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Cornea E-Book

Cornea E-Book

Jay H. Krachmer | Mark J Mannis | Edward J Holland

(2010)

Additional Information

Book Details

Abstract

Cornea, edited by Drs. Krachmer, Mannis & Holland, is the only truly comprehensive clinical reference available that covers external disease, anterior uveitis, and the expanding range of contemporary corneal surgery. In this Third Edition, state-of-the-art coverage, 25 brand-new chapters, and 45 new videos provide expert guidance on performing femtosecond-assisted penetrating keratoplasty, DSAEK, deep anterior lamellar keratoplasty, and many other cutting-edge techniques. Plus, you’ll have easy access to the complete contents and illustrations online at expertconsult.

  • Overcome any clinical challenge related to the cornea, external disease, anterior uveitis, and the expanding range of contemporary corneal surgery with the most complete, authoritative guidance source available.
  • Get superb visual guidance with exceptionally clear illustrations, diagnostic images, and step-by-step surgical photographs.
  • Access the complete contents and illustrations online at expertconsult.
  • Make optimal use of Anterior Segment OCT to plan and choose treatment options and assess post-operative recovery.
  • Master the latest surgical techniques—including femtosecond-assisted penetrating keratoplasty, DSAEK, and deep anterior lamellar keratoplasty—thanks to 25 brand-new chapters and 45 new videos on DVD (a total of 3 hours running time).
  • Understand the full spectrum of corneal diseases with coverage of the new corneal dystrophy classification that incoporates current genetic, clinical, and pathologic information.

Table of Contents

Section Title Page Action Price
Front cover cover
Cornea, 3/e i
Copyright page iv
Table of Contents v
DVD Table of contents xi
Preface xiii
Acknowledgments xiv
Dedication xv
Contributors xvi
I Basic Science: Cornea, Sclera, Ocular Adnexa Anatomy, Physiology and Pathophysiologic Responses 1
1 Cornea and Sclera: 3
Introduction 3
Anatomy and Physiology 3
Structure of the cornea and sclera 3
Optical properties of the cornea 4
Innervation 4
Vascular system 5
Oxygen and nutrient supply 5
Tear fluid 5
Histology and Biochemistry 6
Corneal epithelium 7
Superficial cells 7
Wing cells 9
Basal cells 10
Basement membrane 10
Bowman’s layer 11
Stroma of the cornea and sclera 12
Overview 12
Cells 12
Collagen 13
Proteoglycans 13
Descemet’s membrane 15
Endothelium 15
Maintenance of Normal Corneal Integrity 16
Overview 16
Epithelial maintenance 16
Role of limbal stem cells 16
Epithelial movement 17
Fibronectin–integrin system 17
Hyaluronan 18
Proteolytic enzymes 18
Cytokines and growth factors 18
Epidermal growth factor 18
Transforming growth factor-β 18
Basic fibroblast growth factor and platelet-derived growth factor 18
Interleukins 18
Neural regulation 18
Stromal maintenance 19
Extracellular matrix and stromal repair 19
Cytokines and growth factors 19
Neovascularization in the corneal stroma 19
Development of the Anterior Eye Segment 19
References 21
2 The Conjunctiva: 25
Embryology 25
Anatomy 25
Histology 26
Palpebral and forniceal conjunctiva 27
Bulbar conjunctiva 27
The corneoscleral limbus 27
Conjunctival goblet cells 27
Substantia propria 28
Vascular Supply 29
Lymphatic Drainage 29
Nerve Supply 29
Normal Flora 30
Physiology of the Conjunctiva 30
References 31
3 Tear Film 33
Overview and Function 33
Control of Tear Secretion 33
Tear Layer Thickness 34
Analytical Methods 35
Peptide Components of Tears 36
Acknowledgments 38
References 38
4 The Eyelids 41
Introduction 41
Embryology 41
Anatomy 42
Epithelium 42
Orbicularis oculi 42
Orbital septum 43
Retractors 43
Levator palpebrae superioris 43
Müller’s muscle 43
Capsulopalpebral fascia and inferior retractors 43
Tarsal plates 43
Conjunctiva 43
Eyelid margin 44
The suspensory system of the eyelids 44
Orbital fat compartments 45
Vascular supply 45
Lymphatic drainage 45
Sensory innervation 45
Blink reflex 45
References 45
5 A Matrix of Pathologic Responses in the Cornea 47
Anatomical Regions of the Cornea 47
General Pathologic Responses of the Cornea 47
1. Defects and their repair 47
2. Fibrosis and vascularization 47
3. Edema and cysts 47
4. Inflammation and immune responses 47
5. Deposits 48
6. Proliferation 48
Specific Pathologic Responses of the Cornea 50
Pathologic Responses of the Corneal Epithelium 51
1. Defects (and their repair) 51
2. Fibrosis and vascularization 51
3. Edema and cysts 51
Epithelial edema 51
Epithelial hypoxia and trauma 51
Changes in epithelial maturation 51
4. Inflammation and immune response 51
5. Deposits 52
Elements: iron deposits 52
Drugs: topical and systemic 52
Systemic diseases 52
Corneal dystrophies and degenerations 53
6. Proliferation 53
The Pathologic Responses of the Subepithelial Zone 54
1. Defects (and their repair) 54
2. Fibrosis and vascularization 54
Subepithelial avascular fibrosis 54
Subepithelial vascular fibrosis 55
3. Edema and cysts 55
4. Inflammation and immune responses 55
5. Deposits 55
6. Proliferation of the epithelial basement membrane 55
Pathologic Responses of the Corneal Stroma 55
1. Defects (and their repair) 55
2. Fibrosis and vascularization 58
Stromal fibrosis 58
Stromal vascularization 59
3. Edema and cysts 60
4. Inflammation and immune responses 60
5. Deposits 60
Topical and systemic drugs 60
Ocular diseases 60
Systemic diseases 61
Deposits from dystrophies and degenerations of the stroma 62
6. Proliferation 62
Pathologic Responses of the Corneal Endothelium and Descemet’s Membrane 62
1. Defects (and their repair) 62
Defects in the endothelium 63
Defects in Descemet’s membrane 63
2. Fibrosis and vascularization posterior to Descemet’s membrane 63
Posterior collagenous layer 63
Using the posterior collagenous layer to date the onset of endothelial or Descemet’s membrane disease with transmission electron microscopy 64
3. Edema and cysts 64
4. Inflammation and immune responses 64
5. Deposits 65
Topical and systemic drugs 65
Ocular and systemic diseases 65
Corneal dystrophies and degenerations 65
6. Proliferation 65
The Immune Response: Components and Reactions in the Eye 66
Overview 66
Cells of inflammation and the immune response 66
Cells of the lymphoid system 67
B lymphocytes 67
T lymphocytes 67
Null lymphocytes 72
Cells of the myeloid system 73
Macrophages and the mononuclear phagocytic system 73
Dendritic cells 73
Langerhans cells 73
Other cells of the myeloid system 73
Polymorphonuclear leukocytes 73
Eosinophils 73
Basophils 73
Mast cells 73
Soluble Mediators/Receptors of Inflammation 74
Adhesion molecules 74
Cytokines 74
Chemokines 74
Complement 74
Tissue Components of the Ocular Immune System 75
Mucosa-associated immune system (MALT) 75
The lacrimal functional unit (LFU) 75
The Cell-Mediated Immune (CMI) Response 75
Major histocompatibility complex 75
Antigen presentation and T-cell activation 75
Cell-mediated immune response 76
The Humoral (Antibody-Mediated) Immune Response 76
Immunoglobulins 76
Characteristics of immunoglobulins 76
Anterior Chamber Associated Immune Deviation (ACAID) 76
Immune Hypersensitivity Reactions 77
Type I hypersensitivity response (atopic, allergic reactions) 77
Type II (cytotoxic) hypersensitivity response 77
Type III hypersensitivity response (immune complex) 78
Type IV (delayed-type hypersensitivity [DTH]) response 78
References 78
II Examining and Imaging the Cornea and External Eye 81
1 Basic Evaluation of the Cornea and External Eye 83
6 Examination of the Lids 83
General Principles 83
History of Patient 83
Dermatologic Examination 83
Eyelid Position 83
Tear Meniscus and Puncta 84
Anterior Eyelid 84
Posterior Eyelid 85
Meibomian Gland Expression 85
Mucocutaneous Junction 86
Meibomian Gland Imagery 87
References 87
7 Slit Lamp Examination and Photography 89
The Instrument: Examination and Photography 89
The Instrument: Photography 89
Preparing for Photography 90
Focus 91
The 35-mm format 91
Magnification 91
Centration 91
Control of artifacts 92
Exposure 92
Color balance and sensitivity 92
Intensity of illumination 92
Subject reflectivity 92
Duration of exposure 92
Forms of Illumination: Examination and Photography 92
Direct Illumination 92
Diffuse illumination: examination 92
Diffuse illumination: photography 94
Focal illumination 94
Broad-beam illumination: examination 94
Broad-beam illumination: photography 96
Optic section: examination 96
Optic section: photography 98
Combined direct focal and diffused illumination: photography 99
Tyndall’s light/anterior chamber cells and flare: examination 103
Tyndall’s light/anterior chamber cells and flare: photography 103
Specular reflection: examination 103
Specular reflection: photography 104
Indirect Illumination 106
Proximal illumination: examination 106
Proximal illumination: photography 107
Sclerotic scatter: examination 107
Sclerotic scatter: photography 108
Direct and indirect retroillumination from the iris: examination 109
Direct retroillumination from the iris: photography 110
Indirect retroillumination from the iris: photography 111
Retroillumination from the fundus: examination 112
Retroillumination from the fundus: photography 112
Transillumination of the iris: examination 113
Transillumination of the iris: photography 113
The peripheral cornea (gonioscopy): examination 113
The peripheral cornea: photography 113
Vital dyes: examination 113
The Seidel test: examination 115
Vital dyes: photography 115
The Seidel test: photography 117
Techniques specific to keratoconus: photography 117
Documenting the Fleischer ring 117
Munson’s sign 117
The Examination 117
Further reading 118
References 118
8 Tear Film Evaluation 119
General Inspection 119
Slit Lamp Examination 119
Tear Stability 120
Tear Production 120
Tear Composition and Characteristics 121
Tear ferning 121
Tear osmolarity 121
Meibomian Gland Structure and Excreta 121
Tear Clearance Tests 122
Staining of the Ocular Surface 122
Tests of visual function 122
Conclusion 123
References 123
9 Refraction of the Abnormal Cornea 125
Instrumentation 125
Retinoscopy 125
Keratometry 125
Computer-assisted topographic analysis 127
Trial frame 127
Refracting the Patient 128
Conclusion 129
References 129
10 Corneal Diagnostic Techniques 131
Corneal Staining 131
Pachymetry 134
Aesthesiometry 135
Osmolarity 136
Summary 136
References 136
2 Laboratory Investigations 139
11 Practical Ophthalmic Microbiology for the Detection of Corneal Pathogens 139
Introduction 139
Central Laboratory versus In-office Testing 139
Communication: Ophthalmologist and Laboratory 139
Corneal Specimen Collection 139
Transport media 140
Mailing of diagnostic specimens 140
Stains and Cytologic Specimens 140
Bacterial Laboratory Diagnosis 141
Mycobacteria 142
Nocardia and Actinomyces 142
Antibiotic Susceptibility Testing 143
Laboratory Diagnosis of Fungal Infection 143
Laboratory Detection of Acanthamoeba and Microsporidia 143
Laboratory Diagnosis of Adenovirus Infection 143
Laboratory Testing for Herpes Simplex Virus 145
Laboratory Testing for Varicella-Zoster Virus and Epstein–Barr Virus 145
Laboratory Testing for Chlamydia 146
Laboratory Diagnosis: Unusual Requests 146
Summary 146
References 146
12 Molecular Genetics of Corneal Disease 149
The Value of Molecular Genetics Study of Disease 149
Review of Genetics and Human Disease 149
Techniques Used to Identify Disease-causing Genes 150
Disease-causing Mutations versus Nondisease-causing Sequence Variations 151
Epithelial and Subepithelial Corneal Dystrophies 151
Epithelial basement membrane dystrophy (EBMD, MIM 151
Epithelial recurrent erosion dystrophy (ERED, MIM 151
Subepithelial mucinous corneal dystrophy (SMCD) 151
Meesmann corneal dystrophy (MCD, MIM 152
Lisch epithelial corneal dystrophy (LECD) 152
Bowman Layer Dystrophies 152
Reis-Bücklers corneal dystrophy (RBCD, MIM 152
Thiel-Behnke corneal dystrophy (TBCD, MIM 152
Grayson-Wilbrandt (GWD) 152
Stromal Dystrophies 152
TGFBI Dystrophies 152
Classic lattice corneal dystrophy (LCD1, MIM 153
Lattice corneal dystrophy, gelosin type (LCD2, MIM 153
Granular corneal dystrophy, type 1 (GCD1, MIM 154
Granular-lattice (Avellino) corneal dystrophy (GCD2, MIM 154
Macular corneal dystrophy (MCD, OMIM 155
Schnyder corneal dystophy (SCD, MIM 156
Congenital stromal corneal dystrophy (CSCD, MIM 156
Fleck corneal dystrophy (FCD, MIM 156
Posterior amorphous corneal dystrophy (PACD) 156
Central cloudy dystrophy of Francois (CCDF, MIM 156
Pre-Descemet’s corneal dystrophy (PDCD) 156
Descemet’s Membrane and Endothelial Dystrophies 156
Fuchs’ endothelial corneal dystrophy (FECD, MIM 156
Posterior polymorphous corneal dystrophy (PPCD, MIM 157
Congenital hereditary endothelial dystrophy (CHED) 157
Autosomal dominant congenital hereditary endothelial dystrophy (CHED1, MIM 157
Autosomal recessive congenital hereditary endothelial dystrophy (CHED2, OMIM 217700) 157
X-linked endothelial corneal dystrophy (XECD) 157
Keratoconus (OMIM 148300) 158
X-linked megalocornea (MGC1, OMIM 158
Cornea plana (CNA2, OMIM 158
Conclusion 158
References 158
3 Imaging Techniques of the Cornea 161
13 Keratometry and Topography 161
Keratometry 161
Corneal Topography 162
Placido disk-based topographers 163
Slit scanning tomography 163
Calculations and Surface Reconstruction 164
Placido disk 164
Slit scanning technology 164
Presentation Methods 164
Color-coded maps 164
The Normal Cornea 164
Axial Curvature Maps 165
Refractive Power Map 165
Instantaneous or Tangential Power Map 167
Difference Maps 167
Elevation Maps 167
Pachymetric Maps 169
Quantitative indices 169
Corneal topography indices and screening methods 170
Conclusion 173
References 175
14 Specular Microscopy 177
Optical Principles of Specular Microscopy 177
Patient Preparation 178
Standardization of Imaging Techniques 180
Instrumentation 180
Qualitative Specular Microscopy 180
Epithelium 180
Endothelium: miscellaneous bright and dark structures 183
Endothelium: morphometry 184
Quantitative Specular Microscopy 185
Specular Microscopy in Clinical Trials and the Value of a Reading Center 187
Clinical Applications for Specular Microscopy 188
Aging 189
Corneal guttae 189
Fuchs’ endothelial corneal dystrophy 189
Lattice corneal dystrophy 190
Iridocorneal endothelial syndrome 190
Posterior polymorphous corneal dystrophy 190
Keratoconus 191
Glaucoma 191
Intraocular inflammation 192
Cataract extraction with intraocular lens implantation 192
Refractive surgery 192
Penetrating keratoplasty 193
Endothelial keratoplasty 195
Donor corneas 196
Intraocular irrigating solutions 196
Vitreocorneal contact 196
Epithelialization of the anterior chamber 196
Blunt trauma 197
Contact lens wear 197
Diabetes 197
References 197
15 Confocal Microscopy 205
Background 205
Historical overview 205
Current confocal systems in clinical use 205
In Vivo Confocal Imaging Techniques 207
Normal corneal structures 207
Confocal microscopy through-focusing 208
Clinical Applications 210
Wound healing following refractive surgery 210
Infectious keratitis 212
Imaging Corneal Collagen Using Second Harmonic Generated Signals 213
Normal human corneal stromal collagen organization 214
Collagen organization in keratoconus corneas 216
Conclusions 217
References 217
16 High-Resolution Ultrasound 221
Instrumentation 221
Image resolution 221
Examination Techniques 222
The Normal Cornea 222
Corneal Disease 224
Corneal edema 224
Descemet’s membrane detachment 224
Intraocular lens malposition 224
Imaging the anterior segment behind corneal opacities 224
Corneal dystrophies 224
Peripheral corneal degenerations 224
Keratoconus 225
Corneal Tumors 225
Corneal Surgery 226
Keratoplasty 226
Penetrating 226
Lamellar 227
Refractive surgery 227
Excimer laser keratectomy 227
Laser-associated in situ keratomileusis 227
Summary 227
Acknowledgments 227
References 228
17 Anterior Segment Optical Coherence Tomography 231
Introduction 231
Keratoconus Screening 231
Refractive Surgery Evaluation 232
LASIK flap evaluation 232
Refractive enhancement 232
LASIK complications 233
Corneal Power Calculation 233
Corneal Opacities 233
Cornea Transplant 233
Posterior lamellar keratoplasty 233
Femtosecond-enabled keratoplasty 234
Refractive Implants 234
Corneal implants 234
Phakic Intraocular Lenses 235
Financial interests 236
References 236
III Differential Diagnosis of Selected Problems in Corneal and External Eye Disease 237
18 Congenital Corneal Opacities: 239
Differential Diagnosis 239
History and Physical Examination 239
Sclerocornea (S TUMPED) 241
Tears in the Endothelium and Descemet’s Membrane (S T UMPED) 242
Congenital glaucoma 242
Birth trauma 243
Corneal Ulcers and Inflammation (ST U MPED) 244
Viral diseases 245
Herpes simplex virus infection 245
Congenital rubella 246
Bacterial diseases 246
Neurotrophic keratitis 247
Metabolic diseases (STU M PED) 247
Mucopolysaccharidosis 247
Mucolipidosis 250
Other metabolic diseases 250
Cystinosis 250
Fabry’s disease 250
Tyrosinemia 251
Gangliosidoses 251
Miscellaneous Syndromes 251
Fetal alcohol syndrome 251
Fryns syndrome 251
Cerebro-oculofacio-skeletal syndrome 251
Posterior Corneal Defect (STUM P ED) 251
Peters’ anomaly (STUM P ED) 252
Posterior keratoconus (STUM P ED) 254
Congenital anterior staphyloma (STUM P ED) 255
Endothelial Dystrophy (STUMP E D) 255
Congenital hereditary endothelial dystrophy 255
Posterior polymorphous corneal dystrophy (PPCD) 256
Congenital stromal corneal dystrophy (CSCD) 258
Other dystrophies 259
Congenital Dermoids (STUMPE D) 259
Corneal Keloids 262
References 262
19 Peripheral Corneal Disease 267
The Peripheral Cornea: Its Susceptibility and Response to Disease 267
Congenital/Developmental/Inherited Disorders of the Peripheral Cornea 267
Inflammatory/Autoimmune Disorders of the Peripheral Cornea 268
Neoplastic Disorders of the Peripheral Cornea 271
Degenerative Disorders of the Peripheral Cornea 272
Infectious Disorders of the Peripheral Cornea 274
References 275
20 The Corneal Ulcer 277
Diagnosis 277
Treatment 281
References 281
21 Corneal Edema 283
Physiology 283
Epithelial and endothelial barriers 283
Tear evaporation 283
Intraocular pressure 283
Metabolically active mechanisms 283
Diagnosis 283
Clinical history 283
Examination 284
Ancillary tests 285
Pachymetry 285
Specular microscopy 285
In vivo confocal microscopy 285
Anterior segment optical coherence tomography 285
Treatment 285
Control of associated abnormalities 285
Inflammation 285
Intraocular pressure 286
Management of epithelial and stromal edema 286
Hypertonic agents 286
Bandage contact lens 286
Anterior stromal cautery 286
Conjunctival flap 286
Amniotic membrane 286
Excimer laser 286
Penetrating keratoplasty 286
Endothelial keratoplasty 286
Collagen Cross-linking 287
References 287
22 Corneal Deposits 289
Superficial Deposits 289
Pigmented deposits 289
Cornea verticillata 289
Striate melanokeratosis 289
Epithelial iron lines 289
Spheroidal degeneration 289
Adrenochrome deposition 289
Nonpigmented deposits 290
Subepithelial mucinous corneal dystrophy 290
Coat’s white ring 290
Calcific band keratopathy 290
Fluoroquinolone deposits 291
Mucin balls 292
Refractile/crystalline deposits 292
Meesmann’s dystrophy 292
Gelatinous droplike dystrophy 293
Tyrosinemia II (Richner-Hanhart syndrome) 293
Intraepithelial ointment 293
Gout (urate) 294
Stromal Deposits 294
Pigmented Deposits 294
Phenothiazines 294
Corneal blood staining 294
Bilirubin 294
Siderosis 294
Nonpigmented deposits 295
Granular dystrophy 295
Macular dystrophy 295
Fleck dystrophy 295
Lipid deposition 296
Mucopolysaccharidoses 296
Refractile/crystalline deposits 296
Lattice dystrophy 296
Schnyder’s central crystalline dystrophy 297
Bietti’s crystalline dystrophy 297
Systemic diseases with immunoglobulin deposition 298
Cystinosis 298
Deep Stromal Deposits 298
Pigmented deposits 298
Copper deposition associated with Wilson’s disease 298
Chalcosis 299
Ocular chrysiasis 299
Mottled cyan opacification in contact lens wearers 299
Nonpigmented deposits 299
Cornea farinata 299
Pre-Descemet’s corneal dystrophy 300
X-linked ichthyosis 300
Ocular argyrosis 300
Refractile/crystalline deposits 301
Polymorphic amyloid degeneration 301
References 301
23 Corneal Infiltrates in the Contact Lens Patient 303
History 303
Pain 303
Type of contact lens and pattern of wear 303
Contact lens solutions and hygeine 303
Slit Lamp Examination 304
Diagnosis 304
Treatment 306
Follow-up 306
Case Examples 306
Case 1 306
Case 2 307
Case 3 307
Case 4 307
Case 5 307
Case 6 307
References 307
24 The Red Eye 309
Defining a Red Eye 309
Approaching the Patient 309
Subconjunctival Hemorrhages and Telephone Triage of a Red Eye 309
Redness due to Inflammation 311
Red Eyes due to Vascular Abnormalities 311
The Medical History and Case Examples 311
Physical Examination 312
Conclusion 314
25 Minimal Visual Loss: 315
History 315
Examination Techniques 315
Visual acuity 315
Pinhole aperture 315
Contrast sensitivity function (CSF) 315
Diagnostic rigid contact lens refraction 315
Technique 315
Potential acuity meter 316
Retinoscopy 316
Slit lamp examination 316
Fluorescein evaluation 316
Keratometry 316
Computerized corneal topography 316
Wavefront analysis 317
Selected Conditions Causing Minimal Visual Loss 318
Dry eyes 318
Ectatic disorders 318
Keratoconus 318
Ectasia following refractive surgery 319
Pellucid marginal degeneration 319
Terrien’s marginal degeneration 319
Punctate epithelial keratitis 319
Corneal scars 319
Corneal dystrophies 319
Anterior corneal dytrophies 319
Meesmann’s dystrophy 319
Reis-Bücklers’ dystrophy 320
Stromal corneal dystrophies 320
Granular dystrophy 320
Lattice dystrophy 320
Macular dystrophy 320
Endothelial disorders 320
Fuchs’ endothelial dystrophy 320
Posterior polymorphous dystrophy (PPMD) 320
Iridocorneal endothelial syndrome 320
Corneal degenerations 321
Pterygium 321
Corneal warpage 321
Keratorefractive surgery 321
References 321
26 The Approach to a Patient with Itching and Burning 323
The Primary Symptom 323
Onset 323
Past medical history 323
Contact lens wear 323
Review of systems 323
The Examination 324
External examination 324
Lids and lashes 325
The Ocular Surface 325
Conjunctiva 325
Tear film analysis 326
Cornea 326
References 326
IV Eye Banking 329
27 Eye Banking: 331
Eye Banking: Patient Services and Regulatory Concerns 331
Tissue Acquisition 331
Screening 331
Retrieval or Recovery 332
Tissue Preservation/Storage 332
Donor Eligibility and Tissue Suitability 332
Tissue Evaluation 332
Quality Assurance 332
Facilities, Equipment, Instruments, and Supplies 333
Distribution 333
Further Reading 333
28 Medical Standards for Eye Banking 335
Eye Bank Association of America Medical Standards 335
Federal and State Regulations 335
Standards Relating to Safety of Tissue 336
Dystrophies and degenerations 337
Endophthalmitis and microbial keratitis 337
Rabies 338
Hepatitis B 338
Hepatitis C 339
HIV I and II 339
Other infectious agents 339
Prion disease 340
Malignancies 341
Recalls and Market Withdrawals 341
Primary Graft Failure 342
Mechanical and Optical Integrity 342
References 343
V The Ocular Adnexa 345
1 Diseases of the Lid: Anatomic Abnormalities 347
29 Eyelid Disorders: 347
Entropion 347
Congenital entropion 347
Involutional entropion 347
Cicatricial entropion 348
Acute spastic entropion 348
Differential diagnosis 349
Medical management 349
Surgical management 349
Congenital entropion 349
Involutional entropion 349
Cicatricial entropion 352
Complications 352
Ectropion 352
Congenital ectropion 352
Involutional ectropion 352
Cicatricial ectropion 352
Paralytic ectropion 352
Mechanical ectropion 353
Inflammatory ectropion 353
Differential diagnosis 353
Medical management 353
Surgical management 353
Involutional ectropion 353
Congenital ectropion 354
Paralytic ectropion 354
Cicatricial ectropion 354
Complications 354
Trichiasis and Distichiasis 355
Management of trichiasis 355
Management of distichiasis 356
References 356
30 Lagophthalmos and Other Malpositions of the Lid 357
Floppy Eyelid Syndrome 357
Treatment 359
Lid Imbrication Syndrome 359
Treatment 360
Lagophthalmos 360
Treatment 362
Eyelid Retraction 364
Treatment 364
References 365
2 Diseases of the Lid: Tumors 367
31 Benign Lid Tumors 367
Histology of the Eyelid Skin 367
Approach to Diagnosis and Management 368
Benign Tumors of the Epidermis 368
Acrochordon 368
Milia 369
Seborrheic keratosis 369
Keratoacanthoma 369
Inverted follicular keratosis 370
Cutaneous horn 370
Epidermal inclusion cyst 370
Linear epidermal nevus 370
Nodular elastosis with cysts and comedones (Favre-Racouchot syndrome) 371
Actinic keratosis (solar keratosis) 371
Dermoid and epidermoid cysts 371
Oncocytoma 372
Phakomatous choristoma 372
Benign Tumors of the Dermis 372
Tumors derived from neural tissue 372
Neurofibroma 372
Neurilemoma 373
Neuroma 373
Granular cell tumor 373
Tumors derived from smooth muscle 373
Leiomyoma 373
Tumors derived from vascular tissue 373
Nevus flammeus 373
Capillary hemangioma 374
Cherry hemangioma 374
Cavernous hemangioma 374
Varix 375
Lymphangioma 375
Arteriovenous malformation 375
Pyogenic granuloma 376
Glomus tumor 376
Intravascular papillary endothelial hyperplasia 376
Angiolymphoid hyperplasia with eosinophilia 376
Tumors derived from histiocytes 377
Xanthelasma 377
Xanthoma 377
Juvenile xanthogranuloma 377
Tumors derived from fibrous tissue 378
Dermatofibroma 378
Benign Tumors of the Eyelid Adnexa 378
Tumors of sweat gland origin 378
Tumors of eccrine sweat gland origin 378
Syringoma 378
Eccrine spiradenoma 378
Eccrine acrospiroma 378
Eccrine hidrocystoma 379
Pleomorphic adenoma 379
Tumors of apocrine sweat gland origin 379
Apocrine hidrocystoma 379
Cylindroma 379
Syringocystadenoma papilliferum 380
Tumors of hair follicle origin 380
Trichoepithelioma 380
Trichoadenoma 381
Trichofolliculoma 381
Trichilemmoma 381
Pilomatricoma 381
Tumors of sebaceous gland origin 382
Sebaceous gland hyperplasia 382
Sebaceous adenoma 382
Benign Melanocytic Lesions 382
Nevocellular nevi 382
Junctional nevi 382
Compound nevi 382
Melanoma 382
Intradermal nevi 382
Variants of nevocellular nevi 383
Congenital nevus 383
Blue nevus 383
Nevus of Ota 383
Freckle 384
Lentigo simplex 384
Lentigo senilis 384
Lentigo maligna 384
Conclusion 384
References 384
32 Malignant Eyelid Tumors 387
Basal Cell Carcinoma 387
Clinical appearance 387
Biologic behavior 389
Clinical diagnosis 389
Treatment 389
Mohs’ micrographic surgery 389
Frozen section control 390
Ionizing radiation therapy 390
Cryosurgery 390
Chemotherapy 390
Recurrence 390
Squamous Cell Carcinoma 390
Premalignant Lesions 391
Actinic keratosis 391
Bowen’s disease 391
Epidemiology and Differential Diagnosis 392
Squamous cell carcinoma 392
Clinical presentation 392
Biologic behavior 392
Treatment 392
Sebaceous cell carcinoma 392
Etiology 393
Clinical presentation 393
Treatment 393
Prognosis 394
Merkel cell carcinoma (trabecular carcinoma) 394
Normal Merkel cell 394
Merkel cell carcinomas 394
Clinical presentation 394
Histopathology 394
Treatment 395
Localized disease 395
Extraregional disease 395
Malignant melanoma 395
Lentigo maligna melanoma 395
Superficial spreading melanoma 396
Nodular melanoma 396
Treatment 396
Kaposi’s sarcoma 397
Clinical presentation 397
Histopathology 397
Treatment 397
Systemic Associations 398
Basal cell nevus syndrome (Gorlin-Goltz syndrome) 398
Systemic manifestations 398
Ophthalmic manifestations 398
Treatment 398
Xeroderma Pigmentosum 398
Cutaneous abnormalities 399
Ocular abnormalities 399
Neurologic abnormalities 399
Treatment 399
Muir-Torre Syndrome 399
Summary 399
References 399
3 Diseases of the Lid: Inflammation and Infections 403
33 Blepharitis: 403
Classification 403
Differential Diagnosis 405
Management 405
References 405
34 Meibomian Gland Dysfunction and Seborrhea 407
Normal Anatomy of the Meibomian Glands 407
Terminology 407
Physiology 407
Classification of Meibomian Gland Dysfunction 409
Diagnosis of Meibomian Gland Dysfunction 409
Associated Conditions 410
Associated sequelae 411
Histopathology 411
Models of Meibomian Gland Dysfunction 411
Lipid Composition and Behavior of Human Meibomian Secretion 411
Role of Microorganisms 411
Treatment 412
Conclusion 412
References 412
35 Eyelid Infections 415
Viral Infections 415
Herpes simplex virus 415
Clinical manifestations 415
Treatment 415
Varicella-zoster virus 415
Clinical manifestations of primary VZV infection 415
Clinical manifestations of reactivated VZV 416
Diagnosis 416
Treatment of primary VZV infection 416
Treatment of reactivated VZV 417
Molluscum contagiosum 417
Verruca vulgaris 418
Treatment 418
Bacterial Infections 418
Hordeolum 418
Preseptal cellulitis 418
Post-traumatic suppurative preseptal cellulitis 418
Nonsuppurative preseptal cellulitis in children 419
Erysipelas 419
Impetigo contagiosa 419
Rare bacterial infections 419
Anthrax 419
Syphilis 419
Mycobacterial Infections 419
Actinomycosis 420
Fungal Infections 420
Blastomycosis 420
Coccidiomycosis 420
Cryptococcosis 420
Dermatophytosis/tinea palpebrum 420
Sporotrichosis 421
Mucormycosis 421
Parasitic Eyelid Infections 421
Demodicosis 421
Phthiriasis/pediculosis 421
Onchocerciasis 422
References 422
4 Disorders of Tear Production and the Lacrimal System 425
36 Dry Eye 425
Definition 425
Lacrimal Functional Unit: Anatomy and Physiology 425
Pathophysiology 425
Etiopathogenic Classification 426
Aqueous tear-deficient dry eye (ADDE, tear-deficient dry eye; lacrimal tear deficiency) 426
Sjögren’s syndrome dry eye 427
Non-Sjögren’s syndrome dry eye 428
Primary lacrimal gland deficiencies 428
Secondary lacrimal gland deficiencies 429
Obstruction of the lacrimal gland ducts 429
Reflex hyposecretion 429
Reflex sensory block 429
Diabetes mellitus: 429
Neurotrophic keratitis: 429
Reflex motor block 430
Evaporative dry eye 430
Intrinsic causes 430
Meibomian gland dysfunction 430
Disorders of lid aperture and lid/globe congruity or dynamic 430
Low blink rate 430
Extrinsic causes 430
Ocular surface disease 430
Contact lens wear 430
Diagnosis of Dry Eye 430
History 430
Physical examination 431
Diagnostic tests 431
Tear film stability 431
Diagnostic dye staining: ocular surface health 431
Corneal sensation 433
Tear film composition 433
Osmolarity 433
Tear protein analysis 433
Aqueous tear flow and turnover 433
Schirmer test 433
Delayed tear clearance 434
Other noninvasive methods for assessing the tear film 434
Systemic Work-Up 435
Management of Dry Eyes 435
Tear supplementation: lubricants 435
Tear retention 436
Punctal occlusion 436
Moisture chamber spectacles 436
Contact lenses 436
Tarsorrhaphy 436
Tear stimulation: secretagogues 437
Biological tear substitutes 437
Serum 437
Salivary gland autotransplantation 437
Anti-inflammatory therapy 437
Ciclosporin 437
Corticosteroids 438
Tetracyclines 439
Essential fatty acids 439
Topical vitamin A (retinol) 439
Mucolytics 439
Treatment Guidelines 439
References 440
37 Dacryoadenitis, Dacryocystitis, and Canaliculitis 445
Dacryoadenitis 445
Dacryocystitis 446
Canaliculitis 448
References 450
38 Epiphora 451
Introduction 451
Etiology 451
Overproduction 451
Outflow obstruction 451
Lacrimal pump failure 453
Differential Diagnosis 453
Evaluation 453
Treatment 454
Overproduction 454
Outflow obstruction 455
Lacrimal pump failure 456
Summary 456
References 456
VI The Conjunctiva 459
1 Conjunctival Disease: Tumors 1
39 Squamous Neoplasms of the Conjunctiva 1
Benign Tumefactions 1
Benign hereditary intraepithelial dyskeratosis 1
Pseudoepitheliomatous hyperplasia and keratoacanthoma 1
Conjunctival squamous papilloma 2
Inverted conjunctival papillomas 3
Dacryoadenoma 3
Pterygia and pingueculae 3
Malignant Tumefactions 4
Conjunctival intraepithelial neoplasia 4
Invasive squamous cell carcinoma 6
Corneal epithelial dysmaturation and epithelial dysplasia 9
Mucoepidermoid carcinoma 9
Spindle cell carcinoma 9
Adenoid squamous carcinoma 9
Clear cell carcinoma 9
Sebaceous cell carcinoma 10
Basal cell carcinoma 13
References 13
40 Melanocytic Neoplasms of the Conjunctiva 477
Introduction 477
Conjunctival Nevus 477
Conjunctival Melanosis 478
Epithelial congenital melanosis 478
Subepithelial congential melanosis 479
Secondary acquired melanosis 479
Primary acquired melanosis 479
Malignant Melanoma 481
References 483
41 Subepithelial Neoplasms of the Conjunctiva 485
Congenital Lesions 485
Choristomas 485
Dermoid and dermolipoma 485
Ectopic lacrimal gland; simple and complex choristomas 486
Epibulbar osseous and neuroglial choristomas 487
Hamartomas 488
Conjunctival cysts 488
Reactive, Degenerative, and Inflammatory Lesions 489
Pyogenic granuloma/capillary hemangioma 489
Pinguecula/pterygium 491
Elastofibroma oculi 491
Nodular fasciitis 491
Granulomatous and histiocytic lesions 491
Epibulbar molluscum contagiosum 492
Keloid 492
Amyloid 493
Hematic cyst 493
Neoplastic Lesions 493
Fibrous histiocytoma 493
Kaposi’s sarcoma 494
Oncocytoma (oxyphilic adenoma) 498
Basal cell carcinoma 499
Malignant melanoma 499
Lymphoid lesions 499
Other Subconjunctival Neoplastic Lesions 501
References 504
2 Conjunctivitis 509
42 Conjunctivitis: 509
Conjunctival Injection 509
Conjunctivitis 509
Morphologic responses 510
Papillae 510
Follicles 510
Membranes 510
Cicatrizing changes 512
Granulomas 512
Type of exudate 513
Anatomic localization 513
Acute Conjunctivitis 513
Acute papillary conjunctivitis 513
Acute follicular conjunctivitis 514
Adenovirus 514
Inclusion conjunctivitis 514
Ocular herpes infections 514
RNA-containing viruses 515
Poxviruses 515
Acute membranous conjunctivitis 515
Chronic Conjunctivitis 515
Giant papillary conjunctivitis 516
Vernal keratoconjunctivitis 516
Atopic keratoconjunctivitis 516
Secondary giant papillary conjunctivitis 516
Chronic papillary conjunctivitis 516
Masquerade syndrome 517
Intraepithelial neoplasia 517
Malignant melanoma 517
Sebaceous cell carcinoma 517
Lacrimal drainage system infection 517
Chronic dacryocystitis 517
Chronic canaliculitis 517
Superior limbic keratoconjunctivitis 517
Floppy eyelid syndrome 517
Blepharoconjunctivitis 518
Staphylococcal and seborrheic 518
Meibomian gland dysfunction 518
Keratoconjunctivitis sicca 518
Mucus-fishing syndrome 518
Toxic papillary keratoconjunctivitis 518
Chronic follicular conjunctivitis 519
Chlamydial 519
Trachoma 519
Inclusion conjunctivitis 519
Moraxella 519
Molluscum contagiosum 519
Toxic follicular conjunctivitis 519
Lyme disease 519
Chronic membranous conjunctivitis 520
Cicatrizing and granulomatous conjunctivitis 520
References 520
43 Bacterial Conjunctivitis 521
Nonspecific and Specific Natural Defenses 521
Manifestations of Conjunctivitis 522
Discharge 522
Membranes and pseudomembranes 522
Papillae and follicles 522
Classification 523
Hyperacute bacterial conjunctivitis 523
Associated ocular and systemic complications 524
Diagnosis 524
Treatment 524
Acute conjunctivitis 525
Associated ocular and systemic complications 527
Diagnosis 527
Treatment 527
Chronic conjunctivitis 529
Associated ocular complications 530
Diagnosis 530
Treatment 530
Unusual Causes of Bacterial Conjunctivitis 530
Immunodeficiency and AIDS 531
References 531
44 Viral Conjunctivitis 535
DNA Viruses 535
Adenoviruses 535
Treatment 538
Herpes simplex virus (HSV) 540
Varicella-zoster virus (VZV) 540
Epstein-Barr virus (EBV) 541
Cytomegalovirus (CMV) 541
Variola and vaccinia virus 541
Molluscum contagiosum virus (MC) 541
RNA Viruses 541
Picornaviruses 541
Paramyxoviruses 542
Togaviruses 542
Flaviviruses 542
References 542
45 Chlamydial Infections 545
Introduction 545
Basic Science 545
Trachoma 545
Epidemiology 545
Clinical manifestations 546
Pathophysiology 547
Treatment 547
Neonatal Inclusion Conjunctivitis 548
Adult Inclusion Conjunctivitis 549
Lymphogranuloma Venereum 550
Chlamydia psittaci 551
Conclusion 551
References 551
46 Ophthalmia Neonatorum 553
Pathogenesis 553
The Role of Sexually Transmitted Diseases 553
Causes of Neonatal Conjunctivitis 554
Chemical 554
Bacterial 554
Chlamydial 555
Viral 555
Fungal 556
Laboratory Diagnosis 556
Treatment 556
Ocular Prophylaxis 557
References 558
47 Parinaud’s Oculoglandular Syndrome 559
History 559
Directed Work-up 559
Individual Etiologies 560
Cat-scratch disease 560
Tularemia 562
Tuberculosis 563
Sporotrichosis 563
Syphilis 564
Other causes 564
References 564
48 Seasonal and Perennial Allergic Conjunctivitis 567
Immunopathophysiology 567
Clinical Features of Seasonal Allergic Conjunctivitis 568
Clinical Features of Perennial Allergic Conjunctivitis 569
Treatment of Seasonal and Perennial Allergic Conjunctivitis 570
Advisory interventions 570
Medical therapy 570
Contact Lens Wearers 571
Research in Diagnosis and Treatment 571
References 571
49 Vernal and Atopic Keratoconjunctivitis 573
Vernal Keratoconjunctivitis 573
Definition 573
Demographics 573
Symptoms 573
Signs 573
Pathophysiology 574
Diagnosis 575
Treatment 575
Atopic Keratoconjunctivitis 576
Definition 576
Demographics 576
Symptoms 576
Signs 576
Pathophysiology 577
Diagnosis 578
Treatment 578
References 579
50 Giant Papillary Conjunctivitis 583
Symptoms and Signs 583
Histopathology and Immunopathology 585
Pathophysiology 586
Differential Diagnosis 586
Treatment 587
Prognosis 588
References 588
51 Cicatricial Pemphigoid 591
Definition 591
Epidemiology 591
Pathogenesis 592
Diagnosis 593
Ocular Manifestations 593
Therapy 594
Current Status of Medical Therapy Program for Ocular Cicatricial Pemphigoid 594
References 596
52 Erythema Multiforme, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis 599
History 599
Incidence and Prevalence 599
Clinical Findings 600
Initial presentation 600
Eye findings 600
Acute eye findings 600
Chronic eye findings 600
Nonocular findings 601
Recurrent Disease 602
Incidence of ocular complications 602
Differential Diagnosis 603
Ocular disorders 603
Dermatologic manifestations 603
Etiology 603
Pathogenesis 603
Histopathology 604
Skin 604
Eye 605
Management 605
Systemic disease 605
Ophthalmic disease 605
Acute stage 605
Chronic stage 606
Prognosis 607
References 607
53 Toxic Conjunctivitis 613
Introduction 613
Toxicity versus Allergy 613
Cellular mechanisms 613
Signs and symptoms 613
Diagnostic testing 615
Toxic Keratoconjunctivitis Related to Topical Medications 615
Methods of assessing toxicity 615
Toxicity of specific agents 615
Antivirals 615
Glaucoma medications 615
Antibiotics and antifungals 616
Anesthetics 617
Preservatives 617
Follicular conjunctivitis 618
Hurricane keratitis 618
Drug-induced cicatricial pemphigoid 618
Others Causes of Toxic Keratoconjunctivitis 618
Cosmetics and skin care products 618
Hair care products 619
Tear gas weapons and lacrimating agents 619
Therapeutic Considerations 620
References 620
54 Superior Limbic Keratoconjunctivitis 623
Historical Perspective and Epidemiology 623
Clinical Presentation 623
Histopathology 623
Origin and Pathogenesis 624
Treatment Options 625
Differential Diagnosis 626
Summary 627
References 627
55 Ligneous Conjunctivitis 629
Epidemiology 629
Clinical Findings 629
Pathophysiology/Histopathology 629
Etiology 630
Treatment 631
References 633
56 Conjunctivochalasis 635
Introduction 635
Epidemiology 635
Histopathology 635
Symptoms and Clinical Presentation 636
Diagnosis 636
Treatment 637
Conclusion 638
References 639
VII Diseases of the Cornea 641
1 Developmental Abnormalities of Cornea 643
57 Developmental Corneal Anomalies of Size and Shape 643
Absence of the Cornea 643
Anomalies of Size 644
Megalocornea 645
Microcornea 646
Anomalies of Shape 647
Oval cornea 647
Astigmatism 647
Sclerocornea (cornea plana) 647
Posterior keratoconus 649
Keratoglobus 650
Congenital Anterior Staphyloma and Keratectasia 650
References 651
58 Axenfeld-Rieger Syndrome and Peters’ Anomaly 655
Terminology 655
Axenfeld-Rieger Syndrome 655
History 655
Clinical features 656
Cornea 656
Iridocorneal angle 657
Iris 657
Glaucoma 658
Other ocular findings 658
Nonocular findings 658
Face 658
Teeth 658
Umbilical 658
Genital 659
Others 659
Differential diagnosis 659
Pathogenesis 660
Genetics 660
Chromosome 4q, RIEG1, PITX2 660
Chromosome 13q, RIEG2 660
Chromosome 6p, FOXC1 660
Natural history 661
Treatment 661
Peters’ Anomaly 661
History 661
Clinical features 661
Cornea 661
Anterior chamber 661
Lens 661
Glaucoma 662
Other ocular findings 662
Nonocular findings 662
Differential diagnosis 662
Pathogenesis 662
Genetics 662
Natural history 663
Treatment 663
References 663
2 Corneal Manifestations of Systemic Disease and Therapies 665
59 Corneal Manifestations of Metabolic Diseases 665
Introduction 665
Disorders of Carbohydrate Metabolism 665
Diabetes mellitus – diabetic keratopathy 665
Lysosomal storage disorders 667
Introduction 667
Mucopolysaccharidoses 667
MPS I 668
Hurler’s syndrome (MPS I-H) 671
Scheie’s syndrome (MPS I-S) 672
Hurler-Scheie (MPS I-HS) 673
Hunter’s syndrome (MPS II) 673
Sanfilippo’s syndrome (MPS III) 673
Morquio’s syndrome (MPS IV) 673
Maroteaux-Lamy syndrome (MPS VI) 673
Sly’s syndrome (MPS VII) 674
Natowicz’s syndrome (MPS IX) 674
Corneal histopathology in MPS 674
Disorders of Lipid and Lipoprotein Metabolism 675
Dyslipoproteinemias 675
Hyperlipoproteinemias and Schnyder crystalline dystrophy 676
Hypolipoproteinemias 676
Lipidoses 677
Fabry’s disease 677
Multiple sulfatase deficiency 678
Generalized gangliosidoses 678
Drug-induced lipidoses 678
Chloroquine 678
Amiodarone 679
Other agents 680
Disorders of Glycosaminoglycan and Lipid Metabolism 680
Mucolipidoses 680
Galactosialidosis 681
Disorders of Amino Acid, Nucleic Acid, and Protein Metabolism 681
Cystinosis 681
Tyrosinemia II 682
Alkaptonuria 683
Amyloidosis 683
Gout 684
Porphyria 685
References 685
60 Skeletal and Connective Tissue Disorders with Anterior Segment Manifestations 691
Classification of Skeletal Disorders 692
Craniofacial dysostosis syndromes 692
Goldenhar syndrome 695
Hallermann-Streiff syndrome (oculomandibulodyscephaly, Francois dyscephalic syndrome) 696
Treacher Collins syndrome (mandibulofacial dysostosis; Franceschetti syndrome) 696
Ehlers-Danlos syndrome 696
Osteogenesis imperfecta 700
Stickler syndrome (hereditary progressive arthro-ophthalmopathy), Wagner syndrome, and Marshall syndrome 701
Kniest dysplasia 702
Marfan syndrome 702
Oculo-dento-osseous dysplasia 704
Sotos syndrome 705
Dermo-chondro-corneal dystrophy of Francois 705
Werner syndrome 705
Syndrome of acromegaly, cutis verticis gyrata, and corneal leukoma of Rosenthal and Kloepfer 706
Hypophosphatasia 706
Treatment of Ocular and Corneal Abnormalities in Skeletal Disorders 706
References 707
61 Inflammatory Bowel Disease and Other Systemic Inflammatory Diseases 711
Inflammatory Bowel Disease 711
Etiology and pathogenesis 711
Pathology and clinical manifestations 711
Ocular manifestations 711
Treatment 712
Whipple’s Disease 712
Systemic manifestations 713
Etiology and pathogenesis 713
Ocular manifestations 713
Treatment 713
Chronic Granulomatous Disease 714
Systemic manifestations 714
Ocular manifestations 714
Wegener’s Granulomatosis 714
Systemic manifestations 715
Classic Wegener’s granulomatosis 715
Limited Wegener’s granulomatosis 715
Pathogenesis 715
Ocular manifestations 715
Management 716
Kawasaki disease 716
Epidemiology 716
Etiology and pathogenesis 716
Systemic manifestations 716
Ocular manifestations 717
Management 717
References 717
62 Nutritional Disorders 721
Metabolism of Vitamin A 721
Historical Considerations 721
Classification and Clinical Manifestations of Xerophthalmia 722
Night blindness (XN) 722
Conjunctival xerosis (X1A) and Bitot’s spots (X1B) 722
Corneal xerosis (X2) 723
Corneal ulceration/keratomalacia (X3A/X3B) 724
Pathogenesis of corneal ulceration 724
Interactions with Other Factors 726
Epidemiology 727
Treatment 728
Other Nutritional Deficiencies 729
Vitamin B (riboflavin) 729
Vitamin C 729
Other nutrients 729
Discrete colliquative keratopathy 729
Summary 729
References 729
63 Hematologic Disorders 733
Hematopoiesis 733
Miscellaneous Disorders of the Erythroid Line 733
Iron deficiency anemia 733
Systemic manifestations 733
Ophthalmic manifestations 733
Iron overload 733
VIII The Sclera and Anterior Uvea 1243
1 Disorders of the Sclera 1245
103 Episcleritis 1245
Anatomy 1245
Incidence 1245
Clinical Manifestations 1245
History 1245
Physical examination 1246
Course 1247
Differential Diagnosis 1247
Pathology 1247
Angiography 1247
Complications 1247
Etiology 1248
Laboratory Evaluation 1249
Treatment 1249
References 1250
104 Scleritis 1253
Immune-mediated Scleritis 1253
Epidemiology 1253
Pathogenesis and risk factors 1253
Clinical findings 1254
Associated systemic diseases 1255
Complications 1256
Signs aiding in differential diagnosis 1257
Laboratory investigations 1257
Therapy 1258
Infectious Scleritis 1259
Clinical Findings 1260
Keratoscleritis 1260
Panophthalmitis 1261
Scleritis after scleral buckling surgery, 1261
Post-pterygium excision scleritis 1261
Other postsurgical infectious scleritis 1261
Herpetic scleritis 1261
Syphilitic scleritis 1261
Mycobacterium tuberculosis scleritis 1262
Signs aiding in differential diagnosis 1262
Laboratory investigations 1262
Therapy 1262
References 1263
2 Anterior Uveitis 1267
105 Classification and Diagnosis of Anterior Uveitis 1267
Diagnosis 1267
Symptoms of Anterior Uveitis 1267
History 1267
Demographic Information 1267
Past Medical History and Review of Systems 1268
Social and Family History 1268
Physical Examination 1268
External 1268
Pupils 1268
Sclera and conjunctiva 1268
Cornea 1269
Anterior chamber, anterior chamber angle, and iris 1270
Lens and anterior vitreous 1272
Intraocular pressure 1272
Retina and optic nerve 1272
Classification 1272
Response to Therapy 1272
Diagnostic Evaluation 1273
Treatment 1273
Summary 1275
References 1275
106 Idiopathic Uveitis 1277
Uveitis Classification 1277
Uveitis History 1277
Physical Examination 1277
Laboratory Evaluation 1279
Consultation 1279
Nonspecific Treatment of Uvetis 1279
What to treat 1279
Principles of treatment 1280
Nonsteroidal antiinflammatory agents 1280
Corticosteroids 1281
Immunosuppressive agents 1282
Summary 1283
References 1283
107 HLA-B27-Related Uveitis 1285
HLA-B27 and Pathogenesis of Disease 1285
Acute Anterior Uveitis 1286
Complications and Posterior Pole Involvement in HLA-B27-Positive Patients 1286
Other Associated Conditions 1287
Ankylosing spondylitis 1287
Psoriatic arthritis 1287
Idiopathic inflammatory bowel disease 1287
Reactive arthritis 1288
Summary 1290
References 1290
108 Sarcoidosis 1293
Ocular Manifestations 1293
Eyelids 1293
Lacrimal gland 1293
Lacrimal drainage system 1293
Orbit 1293
Conjunctiva 1294
Cornea 1294
Iris 1294
Anterior uveitis 1294
Posterior uveitis 1295
Optic nerve 1296
Diagnosis 1296
Course and Management 1297
References 1297
109 Behçet’s Disease 1299
Etiology of Behçet’s Disease 1299
Clinical Manifestations of Behçet’s’s Disease 1299
Mucocutaneous 1299
Eye disease 1300
Vascular findings 1302
Central nervous system 1302
Treatment of Behçet’s Disease 1302
Azathioprine 1302
Ciclosporin 1302
Corticosteroids 1303
Interferon-α 1303
Antitumor necrosis factor medications 1303
Mycophenolate mofetil 1303
Other medications 1303
Surgical Therapy in Behçet’s Disease 1303
Summary 1304
References 1304
110 Fuchs’ Heterochromic Iridocyclitis 1307
Clinical Features 1307
Pathology 1308
Differential Diagnosis 1308
Treatment 1309
Prognosis 1309
References 1309
111 Juvenile Idiopathic Arthritis 1311
Epidemiology 1311
Clinical Features 1311
Ocular Clinical Features 1312
Etiology 1313
Treatment of Systemic Disease 1314
Treatment of Ocular Disease 1315
Prognosis 1315
Conclusion 1316
References 1316
IX Keratoplasty 1319
1 Overview 1321
112 The Evolution of Contemporary Keratoplasty 1321
Early Contributions to Corneal Transplantation 1321
Modern Techniques of Corneal Transplantation 1321
The Evolution from Penetrating Keratoplasty Back to Lamellar Keratoplasty 1322
Descemet Stripping Automated Endothelial Keratoplasty 1322
Deep Anterior Lamellar Keratoplasty 1323
Use of the Femtosecond Laser 1323
Conclusions 1323
References 1324
113 Preoperative Considerations and Decision-Making in Keratoplasty 1327
General Considerations 1327
Ocular surface reconstruction procedures 1327
Anterior lamellar keratoplasty procedures 1327
Indications 1327
Contraindications 1328
Advantages of anterior lamellar keratoplasty 1328
Disadvantages of anterior lamellar keratoplasty 1328
Surgical techniques 1328
Lamellar keratectomy (LK) 1328
Tectonic, reconstructive, and excisional anterior lamellar keratoplasty 1328
Automated lamellar therapeutic keratoplasty 1328
Deep anterior lamellar keratoplasty 1328
Femtosecond laser-assisted lamellar keratoplasty 1330
Posterior lamellar keratoplasty procedures 1330
Indications 1330
Contraindications 1330
Advantages of endothelial keratoplasty (EK) 1330
Disadvantages of endothelial keratoplasty (EK) 1330
Surgical technique 1330
Penetrating keratoplasty procedures 1330
Indications 1332
Relative contraindications 1332
Advantages of penetrating keratoplasty 1332
Disadvantages of penetrating keratoplasty 1332
Surgical techniques 1332
Penetrating keratoplasty 1332
Femtosecond laser-assisted penetrating keratoplasty 1333
Permanent keratoprosthesis surgery 1333
Indications 1333
Relative contraindications 1333
Advantages of permanent keratoprosthesis surgery (KPro) 1333
Disadvantages of permanent keratoprosthesis (KPro) 1333
Surgical technique 1333
Summary 1333
References 1333
2 Penetrating Keratoplasty Procedures 1335
114 Penetrating Keratoplasty 1335
History 1335
Patient Selection 1336
Age 1336
Mental impairment 1336
Coexisting ocular disease 1336
Establish Realistic Expectations 1336
Surgical Setting and Anesthesia 1336
Preoperative Preparations 1336
Infection control 1336
Intraocular pressure control 1337
Lens management 1337
Donor corneal tissue management 1337
Anticipate suprachoroidal hemorrhage 1337
Surgical Steps in Phakic Penetrating Keratoplasty 1337
Insertion of lid speculum 1338
Placement of scleral fixation ring 1338
Marking of host cornea 1338
Trephination of donor cornea 1339
Trephination of host cornea 1339
Placement of viscoelastic material in the anterior chamber 1340
Placement of the donor corneal tissue in the host bed 1340
Placement of four interrupted radial 10/0 nylon cardinal sutures 1340
Complete suturing 1340
Readjustment of sutures to minimize astigmatism 1343
Administering medications 1343
Special Circumstances 1344
The postrefractive surgery patient 1344
Rotating autograft 1344
Maximizing penetrating keratoplasty outcome 1344
References 1345
115 Femtosecond Laser-assisted Penetrating Keratoplasty 1349
Introduction 1349
Evaluation and Surgery 1349
Outcomes 1351
Femtosecond Laser-assisted Deep Anterior Lamellar Keratoplasty 1352
References 1353
116 Keratoplasty Suturing Techniques 1355
Fundamentals of Wound Closure 1355
Penetrating Keratoplasty 1355
Single Interrupted Sutures 1357
Combined Continuous and Interrupted Suture Technique 1358
Single Continuous Suture 1359
Double Continuous Suture 1360
Suture Adjustment 1361
Suture removal 1361
Single interrupted sutures 1361
Combined continuous and interrupted sutures 1362
Single continuous suture 1362
Double continuous suture 1364
Lamellar Procedures 1364
Summary of suture adjustment 1365
Conclusions 1365
References 1365
117 Intraoperative Complications of Penetrating Keratoplasty 1367
Technical Complications of Penetrating Keratoplasty 1367
Scleral perforation with fixation sutures 1367
Improper trephination 1367
Eccentric trephination 1367
Damaged donor button 1367
Retained Descemet’s membrane 1368
Iris–lens damage 1368
Torn posterior capsule 1369
Vitreous loss with pseudophakic bullous keratopathy and posterior chamber intraocular lenses 1369
Anterior chamber hemorrhage 1369
Nontechnical Complications 1370
Expulsive choroidal hemorrhage 1370
References 1371
3 Penetrating Keratoplasty: Postoperative Management 1373
118 Routine Management 1373
Immediate Postoperative Care 1373
First 24 hours 1373
Early Postoperative Care 1374
1 to 7 days 1374
Postoperative Care 1376
1 to 12 weeks 1376
Postoperative Care 1381
After 3 months 1381
Postoperative Care in Infants and Children 1382
References 1383
119 Early Postoperative Complications 1385
Wound Leaks and Wound Displacement 1385
Persistent Epithelial Defects 1386
Filamentary Keratitis 1388
Suture-related Complications 1389
Suture exposure 1389
Suture-related infection 1389
Suture-related immune infiltrates 1389
Kaye dots 1390
Elevated Intraocular Pressure 1390
Postoperative Inflammation 1391
Anterior Synechia Formation 1391
Pupillary Block 1392
Choroidal Detachment and Choroidal Hemorrhage 1392
Hyphema 1393
Fixed Dilated Pupil 1393
Postoperative Infection 1393
Primary Donor Failure 1394
Conclusion 1394
References 1395
120 Management of Postkeratoplasty Astigmatism 1397
Preoperative Factors 1397
Intraoperative Factors 1397
Graft diameter 1397
Tissue alignment 1399
Trephination factors 1400
Scleral support ring 1401
Suture technique 1401
Postoperative Factors 1402
Relaxing incisions 1402
Astigmatic keratotomy 1404
Wedge resections 1405
Laser in situ keratomileusis 1405
Photorefractive keratectomy 1406
Summary 1406
References 1407
121 Diagnosis and Management of Corneal Allograft Rejection 1409
Clinical Aspects of Corneal Allograft Rejection 1409
Historical Perspective 1409
Recognition of Risk Factors 1409
Clinical Features of Corneal Allograft Rejection 1410
Differential Diagnosis of Corneal Allograft Rejection 1413
Treatment of Corneal Allograft Rejection 1414
Prevention of Corneal Allograft Rejection 1415
Management Strategy 1415
References 1415
122 Infections after Penetrating Keratoplasty 1417
Microbial Keratitis 1417
Pathogenesis 1417
Pathogens 1418
Clinical approach 1419
Therapeutic approach 1419
Outcomes 1420
Suture Abscess 1420
Pathogenesis 1420
Clinical approach 1421
Therapeutic approach 1421
Infectious Crystalline Keratopathy 1422
Historical background 1422
Pathogenesis 1422
Microscopy 1422
Clinical approach 1423
Therapeutic approach 1423
Outcomes 1423
Endophthalmitis 1423
Incidence 1423
Pathogenesis 1423
Pathogens 1424
Clinical approach 1424
Therapeutic approach 1425
Outcomes 1425
Herpetic Keratitis after Keratoplasty 1425
Recurrence 1425
Newly acquired 1426
Transmission of Unusual Infections 1426
Rabies 1426
Creutzfeldt-Jakob disease 1427
Hepatitis virus 1427
Human immunodeficiency virus 1427
Conclusion 1427
References 1427
123 Retrocorneal Membranes 1431
Epithelial Downgrowth 1431
History 1431
Incidence and etiology 1431
Pathogenesis 1432
Diagnosis 1432
Glaucoma and epithelial downgrowth 1434
Treatment 1434
Fibrous Ingrowth 1435
Incidence and etiology 1435
Pathogenesis 1435
Diagnosis 1436
Treatment 1436
Differential Diagnosis 1437
Conclusion 1437
References 1437
124 Glaucoma after Penetrating Keratoplasty 1441
Incidence 1441
Risk Factors 1442
The Pre-Keratoplasty Evaluation 1444
Clinical Presentation 1444
Glaucoma and Graft Failure 1444
Mechanisms 1445
Management of Postkeratoplasty Glaucoma 1446
Medical management 1447
Surgical management 1448
Laser iridoplasty and trabeculoplasty 1448
Filtering surgery 1448
Glaucoma Drainage Devices 1448
Cyclodestructive Procedures 1450
Summary 1451
References 1452
4 Complex Penetrating Keratoplasty 1455
125 Pediatric Penetrating Keratoplasty 1455
Introduction 1455
Review of the Literature 1455
Indications 1457
Graft Survival 1458
Visual Outcome 1459
Complications 1461
Future Studies 1461
Preoperative Evaluation, Counseling, and Preparation 1462
The initial evaluation 1462
The decision to perform penetrating keratoplasty 1462
What are the chances that penetrating keratoplasty will improve the patient’s vision and quality of life? 1462
What are the risks and costs to the patient and family of performing a penetrating keratoplasty? 1463
What are the benefits, risks, and costs of delayed treatment, no treatment, or alternative treatment? 1463
Counseling the parents and informed consent 1463
Timing and preparation for penetrating keratoplasty 1464
Bilateral opacities 1464
Unilateral opacities 1464
Repeat grafting 1464
The donor tissue 1464
Surgical Management 1464
Preoperative considerations 1464
Surgical technique 1465
Concomitant operative procedures 1466
Postoperative Care 1467
Postoperative Instructions 1467
Examination of Patients 1467
Examination schedule 1467
Early Postoperative Complications 1468
Suture Removal 1468
Graft Rejection 1469
Glaucoma 1469
Optical Correction and Amblyopia Therapy 1470
Advances in Pediatric Corneal Surgery 1470
Conclusions 1470
References 1471
126 Large-Diameter Corneal Grafts 1473
Indications 1473
Surgical Technique 1473
Large-diameter penetrating keratoplasty 1473
Total penetrating keratoplasty 1476
Large-diameter lamellar grafts 1476
Postoperative Management 1476
Complications 1476
Outcomes 1478
References 1478
127 Penetrating Keratoplasty in Herpes Simplex Disease 1481
Indications and Timing for Corneal Grafting 1481
Preoperative Measures 1482
Control of inflammation 1482
Vascularization 1483
Corneal sensation 1484
Antiviral prophylaxis 1484
Donor tissue requirements 1485
Operative Technique 1485
Graft size 1485
Perforated eyes 1485
Suture 1486
‘Triple procedure’ 1486
Anterior lamellar keratoplasty 1486
Femtosecond laser 1486
Boston keratoprosthesis 1486
Postoperative Management 1486
Use of corticosteroids 1486
Suture removal 1487
Persistent epithelial defects 1487
Recurrence of HSV keratitis 1487
The allograft rejection 1489
Herpes simplex virus in corneas for transplantation 1490
Secondary graft failure 1490
Glaucoma 1491
Wound dehiscence 1491
Secondary infections 1491
References 1492
128 Immunologically High-Risk Penetrating Keratoplasty 1495
Introduction 1495
Immunology of Graft Rejection 1495
Current view of the immune response 1495
Histocompatibility antigens 1495
Immune privilege 1495
Allograft rejection 1496
Risk Factors for Immune Rejection (Box 128.1) 1497
Vascularized corneas 1497
Prior graft loss 1498
Graft diameter and eccentric grafts 1498
Anterior synechiae 1498
Previous intraocular surgery 1498
Herpes simplex 1499
History of anterior segment inflammatory disease 1499
Ocular surface disease 1499
Young age 1499
Clinical Management of Immunologically High-Risk Penetrating Keratoplasty 1499
Preoperative considerations 1499
Controlling ocular inflammation 1499
Rehabilitating the ocular surface 1500
Operative considerations 1500
Tissue matching 1500
Surgical technique 1500
Postoperative considerations 1501
Immunosuppression 1501
Corticosteroids 1501
Calcineurin inhibitors 1501
Ciclosporin A 1501
Topical CsA 1501
Systemic CsA 1502
Tacrolimus 1503
Topical tacrolimus 1503
Systemic tacrolimus 1503
Antimetabolites 1503
Azathioprine 1503
Mycophenolate mofetil 1503
Rapamycin 1504
Monoclonal antibodies 1504
Experimental Approaches to Immunomodulation 1505
Inhibiting antigen-presenting cells 1505
Blocking the activation and action of T cells 1505
Monoclonal antibodies to T-cell antigens 1505
Costimulatory blockade 1505
Modulating the immune response with cytokines and peptides 1505
Inhibiting immune access to the graft 1505
Inhibition of adhesion molecules 1505
Reduction of corneal neovascularization 1505
Inhibition of chemokines 1506
Inducing allospecific tolerance 1506
Oral immunization with donor-specific alloantigens 1506
Lymphadenectomy 1506
References 1506
5 Anterior Lamellar Keratoplasty 1511
129 Indications for Anterior Lamellar Keratoplasty 1511
Indications 1511
Contraindications 1511
Keratoconus 1512
Scars 1513
Microkeratome-assisted technique 1513
Keratoglobus 1514
Macular corneal dystrophy 1514
Descemetocele 1514
Pellucid marginal degeneration 1515
References 1515
130 Techniques of Anterior Lamellar Keratoplasty 1517
Introduction 1517
ALK Techniques 1517
Layer-by-layer dissection 1517
Stromal delamination (VIDEO 1) 1518
Automated therapeutic lamellar keratoplasty (VIDEOS 2 and 3) 1519
Intrastromal dissection 1519
Cleavage separation (VIDEO 4) 1519
Donor preparation (VIDEO 5) 1520
References 1520
131 Intraoperative and Postoperative Complications of Anterior Lamellar Keratoplasty 1523
Indications for Anterior Lamellar Keratoplasty 1523
Surgical Instruments and Preoperative Treatment 1523
Intraoperative Complications 1524
Perforations and ruptures of Descemet’s membrane 1524
Trephination 1524
Stromal dissection 1524
Suture needles 1525
Management of Descemet’s membrane ruptures 1525
Postoperative Complications 1525
Pseudoanterior chambers 1525
Pupillary block and fixed dilated pupil (Urrets-Zavalia syndrome) 1525
Sclerocorneal inflammation 1525
Conclusion 1526
References 1526
132 Outcomes of Anterior Lamellar Keratoplasty 1527
Visual Outcomes 1527
Refractive Outcomes 1528
Graft Survival 1528
Suture Management 1529
Resistance to Trauma 1529
Surgical Planning 1529
Summary 1529
References 1529
6 Endothelial Keratoplasty 1531
133 Indications for Endothelial Keratoplasty 1531
Patient Selection 1531
Age 1531
Duration of Corneal Edema 1531
Lens Considerations 1532
Tips for Successful Application of EK in Challenging Eyes 1532
Failed penetrating grafts 1532
Glaucoma tubes 1532
Shallow anterior chambers 1533
ACIOLs 1533
Iris abnormalities, aniridia and aphakia 1533
Conclusions 1533
References 1533
134 Donor Preparation for Endothelial Keratoplasty 1535
Introduction 1535
Issues to Consider 1535
Methods 1536
Techniques 1536
Summary 1540
References 1540
135 Surgical Techniques of Endothelial Keratoplasty 1543
Donor Tissue Preparation 1543
Anesthesia Considerations 1543
Intraoperative Techniques 1544
Wound creation 1544
Recipient preparation 1544
Techniques to Improve Donor Adherence 1545
Donor Insertion Techniques 1545
Donor Apposition Techniques 1547
Early Postoperative Management 1548
Special Considerations for Endothelial Keratoplasty 1549
New Developments in Endothelial Keratoplasty 1549
Summary 1550
References 1550
136 Phacoemulsification and Endothelial Keratoplasty: 1553
Preoperative Planning 1554
Intraoperative Issues 1554
Postoperative Results 1555
Future Trends 1556
References 1556
137 Intraoperative and Postoperative Complications of Endothelial Keratoplasty 1559
Introduction 1559
Intraoperative Complications 1559
Complications with donor tissue preparation 1559
Damaged donor tissue 1559
Eccentric trephination 1559
Thin donor tissue 1559
Retained Descemet’s membrane 1559
Air management 1559
Others complications 1561
Postoperative Complications 1561
Donor dislocation 1561
Primary graft failure 1562
Graft rejection 1562
Pupillary block – glaucoma 1562
Endothelial cell loss 1563
Refractive change 1563
Interface deposits and epithelial ingrowth 1563
Retinal complications 1564
References 1564
138 Outcomes of Endothelial Keratoplasty 1565
Introduction 1565
Results 1565
Endothelial keratoplasty complications 1565
Visual recovery after DSAEK 1565
Astigmatism 1567
Spherical equivalent 1567
Donor endothelial survival 1567
Summary 1568
References 1568
X Therapeutic Procedures 1569
1 Corneal Surgery 1571
139 Management of Corneal Perforations 1571
Etiology 1571
Terminology 1572
Signs and Symptoms of Descemetocele and Perforation 1572
Preoperative Management 1574
Treatment Options 1574
Tissue adhesives 1574
Cyanoacrylate glue 1574
Method of application 1575
Postoperative management 1578
Complications 1579
Penetrating keratoplasty 1579
Patch graft 1580
Amniotic membrane transplantation 1581
Medical management 1581
Prevention of Corneal Perforation 1583
Bandage soft contact lens 1583
Conjunctival flap 1583
Tarsorrhaphy 1584
Amniotic membrane transplantation 1584
Miscellaneous 1584
Conclusion 1584
References 1584
140 Therapeutic Lamellar Keratoplasty 1587
Optical Indications 1587
Tectonic Indications 1587
Peripheral noninflammatory corneal thinning disorders 1587
Peripheral inflammatory corneal disease 1587
Central thinning and ectasia 1587
Limitations of Lamellar Grafts 1587
Mechanical Surgical Technique 1589
Laser-Assisted Anterior Lamellar Keratoplasty 1589
The Future of Lamellar Keratoplasty 1589
References 1591
141 Therapeutic Keratoplasty 1593
Therapeutic Keratoplasty for Infectious Keratitis 1593
Therapeutic keratoplasty for bacterial infections 1594
Therapeutic keratoplasty for fungal keratitis 1594
Therapeutic keratoplasty for Acanthamoeba keratitis 1596
Therapeutic keratoplasty for herpetic keratitis 1596
Therapeutic keratoplasty for persistent epithelial defects and sterile melts 1596
Presurgical Evaluation 1599
Antimicrobial Therapy 1599
Donor Material 1599
Surgical Technique 1599
Postoperative Management of Therapeutic Penetrating Keratoplasties 1601
Visual Prognosis for Therapeutic Keratoplasty 1601
References 1602
142 Surgical Management of Superficial Corneal and Conjunctival Disease 1605
Introduction 1605
Molluscum Contagiosum 1605
Superior Limbic Keratoconjunctivitis 1605
Conjunctivochalasis 1606
Recurrent Corneal Erosions 1607
Band Keratopathy 1608
Partial Limbal Stem Cell Deficiency 1608
Conclusion 1610
References 1610
143 Excimer Laser Phototherapeutic Keratectomy 1613
Introduction 1613
Indications for PTK 1613
Contraindications 1613
Preoperative Evaluation 1614
Ophthalmic history 1614
Medical history 1614
Examination 1614
Ancillary testing 1614
Patient Selection 1615
Techniques 1615
General 1615
Smooth opacities 1615
Rough or elevated opacities 1616
Deep irregular opacities 1616
Recurrent erosions 1617
Antihyperopia treatment 1617
Masking agents 1617
Mitomycin-C 1618
Postoperative Management 1618
Results 1619
Side Effects and Complications 1621
Future Directions 1621
Summary 1622
References 1622
2 Conjunctival Surgery 1625
144 Management of Pterygium 1625
Introduction 1625
Definition and Morphology 1625
Epidemiology of Pterygium 1625
Risk Factors 1625
Ultraviolet radiation 1626
Genetic factors 1626
Other risk factors 1626
Pathogenesis of Pterygium 1626
Degenerative vs proliferative disorder 1626
Limbal stem cell deficiency and epithelial abnormalities in pterygium 1627
The Role of the Fibrovascular Component in Corneal Invasion and Pterygium Recurrence 1627
Therapeutic Options for Pterygium 1627
Bare sclera excision 1627
Excision with conjunctival closure/transposition 1627
Excision with adjunctive medical therapy 1628
Beta irradiation 1628
Mitomycin C 1628
Ocular surface transplantation techniques 1629
Conjunctival autografting 1629
Surgical technique of pterygium excision and conjunctival autografting 1629
Pterygium excision technique 1629
Anesthesia 1629
Exposure/stabilization of the globe 1629
Excision of pterygium tissue 1629
Recurrent pterygium excision 1630
Harvesting of the conjunctival autograft 1630
Harvesting site 1630
Superficial dissection technique 1630
Size of conjunctival autograft 1630
Orientation of conjunctival autograft 1630
Securing the conjunctival autograft 1631
Additional techniques 1631
Postoperative regimen 1631
Complications of Conjunctival Autografting 1631
Causes of recurrence of conjunctival autografting 1631
Conjunctival rotational autografting 1631
Annular conjunctival autografting 1632
Cultivated conjunctival transplantation 1632
Conjunctival–limbal autograft transplantation 1633
Amniotic membrane transplantation (AMT) 1633
Surgical technique of amniotic membrane transplantation 1634
Size of amniotic membrane graft 1634
Scleral bed preparation 1634
Amniotic membrane application 1634
Postoperative management 1634
The role of fibrin glue in pterygium surgery 1634
Lamellar keratoplasty 1635
Potential Future Therapeutic Options 1635
Conclusion 1635
References 1635
145 Conjunctival Flaps 1639
Introduction 1639
Indications 1639
Persistent corneal epithelial defect 1639
Unresponsive ulcerative microbial keratitis 1639
Corneal thinning and perforation 1640
Corneal limbal disease 1640
Scleral necrosis 1640
Glaucoma surgery complications 1640
Surface preparation for a cosmetic scleral shell 1640
Disadvantages 1640
Surgical Techniques 1640
Total conjunctival flap 1640
Removal of corneal epithelium 1641
Mobilization of the conjunctival flap 1641
Conjunctival flap suture 1642
Bipedicle bridge flap 1643
Single pedicle flap 1643
Advancement flap 1643
Complications 1643
Intraoperative complications 1643
Buttonhole formation 1643
Dissection of an inadequate flap 1645
Excessive hemorrhage 1645
Postoperative complications 1645
Retraction of the flap 1645
Ptosis 1645
Cystic flap 1645
Opacification and vascularization 1645
References 1645
146 Indications for and Uses of Amniotic Membrane 1647
The Amniotic Membrane: Histology, Biological Properties, and Clinical Effects 1647
Obtaining and Preserving the Amniotic Membrane 1647
Methods for Amniotic Membrane Transplantation 1647
Indications for Amniotic Membrane Transplantation in Ocular Surface Diseases 1648
Amniotic membrane as a graft in conjunctival reconstruction 1648
Amniotic membrane as a graft in corneal surface reconstruction 1648
Amniotic membrane as a patch in corneal surface reconstruction 1650
Amniotic membrane and limbal stem cells deficiencies 1652
Amniotic membrane as a substrate for culturing epithelial stem cells of the sclerocorneal limbus 1652
Limitations of Amniotic Membrane Transplantation in Ocular Surface Diseases 1653
Complications 1653
References 1653
3 Anterior Segment Surgery 1655
147 Surgical Management and Rehabilitation of Anterior Segment Trauma 1655
Patient Evaluation 1655
History 1655
Examination 1655
Slit lamp examination 1656
Tissue Adhesive 1658
Management of Penetrating and Perforating Trauma 1658
Anesthesia and preparation of the eye 1658
Acute Surgical Management 1659
Corneal laceration repair 1659
Suturing the zig-zag incision 1660
Stellate lacerations 1660
Management of tissue loss 1660
Corneoscleral lacerations 1661
Iris trauma 1662
Iridodialysis 1663
Lens trauma, dislocation 1664
Anterior segment intraocular foreign bodies 1665
Postoperative Care 1665
Suture Removal 1666
Visual Rehabilitation 1666
Optical correction 1666
Postoperative complications 1667
Surgical rehabilitation after primary trauma repair 1667
Conclusion 1667
References 1667
148 Iris Reconstruction Surgery 1671
Iris Suture Techniques 1671
The sliding knot intracameral suture 1671
Pupil cerclage procedure 1671
Iridodialysis Repair 1672
Iris Relaxing Incisions 1673
Scissors Sculpting 1673
Vitrector Sculpting 1673
Iris Prostheses 1673
Large-incision, rigid diaphragm devices 1674
Rigid small-incision devices 1675
Flexible small-incision iris prostheses 1675
Pupillary aperture: pupil versus entrance pupil 1676
Complications 1676
Summary 1677
References 1677
149 Management of Scleral Perforation 1679
General Management Strategies 1679
Anesthesia for Scleral Perforations 1679
Surgical Repair of Scleral Perforations 1680
Preoperative considerations 1680
Operative considerations 1680
Conjunctiva and Tenon’s capsule 1680
Tarsoconjunctival flap 1680
Autologous sclera 1681
Homologous sclera 1682
Fascia lata 1683
Periosteum 1684
Split-thickness dermal graft 1684
Amniotic membrane 1684
Other materials 1685
Summary 1685
References 1685
XI Keratoprosthesis 1687
150 Indications for Keratoprosthesis 1689
Keratoprosthesis Designs Currently in Wide Use and Their Indications 1689
Other Keratoprosthesis Designs 1690
Summary 1691
References 1691
151 Types and Techniques of Keratoprosthesis 1693
Boston Keratoprosthesis Type 1 1693
AlphaCor 1694
OOKP (Osteo-odonto-keratoprosthesis) 1696
References 1697
152 Postoperative Management of Keratoprosthesis 1699
Avoidance of Complications 1699
Postoperative Patient Evaluation 1700
Postoperative Treatment 1701
Antibiotics 1701
Corticosteroids 1701
Glaucoma management 1702
Soft contact lens 1702
Postoperative Complications and Management 1702
Retroprosthetic membrane 1703
Loss of the soft contact lens 1703
Sterile vitritis 1703
Elevated intraocular pressure 1703
Endophthalmitis 1703
Retinal detachment 1703
Corneal melts and keratoprosthesis extrusion 1704
Conclusion 1704
References 1704
153 Outcomes of Keratoprosthesis Surgery 1705
Introduction 1705
Osteo-Odonto Keratoprosthesis 1705
AlphaCorâ„¢ 1705
Boston keratoprosthesis 1706
References 1708
XII Ocular Surface Transplantation 1711
154 Classification and Staging of Ocular Surface Disease 1713
Classification of Ocular Surface Disease 1713
Eyelids and eyelashes 1713
Tear film 1713
Conjunctiva 1714
Limbal Stem Cell Deficiency 1714
Congenital 1716
Aniridia 1716
Dominantly inherited keratitis 1717
Ectodermal dysplasia 1717
Traumatic 1717
Alkali and acid injury 1718
Thermal injury 1719
Iatrogenic limbal stem cell deficiency 1719
Autoimmune Disorders 1720
Stevens–Johnson syndrome 1720
Ocular cicatricial pemphigoid 1721
Staging of Ocular Surface Disease 1721
References 1724
155 Surgical Techniques for Ocular Surface Reconstruction 1727
Introduction 1727
Conjunctival Limbal Autograft (CLAU) 1727
Indications and contraindications 1727
Preoperative considerations 1727
Surgical technique 1727
Living Related Conjunctival Limbal Allograft (lr-CLAL) 1729
Indications and contraindications 1729
Preoperative considerations 1730
Surgical technique 1730
Keratolimbal Allograft (KLAL) 1731
Indications and contraindications 1731
Preoperative considerations 1732
Surgical techniques 1733
General considerations 1733
Preparation of the recipient eye 1733
Technique 1 1733
Technique 2 1734
Conjunctival limbal allograft (CLAL) 1734
Donor eyes 1734
Recipient eye 1735
Combined Conjunctival Limbal and Keratolimbal Allograft (C-KLAL) 1735
Indications and contraindications 1735
Preoperative considerations 1736
Surgical technique 1736
Ex Vivo Tissue Engineered Procedures 1737
Ex Vivo Cultivated Limbal Transplantation 1739
Ex Vivo Stem Cell Allografts 1739
Limbal epithelial culture 1739
Technique 1739
Operative procedure 1739
Ex Vivo Cultivated Conjunctival Transplantation 1739
Ex Vivo Cultivated Mucosal Transplantation 1740
Amniotic Membrane Transplantation (AMT) 1740
Mechanism of action 1740
Clinical applications 1741
Results of AMT in ocular surface disease management 1741
Recommended Treatment Algorithm 1741
Conclusions 1742
Future Directions 1742
References 1742
156 Postoperative Management of Ocular Surface Reconstruction 1745
Introduction 1745
Ocular surface rehabilitation 1745
Immunosuppressive Therapy 1745
Overview 1745
Clinical signs of rejection 1745
Immunosuppressive agents 1747
Evaluation of patients prior to starting immunosuppression 1747
Glucocorticosteroids 1747
Mode of action 1747
Topical steroids 1747
Systemic steroids 1748
Calcineurin inhibitors 1748
Ciclosporin A 1748
Mode of action 1748
Topical ciclosporin 1749
Systemic ciclosporin 1749
Tacrolimus (FK-506) 1749
Antimetabolites 1750
Azathioprine 1750
Mycophenolate mofetil 1750
Other immunosuppressive agents 1751
Sirolimus (rapamycin) 1751
Biological drugs 1751
Prophylactic antimicrobial therapy 1751
General considerations for patients on immunosuppression 1751
Risk of malignancy 1752
Summary 1752
References 1752
157 Corneal Transplantation in Ocular Surface Disease 1755
Introduction 1755
Review of the Literature 1755
Technique 1757
Summary 1758
References 1758
XIII Refractive Surgery 1759
1 Preoperative Considerations 1761
158 Decision Making in Refractive Surgery 1761
Excimer Laser Vision Correction 1761
Patient age 1761
Refractive error 1761
Corneal thickness 1761
Corneal topography 1763
Keratometry 1763
Pupil size 1764
Thin-flap LASIK 1764
Surface Ablation 1764
Conductive Keratoplasty 1764
Arcuate Transverse Keratotomy 1764
Phakic Intraocular Lenses 1764
Intraocular Lens after Phacoemulsification 1765
Retreatments and Sequential Procedures 1765
Intracorneal Inlays 1765
Treatment of Presbyopia 1765
References 1765
159 Patient Evaluation and Selection in Refractive Surgery 1767
Introduction 1767
Evaluation Process 1767
History 1767
Ocular herpes simplex virus 1767
Previous radial keratotomy 1767
History of strabismus 1768
Monocular patients 1768
History of keloid formation 1768
Contact lens history 1768
Pregnancy 1768
Participation in high-risk activities 1768
Medicines 1769
Medical conditions 1769
Examination 1769
Visual acuity 1769
Refraction 1769
Contrast sensitivity 1769
Keratometery 1769
Computed topography 1769
Pupil examination 1770
Case study relating pupil size, patient complaints, and wavefront measurements 1772
Slit lamp examination 1774
Fundus examination 1774
Tonometry 1774
Pachymetry 1775
Endothelial cell evaluation 1775
Anterior chamber depth 1775
Dry eye testing: Schirmer’s test and tear breakup testing 1775
Monovision testing 1775
Ocular dominance determination 1775
Wavefront testing 1775
Informed Consent 1776
References 1778
160 Topographic Analysis in Keratorefractive Surgery 1781
Introduction 1781
Historical Background 1781
Keratometry 1781
Keratoscopy 1782
Videokeratoscopy 1782
Placido-based computerized videokeratoscopes 1782
Elevation-based topography systems 1782
Clinical Applications 1783
Contact lens-induced warpage 1786
Keratoconus and keratoconus suspect 1786
Displaced apex syndrome 1790
Postoperative Evaluations 1790
Contoured ablation pattern 1790
Other Uses 1791
Photokeratoplasty suture removal and modification 1791
Cataract surgery 1791
Future Horizons 1791
References 1791
2 Laser Vision Correction 1793
161 Excimer Laser Surface Treatment: 1793
Excimer Laser Surface Treatment 1793
Indications for Excimer Laser Surface Treatment 1793
Patient Selection 1794
Preoperative Management of Excimer Laser Surface Treatment 1796
PRK surgical techniques 1796
Preoperative medications 1797
PRK Epithelial Removal 1797
Mechanical 1797
Chemical 1798
Laser 1798
Excimer laser 1798
Laser and scrape 1798
Transepithelial 1798
Stromal treatment 1799
Postoperative Management 1800
Medications 1800
Epithelial healing 1801
Results 1801
Myopic PRK 1801
Hyperopic PRK 1803
Wavefront-guided PRK 1803
PRK and monovision 1805
PRK for presbyopia 1805
PRK in children 1805
PRK after refractive surgery 1806
Complications 1806
Intraoperative 1806
Eccentric ablations and decentrations 1806
Postoperative Complications 1807
Epithelial problems 1807
Dry eyes 1807
Corneal infiltrates and infectious keratitis 1807
Central islands 1808
Irregular astigmatism 1808
Undercorrection 1809
Overcorrection 1809
Haze, scarring, and regression 1809
Treatment of haze and regression 1810
Quality of vision 1812
Other Complications 1812
References 1813
162 LASIK Technique 1817
Introduction and Historical Perspective 1817
Microkeratomes 1819
Technique 1820
Calibration and programming of the excimer laser system 1820
Assembly and testing of the microkeratome 1821
Preparation and assembly of the motor group 1821
Preparation and assembly of the suction ring 1821
Preparation and assembly of the microkeratome 1821
Preparation of the patient, sedation, and topical medication instillation 1822
Draping of the eye 1823
Placement of the locking eyelid speculum 1823
Placement of alignment markings 1823
Application of the pneumatic suction ring 1823
Checking for adequate intraocular pressure 1824
Lubrication of the ocular surface prior to microkeratome passage 1825
Insertion of the microkeratome head and creation of the keratectomy 1825
Lifting of the corneal flap and preparation of the stromal bed 1826
Intrastromal ablation 1826
Reapproximation of the corneal flap 1826
Flap alignment 1827
Removing the eyelid speculum 1827
Femtosecond laser flap creation 1828
Conclusion 1828
References 1829
163 LASIK for Myopia 1831
Introduction 1831
History 1831
Excimer lasers 1831
Patient selection 1833
Indications 1833
Limitations and contraindications 1833
Microkeratomes 1834
Operative technique 1834
Postoperative care 1835
Complications 1836
Intraoperative complications 1836
Ablation complications 1836
Postoperative complications 1837
Keratectasia 1839
Results 1839
LASIK enhancements 1839
LASIK in Complex Cases 1839
LASIK after radial keratotomy 1839
LASIK after photorefractive keratectomy 1840
LASIK after penetrating keratoplasty 1840
LASIK after Intraocular Lenses 1840
Intraocular Lens Calculations after LASIK 1841
Summary 1841
References 1841
164 LASIK for Hyperopia 1845
Introduction 1845
Physiological Aspects of Hyperopia 1845
Corneal Surgery for Hyperopia 1845
Preoperative Considerations and Patients Selection 1847
Indications for LASIK for Hyperopia 1848
Primary hyperopia 1848
Secondary hyperopia 1848
Technique and Instrumentation for LASIK for Hyperopia 1849
Technique 1849
Results 1849
Complications 1850
Conclusion 1851
References 1851
165 Surface Ablation: Techniques for Managing the Epithelial Layer 1853
Introduction 1853
Preoperative Evaluation 1853
Surgical Techniques 1854
Photorefractive keratectomy 1854
Laser assisted subepithelial keratomileusis 1854
Azar flap technique 1854
Camellin trephination technique 1854
Vinciguerra butterfly technique 1854
McDonald technique 1855
Brown technique 1855
Epipolis laser in situ keratomileusis (epi-LASIK), 1856
Comparison of Techniques 1856
Postoperative Management and Complications 1858
Conclusions 1858
References 1858
166 LASIK Complications 1861
Introduction 1861
Intraoperative LASIK Complications 1861
Femtosecond laser flap complications 1861
Microkeratome complications 1861
Buttonhole and irregular flaps 1862
Clinical 1862
Management 1862
Prevention 1862
Thin flaps 1862
Index 1915
A 1915
B 1919
C 1922
D 1927
E 1930
F 1934
G 1935
H 1937
I 1939
J 1942
K 1942
L 1944
M 1947
N 1950
O 1951
P 1952
Q 1957
R 1957
S 1959
T 1963
U 1966
V 1966
W 1968
X 1968
Y 1968
Z 1968