|Year : 2014 | Volume
| Issue : 3 | Page : 173-177
Major indications for keratoplasty in the eastern province, Saudi Arabia
Khalid Arfaj1, Reem Abdulqader2
1 Department of Ophthalmology, University of Dammam, Al-Khobar, Saudi Arabia
2 Dhahran Eye Specialist Hospital, Dhahran, Saudi Arabia
|Date of Web Publication||11-Oct-2014|
Department of Ophthalmology, University of Dammam, Al-Khobar, P.O. Box 40033
Purpose: To determine the leading indications for keratoplasty in the Eastern Province of the Kingdom of Saudi Arabia (KSA) over a 5 years period (2005-2010) and to compare these indications with previously published studies.
Materials and Methods: Records of all patients who underwent keratoplasty at different eye specialized hospitals at Eastern Province, KSA between January 1, 2005 and March 31, 2010 were reviewed retrospectively. For each case, the primary surgical indication was identified.
Results: A total of 244 keratoplasties was performed, including 126 penetrating keratoplasties, 73 deep lamellar keratoplasties, 27 triple procedures, 6 descemet's stripping automated endothelial keratoplasties and 4 Boston keratoprosthesis implantations. Of the 244 procedures, 222 were primary and 22 repeat keratoplasties. The leading indication for keratoplasty was keratoconus, performed in 121 eyes (49.6%), followed by bullous keratopathy (13.1%), stromal dystrophies (10.7%), regrafts (8.6%), stromal scarring and Fuchs' endothelial dystrophy (4.5% each), microbial keratitis (3.3%), trauma (1.6%), and herpetic keratitis or undetermined scar etiology (4.1%).
Conclusion: In this series, the leading indications for keratoplasty were keratoconus, bullous keratopathy, stromal dystrophies and regrafts. Other less frequent indications include stromal scarring, Fuchs' dystrophy, ulcer-related microbial keratitis, trauma and herpetic keratitis. This study was held to draw the attention of Ophthalmologist to commonest indication for keratoplasty in Saudi Arabia.
ملخص البحث :
تهدف هذه الدراسة لتحديد أسباب زراعة القرنية في المنطقة الشرقية للمملكة العربية السعودية. وضحت الدراسة أن الأسباب الرئيسة لعملية زراعة القرنية وجود قرنية مخروطية ، قرنية فقاعية ، ضمور الأنسجة وإعادة الزراعة ، وبصورة أقل ندب الأنسجة وضمور فكس وقرحة القرنية الميكروبية أو الفيروسية. أجريت هذه الدراسة لتبيان الأسباب الأكثر شيوعا لعملية زراعة القرنية في المملكة العربية السعودية.
Keywords: Corneal transplantation, penetrating keratoplasty, keratoconus, major indications
|How to cite this article:|
Arfaj K, Abdulqader R. Major indications for keratoplasty in the eastern province, Saudi Arabia. Saudi J Med Med Sci 2014;2:173-7
|How to cite this URL:|
Arfaj K, Abdulqader R. Major indications for keratoplasty in the eastern province, Saudi Arabia. Saudi J Med Med Sci [serial online] 2014 [cited 2019 Jul 19];2:173-7. Available from: http://www.sjmms.net/text.asp?2014/2/3/173/142527
| Introduction|| |
Globally, corneal opacity is the third leading cause of bilateral blindness after cataract and glaucoma, affecting around 7-9 million people, 90% of whom live in the developing world.  With recent advances in ocular immunology, ocular pharmacology, surgical techniques, corneal storage, and eye banking procedures,  keratoplasty has become one of the most widely practiced transplantations in humans.  Despite some fundamental challenges, keratoplasty is the definitive treatment for corneal blindness and can be utilized to successfully treat an estimated 80-90% of corneal blindness in the developing world. 
The leading indications for corneal transplantation differ across the world, primarily due to geographic and socioeconomic factors influencing the etiology of corneal blindness. While pseudophakic corneal edema, keratoconus and regrafts have been the most common clinical indications for corneal transplantation in the developed world since the 1980s,  there has been a gradual change in profile of keratoplasty indications in the developing world in the past two to three decades due to improvements in sanitation and advancements in the medical and surgical ophthalmology.  For example, improvement in hygiene and the use of anti-infectives/antivirals has tremendously decreased the incidence and sequelae of diseases such as trachoma and microbial/herpetic keratitis.  Similarly, the advancements in cataract surgery has decreased the incidence of pseudophakic or aphakic bullous keratopathy. 
In the past few decades, the maturation of the infrastructure of keratoplasty services in the Kingdom of Saudi Arabia (KSA) occurred in parallel with the socioeconomic development and population growth.  In this study, the objective was to determine the indications for keratoplasty in Eastern Province, KSA in the period (2005-2010).
| Materials and Methods|| |
A retrospective analysis of records of all cases of keratoplasty performed between January 1, 2005 and March 31, 2010 was undertaken. All cases were performed at the two tertiary ophthalmology centers of Eastern Province, KSA - Magrabi Eye and Ear Hospital and Dhahran Eye Specialist Hospital. Information obtained was analyzed with respect to patient's age, gender, clinical indications for keratoplasty, laterality, other ocular diseases, systemic diseases, and type of keratoplasty performed. The indications for keratoplasty were divided into ten diagnostic categories [Figure 1].
|Figure 1: Age distribution histogram of the 244 keratoplasties (2005-2010)|
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| Results|| |
A total of 244 keratoplasties were performed between January, 2005 and March, 2010 and all records were available for review and analysis. Of the total 244 cases, 100 patients (41%) were of the age >40 years, 125z(51.2%) were of the age group 20-40 years; and 19 (7.8%) were <20 years (7.8%) with 3 children <12 years [Figure 2]. Patients with keratoconus were the youngest (mean age = 25.7 years), whereas patients with corneal edema were the oldest (mean age = 65.5 years). Overall, sex distribution showed slight male predominance with 54.8% males and 45.2% females. This difference in the sex distribution was also true for individual indications, for example, keratoconus (59.9% males), corneal edema (55.9% males), stromal scarring (60.0% males), and stromal dystrophy (71.4% males).
|Figure 2: Types of keratoplasties in the Eastern Province 2005-2010. PKP: Penetrating keratoplasty, triple PKP: Penetrating keratoplasty with cataract extraction and intraocular lense implantation, DLKP: Deep lamellar keratoplasty, FEK: Femtosecond enabled keratoplasty, DSAEK: Descemet's stripping automated endothelial keratoplasty, BKPro: Boston keratoprosthesis|
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The different types of keratoplasties included penetrating keratoplasties (PKPs), deep lamellar keratoplasties (DLKPs), triple procedures (PKP with cataract extraction and intraocular lens implantation), descemet's stripping automated endothelial keratoplasty (DSAEK) procedures, Boston keratoprosthesis (KPro), femtosecond enabled keratoplasties (FEK) and regrafts. Of these, PKP (55% [126/244]), DLKP (28% [73/244]) and triple procedures (10% [27/244]) were the three most common types of keratoplasty procedures [Figure 3].
|Figure 3: Major indications of keratoplasty in Eastern Province, Kingdom of Saudi Arabia (2005-2010)|
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The chief indication for keratoplasty was keratoconus (n = 121, 49.6%) of which 11 eyes (9.1% [11/121]) had a history of vernal keratoconjunctivitis. The second leading indication was bullous keratopathy or postsurgical corneal edema (n = 32, 13.1%); of which 24 were associated with posterior chamber intraocular lenses, 5 with anterior chamber intraocular lenses (AC IOLs) and 3 with aphakic corneal edema. Stromal dystrophies (n = 26, 10.7%) was the third leading indication; of which 21 eyes had a diagnosis of macular dystrophy, and 5 granular dystrophy. Among the 33 eyes with stromal scarring, 11 (4.5%) eyes had post-trachomatous scarring, 8 (3.3%) microbial keratitis (6 bacterial, 2 fungal), 10 (4.1%) had undetermined etiology, most of which were presumed to have been caused by Herpes simplex virus and 4 (1.6%) had trauma. Other major indications for keratoplasties included regrafts (n = 21, 8.6%) and Fuchs' endothelial dystrophy (n = 11, 4.5%) [Figure 1].
| Discussion|| |
In this study, we evaluated the indications for keratoplasty in 244 cases at the two tertiary eye centers in Eastern Province, KSA. Our objective was to determine the indications for keratoplasty in Eastern Province, KSA in the period (2005-2010).
The major indications for keratoplasty in this study included keratoconus followed by bullous keratopathy and stromal dystrophy [Figure 1]. Less common indications included regrafts, stromal scar, Fuch's dystrophy, microbial keratitis, Herpes keratitis and trauma.
Keratoconus was the leading indication for keratoplasty in our study accounting for nearly 50% of all keratoplasties over a 5 years time span. This may be due to the reason that the incidence and severity of keratoconus in Saudi Arabia is higher with an early onset and rapid progression.  For example, the incidence of keratoconus in Asir Province, Saudi Arabia was found to be 20/100,000, whereas, in United Kingdom, USA and Finland it is <3/100,000.  This difference may be the result of genetic and/or climatic factors that may contribute to a higher prevalence of keratoconus in certain geographic areas.  These findings are consistent with the previous reports from Iran (34.51%),  New Zealand (45.60%),  France (28.80%),  Germany (20.90%)  and Zimbabwe (26.80%),  whereas they contrast sharply with those from the USA (11.40%),  Canada (12%),  UK (15%),  China (13%),  Brazil (13.10%),  India (6%) and Nepal (4%) where keratoconus accounts for only up to 15% of corneal transplants.
In addition, the proportion of 49.6% corneal transplants performed for keratoconus also demonstrates that the trend of increasing proportion of keratoplasties due to keratoconus reported by Al-Towerki et al. from KKESH Hospital, Riyadh, KSA is continuing in the period 2005-2010 [Table 1].
|Table 1: Clinical indications for corneal transplantation (Al-Towerki et al., 1983-2002, KKESH, KSA vs. current study, 2000-2010, Eastern Province)|
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The majority of the patients who underwent keratoplasty in this study were <40 years [Figure 2]. This is because keratoconus affects younger patients and that it was the most common indication for keratoplasty in the region. The second factor contributing to the relatively younger age of patients in our study is the patient selection at our centers. Younger patients with bilateral disease are given priority for keratoplasty over older patients with unilateral disease.
The mean age of the patients at the time of surgery for keratoconus was 25.7 years in our study which, however, contrasts with the mean age of 40.6 years reported by Cosar et al.  from the Wills Eye Hospital in the United States. The earlier age of surgical intervention in keratoconus eyes may be due to the dry and arid climate of the KSA causing early contact lens intolerance and therefore, a need for earlier surgical intervention.  In addition, keratoconus in eyes with co-existing Vernal KeratoconjunctivitisVKC progresses faster as patients tend to rub eyes frequently due to chronic itching. 
Bullous keratopathy was the second most common reason for keratoplasty in our report, accounting for 13% of all cases. While the results are consistent with those reported by Al-Towerki et al. [Table 1], they are in contrast with countries like the USA, , Japan  and Thailand  where bullous keratopathy is reported to be the leading indication for keratoplasty [Table 2].
|Table 2: Comparison of leading indications in previous publications since 2005 listed by country of study center|
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In the developed countries, a large numbers of iris-plane and closed-loop AC IOLs were implanted in the 1970s that resulted in a subsequent increase in cases of aphakic and pseudophakic corneal edema, which has continued to be the leading indication for keratoplasty since early 1980s.  Prior to 1983, cataract surgery was not frequently performed in the KSA, thereby resulting in far fewer iris-plane and closed-loop AC IOLs being implanted compared with the rest of the world.  However, the use of unsatisfactory intraocular lens designs as well as variability in the training and skills of ophthalmic surgeons in the Kingdom at that time, created a small backlog of eyes with postoperative corneal edema. Additionally, it is important to note that keratoplasty for phakic corneal edema is much less common in KSA, primarily because of a much lower prevalence of Fuchs' endothelial dystrophy; for example only 4% of the eyes had Fuch's endothelial dystrophy in our series compared to 23.2% in USA  and 9.3% in UK. 
Stromal dystrophies accounted for 10.7% of the indications for keratoplasty in our study, which was more than the 5-7% reported by Al-Towerki et al. [Table 1]. We believe that this difference is most likely due to chance rather than any differences in the study population between our study and Al-Towerki et al. 
Secondary keratoplasties or regrafts were not that far behind stromal dystrophies with an occurrence rate of 8.6% [Figure 1] and [Figure 4] which differs from most developed countries like the USA,  and Canada,  where regraft has been reported to be the leading indication of keratoplasty and also from other developing countries like India where regraft has been reported to be the second leading indication of keratoplsty [Table 2]. Possible factor affecting the rate of regraft may be that the keratoplasty was mostly used for better prognosis indications like keratoconus and minimal cases of microbial keratitis (3.3%). These findings are consistent with those reported by Al-Towerki et al. [Table 1].
|Figure 4: Primary and repeat keratoplasties in Eastern Province, Kingdom of Saudi Arabia (2005-2010)|
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The decreasing trend of corneal scars described by Al-Towerki et al. (1983-2002) is apparent in our study (2000-2010) [Table 1]. It has decreased from 52% in the 1983-1987 to 19.8% in 1998-2002) and 13.5% in 2000-2010 [Table 1]. While the post-trachomatous scarring was the chief indication between 1983 and 1987,  changing socioeconomic conditions have virtually eliminated active trachoma resulting in a significant reduction in the number of keratoplasties due to trachoma (post-trachomatous scarring contributed only 4.5% keratoplasties in our study 2000-2010). This is in contrast to other developing countries like India and Nepal, where corneal scarring is the leading indication for keratoplasties.
The most common types of keratoplasty used in our study were PKP (55%) and DLKP (28%), while other advanced procedures like DSAEK, FEK and Boston KPro altogether accounted for <10%. We believe that the rates of DLKP and DSAEK are likely to increase in the coming years due to their higher success and increasing availability of the requisite surgical infrastructure and skills.
| Conclusion|| |
The advent of better surgical techniques for lamellar grafting, newer techniques of posterior lamellar and endothelial transplantation and the other factors like the higher availability of donor tissue have influenced the indications for keratoplasty. However, it is interesting to note that the trend demonstrated by Al-Towerki et al. from 1983 to 2002 is continuing into 2005-2010. Keratoconus remains to be the leading indication for keratoplasty in the Eastern Province, followed by bullous keratopathy, regrafts and stromal dystrophies. Other less frequent indications are stromal scarring, Fuchs' dystrophy, ulcer-related, trauma-related, herpetic keratitis and others.
| References|| |
Feilmeier MR, Tabin GC, Williams L, Oliva M. The use of glycerol-preserved corneas in the developing world. Middle East Afr J Ophthalmol 2010;17:38-43.
Dobbins KR, Price FW Jr, Whitson WE. Trends in the indications for penetrating keratoplasty in the midwestern United States. Cornea 2000;19:813-6.
Siganos CS, Tsiklis NS, Miltsakakis DG, Georgiadis NS, Georgiadou IN, Kymionis GD, et al.
Changing indications for penetrating keratoplasty in Greece, 1982-2006: a multicenter study. Cornea 2010;29:372-4.
Lois N, Kowal VO, Cohen EJ, Rapuano CJ, Gault JA, Raber IM, et al.
Indications for penetrating keratoplasty and associated procedures, 1989-1995. Cornea 1997;16:623-9.
Al-Towerki AE, Gonnah el-S, Al-Rajhi A, Wagoner MD. Changing indications for corneal transplantation at the King Khaled Eye Specialist Hospital (1983-2002). Cornea 2004;23:584-8.
Al-Yousuf N, Mavrikakis I, Mavrikakis E, Daya SM. Penetrating keratoplasty: indications over a 10 year period. Br J Ophthalmol 2004;88:998-1001.
Assiri AA, Yousuf BI, Quantock AJ, Murphy PJ. Incidence and severity of keratoconus in Asir province, Saudi Arabia. Br J Ophthalmol 2005;89:1403-6.
Kanavi MR, Javadi MA, Sanagoo M. Indications for penetrating keratoplasty in Iran. Cornea 2007;26:561-3.
Edwards M, Clover GM, Brookes N, Pendergrast D, Chaulk J, McGhee CN. Indications for corneal transplantation in New Zealand: 1991-1999. Cornea 2002;21:152-5.
Legeais JM, Parc C, d'Hermies F, Pouliquen Y, Renard G. Nineteen years of penetrating keratoplasty in the Hotel-Dieu Hospital in Paris. Cornea 2001;20:603-6.
Cursiefen C, Küchle M, Naumann GO. Changing indications for penetrating keratoplasty: Histopathology of 1,250 corneal buttons. Cornea 1998;17:468-70.
Mkanganwi N, Nondo SI, Guramatunhu S. Indications for corneal grafting in Zimbabwe. Cent Afr J Med 2000;46:300-2.
Dorrepaal SJ, Cao KY, Slomovic AR. Indications for penetrating keratoplasty in a tertiary referral centre in Canada, 1996-2004. Can J Ophthalmol 2007;42:244-50.
Xie L, Song Z, Zhao J, Shi W, Wang F. Indications for penetrating keratoplasty in north China. Cornea 2007;26:1070-3.
Sano FT, Dantas PE, Silvino WR, Sanchez JZ, Sano RY, Adams F, et al.
Trends in the indications for penetrating keratoplasty. Arq Bras Oftalmol 2008;71:400-4.
Wagoner MD, Gonnah el-S, Al-Towerki AE, King Khaled Eye Specialist Hospital Cornea Transplant Study Group. Outcome of primary adult penetrating keratoplasty in a Saudi Arabian population. Cornea 2009;28:882-90.
Mendes F, Schaumberg DA, Navon S, Steinert R, Sugar J, Holland EJ, et al.
Assessment of visual function after corneal transplantation: The quality of life and psychometric assessment after corneal transplantation (Q-PACT) study. Am J Ophthalmol 2003;135:785-93.
Randleman JB, Song CD, Palay DA. Indications for and outcomes of penetrating keratoplasty performed by resident surgeons. Am J Ophthalmol 2003;136:68-75.
Chaidaroon W, Ausayakhun S, Ngamtiphakorn S, Prasitsilp J. Clinical indications for penetrating keratoplasty in Maharaj Nakorn Chiang Mai Hospital, 1996-1999. J Med Assoc Thai 2003;86:206-11.
Inoue K, Amano S, Oshika T, Sawa M, Tsuru T. A 10-year review of penetrating keratoplasty. Jpn J Ophthalmol 2000;44:139-45.
Cosar CB, Sridhar MS, Cohen EJ, Held EL, Alvim Pde T, Rapuano CJ, et al.
Indications for penetrating keratoplasty and associated procedures, 1996-2000. Cornea 2002;21:148-51.
Cameron JA, Al-Rajhi AA, Badr IA. Corneal ectasia in vernal keratoconjunctivitis. Ophthalmology 1989;96:1615-23.
Waring GO 3 rd
. The 50-year epidemic of pseudophakic corneal edema. Arch Ophthalmol 1989;107:657-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]