Objectives: In this study, we aimed to analyze the effects of the COVID-19 pandemic in its first year on corneal transplant outcomes performed at a tertiary eye care center in Turkey.
Materials and Methods: Clinical records of patients who underwent corneal transplant between March 2020 and February 2021 (group A) at the Baskent University Faculty of Medicine, Department of Ophthalmology, were analyzed retrospectively. Patient demographics, indications for transplant, type of transplant procedure (lamellar vs penetrating), follow-up duration, and postoperative complications were recorded. The same data were collected for cornea transplant patients who were seen the previous year, between March 2019 and February 2020 (group B). Data from the 2 groups were compared. In related samples, the Wilcoxon signed-rank test was used for statistical analysis, and a
P value < .05 was considered statistically significant.
Results: Six corneal transplants were performed between March 2020 and February 2021 (group A), and 48 corneal transplantations were performed in the previous year (group B). There was an 80% decline in total corneal transplant numbers when compared with the previous year, and lamellar surgeries were not performed at all during the first year of the pandemic. Indications during the pandemic were mainly urgent and limited to tectonic or therapeutic causes. Postoperative follow-up regimens were impaired, and the complication rate was significantly higher during the pandemic period compared with the previous year (67% in group A vs 16% in group B) (P < .001).
Conclusions: There was a steep decline in transplants in 2020, the first year of the pandemic. The prominent increase in complication rates can be attributed to the late diagnosis of corneal rejections due to impaired postoperative follow-up regimens.
Key words : Graft rejection, Lamellar keratoplasty, Penetrating keratoplasty, SARS-CoV-2
The COVID-19 pandemic has imposed a tremendous burden on the public and on health care systems since the World Health Organization declared the outbreak a pandemic in March 2020. COVID-19 has become a threat for solid-organ transplantation since then. Corneal transplantation was especially affected because of significant challenges to cornea procurement from deceased donors, due to concerns regarding disease transmission. Although viral RNA could not be found in the cornea of patients who died from COVID-19,1 it is known that SARS-CoV-2 can bind to angiotensin-converting enzyme receptors found in the conjunctival and corneal epithelial cells.2 In March 2020, the Turkish Health Ministry advocated corneal procurement only from deceased donors with COVID-19 excluded by nasopharyngeal polymerase chain reaction (PCR) testing, keeping in mind the incubation period. Consequently, most eye banks halted their activity. In addition, the lockdown strategies taken to limit the spread of COVID-19 led to impaired patient follow-up, leading to delayed diagnoses of corneal rejection and posttransplant complications.
In this study, we aimed to analyze the effects of the pandemic on corneal transplants performed at the Baskent University Faculty of Medicine, Department of Ophthalmology, which is a tertiary eye care center in Turkey.
Materials and Methods
Clinical records of patients who underwent corneal transplant between March 2020 and February 2021 (group A) at the Baskent University Faculty of Medicine, Department of Ophthalmology, were analyzed retrospectively. Patient demographics, indications for transplant, type of transplant procedure (lamellar vs penetrating), follow-up duration, and postoperative complications were recorded. The same data were collected for cornea transplant patients from the previous year, between March 2019 and February 2020 (group B). All data were tabulated and analyzed by using SPSS software for Windows version 20.0 and Microsoft Office Excel. Descriptive statistics were reported as means and standard deviations or percentages where applicable. Data from the 2 groups were compared using the Mann-Whitney U test.
Six corneal transplant procedures were performed between March 2020 and February 2021 (group A), and 48 corneal transplants were performed in the previous year (group B). All surgeries were penetrating keratoplasties in group A; however, surgeries in group B included 13 lamellar keratoplasties (6 deep anterior lamellar keratoplasty and 7 Descemet membrane endothelial keratoplasty) and 35 penetrating keratoplasties. When we compared the groups, there was an 80% decline in total corneal transplant numbers during the pandemic year versus the previous year and lamellar surgeries were not performed at all during the pandemic year. Table 1 shows patient demographics, indications for transplant, type of transplant procedure (lamellar vs penetrating), frequency of postoperative follow-ups, and postoperative complications in groups A and B.
In group A, indications for transplant were mainly urgent and limited to tectonic or therapeutic causes, including 4 corneal perforations and 2 refractory fungal keratitis cases. However, in group B, indications for transplant included a wider variety of pathologies. Indications included 16 for keratoconus, 8 for Fuchs dystrophy, 4 for graft failure, and 20 for bullous keratopathy. The complication rates were significantly higher in group A (67%) than in group B (16%) (P < .01).
In the first months of the pandemic, cornea procurement was halted for months in many eye banks. A European multinational survey involving 64 eye banks showed a significant reduction in the number of corneas procured and distributed per month from March to May 2020 compared with the 2 previous years.3 Studies from Italy and Brazil also reported negative impacts of the COVID-19 pandemic on corneal donations and transplants during the first year of the pandemic.4,5 In Italy, a modest reduction in corneal procurement and transplant was reported.4 The percentage of distributed tissues reduced in 2020 by more than 30% and 15% compared with the 2 previous years.4 In Brazil, a more prominent decrease was noted in corneal transplant activities.5 Data collected from Brazilian eye banks from January to August 2020 showed that 76.1% of the 3060 donations and 74.5% of the 3167 transplants occurred before the pandemic. They concluded that the negative impact of the COVID-19 pandemic on corneal donations and transplants in Brazil resulted from the recommendation of their health ministry to suspend the retrieval of ocular tissues from donors in cardiopulmonary arrest, which lasted for almost 6 months. Similarly, the Turkish Health Ministry advocated corneal procurement only from deceased donors where SARS-CoV-2 was excluded by nasopharyngeal PCR testing. This led to a steep decline in corneal procurement and consequently corneal transplant numbers in our clinic, which showed an 80% decline compared with the year before the pandemic.
After the initial pause in corneal procurement, due to the lack of information on the risk of SARS-CoV-2 transmission from donor tissue to recipient, the transplant rate began to increase.6 This was encouraged by local governments and was in agreement with national transplant societies. Eye banks have globally developed different guidelines and criteria for evaluating the viability of donor corneas. The recommendations of the Global Alliance of Eye Bank Associations included excluding the donor cornea if the patient had tested positive for the presence of SARS-CoV-2 RNA in their upper respiratory tract specimens in the last 14 days before death, became symptomatic in the last 28 days before death, or had contact with an individual confirmed or suspected of contracting COVID-19 less than 14 days before death.7 During collection of corneas by eye banks, the use of the 5% povidone-iodine disinfection protocol was recommended during their retrieval. According to this protocol, ocular tissue surface is exposed to 5% povidone-iodine for at least 2 minutes and no more than 5 minutes between the time of the donor’s death and tissue preservation. This has been shown to be effective at inactivating SARS-CoV-2, as well as other viruses.8 Current evidence indicates that SARS-CoV-2 transmission via corneal transplants from an infected donor to a healthy recipient host is a very rare event.9 A recent report from India confirmed that there was a gradual and incremental increase in all types of keratoplasties after the lockdown phase had stopped, which exceeded the preceding years’ monthly numbers in February and March 2021.10
The decreased frequency of follow-up visits due to lockdown strategies was another important problem that may have led to decreased patient compliance to postoperative medications and increased prevalence and late diagnosis of corneal rejections during the COVID-19 pandemic.11 This was obvious in our group, which showed a prominent increase in postoperative complications from 16% before the pandemic to 67% during the first year of the pandemic. Graft rejection and infective keratitis were the 2 prevalent complications.
As a result, because of the steep decline in transplants, 2020 can be termed as a lost year in corneal transplantation. The even more prominent decrease in the number of lamellar keratoplasties can be attributed to the lack of spare corneas, which may be needed when intraoperative complications are encountered during lamellar transplants. The indications for corneal transplant changed during the first year of the COVID-19 pandemic, shifting to an urgent care basis. The complication rates also increased significantly due to insufficient follow-up.
Volume : 20
Issue : 8
Pages : 70 - 73
DOI : 10.6002/ect.DonorSymp.2022.O14
From the 1Department of Ophthalmology and the 2Department of General Surgery, Başkent University Faculty of Medicine, Ankara, Turkey
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Leyla Asena, Baskent University Faculty of Medicine, Fevzi Çakmak Caddesi, 06490, Bahçelievler, Ankara, Turkey
Phone: +90 312 203 6868