Kobia Acquah Et Al 2022 Prevalence of Keratoconus in Ghana A Hospital Based Study of Tertiary Eye Care Facilities
Kobia Acquah Et Al 2022 Prevalence of Keratoconus in Ghana A Hospital Based Study of Tertiary Eye Care Facilities
Kobia Acquah Et Al 2022 Prevalence of Keratoconus in Ghana A Hospital Based Study of Tertiary Eye Care Facilities
Abstract
Purpose: To estimate the prevalence of keratoconus in tertiary eye care facilities in Ghana.
Methods and Analysis: In this hospital-based retrospective cohort study, medical records of patients from tertiary/
referral eye care facilities in Ghana were reviewed. Included in the study were records of individuals who visited the
eye care facilities and were diagnosed of keratoconus within the period of January 2016 to December 2019 inclusive.
Data on patients’ demographics, severity of keratoconus, mode of diagnosis, treatment, and visual acuity outcomes
were analysed.
Results: Out of the total of 142,209 records reviewed, 75 patients were diagnosed of keratoconus in at least one eye
(127 eyes; 86.8% bilateral cases), representing a prevalence estimate of 53 per 100000 (95% confidence interval (CI): 41
to 65 per 100000). The mean ± SD age of patients at the time of diagnosis was 21.1 ± 9.5 years (66.2% males). The mean
± SD keratometry in keratoconus patients was 52.1 ± 7.0: majority (76.5%) of the cases were moderate to severe ker-
atoconus. The main primary treatment regimen was corneal transplant (58.8%) followed by spectacles (25.0%), crosslink-
ing (8.8%) and rigid contact lens (7.3%). There was a significant association between post-treatment visual acuity
outcomes and treatment type (p < 0.001).
Conclusion: Our study represents the first prevalence estimate of keratoconus in Ghana. The prevalence of keratoco-
nus estimated in our study is lower than that reported in countries with tropical climates. This could be due to lower
uptake of referrals, underdiagnosis and/or misdiagnosis of the condition in lower-level health facilities.
Keywords
Keratoconus, prevalence, hospital-based, ghana
Date received: 17 January 2022; revised: 2 May 2022; accepted 19 June 2022
myopia which subsequently leads to a negative overall Region, Central Region, Eastern Region, Greater Accra
quality of life impact.9,10 Region, Northern Region, Upper East Region, Upper West
The prevalence of keratoconus varies globally based on Region, Volta Region and Western Region).28 Ghana is in
geographical location, cohort of study participants and cri- the tropical climate zone, with subtle variations in climatic
teria used for diagnosis.4,11,12 Recently, a meta-analysis conditions across the different regional zones: the eastern
review by Hashemi et al. in 2020 estimated the global coastal zone is warm and comparatively dry, the southwest
prevalence of keratoconus to be 1.38 per 1000 (95% CI: corner is hot and humid, and the north is hot and dry.29,30
1.14–1.62 per 1000).12 Population based studies have
reported varying estimates of prevalence of keratoconus:
54.5 per 100 000 population in Minnesota,13 1:375 (265 Study design
cases per 100 000) in Netherlands,14 2.3% in Central This was a hospital-based retrospective cohort study
India,15 2.34% in Jerusalem,16 1.5% in Palestine,17 44 involving review of medical records of patients from four
patients per 100 000 residents in Denmark,18 4.79% in tertiary/referral eye care facilities. The referral facilities
Saudi Arabia,19 and 37.4 cases per 100 000 people in were selected using convenience sampling to reflect four
South Korea.20 In the above studies, controlling factors zones in Ghana: Tamale Teaching Hospital (TTH)
such as cohort of selected subjects, sample size and diag- (Northern zone), Komfo Anokye Teaching Hospital
nostic criteria used varied greatly in each study and subse- (KATH) (Middle zone), Dr Agarwal’s Eye Hospital
quently influenced the estimated prevalence. (DAEH) (Southeast zone), Cape Coast Teaching Hospital
In Africa, data on prevalence of keratoconus is very (CCTH) (Southwest zone). Apart from DAEH (which is
limited. Mugho et. al. (2016) estimated prevalence of ker- private), the rest are all public facilities and were selected
atoconus in patients with allergic conjunctivitis based on because they are advanced eye care facilities within their
diagnostic criteria, and reported 10.6% by clinical diagno- respective zones where keratoconus patients are expected
sis, 14.6% by keratometry and 30.9% by topography.21 to be referred. Medical records of individuals who visited
Other studies have also reported demographic profiles the eye care facilities and were diagnosed of keratoconus
and visual function characteristics in cohorts of diagnosed for the first time within the period of January 2016 to
keratoconus patients.22–26 A recent meta-analysis on kera- December 2019 inclusive, were reviewed. To avoid
toconus in Africa estimated a prevalence rate of keratoco- double counting of same patients who may have visited
nus as high as 7.9%, however, the studies included in the different facilities included in the study, an electronic
meta-analysis were predominantly from cohorts with data abstraction form was used to flag patients with same
high risks of keratoconus.27 The meta-analysis under- name, sex, date of birth, and/or address. These patients
scored the need for more population- and/or hospital-based were then traced to confirm if they had attended multiple
studies to provide an accurate estimate of the keratoconus facilities with the same condition within the study period.
burden in Africa. Considering the logistical challenges in Only data from the first visited facility was then included
conducting population-based studies especially in low- in the analysis. The data abstraction form was initially
resource settings, a hospital-based retrospective study piloted and data abstractors were trained and allowed to
could provide important information on keratoconus and code patient records in a selected health facility not
serve as primary data for future studies. included in the study to ensure consistency and accuracy
At present, there is no prevalence estimate of keratoconus in data abstraction from all health facilities. Included in
in the country. This study will therefore provide the first the study were patients with complete data and whose ker-
prevalence estimate of keratoconus in Ghana. While a previ- atoconus diagnosis were confirmed by an ophthalmologist
ous study on keratoconus has been conducted in Ghana,26 or optometrist. All patients who were diagnosed with ker-
the authors sought to profile keratoconus patients in only atoconus or under treatment for keratoconus during this
one health facility without attempting to estimate the preva- period were included in this study. Patients were diagnosed
lence of keratoconus. The aim of the study is to employ a with keratoconus by an ophthalmologist or optometrist
hospital-based retrospective cohort design to determine for based on the presence of one or more clinical signs
the first time the prevalence of keratoconus in Ghana. observed during slit lamp examination (including
Fleischer ring, Vogt’s striae, central stromal thinning,
and apical scar), refraction, and corneal topography mea-
Materials and methods surements. To ensure reliability of diagnosis, only data
from facilities with corneal topographer (i.e. KATH and
Study setting DAEH) were included in the study – CCTH and TTH
Ghana is in the western part of Africa with a population size were excluded because they did not have corneal topog-
of approximately 30 million as of 2020.28 Although now con- rapher. Corneal keratometric readings were performed
sisting of 16 regions, Ghana was previously made up of using corneal topographer. The severity of keratoconus
10 administrative regions (Ashanti Region, Brong Ahafo was categorised into three grades based on an adaptation
Kobia-Acquah et al. 3187
of the Amsler-Krumeich classification as follows: mild (< 0.22% (95% CI: 0.14% to 0.30%), respectively.
48 D), moderate (48–54 D), and severe (> 54 D).31 Corneal Although CCTH and TTH were excluded from the study,
steepening in stage 1 was confirmed by the topographic a review of their records revealed no report of keratoconus
maps and evaluation of anterior or posterior corneal eleva- at CCTH (total records – 38,763), with only two patients
tion using OCULUS Pentacam HR (Typ 70900, diagnosed at TTH (total records – 41,901) from 2016 to
Optikgerate GmbH, Wetzlar, Germany) at KATH or 2019. The highest and lowest point/annual prevalence of
TOMEY (TMS-4N, Nagoya, Japan) at DAEH. keratoconus were recorded in 2016 (0.06% [95% CI:
0.03% to 0.09%]) and 2017 (0.03% [95% CI: 0.01% to
0.05%]), respectively (Figure 1). There was no statistically
Ethical considerations significant difference in keratoconus prevalence over the
Ethical approval was obtained from the Committee on four-year period (p = 0.36). Data of 68 patients (127
Human Research, Publications and Ethics – KNUST eyes; 86.8% bilateral cases) with complete medical
(CHRPE/AP/683/19) for TTH, KATH, and DAEH and records were analysed. The mean ± SD age of patients at
from the Committee of Ethical Clearance, Cape Coast the time of diagnosis was 21.1 ± 9.5 years (range 5 to 55
Teaching Hospital (CCTHERC/EC/2020/006) for CCTH. years); majority of keratoconus patients were aged 20
Permission was obtained from the facilities to allow for years or below (57.4%). Females (21.4 ± 11.1 years)
data curation. The study was conducted in line with the were slightly older than males (21.0 ± 8.8 years), but the
Tenets of the Declaration of Helsinki. difference was not statistically significant (p = 0.89).
More than two-thirds of keratoconus patients were students
(66.2%), followed by civil servants (14.7%). Table 1 sum-
Statistical analyses marises the characteristics of keratoconus patients.
Statistical analyses were performed using Statistical The mean ± SD keratometry of keratoconus patients
Product and Service Solution (IBM Corporation SPSS® was 52.1 ± 7.0: the majority (76.5%) of the cases were
Statistics, Version 27.0). Data on patients’ demographics, moderate to severe keratoconus. There were statistically
severity of keratoconus, mode of diagnosis, treatment, significant differences in mean keratometry readings
and visual acuity outcomes were analysed. For patients among the different occupations (p = 0.003) and affected
with bilateral keratoconus, the worse eye was chosen for eye (p = 0.008). Patients with bilateral keratoconus had
analysis. Only patients with complete medical records higher mean keratometry readings compared to patients
were included in the analyses. Snellen visual acuity was whose right or left eye only were affected (Table 1). No
converted to logMAR units for statistical manipulation. statistically significant difference in mean corneal thick-
Counting fingers (CF) and Hand movement (HM) were ness was observed in the different age groups (p = 0.80),
assigned logMAR values based on the methods described sex (p = 0.86), and health facility (p = 0.54) (Table 2).
by Schulze-Bonsel et al.32 and Karanjia et al.33 Commonly reported symptoms of keratoconus were
Normality of data distribution was assessed with the blurred vision (75.0%), itching eyes (47.1%) and tearing
Shapiro-Wilk test. Descriptive statistics was used to (27.9%) (Figure 2). The most frequently associated condi-
present data as mean, standard deviation and percentages, tions of keratoconus were vernal keratoconjunctivitis
where appropriate. One-way Analysis of Variance (22.1%), myopia (17.6%), allergic conjunctivitis (10.3%),
(ANOVA) and student t-test were used to evaluate differ- dry eye (10.3%), and glaucoma (1.5%). Corneal topog-
ences in continuous variables. Multiple linear regression raphy (92.6%) was the most used diagnostic equipment
analysis was used to explore associations between visual by clinicians; followed by slit lamp (85.3%), keratometry
acuity outcomes and age, gender, treatment option, and (64.7%), pachymetry (32.4%), and retinoscopy (16.2%).
severity of keratoconus. A p-value of .05 was considered All keratoconus patients in our study received either
statistically significant. surgical or optical therapy as their primary treatment.
The leading primary treatment regimen were corneal trans-
plant (58.8%) and spectacles (25.0%). Penetrating kerato-
Results plasty (PK) and Deep anterior lamellar keratoplasty
Out of the total of 142,209 records reviewed at KATH (DALK) were the only corneal transplant procedures per-
(128,161) and DAEH (14,048) from January 2016 to formed by ophthalmologists. Patients who received
December 2019 (2016–35105; 2017–33443; 2018– contact lenses were treated with either traditional gas per-
36404; 2019–37257), 75 patients (KATH – 44; DAEH – meable lenses (2.9%) or miniscleral contact lenses
31) were diagnosed of keratoconus in at least one eye, (4.4%), none of the patients received soft contact lenses
representing a period prevalence of 0.053% (95% confi- (Figure 3). Only DAEH provided specialty contact lens
dence interval (CI): 0.041% to 0.065%) (66.2% males). treatment among the two health facilities included in the
The respective keratoconus prevalence for KATH and study (Figure 4). The mean ± SD pre- and post-treatment
DAEH were 0.034% (95% CI: 0.024% to 0.045%) and visual acuities were 1.36 ± 0.65 logMAR units and
3188 European Journal of Ophthalmology 32(6)
0.79 ± 0.65 logMAR units respectively (p < 0.001). The prevalence estimate of keratoconus. Higher prevalence
mean ± SD logMAR visual acuity of patients improved estimates have been reported in Kenya (30.89%),21 South
from 1.26 ± 0.66 to 0.50 ± 0.49 with spectacles; from Africa (24.21%),25 and Egypt (1.12%)34 and other devel-
1.13 ± 0.68 to 0.35 ± 0.47 with contact lenses; from 1.53 oping countries [India (2.3%) and Iran (2.5%)]15,35 with
± 0.59 to 1.08 ± 0.65 with corneal transplantation; and similar climatic conditions like Ghana. Comparatively
0.76 ± 0.52 to 0.53 ± 0.32 with crosslinking. There was low prevalence estimates have however been reported in
no autocorrelation between the observations as indicated some developed countries [like USA13 (0.054%) and
by a Durbin-Watson statistic of 1.942. Also, there was no Denmark18 (0.044%)] with cold and temperate climate.
multicollinearity between the variables (variance inflation The high prevalence reported in other African countries
factor of 1.034, 1.137, 1.232, 1.282, and 1.065 for age, is attributable to the cohort of subjects and study popula-
sex, management option, keratoconus severity, and health tion included in those studies. For instance, in Kenya,21
facility, respectively). Multiple linear regression showed the study was conducted among allergic conjunctivitis
that only treatment type (β = 0.185; p < 0.001) and health patients; in South Africa,25 the study took place among
facility (β = 0.306; p = 0.04) were significantly associated contact lens seekers; and in Egypt,34 only refractive error
with post-treatment visual acuity outcomes after adjusting cohort were included in the study.
for age (β = 0.008; p = 0.173), sex (β = 0.027; p = 0.809), In the current study, the authors expected to find a rela-
and severity of keratoconus (β = 0.001; p = 0 .977). tively higher prevalence of keratoconus than reported con-
sidering the preponderance of risk factors of keratoconus
like ocular allergy and sunlight exposure in the
Discussion country.4,6 A reason for the low prevalence of keratoconus
To the authors’ best knowledge, this is the first study to could be due to underdiagnosis/misdiagnosis of keratoco-
provide an estimate of the prevalence of keratoconus in nus. In Ghana, diagnosis and management of keratoconus
Ghana. The overall period prevalence estimate of keratoco- have been a major challenge because of the lack of avail-
nus in the two health facilities was 0.053%, with majority ability of resources especially in lower-level eye care facil-
of keratoconus being bilateral (86.8%) and moderate to ities (district and regional). This is reflected in the
severe cases (76.5%). Surgical treatment (in the form of observation that only KATH and DAEH reported high
PK or DALK) was the most common keratoconus manage- numbers of keratoconus patients. These facilities are in
ment procedure provided by clinicians in Ghana. the capital cities of the two most developed regions
Compared to hospital-based studies in other African (Greater Accra and Ashanti) in the country. In contrast,
countries, the current study found a relatively lower the Central and Northern Regions where CCTH and TTH
Table 1. Characteristics of keratoconus patients.
Sex
Male 45 (66.2) 52.7 ± 7.4 .32 12 50.6 ± 3.8 9 51.3 ± 9.6 11 55.5 ± 11.1 13 53.1 ± 2.9
Female 23 (33.8) 50.9 ± 6.3 9 49.7 ± 7.9 2 56.0 ± 1.8 8 51.3 ± 6.0 4 50.2 ± 4.2
Age at presentation
(years)
≤20 39 (57.4) 51.0 ± 4.2 .33 10 48.9 ± 3.7 7 53.5 ± 3.9 9 49.6 ± 5.4 13 52.2 ± 3.2
21–30 19 (27.9) 53.9 ± 7.1 6 50.3 ± 4.8 2 60.9 ± 12.0 9 54.9 ± 7.5 2 53.0 ± 0.9
>30 10 (14.7) 52.8 ± 13.4 5 52.8 ± 9.7 2 38.6 ± 0.0 1 80.6 2 53.0 ± 7.8
Health facility
KATH 41 (60.3) 53.0 (8.2) .19 12 52.4 ± 7.7 5 51.1 ± 10.1 15 54.5 ± 10.2 9 52.6 ± 0.7
DAEH 27 (39.7) 50.7 (4.5) 9 48.6 ± 3.2 6 54.9 ± 3.8 4 50.9 ± 5.1 8 52.2 ± 5.1
Occupation
Student 45 (66.2) 51.1 ± 5.0 .003 12 48.6 ± 3.9 7 53.5 ± 3.9 13 50.9 ± 6.9 13 52.3 ± 3.2
Civil Servant 10 (14.7) 53.1 ± 5.8 5 49.7 ± 1.6 0 - 3 59.0 ± 5.9 2 52.9 ± 7.8
Vocational 3 (4.4) 43.2 ± 7.9 0 - 2 38.6 ± 0.0 1 52.4 0 -
Self-employed 7 (10.3) 60.1 ± 13.1 3 55.3 ± 12.9 2 60.9 ± 12.0 1 80.6 1 52.4
Unemployed 3 (4.4) 53.2 ± 3.8 1 57.4 0 - 1 50.0 1 52.4
Laterality
Right Eye 4 (5.9) 45.7 ± 1.3 .008 3 45.9 ± 1.5 0 - 1 45.0 0 -
Left Eye 5 (7.3) 45.2 ± 5.0 2 48.3 ± 5.7 2 42.8 ± 5.9 0 - 1 43.9
Both Eyes 59 (86.8) 53.1 ± 7.0 16 51.3 ± 6.1 9 54.2 ± 8.1 18 54.3 ± 9.3 16 52.9 ± 2.7
Severity at
presentation
Mild 16 (23.5) 43.9 ± 2.7 <.001 7 44.7 ± 1.4 3 41.4 ± 4.8 4 43.4 ± 2.3 2 45.6 ± 2.5
Moderate 37 (54.4) 51.8 ± 1.1 12 51.2 ± 1.2 4 52.3 ± 0.9 10 51.8 ± 1.0 11 52.2 ± 0.8
Severe 15 (22.1) 61.5 ± 7.4 2 63.4 ± 8.5 4 60.0 ± 6.5 5 66.1 ± 8.9 4 56.4 ± 2.7
Entrance VA
≤6/60 47 (69.1) 53.0 ± 7.7 .251 15 50.9 ± 6.5 10 52.0 ± 9.2 13 56.3 ± 9.6 9 52.9 ± 2.4
>6/60 to <6/16 16 (23.5) 49.8 ± 4.2 4 50.6 ± 1.5 1 53.4 5 46.4 ± 5.0 6 51.5 ± 3.8
≥ 6/12 5 (7.4) 50.4 ± 6.9 2 44.4 ± 0.3 0 - 1 57.4 2 52.9 ± 7.7
Post-treatment VA
≤6/60 24 (35.3) 53.1 ± 6.7 .204 8 53.1 ± 7.6 7 53.3 ± 9.6 5 54.1 ± 3.9 4 51.5 ± 1.1
>6/60 to <6/16 21 (30.9) 53.2 ± 7.7 5 50.9 ± 1.6 1 57.3 8 54.2 ± 12.6 7 53.1 ± 1.0
≥6/12 23 (33.8) 49.9 ± 6.5 8 46.9 ± 3.7 3 47.7 ± 8.0 6 52.9 ± 8.7 6 52.1 ± 5.8
Total 68 (100) 52.1 ± 7.0 21 (30.9) 50.2 ± 5.8 11 (16.2) 52.1 ± 8.8 19 (27.9) 53.8 ± 9.3 17 (25.0) 52.4 ± 3.4
3189
Komfo Anokye Teaching Hospital – KATH; Dr Agarwal’s Eye Hospital – DAEH; VA – Visual Acuity.
3190 European Journal of Ophthalmology 32(6)
CT – Corneal thickness; Cyl – Cylinder; SE – Spherical equivalent; VA – Visual acuity; DAEH – Dr Argawal’s Eye Hospital; KATH – Komfo Anokye Teaching Hospital; logMAR, logarithm of the minimum angle of
p-value
<0.001
<0.001
0.53
0.06
0.03
0.16
0.29
0.04
oped regions in the country, therefore the low numbers
in these facilities may reflect the lack of adequate resources
in eye care facilities in these regions to effectively diagnose
364 .9 ± 132.5
−4.81 ± 5.48
−1.77 ± 1.78
−5.34 ± 4.90
1.53 ± 0.58
0.98 ± 0.64
56.3 ± 8.5
49.7 ± 8.4
and treat keratoconus patients. The authors also observed
that KATH and DAEH have well-established corneal
KATH
−3.10 ± 2.97
389.7 ± 93.3
1.13 ± 0.67
0.54 ± 0.59
53.5 ± 6.5
47.8 ± 3.9
tools in lower-level eye care facilities,36 there could be a
Facility
DAEH
−3.45 ± 2.6
1.40 ± 0.65
0.75 ± 0.66
53.6 ± 7.2
48.2 ± 5.6
−4.96 ± 4.98
1.33 ± 0.65
0.81 ± 0.64
56.0 ± 8.1
49.3 ± 7.6
−3.00 ± 6.15
−3.05 ± 2.71
386.6 ± 78.8
1.26 ± 0.70
0.83 ± 0.78
−4.3 ± 3.8
1.61 ± 0.54
0.82 ± 0.61
57.3 ± 7.3
50.5 ± 7.6
1.25 ± 0.66
0.77 ± 0.64
−4.0 ± 4.1
54.1 ± 6.0
47.9 ± 3.6
Age groups
years and then steadily progresses until the third and fourth
decades before stabilizing.
Entrance VA, logMAR
Cyl, D
Figure 4. Distribution of treatment across health facilities. Komfo Anokye Teaching Hospital – KATH; Dr. Agarwal’s Eye Hospital –
DAEH. Penetrating keratoplasty – PK; Deep anterior lamellar keratoplasty – DALK. Cl – Contact lens.
quality-of-life of keratoconus patients in Ghana given the surgical treatment, highlighting the need for early interven-
fact that majority of cases in our study are students.10,46 tion with rigid contact lenses at lower levels of eye care
Remarkably, some studies have also shown the effective- facilities. Considering the efficacy of rigid contact lenses
ness of rigid contact lenses in slowing down keratoconus in treating and/or slowing keratoconus progression, it
progression and delaying the need for PK.43,47 Thus, may be important to further explore rigid contact lens as
there is the need to improve access to rigid contact lens ser- a primary treatment option for keratoconus in Ghana.
vices throughout the country to make it the primary treat-
ment of choice for keratoconus patients. The scarcity of
rigid contact lenses in the country could be due to the Acknowledgements
absence of manufacturing facilities, difficulties in import- The authors are grateful to the management of Komfo Anokye
ing rigid contact lenses and cleaning/disinfection solutions, Teaching Hospital, Tamale Teaching Hospital, Cape Coast
and an apparent inexperience in fitting rigid contact lenses. Teaching Hospital, and Dr Argawal’s Eye Hospital for granting
All these factors contribute to making the cost of rigid us permission and providing logistical support for the study.
contact lenses prohibitive to patients who need them.
A limitation of our study was the exclusion of seven
records with missing data as this could have influenced Authors’ contributions statement
the characteristics considering the lower number of ker- The authors’ contributions were as follows: Conceptualization:
atoconus patients reported. Our study was also limited EKA, ENS, and DPA. Methodology: EKA, EKAA, ENN, and
by its retrospective design as we had to assume that DPA. Data Acquisition: ENS and DPA. Formal analysis: EKA,
information provided in the medical records were accur- ENS and DPA. Writing—original draft preparation: EKA, RD,
ate. Despite these limitations, this study provides EKAA, DBK, and MAK. Writing—review and editing: EKA,
important data on the prevalence of keratoconus in RD, EKAA, DBK, and MAK. Supervision: EKA, EKAA, and
Ghana and reasonably reflects the characteristics of ker- DBK. All authors read and approved the final manuscript.
atoconus in tertiary health care facilities in the country.
In conclusion, we found keratoconus in 53 per 100000
patients in two tertiary eye care facilities in the country. Availability of data and materials
Most keratoconus patients in our study reported to the The dataset(s) supporting the conclusions of this article is/are
facilities with moderate to severe cases and received available on reasonable request from the corresponding author.
Kobia-Acquah et al. 3193
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