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Original Article

A prospective study of incidence and risk factors for secondary glaucoma after
penetrating keratoplasty

Aruna Kumari R. Gupta, Roopam Kumar R. Gupta1

Aim: To carry out a prospective study to analyze the incidence and risk factors for secondary glaucoma after penetrating Access this article online
keratoplasty(PK). Materials and Methods: Three hundred and eleven consecutive penetrating keratoplasties that Website:
were performed between January 1, 2006, and December 31, 2008, with a followup of 12 months were prospectively www.jcor.in
analyzed to determine the factors associated with postoperative glaucoma. Results: Of 311 eyes, secondary glaucoma DOI:
developed in 57 cases. This yields an incidence of 18.3%. In conditions, such as aphakic bullous keratopathy, the 10.4103/2320-3897.190794
incidence of postPK glaucoma was 3.0%; in pseudophakic bullous keratopathy 14.0%, and in cases of failed graft Quick Response Code:
16.0%, while in cases of corneal ulcer and corneal opacity it was 49.0% and 18.0%, respectively. Conclusion: We
conclude in our study that the incidence of glaucoma developing postPK was highest in phakic eyes, which may be
due to the formation of posterior synechiae and development of intumescent cataract. Higher incidence of glaucoma
developing in infective cases could be due to recipient hot eye and the high incidence in cases of large graft could be
attributed to the formation of peripheral anterior synechiae.

Key words: Graft size, indications, penetrating keratoplasty, phakic status, secondary glaucoma

The association between penetrating keratoplasty(PK) and had cleared the project. All the patients had given their
the development of postoperative increase in intraocular informed consent.
pressure(IOP) has been first noted by Irvine and Kaufman.[1]
Preoperative examination of the recipients included their
Since then, various authors have reported the incidence of
details, chief complaints, and the presence of any predisposing
glaucoma following PK to be from 9% to 31% in the early
factors such as ocular surface disorders, trauma, contact lens
postoperative period[24] and from 18 to 35% in the late
use, previous history of graft infection, systemic illness, and
postoperative period.[5,6]
history of any ocular surgery.
A variety of factors has been studied for a better
Clinical examination included uncorrected visual acuity,
understanding of the mechanisms involved in the elevation
best corrected visual acuity, cycloplegic refraction(not done in
of IOP following PK. Graft size[610] suture technique[6,8,11]
infective keratitis cases); slit lamp biomicroscopy to determine
and iridocorneal compression[6,11] have been implicated for
any ocular pathology, applanation tonometry(not done in
postoperative secondary glaucoma. Other factors, especially infective keratitis cases). In cases where the recording of IOP
aphakia[2,7] have also been studied. was not possible by Goldman applanation tonometry, digital
Timely diagnosis of postPK glaucoma(PPKG) with initiation tonometry was done. Dilated fundus examination was done
of appropriate treatment is mandatory to preserve optimal for disc evaluation where media was clear and to rule out any
graft clarity and optic nerve head function.[12] The purpose of posterior segment pathology.
this paper was to determine the incidence and risk factors for Investigations included tear film status, gonioscopy, sac
secondary glaucoma after PK. syringing, routine blood investigations such as complete
Materials and Methods blood count, ESR, urine routine and microbiology, blood
urea and serum creatinine, fasting blood sugar and fasting
Between January 1, 2006, and December 31, 2008, a prospective urine sugar, serology to screen for infectious diseases such
study was conducted of consecutive PKs performed at our as AIDS(S.HIV), hepatitis(S.HbsAg), and sexually transmitted
institution. The cases had a followup of 12 months. PK was diseases(S.VDRL). Blood pressure and ultrasonography of
performed following the ethical guidelines for biomedical
research on human subjects issued by the Indian Council of
Medical Research in 2000. The institutional ethics committee This is an open access article distributed under the terms of the Creative
Commons AttributionNonCommercialShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work noncommercially, as long as the
Departments of Ophthalmology and 1Anatomy, C.U. Shah Medical author is credited and the new creations are licensed under the identical terms.
College and Hospital, Surendranagar, Gujarat, India
For reprints contact: reprints@medknow.com
Address for correspondence: Dr.Aruna Kumari R. Gupta,
Department of Ophthalmology, C.U. Shah Medical College
and Hospital, Surendranagar363001, Gujarat, India. Cite this article as: Gupta AR, Gupta RR. A prospective study of incidence
Email:arunagupta.eye@gmail.com and risk factors for secondary glaucoma after penetrating keratoplasty. J Clin
Ophthalmol Res 2016;4:123-6.
Manuscript received: 15.07.2015; Revision accepted: 26.04.2016

2016 Journal of Clinical Ophthalmology and Research | Published by Wolters Kluwer -Medknow 123
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Gupta and Gupta: Incidence and risk factors for secondary glaucoma

the posterior segment was performed to rule out vitreous Results

exudation suggestive of endophthalmitis. The medical records
were reviewed for the indication for which PK was done and Three hundred and eleven PKs were performed between the
the IOP measurements in each case were noted. study period on observing the demographic details mean
age of the patients was 43.04 17.67 (range 6 years to
Patients who had a previous history of glaucoma were 78years). Maximum number of patients was in 4150years
excluded from the study. All PK were performed by standard group (24.0%). In this study, the male recipients were
surgical technique under local anesthesia except in children more(64.0%) than female recipients(36.0%). Right eyes were
where general anesthesia was used. Donor button oversized operated more(59.0%) than the left eyes(41.0%).
by 0.5 mm was used, except in cases of keratoconus, where
Of the 311 eyes, secondary glaucoma developed in 57cases.
the graft of the same size as the recipient was used. Anterior
This yields an incidence of 18.3%. Average preoperative IOP
vitrectomy was performed when required. Donor cornea
was 15.11 mmHg(range 12.220.6). The IOP(mmHg)
was sutured to recipient cornea with interrupted 10.0 nylon
measured on postoperative days averaged 23.58 after 1st week,
monofilament sutures with adjustable suture technique. All
25.20 after 1st month, 26.77 after 3rd month, 23.52 after
cases received amikacin(25 mg), cefazolin(100 mg), and
6 months, and 23.12 after 1year. Maximum increase was seen
dexamethasone (4 mg) subconjunctivally at the end of the
at 3 months(P=0.001). Mean IOP was 24.597.87 mmHg
operation. In cases of infective keratitis, dexamethasone was
(range 22.450.6 mmHg).
not given. Intraoperative data recording included the details of
the surgical procedure, type of surgery, i.e.,whether combined The study of the medical records of these 57 patients
with cataract extraction, intraocular lens removal, secondary showed that in conditions of keratoconus the incidence of
intraocular lens implantation, and anterior vitrectomy. PPKG was 0%, aphakic bullous keratopathy(ABK) 3%; in
Postoperatively, the eyes were patched, and topical steroid pseudophakic bullous keratopathy 14%, failed graft 16.0%,
was administered once the epithelium was intact over the corneal opacity 18.0%, and in cases of corneal ulcer 49.0%.
transplant, except in cases of infective keratitis. Topical Among corneal ulcer cases the incidence was 26.0% in cases
steroid(prednisolone) was instilled in the operated eye of bacterial keratitis and 23.0% in cases of fungal keratitis.
four times a day initially, and the frequency was increased
The records of the phakic status of these 57patients showed
or decreased depending on the degree of inflammation.
that 25patients(44.0%) were phakic, 17patients(30.0%) were
Topical antibiotics(ofloxacin or gatifloxacin) were given four
aphakic, and 15patients(26.0%) were pseudophakic.
times in the initial period. At the end of 1 month following
surgery, most of the patients were shifted to weaker antibiotic We studied the incidence of PPKG with respect to the graft
steroids combination(tobramycin and fluorometholone) size and found that with 7 mm graft size the incidence was
four times a day. This dosage of medication was tapered 8%, with 7.5 mm graft size it was 26.0%, with 8 mm graft size
during the postoperative period to once after 1year. In 8%, 8.5 mm graft size 12.0%, 9 mm graft size 12.0%, 9.5 mm
eyes where inflammatory signs persisted, topical steroids graft size 13.0%, 10 mm graft size 13.0%, 10.5 mm graft size
were continued longer at higher dosage. If there was sign 3.0%, and with 11 mm graft size 5%.
of graft rejection, then intensive topical steroids were given.
Cycloplegic(cyclopentolate 1%) was given twice daily till iritis Discussion
subsided and was discontinued after 1week. Topical antibiotics The definition of PPKG is an elevated IOP(>21 mmHg)
and antifungals were continued till there was no suspicion following PK, with or without optic nerve damage and visual
of infection. Topical antiglaucoma medication(timolol 0.5%) field changes. The etiology of PPKG is multifactorial such
twice daily and lubricants(carboxymethyl cellulose) four times as distortion of the angle with collapse of the trabecular
were given during the initial period. meshwork, suturing technique, and peripheral anterior
synechiae(PAS). Other factors that contribute to postoperative
The patients were evaluated on every followup in the
glaucoma are preexisting glaucoma, use of viscoelastic
same manner as the preoperative assessment including the
substances, steroidinduced glaucoma,[5] and the presence of
condition of the corneal graft was also noted. The raised
ocular inflammation in the preor postoperative period.[1315]
IOP was controlled either medically or surgically. Medical
The leading cause for late PPKG, however, is synechial angle
treatment included oral acetazolamide 250 mg four times
closure,[16] PAS formation preoperatively or as a consequence of
and liquid glycerol 30 cc twice a day and topical antiglaucoma
a preceding intraocular surgery[1719] and floppy atrophic iris.[20]
drops were given. Patients not responding to full medical
The purpose of our study was to determine the incidence and
treatment were treated surgically. Surgical methods included
risk factors for secondary glaucoma after PK at our center.
filtration procedure and/or by cyclocryotherapy as per the
case. The patients were evaluated on the 1st day, at the end of In the present series, the incidence of PPKG was 18.3%.
1st week, 1st month, third and 6 months and then after 1year Other studies reported the incidence of PPKG to be 18%,[5]
postoperatively. Statistical analysis was done using paired 21.5% by Frana et al.,[13] and 27.4% by Sekhar et al.[21] In
and unpaired ttest. another study by Karadag etal.[22] IOP increased in the early

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Gupta and Gupta: Incidence and risk factors for secondary glaucoma

postoperative period in 5.5% of cases and chronically elevated The relationship between donor button size and host bed
IOP was reported in 16.6% of cases. size has also been the subject of several studies.[2,10,11] On
comparing the graft size with the outcome, we observed that
This study shows that the incidence of glaucoma after
with graft size of 8 mm and above there was increased incidence
PK differ significantly based on the indication for PK
of secondary glaucoma which may be due to the formation of
(from a low of 0% for keratoconus to a high of 49.0% after
PAS at the hostgraft junction. Adonor button 0.5 mm larger
Infectious keratitis). Our observation of higher incidence
than the host bed has been shown to be associated with a lower
of secondary glaucoma in infectious keratitis cases may be
incidence of postoperative glaucoma[10,11] but in our study this
due to preoperative and postoperative inflammation and
was not assessed as we used donor button oversized by 0.5 mm
the development of PAS as also reported by Kirkness and in all cases except in cases of keratoconus, where the graft of
Moshegov.[19] Other studies also reported the rate of chronic same size as the recipient was used. In our study, incidence of
glaucoma after PK differed significantly based on the indication glaucoma in cases with difference in suturing technique was
from a low of 012% for keratoconus to a high of 75% after not studied. Studies by Pramanik etal.,[26] Erdurmus etal.[27] and
infectious keratitis.[5,9,12] When the incidence of glaucoma was Fan etal.[28] found IOP elevation related to steroid use following
studied based on microbiology, i.e.,bacterial or fungal there PK, but in our study, we did not observe any steroid responders
was no significant difference in incidence of glaucoma in our so this factor was not evaluated.
study. Studies by Goldberg etal.[2] Simmons etal.,[18] Kirkness
and Moshegov[19] and Polack,[23] also reported a low incidence Conclusion
of secondary glaucoma after PK in keratoconus similar to our
PPKG glaucoma continues to be a clinical problem that can
findings. Goldberg etal.[2] reported increased IOP in cases of
be sight threatening in its ultimate outcome. However,
ABK. In some studies, bullous keratopathy, graft rejection,
recognition of the risk factors, controlling the inflammatory
history of glaucoma, and trauma were reported to be highrisk
response judiciously, and more frequent monitoring of IOP
factors for IOP elevation following PK.[18,19,23] Wagoner etal.[24]
may yield better results. We conclude in our study that the
reported that eyes with corneal edema were significantly more
incidence of glaucoma developing postPK was highest in
likely to develop glaucoma than those with stromal scarring phakic eyes, which may be due to the formation of posterior
dissimilar to our findings. synechiae and development of intumescent cataract. Higher
The study of association of glaucoma with phakic status incidence of glaucoma developing in infective cases could be
found that out of 57patients 25patients(44.0%) were phakic, due to recipient hot eye and the high incidence in cases of
17patients(30.0%) were aphakic, and 15patients(26.0%) were large graft could be attributed to formation of PAS.
pseudophakic. In this study, the incidence of glaucoma was Financial support and sponsorship
more in phakic eyes whereas other studies reported aphakic
Nil.
eyes[7,12] at much higher risk of developing glaucoma. The
proposed mechanism of glaucoma in aphakic cases was more Conflicts of interest
manipulation of eye structures leading to more inflammation There are no conflicts of interest.
by Goldberg etal.,[2] Karesh etal.,[3] and Zimmerman etal.,[7]
angle distortion by Olson and Kaufman,[6] and mechanical References
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