Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfil our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free access (Open Access) to its content, which is likely to attract more readers and citations of articles published in IJCEO. Manuscripts must be prepared in more...

  • Article highlights
  • Article tables
  • Article images

Article statistics

Viewed: 354

PDF Downloaded: 223


Get Permission Waskel, Singh, Kubrey, Dubey, and Kumar: Evaluating the effect of donor and recipient factors on graft survival after penetrating keratoplasty


Introduction

According to the World Health Organization(WHO), corneal diseases are one of the leading causes of visual loss and blindness, after cataracts and glaucoma across the globe. WHO says, globally, approximately 4.2 million people are having preventable visual impairment due to corneal opacities1 In India, approximately 6.8 million people have been documented for having visual acuity less than 6/60 in at least one eye due to corneal diseases; among these, about 1 million people have bilateral involvement.2, 3

Management of corneal blindness requires corneal transplantation which is dependent on voluntary corneal donations and needs tremendous post-operative care and follow-up. The success of the procedure is not an overnight event, it depends upon various donor and Recipient factors, modifiable factors should be taken care of, to increase the success of the procedure. Right from the enucleation procedure, quality of donor tissue, careful tissue preparation, duration of preservation, systematic tissue evaluation, and uneventful transplantation altogether accounts for the good results.

Donor tissue must be intact and needs to be free from ocular surface defects. Donor tissue layers must be assessed and graded as per standard criteria under a slit-lamp prior to transplantation. Endothelial cell density needs to be checked by specular microscopy for better graft survival. Graft survival gets affected by certain donor factors, tissue preparation & preservation factors, and recipient factors.

The present study was conducted to evaluate the role of donor factors and recipient factors in graft survival and complication of surgery at a tertiary care eye center in central India.

Materials and Methods

A prospective study was conducted for 18 months in the eye bank of tertiary care eye center in central India after getting the approval of the institutional ethical committee. The study group consisted of all recipients who underwent penetrating keratoplasty between 2018 to 2020 at the study center.

Demographic details of donor, cause of death, time of death, systemic illness along with the history of intraocular surgeries were noted. The procedure was explained and written consent was taken. Enucleation was performed under aseptic precautions and the eyeball was immediately transferred to a moist chamber. Slit-lamp examination was done and donor corneas were graded using a standard grading system (Eye Bank Association of America).4

After explaining the whole procedure and associated risks, written consent was taken, and penetrating keratoplasty was done. In triple procedure, cataractous lens was removed using the open sky technique, and posterior chamber intraocular lens was implanted.

Recipients were followed-up at 1 week, 1 month, and 3rd month and the effect of various donor and recipient factors on graft clarity was studied. Survival of the graft was assessed on the basis of visual acuity, graft clarity, graft host junction vascularization, anterior chamber, and presence of rejection signs were noted. Modified grading of corneal clarity on the basis of corneal haze was used5 (British Journal of Ophthalmology 2009.

Statistical analysis was done by SPSS 23.0 version. Categorical variables were analyzed using the Chi-Square test. The variables with a p-value <0.05 was considered statistically significant.

Results

In the present study a total of 26 eyes of 13 donors were studied, out of which 23 eyes underwent penetrating keratoplasty, among these, 3 eyes underwent therapeutic penetrating keratoplasty, 16 eyes underwent optical penetrating keratoplasty and 4 eyes underwent triple procedures; penetrating keratoplasty with cataract extraction with posterior chamber intraocular lens implantation.

The majority of donors(38.5%) belonged to the age group of 41-60 years. The mean age of donors was found to be 50.2 ± 2.35 years. The youngest donor was of 15 years of age and the eldest was 88 years of age. Male recipients 19(82.6%) outnumbered the female recipients 4(17.4%).

Seven (26.9%) donor corneas were of very good quality, 15(57.7%) were of good quality, rest 4 were of fair to poor quality corneas. The majority of donated eyes 11(84.6%) were retrieved via Hospital Corneal Retrieval Programme (HRCP) and the remaining 2(15.4%) were retrieved at home. (Table 1)

The mean age of the recipients in this study was 47±19.8 years in the present study. Graft clarity according to age distribution shows no significant difference(p=0.443). There were 19 (82.6%) males and 4(17.4%) females. (Table 2)

Table 1

Effect of donor factors on graft survival at I follow-up(1 week), II follow-up (1 month), and III follow-up (3 months)

Donor Factors

n

Graft clarity grading

P- value

Grade 0 (N=2)

Grade 1 (N=5)

Grade 2 (N=5)

Grade 3 (N=7)

Grade 4 (N=4)

Follow-up

I

II

III

I

II

III

I

II

III

I

II

III

I

II

III

Age Group

<20

2

0

0

1

0

1

2

3

2

1

1

1

0

0

0

0

0.33

21 – 40

2

0

0

0

2

1

0

0

0

3

2

2

1

0

1

0

41 – 60

5

1

1

1

2

2

4

5

2

2

0

3

2

1

1

0

>60

4

0

1

1

3

1

1

3

1

1

0

1

1

0

2

2

Place of Enucleation

Hospital

11

1

2

3

6

4

7

9

5

6

3

5

3

1

4

1

0.352

Home

2

0

0

0

1

1

0

2

0

1

0

2

1

0

0

1

Ambient Room temperature and moistening

Present

9

1

1

1

3

2

2

3

2

1

0

1

3

0

1

0

0.239

Absent

4

0

1

2

4

3

5

8

3

6

3

6

0

1

3

2

Status of Lids

Closed

10

0

1

2

4

4

7

10

4

6

3

6

1

1

3

2

0.047

Open

3

1

1

1

3

1

0

1

1

1

0

1

3

0

1

0

Status of Lens

Transparent

8

0

0

1

2

2

2

3

2

4

3

3

1

0

1

0

0.572

Cataractous

7

1

1

1

2

2

3

3

2

1

0

1

2

1

1

0

Pseudophakic

8

0

1

1

3

1

2

5

1

2

0

3

1

0

2

2

Table 2

Effect of donor factors on graft survival at I follow-up (1 week), II follow-up (1 month), and III follow-up (3 months)

Recipient Factors

n

Graft clarity grading

P- value

Grade 0 (N=100)

Grade 1 (N=7)

2 (N=11)

3 (N=3)

4 (N=1)

Follow-up

I

II

III

I

II

III

I

II

III

I

II

III

I

II

III

Age

<20

3

0

1

0

1

0

0

0

1

1

1

0

0

0

0

1

0.443

21 – 40

4

0

0

0

1

2

1

3

1

2

0

1

1

0

0

0

41 – 60

8

0

1

1

4

1

2

3

3

0

2

3

5

0

1

1

>60

8

1

1

1

1

4

2

5

2

2

0

0

1

1

1

2

Gender

Males

19

1

3

2

6

6

4

9

4

5

2

4

5

1

2

3

0.277

Females

4

0

0

0

1

1

1

2

3

0

1

0

2

0

0

1

Indications of Penetrating Keratoplasty

Adherent Leucoma

9

2

2

1

2

2

4

2

3

3

2

1

0

1

1

1

0.23

Pseudophakic bullous keratopathy

7

1

1

1

2

2

4

3

2

0

0

0

0

0

0

0

Leucomatous corneal opacity

5

1

2

2

1

3

1

5

1

1

0

1

3

0

0

0

Others

1

0

0

0

0

0

0

1

1

1

1

2

2

0

2

2

Pre-operative corneal vascularization

Present

1

0

0

0

5

5

1

8

6

4

2

3

7

1

2

4

0.004

Absent

16

1

3

2

2

2

4

3

1

1

1

1

0

0

0

0

Type of keratoplasty

Optical penetrating keratoplasty

7

1

2

1

4

5

5

9

6

3

2

2

5

0

0

2

0.005

Therapeutic penetrating keratoplasty

16

0

0

0

2

0

0

1

0

0

0

2

1

0

2

2

Triple procedure

3

0

1

1

1

2

0

1

1

2

1

0

1

1

0

0

Discussion

In the present study, graft survival of recipients concerning the transplanted cornea from young as well as old age donors had shown similar graft outcomes. However, the results were statistically insignificant.

Similarly, R. Doyle Stulting et al6 and Mark J Mannis et al7 found no association between the age of the donor and graft survival. Hyeon Yoon Kwon et al8 have also documented similar results.

We found that corneas (84.6%) that were hospital retrieved showed better graft survival on postoperative day seven as well as on final follow-up. However, the difference in recipient graft survival with respect to the place of enucleation of donor tissue was statistically insignificant which can be attributed to the small sample size.

Anders Shehab et al9 also concluded that recipients with donor cornea who are hospital retrieved have better graft survival post-transplantation.

We have found that 12(63.1%) recipients with donor tissue having adequate moistening showed better graft survival on postoperative day seven and also (68.4%) at final follow-up. But the difference in each of the groups was statistically insignificant.(p=0.239) However, there were no such studies in the literature to compare. This can be attributed to fact that the presence of moist air prevents dryness of donor cornea.

In our study, we have found that recipients who underwent penetrating keratoplasty with donor corneas in which eyelids were found open (26.1%) during enucleation have shown significantly poor graft survival at final follow-up. The difference between those two groups was also statistically significant(p=0.047). Michel et al10 documented similar results. After death, if the eyelids remain open for a prolonged duration, the cornea gets exposed to an external environment which results in damage to the epithelium.

Recipients (65.2%) who underwent transplantation from the tissue of the donor's eyes without any intraocular or cataract surgeries have shown better graft survival as compared to pseudophakic donors. This can be attributed to some endothelial compromise post-cataract surgeries or intraocular surgeries, that may affect graft survival. But due to less sample size, these findings were statistically insignificant. R. Doyle Stulting et al6 also found that post keratoplasty eyes with pseudophakic corneal edema underwent more rejections 34%.

In the present study, no significant effect of age and gender of recipients on graft clarity was noted (p=0.277). Sugar A et al11 also similar results.

Recipients without pre-operative corneal vascularization had statistically significantly better graft survival. (p=0.004). Rafael et al12 also documented similar results with a survival rate (74%).

Optical penetrating keratoplasty recipients showed better graft clarity compared to those who had undergone therapeutic penetrating keratoplasty but the difference in the clarity was statistically insignificant(p=0.005).

Conclusion

Modifiable donor and Recipient factors should be taken care of, to increase the success rate of the procedure. Practices like lid closure and eye drop installation should be promoted from the time of death, for preserving donor tissue quality. HCRP should be promoted and practiced at the national level as it is effective in increasing the rate of eye donation and positively affects graft outcomes.

Source of Funding

No source of outside funding.

Conflict of Interest

None declared.

References

1 

RRA Bourne SR Flaxman S Resnikoff P Ackland T Braithwaite MV Cicinelli Global causes of blindness and distance vision impairment 1990-2020: a systematic review and meta-analysisLancet Glob Health2017512122134

2 

MS Oliva T Schottman M Gulati Turning the Tide of Corneal BlindnessIndian J Ophthalmol20126054237

3 

L Dandona R Dandona M Srinivas P Giridhar K Vilas MN Prasad Blindness in Indian State of Andhra PradeshInvest Ophthalmol Vis Sci200142590816

4 

JS Saini MK Reddy S Sharma S Wagh Donor Corneal Tissue EvaluationIndian J Ophthalmol1996441313

5 

R Tandon N Gupta M Kalaivan N Sharma JS Titiyal RB Vajpayee Amniotic membrane transplantation as an adjunct to medical therapy in acute ocular burnsBr J Ophthalmol2011952199204

6 

RD Stulting A Sugar R Beck M Belin M Dontchev RS Feder Effect of Donor and Recipient Factors on Corneal Graft RejectionCornea2012311011417

7 

MJ Mannis EJ Holland RL Gal M Dontchev C Kollman D Raghinaru The effect of donor age on penetrating keratoplasty for endothelial disease: graft survival after 10 years in the Cornea Donor StudyOphthalmology201312012241927

8 

HY Kwon JY Hyon HS Jeon Effect of Donor Age on Graft Survival in Primary Penetrating Keratoplasty with Imported Donor CorneasKorean J Ophthalmol20203413545

9 

A Shehab N Gram A Ivarsen J Hjortdal The Importance of Donor Characteristics, Post-Mortem Time and Preservation Time for Use and Efficacy of Donated Corneas for Posterior Lamellar Keratoplasty. Anders Shehab,Niels Gram,Anders IvarsenActa Ophthalmol202210032696

10 

M Haagdorens SIV Acker VV Gerwen SN Dhubhghaill C Koppen MJ Tassignon Limbal Stem Cell Deficiency: Current Treatment Options and Emerging TherapiesStem Cells Int201620169798374

11 

A Sugar JP Tanner M Dontchev B Tennant RL Schultze SP.Dunn Recipient risk factors for graft failure in the cornea donor studyOphthalmology2009116610238

12 

RI Barraquer L Pareja-Aricò A Gómez-Benlloch R Michael Risk factors for graft failure after penetrating keratoplastyMedicine (Baltimore)20199817e15274.



jats-html.xsl


This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Article type

Original Article


Article page

378-382


Authors Details

Preeti Waskel, Manisha Singh*, Sooraj Kubrey, Aditi Dubey, Kavita Kumar


Article History

Received : 20-06-2022

Accepted : 14-07-2022


Article Metrics


View Article As

 


Downlaod Files