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GWR. 27 th Sep. History. 55 yr old lady, Accidentally poked LE with finger on morning of consult Developed subsequent LE redness and tearing VR 6/21  6/7.5, VL 6/15  6/7.5 IOP R 18, L 14. Approach to peripheral corneal thinning. History Pain Conjunctival injection vs quiet eye

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Presentation Transcript
slide1

GWR

27th Sep

history
History
  • 55 yr old lady,
  • Accidentally poked LE with finger on morning of consult
  • Developed subsequent LE redness and tearing
  • VR 6/21  6/7.5, VL 6/15  6/7.5
  • IOP R 18, L 14
approach to peripheral corneal thinning
Approach to peripheral corneal thinning
  • History
    • Pain
    • Conjunctival injection vs quiet eye
    • Systemic review
    • Preceding trauma / inciting injury
  • Examination
    • VA
    • Unilateral/Bilateral
    • Location of thinning
    • AC activity
    • Associated scleritis
    • Posterior segment exam
    • Systemic examination
slide13

Systemic Involvement

Bacterial Viral

- TB - HIV

- Syphilis - Hep C

- Gonococcus

- Shigella

- Salmonella

Infectious

Non-infectious

Autoimmune Malignancy

- RA - Leukaemia

- SLE

- WG

- PAN

- Relapsing polychondritis

- Sarcoidosis

- IBD

slide14

Systemic Involvement

Bacterial Viral

- TB - HIV

- Syphilis - Hep C

- Gonococcus

- Shigella

- Salmonella

Infectious

Non-infectious

Autoimmune Malignancy

- RA - Leukaemia

- SLE

- WG

- PAN

- Relapsing polychondritis

- Sarcoidosis

- IBD

slide15
Systemic bacterial infections
    • TB
      • History of chronic cough, fever, night sweats
      • ? Previous vaccination
      • Granulomatous uveitis
      • Scleritis
      • Retinitis
      • Vasculitis
      • Choroidal granulomas
      • Optic neuritis
      • FBC for leucocytosis
      • Mantoux
      • CXR: Infective foci, apical lesions
    • Syphilis
    • Gonococcus
    • Shigella
    • Salmonella
slide16
Systemic bacterial infections
    • TB
    • Syphilis
      • Sexual history
      • Granulomatous uveitis
      • Interstitial keratitis
      • Periphlebitis
      • Salt and pepper fundus
      • Optic neuritis
      • FBC for leucocytosis
      • VDRL
      • FTA
      • HIV serology
    • Gonococcus
    • Shigella
    • Salmonella
slide17

Systemic Involvement

Bacterial Viral

- TB - HIV

- Syphilis - Hep C

- Gonococcus

- Shigella

- Salmonella

Infectious

Non-infectious

Autoimmune Malignancy

- RA - Leukaemia

- SLE

- WG

- PAN

- Relapsing polychondritis

- Sarcoidosis

- IBD

slide18
Autoimmune
    • RA
      • Morning stiffness lasting > 1hour
      • Symmetrical arthropathy, involving hand joints
      • Rheumatoid nodules
      • Scleritis, inflammation mainly affects anterior segment
      • Rheumatoid factor
      • Radiographic changes
    • SLE
    • WG
    • PAN
    • Relapsing polychondritis
    • Sarcoidosis
    • IBD
slide19
Autoimmune
    • RA
    • SLE
      • Photosensitivity
      • Malar rash
      • Mucosal ulcers
      • Arthritis
      • Scleritis
      • Anterior uveitis
      • Vasculitis, retinal hemorrhages, CWS
      • CRAO, CRVO
      • Optic neuritis, AION
      • FBC for leuco/lymphopenia, anemia, thrombocytopenia
      • U/E/Cr for renal involvement
      • ANA, Anti-ds DNA
    • WG
    • PAN
    • Relapsing polychondritis
    • Sarcoidosis
    • IBD
slide20
Autoimmune
    • RA
    • SLE
    • WG
      • recurrent epistaxis
      • sinus discharge
      • haemoptysis
      • deafness
      • cerebral vascular accidents
      • orbital inflammatory disease
      • NLD obstruction
      • Scleritis
      • Post segment: Arteritis, CRAO, BRAO
      • AION
      • C-ANCA
      • Urinalysis: Hematuria, proteinuria
      • CXR: Lung granulomas
    • PAN
    • Relapsing polychondritis
    • Sarcoidosis
    • IBD
slide21
Autoimmune
    • RA
    • SLE
    • WG
    • PAN
      • Arthritis
      • Nephritis
      • Interstitial keratitis
      • Scleritis
      • Posterior segment: Arteritis, CRAO, BRAO
      • AION
      • CN palsies
      • P-ANCA
    • Relapsing polychondritis
    • Sarcoidosis
    • IBD
slide22
Autoimmune
    • RA
    • SLE
    • WG
    • PAN
    • Relapsing polychondritis
      • Tinnitus
      • Vertigo
      • Deafness
      • Swollen ear lobes
      • Otitis media
      • Saddle-shaped nose
      • Polyarthritis
      • Scleritis
      • CXR: Calcification of cartilaginous structures
    • Sarcoidosis
    • IBD
slide23
Autoimmune
    • RA
    • SLE
    • WG
    • PAN
    • Relapsing polychondritis
    • Sarcoidosis
      • Serum Ca
      • 24 hour urine Ca
      • Serum ACE level
      • Mantoux: Anergy
      • CXR: Perihilar lymphadenopathy
    • IBD
slide24

Local

Bacterial Viral FungalParasitic

- HSV - Acanthamoeba

- VZV

Infectious

Non-infectious

Inflammatory Corneal DegenOthers

- SJS - Mooren’s - Trauma

- Chemical injury - Terrien’s - Neurotrophic

- Marginal keratitis - PMD - Exp keratopath

- Rosacea - Furrow degen - Dellen

- Nutri def

management
Management
  • Dependent on cause
  • Treat systemic condition
    • Treat infections accordingly
    • Systemic immunosuppressives for inflammatory conditions
      • Prednisolone
      • Azathioprine
      • Cyclophosphamide
      • Methotrexate
  • Prevent corneal perforation
    • Conjunctival recession/resection
    • Judicious topical steroid use in the treatment of patients with PUK associated with systemic disease as may aggravate corneal melt due to collagen synthesis inhibition.
    • Systemic collagenase inhibitors (tetracycline 250 mg tab qds or doxycycline 100 mg tab bd) may help slow progression.
    • AMT
  • In event of perforation
    • Corneal glue (<2mm)
    • Tectonic patch graft
slide28
Corneal dellen found in 16% of pts who had undergone repeat strabismus surgery, and 18% in pts after transposition procedures.

Fresina M, Campos EC. Corneal dellen as a complication of strabismus surgery. Eye 2007

  • More frequent in limbal approach surgeries. Authors suggest careful trimming of conj to avoid bunching and monitoring postoperatively.

Tessler HH, Urist MJ. Corneal dellen in the limbal approach to rectus muscle surgery. Br J Ophthalmol 1975;59:377-9.

  • Found in association with large filtering blebs. Post operative topical steroids may also contribute to its formation.

Soong HK, Quigley HA. Dellen associated with filtering blebs. Arch Ophthalmol 1983;101:385-7.

slide29
Case report of development of central corneal dellen after tarsotomy for cicatricial entropion due to a buckled upper lid defect causing suboptimal lid-globe apposition.

Kwok SK, Tse DT. Central corneal dellen: a complication of upper eyelid tarsotomy. Ophthal Plast Reconstr Surg 2000;16:237-40.

  • Paracentral corneal dellen secondary to Grave’s ophthalmopathy.

Yan J, Wu Z. Paracentral corneal dellen: a rare sign of Graves ophthalmopathy. Yan Ke Xue Bao 2003;19:174-5.

  • Case report of a patient with coughing paroxysms a/w SCH and dellen formation.

Reisli I, Keles S. Arch Pediatr Adolesc Med 2006;160:53-5.