Cornea

Question 1

Treatment for Posterior Polymorphous Dystrophy

Answer 1

Same treatment as for Fuchs’ Endotehlial Dystrophy: Topical ophthalmic hypertonic solution QID and ointment QHS Hypotensive medication for high IOP. If penetration occurs and ruptured EPITHELIUM happens, then treat as corneal ulcer. Finaly Penetrating Keratoplasty (PK) or DSEK. Caution cataract surgeries with patient with a low endothelial count <1000 cells/mm2.

Question 2

Treatment for Interstitial Keratitis

Answer 2

Steroid Q2h-Q4h followed by taper

Question 3

Treatment of Conjunctival Intraepithelial Neoplasia

Answer 3

Refer for excision with supplemental cryotherapy. Alternatively Mitomycin C, or interferon therapy can be used

Question 4

Treatment for Primary Acquired Melanosis

Answer 4

Monitor every 6 months. Lesions that have become nodular, vascular or growth are suspect for Malignant Conjunctival Melanoma and should be refered for biopsy for excision and cryotherapy if malignant.

Question 5

Treatment for Conjunctival Lymphoma

Answer 5

Biopsy with immunohisto-chemical studies followed by ecternal beam radiation

Question 6

Treatment of Pyogenic Granulomas (fast growing to 1/2 inch diameter)

Answer 6

Monitor for change. If bothersome, antibiotic-steroid combo (Tobradex) or surgical excision

Question 7

Recurrent Corneal Erosion
Symptoms: Recurring Pain (especially on waking or during the night), photophobia, FBS and tearing.
Signs: Corneal epithelial dots or microdots, finger print pattern, map-like lines (map-dot-fingerprint), negative staining

Answer 7

Etiology: Any damage to the corneal epithelium or epithelial basement membrane.
Treatment:
Acute episode: Cycloplegic TID and antibiotic ointment (erythromycin or bacitracin) QID. Can use Muro 128 QID. Can also bandage CL with antibiotic solution QID. Oral analgesics as needed. Once healed, PFAT 4-8x/day and ointment QHS x 3-6 month or Muro QID and Muro ointment QHS x 3-6 months.
Follow Up: Every 1-2 days till epithelium heals, then 1-3 months

Question 8

Filamentary Keratopathy
Symptoms: Moderate to severe pain, red eye, FBS, tearing, photophobia
Signs: short strands of epithelium that stain, conj injection

Answer 8

Etiology: Dry eye, SLK (superiorly)
Treatment: Treat underlying condition, remove filaments with forceps. Then PFAT 6-8x/day, punctal occlusion or Acetylcysteine 10% QID. If that doesn’t work, then BCL with FQL.
Follow Up: 1-4 weeks. May need to repeat process.

Question 9

Thygeson SPK
Symptoms: FBS, photophobia, tearing. NO RED EYE. Bilateral and chronic
Signs: Coarse stellate gray-white corneal epithelial opacities that are central and elevated (crumb-like) that stain slightly with NAFL. May have underlying SEIs.

Answer 9

Treatment:
Mild: PFAT 4-8x/day, ointment QHS
Moderate: Mild steroid QID x 1-4 weeks with slow taper. May need to keep low dose steroid for a while.
Follow Up: Weekly during exacerbation, then 3-6 months. Check IOP every 4-12 weeks if on steroid.

Question 10

Band Keratopathy:
Symptoms: Decreased vision, FBS, corneal whitening, may be asymptomatic
Signs: Ant Corneal calcium plaque at Bowman’s, separated from limbus. Swiss chese from 3-9.

Answer 10

Etiology: Chronic Uveitis, IK, corneal edema, truama, phthisis bulbi.
Treatment:
Mild: Treat dry eye with PFAT 6x/day, ointment QHS and possible BCL.
Severe: Removal of calcium with 3-4% Disodium EDTA.
Follow up after surgical intervention is every few days until epithelial defect has healed and then every 3-12 months.

Question 11

Bacterial Keratitis:
Symptoms: Red eye, decreased vision, pain, photophobia, discharge, CL intolerance.
Signs: Infiltrate with epithelial defect and associated stromal thinning.

Answer 11

Treatment:
Low risk of visual loss: FLQ, or trimethoprim Q1-2H while awake. If CL wearer can use both therapies and consider adding ciprofloxacin ointment 1-4x/day
Borderline risk of visual loss: 1-1.5mm diameter infiltrate with epithelial defect, AC rxn or moderate discharge. Same as before but Q1H around the clock. Consider loading dose of every 5 minutes x5 doses, then Q30min for the day.
Vision Threatening: Refer. Fortified tobramycin or gentamicin.
Follow Up: Daily initially.

Question 12

Fungal Keratitis:
Symptoms: Pain, photophobia, redness, tearing, discharge, FBS, Hx of trauma or non healing with tx for anti-bacterial
Signs: Infiltrate with feathery border. Epithelium over infiltrate may be elevated. Can have satellite lesions and conj injection.

Answer 12

Treatment: Culture (Gram, Giemsa, KOH, periodic Acid Schiff, H&E). Treat as bacterial unless that hasnt helped or cultures say otherwise. Natamycin 5% drops, Amphotericin B 0.15% or topical fortified coticonazole 1% initially Q1-2 H around the clock, tapered over 4-6 weeks. Admit to the hospital is necessary as it may take weeks to heal.
Follow Up: Daily.

Question 13

Acanthamoeba Keratitis (Fungal):
Symptoms: Can vary from FBS to severe pain(out of proportion to signs), redness, photophobia over a period of several weeks.
Signs: Epitheliitis with pseudodendrites or SEIs. Late (3-8 weeks) Ring -shaped corneal stromal infiltrate.
At any time can also have lid swelling, conj injection, AC rxn.
Note: This should be considered in all patient that wear CLs, especially with poor hygeine and swimming in lenses. It is important to consider Acanthamoeba in unresolving HSV Keratitis. Initial presentation is similar.

Answer 13

Treatment: One or more of the following, usually in combination or at hospital.
1. Polyhexamethylene Biguanide 0.02% Q1H or Chlorohexidine 0.02% Q1H
2. Propamidine isethionate 0.1% Q1H are typically aded to above treatment.
3. Oral antifungal agent (itraconazole 400 mg po single loading dose then 100-200mg po daily)
Follow Up: 1-4 days until the condition is consistently improving and then 1-3 weeks.

Question 14

Herpes Simplex Virus:
Symptoms: Red eye, pain, FBS, photophobia, tearing, decreased vision, skin lesions
Signs: Macro SPK, dendritic keratitis, geographic ulcer

Answer 14

Treatment of Cornea: Ganciclovir 0.15% (Zirgan) gel 5x/day, Trifluridine 1% (Viroptic) 9x/day or vidarabine 3% ointment 5x/day. Oral anti-virals Acyclovir 400 mg po 5x/day, Valacyclovir 500mg TID, or Famciclovir 250 mg TID. Consider cycloplegics if pain or photphobia. NO STEROIDS. For epithelial defects that do not resolve after 1-2 weeks, bacterial co-infection or Acanthamoeba should be suspected.
Follow up: 2-7 days to check on treatment. Then in 1-2 weeks depending on condition. After 1-2 weeks, taper the dosing to 2 and 4 times a day for 4-7 days. Taper steroids for stromal disease over a period of months to years. Recommend long term acyclovir 400mg BID if recurrent.

Question 15

Herpes Zoster Ophthalmicus/VZV:
Symptoms: Dermatomal pain, skin rash, headache, fever, malaise, blurred vision, eye pain, red eye.
Signs: Unilateral rash, Hutchinson sign, SPK, pseudodendrites.

Answer 15

Treatment: Cool compress, erythromycin ointment BID, PFAT Q1-2H, Ganciclovir 0.15% for corneal involvement, steroid 4-8x/day for stromal keratitis.
Follow Up: 2-7 days, then 1-4 weeks after. After resolution, check the patient every 3-6 months if on steroids.

Question 16

Interstitial Keratitis:
Symptoms:
Signs: Marked corneal stromal blood vessels and edema. AC cells and flare. conj injection.

Answer 16

Etiology: Most common: Congenital syphilis (Hutchinson’s Sign. Bilateral). Common: acquired syphilis, HSV, VZV, TB (unilateral and sectoral).
Treatment: Acute: Cyclo, Steroid (Predforte Q2-6H), treat underlying disease.
Other stages, monitor or corneal graft if affecting vision.
Follow Up: Every 3-7 days and then every 2-4 weeks with taper over months.