Corneal blindness is an important contributor to the burden of global blindness and has a greater prevalence in low-income countries of the developing world where resources and infrastructure are limited. The causes of corneal blindness too are different from high-income countries and include infectious keratitis, ocular trauma, and xerophthalmia. Persons with these indications tend to have unfavourable outcomes after corneal transplantation, limiting their chances of benefitting from this sight-saving procedure. However, most causes of corneal blindness in the developing world are preventable. This highlights the importance of understanding the unique challenges in these regions and the need for targeted interventions. This article discusses various prevention strategies, including primordial, primary, and secondary prevention, aimed at reducing the burden of corneal blindness in low-income countries. These include capacity building, training, and awareness campaigns to reduce the risk factors of ocular trauma, infectious keratitis, and to improve access to first aid. It is also important to promote safe eye practices and tackle nutritional deficiencies through public health interventions and policy changes. Providing the required training to general ophthalmologists in the management of basic corneal surgeries and diseases and enhancing the accessibility of eye care services in rural areas will ensure early treatment and prevent sequelae. Current treatment modalities belong to the tertiary level of prevention and are largely limited to corneal transplantation. In developing nations, there is a scarcity of donor corneal tissue necessitating an urgent expansion of eye banking services. Alternative approaches to corneal transplantation such as 3D printed corneas, cultured stem cells, and biomaterials should also be explored to meet this demand. Thus, there is a need for collaborative efforts between healthcare professionals, policymakers, and communities to implement effective prevention strategies and reduce the prevalence of corneal blindness in the developing world.

OBJECTIVE: To report the visual outcomes and survival analysis of keratoprosthesis without contact lens wearing in a tertiary eye care hospital in Mexico City, Asociación Para Evitar La Ceguera (APEC, Coyoacán, México).
METHODS: Retrospective cohort with survival analysis.
METHODS: Twenty-three eyes (22 patients) received KPro type 1 between 2015 and 2020 with a follow-up time of three years.
METHODS: We included analyzed data about past medical history, preoperative diagnosis, best-spectacle visual acuity (BSCVA), postoperative complications and retention rate. Univariate, bivariate and survival analysis were performed and reported.
RESULTS: The mean age was 58 ± 13.5 years (SD). 60.86% were male patients (14 eyes). Twelve-eyes (52%) achieved a BSCVA of 20/200 or better in the first and second year of follow-up. At 3 years, only 35% achieved 20/200 or better (BSCVA). Retention rate of Boston type 1 KPro was 87% (20 eyes) at 3 years follow-up. The most common complication was retroprosthetic membrane (RPM) which occurred in 9 eyes (39.1%), followed by corneal melting in 7 eyes (30.4%).
CONCLUSIONS: We report the results of a retrospective cohort of twenty-three eyes (22 patients) who were implanted with a Boston type 1 KPro without contact lens wearing to treat corneal blindness. BSCVA improved significantly in most patients achieving 20/200 or better at the 2-year follow-up. Retention rate was 87%, with the presence of RPM as the most common complication.

OBJECTIVE: To compare visual and glaucoma outcomes in patients with known glaucoma after a penetrating keratoplasty (PKP) or a Boston Keratoprosthesis Type 1 (KPro) as a second corneal replacement procedure.
METHODS: Retrospective interventional case series.
METHODS: Charts of 141 eyes that underwent either a PKP or KPro at the Centre hospitalier de l\'Université de Montréal after one failed PKP from 2008 to 2020 were reviewed. Forty-six eyes with preoperative glaucoma were included.
METHODS: Data collected included demographics, indication for the initial surgery, best corrected visual acuity (BCVA), concurrent ocular disorders, number of glaucoma medications, need for glaucoma surgery, cup-to-disc ratios (CDRs), mean RNFL thickness, and visual field (VF) characteristics. Primary outcomes were glaucoma progression trends. Secondary outcomes were visual outcomes and need for additional procedures.
RESULTS: Mean follow-up was 4.7 years for the PKP and 7.3 for the KPro group (P<0.007). 30.6% of PKP compared to 70.5% of KPro patients were diagnosed with glaucoma preoperatively. Glaucoma worsened similarly in both groups; this is based on an analysis of the number of glaucoma medications, CDR, need for glaucoma surgery, and characteristic VF changes. Patients in the PKP group required significantly more regrafts than patients in the KPro group (31.8 vs. 8.3%; P=0.045).
CONCLUSIONS: A preoperative diagnosis of glaucoma does not preclude KPro implantation. In glaucomatous eyes, the disease progressed similarly in both groups. Since both procedures increase the risk of worsening glaucoma, close follow-up is recommended. KPro may decrease the need for further corneal transplantation surgery.

OBJECTIVE: To evaluate long-term visual outcomes of Boston type I keratoprosthesis (KPro) surgery and identify risk factors for visual failure.
METHODS: Single surgeon retrospective cohort study including 85 eyes of 74 patients who underwent KPro implantation to treat severe ocular surface disease, including limbal stem cell deficiency, postinfectious keratitis, aniridia and chemical burns. Procedures were performed at the Centre hospitalier de l\'Université de Montréal from October 2008 to May 2012. All patients with at least 5 years of follow-up were included in the analysis, including eyes with repeated KPro. Main outcome measures were visual acuity (VA), visual failure, defined as a sustained VA worse than the preoperative VA, postoperative complications, and device retention.
RESULTS: Mean follow-up was 7.2±1.3 years (±SD). Mean VA was 2.1±0.7 (logarithm of minimal angle resolution) preoperatively and 1.9±1.2 at last follow-up. In total, 2.4% of patients had VA better than 20/200 preoperatively vs. 36.5% at last follow-up. Maintenance of improved postoperative VA was seen in 61.8% of eyes at 7 years. Preoperative factors associated with visual failure were known history of glaucoma (HR=2.7 [1.2 to 5.9], P=0.02) and Stevens-Johnson syndrome (HR=7.3 [2.5 to 21.4], P<0.01). Cumulative 8-year complication rates were 38.8% retroprosthetic membrane formation, 25.9% hypotony, 23.5% new onset glaucoma, 17.6% retinal detachment, 8.2% device extrusion and 5.9% endophthalmitis. The majority (91.8%) of eyes retained the device 8 years after implantation.
CONCLUSIONS: Nearly two-thirds of patients exhibited improved VA 7 years after KPro implantation. Preoperative risk factors for visual failure were known glaucoma and Stevens-Johnson syndrome.

The Boston keratoprosthesis (BKPro) is a medical device used to restore vision in complicated cases of corneal blindness. This device is composed by a front plate of polymethylmethacrylate (PMMA) and a backplate usually made of titanium (Ti). Ti is an excellent biomaterial with numerous applications, although there are not many studies that address its interaction with ocular cells. In this regard, despite the good retention rates of the BKPro, two main complications compromise patients\' vision and the viability of the prosthesis: imperfect adhesion of the corneal tissue to the upside of the backplate and infections. Thus, in this work, two topographies (smooth and rough) were generated on Ti samples and tested with or without functionalization with a dual peptide platform. This molecule consists of a branched structure that links two peptide moieties to address the main complications associated with BKPro: the well-known RGD peptide in its cyclic version (cRGD) as cell pro-adherent motif and the first 11 residues of lactoferrin (LF1-11) as antibacterial motif. Samples were physicochemically characterized, and their biological response was evaluated in vitro with human corneal keratocytes (HCKs) and against the gram-negative bacterial strain Pseudomonas aeruginosa. The physicochemical characterization allowed to verify the functionalization in a qualitative and quantitative manner. A higher amount of peptide was anchored to the rough surfaces. The studies performed using HCKs showed increased long-term proliferation on the functionalized samples. Gene expression was affected by topography and peptide functionalization. Roughness promoted α-smooth muscle actin (α-SMA) overexpression, and the coating notably increased the expression of extracellular matrix components (ECM). Such changes may favour the development of unwanted fibrosis, and thus, corneal haze. In contrast, the combination of the coating with a rough topography decreased the expression of α-SMA and ECM components, which would be desirable for the long-term success of the prosthesis. Regarding the antibacterial activity, the functionalized smooth and rough surfaces promoted the death of bacteria, as well as a perturbation in their wall definition and cellular morphology. Bacterial killing values were 58 % for smooth functionalised and 68 % for rough functionalised samples. In summary, this study suggests that the use of the dual peptide platform with cRGD and LF1-11 could be a good strategy to improve the in vitro and in vivo performance of the rough topography used in the commercial BKPro.

BACKGROUND: The aim of this work is to evaluate the effect of mesenchymal stem cell transplantation (MSCT) and cultivated limbal epithelial transplantation (CLET) therapies on the limbus of patients suffering from limbal stem cell deficiency (LSCD).
METHODS: A sub-analysis of a phase I-II randomized, controlled, and double-masked clinical trial was performed to assess the changes in the anatomical structures of the limbus. In vivo confocal microscopy (IVCM) analysis was carried out in LSCD eyes before and 12 months after allogeneic MSCT or CLET. Epithelial phenotype of the central cornea, as well as the presence of transition zones and palisades of Vogt in the limbus, were assessed using Wilcoxon test.
RESULTS: Twenty-three LSCD (14 MSCT and nine CLET) eyes were included. The epithelial phenotype of the central cornea improved significantly (p < 0.001) from 15 (eight MSCT, seven CLET) and eight (six MSCT, two CLET) LSCD eyes showing conjunctival and mixed phenotypes, respectively, to eight (five MSCT, three CLET), five (two MSCT, three CLET), and ten (seven MSCT, three CLET) eyes showing conjunctival, mixed, and corneal phenotypes, respectively. Transition areas and palisades of Vogt were observed in at least one quadrant in nine (five MSCT, four CLET) and 16 (nine MSCT, seven CLET), and in four (two MSCT, two CLET) and six (three MSCT, three CLET) LSCD eyes before and after surgery, respectively. Changes in the transition zones and palisades were solely significant (p = 0.046) for the nasal and inferior quadrants, respectively.
CONCLUSIONS: MSCT and CLET improved the central corneal epithelial phenotype despite only minor changes in the anatomical structures of the limbus, as detected by IVCM technology.
BACKGROUND: ClinicalTrials.gov identifier, NCT01562002.

Currently, corneal blindness is affecting >10 million individuals worldwide, and there is a significant unmet medical need because only 1.5% of transplantation needs are met globally due to a lack of high-quality grafts. In light of this global health disaster, researchers are developing corneal substitutes that can resemble the human cornea in vivo and replace human donor tissue. Thus, this review examines ROCK (Rho-associated coiled-coil containing protein kinases) inhibitors as a potential corneal wound-healing (CWH) therapy by reviewing the existing clinical and nonclinical findings. The systematic review was done from PubMed, Scopus, Web of Science, and Google Scholar for CWH, corneal injury, corneal endothelial wound healing, ROCK inhibitors, Fasudil, Netarsudil, Ripasudil, Y-27632, clinical trial, clinical study, case series, case reports, preclinical study, in vivo, and in vitro studies. After removing duplicates, all downloaded articles were examined. The literature search included the data till January 2023. This review summarized the results of ROCK inhibitors in clinical and preclinical trials. In a clinical trial, various ROCK inhibitors improved CWH in individuals with open-angle glaucoma, cataract, iris cyst, ocular hypertension, and other ocular diseases. ROCK inhibitors also improved ocular wound healing by increasing cell adhesion, migration, and proliferation in vitro and in vivo. ROCK inhibitors have antifibrotic, antiangiogenic, anti-inflammatory, and antiapoptotic characteristics in CWH, according to the existing research. ROCK inhibitors were effective topical treatments for corneal infections. Ripasudil, Y-27632, H-1152, Y-39983, and AMA0526 are a few new ROCK inhibitors that may help CWH and replace human donor tissue.

Corneal scarring and opacification are a significant cause of blindness affecting millions worldwide. The current standard of care for corneal blindness is corneal transplantation, which suffers from several drawbacks. One alternative approach that has shown promise is the use of xenogeneic corneal extracellular matrix (ECM), but its clinical applicability is challenging due to safety concerns. This study reports the innovative use of human cornea-derived ECM to prevent post-traumatic corneal scarring. About 30 - 40% of corneas donated to the eye banks do not meet the standards defined for clinical use and are generally discarded, although they are completely screened for their safety. In this study, human cornea-derived decellularized ECM hydrogel was prepared from the non-transplantation grade human cadaveric corneas obtained from an accredited eye-bank. The prepared hydrogel was screened for its efficacy against corneal opacification following an injury in an animal model. Our in vivo study revealed that, the control collagen-treated group developed corneal opacification, while the prophylactic application of human cornea-derived hydrogel effectively prevented corneal scarring and opacification. The human hydrogel-treated corneas were indistinguishable from healthy corneas and comparable to those treated with the xenogeneic bovine corneal hydrogel. We also demonstrated that the application of the hydrogel retained the biological milieu including cell behavior, protein components, optical properties, curvature, and nerve regeneration by remodeling the corneal wound after injury. The hydrogel application is also sutureless, resulting in faster corneal healing. We envision that this human cornea-derived ECM-based hydrogel has potential clinical application in preventing scarring from corneal wounding. STATEMENT OF SIGNIFICANCE: There are significant challenges surrounding corneal regeneration after injury due to extensive scarring. Although there is substantial research on corneal regeneration, much of it uses synthetic materials with chemical cross-linking methods or xenogeneic tissue-based material devices which have to undergo exhaustive safety analysis before clinical trials. Herein, we demonstrate the potential application of a human corneal extracellular matrix hydrogel without any additional materials for scarless corneal tissue regeneration, and a method to reduce the wasting of donated allogenic corneal tissue from eye banks. We found no difference in efficacy between the usage of human tissues compared to xenogeneic sources. This may help ease clinical translation and can be used topically without sutures as an outpatient procedure.

Millions of people worldwide live with corneal opacity, which continues to be one of the leading causes of blindness. Corneal opacity is treatable. However, the surgical methods for treating this condition, such as corneal transplantation and keratoprosthesis, have many complications. The use of an intraocular projector is a promising approach to treat corneal blindness. Like any device using electrical power, an intraocular projection device produces heat, which could potentially damage eye tissue. Australian and international standards state that there cannot be an increase of temperature of 2 °C caused by an implanted device. In order to determine if these standards are met, a 2D axisymmetric thermal analysis of the projector in the human eye is conducted in ANSYS Workbench. With the projector operating at its maximum wattage, our analysis shows that an air gap extension within the projector will help maintain the temperature increase below 2 °C.

Corneal blindness (CB) is one of the leading causes of blindness in India and globally, affecting around 8 million population worldwide. Many of these corneal blind patients may be visually rehabilitated by corneal transplantation (CT). Eye banking plays a crucial role in facilitating CT and ocular research. Many countries have adopted regulatory frameworks, quality assurance programs, and technological advancements to enhance the efficacy and safety of CT. Various infrastructural and organizational frameworks of eye banks (EBs) in India, according to the Eye Bank Association of India (EBAI), aid in establishing guidelines and standards for EB practices. Initiatives such as the National Programme for Control of Blindness (NPCB) have significantly contributed to eye donation rates and improved access to donor corneas. This review article discusses the established eye banking networks in countries such as India, the United States (USA), and Europe, where dedicated EB organizations work collaboratively to ensure efficient procurement, processing, and distribution of corneal tissue. It also highlights specific strategies employed in India and global countries to address EBs\' challenges. These challenges include the shortage of donor corneas, improving donor screening and tissue processing techniques, ensuring timely distribution of corneal tissue, and maintaining high-quality standards. Interestingly, the comparative analysis between India and other developed countries highlights the similarities and differences in eye banking strategies. By understanding the strategies employed by different regions, EBs can learn from each other\'s experiences and work toward achieving optimal outcomes in CT and ocular research worldwide. It underscores the importance of knowledge sharing and collaborative efforts in addressing common challenges and implementing best practices in eye banking.