PREVALENCE, CAUSES AND MANAGEMENT OF CORNEAL BLINDNESS IN SAUDI ARABIA: A SYSTEMATIC REVIEW

Abstract

Background: Corneal disease remains an important, potentially preventable contributor to visual loss, but Saudi Arabia–specific evidence on corneal blindness epidemiology and outcomes is dispersed across surveys and tertiary-care series. This systematic review synthesized Saudi data on (i) prevalence of blindness/visual impairment with corneal cause fractions, (ii) leading corneal etiologies associated with severe vision loss, and (iii) outcomes of key management strategies including keratoplasty and corneal collagen cross-linking (CXL). Methods: The review followed PRISMA 2020 and used planned searches across major databases for studies from 1 January 2000 to 30 June 2025, including community surveys and facility-based cohorts conducted in Saudi Arabia. Risk of bias was appraised using design-appropriate tools (e.g., JBI domains for prevalence studies, ROBINS-I for non-randomized intervention studies), and synthesis was narrative due to heterogeneity. Results: Ten studies met inclusion criteria, comprising three population-based surveys, four keratoplasty outcome/indication studies, and three keratoconus/CXL studies. In RAAB surveys of adults aged ≥50 years, all cause blindness prevalence ranged from 2.6% (Taif) to 3.3% (Jazan), with cataract and posterior segment disease predominating; however, corneal scar was a notable cause fraction in Jazan (reported as 9.5% of blindness causes). Keratoplasty indication data from the Eastern Province (2000–2010) identified keratoconus as the leading indication (49.6%), followed by bullous keratopathy and stromal dystrophies, suggesting keratoconus as a major driver of transplant-level corneal morbidity. Outcomes after penetrating keratoplasty (PKP) were favorable for keratoconus (5-year graft survival ~97.6% with substantial best-corrected visual acuity gains), while repeat PKP showed markedly poorer long-term survival (~49% at 5 years) and modest visual recovery. Controlled and observational CXL studies reported short-term keratometric stabilization/flattening but also measurable reductions in corneal thickness, with heterogeneous responses across parameters and limited longer-term follow up. Conclusions: Corneal scarring remains relevant in some regions, and keratoconus dominates surgical corneal disease, yet nationally representative corneal blindness estimates and standardized outcome reporting are lacking, limiting precise burden quantification and benchmarking.