1. Corneal Disease

2. Anatomy of the Eye

3. Thygeson’s Superficial Punctate Keratopathy
Symptoms
Foreign-body sensation
Photophobia
Tearing
No history of recent conjunctivitis
Usually bilateral and has a chronic course with exacerbations and remissions

4. Thygeson’s Superficial Punctate Keratopathy
Critical sign:
Course punctate gray-white corneal epithelial opacities, often central with minimal or no staining with fluorescein

5. Corneal Abrasion Symptoms: Pain Photophobia Foreign-body sensation
Tearing
History of scratching the eye

6. Corneal Abrasion Critical sign: Other signs:
Epithelial staining defect with fluorescein
Other signs:
Conjunctival injection
Swollen eyelid
Mild anterior-chamber reaction

7. Corneal Abrasion Work-up: Treatment: Slit-lamp exam
Use fluorescein
Measure size of abrasion
Diagram its location
Evaluate for anterior-chamber reaction
Evert eyelids and make certain no further FB
Treatment:
Non-contact lens wearer:
Cycloplegic
Antibiotic ointment or drops
Contact lens wearer:
Tobramycin drops 4-6x/day

8. Corneal Abrasion Follow-up: Follow-up Contact lens wearer
Non-contact lens wearer with a small-noncentral abrasion:
Ointment/drops x 5 days
Return if symptoms worsen
Central or large abrasion:
Recheck 24 hours
If improvement, continue top abx
If no change, repeat initial treatment
Follow-up:
Contact lens wearer
Recheck daily until epithelial defect resolves
May resume contact lens wearing 3-4 days after eye feels completely normal.

9. Corneal Foreign Body Symptoms: Foreign-body sensation Tearing
Blurred vision
Photophobia
Commonly, a history of a foreign body

10. Corneal Foreign Body Critical sign: Other signs:
Corneal foreign body, rust ring, or both.
Other signs:
Conjunctival injection
Eyelid edema
Superficial Punctate Keratitis (SPK)
Possible small infiltrate

11. Corneal Foreign Body Work-up: Treatment:
History – metal, organic, finger, etc
Visual acuity before any procedure
Slit-lamp
With history of high velocity FB – dilate the eye and examine the vitreous and retina
Treatment:
Topical anesthetic
Remove foreign body
Remove rust ring (Ophthalmology recommended)
Document size of epithelial defect
Cycloplegic
Antibiotic ointment/drops

12. Corneal Foreign Body Follow-up:
Small (<1-2 mm in diameter), clean, noncentral defect after removal: antibiotics for 5 days and follow-up as needed.
Central or large defect or rust ring: follow-up ophthalmology within 24 hours to reevaluate.

13. Corneal Laceration Partial-thickness laceration
The anterior chamber is not entered and, therefore, the globe is not penetrated

14. Corneal Laceration Work-up: Complete ocular examination
Slit-lamp to rule out ocular penetration
IOP
Seidel test
Fluorescein stain over site shows streaming. + full thickness.

15. Corneal Laceration Treatment: Follow-up: Intact anterior chamber
Cycloplegic
Antibiotic
Ophthalmology follow-up
Ruptured anterior chamber
Immediate optho consult
Follow-up:
Reevaluate daily until healed

16. Thygeson’s Superficial Punctate Keratopathy
Other signs:
No conjunctival injection
No corneal edema
Treatment:
Mild:
Artificial tears
Moderate/severe
Mild topical steroid for 1 week, then taper slowly.
Follow-up
Every week during exacerbations, then every 3-12 months
If on topical steroids, check IOP

17. Pterygium
Patients present with complaint of tissue growing over their eye.
Caused by exposure to ultraviolet light
More commonly encountered in warm, dry climates or smoky/dusty environments.

18. Pterygium Symptoms: Irritation Redness Decreased vision
Usually asymptomatic

19. Pterygium Critical signs: Work-up:
Wing-shaped fold of fibrovascular tissue arising from the interpalpebral (90%) conjunctiva and extending onto the cornea
Work-up:
Slit-lamp exam to identify lesion.
Treatment
Protect eyes from sun, dust, and wind
Artificial tears, mild vasoconstrictor or topical decongestant/ antihistamine combination
Moderate/severe – mild topical steroid

20. Pterygium
Follow-up
Asymptomatic patients may be checked every 1-2 years
If treating with topical vasoconstrictor, the check in 2 weeks. Discontinue when inflammation subsides.
If topical steroid, check 1-2 weeks and check IOP. Taper and discontinue over several days once resolution.

21. Infectious Corneal Infiltrate/Ulcer
White infiltrate/ulcer that may/may not stain with fluorescein must always be ruled out in contact lens patients with eye pain.
Can occur in patients with recent history of eye trauma.
Slit-lamp beam cannot pass through infiltrate.

22. Infectious Corneal Infiltrate/Ulcer
Symptoms:
Red eye
Mild-to-severe ocular pain
Photophobia
Decreased vision
Discharge

23. Infectious Corneal Infiltrate/Ulcer
Critical sign:
Focal white opacity in the corneal stroma
Other signs:
Conjunctival injection
Inflammation surrounding infiltrate
Corneal thinning
Possible anterior-chamber reaction
Etiology:
Bacterial
Fungal
Acanthamoeba
(contact lens wearers)
Herpes Simplex Virus

24. Infectious Corneal Infiltrate/Ulcer
Work-up:
History: contact lens wear and regimen, trauma, foreign body.
Slit-lamp exam: stain with fluorescein to assess epithelial loss.
Document size, depth, and location.
Assess anterior chamber
Check IOP
Treatment:
Generally treated as bacterial unless there is a high index of suspicion for another form.
Cycloplegic
Topical antibiotics
No contact wearing
Pain med if needed
Ophthalmology consult

25. Herpes Simplex Virus Symptoms: Usually unilateral red eye Pain
Photophobia
Tearing
Decreased vision
Skin rash

26. Herpes Simplex Virus Work-up: History: External exam
Previous episode
Contact lens
Recent steroids
External exam
Slit-lamp with IOP
Dendritic lesion
Check corneal sensation prior to anesthetic
Viral culture

27. Herpes Simplex Virus Treatment: Topical acyclovir tid
Warm soaks tid (if eyelid involved)
Ophthalmology referral
(oral acyclovir if primary herpetic disease)

28. Examination Techniques

29. Slit Lamp Examination Extremely useful instrument
Can reveal pathologic conditions that would otherwise be invisible
Permits detailed evaluation of external eye injury and is definitive tool for diagnosing anterior chamber hemorrhage and inflammation

30. Slit Lamp Examination Indications: Contraindicated:
Diagnosis of abrasions, foreign body, and iritis
Facilitate foreign body removal
Contraindicated:
Patients who cannot maintain upright position, unless using portable device

31. Slit Lamp Examination Set up
Patient’s chin is in chin rest and forehead is against headrest
Turn on light source
Low to medium light source is appropriate for routine exam
Start on low power microscopy

32. Slit Lamp Examination 1ST setup:
For examination of right eye, swing light source out 45º.
Slit beam is set at maximum height and minimal width using white light.
Scan across at level of conjunctiva and cornea, then push slightly forward and scan at level of iris.

33. Slit Lamp Examination Basic setup used to examine for:
Conjunctiva traumatic lesions
Inflammation
Corneal FB
Lids for
Hordeolum
Blepharitis
Complete lid eversion
Examine undersurface

34. Slit Lamp Examination 2nd setup: Same as first, only uses blue filter.
Beam is widened to 3 or 4 mm.
Examine for uptake of fluorescein.

35. Slit Lamp Examination 3rd setup: Search for cells in anterior chamber.
Height of beam should be shortened to 3 or 4 mm.
Switch to high power.
Focus on center of cornea and the push slightly forward, focus on anterior surface of lens
Keep beam centered over pupil.
Look for searchlight affect in anterior chamber

36. Questions?