A cornucopia of cornea: the challenge of being well-informed in an era of rapid change.

Corneal surgery has evolved considerably since Eduard Zirm’s landmark, which is the first successful penetrating keratoplasty 110 years ago. For the last 25 years, that steady evolution has transformed into an exponential revolution of clinical and surgical techniques for the cornea and anterior segment. Major changes have included ‘‘rediscovery’’ and refinement of lamellar corneal transplantation techniques, emergence of laser-assisted in situ keratomileusis (LASIK) and femtosecond laser refractive surgery, as well as the widespread adoption of novel treatment modalities such as corneal collagen cross-linking. Our understanding of disease processes has also leapt forward with the application of molecular genetics in corneal dystrophies and corneal ectasias. This quarter century of ‘‘kerato-revolution’’ has been underpinned by a raft of increasingly sophisticated imaging technology that has emerged from the laboratory to the clinic including corneal topography, in vivo confocal microscopy, and ocular coherence tomography. The recent scientific literature highlights the ongoing evolution in lamellar keratoplasty, with several studies targeting further refinement of relatively new surgical techniques. As an example, an ultrathin Descemet’s stripping automated endothelial keratoplasty (DSAEK) approach, using a double-pass technique, produced 20/40 or better visual acuity in 100% of patients at 2 years and sets the bar increasingly high for endothelial transplant surgery. However, when comparing lamellar with penetrating keratoplasty, either between centers or in population-based studies, the results are more heterogeneous. Surprisingly, despite the global trend toward anterior and posterior lamellar keratoplasty, the published evidence for superior vision and transplant survival is not universal. Although the transformation of clinical and surgical approaches to corneal disease is perhaps most obvious in everyday practice, basic and translational science flourishes at an exponentially greater rate. In the rapidly changing field of molecular genetics of the cornea, exciting developments have occurred in our understanding of disease etiology and avenues for new medical treatments such as the use of topical Rho-associated protein kinase (ROCK) inhibitors to treat Fuchs endothelial corneal dystrophy. The Asia-Pacific Ophthalmology Academic Community has been intimately involved in pushing forward clinical and research boundaries in this millennium and has contributed seminal works that have transformed understanding of corneal disease processes and their management. A few of these include the discovery of a novel gene in macular corneal dystrophy, the use of amniotic membrane and stem cell transplants in the treatment of ocular injury and Q-associated kinase inhibitor for Fuchs endothelial dystrophy, as well as steps toward building of an artificial cornea. With an overload volume of (relatively unfiltered) data in professional magazines and a vast peer-reviewed literature, we must be prepared to encounter and reconcile conflicting evidence with resources such as the Cochrane Database of Systematic Reviews. Interestingly, recent studies have EDITORIAL