R@NR@NU
R@NR@NU

$.'*.0-
.


Retinal Plaques

• - . )/ -
$.
*)
.+ & -.
+) '
*!
'*)8
'' -")8







• -*/$ :
• Several different types of plaques can 8
0.#
Z
*(8
 -
8
0*!/8

 8
– $"#/:
)*)
# (* 4)($''4
.$")$!$)/
.*!/
often be visualized in the retinal -0 -8
 $# -/
'$!$
+',0
/
' !/
-*/$
$!0-/$*)
vasculature #'' )"$)"
. .:
-*)/
/*
&
• 

#$-
– !/:
RMASVY

/ )*.$.
• Pt is typically elderly, has HTN, CAD, • A./
- .$ )/
• .0'-
'$)$:
hypercholesterolemia/hyperlipidemia, and/ -
;
'**( )./ $)
8

• - . )/ -
#.

!$))$'
$)/ - ./
$)
)4
– *)$/*-
' !/
-*/$
,
S
(*.
.
)*
.4(+/*(.
$)
or atherosclerotic disease *//. ' 8

+-* 0/.
( )/$*)
• 3 +/
#
* .
#1
./*&
$)

 -/$)
*!!
'./
4 -
• Often totally asymptomatic and found on *(+)4;;;
– /-/

/# -+4
routine exam

.


.

 

- 1' )

• TN
4 -
*'
- /$-
$'$/-4
)
. - /
. -1$
• "
•  1 -
(
4
/0 4:
N;PY
" )/
• 
• .(*&$)"8

)

• .)=/
#
4 .
# &
$)

! 2
4 -.
• V3
(*-
'$& '4
!/ -
"
TR
1.;
QPARQ
• .0'-
$. .
– !/ -
TR8
P;NY
+- 1' )
• 
OM@OM

2$/#
'*2
#4+ -*+$@./$"(/$
• ./
1.0'-
.0-" -4
– ,0/ .
/*
N;O
($''$*)
+ *+'
2$/#
(*'$
QPAUS

» QRM8MMM
-
TRAUS
•  
– /'
./-*&
P3
.
'$& '4
*1 -
U
4 -.
$)
+/.
2$/#
(*'$8
•  :
($'
' +#8
/-

•  %0./$)"
!*-
*/# -
!/*-.
$"#

#*' ./ -*'
• • *./ -$*-
+*' :
^
•  )^
2*( )
• $'/ -'
1 -4
$)!- ,0 )/'4

.


.
:
.
- 1' )
Retinal Plaques

• :

+',0

• .
• '0
*0)/$)
4
/0 4N;QY
• May present with amarosis fugax, • :
- ! -
!*-
-*/$
*++' -
– :
NPQ@UU
• 8

.(*&$)"8
.0'-
$. .
transient episodes of monocular blindness – .
–  $"#/:
OPS
• 
/$)*
4
/0 4:
M;QY
• Rarely, may report transient ischemic –
- ! -
/*

!*-
()" ( )/
*!
*/# -
-$.&
!/*-.
–  :
PU;O
• (*&$)"8
8

#@*
 8

attack (TIA) , which is above with – .0'-
'$)$
+ ) )/
*)
-*/$
./0 4
– N:
V;V
D E
• $)"+*-
4
/0 4:
M;SY
hemiparesis, parasthesia or aphasia – -$"'4 -$ .:
NTP
D E
• (*&$)"8
#$"#
#*' ./ -*'8
#@*
)"$)
–  :
PN;O
D E
• :
$ /8
0/$*)8
./-/
$).0'$)

N
O
R@NR@NU
R@NR@NU

 /$)'
+',0 .
Retinal Plaques Fibrino-platelet Plaques Retinal Plaques

• Three different types of plaques, but all • Cholesterol (Hollenhorst) plaque • Calcific share strong association to significant – Most common – Appears more whitish than HH cardiovascular disease – shiny yellow-orange in appearance – Dull, non-reflective, white – HH 80% > fibrino-platelet 14% > calcific 6% – from plaque in the ipsilateral carotid artery – Classically within arteriole, not at bifurcation – Rarely causes occlusion, unless multiple – Typically immobile – Typically occurs at bifurcations – Most dangerous, as often cause BRAO – Mobile in nature – Often from cardiac arethromas of heart valves

Cholesterol Plaques Calcific Plaques Retinal plaques

• Talc retinopathy – Represents an exogenous plaques as opposed to others – Appears typically as multiple shiny yellow plaques within capillaries in posterior pole – Typically smaller than other plaques – Typically seen in IV drug users – Rarely cause complications, but reported cases of associated NV and occlusions

Retinal Plaques Talc Retinopathy Others

• Fibrino-platelet • Tamoxifen Maculopathy (Nolvadex) – Appear as dull white to gray, long plugs – Typically within arterioles, not at bifurcations – May break-up and dissolve with time – May lead to BRAO or CRAO – Often associated with carotid disease or mitral valve insufficiency

P
Q
R@NR@NU
R@NR@NU

Canthanxine Maculopathy Retinal plaques -*/$
'/-.*0)
Retinal Plaques
• No direct management of plaques is • $-./
'$)
.- )$)"
/ ./
• After ruling out underlying etiology, see needed • 
  

patient regularly, q 6 -12 mos, to evaluate • Management is aimed at discovering  66
for additional plaques or other disease source of embolus to decrease risk of • )/$!$ .
!'*2
-/
)
Y
associated with vascular disease other emboli, occlusion, or stroke ./ )*.$.
– BRVO/CRVO • Pts need referral to internist for complete • *((*)8
$)/ -)'8
)
– BRAO/CRAO 3/ -)'
physical – NTG • )'4
\OMY
*!
.4(+/*(/$
(*'$
2$''
#1

.$")$!$)/
-*/$
./ )*.$.

 /$)'
',0 .
-*/$
'/-.*0)
Is it worth working up these patients?

• Assess risk factors with PCP • $-./
'$)
.- )$)"
/ ./
– DN, HTN, lipid panels • 
  

 66
• 18% of pts with retinal emboli had internal • Carotid ultrasound or common carotid stenosis>75% PCE • )/$!$ .
!'*2
-/
)
Y
./ )*.$.
• MRA: non-invasive image with 2D/3D • Higher incidence of stroke • *((*)8
$)/ -)'8
)
3/ -)'
 
>?
• TEE: invasive, probe into esophagus to – 8.5% with emboli vs 0.8% w/o per year image heat valves • )'4
\OMY
*!
.4(+/*(/$
(*'$
2$''
#1

• Pts with cholesterol HH emboli have 15% 
 
– Helpful with calcific .$")$!$)/
-*/$
./ )*.$.
mortality at 1 yr, 29% by year 3, and 54% by 7 years • CTA: CT scan of arteries construct 3D images

 /$)'
',0 .
 /$)'
',0 .
BA
.%
#"
 

 
– >
! '/
'$&
.*( /#$)"
2.
LC>6D>J
%"*( %$
ME>6GGJ
• Assess risk factors with PCP ./$)"
(4
4 ?
VA: 20/100 PH 20/30 – DN, HTN, lipid panels • ORAL TREATMENT • SURGICAL TREATMNET SLIT-LAMP: • Carotid ultrasound – >#$.
#++ )
)*/# -
– Anti-Platelet – Carotid /$(
)
/#
*/*-
/*'
SUPERFICIAL SUPERIOR • MRA: non-invasive image with (
/*
0.
*$)/( )/
/
• ASA edarterectomy ABRASION 2D/3D )$"#/?

+ STAINING – Anti-coagulation – Angioplasty • TEE: invasive, probe into • 4+

$ / .
• Comadin, platelet esophagus to image heat valves •  
– Cholesterol meds – Reduces risk of – Helpful with calcific future stroke! • CTA: CT scan of arteries construct 3D images DX: CORNEAL EROSION > 
 
?

R
S
R@NR@NU
R@NR@NU

87% of all RCE occurs in what part of the cornea? #/
-
.*(
'  $)"
0. .
*!
7
Inferior Cornea Reidy JJ, Pauli MP et al. Cornea 2000 Nov.

46% of all patients in this study Non-Treatment: had EBMD

• James Reidy et al. Recurrent erosions • What medications should 
of the cornea: epidemiology and treatment. Cornea 2000 Nov; 19(6): be avoided? 767-71 • Bland Artificial Tear • The remainder had trauma induced Ointments Epithelial Basement causes Membrane Dystrophy: – Fingernail Eke T, et al. Recurrent symptoms Map Dot Fingerprint – Paper cut, etc. following traumatic corneal abrasion. Eye 1999 June.

..$1
- /( )/
!


•  
–  &A '
+ -
– '" -
-0.#
• ) "
).
• -* A.+ /-0(


T
U
R@NR@NU
R@NR@NU

TREATMENT Long Term TX Regimen Recalcitrant RCE

STANDARD PROTOCOL: • BCL • FreshKote TID x 2 months • ANTI-BIOTIC

• ANTI-INFLAMMATORY • Lotemax Gel QID x 2 weeks then BID • RTC x 6 weeks • NEW REGIMENT Active Treatment….Dry or Wet?? • Doxy (20 or 50mg) BID x 2 months NON-HEALING ABRASION • AMNIOTIC MEMBRANE • LATERAL TAPE • Restasis Bid! TARSORAPHY • PATIENT EDUCATION

• RTC 5 DAYS

R

 A
()$*/$
 (-)
P

 A

Amniotic membrane is the inner most lining of the Cryopreserved amniotic membrane is a • “MY EYE FEELS GREAT” placenta (amnion) and shares the same cell origin as “THE PAIN IS GONE” • VASC: 20/15 the fetus biologic therapy that can: • REMOVEDPROKERA • SLIT-LAMP: CLEAR CORNEA
Promote regenerative healing
Contains cytokines and growth factors • VASC: 20/15 • DX:
Anti-Inflammatory (protease inhibitors)
Reduce inflammation SLIT-LAMP:
Anti-Angiogenic
Minimize scar formation CORNEAL CLEAR PCE (PREVENTED CORNEAL EROSION)
Aids in rapid wound healing and re-epithelialization
Inhibit angiogenesis
Anti-Scarring TX: CPM(RESTASIS)
Minimize pain TX: RESTASIS BID RTC 4-6 WEEKS




• SU
4 -
*'
('
• - . )/.
2$/#
@*
!'.# .
!'*/ -.

3
O
4.
– *
+$)
– *
#)"
$)
0$/4
• 
#3:
4+
O

3
O
4 -.8
2 ''
*)/-*'' 9
9

•  .:
 /!*-($)8
8
$+$/*-8
$"-
• 
3:

)- (-&'

V
NM
R@NR@NU
R@NR@NU





The Vitreous Humor Physiologic Changes • )/ -$)"
:
OM@OR

• $/- *0.
//#
(*./
!$-('4
/
– 0'
• With age, liquifaction •  :


• 
due to reduction in – $/- *0.
.
• 
NQ
((

– -*0)
*+/$
) -1
# 
hyaluronic acid • :

•  $..=
$)"
causes loss of – '.*8
.*(
/-/$*)


















































support. *)
'**
1 .. '.
• This process is • $/
# (
referred to as synchesis.





)$ )
*!

Physiologic Changes

• .. ..( )/:
•  ''4
)*
*). ).0.

$ $
• Vitreous shrinkage, – 0/


• 4(+/*(/$

2$/#*0/
- /$)'
- &
^PM

contraction and – :NAO
2 &.
collapse can cause PMARV
NMY
–
2
&$ $
%$
(.#&)%#(0
' (!
)%'(
$
• '):
traction. SMASV
OTY
" $ "
 $ $(2

• This process is – /
0/$*)
• ?6D
,!(
^TM
SPY
referred to as • $")[email protected](+/*(.
*!

•  $
D
#%(
)%
?
.'
^UM
TRY
syneresis. – 
, $/

– ' 1 ')
'$)$:
QAS
 &.
– /# -.:

$!
)*
# (
*-
*/# -
$..0 .8
1 -4
'*2
-$.&
.*
)*
)
/*
.
/*
&
• SRY^SR





''*…;-;
$ ..
)$ )
*!

.
• • '*/ -.
-
/4+$''4
(*./
*((*)
.4(+/*(
• )$ )
(4

 ' -/

4
**
 2.:
–  /$)'
 -.@- &.
!(*!,
0)*((*)
– *2 .
– 4*+$
• )
./0 4:
*)'4
TANRY
*!
.4(+/*(/$
.
#1

- /$)'
- &
– – $' .
-0(
– UAOSY
0/
.
#1
)
..*$/
@
/
/#
– $-.
– -$*-
1$/- *- /$)'
$. .
/$(
/# 4
+- . )/
D+#/#'(*'*"4

OMNQE
• '.# .
– 0-" -4
• 
) 2.:
– ) $/$1
*!
/-/$*)
*)
- /$)8
0/
)*/
)  ..-$'4
– )!'((/$*)
– TANRY
#1

- /$)'
- &
– 
/ -
*-
- &
• 4(( /-$'
VMY
*!
/#
/$(
#
#) .
*!

/# -
!/ -
$.
]OARY
• ++ ).
/*
. *)
4
2$/#
NAO
4 -.

NN
NO
R@NR@NU
R@NR@NU

4
- *(( ) /$*).
QU


34


Risk Factors 
2
,&'
$
• 
 
 
 
• $)
./-/$)"
'/)

-  $)".:
• $"( )/
•  
 @


– [NTANV((
"
– # !! -G.
$")
• 

S
 
– [NUAOM((
"



• ) $/ .
- &
$.
+*..$'
• 

  
 

• (*-#"
• 
 
8
 


• – VMY
#1
- &
- 1$*0.
*/*-
! '/
/#/
+/$ )/
2.
 $)"
 
.! '4
/- /
/
/#$.

' 1 ';
• )!'((/*-4
 ''.
– $/- *0.
# (
– /
$.
24 -@!/# -A$)A'28
/
– 0./
* .)=/

! '
-$"#/

QU


QU


)$/$'
3(
$)
#* )$3
!/
4 :
#* )$3
)$''-4
/ ./.
• 
OM@OM

• A

*1 …;
Case • 
[NT((
"


[NU((
"

• 0% /$1 '48

/#
+/$ )/
–  +*-/.
3 '' )/
*(+'$)
–  )$ .
)4
.$ A !! /.

QU


$.0'
$ '
-*"- ..$*)

'
"$&&
')'('
QU


- /( )/
$./*-4
$)
0++++ -
/ ).
%%&
(#'
&

!$+
#$)
• $")*.
2$/#

NVVR
• )$/$'
/# -+4
$(*'*'
M;RY
• $")*.$.
(
4
*+#/#'(*'*"$./
$)
– $.*)/$)0
!/ -
O
(*)/#.
$)) .*/
– $
!! /.
*!
- 4- $
H
!/$"0
•  '*/
/*
#* )$38

..0(
-


• )/- /
+ &

• 0-- )/
 $'
 "$( ):
– [OT((
"

– '/)
*0
,(
3
O
4-.
– [OV((
"

NP
NQ
R@NR@NU
R@NR@NU

Hysteresis: Not a New Concept

"(( 
4 .()'( (
%%&5
Basic Parameters
 '
#(
"'
,

$


)/$!$
/#
+# )*( )*)
*!
#4./ - .$.
)
*$)
/#


/ -(
$)
NUVM
C  
A
*' ())
*-- '/


C  
A
*-) '
*(+ )./

• 
( .0- ( )/
/#/
#-/ -$5 .
- .+*).
/*
 
 


7
++'$/$*)
)
- (*1'
*!
!*-
D'* @0)'* EN
C
A
*-) '
4./ - .$.
– *0)
$)
(/ -$'.
*-
.4./ (.
/#/
*
)*/
$)./)/'4
C
A
*-) '
 .$./)
/*-

!*''*2
!*- .
++'$
/*
/# (
0/
- /
.'*2'48
$&
''%(

%$&($#
$
(
%%!
#&,
N

ORA Reichert • *-
/#)
TRMM
++ -.
+0'$.#

*)
#4./ - .$.
$)

1-$ /4
*!
( $'
!$ ' .O

– -$*0.
/$..0 .
)
./-0/0- .
D/ ) *)8
'0)"8
-/ -$ .8
/E
MORE TESTING IS – #
$(+*-/)
*!
*-) '
1$.*A './$$/4
#
 )
E






$.0..
)
3+'*-
D/  1
+-$*-
/*
/#
P
NEEDED C  
A
*' ())
*-- '/

C  
A
*-) '
*(+ )./


1. Vincent J. Basic elasticity and viscoelasticity. In: Vincent J, ed. Structural Biomaterials. 3rd ed. Princeton, NJ: Princeton University Press; 2012:1-28. 2. PubMed Search for “hysteresis” on October 3, 2014 returned 7696 results. 3. Hjortdal JO1. On the biomechanical properties of the cornea with particular reference to refractive surgery. Acta Ophthalmol Scand Suppl. 1998;(225):1-23.

$")'
'*/

) -./)
/#
*-) 8
) -./)
/#
- ..0-


Corneal Hysteresis: *-) '
$*( #)$.
)
0-/

$)
)
$(+'
)./-0( )/
A New Ocular Parameter

4
 /0- . Bioengineering of the Eye • 
$.
/#
*)'4
1$
$)
/#
2*-'
+'
*!
( .0-$)"
*-) '
4./ - .$.
D E8
$"#/@ !/
4
4./ - .$. 
1.

A
PPV
*-('
4 .
2#$#
$.
)
$) $/*-
*!
$*A( #)$'
+-*+ -/$ .
*!
/#
*-) 
D/$..0
+-*+ -/$ .E
• $.* './$
/$..0
2$/#
*(+' 38
•
.
$/
./-*)"
*-
2 &8
/*0"#
*-
.*!/
$)/ -*)) /
($-*./-0/0- N
18.00

R2 = 0.6625 • 
(
    
&' ) +
%
+ (*"
 "
&'%'(( %$0
, 
"&(
" $  $(
•  *( /-$'
//-$0/ .
-
)*/

16.00 #!
#&%')$)
)')#$)
 ( %$(
'" '
.0--*"/
!*-
$*( #)$'
14.00 • 
'
')%&$&
($
,"(&,
01
'

!)$"
&'
''''"#(
($$!
+-*+ -/$ .N
12.00 – ":

* .
)*/
.-$
• 
 " ))(
%*'
%'$"
%#&$()

8 92
$

#(*'#$)
) )
1$.* './$$/4
10.00 (
"((
$"*$
.
%'$"
&'%&') (
) $
%) '
)%$%#)'(0
$"* $

%"#$$3


• 8.00 • #
4
++ -.
/*


( #)$'
'
'
')%&$&
($
/'

 )'("#(-
+
'
#
'&(
O ./-0/0-'
*)/$)00(
6.00 – $..0
+-*+ -/$ .
(4
+-*1$
• # -
-
*1 -
QOR
+ -A- 1$ 2
+0'$/$*).
*0/

$)
/#
'$/ -/0-
4.00  $/$*)'
$")*./$
$)!*-(/$*)P
• 
$.
!./8
*% /$1 8
)*)A*)//8
)
*+ -/*-
!-$ ) '4
2.00

IOMMO
-&
/
';
#*'(
%(!"$!
'
. 0.00
1. Glass DH et al. Invest Ophthalmol Vis Sci. 2008;49:3919-3926. 0.00 5.00 10.00 15.00 20.00 2. Taylor DA et al. Corneal Biomechanics. In: Copeland RA Jr., Afshari NA, eds.: Copeland and Afshari’s Principles and Practice of Cornea. Two Volume Cornea Textbook. Jaypee Brothers. 2012:148-157.

)
%*')(.
,
$"$
%""
%
&)%#)'.

NR
NS
R@NR@NU
R@NR@NU

*-('

1'0 .
A

A.

*-- /$*)
$.
",3
#
+-*' (
2$/#
A.

0((-4
*!
+0'$.#
- .0'/. 
1.;

A
NUQ
)*-('
4 .

 %0./( )/
*) %'(



+


'.
) !
%'$(
)$

!

)%
#(*'


$-2)8

!
D - ') E

NM;U

_
N;R
##
/
';
D E



NM;T
_
O;M

-/$5
D+$)E


NM;U
_
N;R
" -
/
';
D -()4E



NM;S
_
O;P

*0*0'
/
'
D-) E



NM;OS
(
/
';
D#$)E



NM;V
*)/ .8
/
'
D-5$'E



NM;NT
_
N;UO
#*)"*

D '"$0(E


NM;V
_
N;P
*)5' 5A $%*(
D*-/0"'E

NN;Q
_
N;R
($4
D +)E


NM;O
_
N;P
-*)-*
D E


NM;OQ
_
N;OQ
'.
) $
%'$(
)$
*)/-
D-) E


NM;OR
_
N;S
)%
#(*'
"%,

$ 
/
'
D
RMAUM
 0'/.E

NM;Q
_
N;N
$ 
/
'
D
*0)"
 0'/.
OMAOSE

NN;U
_
N;S
*)"
D#$) .
#$' - )E


NM;T
_
N;S
$(
/
'
D$)"+*- )
#$' - )E

NN;U
_
N;RR

$-2)8

!
OMMU
D -$.#
#$' - )E
NO;R

_
N;PR

But SCATTER in the data makes accurate mathematical adjustment of IOP impossible for individuals!

)
%*')(.
,
$"$
%""
%
&)%#)'.
)
%*')(.
''.
* ".0
 "#'
.
$() )*)
)
%*')(.
,
$"$
%""
%
&)%#)'.

#4
A.

*-- /$*)
$.
!'2

$)
*-) '
/#*'*"$ .

$)
*-) '
/#*'*"$ .
The Cornea and Glaucoma

CCT 455 *#'%*(
()* (0
(*
(
) 
*"'
.&')$( %$
CH 11.2 ')#$)
)*.
8 9
+
%*$
) )
%'$"
CRF 10.8 ) !$((
(
$
$&$$)
$ )%'
%
"*%#
' (!3


Thin Cornea with no ectasia %'
'$)
'('
(
$ )
) )
) 
%'$"
.()'( (
#(*'#$)
&&'(
)%


+$
#%'
CCT 500 &%,'*"
$
) (
''3
CH 8.1 CRF 7.9 *-) '
 .$./)
/*
 ) $)"
$.
)*/
+ ) )/
/#$&) ..8
0/
*)
(/ -$'
+-*+ -/$ .

Thin Cornea with Keratoconus Thick and thin is WRONG. Think weak and strong

)
%*')(.
  0
'$)0
&%(0
()""$%
)
%*')(.
$)%
#'%( %0

6

@>>D

Define & Describe IOPcc 
$)
*-) '
/#*'*"$ .

$./-$0/$*)
A
*-('.
H
'0*(
Corneal-Compensated Intraocular Pressure

#
#(&$)!&
&'')&
"')&"#(
((
'
'#
($
"(
CCT 605 $!"##
($#$"(&,
$#
*&-
)(
'
!''
(
,
$&#!
CH 11.3 %&$%&('
(#
$(&
"($'
$
($#$"(&,-
#!)#
$!"##
CRF 10.7 The Cornea, IOP, and Glaucoma 01.




#.
.. )/$''4
5 -*
*-- '/$*)
2$/#

$)
)*-('
4 .
)
./4.
- '/$1 '4
*)./)/
+*./A  ;
CCT 597
CH 8.4 
#.
 )
.#*2)
/*

(*-
..*$/
2$/#
+-*"- ..$1
!$ '
CRF 7.2 '*..
/#)



Glaucoma subjects have lower CH than normals, especially those who are
still progressing in the disease. 
K
@
6
8>3BA:?9

)
%*')(.
$)%
#'%( %0

6

@>>D
)
%*')(.
,
$"$
%""
%
&)%#)'.
$
)(**
 ##.%0


NT
NU
R@NR@NU
R@NR@NU


0-4 Background   
1.;

A
NUQ
)*-('
4 .

0-4 "8

*-- '/$*)
2$/#
*' ())
)


"
*-- '/$*)
2$/#
*' ())

/#

)

2 -
#$"#'4
*-- '/
D-[
M;URE
%$"*( %$(2


( .0- ( )/.
. (
/*
+-*1$
)
./$(/
*!

/#/
$.
' ..
$)!'0 )
4
*-) '
+-*+ -/$ .
/#)
/#*.
+-*1$
4

)!'0 )
*!
*-) '
/-0/0- 8
*-) '
 .+*).$1 ) ..8
)
/# -

0'-
-( / -.
*)
*)*( /-$
 .0- ( )/
*!
)/-*0'-
- ..0-

1'0/$*)
*!
/#
)!'0 )
*!
*-) '
$*( #)$'
-*+ -/$ .
*)

-*()
8
*)" *)
8
) )A*#
8
0$"' 4
;
)/-*0'-
- ..0-
 .0- ( )/.
.$)"
/#
0'-
 .+*).
)'45 -;

'0*(;
OMMT
/A*19NSDTE:RUNAU;
 '$+
;
 $-*.8

)
* -/
;
 $)- 8


'0*(
OMMS9NR:PSQBPTM;
)
%*')(.
'3
+ 
()""$%0

'3
.
&%(0

)
%*')(.
,
$"$
%""
%
&)%#)'.


.
3(+'
'0*( 
$.
)
) $/*-
*!
-*"- ..$*)
$)
'0*(
IOPCC vs CCT 184 Normals 28 eyes Pre/Post LASIK IOPcc

57 yo post LASIK female • Complaining of blurry vision and pain in right eye %$"*( %$(2
#$)) -

2.
..*$/
2$/#
/#
.//
*!
"'0*(
("
.
• GAT: 15 mmHg $) $/
4
;

3$'
' )"/#
)
*-) '
• • IOPcc: 46 mmHg!! 4./ - .$.
2 -
..*$/
2$/#
+-*"- ..$1
• OCT image showed fluid under the flap !$ '
2*-. )$)"

/$ )/
$")*.
2$/#

The accuracy of current tonometers is affected by refractive surgery procedures, )"'
'*.0-
'0*(
such as LASIK. IOPcc is more accurate in these corneas.  )/-'
*-) '
#$&) ..
)
*-) '
4./ - .$.

..*$/
$/#
'0*(
("
26% IOP drop 3% IOP drop *)" *)
8
-*()
8
) )A*#
8
-*1 -
8
0$"' 4
;
(

+#/#'(*'
OMMS9
NQN:USUBUTR;

)
%*')(.
'3
+ 
()""$%0

Data Courtesy of William Wiley, MD )
%*')(.
,
$"$
%""
%
&)%#)'.
'3
.
&%(0

Cleveland Clinic

'0*( QU


IOPcc in Normal Tension Glaucoma 
- $/.
-*"- ..$*)
$)
'0*(

#.
/#
#$"# ./
* .
-/$*
*!
+- $/$)"
"'0*(
+-*"- ..$*)
• 
:
T;P
:
S;V
– 
"
:
NV
((
"



:
OR
((
"
– 
"
:
NT
((
"




:
O




*##'.
%

• /$ )/
.2$/#
!-*(
'
/*
0($")
" $ "
 $ $(

• 
/
O
2&.
!/ -
.2$/#

– 
[NO((
"

– 
[NP((
"
• 
P
(*)/#.
!/ -
.2$/#
– 
[MV((
"

IOPcc measures higher than current tonometers in NTG eyes. This enables Lower Corneal Hysteresis is Associated With More Rapid Glaucomatous Visual Field Progression – 
[NN((
"
physicians to identify at-risk patients earlier with ORA. J Glaucoma 2012;21:209–213 Carlos Gustavo De Moraes, MD, Celso Tello, MD, Victoria Hill, BS, Jeffrey M Liebmann, MD Robert Ritch, MD

)
%*')(.
)(**
 ##.%0


NV
OM
R@NR@NU
R@NR@NU

QU


0((-4
0#=.
4./-*+#4
0#=.
4./-*+#4
•  
T
.. -/.
/#/

- 0/$*)
*-- '/ .
• 0/*.*('
*($))/
$)# -$/)
•
#-/ -$5
2$/#
1$.0'
!$ '
+- . -1/$*);

• $'/ -'
@
.4( /-4
– *-) '
0///
• (''
- !-/$'
> -*+.?

• /
*). /
^
RM
4;*;
*)
*-) '
) */# '$0(
• *2
/ ).
+- . -1
1$.0'
!$ '
 // -
/#)
•  (' .
!! /
P
/$( .
(*-
/#)
(' .
• !! /.
/#
>+0(+?
/$*)
0++ -
/ ).
*!
/#
) */# '$0(
– R;T
Y
1 '*+
(
–  (

• #-/ -$5

• - / -
$)
/#

•  .$/ .
.
4
"* .
*)
•  2 -
( $/$*).
$(+-*1
*(+'$)

…
– *-) '
"0///
• *)"
./) $)"
(
(4
• 3 ..$1
0(0'/$*)
*!
)*-('
) */# '$'
. - /$*).
' 
/*
*-) '
.--$)"
• ++ -.
$)
PMAQM/#
4 -
*!
'$!
• =.
*((*)

#*/*
*0-/ .4
-4
2-/5
8

#*/*
*0-/ .4
-4
2-/5
8


.
/0 4
.
/0 4
0#=.
4./-*+#4
 =
 

• ST
4 -
*'

• 
• 4(+/*(.
1-4
2$/#
"-
*!
"0///
)
*(+-*($.
*!
/#
) */# '$'
/$..0
• >4
1$.$*)
$.
)*/
"** <
#1
'0--
1$.$*);
– OM@PM
D AOM@OME

• * -/
"0///
4
4 .
-4

'*/
/**;
# 4
-4
''
/#
/$( ;?
– OM@NMM
D AOM@TME

– 4
!! /
1$.0'
!0)/$*)

• Z 
D $ /
*)/-*''
NR
4 -.E
•  
– 4
$) 0
($' A(* -/
(
•  
– OZ
"0///A
• '*.
-*0)
'$"#/.
– $'
+$"( )/
*)
) *A
• 54
1$.$*)
^
;(;
• $./*-4
*!
.&$)
' .$*)
- (*1
!-*(
# &
• – N@OZ
@-
A
 1 -
"0///
– $.$*)
- . .
– OZ@OZ
A
– *..$'
0''*0.
1 '*+.

#*/*
*0-/ .4
-4
2-/5
8


/-/
0-" -4

0#=.
4./-*+#4
0#G.
4./-*+#4

• 
• - /( )/
– OM@NMM
– -'4
./" .
*!
$. .
• )- .
-/$!$$'
/ -.
– OAPZ
/-$
• 4+ -*.(*/$.
,#.
– PZ

• 
0.
$!
0''*0.
$.
+- . )/
•  6
– NZ
 ''.
– $.0'
!0)/$*)
$.
.$")$!$)/'4
*(+-*($.
– ).
 )/ -
•  ) /-/$)"
& -/*+'./4
– 
•  +
( ''-
) */# '$'
& -/*+'./4
D  E
• NQ
(( "
DE
•  . ( /
./-$++$)"
0/*(/
) */# '$'
& -/*+'./4
D E

#*/*
*0-/ .4
-4
2-/5
8


ON
OO
R@NR@NU
R@NR@NU

0#=.
4./-*+#4
.
/0 4

4
4

•  
• S
(*)/#.

(
@
(
A
–  $+$ )/
*-) 
$.
./-$++
*!
 . ( /=.
( (-)
– 
• RO
4*
! ('
• QR
4*
! ('
)
) */# '$0(
• OM@PMA
• *)//
' ).
2 - -
• )*(!*-/'
4
– -).+')//$*)
*!
*)*-
*-) 

/#-*0"#
.(''
.

• 
4
3
P
#*0-.
• )
)
*!!
3
U
(*)/#.
$)$.$*)
• ' 3
–  ''
 )/ -
' ).
• *
$.*(!*-/8
0/
! '.
-4
• *.$/$1
'' -"4
#$./*-4
–  .0'/.
$)
– PZ
"0///
• (+-*1 .
) */# '$'
!0)/$*)8
*-) '
'-$/4
)
- ./*- .

(
. $)"

• 
0)!! /
• *
.4./ ($
( .
*/# -
– 1$.$*)
$'
+$"( )/
) *

/# )

'' -"4
• 
– $)$(''4
!! /.
- !-/$*)

– NR
(( "
DE
– )
+-*1$
-+$
1$.0'
- *1 -4
• **
# '/#
• 1 -''
"**
# '/#
– $)/$).
./-0/0-'
$)/ "-$/4
*!
/#
*-) 

*)%0)/$1'
 0) )4
.
/0 4


#/
*
/# .
#1
$)
*((*)7
*)%0)/$1*#'.$.
•  !$)
.

- 0) )/
'**.
)*) (/*0.
$)! -$*-
• NP
(*)/#.
'/ -
• 
*)%0)/$1
– /$ )/
''.<;
– A
• */
 /2 )
/#
"'*
)
$)! -$*-
4 '$
– >*--4
/*
*/# -
4*0
*)

0) 48
0/
(4
4
$.
– 
– *)%0)/$1'
!*' .
'4$)"
'*)"
/#
$)! -$*-
'$
(-"$)
• *(
+-*+*.
 :
'0--4
/* 4
)
$/
#0-/.
'$//' ;?
• OO
(( "
DE
– "$)"
– >
#1
. )
/#
*-) '
.0-" *)
-  )/'4
)
#

– 0'-
.0-!
$)!'((/$*)
.$
(4
*-) 
'**&
"** ;?
–  '4
/ -
' -)
D0.
*-
.4(+/*(7E
– *-
*((*)
$)
! (' .
– >
2.
OM@PM;
* 4
$/
$.
)*/
.*
"- /;;?
– *-
*((*)
$)
' +#-$/$.
+/$ )/.
– <;

# 
$)/*
.
+/$ )/<
– *A 3$./$)"
+$)"0 0'
• /$ )/.
-
(*./'4
.4(+/*(/$9
#*2 1 -
*-- /
$")*.$.
-0$'
$)
.4(+/*(/$
+/$ )/.

 0) )/
*)%0)/$1'
*' .
*)%0)/$1'
 0) )4

*)%0)/$1*#'.$.

OP
OQ
R@NR@NU
R@NR@NU

*)%0)/$1'
 0) )4
*)%0)/$1'
 0) )4
*)%0)/$1*#'.$.
% *)%0)/$1*#'.$.

ALL YOU SEE IS THE TIP OF THE ICEBERG Anatomical Tear Reservoir How Is Tear Flow Interfered by CCh?

Obstructed Tear • #
'*&.
/ -
!'*2
$)/*
/#
+0)/0(
/*
Meniscus 0.
'4
/ -
' -)

*
3
& ) "#%"
"()
%$()
*'3
?GFD1@2@C7@F
(! $3
%'$3
@>>F1@E2DBB6G3

•
#
$)/ -! - .
2$/#
/#
/ -
( )$.0.
""'
;
($3

    
&&%!  "
*#*(
)
"3


"$&%%#
Obliterated Tear • '$)&$)"
# '+.

-4
4 8
0/
)*/
#
Reservoir -4
44 4

(*"
)
"3

!%% %% &

 .
'
(%#


&) $)(

(.#&)%#) /
A DRY RESERVOIR TRANSLATES TO A DRY OCULAR SURFACE

*
/*
/#
*0- :
*)%0)/$1'
 0) )4
#/
-
)$,0
'$)$'
 /0- .
*!
-4
4
*)%0)/$1'
 0) )4
4 -* 4)($.
D/ -
*1 ( )/E
/#/
4 -/ .
/#
0'-
0-!
*)%0)/$1*#'.$.
0.
4
#7
*)%0)/$1*#'.$.
• 4(+/*(.:
1 FORNIX –  -$)"@ +$+#*-A .+ $''4
2$/#
).'
!*' .
0
/*
'*&"
*!
+0)/0(
– -4) ..F
2 3 MENISCUS – 
–  ) ..
2 – 4
+$)
3 OCULAR SURFACE – '0--4
1$.$*)9
.+ $''4
$)
*2)
"5
1

$
.0'
/
'
&

%(!"$!8

OMMQ

OR
OS
R@NR@NU
R@NR@NU

*)%0)/$1'
 0) )4
*)%0)/$1'
 0) )4
*)%0)/$1*#'.$.
*)%0)/$1*#'.$.
• - /( )/:

– 0-$)/.
– )/$#$./($) .
#)&.6
– *+$'
/ -*$ .
– 0-"$'
- . /$*)
*!
/#
*)%0)/$1
/

 .
(

')%'.
)%
%$+$) %$"
'.
.
')#$)(/

• %'$ -
" )') %$
.

•
))*/
#*'
+/$ )/=.
*2)
/ -.

•
 ' *(
 ) !$/
!-*(
-/$!$$'
/ -.
•
.4
/*
" ) -/
>*1 -!'*2?
•
 ./.$.J
$.
)*/
# '+!0'

OMQ

*)'0.$*)
Key Surgical Steps • #
$.
)
*1 -'**&
0.
*!
-4
4 ;
Conjunctivochalasis is a disease • #
-4
4
$!! -.
!-*(

-4
4
$)
$0-)'
of the Tenon’s. 1-$/$*)8
.4(+/*(.
#)"
4
"5 .
)
Key CCharacteristic of CCh: Key Characteristic of CCh: '$)&$)";
Key Characteristic of CCh: • Excess, loose • Obliterated tear reservoir • • Dissolved and conjunctiva in the lower and obstructed tear 4(+/*(/$
#
$.
0
/*
DNE
$)/ -! - )
*!
degenerated Tenon’s fornix and fat prolapse meniscus / -
( )$.0.8
DOE
+0)/'
-$)"
)
DPE
$)/ -! - )
*!
/ -
!'*2
!-*(
/#
!*-)$3
/*
/#
Treatment Strategy:y: Treatment Strategy:y: Treatment Strategy: ( )$.0.;
• Removal of all • Rearrangement of • Fornix reconstruction unhealthy Tenon’s conjunctiva and to deepen the tear • 0-"$'
/- /( )/
.#*0'

$- /
/*
and replacement replacement of the reservoir and reinforce with one layer of second layer of the orbital septum + )$)"
/#
!*-)$3
2$/#
;
AmnioGraft® AmnioGraft® with anchoring sutures in the fornix

OT
OU