Clinical Results of 90 Eyes of Keratoplasty

Kim, Jae Ho

Abstract

Needless to say, the essence of keratoplasty is the maintenance of the vitality and clarity of the graft. About 60 years ago, Dr. Elschnig performed the first successful and well-documented partial iso- and allografts of human cornea with von Hippel's original trephine. In Korea, the first successful corneal graft was performed 40 years ago by Drs. Hayano and Sadake, Japanese ophthalmologists in Seoul. They used an 8mm trephine and fixed the graft by the overlapping method in which a square thin rubber piece was fixed to the subconjunctival tissues by direct suture at its four corners. After the World War II, the keratoplasty was not very popular in Korea untill about 1960, for various reasons, including the Korean war, lack of available donor corneas and above all well-trained corneal surgeons. Only scattered cases of keratoplasty were reported by a few Korean ophthalmologists with some successful results. The recent advances in keratoplasty in Korea has been greatly stimulated by the lectures and practice courses on keratoplasty which were conducted by Drs. David Paton and Miguel Martinez, expert corneal surgeons of Johns Hopkins Hospital, U.S.A., and by the donation to the EyeBank of St. Mary's Hospital of a set of instrument and basic equipment from Dr. J. H. King, Jr. in Washington, D.C. in 1967. Although a few eye banks were launched in Korea in the sixties, their activities have been. greatly restricted on account of the peculiar custom of the Korean people's reluctance to donate their eyes after death. In Korea, 231 cases of keratoplasty have been performed until 1975, which means that only about twenty patients per year undergo corneal grafts althogh many more registered patients are waiting for operation. CORNEAL BLINDNESS AND ITS STATISTICS ON HOSPITAL EYE PATIENTS. The population of South Korea is about thirty-five millions, among whom the number of the blind is estimated to amount to 100,000 equivalent to 0.3% of the total population. According to a survey of blindness (the definition of blindness applies to corrected visual acuity under 20/200) on 94,799 hospital patients selected at ramdom in seventeen hospitals in Korea (Koo and Chai, 1974). the estimated number of blind patients was 1,763 (1.9%) in binocular and 4,585 (4.8%) in monocular blindness, the proportional percentages of the causes being in the descending order of senile cataract (36.10% in binocular and 25.5% in monocular), retinal diseases (13.18%,10.70%), corneal diseases (8.16%, 17.88%), and others such as glaucoma (7.78%, 6.13%), myopia (8.16%, 6.17%) and optic nerve diseases (9.33%, 4.03%) etc. (Table 7) The main causes of corneal blindness were infectious diseases such as herpes simplex keratitis and bacterial ulcers (0.65% in binocular, 6.06% in monocular), of corneal opacities from injuries and burns (2.07%, 5.83%) and general diseases (1.56%, 2.72%). The most prevalent area was Kangwon-do Province, where binocular corneal blindness was 16.05% and monocular blindness 28.73% of the whole blind patients. Comparing this data with that of other advanced countries, the corneal blindness in Korea occupies the same position as in the case of Sweden, representing the third largest causes of blindness among all the causes of blindness. However, the combined percentage of monocular and binocular blind patients was 6.7% (6,348 patient among the total of 94,799) in the survey of 1971-72. Although the present demand for keratoplasty increases day by day, the supply of donor corneas is still in great shortage. THE EYE BANK AND SUPPLY OF CORNEAS. In answer to the large demand of donor corneas, an eye bank was first opened at the Department of Ophthalmology, Seoul National University Hospital in 1962. But the supply of corneas by the eye bank was scanty due to the lack of donors and traditional Korean customs. A few years later, two more eye banks were launched. Thereafter, the Central Eye Bank attached to the Department of Ophthalmology, St. Mary,s Hospital, Catholic Medical College, Seoul, was inaugurated on April 19, 1967 with the help and contribution from Dr. J.H.King, Jr. Director of Interilational Eye Foundation, Washington, D.C. At the request of Dr. B.S.Koo, former professor of ophthalmology, Catholic Medical College, Dr. King sent in November, 1965, two corneal surgeons, Drs. David Paton and Miguel Martinez of Baltimore, to Korea for the instruction of keratoplasty and opening of the Central Eye Bank of St. Mary's Hospital which was designed to supply corneas to all hospitals of korea. This served as a big stimulus for Korean ophthalmologists. Table 2 shows data regarding donor eyes supplied by the Central Eye Bank from 1967 to 1975. The Central Eye Bank has enucleated 182 eyes from donors and supplied 90 corneas for keratoplasty at St. Mary's Hospital. It also supplied corneas to many eye surgeons of other hospitals or corneal graft operations. Pamphlets for enlightenment and publicity were distributed among hospitals, clinics, and varlous other organizations, and in response to the publicity activities, so far 300 noted persons desiring to give their eyes have been registered with this eye bank. Although a considerable number of willed persons registered as would-be donors, practically almost all the donor eyes in the past were obtained from such cadavers as hae no relatives and families and died of chronic or senile diseases in hospitals. Because of such limited supply of donor corneas, and of the socioeconomic problems of poor patients in my country where no medical insurance system has been established yet, the activities of the eye banks in Korea are very inactive although the Enucleation Act for research was put into practice in 1973 by the Ministry of Health and Wellfare of Korea. RETROSPECTIVE CUNICAL REVIEW. In Korea, 231 cases of keratoplasty have been performed by different surgeons and different techniques from 1935 to the present time. Among them, the most common grafting method was penetrating keratoplasty which was performed on 208 patients. The rates of clear grafts greatly differ depending upon surgeons and the time of operations, ranging from 60% to over 90%. Fig. 1 shows the total numbers of cases of penetrating and lamellar keratoplasty which were performed during the past 40 years in Korea. 90% (208 eyes) of them were performed by penetrating keratoplasty. As memiomed above in the introduction, the first penetrating keratoplasty using a square thin rubber for overlapping fixation was performed separately in Korea by Drs. Hayano and Sadake in Seoul between 1935-40. But the postoperative results for these patients are not known. During about 10 years following the Second World War, Dr. S.M.Hong, former professor of ophthalmology, Chun Nam University and his assistants performed 5-7mm small penetrating grafts with good results in two cases out of four. They used a conservative fixation method such as thick sutures for fixatian of an overlapped rubber piece to the bulbar subconjunctival tissues. Practically, keratoplasty has become popular since 1963. During this revival stage of keratoplasty, Dr. Ko, C.J., former chief of ophthalmology, Seoul Red Cross Hospital, made operations by himself for sixty eyes of all penetrating grafts with a success rate of about 70%. Inconsideration of the various disadventages mentioned above, it can be said to be exceptional that a surgoon should have performed sixty grafts singlehandedly. Four fresh donor corneas were sent to Yun Sei University Hospital via air mail from an International Eye Bank of Sliranka. Only two cases out of four eyes maintained a clear graft after penetrating keratoplasty. Direct suture technique with 6-0 silk around the margin of a corneal button was popularized since 1957. But ten years later, 8-0 virgin silk (or chromic gut) for direct or continuous sutures was then introduced in keratoplasty. Since this time an operating microscope with fine micro-surgical instruments and sutures has been used as an essential surgical instrument in our operating rooms. Continuous suturing technique with 10-0 monofilament nylon under the operating microscope is now a common practice and has increases the success rate greatly since 1971. With the opening of the Central Eye Bank of St. Mary's Hospital in 1967, our activities in keratoplasty have been greatly accelerated and we have been given more opportunities to collect patients indicated for keratoplasty. Anyhow, during the period of 1967-1975, we performed keratoplasty in 90 recipient eyes which correspond to two thirds of the total 135 grafts in this period. Table 1 shows incidence of causative diseases of corneal opacity and corneal conditions at the time of keratoplasty seen in 90 eyes (87 patients; one patient received two grafts on both eyes, and two patients received regrafts because of an opaque graft). The successful results of our early cases showed 71% (19 of 27 grafted eyes); however, due to the improvement of surgical techniques, careful selection of donor-recipients, and the use of fine microsurgical instruments, sutures and needles under the operating microscope since 1970, the results are getting better; 55 eyes, which amounted to 87.3% of 63 eyes grafted successfully, maintained their clarity. Fourteen eyes of clear grafts that did not improve vision had reasons such as amblyopic eye (cosmetic graft, 7 eyes), therapeutic pterygium(2), progressive cataract (1) and cloudy host tissues under lamellar graft(4). Most cases of opaque grafts resulted from irreversible graft rejection which was seen in eleven eyes. Another four eyes showing graft rejection were controlled by topical (0.5% hydrocortisone drop per hour) and systemic use (60mg. of prednisone per day in adult) of corticosteroids and three eyes by systemic use of Azathioprine (100-200mg per day in adult). Another complications were as follows; bullous keratopathy(5 eyes), wound gapping with or without iris incarceration (5), anterior or posterior synechia(5), neovascularization(3), complicated cataract(1), complicated glaucoma (1) and retrocorneal membrane (1). Almost all donor corneas which were used for keratoplasty in Korea were supplied as the condition of a fresh or a 40 degrees C wet chamber stored fresh cornea. Only a few glycerine preserved corneas were used for lamellar grafting with good results. Recently, I have experienced one successful case of 7mm partial penetrating keratoplasty by using of full 5 days wet-chamber stored cornea. obtained from 24 year old young donor. This 5 days stored cornea was, anyhow, grafted to a man (29 year old) whose right eye had been blind from leucoma cornea adherens since childhood because of measles. The graft retained crystal clear after operation, postoperative vision being 20/100 without a contact lens. SUMMERY. In Korea, the first successful keratoplasty was performed 40 years ago by two Japanese ophthalmologists in Seoul. The combined percentage of monocular and binocular blind patients was 6.7% in a survey of hospital patients of year 1971-72. Among them, the combined percentage of monocular and binocular corneal blind patients was 26.58%. The recent progress of keratoplasty in Korea has been greatly stimulated by the intensive lectures, experiments and technical practice on keratoplasty which were conducted by the intensive lectures, experiments and technical practice on keratoplasty which were conducted by Drs. D. Paton and M. Martinez of Johns Hospkins Hospital in 1967. At the same time, through these two doctors, Dr. J.H. King, Jr. of Internationsl Eye Foundation, Washington, D.C. donated many medical instruments and a great deal of materials, including eye preservation containers, preserved corneas, atc. The Central Eye Bank of Catholic Medical College has enucleated 182 eyes from donors and supplied 124 fresh corneas for keratoplasty during the last 7 years. 231 cases of keratoplasty have been performed by different surgeons and different techniques from 1935 to 1975. The most common grafting method has been penetrating keratoplasty(90%). Continuous suturing technique with 10-0 monofilsment nylon under the operating microscope is now a common procedure and has increased the success rate greatly. In our hospital, we performed keratoplasty in 90 recipient eyes during the improvement of surgical techniques, careful selection of donor-recipients, and the use of fine microsurgical instruments, sutures and needles under the operating microscope since 1971, the results are getting better; 55 eyes, which amounted to 87.3% of 63 eyes grafted successfully, maintained their clarity.

Clinical Results of 90 Eyes of Keratoplasty

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