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Traumatic Cataract

Key Points Traumatic cataracts are caused by either blunt or penetrating ocular trauma, causing varying degrees of lenticular opacity. They can be associated with damage to adjacent structures such as the iris, the trabecular meshwork, and the zonular apparatus. The management of a traumatic cataract includes different areas of anterior segment reconstruction, such as iris repair, zonular weakness management, and secondary intraocular lens fixation techniques. Introduction…

Intraocular Lens Exchange and Secondary Intraocular Lens Placement

Key Points The most common indications for intraocular lens (IOL) removal and exchange include IOL decentration, refractive error, and dysphotopsia. Secondary IOL implantation is often required for patients with a history of aphakia after complex cataract surgery or trauma. New techniques and technologies have made secondary IOL implantation safer with better visual outcomes. Suture-less scleral-fixated IOLs are the newest and most promising techniques but more research…

Pediatric Cataract Surgery

Key Points Pediatric cataract is an important cause of treatable blindness in children. In addition to the cataract, several comorbidities can be present in a child’s eye, and these can impact visual prognosis and require adjustments in the surgical technique and/or postoperative drug regimen. Careful preoperative assessment is important for surgical planning and follow-up. Successful outcomes depend on the surgical technique implemented, effective postoperative inflammation modulation,…

Retinal Considerations in Cataract Surgery

Key Points Do not let your cataract surgery get blamed for preexisting retinal disease! ■ Preoperative identification and management of posterior segment disease, especially vasculopathic macular edema and age-related macular degeneration, are essential. ■ Optical coherence tomography is a key part of preoperative assessment to help identify macular pathology, especially in multifocal intraocular lens candidates. ■ Peripheral retinal pathology should be identified preoperatively. Other than a…

Corneal Transplantation in Ocular Surface Disease

Key Concepts A multidisciplinary approach is necessary for ocular surface reconstruction. Optimizing the ocular surface is vital prior to performing keratoplasty. Two-stage approach is preferred over simultaneous ocular surface reconstruction and keratoplasty. Systemic immunosuppression is generally well tolerated and safe. Boston keratoprosthesis type 1 is not recommended in advanced Stevens-Johnson syndrome and mucous membrane pemphigoid. You’re Reading a Preview Become a Clinical Tree membership for Full…

Postoperative Management of Ocular Surface Reconstruction

Key Concepts The postoperative care of the limbal transplant patient is perhaps the most critical part of the care. Problems such as persistent inflammation or epitheliopathy should be addressed early by increasing immunosuppression or using adjunctive measures such as punctal occlusion, bandage lens, and tarsorrhaphy. Acute rejection can be severe and present with limbal graft swelling and injection, but can also be low grade and have…

Simple Limbal Epithelial Transplantation

Key Concepts Simple limbal epithelial transplantation (SLET) is a single step surgical procedure addressing unilateral limbal stem cell deficiency. SLET induces only minor damage to the donor eye. SLET does not require expensive and sophisticated infrastructure required for ex-vivo expansion protocols. SLET can be repeated if recurrence of limbal stem cell deficiency (LSCD) appears. Introduction The corneal epithelium, the most superficial corneal layer, functions as a…

Cultivated Limbal Epithelial Transplant

Key Concept The goal of management of limbal stem cell deficiency to restore the limbal microenvironment. Advances in cell culture techniques have led to the use of cultured epithelial transplantation as an alternative procedure for the treatment of limbal stem cell deficiency. Both autologous and allogeneic sources of limbal epithelial stem cells have been used in clinical trials. Introduction In recent years, research in Limbal epithelial…

Keratolimbal Allograft

Key Concepts Keratolimbal allograft (KLAL) is a surgical treatment for limbal stem cell deficiency where deceased donor tissue is used. Systemic immunosuppression is required to prevent rejection of the highly immunogenic vascularized limbal donor tissue. Structural lid abnormalities, glaucoma, and ocular surface inflammation should be treated prior to KLAL. Ideal patients have normal conjunctiva, and signs and symptoms of limbal stem cell deficiency (decreased vision, eye…

Living-Related Conjunctival Limbal Allograft

Key Concepts Living-related conjunctival limbal allograft (LR-CLAL) transfers fresh allogenic limbal and conjunctival (with goblet cells) tissue from a matched living relative for treatment of symptomatic partial or total limbal stem cell deficiency (LSCD). Proper donor selection maximizes the success of this procedure by minimizing the antigenic burden through identification of the best living-related donor candidate. Compared with keratolimbal allograft, LR-CLAL has demonstrated improved outcomes in…

Conjunctival Limbal Autograft 1

Key Concepts Conjunctival limbal autograft (CLAU) represents the first surgical option for unilateral limbal stem cell deficiency, given the good long-term survival results and visual outcomes. The most important risk factors contributing to graft failure are severe dry eye, chronic inflammation, and associated adnexal abnormalities. Although there is potential risk to donor eyes, no serious complications have been reported in healthy donor eyes when appropriate precautions…

Classification and Staging of Ocular Surface Disease

Key Concepts Renewal of the corneal epithelium results from limbal epithelial stem cells (LESCs) located at the basal layer of epithelium found at the corneoscleral limbus. The limbal stem cell niche has a crucial impact on LESC function and regulation. The replacement of corneal epithelium with conjunctival tissue is responsible for many of the clinical findings of limbal stem cell deficiency. From a histologic perspective, the…

Contemporary Approaches to the Biosynthetic Cornea: Overview and Classification

Key Concepts Cornea transplantation has made tremendous progress over the last decade, but major problems still exist: worldwide blindness, immune rejection, and severe ocular surface disease. An artificial cornea is needed due to major deficiencies in current eye banking and storage issues with human corneas. The concept of an artificial cornea has been around for decades, but visual outcomes are still poor and associated with high…

Osteo-Odonto-Keratoprosthesis

Key Concepts The osteo-odonto-keratoprosthesis (OOKP) is a form of keratoprosthesis that is indicated in cases of severe, end-stage ocular surface and corneal disease, such as Stevens-Johnson syndrome or chemical injury, where the severely compromised or dry ocular surface environment precludes long-term success in corneal or ocular surface transplantation. OOKP surgery involves implantation of a polymethyl methacrylate optical cylinder cemented into an autologous tooth, coupled with replacement…

Boston Keratoprosthesis Type 2 Surgical Techniques, Complications, and Outcomes

Key Concepts Boston keratoprosthesis type 2 implantation can provide sustained improvement of vision in a select, high-risk population of patients, but is associated with significant complications and requires lifelong postoperative care. The Boston keratoprosthesis type 2 is reserved for patients with severe autoimmune ocular surface diseases, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, mucous membrane pemphigoid, end-stage keratoconjunctivitis sicca, and after severe chemical burns. Preoperative planning…

Outcomes of Boston Keratoprosthesis Type 1

Key Concepts The Boston keratoprosthesis type 1 is a viable therapeutic option for patients who have previously failed penetrating keratoplasty and increasingly as a first-line option for patients at high-risk for conventional keratoplasty. The visual outcomes of keratoprosthesis implantation are generally favorable, with most patients experiencing significant improvements in visual acuity. With proper postoperative care, keratoprosthesis retention rates are excellent: 80%–95% in the first 1–2 years…

Complications of Boston Keratoprosthesis Type 1

Key Concepts The keratoprosthesis (KPro) may have expanded indications, but there remain many difficulties in its postoperative management. The KPro is not ideal for patients with severe ocular surface disease, such as Stevens-Johnson syndrome, mucous membrane pemphigoid, and severe chemical injuries that are at risk for greater adverse events. Retroprosthetic membrane formation is the most frequent complication after KPro surgery. Accurate assessment of intraocular pressure is…

Postoperative Management of Boston Keratoprosthesis Type 1

Key Concepts Keratoprosthesis is a reasonable option in eyes not amenable to conventional keratoplasty. Advances in the design of the Boston keratoprosthesis type 1, such as the titanium back plate, have improved outcomes. Changes in the postoperative management of the Boston keratoprosthesis type 1 device have reduced complications. Postoperative management is critical including the use of antibiotics, steroids, therapeutic bandage contact lens, and intraocular pressure control.…

Boston Keratoprosthesis Type 1 Surgical Technique

Key Concepts Success of the Boston type 1 keratoprosthesis (KPro) begins with a thorough preoperative evaluation. The Boston type 1 keratoprosthesis is assembled from a front plate and stem made from polymethylmethacrylate (PMMA), a corneal graft, a back plate made from either PMMA or titanium, and a locking ring in certain models. The host cornea is trephinated, and the assembled keratoprosthesis is sutured in place similar…

Indications for Keratoprosthesis

Key Concepts Widespread use of keratoprosthesis devices has led to indications of improved vision in many patients with no other treatment options. The prognosis for keratoprosthesis recipients can be classified into three main groups, in decreasing order of success: (a) corneal allograft failure, (b) chemical injury, and (c) autoimmune-related, cicatricial, keratoconjunctival scarring. The two designs used most commonly in the United States and Europe are the…