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Postoperative Management

Key Concepts Close follow-up after penetrating keratoplasty is critical to long-term success. Early postoperative complications include elevated intraocular pressure, wound leaks, and failure to epithelialize the new graft. Surgical factors and patient characteristics influence the success rate. Infants and young children undergoing penetrating keratoplasty require special consideration, including more frequent follow-up and a team approach to management. Epithelial downgrowth and fibrous ingrowth, while uncommon, should be…

Femtosecond-Assisted Penetrating Keratoplasty

Key Concepts The use of femtosecond lasers in corneal transplant surgery was investigated in 2006, and since then, multiple customized trephination patterns have been conceptualized to improve wound architecture and healing. Trephination profiles, including the “top-hat,” “mushroom,” and “zig-zag,” among others, can be programmed to match the donor and host to allow precise vertical alignment of tissue. These customized trephinations provide greater surface area for rapid…

Intraoperative Complications of Penetrating Keratoplasty

Key Concepts Intraoperative complications during penetrating keratoplasty can be related to anesthesia, fixation ring placement, trephination, damage to intraocular structures, and bleeding. Intraoperative complications are best dealt with at the time of surgery and with adequate preparation can be successfully managed. The successful prevention and management of positive vitreous pressure can decrease the risk of intraoperative complications. A vitrectomy unit that is set up ahead of…

Penetrating Keratoplasty: The Fundamentals

Key Concepts Penetrating keratoplasty (PK) plays an important role for corneal disease not suitable for lamellar grafts. PK has excellent outcomes in terms of graft clarity, but high levels of postoperative astigmatism or anisometropia remain an issue. Risk factors for PK failure include previous graft failure, glaucoma, anterior and posterior synechiae, corneal neovascularization, aphakia or pseudophakia, and long operation time. Patients need to be counseled regarding…

Preoperative Considerations and Decision-Making in Keratoplasty

Key Concepts There has been a major paradigm shift in corneal surgery from penetrating keratoplasty to layer-specific corneal grafts. The preoperative evaluation includes not only a general medical history but, in addition, emphasis on the specific layer of the cornea involved with disease. Options in keratoplasty include ocular surface reconstruction, anterior or posterior lamellar procedures, penetrating keratoplasty, and keratoprosthesis. Posterior lamellar procedures (DSAEK or DSEK, DMEK,…

The Evolution of Contemporary Keratoplasty

Key Concepts The development of contemporary corneal transplantation has been evolutionary and largely evidence-based over the past century. The first successful, documented corneal graft was reported in 1906. Ramon Castroviejo is recognized as the pioneer of modern keratoplasty, and R. Townley Paton is the father of eye banking. Contemporary keratoplasty has moved away from penetrating keratoplasty and has focused on layer-specific transplantation contributing to a re-emergence…

Juvenile Idiopathic Arthritis-Associated Uveitis

Key Concepts Early diagnosis of juvenile idiopathic arthritis improves ocular morbidity and long-term outcome. Despite growing understanding of immunopathogenic mechanisms, the etiology of juvenile idiopathic arthritis remains speculative. Frequent ocular examination of high-risk juveniles is key to early initiation of treatment. Despite intensive screening programs, juvenile idiopathic arthritis-associated uveitis remains a blinding disease if not recognized early and treated aggressively. Aggressive control of intraocular inflammation reduces…

Fuchs Uveitis Syndrome

Key Concepts Fuchs uveitis syndrome (FUS) is a chronic iridocyclitis that may be underdiagnosed and over treated. The diagnosis is clinical, with characteristic features. A viral etiology is suspected, with rubella virus and cytomegalovirus as primary candidates. The inflammation in FUS rarely necessitates treatment. Cataract and elevated intraocular pressure are frequent complications. The prognosis in FUS is generally excellent. Fuchs uveitis syndrome (FUS) is a form…

Behçet Disease

Key Concepts The main clinical findings in Behçet disease are systemic and ocular vasculitis. Behçet disease is characterized by exacerbations and spontaneous remissions with structural damage of the involved tissue. Anterior segment manifestations include peripheral corneal infiltration, peripheral ulcerative keratitis, corneal perforation, scleritis, episcleritis, increase in corneal pachymetry, keratic precipitates, and nongranulomatous uveitis. Major criteria include ocular lesions, aphthous ulcers, genital ulcers, and skin lesions. Loss…

Sarcoidosis

Key Concepts Sarcoidosis is a multisystem chronic inflammatory disorder with a high incidence of ocular involvement. Uveitis is the most common ocular manifestation; it may be acute or chronic, anterior or posterior, and is frequently granulomatous in appearance. Involvement of the lids, lacrimal glands, orbit, cornea, conjunctiva, and optic nerve may also occur. The diagnosis of sarcoidosis is supported by elevated serum angiotensin-converting enzyme or lysozyme…

HLA-B27–Associated Uveitis

Key Concepts Human leukocyte antigen (HLA)-B27–associated uveitis is the most common cause of hypopyon uveitis in North America. HLA-B27–associated uveitis is nongranulomatous, anterior, and often severe. It is typically of sudden onset and limited duration but occasionally becomes chronic. It typically occurs in one eye at a time, although it may occasionally be bilateral, particularly the first episode. Uveitis or arthritis may be triggered in HLA…

Idiopathic Anterior Uveitis

Key Concepts Idiopathic uveitis is a diagnosis of exclusion that should be made only after a significant attempt to find etiologic associations—not only at the initial presentation but also at every follow-up visit—as the causative relationship may subsequently reveal itself. Comprehensive history taking, a thorough review of systems, careful ocular and physical examination, and proper diagnostic investigations are crucial to find potential related causes. The authors…

Classification and Diagnosis of Anterior Uveitis

Key Concepts Using the Standardization of Uveitis Nomenclature (SUN) criteria facilitates standardized description of uveitis and aids in the development of differential diagnoses as well as investigative studies. Acquiring a detailed past medical history, review of systems, social history, and family history is of paramount importance prior to examining the uveitis patient. Determining whether uveitis is infectious, noninfectious, or a masquerade syndrome determines what diagnostic studies…

Scleritis

Key Concepts Scleritis is characterized by a chronic inflammatory response centered in the sclera with possible spillover to involve adjacent ocular structures, mainly the cornea and the uvea. Scleritis may be idiopathic (50%) or associated with systemic autoimmune diseases (40%) or local or systemic infections (5%−10%). Because some of the systemic autoimmune diseases are potentially lethal, early diagnosis and subsequent therapy are extremely important. Infectious scleritis…

Episcleritis

Key Concepts Simple episcleritis is usually benign and self-limiting. Simple episcleritis is much more common than nodular episcleritis. Nodular episcleritis has a well-demarcated, elevated area of inflammation. Severe discomfort is rare and may represent scleritis. Appearance is a brick red discoloration. Cases are most often idiopathic. Treatment is usually unnecessary with simple episcleritis. Episcleritis is a relatively benign, self-limiting condition affecting the outer coat of the…

Complications of Contact Lens Wear

Key Concepts Compliance to proper hygiene is key. Single-use (daily) lenses are the safest type of contact lenses in terms of avoiding complications. Initial treatment for contact lens-induced keratitis is usually broad-spectrum antibiotic. In cases of contact lens-related keratitis, corticosteroids should not be used unless fungal or amoebic keratitis are ruled out. A complete history including contact lens and cleaning agents used is important for diagnosis…

Contact Lens Applications in Corneal Disease

Key Concepts There is a role for contact lenses beyond the routine correction of refractive error. Innovations in lens materials and in lens design have expanded the role of contact lenses in the treatment of distorted corneas and in ocular surface disease. Soft lenses made of hydrogels and silicone-hydrogel have utility as bandage therapeutic lenses after trauma and surgical intervention, with silicone-hydrogel lenses offering maximal oxygen…

External Eye Manifestations of Biological and Chemical Warfare

Key Concepts The use of biological and chemical agents as weapons is not a new concept. Recognition and preparation are essential to limit exposure and treat victims. Anthrax, botulism, smallpox, vaccinia, tularemia, and the viral hemorrhagic fevers have characteristic ophthalmic signs. Chemicals such as sarin nerve gas and sulfur mustard have been used as weapons with significant ocular manifestations. The spectrum of biological and chemical agents…

Corneal Complications of Intraocular Surgery

Key Concepts Advances in our understanding of intraocular surgery and in surgical techniques have greatly reduced the rate of corneal complications after intraocular surgery. However, since cataract surgery is the most common surgery performed in the United States, even low rates of complications can affect many people. Thermal burns can be limited with the use of microburst/hyperpulse phacoemulsification settings, torsional handpieces, and potentially femtosecond laser technology.…

Chemical and Thermal Injuries of the Eye

Key Concepts Chemical injuries are true ophthalmic emergencies. Treatment should commence immediately—detailed history can wait. Copious irrigation with a neutral solution is primary treatment. Delayed treatment may result in penetration of chemical to anterior chamber. Remove particulate matter during irrigation. pH should be checked regularly and continued after irrigation ceases. Strong acids and alkalis are equally destructive. Medical treatment should include antibiotics, corticosteroids, citrate, and ascorbate.…