DOCSLIB.ORG

Intraocular Surgery Following Penetrating Keratoplasty: the Risks and Advantages

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Intraocular Surgery Following Penetrating Keratoplasty: the Risks and Advantages Eye (1990) 4, 693-697 Intraocular Surgery Following Penetrating Keratoplasty: The Risks and Advantages L. A. FICKER, C. M. KIRKNESS, A. D. McG STEELE, N. S. C. RICE, A. M. E. GILVARRY London Summary Graft survival has been evaluated for patients who underwent subsequent intra­ ocular surgery (extra-capsular cataract surgery or trabeculectomy) between 1983 and 1989. The patients were different from the majority of keratoplasty patients as evidenced by the indications for keratoplasty; corneal perforation was the indication in 24% of cases. Perforated and inflamed eyes were treated aggressively at the time of the acute event, including emergency keratoplasty and intensive topical steroids. Visco-elastic fluids were routinely used during secondary surgery and topical ste­ roids were administered intensively post-operatively. The incidence of post-oper­ ative graft rejection was low (less than 14%). Rejection episodes were diagnosed early, prior to the appearance of a Khodadoust line, and were treated aggressively with intensive topical steroids. Glaucoma which was not controlled by topical ther­ apy was surgically managed by trabeculectomy in the first instance. If this failed, tube drainage was performed and long-term topical steroids were administered. The only risk factor identified was uncontrolled glaucoma, P=O.1. The probability of graft survival (at five years) was 0.83 after cataract surgery and 0.62 after trabecu­ lectomy, but wide confidence limits indicate the difference is not significant. The impact of intraocular surgery upon a pre­ For patients in whom corneal disease co­ existing penetrating keratoplasty (PK) is per­ exists with early cataract there are advantages tinent to various sub-groups of patients with in deferring cataract surgery in patients corneal disease. The most frequent proce­ undergoing PK. Stable keratometry following dures to be performed subsequently are PK should allow greater accuracy in calculat­ cataract extraction aud trabeculectomy. En­ ing IOL power. Furthermore, when PK is per­ dothelial cell loss is known to be accelerated formed as an emergency procedure for by intra-ocular surgery. 1 Expected graft sur­ perforation or progressive microbial keratitis, vival may therefore be compromised by accel­ deferred cataract surgery (in the absence of an erated endothelial cell loss following such intumescent lens) may reduce post-operative surgery. Glaucoma may also threaten graft inflammation, hence reducing the risk of early survival. It may be a complication of ker­ graft rejection.4 Knowledge of the risks and atoplasty, or previously controlled glaucoma advantages of combined compared with two­ may become uncontrolled after further intra­ stage procedures would be useful in planning ocular surgery. 2 The introduction of visco­ the management of complicated cases such as elastic fluids, topical beta-blockade and tube these. drainage procedures3 represent therapeutic Glaucoma which is uncontrolled by topical advances with respect to these complications. therapy requires surgery. Trabeculectomy Correspondence to: Linda Ficker FRCS, FCOphth, Moorfields Eye Hospital, City Road, London EC1 2CV. 694 L. A. FICKER ET AL. and tube drainage surgery have been per­ between 4mm diameter and 9x12 mm. The formed in patients with a pre-existing corneal post-operative steroid regime was initially i-2 graft and it would be useful to identify any risk hourly topical dexamethasone 0.1% and was factor for graft survival which may be related to reduced according to the clinical course. Com­ glaucoma surgery. plications, graft survival, refractive and visual The effects upon graft survival of modem outcomes were analysed. microsurgery for cataract and glaucoma have been reported infrequently. We therefore Trabeculectomy reviewed our experience in the Corneal Clinic Trabeculectomy was performed aftef a mean at Moorfields Eye Hospital. Since 1983, ECCE post-PK interval of 7.8 months (n=29), ten of (mostly with lens implantation) has been the which were within one month. The most fre­ routine surgical technique for cataract surgery quent indications for grafting were keratitis and and tube drainage was adopted in the manage­ trauma as shown in Table I. Trabeculectomy ment of failed trabeculectomy, in preference to alone was performed in 20 patients; nine others cyclocryo-ablation.5 In addition, visco-elastic underwent additional surgery; tube drainage fluids were routinely used by this time for intra­ (5), ECCE (2), cyclo-cryotherapy (1) or com­ ocular surgery in the presence of a graft. bined ECCE + IOL (1). PK had been com­ bined with intra-capsular cataract extraction (ICCE) in eight cases; overall, 19 patients were Patients and Methods aphakic or pseudophakic, 13 following ICCE Patients who underwent intraocular surgery and six following ECCE. Most PKs (28) were after prior penetrating keratoplasty, between central, mean diameter 8.1 min, and only one 1983 and 1989, were identified from the Cor­ 9 mm PK was eccentric. Twenty-five were first neal Clinic database. Twenty-five patients and four were second PKs. Post-operative ste­ underwent extracapsular cataract extraction, 17 roids were given initially 1-2 hourly dexame­ with additional lens implantation. Two further thasone 0.1%, as for cataract surgery, and were patients underwent secondary lens implan­ reduced as indicated by the clinical course. Ste­ tation following combined PK and ECCE. roids were maintained indefinitely following Twenty-nine patients underwent trabeculec­ tube drainage to avoid the complication of tomy after PK and five of these underwent rejection.5 Complications, graft survival and tube drainage procedures following failed visual outcomes were analysed. trabeculectomy. Rejection episodes were diagnosed in the presence of anterior chamber cells with graft Extracapsular Cataract Extraction Table I Indications for PK prior to further intraocular The mean post- PK interval was 73.3 months surgery overall (n=25) and 33.4 months for the sub­ group which had IOL implantation (n=17). Total number patients (%) The interval was shorter (9 months) for ECCE (± IOL) Trabeculectomy inflamed eyes; two intumescent lenses were 25 (100%) 29 (100%) removed within one month. The two secondary Keratoconus 6 (24%) implants were inserted at a mean interval of 91 1 (3%) Interstitial keratitis 6 (24%) 3 (10%) months. Removal of graft sutures had pre­ Corneal perforation 6 (24%) 7 (24%) viously been performed in about half the cases. Acanthamoeba 3 (12%) 1 (3%) The most frequent indications for PK were ker­ Corneal dystrophies 2 (8%) atoconus, interstitial keratitis and corneal per­ Trauma 1 (4%) 4 (14%) HSK 1 (4%) 4 (14%) foration (Table I). There were 20 first, five ABK 3 (10%) second and two subsequent PKs. Trabeculec­ PBK 2 (7%) tomy had previously been performed in four Glaucoma cases. Most (22) were central grafts, mean complications 4 (14%) 7.6 mm diameter. Three were eccentric, ABK: aphakic bullous keratopathy adjacent to the limbus and measuring PBK: pseudo-phakic bullous keratopathy. INTRAOCULAR SURGERY FOLLOWING PENETRATING KERATOPLASTY 695 endothelial keratic precipitates; a Khoda­ pneumoniae and P. aeruginosa). Two cases doust line was not required for the diagnosis. were successfully treated; one with a suture Graft failure was defined as irrecoverable loss abscess (S. viridans) and one with endoph­ of graft clarity. thalmitis following tube drainage (S. epidermidis) . Results Eight grafts failed; three due to uncontrol­ Extracapsular Cataract Extraction led intra-ocular pressure (lOP), two due to Mean follow-up was 98 months post-PK and irreversible rejection, two due to recurrent 32 months post-ECCE (minimum six Herpes simplex keratitis (HSK) and one months). Kaplan-Meier survival curves6 were gradual decompensation after tube insertion. constructed to demonstrate graft survival. Trabeculectomy alone controlled lOP in The probability of graft survival after ECCE, ten cases, additional topical therapy was with or without lens implantation, was 0.83 required in 11 (timolol 0.25% and/or pil­ after 66 months. The incidence of rejection ocarpine 4%) with acetazolamide in three was 12% (three cases), all of which occurred cases. Of the five cases which required tube during the immediate post-operative period. drainage, four were controlled. Visual out­ None resulted in graft failure. One patient come for this group was poor; 6/12 or better with dry eyes developed a suture abscess was achieved in only 35% of patients with (Streptococcus pneumoniae) which was suc­ clear grafts. Patients with vision less than cessfully treated. One patient required resu­ 6/36 (n=6) were noted to have glaucomatous turing of the PK after traumatic wound disc cupping (4), choroidal haemorrhage (1) dehissence. Four patients grafted for keratitis and poor ocular surface (1) which probably developed glaucoma; two after Acantha­ influenced visual potential. mo�ba keratitis (one required trabeculec­ tomy and a subsequent tube). There were Discussion three failures; due to intractable secondary Graft survival has been considered separ­ glaucoma (1), gradual decompensation (1) ately for patients who underwent subsequent and vascularisation of a 4 mm paralimbal cataract extraction or trabeculectomy. patch graft (1). Corneal disease more commonly co-exists Corrected visual acuity was 6/12 or better with cataract and is frequently managed by in 65% of cases with clear grafts. Poor vision combined surgery. Where corneal disease was attributable to graft failure in two cases. requires
Load more

Recommended publications
  • Update on Pathologic Diagnosis of Corneal Infections and Inflammations
    [Downloaded free from http://www.meajo.org on Tuesday, March 27, 2012, IP: 41.234.93.234] || Click here to download free Android application for this journal Eye Pathology Update Update on Pathologic Diagnosis of Corneal Infections and Inflammations Geeta K. Vemuganti, Somasheila I. Murthy1, Sujata Das2 ABSTRACT Access this article online Website: One of the most frequent types of corneal specimen that we received in our pathology laboratory www.meajo.org is an excised corneal tissue following keratoplasty. Several of these cases are due to corneal DOI: infections or the sequelae, like corneal scar. Advances in the histological and molecular 10.4103/0974-9233.90128 diagnosis of corneal infections and inflammations have resulted in rapid and accurate diagnosis Quick Response Code: of the infectious agent and in the overall understanding of the mechanisms in inflammatory diseases of the cornea. This review provides an update of histopathological findings in various corneal infections and inflammations. Key words: Corneal Histopathology, Corneal Infiltrate, Corneal Inflammations, Microbial Keratitis, Moorens’ Ulcer INTRODUCTION Corneal infections often commence as epithelial ulceration followed by stromal infiltration by polymorphonuclear (PMN) eratitis is an important cause of ocular morbidity worldwide, and lymphomononuclear cells leading to destruction of Bowman’s Kthe outcome of which depends on early diagnosis, prompt layer, stromal necrosis and perforation of the Descemet’s 1 and effective treatment and various host and agent factors. Some membrane in severe cases. Suppurative infections like bacterial of the common causes of infectious keratitis include bacterial, and fungal lead to infiltrates in anterior 2/3 of stroma and abscess fungal, viral, and protozoan, the diagnosis of which is made on formation.
    [Show full text]
  • Read PDF Edition
    REVIEW OF OPTOMETRY EARN 2 CE CREDITS: Positive Visual Phenomena—Etiologies Beyond the Eye, PAGE 58 ■ VOL. 155 NO. 1 January 15, 2018 www.reviewofoptometry.comwww.reviewofoptometry.com ■ ANNUAL CORNEA REPORT JANUARY 15, 2018 ■ CXL ■ EPITHELIAL DEFECTS How to Heal Persistent Epithelial Defects PAGE 38 ■ TRANSPLANTS Corneal Transplants: The OD’s Role PAGE 44 ■ INFILTRATES Diagnosing Corneal Infiltrative Disease PAGE 50 ■ POSITIVE VISUAL PHENOMENA CXL: Your Top 12 Questions —Answered! PAGE 30 001_ro0118_fc.indd 1 1/5/18 4:34 PM ĊčĞĉėĆęĊĉĆĒēĎĔęĎĈĒĊĒćėĆēĊċĔėĎēǦĔċċĎĈĊĕėĔĈĊĉĚėĊĘ ĊđĎĊċĎēĘĎČčę ċċĊĈęĎěĊ Ȉ 1 Ȉ 1 ĊđđǦęĔđĊėĆęĊĉ Ȉ Ȉ ĎĒĕđĊĎēǦĔċċĎĈĊĕėĔĈĊĉĚėĊ Ȉ Ȉ ĔēěĊēĎĊēę Ȉ͝ Ȉ Ȉ Ƭ 1 ǡ ǡǡǤ͚͙͘͜Ǥ Ȁ Ǥ ͚͙͘͜ǣ͘͘ǣ͘͘͘Ǧ͘͘͘ ĕĕđĎĈĆęĎĔēĘ Ȉ Ȉ Ȉ Ȉ Ȉ čĊĚėĎĔē̾ėĔĈĊĘĘ Ȉ Ȉ Katena — Your completecomplete resource forfor amniotic membrane pprocedurerocedure pproducts:roducts: Single use speculums Single use spears ͙͘͘ǡ͘͘͘ήĊĞĊĘęėĊĆęĊĉ Forceps ® ,#"EWB3FW XXXLBUFOBDPNr RO0118_Katena.indd 1 1/2/18 10:34 AM News Review VOL. 155 NO. 1 ■ JANUARY 15, 2018 IN THE NEWS Accelerated CXL Shows The FDA recently approved Luxturna (voretigene neparvovec-rzyl, Spark Promise—and Caution Therapeutics), a directly administered gene therapy that targets biallelic This new technology is already advancing, but not without RPE65 mutation-associated retinal dystrophy. The therapy is designed to some bumps in the road. deliver a normal copy of the gene to By Rebecca Hepp, Managing Editor retinal cells to restore vision loss. While the approval provides hope for patients, wo new studies highlight the resulted in infection—while tradi- the $425,000 per eye price tag stands as pros and cons of accelerated tional C-CXL has a reported inci- a signifi cant hurdle.
    [Show full text]
  • Anterior Segment Surgery and Complications CATARACT EXTRACTION and INTRAOCULAR LENS IMPLANTATION
    10 Anterior Segment Surgery and Complications CATARACT EXTRACTION AND INTRAOCULAR LENS IMPLANTATION Complications PENETRATING KERATOPLASTY Complications Correction of Astigmatism in a Corneal Graft LAMELLAR KERATOPLASTY SUPERFICIAL KERATECTOMY EXCIMER LASER PHOTOTHERAPEUTIC KERATECTOMY CONJUNCTIVAL FLAP LIMBAL STEM CELL TRANSPLANTATION PTERYGIUM EXCISION AND CONJUNCTIVAL AUTOGRAFT CONJUNCTIVAL AND CORNEAL TUMOR EXCISION CORNEAL PERFORATION SURGERY PERMANENT KERATOPROSTHESIS REFRACTIVE SURGERY Radial Keratotomy Excimer Laser Photorefractive Keratectomy Laser In Situ Keratomileusis CONCLUSION Anterior segment surgery ranges from routine cataract extraction and lens implantation, one of the most common surgical operations in the United States, to rarely performed surgery such as permanent keratoprosthesis. It also encompasses surgery first performed centuries ago, such as rudimentary pterygium excision, to the latest in keratorefractive surgery. CATARACT EXTRACTION AND INTRAOCULAR LENS IMPLANTATION The many reasons for the development of cataracts are discussed in detail in Chapter 8. Most cataracts are acquired, but they can also be congenital. This section focuses primarily on the treatment of acquired cataracts in adults. Cataracts in adults are generally age related, but some lens opacities may result from other causes such as trauma, inflammation, systemic illness such as diabetes, or medications such as corticosteroids. Cataracts generally advance slowly over years but can advance rapidly over months, or even faster in some patients. The primary indication for cataract extraction is diminished vision caused by the cataract, significantly affecting the patient's lifestyle. The exact point at which this hardship occurs depends on the patient. Certain patients require little visual function and may delay cataract surgery for years or indefinitely. Other patients with high visual needs seek cataract surgery with much smaller degrees of visual loss.
    [Show full text]
  • Cornea/External Disease 2017-2019
    Academy MOC Essentials® Practicing Ophthalmologists Curriculum 2017–2019 Cornea/External Disease *** Cornea/External Disease 2 © AAO 2017-2019 Practicing Ophthalmologists Curriculum Disclaimer and Limitation of Liability As a service to its members and American Board of Ophthalmology (ABO) diplomates, the American Academy of Ophthalmology has developed the Practicing Ophthalmologists Curriculum (POC) as a tool for members to prepare for the Maintenance of Certification (MOC) -related examinations. The Academy provides this material for educational purposes only. The POC should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all the circumstances presented by that patient. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any information contained herein. References to certain drugs, instruments, and other products in the POC are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
    [Show full text]
  • Ben Connell Totally Random Cases Handout
    Totally random: A recall of cases I’ve learnt from Dr Ben Connell FRANZCO MPH Eye Surgery Associates Melbourne Corneal Unit Royal Victorian Eye and Ear Hospital Ben Connell 1 Acknowledgements • ESA Orthoptists and administration staff No financial disclosures Ben Connell 2 Learning objectives 1. Diagnose a range of “once in a lifetime” conditions 2. Insights: condition that are easy to miss. Gain some awareness on what these conditions are (?learn from when Ben has done this) 3. Improve skills in managing patient expectations No financial disclosures Ben Connell 3 Q1: Contact lens wearer 21 year old contact lens wearer • 1 week of eye pain and headache • What is your diagnosis? 1. Microbial keratitis 2. Marginal keratitis 3. Acanthamoeba keratitis 4. HSV keratitis Ben Connell 4 Q2: Corneal changes 48 year old • PK for HSV, long term Flarex • Slight blur in vision • What is your diagnosis? 1. Microbial keratitis 2. Infectious crystalline keratopathy 3. HSV keratitis 4. Christmas eye Ben Connell 5 Q3: Microbial keratitis 23 year old • Contact lens wearer • Blurred vision Could I go blind doctor? 1. Yes 2. No Ben Connell 6 Q4: Contact lens related microbial keratitis Contact lens microbial keratitis • Which organism is least likely to cause this? 1. Staph Epidermidis 2. Staph Aureus 3. Pseudomonas 4. Streptococcus • Important to review day 1 • Will often get worse before better • Keratoplasty Ben Connell 7 Commonest micro report Ben Connell 8 Microbial keratitis What are your exam findings? Ben Connell 9 Q5: What is your diagnosis? 28 yo Woman • Rings around lights when night driving • A bit red a few weeks ago • Son has sore throat What is your diagnosis? 1.
    [Show full text]
  • Cornea/External Disease 2017-2019
    Academy MOC Essentials® Practicing Ophthalmologists Curriculum 2017–2019 Cornea/External Disease *** Cornea/External Disease 2 © AAO 2017-2019 Practicing Ophthalmologists Curriculum Disclaimer and Limitation of Liability As a service to its members and American Board of Ophthalmology (ABO) diplomates, the American Academy of Ophthalmology has developed the Practicing Ophthalmologists Curriculum (POC) as a tool for members to prepare for the Maintenance of Certification (MOC) -related examinations. The Academy provides this material for educational purposes only. The POC should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all the circumstances presented by that patient. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any information contained herein. References to certain drugs, instruments, and other products in the POC are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
    [Show full text]
  • New and Emerging Approaches to Ocular Surface Inflammation
    MEDICAL ED NG UC UI AT A CONTINUING TIN IO CON N MEDICAL EDUCATION PUBLICATION CME ISSUE 20 New and Emerging Approaches to Ocular Surface In ammation A STEPHEN PFLUGFELDER, MD The immune zyme, and immunoglobu- environment of the ocular surface o ers multiple lins, which exert antimicro- opportunities for pharmaceutical intervention. bial and antiinflammatory Following the exa mple of other medical specialties, eff ects.1 Transmembrane and ophthalmologists are likely to see an in ux of more secreted mucins are released targeted therapies for ocular surface in ammation. in response to foreign, nox- ious, or antigenic stimuli. B Secreted mucins (such as Under normal circumstances, complex, tightly woven MUC5AC and MUC7) may immune mechanisms on the ocular surface keep the eye safe participate in defense by from invasion or insult. A certain level of transient, physi- preventing pathogen bind- ological infl ammation is a necessary part of this operation, ing or by surrounding and dominated by the elements of the innate or intrinsic immune removing contaminants.2 FIGURE 1 A. Neovascularization and system. Infl ammation becomes pathological when these same Resident immune cells like infi ltrates in a 13-year-old patient elements become dysregulated, as in autoimmune or chronic macrophages deal with ocu- with chronic recurrent blepharitis infl ammatory conditions, and go from being protective to and marginal keratitis. B. Regression lar surface invasion in rela- of corneal neovascularization after 1 damaging of host ocular surface tissues. tively nonspecifi c ways, but month of topical corticosteroid. (Images Treating pathological infl ammation always carries the risk do have pattern-recognition courtesy of Dr.
    [Show full text]
  • Repeat Penetrating Keratoplasty: Indications and Prognosis, 1995-2005
    European Journal of Ophthalmology / Vol. 19 no. 3, 2009 / pp. 362-368 Repeat penetrating keratoplasty: indications and prognosis, 1995-2005 ZULEYHA YALNIZ-AKKAYA, AYSE BURCU NUROZLER, ELVIN HATICE YILDIZ, MUSTAFA ONAT, KORAY BUDAK, SUNAY DUMAN Department of Ophthalmology, Ankara Training and Research Hospital, Ankara - Turkey PURPOSE. To evaluate the data of penetrating keratoplasty over a 10-year period and to com- pare indications and outcomes of eyes undergoing single graft with those of eyes requiring re- grafting. METHODS. A total of 652 eyes of 613 patients required single graft (Group I). Sixty-one regrafts were performed on 53 eyes (Group II). The mean follow-up time was 23.4±21.3 months (range 6–132 months). The results were evaluated for the following criteria: primary indications, allo- graft reactions, graft clarity, final postoperative visual acuity, and complications leading to re- duction in vision. RESULTS. The most common indication was keratoconus (228 eyes; 35.0%) in Group I, and vas- cularized corneal scar (12 eyes; 22.6%) in Group II. Allograft reactions occurred in 96 eyes (14.7%) in Group I, and 17 eyes (32.0%) in Group II (p=0.001). At the end of the study period, 76.4% of patients in Group I had entirely clear grafts, whereas 45.3% of patients in Group II had entirely clear grafts (p=0.000). The main causes of corneal graft failure were irreversible allograft reaction, endothelial failure, and graft infection, which were all seen in higher per- centage in the regraft group. A best-corrected visual acuity of 20/100 or better was achieved in 377 eyes (57.8%) in Group I and 11 eyes (20.7%) in Group II (p=0.000).
    [Show full text]
  • Associated with Congenital Glaucoma: ?
    1 For each statement, identify with which it is associated: Q Horizontal corneal lines, or Vertical corneal lines Associated with congenital glaucoma: ? V ertical Horizontal 2 For each statement, identify with which it is associated: A Horizontal corneal lines, or Vertical corneal lines Associated with congenital glaucoma: Horizontal ertical orizontal V High IOP 3 For each statement, identify with which it is associated: Q Horizontal corneal lines, or Vertical corneal lines Associated with congenital glaucoma: Horizontal What is the name for the horizontal corneal finding associated with congenital glaucoma? Haab striae What do Haab striae look like? A pair of parallel lines that taper and meet at their ends Haab striae represent what sort of pathology, ie, which corneal structure is damaged, and in what way? Tears in Descemet’s secondary to corneal stretching What is the mechanism? Mechanical deformation caused by the elevated IOP ertical orizontal V High IOP 4 For each statement, identify with which it is associated: A Horizontal corneal lines, or Vertical corneal lines Associated with congenital glaucoma: Horizontal What is the name for the horizontal corneal finding associated with congenital glaucoma? Haab striae What do Haab striae look like? A pair of parallel lines that taper and meet at their ends Haab striae represent what sort of pathology, ie, which corneal structure is damaged, and in what way? Tears in Descemet’s secondary to corneal stretching What is the mechanism? Mechanical deformation caused by the elevated IOP
    [Show full text]
  • June 2018 Examination
    June 2018 Examination 1 CLINICAL MANAGEMENT GUIDELINES Atopic Keratoconjunctivitis (AKC) Aetiology Severe ocular surface disease affecting some atopic individuals Complex immunopathology Sometimes follows childhood Vernal Keratoconjunctivitis (VKC) (see Clinical Management Guideline on Vernal Keratoconjunctivitis) Predisposing factors Typically affects young adult atopic males There may be a history of asthma, hay fever, eczema and VKC in childhood Most patients have atopic dermatitis affecting the eyelids and periorbital skin There is a strong association with staphylococcal lid margin disease Specific allergens may exacerbate the condition Symptoms Ocular itching, watering, usually bilateral Blurred vision, photophobia White stringy mucoid discharge Onset of ocular symptoms may occur several years after onset of atopy Symptoms usually year-round, with exacerbations Signs Eyelids may be thickened, crusted and fissured Associated chronic staphylococcal blepharitis Tarsal conjunctiva: giant papillary hypertrophy, subepithelial scarring and shrinkage Entire conjunctiva hyperaemic Limbal inflammation Corneal involvement is common and may be sight-threatening: beginning with punctate epitheliopathy that may progress to macro-erosion, plaque formation (usually upper half), progressive corneal subepithelial scarring, neovascularisation, thinning, and rarely spontaneous perforation These patients are prone to develop herpes simplex keratitis (which may be bilateral), corneal ectasia such as keratoconus, atopic (anterior or posterior polar) cataracts,
    [Show full text]
  • Management of Cytomegalovirus Corneal Endotheliitis Angela H
    Wong et al. Eye and Vision (2021) 8:3 https://doi.org/10.1186/s40662-020-00226-y REVIEW Open Access Management of cytomegalovirus corneal endotheliitis Angela H. Y. Wong1, Wee Nie Kua1, Alvin L. Young2,3 and Kelvin H. Wan3* Abstract Background: Cytomegalovirus (CMV) can manifest as corneal endotheliitis in immunocompetent individuals. Early diagnosis is prudent to prevent endothelial cell loss, which could ultimately lead to corneal decompensation. CMV DNA was first detected in an eye with corneal endotheliitis in 2006; since then, clinical evidence from numerous case reports and case series have accumulated. Main text: In this narrative review, we identified several drugs, including ganciclovir, valganciclovir, and their combination in oral, intravenous, intravitreal, and topical forms in different concentrations, together with the judicious use of topical steroids, have reported variable success. There has yet to be any prospective comparative study evaluating the efficacy and safety of these assorted forms of treatment; clinical evidence is based on case reports and case series. CMV endotheliitis presenting with corneal edema can masquerade as other corneal diseases and thus poses a great challenge especially in post-keratoplasty eyes. Heightened awareness is needed before and after keratoplasty to start prompt prophylaxis and treatment. Conclusion: There is no consensus on the management of CMV endotheliitis. Further studies are much needed to elucidate the optimal treatment modality, regime, and duration in the treatment and prophylaxis
    [Show full text]
  • Uveitis and Ocular Inflammation: Updated Index
    9 Uveitis and Ocular Inflammation: Updated Index 2019–2020 BCSC Basic and Clinical Science Course™ Editorial Committee H. Nida Sen, MD, MHSc, Chair Thomas A. Albini, MD Bryn M. Burkholder, MD Sam S. Dahr, MD, MS Emilio M. Dodds, MD Thellea K. Leveque, MD, MPH Wendy M. Smith, MD Daniel V. Vasconcelos-Santos, MD, PhD Note: This index updates pp. 361–383 of Section 9 and is also available online at www.aao.org/bcscindex_s09. Index (f = figure; t = table) Abatacept, for uveitis, 112 Adaptive immune response/adaptive immunity Accessory molecules, helper T cell expression of, 31 conjunctiva and, 53 Acquired immunodeficiency syndrome. See AIDS definition of, 1 Acrodermatitis chronica atrophicans, 228 effector responses of Actinomycetes, infectious scleritis caused by, 119f antibody- dependent cellular cytotoxicity, 47–48 Activated neutrophils, 10 antibody- mediated, 39f, 39–42, 40t Acute anterior uveitis. See Anterior uveitis, acute lymphocyte- mediated, 42–46, 43f, 44t Acute macular neuroretinopathy, multiple evanescent natu ral killer cells in, 46 white dot syndrome and, 189 types of, 38t Acute posterior multifocal placoid pigment innate immune response versus, 27 epitheliopathy (APMPPE) mechanisms of, 36, 36f, 38 ce re bral vasculitis and, 170 purpose of, 27–28 characteristics of, 162–164t subclinical presence of, 6 definition of, 169 Adaptive T regulatory cells, 34 diagnosis of, 170–172, 171–172f Adeno- associated virus, 58 fluorescein angiography findings in, 163t, 170, Adenovirus, 272 171f Adult T- cell leukemia/lymphoma, 265, 266f fundus autofluorescence findings in, 163t, 171, Aedes aegypti, 267 172f Afferent lymphatic channels. See Lymphatics indocyanine green angiography findings in, 163t, Afferent phase, of immune response arc, 29f, 29–30 170–171, 171f AIDS.
    [Show full text]