Original research article- Keratoconus

European Journal of Ophthalmology

2022, Vol. 32(6) 3185–3194
Prevalence of keratoconus in Ghana: © The Author(s) 2022
Article reuse guidelines:
A hospital-based study of tertiary eye sagepub.com/journals-permissions
DOI: 10.1177/11206721221113197

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Emmanuel Kobia-Acquah1 , Esther Nutifafa Senanu1,

Ellen Konadu Antwi-Adjei1, Dora Pomaa Appiah1,
David Ben Kumah1, Mohammed Abdul-Kabir1
and Richard Donkor2

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

Introduction genetics7,8 have been reported to play major role.

Keratoconus is a bilateral (mostly asymmetrical) corneal
ectatic disease that frequently results in vision impairment.
The most common characteristic signs include progressive
corneal thinning, protrusion and scarring, breaks in
Bowman’s layer, stromal thinning and iron deposition in
the epithelial basement membrane.1–3 The aetiology of ker-
atoconus is still not well understood, however, environ-
mental factors (contact lens wear, chronic eye rubbing,
atopy, sun exposure and allergic eye disease)4–6 and
Keratoconus patients typically experience reduced distance
vision because of the induced irregular astigmatism and
1
Department of Optometry and Visual Science, Kwame Nkrumah
University of Science and Technology, Kumasi, Ghana
2
Retina Associates of Cleveland, Cleveland, OH, USA
Corresponding author:
Emmanuel Kobia-Acquah, Department of Optometry and Visual Science,
KNUST, Kumasi, Ghana.
Email: ekobiaacquah.cos@knust.edu.gh
3186
myopia which subsequently leads to a negative overall
quality of life impact.9,10
The prevalence of keratoconus varies globally based on
geographical location, cohort of study participants and cri-
teria used for diagnosis.4,11,12 Recently, a meta-analysis
review by Hashemi et al. in 2020 estimated the global
prevalence of keratoconus to be 1.38 per 1000 (95% CI:
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
cases per 100 000) in Netherlands,14 2.3% in Central
India,15 2.34% in Jerusalem,16 1.5% in Palestine,17 44
patients per 100 000 residents in Denmark,18 4.79% in
Saudi Arabia,19 and 37.4 cases per 100 000 people in
South Korea.20 In the above studies, controlling factors
such as cohort of selected subjects, sample size and diag-
nostic criteria used varied greatly in each study and subse-
quently influenced the estimated prevalence.
In Africa, data on prevalence of keratoconus is very
limited. Mugho et. al. (2016) estimated prevalence of ker-
atoconus in patients with allergic conjunctivitis based on
diagnostic criteria, and reported 10.6% by clinical diagno-
sis, 14.6% by keratometry and 30.9% by topography.21
Other studies have also reported demographic profiles
and visual function characteristics in cohorts of diagnosed
keratoconus patients.22–26 A recent meta-analysis on kera-
toconus in Africa estimated a prevalence rate of keratoco-
nus as high as 7.9%, however, the studies included in the
meta-analysis were predominantly from cohorts with
high risks of keratoconus.27 The meta-analysis under-
scored the need for more population- and/or hospital-based
studies to provide an accurate estimate of the keratoconus
burden in Africa. Considering the logistical challenges in
conducting population-based studies especially in low-
resource settings, a hospital-based retrospective study
could provide important information on keratoconus and
serve as primary data for future studies.
At present, there is no prevalence estimate of keratoconus
in the country. This study will therefore provide the first
prevalence estimate of keratoconus in Ghana. While a previ-
ous study on keratoconus has been conducted in Ghana,26
the authors sought to profile keratoconus patients in only
one health facility without attempting to estimate the preva-
lence of keratoconus. The aim of the study is to employ a
hospital-based retrospective cohort design to determine for
the first time the prevalence of keratoconus in Ghana.
Materials and methods
Study setting
Ghana is in the western part of Africa with a population size
of approximately 30 million as of 2020.28 Although now con-
sisting of 16 regions, Ghana was previously made up of
10 administrative regions (Ashanti Region, Brong Ahafo
European Journal of Ophthalmology 32(6)
Region, Central Region, Eastern Region, Greater Accra
Region, Northern Region, Upper East Region, Upper West
Region, Volta Region and Western Region).28 Ghana is in
the tropical climate zone, with subtle variations in climatic
conditions across the different regional zones: the eastern
coastal zone is warm and comparatively dry, the southwest
corner is hot and humid, and the north is hot and dry.29,30
Study design
This was a hospital-based retrospective cohort study
involving review of medical records of patients from four
tertiary/referral eye care facilities. The referral facilities
were selected using convenience sampling to reflect four
zones in Ghana: Tamale Teaching Hospital (TTH)
(Northern zone), Komfo Anokye Teaching Hospital
(KATH) (Middle zone), Dr Agarwal’s Eye Hospital
(DAEH) (Southeast zone), Cape Coast Teaching Hospital
(CCTH) (Southwest zone). Apart from DAEH (which is
private), the rest are all public facilities and were selected
because they are advanced eye care facilities within their
respective zones where keratoconus patients are expected
to be referred. Medical records of individuals who visited
the eye care facilities and were diagnosed of keratoconus
for the first time within the period of January 2016 to
December 2019 inclusive, were reviewed. To avoid
double counting of same patients who may have visited
different facilities included in the study, an electronic
data abstraction form was used to flag patients with same
name, sex, date of birth, and/or address. These patients
were then traced to confirm if they had attended multiple
facilities with the same condition within the study period.
Only data from the first visited facility was then included
in the analysis. The data abstraction form was initially
piloted and data abstractors were trained and allowed to
code patient records in a selected health facility not
included in the study to ensure consistency and accuracy
in data abstraction from all health facilities. Included in
the study were patients with complete data and whose ker-
atoconus diagnosis were confirmed by an ophthalmologist
or optometrist. All patients who were diagnosed with ker-
atoconus or under treatment for keratoconus during this
period were included in this study. Patients were diagnosed
with keratoconus by an ophthalmologist or optometrist
based on the presence of one or more clinical signs
observed during slit lamp examination (including
Fleischer ring, Vogt’s striae, central stromal thinning,
and apical scar), refraction, and corneal topography mea-
surements. To ensure reliability of diagnosis, only data
from facilities with corneal topographer (i.e. KATH and
DAEH) were included in the study – CCTH and TTH
were excluded because they did not have corneal topog-
rapher. Corneal keratometric readings were performed
using corneal topographer. The severity of keratoconus
was categorised into three grades based on an adaptation
Kobia-Acquah et al.
of the Amsler-Krumeich classification as follows: mild (<
48 D), moderate (48–54 D), and severe (> 54 D).31 Corneal
steepening in stage 1 was confirmed by the topographic
maps and evaluation of anterior or posterior corneal eleva-
tion using OCULUS Pentacam HR (Typ 70900,
Optikgerate GmbH, Wetzlar, Germany) at KATH or
TOMEY (TMS-4N, Nagoya, Japan) at DAEH.
Ethical considerations
Ethical approval was obtained from the Committee on
Human Research, Publications and Ethics – KNUST
(CHRPE/AP/683/19) for TTH, KATH, and DAEH and
from the Committee of Ethical Clearance, Cape Coast
Teaching Hospital (CCTHERC/EC/2020/006) for CCTH.
Permission was obtained from the facilities to allow for
data curation. The study was conducted in line with the
Tenets of the Declaration of Helsinki.
Statistical analyses
Statistical analyses were performed using Statistical
Product and Service Solution (IBM Corporation SPSS®
Statistics, Version 27.0). Data on patients’ demographics,
severity of keratoconus, mode of diagnosis, treatment,
and visual acuity outcomes were analysed. For patients
with bilateral keratoconus, the worse eye was chosen for
analysis. Only patients with complete medical records
were included in the analyses. Snellen visual acuity was
converted to logMAR units for statistical manipulation.
Counting fingers (CF) and Hand movement (HM) were
assigned logMAR values based on the methods described
by Schulze-Bonsel et al.32 and Karanjia et al.33
Normality of data distribution was assessed with the
Shapiro-Wilk test. Descriptive statistics was used to
present data as mean, standard deviation and percentages,
where appropriate. One-way Analysis of Variance
(ANOVA) and student t-test were used to evaluate differ-
ences in continuous variables. Multiple linear regression
analysis was used to explore associations between visual
acuity outcomes and age, gender, treatment option, and
severity of keratoconus. A p-value of .05 was considered
statistically significant.
Results
Out of the total of 142,209 records reviewed at KATH
(128,161) and DAEH (14,048) from January 2016 to
December 2019 (2016–35105; 2017–33443; 2018–
36404; 2019–37257), 75 patients (KATH – 44; DAEH –
31) were diagnosed of keratoconus in at least one eye,
representing a period prevalence of 0.053% (95% confi-
dence interval (CI): 0.041% to 0.065%) (66.2% males).
The respective keratoconus prevalence for KATH and
DAEH were 0.034% (95% CI: 0.024% to 0.045%) and
3187
0.22% (95% CI: 0.14% to 0.30%), respectively.
Although CCTH and TTH were excluded from the study,
a review of their records revealed no report of keratoconus
at CCTH (total records – 38,763), with only two patients
diagnosed at TTH (total records – 41,901) from 2016 to
2019. The highest and lowest point/annual prevalence of
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
significant difference in keratoconus prevalence over the
four-year period (p = 0.36). Data of 68 patients (127
eyes; 86.8% bilateral cases) with complete medical
records were analysed. The mean ± SD age of patients at
the time of diagnosis was 21.1 ± 9.5 years (range 5 to 55
years); majority of keratoconus patients were aged 20
years or below (57.4%). Females (21.4 ± 11.1 years)
were slightly older than males (21.0 ± 8.8 years), but the
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-
marises the characteristics of keratoconus patients.
The mean ± SD keratometry of keratoconus patients
was 52.1 ± 7.0: the majority (76.5%) of the cases were
moderate to severe keratoconus. There were statistically
significant differences in mean keratometry readings
among the different occupations (p = 0.003) and affected
eye (p = 0.008). Patients with bilateral keratoconus had
higher mean keratometry readings compared to patients
whose right or left eye only were affected (Table 1). No
statistically significant difference in mean corneal thick-
ness was observed in the different age groups (p = 0.80),
sex (p = 0.86), and health facility (p = 0.54) (Table 2).
Commonly reported symptoms of keratoconus were
blurred vision (75.0%), itching eyes (47.1%) and tearing
(27.9%) (Figure 2). The most frequently associated condi-
tions of keratoconus were vernal keratoconjunctivitis
(22.1%), myopia (17.6%), allergic conjunctivitis (10.3%),
dry eye (10.3%), and glaucoma (1.5%). Corneal topog-
raphy (92.6%) was the most used diagnostic equipment
by clinicians; followed by slit lamp (85.3%), keratometry
(64.7%), pachymetry (32.4%), and retinoscopy (16.2%).
All keratoconus patients in our study received either
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-
plasty (PK) and Deep anterior lamellar keratoplasty
(DALK) were the only corneal transplant procedures per-
formed by ophthalmologists. Patients who received
contact lenses were treated with either traditional gas per-
meable lenses (2.9%) or miniscleral contact lenses
(4.4%), none of the patients received soft contact lenses
(Figure 3). Only DAEH provided specialty contact lens
treatment among the two health facilities included in the
study (Figure 4). The mean ± SD pre- and post-treatment
visual acuities were 1.36 ± 0.65 logMAR units and
3188
Figure 1. Pattern of keratoconus in tertiary eye care facilities.
0.79 ± 0.65 logMAR units respectively (p < 0.001). The
mean ± SD logMAR visual acuity of patients improved
from 1.26 ± 0.66 to 0.50 ± 0.49 with spectacles; from
1.13 ± 0.68 to 0.35 ± 0.47 with contact lenses; from 1.53
± 0.59 to 1.08 ± 0.65 with corneal transplantation; and
0.76 ± 0.52 to 0.53 ± 0.32 with crosslinking. There was
no autocorrelation between the observations as indicated
by a Durbin-Watson statistic of 1.942. Also, there was no
multicollinearity between the variables (variance inflation
factor of 1.034, 1.137, 1.232, 1.282, and 1.065 for age,
sex, management option, keratoconus severity, and health
facility, respectively). Multiple linear regression showed
that only treatment type (β = 0.185; p < 0.001) and health
facility (β = 0.306; p = 0.04) were significantly associated
with post-treatment visual acuity outcomes after adjusting
for age (β = 0.008; p = 0.173), sex (β = 0.027; p = 0.809),
and severity of keratoconus (β = 0.001; p = 0 .977).
Discussion
To the authors’ best knowledge, this is the first study to
provide an estimate of the prevalence of keratoconus in
Ghana. The overall period prevalence estimate of keratoco-
nus in the two health facilities was 0.053%, with majority
of keratoconus being bilateral (86.8%) and moderate to
severe cases (76.5%). Surgical treatment (in the form of
PK or DALK) was the most common keratoconus manage-
ment procedure provided by clinicians in Ghana.
Compared to hospital-based studies in other African
countries, the current study found a relatively lower
European Journal of Ophthalmology 32(6)
prevalence estimate of keratoconus. Higher prevalence
estimates have been reported in Kenya (30.89%),21 South
Africa (24.21%),25 and Egypt (1.12%)34 and other devel-
oping countries [India (2.3%) and Iran (2.5%)]15,35 with
similar climatic conditions like Ghana. Comparatively
low prevalence estimates have however been reported in
some developed countries [like USA13 (0.054%) and
Denmark18 (0.044%)] with cold and temperate climate.
The high prevalence reported in other African countries
is attributable to the cohort of subjects and study popula-
tion included in those studies. For instance, in Kenya,21
the study was conducted among allergic conjunctivitis
patients; in South Africa,25 the study took place among
contact lens seekers; and in Egypt,34 only refractive error
cohort were included in the study.
In the current study, the authors expected to find a rela-
tively higher prevalence of keratoconus than reported con-
sidering the preponderance of risk factors of keratoconus
like ocular allergy and sunlight exposure in the
country.4,6 A reason for the low prevalence of keratoconus
could be due to underdiagnosis/misdiagnosis of keratoco-
nus. In Ghana, diagnosis and management of keratoconus
have been a major challenge because of the lack of avail-
ability of resources especially in lower-level eye care facil-
ities (district and regional). This is reflected in the
observation that only KATH and DAEH reported high
numbers of keratoconus patients. These facilities are in
the capital cities of the two most developed regions
(Greater Accra and Ashanti) in the country. In contrast,
the Central and Northern Regions where CCTH and TTH
Table 1. Characteristics of keratoconus patients.

2016 2017 2018 2019

Average Average Average Average

k-reading (mean k-reading (mean Average k-reading k-reading (mean k-reading (mean
Variables N (%) ± SD D) p-value N ± SD D) N (mean ± SD D) N ± SD D) N ± SD D)
Kobia-Acquah et al.

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)

are located, respectively, are two of the most underdevel-

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

clinics comprised of consulting corneal specialists and

advanced instruments such as corneal topographer for
diagnosing corneal ectatic diseases. Considering the
−1.49 ± 2.38
−3.27 ± 1.80

−3.10 ± 2.97
389.7 ± 93.3

general lack of eye care infrastructure and diagnostic

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

high possibility of both underdiagnosis/misdiagnosis of

keratoconus in Ghana. In addition, there could also be a
general lack of uptake of referrals by patients who are diag-
p-value

nosed with keratoconus, given the apparent low level of

0.86
0.16
0.07
0.23
0.55
0.18
0.55
0.65

knowledge, and understanding of the condition in the

country. Finally, unstructured mode of referrals in Ghana
may be a contributing factor to the low prevalence of ker-
−2.12 ± 2.57
−2.08 ± 2.09
386.6 ± 87.9

−3.45 ± 2.6
1.40 ± 0.65
0.75 ± 0.66
53.6 ± 7.2
48.2 ± 5.6

atoconus recorded in our study. The referral systems in

Female

Ghana are not structured in a way that allows patients to

be tracked and monitored.37 Therefore, there could have
been a significant proportion of patients who were referred
but did not access the referral services with no means of
378.1 ± 115.6
−3.99 ± 5.36
−3.05 ± 1.36

−4.96 ± 4.98
1.33 ± 0.65
0.81 ± 0.64
56.0 ± 8.1
49.3 ± 7.6

tracking them. Despite these issues, the prevalence esti-

mate found in our study may be a reasonable reflection
Male

of the current keratoconus cases in tertiary hospitals in

Sex

the country and provides a good baseline for a future

population-based study to fully understand the keratoconus
p-value

burden in the country.

0.80
0.46
0.73
0.34
0.39
0.45
0.02
0.90

Approximately two-thirds of the keratoconus cases

found in our study were males (male:female ratio of 2:1).
Table 2. Ocular parameters in keratoconus eyes by age, sex, and health facility.

−3.00 ± 6.15
−3.05 ± 2.71
386.6 ± 78.8

Similar findings of a higher male preponderance of kerato-

55.8 ± 13.6
49.7 ± 13.3

1.26 ± 0.70
0.83 ± 0.78
−4.3 ± 3.8

conus have been reported in Ghana26 and previous studies

in other countries.16,38 However, there has been contrasting
>30

evidence of an association between sex and keratoconus

prevalence in the literature – some studies found a higher
360.1 ± 137.6
−4.49 ± 4.92

prevalence of keratoconus in females39 while other

−5.5 ± 5.09
−2.39 ± 2.0

1.61 ± 0.54
0.82 ± 0.61
57.3 ± 7.3
50.5 ± 7.6

studies found no difference in keratoconus prevalence in

males and females.13,20 The higher prevalence in males
21–30

found in our study could reflect the higher prevalence of

allergic/vernal conjunctivitis (a known risk factor of kera-
toconus) reported in males in the country.40 We found most
389.1 ± 102.9
−2.82 ± 4.38
−2.31 ± 1.8

1.25 ± 0.66
0.77 ± 0.64
−4.0 ± 4.1
54.1 ± 6.0
47.9 ± 3.6
Age groups

resolution. Values are presented as mean ± SD.

keratoconus cases in patients in their late teenage (57.4%)

and early adult (21–30; 27.9%) years, consistent with lit-
≤ 20

erature.18,20 This could be underpinned by most keratoco-

nus patients observed in our study being students (66.2%).
The characteristic onset of keratoconus is from adolescent
Post treatment VA, logMAR

years and then steadily progresses until the third and fourth
decades before stabilizing.
Entrance VA, logMAR

Commonly reported symptoms of keratoconus in our

study were blurred vision, itching eyes, and tearing.
These findings are corroborated by the observation of
Steep K, D
Sphere, D

common diseases – myopia (17.6%), vernal keratocon-

Flat K, D
CT, μm

Cyl, D

junctivitis (22.1%), and allergic conjunctivitis (10.3%) –

SE, D

known to be associated with keratoconus. An important

Kobia-Acquah et al.
Figure 2. Presenting symptoms of keratoconus patients.
Figure 3. Primary treatment regimen for keratoconus patients.
Penetrating keratoplasty – PK; Deep anterior lamellar
keratoplasty – DALK. Cl – Contact lens
risk factor of keratoconus is eye rubbing12 associated with
atopy and allergic conjunctivitis. Therefore, it is not sur-
prising that we found a high number of keratoconus with
vernal and allergic conjunctivitis. The association of kera-
toconus with vernal and allergic conjunctivitis in Ghana
may be due to high incidence of eye rubbing among chil-
dren and young adults. For instance, a community-based
study in Ghana reported a high prevalence of allergic con-
junctivitis (39.9%) in school-going children.40 Studies in
3191
other African countries have also reported higher preva-
lence of allergic conjunctivitis and its association with
keratoconus.21,41
Multiple linear regression showed that treatment type (p
< 0.001) and health facility (p = 0.004) were the only vari-
ables significantly associated with post-treatment visual
acuity outcomes, after adjusting for age, sex, and severity
of keratoconus. Rigid contact lenses provided the highest
improvement in visual acuity outcomes compared to
corneal transplant and spectacles. Interestingly, only
7.3% of keratoconus patients received rigid contact lens
treatment, with DAEH being the only facility providing
rigid contact lens services. Despite the advances in surgical
treatment for keratoconus, rigid contact lenses remain the
mainstay treatment regimen for keratoconus patients even
in advanced countries (with similar prevalence estimates)
where keratoconus management is well established.42–44
Therefore, the general lack of these services in the
country presents a significant challenge in the treatment/
management of keratoconus patients in Ghana especially
as even mild to moderate cases are compelled to undergo
surgical treatment – which sometimes results in unintended
immune reactions and corneal complications.45 The
absence of rigid contact lenses in the country may also
have a lasting impact on the education and overall
3192
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
fact that majority of cases in our study are students.10,46
Remarkably, some studies have also shown the effective-
ness of rigid contact lenses in slowing down keratoconus
progression and delaying the need for PK.43,47 Thus,
there is the need to improve access to rigid contact lens ser-
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
absence of manufacturing facilities, difficulties in import-
ing rigid contact lenses and cleaning/disinfection solutions,
and an apparent inexperience in fitting rigid contact lenses.
All these factors contribute to making the cost of rigid
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
the characteristics considering the lower number of ker-
atoconus patients reported. Our study was also limited
by its retrospective design as we had to assume that
information provided in the medical records were accur-
ate. Despite these limitations, this study provides
important data on the prevalence of keratoconus in
Ghana and reasonably reflects the characteristics of ker-
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.
Most keratoconus patients in our study reported to the
facilities with moderate to severe cases and received
European Journal of Ophthalmology 32(6)
surgical treatment, highlighting the need for early interven-
tion with rigid contact lenses at lower levels of eye care
facilities. Considering the efficacy of rigid contact lenses
in treating and/or slowing keratoconus progression, it
may be important to further explore rigid contact lens as
a primary treatment option for keratoconus in Ghana.
Acknowledgements
The authors are grateful to the management of Komfo Anokye
Teaching Hospital, Tamale Teaching Hospital, Cape Coast
Teaching Hospital, and Dr Argawal’s Eye Hospital for granting
us permission and providing logistical support for the study.
Authors’ contributions statement
The authors’ contributions were as follows: Conceptualization:
EKA, ENS, and DPA. Methodology: EKA, EKAA, ENN, and
DPA. Data Acquisition: ENS and DPA. Formal analysis: EKA,
ENS and DPA. Writing—original draft preparation: EKA, RD,
EKAA, DBK, and MAK. Writing—review and editing: EKA,
RD, EKAA, DBK, and MAK. Supervision: EKA, EKAA, and
DBK. All authors read and approved the final manuscript.
Availability of data and materials
The dataset(s) supporting the conclusions of this article is/are
available on reasonable request from the corresponding author.
Kobia-Acquah et al.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Emmanuel Kobia-Acquah https://orcid.org/0000-0002-5955-
7992
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