Changing Indications And Trends Of Keratoplasties In A Multi Tier Hospital Network In India Over Three Decades

Corneal blindness is a major cause of blindness globally as well as in India, accounting for 7.5% of the burden of blindness.In developing nations including India, corneal scarring secondary to infections, microbial keratitis and bullous keratopathy are more common.Although these trends have been described in literature from developed countries, there is a lack of a standardised registry for reliable information regarding the indications and outcomes of keratoplasties in the Indian population barring a few isolated studies, the latest one published in 2004. The present study aims to evaluate the trends of changing indications and techniques of keratoplasties in a network of tertiary eye care centres in India.

The study was retrospective records-based, encompassing all penetrating and lamellar keratoplasties done across a network of 4 tertiary centres and 5 secondary centres in India. Medical records in the physical form were reviewed for the period 1987-2015 to identify patients who underwent keratoplasty. Electronic medical records (EMR) were reviewed from 2016-20 using the key words “Keratoplasty”. These records were verified with the help of eye bank-based records for the same period.

 34680 patient case records were found during the study period. 2180 records were found to be incomplete and were therefore excluded from further analysis. Data from 32500 eligible records was extracted manually into a digital spreadsheet (Microsoft Excel). Indications were classified broadly into 10 categories with several subcategories for subgroup analysis.

Statistical analysis was done using the SPSS software (v26.0). Percentages and proportions were calculated for each indication category and graft type. Continuous variables were tested for normality and represented using mean with standard deviations. The study period was split into 7 subgroups, each at 5-year intervals and subgroup analysis was performed to assess the changing trend.

62.5% of the patients were males with a mean age of 44.77 +/- 20.96 years. Infectious keratitis was the most common indication for KP (n=7987; 27.2%) followed by endothelial disorders(ED) (n=6438; 22.4%).18.5% were regrafts.The most common procedure performed was optical PK (n=10769; 40.9%). Lamellar KP accounted for 26.8% of all surgeries done.An overall increase in the total number of keratoplasties was seen with the maximum number in 2018 (n=2634) The number of optical PKPs done per year showed a steady decline after 2012 with a corresponding increase in the number of lamellar procedures . In the period 2016-20, EK accounted for 80% of procedures done for ED whereas DALK accounted for 62.5% of procedures done for dystrophies and ectasias

There is limited data regarding the indications, types and outcomes of keratoplasties in India.Our study included 32500 records collected over a period of 35 years which makes the evidence more robust.Infectious keratitis was the single most common indication in agreement with other studies from developing nations.Endothelial diseases and dystrophies accounted for 17.9% of the total keratoplasties performed and was the 4th most common indication.This is in contrast to studies performed in the developed world.Re-grafting accounted for 28.4% of all surgeries.This may be due to the higher number of full thickness and therapeutic grafts performed in our study population which increases the probability of graft rejection and failure.