FIGURE 10-1. (continued) C. This posterior chamber IOLs has subluxed inferiorly. An oblique rent in the posterior capsule can be seen, compromising capsular support. An inferior subluxation is often termed a “sunset syndrome.” Pupillary capture. D. This posterior chamber IOL is partially captured by the iris in this eye 2 weeks after cataract surgery. It was repositioned into the posterior chamber in the operating room.

FIGURE 10-1. (continued) Posterior capsular opacity (PCO). E. A moderate PCO is evident in this eye several years after cataract surgery. Fibrosis of the initially clear posterior capsule often occurs after cataract surgery and can affect visual clarity. Note the arc of opacified anterior capsular rim inferiorly and the fibrotic posterior capsule centrally. When this affects visual function, treatment is with a laser capsulotomy. F. Using retroillumination of the retina, significant posterior capsule opacity is readily appreciated in this eye after combined penetrating keratoplasty and cataract surgery.

FIGURE 10-2. Corneal transplant. A. A clear corneal transplant is seen 6 weeks after surgery for herpes simplex scarring. Sixteen interrupted 10-0 nylon sutures are in place. B. A clear corneal transplant is seen 4 months after a corneal transplant for worsening Fuchs dystrophy with scarring after cataract surgery. Also, 12 interrupted and 12 bite running 10-0 nylon sutures are present. C. An old square corneal transplant performed by Dr. Castroviejo in New York City about 40 years earlier. The graft remains remarkably clear, although a cataract is developing.

FIGURE 10-2. (continued) Corneal transplant complication—early endophthalmitis. D. Ten days after a corneal transplant, severe intraocular inflammation with fibrin in the anterior chamber and a small hypopyon at the graft-host margin inferiorly can be seen. Endophthalmitis was suspected, and a vitreous tap revealed Staphylococcus epidermidis, which responded well to antibiotic treatment. Corneal transplant complication—primary graft failure. E. Diffuse severe corneal edema with whitening of the corneal stroma is present 1 day after a corneal transplant in an eye with primary graft failure. Primary graft failure generally occurs as a result of poor-quality tissue or damage to the corneal endothelium during surgery. Corneal transplant complication—wound leak. F. A wound leak is seen 3 days after a corneal transplant. Dark, concentrated fluorescein dye was placed at the graft-host margin at the 9 o’clock position. Aqueous fluid leaking through the graft-host wound can be seen to dilute the dye and turn it bright yellow-green. If the leak is minimal and the anterior chamber is formed, it can be treated medically and followed closely. If the leak is significant or the chamber is flat, the leak should be repaired surgically.

FIGURE 10-2. (continued) Corneal transplant complication—wound melt. G. A severe corneal wound melt is present in the inferior half of this cornea 5 months after a corneal transplant. Multiple loose sutures can be seen. A small, permanent lateral tarsorrhaphy had already been performed. Corneal transplant complication—suture abscess. H. A broken corneal transplant suture and underlying abscess are present at the 10 o’clock position. A large hypopyon with a second small hypopyon at the graft-host junction can be seen inferiorly. Corneal transplant complication—epithelial downgrowth. I. A curvilinear retrocorneal membrane can be seen from 9 o’clock toward 12 o’clock and back down toward 3 o’clock. It is again visible around 5 o’clock. It advanced centrally over several weeks. It was diagnosed as epithelial downgrowth.

FIGURE 10-2. (continued) Corneal transplant complication—broken interrupted suture. J. A broken corneal transplant suture is present at the 2 o’clock position. Fluorescein dye and cobalt blue light demonstrate the “windshield wiper” effect of the broken suture. Corneal transplant complication—loose, exposed running suture. K. An extremely loose and exposed running suture can be seen a year after corneal transplant. There is mucus adherent to the suture and secondary peripheral corneal neovascularization superiorly and corneal edema centrally. Expulsive hemorrhage after a corneal transplant wound dehiscence. L. Several years after a penetrating keratoplasty, blunt trauma caused the wound to dehisce that resulted in an expulsive hemorrhage. Note the large clot of blood exiting the wound. Iris pigment and vitreous jelly can be seen on the inferior cornea.

FIGURE 10-3. (continued) C. Five weeks after DSEK surgery, the graft is perfectly centered and clearing nicely. D. Slit-beam view 5 weeks after surgery showing that the DSEK graft has minimal edema. The slit beam highlights the interface between the host anterior cornea and the thin posterior donor DSEK graft.

FIGURE 10-3. (continued) E. Dual Scheimpflug photography using the Galilei system showing the DSEK graft to be attached to the recipient cornea on postoperative day 1. There is mild DSEK edema centrally, but moderate edema at the edge of the graft. This peripheral graft edema typically resolves over several months. F. Moderate folds in this DSEK are seen a few days after surgery. Note the small air bubble still present superiorly. While the folds improved somewhat with time, vision did not improve significantly until the DSEK was repeated.

FIGURE 10-3. (continued) G. On postoperative day 1, the host cornea and DSEK button are severely edematous because of a large fluid cleft in the interface. The edema did not resolve over the next 2 weeks. The DSEK graft was rebubbled in the office 2 weeks postoperatively and was 100% attached and essentially clear the following day! H. One day after surgery, this DSEK graft is detached and inferiorly displaced. There is also a large inferior epithelial defect. It was thought that the eye’s low pressure from previous glaucoma surgery predisposed it to poor graft adherence.

FIGURE 10-3. (continued) I. A fairly prominent reticular interface haze is seen in this eye 1 week after DSEK. It resolved slowly over many months.