34. Corneal inflammation and surface disorders Flashcards
Corneal Anatomy
* Thickness = ...
microns centrally
* Epithelium = ...
cells thick, can therefore prevent diffusion of fluorescein
* ...
membrane - significant in RCE
* ...
/ ...
- cannot regenerate after trauma
* Stroma
* ...
/...
- folds during oedema
* Endothlium = ...
decreases with age and does not ...
Corneal Anatomy
* Thickness = 490-560
microns centrally
* Epithelium = 6-8
cells thick, can therefore prevent diffusion of fluorescein
* Basement
membrane - significant in RCE
* Anterior limiting lamina
/ Bowman's
- cannot regenerate after trauma
* Stroma
* Posterior limiting lamina
/Descemet's
- folds during oedema
* Endothlium = cell number
decreases with age and does not regenerate
Filamentary keratopathy is ...
. It arises due to the abonormal areas of the ...
and excess ...
in tears. The filaments arise from ...
strands attached to abnormal ...
which adhere strongly to the corneal surface. This is thought to be exacerbated by the ...
in the components of the ...
and/ or abnormalities of the ...
.
Filamentary keratopathy is associated with ...
, ...
, ...
, ...
and ...
.
Filamentary keratopathy is uncommon
. It arises due to the abonormal areas of the corneal epithelium
and excess mucous
in tears. The filaments arise from mucous
strands attached to abnormal epithelial cell plaques
which adhere strongly to the corneal surface. This is thought to be exacerbated by the alteration
in the components of the tear film
and/ or abnormalities of the corneal surface
.
Filamentary keratopathy is associated with severe dry eye
, superior limbic kertoconjunctivitis
, ocular Sx e.g. cataract, corneal graft
, RCEs
and neurotrophic keratopathy
.
**Filamentary keratopathy
**
Px symptoms:
* ...
due to pulling on ...
with blink
* ...
due to stimulated ...
* Decreased ...
* ...
Clincial signs:
* ...
filaments, several mm in length
* Stain well with ...
& ...
, but less well with ...
but does pool around filaments
* Adherent to ...
at proximal end of strand
**Filamentary keratopathy
**
Px symptoms:
* FB sensation
due to pulling on filaments
with blink
* Watery eye
due to stimulated reflex tears
* Decreased vision
* Photophobia
Clincial signs:
* Greyish
filaments, several mm in length
* Stain well with Rose Bengal
& Lissamine green
, but less well with NaCl
but does pool around filaments
* Adherent to corneal plaque
at proximal end of strand
Treatment of Filamentary Keratopathy
* Treat ...
to prevent recurrences
* Removal of filaments under ...
with ...
* Rx ...
e.g.... *frequency*
due to epithelila defect caused by remova l
* Rx ...
for comfort and dry eyes e.g. ... *frequency*
* Rx ...
e.g. ... *frequency*
can help reduce inflammation and ...
* Rx ...
= mucolytic agent used to ...
however it is not available in Aus and is rarely used long term due to ...
feeling
* Use of ...
may be helpful in breaking cycle of epithelial damage and filament formation
Treatment of Filamentary Keratopathy
* Treat underlying conditions
to prevent recurrences
* Removal of filaments under local anaesthetic
with sterile forceps
* Rx topical antibiotics
e.g.Chloramphenicol QID
due to epithelila defect caused by remova l
* Rx ocular lubricants
for comfort and dry eyes e.g. Hyloforte QID
* Rx topical corticosteroids
e.g. FML BID
can help reduce inflammation and filament formation
* Rx topical acetylcysteine
= mucolytic agent used to dissolve filaments
however it is not available in Aus and is rarely used long term due to stinging
feeling
* Use of bandage CLs
may be helpful in breaking cycle of epithelial damage and filament formation
What are the 4 advices that should be given to a px with filamentary keratopathy?
- May take weeks to months before adequate resolution, depending on the etiology, severity and aggressiveness of care
- Underlying condition is often chronic and filaments may recur after therapy is discontinued
- Proper long-term care includes ongoing treatment for ocular surface disease with close monitoring e.g. 3-4 times annually
- Px with chronic or severe dry eye disease may benefit from a rheumatological investigation to determine the presence of Sjogren’s syndrome
SPK stands for ...
, also known as ...
. This is very ...
and is caused by ...
of the corneal ...
. There are a number of possible causes:
* ...
, ...
= Inferior
* ...
, ...
= Diffused
* ...
= Tracking SPK
* ...
= Central SPK
* ...
, ...
,...
, ...
, ...
= Superior
* ...
= 3 & 9 o’clock SPK
* ...
, ...
, ...
= Interpalpebral
SPK stands for superficial punctate keratopathy
, also known as punctate epithelial erosions
. This is very common
and is caused by superficial damage
of the corneal epithelium
. There are a number of possible causes:
* Lagophthalmos
, Lid margin disease
= Inferior
* Drug toxicity
, Conjunctivitis
= Diffused
* FB
= Tracking SPK
* CL overwear
= Central SPK
* Hypoxia
, Tight lid
,Vernal disease
, Superior limbic keratoconjunctivitis
, floppy eyelid syndrome
= Superior
* Rigid CLs
= 3 & 9 o’clock SPK
* Dry eye
, Exposure
, UV keratopathy
= Interpalpebral
What are the px symptoms and clinical signs of superficial punctate keratopathy?
Symptoms:
* May be asymptomatic
* If symptomatic: gritty, photophobia
* If dense may affect vision
Signs:
* Fine, coarse, dense or sparse areas of superficial corneal epithelial erosions
* No corneal infiltrates
* Eye remains white and clear
What are the treatments and managements of SPK?
Treatment:
* Identify the cause and faciliate the recovery of the ocular surface
* Mild SPK = tear supplements e.g. Hyloforte QID prevent preservatives, BAK
* Severe SPK or full thickness = prophylatic topical antibiotics e.g. Chloramphenicol ointment QID for a week
* Cease CL wear until resolution
Management
* Mild SPK heals within 24 hours, no review required unless symptomatic
* Severe SPK or full thickness defect = review after 3 days or sooner if any worsening symptoms
Subepithelial infiltrates are relatively ...
and is caused by the ...
. These are ...
areas of ...
composed of ...
, ...
and ...
. They appear as ...
, grey, roundish ...
and can have ...
overlying.
These are common caused by ...
, ...
, ...
, ...
, ...
and ...
.
Symptoms of subepithellial infiltrates are:
* ...
* ...
* ...
* ...
Subepithelial infiltrates are relatively common
and is caused by the inflammatory response within anterior cornea
. These are focal
areas of inflammation
composed of neutrophils
, cellular debris
and protein
. They appear as diffuse
, grey, roundish opacities
and can have epithelial defect
overlying.
These are common caused by severe prolonged infection or inflammation
, viral infection
, blepharitis
, Thygeson's SPK
, preservative toxicity
and contact lens wear
.
Symptoms of subepithellial infiltrates are:
* FB sensation
* Photophobia
* Watery eye
* Decreased vision
What are the treatments for subepithelial infiltrates?
- Depends on the underlying condition
- Rx topical corticosteroids with slow taper e.g. FML QID, reduced by one drop per week
- Rx ocular lubricants if symtomatic e.g. Hyloforte QID
- Rx topical antibiotics if significant epithelial breakdown over infiltrate e.g. Chloremphenicol (Chlorsig) QID for 1 week; if CL wearer use Tobramycin (Tobrex) QID
How are sterile infiltrates and infectious infiltrates differentiated?
PEDALS = Pain, Epithelial defect, Discharge, Anterior chamber reaction, Location, Size
Infectious:
* Pain & photophobia
* Significant epithelial defect = size of staining = size of stromal lesion
* Mucopurulent discharge
* Anterior chamber reaction
* Lid edema, tear film debris, hypopyon
* More central/ mid-peripheral
* Larger lesion >1mm
Non-infectious:
* Minimal pain/ photophobia
* Partial/ intact epithelium
* No discharge
* No AC reaction
* Peripheral
* <1mm (staining smaller in size than infiltrate)
Thygeson’s Superficial Punctate Keratopathy is ...
and is usually a ...
corneal ...
condition of ...
aetiology. The onset is greatest in the ...
decade e.g. ...
. This is characterised by ...
and ...
of active phase. Active phase can last for ...
months, followed by remission of up to ... months
. Attacks tend to ...
in frequency with ...
and ...
after many years. This often resolves without ...
after 2-4 years, but may last up to ...
years.
Px may experience ...
, ...
, ...
and may have mild decrease in ...
.
Thygeson’s Superficial Punctate Keratopathy is rare
and is usually a bilateral
corneal inflammatory
condition of unknown
aetiology. The onset is greatest in the second
decade e.g. young adults in early 20s
. This is characterised by remissions
and exacerbations
of active phase. Active phase can last for 1-2
months, followed by remission of up to 2 months
. Attacks tend to decrease
in frequency with age
and cease
after many years. This often resolves without sequelae/ consequences
after 2-4 years, but may last up to 20
years.
Px may experience photophobia
, tearing
, FB sensation
and may have mild decrease in vision
.
What are the 6 clinical signs of an active Thygeson’s SPK and 1 clinical sign of an inactive Thygeson’s?
Active phase:
* Raised epithelial lesions
* Negative or no fluorescein stain
* Can have faint epithelial haze - never scars
* Gives corneal surface an appearance of having coarse breadcrumbs on surface
* Mild conjunctival injection
* 1-2o lesiions most common presentation
Inactive phase:
* Lesion may disappear or leave flat epithelial grey area
What are the treatments for Thygeson’s SPK?
- Rx ocular lubricants for discomfort e.g. Hyloforte, Hylofresh, Systane, Refresh
- Rx topical steroid during exacerbation + taper e.g. FML tapered over 1 month & monitor IOP
- Bandage CL to reduce symptoms if px uncomfortable
- Rx cyclosporine if px is a steroid responder e.g. Cequa 0.09%, Restasis 0.05%
...
(RCES) is a common disorder that involves repeated episodes of ...
breakdown. This predisposes the cornea to ...
. The cause of RCES can be ...
, ...
(45-64%), ...
and ...
.
Px may experience ...
, unilateral ...
upon waking.
Clinical signs include:
* ...
- minor episodes that last ...
but with an ...
* ...
- more severe episodes that last for ...
, with ...
and an ...
.
* Px may have signs of underlying ...
or ...
* ...
with NaFl
Recurrent Corneal Erosions
(RCES) is a common disorder that involves repeated episodes of corneal epithelium
breakdown. This predisposes the cornea to infection
. The cause of RCES can be idiopathic
, corneal trauma
(45-64%), posterior blepharitis
and epidermolysis bullosa
.
Px may experience sharp
, unilateral pain
upon waking.
Clinical signs include:
* Microform erosions
- minor episodes that last 30 mins
but with an intact epithelium
* Macroform erosions
- more severe episodes that last for several days
, with epithelial defects
and an oedematous epithelium
.
* Px may have signs of underlying anterior dystrophy
or posterior blepharitis
* Negative staining
with NaFl