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Conjunctiva

Bacterial conjunctivitis Acute bacterial conjunctivitis Pathogenesis: direct eye contact with infected secretions; most common isolates are S. pneumoniae , S. aureus , H. influenza , and Moraxella catarrhalis ; uncommon but serious are gonococci and meningococci. Diagnosis Presentation: acute onset of redness, grittiness, burning and sticky discharge affecting first one then both eyes. Conjunctival injection: maximal toward the fornices ( Fig. 5.1 ). Discharge: (a) typically…

Dry eye

Definitions Keratoconjunctivitis sicca (KCS): eye with some degree of dryness. Xerophthalmia: dry eye associated with vitamin A deficiency. Xerosis: extreme dryness with keratinization occurring secondary to severe conjunctival cicatrization. Sjögren syndrome: autoimmune inflammatory disease of which KCS is a typical feature (see below). You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member.…

Orbit

Thyroid eye disease Pathogenesis: organ-specific autoimmune reaction in which a humoral agent (IgG antibody) produces inflammation and swelling of orbital tissue, especially extraocular muscles. It consists of an active inflammatory stage (<3 years) followed by a quiescent/fibrotic stage. Diagnosis Lid retraction: (a) superior lid margin is either level with or above the superior limbus, with ‘scleral show’ ( Fig. 3.1 ), (b) Von Graefe sign (‘lid…

Lacrimal drainage system

Acquired obstruction Primary punctal stenosis Causes: (a) idiopathic, (b) chronic marginal blepharitis, (c) herpetic (simplex, zoster) lid infection, and (d) conjunctival cicatrization. Diagnosis: narrow inferior punctum in the absence of punctal malposition. Treatment: dilatation alone ( Fig. 2.1 ) rarely confers long-term improvement; surgical punctoplasty is usually necessary ( Figs. 2.2 and 2.3 ). Secondary punctal stenosis Diagnosis: narrow inferior punctum associated with punctal eversion (…

Eyelids

Benign nodules and cysts Chalazion (meibomian cyst) Definition: very common chronic sterile inflammation of a meibomian gland that may resolve spontaneously. Diagnosis Signs: (a) gradually enlarging tarsal nodule ( Fig. 1.1 ); (b) conjunctival granulomatous extension is common, and (c) secondary infection (internal hordeolum; Fig. 1.2 ) may occur. Associations: (a) meibomian gland dysfunction, (b) acne rosacea, and (c) seborrhoeic dermatitis. Treatment: (a) incision and curettage…

Refractive Enhancements After Cataract Surgery

Key Points There can be several contributing factors to a refractive surprise after cataract surgery, such as incorrect intraocular lens (IOL) calculations as a result of keratometry and/or axial length measurements, postrefractive surgery eyes, or toric IOL rotation (see Chapter 31 ). Steps that can be taken to correct postoperative refractive surprises beyond spectacle/contact lens correction include laser vision correction (LASIK/PRK), piggyback lens, IOL exchange, or…

Management of Dysphotopsia

Key Points Dysphotopsias (positive, negative, and diffractive optic) represent undesirable subjective optical phenomena that may occur after uncomplicated, seemingly “perfect” cataract surgery. They are, in part, related to IOL design and IOL position. Positive dysphotopsia (PD) is described by patients as light streaks, light arcs, flashes, and starbursts that are all induced by an external light source. Negative dysphotopsia (ND) is manifest as a temporal arc-shaped…

Neodymium:Yttrium-Aluminum-Garnet Laser Applications in the Cataract Patient

Key Points Posterior capsular opacification is very common after cataract extraction. Nd:YAG laser capsulotomy is the treatment of choice. Nd:YAG laser can also be used to perform laser peripheral iridotomy and anterior hyaloid vitreolysis to address pupillary block glaucoma. For patients with vitreous strands associated with cystoid macular edema after cataract extraction, Nd:YAG laser vitreolysis may be helpful. Introduction The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is a short,…

Subluxated Intraocular Lenses

Key Points Detailed ocular examination in patients with subluxated IOLs is a must, including undilated gonioscopy and dilated slit lamp evaluation to reveal the status of the zonules, capsular bag, and any endocapsular device in situ. Subluxated IOLs may result from missed systemic entities. Hence, complete evaluation including family history and general examination is a must in all cases. It is important to rule out any…

Retinal Complications of Cataract Surgery

Key Points It is important for the cataract surgeon to assess for preoperative and intraoperative risk factors for retinal complications. The anterior segment surgeon can take several key steps during and after surgery to maximize visual outcomes despite the occurrence of a retinal complication. Prompt diagnosis and management, usually in conjunction with a retinal specialist, is essential. Introduction Cataract surgery may have complications. Although the evolution…

Glaucoma After Cataract Surgery

Key Points Clear corneal phacoemulsification generally reduces intraocular pressure (IOP) in glaucoma and ocular hypertensive eyes. A list of differential diagnoses should exist in the minds of all cataract surgeons when evaluating patients with elevated IOP after cataract surgery. Immediate postoperative IOP spikes can be common, especially in glaucoma patients, and can be mitigated using specific medical agents. Warning signs and risk factors for the development…

Corneal Edema After Cataract Surgery

Key Points The etiology of postoperative corneal edema is broad. Thorough preoperative evaluation can help elicit patients at higher risk for postoperative corneal edema. Corneal edema can lead to acute and chronic changes in visual acuity and to eye pain. Management is tailored to the patient’s specific cause of corneal edema but can involve hypertonic solutions, antiinflammatory therapies, Descemet’s membrane reattachment, intraocular lens (IOL) exchange, and/or…

Surgical Instrument Care and Toxic Anterior Segment Syndrome

Key Points All personnel involved in the handling of intraocular surgical instruments should adhere to established protocols to ensure that the instruments are safely prepared for use. Although many general principles of cleaning and sterilization of surgical instruments apply to intraocular instruments, there are important distinctions that must be made because of the unique characteristics of the eye and intraocular surgery. Some important considerations include the…

Issues in Wound Management

Introduction The cataract incision serves as more than just the access point to the anterior segment. It affects corneal stability and overall ocular integrity. Wound construction is the critical determinant of this integrity, and two key elements of the wound involve size and architecture. Wound management after cataract surgery is required in cases of wound leakage, burns, or dehiscence. This chapter reviews wound construction, mechanisms of…

Vitrectomy for the Anterior Segment Surgeon

Key Points Cataract surgery is not without complications, which may require intraoperative vitreous management and therefore a fundamental knowledge of vitreous anatomy to achieve the best postsurgical outcomes. Anterior segment surgeons may encounter the need for intraoperative vitrectomy for a variety of reasons, including capsular rupture, zonular dialysis, trauma, pediatric cataract, and posterior pressure. Management of vitreous requires a few general principles, including maintenance of the…

Intraoperative Complications

Key Points Intraoperative complications can occur at any point in cataract surgery. Successful outcomes depend on the following: ■ Careful preoperative evaluation ■ Having strategies in mind to handle intraoperative challenges and complications ■ As the situation demands, flexibility to adjust any aspect of the procedure to optimally address any complication that arises Anesthesia Patient Movement One primary drawback of local anesthesia is that the patient…

Risk Management in Cataract Surgery

Key Points Juries and judges understand that complications happen, and ophthalmologists often can defend themselves successfully, as long as the risks were disclosed in the informed consent and any intraoperative and postoperative issues were handled correctly. Good communication with patients is an essential part of providing care but also can decrease liability risk both preoperatively during the informed consent and postoperatively in the case of any…

Surgery in Short and Eyes

Key Points Eyes at the extremes of axial length pose unique challenges for preoperative planning, surgery, and postoperative management. Management of cataracts in very short eyes can be complicated by difficulties in IOL selection, intraoperative technical challenges, and postoperative issues such as choroidal effusion. When managing cataracts in very long eyes, the surgeon may encounter issues with zonulopathy, lens iris-diaphragm retropulsion syndrome, and a higher risk…

Iris Repair and Iris Prosthesis

Key Points The globe needs to be pressurized during iris repair and iris prosthesis surgery. Congenital iris coloboma requires effective repair at the time of cataract surgery. Iris diathermy is an excellent tool for pupil shaping and centration. An iris cerclage suture should be used only in the setting of 360-degrees of absent sphincter function. Intraocular knots should be cinched inside the eye at the location…