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Anterior Seg > Cornea > Flashcards

Cornea Flashcards

1
Q

What is the refracting power of the cornea?

A

40-44D ~2/3rd refracting power of the eye

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2
Q

Ehlers-Danlos Syndrome

  • Features? Characteristics?
  • 6 Major forms?
  • Ocular findings
  • Systemic findings?
A
  • Systemic collagen disorder
  • Features
    • Hyperextensible joints
    • skeletal abnormalities
    • Blue sclera
    • Mottled teeth
    • Neurosensory deafness
  • 6 major forms
    • Type VI (Kyphoscoliosis) - most ocular involvement ***
      • AR deficiency in enzyme responsible for collagen stability & strength
    • Ocular findings
      • Scleral fragility
      • Risk of globe rupture
      • KCN
      • Retinal detachment
      • Glaucoma
    • Systemic findings
      • ​Muscle hypotonia
      • Joint laxity
      • Kyphoscoliosis & other skeletal changes
      • Abnormal skin
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3
Q

Band Keratopathy

  • What does it look like?
  • Causes?
  • Symptoms?
  • Treatment?
A
  • Interpalpebral deposition of calcium phosphate salts in bowman’s membrane
    • Begins peripherally & moves centrally
    • 3 & 9
    • Starts grey, becomes chalky white
    • Clear intervening zone between peripheral edges & limbus
    • Swiss cheese pattern
      • Represent corneal nerves that penetrate Bowman’s layer
    • Late stage progresses anteriorly through epithelium
  • Causes
    • ​DES
    • Chronic exposure
    • Chronic inflammation
      • Uveitis
      • Pthisis bulbi
      • Interstitial keratitis
    • Long-standing glaucoma
    • Repeated trauma
  • Underlying systemic disease
    • ​Hyperparathyroidism
    • Vitamin D toxicity
    • Sarcoidosis
    • Paget’s disease
    • Multiple myeloma
    • Metastatic cancer to bone
    • Norrie’s disease
  • Symptoms
    • ​Asymptomatic
    • Decreased VA
    • Pain
    • FBS
    • Epithelial erosions
  • Treatment
    • ​Lubrication
      • Drops
      • Drops Gels
      • Ointments
    • BCL
    • RGP/Scleral lenses for induced astigmatism correction
    • Chelation with EDTA & superficial keratectomy (corneal scraping)
    • PTK
      • Reserved for recurrent or advanced cases
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4
Q

Disciform endotheliitis

A
  • Most common presentation
  • Symptoms
    • ​photophobia
    • Mild to moderate discomfort
    • Decreased vision possible
  • Many cases self-limited
  • Presentation
    • ​Limbal injection
    • Round area of stromal edema
      • Central paracentral
      • Entire thickness of stroma involved
    • Overlying microcystic edema to bullae formation
  • Iritis
  • Elevated IOP
  • Responds well to tx
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5
Q

Lattice dystrophy

  • Characteristics?
  • Symptoms?
  • Treatment?
A
  • AD inheritance
  • TGFB1 gene mutation
  • Presents 1st decade
  • Primary, localized corneal amyloidosis
  • Begins with development of refractile lines in anterior stroma which progressives to stromal opacification
  • Symptoms
    • ​Blurred vision
    • Corneal erosions
  • Treatment
    • ​Bandage CL
    • PK
      • Tends to recur in graft
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6
Q

Salzmann’s Nodular Degeneration

  • Statistics?
  • Associations?
  • What does it look like?
  • Symptoms?
  • Complications?
  • Treatment?
A
  • Female >> males
    • 72-88%
  • Caucasian
  • 6th decade
  • Bilateral
    • 58-67%
  • Associations
    • Idiopathic
    • Corneal inflammatory disease
      • MGD, ocular rosacea
      • Phlyctenular disease
      • Vernal keratoconjunctivitis
      • Trachoma
      • Interstitial keratitis
  • Yellow-white to blue elevated nodular lesions
    • ​Single or multiple
    • Usually in annular pattern in mid periphery
    • Adjacent to corneal scars or pannus
    • Iron lines may be present surrounding lesions
    • Vascularization may be adjacent to lesion
  • Symptoms
    • ​Asymptomatic 15%
    • FBS
    • Possible to develop epi-erosions over lesions →
      • Pain
      • Lacrimation
      • Photophobia
    • Decreased VA possible if nodule over visual axis
  • Complications
    • ​Corneal erosion
    • Photophobia
    • Blepharospasm
    • Lacrimation
    • Corneal Irregularity
      • Hyperopic shift
      • Irregular astigmatism
  • Treatment
    • ​Lubrication
    • Warm compressess
    • Lid hygiene
    • Topical steroids
    • Superficial keratectomy (Super-K)
    • Lamellar or penetrating keratoplasty
  • Recurrence possible
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7
Q

Senile Furrow Degeneration

  • What does it look like?
  • Where does it occur & diameter?
  • Symptoms?
  • Treatment?
A
  • Rare, idiopathic
  • Shallowing thining in the avascular zone between acrus senilis & limbus in elderly pt
    • Occurs circumferentially
    • <0.5mm width
    • Shallow
    • No visual significance
  • No inflammation or vascularization
  • Symptoms
    • Asymptomatic
    • Not visually significant
  • Treatment
    • None
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8
Q

Fusarium

A
  • Filamentous
  • Widely distributed in plants/soil
  • Readily colonize on tissue that has been injured by other means
  • Thrives in hot, humid environments
  • Can grow on improperly cleaned CLs
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9
Q

Congenital hereditary stromal dystrophy

  • Characteristics?
  • Symptoms?
  • Treatments?
A
  • AD inheritance
    • Cornea clear at birth, clouding begins at 1-2yrs
  • AR inheritance
    • opacification appears w/in neonatal period
  • Mutation of DCN gene
    • codes for decorin protein
  • Non-progressive to slowly progressive
  • Thought to be caused by disordered stromal fibrogenesis
  • Diffuse haze with flaky lesions in central anterior stroma
    • Ground glass corneal apperance
  • Symptoms
    • ​Decreaseed VA
    • Dense amblyopia
    • Esotropia
    • Nystagmus - associated with AR form
  • Treatment
    • ​PK at early age
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10
Q

What are the dimensions of the cornea?

A
  • 11-12mm H x 9-11 mm V
  • 0.5mm centrally
  • 0.7mm peripherally
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11
Q

Clinical Exams and Diagnostic testing for keratoconus?

A

Clinical Exam

  • Assessment of vision: c/o ghosting or smeared images
  • Retinoscopy: Scissor reflex retinoscopy​
  • Refraction: inability to correct vision to 20/20
  • External exam:
    • look at lids (including eversion) for signs of atopy
    • Munson sign
  • Slit lamp examp
    • ​Thorough corneal evaluation
    • Look for surgical scars
    • Presence & location of thinning

Diagnostic Testing

  • Keratometry
    • Done in normal gaze position - failure to superimpose rings
    • Repeat in upgaze (to capture steepest portion of cornea)
    • No specific K-value that defines KCN
  • Pachymetry
    • ​Compare thinning to “normal” corneas
    • Can achieve with ultrasound or optically pachys
  • Corneal topography
    • ​Placido disk
    • Scheimpflug photography (Pentacam)
  • Anterior segement OCT
  • Specular microscopy
    • ​show evidence of endothelial cell damage
  • Aberrometry
    • ​Vertical coma is most typical aberration
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12
Q

Lab work up for bacterial keratitis?

A
  • Indicated in cases where corneal infiltrate is central, large, deep, chronic, or has atypical features suggestive of fungal, amoebic, or mycobacterial keratitis
  • Corneal scraping for culturing
  • Cytology
    • Gram staining
  • Susceptibility testing
  • Start tx empirically after scraping with broad spectrum & adjust tx once results come in
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13
Q

Describe the reactivation infection for Herpes simplex?

A
  • Reactivation infection
    • Latency in sensory ganglia - ocular infection latency occurs in trigeminal gnaglia
      • Viral replication leads to cytopathic effects in cells, or immune response to virion
      • Clinical disease varies based on reaction to virus
    • Reactivation can occur at any time
    • Blepharoconjunctivitis
    • Keratitis - epithelial, stromal or endothelial disease
    • Uveitis
    • Retinitis
    • Any ocular structure possible
  • More likely to cause severe visual consequences from scarring & inflammation
    • Essential to make a prompt diagnosis & initiate tx to preserve ocular function
    • Careful evaluation of each ocular structure is critical
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14
Q

Blunt Force Trauma

A
  • Injury from impact of noncutting instrument
  • Contusive: direct impact
    • Bruising or fractures
  • Concussive: rapid acceleration, deceleration, or oscillation of tissues causing energy transfer to surrounding tissues
  • Damage often not localized to only the cornea
  • Diffuse endotheliopathy
    • Endothelial rings
  • Stromal injury & fracture
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15
Q

LASEK

A
  • Laser epithelial keratomileusis
  • Hybrid of PRK & LASIK
  • Procedure
    • Epithelium softened with alcohol & rolled back
    • Laser ablation of stromal tissue
    • Epithelium rolled back into place
  • Benefits
    • ​Reduced post-op haze
    • Increase healing time
    • Reduce post-op pain
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16
Q

Reis-Bucklers Corneal Dystrophy (CBD I)

  • Characteristics
  • Mutation of which gene?
  • Presentation?
  • Symptoms?
  • Treatments?
A
  • AD
  • Presents in 1st decade of life
  • Born with normal corneas
  • TGFB1 gene mutation
    • Subepithelial reticular changes
      • Deposits of hyaline-like material that disrupts & may replace bowmans
  • Progress until middle age
  • Presentation
    • Fine, reticular superficial opacities
    • Become honeycomb-shaped
    • Diffuse superfical haze
    • Increased central corneal thickness
    • Irregular astigmatism
    • Decreased corneal sensation
    • Prominent corneal nerves visible
  • Symptoms
    • ​Episodic corneal erosions
    • Vision loss
      • Irregular astigmatism & opacification
      • Occurs early in life
    • Treatments
      • Bandage CLs
      • Lamellar keratoplasty
      • Penetrating keratoplasty
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17
Q

Filamentary keratopathy

  • Characteristics
  • Clinical signs
  • Causes
  • Symptoms
  • Treatment
A
  • Women>Men
  • Incidence increases with age
  • Filaments attach to corneal epithelium
  • Filaments adherent to corneal epithelium
    • ​Loose area of epithelium acts as a focus for deposition of mucus & cellular debris
    • Filaments small, gelatinous strands
      • Differ in size, composition & distribution
        • 0.5-10mm
    • Location of filament helps assist in diagnosis of underlying cause
  • Abnormally high mucous to aqueous
    • Aqueous deficiency
    • Increased mucin production

Clinical Signs

  • Strands of degeneration epithelial cells & mucs that move with blinking, attached at one end to the cornea
  • Small epithelial defect may be present at the base of filaments
  • Chronic filaments → plaques
  • Filaments stain well with rose bengal, less with NaFL

Causes

  • Aqueous deficiency DES
  • Excessive CL wear
  • Corneal epithelial instability
  • SLK
  • Bullous keratopathy
  • Neurotrophic keratitis
  • Prolonged or frequent eye closure
  • Ocular surgeries

Symptoms

  • Discomfort with mild to severe FBS
  • Redness
  • Occasional photophobia
  • Epiphora (overlow of tears)
  • Blepharospasm

Treatment

  • Treat underlying cause
  • D/C all unnecessary medications
  • Manual removal of filaments
  • Mucolytic agent - acetylcysteine
  • Tropical NSAIDs
  • Hypertonic saline
  • Bandage CL
  • Punctal occlusion
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18
Q

Spheroidal Degeneration

  • What other names is it also known as?
  • Statistics? (Men/Women, Bilateral/Uni)
  • Etiology?
  • What does it look like? Diameter range?
  • What are the 3 types?
  • Complications?
  • Treatment?
A
  • AKA
    • Labrador keratopathy
    • Bietti nodular hyaline bandshape keratopathy
    • Climatic droplet keratopathy
    • Proteinaceous corneal degeneration
    • Elastotic degeneration
    • Fisherman’s keratopathy
    • Eskimo’s corneal degeneration
  • Bilateral
    • Unilateral, asymmetric cases possible
  • Men > Women
  • Asymptomatic until crosses visual axis
  • Etiology
    • UV exposure
    • Microtrauma
    • Disease entities associated with neovascularization
  • Clear, to yellow-gold spherules seen in subepithelium, within bowman’s, or in superficial corneal stroma
    • Proteinaceous material
      • 0.1-0.4mm in diameter
    • Continued exposure → coalescence & enlargement of spherules extending deeper corneal stroma & centrally across corneal surface creating a band
    • Darken with age: Light yellow → brownish-yellow
  • 3 Types
    • ​Primary corneal involvement
      • Age-related
      • Starts nasally → temporally (3&9 o’clock) near limbus
    • Corneal involvements secondary to underlying process
      • ​Previous corneal disease/trauma
      • May be diffuse or begin centrally
    • Conjunctival involvement
      • ​May occur with type 1 or 2
      • Begins 3 & 9 o’clock on conj
      • Lesions smaller & less numerous
      • May be present with pinguecula
  • Complications
    • ​Decreases vision
    • Epithelial disruptions
    • Ulceration of tissue
      • Hypoesthetic or anesthetic
      • Often become infected
    • Cicatricial changes to cornea or conjunctiva
  • Treatment
    • ​None-asymptomatic
      • Observation
    • UV protection
    • Surgical
      • Penetrating keratoplasty (PK)
      • Phototherapeutic keratectomy (PTK)
      • Excision of conjunctival lesions
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19
Q

Bacterial Keratitis Presentation?

A
  • Depends on causative organism, duration of infection, pre-existing conditions, immune status of pt, & previous drug use (antibiotics, steroids, etc)
  • Pain
  • Photophobia
  • +/- decreased vision
    • depends on location of ulcer & severity
    • Marked conjunctival injection
    • anterior chamber reaction
  • +/- Hypopyon
  • Pupillary constriction & ciliary flush
  • Lacrimation
  • Discharge
    • Generally mucopurulent
  • Tissue loss
    • Ragged,irregular epithelial ulceraction with underlying necrotic stroma infiltrations & surrounding epithelial edema
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20
Q

DMEK

A
  • Descemet’s Membrane Endothelial Keratoplasty
  • Transplant of endothelium
  • Donor tissue includes Descemet’s membrane & endothelium, doesn ot include stromal tissue
  • Benefits
    • Improved acuity after surgery
    • Improved healing time
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21
Q

Note the difference between Terrien’s vs. Senile Furrow Degeneration

A
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22
Q

List types of corneal surgeries

  • Refractive Surgeries
  • Transplants
  • Other
A

Refractive surgeries

  • LASIK
  • PRK
  • LASEK
  • RK/AK
  • Phakic IOLs
  • ICL
  • Verisyse

Transplants

  • PK/PKP
  • DALK
  • DSEAK
  • DMEK

Other

  • PTK
  • Super-K
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23
Q

Corneal Foreign Body

  • What is it?
  • Presentation
  • Symptoms
  • Examination
  • Treatment
A
  • One of the most common ocular traumas
  • Often occur at work
  • Most often pts not wearing eye protection
  • Symptoms
    • Pain
    • Photophobia
    • Tearing
    • Inability to open eye
    • Redness
  • Presentation
    • ​Generally obvious FB
    • Multiple FBs are common
    • Rust ring
    • Conjunctival injection
  • Examination
    • ​History: pt specific about injury
    • VA: may/may not be reduced depending on location
    • SLE: anesthetic, seidel sign, everts lids
    • DFE: check for intraocular FB
  • Treatment
    • ​Superficial
      • ​Removal at slit lamp
      • Treat as abrasion
    • Deep/Penetrating
      • ​DO NOT REMOVE
      • Protect eye with fox shield
      • Send to cornea specialist for surgery
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24
Q

Stromal corneal Abrasions

A
  • Uncommon
  • Injury extends into stromal tissue = WILL SCAR
  • Without flap: treat like epithelial abrasion
  • With flap:
    • Smooth: BCL until surface reepithelializes, then
    • Rough: sutures
  • More likely to need specialty CL fitting or surgical repair
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25
Q

Posterior Polymorphous Dystrophy

  • Characteristics
  • What are the 3 patterns?
  • Associations?
A
  • AD
  • Disorder at the level of Descemet’s membrane & endothelium
  • Bilateral, asymmetric
  • Presents in 2nd-3rd decade
  • 3 patterns
    • Vesicle-like lesions - hallmark **
      • 0.1-1.0 mm diameter
      • Sharply demarcated round area
    • Band lesions
      • ​typically horizontal with parallel scalloped edges that do not taper at the ends
      • Mostly found just inferior to visual axis
    • Diffuse opacity
      • ​Small, macular, gray-white lesions
      • Large sinuous geography lesions
      • 0.5-2.0mm
  • Associations
    • Corneal edema
      • Minimal stromal thickening to bullous keratopathy
    • Unclear if keratoconus or similar variant
  • Symptoms
    • ​Stable & asymptomatic
    • Secondary glaucoma
    • Rarely may be progressive & debilitating
  • Treatment
    • ​None
    • PK - PPD can recur
    • Treat associated conditions
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26
Q

Herpes Zoster Opthalmicus

  • Reactivation along what nerve?
  • Cutaneous lesions?
  • Prodromal?
  • Clinical course last how long?
A
  • Reactivation along CN V1
  • Cutaneous lesions
    • 25% involvement of ophthalmic division of CN V
    • Acute, painful vesicular eruptions
  • Prodromal period not uncommon
    • ​Fever, malaise, HA, eye pain or pressure, tearing, ocular redness, decreased vision
    • Pain occurs along affected dermatome most commonly
  • Clinical course 2-6 weeks for vesicle to clear
    • Corneal involvement may take longer
      • Ocular involvement begins within 3 weeks of rash
      • Virus presumably reaches eye via ciliary nerves
    • **Pt presents to you initially with rash on lids and skin lesions without involvement of the globe = must follow pt weekly for minimum of 3 weeks
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27
Q

Graft vs Host Disease

  • What is it?
  • What are some tissues that may be affected?
  • Occurs in which pts?
  • Clinical diagnosis?
  • Sx?
  • Signs?
  • Complications?
  • Goals?
  • Tx?
A
  • Donor cells (graft) mount an immune response against recipient (host)
  • Affected tissues
    • Skin
    • GI system
    • Liver
    • Mouth
    • Lungs
    • Eyes (60-90% with GVHD)
  • Occurs in wide range of pt
    • Age
    • Histocompatibility
    • Prophylaxis
    • Host environment
  • Clinical diagnosis
    • Thorough hx regarding nature of transplant & systemic presentation of GVHD
    • Systemic medications = including immunosuppressants
    • Complete ocular exam
  • Symptoms
    • ​FBS
    • Itching
    • Burning
    • Moderate conjunctival redness
    • Advanced disease
      • Decreased vision
      • Pain
      • Photophobia
    • Exacerbated by wind, blinking or prolonged reading
  • Signs
    • ​Conjunctival
      • Hyperemia
      • Chemosis
      • Pseudomembranous conjunctivitis
      • Mucoid discharge
    • Cornea
      • Decreased tear lake
      • KCS
      • Filamentary keratitis
      • Corneal erosions
  • Complications
    • ​Corneal scarring
    • Neovascularization
    • Cicatricial changes of conjunctiva
  • Goals
    • ​Lubrication
    • Control evaporation
    • Decreased ocular surface inflammation
  • Treatment
    • ​Treat associated systemic disease
      • Coordination of care with transplant team
    • Lubrication
    • Punctal occlusion
    • Humidifiers
    • Sleep masks
    • Tarsorrhaphy
    • Immunosuppression
      • Directed at affected organ system
      • Restasis, topical steroids
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28
Q

Keratitis

A
  • Typically unilateral
    • Bilateral disease in about 3%
  • Can affect all levels of cornea
    • Epithelium
      • Infectious epithelial keratitis
      • Neurotrophic keratopathy
    • Stroma
      • Immune stromal (Interstitial) keratitis
      • Necrotiizing stromal keratitis
    • Endothelium
      • Disciform endotheliitis
      • Diffuse endotheliitis
      • Linear endotheliitis
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29
Q

List the Parasitic that can infect the eye

A
  • Acanthomoeba
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30
Q

Pathogens that can cause Bacterial Keratitis

A
  • Staphylococcus aureus
    • Gram + cocci
    • MOST COMMON cause of ulcers & conjunctivitis
      • Occurs in normal ocular flora
    • Rapidly progressive corneal infiltration & AC reaction with hypopyon
    • Ulcers centrally located
  • Streptococcus pneumoniae
    • ​Gram + diplococci
    • ​Acute, purulent, & rapidly progressive
    • Severe AC reaction with hypopyon
    • Perforation common (7-10 days without tx)
    • Ulcer centrally located
  • Pseudomonas areuginosa
    • ​Gram - bacillus
    • Ubiquitous organism
    • Ability for proteolysis
    • MOST COMMON cause of bacterial keratitis in CL wearers
    • Central or paracentral ulcers
    • Highly destructive
    • Adherent greenish mucopurulent discharge
    • Dense stromal infiltration & necrosis
    • Stromal melting with early descemetocele
    • Perforation within 72 hours if untrated
    • Intense AC reaction w/ hypopyon
  • Moraxella lacunata
    • ​Gram - coccobacilli
    • Paracentral ulcer
    • Older, debilitated individuals & homeless pt
    • Perforation in days to 1 week without tx
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31
Q

Fish-Eye Disease

A
  • LCAT deficiency
  • Progressive arcus which begins in adolescence
  • May result in complete opacification of cornea
  • AR inheritance
    • ~30 cases described
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32
Q

Marginal Staphylococcal Keratitis

  • What is it?
  • Sx?
  • Presentation
  • Tx?
A
  • Inflammatory infiltration that may lead to ulceration
    • Antibody response to toxins rather than bacteria
    • Type III hypersensitivity
    • Associated with staphylococcal blepharoconjunctivitis
  • Most common disorder of peripheral cornea****

Symptoms

  • Mild discomfort to pain
  • Conjunctival injection
  • Lacrimation
  • Photophobia

Presentation

  • Peripheral stromal infiltrates - separated by 1-2mm clear zone
    • Develop where lid crosses limbus
    • Ulceration & necrosis possible
    • May develop vascularization between limbus & infiltrate or area of necrosis
  • Often chronic blepharitis
    • ​Staphylococcal blepharitis most common***
    • Angular blepharitis or strep species possible***

Treatment

  • Lid hygiene - tx underlying cause
  • Weak topical steroid
  • Antibiotic
  • Oral doxycycline - recurrence or maintenance
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33
Q

Fleck Corneal Dystrophy

  • Characteristics? Gene mutation?
  • Symptoms?
  • Treatment
A
  • AD inheritance
  • PIP5K3 gene mutation
  • Bilateral, asymmetric
  • Flat, gray-white, discrete flecks throughout stroma
    • May be oval, circular, comma, or stellate shaped
    • Fine, granular texture
  • Limbus to limbus
  • Little progression
  • Symptoms
    • ​Generally asymptomatic
    • VA unaffected
    • Mild photophobia occasionally
    • Decreased corneal sensation occasionally
  • Treatment
    • ​None
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34
Q

The cornea is composed of mainly..?

A

Collagen fibers

Transparent refracting surface

10% outer coat of eye

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35
Q

Corneal Epithelial Abrasions

  • Sx
  • Presentation
  • Examination
  • Tx
A
  • One of the most common ophthalmic injuries
  • Removal of all or part of corneal epithelium
    • If Bowman’s layer undisturbed = no scarring

Symptoms

  • Pain- generally out of proportion to injury
    • UV/CL keratitis delayed onset of pain
  • Photophobia
  • FBS
  • Lacrimation
  • Decreased VA if central or significant edema

Presentation

  • Variable size/shape epithelial defect
  • Loose flap of epithelium possible
  • Conjunctival injection
  • Lid edema possible

Examination

  • History - pts generally specific about injury
  • VA - may or may not be reduced
  • SLE - best to use anesthetic & NaFL
    • Evert lids!
  • DFE - any risk of penetrating injury

Treatment

  • Antibiotic
  • Cycloplegia
  • Patching/BCL
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36
Q

List the immunologic disorder of the cornea

A
  • Rheumatoid arthritis
  • Phlyctenular keratoconjunctivitis
  • Marginal staphylococcal keratitis
  • Mooren’s Ulcer
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37
Q

Keratoglobus

A
  • Rare
  • Bilateral
  • Globular cornea which leads to high myopia & astigmatism
  • Congenital & acquired variants
    • Often present at birth
    • Associated conditions
      • Leber’s congenital amaurosis
      • Ehlers-Danlos syndrome type VI
    • Cornea clear, normal size to slightly large
  • Stroma diffusely thinned 1/3 - 1/5 normal thickness
    • More pronounced in mid-peripheral cornea
  • Corneal Structure
    • ​Fragmented or absent bowmans layer
    • Diffusely thinned stroma
    • Thinned Descemet’s membrane
    • Normal endothelium
    • Thinned sclera
  • Breaks in Descemet’s membrane possible
    • ​leads to opaque, edematous cornea
    • Takes weeks to months to heal
  • Characteristics findings in KCN not present
    • ​No striae
    • No iron lines
    • No subepithelial
  • Keratometry readings 60-70D
  • Acute hydrops rare
  • Perforation may ocur after minimal trauma
  • Treatment
    • ​Spectacle correction
    • Keratoplast - difficult, should be delayed when possible
    • CLs considered - esp scleral, but must consider increased risk for rupture
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38
Q

Herpes zoster (Shingles)

  • What is it?
  • Prodrome?
  • Presentation?
A
  • Reactivation of virus following a dermatome
    • Must have prior exposure to virus to develop shingles - either wild-type or vaccine
    • Replicates in nerve cells & sends virions down the axon to the skin
    • Presentation is the result of immune response to virions (not the virions themselves)
  • Prodrome (early signs/sx)
    • Fever, malaise, HA, pain in the dermatome
    • Affective disorder possible - anorexia, lassitude (lack of energy) , mood changes, antisocial behavior, severe depression, insomnia
  • Presents as acute, painful, vesicular eruptions
    • ​Rash progression: erythematous → macules → papules → vesicle → pustules → crusting
    • Generally occurs in cluster
    • Lesion formation occurs ~3-7 days
    • Resolution in 2-6 weeks
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39
Q

PTK

A
  • Phototherapeutic keratotomy
  • Ablative photodecomposition of epithelium to eliminate surface irregularities
    • Laser ablation to depth of anterior stroma
  • Indications
    • Corneal dystrophies or degenerations
    • Scars
    • Band keratopathy
    • Infectious
    • Therapeutic & visual improvements
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40
Q

Fuch’s Endothelial Dystrophy

  • Characteristics?
  • Where does it usually begin in the eye?
  • Sx?
  • Tx?
A
  • AD
  • Late onset - 5th decade
  • Slowly progressive
  • Women > men
    • Earlier presentation
    • More severe
  • Guttata - refractile excrecences on the posterior cornea
    • Abnormal functioning endothelial cells
  • Begins centrally & spreads peripherally
  • Leads to corneal edema
    • ​Worse in am, improves throughout the day
  • Symptoms
    • ​None in early disease
    • Blurred vision - worse upon waking
      • Improves throughout the day
    • Bullae formation -> pain, photophobia
  • Treatment
    • ​None early disease
    • hypertonic solutions
    • Muro128 gtt or ung (dehydrates cornea)
    • Hair-dryer aimed at eyes - pts find this uncomfortable
    • Reduction of IOP - only at higher IOP levels
    • Bandage CL, if pt has bullae formation
    • DSAEK/DMEK (corneal surgery/endothelial transplant)
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41
Q

Diffuse Endothelitis

A
  • Rare, more severe presentation
  • Symptoms
    • Pain
    • Photophobia
    • Injection
    • Decreased vision
  • Clinical course similar to disciform
  • Responds well to tx
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42
Q

Varicella Zoster Virus

A
  • Primary infections occurs in childhood is chickenpox
  • Reactivation infection occur as shingles
    • Generally in older or immunocompromised patients
    • In otherwise healthy young adults, be suspicious for generalized immunosuppressive diseases
  • Virus remains latent in sensory ganglions
  • Reactivation follows a dermatome
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43
Q

List the Descemet’s & Endothelial Dystrophies

A
  • Posterior polymorphous dystrophy
  • Fuch’s endothelial dystrophy
  • Congenital hereditary endothelial dystrophy
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44
Q

Meesmann’s Dystrophy

  • Characterisics? What is another name?
  • Symptoms?
  • Treatment?
A
  • AKA: Juvenile hereditary epithelial dystrophy
  • AD inheritance
  • Intraepithelial microcysts/vesicles
    • Most prominent interpalpebral zone
  • Central & mid-peripheral
  • Slowly progressive
  • Bilateral, symmetric
  • First 1-2 years of life
  • Symptoms
    • ​Mild to nonexistent
    • Vision good initially
      • Worsens as cyst increase in size & number which leads to irregularity of corneal surface
    • Glare sensitivity
    • FBS
    • Erosions or PEK not common
  • Treatment
    • ​Bandage CL
    • Lubrication
    • Superficial corneal debridement
    • PTK (photo therapeutic keratectomy)
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45
Q

Arcus Senilis

  • What other names are they known as?
  • What is it?
  • Statistics? (men/women/age)
  • What can arcus senilis indicate?
  • What location does it begin to grow in the eye?
  • Symptoms?
  • Treatment?
A
  • AKA:
    • Corneal arcus
    • Gerontoxon
  • Degenerative change involving depostion of lipid in the peripheral cornea
    • Grey/white arc that as it progresses becomes a ring around cornea
    • Near limbus with clear intervening zone
  • Normal older adults
    • Men > Women
    • Extremely common
      • 60% in 50-60yo pts
      • Nearly 100% affected by age 80
  • May indicate disruption in lipid metabolism
    • Young pts should warrant a visit to PCP for lipid panel testing
  • Begins inferiorly then superiorly
    • Spreads circumferentially
    • Bilateral
    • Symmetric
  • Symptoms
    • ​None, Cosmesis
  • Treatment
    • ​None, Refer to PCP for lipid panel testing in young pt
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46
Q

Granular Dystrophy Type I

  • Presentation?
  • Symptoms?
  • Treatment?
A
  • AD inheritance
  • TGFB1 gene mutation
    • Leads to deposition of hyaline-like material in stroma
  • Presents 1st-2nd decade
  • Bilateral
  • Grayish white opacities form in CENTRAL anterior stroma with clear intervening space
    • Drop-shaped, crumb-shaped, ring-shaped
  • Symptoms
    • ​Glare
    • Decreased vision late (_>_40)
  • Treatment
    • ​None until late
    • Lamellar or penetrating keratoplasty if vision reduced
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47
Q

List the stromal dystrophies

  • Autosomal Dominant Inheritance
  • Autosomal Recessive Inheritance
  • Unknown Inheritance pattern
A
  • Autosomal dominant inheritance
    • ​Granular dystrophy
    • Avellino dystrophy
    • Lattice dystrophy
    • Schneider’s crystalline dystrophy
    • Fleck corneal dystrophy
    • Posterior amorphous corneal dystrophy
  • Autosomal recessive inheritance
    • ​Congenital hereditary stromal dystrophy
      • Has both AR & AD inheritance patterns
    • Macular dystrophy
  • Unknown inheritance pattern
    • ​Central cloud dystrophy of Francois
    • Pre-Descemet’s corneal dystrophy
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48
Q

Stromal keratitis

A
  • Accounts for 20-48% of recurrent disease
  • Primary involvement
    • Necrotizing stromal keratitis
      • Direct viral invasion of stroma
    • Immune stromal keratitis
      • Immune reaction in stroma
  • Secondary involvement
    • Sequelae of epithelial, neurotrophic or endothelial infection
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49
Q

What are the characteristics for corneal degeneration?

A
  • Definition: Deterioration & decrease in function
    • May be unilateral or bilateral
    • Often asymmetric
    • Often considered aging changes
    • Often eccentric or peripheral & correspond with vascularity
    • Progression variable
    • Local & systemic disease associations often
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50
Q

List the Bowman’s Layer Dystrophy

A
  • Reis-Buckler corneal dystrophy (CBD I)
  • Thiel-Behnke Honeycomb dystrophy
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51
Q

Describe the vascularization and nutrition of the cornea

A
  • Avascular
  • Vascular arcade in the limbal region provides nutrition to the cornea
    • Anterior ciliary artery anastomoses with facial branch of external carotid artery
  • Glucose obtained by diffusion from aqueous humor
  • Oxygen obtained by diffusion from tears
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52
Q

Tamoxifen

A
  • Blocks action of estrogen
    • Used in tx of breast cancer
  • Ocular side effects
    • Decreased VA
    • Corneal microdeposits
    • Retinopathy
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53
Q

Necrotizing stormal keratitis

A
  • Rare
  • Direct viral invasion of stroma
  • Presentation
    • Necrosis
    • Dense stromal infiltration with overlying epithelial defect
    • Thinning & perforation possible after short period of time
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54
Q

Super K

A
  • Superficial keratectomy
  • Removal of epithelium with alcohol & manual scraping
  • USed to improve epithelium
    • Corneal dystrophies & degenerations
    • Recurrent corneal erosions
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55
Q

PixL

A
  • Photorefractive intrastromal corneal cross-linking
  • Non-surgical tx for low myopia
    • ~0.75D myopia correction potential
  • 2 studies have shown good results after 12 months
    • Not approved in US & not currently in clinical trials
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56
Q

Phakic IOLs

A
  • FDA approved for moderate to high myopia correction
  • Not currently approved for hyperopic or astigmatic correction
  • Reversible
  • Increased risk for cataract development
  • Possible corneal decompensation
  • ICL (Implantable collamer Lens)
    • Visian
    • Lens placed between lens & iris
    • -3D to -20D
    • Cannot see with naked eye
  • Verisyse
    • Lens to anterior chamber
    • -5 to -20
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57
Q

Fluoroquinolones

A
  • 2nd gen
    • Ciprofloxacin 0.3%
    • Ofloxacin 0.3%
  • 3rd gen
    • Levofloxacin 0.5%
    • Levofloxacin 1.5%
  • 4th gen
    • Moxifloxacin 0.5%
    • Besifloxacin 0.6% = no systemic equivalent
  • 2nd & 3rd generation
    • Single agent therapy
    • Available in commercial prep
    • Bactericidal activity
    • Broad antimicrobial spectrum
    • Low incidence of resistance
  • 4th gen
    • Improved gram + coverage with maintenance of gram - coverage
    • Excellent potency against atypical mycobacteria
    • Effective against MRSA & fluoroquinolone resistant pseudomonas
    • Better penetration
    • Less likely to develop resistance
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58
Q

Meesman’s vs EBMD

  • Inheritance pattern
  • Age of onset
  • Presentation
  • Symptoms?
  • Treatment?
A
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59
Q

Macular Dystrophy

  • Characteristics? Gene mutation?
  • Most prevalent where?
  • Treatment?
A
  • AR inheritance
  • Mutation in CHST6 gene
  • Intra & extracellular deposits within the stroma
  • Least common stromal dystrophy
  • Most severe
  • Most prevelent in Iceland & Saudia Arabia
  • Characterized by attacks of irritation & photophobia
  • Anterior stroma becomes hazy 1st decade, progressing to opacified lesions
    • Haze extends to peripheral cornea
    • Involves entire thickness by 2nd decade
  • Vision loss by 20s to 30s
  • Treatment
    • Variable, depends on severity of tx
    • Tinted CL to reduce photophobia
    • Tx of recurrent erosions
    • PK - reccurence possible in graft
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60
Q

Hepres simplex

Primary infection & Presentation?

A
  • ~6% of pt manifest disease, therefore 94% of pt do not
  • Neonatal infection
    • HSV II
    • Acquired during vaginal delivery
  • Post-neonatal infection
    • HSV I
    • Acquired from exposure to infectious secretions
  • Incubation period
    • 1-28 days
  • Presentation
    • ​Nonspecific URI - often not recognized as HSV
    • Variable ocular presentation
      • Periocular skin vesicles
      • Follicular conjunctivitis
      • Keratitis
      • Preauricular adenopathy
      • Blepharoconjunctivitis - unilateral vesicular lesions on lid or adnexa, follicular conjunctivitis & PAN
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61
Q

Kayser-Fleischer Ring

  • What is it?
  • Where is it usually seen in the eye?
  • What occurs with this?
  • Treatment?
A
  • Copper deposition in Descemet’s layer at corneo-scleral junction
    • Begins at Schwalbe’s line & extends into cornea <5mm
    • Deposit and extend into trabecular meshwork
  • Golden to green-brown band in peripheral cornea
    • Gonioscopy necessary in early disease cases
  • Bilateral
  • Begins superiorly, then inferiorly & moves circumferentially
  • Wilson’s hepatolenticular degeneration
    • AR
    • 1st & 4th decades
    • Inborn error copper metabolism
      • ATB7B gene
      • Sx typically present in teens to 20s
      • Leads to retained copper in the body causing liver & brain damage
    • Cirrhosis, renal disease, neurologic dysfunction
    • 95% WD with neurologic signs have KF ring
    • 65% WD with hepatic signs have KF ring
    • Fatal if left untreated
    • Dissappears with treatment
  • Treatment
    • ​Copper chelation to fade ring
    • Low copper diet
    • Systemic treatment of Wilson’s disease
      • Copper chelators
      • Zinc therapy
    • Surgical treatment
      • Liver transplant in severe cases
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62
Q

Candida

A
  • Thin walled small yeast
  • Found in soil, inanimate objects, food & hospital environments
  • Part of microbiota
63
Q

Coat’s White Ring

  • What does it look like? Diameter? What layer is it located in?
  • What causes this?
A
  • White rings in cornea <1mm diameter at the level of Bowmans layer
    • May be oval or incomplete
    • Discrete white dots with areas of coalescence
      • Granular
    • Usually inferior position
    • Iron or calcium deposit
  • Often associated with previous trauma - espc metalic FB
  • Asymptomatic, incidental finding
64
Q

Iron Lines

  • What does it look like?
  • What are the types of iron lines? Characteristics of each?
A
  • Faint yellow to dark brown discoloration in the epithelium
    • Easier to see with cobalt filter
    • Etiology unclear
  • Types
    • Hudson-Stahili line
    • Fleischer ring
    • Stocker’s line
    • Ferry’s line
65
Q

DSAEK

A
  • Descemet’s Stripping Automated Endothelial Keratoplasty
  • Replaces diseases corneal endothelium w/ donor tissue
  • 100-200um donor tissue
  • Final vision approx 1-6 months
66
Q

Herpes Simplex

  • Characteristics
  • Type I vs. Type II
A
  • Enveloped, DS, DNA virus
  • Occurs as primary & reactivation infections
    • Undergoes true latency in trigeminal ganglion
  • Orofacial lesion is most common manifestation = cold sore
  • Genital herpes is 2nd most common venereal disease in US
  • Major cause of blindness worldwide
  • Prevalence
    • 80% of population over age 20 infected, about 6% manifest clinically
    • 100% of population in pts >60yo
  • Type I
    • ​Eye, mouth, skin
    • Less commonly affects genitals
    • Transmission - direct contact
  • Type II
    • ​Genitals
    • Less commonly affects eye, but more severe
    • Sexual & neonatal transmission
67
Q

RK/AK

A
  • Radial keratotomy/Astigmatic keratotomy
  • Introduced in 1980’s Myopic correction
  • Creates incision to flatten cornea
    • RK - radial incisions for myopic correction
    • AK - arc incisions for astigmatism correction
  • Count & note location of incisions for documentation
    • 4-24 RK
    • Generally 1 or 2 AK
  • Complications
    • Progressive flattening
    • Refractive fluctations
    • Challenge with ocular surgeries
  • Considerations
    • Corneal cross linking
68
Q

Management for bacterial keratitis?

A
  • Goals:
    • Quickly eradicate organism
    • Control inflammation
      • Minimizes scarring
    • Promote healing
  • Hospitalization
    • ​If impending perforation
    • If pt unable to use meds as indicated - often around the clock initially (q30min-1hr)
    • If failure to respond to out-patient tx
    • Often not necessary
  • Antibiotic therapy administration
    • ​Solution vs ointment
    • Subconjunctival injection (children)
    • Continuous lavage (impractical)
    • Collagen shield delivery
  • Fortified antibiotic or fluoroquinolone given every 30 mins to 1 hour around the clock initially
  • Close follow-up essential!!
    • See next day
  • Initial antibiotic selection
    • Broad spectrum therapy vs selection based on gram staining results
    • Cefazolin 33-50 mg/ml with tobramycin 11 mg/ml
    • May substitute bacitracin 9600 u/ml for cefazolin if PCN sensitive
    • Require extemporaneous preparation - not commercially available
  • Fluoroquinolone antibiotics
    • 2nd generation
    • 3rd generation
    • 4th generation *** best choice
  • Initial therapy
    • ​Antibiotic - initially every 30 mins - 1 hr around the clock = wake up at night for meds
    • Concomitant cycloplegic
      • Cyclopentalate
      • Homatropine
    • Follow at least q24 hrs first 2-3 days
  • Modification of therapy
    • ​Change antibiotic
      • Based on preliminary culture results
      • Further modified by final identification and susceptibility testing
    • Tapering antibiotic
      • With signs of improvement after 2-3 days
        • Decreased infiltration, edema, blunting of perimeter, re-epithelialization, corneal vascularization or scarring
      • Double time between drops
      • Do not use less frequently than QID - higher risk of resistance
      • Switch to commercial strength if using fortified
    • Treat QID until total epithelial healing then another week
  • Steroids
    • ​Decreases cornea toxic inflammation and stromal loss
    • Helps prevents scarring
    • Must give sufficient time for antibiotic to sterilize ulcer before beginning therapy
      • ** NOT given on first day
69
Q

Comparison of Corneal Transplant surgery

70
Q

Chloroquine/Hydroxychloroquine

A
  • Antimalarial
  • Used in autoimmune disease
    • RA, SLE
  • Ocular side effects
    • Blurred vision - accommodative weakness
    • Transient corneal edema
    • Corneal microdeposits
    • Decreased corneal sensation
    • Retinal/optic nerve complications
71
Q

Bacterial Keratitis

  • Defenses to infection?
  • Predisposing Factors to bacterial keratitis?
A
  • Defenses to infection
    • Eyelids
    • Tearfilm
      • Make proteins with antimicrobial properties
    • Intact corneal epithelium
      • Epithelial cells capable of phagocytosis & intracellular transport of ingested particles
      • Most bacteria cannot penetrate intact corneal epithelium
    • Normal ocular flora
      • Staphylococcus epidermidis
      • Aerobic & anaerobic diptheroids
      • Transient pathogens
  • Predisposing factors
    • ​CL wear - MOST COMMON risk factor in developed countries, 1/5% chance bacterial keratitis in lifetime
    • Trauma
    • Corneal surgery
    • Ocular surface disease
    • Systemic disease
    • Immunosuppression
    • Antibiotic overuse
72
Q

Neurotrophic Keratitis

  • Characteristics?
  • Causes
  • Stages?
  • Complications
  • Signs
  • Diagnosis
  • Treatment
A
  • Loss of trigeminal innervation to the cornea resulting in anesthesia (partial or complete)
  • Degeneration of corneal epithelium
  • Causes
    • Acquired CN V damage
    • Systemic disease
    • Ocular disease
    • Congenital
    • Toxicity from long term medication use

Stages

  • Stage 1
    • ​Mild, nonspecific sn/sx
    • Rose bengal staining of inferior palpebral conjunctiva
    • Increased viscosity of tears with decreased TBUT & subsequent dry patches on the cornea
      • Stain with NaFL
    • Vascularization & scarring occur if progression not halted
  • Stage 2
    • ​Non-healing corneal epithelial defect with surrounding loosening of epithelial tissue
    • Folds in Descemet’s develop as stromal edema increases
    • Punched-out lesion develops
  • Stage 3
    • ​Stroma melting which leads to perforation
    • No pain due to decreased corneal sensation ​

Complications

  • Intracellular edema
  • Exfoliation of epithelial cells
  • Impairment of epithelial healing
  • Loss of goblet cells
  • Persistent ulceration

Signs

  • Interpalpebral punctate keratopathy
  • Epithelial opacification
  • Persistent epithelial defect with rolled edges
  • Enlargement of defect with stromal edema & infiltration
  • Stromal corneal melting
  • Perforation uncommon, generally a result of secondary infection

Treatment

  • D/C toxic medication
  • Topical lubrication
    • PFAT drops or ointment
  • Punctal occlusion
  • Protect ocular surface
    • Lid taping at night
    • Prophylactic antibiotic
    • BOTOX injection to induce ptosis
    • Tarsorrhaphy
    • Therapeutic CL
    • Amniotic membrane
  • Corneal transplant in late disease
73
Q

Recurrent Corneal Erosions

  • Characteristics
  • Symptoms
  • Risk Factors
  • Presentation
  • Tx
A
  • Episodic erosion/ denuding of corneal epithelium
  • Complete resolution between attacks
  • Unpredictable & variable presentation
  • Abnormally weak attachment between basal cell in corneal epithelium and basement membrane

Symptoms

  • Begins in late evening/early morning hours
  • Abrupt ripping/tearing sensation
  • Severe pain
  • Photophobia
  • Redness
  • Blepharospasm
  • Watering
  • Decreased vision
  • Epithelial defect often present, although may be healing when pt presents to clinic

Risk Factors

  • Prior corneal trauma**
  • EBMD**
  • Epithelial, Bowman’s & stromal dystrophies
  • Lid margin disease &/or dry eye
  • Bullous keratopathy
  • Diabetes

Presentation

  • Area of epithelial irregularity
    • Punctate defects
    • Large area of absent epithelium with ragged edges
  • Conjunctival injection
    • More dense near area of abrasion
  • Lid edema possible
  • Significant watering
  • Rarely mild anterior chamber reaction
  • Pt likely comes in with sunglasses or eyes closed

Treatment

  • Acute management
    • ​Lubrication
    • Antibiotics ointment
    • Cycloplegia
    • Tropical/oral NSAID
    • Debridement of loose epithelial edges
    • Bandage CL
    • Hypertonic saline
  • Recurrent/maintenance
    • ​Tropical ointment or gel prior to sleep
  • Others
    • ​Autologous serum
    • Doxycycline
  • Surgical
    • ​Anterior stromal micropuncture
    • Debridement & super-K
    • PTK
74
Q

Endotheliitis

  • Management?
A
  • Topical steroids
    • Mild to moderate disciform or diffuse endotheliitis
  • Oral steroids
    • Severe disciform or diffuse endotheliitis
    • All cases of linear endotheliitis
  • Oral antivirals
    • ​Select cases of disciform or diffuse endotheliitis
    • All cases of linear endotheliitis
75
Q

Lipid Degeneration

  • What is it?
  • What is the difference between primary & secondary lipid degeneration?
  • What are the secondary disease associations?
  • Complications?
  • Treatments?
A
  • Dense, yellow-white opacity that may fan out with feathery edges from blood vessels
    • Deposit consist of cholesterol, fats & phospholipids
  • Multicolored crystals may be seen at the edge of opacity
  • Primary
    • Rare, spontaneous development
    • Not associated with vascularization
    • No previous trauma
    • Serum lipids in normal range
    • Lipid deposition central or peripheral
    • Lesion consists of cholesterol, triglycerides, & phospholipids
    • Theorized that may be due to increased vascular permeability of limbal vessels
    • Women > Men
  • Secondary
    • ​More common
    • Develops rapidly in an area with long-standing vascularization
    • Grey to yellow-white lesion
    • Variable appearance to lesions
      • Sea-fan shaped with feathery edges (post-inflammatory)
      • Dense discoid (active inflammation)
    • Regression possible with normalization of lipids or decrease of inflammation
  • Secondary Disease Associations
    • ​Trauma
    • Ulceration
    • Hydrops
    • Interstitial keratitis
    • HZO
  • Complication
    • ​Cosmesis
    • Decreased vision
      • ​May be rapid onset
  • Treatment
    • ​Argon laser to feeder vessels
    • Needle point cautery to feeder vessels
    • PK - may recur in graft
76
Q

Congenital Hereditary Endothelial Dystrophy (CHED)

  • Characteristics?
  • Symptoms?
  • Signs?
  • Tx?
A
  • AR & AD
  • Congenital to 1-2 years
  • Saudia Arabia & India
  • Bilateral, symmetric
  • Noninflammatory corneal clouding
    • Extends to limbus without clear zones
    • No other anterior segment anomalies
  • Dx of exclusion
  • Sx
    • Blurred vision
    • Photophobia
    • Tearing
    • Nystagmus - in AR cases
  • Signs
    • Level of clouding variable
      • Mild haze to dense clouding
    • Increased corneal thickness & thickening of Descemet’s
  • Treatment - PK
77
Q

List the non-infectious keratopathy

A
  • Recurrent corneal erosion
  • Filamentary keratitis
  • Thygeson’s superficial punctate keratitis
  • Neurotrophic keratitis
  • Graft vs Host Disease (GVHD)
78
Q

Lasik

A
  • Laser-Assisted in Situ keratomileusis
  • NOT LASIX (furosemide) = diuretic used in HTN
  • Approved for myopic, hyperopic, astigmatism correction
  • Procedures
    • Flap created
    • Laser ablation of stromal tissue
    • Flap returned to position
  • Benefits
    • Wide range of corrections
    • Fast recovery period
  • Complications
    • Incomplete or excessive correction
    • Flap dislocation
    • DLK
    • Photophobia
    • Glare/haloes
    • Transient increased IOP
    • Epithelial ingrowths
    • Corneal ectasia
    • Dryness
    • Regression
79
Q

Describe the image

80
Q

Crocodile Shagreen

  • What does it look like?
  • What are the 2 forms?
  • Tx?
A
  • Bilateral, central, grey-white opacification in anterior or posterior cornea
    • Mosaic or cracked ice pattern
  • Anterior form = senile change or associated with ocular trauma/inflammatory conditions
  • Posterior form = solely senile change generally not visually significant
  • Tx = none
81
Q

Thygeson’s Superficial Punctate Keratitis

  • Characteristics
  • Features
  • Symptoms
  • Signs
  • Treatments
A
  • Uncommon, usually bilateral
    • Asymmetric
  • Idiopathic keratopathy
    • Viral & immunologic mechanisms speculated
  • Most commonly affects young adults, but can occur at any age
  • Female>men - slight

Characteristics

  • Coarse punctate epithelial keratitis
    • Often occur in central cornea
  • Little or no hyperemia of the bulbar or palpebral conjunctiva
  • Episodes of exacerbations & remissions
    • Episode can last 1-2 months
    • Remissions ~6 weeks

Features

  • Chronic, bilateral punctate epithelial keratitis
  • Long duration with remission & exacerbations
  • Healing without scars
  • Lack of response to systemic or topical antibiotics sulfonamides or to the removal of the corneal epithelium
  • Striking symptomatic response to topical steroids

Symptoms

  • Recurrent attacks
  • FBS
  • Photophobia
  • Blurred vision
  • Watering
  • Minimal decrease VA

Signs

  • Oval to round grouped punctate intraepithelial deposits
    • Numerous, discrete, granular, white/grey opacities
    • Slightly elevated
    • May have stellate appearance
    • Often in/near visual axis
    • No staining during inactive phase
    • Staining with NaFL/Rose Bengal during active phase
  • Mild epithelial/subepithelial edema or haze
  • No infiltration
  • White eye

Treatment

  • Lubrication in mild cases
  • Steroids with gradual tapering
  • Restasis
  • CLs - if steroids contraindicated or in addition
  • PTK
82
Q

Fleischer’s ring (Iron lines)

A
  • Forms at base of keratoconus, may progress to full ring
  • Ferritin deposits in cytoplasm of corneal epithelial cells & in widened epithelial intercellular space
83
Q

List the Ocular Infection (Recurrent)

A
  • Conjunctivitis
  • Keratitis
  • Iridocyclitis
  • Retinal involvement
84
Q

Granular Dystrophy Type 2 (Avellino Dystrophy)

  • Inheritance? Mutation?
  • Characteristics?
A
  • AKA: Avellino Dystrophy
  • AD inheritance
  • TGFBI gene mutation
  • Combined granular-lattice corneal dystrophy
    • Early diseases has granular appearance & develops lattice lines later
  • Presents in 2nd decade
  • Characteristics
    • ​Anterior stromal discrete white-grey granular deposits
      • Become larger & coalesce with age
    • Mid to posterior stromal lattice lesions
      • Move more centrally with age
    • Anterior stromal haze
  • Symptoms
    • ​FBS
    • Pain
    • Photophobia
  • Treatment
    • ​Lubrication/BCL for epi erosions
    • PK
85
Q

Infectious epithelial keratitis/Dendritic keratitis

  • Epithelial dendrite?
  • Sx?
  • Signs?
A
  • Reactivation of live virus
  • Epithelial dendrite
    • Most common presentation in herpes simplex keratitis
    • Linear, branching ulcerated lesion with terminal end bulbs
      • Ulcerations = represent areas of epithelial breakdown due to cytopathic effects of herpes simplex virus
    • Terminal end bulbs
      • Intact, virally-infected epithelium
      • Lead edge of the dendrite
    • Stain with NaFL & Rose Bengal
  • Symptoms
    • Tearing
    • Photophobia
    • Pain
    • Blurred vision
      • If cenral lesions present
    • Decreased corneal sensation
    • Intense ciliary injection
    • **Most painful at first manifestation
  • Signs
    • ​Corneal vesicles
    • Ulcer develop within 24 hrs
      • Dendritic ulcers
        • Linear, branching ulcerated lesion with terminal end bulbs
        • Most common presentation of HSV keratitis
          • Stains w/ NaFL along length of lesion & Rose Bengal at base of lesion
        • Ulcerations
          • Represent areas of epithelial breakdown due to cytopathic effects of herpes simplex virus
        • Terminal end bulbs
          • Intact, virally-infected epithelium
          • Leading edge of the dendrite
    • ​Geographic ulcers
      • Enlarged, non-linear ulcer with scalloped borders
      • Associated with longer duration of sx & longer healing time
    • Marginal ulcer
      • Ulceration near limbus
      • Stromal infiltrate directly under ulcer
      • Adjacent limbal injection uncommon
86
Q

Herpetic Eye Disease Study (I & II)

  • What are the typical treatments for HSV in the eye?
  • What can these treatments help prevent or help? What are the specific medications and what does it help treat for?
A
  • Goals
    • Determine appropriate treatment of ocular involvement using topical steroids or oral antivirals
  • Outcomes
    • Oral antiviral prophylaxis reduces epithelial & or stromal keratitis
    • Use of topical steroids is of benefit of stromal keratitis
    • Use of oral acyclovir may be of help in iridocyclitis
    • Prophylactic oral acyclovir helps prevent recurrences of herpetic keratitis, particularly stromal with a history of recurrence (herpes gift of giving)
87
Q

Reis-Buckler’s Vs. Thiel-Behnke

  • Inheritance pattern
  • Age of onset
  • Presentation
  • Symptoms
  • Tx
88
Q

Hudson-Stahli line (Iron lines)

A
  • Formed in inferior 1/3 of cornea in band zone where the lids meet
  • Iron deposition in cytoplasm of epithelial cells
  • Normal aging process
    • 5th-6th
  • Association with chronic DES
89
Q

Infectious epithelial keratitis/Dendritic keratitis (HSV I & II)

  • Management?
A
  • Antiviral ointment q2hr until total epithelial helaing then q4hr x 7 days
    • Lesion generally heal in 3-7 days
  • Oral antiviral optional
    • Acyclovir 400mg 5x/day
    • Valacyclovir 500mg TID
    • Famciclovir 250mg TID
  • Cycloplegic for comfort (decrease photophobia & pain)
  • Frequent artificial tears
  • AVOID STEROIDS **** (Can cause geographic keratitis, contraindicated in epithelial keratitis)
  • Initial follow-up 24 hours, then 4-5 days
90
Q

Describe management and treatment of keratoconus? Follow up?

A
  • Management
    • ​ Varies based on severity of disease & risk of progression
      • More aggressive treatment in younger pt
    • Tailored to the individual
      • Depends on degree of visual impairment & likelihood of progression
    • Avoid eye rubbing
    • No corneal refractive surgeries
    • Vision correction
    • Corneal cross-linking (removing epithelium layer off eye)
    • Surgical procedures
      • Intacts
      • Penetrating keratoplasty
  • Treatment
    • ​Spectacle correction
      • Good for early disease
    • Contact lens correction
      • RGP Scleral or mini-scleral
      • Hybrid designs
      • Specialty soft lenses
      • Piggyback lenses
    • Surgical options
      • PK
        • full thickness transplant
        • Highly successful, but last resort
      • Intacs
        • PMMA rings inserted into stroma
        • Goal is central flattening to improve vision
        • DOES NOT halt progression
      • Corneal cross linking
        • FDA approved april 2016
        • Increases corneal rigidity to halt progression of disease
  • Follow up
    • ​Variable depending on status of disease & tx protocal used
  • Generally
    • ​young pt: see every 4-6 mo
    • 20-30s: see every 6-12 months
    • 40+: annual exams usually sufficient
91
Q

Endotheliitis

A
  • Immune response to viral antigen
  • Features
    • ​Stromal & epithelial edema without infiltrate
    • Keratic precippitates
    • Iritis
  • Types
    • ​Disciform
    • Diffuse
    • Linear
92
Q

Iridocyclitis

  • Management?
A
  • Oral antiviral
    • Oral antiviral
  • Topical steroid
    • Oral in severe cases
  • Cyclopegic comfort
  • IOP management
93
Q

Management Recommendations for bacterial keratitis?

A
  • Small ulcer away from visual axis
    • Treat with broad spectrum commercial antibiotic
    • May not need initial culture
  • Large ulcer on visual axis
    • Treat with broad spectrum fortified antibiotic
    • Culture immediately
    • Must follow pt carefully
  • Medical-legal standpoint
    • Standard of care in community is usually ok, but universal precautions better
94
Q

Thiel-Behnke Honeycomb Dystrophy (CBD II)

  • Characteristics?
  • Presentation?
  • Symptoms?
  • Treatment?
A
  • AD
  • TGFB1 gne mutation
  • Considered a variant of Reis-Bucklers
  • Born with normal cornea
  • Develops in 1st & 2nd decades
  • VA retained later than Reis-Bucklers
  • Presentation ​
    • ​Corneal opacification
    • Severe recurrent erosions
    • Reticular corneal scarring
    • Honeycomb changes in Bowman’s layer
    • Normal corneal sensation
    • Smooth epithelial surface
  • Symptoms
    • ​Pain, photophobia, from corneal erosion
    • Decreased vision
      • VA retained later in life compared to CBD I
  • Treatment
    • Superficial debridement
    • PTK
    • PK
      *
95
Q

Dellen

A
  • Area of localized thinning located adjacent to a paralimbal elevation
  • Cause
    • Age-related change
    • Local dehydration of the cornea
  • Short-lived - usually last 24-48 hrs
  • Treatment
    • Lubrication (tears or ointments)
    • Pressure patch
96
Q

What are the different stages of keratoconus?

A
  • Forme fruste
    • Early or incomplete
    • Disease barely detectable & often missed
  • Modest keratoconus
    • ​Generally begin to have vision difficulties in softs CLs or spectacles
  • Advanced keratoconus
    • ​obvious clinical signs
    • Poor vision with spectacle correction
  • Severe keratoconus
    • Significant clinical signs
    • Consideration of surgical therapies
  • Acute keratoconus/corneal hydrops
    • ​Only occurs with severe diseases
    • Rupture in descemet’s membrane leads to severe stromal swelling
    • Must be manged clinically before surgery considered
97
Q

Ferry’s Line (Iron lines)

A
  • Forms in front of filtering bleb
  • Iron deposited in cytoplasm of basal epithelial cells
  • Only forms in elevated bleb
98
Q

Hassell-Henle Bodies

  • What layer is this found in?
  • What is it?
  • What is identical to?
A
  • Descemet’s warts
  • Excresence of descemet’s membrane in peripheral cornea
    • Localized thickening occurring in peripheral cornea
  • Histologically identical to guttata
    • DO NOT signify cornea disease
  • One of the most common age-related corneal changes
99
Q

Fabry’s Disease

  • Characteristics?
  • Systemic?
  • Ocular effects?
A
  • X-linked recessive disorder
    • Males = full expression
    • Females = carriers, can exhibit disease characteristics
  • Multisystemic disorder that ultimately results in irreversible, potentially life-threatening disease of kidney, heart & brain
  • Deficiency of a-galactosidase A
  • Lysosomal storage disorder
  • Disease characteristics
    • ​Angiokeratomas
    • Febrile crises with peripheral extremity pain
    • Renal failure
    • CVD
    • Neurologic changes
  • Symptoms generally appear in childhood, but go unrecognized until adulthood
    • damage already ocurred
  • Corneal changes are earliest & most consistent ocular abnormality
    • Affected males & females carriers
  • Systemic
    • Progressive &/or unexplained kidney disease
    • Premature cardiac disease
    • Premature stroke
    • Burning pain in hands/feet
    • Hypohydrosis/Anhydrosis
    • Angiokeratomas
  • Ocular
    • ​Corneal verticillata
    • Posterior subcapsular cataracts
      • Whitish spoke-like deposits of granular material
    • Aneurysmal dilation of venules on bulbar conjunctiva
    • Mild to marked tortuosity & angulation of retinal vessels
100
Q

What are some systemic disease associated with keratoconus?

A
  • Albinism
  • Congenital rubella
  • Crouzon syndrome
  • Down syndrome
  • Ehlers-Danlos syndrome
  • Marfan syndrome
  • Neurfibromatosis
  • Osteogenesis imperfecta
  • Retinitis pigmentosa
  • ** DM has decrease risk of KCN (DM x II has increase risk of KCN)
101
Q

List the infections of cornea

A
  • Bacterial keratitis
  • Viral keratitis
    • Herpes simplex keratitis
    • Herpes zoster keratitis
    • Less common viral infection
  • Fungal keratitis
  • Parasitic corneal infection
    • Acanthomoeba
102
Q

Acanthamoeba

  • Characteristics?
  • What can it cause?
A
  • One of the most ubiquitous organisms in the environment, rarely causes infection
  • Infections serious & vision threatening
  • Increased risk: CL use
    • 80% cases associated with CL use
    • Using tap water to clean CLs or CL case
    • Swimming with CLs in, esp in lakes & rivers
    • Poor CL hygiene
  • Any age of onset
  • No sex predilection
  • Usually Unilateral

Acanthomoeba keratitis

  • Severe, incapaciting pain
  • Ring infiltrate
  • Decreased VA
  • Radial keratoneuritis
  • Photophobia
  • Limbitis
  • Scleritis
  • Uveitis
  • Eyelid edema
  • Dacryoadenitis (inflammation of lacrimal glands)

Radial keratoneuritis

  • Inflammatory response of the corneal nerves
  • Infiltrate along corneal nerves
  • Clinical appearance
    • Thickened corneal nerves with ragged borders
    • Located in the anterior or mid-stroma
    • Distributed in a linear radial pattern
  • Occurs early in acanthamoeba corneal infection
103
Q

The limbus is ….?

A

Highly vascularized and contains pluripotent stem cells

104
Q

List the Corneal Manifestations of Metabolic Disease

A
  • Fabry disease
  • Drug induced
    • Chloroquine
    • Amiodarone
    • Tamoxifen
105
Q

HZO

  • Complications?
  • Management?
  • Prevention?
A

Complications

  • Exposure keratitis
  • Neurotrophic keratitis
  • Motor nerve involvement
  • Post-herpetic neuralgia
    • 7% all zoster pt
    • Chronic pain, variable duration
    • Approximately half of pt describe their pain as “horrible” or excruciating”, ranging in duration from a few mins to constant, on a daily or almost daily bases
    • There have been reports of suicide in elderly pt because of the unbearable pain

Maangement

  • Oral antiviral for 7-10 days
    • ​Acyclovir 800mg 5x/day x 10 days
    • Valacyclovir 100mg TID x 7 days
    • Famciclovir 500mg TID x 7 days
    • Decreases incidence of ocular involvement from 70% to 40%
    • Most effective when start within 72 hours onset
  • Topical antiviral
  • Steroids
    • Decreased severity

Prevention

  • Varicella vaccine
    • Children
    • Introduce in 1995
    • 2 doses - between 12-15 months & between 4-6yrs
  • Shingles vaccine
    • Adults
    • Introduced in 2006
    • CDC recommends in adults _>_60yo (approved for pt over 50)
      • Protections last ~yrs
    • Reduces risk of development of shingles by 51%
    • Reduces risk of post herpetic neuralgia by 67%
106
Q

List the Epithelial Dystrophies

A
  • Meesmann’s dystrophy
  • Epithelial basement membrane dystrophy (EBMD)
107
Q

Central cloudy dystrophy of Francois

  • Characterisitics?
  • Symptoms?
  • Treatment?
A
  • Uknown inheritance
    • AD supsected
  • Bilateral, symmetric
  • Non-progressive
  • Cloud central polygonal or rounded stromal opacities
    • Occur in central 1/3 of cornea
    • Deep stromal layers
  • Develops in 1st decade
  • Symptoms - Mostly asymptomatic
  • Treatment - None
108
Q

List the viral keratitis

A

Herpes simplex, Herpes zoster, Less common

109
Q

Review of stromal corneal dystrophies

  • Inheritance pattern
  • Age of onset
  • Presentation
  • Sx
  • Tx
110
Q

Linear endothelitis

  • Sx?
  • Presentation?
  • tx?
A
  • Sx similar to other forms of endothelitis
    • MOST SEVERE presentation & hardest to get them undercontrol
  • Presentation
    • ​Line of KPs that progress centrally from the limbus
      • May be sectoral or circumferential
    • Peripheral stromal & epithelial edema
  • Tx difficult
111
Q

Describe the innervation of the cornea?

A
  • Heavly innervated & sensitive tissue
    • Density of nerve endings about 300-400x greater in cornea than in skin
  • Derived from ciliary nerves
    • Penetrate cornea in deep peripheral stroma radially and move anteriorly
    • Lose myelination shortly after entering cornea
    • Penetrate Bowman’s layer
    • Terminate in wing cells of corneal epithelium
  • Sensation helps maintain functional integrity of the cornea
    • Reflex tearing
    • Blinking
  • Innervation
    • ​Enlarged, prominent corneal nerves
112
Q

Pre-Descemet’s Corneal Dystrophy

  • Characteristics?
  • Sx?
  • Tx?
A
  • Unknown Inheritance
    • AD, sporadic, age-related theorized
  • Bilateral, symmeric
  • Older adults
    • _>_30yo
  • Focal, fine gray opacities in deep stroma
    • Some lesions larger
    • Variable shape - snowflake
  • Symptoms
    • ​Asymptomatic - VA not affected
  • Treatment
    • ​None
113
Q

Name the 6 layers of the cornea ? What are the characteristics of each?

A

Epithelium

  • Surface layer
  • 55um
  • Barrier function: block debris, bacteria & foreign substances
  • Constantly regnerating & sloughed

Bowman’s Layer

  • Basement membrane
  • 5um
  • Prevents forward corneal swelling

Stroma

  • Majority of cornea
  • 485um
  • Strength elasticity

Dua’s Layer

  • newly discovered
  • 10-15um

Descemet’s membrane

  • basement membrane
  • 10um
  • endothelial cell health

Endothelium

  • innermost layer
  • 5um
  • Barrier pump maintaining proper hydration of cornea
  • single cell layer thickness
114
Q

Schnyder’s Corneal Dystrophy

  • Other names?
  • Characteristics? Gene mutation?
  • Symptoms?
  • Treatment?
A
  • AKA: Schnyder’s crystalline dystrophy, central stromal crystalline dystrophy
  • AD inheritance
  • Rare
    • <100 case reported
    • Large cohort from central MA
  • Presents 1st decade
  • Mutation in UBIAD1 gene
    • Leads to improper metabolism of corneal keratocytes and deposition of crystalline cholesterol & phospholipids in the stroma
    • Strong association with hypercholesterolemia
  • Ring-shaped accumulation of fine needle shaped polychromatic crystal deposits
    • Throughout entire stroma
  • Symptoms
    • ​Vision loss in middle age
    • Decreased corneal sensation possible
  • Treatment
    • ​PTK - ablate crystals
    • PK - deeper involvement
115
Q

Congenital Anterior Staphyloma

A
  • Rare
  • Bulging, opaque cornea lined with uveal tissue that protrudes beyond normal plane of lids
  • Unilateral or bilateral
  • Variable thinning of cornea
  • Deep, disorganized anterior chamber
    • Lens may be adherent to cornea
  • Cause
    • ​Abnormal migration of neural crest cells into developing cornea
    • Abnormal differentiation of mesodermal cells
    • Intrauterine keratitis
  • Bilateral anterior staphyloma
  • B-scan showing iris adherent to cornea
  • T2 MRI showing enlarged globes & lens displaced into vitreous cavity
  • Complication
    • ​Blind eye
    • High risk of glaucoma
  • Treatment
    • ​Penetrating keratoplasty
      • Graft failure common due to size
      • Boston K-pro
      • Glaucoma filtering surgery
      • Enucleation
116
Q

Chickenpox

  • What is it?
  • Accompanied by what?
  • Ocular manifestations?
A
  • Acute infectious exanthema (skin rash) with vesicular eruptions of the skin
  • Acompanied by
    • Fever, sore throat, myalgia, anorexia, HA
  • Ocular manifestations possible
    • Mild conjunctivitis & episcleritis
    • Less commonly: micro-dendritic keratitis, nummular keratitis, disciform keratitis, mucous plaque keratitis, sclerokeratitis & iritis
  • Infection in childhood generally self-limiting
  • Infection in neonates, adults or elderly generally severe
    • Can lead to pneumonia or encephalitis
  • Routine vaccination now common
117
Q

Corneal dystrophy

  • Define
  • Which layers are affected? Characteristics of each?
A
  • corneal opacity or alteration which is most often bilateral & progressive, occurs after birth, & is not inflammatory
  • Characterized by layer affected
    • Epithelial
    • Bowman’s layer
    • Stromal
    • Descemet’s & Endothelial layer
118
Q

Rheumatoid Arthritis

  • What is it? Statistics?
  • Ocular complications?
  • Tx? Systemic & ocular
A
  • Auto-immune inflammatory condition mostly affecting joints
    • Chronic, progressive disease
    • Inadequate tx leads to 40-50% mortality at 5 years
    • Women > Men
    • 4th-6th decades
    • Ocular complications indicate more severe presentation

Ocular Complications

  • Keratitis
    • ​Sclerosis keratitis
      • ​Occurs mostly in area adjacent to area of active scleritis
      • Peripheral cornea thickens & becomes vascularized
      • May extend circumferentially as disease progresses
    • Acute stromal keratitis
    • Limbal guttering
    • Peripheral ulcerative keratitis
      • ​Often associated with necrotizing scleritis
      • Juxtalimbal thinning of stromal tissue with an overlying epithelial defect
      • Crescent shaped corneal ulceration within 2-5mm from limbus
      • Thinning may be severe enough to cause perforation
      • Pts c/o pain, redness, tearing, photophobia, decreased vision

Treatment

  • Systemic disease
    • Immunomodulators
    • NSAIDs
  • Ocular Treatment
    • ​Lubrication
    • Restasis
    • Topical steroids
    • Oral NSAIDs
    • PK
    • Amniotic membrane therapy
119
Q

Refractive Surgery

A
  • Contraindications
    • Fuch’s dystrophy
    • EBMD
    • Peripheral retinal thinning or tears
    • Systemic autoimmune disease
    • Pregnancy or nursing
    • Severe dry eye or lid margin disease should be addressed & managed prior to surgery
  • Evaluation
    • ​VA: corrected/uncorrected
    • Refraction: Including cycloplegic
    • Keratometry
    • Pupil testing
      • Evaluation of pupil size in bright & dim conditions
    • Pachymetry
    • Complete dilated eye exam
    • Dry eye testing
    • Corneal topography
  • Refractive surgery
    • ​Determination of power correction & residual stromal tissue
      • t = S2 x D/3
        • t = thickness, S = diameter of correction, D = dioptric power
        • Average treatment diameter of 6mm = 12um removed
      • pachy - (flap - t) = residual
        • Residual stromal bed of at least 250um
120
Q

Stocker’s line (Iron lines)

A
  • Vertical line that forms at advancing edge of pterygium
  • Color yellow to golden brown
  • Role in development of pterygia is unknown
121
Q

List the corneal degenerations

A
  • Arcus Senilis
  • Lipid degeneration
  • Spheroid degeneration
  • Climatic proteoglycan stromal keratopathy
  • Amyloid degeneration
  • Salzmann’s nodular degeneration
  • Corneal keloids
  • Limbal girdle of Vogt
  • Band keratopathy
  • Iron lines
  • Coat’s White ring
  • Hassall-Henle bodies
  • Crocodile shagreen
  • Senile furrow
  • Corneal farinata
  • Dellen
122
Q

Limbal Girdle of Vogt

  • What does it look like, where does it mostly occur?
  • At what age does it start?
  • What are the 2 types? Characteristics for each?
A
  • Yellow-white crescent-shaped band in interpalpebral limbus
    • Nasal > Temporal
    • Inferior possible
  • Incidence increases with age
    • ​< 20 yo = 0
    • 40-60 yo = 55%
    • _>_80 yo = 100%
  • Types
    • ​Calcific - lucid interval at limbus
      • May contain holes
      • Central border sharply defined with no extensions
      • Thought to represent early calcific band keratopathy
    • Elastotic - no lucid interval
      • ​True limbal girdle
      • Chalky band
      • No holes
      • Central irregular linear extension
123
Q

Posterior amorphous corneal dystrophy

  • Characteristics?
  • Symptoms?
  • Treatments?
A
  • AD inheritance
  • Gene mutation has not been determined
  • Appears in 1st decade
  • Slow progression
  • Bilateral, symmetric
  • Diffuse, gray-white, sheet-like opacities in the posterior stroma
  • Central corneal thinning
  • Flat topography
  • Symptoms
    • ​Mild vision reduction
    • >20/40
  • Treatment
    • ​None
124
Q

Amyloid Degeneration

  • What does it look like?
  • Characteristics?
  • Describe primary vs secondary form?
  • What are the systemic associations for amyloid degeneration?
  • Treatment?
A
  • Group of proteins with starch-like staining characteristics
    • Stains w/ congo red
    • Exhibits birefringence in polarized light
    • Exhibits dichromism in green light
  • Local or systemic
    • Systemic rarely has ocular manifestations
  • Primary or Secondary
    • Primary
      • ​Pleomorphic amyloid degeneration
        • Pleomorphic punctate of filamentous opacities in the central cornea
          • Refractile, polygonal grey-white opacities in central cornea
        • _>_50 yo age related change
        • No visual effect
        • Not associated with systemic disease
      • Conjunctival amyloidosis
        • Yellow or pinkish mass located in eyelids or conjunctival fornix
          • Rarely occurs on bulbar conj
        • Warrants a referral to r/o life-threatening disease
    • Secondary
      • ​Occur in association with trauma or prolonged inflammatory conditions
      • Most common cause of corneal amyloidosis involvement
      • Associations
        • Trauma
        • ROP
        • Trachoma
        • Phlyctenular disease
  • Amyloid Degeneration: Systemic Associations
    • Primary
      • Cardiomyopathy
      • GI disease
      • Peripheral neuropathies
      • Facial nerve palsies
    • Secondary
      • Tuberculosis
      • Osteomyelitis
      • Rheumatoid arthritis
      • Syphilis
      • Leprosy
  • Treatment
    • Depends on presentation, patients sx & visual significance
    • Conjunctival
      • Conservative therapy
      • Liquid nitrogen cryotherapy
    • Monitor/treat IOP
    • Vitreal
      • Pars plana vitrectomy (PPV)
125
Q

Corneal Transplants implications?

A
  • Corneal opacification
  • Endothelial disease
  • Ectasic disease
126
Q

Posterior Keratoconus

A
  • Rare, development condition
  • More commonly unilateral
  • Usually present at birth
  • Non-progressive
  • Thinning due to increased curvature of posterior cornea
  • Guttata occasionally seen within lesion
  • Pigment occasionally present at edge of lesion
  • Mild to moderate corneal astigmatism
  • Decrease vision
    • Corneal scarring
    • Associated ocular disease
    • Amblyopia
  • Forms
    • ​Generalized
      • Increased posterior curvature with shorter radius
      • Normal anterior curvature
      • Central cornea may be thinned
      • Cornea clear
    • Focal
      • More common
      • One or more localized, crater-like lesions in central or peripheral posterior cornea
      • Corneal clouding common
      • Thinning variable
      • Associated with ocular or systemic anomalities
  • Complications
    • ​corneal clouding possible
    • Rarely affects VA
      • Myopic astigmastims most frequent
  • Treatment
    • ​None
    • Spectacle correction
    • Penetrating keratoplasty (PK)
127
Q

Mooren’s Ulcer

  • What is it?
  • Presentation?
  • Types?
A
  • Painful, progressive, idiopathic chronic ulcerative keratitis
  • Begins peripherally & moves circumferentially & central
  • No associated systemic disease or scleritis
  • Men > Women
  • 40-70yo, but any age possible
  • More common unilateral

Presentation

  • Grey-white crescent shaped infiltrate & ulceration in peripheral cornea
  • Progressive circumferential & central stromal thinning
  • Vascularization involving bed of ulcer up to the lead age
  • Thinning, vascularization & scarring

Types

  • Unilateral Mooren’s Ulceration
    • ​Painful, progressive ulceration in ELDERLY pts
    • Associated w/ non-perfusion of superfical plexus of the anterior segment
  • Bilateral, aggressive Mooren’s ulceration
    • ​YOUNG pts
    • Ulceration that progresses circumferentially, then centrally
    • Vascular leakage & neovascularization extending to the base of the ulcer
  • Bilateral, indolent Mooren’s ulceration
    • ​Middle-AGED pts
    • Bilateral, progressive peripheral guttering
    • Little inflammatory response
    • No vascular changes or neovascularization

Symptoms

  • Pain - often out of proportion to inflammation
  • Photophobia
  • Injection
  • Lacrimation
  • Blurred vision - due to 2^iritis, central corneal involvement or irreg. astigmatism

Complications

  • Severe irregular astigmatism
  • Perforation from minor trauma
    • More common in peripheral ulceration, compared to total ulceration
  • Infection
  • Cataract
  • Glaucoma

Treatment

  • Tropical steroids - hourly
  • Prophylactic antibiotic Restasis - takes weeks to become effective
  • Restasis - takes weeks to become effective
  • Supportive therapy
  • Conjunctival resection
  • Systemic immunosuppression
  • Doxycycline
  • Lamellar/penetrating keratoplasty
128
Q

What are some clinical signs of HZO?

A
  • Periocular
    • ​Viscular rash on upper lid, forehead & scalp of affected side
    • Hutchinson sign
  • Lids
    • ​Ptosis
    • Blepharitis
    • Edema
    • Trichiasis, madarosis, lash loss
  • Conjunctiva
    • ​Chemosis
    • Mucopurulent conjunctivitis
  • Scleritis or episcleritis
  • Cornea
    • ​PEK
    • Infiltrates
    • Pseudodendrites
    • Nummular keratitis
  • Uvea
    • ​Chronic non-granulomatous uveitis
      • Most common presentation******
      • Often with elevated IOP
  • Other
    • ​Retinitis
    • Acute retinal necrosis
    • Choroiditis
129
Q

Review of endothelial corneal dystrophies

130
Q

Iridocyclitis

A
  • May occur with ocular involvement or as only sign
  • Clinical manifestation
    • Often very mild cell/flare with grossly elevated IOP
    • IOP responds well to tx with B-blocker
    • Inflammatory vs infectious
    • PGA contraindicated
131
Q

List the Non-inflammatory ectatic disorders

A
  • Keratoconus
  • Pellucid marginal degeneration
  • Keratoglobus
  • Posterior keratoconus
  • Congenital anterior staphyloma
132
Q

PK/PKP

A
  • Penetrating keratoplasty
  • Corneal transplant
  • Highly successful surgery
    • >90% success of restoring vision
133
Q

Corneal Verticillata

A
  • AKA: corneal whorls
  • Whorl-like pattern of powdery, white, yellow or brown corneal epithelial depositis
  • Form in a vortex pattern in inferocentral cornea & swirls outward sparing the limbus
  • Cause
    • Amiodarone
    • Chloroquine
    • Tamoxifen
    • Fabry’s disease
134
Q

Fungal keratitis

  • Symptoms?
  • Signs?
A
  • Varies by organism

Similar sx to bacterial uclers

  • Pain
    • Initially FBS x several days that worsens to increasing pain
  • Photophobia
  • Decreased VA
  • Redness
  • Lid swelling
  • Discharge
  • Pt report of “white spot” on eye

Sign

  • ​Feathery, poory defined borders of infiltrate***
  • Unifocal or multifocal infiltrate
  • Rough looking surface texture
  • Ulcer may be elevated & exhibit branching lines
  • White PMN ring often present
  • Possible neovascularization
  • Superficial epithelium may heal while organism continues to invade deeper into tissue
  • Hypopyon
  • Keratitis 1-3 weeks after trauma
  • **Definitive diagnosis of bacterial vs fungal keratitis cannot be made by clinical appearance alone

Management

  • Culture!
    • Sabouraud’s agar without cyclohexamide
    • Thioglycolate broth
    • PCR
    • Confocal microscopy
  • Therapy usually not begun until microbial evidence
  • Usually lasts 6 weeks
  • Daily mechanical debridement because antifungals have poor corneal penetration
  • Filamentous fungi
    • Natamycin
      • only commercially available antifungal
      • Q1hr around the clock
    • Yeast
      • Q30 mins x 1st 24 hrs
      • Q1hr x 2nd 24 hrs
      • Slow taper according to clinical response
    • Oral antifungals
      • Usually maintained x 12 weeks
    • NO STEROIDS
    • Subconjunctival injection for severe keratitis or keratoscleritis
    • Considered hospitalization
135
Q

Corneal Surgery Post/op meds & Protocol?

A
  • Post-op meds
    • ​Topical antibiotics - generally given for 1 wk
    • Topical steroids - tapered
    • Topical NSAID possible
      • depends on surgeon & procedure varaible duration
    • PFATs
      • Used frequently to improve ocular surface comfort & healing
    • Other
      • Eyeshield at bedtime
      • Avoidance of water in eye
136
Q

Describe the CLEK study (Collaborative Longitudinal Evaluation of Keratoconus)

A
  • Goal: describe the clinical course of KCN & identify risk & protective factors that influence severity & progression
  • Weak association with CT disease than originally thought
  • 50 % of pt reported eye rubbing or atrophy
  • Presentation ocurring earlier in life at higher risk of progression
    • Progression slows by the 4th decade
  • Decrease in high & low contrast acuity
  • Acuity <20/40 report decreased quality of life scores
137
Q

Neurotrophic Keratopathy

A
  • Results from impaired corneal innervation & decreased tear production
  • Presentation
    • ​Corneal irregularity
    • Lack of normal corneal luster
    • Oval shaped epithelial defect with smooth borders
    • Leads to stormal ulceration
  • Complications
    • ​Corneal neovascularization
    • Necrosis
    • Perforation
    • Secondary Infection
138
Q

Keratoconus

  • Characteristics?
  • Signs?
  • Sx?
A
  • Progressive thinning and protrusion of cornea leading to conical shape
    • Cone apex usually just below visual axis
  • Bilateral, often asymmetric
  • Onset around puberty
    • Progression x 10-20 yrs until gradually stabilizes
    • Rate of progression variable
    • Generally stabilizes by 40s
  • No gender predilation
  • Affects all races - some to higher degree
  • Inheritance unknown
  • Incidence ~1:2000
  • Symptoms
    • Progressive visual blurring
      • Snellen acuity initially preserved
      • Contrast sensitivity descreases earlier
    • Distortion
    • Photophobia
    • Glare
    • Monocular diplopia
    • Ocular irritation
  • Keratoconus Signs
    • High, irregular astigmatism
    • Scissor reflex with retinoscopy
    • Munson’s sign (V-shaped indentation observed in the lower lid)
    • Fleischer ring (Iron deposition)
    • Corneal thinning
      • 1/2 to 1/5 normal thickness
    • Prominent corneal nerves
    • Vogt Striae in posterior stroma
    • Corneal scars at apex - ruptures in Bowmans layer
    • Corneal hydrops (caused by acute disruption of descemet’s membrane in setting of corneal ectasia, abnormal accumulation of fluid ina . body tissue or cavity)
139
Q

Immune stroma (interstitial) keratitis

A
  • Occurs in ~20% of chronic recurrent HSV
  • Inflammation due to retained viral antigen in stromal tissue
  • Presentation
    • Stromal inflammation
      • Intact epithelium
    • Stromal infiltration
    • Immune ring
    • Stromal neovascularization
140
Q

Aspergillus

A
  • Filamentous
  • Ubiquitous fungus found in nature
  • Commonly isolated from soil, plant debris, & indoor air environment
141
Q

Neurotorphic Keratitis

  • Management?
A
  • Management
    • Goal: decrease toxic corneal exposure, improve lubrication
    • D/C all unnecessary topical medications
      • Esp. antivirals
    • Frequent PFATs
    • Prophylactic antibiotic therapy (Prevent disease)
    • Soft steroid may be necessary (Weak steroids)
    • Corneal debridement in severe cases
    • BCL
    • Tarsorrhaphy
      • Tape, Botox, surgical
142
Q

Terrien’s Marginal Degeneration

  • What is it?
  • Statistics?
  • What does it look like?
  • What are the 2 types?
  • Presentation?
  • Symptoms?
  • Treatment?
A
  • Peripheral inflammatory condition
  • Rare, etiology unkown
  • Men 3:1
  • 20-40 yo most common
    • any age possible
  • Bilateral & symmetric
  • Non-inflammatory peripheral thinning with pannus
    • Grey/white band 1-2mm width
    • Starts supernasally & spreads circumferentially
      • Fine punctate opacities in anterior stroma
      • Rarely involves inferior limbus
      • Epithelium remains intact
    • Gutter forms between opacity & limbus
    • Slowly progressive stromal thinning over many years
    • Extends circumferentially or centrally
    • Rarely causes perforation
      • Easy perforation with mild trauma
    • Lipid deposits at leading (central) edge of pannus
  • Types
    • ​Quiescent
      • ​More common
      • Older pt
      • Painless lesions
    • Inflammatory
      • ​Less common
      • Younger pts
      • Recurrent episodes of inflammation, episcleritis
  • Presentation
    • ​Leading edge of lipid
    • Steep central edge
    • Sloping peripheral edge
    • Intact epithelium
    • Superficial vascularization
    • High against the rule of oblique astigmatism
    • Peripheral thinning from collagen degeneration
      • May develop aqueous pockets
  • Symptoms
    • ​Painless
    • Blurred vision due to astigmatic changes
    • Rare perforations
  • Treatment
    • ​CL or spectacle correction
    • Keratoplasty if risk of perforation
143
Q

Amiodarone

A
  • Antiarrhythmic drug
    • Used in tx of ventricular tachycardia or ventricular fibrillation
  • Ocular side effects
    • Blurred vision/Halos
    • Corneal microdeposits
      • 69-100%
    • Lenticular changes
    • Madarosis
    • Retinal/optic nerve complications
144
Q

Pellucid Marginal degeneration

  • Characteristics?
  • Signs?
  • Tx?
A
  • Bilateral
  • Peripheral cornea ectatic disorder
    • Characterized by a band of thinning 1-2mm typically in inferior cornea
    • Inferior thinning at 4 & 8 o clock
  • Max corneal protrusion usually just superior to area of thinning
  • Protruding cornea is of NORMAL thickness
  • No gender or racial predilection
  • Present in 2nd-5th decade
  • 2nd most common ectatic disorder
  • Signs
    • ​Kissing doves, lobster claw
    • Irregular astigmatism
    • No iron rings
    • No Striae
    • Scarring at level of Descemet’s
    • Hydrops possible
  • Treatment
    • ​Same as KCN
145
Q

Penetrating/Perforating Injury

A
  • Ocular trauma involving foreign body entering the eye
  • Males 3:1
  • Younger 15-35 yo
  • Size/damage depends on nature of injury

Signs of open globe

  • Seidel sign
  • Prolapsed uveal tissue
  • Low IOP
  • Decreased vision
  • Shallow or flat anterior chamber
  • Hyphema
  • Iris deformities
  • Dislocated lens
  • Retinal detachment

Complications

  • Infection
    • Endophthalmitis
    • Panophthalmitis
  • Hypotyony
    • Hypotony maculopathy
  • Secondary glaucoma
    • Damage to angle structures
  • Corneal scarring
  • Retinal complications

Symptoms

  • Pain
  • Lacrimation
  • Injection
  • Photophobia
  • Decreased vision

Signs

  • Entrance wound
  • Corneal edema
  • Seidel leak
  • Hyphema
  • Moderate to severe anterior chamber reaction
  • Prolapsed uveal tissue
  • Peaked pupil
  • Irodialysis

Treatment

  • ​Bandage CL
  • Sutures
  • Cataract extraction
  • Retinal repair
  • Antibiotic
  • Cycloplegia
146
Q

PRK

A
  • Photorefractive keratectomy
  • Approved for
  • Procedure
    • Epithelium removed w/ alcohol
    • Laser ablation of stromal tissue
    • BCL inserted to allow for reepithelialization
  • Pros
    • No flap complications
    • Tx of thinner cornea possible
  • Cons
    • Longer healing time
    • Significantly more discomfort
147
Q

Review of Corneal Dystrophies

  • Inheritance pattern
  • Age of onset
  • Presentation
  • Sx
  • Tx
148
Q

Fungal Keratitis

  • Predisposing factors?
  • Most common species that cause keratitis & ulceration?
  • Incidence varies by?
A
  • Fungi are opportunistic invaders which rarely infect healthy cornea
  • Predisposing factors
    • Trauma, esp associated with vegetative material
    • Ocular surface disease
    • Systemic disease/immunosuppression
    • Improper use of corticosteroids
    • CL wear
  • Most common species that cause keratitis & ulceration
    • Fusarium: south
    • Aspergillus: north
    • Candida: north
  • Incidence varies by
    • Geographic location: tropical latitudes
    • Age: 30-40s
    • Gender: males>females
149
Q

Trauma - Define the following

  • Closed injury
  • Open injury
  • Contusion
  • Rupture
  • Laceration
  • Lamellar laceration
  • Incised injury
  • Penetrating injury
  • Perforation
A
  • Closed injury: Corneoscleral wall of globe is inteact
    • Blunt trauma
  • Open injury: full-thickness wound of corneoscleral envelope
  • Contusion: closed injury resulting from blunt trauma
    • Damage may occur distant to impact site
  • Rupture: Full-thickness wound caused by blunt trauma
    • Globe give way at weakest point, may be away from injury site
  • Laceration: Full-thickness defect in eye wall produced by a tearing injury
    • Direct impact
  • Lamellar laceration: partial thickness laceration
  • Incised injury: caused by sharp object
    • Glass, knife
  • Penetarting injury: single, full-thickness wound WITHOUT an exit wound
    • Often from sharp object
  • ​Perforation: 2 full-thickness wounds- one entry, one exit
    • Projectile
150
Q

List the fungal infections

A
  • Fusarium
  • Aspergillus
  • Candida
151
Q

Epithelial Basement Membrane Dystrophy (EBMD)

  • Other names?
  • Characteristics?
  • Symptoms?
  • Treatment?
  • Medical therapy?
  • What surgery must be avoided?
A
  • AKA: anterior basement membrane dystrophy, map-dot fingerprint dystrophy, Cogan dystrophy
  • Most common anterior corneal dystrophy
    • Affects 2% of population
  • Variable onset
  • Microcyst formation in the epithelium with alterations in basement membrane
  • Defect in formation & maintenance of epithelial basement membrane adhesion complex
    • Leads to thickened, multilaminar or redundant, & misdirected into epithelium
  • Symptoms
    • ​Spontaneous corneal erosion
    • Blurred vision
      • Variable
    • Dry eye
    • Photophobia
    • Slowed healing time after surgery
  • Treatment
    • ​None - most pts asymptomatic
    • Bandage CL
    • Lubrication
    • Punctal occlusion
    • Hypertonic solution
    • RGP/Scleral lenses
  • Medical therapy
    • ​FreshKote
    • Steroids
    • Restasis
    • Low dose oral doxycycline
  • Surgical
    • ​PTK
    • Super-K
  • ** Lasik NOT recommended due to increased risk of epithelial sloughing & other complications
152
Q

Conjunctivitis

A
  • Most common form of recurrence
    • 83%
  • Clinical manifestation
    • Acute follicular conjunctivitis
      • Lid lesions possible
      • Keratitis possible
    • Conjunctival dendritic ulcer possible
153
Q

Corneal Farinata

A
  • Innumberable centrally located tiny, dust-like grey dots & flecks in the deep stroma
    • Flour-dust appearance
  • Usually bilateral
  • No decrease in VA
154
Q

Phlyctenular keratoconjunctivitis

  • What is it?
  • Symptoms
  • Presentation?
  • Treatment?
A
  • Phlyctenulosis
  • Non-infectious inflammatory nodule occuring on conjunctiva or cornea
    • Type IV hypersensitivit reaction to bacterial antigen
      • Staphylococcus
      • Tuberculosis
    • Requires sensitization of cornea to antigen
    • Repeated exposure to antigen

Symptoms

  • FBS
  • Tearing
  • Mild itching
  • +/- photophobia

Presentation

  • Conjunctiva
    • Pink, fleshy nodule, 1-2mm dia.
    • Mostly occur near limbus
  • Cornea
    • ​Small white nodule with adjacent conj. Injection
    • Often ulcerate forming a marginal ulcer → stromal scarring
    • Pannus may develop (abnormal layer of fibrovascular tissue)
    • Subsequent phlyctenules occur at edge of pannus
      • Move centrally across the cornea

Treatment

  • Short term management
    • Steroids
    • Topical antibiotics if corneal ulceration
    • Cycloplegic agent
  • Long term management
    • Eyelid hygiene - address cause
    • Oral tetracyclines
    • PK in severe scarring

Anterior Seg (4 decks)

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