Corneal Disorders Flashcards
Corneal Disorders include?
Subconjunctival hemorrhage, Keratoconus, Corneal abrasions, Foreign bodies, Corneal ulcers (bacterial, herpes simplex, fungal, acathamoeba, herpes zoster)
Red Flags Include?
Reduction of visual acuity. Severe deep eye pain. Ciliary flush. Photophobia. Severe foreign body sensation that prevents the patient from keeping the eye open. Corneal opacity. Fixed pupil. Severe headache with nausea
Describe a Subconjunctival Hemorrhage
This is blood that has extravasated from the vessels (this is NOT injection)
May occur spontaneously or with coughing, sneezing, straining, or vomiting
Subconjunctival Hemorrhage symptoms
Normal visual acuity. Absence of: discharge, photophobia, and foreign body sensation
Subconjunctival Hemorrhage treatment
Patient should be educated that the blood will be resorbed over a 1-2 week period. If recurrent or family history of bleeding disorder, consider a workup for hematologic or coagulation abnormality
Keratoconus
A degenerative disorder of the eye in which structural changes within the cornea cause it to thin and change to a more conical shape than its normal gradual curve.
Keratoconus symptoms
Substantial distortion of vision. Photophobia.
Typically diagnosed in the patient’s adolescent years. If both eyes, patients may have difficulty with driving or reading.
Keratoconus treatment
corrective lenses fitted by a specialist are effective enough to allow the patient to continue to drive legally and likewise function normally. Further progression of the disease may require surgery, including intrastromal corneal ring segments, cross-linking, mini asymmetric radial keratotomy and, in 25% of cases, corneal transplantation.
Corneal Abrasion
any defect in the corneal surface epithelium.
Corneal Abrasion Classifications
Traumatic. Foreign-body related. Contact lens related. Spontaneous (also known as recurrent erosions)
Traumatic Corneal Abrasion
Mechanical trauma to the eye which results in defect in epithelial surface
Causes of traumatic corneal abrasion
Fingernails. Paws. Pieces of paper or cardboard. Make-up applicators. Hand tools. Branches. Leaves.
Foreign body lodged under eyelid
Foreign Body Related Corneal Abrasion
Defects in corneal epithelium that are left behind after removal or spontaneous dislodging of a corneal foreign body
Causes of Foreign Body Related Corneal Abrasion
Wood. Glass. Plastic. Fiberglass
Contact Lens Related Corneal Abrasions
Defects in corneal epithelium that are left behind after removal of over-worn, improperly fitting, or improperly cleaned contact lens
Causes of Contact Lens Related Corneal Abrasions
Caused by physical contact with the lens, debris on or under the lens or poor handling of the lens during insertion or removal
***Results from a foreign body that is associated with specific pathogens
Clinical Presentation Corneal Abrasions
Usually a lot of eye pain. Inability to open eye due to foreign body sensation. Photophobia. Patients are often too uncomfortable to work, drive, or read
Presumed Corneal Abrasion
Pain + Foreign body sensation
What does PERRLA stand for?
Pupils equal round reactive to light accommodation
Large nonreactive or irregular pupil?
Suggests injury to pupillary sphincter from penetrating trauma or blunt trauma… need to call the ophthalmologist
Eye examination of possible corneal abrasion
visual acuity!! May be normal if the abrasion is away from visual axis. Abnormal if abrasion is in visual axis. Injection. There should be no discharge other than tears. There should be no corneal opacity. Perform funduscopic exam. Fluoroscein staining. upper eyelid eversion to search for retained foreign body
Traumatic and foreign body abrasions
treatment
Topical antibiotics, Ointment is better than drops because it functions as a lubricant
Erythromycin and sulfacetamide are excellent choices IN THE ABSENSE OF CONTACT LENS TRAUMA. Usually give every 4-6 hours for 5 days.
Patching problems
irritating and results in loss of depth perception.
Restricts visual fields. Patients shouldn’t drive with patch. Some patient’s may be incapacitated by it.
May obscure if an infectious process is developing
Traumatic and foreign body abrasions
pain control
Cycloplegic agents- Inhibit pupil constricting to light which helps with pain (will NOT usually relieve foreign-body sensation however). Examples include Topicamide or Cyclopentolate (Cyclogyl)
Systemic therapy-Opioids
Contact Lens Related Abrasion
Infectious pseudomonas keratitis can result in corneal melting and perforation within 24 hours… Because of the severe risk of infection, patients should NEVER be patched!
Contact lens wear is the most common cause of infectious keratitis in industrialized nations!!
Contact Lens Related Abrasion
treatment
the fluoroquinolone drops such as ofloxacin (Ocuflox) or ciprofloxacin (Ciloxan). Cyloplegic agents. Opioids as necessary
General rule of thumb for ALL types of abrasions
Follow up every 24 hours for subsequent evaluation until abrasion is fully healed and give careful ER instructions!!
Foreign body symptoms
Eye pain and an inability to open the eye because of foreign body sensation. ranges from a mild foreign body sensation in cases of small abrasions to excruciating pain in large abrasion. Excessive tearing, conjunctival injection and eyelid swelling may be present
Foreign Body Removal
Try irrigation. Try the swab. Refer to someone trained in removing foreign bodies and in the meantime.Treat with topical antibiotic ointment (erythromycin). No patches
Most common infectious Corneal Ulcers causes
Bacteria
Viruses
Fungi
Amoebas
Most common non-infectious Corneal Ulcers causes
Neurotrophic keratitis. Exposure keratitis. Severe dry eyes. Severe allergic eye disease
keratitis
Inflammation of the cornea
Signs and symptoms of keratitis
Photophobia. Tearing. Reduced vision. Red eye. Ciliary flush. Purulent or watery discharge. Corneal appearance is variable depending on the cause and duration of condition
Bacterial keratitis most common pathogens
Pseudomonas aeruginosa
Pneumococcus
Moraxella
Staphylococcus
Bacterial keratitis symptoms
Precipitating factors are contact lens wear (especially overnight wear) or trauma
Cornea is hazy with central ulcer and stromal abscess
Hypopyon is often present
Bacterial keratitis treatment
Gram stain or culture can be done
Usually treated empirically with round-the-clock high-concentration topical antibiotic
Fluoroquinolones are preferred agents (Ciprofloxacin, ofloxacin, or norfloxacin)
Herpes Simplex Keratitis
Dendritic, branching ulcer is most characteristic
Viruses ability to colonize the trigeminal ganglion leads to recurrent clinical problems
Herpes Simplex Keratitis treatment
Can be treated with debridement and patching; +/- topical antivirals (YOU NEED TO REFER ALL TO OPHTH)
Stromal HSV keratitis symptoms
produces increasingly severe corneal opacity with each reoccurrence
Stromal HSV keratitis treatment
need topical antivirals, oral antivirals, and topical steroids - - BUT - - They need a to be under the care of an Opthomologist or Opthomolgy PA.
Fungal Keratitis causes
Tends to occur after injury from plant material or agricultural settings. Also seen in patients with chronic ocular surface disease and in contact lens wearers. Usually see multiple stromal abscesses with little epithelial loss. Intraocular infection is common
Fungal Keratitis treatment
Need stromal scrapings for culture and treatment is usually difficult and corneal grafting may be required
Acanthamoeba Keratitis symptoms
One of the leading causes of suppurative keratitis in contact lens wearers. SEVERE PAIN. Perineural and ring infiltrates in the corneal stroma are characteristic
Acanthamoeba Keratitis treatment
Treatment is difficult due to organisms ability to encyst. Corneal grafting may be required in acute stage to arrest progression of infection. REFER IMMEDIATELY TO THE OPHTHALMOLOGIST!!!
Herpes Zoster Ophthalmicus symptoms
Malaise, fever, headache, periorbital burning and itching. Rash is initially vesicular pustular crusted (like chickepox). Involvement of the tip of the nose predicts eye involvement. Ocular signs include conjunctivitis, episcleritis, anterior uveitis, and increased intraocular pressure. Optic neuropathy or cranial nerve palsies are possible in acute stage
Herpes Zoster Ophthalmicus treatment
Treatment is oral vancycylovir (1 gram TID) started within 72 hours of rash. Anterior uveitis requires topical steroids and cycloplegia, so referral to Ophthalmology is recommended. Post HSV neurotrophic keratitis causes long term morbidity
Why should topical anesthetics never be prescribed for pain relief?
they delay corneal epithelium healing
