Penetrating Keratoplasty in Corneal Scarring due to Trachoma Khalil ERRAIS, Olfa FEKIH, Omar BELTAIEF, Amel OUERTANI. Charles Nicolle University Hospital,

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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 lesions 2. 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 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 spectacles 2. 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 : years. Mean preoperative best corrected visual acuity: 2.4 / 100 Preoperative findings: Patients % Conjonctival scarring44100% Adnexial abnormalities715.9% Corneal Neovascularisation % Anterior synechiae511.3% Cataract % 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 % 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 procedurecases% Cataract surgery % Vitrectomy24.54% Gonioplasty12.27% Synechiolysis511.36%

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.  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 FactorGraft rejectionGraft failure Patient’s age > 50 yearsP=0.201P=0.341 EntropionP=0.469P=0.550 TrichiasisP=0.543P=0.631 History of cataract surgeryP=0.092P=0.015 NeovascularisationP=0.002P=0.004 Preoperative high ocular pressureP=0.390P= Local anesthesiaP=0.901P=1 Emergency graftP=0.003P=0.004 Graft term storage ≥ 7 days P=0.701P=0.002 Graft diameter < 7mmP=1 Graft diameter ≥ 8mmP=1 Donor ageP=1 Combined cataract surgeryP=0.004P= VitrectomyP=1 Interrupted suturesP=0.897P=0.564 Epithelial defectP=0.03P=0.048 Early postoperative inflammationP=0.039P=0.003 Early postoperative high ocular pressureP= P=0.002 Late postoperative inflammationP=0.0173P= Late postoperative high ocular pressureP= P=0.004 Infectious keratitisP=1P=0.654 Broken suturesP=0.684P=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 studyAl.Fawaz 5 Kocak Midillioglu 6 Graft rejection40.9%17.3%31.3% Graft failure (5 years)29.5 %23.4%24.5% VA> 5/1028.8%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

References: 1. Remiskaff S, Pascolini D, Etay’ale D, Kocur I, Pararjasegaram R, Pokharel GP, Mariotti SP. Global data on visual impairment in the year Bull world health Organ Nov; 82(11): Epub Porter M, Mak D, Childow G, Harnet GB, Smith DW. The molecular epidemidogy of ocular Chlamydia trachomalis infections in western Australia: implications for trachoma control. Am J Trop Med Hyg Mar; 78(3): Burton MJ. Trachoma: an over view. Br Med Bull. 2007; 84: Epub 2008 Jan Paufique L, Charleux J. Keratoplasty and trachoma Rev Int Trach ; 41 : Al Fawaz A, Wagoner D. Penetating heratoplasty for trachomatous corneal scarring. Cornea 2008; 27: Kocak –Midillioglu I, Akova YA, Kocak Altinas AG, Aslan BS, Duan S. Penetrating keratoplasty in patients with corneal scarring due to trachoma. Ophthalmic Surrg Lasers 1999; 30: Dhanda RP. 175 cases of heratoplasty. Experiences in trachomatous Country like India. Rev Int Trach. 1963; 40: