This study evaluated a unique cohort of patient with a history of keratoplasty who presented to an ophthalmic emergency department. The proportion of males patients was greater than female patients. The main complaints were pain and red eye. The rate of SVI in eyes remained similar before and after management. SVI was significantly lower in eyes with keratoconus. Graft rejection was not correlated to pre-emergency factors including the interval between keratoplasty and emergency. Ophthalmic emergences are initially received by triage members who include junior residents and trained ophthalmic nurses. On inquiry of history and initial assessment, if they find that patients had undergone keratoplasty in the eyes with the emergency, their decision to seek help from a senior physician is often not evidence based. The present study indicated that many of these post-keratoplasty patients had trivial suture related issues while others were beginning to show early signs of sight threatening complications. The two main concerns of keratoplasty are graft rejection and infection.
In our study, 13.4% of patients had graft rejection. A retrospective study15 of 140 patients of patients who had corneal graft surgery reported 45 patients with graft rejection. Kamp et al16 found that in a group of high-risk patients, nearly 70% of graft rejection episodes were preceded by patient symptoms and only 30% of graft rejections were identified on routine clinical examination.
The rate of graft rejection in our study is low mainly due to good patient education about the symptoms and the need to present immediately to emergency to avoid further post-keratoplasty complications. Early recognition is the best therapeutic option that can enhance long-term graft survival and final vision acuity .17 This observation is valid for graft rejection and for all other causes of complications that cause graft failure. 18
In our center, all patients are routinely educated to coordinate same day emergency visit if they encounter any symptoms in the eye that has undergone keratoplasty. Microbial keratitis is a sight-threatening complication of keratoplasty. Newer keratoplasty techniques, including endothelial and ALKs, may have a lower rate of postoperative infectious keratitis.18. In the current study microbial keratitis was found in 10% of patients among them one had corneal abscess and one with a corneal melt. In western countries, the incidence of late microbial keratitis after PKP ranges from 1.8 to 4.9%. However, rates as high as 11.9% have been reported in other countries19,20 which is similar to our results. The higher rates are due to the environment and the ethnic group in the Middle East. Microbial keratitis after corneal transplantation can be devastating and may result in graft failure and poor visual outcome. 21,22 In the current study, the main cause of wound dehiscence was trauma in 14% of patients. Patients with keratoconus usually belong to a younger age group and may be prone to ocular trauma and possible wound dehiscence and this is consistent with previous studies.23 Patients with corneal transplant are susceptible to eye injury as corneal wound healing does not restore the original tensile strength of the cornea .24 Traumatic wound dehiscence after keratoplasty has the worse prognosis than other cases of traumatic globe rupture. 25,26
In our sample, loose sutures necessitating removal was reported in 24% followed by epithelial defect at the suture site in 7.4%; these clinical conditions should not be overlooked as delay in management may result in sight threatening complications such as graft infection and/or rejection 27,28. Prevention of suture-related complications require frequent monitoring and timely intervention. Prophylactic topical antibiotic and steroid cover is recommended after this procedure as both infection and rejection may follow suture removal.29,30
We found that the incidence of SVI remained similar despite management of the emergencies. Previous studies reported that early presentation, diagnosis, and management resulted in preservation of visual acuity in 96.3%12 and 95%13 of patients. A study from Saudi Arabia from the same center31 reported that excellent graft survival was achieved for eyes with keratoconus, stromal dystrophy, and stromal scarring. In our study the most common indication for keratoplasty was keratoconus, which concurs with previous studies.11–13,31,32 Hospital admission was required for re-suturing as this was not an outpatient service and for follow-up of patients who had to travel excessive distances to the hospital. In the current study, 40 patients (32.2%) were admitted, which is higher than previous studies that reported admission rates of 8.9% 11 and 5.4%.33
Ophthalmic triage can be refined for cases with post-keratoplasty corneal problems; almost all emergency visits in our series were extremely relevant, and no cases were diagnosed as clinically normal.
There are some limitations to this study including its retrospective nature. At emergency units, the main concern is to provide urgent care and detailed information is often missing for thorough research analysis is required and data are not uniformly documented. As this study was performed at a tertiary eye care hospital, once the patient’s condition was stabilized, it is possible that further care was delivered at a secondary eye care hospital resulting in loss to follow up. Therefore, long term information on outcomes is not available for all participants. To overcome these limitations, a prospective study is required to confirm our findings. Additionally, we strongly recommend public health policy briefings to improve eye care in this vulnerable group.