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• • • • •
• • • • • • • – – –
• – – – – – –
•
• – –
• – –
Ret
inal
Pla
ques
• S
ever
al d
iffer
ent t
ypes
of p
laqu
es c
an
ofte
n be
vis
ualiz
ed in
the
retin
al
vasc
ulat
ure
• P
t is
typi
cally
eld
erly,
has
HTN
, CA
D,
hype
rcho
lest
erol
emia
/hyp
erlip
idem
ia, a
nd/
or a
ther
oscl
erot
ic d
isea
se
• O
ften
tota
lly a
sym
ptom
atic
and
foun
d on
ro
utin
e ex
am
• • • • • • •
• • •
– – »
–
• •
• •
• •
• •
Ret
inal
Pla
ques
• M
ay p
rese
nt w
ith a
mar
osis
fuga
x,
trans
ient
epi
sode
s of
mon
ocul
ar b
lindn
ess
• R
arel
y, m
ay re
port
trans
ient
isch
emic
at
tack
(TIA
) , w
hich
is a
bove
with
he
mip
ares
is, p
aras
thes
ia o
r aph
asia
• Th
ree
diffe
rent
type
s of
pla
ques
, but
all
shar
e st
rong
ass
ocia
tion
to s
igni
fican
t ca
rdio
vasc
ular
dis
ease
–
HH
80%
> fi
brin
o-pl
atel
et 1
4% >
cal
cific
6%
Ret
inal
Pla
ques
• C
hole
ster
ol (H
olle
nhor
st) p
laqu
e –
Mos
t com
mon
–
shin
y ye
llow
-ora
nge
in a
ppea
ranc
e –
from
pla
que
in th
e ip
sila
tera
l car
otid
arte
ry
– R
arel
y ca
uses
occ
lusi
on, u
nles
s m
ultip
le
– Ty
pica
lly o
ccur
s at
bifu
rcat
ions
–
Mob
ile in
nat
ure
Cho
lest
erol
Pla
ques
Ret
inal
Pla
ques
• Fi
brin
o-pl
atel
et
– A
ppea
r as
dull
whi
te to
gra
y, lo
ng p
lugs
–
Typi
cally
with
in a
rterio
les,
not
at b
ifurc
atio
ns
– M
ay b
reak
-up
and
diss
olve
with
tim
e –
May
lead
to B
RA
O o
r CR
AO
–
Ofte
n as
soci
ated
with
car
otid
dis
ease
or m
itral
va
lve
insu
ffici
ency
Fibr
ino-
plat
elet
Pla
ques
R
etin
al P
laqu
es
• C
alci
fic
– A
ppea
rs m
ore
whi
tish
than
HH
–
Dul
l, no
n-re
flect
ive,
whi
te
– C
lass
ical
ly w
ithin
arte
riole
, not
at b
ifurc
atio
n –
Typi
cally
imm
obile
–
Mos
t dan
gero
us, a
s of
ten
caus
e B
RA
O
– O
ften
from
car
diac
are
thro
mas
of h
eart
valv
es
Cal
cific
Pla
ques
R
etin
al p
laqu
es
• Ta
lc re
tinop
athy
–
Rep
rese
nts
an e
xoge
nous
pla
ques
as
oppo
sed
to o
ther
s –
App
ears
typi
cally
as
mul
tiple
shi
ny y
ello
w
plaq
ues
with
in c
apill
arie
s in
pos
terio
r pol
e –
Typi
cally
sm
alle
r tha
n ot
her p
laqu
es
– Ty
pica
lly s
een
in IV
dru
g us
ers
– R
arel
y ca
use
com
plic
atio
ns, b
ut re
porte
d ca
ses
of a
ssoc
iate
d N
V a
nd o
cclu
sion
s
Talc
Ret
inop
athy
O
ther
s
• Ta
mox
ifen
Mac
ulop
athy
(Nol
vade
x)
Can
than
xine
Mac
ulop
athy
R
etin
al p
laqu
es
• N
o di
rect
man
agem
ent o
f pla
ques
is
need
ed
• M
anag
emen
t is
aim
ed a
t dis
cove
ring
sour
ce o
f em
bolu
s to
dec
reas
e ris
k of
ot
her e
mbo
li, o
cclu
sion
, or s
troke
•
Pts
nee
d re
ferr
al to
inte
rnis
t for
com
plet
e ph
ysic
al
• A
sses
s ris
k fa
ctor
s w
ith P
CP
– D
N, H
TN, l
ipid
pan
els
• C
arot
id u
ltras
ound
•
MR
A: n
on-in
vasi
ve im
age
with
2D
/3D
•
TEE
: inv
asiv
e, p
robe
into
eso
phag
us to
im
age
heat
val
ves
–
Hel
pful
with
cal
cific
•
CTA
: CT
scan
of a
rterie
s co
nstru
ct 3
D
imag
es
• • • • •
• O
RA
L TR
EAT
ME
NT
– A
nti-P
late
let
• A
SA
– A
nti-c
oagu
latio
n •
Com
adin
, pla
tele
t
– C
hole
ster
ol m
eds
• S
UR
GIC
AL
TRE
ATM
NE
T –
Car
otid
ed
arte
rect
omy
– A
ngio
plas
ty
– R
educ
es ri
sk o
f fu
ture
stro
ke!
• A
sses
s ris
k fa
ctor
s w
ith P
CP
– D
N, H
TN, l
ipid
pan
els
• C
arot
id u
ltras
ound
•
MR
A: n
on-in
vasi
ve im
age
with
2D
/3D
•
TEE
: inv
asiv
e, p
robe
into
es
opha
gus
to im
age
heat
va
lves
–
Hel
pful
with
cal
cific
•
CTA
: CT
scan
of a
rterie
s co
nstru
ct 3
D im
ages
• • • • •
Ret
inal
Pla
ques
• A
fter r
ulin
g ou
t und
erly
ing
etio
logy
, see
pa
tient
regu
larly
, q 6
-12
mos
, to
eval
uate
fo
r add
ition
al p
laqu
es o
r oth
er d
isea
se
asso
ciat
ed w
ith v
ascu
lar d
isea
se
– B
RV
O/C
RV
O
– B
RA
O/C
RA
O
– N
TG
Is it
wor
th w
orki
ng u
p th
ese
patie
nts?
• 18
% o
f pts
with
retin
al e
mbo
li ha
d in
tern
al
or c
omm
on c
arot
id s
teno
sis>
75%
•
Hig
her i
ncid
ence
of s
troke
–
8.5%
with
em
boli
vs 0
.8%
w/o
per
yea
r •
Pts
with
cho
lest
erol
HH
em
boli
have
15%
m
orta
lity
at 1
yr,
29%
by
year
3, a
nd 5
4% b
y 7
year
s
PC
E
– –
• •
VA
: 2
0/1
00
PH
20
/30
S
LIT-
LAM
P:
SU
PE
RF
ICIA
L S
UP
ER
IOR
A
BR
AS
ION
+
STA
ININ
G
DX
: C
OR
NE
AL
ER
OS
ION
Epith
elia
l Bas
emen
t M
embr
ane
Dys
trop
hy:
Map
Dot
Fin
gerp
rint
87%
of a
ll R
CE o
ccur
s in
wha
t par
t of t
he c
orne
a?
Infe
rior
Cor
nea
Rei
dy J
J, P
auli
MP
et a
l. C
orne
a 20
00
Nov
.
46%
of a
ll pa
tient
s in
this
stud
y ha
d EB
MD
• Ja
mes
Rei
dy e
t al.
Rec
urre
nt e
rosi
ons
of th
e co
rnea
: epi
dem
iolo
gy a
nd
trea
tmen
t. C
orne
a 2
000
Nov
; 19(
6):
767-
71
• Th
e re
mai
nder
had
trau
ma
indu
ced
caus
es
– Fi
nger
nail
– Pa
per
cut,
etc.
Non
-Tre
atm
ent:
• W
hat m
edic
atio
ns s
houl
d be
avo
ided
? •
Bla
nd A
rtif
icia
l Tea
r O
intm
ents
Eke
T, e
t al.
Rec
urre
nt sy
mpt
oms
follo
win
g tr
aum
atic
cor
neal
abr
asio
n.
Eye
1999
Jun
e.
• – –
• •
NO
N-H
EA
LIN
G A
BR
ASI
ON
A
cti
ve
Tre
atm
en
t….D
ry o
r W
et?
?
TRE
ATM
EN
T
ST
AN
DA
RD
PR
OT
OC
OL
:
• B
CL
• A
NT
I-B
IOT
IC
• A
NT
I-IN
FL
AM
MA
TO
RY
• R
TC
• N
EW
RE
GIM
EN
T
• A
MN
IOT
IC M
EM
BR
AN
E
• L
AT
ER
AL
TA
PE
T
AR
SO
RA
PH
Y
• P
AT
IEN
T E
DU
CA
TIO
N
• R
TC
5 D
AY
S
A
mni
otic
mem
bran
e is
the
inne
r mos
t lin
ing
of th
e pl
acen
ta (a
mni
on) a
nd s
hare
s th
e sa
me
cell
orig
in a
s th
e fe
tus
C
onta
ins
cyto
kine
s an
d gr
owth
fact
ors
Ant
i-Inf
lam
mat
ory
(pro
teas
e in
hibi
tors
) A
nti-A
ngio
geni
c A
ids
in ra
pid
wou
nd h
ealin
g an
d re
-epi
thel
ializ
atio
n A
nti-S
carr
ing
Cry
opre
serv
ed a
mni
otic
mem
bran
e is
a
biol
ogic
ther
apy
that
can
: P
rom
ote
rege
nera
tive
heal
ing
Red
uce
infla
mm
atio
n M
inim
ize
scar
form
atio
n In
hibi
t ang
ioge
nesi
s M
inim
ize
pain
Long
Ter
m T
X R
egim
en R
ecal
citr
ant R
CE
• Fr
eshK
ote
TID
x 2
mon
ths
• Lo
tem
ax G
el Q
ID x
2 w
eeks
then
BID
x
6 w
eeks
• D
oxy
(20
or 5
0mg)
BID
x 2
mon
ths
• R
esta
sis B
id!
“T
HE
PA
IN I
S G
ON
E”
•
RE
MO
VE
DP
RO
KE
RA
•
VA
SC
: 2
0/1
5
SLI
T-LA
MP
: C
OR
NE
AL
CLE
AR
T
X:
RE
ST
AS
IS B
ID
RT
C 4
-6 W
EE
KS
• “
MY
EY
E F
EE
LS
GR
EA
T”
•
VA
SC
: 2
0/1
5
• S
LIT
-LA
MP
: C
LE
AR
CO
RN
EA
•
DX
:
PC
E (
PR
EV
EN
TE
D C
OR
NE
AL
ER
OS
ION
) T
X:
CP
M(R
ES
TA
SIS
) • •
– – • • •
• • • • • –
• –
•
–
• • – –
• • – –
• – – –
• –
…
The
Vitre
ous
Hum
or
• –
• – –
• –
•
Phy
siol
ogic
Cha
nges
• W
ith a
ge, l
iqui
fact
ion
due
to re
duct
ion
in
hyal
uron
ic a
cid
caus
es lo
ss o
f su
ppor
t. •
This
pro
cess
is
refe
rred
to a
s sy
nche
sis.
Phy
siol
ogic
Cha
nges
• Vi
treou
s sh
rinka
ge,
cont
ract
ion
and
colla
pse
can
caus
e tra
ctio
n.
• Th
is p
roce
ss is
re
ferr
ed to
as
syne
resi
s.
•
• – – – – –
• •
• –
•
–
• – –
Ris
k Fa
ctor
s
• –
•
• –
•
• • • • •
– – –
…C
ase
• • • • – –
• – –
• –
• – –
• • • • • – –
MO
RE
TE
STIN
G I
S N
EE
DE
D
OR
A R
eic
he
rt
• • •
•
•
•
• •
B
ioen
gine
erin
g of
the
Eye
• •
–
•
–
1.
Gla
ss D
H e
t al.
Inve
st O
phth
alm
ol V
is S
ci. 2
008;
49:3
919-
3926
. 2.
Tayl
or D
A e
t al.
Cor
neal
Bio
mec
hani
cs. I
n: C
opel
and
RA
Jr.,
Afs
hari
NA
, eds
.: C
opel
and
and
Afsh
ari’s
Pri
ncip
les
and
Prac
tice
of C
orne
a. T
wo
Volu
me
Cor
nea
Text
book
. Jay
pee
Bro
ther
s. 20
12:1
48-1
57.
Hys
tere
sis:
Not
a N
ew C
once
pt
•
–
•
– –
1.
Vin
cent
J. B
asic
ela
stic
ity a
nd v
isco
elas
ticity
. In:
Vin
cent
J, e
d. S
truc
tura
l Bio
mat
eria
ls. 3
rd e
d. P
rince
ton,
NJ:
Prin
ceto
n U
nive
rsity
Pre
ss; 2
012:
1-28
. 2.
PubM
ed S
earc
h fo
r “hy
ster
esis
” on
Oct
ober
3, 2
014
retu
rned
769
6 re
sults
. 3.
Hjo
rtdal
JO1.
On
the
biom
echa
nica
l pro
perti
es o
f the
cor
nea
with
par
ticul
ar re
fere
nce
to re
frac
tive
surg
ery.
Act
a O
phth
alm
ol S
cand
Sup
pl. 1
998;
(225
):1-2
3.
Bas
ic P
aram
eter
s
Cor
neal
Hys
tere
sis:
A
New
Ocu
lar P
aram
eter
R2 =
0.6
625
0.00
2.00
4.00
6.00
8.00
10.0
0
12.0
0
14.0
0
16.0
0
18.0
0 0.00
5.00
10.0
015
.00
20.0
0
Thin
Cor
nea
with
Ker
atoc
onus
Thin
Cor
nea
with
no
ecta
sia
CC
T 45
5 C
H
11.2
C
RF
10.8
CC
T 50
0 C
H
8.1
CR
F 7.
9
CC
T 60
5 C
H
11.3
C
RF
10.7
CC
T 59
7 C
H
8.4
CR
F 7.
2
The
Cor
nea,
IOP,
and
Gla
ucom
a
But
SC
ATT
ER
in th
e da
ta m
akes
acc
urat
e m
athe
mat
ical
ad
just
men
t o
f IO
P im
poss
ible
for
indi
vidu
als!
Thi
ck a
nd th
in is
WR
ON
G. T
hink
wea
k an
d st
rong
The
Cor
nea
and
Gla
ucom
a
Gla
ucom
a su
bjec
ts h
ave
low
er C
H th
an n
orm
als,
espe
cial
ly th
ose
who
are
st
ill p
rogr
essi
ng in
the
dise
ase.
Def
ine
& D
escr
ibe
IOPc
c C
orne
al-C
ompe
nsat
ed In
traoc
ular
Pre
ssur
e
Bac
kgro
und
• IOPC
C v
s CC
T 18
4 N
orm
als
28 e
yes P
re/P
ost L
ASI
K IO
Pcc
26%
IOP
drop
3%
IOP
drop
Th
e ac
cura
cy o
f cur
rent
tono
met
ers i
s affe
cted
by
refr
activ
e su
rger
y pr
oced
ures
, su
ch a
s LA
SIK
. IO
Pcc
is m
ore
accu
rate
in th
ese
corn
eas.
IOPc
c in
Nor
mal
Ten
sion
Gla
ucom
a
IOPc
c m
easu
res h
ighe
r tha
n cu
rren
t ton
omet
ers i
n N
TG e
yes.
Thi
s ena
bles
ph
ysic
ians
to id
entif
y at
-ris
k pa
tient
s ear
lier w
ith O
RA
.
Dat
a C
ourte
sy o
f Will
iam
Wile
y, M
D
Cle
vela
nd C
linic
57 y
o po
st L
AS
IK fe
mal
e •
Com
plai
ning
of b
lurr
y vi
sion
and
pai
n in
righ
t eye
•
GAT
: 15
mm
Hg
• IO
Pcc
: 46
mm
Hg!
! •
OC
T im
age
show
ed fl
uid
unde
r the
flap
Low
er C
orne
al H
yste
resi
s is A
ssoc
iate
d W
ith M
ore
Rap
id G
lauc
omat
ous V
isua
l Fie
ld P
rogr
essi
on
J Gla
ucom
a 20
12;2
1:20
9–21
3 C
arlo
s Gus
tavo
De
Mor
aes,
MD
, Cel
so T
ello
, MD
, Vic
toria
Hill
, BS,
Jeffr
ey M
Lie
bman
n, M
D R
ober
t Ritc
h, M
D
• – –
• • – –
• – –
• • • ……
• • • • •
• – –
• – – – –
• – – – – – –
•
• • • • –
• –
• •
• –
• •
– • • • •
• • – –
• •
• – –
• –
• • • • –
• • •
• – – –
•
– – –
• –
• • – – –
• –
• – – – – –
• – –
•
• • • • • •
• • • • • •
• • –
• – – – – – –
•
ALL
YO
U S
EE
IS T
HE
TIP
OF
THE
ICE
BE
RG
Obs
truct
ed T
ear
Men
iscu
s
Obl
itera
ted
Tear
R
eser
voir
An
ato
mic
al T
ear
Res
ervo
ir
A D
RY R
ESER
VO
IR T
RA
NSL
ATE
S TO
A D
RY O
CU
LAR
SU
RFA
CE
1
2
3
OC
ULA
R
SUR
FAC
E
MEN
ISC
US
FOR
NIX
1 2 3
• – – – – – –
How
Is T
ear F
low
Inte
rfer
ed b
y C
Ch?
•
• •
• – – – –
• • • • •
• • • •
Key
Cha
ract
eris
tic o
f CC
h:
• O
blite
rate
d te
ar re
serv
oir
and
obst
ruct
ed te
ar
men
iscu
s
Key
Cha
ract
eris
tic o
f CC
h:
• D
isso
lved
and
de
gene
rate
d Te
non’
s
Key
Cha
ract
eris
tic o
f CC
h:
• E
xces
s, lo
ose
conj
unct
iva
in th
e lo
wer
fo
rnix
and
fat p
rola
pse
Key
Sur
gica
l Ste
ps
C
Con
junc
tivoc
hala
sis
is a
dis
ease
of
the
Teno
n’s.
Trea
tmen
t Str
ateg
y:
• R
emov
al o
f all
unhe
alth
y Te
non’
s an
d re
plac
emen
t w
ith o
ne la
yer o
f A
mni
oGra
ft®
y:Tr
eatm
ent S
trat
egy:
•
Forn
ix re
cons
truct
ion
to d
eepe
n th
e te
ar
rese
rvoi
r and
rein
forc
e th
e or
bita
l sep
tum
Trea
tmen
t Str
ateg
y:
• R
earr
ange
men
t of
conj
unct
iva
and
repl
acem
ent o
f the
se
cond
laye
r of
Am
nioG
raft®
with
an
chor
ing
sutu
res
in th
e fo
rnix
y: