Importance Corneal transplantation restores visual function when visual impairment caused by a corneal disease becomes too severe. It is considered the world’s most frequent type of transplantation, but, to our knowledge, there are no exhaustive data allowing measurement of supply and demand, although such data are essential in defining local, national, and global strategies to fight corneal blindness. Objective To describe the worldwide situation of corneal transplantation supply and demand. Design, Setting, and Participants Data were collected between August 2012 and August 2013 from a systematic review of published literature in parallel with national and international reports on corneal transplantation and eye banking. In a second step, eye bank staff and/or corneal surgeons were interviewed on their local activities. Interviews were performed during international ophthalmology or eye-banking congresses or by telephone or email. Countries’ national supply/demand status was classified using a 7-grade system. Data were collected from 148 countries. Main Outcomes and Measures Corneal transplantation and corneal procurements per capita in each country. Results In 2012, we identified 184 576 corneal transplants performed in 116 countries. These were procured from 283 530 corneas and stored in 742 eye banks. The top indications were Fuchs dystrophy (39% of all corneal transplants performed), a primary corneal edema mostly affecting elderly individuals; keratoconus (27%), a corneal disease that slowly deforms the cornea in young people; and sequellae of infectious keratitis (20%). The United States, with 199.10 −6 corneal transplants per capita, had the highest transplantation rate, followed by Lebanon (122.10 −6 ) and Canada (117.10 −6 ), while the median of the 116 transplanting countries was 19.10 −6 . Corneas were procured in only 82 countries. Only the United States and Sri Lanka exported large numbers of donor corneas. About 53% of the world’s population had no access to corneal transplantation. Conclusions and Relevance Our survey globally quantified the considerable shortage of corneal graft tissue, with only 1 cornea available for 70 needed. Efforts to encourage cornea donation must continue in all countries, but it is also essential to develop alternative and/or complementary solutions, such as corneal bioengineering.

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Global Survey of Corneal Transplantation and Eye Banking

Evaluation and outcome of young children with chronic cough.

This report updates and combines into one document earlier versions of guidelines for preventing and treating opportunistic infections (OIs) among HIV-exposed and HIV-infected children, last published in 2002 and 2004, respectively. These guidelines are intended for use by clinicians and other health-care workers providing medical care for HIV-exposed and HIV-infected children in the United States. The guidelines discuss opportunistic pathogens that occur in the United States and one that might be acquired during international travel (i.e., malaria). Topic areas covered for each OI include a brief description of the epidemiology, clinical presentation, and diagnosis of the OI in children; prevention of exposure; prevention of disease by chemoprophylaxis and/or vaccination; discontinuation of primary prophylaxis after immune reconstitution; treatment of disease; monitoring for adverse effects during treatment; management of treatment failure; prevention of disease recurrence; and discontinuation of secondary prophylaxis after immune reconstitution. A separate document about preventing and treating of OIs among HIV-infected adults and postpubertal adolescents (Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents) was prepared by a working group of adult HIV and infectious disease specialists. The guidelines were developed by a panel of specialists in pediatric HIV infection and infectious diseases (the Pediatric Opportunistic Infections Working Group) from the U.S. government and academic institutions. For each OI, a pediatric specialist with content-matter expertise reviewed the literature for new information since the last guidelines were published; they then proposed revised recommendations at a meeting at the National Institutes of Health (NIH) in June 2007. After these presentations and discussions, the guidelines underwent further revision, with review and approval by the Working Group, and final endorsement by NIH, CDC, the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Disease Society (PIDS), and the American Academy of Pediatrics (AAP). The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of the evidence supporting the recommendation so readers can ascertain how best to apply the recommendations in their practice environments. An important mode of acquisition of OIs, as well as HIV infection among children, is from their infected mother; HIV-infected women coinfected with opportunistic pathogens might be more likely than women without HIV infection to transmit these infections to their infants. In addition, HIV-infected women or HIV-infected family members coinfected with certain opportunistic pathogens might be more likely to transmit these infections horizontally to their children, resulting in increased likelihood of primary acquisition of such infections in the young child. Therefore, infections with opportunistic pathogens might affect not just HIV-infected infants but also HIV-exposed but uninfected infants who become infected by the pathogen because of transmission from HIV-infected mothers or family members with coinfections. These guidelines for treating OIs in children therefore consider treatment of infections among all children, both HIV-infected and uninfected, born to HIV-infected women. Additionally, HIV infection is increasingly seen among adolescents with perinatal infection now surviving into their teens and among youth with behaviorally acquired HIV infection. Although guidelines for postpubertal adolescents can be found in the adult OI guidelines, drug pharmacokinetics and response to treatment may differ for younger prepubertal or pubertal adolescents. Therefore, these guidelines also apply to treatment of HIV-infected youth who have not yet completed pubertal development. Major changes in the guidelines include 1) greater emphasis on the importance of antiretroviral therapy for preventing and treating OIs, especially those OIs for which no specific therapy exists; 2) information about the diagnosis and management of immune reconstitution inflammatory syndromes; 3) information about managing antiretroviral therapy in children with OIs, including potential drug--drug interactions; 4) new guidance on diagnosing of HIV infection and presumptively excluding HIV infection in infants that affect the need for initiation of prophylaxis to prevent Pneumocystis jirovecii pneumonia (PCP) in neonates; 5) updated immunization recommendations for HIV-exposed and HIV-infected children, including hepatitis A, human papillomavirus, meningococcal, and rotavirus vaccines; 6) addition of sections on aspergillosis; bartonella; human herpes virus-6, -7, and -8; malaria; and progressive multifocal leukodystrophy (PML); and 7) new recommendations on discontinuation of OI prophylaxis after immune reconstitution in children. The report includes six tables pertinent to preventing and treating OIs in children and two figures describing immunization recommendations for children aged 0--6 years and 7--18 years. Because treatment of OIs is an evolving science, and availability of new agents or clinical data on existing agents might change therapeutic options and preferences, these recommendations will be periodically updated and will be available at http://AIDSInfo.nih.gov.

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Guidelines for the Prevention and Treatment of Opportunistic Infections Among HIV-Exposed and HIV-Infected Children: Recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics

PURPOSE\nThe safety and efficacy of corneal collagen cross-linking (CXL) and topography-guided photorefractive keratectomy (PRK) using a different sequence and timing were evaluated in consecutive keratoconus cases.\n\n\nMETHODS\nThis study included a total of 325 eyes with keratoconus. Eyes were divided into two groups. The first group (n=127 eyes) underwent CXL with subsequent topography-guided PRK performed 6 months later (sequential group) and the second group (n=198 eyes) underwent CXL and PRK in a combined procedure on the same day (simultaneous group). Statistical differences were examined for pre- to postoperative changes in uncorrected (UCVA, logMAR) and best-spectacle-corrected visual acuity (BSCVA, logMAR), manifest refraction spherical equivalent (MRSE), keratometry (K), topography, central corneal thickness, endothelial cell count, corneal haze, and ectatic progression. Mean follow-up was 36+/-18 months (range: 24 to 68 months).\n\n\nRESULTS\nAt last follow-up in the sequential group, the mean UCVA improved from 0.9+/-0.3 logMAR to 0.49+/-0.25 logMAR, and mean BSCVA from 0.41+/-0.25 logMAR to 0.16+/-0.22 logMAR. Mean reduction in spherical equivalent refraction was 2.50+/-1.20 diopters (D), mean haze score was 1.2+/-0.5, and mean reduction in K was 2.75+/-1.30 D. In the simultaneous group, mean UCVA improved from 0.96+/-0.2 logMAR to 0.3+/-0.2 logMAR, and mean BSCVA from 0.39+/-0.3 logMAR to 0.11+/-0.16 logMAR. Mean reduction in spherical equivalent refraction was 3.20+/-1.40 D, mean haze score was 0.5+/-0.3, and mean reduction in K was 3.50+/-1.3 D. Endothelial cell count preoperatively and at last follow-up was unchanged (P<.05) in both groups. Statistically, the simultaneous group did better (P<.05) in all fields evaluated, with improvement in UCVA and BSCVA, a greater mean reduction in spherical equivalent refraction and keratometry, and less corneal haze.\n\n\nCONCLUSIONS\nSame-day simultaneous topography-guided PRK and CXL appears to be superior to sequential CXL with later PRK in the visual rehabilitation of progressing keratoconus.

Long Term Comparison of Sequential vs. Same-Day Simultaneous Collagen Cross-Linking and Topography-Guided PRK for Treatment of Keratoconus

Physicians today are increasingly faced with healthcare challenges that require an understanding of global health trends and practices, yet little is known about what constitutes appropriate global health training. A literature review was undertaken to identify competencies and educational approaches for teaching global health in medical schools. Using a pre-defined search strategy, 32 articles were identified; 11 articles describing 15 global health competencies for undergraduate medical training were found. The most frequently mentioned competencies included an understanding of: the global burden of disease, travel medicine, healthcare disparities between countries, immigrant health, primary care within diverse cultural settings and skills to better interface with different populations, cultures and healthcare systems. However, no consensus on global health competencies for medical students was apparent. Didactics and experiential learning were the most common educational methods used, mentioned in 12 and 13 articles respectively. Of the 11 articles discussing competencies, 8 linked competencies directly to educational approaches. This review highlights the imperative to document global health educational competencies and approaches used in medical schools and the need to facilitate greater consensus amongst medical educators on appropriate global health training for future physicians.

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Global health competencies and approaches in medical education: a literature review

Purpose:To report the safety and efficacy of descemetorhexis without grafting as a primary intervention in Fuchs dystrophy, and the use of a ROCK inhibitor, ripasudil as a salvage agent in failing cases.Methods:Twelve eyes of 11 patients underwent central descemetorhexis not exceeding 4 mm. All had

Descemetorhexis Without Grafting for Fuchs Endothelial Dystrophy-Supplementation With Topical Ripasudil.

PURPOSE: The aim of this study was to report the evolving indications for keratoplasty and the shift in the type of keratoplasty performed in British Columbia, Canada, over a 10-year period from 2002 to 2011. METHODS: This was a retrospective database review of all the records of corneal transplant tissues at the Eye Bank of British Columbia, Canada, from January 2002 to December 2011. The patient demographics, indications, and types of transplant performed were analyzed. RESULTS: A total of 4843 corneal transplants were performed in 3742 patients (1968 male and 1774 female) from January 2002 to December 2011. The number of keratoplasties performed ranged from 420 in 2008 to 578 in 2011. The top 4 indications over the 10-year period were Fuchs endothelial dystrophy (FED; 18.9%), aphakic/pseudophakic bullous keratopathy (17.4%), regraft (17.1%), and keratoconus (15.5%). Penetrating keratoplasty (PKP) accounted for 86.5% (4191 transplants) of all keratoplasties performed. Since the introduction of Descemet stripping automated endothelial keratoplasty (DSAEK) in 2007, there was a significant increase in the number of DSAEKs (P < 0.0001) performed and a statistical decline in the number of PKPs (P < 0.0001) performed. Despite only 30 deep anterior lamellar keratoplasties being performed, an increasing trend was observed after 2008 (P = 0.0087). A decreasing trend in PKPs and an increasing trend in DSAEKs were observed for surgeries performed for FED, aphakic/pseudophakic bullous keratopathy, and regraft. CONCLUSIONS: FED has become the top indication for performing a keratoplasty over the 10-year period. There was a shift from PKP to DSAEK performed for endothelial failure. Although the number of deep anterior lamellar keratoplasty surgeries was small, there was a significant increasing trend.

Evolving indications for and trends in keratoplasty in British Columbia, Canada, from 2002 to 2011: a 10-year review.

Purpose To report results of a series of highly aberrated corneas treated with a topography-guided excimer laser ablation. Methods Retrospective, nonrandomized, consecutive series of eyes treated with topography-guided photorefractive keratectomy (TG-PRK) with the customized topographical neutralization technique (TNT). Cases included postoperative refractive surgery decentered ablations, optical zone enlargement, asymmetrical astigmatism, postoperative radial keratotomy (RK), postoperative keratoplasty, keratoconus combined with collagen cross-linking (CXL), and postoperative LASIK ectasia combined with CXL. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refraction were analyzed preoperatively and 6 months postoperatively. Results In decentered ablation cases, 94% of 37 eyes were within 1.00 diopter (D) of the attempted refractive outcome, with 76% within 0.50 D. Mean topographic, central, optical zone of uniform (monodioptric) power increased from 3.5 to 5.2 mm in 25 eyes. Thirty-one eyes treated for asymmetrical astigmatism showed improvement in cylinder from mean 1.31 to 0.52 D. Ten of 11 eyes treated for previous RK astigmatism achieved postoperative UDVA 20/40 or better. Twenty-seven eyes with postoperative keratoplasty astigmatism were treated, with 7 (25.9%) eyes gaining > or = 2 lines and 12 (44.4%) eyes gaining > or = 1 line of CDVA. Of eyes with keratoconus that were treated using TG-PRK with CXL, 42 (58%) eyes had UDVA 20/40 or better, and 66 (92%) eyes had CDVA 20/40 or better. Twelve (71%) of 17 eyes treated for postoperative LASIK ectasia using TG-PRK with CXL had UDVA 20/40 or better. Nine (53%) eyes gained > or = 2 lines of CDVA. Conclusions Topography-guided laser treatment with custom TNT, combined with CXL in keratoconus and ectasia, is an effective, safe, and increasingly predictable option for highly aberrated corneas.

Clinical results of topography-based customized ablations in highly aberrated eyes and keratoconus/ectasia with cross-linking.

Purpose of review To summarize the recent literature regarding descemetorhexis stripping without endothelial keratoplasty (DWEK), increasingly referred to as Descemet's stripping only (DSO). To report the characteristic clinical, confocal and histologic findings associated with this procedure. Recent findings Reported clearance rates following DSO range from 63 to 100% in recent series, with variation between surgical techniques. Topical Rho-kinase inhibitor has been reported as successfully salvaging failing cases. Its use as an adjuvant to the surgery is gaining widespread adoption with the results of early series now arriving. Apart from a phenotype of central guttata with clear periphery, patient characteristics which determine success remain elusive. Surgical factors affecting success are increasingly well understood, with stromal injury felt to be a retardant to healing. Characteristic clinical signs have been observed and are described herein. Clinical, confocal and light microscopic images are obtained from patients in clinical trials of DSO with ripasudil. Summary DSO is gaining acceptance as a surgical option for a subset of patients with Fuchs' Dystrophy. The addition of Rho-associated kinase inhibitor appears to improve predictability but further results to this effect must be published and scrutinized.

Descemet's stripping without endothelial keratoplasty.

Objective To describe 2 cases of spontaneous corneal clearing after Descemetorhexis: 1 after iatrogenic trauma (Case 1) and 1 as an intentional surgical intervention for Fuchs endothelial dystrophy (Case 2). Methods Retrospective case reports. Results Full corneal clarity was observed to restore at approximately 1 month after surgery in both cases. Central endothelial cell counts were recorded as 753 and 731 cells/mm 2 in cases 1 and 2, respectively, at last follow-up. Best spectacle corrected visual acuity (BSCVA) at was 6/6 in both cases at 6 weeks and is retained at 9 months. Conclusions Selective Descemetorhexis may offer visual rehabilitation without the need for a graft in select cases of Fuchs endothelial dystrophy. Descemetopexy in anticipation of corneal clearing is a viable initial strategy in cases of iatrogenic Descemet trauma with detachment.

Gregory Moloney

Papers

Descemetorhexis Without Grafting for Fuchs Endothelial Dystrophy-Supplementation With Topical Ripasudil.

Evolving indications for and trends in keratoplasty in British Columbia, Canada, from 2002 to 2011: a 10-year review.

Clinical results of topography-based customized ablations in highly aberrated eyes and keratoconus/ectasia with cross-linking.

Descemet's stripping without endothelial keratoplasty.

Descemetorhexis for Fuchs' dystrophy.