[Simultaneous phacoemulsification and graft refractive surgery in post-penetrating keratoplasty eyes]

To report the outcomes of graft refractive surgery [GRS] together with clear-cornea phacoemulsification and intraocular lens [IOL] implantation in post-penetrating keratoplasty [PKP] eyes. Fourteen eyes of 13 patients who had received PKP underwent simultaneous GRS [relaxing incisions with or without counter-quadrant compression sutures] and clear-cornea phacoemulsification with IOL implantation. To calculate IOL power, preoperative keratometry readings and the SRK-T formula were used. Mean patient age and follow-up period were 50.5 +/- 14.4 years and 14.6 +/- 7.1 months, respectively. A significant increase was observed in best spectacle-corrected visual acuity [from 0.55 +/- 0.18 logMAR to 0.33 +/- 0.18 logMAR, P=0.001]. There was a significant decrease in vector keratometric astigmatism by 6.22 D [P=0.03]. Spherical equivalent refraction was reduced from -3.31 +/- 3.96 D to -1.69 +/- 2.38 D [P=0.02] which did not significantly differ from the target refraction [-0.76 +/- 0.14 D, P=0.20]. No complications developed and all the grafts remained clear at the final examination. Simultaneous phacoemulsification and GRS is a safe and effective method to address post-PKP astigmatism and lens opacity. IOL power can be calculated from preoperative keratometry readings with an acceptable accuracy. However, patients should be informed about the possibility of high refractive errors postoperatively

CMV infection after renal transplantation: a multicenter study of 3065 cases

Cytomegalovirus [CMV] infection is a common complication following kidney transplantation. To assess the incidence and risk factors of CMV infection among renal transplant recipients. In a retrospective multicenter study, 3065 renal transplant recipients from 17 transplant centers of Iran were studied between April 2008 and January 2011. Kidney transplant patients were routinely monitored by sequential blood samples drawn for use in the CMV-pp65 antigenemia assay, and for hematological and biochemistry tests. 63% of studied patients were males; the mean +/- SD age of participants was 38 +/- 15 years. The majority of cases [81%] received a kidney from a living unrelated donor [LURD], 9% from living related donor [LRD], and 10% from deceased donors. 671 patients experienced CMV viremia. The incidence of CMV infection was 21.9% [95% CI: 20.4%-23.4%]. The rate was higher in the first 6 months after transplantation [p<0.001]; in recipients with higher level of cyclosporine [p<0.001]; in those with lower hemoglobin concentration [p=0.02]; patients with elevated ALT [p<0.001]; those with increased fasting blood sugar [p=0.005]; recipients with dyslipidemia [p<0.05]; deceased kidney recipients [p=0.006]; and patients with kidney graft impairment [p=0.01]. In multivariate regression analysis, time since kidney transplantation [p<0.001] and renal allograft failure [p<0.001] were the only risk factors associated with CMV infection. CMV infection was a common complication in the first 6 months of kidney transplantation, particularly among patients with kidney graft impairment

National strategies of ophthalmic education in Iran

Academic medicine is in a state of dramatic transformation. For this reason strategic thinking is the most essential part of educational planning. The main purpose of the present study was developing the strategic educational planning of Ophthalmology in Iran from 2007 to 2010. A qualitative investigation using focus group discussion has been implemented successfully tor developing educational planning. Six to twelve representatives of key stakeholders in the ophthalmic education of Iran participated to this study. Strengths, weaknesses, opportunities and threats of ophthalmology education in Iran were analyzed. Strategic goals in education, research, and health service providing domains were being developed. Educational goals were defined as training of human resources in accordance with the community needs at the level of general practitioner, specialist, and fellowships in ophthalmology. Research goals of the program were defined as scientific interdepartmental and international communications, in order to promote the level of education, research, and treatment in the country. Also, in the field of health services according to the community needs, providing services by the means of advanced and cost effective methods were defined as strategic objectives. Based on this strategic plan in the last three years ophthalmic education in Iran shall be many changes in educational, research and health care provision for social accountability

impact of hepatitis b infection on outcome of kidney transplantation: a long-term study

With the success of kidney transplantation, liver disease has emerged as an important cause of morbidity and mortality in kidney recipients. To determine the impact of hepatitis B virus [HBV] infection on patients and graft survival in both short- and long-terms. 99 renal transplant patients infected with HBV on follow-up in two major transplant centers were included in a retrospective study. These patients were grafted between 1986 and 2005 and divided into two groups: [1] those only positive for hepatitis B surface antigen [HBsAg] and [2] those who were also positive for hepatitis C virus antibodies [HCV Ab]. There were 88 patients with HBsAg[+] and 11 with both HBsAg[+] and HCV Ab[+]. The mean +/- SD age of patients was 38.8 +/- 13.2 years, and the median follow-up after transplantation was 19 months. Although not significant, the allograft survival rate in the first group [HBV[+] was better compared to that in the second group [HBV[+] and HCV[+]; 1, 5 and 10 years graft survival rates were 91, 77 and 62 in the first group and 70, 56 and 28 in the second group, respectively [P=0.07]. The overall mortality was 5% [4 of 88] in the first and 27% [3 of 11] in the second group [P=0.02]. Renal allograft recipients with HBV and HCV infections has a poor survival rate compared to pa- tients with only HBV infection. However, there is no significant difference in terms of renal graft survival between the two groups

[Corneal endothelial cell loss after phacoemulsification in relation to hydrodynamic parameters: low versus high vacuum techniques]

To evaluate the effect of vacuum and flow rate on endothelial cell loss after high versus low vacuum phacoemulsification. This randomized clinical trial was performed on 60 eyes of 60 patients with moderate lens opacity [nuclear sclerosis 3+]. All surgeries were performed by one experienced surgeon using stop and chop technique with Sovereign white star machine [AMO]. Patients were randomly assigned to high and low vacuum techniques in equal numbers. The machine was set on 400 mmHg vacuum and 40 ml/min flow rate in the high vacuum group and on 200 mmHg vacuum and 20 ml/min flow rate in the low vacuum group during the chop stage. All other parameters were similar in both groups. Phacotime multiplied by average ultrasound power was defined as total ultrasound energy. Specular microscopy was performed before and 1, 6 and 12 weeks after the operation. After 12 weeks, mean endothelial cell loss was 9.0 +/- 4.0% versus 9.6 +/- 4.6% in the low and high vacuum groups, respectively [P=0.6]. Mean ultrasound power was 9.2 +/- 4.3% and 13.1 +/- 4.6% in the low and high vacuum groups, respectively [P=0.001]. Mean phacotime was 1.28 +/- 1.0 minutes in the low vacuum group versus 0.88 +/- 0.6 minutes in the high vacuum group [P=0.04]. Total ultrasound energy and total fluid volume used [turbulence] during phacoemulsification was similar between the two study groups. Total ultrasound energy was the most powerful predictor of endothelial cell loss [R2=0936, P=0.001], but turbulence was not a significant predictor [R2=0.924, P=0.1]. No significant difference in endothelial cell loss was found between low and high vacuum techniques. This study supports advice to junior surgeons to choose lower hydrodynamic phaco machine parameters; experienced surgeons can choose higher parameters to reduce phacotime

[Risk factors for posterior capsular tear and vitreous loss during phacoemulsification in a tertiary eye center]

To report the rate of vitreous loss during phacoemulsification and its contributing risk factors in patients operated on at Labbafinejad Medical Center. This prospective comparative descriptive study included patients with cataract undergoing phacoemulsification by ophthalmology residents or cornea fellows from November 2006 to November 2007. All patients underwent a complete ocular examination including visual acuity, slitlamp examination, and dilated funduscopy, preoperatively. Phacoemulsification was performed under local or general anesthesia using Divide and Conquer technique. Main outcome measures included posterior capsular tear and vitreous loss and predisposing factors such as surgeon's experience, ocular and systemic conditions, and type and severity of the cataract. Overall 767 patients including 393 male and 374 female subjects with mean age of 62.7 +/- 12.0 [range 6-96] years were studied. The overall rate of vitreous loss was 7.3% which was 5-fold higher in the hands of residents than fellows. Patients' age and female sex, small capsulorrhexis, small pupil, pseudoexfoliation, and high myopia were other significant risk factors. The highest rate of vitreous loss occurred in patients with dense nuclear cataracts. Since ophthalmology residents had a higher rate of vitreous loss, patients with risk factors such as pseudoexfoliation, high myopia, and dense nuclear cataracts are better operated by more experienced surgeons

[Keratolimbal allograft in total limbal stem cell deficiency]

To investigate the outcomes of keratolimbal allograft [KLAL] for treatment of total limbal stem cell deficiency [LSCD]. Patients with total LSCD and adequate tear production were included. A total of 27 KLAL procedures were performed in 21 eyes of 20 patients with LSCD. Immunosuppression was achived using mycophenolate and cyclosporine. Main outcome measure was improvement in vision; in addition, KLAL survival and post operative complications were studied. Mean follow up period was 22.14 +/- 11.83 months [range 6-39]. Mean visual acuity improved from 2.53 +/- 0.21 to 1.49 +/- 0.77 LogMAR [P<0.0001]. Six KLALs never re-epithelialized and were considered as primary failures. Mean KLAL survival was 14.23 +/- 1.5 months. Graft survival rate was 61.9% at 1 year and 31% at 20 months. Complications included corneal ulcers in 6, glaucoma in 2 and scleral thining in 1 case. Keratolimbal allograft surgery is successful in the short term for visual rehabilitation of patients with total limbal stem cell deficiency

[Results of descemet`s stripping with endothelial keratoplasty [dsek] in patients with bullous keratopathy after cataract surgery]

To evaluate the anatomical and visual outcomes of Descemet`s stripping with endothelial keratoplasty [DSEK] in patients with bullous keratopathy after cataract surgery. The study was performed on 20 eyes of 20 patients [13 male, 7 female] with bullous keratopathy [pseudophakic=15, aphakic=5]. Donor lenticule was prepared using a micro keratome [n=12] or manual dissection [n=8]. Patients were excluded in case of extensive corneal scarring and/or vascularization. DSEK surgery was performed by removal of recipient endothelium and Descemet`s membrane, and replacement by the donor lenticule. Patients were followed at least for 6 months. Mean age at surgery was 64.6 +/- 6.7 years and mean follow up was 7.3 +/- 2.1 months. At final follow up 15 grafts were clear. Failure was seen in 5 cases. Visual acuity LogMAR was 1.96 +/- 0.38 before and 0.52 +/- 0.09 after the procedure [P<0.0001]. Mean topographic keratometry was 46.0 +/- 2.9 D before surgery which reached 44.4 +/- 1.7 D postoperatively [P=0.219]. Preoperative astigmatism was 2.5 +/- 1.7 D which decreased to 1.1 +/- 2.3 D at final follow up [P=0.229]. Mean pre- and postoperative surface regularity index [SRI] were 1.47 +/- 0.60 and 0.43 +/- 0.17, respectively [P=0.006]. No case of endothelial rejection was observed. DSEK surgery is an effective treatment modality in cases of bullous keratopathy after cataract surgery with acceptable anatomical and visual outcomes

[Amniotic membrane transplantation in acute ocular chemical burns]

To evaluate the role of amniotic membrane transplantation [AMT] in acute ocular chemical burns. Patients with grade II-IV [GII-GIV] ocular chemical burns [Roper-Hall classification] of less than two weeks' duration underwent AMT in addition to medical therapy. Patients were followed for at least 6 months and evaluated for ocular pain, visual acuity, epithelial defect healing, symbelpharon formation, and corneal opacity and neovascularization. Twelve eyes of 8 patients [6 male, 2 female] with mean age of 28.75 +/- 11.8 [range 12-44] years were operated. Mean duration between chemical burn and surgery was 2.5 +/- 3.3 days [range, 2 hours to 10 days]. Mean follow up period was 11.5 +/- 1.5 [range 10-13] months. The chemical agent was acidic in six eyes and alkaline in the other six. Ocular burns were GII in one eye, GIII in four eyes and GIV in seven eyes. Pain and discomfort decreased in all patients. Visual acuity improved completely in the eye with GII burn. It also improved in three eyes and remained unchanged in one eye with GIII burn. In eyes with GIV burn, two underwent tectonic corneal grafts due to perforation and two were phthisical, however visual acuity decreased in two and increased in one of the remaining eyes. The epithelial defect healed within 6 days in the eye with GII burn. Mean time for healing was 53.75 +/- 5.2 days in eyes with GIII burn. Keratolimbal allograft surgery was performed in one eye with persistent epithelial defect and severe corneal thinning. In the other two eyes, the epithelium healed in 70 and 75 days. Corneal neovascularization was seen in two eyes with GIII and all eyes with GIV burns. Corneal opacity developed in all eyes with GIII and GIV burns. Only mild symblepharon was seen in four eyes with GIV burn. AMT seems to be effective in pain reduction and prevention of symblepharon formation. It seems ineffective in preventing corneal opacification and neovascularization. The role of AMT in accelerating epithelial healing and improving visual acuity in patients with GII and GIII ocular burns needs to be evaluated in a clinical trial. It seems that prevention of symblepharon formation is the only role of AMT in eyes with GIV chemical burns

Risk factors and laboratory diagnostics for post renal transplant tuberculosis: a case-controlled, country-wide study on definitive cases

Tuberculosis [TB] is a common cause of morbidity and mortality in renal transplant recipients. It is usually misdiagnosed because of lack of medical awareness and its infrequency in renal transplant recipients. 44 cases [0.3%] with post-transplant TB out of 12820 patients who had renal transplants performed between 1984 to 2003 were found from the hospital records of 12 major kidney transplantation centers in Iran. These cases were compared with 184 healthy transplant subjects whose transplants were performed by the same surgical team as the controls. The mean age of cases and controls was 37.7 [13-63] and 35.6 [8-67] years [p=0.3], respectively. The mean duration of pre-transplantation hemodialysis was 30.3 [3-168] months in cases and 18.2[1-180] months in controls [p=0.03]. A past history of tuberculosis was detected in 2 cases and 1 control [p=0.3]. The mean doses of initial and maintenance immunosuppressive drugs in cases and controls were not significantly different. A total of 25 cases [56.8%] and 60[32.6%] controls had rejection prior to diagnosis of TB [p=0.004; OR=2.7, CI95%: 1. 3-5.6]. To our knowledge, this is the first study that demonstrated increasing risk of post-transplant TB by extending the duration of pre-transplant hemodialysis and the number of post-transplant rejection episodes. Further study is needed to clarify our new findings specifically in respect of different immunosuppressive regimens

[Relationship between ADPKD and post renal transplant diabetes mellitus]

Autosomal-dominant polycystic kidney disease [ADPKD], a common hereditary disease, is characterized by the progressive development and enlargement of multiple cysts in both kidneys, and typically resulting in end stage renal disease [ESRD] by the fifth decade of life. Post-transplant diabetes mellitus [PTDM], a common complication after transplantation with an incidence rate of 2.5-20%, is associated with poor graft and patient survival. In few studies, PTDM has been more frequent in ADPKD transplanted patients. In the present study, we investigated whether there is any association between PTDM and ADPKD in our patients. In this prospective study, 140 non-diabetic and nonsmoker successfully transplanted patients [27 ADPKD and 113 non ADPKD patients] were enrolled during three years. Both groups were matched for age, sex, body mass index [BMI], duration of renal replacement therapy before transplantation and also immunosuppressive protocols after transplant. Post-transplant diabetes mellitus was defined as Clinical Practice Guidelines advocated by Canadian Diabetes Association. All patients were followed for 12 months. PTDM occurred in 11.1% of ADPKD patients and in 13.1% of control group which was statistically insignificant [P > 0.05]. The development of PTDM in ADPKD group was not related to sex, age, and hypertension, duration of renal replacement therapy before transplantation, BMI and serum creatinine levels [P > 0.05]. Post-transplant diabetes mellitus appears not to be associated with autosomal-dominant polycystic kidney disease as an etiology of end stage renal disease

Outcomes of clear Cornea and Scleral Tunnel Incisions for Phacoemulcification

To compare clear corneal incision and scleral tunnel incision in terms of intraocular pressure [IOP], post-operative inflammation, induced astigmatism, and corneal edema in phacoemulcification. This non-controlled clinical trial was conducted on 78 eyes with senile cataract. A clear corneal incision was made in 40 eyes and a scleral tunnel incision was made in 38 eyes. All eyes underwent standard phacoemulsification. Post-operative inflammation and corneal edema was measured 1, 7, and 60 days post-operatively. IOP was also measured preoperatively and 1, 7, and 60 days post-operatively. Corneal astigmatism was measured before and 7 and 60 days after surgery. Results: Post-operative inflammation was greatest on the first post-operative day in both groups, but there was no significant difference between them. In both groups, IOP was highest on the first postoperative day with no significant differences at any times of follow up. Mean decrease of IOP at 2 month comparing to preoperative value was 1.4 mmHg in the scleral tunnel group and 1.1 mmHg in the clear corneal group. Mean astigmatism preoperatively and on post-operative days 7 and 60 was 1.052 +/- 0.805, 0.993 +/- 0.653, and 0.730 +/- 0.527 diopter, and 0.893 +/- 0.850, 1.137 +/- 1.011, and 0.975 +/- 1.012 diopter in the scleral tunnel and clear cornea groups, respectively. Astigmatism on days 7 and 60 were grater in clear cornea incision. Against the rule induced astigmatism was more frequent in the clear corneal group. [p<0.04] In both groups, corneal edema was highest on the first post-operative day with no significant differences between the two groups. Scleral tunnel incision is better than clear corneal incision for minimizing post-operative corneal astigmatism in small incision cataract surgery

Culture and proliferation of human limbal stem cells in vitro

To evaluate the properties of cultured limbal stem cells for corneal surface reconstruction. Specimens of timbal explants were prepared from the Eye Bank of l.R. Iran. The explants were cultured and expanded on acellular amniotic membrane for 21 days. The cultured cells ''.ere evaluated for expression of Connexin 43 and keratinine K3 by immunocytochemistry and expression of K12 keratininc and P63 by RT-PCR. After 2 to 3 weeks, the limbal epithelial cells grew to form a sheet approximately 2x2 cm' in size on the amniotic membrane. On histological examination the epithelial sheet was composed of 4 to 5 cell layers at the margin of the sheet and from 1 to 4 cell layers in the area between the margin and the original explant tissue. Immunocytochemistry analysis showed Keratinine K3 and Connexin 43 were expressed in normal cornea. The markers were expressed weakly in cultured limbal cells. Also, RT-PC'R analysis revealed that P63 and K12 were expressed in cultured and normal limbal cells. The normal cornea expressed K3 and K12 but not P63 These data support the notion that expansion of limbal stem cells on amniotic membrane can be used of tranplantation to patients with limbal stem cell deficiency

[Early results of autologous cultivated limbal stem cell transplantaion in total limbal stem cell deficiency]

To report the early results of transplantation of autologous limbal stem cell cultivated on amniotic membrane in total limbal stem cell deficiency. Four eye of 4 patients with total unilateral stem cell deficiency secondary to severe chemical or thermal burn included. Stem cell deficiency was confirmed with impression cytology in all cases. Under topical anesthesia, a small limbal sector [1x1 mm] was removed from the sound eye and cultivated on amniotic membrane. Cell expansions were transplanted to the affected eye 2 weeks later. Patients were regularly followed up. At each follow-up visit, corneal eye examination with special attention recurrence or regression of vascularization, corneal pacification, and healing of epithelial defect was performed. Digital imaging was performed at each follow-up visit. Impression cytology was repeated in all cases after surgery. The patients were followed for 5-13 months. Decrease in corneal opacification and vascularization was obvious in 3 cases, in which the surface of the cornea was covered with corneal epithelium. Sectoral conjunctivalization was evident in these 3 cases, but their corneas were ready for corneal transplantation. The procedure failed in one case with total corneal conjunctivalization. Visual acuity improved in all cases. Autologous cultivated stem cell transplantation on amniotic membrane seems to be an effective way for stem cell transplantation. More definite judgment needs longer follow-up together with long-term results of corneal transplantation in these patients

Reorientation of educational deputy of Ministry of health and medical education in accreditation and evaluation

Background: Recently the Government of Islamic Republic of Iran has considered radical changes and innovation in the structure of medical education at all levels. Therefore the "Accreditation and Evaluation Plan of Medical Universities in Iran" is approved and emphasized in the Third 5-Year Development Program

Method: The Educational Deputy [ED] of Ministry of Health and Medical Education [MOHME] considered three main plans: [1] Goal-based internal evaluation, and external evaluation of educational departments of medical universities based on internal evaluation. In 1995-6 ED began the internal evaluation, defining quality as fitness for purpose; and in 2000 started the external evaluation in some medical schools as a pilot study, based on previous internal evaluation. [2] Collaboration with World Federation for Medical Education [WFME], according to International Standards for Basic Medical Education Pilot Studies. Shiraz Medical University was co-opted by WFME to collaborate in the first stage; three medical universities [Tehran, Shahid Beheshti and Ahvaz] are accepted for the second stage. [3] The project of "Standardization of Medical Education in Iran for Achieving International Accreditation". This process is being performed in several steps: [a] Study of three different sets of national [Australia, US and Mexico] and international [WFME] standards; [b] Collection of the experts' viewpoints specialized in medical education in this regard; [c] Development of the first action plan; and [d] Conduction of this project as pilot study in a number of medical universities

Results: Having primary results disseminated, motivated many other medical universities so that some announced their readiness to begin internal and external evaluation or standardization process

Conclusion: Regarding the importance of quality improvement in medical education, it is expected that even if this process would not lead to international accreditation acquisition, it will result in improvement and essential changes in basic medical education

[Chronic and delayed onset mustard gas keratitis: report of 48 patients]

Purpose: to report the clinical features of 93 eyes with chronic and delayed onset mustard gas keratitis in 48 patients

Methods: forty-eight Iranian survivors of Iraqi chemical warfare with chronic or delayed onset mustard gas keratitis were enrolled. We reviewed the symptoms, signs, clinical course, and treatment of our patients. In 5 cases, histopathologic features of corneal and conjunctival specimens are presented

Results: of 48 patients, 3 1 [64.6%] had chronic symptomatology whereas 17 [3 5.4%] experienced delayed onset lesions. Visual acuity at referral ranged from hand motions to 20120. Ocular surface changes included chronic blepharitis and decreased tear meniscus in all, limbal ischemia [81.3%] and conjunctival vascular abnormalities [50%]. Corneal signs in order of frequency were: scar/opacity [87.5%], neovascularization [70.8%], thinning [58.3%], lipoid deposits [52. I%], amyloid deposits [43.8%], and epithelial defects and irregularity [3 1.3%]. Twenty patients received conservative treatment; others underwent allograft stem cell transplantation [20 eyes of 17 patients], penetrating keratoplasty [12 eyes of 12 patients], and lamellar keratoplasty [4 eyes of 3 patients]. Conjunctival specimens were evaluated by light microscopy. Decreased goblet cell density, attenuated or thickened epithelium, scarring in the substantia propria associated with plasmacytic and lymphocytic infiltration, and dilated lymphatic vessels were noted. Excised corneal buttons disclosed absence of epithelium and Bowman's layer, firbrovascular pannus, stromal scarring, and vascularization

Conclusion: mustard gas may cause chronic and delayed destructive lesions in the ocular surface and cornea leading to progressive visual deterioration and ocular irritation. The pathophysiology of these changes is not clearly identified. Excised conjunctival and corneal specimens revealed a mixed inflammatory response without any specific features. Based on the clinical appearance of the lesions and histopathologic findings, an immune-mediated component seems possible

[Results of penetrating keratoplasty in macular corneal dystrophy]

Purpose: to evaluate the outcomes of penetrating keratoplasty [PIS] in macular corneal dystrophy [MCD] at Labbafinejad Medical Center, Tehran-Iran [1986-2002]

Methods: in a descriptive study, records of patients with MCD who had undergone PK were reviewed. All cases were recalled for a complete ocular examination. Patients who participated in the recall examination with at least 6 months follow up were enrolled in the study

Results: sixty-two eyes of 39 patients were included. The age of patients at first examination [before keratoplasty] was 30 +/- 12 [12-58] and at the time of keratoplasty was 34 +/- 10.3 [13-58] years. Duration of follow up after PK was 52 +/- 47.3[6-190] months. Best corrected vision before surgery in LogMAR notation was 1.4 +/- 0.4 [4/100]. After PK, uncorrected visual acuity improved to 0.6 +/- 0.44 LogMAR [20/28] [P<0.0001] and best spectacle corrected visual acuity [BSCVA] at the end of follow up was 0.2 +/- 0.32 LogMAR [20/32]. Spherical equivalent refractive error after surgery was -2.28 +/- 3.24 diopters and refractive astigmatism was 3.32 +/- 2.05 diopters. Suturing technique had no effect on final astigmatism after PK [P=0.9]. BSCVA in 36 eyes who were operated before 35 years of age was 0.16 +/- 0.37 LogMAR and in 26 eyes operated at or after age 35 was 0.26 +/- 0.25 [P=0.005]. Immunologic graft rejection occurred in 12 eyes [1 9.4%] during the follow up period. The first rejection occurred at 6.1 +/- 3.5 [2-14] months after PK. Graft opacification and failure occurred only in one eye following ocular trauma and wound dehiscence. The rest of the grafts [98.4%] were clear at the end of follow up

Conclusion: PK in patients with MCD improves vision significantly with excellent graft survival rates. In this study, patients who underwent PK before 35 years of age had better final visual acuity