Penetrating Keratoplasty in Corneal Scarring due to Trachoma

Penetrating Keratoplasty in Corneal Scarring due to Trachoma

Khalil ERRAIS, Olfa FEKIH, Omar BELTAIEF, Amel OUERTANI.

Charles Nicolle University Hospital, Tunis, Tunisia.

The authors have no financial interest in the subject matter of this poster.

Introduction:Trachoma: Still one of the world’s major blinding

diseases:7.6 million people were severely visually impaired or blind as a result of trachoma.

Remains an important public health concern in developing countries:84 million people were suffering from active trachoma.

Results in chronic inflammation of the eyelids. This chronic inflammation of the eyelids produces

:1. scarring of the conjunctiva

2. entropion - trichiasis

3. alteration of lacrimal function

4. corneal opacity and consequent vision loss

Introduction: Scared trachomatous corneas: realize a very extensive and shaded scale of

scarred corneas.

The conventional treatment of these corneal opacities is penetrating keratoplasty (PKP).

General agreement :corneal grafting carries a guarded prognosis when done for corneal scarring secondary to trachoma.

Aim: 1. Study the possibilities of PKP in trachomatous corneal

lesions2. Evaluate:

graft survival visual outcome

3. Identify risk factors of corneal graft failure and rejection.

Materials and Methods: 44 eyes of 44 patients who underwent 44 PKP at

Charles Nicole University Hospital of Tunis between December 1997 and June 2005.

Criteria for the diagnosis of trachomatous corneal scarring were based on: Ocular findings consistent with evidence of healed

trachoma (eg, conjunctival fibrosis, Herbert pits) Absence of other explanations for corneal opacification.

Eyes were graded using the WHO system for assessement of trachoma and its complications.

Materials and Methods: Ocular findings were noted :

1. preoperative best corrected visual acuity using spectacles2. lid and conjunctival findings,3. corneal abnormalities ( site, number and density of

opacities, presence of neovascularisation , ulcers), 4. intra ocular pressure, 5. presence of cataract,6. fundus.

Preoperative treatment of the mechanical factors damaging the cornea :1. tear insufficiency, 2. meibomian gland dysfunction, 3. surgical correction of cicatricial entropion.

All data were entered onto a statistical analysis software (Epi info), the fisher exact test was used for all comparisons, and the term significance was accepted if p <= 0.05.

Results: Mean age : 65.16 years. Mean preoperative best corrected visual acuity: 2.4 / 100 Preoperative findings:

Patients %Conjonctival scarring 44 100%

Adnexial abnormalities 7 15.9%

Corneal Neovascularisation

21 47.73%

Anterior synechiae 5 11.3%

Cataract 37 84.09%

6.82% of patients had high ocular pressure controlled by topical glaucoma medications in all the cases.

Results:

Graft rejection: - 18 patients presented graft rejection (40.9 %).

- Average delay: 13.7 months .- 66.66% of cases during the first year after PKP

- Complete recovery after medical treatment was achieved in 13 of

these 18 patients.

Peroperative associated surgical procedures:

Surgical procedure cases %

Cataract surgery 24 54.55%

Vitrectomy 2 4.54%

Gonioplasty 1 2.27%

Synechiolysis 5 11.36%

Results:

The mean postoperative best corrected visual acuity:

• 2.5/10 • 3.8/10 in clear graft.

Visual acuity:• improved in 61.36% of cases• remained the same in 13.64% of cases • worsened in 25% of cases.

18,97

2,4

10

12,7

16,16

25

0

5

10

15

20

25

30

Initial VA 3 Months 6 Months 9 Months 12 Months Final VA

77.3% of patients achieved clear grafts after an average delay of 29 months. Graft survival was : *86.4% at 1 year *70.5% at 5 years.

Mean VA /100

Factors significantly affecting graft rejection and graft survival

Factor Graft rejection Graft failure

Patient’s age > 50 years P=0.201 P=0.341

Entropion P=0.469 P=0.550

Trichiasis P=0.543 P=0.631

History of cataract surgery P=0.092 P=0.015

Neovascularisation P=0.002 P=0.004

Preoperative high ocular pressure P=0.390 P=0.0009

Local anesthesia P=0.901 P=1

Emergency graft P=0.003 P=0.004

Graft term storage≥ 7 days P=0.701 P=0.002

Graft diameter < 7mm P=1 P=1

Graft diameter ≥ 8mm P=1 P=1

Donor age P=1 P=1

Combined cataract surgery P=0.004 P=0.0325

Vitrectomy P=1 P=1

Interrupted sutures P=0.897 P=0.564

Epithelial defect P=0.03 P=0.048

Early postoperative inflammation P=0.039 P=0.003

Early postoperative high ocular pressure

P=0.00785 P=0.002

Late postoperative inflammation P=0.0173 P=0.0234

Late postoperative high ocular pressure P=0.00486 P=0.004

Infectious keratitis P=1 P=0.654

Broken sutures P=0.684 P=0.691

Discussion:Our results :

Limited in comparison with other indication of PKP :• Numerous risk factors of graft failure and rejection. • Important number of combined procedures (high incidence

of cataract)

Comparable with others studies of PKP in Corneal Scarring

due to Trachoma: Our study Al .Fawaz 5 Kocak Midillioglu 6

Graft rejection 40.9% 17.3% 31.3%

Graft failure (5 years) 29.5 % 23.4% 24.5%

VA> 5/10 28.8% 43.3% 12.5%

Conclusion:

PKP can be performed with a reasonable prognosis for graft survival and good visual outcome for patients with trachomatous corneal scarring.

Several precautions should be taken for the keratoplasty in trachomatous eyes:

- Preoperative preparation is very important:• fighting against neovascularisation,• correction of eyelid abnormalities such trichiasis and

entropion • management of ocular surface disease

- Judicious selection of cases without hopeless scarring

-Identification of high risk patients who need peri-operative immunosuppressive therapy

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3. Burton MJ. Trachoma: an over view. Br Med Bull. 2007; 84: 99 -116. Epub 2008 Jan 5.

4. Paufique L, Charleux J. Keratoplasty and trachoma Rev Int Trach. 1964 ; 41 : 1 -202.

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