Corneal Transplantation: Main Indications and Evaluation of Epidemiological Profile in a University Hospital

Original Research | Open Access | Volume 8 | Issue 1

  • 1. Bianca Prado Patrús, department of ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil
  • 2. Augusto Terra Baccega, department of ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil
  • 3. Gustavo Lustosa Neves, department of ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazi
  • 4. Flavia Santos, department of ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil
  • 5. Larissa Batista Pegorin Ribeiro dos Santos, department of ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil
  • 6. Marcelo Vicente de Andrade Sobrinho, department of ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil
+ Show More - Show Less
Corresponding Authors
Dra. Bianca Prado Patrús, Hospital Puc – Campinas, Av John Boyd Dunlop s/n Jardim Ipaussurama, Postal Code: 13059-900,Campinas – SP, Brazil

Among transplants, the corneal is the most numerically expressive. This is due to the immunological privilege of the cornea which presents reduced rejection rates. In addition, capture, conservation and surgical techniques also contribute to this success.

Keratoconus, leukoma, corneal dystrophy and post-facectomy decompensation are the main causes of optical transplants, having the latter a relationship with the number of preoperative cells and the skill of the surgeon. In hospitals where there are surgeons in training, there is an increase in corneal decompensation after facectomy.

In terms of tectonic transplants in which the purpose is the preservation of the ocular structure, the main etiology is perforation due to trauma.

From the observational and retrospective analysis of about 60 medical records of patients submitted to keratoplasty in the years 2015 to 2020, it is possible to understand the patients’ profile and main pathologies that evolve to transplantation in order to have an early diagnosis and to optimize their treatment. According to Sobrinho et al., from 2001 to 2009 it was noticed that patients in the state of Pará waited an average of 1 to 3 years in line for corneal transplantation. 9 In another study, Almeida et al. noticed in a 15-year review of corneal transplants that patients waited from 1 to 6 months for the performance of a keratoplasty in Brazil.10 Thus, because of its heterogeneous extension and distribution of specialized centers, Brazil has different realities in each region.


Patrús BP, Patrús BP, Neves GL, Santos F, Pegorin Ribeiro dos Santos LB, et al. (2021) Corneal Transplantation: Main Indications and Evaluation of Epidemiological Profile in a University Hospital. J Surg Transplant Sci 8(1): 1084.


•    Corneal transplantation
•    Penetrating
•    Lamellar keratoplasty


Corneal pathologies are the third most frequent cause of blindness, after cataracts and glaucoma. About 10 million people worldwide have bilateral blindness caused by corneal diseases. [1]

In 1905, Eduard Zirm transplanted a cornea of an enucleated eye to a patient with bilateral opacity due to burns by alkaline substance, which was the first successful corneal transplant. [2]

Among the numerous transplants, the corneal is the most performed worldwide. [1] According to the Brazilian Registry of Transplants (RBT-2019) between 2015 and 2019, 73,375 corneal transplants were performed. In 2019, 14,943 were performed, among which 5,400 were in the state of São Paulo. Despite the significant number, about 10,741 people still remain in line for corneal transplantation. [3]

In the first semester of 2020, compared to 2019, there was a decrease in the number of corneal transplants (44.3%), due to the suspension of the activities of most of the services during the COVID-19 pandemic. [4]

Currently, Brazil occupies the 2nd position in absolute terms of transplantations, but in terms of transplants by millions of people the country falls to the 21st position. [5]

Some factors contribute to this numerical success of corneal transplants, including the organization of eye banks, advances in tissue conservation, immunology and surgical techniques. [5]

The main barrier to cornea donation is the lack of information to the potential donors besides logistical, legal and religious issues. [5]

Corneal transplantation can be classified in relation to the biological type. In autologous transplantation the donated cornea and recipient eye are of the same individual; corneal allogen is transplanted to individuals of the same species and xenogen, in which the cornea is given to individuals of different species. [6]

It can also be classified according to the surgical technique used. The lamellar, which is the replacement of part of the corneal thickness. The penetrating keratoplasty is the replacement of the total thickness of the cornea. [6] The first type is a technique that has been growing in the last 10 years, but penetrating transplantation still accounts for about 80% of keratoplasties performed worldwide. [1]

Transplantation can be performed according to its purpose: optical, tectonic and therapeutic. [7]

Cataract surgery has become popular and is the most performed surgical procedure globally. This increasing performance of facectomy was accompanied by increased corneal decompensation after the procedure. Thus, contributing to the increasing indication of corneal transplantation in these cases. [8]

According to Sobrinho et al., from 2001 to 2009 it was noticed that patients in the state of Pará waited an average of 1 to 3 years in line for corneal transplantation. [9]

In another study, Almeida et al. noticed in a 15-year review of corneal transplants that patients waited from 1 to 6 months for the performance of a keratoplasty in Brazil. [10]

Thus, because of its heterogeneous extension and distribution of specialized centers, Brazil has different realities in each region.

According to Chua P.Y. et al, there is a relationship between socioeconomic status and the life of corneal transplantation. In his study, conducted in the United Kingdom, it was observed that patients with worse socioeconomic conditions had high rates of graft failure in 5 years. [11]

Jonas, J.B. et al. noticed that in his study evaluating 245 patients submitted to penetrating keratoplasty for different etiologies, there was an improvement from 0.12 to 0.46 in visual acuity. In addition, it was noticed that the patient’s corneal disease directly influenced his/her visual acuity after transplantation. According to the study the indications for keratoconus had better visual acuity while those by bullous keratopathy in pseudophakic and aphakic patients had worse visual prognosis. [12]


An observational, descriptive and retrospective study was conducted based on the evaluation of about 60 medical records of patients undergoing corneal transplantation from January, 2015 to December, 2020.

The medical records for data collection were obtained through the written request from the coordination of the outpatient clinic of PUC-Campinas Hospital.

Age, laterality, indication of the type of transplant and corneal pathology.

Indications were classified as: keratoconus, bullous keratopathy, corneal dystrophy, leukoma, corneal perforation, post-facectomy decompensation, graft failure and corneal ulcer.

The Microsoft Excel 2019 program was used ® to organize and analyze the data.


From the 60 transplants performed during this period, 30 patients were female (50%) and 30 males (50%). The age of the patients ranged from 20 to 90 years old, with an average age of 61.

Regarding the indications of transplants: the bullous keratopathy was responsible for 14 cases (23.3%), previous transplant failure for 11 cases (18.3%), leukoma for 10 cases (16.6%); keratoconus for 9 cases (15%); Fuchs dystrophy for 6 cases (10%), corneal ulcer for 3 cases (5%), perforation for 3 cases (5%), band keratopathy for 1 case (1.7%), macular dystrophy for 1 case (1.7%), granular dystrophy for 1 case (1.7%), and sequelae of trachoma for 1 case (1.7%).

As for the surgical technique used, the main one was the penetrating technique, being responsible for 38 of the cases (63.3%), followed by the penetrating technique combined with phacoemulsification surgery, also called triple transplantation, responsible for 14 cases (23.3%). The Lamellar technique DMEK was performed in 4 cases (6.6%), and in 1 of these cases phacoemulsification surgery was combined. The DALK technique was performed in 1 case (1.7%). Tectonic transplantation was performed in 2 cases (3.3%). Penetrating transplantation combined with IOL fixation was performed in 1 case (1.7%).

In this study, a series of non-comparative, retrospective and descriptive cases were evaluated. Thus, the relationship between causes and results is restricted.

The bullous keratopathy as the main indication of transplantation found in the study is in line with data from the literature, which ranges from 20-30% which can be justified by the popularization of phacoemulsification and intraocular implants. [13-14]In addition, the studied Service receives patients from other Services which do not carry out this type of procedure. Although PUC-Campinas Hospital is a medical residency service with surgeons in training, none of the cases came from this hospital.

The results differed from the study by Flores et al. which was performed in the same city, but in another hospital. In this study the main indication was keratoconus responsible for about 49.82% of the cases. [7]

Most of the patients are attended for a long period in our outpatient clinics. According to Coster et. al., under favorable conditions, the half-life of a transplant is 12 years. However, in adverse conditions, such as inflammation, the duration drops to 2 to 5 years. [15]

Zare et al. evaluated 1,859 eyes of 1,624 transplanted patients and observed that the main indication was keratoconus, followed by bullous keratopathy and previous transplant failure. In this same study, it was noticed that the main technique used in about 70.9% of the surgeries was penetrating keratoplasty, followed by DALK (deep anterior lamellar keratoplasty), DMEK (Descemet Membrane Endothelial Keratoplasty) and DSAEK (Descemet Stripping Automated Endothelial Keratoplasty). Although lamellar transplants are still numerically smaller, mainly due to technical difficulties in relation to penetrating transplantation, there is a considerable increase in lamellar transplants due to the advantages of the technique. [16]

Kymionis et al. in a review about lamellar keratoplasty, discuss about the advantages of lamellar in comparison to penetrating keratoplasty. The lower rate of graft rejection, less endothelial cell loss, faster visual rehabilitation and enhanced resistance to closed injury are some examples of these advantages. [17]

Matthaei et al. in a review of the main indications of penetrating keratoplasty noticed that Keratoconus was the predominant indication in South America. Pseudophakic bullous keratopathy or aphakic bullous keratopathy was the second most common indication. [18]


In this study the average age was 61 years old and the main causes of indication for transplantation were bullous keratopathy, previous transplant failure and leukoma. This study contributed to a better knowledge of the patients treated in our ophthalmology service.

More important than knowing the main causes and types of keratoplasty surgeries, it is necessary to evaluate what led the patient to low visual acuity. Also, to apply some individual and collective measures aimed at preventing the patient from requiring a transplant surgery. As stated in the review on Corneal Blindness in analogy with Plato’s Cave from Barbosa et al. Al, we must leave the cave to be able to properly analyze and face blindness of corneal etiology. [19]


The authors would like to thank Dra. Flavia Santos, Dr. Henrique Silva Delloiagono and Dra. Larissa Batista Pegorin Ribeiro dos Santos the surgeons that performed the transplants and the for all knowledge shared.


1. Gain P, Jullienne R, He Z, Aldossary M, Acquart S, e al. Global survey of corneal transplantation and eye banking. JAMA Ophthalmology. 2016; 134: 167-173.

2. Crawford A, Patel D, McGhee C. A brief history of corneal transplantation: From ancient to modern. Oman J Ophthalmol. 2013; 6: S12-7.

3. BrazilianAssociation of Organ Transplants. Brazilian Registry of Transplants. Sizing transplants in Brazil and in each state. 2019.

4. BrazilianAssociation of Organ Transplants. Brazilian Registry of Transplants. Sizing transplants in Brazil and in each state. 2020.

5. Almeida HG, Hida RY, Kara-Junior N. Review of developments in corneal transplantation in the regions of Brazil - Evaluation of corneal transplants in Brazil. Clinics. 2016; 71: 537-543.

6. Netto AA, Botelho CAS, Felicíssimo LC. Indications and epidemiological profile of patients undergoing keratoplasty. Braz J Ophthalmol. 2014; 73: 162-166

7. Flores VGC, Dias HLR, de Castro RS. Indications for penetrating keratoplasty at the Hospital das Clínicas-UNICAMP. Braz Arch Ophthalmol. 2007; 70: 507-508.

8. Sharma N, Singhal D, Nair SP, Sahay P, Sreeshankar SS, Maharana PK.(2017) Corneal edema after phacoemulsification. Indian J Ophthalmol 2017;65:1381-1389.

9. Sobrinho EFA, Negra?o BA, Almeida HG. Epidemiological profile of patients waiting for penetrating keratoplasty in state of Para?, Brazil. Rev Bras Oftalmol. 2011; 70: 384-390.

10. Almeida HG, Souza ACD. Epidemiological profile of patients waiting for penetrating keratoplasty in state of Pernambuco, Brazil. Rev Bras Oftal. 2014; 73.

11. Chua PY, Mustafa MS, Scott NW, et al. Relationship between socioeconomic deprivation or urban/rural residence and visual acuity before cataract surgery in Northern Scotland. Eur J Ophthalmol. 2013; 23: 831-835.

12. Jonas JB, Rank RM, Budde WM. Visual outcome after allogenic penetrating keratoplasty. Graefe’s Arch Clin ExpOphthalmol. 2002; 240: 302-307.

13. Thompson RW Jr, Price MO, Bowers PJ, Price FW Jr. Long term graft survival after penetrating keratoplasty. Ophthalmology. 2003; 110: 1396-1402.

14. Sridhar MS, Cohen EJ, Held EL, Alvim PT, Rapuano CJ, et al. Indications for penetrating keratoplasty and associated procedures, 1996-2000. Cornea. 2002; 21:148-151

15. Coster DJ, Williams KA. The impact of corneal allograft rejection on the long-term outcome of corneal transplantation. Am J Ophthalmol. 2005; 140: 1112-1122.

16. Zare M, Javadi MA, Einollahi B, Karimian F, Rafie AR, Feizi S, et al. Changing indications and surgical techniques for corneal transplantation between 2004 and 2009 at a tertiary referral center. Middle East Afr J Ophthalmol. 2012; 19: 323-329.

17. Kymionis GD, Mikropoulos DG, Portaliou DM, Boboridis KG, Voudouragkaki IC, et al. New perspectives on lamellar keratoplasty. Adv Ther. 2014; 31: 494-511.

18. Amanda PB, Monica A, João MFF, Leidiane AFN et al. Corneal blindness in Plato’s cave: the acting forces to prevent and revert corneal opacity. Part I: epidemiology and new physiopathological concepts. Arq Bras Oftalmol. 2020; 83: 437-446.

Received : 01 Jul 2021
Accepted : 22 Jul 2021
Published : 26 Jul 2021
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X