The last decade has heralded a revolutionary shift in the treatment of corneal endothelial disease. Only 15 years ago, the only surgical treatment for pseudophakic bullous keratopathy and Fuchs dystrophy was penetrating keratoplasty (PK). Although used successfully for over a century, PK requires many months of refractive adjustments before the eye achieves visual stability. Starting with the advent of posterior lamellar keratoplasty in the late 1990s, a number of procedures have been developed, refined, and widely adopted, which have given patients faster recoveries and improved globe stability in comparison to traditional corneal transplantation. Each iteration of endothelial keratoplasty (EK) has involved the increasingly selective transplantation of corneal endothelial cells. Preliminary results of the most recent form of EK, Descemet's membrane EK, suggest that pure endothelial cell transplantation is on the horizon.

Limbal epithelial stem cells are the primary source of corneal epithelial cell regeneration. Limbal stem cell deficiency (LSCD) can develop in traumatic, immunologic, or genetic diseases that affect the ocular surface. LSCD leads to conjunctivalization, with corneal vascularization and opacification and subsequent loss of vision. Limbal stem cell transplantation is a surgical treatment to address LSCD and restore a corneal epithelial phenotype. Based on the source of cells, limbal transplant can be autologous or allogenic. Many surgical techniques are defined according to the source of the stem cells and the carrier tissues that are used. More recently, ex vivo expanded bioengineered epithelial cells have been used to reconstruct the corneal surface using autologous cells to eliminate the risk of rejection. Before transplantation, a systematic exam of the lids, eyelashes, fornices, and aqueous tears is mandatory and every effort should be made to optimize ocular surface health and control inflammation to enhance the chances of graft survival. Postoperative care is also another major determinant of success. Any factor that destabilizes the ocular surface needs to be addressed. In addition, systemic and topical immunosuppressants are also needed in all allograft recipients. In addition to pre-operative and postoperative care and the surgery itself, the etiology of LSCD also has an impact on the outcome. The prognosis of inflammatory diseases such as Stevens-Johnson syndrome is the worst among disorders causing LSCD.

Keratoconus is a non-inflammatory, progressive thinning process of the cornea. It is a relatively common disorder of unknown etiology that can involve each layer of the cornea and often leads to high myopia and astigmatism. Computer-assisted corneal topography devices are valuable diagnostic tools for the diagnosis of subclinical keratoconus and for tracking the progression of the disease. The traditional conservative management of keratoconus begins with spectacle correction and contact lenses. Several newer, more invasive, treatments are currently available, especially for contact lens-intolerant patients. Intrastromal corneal ring segments can be used to reshape the abnormal cornea to improve the topographic abnormalities and visual acuity. Phakic intraocular lenses such as iris-fixated, angle-supported, posterior chamber implantable collamer and toric lenses are additional valuable options for the correction of refractive error. Corneal cross-linking is a relatively new method of stiffening the cornea to halt the progression of the disease. The future management of keratoconus will most likely incorporate multiple treatment modalities, both simultaneous and sequential, for the prevention and treatment of this disease.

Corneal collagen cross-linking (CXL) with riboflavin and ultraviolet-A (UVA) is a new technique of corneal tissue strengthening by using riboflavin as a photosensitizer and UVA to increase the formation of intra- and interfibrillar covalent bonds by photosensitized oxidation. Keratocyte apoptosis in the anterior segment of the corneal stroma all the way down to a depth of about 300 microns has been described and a demarcation line between the treated and untreated cornea has been clearly shown. It is important to ensure that the cytotoxic threshold for the endothelium has not been exceeded by strictly respecting the minimal corneal thickness. Confocal microscopy studies show that repopulation of keratocytes is already visible 1 month after the treatment, reaching its pre-operative quantity and quality in terms of functional morphology within 6 months after the treatment. The major indication for the use of CXL is to inhibit the progression of corneal ectasias, such as keratoconus and pellucid marginal degeneration. CXL may also be effective in the treatment and prophylaxis of iatrogenic keratectasia, resulting from excessively aggressive photoablation. This treatment has also been used to treat infectious corneal ulcers with apparent favorable results. Combination with other treatments, such as intracorneal ring segment implantation, limited topography-guided photoablation and conductive keratoplasty have been used with different levels of success.

The concept of lamellar keratoplasty (LK) is not new. However, it had been abandoned and largely replaced by the time-honored technique of penetrating keratoplasty (PK) because LK is technically demanding, time consuming and gives suboptimal visual outcomes due to interface irregularity arising from manual lamellar dissection. Recent improvements in surgical instruments and introduction of new techniques of maximum depth of corneal dissection as well as inherent advantages such as preservation of globe integrity and elimination of endothelial graft rejection have resulted in a re-introduction of LK as an acceptable alternative to con ventional PK. This review article describes the indications, different techniques, clinical outcomes and complications o f deep anterior LK.

Corneal opacity is the third leading cause of blindness in the developing world and encompasses a wide variety of infectious, inflammatory and degenerative eye diseases. Most caes of corneal blindness are treatable with partial or full-thickness keratoplasty, provided adequate corneal tissue and surgical skill is available. However, access to sight-restoring keratoplasty in developing countries is limited by the lack of developed eye banking networks and a critical shortage of tissue suitable for transplantation. Beyond the developed world, corneal transplantation using fresh corneal tissue (FCT) is further hindered by unreliable storage and transportation facilities, unorganized distribution networks, the cost-prohibitive nature of imported tissue, unreliable compliance with medications and follow-up instructions and inadequate health and education services. Glycerol-preserved corneas overcome many of these limitations inherent to the use of FCT. As surgical innovation in lamellar corneal surgery expands the potential use of acellular corneal tissue, long-term preservation techniques are being revisited as a way to increase availability of corneal tissue to corneal surgeons throughout the developing world. Herein, we discuss the advantages of using and the applications for glycerol-preserved corneal tissue throughout the developing world.

The introduction of different techniques and computerized devices into clinical ophthalmology has significantly improved our knowledge of the eyes, optics, and eye conditions. Today, corneal topography is performed with a wide range of devices that implement a variety of techniques. Advance computerized analysis systems provide us with simple and quick evaluation procedures, yet the sophisticated data and clinical information that is generated can only be interpreted with adequate knowledge of the system itself as well as the accepted normal ranges of various properties assessed with these systems. Two computerized topography systems that are in common use are the Orbscan (Bausch and Lomb Inc., Rochester, NY, USA) and the Pentacam (Oculus GmBH, Wetzlar, Germany). The Orbscan is a slit-scanning device and the Pentacam is Scheimpflug imaging device. In this review, we present a brief description of both technologies, the techniques implemented in each device and the acquisition process with each. This will be followed by a list of corneal parameters that need to be assessed in screening patients for refractive surgery. We will discuss how these parameters are displayed, how each parameter may serve as clinic criteria, and how data should be interpreted. We will also try to provide evidence regarding the accuracy of different measurements, and the comparability of the two devices.

An essential step of laser in situ keratomileusis surgery is corneal flap creation, Femtosecond (FS)-assisted or mechanical microkeratome. Each type has rare intraoperative and postoperative complication rates. Several recent studies have identified risk factors and guidelines to help manage these complications. Fortunately, studies have shown no loss of best-corrected visual acuity (BCVA) after the management of intraoperative and postoperative complications in IntraLase FS and mechanical microkeratome. Refractive surgeons need to be aware of the types of complications that can occur, how to avoid them and how to manage them to ensure the best possible outcomes.

The Central Toxic Keratopathy (CTK) syndrome describes a rare, acute, self-limited, non-inflammatory process that yields central corneal opacification and significant hyperopic shift after refractive surgery. Despite being exceedingly rare, certain clinical features of CTK give the condition a striking resemblance to other more serious inflammatory conditions, including diffuse lamellar keratitis (DLK). As the authors demonstrate in this article, despite the overlapping clinical features, CTK is a disease process that is distinct from DLK and, therefore, in need of distinct management interventions.

Cataract surgery after corneal refractive surgery can be challenging for the ocular surgeon due to the difficulty with accurate intraocular lens (IOL) power determination and unexpected refractive surprises. As clinicians have done more work, a number of error sources have been determined. Furthermore, an increasing number of methods to avoid these refractive surprises have been proposed. The combination of this work has resulted in recommendations for the modification of standard IOL power calculations to improve outcomes. The following article includes a brief on, and by no means, inclusive, error sources and ways to compensate for them.

Purpose: To compare various outcome measures using torsional mode and longitudinal mode in the phacoemulsification of cataract with different nuclear densities. Setting: Magrabi Eye Hospitals, Kingdom of Saudi Arabia. Design: A randomized comparative clinical study. Materials and Methods: This study includes 200 eyes of 156 patients (100 in the ultrasound longitudinal "US" group and 100 in the torsional group). All eyes received AcrySof^® single piece intraocular lens (Alcon Surgical, Fort Worth, TX). The primary outcome measures were ultrasound time (UST), cumulative dissipated energy (CDE), and surgical complications. Postoperative outcome measures were the degree of corneal edema on the first postoperative day and final best corrected visual acuity (BCVA) and CCT (central corneal thickness). Results: The differences in UST and CDE between subgroups of nucleus hardness were statistically significant (P < 0.01). The UST and CDE consistently increased in eyes with higher grades of nucleus density. On day one, the mean BCVA was 0.61 ± 0.13 decimals in the ultrasound (US) group and 0.67 ± 0.11 decimals in the torsional group (significant P < 0.05).Corneal edema was significantly less in the torsional group (P < 0.05). At 30 days, the mean BCVA was 0.94 ± 0.22 decimals in the US group and 1.0 ± 0.12 decimals in the torsional group but this difference was not statistically different (P > 0.05). Conclusions: The torsional mode provides an effective and safe method for cataract removal with lower energy usage as compared to longitudinal traditional phacoemulsification. However, the final visual outcome was similar for both study groups.

Purpose: To study the point prevalence of pseudoexfoliation syndrome (PXS) among Yemeni patients in different governorates with age-related cataract scheduled for surgery. Settings: Eye camps organized by the Nibras Health Society to perform cataract surgeries during the years 2002-2006. All patients aged 40 years and above were included in the study. Materials and Methods: A total of 2535 eyes of 2535 patients from 13 governorates, scheduled for cataract surgery in eye camps, were included. All eyes underwent complete eye examination before the surgery and were evaluated for the signs of pseudoexfoliation material in the pupil, iris and lens capsule on dilated slit lamp examination. Results: The study found 495 of the 2535 eyes (19.53%) with PXS with males more commonly affected than females (55.2 and 44.8%, respectively). The mean age of patients with PXS was 66.2 years while it was 64.6 years in non-PXS patients. The prevalence of pseudoexfoliation syndrome increased with age (10.1% in the age group of 41-50 years that increased to 28.8% in the age group of more than 81 years old). The rate of PXS detection in camps in 13 governorates ranged from 13.33 to 24.22% with an overall rate of 19.53%. The lowest rate was noticed in Sana'a and the highest in Al-Dhale governorate. Conclusion: This pilot study confirms that PXS was common in patients undergoing cataract surgery in Yemen with an increased detection rate with age. This study also highlights the prevalence of an ocular disease that is associated with systemic and ocular complications; however, further studies based on population studies are needed.

Aims: To determine whether the LV Prasad-Functional Vision Questionnaire (LVP-FVQ) could be used to assess self-reported visual function and quality of visual life in Egyptian school aged children. Materials and Methods: The LVP-FVQ was used to assess the quality of visual function in school-age children. All subjects were students at the time of assessment. Subjects underwent a visual function assessment that included distance and near visual acuity, contrast sensitivity, color vision and visual field examination where possible. Data analysis were for both descriptive and inference statistics. A P < 0.05 was considered statistically significant. Results: Fifty children aged 11.28 ± 3.5 years (range, 5 years to 18 years) with moderate-to-severe visual impairment most of their lives were enrolled. Twenty-two subjects (44%) had albinism, 18 (36%) subjects had hereditary retinal dystrophy, 6 (12%) subjects had cone dystrophy, 2 (4%) subjects had bilateral amblyopia and 2 (4%) subjects had congenital coloboma without other disabilities. The four most difficult tasks were related to the following daily activities alluded to in the questionnaire such as reading a textbook at arms length, copying from the blackboard, seeing somebody across the road and identifying colors. There was no statistically significant association between the demographic variables and the level of visual functioning, sex, age, type of school, family history or consanguinity (P > 0.05 for all variables). Conclusion: LVP-FVQ can be used to screen Egyptian children with visual impairment. Input and integration of the parents and the school teachers to evaluate the child s behavior at home and the school is essential to developing a balanced questionnaire.

Purpose: To evaluate challenges, attitudes and practices among spectacle wearers to effect positive change when necessary, and determine positive change in a resource-limited economy. Materials and Methods: A multi-hospital descriptive, cross sectional survey of spectacle wearers was conducted between May 2007 and December 2008 in Nigeria. Results: A total of 214 wearers comprising 43.5% males and 56.5% females aged 18-84 years were surveyed. The majority of subjects (92.6%) had at least secondary education. The wearers' challenges included expensive spectacles (43.0%), falling/ scratched/broken lenses (29.4%) and fear that spectacles would damage the eyes (23.8%). The wearers' attitudes were comprised of consultations with 'road side dispensers' (7%) and permitting other individuals to select spectacle frames for them (26%). Care and maintaince practices included use of handkerchief, tissue paper, fingers and water to clean spectacles (49.5%) and placing spectacles inside spectacle cases (30.4%). There were no associations (P > 0.05) between gender or literacy levels and who selected the frames for the subjects, caregivers consulted for spectacles, and cleaning materials for spectacles. The placement of spectacles when not in use was significantly associated (P < 0.05) with the wearers' gender and literacy levels but not with the length of spectacle wear. Conclusion: Attitudes and practices requiring positive change crossed gender and educational levels among spectacle wearers. The cost of spectacles should be regulated and availability of standard eye care practices would reduce challenges including lens-related defects and quackery. During consultation with a recognized eye care professional, counseling of wearers on positive attitudes/practices as well as allaying fear of spectacle wear is required.

Purpose: To evaluate the intraocular pressure (IOP) lowering efficacy of Garcinia kola 0.5% aqueous solution eye drops in patients with newly diagnosed primary open-angle glaucoma or ocular hypertension (POAG/OH). Materials and Methods: A randomized, double-masked, multicenter, active-controlled prospective study. Patients who met the inclusion criteria were randomly assigned in equal numbers to receive Timolol 0.5% eye drops as a control medication (A = Group 1 eyes) or Garcinia kola 0.5% eye drops as the study medication (B = Group 2 eyes). All drops were instilled at 6 am and 6 pm daily. Goldman applanation tonometry was performed at 9 am, 12 pm and 3 pm at baseline, week-6, week-12 and week-24 visits. Voluntary and actively elicited reports of adverse events were documented. The mean change in IOP over 24 weeks was the primary outcome measure. Both groups were compared for statistically significant differences at all visits. A P < 0.05 was considered statistically significant. Results: A total of 178 patients were randomly assigned to G. kola and Timolol groups. At baseline there were no differences in mean IOP between groups, based on age, sex, or diagnosis. At the end of the study period (24 ^th week), the mean (± SD) reduction in IOP was 12.93 ± 2.3 mmHg (47.8% ± 0.8% reduction) in G. Kola group and 13.09 ± 2.8 mm Hg (48.2% ± 1.03% reduction) in the Timolol group (P> 0.05). Adverse events were mild in nature with no statistically significant differences between groups (P > 0.05). Conclusions: Garcinia kola ophthalmic solution significantly reduces IOP as compared to baseline. The IOP lowering effect of both treatments was equivalent.

Purpose: To study and compare the effects of the micro-incision cataract surgery (MICS-sub 1.8 mm) and mini-incision coaxial phacoemulsification (2.2 mm) on the optical quality of the cornea characterized in terms of corneal aberrations. Materials and Methods: Fifty eyes underwent MICS and 50 mini-incision phacoemulsification, by the same surgeon. Both types of cataract surgery were performed using low ultrasound power and through a clear corneal incision, placed on the steepest corneal meridian ranging from 1.6 to 1.8 in MICS (Group I) and from 2.12 to 2.3 mm in mini-incision coaxial phacoemulsification (Group II). Seidel and Zernike aberration coefficients and RMS values were obtained for a 6-mm pupil preoperatively and one month after surgery. Results: The corneal astigmatism did not show statistically significant changes in either of the two groups: (MICS: -0.73 ± 0.63, -0.65 ± 0.53 D, P = 0.25), (mini-incision phacoemulsification; -1.21 ± 1.52, -1.00 ± 1.19 D, P = 0.12). The total RMS remained unchanged after MICS (1.77 ± 1.7, 1.65 ± 1.3 µm, P = 0.18) and mini-incision phacoemulsification (2.00 ± 1.87, 2.09 ± 1.8 µm, P = 0.41). Statistically significant changes were found for coma (P = 0.004) and higher-order aberrations (P < 0.001), showing MICS significantly less changes in cornea. Conclusions: Both MICS and mini-incision phacoemulsification do not degrade the optical quality of the cornea. Both surgeries do not induce a modification of the corneal astigmatism, even in the axis. It seems that 2 mm is the limit around which no optical changes are induced by cataract surgery in the human cornea.

Intralesional injection of corticosteroids has been used successfully in the treatment of adenexal hemangiomas, with advantages of easy administration, rapid action, repeatability, efficacy and safety. We report a case of an eight-month-old female infant who underwent intralesional corticosteroid injection for capillary hemangioma that had resulted in amblyopia of her left eye from ptosis. Two weeks after the injection, the hemangioma showed some regression but at that point iris depigmentation of the affected eye was noted. The iris depigmentation remained unchanged during her follow-up visit with significant regression of the hemangioma, associated ptosis and astigmatism.

A 16 year old male experienced blunt ocular trauma causing rupture of the anterior lens capsule and mature cataract development. The trauma was due to a stone that impacted the left eye. In an otherwise clear lens, an anterior lens capsule defect formed post-trauma that progressed to a mature cataract over four months reducing distance vision from 20/125 to hand motion. The patient underwent phacoemulsification with posterior chamber intraocular lens implantation in the left eye. One year postoperatively, the vision in the left eye increased to 20/25 without correction. This is a rare case of cataract formation due to a defect in the anterior lens capsule caused by blunt ocular trauma.