Diagnostic Procedures

When the graft surface is smooth, the epithelium is intact, and the mires are regular, Goldmann applanation tonometry can be used to measure the IOP. Marked corneal astigmatism causes an elliptical fluorescein pattern. To obtain an accurate reading with the Goldmann applanation tonometer, the clinician should rotate the prism so that the red mark on the prism holder is set at the least curved meridian of the cornea (along the negative axis). Alternatively, 2 pressure readings, taken 90 degrees apart, can be averaged. The accuracy of applanation tonometry in general is reduced in certain situations, such as the presence of corneal edema, scars, or bloodstaining or any condition that thickens or alters the cornea. Corneal epithelial edema and stromal edema predispose to inaccurately low readings, and pressure measurements taken over a corneal scar will be falsely high. Thin corneas result in underestimation, and thick corneas result in overestimation.

A meta-analysis comparing the accuracy of various tonometers against the diagnostic standard Goldmann applanation concluded that noncontact tonometers and handheld applanation tonometers appeared to best correlate with Goldmann applanation measurements (66% and 59%, respectively). This is important to keep in mind since measurement of IOP with Goldmann applanation in the early postoperative period is not recommended because the corneal surface is irregular.^[33]

The pneumatic tonometer is a better choice for measurement of IOP in a patient with corneal surface irregularities. The pneumatic tonometer has a pressure-sensing device that consists of a gas-filled chamber covered by a Silastic diaphragm. The gas in the chamber escapes through an exhaust vent. As the diaphragm touches the cornea, the gas vent is reduced in size and the pressure in the chamber rises. Because this instrument applanates only a small area of the cornea, it has the advantage of measuring the IOP when corneal surface irregularities such as corneal scars or edema are present or when only a small portion of the cornea is visible (large tarsorrhaphy). In addition, in patients with neurotrophic corneas, this device can be used to measure the IOP with minimal disturbance of the epithelium.

In patients with complete tarsorrhaphy, an attempt must be made to measure the IOP by digital palpation. Measuring the IOP in the normal eye using one of the standard techniques (eg, Goldmann applanation tonometer) is helpful; then digital palpation can be performed on both eyes.

Optic disc imaging

Optic disc changes should be monitored in all patients with elevated IOP. Monitoring can be done either by serial disc photography (where possible) or by serial optic disc diagrams from the same observer. Visual fields may be difficult to perform in patients with corneal grafts, especially in the early postoperative period. In patients with reasonable vision, Humphrey visual field testing or Goldmann visual field testing should be performed.

Ultrasound biomicroscopy

Dada and colleagues^[25] also concluded that ultrasound biomicroscopy is a useful tool for anterior segment evaluation in patients with secondary angle closure caused by anterior synechiae formation and can be useful in determining sites for glaucoma filtering surgeries and drainage devices.

Histologic Findings

Chronic elevations of IOP potentially compromise graft endothelial function, leading to graft failure. Depending on its degree and duration, elevated IOP can result in significant endothelial cell loss. After an acute attack of angle-closure glaucoma, endothelial cell loss of 10 to 33% has been reported, and cell loss of 77% has been reported in eyes with acute angle-closure glaucoma lasting more than 12 days.^[34] Morphologic changes in the endothelial cells, such as vacuolization, loosening of cell junctions, blebbing, disruption of the plasma membrane, exkaryocytosis, and loss of whole cells, have been observed in experimentally induced acute glaucoma.^[35]

Treatment & Management

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Table 1. Physiologic Targets Affecting Aqueous Humor Production or Outflow and Disadvantages of the Various Glaucoma Medications in Patients with PKPG

Table 1. Physiologic Targets Affecting Aqueous Humor Production or Outflow and Disadvantages of the Various Glaucoma Medications in Patients with PKPG

Glaucoma medications	Physiologic targets	Potential problems in patients with PKPG
β-Blockers	Decrease aqueous humor production	Superficial punctate keratitis, corneal anesthesia, dry eyes, subconjunctival fibrosis
α2-Adrenergic agonists	Decrease aqueous humor production and increase aqueous outflow	Epithelial toxicity such as superficial punctate keratitis, dry eyes, and allergic reactions. Cystoid macular edema in aphakia and pseudophakia
Miotics	Increase aqueous humor outflow through contraction of ciliary muscle	Inflammation, graft rejection, retinal detachment, subconjunctival fibrosis
Topical carbonic anhydrase inhibitors	Decrease aqueous humor production	Permanent graft failure in eyes with borderline endothelial counts
Systemic carbonic anhydrase inhibitors	Decrease aqueous humor production	Paresthesias, tinnitus, nausea, fatigue, depression, anorexia, weight loss
Prostaglandin analogues	Increase aqueous humor outflow through the uveoscleral tract	Uveitis, cystoid macular edema in aphakia and pseudophakia, recurrent herpes simplex infection in patients with history of herpes
Rho kinase inhibitors	Increase aqueous humor drainage through trabecular meshwork	Epithelial keratopathy, reticular epithelial edema

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Author

Shibandri Das, MD Resident Physician, Department of Ophthalmology, Kresge Eye Institute, Wayne State University School of Medicine

Shibandri Das, MD is a member of the following medical societies: Association for Research in Vision and Ophthalmology, Association of Women Surgeons, Women in Ophthalmology, Inc

Disclosure: Nothing to disclose.

Coauthor(s)

Nariman Nassiri, MD, MPH Resident Physician, Department of Ophthalmology, Kresge Eye Institute, Wayne State University School of Medicine

Nariman Nassiri, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Association of Public Health Physicians, Association for Research in Vision and Ophthalmology, Institute for Health Metrics and Evaluation

Disclosure: Nothing to disclose.

Sabrina Dass MD Candidate, Wayne State University School of Medicine

Sabrina Dass is a member of the following medical societies: American Medical Association, American Medical Women's Association

Disclosure: Nothing to disclose.

Mark S Juzych, MD, MHSA Chair and Professor (Clinician-Educator), Department Ophthalmology, Wayne State University School of Medicine; Director, Kresge Eye Institute; Ophthalmology Service Chief, Karmanos Cancer Center

Mark S Juzych, MD, MHSA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Glaucoma Society, American Medical Association, American Society of Cataract and Refractive Surgery, Association for Hospital Medical Education, Association for Research in Vision and Ophthalmology, Association of University Professors of Ophthalmology, Michigan Society of Eye Physicians & Surgeons, Michigan State Medical Society, Phi Beta Kappa, Society of Heed Fellows, Ukrainian Medical Association of North America, Wayne County Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Louis E Probst, MD, MD Medical Director, TLC Laser Eye Centers

Louis E Probst, MD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Inci Irak Dersu, MD, MPH Associate Professor of Clinical Ophthalmology, State University of New York Downstate College of Medicine; Attending Physician, SUNY Downstate Medical Center, Kings County Hospital, and VA Harbor Health Care System

Inci Irak Dersu, MD, MPH is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Additional Contributors

Bradford Shingleton, MD Assistant Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary

Bradford Shingleton, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Ramesh S Ayyala, MD, FRCOphth, FRCS Chief, Section of Ophthalmology, Director of Glaucoma Services, Charity Hospital of New Orleans; Assistant Professor, Department of Ophthalmology, Tulane University School of Medicine

Ramesh S Ayyala, MD, FRCOphth, FRCS is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association

Disclosure: Nothing to disclose.

Edney de Resende Moura Filho, MD Chief of the Glaucoma Department, Pacini Hospital, Brazil

Edney de Resende Moura Filho, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Rajesh Shetty, MD Glaucoma and Cataract Surgeon, Florida Eye Specialists, Jacksonville, Florida

Rajesh Shetty, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Received honoraria from Alcon for speaking and teaching; Received honoraria from Zeiss for speaking and teaching; Received honoraria from Allergan for speaking and teaching.

Saiyid A Hasan, MD Assistant Professor of Ophthalmology, College of Medicine, Mayo Clinic; Senior Associate Consultant, Education Coordinator, Department of Ophthalmology, Mayo Clinic, Jacksonville

Saiyid A Hasan, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Kristin Schmid Biggerstaff, MD, MS Associate Professor, Department of Ophthalmology, Baylor College of Medicine; Glaucoma Staff Physician, Michael E DeBakey Veterans Affairs Medical Center

Kristin Schmid Biggerstaff, MD, MS is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Weijie Violet Lin Baylor College of Medicine

Disclosure: Nothing to disclose.