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Collagen Crosslinking for Infectious Keratitis

Key Concepts Corneal crosslinking (CXL) could be considered an adjunct treatment in infectious keratitis. CXL should be considered in cases of severe unresponsive infectious keratitis. Indirect benefits of CXL, such as corneal melting improvement, may help clinical and visual outcomes of treatments for corneal infections. CXL potentially shortens corneal reepithelization time and reduces pain symptoms. Although published studies cover mostly ultraviolet-A (UVA)-light/riboflavin-mediated CXL, green light/rose Bengal-mediated…

Collagen Crosslinking for Postrefractive Ectasia

Key Concepts Corneal collagen crosslinking (CXL) is a treatment designed to decrease the progression of keratoconus and postrefractive ectasia. Maximum keratometry generally stabilizes and flattens, on average, by approximately 1.6 and 0.7 D after CXL for keratoconus and ectasia, respectively. Average best corrected visual acuity significantly improves by approximately 1 Snellen line. After CXL, clinical outcomes appear to worsen at 1 month and then improve between…

Collagen Crosslinking for Keratoconus

Key Concepts Corneal collagen crosslinking (CXL) has become the mainstay of treatment to prevent progression of keratoconus (KCN). The standard Dresden protocol involves epithelial removal, a 30 minute topical application of riboflavin, followed by a 30-minute ultraviolet light exposure. Multiple long-term studies demonstrate excellent efficacy for halting the progression of keratoconus (KCN). Complications have been described and are typically not severe or common. Modifications to this…

Management of Scleral Perforation

Key Concepts Management of the underlying disease is critical to the successful management of scleral perforations. Multiple options and materials are available for the surgical closure of scleral perforations. The physician should consider the use of homologous materials for repair of scleral perforations in the setting of autoimmune disease. Vascular flaps may be of benefit in the setting of scleral perforation secondary to infectious processes. Preserved…

Iris Reconstruction Surgery

Key Concepts Iris defects not only cause light sensitivity and glare but may also cause monocular diplopia, shadow images, and contrast degradation. The type of suture repair for an iris depends on the size and location of the defect as well as the functional complaint of the patient. There are a variety of suture techniques available for iris repair and reconstruction. There are multiple iris subtractive…

Surgical Management and Rehabilitation of Anterior Segment Trauma

Key Concepts Careful history and examination documentation are required for ocular trauma patients. Tissue adhesive may repair corneal perforations less than 2 mm in diameter. Careful primary surgical repair may eliminate the need for secondary surgical intervention. Wound override should be avoided in restoration of the normal corneal curvature. Repositioning and repair of iris trauma requires specific suturing techniques. Anterior segment intraocular foreign bodies require prompt…

Indications for and Uses of Amniotic Membrane: Operating Room

Key Concepts Amniotic membrane (AM) promotes epithelialization, inhibits inflammation, and has antimicrobial properties with negligible immunologic response. As a graft, AM is used in cases of epithelial and stromal defects. Epithelialization occurs over the AM. As a patch, the AM acts as a biologic contact lens that reduces inflammation and promotes epithelialization. The prognosis of AM transplantation (AMT) depends on the underlying disease and the quality…

Indications for and Uses of Amniotic Membrane: Clinic

Key Concepts Amniotic membrane (AM) promotes epithelialization, inhibits inflammation, and has antimicrobial properties with negligible immunologic response. As a patch, the AM acts as a biologic contact lens that reduces inflammation and promotes epithelialization beneath. In partial limbal deficiencies, AM helps to reestablish the environment for stem cells (SC) at the corneoscleral limbus, reduces inflammation, and stimulates the proliferation of limbal SCs. There are several options…

Conjunctival Flaps

Key Concepts Conjunctival flaps are a well-established treatment modality for corneal and ocular surface disorders. Indications include persistent corneal epithelial defect, bullous keratopathy, corneal and scleral melting, corneal perforation, unresponsive ulcerative infectious keratitis, corneal limbal disease, glaucoma surgery complications, lacrimal punctal occlusion, and ocular surface preparation for a cosmetic scleral shell. The different types of conjunctival flaps are total conjunctival flap, bipedicle bridge flap, single pedicle…

Management of Recurrent Pterygium

Key Concepts While restoration of the ocular surface is the central aim of pterygium surgery, this is more difficult to achieve for recurrent pterygium. Reconstructive rather than destructive techniques are more likely to achieve this goal with reduced risk of long-term sequelae. The lack of consensus on definition of pterygium recurrence has likely affected the reporting of recurrence rates and should be considered in interpreting reports of…

Management of Primary Pterygium

Key Concepts Pterygium is a fibroproliferative condition of the ocular surface linked to chronic ultraviolet light exposure and is common in geographical regions with warm climates. Simple bare sclera excision of a pterygium is associated with high rates of recurrence and should no longer be performed. With reported low recurrence rates and minimal complications, pterygium excision with a conjunctival autograft is the recognized standard of treatment.…

Excimer Laser Phototherapeutic Keratectomy

Key Concepts The best candidates for excimer laser phototherapeutic keratectomy (PTK) are eyes with anterior corneal pathology (top 10%−15%) and certain elevated lesions. Eyes with recurrent erosions that do not respond to other treatments are also good candidates for PTK. It is important to attempt to determine the depth of the corneal pathology preoperatively with a combination of slit lamp examination, pachymetry, and corneal imaging. When…

Surgical Management of Superficial Corneal and Conjunctival Disease

Key Concepts Corneal micropuncture, diamond burr, and phototherapeutic keratectomy are useful techniques for the treatment of recurrent corneal erosions. Ethylenediaminetetraacetic acid (EDTA) application for chelation and scraping is an effective treatment for band keratopathy. Selective epithelial debridement can be used for the treatment of partial limbal stem cell deficiency. Nodulectomy techniques are a simple and effective method for treatment of Salzmann nodular degeneration. Superior limbic keratitis…

Therapeutic Keratoplasty

Key Concepts Therapeutic keratoplasty is indicated for recalcitrant infectious, inflammatory, or noninflammatory conditions of the cornea, including trauma, which threaten the integrity of the globe. Penetrating and lamellar are the two types of therapeutic keratoplasty, and each has advantages and disadvantages that must be considered when performing this type of corneal transplant. Advantages of anterior lamellar keratoplasty compared to penetrating keratoplasty include absence of endothelial rejection,…

Management of Corneal Perforations

Key Concepts Prevention of corneal perforations is of paramount importance. Aggressive lubrication, punctal occlusion, bandage soft contact lenses, tarsorrhaphy, amniotic membrane tissue, and conjunctival flaps may help prevent impending perforations from perforating. Corneal perforations are ophthalmic emergencies that may require immediate surgical repair in the operating room. Etiology and size of the perforation help direct treatment. Small (<1−2 mm diameter), relatively central perforations are typically best…

Cultivated Corneal Endothelial Cell Transplantation

Key Concepts Animal-model experiments showed that a cell-injection therapy combined with the use of a Rho-associated protein kinase (ROCK) inhibitor promotes cultured corneal endothelial cell (CEC) adhesion onto the posterior cornea, ultimately resulting in the recovery of corneal transparency. The proliferative ability of human CECs (HCECs) is strictly limited, thus making the establishment of an optimal HCEC culture protocol a critical aspect for the clinical application…

Complex Endothelial Keratoplasty

Key Concepts Endothelial keratoplasty (EK) offers many advantages over penetrating keratoplasty (PK) and should be attempted instead of PK whenever possible. Descemet membrane endothelial keratoplasty (DMEK) offers many advantages over Descemet stripping endothelial keratoplasty (DSEK) and should be attempted instead of DSEK whenever possible. DMEK is more difficult than DSEK in complicated eyes because DMEK grafts do not adhere to the recipient as readily, are more…

Outcomes of Descemet Membrane Endothelial Keratoplasty

Key Concepts Descemet membrane endothelial keratoplasty (DMEK) offers improved functional results over many other techniques for posterior lamellar surgery. DMEK reconstitutes normal corneal anatomy. DMEK eliminates interface problems and reduces higher order aberrations of the posterior surface. DMEK grafts can be prepared safely with reproducibility. The risk of graft rejection is significantly lower after DMEK compared with rejection rates in Descemet stripping automated endothelial keratoplasty (DSAEK)…

Intraoperative and Postoperative Complications of Descemet Membrane Endothelial Keratoplasty

Key Concepts Descemet membrane endothelial keratoplasty (DMEK) provides excellent visual outcomes and minimal failure rates with proper surgical technique. Damage to donor tissue during graft preparation can be reduced by decreasing mechanical stress. Common intraoperative challenges include difficulty handling and unfolding the graft and ensuring proper orientation prior to graft adherence. Donor dislocation is the primary postoperative complication and can be minimized with increased air-fill time,…

Surgical Technique for Descemet Membrane Endothelial Keratoplasty

Key Concepts A closed-system injector is ideal for controlled delivery of a Descemet membrane endothelial keratoplasty (DMEK) graft. Creating a recipient stromal bed of slightly greater diameter than the donor graft improves graft attachment. Creating a peripheral iridotomy aids in preventing pupillary block. Obtaining correct graft orientation is critical for a successful outcome. The primary techniques used to unfold and center a DMEK graft include fluid…