Corneal Path

Lecture 08/25/08: Corneal Dystrophies

Arcus Senilis Elevated Cholesterol See PCP for blood work-up

Arcus Senilis

Hudson Stahli Line A brown, horizontal line across the lower third of the cornea, occasionally seen in the aged. No Tx

Hudson Stahli Line

Band Keratopathy Precipitation of calcium salts on the corneal surface (directly under the epithelium) Patients with band keratopathy complain of the following: –Decreased vision –Foreign body sensation –Ocular irritation –Redness (occasionally) Tx: Debridement

Band Keratopathy

Limbal Girdle of Vogt Very common, bilateral, age-related condition. Corneal degeneration. Clinical features: Symptoms: asymptomatic and requires no therapy. Signs: Crescenteric, white opacities of the peripheral cornea in the interpalpebral zone along the nasal and temporal limbus May be separated from the limbus by a clear zone or without a clear zone in between

Limbal Girdle of Vogt

Salzmann’s Nodular Degeneration Usually following trachoma or phlyctenular keratitis Characterized by multiple superficial blue white nodules in the midperiphery of the cornea Medical therapy consists of lubrication, warm compresses, lid hygiene, topical steroids, and/or oral doxycycline

Salzmann’s Nodular Degeneration

Climatic Droplet Keratopathy Degenerative condition characterized by the accumulation of translucent material in the superficial corneal stroma Sector iridectomy, corneal epithelial debridement, lamellar keratoplasty, and penetrating keratoplasty have all been employed in the treatment of visually incapacitating CDK.

Climatic Droplet Keratopathy

Corneal Farinata Bilateral speckling of the posterior part of the corneal stromaBilateralposterior partcornealstroma VA unaffected

Corneal Farinata

Pellucid Marginal Degeneration / Keratoglobus Bilateral, noninflammatory, peripheral corneal thinning disorder characterized by a peripheral band of thinning of the inferior cornea Tx: RGPs / Keratoplasty Surgery needed for Keratoglobus

Pellucid Marginal Degeneration

Keratoglobus

Lecture 09/08/08 EBMD (Bergmanson) Keratoconus (continued) –Making the Dx

Voght Striae

Fleisher’s Ring Cause: Thickened tear film where lids meet

Hydrops Rupture in Descemet’s membrane

EBMD Epithelial Basement Membrane Dystrophy

Meesmann’s Dystrophy Intraepithelial cysts with amorphous material/cellular debris Tx: usually not needed

Map/ Dot/ Fingerprint Dystrophy aka “Anterior Membrane Dystrophy” BM is laid down abnormally by epithelial cells  build up of material Pts > 60 Negative staining

Recurrent Corneal Erosion Syndrome

Tx: for EBMD –Lubricant/gtts; ung –Bandage CL –Stromal puncture –Epithelial scraping –PTK

Surgical Tx PKP (Penetrating) vs. LKP (Lamellar) –Most surgeons tx w/ PKP –Adv of LKP Not intraocular Fewer complications Preserved endothelium Low risk of rejection Preserves global strength

Dystrophies of Bowman’s Layer

Reis-Buckler’s Dystrophy Autosomal dominant dystrophy Characterized by small discrete opacities centrally just under the epithelium which may have a honeycomb pattern ALL is being replaced by reticular material (scar-like tissue)

Honeycomb dystrophy of Thiel and Behnke

Inherited Band Keratopathy Tx: Chelating agent EDTA

Stromal Dystrophy Granular Dystrophy Lattice Dystrophy Gelatinous drop-like dystrophy

Granular Dystrophy

Corneal Trauma Management

Bacterial Keratitis -WBCs only found in infectious keratitis. -Acute (24-48 hrs), rapidly progressive corneal destructive process or a chronic process. -Caused by corneal epithelial disruption caused by trauma, contact lens wear, contaminated ocular medications and impaired immune defense mechanisms. -Tx. With Polytrim, Vigamox, and broad spectrum antibiotics

Radial Keratotomy Problems *Refractive surgery procedure to correct mild to moderate degrees of myopia (2 to 5 D). *Incisions can split open making them vulnerable to corneal infections (fungal/bacterial) -If infection happens w/i hrs, bacterial and not fungal. -Tx aggressively with Polytrim, Vigamox, or broad spectrum antibiotics. -F/U in 1 day.

Fungal Keratitis Feathery Borders, w/ hx of plant/vegetable matter trauma. Tx w/ prolonged course of systemic and topical anti-fungal (Natamycin), and frequent scrapings or localized debridement to remove necrotized epithelial tissue.

Lecture 09/22/08: Corneal Trauma Mgmt

Pseudomonas Keratitis *Pseudomonas can progress fast! Within 24 hours -hypopyon, infiltrates in cornea, KPs, plasmoid aqueous (AC is jello) -pain, decreased VAs, redness

Corneal FB *May develop corneal ulcer. *r/o intraocular FB. *Remove FB, unless removal will cause more damage than leaving it undisturbed. -Topical antibiotics after removal -Topical NSAID (Ketorolac) or short acting cycloplegic for relief of symptoms

Intraocular Foreign Body *Intraocular FB –passes basement membrane of cornea. -Improper removal can cause collapsed AC, traumatic glaucoma, endophthalmitis if infected. *Refer to surgeon.

Traumatic Cataract *Most common complication of non-perforating and perforating injuries to the globe.

Hypermature/Morgagnian Cateract *May me caused by severe trauma. *Liquified cat with intact nucleus inferiorly displaced.

Bollus Keratopathy *Compromised endothelial cell pump mechanism as the endothelial cell density decreased and decompensated; Folds in stroma from stromal edema. *Can be induced by cataract surgery or other trauma. *Manage w/ NaCl 5% gtts and ung; CL for pain; IOP lowering meds; Penetrating Keratoplasty in advanced cases.

RA-associated peripheral ulcerative keratitis *Hx of CT dz. *May cause stromal thinning, descemetocele (only PLL and endothelium left due to corneal thinning) in progressive keratolysis, and perforation. *Promote re-epithelialization by ocular surface lubrication, patching or bandage soft contact lens.

Alkaline Burn *Immediate irrigation of eye until the pH of the cul-de-sac has returned to neutrality. (pH= 7.0) *Prophylactic broad spectrum antibiotic; cycloplegic drops; topical steroids to decrease inflammation; lubrication; soft CL…

Lecture 09/29/08: Corneal Trauma Mgmt (cont.)

Pseudomonas Keratitis Vigamox

Bacterial corneal Ulcer gram (+) Vigamox, gram (-) Zymar

Fungal Keratitis Natamycin

Acanthamoeba keratitis Epithelial debridement

Epithelial Herpes Simplex Viroptic

Marginal Keratitis Vigamox

Bacterial infiltrate 2 nd to RK Vigamox

Dellen Artificial tears

Pubic lice Bacitracin ointment

Iris nevus Asymptomatic, no tx Malignant with growth, refer

Lecture 10/06/08: Corneal Dystrophy (cont.)

Lecture 10/20/08: Therapeutic Strategy for Ant. Segment Dz

Combination Antibiotics Tobramycin Polymixin B Neomycin (hypersensitvity common) Sulfacetamide Bacitracin Medications used to treat ocular inflammation and prevent microbial infection. Also used for superficial burns. Examples: corneal infiltratres, meibomian gland dys., blepharitis

Corneal Ulcers TOC: 4 th generation fluoroquinalones - Zymar (gatifloxacin) 0.3% -Vigamox (moxifloxacin) 0.5% -Quixin (levofloxacin) 0.5%-- 3 rd generation -Iquix (levofloxacin 1.5%) qd or bid– 3x conc of Quixin and works better than Zymar and Vigamox without toxicity. Preservative free.

Corneal Ulcers (additional treatments) Antibiotics - Gentamycin (ung, gtt) -Ofloxacin (gtt) -Ciprofloxacin (gtt) -Tobramycin sulfate (ung, gtt) Mixes -Polysporin ung ( polymixin B & bacitracin) -Neosporin ung ( poly b/ neomycin / bacitracin) -Polytrim gtt ( poly B & trimethoprim) -- least toxic

Bacterial Conjunctivitis - Azasite (azithromycin 1%) bid-tid steroid added post AB treatment to prevent corneal scarring - Vigamox (moxifloxacin) FDA approved for bacterial conjunctivits

Topical anit-inflammatories Steroids - Maxidex (Dexamethasone 0.1%) susp - FML (flouromethalone 0.1%) – ung or susp - Pred forte (prednisilone 1%) – susp Soft steroids - Lotepredenol etabonate Alrex 0.2% Lotemax 0.5% NSAIDS (analgesic effect) - Diclofenac (Voltaren 0.1%) soln -Ketorolac (Acular 0.4%) soln

Allergic and CLPC- (contact lens induced papillary conjunctivitis) Treat with… - Mast cell stabilizers Crolom bid, Alomide or Alomast qid, Alocril bid - Mast cell stabilizing antihistamines Patanol bid/ Pataday qd, Elestat bid, Zaditor bid, Optivar bid - NSAIDS Acular qid - Steroids (only if severe) Alrex, Lotemax, or Pred Forte qid