Cornea & Conjunctiva & Sclera Flashcards
RTC for recurrent corneal erosions
1 day, RTC every 1-2 days to ensure healing
Treatment of RCE
Erythromycin ung QID
lubricating tears q2h
Bandage CL if erosion is large
Cause of RCE?
Secondary to trauma that causes initial corneal abrasion (fingernail or tree branch)
What is this corneal finding?
Mutton-fat (granulomatous) keratic precipitates
*associated with granulomatous anterior uveitis (aka iritis)
Which organisms can penetrate an intact corneal epithelium? (4)
- Corynebacterium diptheriae
- Haemophilus
- Listeria
- Neisseria gonorrhoea
Bacterial conjunctivitis in kids is caused by?
Haemophilus influenzae
Bacterial conjunctivitis in adults is caused by?
S. Aureus
True or false
Preauricular lymphadenopathy is present in bacterial conjunctivitis
FLASE
RTC for giant papillary conjunctivitis
2 to 4 weeks
Treatment for corneal abrasion in patients who wear CL
AB that protects against pseudomonas (fluoroquinolone or tobramycin QID)
If patient with corneal abrasion is extremely photophobic, what can you prescribe them?
Cycloplegic agent such as homatropine
RTC for small corneal abrasion
2 to 5 days later and FU until healed
True or False
Patching is recommended for CL wearers for corneal abrasion caused by vegetative or organic matter
FLASE
* do NOT patch these patients
Treatment for corneal abrasion for non-CL wearer
Antibiotic ointment Q2H or Q4H
Or
Antibiotic drops to ensure sterility
(Fluoroquniolone QID)
Patient presents with unilateral arcus. What should you do next?
Refer for carotid artery doppler contralateral to the eye with arcus to check for potential artery occlusion
Corneal arcus initially appears in which areas on the peripheral cornea?
Inferior
Superior
Then coalesces circumferentially
Cholesterol deposits in which layer of the cornea in Corneal Arcus?
Stromal periphery
Punctal atresia is asymptomatic when the absence of puncta is located where?
Upper eyelid
What is punctual atresia?
Congenital absence of puncta
Treatment for punctal atresia
Cannulation with placement of silicone tubes
Tx for endophthalmitis
Immediate referral to OMD for Intravitreal antibiotic injection of vancomycin and ceftazidime
What is the most likely causative organism of acute post operative endophthalmitis?
Staphylococcus epidermidis
Iron pigment line on pterygium
Stocker line
* sign of stability
Hudson-stahli line
Observed in inferior mid-peripheral region of corneas of patients with advanced age
- iron deposit line where tear film is stagnant
- asymptomatic
Fleischer ring
At base of the cone in patients with keratoconus
If a rust ring is present with a metallic foreign body, how should it be removed?
Alger brush
* ophthalmic drill
* stop spinning if pushed too deep, can’t go to bowman’s layer
Symptoms of acute interstitial keratitis
- Red, painful eyes with lacrimation and photophobia, decreased vision
Name the condition:
- Fine keratitic precipitates on endothelium
- Stromal neovascularizarion with corneal edema
Interstitial keratitis
What is the most common cause of interstitial keratitis?
Congenital syphilis
* Hutchinson triad
1. Pegged shaped teeth
2. Interstitial keratitis
3. Deafness
Iron deposits at the base of the cone at the corneal epithelial level in Keratoconus
Fleischer Ring
Minimal corneal thickness for CXL after removal of corneal epithelium to prevent endothelial damage
400 microns
* if patient has less than 400 microns they are not a candidate for CXL
Contraindications for CXL
HX of herpes infection
Concurrent infection
Severe corneal scarring or opacification
Poor wound healing
Severe ocular surface disease
Autoimmune disorders
RTC for corneal dellen
1-7 days
Treatment for Mucin balls (secondary from soft or hard CL wear)
Steepen base curve of lens
Poor CL fit bubbles of CO2 trapped under lens, causing indentations in corneal epithelium, leaving tiny circular depressions that pool with sodium Fl
Dimple Veiling
* golf ball appearance
How to resolve dimple veiling from poor fitting GPCL?
Decrease overall diameter
Decrease optic zone diameter
*flatten base curve because GPCL is too steep and causing dimple veiling
Clinical signs of bacterial corneal ulcer
White stromal infiltrate with overlying epithelial defect surrounding edema and conjunctival injection
* plus iritis, hypopyon, mucopurulent discharge and eyelid edema/erythema
Treatment for corneal ulcers located peripherally, don’t stain with FL and are less than 1mm in size
Broad spectrum AB
* ciprofloxacin every 2-4 hours
* because location of ulcer lower risk of vision loss
What size and location of a corneal ulcer should be treated with fluoroquinolone every hour around the clock?
Ulcers in periphery but are larger 1-1.5mm with an epithelial defect, mild anterior chamber reaction, and moderate discharge
What is considered a high risk corneal ulcer?
Centrally located or larger than 1.5 mm
Treatment for high risk corneal ulcers
Fortified (stronger med) Tobramycin or gentamycin alternated with cefazolin or vancomycin every half hour
Or
Topical fluoroquniolone
1 gtts q5min for 25 min
Then every 15 minutes for 45 min
Then every 30 minutes for 24 hours
RTC for bacterial corneal ulcer
1 day
* sight threatening, patient must be followed daily
* pay attention to size and depth, amount of epi staining/defect and symptoms of pain or anterior chamber reaction
What organism is MOST likely to cause CL associated keratitis?
Pseudomonas aeruginosa
* bacteria can produce enzymes that can easily liquefy the cornea in 1-2 days, need treatment ASAP
For GP lenses as oxygen permeability (Dk) increases what occurs?
Increase in O2 to cornea
But decrease in wettability and less durable
* less durable meaning prone to scratches, flexure and warpage
RTC for Terrien’s marginal degeneration
6 months
* minimal risk except in advanced cases, pt can be seen every 6-12 months
* slow progressive thinning of peripheral cornea, superior, in males
Tx for diffuse scleritis
Oral NSAIDS
* indomethacin 50 mg TID
*Or Ibuprofen 600 mg TID
If patient with diffuse scleritis does not respond well to oral NSAIDs then what is next tx?
Oral steroids
* starting dose 1 mg/kg/day
Tx contraindications for necrotizing scleritis
Steroid injections are contraindicated because can cause further thinning of tissue and increase risk of perforation
RTC for diffuse scleritis after initial tx?
1 week
* to ensure tx is working
Which systemic condition is MOST associated with diffuse scleritis?
Rheumatoid arthritis
* reoccurrences are common therefore need to determine underlying etiology
Average corneal thickness
520-540 microns
Condition characterized by small thin filaments composed of degenerating epithelial cells and mucus
Filamentary keratitis
Symptoms of filamentary keratitis
- range of symptoms from mild to severe pain
- burning, photophobia, FBS, increased blinking
- decreased VA
What is the most common etiology of filamentary keratitis?
Keratoconjunctivitis sicca
* secondary to aqueous tear deficiency
How long before LASIK must a patient not wear soft contact lenses?
2 weeks
* 1 weeks for soft spherical
* 2 weeks for soft Toric
How long before LASIK must a patient not wear soft contact lenses?
2 weeks
* 1 weeks for soft spherical
* 2 weeks for soft Toric
How long before LASIK should a patient with GPCL stop wearing them?
Minimum 1 month, with added recommendation of 1 month for every decade of wear (or until corneal topography is stable
FDA minimum post treatment residual thickness requirement of the corneal bed for LASIK
250 microns
* minimize risk of ectasia
What is Superior Limbic Keratoconjunctivitis (SLK)?
Superior lid chafes on superior bulbar conjunctiva
* friction can be caused by proptosis due to thyroid disease, dry eye, rheumatoid arthritis, Sjogrens, and excessive CL wear
An ocular condition characterized by chronic, recurrent inflammation of the superior limbus and bulbar conjunctiva, superior corneal epithelial keratitis, and papillary hypertrophy of the superior tarsal conjunctiva
What age and gender is most commonly affected by SLK? (Superior limbic keratoconjunctivitis)
Middle-aged females
What are the common symptoms of SLK?
Irritation, redness, mucous discharge, foreign body sensation, pain, photophobia, blepharospasm, pseudo-ptosis
True or False: SLK usually presents unilaterally.
False
What is the most accepted theory regarding the pathogenesis of SLK?
Occurs as a result of mechanical trauma during blinking due to abnormal forces between tight upper lids and/or loose, redundant conjunctiva
What role does tear film deficiency play in SLK?
It leads to decreased ability of the upper eyelid to move freely over the conjunctiva, causing increased movement of the bulbar conjunctiva and subsequent damage
What condition is associated with an increased risk of SLK? (Superior limbic keratoconjunctivitis)
Thyroid dysfunction-induced exophthalmos
Fill in the blank: Symptoms in patients with SLK commonly vary significantly, with periods of _______ and exacerbations.
remissions
What are some non-specific complaints patients with SLK may present with?
Irritation, redness, mucous discharge, foreign body sensation
Why is SLK likely under-diagnosed?
Symptoms often outweigh signs
What other factors have been suggested to contribute to SLK aside from mechanical trauma?
- Viral infections
- Autoimmune diseases
What symptom might a patient note that is specifically related to eye movement in SLK?
Increased irritation on upgaze
What is papillary hypertrophy in the context of SLK?
Enlargement of the papillae on the superior tarsal conjunctiva
What is Superior Limbic Keratoconjunctivitis (SLK)?
A condition characterized by bilateral, localized hyperemia and thickening of the superior bulbar conjunctiva.
What are the conjunctival signs of SLK?
- bilateral hyperemia
- thickening of the superior bulbar conjunctiva
- redundant and keratinized appearance
- fine punctate staining with fluorescein or rose bengal.
What is observed when light pressure is applied to the upper eyelid in SLK?
A fold of redundant conjunctiva crosses over the superior limbus.
What are the corneal signs associated with SLK?
Fine epithelial staining of the superior cornea, micropannus, and potential filament development.
What is the primary goal of SLK treatment?
To reduce the abnormal mechanical interaction between the superior bulbar and palpebral conjunctiva.
What types of topical lubricants are used in SLK treatment?
Artificial tears and ointments/gels.
What is the role of topical cyclosporine in SLK treatment?
Helpful in managing coexisting keratoconjunctivitis sicca.
When is topical acetylcysteine indicated in SLK?
In patients with associated filamentary keratitis.
How can soft contact lenses aid in the treatment of SLK?
They offer a barrier to mechanical trauma between the lid and superior bulbar conjunctiva.
Fill in the blank: The bulbar conjunctiva in SLK appears _______.
redundant, keratinized, and thickened.
True or False: Limbal papillary hypertrophy is commonly absent in SLK.
False.
What surgical procedure involves resection of the superior limbal conjunctiva?
Resection of the superior limbal conjunctiva and Tenon’s capsule
What happens to the remaining conjunctiva after resection in SLK treatment?
It grows on the sclera and becomes immobile
Which modalities have shown effectiveness in treating SLK?
Cryotherapy or thermocautery
True or False: Topical application of silver nitrate is currently available for SLK treatment.
False
What was the previous treatment option for SLK that showed some success but is no longer available?
Topical application of silver nitrate
What causes Ultraviolet Keratopathy?
Excessive exposure to UV light resulting in painful and severe keratopathy
What is a common history associated with patients suffering from Ultraviolet Keratopathy?
History of sunlamp usage or welding without proper ocular protection
List the symptoms of Ultraviolet Keratopathy. (5)
- Moderate to severe pain
- Blurred vision
- Photophobia
- Excessive lacrimation
- Foreign body sensation
When do symptoms of Ultraviolet Keratopathy typically onset after exposure?
6-12 hours after exposure
What are the clinical signs of Ultraviolet Keratopathy? (Name 2)
- Conjunctival injection
- Superficial punctate keratopathy in the interpalpebral area that may appear coalesced and stains with sodium fluorescein
- Eyelid edema
- Associated iridocyclitis may be present
What treatment is recommended for Ultraviolet Keratopathy?
- Preservative-free artificial tears every two to three hours
- Topical antibiotic drops during the day and ointment at night
- Treatment of iridocyclitis if present
- Topical NSAIDs and/or oral analgesics for pain management
- Pressure patch if the ocular surface is severely compromised
How often should patients with Ultraviolet Keratopathy be followed up?
Every 1 to 2 days to ensure resolution of symptoms and clinical signs
Fill in the blank: Ultraviolet Keratopathy is caused by excessive exposure to _______.
[UV light]
True or False: Eyelid edema may be present in Ultraviolet Keratopathy.
True
What medication is suggested for pain management in Ultraviolet Keratopathy?
Topical NSAIDs and/or oral analgesics
What is the recommended dosage for cyclopentolate in treating associated iridocyclitis?
1% t.i.d.
What is Vernal Keratoconjunctivitis (VKC)?
A recurring allergic disorder characterized by severe ocular symptoms such as itching and burning, photophobia, and lacrimation
VKC often results in significant irritation and discomfort.
What type of hypersensitivity is involved in VKC?
Type I hypersensitivity
IgE and cell-mediated immune mechanisms are important in the pathogenesis.
In which demographic does VKC primarily present?
Males within the first decade of life
VKC typically resolves by the late teens in about 95% of cases.
*warmer climates
What role do IgE, histamine, and mast cells play in VKC?
They are increased in the tears of patients with VKC
These components are associated with the allergic response.
What is the seasonal pattern of VKC symptoms?
Symptoms are usually more significant in late spring and summer
Some patients may endure mild symptoms year-round.
What percentage of VKC patients have a history of atopy or family history of allergic disorders?
60-75%
These patients often develop other allergic conditions at a young age.
What is the most pronounced symptom associated with VKC?
Intense itching
Other symptoms may include lacrimation, photophobia, and burning.
What are some additional symptoms of VKC?
Lacrimation, photophobia, burning, foreign body sensation, thick mucoid discharge, heaviness of the eyelids
Patients often experience constant blinking, which can be misdiagnosed.
True or False: The periorbital skin is affected in VKC.
False
In contrast to allergic keratoconjunctivitis, the periorbital skin remains unaffected.
Fill in the blank: VKC is more common in _______ climates.
[warmer]
Rarely occurs in temperate regions.
What is primarily involved in palpebral disease?
The upper tarsal conjunctiva of both eyes
Significant associated corneal disease may occur due to the close relationship between corneal epithelial tissue and the inflamed upper tarsus.
What appearance do the papillae in palpebral disease resemble?
Cobblestones
They have a hard, flat-topped, polygonal appearance.
What type of cells infiltrate the papillae in palpebral disease?
Lymphocytes and eosinophils
This infiltration contributes to the inflammation observed.
What is commonly observed between the giant papillae in palpebral disease?
Thick, ropy mucus discharge
This discharge is a characteristic symptom of the condition.
What happens to tarsal papillae during periods of disease activity?
They become hyperemic and edematous
Tarsal papillae may persist even when the disease appears quiescent.
Which populations are most commonly affected by limbal disease?
African-American and Asian populations
This demographic prevalence is notable in the occurrence of limbal disease.
What is a characteristic feature of limbal disease?
Single or multiple gelatinous, thickened papillae at the limbus
These papillae are often more prevalent and severe superiorly.
What are Tranta’s dots?
Discrete, whitish, raised dots at the apices of limbal papillae
They consist of collections of eosinophils and epithelial cells, seen in vernal keratoconjunctivitis
What additional symptom is common in limbal disease?
Redness and congestion of the bulbar conjunctiva
This symptom reflects the inflammatory response in the area.
What is more commonly associated with corneal involvement in vernal keratopathy?
Palpebral disease
Corneal findings typically arise from this condition.
What are the earliest corneal findings in vernal keratopathy?
Punctate epithelial erosions noted in the superior cornea
These erosions are indicative of corneal involvement in the disease.
What can coalescence of punctate erosions lead to?
Small corneal epithelial erosions
These can evolve into larger characteristic ‘shield’ ulcers.
What are shield ulcers?
Non-infectious corneal ulcers caused by mechanical trauma and damaging toxins
They can occur in patients with Vernal Keratoconjunctivitis (VKC) and are found in the central/superior cornea.
Describe the progression of shield ulcers.
Initially shallow, coated with inflammatory debris, mucous, and calcium phosphate, leading to plaque formation
The base of the ulcer becomes pacified over time.
What percentage of VKC patients develop corneal ulcers?
About 10%
Of these, 6% may develop permanent decreased visual acuity.
What is pseudogerontexon?
Peripheral vascularization or pacification in recurrent limbal disease
It resembles localized arcus senilis adjacent to previously inflamed limbus.
What can significant limbal lesions cause in VKC patients?
Substantial astigmatism
This is a complication arising from the disease.
What is the relationship between VKC and keratoconus?
Patients with VKC have a higher incidence of keratoconus
This indicates a potential association between the conditions.
*associated with atopy, allergies
What are some supportive therapies for VKC?
Cool compresses and avoidance of allergens
These therapies help alleviate symptoms.
How effective are mast cell stabilizers and antihistamines as sole treatment for VKC?
Rarely sufficient as sole treatment
They may reduce the need for steroids.
When are corticosteroids often required in VKC?
For associated keratopathy and/or severe discomfort
Topical corticosteroids are commonly used in these cases.
What is Vernal Keratoconjunctivitis (VKC)?
A type of allergic conjunctivitis characterized by inflammation of the conjunctiva and cornea.
What is the role of Acetylcysteine (Topical) in VKC?
A mucolytic agent helpful in cases involving substantial mucous discharge and early plaque formation.
What symptoms does Cyclosporine (Topical) reduce in VKC?
Epithelial ulceration, limbal infiltrates, conjunctival hyperemia, and symptoms of photophobia.
What is the purpose of a Supratarsal Steroid Injection?
Reserved for non-compliant patients or those resistant to conventional treatment.
What is the volume of a Supratarsal Steroid Injection?
0.1ml of either dexamethasone or triamcinolone.
Name some systemic immunosuppressive agents used in VKC.
- Steroids
- Cyclosporine
- Azathioprine
What additional benefit do oral antihistamines provide in VKC?
They may help with sleep and eye-rubbing during the night.
What is the purpose of a Superficial Keratectomy in VKC?
To remove plaques.
What is involved in the surgical procedure of Superficial Keratectomy?
Removal of the epithelium and a very superficial dissection.
What is an Amniotic Membrane Overlay Graft used for?
For severe, persistent epithelial defects with corneal ulceration.
True or False: Cyclosporine (Topical) has shown improvement in giant papillae.
False.
What is vortex keratopathy also known as?
Corneal verticillata
Which genetic disorder is associated with vortex keratopathy?
Fabry’s disease
Name a common medication that can cause vortex keratopathy.
Amiodarone
Other medications include chloroquine, hydroxychloroquine, indomethacin, and tamoxifen.
What are the common symptoms of vortex keratopathy?
Asymptomatic, glare, decreased vision
What is the appearance of corneal deposits in vortex keratopathy?
Inferocentral, bilateral yellow/brown or white powder-like
How do the corneal opacities in vortex keratopathy appear?
Swirl outward from a focal point while sparing the limbus
What type of inheritance pattern does Fabry’s disease follow?
X-linked recessive
List 4 clinical signs of Fabry’s disease.
(X-linked lysosomal storage disease, abnormal tissue accumulation of glycolipid)
- whorl keratopathy (deposits form I’m a swirling whorl pattern on corneal epithelium)
- wedge shaped posterior cataract
- corkscrew vessels and aneurysms of the conjunctiva
- retinal vascular tortuosity
What treatment is typically required for vortex keratopathy?
Typically not required
What happens if the medication causing vortex keratopathy is ceased?
(Aka corneal verticillata aka whorl keratopathy)
Resolution of the corneal deposits
True or False: Most patients with vortex keratopathy experience significant vision problems.
False
Name one type of edema associated with Fabry’s disease.
- Macular edema
- Retinal edema
- Edema of the nerve
What is the typical visual impact of vortex keratopathy on patients?
Most are asymptomatic, but some may experience glare or decreased vision
What is episcleritis?
Acute inflammation of the episclera, the connective tissue lying superficial to the sclera and deep to Tenon’s capsule.
Episcleritis is usually benign and self-limiting.
In which demographic is episcleritis most frequently observed?
Young adults, more commonly in women than men.
This condition tends to recur.
What are common etiologies of episcleritis?
- Idiopathic
- Connective tissue disorders (e.g., rheumatoid arthritis)
- Gout
- Infections (e.g., herpes zoster)
- Inflammatory bowel disease
- Thyroid disease
- Atopy
- Rosacea
Idiopathic causes are the most common.
What are the key symptoms of episcleritis?
- Acute onset of ocular redness (sectoral or diffuse)
- Mild tenderness and irritation
- Patients may report epiphora
- No discharge present
Symptoms typically indicate inflammation.
What is the most common form of episcleritis?
Simple episcleritis.
It appears as diffuse or sectoral injection of the episclera.
What characterizes nodular episcleritis?
A mildly tender, raised, and mobile nodule.
Vision is typically unaffected.
How is simple episcleritis treated?
- Self-resolving
- Artificial tears (qi.d.) may be used
- Some prefer vasoconstrictors
Treatment aims to speed up resolution and decrease symptoms.
How does nodular episcleritis differ in treatment duration compared to simple episcleritis?
Nodular episcleritis typically resolves over a longer period of time than simple episcleritis.
Treatment may include similar approaches but requires patience.
What type of medication may be prescribed for moderate to severe episcleritis?
- Topical steroids (e.g., fluorometholone 0.1% or Lotemax® qi.d.)
- Oral NSAIDs (e.g., ibuprofen 200mg to 600mg t.i.d. or qi.d.)
These help manage inflammation and pain.
True or False: Discharge is commonly present in episcleritis.
False.
Discharge is not present in episcleritis.
Fill in the blank: The connective tissue that lies superficial to the sclera and deep to Tenon’s capsule is called the _______.
episclera.
It is highly vascular and involved in the condition of episcleritis.
Follow up for episcleritis
- monitor every few weeks unless gets worse or persists
- pt prescribed topical steroids RTC every 1-4 weeks to check IOP and tapering if resolution permits
Difference between Fleischer ring and Kayser- Fleischer ring
Fleischer ring: iron deposits at base of keratoconus cone
Kayser-Fleischer ring: copper deposits associated with Wilson’s disease
How many diopters of power does the cornea contribute?
The cornea serves as the major refractive source for the eye, accounting for roughly 43 diopters of power.
The cornea is crucial for focusing light onto the retina.
What is the normal thickness range of the cornea?
420-640 microns, with an average of about 520-580 microns in humans.
Corneal thickness can vary among individuals and may affect eye health.
What type of cells make up the corneal epithelium?
Stratified squamous, non-keratinized cells.
This structure is important for protection and maintaining the cornea’s integrity.
What are the five layers of the cornea in order from superficial to innermost?
- Epithelium
- Bowman’s layer
- Substantia propria (stroma)
- Descemet’s membrane
- Endothelium
Each layer has distinct functions and structural properties.
How does the corneal epithelium regenerate?
Corneal epithelial cells transition from basal to columnar to wing cells and are ultimately sloughed off over a 7-day period.
This rapid turnover is vital for maintaining a healthy corneal surface.
What is the thickness of Bowman’s layer?
Roughly 12 microns thick.
Bowman’s layer provides structural support for the epithelial cells.
What happens if Bowman’s layer is penetrated?
Permanent scarring will occur.
Damage to this layer can have lasting effects on vision.
What are the three zones of the corneal epithelium?
- Basal cell layer
- Wing cell layer
- Superficial cell layer
Each zone has a specific role in the structure and function of the cornea.
True or False: The corneal epithelium will scar when injured.
False.
The epithelium has remarkable regenerative capabilities.
What types of collagen are found in Bowman’s layer?
- Collagen type IV
- Collagen type VII
- Collagen type XII
These types contribute to the structural integrity of the cornea.
What is the composition of the stroma in the cornea?
Collagen, keratocytes, and mucopolysaccharides
The stroma makes up roughly 90% of the thickness of the cornea.
How many lamellae are present in the corneal stroma?
Approximately 250 lamellae
These lamellae are organized in a precise orthogonal arrangement to allow for corneal transparency.
What maintains the space between collagen bundles in the corneal lamellae?
Proteoglycans
Proteoglycans are composed of proteins and carbohydrates and have a negative charge that repels each other.
What is Dua’s Layer?
A possible sixth corneal layer
It is acellular and 10-15 micrometers thick, requiring more research for further understanding.
What is Descemet’s Membrane?
The basement membrane for the endothelium
It thickens with age and is composed of collagen fibers.
What is the innermost layer of the cornea called?
The Endothelium
This layer consists of a single flattened layer of cells forming tight junctional complexes.
Do endothelial cells in the cornea replicate?
No
Endothelial cells do not replicate, which is significant for corneal health.
Which corneal cells consume the greatest amount of oxygen?
Endothelial cells
They play a crucial role in maintaining corneal clarity and hydration.
What do endothelial cells actively pump out to maintain corneal hydration?
Ions
This process sets up an osmotic gradient preventing corneal swelling and opacification.
What is the typical cellular density of a healthy corneal endothelium?
Approximately 3,000 cells/mm²
This density is crucial for maintaining corneal function.
What is marginal keratitis?
A self-limiting condition characterized by sterile infiltrate that resolves over 3-4 weeks if untreated.
Marginal keratitis may leave a residual zone of mild corneal thinning and a faint superficial scar, usually without vascularization.
What is the typical resolution time for marginal keratitis if left untreated?
3-4 weeks
There may be a residual zone of mild corneal thinning in the area of the lesion.
How quickly do infiltrates from marginal keratitis respond to steroids?
Usually resolve within a few days if properly treated.
This indicates that steroid treatment is effective for marginal keratitis.
Is there a risk of bacterial invasion leading to an ulcer or corneal perforation in marginal keratitis?
Very unlikely
Marginal keratitis typically does not lead to bacterial complications.
What may remain after the resolution of marginal keratitis?
A residual zone of mild corneal thinning and a faint superficial scar
The scar is usually without vascularization.
Fill in the blank: Marginal keratitis is characterized by a sterile infiltrate that will resolve over _______ if left untreated.
3-4 weeks
True or False: Marginal keratitis lesions can develop bacterial invasion leading to corneal perforation.
False
It is very unlikely for these lesions to develop bacterial invasion.
Best initial treatment for marginal keratitis
Tx concurrent blepharitis
* warm compress
* eyelid hygiene
* fluoroquinolone AB QID
* bacitracin or erythromycin ung qhs
Etiology of marginal keratitis
Hypersensitivity reaction to staphylococcal bacterial exotoxins
* marginal infiltrates are sterile
What is a key characteristic of viral conjunctivitis?
Presence of follies and positive lymphadenopathy
What is the primary treatment goal for viral conjunctivitis?
Alleviating symptoms
What can be used for comfort in viral conjunctivitis?
Artificial tears
What type of medication can help reduce inflammation in viral conjunctivitis?
Topical steroids
What is the most common cause of viral conjunctivitis?
Adenoviral conjunctivitis
How long is adenoviral conjunctivitis contagious?
Up to 14 days
What are common symptoms of adenoviral conjunctivitis?
Foreign body sensation, itching, burning, gritty feeling
What are the signs of adenoviral conjunctivitis?
Serous discharge, hyperemia, positive lymphadenopathy, lid edema
What are the three types of adenoviral conjunctivitis?
- Nonspecific
- Epidemic Keratoconjunctivitis (EKC)
- Pharyngoconjunctival fever
What differentiates Epidemic Keratoconjunctivitis (EKC) from other types?
Presence of subepithelial infiltrates (SEIs)
When do subepithelial infiltrates (SEIs) occur in EKC?
2-3 weeks after onset of the infection
What is a distinguishing feature of Pharyngoconjunctival fever?
Presence of fever and pharyngitis
(Inflammation of the pharynx, back of throat)
What should patients be educated about regarding adenoviral conjunctivitis?
The contagious nature of the disease
contagious for 14 days
What hygiene recommendations should be made to patients with adenoviral conjunctivitis?
Clean their bedsheets and towels
What is the recommended follow-up time for patients with adenoviral conjunctivitis?
2-3 weeks
What is epidemic keratoconjunctivitis (EKC)?
A very common and contagious ocular infection of viral etiology
What virus causes epidemic keratoconjunctivitis?
Adenovirus
Which strains of adenovirus are most commonly associated with ocular infections?
- Serotype 8
- Serotype 19
What is the ‘rule of 8s’ in relation to EKC?
1) Type 8 is the most frequently isolated strain
2) signs/symptoms occur 8 days after exposure
3) followed by 8 days of SEI (central and non-contagious)
*total 16 days after initial exposure
What typically occurs on the 8th day after infection with EKC?
The patient presents with diffuse superficial punctate keratitis (SPK)
What follows 8 days after the presentation of SPK in EKC?
Formation of subepithelial infiltrates (SEIs)
When is a patient with EKC considered no longer contagious?
Once subepithelial infiltrates (SEIs) are present
What are some signs of epidemic keratoconjunctivitis?
- Follicular conjunctivitis
- Positive lymphadenopathy
- Mild eyelid edema
What additional symptoms may be present in EKC?
- Small subconjunctival hemorrhages
- Circumcorneal conjunctival injection
- Pseudo-membranes
- Iritis
Pt education for EKC (epidemic keratoconjunctivitis)
EKC is very contagious!!
- wash hands
- do not share towels, pillow cases
- all infected articles should be washed in hot water and dried at high heat to sterilize
- incubation of virus is 4-10 days
Tx for EKC
PF AT’s q2h OU
Topical vasoconstrictor QID OU
Cool compress
Topical NSAIDs
Sunglasses
What does EBMD stand for?
Epithelial Basement Membrane Dystrophy
Also known as ABMD, map-dot-fingerprint dystrophy, or Cogan microcystic dystrophy.
In which decade of life does EBMD typically present?
Second decade of life
What is the common visual acuity status of patients with EBMD?
Minimally affected, if at all
What causes the appearance of map-like, dot-like, or fingerprint-like lesions in EBMD?
Deposition of fibrillary protein between Bowman’s layer and the epithelial basement membrane
What type of staining may the opacities in EBMD display?
Negative staining with sodium fluorescein
What is lattice dystrophy?
An autosomal dominant dystrophy with four subtypes categorized by age of onset, systemic involvement, causative mutation, and appearance
What is the primary cause of visual acuity decrease in lattice dystrophy?
Deposition of amyloid
What do the pacifications in lattice dystrophy appear as?
Thick or thin lines and dots
What causes granular dystrophy?
Deposition of eosinophilic hyaline in the anterior stroma of cornea
* autosomal dominant
What is the inheritance pattern of granular dystrophy?
Autosomal dominant
In which decade of life does granular dystrophy typically onset?
First decade of life
*asymptomatic before adulthood
What is the characteristic appearance of granular dystrophy?
Clear limbal zone and clear stroma between opacities in early stages
What causes macular dystrophy?
Deposition of glycosaminoglycans (mucopolysaccharides) in the stroma
What is the inheritance pattern of stargardt and fundus flavimaculatus?
Autosomal recessive
At what age does macular dystrophy typically cause poor vision?
20-30 years of age
What surgical intervention is preferred for macular dystrophy?
Corneal transplant
Which stromal dystrophy is considered the most visually devastating?
Macular dystrophy
What does corneal farinata appear as?
Small white specks located in the interpalpebral zone of the posterior stroma
Is corneal farinata generally bilateral or unilateral?
Bilateral
Does corneal farinata usually affect vision?
No
Does corneal farinata require treatment?
No
What ocular complication is most associated with EBMD?
Recurrent corneal erosion
* because epi basement membrane is abnormal causing poor hemidesmosome formation of basal epi cells —> RCE
What is retro-illumination used for?
Detection and observation of subtle corneal abnormalities
Retro-illumination helps reveal faint features that may be overlooked with bright direct light.
How is retro-illumination achieved?
By forming an angle between the lighthouse and the oculars to split a parallelepiped beam
The light reflected off the iris is utilized to observe corneal features.
What is an optic section?
A technique to ‘slice’ the cornea into its constituent layers for depth localization
Achieved by setting the beam width on the biomicroscope to roughly 0.5 mm.
What is the purpose of diffuse illumination?
Allows for gross evaluation of structures such as lids, lashes, and conjunctiva
Accomplished by increasing the aperture size of the light beam to greater than 4 mm in width.
What does a conical beam assess?
The anterior chamber for possible cells and flare related to inflammation
It involves adjusting the aperture width and height to the smallest possible size.
What should be done to maximize visibility when using a conical beam?
Turn off all other sources of light in the examination room and ensure the examiner is dark-adapted
This enhances the assessment of the anterior chamber.
Fill in the blank: An optic section is also used to determine _______.
angle estimation
Are patients with keratoconus candidates for LASIK?
No. Because keratoconus is a type or corneal ectasia
What is the purpose of corneal collagen cross-linking?
To strengthen and increase the stability of the cornea
This procedure aims to prevent further corneal steepening and thinning.
What substance is applied to the cornea during the cross-linking procedure?
Riboflavin drops
Riboflavin is a type of vitamin B2 that plays a crucial role in the process.
What must be removed from the cornea before applying riboflavin drops? (In CXL)
The epithelium
The removal of the epithelium allows better penetration of riboflavin.
What type of light is used in the corneal collagen cross-linking procedure?
Ultraviolet-A (UVA) light
UVA light is crucial for activating the riboflavin and strengthening the corneal tissue.
For how long is the cornea exposed to UVA light during the procedure?
~30 minutes
This exposure time is essential for effective cross-linking.
What is the main goal of corneal collagen cross-linking?
To stabilize the cornea and prevent further vision loss
It does not aim to improve visual acuity or correct refractive error.
True or False: Corneal collagen cross-linking is intended to improve visual acuity.
False
The treatment is not designed to enhance vision but to prevent deterioration.
What condition occurs when Descemet’s membrane ruptures in keratoconus?
Acute hydrops
Acute hydrops is characterized by a sudden influx of aqueous into the cornea.
What are the symptoms of acute hydrops?
Sudden decrease in visual acuity, redness, and pain in the involved eye
Symptoms arise from the corneal swelling and inflammation.
What findings are typically observed during a slit lamp examination in acute hydrops?
- Prominent central or inferior corneal edema
- clouding
- conjunctival hyperemia
These findings indicate significant changes in the cornea due to hydrops.
How does keratoconus typically present in the contralateral eye?
Exhibits findings of keratoconus, but without hydrops
This suggests a unilateral progression of the disease.
Is keratoconus usually symmetric or asymmetric?
Asymmetric
Most cases show one eye with a more advanced stage of the disease.
What is the typical duration for acute hydrops to resolve?
Approximately 8-10 weeks
This timeframe indicates the self-limiting nature of acute hydrops.
What conservative therapies are recommended for acute hydrops?
5% sodium chloride drops during the day and 5% sodium chloride ointment at night
These treatments help to manage corneal swelling.
Why might broad-spectrum antibiotics be used in acute hydrops?
To protect the compromised cornea from possible secondary infection
The integrity of the cornea is at risk during hydrops.
What is a common consequence after resolution of an acute hydrops episode?
Corneal scarring
Scarring can occur due to the damage sustained during hydrops.
What treatment may be utilized to minimize resultant scar formation after hydrops?
Steroid drops
Steroids can help reduce inflammation and scarring in the cornea.
RTC for small corneal abrasion
2-5 days
* if abrasion is large, within visual axis or if pt wears CL, RTC 1-2 days until cornea healed
What condition has these S/S?
Unilateral follicular conjunctivitis
Lymphadenopathy
Tearing, ocular irritation
Photophobia
Skin vesicles in periocular area
Dendritic ulcer
Herpes simplex virus keratitis
Tx for herpes simplex keratitis
Zirgan ophthalmic drops 5x daily
Or oral acyclovir if pt not complaint with dosing schedule
Patient with HSV keratitis is not compliant with topical medicated drops, and conditions is not improving, what is the next best treatment option?
Corneal debridement
Most common etiologies of episcleritis
Idiopathic
Rheumatoid arthritis
TB
Syphilis
Her
Herpes zoster
Other collagen vascular diseases
What is the first ancillary test used to differentiate episcleritis from other diagnoses?
Instillation of topical 2.5% phenylephrine drops
This test helps assess the vascular pattern after 10-15 minutes.
What observation indicates a diagnosis of episcleritis when using 2.5% phenylephrine drops?
Engorged and inflamed blood vessels of the episclera will blanch
In cases of scleritis, the vessels will not blanch.
What is the second ancillary test for diagnosing episcleritis?
Mechanical manipulation with a cotton-tipped applicator
This test involves anesthetizing and moving the conjunctiva to determine the depth of injected blood vessels.
What happens to inflamed episcleral vessels during mechanical manipulation?
They will move over the deeper sclera
This movement indicates that the vessels are superficial.
What is noted about inflamed vessels in scleritis during mechanical manipulation?
Inflamed vessels will remain stationary
This indicates that the vessels are deeper and not affected by the manipulation.
Tx for episcleritis
Topical mild steroid QID
* fluorometholone = FML
* taper to prevent rebound inflammation
Tx for photokeratitis
- PF artificial tears q2h and topical antibiotic drops or ointment (to protect against bacterial infection of exposed epithelium)
- sunglasses
- Moxeza qid OU
- can also put bandage CL if corneal defects have coalesced
Prognosis of photokeratitis if not treated
Very good
* condition will resolve on its own
What type of refractive errors and diopter values are LASIK and PRK approved to treat in the United States?
+6.00 D of hyperopia
LASIK and PRK are both currently approved for treatment of hyperopia up to +6.00 D at the corneal plane.
Is a patient with a refractive error above +6.00 D a candidate for LASIK or PRK?
No
The patient would not be a candidate if the goal was to correct the full amount of her refractive error.
What is the typical recommendation for treating hyperopia above which diopter level?
+4.00 to +5.00 D
Many surgeons do not typically recommend treating hyperopia above these levels due to less predictable surgical results.
What is the potential outcome of correcting a large amount of a patient’s hyperopia with LASIK or PRK?
Less reliance on glasses or contact lenses
However, achieving plano OU post-surgery would be unattainable.
What is SMILE?
The newest approved corneal refractive surgery technique in the United States
SMILE stands for Small Incision Lenticule Extraction.
What range of myopia can SMILE correct?
-1.00 to -9.00 D
SMILE can correct myopia within this range.
What is the maximum amount of astigmatism that SMILE can correct?
Up to 3.00 D
SMILE is effective for treating astigmatism up to this level.
Is SMILE approved for hyperopic refractive errors?
No
SMILE is not currently approved for treating hyperopia.
Fill in the blank: LASIK and PRK are approved for hyperopia treatment up to _______.
+6.00 D
True or False: SMILE can correct hyperopia.
False
SMILE is not approved for hyperopic refractive errors.
True or false
High hyperope is a candidate for ICL (Intraocular collamer lenses)
FALSE!!
* surgery is only approved for myopia and myopic astigmatism NOT hyperopia
* pt also not a candidate because of shallow anterior chamber depth (needs to be 3 mm or greater to qualify)
Absolute contraindications for LASIK
- Progressive keratoconus
- pellucid marginal degeneration
- Pregnancy or breastfeeding
What type of lasers are utilized for creating the corneal flap during LASIK surgery?
Femtosecond lasers
Femtosecond lasers operate at extremely short time scales, allowing precise tissue manipulation.
What is generated by each pulse of the femtosecond laser during LASIK surgery?
Free electrons and ionized molecules
These reactions are critical for the formation of gas bubbles in the corneal tissue.
What do the microscopic gas bubbles formed in the corneal tissue lead to?
The formation of a cleavage plane
This cleavage plane is essential for lifting the corneal flap during LASIK.
How are the gas bubbles created in the corneal tissue during LASIK?
Multiple pulses are applied adjacent to each other
This technique ensures a consistent and controlled flap creation.
What happens after the corneal flap is created and lifted during LASIK surgery?
An excimer laser is used to reshape the cornea
The excimer laser provides precision in correcting vision by reshaping the corneal surface.
Tear volume in a normal healthy adult is?
6.0-8.0 microliters
What is endophthalmitis?
A serious intraocular infection that may occur acutely or have a delayed onset after intraocular surgery or foreign body penetration of the ocular tunic.
What are the possible onset times for endophthalmitis?
Acute (within several days) or delayed (within several weeks) onset.
What are some preventative measures against endophthalmitis?
Strict sterilization methods, treatment of pre-existing ocular/skin conditions, prophylactic antibiotics.
What are the symptoms of acute postoperative endophthalmitis?
- Sudden onset of decreased vision
- Ocular pain
- Perception of floaters
What are the symptoms of delayed onset endophthalmitis?
- Gradually changing, varying levels of decreased vision
- Increasing levels of ocular pain
What symptoms may occur with endophthalmitis secondary to intraocular foreign body?
Similar to acute postoperative endophthalmitis; symptoms may be delayed depending on the causal organism.
What are the clinical signs of endophthalmitis?
- Severe anterior chamber reaction
- Various levels of hypopyon formation
- Vitreous chamber reaction
- Lid erythema
- Chemosis
- Conjunctival injection
True or False: If the infection is severe, views of the fundus may be limited or completely obstructed.
True
What is Endophthalmitis?
A severe intraocular infection that can lead to vision loss
It can occur postoperatively or due to trauma, especially in immunocompromised patients.
What are the initial treatment steps for patients with severe Endophthalmitis with vision limited to light perception?
- Hospitalization
- Pars plana vitrectomy
These steps are crucial for patients with severe infections to manage the condition effectively.
What are the treatment steps for patients with hand motion vision or better?
- Culture specimens taken to identify the pathogen
- Intravitreal injection of antibiotics (vancomycin, amikacin, ceftazidime)
- Topical steroids (prednisolone acetate 1%)
- Topical fortified antibiotics (vancomycin, cefazolin, tobramycin, fluoroquinolone)
The treatment is tailored based on the identified pathogen and patient response.
How often should follow-up examinations occur after treatment?
Every 12 hours
This frequent monitoring helps assess the patient’s improvement and response to treatment.
What improvements should a patient report after 48 hours of treatment?
- Improvement in vision
- Decrease in ocular pain
- Diminished anterior chamber reaction
These signs indicate a positive response to the treatment regimen.
True or False: Endophthalmitis can occur due to trauma or the introduction of bacteria in immunocompromised patients.
True
This highlights the importance of monitoring at-risk populations for signs of Endophthalmitis.
What is Ehlers-Danlos syndrome?
A connective tissue disorder that results in abnormal collagen production
It affects the structure and function of connective tissues, leading to various clinical manifestations. (Angioid streaks, blue sclera, keratoconus, high myopia)
How many sub-types of Ehlers-Danlos syndrome are there?
11 sub-types
Each sub-type displays different characteristics and clinical features.
Which type of Ehlers-Danlos syndrome has the most ocular involvement?
Type 6
This type is autosomal recessive and is characterized by significant eye-related complications.
What are common physical features of patients with Ehlers-Danlos syndrome?
Hyperelasticity of the skin and hyperextended joints
These features are due to the abnormal collagen production affecting the connective tissue.
What serious complications can arise in patients with Ehlers-Danlos syndrome?
Spontaneous rupture of large blood vessels and prolapse of the mitral valves
These complications can lead to significant morbidity and mortality.
What ocular complications are associated with Ehlers-Danlos syndrome? (Name at least 4)
Rupture of the globe
blue sclera
microcornea
megalocorea
keratoconus
retinal detachment
high myopia
ectopia lentis
cornea plana (flat cornea, corneal curvature = scleral curvature)
angioid streaks
These complications are due to the fragility of connective tissues in the eye.
True or False: Ehlers-Danlos syndrome only affects skin and joints.
False
It also affects vascular structures and can lead to ocular complications.
Fill in the blank: Ehlers-Danlos syndrome results in abnormal _______ production.
collagen
Collagen is crucial for the strength and flexibility of connective tissues.
What is NOT an appropriate Tx for filamentary keratitis
Bandage CL
* DO NOT USE FOR CHRONIC DRY EYE ETIOLOGY
* can cause epithelial hypoxia and infectious keratitis
Tx for filamentary keratitis secondary to keratoconjunctivitis related to Sjogren syndrome
- PF AT and lubricating ointment qhs
- Punctal occlusion
- diclofenac sodium (NSAID) for inflammation and analgesia
- restasis
What is a common demographic for corneal and conjunctival intraepithelial neoplasia (CIN)?
Fair-skinned, middle-aged, or older patients
Typically those with considerable exposure to UV light
In which type of patients is CIN more frequently observed?
Immunosuppressed patients, particularly those with HIV
*also seen in fair skin, UV B exposure, smoking
*HIV/HPV —> Bowen’s disease
* most common pre-malignant conjunctival lesion
Can progress to SCC
What viral infection is associated with a high incidence of CIN?
Human papillomavirus (HPV)
HPV is a common virus that can lead to various types of cancer
Describe the appearance of CIN lesions.
Fleshy or gelatinous, elevated, grayish lesion
Commonly observed at the limbus within the interpalpebral fissure
How do CIN lesions typically extend?
Variably extends into the adjacent corneal epithelium
This may involve a superficial opacity
What is CIN?
Conjunctival intraepithelial neoplasia
* unilateral papillomatous, gray-white mass that is elevated and vascularized
*can evolve into SCC (squamous cell carcinoma)
Tx: complete excisional biopsy + topical mitomycin C, 5-fluorouracil, and interferon
What histological feature is characteristic of conjunctival epithelial dysplasia?
Dysplastic cells confined to the basal layers of the epithelium
This is the least severe form of dysplasia
What does carcinoma in situ indicate in CIN histology?
Dysplastic cells have replaced the full thickness of the epithelium
This represents a more advanced stage than dysplasia
What defines squamous cell carcinoma in the context of CIN?
Dysplastic cells have invaded the basement membrane and occupied the underlying stroma
This indicates the most severe form of dysplastic progression
What are the most common risk factors for developing CIN (conjunctival intraepithelial neoplasia)?
- UV light exposure
- human papillomavirus infection
- HIV should also be ruled out if pt under 50 years old
Treatment for localized corneal intraepithelial neoplasia (localized to epithelium)
Complete excision with adequate margins
* removal of growth performed by alcohol corneal epitheliectomy and partial lamellar sxlerokeratoconjuncticectomy
If corneal or conjunctival intraepithelial neoplasia is not treated early or successfully, the condition can progress to what lesion?
Squamous cell carcinoma
Arlt line
- characteristic find of trachoma (infection caused by chlamydia trachomatis)
Thick band of scar tissue runs horizontally on upper palpebral conjunctiva
Vogt striae
Keratoconus
* thin parallel vertical lines
* radiate through center of cone and represent stressed collagen lamellar deep within deep corneal stroma and descemet’s
What is the initial management for mild cases of granular dystrophy?
Ocular lubrication for associated dry eye symptoms
Ocular lubrication helps alleviate dryness and discomfort.
What may be used for advanced cases of granular dystrophy with corneal erosions?
A bandage contact lens
Bandage contact lenses can protect the cornea and help with healing.
List some surgical interventions that may benefit patients with advanced granular dystrophy.
- Superficial keratectomy
- Excimer laser phototherapeutic keratectomy (PTK)
- Lamellar keratoplasty
- Penetrating keratoplasty
These procedures can help restore vision and address corneal issues.
How does the visual acuity of patients with granular dystrophy typically present?
Relatively good, with discreet borders of deposits
Areas of clear cornea between deposits contribute to better visual acuity.
What is the outcome for the patient mentioned in the text regarding visual acuity and symptoms?
Mildly decreased visual acuity and symptomatic
This indicates the need for surgical intervention.
What surgical intervention is suggested for a patient with mild visual acuity decrease due to granular dystrophy?
Excimer laser phototherapeutic keratectomy (PTK)
PTK can help in managing symptoms and improving vision.
True or False: Granular dystrophy is a condition that does not recur after surgical interventions.
False
Recurrence is common within 3 to 5 years after PTK or corneal transplantation.
Fill in the blank: Granular dystrophy may cause _______ if corneal erosions are present.
Visual acuity to be adversely affected
Corneal erosions can lead to significant vision problems.
What is Vernal Conjunctivitis?
A very rare condition typically seen in boys under the age of 10 who live in hot climates and have a predilection for atopy
Characterized by seasonal outbreaks that decrease in severity over time and spontaneously resolve during puberty.
What age group is most commonly affected by Vernal Conjunctivitis?
Boys under the age of 10
In what type of climate is Vernal Conjunctivitis commonly seen?
Hot climates
What are the additional symptoms of Vernal Conjunctivitis?
Photophobia and pain
What are Horner-Trantas dots?
Collections of eosinophils at the limbus
What type of discharge is associated with Vernal Conjunctivitis?
Thick ropy discharge
What is a shield ulcer?
A superiorly located, sterile, well-delineated, grey infiltrate
Where do papillae manifest in Vernal Conjunctivitis?
In the superior palpebral conjunctiva as large cobblestones
What is the primary treatment for Vernal Conjunctivitis?
Treat the allergic conjunctivitis and the shield ulcer if present
Signs of vernal keratoconjunctivitis
- thick ropy discharge
- Horner-Trantas dots (eosinophils at the limbus)
- shield ulcer (superior, grey infiltrate)
- large cobble stone papillae
Tx for idiopathic episcleritis (first occurrence)
Topical naphazoline (vasoconstrictor)
Artificial tears
* first occurrence of episcerlitis
* idiopathic, self-limiting
Tx for acne rosacea
- oral doxycycline
Or - oral tetracycline
Or - oral erythromycin’s
What is posterior polymorphous dystrophy?
A corneal condition characterized by gray/white vesicles or rings within Descemet’s membrane
Often described as a ‘railroad track’ lesion
How does posterior polymorphous dystrophy typically present?
Bilateral, asymmetrical, and very slowly progressive
Most patients are asymptomatic and do not require treatment
What is a potential complication of posterior polymorphous dystrophy?
Development of glaucoma due to formation of peripheral anterior synechia
This may block the trabecular meshwork
What may be required if severe corneal decompensation occurs in posterior polymorphous dystrophy?
Corneal transplant
Severe corneal decompensation is quite rare
True or False: Most patients with posterior polymorphous dystrophy require treatment.
False
Most patients are asymptomatic
Fill in the blank: Posterior polymorphous dystrophy is often described as a _______ lesion.
railroad track
Refers to the appearance of the vesicles or rings
What is calcific band keratopathy?
A condition involving white/hazy calcium ion deposits in the superficial cornea, especially Bowman’s membrane
It appears in a Swiss cheese-like pattern.
Where does calcific band keratopathy occur in the eye?
In the interpalpebral region of the superficial cornea, Bowman’s membrane
What are common symptoms of calcific band keratopathy?
Decreased vision and foreign body sensation
Patients often report these sensations.
What are some secondary causes of calcific band keratopathy?
- Chronic dry eye
- Exposure keratopathy
- Chronic ocular inflammation (uveitis, iritis)
These conditions contribute to the development of calcific band keratopathy.
What patient history may contribute to the occurrence of calcific band keratopathy?
- Multiple ocular surgeries
- Ocular trauma
- Longstanding glaucoma
These factors increase the risk of developing the condition.
What systemic conditions can lead to calcific band keratopathy?
- Hypercalcemia
- Sarcoidosis
- Vitamin D toxicity
These systemic issues can result in calcium deposits in the eye.
How are elevated phosphorus levels related to calcific band keratopathy?
Elevated phosphorus levels, such as in chronic renal failure, are associated with this condition
High phosphorus levels can exacerbate the deposition of calcium.
What is band keratopathy?
A condition caused by calcium deposition at the level of Bowman’s membrane
Band keratopathy often leads to visual impairment and can be associated with various systemic conditions, ex: gout
What causes corneal arcus?
Lipid leakage into the cornea from limbal blood vessels
Corneal arcus is often seen in older adults and can be a sign of hyperlipidemia in younger individuals.
What are pterygia?
Proliferation of fibrovascular tissue onto the cornea
Pterygia can cause discomfort and may lead to vision problems if they encroach on the visual axis.
What is granular dystrophy?
A condition that results from a deposition of eosinophilic hyaline in the anterior stroma
Granular dystrophy is a hereditary corneal dystrophy characterized by the presence of discrete, gray-white opacities.
Kayser-Fleischer ring
Copper in corneal periphery at the level of Descemet’s membrane, associated with Wilson’s disease
What is Primary acquired melanosis (PAM)?
A condition found almost exclusively in middle-aged Caucasians.
Is PAM typically unilateral or bilateral?
Unilateral.
What characterizes PAM without atypia?
(Primary acquired melanosis)
It is benign and limited to the basal layer of the conjunctiva.
What is the risk of PAM with atypia?
It has a 50% chance of becoming malignant.
What layers of the conjunctiva does PAM with atypia extend to?
All layers of the conjunctiva.
What age group is PAM usually observed in?
After the age of 45.
How does PAM typically appear?
As flat brown lesions that can be moved over the sclera.
What changes may occur with PAM over time?
It can become larger or smaller, with increased or decreased levels of pigmentation.
What features in PAM should raise suspicion of malignancy?
Areas that become elevated or vascularized.
What is a melanocytoma?
A congenital, evenly pigmented, black/dark brown lesion with well-demarcated borders.
How does a melanocytoma behave in relation to the scleral surface?
It does not move freely over the scleral surface.
What is the growth rate of melanocytomas?
They are slow-growing.
In which age demographic is conjunctival melanoma typically observed?
Middle-aged to elderly patients.
What is a common appearance of melanomatous lesions?
They are usually elevated and vascularized.
What can be observed at the site of a melanoma?
A large feeder vessel.
Where do melanomas frequently occur?
At the limbus.
What is the typical pigmentation of melanomas?
Generally darkly pigmented, although they may also be amelanotic.
From what can melanomas develop?
- Primary acquired melanosis
- Existing nevi
- Spontaneously
Where may conjunctival melanomas metastasize?
- Preauricular nodes
- Anterior cervical lymph nodes
What is crucial if a melanoma is suspected?
Palpation of the preauricular and anterior cervical lymph nodes.
What type of hypersensitivity reaction is associated with giant papillary conjunctivitis (GPC)?
Both type IV delayed hypersensitivity reaction and immediate type I, IgE mediated reaction
GPC exhibits characteristics of two types of hypersensitivity reactions.
What types of inflammatory cells are typically increased in patients with GPC?
- Lymphocytes
- Mast cells
- Eosinophils
- Basophils
- Plasma cells
These cells contribute to the inflammatory response in the conjunctiva.
What are the effects of the chemical inflammatory mediators released by the inflammatory cells in GPC?
- Vasodilation
- Edema
- Increased production of mucous
These effects occur locally in the tissue of the conjunctiva.
What structural cells are involved in the inflammatory process of GPC?
- Epithelial cells
- Fibroblasts
These cells also play a role in tissue remodeling.
What is the result of the inflammatory process in patients with GPC?
Formation of giant papillae
The inflammatory response leads to structural changes in the conjunctiva.
What is typically observed in the tear film of patients with GPC?
High levels of IgE
Elevated IgE levels are indicative of an allergic response.
What remains unclear about the development of GPC?
The exact etiology of the development of GPC
What has research suggested is responsible for the observed tissue changes in GPC?
An immune response
What is the controversy related to in GPC?
The cause of the inflammatory response
What do some investigators believe elicits the inflammation in GPC?
An immune reaction to the patient’s own tear proteins
What role do contact lens hygiene solutions play in GPC?
They presumably denature tear proteins
How do tear proteins contribute to GPC when attached to contact lenses?
They act as antigens to which antibodies may bind
What additional factor do some researchers believe contributes to GPC?
Mechanical trauma induced by the edges of contact lenses
What specific area may be irritated by contact lenses contributing to GPC?
The upper tarsal conjunctiva
True or False: The inflammatory response in GPC is solely due to mechanical trauma from contact lenses.
False
Fill in the blank: Some researchers believe that _______ may also play a role in the development of GPC.
mechanical trauma
What is acute corneal hydrops?
A condition caused by ruptures in Descemet’s membrane allowing aqueous influx into the corneal stroma
What are the symptoms of acute corneal hydrops?
Reduction in visual acuity, loss of corneal clarity, ocular discomfort, redness, foreign body sensation, and watering of the eyes
What does a slit-lamp examination reveal in cases of acute corneal hydrops?
Significant central or inferior corneal edema with associated hyperemia of the conjunctiva
How many eyes are typically affected by acute corneal hydrops?
Typically one eye at a time
What is usually observed in the contralateral eye of a patient with acute corneal hydrops?
Signs of keratoconus but without the presence of hydrops
Is acute corneal hydrops a self-limiting condition?
Yes
How long does it typically take for the cornea to heal and edema to resolve in acute corneal hydrops?
Up to 8 to 10 weeks
Fill in the blank: Acute corneal hydrops is caused by ruptures in _______.
Descemet’s membrane
True or False: Acute corneal hydrops affects both eyes simultaneously.
False
What is Terrien?
Non-inflammatory corneal condition
Terrien is characterized by progressive thinning of the cornea.
In which age and gender demographic is Terrien more frequently observed?
Occurs more frequently in males in their 2nd to 4th decade
This demographic trend highlights the age and gender predispositions.
What are the early stage signs of Terrien?
Bilateral, superior thinning of the peripheral cornea along with pannus and potentially lipid deposition
These signs are indicative of the initial phase of the condition.
What happens as Terrien progresses?
Thinning extends circumferentially and creates a vascularized gutter around the corneal periphery
This progression can lead to more severe visual impairment.
What may be observed in long-standing cases of Terrien?
Pseudopterygia
Pseudopterygia are abnormal growths that can occur due to chronic irritation or thinning.
Are patients with Terrien typically symptomatic?
Patients are generally asymptomatic
However, some may report blurry vision.
What causes blurry vision in patients with Terrien?
Against-the-rule astigmatism
This type of astigmatism results from the corneal shape changes associated with the condition.
What are pterygia and pingueculae caused by?
Excessive exposure to ultraviolet light or prolonged exposure to dry, dusty environments
These conditions result from the ocular surface reacting via proliferation of fibrovascular tissue.
How do pterygia typically appear?
As elevated triangular growths with their apexes pointing towards the pupil
Pterygia are more commonly observed nasally than temporally.
When is surgical intervention warranted for pterygia?
In the event of excessive irritation, irregular astigmatism, risk of encroachment into the visual axis, or patient dissatisfaction with cosmesis
These criteria help determine the necessity of surgical treatment.
What is phlyctenulosis?
A corneal condition resulting from a hypersensitivity reaction to toxins released by Staphylococcus bacteria
It is often observed in conjunction with blepharitis.
What do phlyctenules look like?
Round, elevated nodules originating from the limbus
They are associated with a hypersensitivity reaction.
What is the treatment for phlyctenulosis?
Management of concurrent blepharitis and administration of antibiotic ointments and/or topical steroids
In rare cases, phlyctenules may be associated with tuberculosis.
What characterizes Mooren ulcer?
Painful corneal ulceration with unknown etiology
Patients present with intense limbal inflammation and swelling of the episclera and conjunctiva.
How do corneal findings in Mooren ulcer typically appear?
As gray lesions within 2-3 mm of the limbus that grow circumferentially and centrally
This growth occurs over a period of 4-12 months.
What shape are the ulcers in Mooren ulcer described as?
Crescent-shaped
Damage typically affects the stromal tissue, leaving the epithelium and endothelium intact.
What does Salzmann nodular degeneration look like?
The appearance of singular or multiple elevated, smooth, white/gray nodules on the cornea
These nodules typically do not extend past the limbus.
What conditions can lead to Salzmann nodular degeneration?
- Phlyctenulosis
- Vernal keratoconjunctivitis
- Keratoconjunctivitis sicca
- Rigid contact lens wear
- Other conditions causing keratopathy
These conditions may contribute to the development of Salzmann nodular degeneration.
What is the treatment for symptomatic Salzmann nodular degeneration?
Epithelial scraping and/or excimer laser phototherapeutic keratectomy (PTK)
Ocular lubrication is used unless the patient is symptomatic.
What is the Stocker line?
An iron pigment line that deposits just anterior to the leading aspect of a pteryglum, considered a sign of stability.
Where is the Hudson-Stahli line commonly observed?
In the inferior mid-peripheral region of the corneas of patients with advanced age.
What are Fleischer rings associated with?
They are often found at the base of the cone in patients with keratoconus.
What is the Ferry line?
A corneal pigmented line associated with the presence of a filtering bleb.
What is the maximum corneal power that should be considered for CXL?
65D
Higher keratometric values are associated with increased failure rates.
What is the age demographic that has a greater risk of visual acuity loss after CXL treatment?
Patients over the age of 35
These patients also have a distance visual acuity of 20/25 or better.
What corneal thickness is an exclusion criterion for CXL using the standard protocol?
Less than 400 microns
This is to reduce the chance of UVA-induced corneal endothelial damage.
Who are the best candidates for CXL?
Patients who are 35 years of age or younger
Ideal candidates also have moderate keratoconus, with max K value less than 65D, corneal thickness greater than 400 microns, and visual acuities of 20/30 or worse.
What visual acuity is associated with the best candidates for CXL?
20/30 or worse
This is in conjunction with other qualifications like age and keratoconus severity.
True or False: A corneal thickness greater than 400 microns is necessary for CXL.
True
This requirement helps to prevent corneal endothelial damage.
Fill in the blank: The maximum keratometric value for CXL candidates should be less than _______.
65D
Higher values are linked to increased failure rates.
What condition must be present for eyes at the time of diagnosis in children to qualify for CXL?
Progression
This is also a consideration for adults.
What is the etiology of marginal keratitis?
Hypersensitivity reaction to staphylococcal bacteria exotoxins
* sterile lesions, separated from limbus by a zone of clear cornea
* located superiorly or inferiorly (where the lid margin rests against surface of cornea)
What characterizes PAM with atypia
It’s a pre-cancerous lesion
Pathophysiology of ICE syndrome
(Iridocorneal endothelial syndrome)
corneal endothelium proliferates across the anterior chamber angle, causing contraction of the Iris and secondary angle closure glaucoma
* mostly occurs in women
Symptoms of ICE syndrome
Initially symptomatic
But as Iris changes occur in late stages, patients complain of blur and monocular diplopia
What are the three types of ICE syndromes?
Essential Iris Arrophy
Chandler Syndrome
Iris Nevus/Cogan-Reese Syndrome
What is the most common cause of “pink eye”
Adenoviral conjunctivitis
* highly contagious for 12-14 days, transmitted via contact
What are the 3 types of viral conjunctivitis?
1) non-specific (most common)
2) EKC
3) pharyngoconjunctival fever (swimming pool conjunctivitis)
What is EKC? And how is it different from the other forms of viral conjunctivitis?
Epidemic keratoconjunctivitis
* different because has SEI (subepithelial infiltrates) = pt no longer contagious
* occur 2-3 weeks after onset of infection (rule of 8: s/s 8 days after exposure followed by 8 days of SEI)
* causes severe pain
Does EKC cause severe pain?
Yes
What type of viral conjunctivitis involves a sore throat and fever?
Swimming pool conjunctivitis aka pharyngoconjunctival fever
Phlyctenule is caused by hypersensitivity to what organisms?
Staphylococcus
Mycobacterium
Candida
Coccidioides
Chlamydia
Nematodes
*located on bulbar conj or at limbus
* can go across cornea, causing neovasc and scarring behind leading edge
Adenovirus conjunctivitis types (3)
- Acute non-specific (most common)
- Pharyngoconjunctival fever (follicular conjunctivitis + low grade fever + pharyngitis
- Epidemic keratoconjunctivitis (pain + SEIs)
