VOL. 30 NO. 4 PHILIPPINE JOURNAL OF Ophthlmology OCTOBER ORIGINAL ARTICLE - DECEMBER 2005 M. Doming B. Pdill, MD Mrie Antonette T. Eltnl-Pscul, MD Snt Luci Interntionl Eye Bnk of Mnil Sentro Oftlmologico Jose Rizl University of the Philippines-Philippine Generl Hospitl Mnil, Philippines Indictions for penetrting kertoplsty in the Philippines ABSTRACT Objective To determine the indictions for penetrting kertoplsty (PKP) in the Philippines. Method This is retrospective review of dt collected by the St. Luci Interntionl Eye Bnk Foundtion (SLIEBF) of Mnil bsed on postopertive reports of penetrting kertoplsty. Correspondence to M. Doming B. Pdill, MD Snt Luci Interntionl Eye Bnk of Mnil Second Floor, Sentro Oftlmologico Jose Rizl Philippine Generl Hospitl Tft Avenue, Ermit 1000 Mnil, Philippines Telephones : +63-2-3026282, +63-2-3026287 Fx : +63-2-3026285 Emil : mpdillmd@yhoo.com No finncil ssistnce ws received for this study. Dr. Pdill is the founder nd president while Dr. Eltnl-Pscul serves s technicl supervisor of Snt Luci Interntionl Eye Bnk of Mnil. Results A totl of 2,131 postopertive reports from 1996 to 2004 were reviewed. The verge ge of recipients ws 47.2 yers. The ge distribution ws bimodl, with peks t 35 to 45 yers nd t 65 to 75 yers. The leding indictions for PKP were cornel scrs (23.9%), pseudophkic bullous kertopthy (PBK) (19.7%), microbil kertitis (17.6%), regrfts (9.8%), nd phkic bullous kertopthy (ABK) (%). Indictions for PKP showed incresing trend for regrft nd decresing trend for cornel scr. Trum, microbil kertitis, nd cornel scr were more common mong mles while Fuch s dystrophy, cornel stroml dystrophy, PBK, nd glucom cusing bullous kertopthy were more common mong femles. Cornel scr, microbil kertitis, nd virl infection were frequently seen mong those in the lower socioeconomic groups while PBK, ABK, regrft, Fuch s, nd kertoconus were seen mong more ffluent ptients. Conclusion Cornel scr, PBK, nd microbil kertitis were the leding indictions for PKP in the Philippines from 1996 to 2004. There ws n incresing trend towrd regrft nd decresing trend for cornel scr during the period. Keywords: Penetrting kertoplsty, Cornel trnsplnttion, Cornel scr, Bullous kertopthy, Kertitis, Fuch s dystrophy PHILIPP J OPHTHALMOL 2005; 30(1): 148-152 148 PHILIPP J OPHTHALMOL VOL 30 NO. 4 OCTOBER - DECEMBER 2005
CORNEAL trnsplnttion hs become one of the most successful procedures in orgn trnsplnttion in the pst six decdes. Though this success is ttributble to the reltive immune privilege nturlly inherent to the corne nd to dvnces in surgicl techniques nd instrumenttion, it is lso lrgely the estblishment of relible eye bnks round the world tht resulted in incresed vilbility nd better qulity of donor cornel tissues. In res of the world with estblished eye bnks where penetrting kertoplsty (PKP) hs become routine procedure, the indictions for PKP nd the chnging trends of those indictions hve been well studied. 1-6 In the Philippines, however, this informtion is lcking. Prior to the founding of the Eye Bnk Foundtion of the Philippines nd the subsequent opening of its eye bnk, the Snt Luci Interntionl Eye Bnk of Mnil (SLIEB), PKP hd been performed spordiclly using eyeblls hrvested from cdvers nd stored in mke-do moist chmbers nd the cornel buttons occsionlly donted from brod. Since its estblishment, the SLEBIF hs become the mjor source of trnsplntble cornel tissues for medicl institutions nd privte clinics in the Philippines, with PKP becoming routine procedure. This study determined the leding indictions for PKP in the Philippines using records of the SLIEBF nd compred these indictions with those of other countries. METHODOLOGY Ech donor cornel button distributed to surgeon or medicl institution by the SLIEBF ws ccompnied with request for the following informtion: (1) surgeon/institution performing the PKP; (2) generl recipient informtion, such s ge nd sex, medicl nd ophthlmic history; nd (3) type of procedure performed (i.e. whether combined with ctrct extrction, etc). This postopertive report becme prt of the SLIEBF dtbse. Postopertive reports returned to the SLIEB from Jnury 1, 1996 to December 31, 2004 were reviewed. The indictions for PKP were tbulted nnully nd cumultively over nine-yer period. The sme nomenclture ws used to fcilitte comprison with other published studies. Ctegories of indictions listed were the following: pseudophkic bullous kertopthy (PBK), phkic bullous kertopthy (ABK), Fuch s dystrophy, cornel dystrophies, kertoconus, cornel scr, microbil kertitis, virl infection, noninfectious kertitis, trum, regrft, Steven Johnson Syndrome, congenitl defect, nd glucom. Cornel scr included those due to unspecified cuses, whether from previous inflmmtion or infection or old oculr trum. Regrft, whether due to grft rejection or filure, ws given priority over ll other dignoses regrdless of the primry indiction for PKP. Introculr lens implnts (IOLs) included both nterior- (AC) nd posterior-chmber (PC) lenses. Microbil kertitis included both ctive nd old microbil cses. Virl infection included herpes simplex kertitis nd meslesssocited infections. Cuses of trum were chemicl, mechnicl, or therml injuries. Cornel dystrophies included dystrophies other thn Fuch s dystrophy. Miscellneous cuses were listed under others. Those without ny indiction were listed under unspecified. Demogrphic dt of the recipient included ge, sex, nd socioeconomic sttus (i.e. chrity when the ptient ws operted in trining institution with reduced fees versus py when the ptient pid the regulr processing fees). For ech indiction for PKP, the differences in gender nd socioeconomic conditions were nlyzed using Chi-squre test. A p vlue less thn 0.05 ws considered significnt. RESULTS SLIEBF processed totl of 6,225 cornel tissues from Jnury 1996 to December 2004. Of these, 1,265 could not be used due to positive serologic testing, mostly for ctive heptitis B (971 or 76.8% of serologiclly unfit tissues). A totl of 4,074 cornel tissues were used for opticl PKP, of which 2,874 (70.5%) were distributed to 109 institutions nd ophthlmologists in the Philippines nd 1,200 (29.5%) to 24 other countries. The remining cornes were set side for tectonic use, reserch, or were found unsuitble for surgery due to coexisting medicl conditions. Of the 2,874 cornes distributed loclly, 2,131 postopertive reports were obtined (retrievl rte of 74.1%) nd reviewed for inclusion into the study. The ge of the recipients requiring PKP rnged from 2 months to 96 yers old, with men of 47. 2 yers. A bimodl distribution with peks t ge groups 35 to 45 nd 65 to 75 yers ws seen (Figure 1). 59.5% of the recipients were mles nd 53.8% belonged to the lower socioeconomic sttus. The min indictions for PKP were cornel scr, PBK, microbil kertitis, regrft, nd ABK (Tble 1). These top 5 indictions ccounted for 76.6% of cses. Yerly tbultion of the top 5 indictions for PKP showed PBK peking from 1996 to 1998 nd going down therefter. There ws n incresing trend for regrft since the middle of 2001, nd decresing trend for cornel scr (Figure 2). As indictions for PKP, cornel scr, microbil kertitis, nd trum were 74%, 60%, nd 33% respectively more common in mles thn femles (Tble 2). PBK, Fuch s dystrophy, cornel stroml dystrophy, nd glucom cusing bullous kertopthy were more frequent mong femles. In prticulr, Fuch s, stroml dystrophy, nd PHILIPP J OPHTHALMOL VOL 30 NO. 4 OCTOBER - DECEMBER 2005 149
Number 400 350 300 250 200 150 100 50 0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90 up Age Groups Figure 1. Generl ge distribution of cornel recipients, 1996 2004. Tble 1. Indictions for penetrting kertoplsty in the Philippines, 1996-2004. Indictions Cornel scr Pseudophkic bullous kertopthy Microbil kertitis Regrft Aphkic bullous kertopthy Fuch s dystrophy Virl infection Trum Cornel dystrophy Glucom Kertoconus Congenitl defect Noninfectious ulcertive kertitis Steven Johnson syndrome Others Unspecified Totl Number 509 420 376 208 120 110 91 60 57 44 41 29 19 8 23 16 2,131 Percent 23.9 19.7 17.6 9.8 5.2 4.3 2.8 2.7 2.1 1.9 1.4 0.9 0.4 1.1 0.8 100.0 glucom s indictions for PKP were 2 times more likely to be seen in femles (Tble 2). Cornel scr, microbil kertitis, nd virl infection were the more frequent indictions mong the lower socioeconomic (chrity) group, while PBK, ABK, regrft, Fuch s, glucom, nd kertoconus were the more common indictions mong the higher socioeconomic group (Tble 2). Among py ptients, the conditions cited were lmost 2 times more common, with the exception of kertoconus which ws 3.5 times. DISCUSSION The leding indictions for PKP in the developed world re PBK, regrft, nd kertoconus, 1-6 in contrst to developing countries like Indi, Tiwn, Isrel, nd Chin 9-12 where the most common indictions re cornel scr nd microbil kertitis. The results of this study were very similr to those of studies in the developing world, with n overll rte of greter thn 20% nd 10% for cornel scr nd microbil kertitis respectively (Tble 3). Cornel scr nd microbil kertitis together mde up Percent 90 80 70 60 50 40 30 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 Yer Cornel Scr Pseudophkic Bullous Kertopthy Microbil Kertitis Aphkic Bullous Kertopthy Regrft Figure 2. Trends of top five indictions for penetrting kertoplsty, 1996 2004. Tble 2. Gender nd socioeconomic sttus s fctors predictive of penetrting kertoplsty. Indictions Cornel scr Pseudophkic bullous kertopthy Microbil kertitis Regrft Aphkic bullous kertopthy Fuch s dystrophy Virl infections Trum Stroml dystrophy Glucom Kertoconus Congenitl defects Noninfectious kertitis Steven Johnson syndrome Others Missing dt Gender Socioeconomic sttus OR p CI OR p CI 0.74 1.44 0.61 0.96 1.33 2.47 0.88 0.33 2.02 2.33 0.85 1.19 1.07 2.45 2.75 0.67 0.004 0.001 0.76 0.13 0.55 0.001 0.008 0.005 0.61 0.64 0.89 0.21 0.02 0.45 0.60; 0.91 1.16; 1.79 0.47; 0.78 0.70; 1.29 0.90; 1.95 1.64; 3.77 0.55; 1.38 0.15; 0.65 1.15; 3.60 1.22; 4.59 0.41; 1.67 0.53; 2.66 0.37; 2.93 0.47; 15.8 1.09; 7.53 0.18; 2.09 0.53 2.16 0.32 1.94 1.94 2.30 0.52 1.33 0.91 2.04 3.61 1.25 1.05 0.39 1.52 1.50 0.004 0.27 0.73 0.02 0.55 0.92 0.23 0.32 0.42 0.43; 0.66 1.73; 2.71 0.24; 0.42 1.44; 2.64 1.31; 2.91 1.51; 3.55 0.32; 0.83 0.77; 2.31 0.51; 1.60 1.06; 4.06 1.71; 8.30 0.56; 2.81 0.38; 2.89 0.04; 2.18 0.61; 3.88 0.49; 4.75 40.5% of ll indictions for PKP in this study. From 1971 to 1991, the most common condition treted t the Corne nd Externl Disese Section of the Deprtment of Ophthlmology, University of the Philippines-Philippine Generl Hospitl ws microbil kertitis. 14 Most of the infectious cornel ulcers ended up in significnt scrring of the corne. Both conditions were lso more common mong ptients of lower socioeconomic sttus (Tble 2), similr to the results found in Indi. 9 This my reflect the fct tht poor ptients hve less resources for proper medicl tretment nd limited ccess to immedite cre, especilly in the rurl res. Conversely, microbil kertitis nd cornel scr were less common mong welthy ptients who were more likely to seek immedite cre before the condition worsened nd cused significnt visul impirment. Approximtely 50% of the infectious kertitis in this study were fungl in etiology which ws ssocited with vegetble-mtter injury, 15,16 commonly seen 150 PHILIPP J OPHTHALMOL VOL 30 NO. 4 OCTOBER - DECEMBER 2005
mong poor frmers in the Philippines. Figure 2 shows tht the incidence of cornel scr peked during the yers 1996 to 1998 with grdul decrese therefter. The high numbers of PKP done for cornel scr in the erly yers of the eye bnk my be reflection of the bcklog of these cses prior to the estblishment of the eye bnk, nd which decresed once cornes becme more vilble. PBK ws the second leding indiction for PKP in this study t 19.7%, with peks from 1996 to 1997 reflecting bcklog nd stbiliztion therefter (Figure 2). Other 1, 3-12 studies lso showed incidences greter thn 10%, except for the UK study where its reltively low percentge of 7.6% ws ttributed to more conservtive pproch nd slower cceptnce of introculr lenses 2 during the period of the study. The ge distribution in this study ws bimodl, with peks t two ge groups; the first t 35 to 45 yers due to cornel scrs nd microbil kertitis, nd the second t 65 to 75 yers due to PBK (Figure 1). This distribution fits the ge group (20 to 50 yers) when microbil kertitis is usully found, 15 nd the elderly group when PBK nd ctrct re higher. This bimodl distribution ws lso seen in other studies. 1, 6 The rte of regrft (9.8%) in this series ws considerbly lower thn those reported in developed countries where incidences pproched 20% or more (Tble 3). From 2001 onwrds, however, there ws stedy increse, reflection of the incresing number of PKPs performed over time nd the potentil for grft filure, 10 trend similr to those 10, 17, 18 of other studies. Fuch s dystrophy ws more common mong femles in this study, consistent with well-known epidemiologicl dt on Fuch s. 19 In developed countries, kertoconus is one of the leding indictions for PKP, unlike in developing countries in Asi including the Philippines where the incidence is much lower (Tble 3). The reson for this difference is not cler. Mmlis et l. 4 suggested tht there my be higher incidence of kertoconus mong Cucsins, prticulrly those from Northern Europe or Scndinvi. PBK, ABK, regrft, Fuch s dystrophy, nd kertoconus s indictions for PKP were more common mong those belonging to the higher socioeconomic sttus. This cn be ttributed to the fct tht poorer ptients treted t trining institutions were more likely to dely surgery due to finncil constrints nd likely to tolerte the blurry vision longer. Welthier ptients hve greter ccess to expert cre nd were more likely to hve the conditions treted erlier. Trum s cuse for PKP is much more common mong mles, s reported in both foreign nd locl studies. 15, 20, 21 Mles hve been shown to be t higher risk for trumtic eye injury in occuptionl nd recretionl settings 15 nd re ssocited with higher incidences of microbil kertitis nd cornel scr. Vlenton found tht trum ws the predisposing fctor in 75% of bcteril nd fungl kertitis nd tht mnul lborers, frmers, nd construction workers were prticulrly vulnerble. In our study, microbil kertitis nd cornel scr were seen more frequently mong poorer ptients while trum ws not ssocited with socioeconomic sttus. Possible explntions include the type of surgery done most of the poorer ptients my hve opted for cheper surgicl tretments such s primry repir or tectonic grfts insted of PKP. Virl infections were lso more common mong the chrity ptients undergoing PKP. Though timely medicl tretment with topicl nd orl ntivirl medictions my provide cure, ptients with fewer funds nd less ccess to expert cre my hve poorer control of the disese process leding to significnt cornel scrring. The top 5 indictions for PKP in this study hve reltively poorer prognosis due to the ssocited neovsculriztion nd ctive inflmmtion commonly present tht re well-known risk fctors for grft filure. 19 This is in contrst to kertoconus s leding indiction in developed countries with better prognosis. Regrft s n Tble 3. Comprison of leding indictions (in percent) for penetrting kertoplsty. Pdill, Philippines 1996-2004 n = 2,131 23.9 19.7 17.6 9.8 5.2 1.9 Wei-Li Chen, 10 Tiwn 1987-1999 n = 770 27.9 17.6 17.9 b 21.0 4.5 2.5 Cornel scr PBK Microbil Kertitis Regrfts ABK Fuch s Dystrophy Kertoconus Dndon, 9 Indi 1987-1995 n = 1,964 28.1 10.6 12.2 17.1 11.8 6 Zhng, 12 Chin 1994-2003 n = 229 55.9 12.2 12.2 10.5 5.7 Liu, 3 Cnd 1986-1995 n = 904 2.9 28.5 4.3 22.3 6.2 7.7 10 Edwrds, Zelnd 1991-1999 n = 1,370 17.9 3.3 8.7 4.4 4 Al-Yousuf, 2 UK 1990-1999 n = 784 7.6 40.9 9.3 15 Meno, 1 Cnd 1964-1997 n = 6,222 15.3 18.0 9.6 16.0 Mmlis, 4 USA 1981-1990 n = 999 8.2 23.0 5.7 13.1 5.8 24.2 indictes percentge of PBK nd ABK combined b includes ll cuses of necrotizing nd ulcertive kertitis PHILIPP J OPHTHALMOL VOL 30 NO. 4 OCTOBER - DECEMBER 2005 151
indiction for PKP is, therefore, likely to increse. In summry, cornel scr ws the most frequent indiction for PKP in the Philippines from 1996 to 2004, followed by PBK nd microbil kertitis. Those belonging to the lower socioeconomic sector were more likely to hve cornel scr, microbil nd virl infection while welthier ptients were more likely to hve kertoconus, PBK, ABK, nd Fuch s dystrophy. Regrft s n indiction for PKP hs lso incresed since 2001. References 1. Meno A, Nor J, Lee HM, et l. Three decdes of cornel trnsplnttion: indictions nd ptient chrcteristics. Corne 2000; 19: 7-11. 2. Al-Yousuf N, Mvrikkis I, Mvrikkis I, Dy M. Penetrting kertoplsty: indictions over 10-yer period. Br J Ophthlmol 2004; 88: 998-1001. 3. Liu E, Slomovik AR. Indictions for penetrting kertoplsty in Cnd, 1986-1995. Corne 1997; 16: 414-419. 4. Mmlis N, Anderson CW, Kreisler KR, et l. Chnging trends in the indictions for penetrting kertoplsty. Arch Ophthlmol 1992; 110: 1409-1411. 5. Lois N, Kowl VO, Cohen EJ, et l. Indictions for penetrting kertoplsty nd ssocited procedures, 1989-1995. Corne 1997; 16: 623-629. 6. Edwrds M, Clover GM, Brookes N, et l. Indictions for cornel trnsplnttion in New Zelnd, 1991-1999. Corne 2002; 21: 152-155. 7. Lindquist TD, McGlothn JS, Rotkis WM, Chndler JW. Indictions for penetrting kertoplsty: 1980-1988. Corne 1991; 10: 210-216. 8. Robin JB, Gindi JJ, Koh K, et l. An updte of the indictions for penetrting kertoplsty. Arch Ophthlmol 1986; 104: 87-89. 9. Dndon L, Rgu K, Jnrthnn M, et l. Indictions for penetrting kertoplsty in Indi. Indin J Ophthlmol 1997; 45:163-168. 10. Chen WL, Hu FR, Wng IJ. Chnging indictions for penetrting kertoplsty in Tiwn from 1987-1999. Corne 2001; 20: 141-144. 11. Frucht-Pery J, Stibel H, Solomon A, et l. Thirty yers of penetrting kertoplsty in Isrel. Corne 1997; 16: 16-20. 12. Zhng C, Xu J. Indictions for penetrting kertoplsty in Est Chin, 1994-2003. Grefes Arch Clin Exp Ophthlmol 2005; 243: 1005-1009. 13. Dndon L, Nduvilth TJ, Jnrthnn M, et l. Survivl nlysis nd visul outcome in lrge series of cornel trnsplnts in Indi. Br J Ophthlmol 1997; 81: 726-731. 14. Vlenton MJ, Dylicco JU, Espiritu C. Corne nd externl eye disese problems in the Philippines. A twenty-yer survey (1971-1991): summry nd highlights. Philipp J Ophthlmol 1993; 22 (Suppl): 32-37. 15. Vlenton MJ. Centrl microbil kertitis: etiology, epidemiology, clinicl fetures nd tretment. Philipp J Ophthlmol 2000 ; 25: 23-26. 16. Tbbr KF, Hyndiuk RA. Infections of the Eye, 2nd ed. Boston: Little, Brown, nd Compny, 1996; 349-350. 17. Flowers CW, Chng KY, McLeod SD, et l. Chnging indictions for penetrting kertoplsty, 1989-1993. Corne 1995; 14: 583-588. 18. Cursiefen C, Kuchle M, Numnn GO. Chnging indictions for penetrting kertoplsty: histopthology of 1,250 cornel buttons. Corne 1998; 17: 468-470. 19. Leibowitz HM, Wring GO. Cornel Disorders: Clinicl Dignosis nd Mngement 2nd ed. Phildelphi: WB Sunders Co., 1998; pp. 1172. 20. Liggett PE, Pince KJ, Brlow W, et l. Oculr trum in n urbn popultion: review of 1132 cses. Ophthlmology 1990; 97: 581-584. 21. Fong LP. Eye injuries in Victori, Austrli. Med J Aust 1995; 162: 64-68. Acknowledgement The uthors grtefully cknowledge the sttisticl ssistnce of Dr. Mrie Crmel Lpitn of the Deprtment of Urology, Philippine Generl Hospitl. 152 PHILIPP J OPHTHALMOL VOL 30 NO. 4 OCTOBER - DECEMBER 2005