|Year : 2014 | Volume
| Issue : 2 | Page : 92-95
Early results following penetrating keratoplasty at a secondary care center, India
Kamal R Dodia1, Hiren Vaghela1, Rajesh K Chudasama2
1 Department of Ophthalmology, P. D. U. Medical College, Rajkot, Gujarat, India
2 Department of Community Medicine, P. D. U. Medical College, Rajkot, Gujarat, India
|Date of Web Publication||20-Jun-2014|
Rajesh K Chudasama
Vandana Embroidery, Matoshree Complex, Sardar Nagar Main Road, Rajkot - 360 001, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Penetrating keratoplasty (PKP) is a safe, effective, and a reasonable treatment for corneal blindness in many countries. The study was conducted with the objective to assess the visual outcome after optical PKP at a secondary-level hospital. Materials and Methods: A total of 30 eyes of 30 patients enrolled prospectively in the hospital for surgery were selected for the study from May 2010 to April 2011. Age, gender, eye, indication of PKP, and best-corrected visual acuity (BCVA) constituting the preoperative data were recorded in a predesigned proforma. Follow-up examinations were done at the time of discharge, second at 1 month, and third on completion of 3 months postoperatively. Results: Common indications for optical PKP were bullous keratopathy either pseudophakic or aphakic; corneal scar following viral keratitis or trauma, corneal dystrophy, and graft failure. At 3 months follow-up, BCVA of ≥6/18 was obtained in six patients (20%), 6/18-6/60 in 43.33% and ≤6/60 in 36.67% patients. Persistent epithelial defects, graft rejection mainly endothelial type late graft rejection, and secondary glaucoma were the most common complications found. Conclusion: The study found the main indication for optical PKP was bullous keratopathy, either pseudophakic or aphakic. The persistent epithelial defect and graft rejection were the main complications in the study. Astigmatism, preexisting abnormalities such as glaucoma, optic atrophy, and graft failure were probable causes of less BCVA.
Keywords: Best-corrected visual acuity, graft, penetrating keratoplasty, visual outcome
|How to cite this article:|
Dodia KR, Vaghela H, Chudasama RK. Early results following penetrating keratoplasty at a secondary care center, India. Saudi J Health Sci 2014;3:92-5
| Introduction|| |
In developing countries, corneal opacity is a common cause of ocular morbidity. , The main purpose of majority of corneal graft is to improve vision. Zirm  reported the first full-thickness corneal transplantation; since then penetrating keratoplasty (PKP) has become one of the most popular and successful organ transplantation techniques used worldwide. It is widely used in the treatment of various corneal diseases. The indications for PKP vary by geographic regions along with economic development and social conditions.  PKP can be performed as an elective procedure to improve visual acuity or as an emergency procedure (therapeutic or tectonic keratoplasty) to treat a perforated or nonhealing corneal ulcer to remove the perforation site and save the eye (tectonic keratoplasty).  The successful outcomes enjoyed by patients who undergo modern PKP and lamellar keratoplasty are the result of advances in operating microscope design, suture technology, surgical techniques, disposable trephine, corneal topography, and the availability of carefully preserved corneal tissue, along with a better understanding of corneal and ocular surface physiology. Studies reported PKP is a safe, effective, and a reasonable treatment for corneal blindness in many countries. , The purpose of this study was to assess the visual outcome after optical PKP at a secondary-level hospital.
| Materials and methods|| |
This study was conducted at Ophthalmic Department, P D U Medical College and Civil Hospital, Rajkot, a secondary-level center to assess the visual outcome after optical PKP. Usually, the secondary eye center has a working operation theater and the facility to conduct cataract surgery in the study area. The present center is attached to the Government Medical College and equipped with various instruments such as high-class surgical microscope, phaco-emulsification machine, A-scan, B-scan, fundus camera, YAG laser machine, and anesthesia trolley to perform highly complex surgery and manage related potential complications. A total of 30 eyes of 30 patients enrolled prospectively in hospital for surgery were selected for the study from May 2011 to April 2012, after ethical clearance from institutional ethical committee. Age, gender, eye, indication of PKP, and best-corrected visual acuity (BCVA) constituting the preoperative data were recorded in a predesigned proforma. The BCVA was checked preoperatively and postoperatively with Snellen's visual acuity chart. Informed written consent was taken and preoperative assessment was carried out using the following criteria: Each case was studied and assessed with slit-lamp biomicroscopy and fundus examination, detailed history regarding any ocular problem with/without treatment, intraocular pressure assessment by Schiotz tonometer, lacrimal passage patency checked by sac syringing, and routine investigation for any systemic disease.
The eyeballs were stored and preserved in normal saline media in refrigerator between enucleation and keratoplasty. Preoperative preparations included full anterior and posterior segment examination of the eye to be operated, decision about graft size taken by slit-lamp biomicroscopy, keeping enucleated donor eyeball in gentamicin solution for half an hour before surgery, giving intramuscular atropine and test dose of lignocaine half an hour before surgery to the patient, instilling topical povidone iodine eye drop on operative eye, and finally the patient was taken into the operation theater and peribulbar block was given followed by the application of super pinky's ball for 10 min. Pinky ball looks like a small tennis ball with band used after peribulbar anesthesia to give pressure to eye ball for distribution of anesthetic agent.
During operative procedure, donor graft was taken using disposable trephine of appropriate size as decided preoperatively, 0.5 mm larger than the recipient's corneal bed size. The donor graft was then secured over Teflon block with endothelial side up and viscoelastic substance was kept over it. Then donor graft was put over recipient's iris surface and four primary sutures (10/0 nylon) were taken in 12, 3, 6, and 9 o'clock positions. The 10/0 nylon sutures were used for suturing of donor corneal graft to recipient eye ball. There are two types of suturing including continuous and interrupted. After the placement of the four cardinal sutures, a variety of techniques were used to fixate the graft, like interrupted sutures only, combination of interrupted and continuous suture, a single running suture, or double running sutures. The wound was closed and postoperative steroids, antibiotics, and lubricants were instilled in the operated eye. The eye was opened 24 h postoperatively followed by use of appropriate antibiotic drops and systemic antibiotics. The standard postoperative treatment was steroid eye drop and antibiotic eye drop to be instilled 6-10 times per day, antiglaucoma drops were given twice a day, and systemic steroid was given according to the dose required in 5 days tapering dose.
During follow-up visits, slit-lamp examination, intraocular pressure measurement, fundus examination, and visual acuity measurement with Snellen's visual acuity chart were carried out-at the time of discharge, at 1 month, and on completion of 3 months postoperatively. Statistical analysis was done with Epi Info version 3.5.1 statistical software (CDC, Atlanta, GA, USA). 
| Results|| |
Common indications for optical PKP in study settings were bullous keratopathy either pseudophakic or aphakic, corneal scar following viral keratitis or trauma, corneal dystrophy, and graft failure [Table 1], out of which the most common were pseudophakic or aphakic bullous keratopathy comprising 63.33% (19/30) followed by regrafts 23.33% (7/30), corneal scar 10% (3/30), and corneal dystrophy 3.33% (1/33) [Table 1].
At 3 months follow-up, BCVA of ≥6/18 were obtained in six patients (20%), 6/18-6/60 found in 43.33% (13/30) and ≤6/60 in 36.67% (11/30) patients. More than two-fifths, i.e., 43.33 (13/30) reported BCVA of 6/18-6/60. Out of six patients having BCVA ≥6/18, only one had received graft from the eye of donor with age less than 30 years, whereas in 11 patients having BCVA of ≤6/60 and 7 had received eyes of more than 40 years of age [Table 2]. Out of six patients having BCVA of ≥6/18, four had the graft size of donor more than 8 mm. Out of 11 patients having BCVA of ≤6/60, five had the graft size of donor <7 mm. Out of five patients undergoing keratoplasty after more than 8 h between enucleation and the surgery, three had final visual outcome ≤6/60, out of six patients having visual outcome of ≥6/18, four had received eyes within 4 h of enucleation.
Persistent epithelial defects, graft rejection mainly endothelial type late graft rejection, and secondary glaucoma were the most common complications found. Secondary glaucoma was observed in two cases during follow-up [Table 3]. Primary graft failure, graft infection, and wound dehiscence were observed in one patient each. Out of 30 patients who had undergone optical PKP, 11 patients had adverse recipient's factors and 19 patients were not having any adverse recipient factors [Table 4]. Totally 63.3% of patients reported graft clarity after 3 months follow-up. Astigmatism (40%); preexisting abnormalities (16.7%) such as glaucoma and optic atrophy; and graft failure (irreversible edema) (13.4%) were the probable causes of less BCVA.
|Table 4: Occurrence of complication according to the adverse recipient factors|
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| Discussion|| |
PKP is considered to be a successful surgical procedure. However, postoperative rehabilitation after surgery is prolonged due to a slow healing process. The outcome of PKP depends on indications, operative techniques, and postoperative care. ,,, Many of the factors that affect visual outcome are uncertain. This is very important with this procedure, to try to understand more about what may be achieved in the long term.  In this way, we can not only improve patient selection for corneal transplantation but also better counsel patients, giving them more realistic expectations regarding postoperative results. This study was conducted among small groups of study participants (30 patients) at secondary eye center and the study participants were followed up for a period of 3 months, which limits the outcome assessment of keratoplasty.
This study reported bullous keratopathy (63.3%) as an indication for PKP, with higher prevalence than that reported from a previous study from India,  and also from other countries such as Kenya (6.5%),  Jerusalem (10%),  and Sweden (21%).  These studies have reported mainly keratoconus as an indication for PKP, but this study reported no case of keratoconus. This study reports 23.3% regrafts of all PKP, higher than the other studies reported in different countries ranging from 7% to 18%. ,,,,,,
Half of the eyes were donated by the donors above 40 years of age. The common method of collection of donor cornea was enucleation followed by preservation in saline media, which can be used within 24 h. The study reported that use of older cornea is equally effective for the PKP in adults. , The incidence of allograft rejections and the postoperative corneal curvature is greater in adult eyes undergoing PKP with young donor corneas compared to those undergoing PKP with older donor eyes.  In our study, graft size of >8 mm was reported in 47% donors, 7-8 mm in 33% donors. Study from India reported that graft size does not affect the graft survival.  Within 4 h of enucleation, 53% patients had received eyes in this study, while 30% patients received it within 4-8 h of enucleation.
At 3 months follow-up, BCVA of ≥6/18 were obtained in six patients (20%), higher than other studies (6%-17%). ,, Almost half of the patients (47.36%) reported BCVA of 6/18-6/60. Visual outcome was poor in regrafts in more than 50% patients. Out of five patients undergoing keratoplasty after more than 8 h between enucleation and the surgery, three had final visual outcome ≤6/60, out of six patients having visual outcome of ≥6/18, four had received eyes within 4 h of enucleation.
Persistent epithelial defects, graft rejection mainly endothelial type late graft rejection, and secondary glaucoma were the most common complications found. The indications for graft failure include dimness of vision, photophobia, and redness of eye. The preventive measures for graft failure include steroid eye drops, cyclosporine eye drops, if indicated systemic steroid, green laser vascular ablation of corneal vessels, etc., This study reported 3/30 (10%) graft rejection which may be because of noncompliant patients. Secondary glaucoma was observed in two cases during follow-up. Primary graft failure, graft infection, and wound dehiscence were observed in one patient each. The common causes of graft failure such as persistent epithelial defect, graft rejection, secondary glaucoma, and graft infection, were reported by various studies. ,,,,,,
Out of 30 patients who had undergone optical PKP, 11 patients had adverse recipient's factors and 19 patients did not have any adverse recipient factors. The recipient factors mean recipients having preexisting glaucoma, iridocyclitis, and optic atrophy which limits visual rehabilitation. So totally 63.3% of patients reported graft clarity after 3 months follow-up. Astigmatism (40%); preexisting abnormalities (16.7%) such as glaucoma and optic atrophy; and graft failure (irreversible edema) (13.4%) were the probable causes of less BCVA.
This study has limitations and should be interpreted with caution. First, it was conducted among a small population (30 patients) at secondary eye center. Second, the small sample size limits the use of statistical test. Third, the short follow-up period of 3 months limits the long-term outcome assessment of keratoplasty. Further study involving larger sample size and longer follow-up for at least 1 year will be more helpful in assessing the outcome of keratoplasty.
| Conclusion|| |
The study found the main indication for optical PKP was bullous keratopathy, either pseudophakic or aphakic. The persistent epithelial defect and graft rejection were the main complications in the study. Astigmatism; preexisting abnormalities such as glaucoma and optic atrophy; and graft failure were the probable causes of less BCVA.
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[Table 1], [Table 2], [Table 3], [Table 4]