All About Your
Cornea: Corneal
& Refractive
Diseases &
Treatments
Jennifer Nottage, MD
www.SpringfieldClinic.com
Anatomy of the Eye
Anatomy of the Cornea
Epithelium
Bowman’s
Stroma
Descemet’s
Endothelium
Nearsighted Farsighted
Astigmatism
Types of Corneal Surgeries
• Refractive procedures:
– LASIK
– PRK
– RK
– Intacs
– Implantable CL
– Clear lens exchange
• M...
Refractive Procedures
Am I a candidate for
Refractive Surgery?
To be a candidate for Refractive
Surgery, you must:
• Be at least 18 years old. This age requirement is
necessary to ensur...
Refractive Surgery
• LASIK (laser in-situ keratomileusis)
• PRK (photorefractive keratectomy)
• RK (radial keratotomy)
• I...
RK
• Radial keratotomy
• Correct nearsightedness
• Procedure involves making radial incisions
in the cornea to alter the c...
LASIK
LASIK
• Used to correct nearsightedness, farsightedness,
and astigmatism.
• Reshaping the cornea using an excimer laser.
–...
LASIK
• Recovery:
– Fast with minimal discomfort
– Limited time off of work
• The vision usually stabilizes between 3-6 mo...
LASIK- Possible Side Effects
• Eye discomfort (mostly during the first 24 hours
following surgery)
• Dry eyes (during the ...
PRK
PRK
• Used to correct nearsightedness,
farsightedness, and astigmatism.
• Reshaping the cornea using an excimer
laser.
– T...
PRK
• Recovery
– 2-4 weeks for the cornea to heal
– Mild corneal haze
– Glare/halos
– The eye is not weakened because a fl...
Clear lens exchange
• Same procedure as cataract surgery but
the lens is not opaque
• Same risks of cataract surgery
• Los...
Implantable Contact Lens
• Also called Phakic IOL (intraocular lens)
• Two options in the US
– Visian ICL
• Placed behind ...
Intacs
• Intracorneal ring segments
• Plastic rings that are placed into
the cornea to reshape the
curvature of the cornea...
Options for refractive correction
• Correction for distance vision
• Correction for near vision
• Monovision
Medical Corneal
Procedures
Penetrating Keratoplasty
Penetrating Keratoplasty
• Full thickness corneal transplant
• Treatment for patients that have disease in
multiple or all...
Penetrating Keratoplasty
• Requires post-op steroid drops for life to
prevent graft rejection
• Postoperative astigmatism ...
Deep Anterior Lamellar
Keratoplasty
Deep Anterior Lamellar
Keratoplasty
• Abbreviated DALK
• Partial thickness corneal transplant of the
upper layers of the c...
DALK
• Because only the top part of the cornea is transplanted, the
risk of rejection is lower.
• Better structural integr...
Descemet’s Stripping Endothelial Keratoplasty
Descemet’s Stripping Endothelial Keratoplasty
• Abbreviated DSEK, DSAEK (automated)
• Partial thickness corneal transplant...
DSEK
• Required constant face up positioning for 2-3
days after surgery (except meals and
bathroom). The head up positioni...
DSEK
• Faster visual recovery than PK
• Less astigmatism (irregular shape of the cornea)
• Long term post-op steroid drops...
DSEK can be used if a patient has a
failed PK
• The new DSEK graft can be placed under
the old PK (full thickness graft).
...
Descemet’s Membrane Endothelial Keratoplasty
Descemet’s Membrane Endothelial Keratoplasty
• Abbreviated DMEK
• Partial thickness corneal transplant of the inner
layers...
Descemet’s Membrane Endothelial
Keratoplasty
• Limitations-
– Difficult to obtain the tissue
– Difficult to insert tissue ...
Boston Keratoprosthesis
(artificial cornea)
• Type 1 • Type 2
Boston Keratoprosthesis type 1
Boston Keratoprosthesis type 1
• Abbreviated- K- Pro, Boston K-Pro
• Artificial cornea made of plastic and titanium
• Requ...
Boston Keratoprosthesis type 1
• This surgery is reserved for patients with
extensive scarring or multiple failed grafts
w...
Questions?
More Resources
Find videos, handouts and more
resources at
www.SpringfieldClinic.com/DoctorIsIn
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All About Your Cornea: Corneal & Refractive Diseases & Treatments

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The cornea, the outer most layer of the eye, is crucial to the process of sight. But its position leaves it susceptible to a number of diseases and injuries, ranging from a mild case of pink eye to something more severe like Fuchs' dystrophy or keratitis. Luckily, modern innovations have led to many treatment options for patients with corneal or refractive conditions. Dr. Jennifer Nottage presents a wide array of options for corneal and refractive diseases—from LASIK to corneal transplants.

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  • astigmatism means blurring caused by an irregularly shaped cornea)
  • Photo taken from the FDA website/devices approved: http://www.google.com/imgres?imgurl=http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm080963.gif&imgrefurl=http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm080953.htm&usg=__qhAmnweRsHFXmJzK6bVqa1ejqrU=&h=200&w=255&sz=8&hl=en&start=1&sig2=v2nCVUZMozcoezsM_-3wkA&zoom=1&tbnid=FqxOELno1_o3rM:&tbnh=87&tbnw=111&ei=Y-bBUb2iNIbwyAHH8oHICg&prev=/search%3Fq%3Dintacs%26um%3D1%26sa%3DN%26hl%3Den%26gbv%3D2%26tbm%3Disch&um=1&itbs=1&sa=X&ved=0CCwQrQMwAA
  • (2 year rejection free survival rate- DMEK- 99.4%, DSEK- 95%, PK- 82%)
  • Photo taken from Massachusetts Eye and Ear Infirmary website. http://www.masseyeandear.org/for-professionals/physician-resources/keratoprosthesis/
  • All About Your Cornea: Corneal & Refractive Diseases & Treatments

    1. 1. All About Your Cornea: Corneal & Refractive Diseases & Treatments Jennifer Nottage, MD
    2. 2. www.SpringfieldClinic.com
    3. 3. Anatomy of the Eye
    4. 4. Anatomy of the Cornea Epithelium Bowman’s Stroma Descemet’s Endothelium
    5. 5. Nearsighted Farsighted
    6. 6. Astigmatism
    7. 7. Types of Corneal Surgeries • Refractive procedures: – LASIK – PRK – RK – Intacs – Implantable CL – Clear lens exchange • Medical procedures: – PK – DSEK – DALK – Keratoprosthesis
    8. 8. Refractive Procedures Am I a candidate for Refractive Surgery?
    9. 9. To be a candidate for Refractive Surgery, you must: • Be at least 18 years old. This age requirement is necessary to ensure the eyes have finished growing. • Have mild to moderate nearsightedness (myopia), farsightedness, or astigmatism. • Be free of eye disease including problems with the retina or scarring of the cornea. • Have the financial ability to pay for the cost of surgery since insurance may not cover the procedure. • Be aware of all the side effects, risks, benefits, and alternatives of the surgery.
    10. 10. Refractive Surgery • LASIK (laser in-situ keratomileusis) • PRK (photorefractive keratectomy) • RK (radial keratotomy) • Intacs • Clear lens exchange • Implantable contact lens
    11. 11. RK • Radial keratotomy • Correct nearsightedness • Procedure involves making radial incisions in the cornea to alter the curvature. • Outcomes are variable. • The procedure can weaken the structural integrity of the cornea. • Rarely preformed at this time.
    12. 12. LASIK
    13. 13. LASIK • Used to correct nearsightedness, farsightedness, and astigmatism. • Reshaping the cornea using an excimer laser. – A flap of tissue if formed using either a blade or a laser. – The laser is then preformed to remove tissue and the flap is repositioned. • Wavefront guided LASIK – Also called custom LASIK – Allows for the LASIK procedure to be tailored to each patient which can increase the quality of vision. • “All laser LASIK”
    14. 14. LASIK • Recovery: – Fast with minimal discomfort – Limited time off of work • The vision usually stabilizes between 3-6 months after LASIK surgery. • Post-operative care is usually limited to using eye drops for a few weeks after surgery. • The eye is not weakened because only one flap is cut into the cornea (compared to RK). • LASIK usually causes little or no scarring of the cornea. • LASIK can be repeated if needed to correct the vision further.
    15. 15. LASIK- Possible Side Effects • Eye discomfort (mostly during the first 24 hours following surgery) • Dry eyes (during the healing process) • Overcorrected or undercorrected vision • Blurry vision or vision loss • Irregular astigmatism, which can decrease the corrected vision • Corneal haze, glare, or sensitivity to light • Corneal scarring • Inflammation or infection • Inability to wear contact lenses in the future • Loss of the corneal flap, requiring a corneal graft
    16. 16. PRK
    17. 17. PRK • Used to correct nearsightedness, farsightedness, and astigmatism. • Reshaping the cornea using an excimer laser. – The epithelium (outer layer of the cornea) is removed. – The laser is then preformed to remove tissue – A contact lens is placed over the cornea – The epithelium will heal slowly
    18. 18. PRK • Recovery – 2-4 weeks for the cornea to heal – Mild corneal haze – Glare/halos – The eye is not weakened because a flap is not created in the cornea(compared to RK). • Side effects – Similar to LASIK
    19. 19. Clear lens exchange • Same procedure as cataract surgery but the lens is not opaque • Same risks of cataract surgery • Loss of accommodation – But may have a bifocal lens placed (ReSTOR, ReZoom) • No glare/halos
    20. 20. Implantable Contact Lens • Also called Phakic IOL (intraocular lens) • Two options in the US – Visian ICL • Placed behind the iris – Verisyse • Attaches to the iris • Can be used in cases when patients are not LASIK or PRK candidates, such as: – High amounts of nearsightedness or farsightedness – Thin cornea, corneal scarring • Reversible • Requires a laser procedure before surgery • May develop a cataract or elevated pressure in the eye
    21. 21. Intacs • Intracorneal ring segments • Plastic rings that are placed into the cornea to reshape the curvature of the cornea. • Only approved for patients with a low degree of nearsightedness and in patients with keratoconus. • Reversible • Side effects: cornea scarring, glare/halos, inflammation, infection
    22. 22. Options for refractive correction • Correction for distance vision • Correction for near vision • Monovision
    23. 23. Medical Corneal Procedures
    24. 24. Penetrating Keratoplasty
    25. 25. Penetrating Keratoplasty • Full thickness corneal transplant • Treatment for patients that have disease in multiple or all layers of the cornea • Sutures are needed to hold the graft in position
    26. 26. Penetrating Keratoplasty • Requires post-op steroid drops for life to prevent graft rejection • Postoperative astigmatism (irregular shape of the cornea) • Suture problems Pre op Post op
    27. 27. Deep Anterior Lamellar Keratoplasty
    28. 28. Deep Anterior Lamellar Keratoplasty • Abbreviated DALK • Partial thickness corneal transplant of the upper layers of the cornea (epithelium, bowman’s, and stroma) • This surgery is used for patients with keratoconus or a corneal scar • This surgery requires normal endothelium
    29. 29. DALK • Because only the top part of the cornea is transplanted, the risk of rejection is lower. • Better structural integrity • Risk of haze in between the graft and the host cornea • Similar suture issues/complications as with a full thickness corneal transplant. • Risk of intra-operative break of the remaining corneal tissue that would require a conversion to a full thickness corneal transplant. Pre op Post op
    30. 30. Descemet’s Stripping Endothelial Keratoplasty
    31. 31. Descemet’s Stripping Endothelial Keratoplasty • Abbreviated DSEK, DSAEK (automated) • Partial thickness corneal transplant of the inner layers of the cornea (descemet’s and endo). • This surgery is used for patients with Fuchs’ corneal dystrophy or Pseudophakic bullous keratopathy. • No sutures used on the graft • An air bubble is used to hold the tissue in place for the first few days. • Maintains the structural integrity of the eye.
    32. 32. DSEK • Required constant face up positioning for 2-3 days after surgery (except meals and bathroom). The head up positioning allows the bubble to hold the graft in position until the graft attaches. • Risk of graft dislocation, haze/scar formation between the graft and the host cornea.
    33. 33. DSEK • Faster visual recovery than PK • Less astigmatism (irregular shape of the cornea) • Long term post-op steroid drops are needed prevent rejection Pre op Post op
    34. 34. DSEK can be used if a patient has a failed PK • The new DSEK graft can be placed under the old PK (full thickness graft). – Offers a faster visual recovery – No sutures Pre-op Post-op
    35. 35. Descemet’s Membrane Endothelial Keratoplasty
    36. 36. Descemet’s Membrane Endothelial Keratoplasty • Abbreviated DMEK • Partial thickness corneal transplant of the inner layers of the cornea (descemet’s and endo, no stroma tissue) • This surgery is used for patients with Fuchs’ corneal dystrophy or Pseudophakic bullous keratopathy • No sutures used on the graft • An air bubble is used to hold the tissue in place for the first few days • Maintains the structural integrity of the eye.
    37. 37. Descemet’s Membrane Endothelial Keratoplasty • Limitations- – Difficult to obtain the tissue – Difficult to insert tissue because it is so thin • May decrease the number of endothelial cells – Higher rebubble rate • Potential Benefits- – Smaller incision – Better visual result – Less graft rejection
    38. 38. Boston Keratoprosthesis (artificial cornea) • Type 1 • Type 2
    39. 39. Boston Keratoprosthesis type 1
    40. 40. Boston Keratoprosthesis type 1 • Abbreviated- K- Pro, Boston K-Pro • Artificial cornea made of plastic and titanium • Requires sutures around the graft
    41. 41. Boston Keratoprosthesis type 1 • This surgery is reserved for patients with extensive scarring or multiple failed grafts with a potential to have good vision. • Because of the prosthesis, patients will need to wear a contact lens and use drops to prevent an infection.
    42. 42. Questions?
    43. 43. More Resources Find videos, handouts and more resources at www.SpringfieldClinic.com/DoctorIsIn

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