An Investigation of Keratoplasty Procedures and Their Outcomes in Iraq

various forms


Introduction:
The treatment of corneal disorders involves the use of various forms of keratoplasty.The objective of this study was to provide a detailed description of the various types of keratoplasty procedures performed in Iraq, as well as their corresponding outcomes.Methods: An observational study was conducted at Al-Zahraa Teaching Hospital to document cases of keratoplasty.The collected data included age, gender, types of keratoplasty, indications, previous surgical or medical history, and postoperative outcomes.The types of keratoplasty included penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), and Descemet's stripping endothelial keratoplasty (DSEK).Additionally, we performed cataract surgery and intraocular lens (IOL) insertion for those with cataracts, using either IOLs with scleral fixation or IOLs with iris fixation.We complete the task on the first day following the purchase order, then the first week, the first month, and every six months thereafter.Prior to surgery, patients with corneal vascularization had laser photocoagulation of the blood vessels in the cornea.Results: Ages range from 4 to 90.People over 40 (60.8%) were the most common age group.The female prevalence was 52.9%.Right-eye illness was diagnosed 51.6% of the time.60% of patients underwent PKP.26.8% had DALK, 12.4% had DSEK.Post keratoplasty, the statisticallysignificant improvement-ratio was 68.5% as eyes best corrected visual acuity (BCVA) improvement, while 12.2% of eyes showed a decline in BCVA and 19.3% discharged with no changes in BCVA.Postoperatively, BCVA was significantly lower in cases with a duration below 1 year (1.5), and better among the duration > 3 years (0.5).The greatest improvements were seen in cases with infective keratitis (-0.7), corneal dystrophies (-0.6), and advanced keratoconus (-0.7) whereas the lowest rates were documented in cases with a graft rejection (-0.3), and bullous keratopathy (-0.3)Conclusion: Keratoplasty is associated with a substantial enhancement of visual acuity in the younger population.Infective keratitis, keratoconus, and corneal dystrophy produce the most optimal and superior results.The PKP method is the most frequently performed.
e-ISSN: 2722-9807 corneal tissues), and cosmetic (intended to enhance the appearance of the eye). 5In general, the success rates of keratoplasty are higher compared to other organ transplantations. 6Over time, ophthalmologists' enhanced skills, technique advancements, the availability of post-operative anti-inflammatory targets, and immune-suppressive agents have all contributed to the improvement in outcomes. 6The outcomes of keratoplasty differ according to geographic areas, ethnicity, and socioeconomic background. 7The objective of this study was to ascertain the demographics, indications, and outcomes of keratoplasty procedures.

Penetrating keratoplasty
In order to prepare and punch the donated tissues, a paracentesis blade was used to cut into the host eye, and viscoelastic was used to fill the chamber.Then, a marker was used to mark the host eye, and it was trephined.After that, the donor tissues were put in the eye of the receiver.Then repaired the eye.The viscoelastic was then taken off, and a balanced salt solution was introduced into one of the holes in the graft host junction.Every stitch is turned.The eyes receive the administration of steroids and antibiotics.
A cover is put over the eye, and a patch is put over it. 8

Deep-anterior-lamellar-keratoplasty (DALK)
There are several approaches to performing DALK: Once the donor disc is in tight apposition with no or minimal interface fluid between the donor and the recipient stroma, partially remove the air in the chamber and replace it with BSS. 10

Follow-up
It is done on the 1 st PO day, then at the 1st week then at the 1st month, then every 6 months.Case with a history of HVS keratitis received systemic acyclovir (400 mg twice daily).Cases with corneal vascularization underwent laser photocoagulation of vessels in the cornea prior to surgery (Nd-Yag frequency double 1064 nm laser photocoagulation or intrastromal bevacizumab).

Statistical analysis
Data was analyzed by SPSS version 24 (IBM, US).
Frequency and percent described nominal variables while mean and SD described ordinal variables.The comparison was done by using the Wilcoxon Signed Rank chi-square test.P <0.05 was considered statistically significant.

Results
The age range is between 4 and 90 years old.The most frequent age group was above 40 years (60.8%).

Discussion
[24] The study demonstrates a graft rejection rate of merely 12.2%.The bigger groups of patients who underwent corneal replacement surgery showed a post-transplant rate ranging from 18% to 21%. 25 The incidence of epithelial rejection is 2%, while subepithelial rejection occurs in 1% of cases.
Endothelial rejection occurs in 50% of cases, making it the most frequent type of rejection.The occurrence of a mixture is 30%.The incidence of DELK ranges from 1% to 24%.The DSEK procedure has a 5% incidence rate, and the average rate of endothelium rejection is 10%. 26The frequency of primary and secondary graft failure was 1.7-2.2%and 2.2%, respectively.In their investigation, Jonas et al.
discovered that around 14% of patients experienced immunologic graft rejection due to loose sutures and vascularization before and after the operation. 27e

Conclusion
Keratoplasty is associated with a significant improvement in visual acuity in younger patients.
Cases involving infective keratitis, keratoconus, and corneal dystrophy yield the most optimal and superior results.Keratoplasty exhibits higher success rates.
retrospective, observational study of keratoplasty cases records in Al-Zahraa Teaching Hospital.Data collected included age, sex, keratoplasty types, indications, past surgical or medical history, and postoperative outcomes.The timeframe for data collection was extended for 8 years from 2014 to 2022.The inclusion criteria were patients diagnosed with a traumatic eye injury, keratoconus and ectasias, corneal degenerations and dystrophies, noninfectious ulcerative keratitis, infective keratitis (fungal, bacterial, and viral), scarring post-infectious keratitis, congenital opacities, and bullous keratopathy.This study has received ethical approval from the hospital system authority.General anesthesia was used during surgery.The forms of keratoplasty included penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), and Descemet's stripping endothelial keratoplasty (DSEK).Additionally, cataract surgery and intraocular lens (IOL) insertion were performed for individuals with cataracts.For patients without capsular support, IOLs were either fixated to the sclera or to the iris.Pupilloplasty and synechiolysis were performed when needed.
first, by removing the host's anterior corneal tissue layer-by-layer until it reaches the deep stroma or bare Descemet's membrane.The surgery technique consists of steps, which are: (1) In the recipient's eye, the anterior corneal surface is cut by a suction trephine set.Then the layers are dissected by a rounded blade, angled parallel to the membrane.Then fluid (or air) is injected into the deep stroma and membrane to separate layers.Others can use intrastromal air injection, hydro-delamination, viscoelastic dissection, big bubbles, or anterior chamber air.(2) In the donor eye, the fresh corneas are prepared by the surgeon.Descemet's membrane and endothelium are removed by dry cellulose sponges or forceps.Then a corneal button is punched out of the tissues.After suturing, a bandage soft contact lens is placed on the cornea. 9Descemet-stripping-automated-endothelialkeratoplasty (DSEK) Both the endothelium and Descemet's membrane are stripped away by incision.Then a circular disc is removed from the inner lining of a donor, transplanted into the recipient's eye, and attached to the posterior portion of the recipient.Organ culture excises corneoscleral buttons from donors' globes and stores them.Dissection spatulas are used to manually make a stromal dissection and then extend it up to the limbus.About 16.0 mm of the corneo-scleral rim is excised.To score and strip a circular section of membrane from the posterior stroma, use a reverse Sinskey hook.A crescent knife creates a temporal selfsealing 5.0 mm sclera-corneal incision.After trephinating, DSEK was grafted from the predissected corneoscleral rim.The graft is inserted with irrigating inserters or push-through techniques using specialized forceps or sutures on the opposite side of the main wound to draw the donor disc into the anterior chamber, with or without a glide.Manually, use the folding forceps insertion technique and insert and rotate the graft.The graft is positioned centrally by brushing, tapping, sweeping, and dragging techniques, then filling the anterior chamber with air.
Keratoplasty is a highly successful form of solid-organ transplantation.A 2011 study at Ibn Al-Haitham Hospital revealed that younger individuals in Iraq underwent a higher percentage of keratoplasty procedures. 2 Keratoplasty outcomes vary between developing and industrialized countries due to differences in case profiles, indications, cornea storage, and socioeconomic position.
Figure 1.The overall outcomes of keratoplasty.

Table 2 .
Distribution BCVA changes post keratoplasty according to the duration of follow-up and the types.
11 Individuals over 40 are the predominant age group in this study.Zare et al. 11 conducted a study in Iran from 2004 to 2009, which aligns with this conclusion.This study's age distribution matches that of previous Turkish research, which reported a median age of 53.8 years for keratoplasty. 1A study in Spain also reported a median age of 53.2 years. 12