye would not go without a blood supply for too long, surgeons connected the artery that supplied the donor's eye to a branch of the donor's external carotid artery, a large vessel that begins near the neck. The entire structure was then transplanted into James, a procedure that has never been performed on humans. “They figured out how to restore an eyeball in a way that doesn’t damage blood flow,” says Pomahač.

Another advance was the creation of a set of 3D printed surgical templates that allowed surgeons to harvest just the right amount of donor bone that James' face needed. The templates were based on CT scans of Donor and James' faces and were placed over their faces during surgery. “The donor piece fits exactly in, like a precise puzzle piece,” says Ceradini.

After all this, no one knew how the transplanted eyeball would behave, says Ceradini: "Does it shrink? Does the retina work?"

An itching feeling

When James woke up from surgery, the first thing he noticed was the smell. After two years without sense of smell He was grateful, even though the smell was “hospital-like,” he says with a laugh.

After about a week and a half he saw his new face for the first time. Even now, when he walks past a mirror, he stops in fascination. He no longer wears the blindfold and mask when he goes out like he did before the transplant. He is excited to grow a beard again.

The transplanted eye cannot move or see, but has normal pressure and a good blood supply, and the retina responds to light. James may experience an itching sensation deep in the eye socket, and the sensation around the eye begins to return. The peripheral nerves around the eye grow back at random, says Ceradini.

Restore vision

It is unclear whether an eye transplant that restores vision to the recipient will one day be feasible. Ceradini believes it is “an achievable goal in the near future.” Pomahač disagrees. However, both agree that the missing crucial element to achieve this is figuring out how to regenerate the optic nerve. Pomahač believes this is unlikely. “It could happen if we figure out brain or spinal cord regeneration,” he says.

Still, James, his wife Meagan and their 19-year-old daughter Allie are in good spirits, which for them means teasing each other. Allie recently posted on TikTok and rated the things her dad did, Meaghan recalls. “100/10, made medical history,” Allie posted. “Still bald, though.”