Corneal Disorders

Question 1

Corneal Disorders include?

Answer 1

Subconjunctival hemorrhage, Keratoconus, Corneal abrasions, Foreign bodies, Corneal ulcers (bacterial, herpes simplex, fungal, acathamoeba, herpes zoster)

Question 2

Red Flags Include?

Answer 2

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

Question 3

Describe a Subconjunctival Hemorrhage

Answer 3

This is blood that has extravasated from the vessels (this is NOT injection)
May occur spontaneously or with coughing, sneezing, straining, or vomiting

Question 4

Subconjunctival Hemorrhage symptoms

Answer 4

Normal visual acuity. Absence of: discharge, photophobia, and foreign body sensation

Question 5

Subconjunctival Hemorrhage treatment

Answer 5

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

Question 6

Keratoconus

Answer 6

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.

Question 7

Keratoconus symptoms

Answer 7

Substantial distortion of vision. Photophobia.
Typically diagnosed in the patient’s adolescent years. If both eyes, patients may have difficulty with driving or reading.

Question 8

Keratoconus treatment

Answer 8

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.

Question 9

Corneal Abrasion

Answer 9

any defect in the corneal surface epithelium.

Question 10

Corneal Abrasion Classifications

Answer 10

Traumatic. Foreign-body related. Contact lens related. Spontaneous (also known as recurrent erosions)

Question 11

Traumatic Corneal Abrasion

Answer 11

Mechanical trauma to the eye which results in defect in epithelial surface

Question 12

Causes of traumatic corneal abrasion

Answer 12

Fingernails. Paws. Pieces of paper or cardboard. Make-up applicators. Hand tools. Branches. Leaves.
Foreign body lodged under eyelid

Question 13

Foreign Body Related Corneal Abrasion

Answer 13

Defects in corneal epithelium that are left behind after removal or spontaneous dislodging of a corneal foreign body

Question 14

Causes of Foreign Body Related Corneal Abrasion

Answer 14

Wood. Glass. Plastic. Fiberglass

Question 15

Contact Lens Related Corneal Abrasions

Answer 15

Defects in corneal epithelium that are left behind after removal of over-worn, improperly fitting, or improperly cleaned contact lens

Question 16

Causes of Contact Lens Related Corneal Abrasions

Answer 16

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

Question 17

Clinical Presentation Corneal Abrasions

Answer 17

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

Question 18

Presumed Corneal Abrasion

Answer 18

Pain + Foreign body sensation

Question 19

What does PERRLA stand for?

Answer 19

Pupils equal round reactive to light accommodation

Question 20

Large nonreactive or irregular pupil?

Answer 20

Suggests injury to pupillary sphincter from penetrating trauma or blunt trauma… need to call the ophthalmologist

Question 21

Eye examination of possible corneal abrasion

Answer 21

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

Question 22

Traumatic and foreign body abrasions

treatment

Answer 22

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.

Question 23

Patching problems

Answer 23

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

Question 24

Traumatic and foreign body abrasions

pain control

Answer 24

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

Question 25

Contact Lens Related Abrasion

Answer 25

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!!

Question 26

Contact Lens Related Abrasion

treatment

Answer 26

the fluoroquinolone drops such as ofloxacin (Ocuflox) or ciprofloxacin (Ciloxan). Cyloplegic agents. Opioids as necessary

Question 27

General rule of thumb for ALL types of abrasions

Answer 27

Follow up every 24 hours for subsequent evaluation until abrasion is fully healed and give careful ER instructions!!

Question 28

Foreign body symptoms

Answer 28

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

Question 29

Foreign Body Removal

Answer 29

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

Question 30

Most common infectious Corneal Ulcers causes

Answer 30

Bacteria
Viruses
Fungi
Amoebas

Question 31

Most common non-infectious Corneal Ulcers causes

Answer 31

Neurotrophic keratitis. Exposure keratitis. Severe dry eyes. Severe allergic eye disease

Question 32

keratitis

Answer 32

Inflammation of the cornea

Question 33

Signs and symptoms of keratitis

Answer 33

Photophobia. Tearing. Reduced vision. Red eye. Ciliary flush. Purulent or watery discharge. Corneal appearance is variable depending on the cause and duration of condition

Question 34

Bacterial keratitis most common pathogens

Answer 34

Pseudomonas aeruginosa
Pneumococcus
Moraxella
Staphylococcus

Question 35

Bacterial keratitis symptoms

Answer 35

Precipitating factors are contact lens wear (especially overnight wear) or trauma
Cornea is hazy with central ulcer and stromal abscess
Hypopyon is often present

Question 36

Bacterial keratitis treatment

Answer 36

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)

Question 37

Herpes Simplex Keratitis

Answer 37

Dendritic, branching ulcer is most characteristic

Viruses ability to colonize the trigeminal ganglion leads to recurrent clinical problems

Question 38

Herpes Simplex Keratitis treatment

Answer 38

Can be treated with debridement and patching; +/- topical antivirals (YOU NEED TO REFER ALL TO OPHTH)

Question 39

Stromal HSV keratitis symptoms

Answer 39

produces increasingly severe corneal opacity with each reoccurrence

Question 40

Stromal HSV keratitis treatment

Answer 40

need topical antivirals, oral antivirals, and topical steroids - - BUT - - They need a to be under the care of an Opthomologist or Opthomolgy PA.

Question 41

Fungal Keratitis causes

Answer 41

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

Question 42

Fungal Keratitis treatment

Answer 42

Need stromal scrapings for culture and treatment is usually difficult and corneal grafting may be required

Question 43

Acanthamoeba Keratitis symptoms

Answer 43

One of the leading causes of suppurative keratitis in contact lens wearers. SEVERE PAIN. Perineural and ring infiltrates in the corneal stroma are characteristic

Question 44

Acanthamoeba Keratitis treatment

Answer 44

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!!!

Question 45

Herpes Zoster Ophthalmicus symptoms

Answer 45

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

Question 46

Herpes Zoster Ophthalmicus treatment

Answer 46

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

Question 47

Why should topical anesthetics never be prescribed for pain relief?

Answer 47

they delay corneal epithelium healing