Bennie H. Jeng Editor From Diagnosis to Procedure

After external and anatomical considerations, the next step in diagnosing DES is to assess which part of the tear film is dysfunctional. Newer tests are currently being evaluated that can better assess the dynamic state of the tear film including function.

Treating Inﬂ ammation
Punctal Occlusion
Treating Lid Disease
Nutritional Considerations
Recalcitrant Dry Eye Syndrome

Immunomodulatory effect of the topical ophthalmic Janus kinase inhibitor tofacitinib (CP-690,550) in patients with dry eye disease. In vivo confocal evaluation of the ocular surface morpho-functional unit in dry eye.

Introduction

Advances in the Diagnosis

Diagnosis

Bacteria
Fungi
Virus
Parasitic
Corneal Imaging and Corneal Biopsy
Molecular Diagnosis

Management

Bacteria
Fungi
Virus
Parasitic

Introduction
Allergic Conjunctivitis

Historical Perspective
Epidemiology

Monoclonal antibodies and PCR of corneal scrapings have been reported, but are rarely done (Pfl ugfelder et al. 1990). Similar results have been reported in the detection of the slender, septate branches of corneal fungal pathogens (Vaddavalli et al. 2011; Tu and Park 2007) and yeast.

Allergic Disease of the Eye

Clinical Features
Patient Evaluation, Diagnosis, and Differential Diagnosis
Treatment
Atopic Keratoconjunctivitis .1 Historical Perspective

Epidemiology
Clinical Features
Treatment

Vernal Keratoconjunctivitis .1 Historical Perspective

Epidemiology
Clinical Features
Treatment

Giant Papillary Conjunctivitis

Epidemiology
Clinical Features
Treatment

Conjunctival Provocation Testing

Epidemiology
Clinical Features
Treatment

Introduction
Confocal Microscopy

Function

A double-blind, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. Preliminary evidence of the efficacy of probiotic eye drop treatment in patients with vernal keratoconjunctivitis.

Imaging Techniques for Corneal Disorders

Normal Anatomy
Clinical Uses
Specular Microscopy

Normal Anatomy
Clinical Uses

Anterior Segment Optical Coherence Tomography

Function
Clinical Uses
AS-OCT Versus UBM

Contact Lens

Soft Lens for Ocular Surface Disease

The sections obtained are oriented parallel to the surface of the tissue imaged by confocal microscopy. After penetrating keratoplasty, a decrease in the density of cells at all levels of the transplanted cornea has been reported (Niederer et al. 2007. -OCT imaging provides the clinician with an in vivo cross-sectional image of the cornea and anterior segment.

Confocal microscopy provides the clinician and researcher with in vivo imaging of the cornea at cellular-level resolution. Age-related changes in the corneal endothelium and stroma as seen in vivo by specular microscopy.

Advances in Contact Lens for the Treatment of Ocular

Surface Disease and the Corneal Ectasias

Rigid Lens for Ocular Surface Disease
PROSE Treatment for Ocular Surface Disease
Recent Advances: Ocular Surface Disease

Soft Lens
Rigid Gas-Permeable Scleral Lenses
PROSE Treatment for Ocular Surface Disease

Contact Lens
Recent Advances: Corneal Ectasia

Soft Lens
Rigid Gas-Permeable Corneal Lenses
Piggyback Systems
Hybrid Lenses
RGP Mini-scleral and Scleral Lens
PROSE Treatment

Future Innovations
Introduction
Pathophysiology

Scleral lenses have recently been shown to be effective in the treatment of LSCD (Schornack 2011) and in the management of ocular cicatricial pemphigoid (Schornack and Baratz 2009), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) (Tougeron -Brousseau et al. The utility of mini-scleral RGP lenses for the treatment of moderate to severe dry eye has been reported (Alipour et al. 2012. PROSE treatment has been shown to be successful in the management of LSCD after treatment of conjunctival melanoma (Grover et al. 2010.

PROSE treatment has been reported to be effective in treating patients in burn units (Kalwerisky et al. Contact lenses can be used as a vehicle to deliver and transplant corneal stem cells for reconstruction of the ocular surface (Di Girolamo et al. 2009).

Corneal Collagen Cross-Linking for Keratoconus and Corneal

The Cross-Linking Procedure
Clinical Outcomes

Visual Acuity and Refractive Outcomes
Topographic Outcomes
Topographic Keratoconus Indices
Higher-Order Aberrations
Patient Satisfaction
Postoperative Timecourse

Biomechanical Changes
Complications .1 Postoperative Haze

Corneal Pachymetry

Predictors of Outcomes
Future of Corneal Collagen Cross-Linking
Introduction

In the corneal collagen cross-linking procedure, riboflavin (vitamin B 2 ) is administered in conjunction with ultraviolet A (UVA 370 nm) irradiation. Similarly, the collagen cross-linking process appears to have a predominant effect on the anterior 300 μm of the cornea (Wollensak et al. 2004b. The essential goal of collagen cross-linking is to stabilize the progression of the ectatic cornea.

Patient subjective visual function after corneal collagen cross-linking for keratoconus and corneal ectasia. Effect of topographic cone location on corneal collagen cross-linking results for keratoconus and corneal ectasia.

Advancements in Anterior Lamellar Keratoplasty

Indications
Donor Tissue Selection
Anesthesia Planning
Surgical Procedures

Superﬁ cial Anterior Lamellar Keratoplasty
Manual Dissection
Microkeratome-Assisted Superﬁ cial ALK
Sutureless Femtosecond Laser-Assisted Anterior

Deep Anterior Lamellar Keratoplasty

Manual Dissection
Melles Technique
Anwar’s Big-Bubble Technique
Femtosecond Laser-Assisted Deep Lamellar Anterior

Technique
Outcomes
Surgical Complications and Management
History, Innovations, and Terminology

When considering superficial anterior lamellar keratoplasty (sALK), a thorough ophthalmic evaluation is warranted with particular attention to the degree of anterior scarring and the amount of regular versus irregular astigmatism. It is recommended to mark the anterior surface of the corneal graft for proper orientation. To prevent perforation of Descemet's membrane during trephination, it is important to have a caliper available to provide the surgeon with information on the thinnest point of the host's cornea.

When perforation of Descemet's membrane occurs during stromal dissection, anterior chamber pressure should be reduced to reduce extension of the perforation. Comparative cohort study of the outcomes of deep lamellar keratoplasty and penetrating keratoplasty for keratoconus.

Endothelial Keratoplasty

DSEK
DMEK
Hybrid Techniques
Ultrathin DSAEK

Forceps: The donor tissue is folded into a 60/40 configuration (with the endothelium facing inwards and protected with a small amount of viscoelastic material) and inserted into the anterior chamber using atraumatic, non-coaptant forceps (e.g. Charlie II, Goosey, Kelman forceps) (Melles et al. 2002a; Price and Price b. The donor edge is grasped with the forceps and pulled into the anterior chamber (pull-through method) (Mehta et al. 2007. The donor lenticule is carefully folded in half with the suture to the leading edge and the leading edge of the incision are lifted at both ends.

As in DSEK, the central host DM is removed before insertion of the donor tissue. After the roll is partially unwrapped, a small air bubble is injected under the donor to ensure orientation (Guerra et al. 2011a.

Surgical Considerations with Ocular Comorbidities

Aphakic Eyes with Complete or Partial Aniridia
Phakic Eyes
Prior Glaucoma Filtering/Tube Surgery
Vitrectomized Eyes
Failed Prior PK
Iridocorneal Endothelial (ICE) Syndrome
Pediatric Endothelial Keratoplasty

In aniridic eyes with an artificial iris implant, the graft may slip between the edge of the implant and the eye wall and fall into the posterior segment. The probability of cataract progression requiring extraction is significantly related to the age of the patient (Price et al. 2010. In eyes with glaucoma drainage devices, it is important to ensure that mechanical contact between the graft and the tube is avoided by appropriate incision and repositioning the tube, if required.

This prevents the weakening of the graft-host junction that can occur inadvertently during the stripping maneuver. Surgical challenges include inserting and unfolding the donor tissue into the small anterior chamber of a child, avoiding trauma to the crystalline lens, postoperative positioning, and anesthesia issues.

Refractive Results
Endothelial Cell Loss
Graft Survival

Postoperatively, frequent follow-up and aggressive IOP control are necessary for graft survival (Chaurasia et al. 2013. Compared with the 5-year cell loss experienced with PK procedures performed in the Cornea Donor Study for Similar Indications , cell loss at 5 years appears to be lower with DSEK (Price et al. 2013. In a report by Tourtas et al., mean endothelial cell loss at 6 months after DMEK and DSAEK was comparable (Tourtas et al 2012.

In another comparative study between DMEK and DSAEK, there was no difference in endothelial cell loss after 1 year (Guerra et al. 2011b). Previous glaucoma surgery was the most important risk factor for early graft failure (Price et al. 2013).

Complications

Early Postoperative Raised IOP
Primary Graft Failure
Glaucoma
Interface Abnormalities
Infections

D attributed to resolution of the corneal edema after restoration of endothelial function (Laaser et al. With this risk factor taken into account, the 5-year DSEK survival rate was comparable to 5-year PK survival rates at the same center (Price et al. 2011. In an early report by Guerra et al., the rebubble rate was 62% in a prospective series of eyes undergoing DMEK (Guerra et al. 2011a.

With modifications in insertion techniques that avoided the use of viscoelastics, the rebudding rate dropped to 15% (Feng et al. 2013b. The rate of primary graft failure after DMEK was 8–9% in early studies involving initial cases. Guerra et al. al., 2011a, b.

Future Prospects

Descemet's stripping endothelial keratoplasty under failed penetrating keratoplasty: visual rehabilitation, complications, and graft survival rate. A modified technique for the descemet membrane stripping automated endothelial keratoplasty to minimize endothelial cell loss. Descemet membrane endothelial keratoplasty: clinical results of single versus triple procedures (combined with cataract surgery).

Endothelial keratoplasty: fellow eyes comparison of automated Descemet stripping endothelial keratoplasty and Descemet membrane endothelial keratoplasty. Automated non-Descemet stripping endothelial keratoplasty for endothelial dysfunction secondary to argon laser iridotomy.

Introduction

Indications

Autoimmune disease (such as Stevens-Johnson syndrome (SJS) or ocular cicatricial pemphigoid (OCP)) was once considered a relative contraindication due to their propensity for corneal melting (Colby and Koo 2011. More recently, advances in postoperative management has expanded the field of keratoprosthesis surgery to include these complicated patient populations (Colby and Koo 2011; Sayegh et al. 2008. The procedure should be performed by a surgeon well experienced in penetrating keratoplasties, providing direct access to a eye bank, and a multidisciplinary ophthalmology team (glaucoma, retina and oculoplastic specialists) (Aldave et al.

Design

Surgical Procedure

The choice of the appropriate backing plate is largely determined by the size of the host trephination created. The selected back plate is then centered over the stem of the front plate and placed on top of the endothelial side of the donor cornea. Finally, the titanium locking ring is the last and most posterior component of the Boston type I keratoprosthesis.

The recipient trephination should be 0.25–0.5 mm smaller than the selected diameter of the donor corneal button size. If the patient is (or will be) aphakic at the time of transplantation, the axial length of the eye is needed to calculate the refractive power of the Boston type I keratoprosthesis.

Intraoperative Complications

Postoperative Management

At the end of the operation, a plano soft contact lens (Kontur Kontact Lens Co., Hercules, CA) with a diameter of 16 mm and a base curve of 9.8 mm is placed on the eye (Fig. 9.4). Patients should keep a Kontur soft contact lens. Always place the lens in the eye after the operation. The primary purpose of this contact lens is to prevent drying of the surface of the eye, which has led to dermatitis.

Other functions served by this contact lens include increased patient comfort, overall protection of the ocular surface, reduction of cosmetics and glare (colored contact lenses), and correction of any residual refractive error (Harissi-Dagher et al 2008. This contact lens should be replaced with a new contact lens every 3-4 months and the old lens should be cultured (Ament et al. 2009.

Visual Acuity Outcomes

Postoperative Complications

Future of Keratoprosthesis

Despite the initial costs of keratoprosthesis, surgery and hospitalization, as well as the costs of frequent future complications and additional procedures required, this treatment modality was considered a highly cost-effective option, resulting in a 20.3% improvement (Ament et al. 2010a. Other legitimate concerns regarding the use of keratoprostheses in non-industrialized countries include extreme weather, high likelihood of corneal infections, unfavorable geographic location leading to the impracticality of consistent postoperative monitoring, impure water supplies, and cultural barriers to care (Ament et al. 2010b. Research work with contact lenses, that secrete drugs may eventually help combat post-operative infections resulting from patient nonadherence to treatment regimens (Ciolino et al. 2009.

Long-term visual outcomes and complications with Boston type I keratoprosthesis at the University of California, Davis. Expanding use of Boston type I keratoprosthesis due to design advances and improved postoperative therapeutic strategies.

Introduction

Femtosecond Lasers in Ophthalmology

Laser-Assisted Keratoplasty and Post-keratoplasty

Management

The Femtosecond Laser- Enabled Keratoplasty (FLEK)
Patient Selection and Evaluation
Tissue Preparation and Surgical Procedure
Literature Review of Femtosecond

Femtosecond Laser-Enabled Lamellar Keratoplasty
Deep Anterior Lamellar Keratoplasty
Anterior Lamellar Keratoplasty
Endothelial Keratoplasty
Pediatric Keratoplasty
Post-keratoplasty Management

Femtosecond Incisions for Correction of Post-

In the case of Descemet's tear during dissection, conversion to a full-thickness graft can be performed while maintaining the benefits of the femtosecond laser incision (Price et al. First, keratoplasty using the femtosecond laser usually starts incision from deep to superfi). Standardized big-bubble technique in deep anterior lamellar keratoplasty assisted by the femtosecond laser.

Efficacy and safety of femtosecond laser-assisted corneal endothelial keratoplasty: a randomized multicenter clinical trial. Long-term outcomes of femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty.

Eye Banking: What the Eye Bank Can Do for You Now

Eye Bank for Sight Restoration (New York), Iowa Lions Eye Bank, Buffalo Eye Bank (New York), Eye Foundation of Delaware Valley (Pennsylvania, New Jersey and Delaware), Lions of District 22-C of Washington, DC, North Carolina Eye Bank, Hawaii Eye Bank, Southern Eye Bank (Louisiana), and Rochester Eye Bank (New York) were the founding members (Fanko-Gazzari 1991. Regardless of the etiology, an adverse event creates concern for the surgeon. In each of these situations, the eye bank can play a central role in assisting the surgeon.

The eye bank can help promote surgical skills, and some eye banks have facilities that can be used for practice, training and research. After the eye bank became aware of the situation, he offered to explore options to see if they could help.