Trendsintheindicationsforpenetratingkeratoplasty 窑ClinicalResearch窑 Trends in the indications for penetrating keratoplastyinShandong,2005-2010

Foundation item: SupportedbyNationalNaturalScience DOI:10.3980/j.issn.2222-3959.2011.05.07 FoundationofChina(No.30630063) 1 DepartmentofOphthalmology,RenminHospitalof Wuhan WangJY,XieLX,SongXS,ZhaoJ.Trendsintheindicationsfor University,Wuhan430060,HubeiProvince,China penetratingkeratoplastyinShandong,2005-2010. 2 StateKeyLaboratoryCultivationBase,ShandongProvincialKey 2011;4(5):492-497 LaboratoryofOphthalmology,ShandongEyeInstitute,Shandong AcademyofMedicalSciences, Qingdao 266071,Shandong INTRODUCTION Province,China incethefirstfull-thicknesscornealtransplantation Correspondenceto: Li-XinXie.StateKeyLaboratoryCultivation [1] Base,ShandongProvincialKeyLaboratoryofOphthalmology, S reportedbyZirm ,penetratingkeratoplasty(PKP)has ShandongEyeInstitute,ShandongAcademyofMedicalSciences, becomeoneofthemostpopularandsuccessfulorgan Qingdao266071,ShandongProvince,[email protected] transplantationtechniquesusedworldwide.Itiswildlyused Received:2011-09-19Accepted:2011-10-08 inthetreatmentofvariouscornealdiseases.Theindications forPKPvarybygeographicregionsalongwitheconomic Abstract developmentandsocialconditions.Withthespreadof phacoemulsificationandintraocularlens(IOL)implantation, ·AIM:Toidentifythecurrentindicationsandthetrendshifts cornealedemafollowingcataractsurgeryincreasedabruptly, forpenetratingkeratoplasty(PKP)inShandong. andhasbeentheleadingindicationinthedeveloped · METHODS:Themedicalchartsofallpatientswho countries(e.g,USandEurope)sincethe1980s [2-6].Atthe underwentPKPatShandongEyeInstitutefromJune1,2005 sametime,theleadingindicationsforPKPindeveloping toMay31,2010wereanalysedretrospectively. countries(e.g,ChinaandIndia)haveremainedinfectious ·RESULTS:Atotalof875patients(875eyes)receivedPKP ,cornealscarring [7-10].Accompanyingthe inthis5-yearperiod,accountingfor61.6%ofallcorneal improvementinsurgicaltechniquesbypioneeringcorneal transplantationsurgeries.TheleadingindicationsforPKP surgeonsandavailabilityofsurgicalinstruments,anterior wereinfectiouskeratitis(37.1%),HSK(19.1%), lamellarkeratoplasty(ALK) and Descemet-stripping (11.2%),bullouskeratopathy(8.5%),regrafting(6.7%)and endothelialkeratoplasty (DSEK)havebeendevelopedand cornealscarring(4.8%).ThepercentageofPKPfor implementedworldwide.Correspondingly,therehasbeena keratoconusdeclinedyearbyyear,whereasthepercentage declineintheindicationsforPKPinrecentyears.TheEye ofbullouskeratopathyhadamildannualincrease.Fungal BankAssociationofAmerica(EBAA)retrospectively infectionsaccountedfor65.2%oftheinfectiouskeratitis cases,remainingtheleadingcauseofcornealinfection.In reviewedcornealtransplantationsoverthepast5years,and addition,54.1%ofbullouskeratopathycaseswereassociated showedthatthemostcommonindicationsforPKPhave withcataractsurgery.Theleadinginitialdiagnosesassociated shiftedtocornealscars/interstitialkeratitis (24%)and withregraftingwereinfectiouskeratitis(38.9%),HSK keratoconus(21%).Inthiscontext,thereisaquestionwhat (18.6%)andcornealburn(16.9%).Themajorcausesof PKPindicationchangesinChinahaveoccurred?To regraftingincludedgraftendothelialdysfunction(39.0%), investigatethecurrentindicationsandtheindicationshifts graftulcer(28.8%)andprimarydiseaserecurrence(15.3%). forPKPinShandong,whichisoneofthelargestprovince · CONCLUSION:Infectiouskeratitisremainedtheleading inNorthChina,wereviewedthePKPproceduresperformed indicationforPKPinShandong,andfungalinfectionswere attheShandongEyeInstituteinthepast5yearsand stillthemajorcauseofcornealinfections.Therewasan contrastedtheindicationsforPKPwiththosereportedinour increasingtrendinthepercentageofPKPcasesindicatedfor previousstudy(1997-2002) [8]. bullouskeratopathybutadeclineinthesamefor MATERIALSANDMETHODS keratoconus.Evenwithadeclineintheoverallproportion ThechartsofallpatientswhounderwentPKPatShandong amongallcornealtransplantationsurgeries,PKPisstillthe EyeInstitute,China,atertiaryreferralcentre,duringthe majorcornealtransplantchoiceinShandong. period fromJune1,2005,toMay31,2010were ·KEYWORDS:penetratingkeratoplasty,indication,infectious retrospectivelyreviewed.Themedicaldatawereanalysed keratitis withrespecttoage,sexandpreoperativeclinicaldiagnosis. 492 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 4熏晕燥援 5熏 Oct.18, 圆园11 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 TheindicationsforPKPweredividedinto11diagnostic categories.Amongthesecategories,infectiouskeratitiswas furtherclassifiedaccordingtopathogenicspecies(fungus, bacteriaandAcanthamoeba).Herpessimplexkeratitis includedcaseswithbothactiveherpetickeratitisandhealed herpeticscars.Theaetiologyofbullouskeratopathywas recorded.Forregrafts,anadditionalanalysisofthecauseof thepreviousgraftfailureandtheoriginaldiagnosiswasalso performed.Thealterationofthepreferredsurgicalapproach Figure1Proportionsofpenetratingkeratoplasty (PKP)and wasexplored primarilyaccordingtothetop three lamellarkeratoplasty (LKP)from1996to2010.Therewasa indicationsforPKPinourcentre. significantdeclineinthefrequencyofPKPprocedure,buta remarkableincreaseinthesameofLKPcomparedthedata RESULTS inourpreviousstudy[12] Atotalof875PKPcaseswereincludedinthestudy,which accountedfor61.6%oftotalkeratoplasties.Theagesranged from3monthsto82years,withameanageof43.5 18.6 years.Therewere583malesand292females. 依 ChangesoffrequenciesofPKPinallkeratoplasties PKPproceduresaccountedfor61.6%ofkeratoplasties duringthe5yearsofthestudyperiod,andthisfrequency representsasignificantdeclinewhencomparedtothe resultsofourpreviousstudy (1996-2007) [11].Conversely, therewasaremarkableincreaseinLKP( 2=77.997, = Figure2PercentageofPKPperformedamongeyeswiththe 0.000,Figure1).Infectiouskeratitis,HSKandkeratoconus leadingindicationsfrom1996to2010.ThePKPproportions forallthreediseasesrepresentasignificantdeclinecompared servedastheleadingindicationsforPKP,however,agreat withthedatainourpreviousstudy[12] numberofpatientssufferingfromthesediseasesreceived LKPratherthanPKP.PKPaccountedfor56.5%,81.1% and48.8%ofkeratoplastiesassociatedwithabovediseases respectively.ThePKPproportionsforallthreediseases representasignificantdeclinecomparedwiththedatainour previousstudy [12] ( 2=79.209, =0.000; 2=80.396, = 0.000; 2=85.168, =0.000;Figure2). TrendsinindicationsforPKP Infectiouskeratitis(325 cases,37.1%)wastheleadingindicationforPKP,followed byHSK(167cases,19.1%),keratoconus(98cases,11.2%), Figure3ClinicalIndicationsforPKPbetweenJune2005and bullouskeratoplasty(74cases,8.5%),regrafting(59cases, May2010.Infectiouskeratitisremainedtheleadingindication 6.7%)andcornealscarring(42cases,4.8%,Table1). forPKP.Therewasanincreasingtrendinthepercentageof ThepercentageofPKPproceduresusedtotreatkeratoconus PKPcasesindicatedforbullouskeratopathybutadeclinein thesameforkeratoconus decreasedannuallyduringthe5years( =14.918, =0.031). Conversely,thepercentageassociatedwithbullous decreasedfrom28.6%to18.8%( 2=11.194, =0.001, keratopathydemonstratedanincreasingtrendoverthesame Table2,3).Therewasaslightincreaseinthenumbercases period( =14.010, =0.033)andhasnowbecomethethird ofacanthamoebickeratitisbecauseoftheuseofconfocal majorPKPindicationasofJune1,2008(Figure3). microscopyandanincreasingknowledgeofhowtoidentify Comparedwiththedataofpreviousstudy [8],thepercentage therelevantcysts,buttherewasnostatisticaldifference ofPKPproceduresperformedincreasedforthetreatmentof 2 infectiouskeratitis,HSK,bullouskeratoplastyand betweenourtwostudiesduetothesmallsamplesize ( = regrafting,butdecreasedinregardstokeratoconus,corneal 3.258, =0.071,Table2,3). scarring,cornealburnandtrauma. Theaetiologyofbullouskeratopathy Intraocularsurgery PKPforinfectiouskeratitis Infectiouskeratitiswasthe wasthemostcommonaetiologyofbullouskeratoplasty.In leadingindicationforPKP.Fungalinfection(65.2%)was ourcurrentstudy,32cases(43.3%)wereassociatedwith stillthemostcommonindicationforPKPamongcorneal cataractextraction,9cases(12.2%)withanti- infections,justasinourpreviousstudy [8] ( 2=0.036, = surgery,and8cases(10.8%)withcombinedglaucomaand 0.849,Table2,3).However,theproportionofbacterial cataractoranteriorsegmentvitrectomysurgeries.Ofthese infection(13.5%)increased( 2=22.098, =0.000,Table 40cases,aftercataractextraction,25casesrecieved 2,3).Infectiouskeratitisrelatedtoanunidentifiedpathogen posteriorchamberintraocularlens(PC-IOLs)implants,7 493 Trendsintheindicationsforpenetratingkeratoplasty

Table 1 Annual clinical indications for penetrating keratoplasty from June 2005 to May 2010 n(%) Indication June 2005- June 2006- June 2007- June 2008- June 2009- Total May 2006 May 2007 May 2008 May 2009 May 2010 Infectious keratitis 86(35.7) 53(36.3) 65(48.9) 58(36.9) 63(31.8) 325(37.1) Viral keratitis 46(19.1) 20(13.7) 24(18.0) 29(18.5) 48(24.2) 167(19.1) Keratoconus 37(15.4) 25(17.1) 12(9.0) 15(9.6) 9(4.5) 98(11.2) Bullous keratopathy 17（7.1） 10(6.8) 10(7.5) 16(10.2) 21(10.6) 74(8.5) Regrafting 16(6.6) 12(8.2) 7(5.3) 9(5.7) 15(7.6) 59(6.7) Corneal scarring 15(6.2) 5(3.4) 1(0.8) 8(5.1) 13(6.6) 42(4.8) Corneal dystrophy and 5(2.1) 2(1.4) 7(5.3) 10(6.4) 6(3.0) 30(3.4) degeneration Corneal burn 7(2.9) 4(2.7) 4(3.0) 2(1.3) 8(4.0) 25(2.9) Ocular trauma 4(1.7) 5(3.4) 1(0.8) 5(3.2) 4(2.0) 19(2.2) Congenital keratitis 4(1.7) 3(2.1) 0(0) 2(1.3) 4(2.1) 13(1.5) Others 4(1.7) 7(4.8) 2(1.5) 3(1.9) 7(3.5) 23(2.6) Total 248(100) 146(100) 133(100) 154(100) 194(100) 875(100)

Table 2 Infectious keratitis for penetrating keratoplasty from June 2005 to May 2010 n(%) Indication June 2005- June 2006- June 2007- June 2008- June 2009- Total May 2006 May 2007 May 2008 May 2009 May 2010 62(72.1) 31(58.5) 43(66.2) 36(62.1) 40(43.5) 212(65.2) Bacterial keratitis 14(16.3) 6(11.3) 9(13.8) 7(12.1) 8(12.7) 44(13.5) Acanthamoebic keratitis 2(2.3) 2(3.8) 1(1.5) 2(3.4) 1(1.6) 8(2.5) Infectious keratitis with 8(9.3) 14(26.4) 12(18.5) 13(22.4) 14(22.2) 61(18.8) unidentified pathogen Total 86(100) 53(100) 65(100) 58(100) 63(100) 325(100)

Table 3 Shifts of each pathogen in infectious keratitis between 1997-2002 and 2005-2010 n(%) Year Bacterial Acanthamoebic Infectious keratitis with Fungal keratitis Total keratitis keratitis uncertain pathogen 1997-2002 357(65.9) 25(4.6) 5(0.9) 155(28.6) 542(100) 2005-2010 212(65.2) 44(13.5) 8(2.5) 61(18.8) 325(100) χ2 0.036 22.098 3.258 11.194 P 0.849 0.000* 0.071 0.001* *means P<0.05 casesreceivedanteriorchamberintraocularlens(AC-IOLs) analysedthecornealtransplantationoperationsoverthepast implants,and8caseswereaphakic. 5years,andindicatedthatoneofthemostimpressive Causesandoriginaldiagnosisofregrafting Thecauses changeshasbeentheshiftineyebankingproceduresto forregraftingweregraftendothelialdysfunction(39.0%), accommodateEK.ThevolumeofEKprocedureshasgrown graftulcer (28.8%),recurrenceoftheprimarydiseases exponentiallyfromonly1429reportednationwidein2005 (15.3%),graftopacities(8.5%),graftmelt(8.5%).The to17468in2008 [11].AnotherAmericanstudyalsoindicated majororiginaldiagnosisassociatedwithregraftingremained apersistentdeclineintheoverallnumberofPKPprocedure infectiouskeratitis(38.9%),HSK(18.6%)andcornealburn andthattheaveragenumberofPKPsfellfromahighof397 (16.9%),buttheproportionofinfectiouskeratitisincreased in1987to196in2005 [14].WehaveanalysedthePKP significantly,whereasthecornealburnpercentagedecreased. frequencyinthewholecornealtransplantproceduresfrom DISCUSSION 1996to2007andfoundapersistentdeclinefrom76.0% Changes in the rate of PKP in whole corneal (1996-1998)to61.8%(2005-2007) [12]. transplantprocedures ThepredominanceofPKPhas Inthepresentstudy,wereviewedthePKPfrequencyin beenchallengedbythediversificationofthemethodsused wholecornealtransplantprocedures,whichdeclined forkeratoplasty.Inthepast10years,annualPKPoperations significantlycomparedwiththeresultsofthepreviousstudy [12]. undertheNHSBloodandTransplant(NHSBT)programme Whenanalysingthecauseofthedeclines,weobservedthat intheUKdecreasedfrom1901(1999/00)to1473(2008/9), theproportionofPKPincornealtransplantproceduresfor and during thesameperiod, deepanteriorlamellar thetreatmentofinfectiouskeratitisandHSKdecreased keratoplasty (DALK)operationsincreasedfrom91to327 from92.9%and97.0%in1996-1998to56.5%and81.8% peryear,whileendothelialkeratoplasty(EK)operations in2005-2010,respectively.ThePKPproportionin increasedfrom2to569peryear [13].StudiesfromEBAA keratoconustreatmentfirstincreasedandthendeclined 494 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 4熏晕燥援 5熏 Oct.18, 圆园11 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 Table 4 Comparision of percentage of major indications for penetrating keratoplasty in different regions Diagnosis Faris et al [4] Stephen et al [22] Charalambos et al [6] Claudia et al [25] U.S (2001-2005) Canada (1996-2004) Greece (1982-2006) Israel(1961-2000) Bullous keratopathy 44.4% 39.3% 33.7% 14.0% keratoconus 16.0% 12.0% 26% 28.4% Scar 4.5% 7.7% 6.7% regrafting 22.0% 26.9% 11.9% 13.4% Infectious keratitis 4.0% 4.2% 8.4% 6.8% HSK 2.7% 5.3% 4.6% 7.4% Diagnosis Kanavi et al[26] Parul et al [7] Zhang and Xu [9] Previous study[8] Present study Iran India China China China (1994-2004) (1997-2003) (2001-2003) (1997-2002) (2005-2010) Bullous 15.3% 13.5% 15.7% 6.9% 8.5% Keratopathy Keratoconus 34.5% 2.4% 5.7% 12.9% 11.2% Scar 18.7% 38.0% 32.8% 9.6% 4.8% Regrafting 5.28% 11.5% 10.5% 4.5% 6.7% Infectious 28.4% 16.1% 31.9% 37.1% keratitis HSK 19.2% 17.6% 19.1% Bullous keratopathy including PBK, ABK, Fuch’s dystrophy, Non-Fuch’s dystrophy, ICE syndrome and corneal edema contributed to other diseases(PBK= pseudophakic bullous keratopathy, ABK= aphakic bullous keratopathy) rapidlyto48.8%.However,theratioofLKPincreased PKPcontrolsinfectionandrescueseyes.Ontheotherhand, inverselyinthecorrespondingperiod.Thesetrendswere LKPisperformedinatimelymanneronmildpatientsin mainlyattributedtochangesinthetreatmentprincipleand whichinfectionhasnotyetinvolvedthewholecornea. proceduralpreferenceduethespreadoftheknowledgeof Thus,ourresultsindicatedthattheproportionofinfectious theadvantagesofLKP.Asanon-penetratingoperation, keratitis amongtheindicationsforPKP continuously LKP,especiallyDALK,holdsadvantagesoverPKPsuchas increasedcomparedwiththeresultsofourpreviousstudies, maintenanceofglobeintegrity,nearlycompleteabsenceof 1993-1996 [16] and1997-2002 [8].Moreover,inallcorneal graftrejectionandalowrateofintraoperative/postoperative transplantproceduresforinfectiouskeratitis,therewasa complicationsandacute/chronicendothelialcellloss.The correspondingincreaseintheselectionofLKPtoadecline lowrateofendothelialcelllosshasledtoLKPbecoming inPKP.Itisimportantthatwealsoaccepttherealityofa theoptionofchoiceforpatientswithnormallyfunctioning criticalshortageofcornea,largenumberofwhichhaveto endothelialcells [15].InChina,adiversifiedtreatmentsystem beusedfortheemergencymanagementofinfectious hasformedforinfectiouskeratitis,andearlieroperative keratitiseachyear.Giventhefactthatinfectiouskeratitisis interventionsdoneforfurtheropticalkeratoplastieshas apreventabledisease,thereshouldbeanemphasison becomeanimportantprincipleinthistreatmentsystem. preventionovertreatment. Nevertheless,PKPisstillthepredominantprocedure.PKP Theproportionofinfectiouskeratitiscausedbyunidentified proceduresrepresentmorethanhalfofallcornealtransplant pathogensdeclinedfrom28.6%in1997-2002to18.8%in proceduresinmostcountries [2-14]. thepresentstudyduetotheimprovementofpathogen TrendsofindicationsforPKP cultureandspeciesidentificationtechniques.Bacterial Infectiouskeratitis Asnotedinourpreviousstudies [8,16], cultureisthegoldenstandardforthediagnosisofbacterial infectiouskeratitiswasthemostcommonindicationfor keratitis,butthepositiverateisgenerallylowthroughout PKPoverallandineachindividualyear.Theseresultsare theworld.Resultsfromstudiesinourcenterindicate similartostudiesfromIndiaandtheTaiwanregioninChina [7,10] positiverateof18.2%.OtherreportsfromChinaindicatea (Table4).Asalargeagricultureprovince,thereisalarge positiveratefrom14.1%to22.1% [17,18]，bothofwhichare proportionoffarmworkerswithpoorsafetyawarenessand generallylowerthanthosereportedbyresearchersinother lowlevelmedicalservicesinShandong,whichwouldbethe conturies (40%-60%)[19] .Incontrast,itismucheasierto reasonforthehigherprevalenceofinfectiouskeratitis. detectfungus.Studieshavereportedthattherelevanceratio Moreover,amajorityofthesefarmworkerscouldnotobtain ofmicroscopyisupto90% [20],andfurthermore,confocal effectivetreatmentfortheirinfection,leadingtoserious microscopy,fungalcultureandpathologicalexaminationall endophthalmitisthatresultedinenucleation.Inrecentyears, contributetodiagnosis.Inaddition,themorbidityof duetoanimprovedreferralsystem,patientswithinfectious Acanthamoebickeratitisismuchlowerthanotherformsof keratitisnowreceiveanearlyandaccuratediagnosis.On infectiouskeratitis,sotheunidentifiedpathogencasescan theonehand,forpatientswithsevereinfectiouskeratitis, beregardedasbacterialkeratitis.Asaresult,inthepresent 495 Trendsintheindicationsforpenetratingkeratoplasty study,thepercentageofbacterialkeratitisincreasedto performedonpatientswhoseconditioncouldnotbe 32.3%,whichissimilartotheresultsofourpreviousstudy resolvedbyDALK.TheratioofPKPwaslowerthanthatof in1997-2002(33.2%). DALKinthetreatmentofkeratoconusduringtheperiodof HSK HSKisregardedasamajorcauseofvisualmorbidity 2005-2010. worldwide,especiallyindevelopedcountries.Thenumber Bullouskeratopathy Bullouskeratopathyaftercataract ofherpessimplexinfectioncasesisincreasingatarapid surgeryhasbeentheleadingindicationforPKPinthe rate,withaboutoneinsixadultsnowinfectedintheUnited developedcountriessincethe1980sandhasaccompanied Statesandsimilarratesintherestofthedevelopedworld [21]. theextensionofphacoemulsificationandintraocularlens Theannualincidenceofherpeticocularsurfacedisease (IOL)implantation [2-6].Inrecentyears,becauseofthe rangesfrom5.9to20.7per100000people,witha significantadvancementincataractsurgerytechniques, prevalenceof149per100000people [22].Althoughthereis viscoelastics,improvementofIOLtechnology,aswellas lessinformationavailable,theprevalenceandincidenceof thedevelopmentofDSEK,bullouskeratopathyisnolonger herpeticeyediseaseindevelopingcountriesmaybeeven themostcommonindicationforPKPindevelopedcountries higher.Inthepresentstudy,HSKwasthesecondmost [11,13].However,inChina,thesituationisdifferent.First, commonindicationforPKP.Theresultwasmuchhigher cataractsurgeryinChinawasneveraspopularasin thanobservedinofsimilarstudiesfromothercountries [4,6,14,23] developedcountries.Second,asanimportantaetiologyof (Table 4).Manyresearchershavedemonstratedthat bullous keratopathy,Fuchs'endothelialdystrophyin systemicoralacyclovirtherapyiseffectiveinpreventingthe developedcountries,whencomparedtoChina,represented recurrenceofHSK [24].However,duringourstudyperiod, alargepercentageinPKPindicationsvaryingfrom9.3%to systemicanti-viraltherapywasnotavailableformostofthe 16.3% [2-5,14,24].Theproportionofbullouskeratitisunderlying patients,whichgreatlyincreasedtherecurrencefrequencies cornealdiseasesindevelopedcountriesismuchhigherthan andledtoseverecorneallesionandeventoperforation. thatinChina(Table4).ThelatestreasearchintheUSA Thoseissuesarelikelywhytherewasamuchhigher indicatedthatover25000cornealtransplantationsare percentageofHSKindicationforPKP. performedyearlyforendothelium dysfunction,which Moreover,PKPwasnevertheonlyoptionforpatientswith accountsforroughly57%ofallkeratoplasties [34].Inthe HSK.Multi-centretrialsindicatedthatprophylacticoral past,PKPwastheonlywaytoresolvethisproblem,butin acyclovirusepre-andpostoperativelyiseffectivein recentyears,theuseofDSEKhasincreaseddramatically preventingrecurrence [25,26].DALKcombinedwithanti-viral duetoitsadvantagesoffastervisualrehabilitation,reduced therapy therebyhas becomeanalternativeandsafe , lesssuture-relatedinfectionandgraft procedureforthetreatmentofHSKinpatientswithhealthy vascularisation,lowlikelihoodofrejectionandimproved endothelium [27,28].Inthecurrentstudy,18.9%ofpatients globeintegrity.ReportsfromAmericanresearchersindicate withHSKreceivedDALKbutnotPKP. thatthenumberofDSEKsurgerieshasrisenrapidly, Keratoconus Percentageofkeratoconusindicationsfor increasing3-foldbetween2007-2008,andthenumberof PKPvariedfrom2.7%to45.6%bygeographicregion[2-10,14,22,29-31] DSEKproceduresnowaccountesfor32%ofallAmerican (Table4).KeratoconusistheleadingindicationforPKP cornealtransplantationsurgeries [34].Thus,theappearanceof accordingtoreportsfromNewZealand,IsraelandIran [29-31]. DSEKbroughtgreatchangestotheindicationsforPKPand InShandong Province,thetherapeuticmethodsfor tothedistributionofallcornealtransplantationsurgeries [11,13] keratoconushavechangedalotinrecentdecades.Inour However,mostoftheChineseophthalmologiststakea previousstudy,theproportionofkeratoconusindicationsfor wait-and-seeapproachtoDSEK.Althoughthereisasmall PKPincreasedcontinuouslyfrom1997through2002,and increase,theuseoftheprocedureforbullouskeratopathyis hadbecomethesecondleadingindicationforPKPsince stillnotaspopularasthatindevelopedcountries.One 2000,whichmightbeexplainedbytheincreaseofin considerationisthatthenumberofcorneadonorsisstill presentationrate.However,inthisstudy,theproportionof severelylimitedfortheemergencyrescueforinfectious keratoconusindicationsinPKPcasespresentedasustained keratitisinChina,andcornealsourcesare generally declineandhasbeenexceededbybullouskeratopthaysince insufficient.DSEKwouldnotinlinewithChina'sactual June1,2008.Asystemictreatmentengineeringprocesses conditionsintheshorttermduetoahigherrequirementsfor hasgraduallyformedinthetreatmentofkeratoconusin corneasourcesandthelargerriskrateofgraftfailure recentyears.FrameglassesandRGPhavebeengradually resultingfromgraftenfoldmentordislocation [34,35]. receivedbymorepatientsinanearlydiseasestage.When Regrafting Regraftinghasbeenreportedasthemost RigidGasPermeable(RGP)can'tbetolerated,norvisual commonindicationforcornealtransplantationinCanada [23]. acuitybecorrected,DALK,insteadofPKP,hasbecomethe Theproportionindifferentstudiesvariedfrom10.1%to bestchoiceforpatientswithintactendotheliumduetoits 40.9% [2-7,14,23,36,37] (Table4).Weobservedregraftproportion similarvisualimprovement,lowerriskofrejectionand of6.7%,whichwasmuchlowerthantheresultsobservedin complications [32,33].Duringthestudyperiod,PKPwasonly otherstudies.Multiplefactorscontributedtothelow 496 陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 4熏晕燥援 5熏 Oct.18, 圆园11 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-83085628 耘皂葬蚤造押陨允韵援圆园园园岳员远猿援糟燥皂 regraftingrate.First,improvedsurgicaltechniquesand 13KeenanTD,CarleyF,YeatesD,JonesMN,RushtonS,GoldacreMJ.Trendsin improvementsintheskillofsurgeonshasbenefitedthePKP cornealgraftsurgeryintheUK. 2011;95:468-472 14GhoshehFR,CremonaFA,RapuanoCJ,CohenEJ,AyresBD,Hammersmith successrate,especiallyineyeswithinfectiouskeratitis.As KM,etal.TrendsinpenetratingkeratoplastyintheUnitedStates1980-2005. peroureyebankpolicy,apatienthastoregisteronthe 2008;28:147-153 waitinglistforcornealtransplantation,althoughheorshe 15TanDT,AnshuA.Anteriorlamellarkeratoplasty:'BacktotheFuture'-a haspriority.Thismaybeanotherreasonforthelower review. 2010;38:118-127 proportionofregraftsobservedinourstudy.Inaddition,the 16XieL,CuiY,DongX,LiS,YangX.Anepidemiologicalstudyof432casesof penetratingkeratoplasty. 1997;15:243-245 costofregraftinghasremainedamajorproblem,andsome 17SunX,WangZ,LuoS,JinX,ZhangW.Distributionandshiftingtrendsofthe patientscouldnotaffordasecondaryPKPwhenthegrafts pathogensforbacterialkeratitis. 200;38:292-294 becameopaque. 18ZhangC,LiangY,DengS,WangZQ,LiR,SunXG.Distributionofbacterial Inthepresentseries,only4.8%ofeyeswithcorneal keratitisandemergingresistancetoantibioticsinChinafrom2001to2004. scarringunderwentPKP,aproportionthatismuchlower 2008;2:575-579 19MarangonFB,MillerD,AlfonsoEC.Impactofpriortherapyontherecovery thanwhathasbeenobservedintheIndian,EastChinaand andfrequencyofcornealpathogens. 2004;23:158-164 [7-10] Taiwaneseregions (Table4).Thismightbeassociated 20BharathiMJ,RamakrishnanR,MeenakshiR,MittalS,ShivakumarC, withdifferencesinclassification.Inthepresentstudy, SrinivasanM.Microbiologicaldiagnosisofinfectivekeratitis:comparativeevaluation cornealscarringwasclassifiedbytheirinitialdiseases.Only ofdirectmicroscopyandcultureresults. 2006;90:1271-1276 ifpatientswithuncertainaetiologywereclassifiedas 21LiesegangTJ.Herpessimplexvirusepidemiologyandocularimportance. 2001;20:1-13 sufferingcornealscarring. 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