Disorders of the cornea
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Disorders of the Cornea. Kelli Y. Shaon, O.D. Trauma/Injury. Corneal Abrasion/Corneal Foreign Body Treatments - Topical antibiotic to prevent infection (Vigamox, Zymar) Cycloplegic to reduce inflammation Pain medication Follow-up: Daily until resolved

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Disorders of the Cornea

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Disorders of the cornea

Disorders of the Cornea

Kelli Y. Shaon, O.D.


Trauma injury

Trauma/Injury

  • Corneal Abrasion/Corneal Foreign Body

    • Treatments -

      • Topical antibiotic to prevent infection (Vigamox, Zymar)

      • Cycloplegic to reduce inflammation

      • Pain medication

      • Follow-up: Daily until resolved

      • Bandage contact lens if large abrasion or poor healing


Noninfectious cornea

Corneal Dystrophy

Bilateral

Symmetrical

Central

Avascular

Inherited

Earlier onset

Not systemic Dz related

Non-inflammatory

Usually only 1 corneal layer

Corneal Degeneration

Unilateral

Asymmetrical

Peripheral

Vascular

Not inherited

Later onset

Often associated w/ systemic disease

Inflammation possible

Multiple corneal layers

Noninfectious Cornea


Corneal dystrophy

Corneal Dystrophy

  • Epithelium

    • EBMD (Map-dot-fingerprint dystrophy)** Common

      • Often superior Cornea

      • Common cause of RCE –

        • Treat like abrasion, until healed

        • After healed tears/ointments or 5% Muro BID-QID

      • If not associated w/ RCE, pt often asymptomatic

        • Often artificial tears & ointments if needed

    • Reis-Buckler’s Dystrophy

      • Sub-epithelial honeycomb pattern of opacification

      • Often younger patients

    • Meesman’s Dystrophy

      • Intraepithelial microcysts that are seen well on retroillumination

      • Rare


Corneal dystrophy1

Corneal Dystrophy

  • Stromal

    • Lattice dystrophy

      • Amyloid deposits

      • Seen as branching whitish lines with haze

    • Macular dystrophy **(AR inheritance)**

      • Mucopolysaccarides deposition

      • Grayish-white spots with diffuse haze

    • Granular

      • Hyaline deposits

      • White snowflake like central opacities

    • Schnyder’s (Central crystalline)

      • Cholesterol deposits

      • Central, whitish crystalline like deposits


Corneal dystrophy stromal

Corneal Dystrophy - Stromal


Corneal dystrophy2

Corneal Dystrophy

  • Endothelium

    • Fuch’s Dystrophy

      • Corneal guttata – thickened Descemet’s mmb

      • Bullae in later stages, with varying degrees of edema

    • Congenital Hereditary Endo Dystrophy (CHED)

      • Bilateral corneal edema due to endo dysfunction

      • Present at birth


Corneal degenerations

Corneal Degenerations

  • Corneal Depositions-

    • Arcus Senilis: bilateral, white lipid depositions

    • Band keratopathy: subepithelial calcium deposits @ 3:00 & 9:00; Often patchy appearance; Present in eyes w/ chronic inflammation

    • Salzmann’s nodular: elevated, bluish-white opaque deposits; Often secondary to chronic keratitis

    • Limbal Girdle of Vogt: bilateral white, needle like opacities in peripheral cornea - seen in elderly patients

    • Crocodile shagreen: bilateral, gray-white opacification in mosaic or cracked ice pattern


Corneal degenerations1

Corneal Degenerations


Corneal degenerations2

Corneal Degenerations

  • Peripheral degenerations – thinning

    • Terrien’s Marginal Degeneration: non-inflammatory superior peripheral thinning; induces ATR astigmatism

    • Furrow degeneration: thinning in clear zone b/w arcus and limbus

    • Dellen: thinning secondary to corneal drying adjacent area of tissue elevation

    • Pellucid Marginal degeneration: bilateral inferior peripheral corneal thinning

    • Peripheral Ulcerative Keratitis: (PUK)

      • Marginal Keratolysis – melting due to autoimmune/collagen disease

      • Mooren’s Ulcer – inflammatory, progressive peripheral thinning


Corneal degenerations3

Corneal Degenerations

  • Keratoconus:

    • Bilateral, cone-shaped central corneal thinning

      • Munson sign (protrusion of LL); Vogt’s striae (breaks in Bowman’s); Scarring in later stages


Additional corneal findings

Additional Corneal Findings

  • Superficial Punctate Keratitis (SPK): pinpoint epithelial defects, best seen by staing with NaFL

    • Associated with dry eye, CL wear, blepharitis, medications, etc.

  • Filamentary keratitis: strands of mucous and devitalized epithelial cells still adherent to cornea

  • Thygeson’s SPK: bilateral, gray-white lesions (similar to sub-epithelial infiltrates) in white, quite eye – no staining


Additional corneal findings1

Additional Corneal Findings

  • Subepithelial infiltrates:

    • whitish round, fluffier (non-distinct edge) deposits

    • often seen with adenovirus

  • Keratic precipitates (KPs):

    • Deposits of inflammatory cells on endothelium (associated w/ uveitis)

    • Whitish-gray round, more defined deposits


Infectious cornea

Infectious Cornea

  • Bacterial Keratitis

    • Signs: Photophobia, pain, redness, VA decrease possible, mucous discharge

    • Symptoms: Infiltrate (white opacity) in stroma, ulcerative if overlying epi defect w/ staining

    • Etiology: Bacteria – Most common:

      • Staphylococcus: well defined gray-white infiltrate

      • Streptococcus:very purulent & AC reaction more common

      • Pseudomonas:progressive, necrotic infiltrate w/ mucopurulent discharge & sometime AC hypopyon – more common in CL wearer


Bacterial keratitis ulcer

Bacterial Keratitis/Ulcer

  • Treatment/Management:

    • NO STEROID, if epithelium defect

    • Cycloplegic for comfort – Homatropine 5% BID

    • Oral pain medication

    • Small, peripheral Ulcer - Vigamox or Zymar loading dose, followed by q1h & Ciloxin or torbramycin ung qhs, then taper gtts

    • Larger, Ulcer or infiltrate near visual axis –

      • Culture bacteria

      • Fortified antibiotics (Tobramycin q30min, alt w/ cefazolin q1h)

      • Start topical Vigamox with loading dose of gtt q5-15 x4-5 doses, then q 15 min for 3-5 doses, then q30-60 min aroind clock


Infectious cornea1

Infectious Cornea

  • Fungal Keratitis

    • Often after ocular trauma w/ vegetable matter

    • Signs: Stromal gray-white opacity with feathery borders, satellite lesions possible, if treated bacterial – poor response to Antibiotic

    • Treatment: Natamycin 5% gtts q1-2 h around the clock with taper over next weeks


Infectious cornea2

Infectious Cornea

  • Acanthamoeba

    • Often in CL wearer w/ poor hygeine (use of tap water, swimming in lenses, or hot tub use w/ CL)

    • Severe pain (not in proportion to ocular signs)

    • Treatment: Baquacl q1h or Brolene q 30m-2h; Cycloplegic, Oral pian meds – K transplant as last resort


Infectious cornea3

Infectious Cornea

  • Herpes Simplex Virus (HSV)

  • Unilateral

  • The great Masquerader – presents in many forms

    • Dermatological – clear vesicles w/ crusting

    • Conjunctivitis – unilateral, follicular response (often due to vesicles shedding the virus)

    • Dendritic keratitis – thin linear branches w/ terminal bulbs – stains w/ NaFL & Rose bengal

    • Geographic ulcer – large epi defect

    • Stromal – stromal edema w/ intact epithelium

    • Uveitis – AC reaction often as result of stromal involvement


Herpes simplex virus hsv

Herpes Simplex Virus (HSV)

  • Treatment:

    • Eyelid/Skin: Antibiotic ung – Erythromycin or Bacitracin ung BID; Oral Antivirals may be used to prevent primary infection

    • Conjunctivitis: Viroptic 1% 5x/day

    • Epitheial defect: NO Steroids, Viroptic 5x/day, cycloplegic (homatropine 5% BID)

    • Stromal: Cycloplegic, Viroptic for phophylaxis TID; Topical Steroid (Pred Forte 1%) QID if risk of vision loss, if NO overlying epi defect


Herpes zoster virus hzv

Herpes Zoster Virus (HZV)

  • Obeys the midline – follows the dermatone

  • Hutchinson sign (rash involving tip of nose) may indicate more ocular involvement

  • Skin: rash respecting midline

    • Oral Antiviral (Valtrex 1g TID x 7-10 d)

    • Ung to lesions BID (same as HSV)

  • Corneal – Can have corneal Psuedo-dendrites (no terminal bulbs) or SPK

    • no antiviral gtts; Use tears PF freq & Steroids may help occasionally


Hsv vs hzv

HSV vs. HZV


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