Bajracharya L et al

Indications for Keratoplasty in Nepal: 2005-2010

Nepal J Ophthalmol 2013; 5 (10):207-214

Original article

Indications for keratoplasty in Nepal: 2005 - 2010

Bajracharya L1, Gurung R1, DeMarchis EH2, Oliva M3, Ruit S1, Tabin G4
1
Tilganga Institute of Ophthalmology, Gaushala , Kathmandu, Nepal
2
Stanford University School of Medicine, Stanford, California, USA
3
Department of Ophthalmology, Oregon Health Sciences, University, Portland, Oregon, USA
4
John A Moran Eye Centre, University of Utah, Salt Lake City, Utah, USA

Abstract
Introduction: Corneal disease, especially infective keratitis, is one of the major causes of
visual impairment and blindness in developing countries. Objective: To find out the current
indications for keratoplasty, how these indications have changed over time as well as how
they are different from those in other parts of the world. Materials and methods: A
retrospective study of a case series of 645 keratoplasty surgeries (589 patients) was conducted
at the Tilganga Institute of Ophthalmology from January 2005 to December 2010. Outcome
measures: The cases were evaluated in terms of demographic parameters, preoperative
diagnosis and the type of surgery performed. Results: The most common indication for
surgery was active infectious keratitis (264 eyes, 40.9 %), followed by corneal opacity (173
eyes, 26.8 %), regraft (73 eyes, 11.2 %), bullous keratopathy (58 eyes, 9.0 %), keratoconus
(45 eyes, 7.0 %) and corneal dystrophy (11 eyes, 1.7 %). The mean recipient age was 41.7
± 19.9 years with over a half of the patients between 15 to 49 years of age. More men (64.1
%) underwent keratoplasty than women (35.8 %). 59.8 % of the eyes with infectious keratitis
had a perforated corneal ulcer. 49.7 % of corneal opacities were due to previous infectious
keratitis. 72 % of regrafts were for endothelial failure of various causes. In older patients (>
50 years), bullous keratopathy was an important indication, after infectious keratitis.
Keratoconus and corneal scar were major causes of keratoplasty in children of 14 years or
less. Four percent of the patients had keratoplasty in both the eyes. 17.1 % of the patients
who had one eye operated on had a blind fellow eye with a vision of less than 3/60. Conclusion:
Currently, keratitis, either active or healed, is the major indication for keratoplasty, suggesting
that improved primary eye health care is necessary to decrease the prevalence of corneal
blindness.
Keywords: keratoplasty, infectious keratitis, developing countries, corneal blindness
Introduction
Corneal diseases are a major cause of visual method of visual restoration for corneal blindness.
impairment and blindness in developing countries. In Nepal, the first keratoplasty surgery was done in
Corneal pathology is second only to cataract as an 1967. In the subsequent three decades, few
etiology for visual impairment in Nepal (Whitcher keratoplasty surgeries were performed because
et al, 1997). Keratoplasty is frequently the only corneal tissue had to be imported from abroad.
Received on: 19.12.2012 Accepted on: 17.04.2013
Address for correspondence: Dr Leena Bajracharya, MD The establishment of the Nepal Eye Bank in the
Tilganga Institute of Ophthalmology, Gaushala, Kathmandu, Nepal. Tilganga Institute of Ophthalmology (TIO) in 1994
G.P.O Box 561
Tel : 977-1-4493775, 977-1-4493684; Fax No: 977-1-4474937
permitted an increase in surgical volume; however,
Email: lbajra@yahoo.com a growing population and an increasing prevalence

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Indications for Keratoplasty in Nepal: 2005-2010
Nepal J Ophthalmol 2013; 5 (10):207-214

of corneal blindness have made it difficult to keep Table 1: Distribution of surgeries by age group
up with the escalating tissue demands. This study Age group (years) Surgical eyes Patients
examines the indications for keratoplasty, including <15 40 (6.20%) 34 (5.80%)
demographics and types of surgeries performed in 15 to 49 356 (55.2%) 323 (54.8%)
50+ 249 (38.6%) 232 (39.4%)
the TIO, a tertiary eye center in Kathmandu, Nepal. Total 645 589
The findings of the study are compared with those One hundred and forty-four (24.5 %) patients were
in the published literature, including that of ours from the Kathmandu Valley, a 220 square mile area
(Tabin et al, 2004). encompassing three urban districts: Kathmandu,
Materials and methods Lalitpur and Bhaktapur. Three hundred and eighty-
Patient records of all consecutive cases of nine (66.0 %) came from the remaining 72 districts
keratoplasty performed in the TIO between January of Nepal (Figure 1). Fifty-six patients (9.50 %) were
2005 and December 2010 were retrospectively from foreign countries, the majority of them (49
reviewed. Information collected from the records patients, 87.5 %) from India. The others were from
included: age, sex, the distance the patients had to Bhutan (4), Cambodia (2) and Tibet (1). Of the
patients who underwent keratoplasty for infectious
travel to reach the TIO, preoperative diagnosis,
keratitis, 79.8 % were from the districts outside the
preoperative visual acuity of both eyes, type of
Kathmandu Valley and 8.9 % were from India.
surgery (penetrating keratoplasty (PK), deep
anterior lamellar keratoplasty (DALK), Descemet’s Pre-operative visual acuity
stripping and automated endothelial keratoplasty The majority of the operated eyes (584 of 645,
(DSAEK), patch graft, or others) and the 90.5 %) had a pre-operative vision of < 6/60.
procedures performed in addition to the main Six eyes (< 1 %) had a vision of 6/6 to 6/18, and
surgery. The patients were stratified into three age required keratoplasty for peripheral corneal disease
groups: 0 to 14 years, 15 to 49 years, and 50 years or scleral thinning. Twenty-four patients (4 %) had
and above. Indications for keratoplasty were bilateral keratoplasty done. Of the 565 patients who
divided into seven main diagnostic categories: had only one eye operated on, 97 (17.1 %) had a
infectious keratitis, corneal opacity, regrafts, bullous blind fellow eye (vision < 3/60); 82 (14.5 %) of the
keratopathy, keratoconus, corneal dystrophy, and fellow eyes were visually impaired with the best
others. Keratoplasty performed for active bacterial, corrected vision of < 6/18 and > 3/60.
fungal or viral ulcers were included under infectious Indications
keratitis. For patients with corneal opacity and The most common indication for keratoplasty was
regrafting, the causes for opacification and reasons infectious keratitis (40.9 %), followed by corneal
for the graft failure were noted. The ‘others’ opacity (26.8 %), regraft (11.3 %), bullous
category included: metabolic corneal disorders, keratopathy (BK) (9.0 %), keratoconus (7.0 %)
corneal degenerations and tectonic patch grafts for and corneal dystrophy (1.7 %) (Table 2 and Figure
peripheral corneal diseases or scleral thinning. 2).
Results Table 2: Indications for keratoplasty
Demographics Indications Surgical eyes
A total of 645 eyes from 589 patients were Infective keratitis 264 (40.9%)
Corneal opacity 173 (26.8%)
reviewed for this study. The mean patient age at the Regraft 73 (11.3%)
time of surgery was 41.7 ± 19.9 years (range 15 Bullous keratopathy 58 (9.0%)
months to 87 years). More than 50 % of the patients Keratoconus 45 (7.0%)
were 15 to 49 years old (Table 1). 378 (64.2 %) Corneal dystrophy* 11 (1.7%)
#
Other 21 (3.3%)
patients were male and 211 (35.8 %) were female.
Total 645

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Indications for Keratoplasty in Nepal: 2005-2010
Nepal J Ophthalmol 2013; 5 (10):207-214

*The different types of corneal dystrophy include * Unspecified interstitial keratitis, corneal scar of
congenital hereditary endothelial dystrophy (CHED) congenital glaucoma, chemical injury
(3 eyes), stromal dystrophy (6 eyes) and Fuchs’ Of the eyes with BK, 40 (68.9 %) had a posterior
dystrophy (2 eyes).s chamber intraocular lens (PCIOL), 8 (13.7 %) had
#
Scleral thinning, metabolic diseases, corneal an anterior chamber intraocular lens (ACIOL), nine
degenerations,+ Mooren’s ulcer, limbal dermoid, (15.5 %) were aphakic and one was phakic (1.72
corneal trauma, squamous cell carcinoma, exposure %). Fity-five eyes (94.8 %) with BK were sequellae
of glaucoma drainage implant of cataract surgery and the remaining were due to
The types of corneal degeneration included Terrien’s corneal trauma.
marginal degeneration and Salzmann’s nodular Stratifying by age (Table 5), the most common
degeneration. All of the infectious keratitis cases by indications for surgery were infectious keratitis and
definition had active infections. One hundred and corneal opacity in the 15 to 49 years group, and
fifty-six eyes (59.8 %) had perforated corneal ulcers infectious keratitis and BK in the over 50 years
and 106 eyes (40.1 %) had ulcers which were either group. Corneal opacity and keratoconus were the
not responding to treatment or were impending to most common causes for keratoplasty in children
perforate. The majority of the eyes with corneal under 15 years of age.
opacity (86 eyes, 49.7 %) were due to prior
keratitis (fungal, bacterial, or viral), followed by Table 4: Causes of graft failure
trauma (39 eyes, 22.5 %) (Table 3). The patients Graft pathology Surgical eyes
Endothelial failure 53 (72.6%)
associated with past or present Vitamin A deficiency
Endothelial rejection 16(30.2%)
had bilateral corneal lesions and either one or both Primary failure 9 (17.0%)
eyes were operated on. Table 4 shows that 72.6 % Glaucoma 4(7.60%)
of the graft failures were due to endothelial Cataract surgery 1 (1.90%)
decompensation, followed by infectious keratitis Other 23 (43.3%)
Infective keratitis 10 (13.7%)
(13.6 %). Microbial keratitis 3 (30.0%)
Table 3: Causes of corneal opacity Viral keratitis 7 (70.0%)
Causes of corneal opacity Surgical eyes Trauma 5 (6.85%)
Infective keratitis 86 (49.7%) Others* 5 (6.85%)
Microbial keratitis 50(58.1%) Total 73
Viral keratitis 36 (41.9%)
*Vascularization, astigmatism due to patch graft,
Trauma 39 (22.5%)
Unspecified 32 (18.5%) recurrence of primary disease
Vitamin A deficiency 9 (5.20%)
Others* 7 (4.0%)
Total 173

Table 5: Indications for keratoplasty in < 50, >50 age group and <14 years
Indications 15 to 49 year >50 years <14 years
(Surgical eyes ) ( Surgical eyes ) ( Surgical eyes)
Infective keratitis 142 (39.8%) 114 (45.7%) 8 (20.0%)
Perforated ulcer 87 (61.3%) 66 (57.9%) 5 (62.5%)
Non healing ulcer 55 (38.7%) 48 (42.1%) 3 (37.5%)
i
Corneal opacity 113 (31.7%) 47 (18.8%) 13 (32.5%)
Regraft 44 (12.3%) 27 (10.8%) 2 (5.00%)
Bullous keratopathy 8 (2.2%) 49 (19.6%) 1 (2.50%)
Keratoconus 31 (8.7%) 1 (0.4%) 13 (32.5%)
ii # ##
Corneal dystrophy 6 (1.6%) 2 (0.8%) 3 (7.50%)
Others* 12 (3.3%) 9 (3.6%) 0 (0%)
Total 356 249 40

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 Bajracharya L et al
Indications for Keratoplasty in Nepal: 2005-2010
Nepal J Ophthalmol 2013; 5 (10):207-214

*Corneal degeneration, Mooren’s ulcer, corneal

trauma, limbal dermoid, metabolic disease, sclera
thinning, squamous cell carcinoma, exposure of
glaucoma drainage implant
i
Includes scar from congenital glaucoma (2 eyes);
healed infective keratitis (4 eyes); vitamin A related
(4 eyes ); traumatic scar (3 eyes )
ii
Stromal dystrophy
#
Fuchs’ dystrophy
##
Congenital hereditary endothelial dystrophy
Table 6: Types of keratoplasties performed
Procedures Surgical eyes
Penetrating keratoplasty (PK) 560 (86.8%)
Deep anterior lamellar 46 (7.1%)
Figure 2: Indications for keratoplasty surgery
keratoplasty (DALK) Surgical information
Descemet's stripping automated 19 (2.9%)
The vast majority of the surgeries performed were
endothelial keratoplasty (DSAEK)
Patch graft 10 (1.5%) penetrating keratoplasties (PK) (560 eyes, 86.8 %).
Others* 10 (1.5%) There was a much smaller number of DALK (46
Total 645 eyes, 7.1 %), DSAEK (19 eyes, 2.9 %) and patch
* Scleral graft, lamellar graft, rotational graft, grafts (10 eyes, 1.5 %) (Table 6).
keratoprosthesis 124 eyes (19.2 %) had additional procedures
performed simultaneously with the main surgery, the
Table 7: Procedures performed alongside
majority (76.2 %) being extracapsular cataract
keratoplasty
extraction (ECCE) with PCIOL implantation
Keratoplasty Associated procedure Surgical eyes
PK ECCE PCIOL 96 (76.2%) (Table 7).
Secondary IOL 9 (7.14%) There was a 19.5 % increase in the overall number
ECCE 5 (3.97%)
Removal of IOL 3 (2.37%) of keratoplasties performed in this study period,
Intravitreal injection 3 (2.37%) compared to that of our report of the period of 1994
Others* 8 (6.45%) to 1999 (Tabin et al, 2004).
DSAEK ECCE PCIOL 2 (1.59%)
Total 124 Discussion
* Core vitrectomy, intracapsular cataract extraction, Demographics
exchange of IOL, tarsorrhaphy In this study, the mean age of the patients was similar
to that reported from India (Sony et al, 2005;
Dandona et al, 1997) and China (Xie et al, 2009),
but quite different from that of the UK and the US,
where the mean age of the subjects was 54 and 63
years respectively (Yousuf et al, 2004; Ghosheh et
al, 2008). The young age of keratoplasty patients
in the developing world implies that corneal
blindness is more prevalent in the working age
population, which could profoundly affect the
Figure 1: Geographic distribution of the study economic condition of the families and of the nation
patients in Nepal as a whole.

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Indications for Keratoplasty in Nepal: 2005-2010
Nepal J Ophthalmol 2013; 5 (10):207-214

By gender, more males underwent keratoplasty than the major factors taken into account when projecting
females (1.79:1), similar to that in India (Sony et al, graft survival is the likelihood of the patient’s follow-
2005; Dandona et al, 1997); but in China, this ratio up. In Nepal, it is difficult for patients from remote
was even greater (2.7:1) (Xie et al, 2009). The ratio areas to reach a tertiary eye center, so patients need
was lower in the UK (1.2:1) (Yousuf et al, 2004), to be selected on the basis of possible follow-up
and was seen to be flipped in the USA (0.88:1) care. Exceptions to this selection criterion include
(Ghosheh et al, 2008). The observed trends in the therapeutic keratoplasty and bilaterally blind
developing countries may be explained by two patients. Both these groups should naturally get
different gender bias theories. Firstly, males priority on the waiting list.
frequently have more privileged access to health care A significant portion of the patients in this study lived
and treatment facilities, and thus may have made in the Kathmandu Valley and the surrounding
up more of the surgical population. Secondly, the districts (Figure 1), due to the above selection
typical male occupations in the developing world criteria. However, fewer patients were from the
(i.e., agriculture and hard labor) could have made Kathmandu Valley in this study than were in our
them more prone to work-related trauma, leading previous study. Previously, 49.4 % of the
to keratitis. keratoplasty patients were from the Kathmandu
Keratoplasty in patients under the age of 15 years Valley (Tabin et al, 2004), whereas only 24.5 % of
accounted for only 40 eyes (6.2 %), which is similar the patients were from the Valley in this study. The
to the proportion in France (5.2 %) (Legeais et al, reduced proportion of the patients from the Valley
2001) (Tables 1 and 5). As mentioned previously, is likely because the TIO performs a larger number
keratoconus and corneal opacity were the most of emergency eye saving transplants at present,
common indications for surgery in the under 15 years whereas in the past, the majority of the transplants
group (32.5 % each), followed by infectious keratitis were done for optical purpose (72 %). The majority
(20 %) (Table 5). In the USA, a review of 106 of the patients (79.8 %) needing keratoplasty for
pediatric keratoplasties showed congenital corneal infective keratitis in this study were from outside
opacity and dystrophy as 61 %, while infectious the Valley.
causes accounted for 18.4 % and keratoconus for
Infectious keratitis
only 3.3 % (Huang et al, 2009). In India, 43 % of
The leading indication for keratoplasty in this study
pediatric keratoplasties (out of 168) are reportedly
was active infectious keratitis (40.9 %), which
done for healed or active keratitis and 33.9 % for
differs from the reports from India, Taiwan and
congenital causes but none for keratoconus
Thailand, where active infections were second (Sony
(Sharma et al, 2007). A small pediatric sample
et al, 2005; Dandona et al, 1997), third (Chen et al
size was the limitation of our study.
, 2001) and fourth (Chaidaroon et al, 2003)
Although the Nepal Eye Bank has been providing respectively. Although our findings were more similar
a greater number of corneas than previously, there to those in other developing countries, where corneal
are still barriers to performing a greater number of ulceration is considered a silent epidemic (Whitcher
keratoplasties in Nepal. These include a continued et al, 1997), the similarities do not carry over to the
shortage in locally available corneal tissue, an developed world. In the UK, for example, only 8.3
undersupply of corneal surgeons, and, especially in % of grafts were done for infective keratitis (Yousuf
the peripheral hospitals, lack of the surgeon’s time et al, 2009). The high rates of active infection
for corneal subspecialty care due to the high demand demand the need for primary eye care services.
for other ophthalmologic services. The high demand
Since the TIO is a tertiary referral centre in Nepal
for corneas necessitates criteria for selecting patients
for cornea service, many patients with ulcerative
for surgery in non-emergency situations. One of

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Indications for Keratoplasty in Nepal: 2005-2010
Nepal J Ophthalmol 2013; 5 (10):207-214

keratitis present at a severe, perforated or 5.28 % in Iran (Kanavi et al, 2007). In our study,
intractable stage requiring keratoplasty. the majority of graft failures were due to endothelial
decompensation (Table 4), whereas in India, ocular
Corneal scar surface problems (33 %), allograft rejection and
Corneal scar is the second commonest cause for endothelial failure (together 28.2 %) were the major
keratoplasty (26.8%). In this study, the leading causes (Vanathi et al, 2005). In the UK, 42 % of
cause of corneal opacification was previous infective regrafts were for endothelial failure and 16.5 % for
keratitis, followed by trauma. The proportion of rejection (Yousuf et al, 2009). It is recognized that
trauma related scars is similar to that reported from keratoplasty in the setting of active inflammation
India (16.7-21.0%) (Sony et al, 2005; Dandona decreases the long term survival rates of the corneal
et al, 1997). Corneal scar is a much less frequent graft (Yorston et al, 1996). As the rates of
indication for keratoplasty in the developed world, keratoplasty continue to rise in Nepal and
accounting for only 2.5 % of the keratoplasties in surrounding countries, regrafting is likely to make
France (Legeais et al, 2001) and <2.5 % in the up a larger proportion of the indications for
USA (Ghosheh et al, 2008). The majority of the keratoplasty in the near future.
cases with unspecified etiology (18.5%) for corneal
scarring in our study are also likely to be attributable Bullous keratopathy
to keratitis. In the developing world, keratitis is The fourth indication for keratoplasty was BK (9
frequently associated with agriculture related trauma %). In the USA and New Zealand, it was one of
(Whitcher et al, 1997), lack of education, lack of the top two reasons for keratoplasty (Ghosheh et
accessibility to eye care facilities and poverty. al, 2008; Edwards et al, 2002). In our study, 48
Ten years ago, at the time when keratoplasty was eyes (82.7 %) were pseudophakic (PCIOL
started regularly at the TIO, the primary indication [68.9%], ACIOL [13.7%]) and only 15.5 % were
was corneal scar (72%) (Tabin et al, 2004). During aphakic. Since the establishment of the Fred
that time, there had been a large backlog of the Hollows Intraocular Lens Laboratory in the TIO in
patients blind from old infectious keratitis; surgery 1994, ECCE with PCIOL implantation has been
for active infectious keratitis was less commonly possible to be performed at a lower cost and more
performed. As the awareness of eye diseases in widely, making aphakia less common than in the
Nepal has improved, the number of patients other developing countries, where the prevalence
presenting to the corneal service for active infectious of aphakic BK is higher (Sony et al, 2005; Dandona
keratitis treatment has increased. This is likely to et al, 1997; Kanavi et al, 2007). The proportion of
explain the increased proportion of keratoplasty keratoplasties performed for BK is expected to
performed for active infectious keratitis in this report. increase in the near future as more preventable
As Nepal’s primary and secondary eye health causes of keratoplasty drop and cataract surgery
services expand, it is anticipated that infectious rates increase.
keratitis will be more successfully treated or Keratoconus
prevented so that less therapeutic and tectonic Keratoconus ranks fifth in our study (7%), and was
keratoplasties will be required. similar to rates in India (2% to 6%) ( Sony et al,
Regraft 2005; Dandona et al, 1997), but lower than that in
It was the third indication for keratoplasty in our New Zealand, France and Iran, where it accounted
study (11.3%). Graft failure was the most common for 29 % to 45 % of cases ( Legeais et al, 2001;
indication for keratoplasty in the UK (41%) Kanavi et al, 2007; Edwards et al, 2002). In the
(Ghosheh et al, 2008) and accounted for 22 % of UK and USA, keratoconus was the third common
the cases in the USA (Yousuf et al, 2009) versus cause for keratoplasty accounting for 15 - 16 %,

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Indications for Keratoplasty in Nepal: 2005-2010
Nepal J Ophthalmol 2013; 5 (10):207-214

whereas in Taiwan, it played a role in only 2.5 % of Conclusion

the cases (Yousuf et al, 2009; Ghosheh et al, 2008; The inications for kertoplasty in Nepal, in decreasing
Chen et al, 2001). The low rates of keratoconus in order of frequency are infective keratitis, corneal
Nepal and India may be due to the greater ethnic opacity, regraft, bullous keratopathy, keratoconus
diversity than in the European populations (Mamalis and corneal dystrophy. The importance of reducing
et al, 1992). corneal blindness is clear by the number of working
age patients affected, with probable harmful
Dystrophy socioeconomic impacts.
The corneal dystrophies were relatively uncommon
indications (1.7%) in our study, and Fuchs’ The shift in indications for keratoplasty over the past
dystrophy was negligible. The studies from India decade demonstrates that it is possible to expand a
have reported slightly higher rates of non-Fuchs’ keratoplasty program in a developing country over
dystrophy (3.8 - 8.4 %), but similar rates of Fuchs’ a relatively short period of time and outlines where
dystrophy (0.74 - 1.2 %) (Sony et al, 2005; attention should be focused for future progress.
Dandona et al, 1997). In the UK and USA, <4 % References
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Source of support: nil. Conflict of interest: none

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