Thai J Ophthalmol Clinical Indications for Penetrating Keratoplasty in Maharaj Nakorn Chiang Mai Hospital, 1990-1 995 Somsanguan Ausayakhun, M.D.* Jinda Juntaramanee** ABSTRACT The preoperative clinical indications for 103 penetrating keratoplasties performed at Maharaj Nakorn Chiang Mai Hospital from 1990 through 1995 were reviewed. Corneal ulcer was the most common indication, accounting for 37.9%. Other major indications for penetrating keratoplasty were corneal leukoma (24.2%), bullous keratopathy (15.5%), corneal dystrophy and degeneration (11.7%) and regraft (8.7%). Comparision with previous report and other series was done. Thai J Ophthalmol 1997 ; January-June ll(1) : 17-23. Key words : penetrating keratoplasty, corneal ulcer, leukoma, bullous keratopathy, dystrophy, degeneration, regraft. Introduction Changing indications for penetrating keratoplasty have been reports since the early 1940.'-~ The leading indications for penetrating keratoplasty varied not only from country to country but also institution to institution previous report and to other Material and Methods We reviewed the charts of all patients who underwent penetrating keratoplasty at our institution in the same Changes in the frequency of during the six-year period from January 1, 1990 through corneal disease, improvements in surgical technique, instrumentation, donor tissue preservation and pharmaw cological advances and the introduction of intraocular lenses have contributed to increasing numbers of December 31, 1995. Information obtained included patient age and sex, date of surgery and the preoperative clinical diagnosis for which penetrating keratoplasty was performed. penetrating keratoplasties in recent years?-" To identify. In cases of corneal ulcer, the etiologic causa- new trends in the changing indications for penetrating keratoplasty in our institution, we reviewed the clinical indications for 103 penetrating keratoplasty performed between 1990 and 1995 and compared these to our tive agents and the previous surgical procedures were recorded. In cases of regraft, the previous underlying diagnosis was noted when available. In cases of pseudophakic bullous keratopathy, the type of intraocular Department of Ophthnlmology, Faculty of Medicine, Chiang Mai University. ** Eye service, Out-Patient Department, Maharaj-Nakorn Chiang Mai Hospital. Vol. 11 No. 1
lens was recorded. Information was also obtained extensive ulcer, 16 of them (41%) had previous surgery regarding the frequency of combined penetrating before which were scleral graft (12 cases), conjunctival. keratoplasty and lens extraction with and without irltraocular lens implantation. Result Of the 103 penetrating keratoplasties, there were 96 patients whom 70' (72.9%) were male and flap (3 cases) and glue with contact lens (1 case). The etiologic causes of corneal ulcer were shown in Table 2. Fungal corneal ulcer was the most frequency among them (48.7%). Corneal leukoma was the second common indidation (24.2%). Bullous keratopathy ranked as the 26 (27.1%) were female. Three eyes had been operated third most frequent indication (15.5%). Pseudophakic twice and four patients had penetrating keratoplasty in bullous keratopathy was found in 8 cases while aphakic both eyes. The mean age of the patients was 42.3 bullous keratopathy was found in 2 of them (Table. 1). (standard deviation 20.1) years ; they ranged in age Other causes of bullous keratopathy included following " from 5 to 94 years. The age range of patients show a birnodial distribution, with a peak at the third decade glaucoma surgery (2 cases), postinflammation (2 cases), post surgery for remove foreign body in anterior and another peak at the sixth decade (Figure 1). Corneal ulcer was the most common indication, accounting for 37.9% of all penetrating keratoplasties chamber (I case) and idiopathic (1 case). Corneal dystrophy and degeneration was the fourth common indication of them (11.7%). Types of performed (Table 1). '~ost of them had perforated or dystrophy and degeneration were shown in Table 3. Age Range (decades) Fig. 1 Age distribution of patients undergoing penetrating keratoplasty in Maharaj Nakorn Chiang Mai Hospital, 1990-1995. 18 Thai J Ophthalmol January - June 1997
Clinical Indications for Penetrating Keratoplasty in Maharaj Nakorn Chiang Mai Hospital, 1990-1995 I Table 1 Clinical indications for penetrating keratoplasty by year Indication 1990 1991 1992 1993 1994 1995 Total (%) - Corneal ulcer 4 8 13 6 3 5 39 (37.9) Corneal leukoma 2 7 8 3 2 3 25 (24.2) Bullous keratopathy 1 2 3 2 1 7 16 (15.5) - Pseudophakic 1 2 1 4 8 (7.8) - Aphakic 1 1 2 (1.9) - Other 1 2 3 6 (5.8) Degeneration, dystrophy 1 1 5 1 2 2 12 (11.7) ' Regraft 1 2 2 1 3 9 (8.7) Trauma 2 2 (1.9) Total 1 9 122 131 113 1 8 120 1 lo3 (loo) -. Table 2 Etiologic causes,of corneal ulcer Organism Eye % Fungus 19 48.7 Bacteria 13 33.3 Virus (HSV) 2 5.1 Undetermined 5 12.8 Total 39 100.0 Table 3 Types of corneal dystrophy and degeneration Types Eyes % Gelatinous drop-like dystrophy 6 50.0 Fuchs' dystrophy 2 16.7 Band keratopathy 2 16.7 Lattice dystrophy 1 8.3 Keratoconus 1 8.3 Total.I2 100.0 Vol. 11 No. 1 19
i Table 4 Previous diagnosis in regrafts Diagnosis Eyes % - Corneal ulcer Bullous keratopathy (Pseudophakic) (Aphakic) Gelatinous drop-like dystrophy Corneal leukoma 3 3 2 1 2 1 33.3 33.3 22.2 11.1 22.2 11.1 Total 9 100.0 Table 5 Lens extraction procedures associated with penetrating keratoplasty w Associated procedure Eyes % Triple procedure Intracapsular lens extraction Extracapsular lens extraction 8 5 4 47.1 29.4 23.5 Total 17 100.0. - Table 6. Comparison reviews of indication for penetrating keratoplasty (%) Chiang Mai University Ramathibodi Hospital Chiang Mai University Vancouver (1990-95) (1981-92)8 (1985-8'7)' (1978-87)6 Will's Eye Hospital (1983-88)' C. ulcer 37.9 C ulcer 38.9 C. leukoma 58.9 Bullous K 22.2 Pseudophakic BK 22.9 C. leukoma 24.2 C. leukoma 17.1 C. ulcer 23.3 (Pseudophakic) 10.5 Fuchs' dystrophy 16.3 Bullous K 155 Regraft 9.7 Dystrophy 5.4 (Aphakic) 7.6 Keratoconus 15.1 (Pseudophakic) 7.8 Aphakic BK 9.3 Aphakic BK 4.1 (Other) 4.1 Aphakic BK 14.4 (A~hakic) 1.9 Pseudophakic BK 5.6 Pseudophakic BK 4.1 Keratoconus 17.1 Regraft 9.0 (men) 5.8 C. leukoma 13.5 Degeneration 11.7 Regraft 12.1 & dystrophy Virus 9.0 Regraft 8.7 20 Thai J Ophthalmol January -June 1997
Clinical Indications for Penetrating Keratoplasty in Maharaj Nakorn Chiang Mai Hospital, 1990-1995 c Gelatinous drop-like dystrophy was in 50% of them which occured in 4 patients, 2 of them had penetrating keratoplasty in both eyes. Others included Fuchs' dystrophy (2 cases), band keratopathy (2 cases), keratoconus (1 case) and lattice degeneration (1 case). Regraft was the fifth frequent indication for penetrating keratoplasty in this report, accounting for 8.7% of them. In these regraft cases, corneal ulcer and bullous keratopathy were found to be the most common clinical diagnosis for the previous penetrating after corneal leukoma. Despite improvements in the medical management of corneal ulcer, the patiedts often. came in the advanced stage of the disease so most of them were therapeutic penetrating keratoplasty. Fungal corneal ulcer appeared to be the most causative agent, accounting for 49% of them. Corneal leukoma ranked as the second common indication. This disorder was usually the sequelae of corneal ulcer. When combined these two conditions together, corneal ulcer and corneal leukoma were the keratoplasty (33.3%), followed by gelatinous drop-like b dystrophy (22.2%) and corneal scar (11.1%) respectively (Table 4). Traumatic ruptured cornea was the least frequent indication among them, only 2 cases (19%) of all (Table 1). Penetrating keratoplasty was combined with lens extraction in 17 of 90 phakic eyes (Table 5). The triple procedures (combined penetrating keratoplasty, lens extraction and intraocular lens implantation) were major indication of penetrating keratoplasty in our country which was different from other reports of developed countriessp8 (Table 6). Bullous keratopathy was the third frequent indication for penetrating keratoplasty in our study. Pseudophakic bullous keratopathy seemed to be the major role among them. Differed from other reports, we found more common in the posterior chamber intraocular lens (6 in 8 cases). This finding may be caused by multifactorial factors. 8 (47.1%) while penetrating keratoplasty with Corneal dystrophy and degeneration was the extracapsular lens extraction or intracapsular lens fourth common indication for penetrating keratoplasty. L extraction were 5 (29.4%) and 4 (23.5%) respectively. Gelatinous drop-like dystrophy was more common among them since we found this disorder in 4 patients Discussion Our review showed that corneal ulcer has been the leading indication for penetrating keratoplasty, accounting for 38% of all the transplants done. This finding was the same that found in Ramathibodi Hospital review of 1981-1992 period but differed from who 3 of them were in the same family. The same finding in. the literature that they were always bilateral and usually developed again in the transplanted graft.'2 Regraft was the fifth common indication. The frequency of regrafts in our study did not reflect the prognosis or the success rate of the primary operation our previous report conducted during 1985-1989.~~' since we gave priority for penetrating keratoplasty to At that time it was the second most common indication preserve eyes in the advanced diseases such as per- Vol. 11 No. 1 21
arraqau C~yq~r ila:: aum a'unrud 9 i forated corneal ulcer because we still had limited 1976 ; 81 : 313-8. numbers of corneal donors. The previous diagnosis of 2. Smith RE, Mc Donald HR, ~esburn AB, Minckler ' DS. Penetrating keratoplasty : Changing indications,.. regrafts was similar to the primary indication which 1947-1978. Arch Ophthalmol 1980 ; 98 : 1226-9. 3. Robin JB, Gindi JJ, Koh K, et al. An update of were corneal ulcer, bullous keratopathy, corneal dysthe indications for penetrating keratoplasty, 1979 - - - trophy and corneal leukoma. through 1983. Arch Ophthalmol 1986 ; 104 : 87-9. Traumatic rupture cornea was rarely done 4. Mohamadi P, Mc Donnell JM, Irvine JA, Mc penetrating keratoplasty since we usually had it done Donnell PJ, Rao N, Smith RE. Changing indications for penetrating keratoplasty, 1984-1988. Am J later when it became corneal scar. Ophthalmol 1989 ; 107 : 550-2. The frequency of lens extraction combined with 5. Brady SE, Rapuano CJ, Arentsen JJ, Cohen EJ, Laibson PR. Clinical indications for and procedures penetrating keratoplasty was found in 17 of 90 phakic associated with penetrating keratoplasty, 1983-1988. Am J Ophthalmol 1989 ; 108 : 118-22. eyes (19%). All of the intracapsular lens extraction 6. Damji KF, Rootman J, White VA, Dubord PJ, -' accidentally occured in cases of perforated corneal ulcer Richards JSF. Changing indications for penetrating with extensive synechiae. The triple procedures keratoplasty in Vancouver. 1978-1987. Can J Ophthaimol 1990 ; 25 : 243-8. (penetrating kerato~1ast~7 lens and IoL 7. Duangratana S, Trakarnsilp S, Kitcharoen P. implantation) were found in 8 of them (47%). Penetrating keratoplasty in Maharaj Nakorn Chiang We did not report the visual outcome and the Mai Hospital : the visual result. Thai J Ophthalmol 1989 ; 3 : 69-75. success rate of penetrating keratoplasty in this study. 8. Poonyathalang A. Simaroj P. Penetrating kerato- The main reason was some patients had lost follow up plasty in Ramathibodi Hospital (1981-1992). Thai J Ophthalmol 1993 ; 7 : 13-20. and Some of them went to follow Up at the private 9. Lang GK, Naumann GOH. The frequency of - clinics. corneal dystrophies requiring keratoplasty in Europe and the USA. Cornea 1987 ; 97 : 209-11. In summary7 the indications for 10. Cohen EJ. Brady SE. Leavitt K, et al. Pseudopenetrating keratoplasty, in order of decreasing phakic bullous keratopathy. Am J Ophthalmol 1988 frequency, were corneal ulcer, corneal leukoma, bullous ; 106 : 264-9. 11. Speaker MG, Lugo M, Laibson PK, et al. Penekeratopathy, corneal dystrophy and degeneration and trating keratoplasty for pseudophakic bullous regraft. Corneal ulcer was the most common indication, keratopathy : Management of the intraocular lens. Ophthalmology 1988 ; 95 : 1260-8. accounted for 38% of all. 12. Smolin G. Corneal dystrophies and degenerations. In : Smolin G, Thoft RA, eds. The cornea : References Scientific foundations and clinical practice. Third 1. Arentsen JJ, Morgan B, Green WR. Changing edition. Boston : Little, Brown and company, indications for keratoplasty. Am J Ophthalmol 1994 : 499-533. Thai J Ophthalmol January -June 1997
Clinical lndications for Penetrating Keratoplasty in Maharaj Nakorn Chiang Mai Hospital, 1990-1995 Clinical lndications for Penetrating Keratoplasty in - Maharaj Nakorn Chiang Mai Hospital, 1990-1995 a - Key words : penetrating keratoplasty, corneal ulcer, leukoma, bullous keratopathy, dystrophy, degeneration, regraft. Vol. 11 No. 1