Cornea

This book, with contributions by some distinguished ophthalmologists, neatly summarizes some of the recent advances in corneal diseases and their management. The opening chapter by Dua and Said, is an appropriate introduction to the book, dealing as it does with the fundamental basics of ocular health – the tear film, conjunctiva, the limbus with its reservoir of stem cells and corneal nerves. The authors’ summary of the current principles in the management of some commonly encountered diseases of the ocular surface like dry eye, infective keratitis and allergic eye disease would be useful to all general ophthalmologists. The algorithmic approach in the treatment of the more complex group of cicatrizing disorders of the ocular surface has been dealt with nicely.

A clear corneal graft is no longer considered the only end point for a corneal transplant. To earn the term “successful” it should result in an acceptable refractive outcome as well. Keratoplasties are notorious for the high and unpredictable astigmatism following surgery. Nuijts, Jonker and Saelens deal with various surgical methods of reducing postoperative astigmatism in the second chapter entitled, “Surgical Management of Post-Keratoplasty Astigmatism”. More recently attempted techniques such as the femtosecond laser-assisted intrastromal corneal ring segment (ICRS) implantation have also been included. The important subject of post-keratoplasty astigmatism, would, however, have been more completely dealt with if the authors had included non-surgical techniques, like the contact lenses, including specialized ones meant for correction of irregular astigmatism.

Chapter 6, “High-Risk Corneal Transplantation” which should ideally have followed the first chapter, “The Ocular Surface: Functional Anatomy, Medical and Surgical Management”, is a brief overview of the risk factors and the post-operative management in conditions generally seen as “high risk” situations for keratoplasty. It is a common terminology for a variety of conditions, some of which are often encountered by a practicing clinician. It would have been useful if these were dealt with as subsets (e.g., chemical injuries, regrafts, post-herpetic keratitis, etc.) explaining the nuances of management in each subset, with illustrated examples.

Although keratoplasty has been in practice on human eyes for more than a century, the last couple of decades have seen significant changes that make it a more precise and safe method of corneal replacement. Chapter 3, “Femtosecond Laser-Assisted Penetrating and Lamellar Keratoplasty” should have been sequenced in tandem with the last two chapters on deep anterior lamellar keratoplasty and descemet membrane endothelial keratoplasty. Together, these summarize the latest and most refined techniques in keratoplasty. All three chapters are particularly well illustrated and the description of the surgical steps is equally instructive. Several techniques are described as also the management of frequently encountered problems.

The standard treatment for keratoconus has always been contact lenses until the disease progresses to a stage when the more definitive treatment of corneal transplantation is required. In the last couple of decades, the introduction of corneal collagen crosslinking (CXL) marks a paradigm shift in the approach to management of keratoconus. Cassagne, El Hout and Melecaze describe not only the conventional method of CXL but also new techniques like iontophoresis which are being investigated to facilitate the stromal penetration of riboflavin without the need to remove corneal epithelium, in chapter 4. While CXL achieves stabilization of the disease, it is the grossly misshapen cornea that causes profound visual impairment. Kymionis discusses the role of intracorneal ring segments in chapter 5, with the help of example cases to achieve refractive adjustments in keratoconus.

On the whole, this book has brought together the more recent advances in this field and could serve as a supplement to standard textbooks. The book is bound to be useful for trainee corneal surgeons and corneal specialists as well. The selection of topics has been imaginative and the authors have done justice to them. A chapter on keratoprosthesis is however, conspicuous by its absence. It would have been a fitting ‘wrap-up’ to the chapter on the ocular surface and to the one on high-risk corneal transplantation. A variety of keratoprostheses have been in surgical use, proving to be vision-saving devices in desperate situations. Likewise, a chapter on newer diagnostic tools which have been introduced into clinical practice would have made it a welcome resource. Overall, the book is well written and carefully edited. It is handy and readable, the illustrations are relevant and instructive.