Pterygiumectomy
I.
Definition of pterygium
A wing-like progressive growth of fibrovascular tissue involving the
interpalpebral epibulbar conjunctiva and cornea
II.
Indications
A.
B.
C.
D.
E.
III.
Loss of clarity within visual axis
Increasing corneal astigmatism
Chronic irritation and inflammation
Cosmesis
Motility restriction
Surgical approaches
A.
B.
C.
D.
E.
Bare scleral excision / avulsion
Conjunctival flap
Conjunctival autograft
Peripheral lamellar keratoplasty
Adjunctive therapy
1. Chemotherapy
2. Radiation therapy
IV.
V.
Normal postoperative follow-up
A.
1 day, 1 week, 3 weeks, 5 weeks, 3 months
B.
Patch 1st night
C.
D.
Vicoden ES 1 tablet q 4 hrs prn for pain
TobraDex 1 drop qid x 1 week
E.
Then Pred Forte 1 drop qid with taper until quiet
F.
G.
Artificial tears 1 drop qid x 1 month and regularly thereafter
UV protection
Complications
A.
Recurrence (bare sclera 40%, autograft <10%)
B.
C.
D.
E.
F.
G.
Subepithelial scarring
Scleral melt – mitomycin C
Muscle insertion damage
Graft inversion
Dellen
Steroid complication
Penetrating Keratoplasty
I.
Indications
A.
B.
C.
D.
II.
Visual
Structural
Therapeutic
Cosmetic
PKP surgical techniques
A.
B.
Anesthesia
Corneal trephine
1. 7.5mm diameter button removed
2. 8.0mm diameter donor
C.
Suturing
1.
2.
3.
4.
D.
Single running suture – adjustable
Interrupted sutures – if corneal scarring secondary to inflammation
Double running
Running and interrupted combination
Advantages of suture adjustment
1. More rapid visual rehabilitation
2. Decreased early postoperative astigmatism
3. Increased regular corneal topography
4. Better visual acuity in early postoperative period
III.
Postoperative evaluation
A.
Ideal one day post-op
Epithelium intact, clear graft, sutures intact, negative Seidel, formed
anterior chamber, normal IOP
B.
Medications
1. Pred Forte 1 drop q2 hrs - qid
2. Ocuflox 1 drop qid
3. Celluvisc 1 drop qid (and qhs)
4. Artificial tears prn
C.
Follow-up intervals (variable)
1 day, 3 days, 1 week, 3 weeks, 5 weeks, 2 months, 3 months,
6 months
D.
Complications
1. Graft rejection – early, late
2. Endophthalmitis
3. Glaucoma
4. Wound leak
5. Delayed reepithelialization
LASIK
I.
Immediate preoperative patient preparation
A.
B.
C.
D.
E.
II.
III.
Immediate preoperative surgical considerations
A.
B.
C.
Primary vs. enhancement
Socket configurations – deep set/shallow set
Corneal curvature
D.
Treatment zone based on pupil size, Rx, and pachymetry
Operative procedure
A.
B.
C.
D.
E.
F.
G.
H.
IV.
VI.
Patient positioning
Topical anesthesia
Suction ring
Microkeratome
Pre-ablation flap management
Fixation and monitoring
Ablation
Post-ablation flap management
Intraoperative challenges
A.
B.
C.
D.
E.
V.
Optometric preoperative evaluation and documentation review
Corneal topography, pachymetry, scotopic pupil size, excimer Rx and refractive
target
Informed consent
Sedation
Laser data entry
Stall
Suction loss
Rolled epithelium
Thin/incomplete cap
Free cap
Immediate postoperative evaluation and considerations
A.
Slit lamp evaluation
B.
Flap repositioning indications
C.
Postoperative patient instructions
Postoperative challenges
A.
B.
C.
Epithelial defects
Cap striae
Epithelial ingrowth
D.
E.
Cap interfaces infiltrate – diffuse lamellar keratitis (DLK)
Dry eye