Inflammatory Corneal Disorders Flashcards
what disorder is caused by a hypersensitivity reaction to staphylococcal exotoxins & cell wall proteins
marginal keratitis
marginal keratitis is frequently associated with what two conditions
blepharitis & ocular rosacea
sign:
subepithelial infiltrate w/ adjacent conjunctival hyperemia
infiltrates are usually separated from limbus by a clear zone
marginal keratitis
what do you use to treat marginal keratitis to stop the toxins
antibiotic-steroid combo for 1-2 weeks
what corneal disorder has an acute & rapid onset of a subepithelial inflammatory nodule
phlyctenulosis
what are the implicated organisms in phlyctenulosis
staph aureus – in US
active mycobacterium tuberculosis – in developing countries
chlamydia trachomatis – in adults
sign:
small white limbal or conjunctival nodule w/ adjacent redness & hyperemia
phlyctenulosis
if the phlyctenulosis nodule extends past the limbus, what will occur
corneal haze & formation of superficial vessels
phlyctenulosis is common in
children (usually staph) & adolescents
what is the associated findings in phlyctenulosis
blepharitis
why do we still need to treat phlyctenulosis if it can self-resolve
because we don’t know which ones will self-resolve & which ones won’t
prognosis:
upon resolution → a wedge-shaped fibrovascular scar may remain on the cornea
phlyctenulosis
what steroid-antibiotic combinations can we use to treat phlyctenulosis
tobradex, zylet
when phlctenulosis has significant corneal involvment, how do we treat it & what medication
aggressive steroid therapy w/ slow taper
prednisone acetate 1% ophth susp q2h
what underlying etiology should be managed to prevent phlyctenulosis from recurring
blepharitis
what condition is a localized non-infectious type IV reaction to a bacterial antigen
phlyctenulosis
a rare autoimmune reaction against corneal stromal tissue
Mooren’s ulcer
which corneal disorder is a diagnosis of exclusion (no underlying systemic disease present)
Mooren’s ulcer
which corneal disorder may be associated with Hep. C infection
Mooren’s ulcer
these complications are related to which corneal disorder –
severe astigmatism
perforation after minor tumors; not likely on its on
secondary bacterial infections
Mooren’s ulcer
these signs can help you differentiate which corneal disorder from others:
- infiltrated WBC’s on leading edge
- no scleritis present
Mooren’s ulcer
peripheral corneal ulceration & thinning which then spreads centrally is a clinical finding in which corneal disorder
Mooren’s ulcer
why are topical steroids used to treat Mooren’s ulcers
to control inflammation (may need frequent dosage)
what treatment would you use for immunosuppression of a Mooren ulcer
it should be used especially when
topical cyclosporine (Restasis)
especially when there’s an IOP spike
when a Mooren’s ulcer has significant epithelium compromise, what would you use to treat it
prophylactic topical antibiotic
using doxycycline to treat a Mooren’s ulcer inhibits what
collagenase
what corneal disorder can precede or follow onset of systemic collegen-vascular autoimmune disease
peripheral ulcerative keratitis (PUK)
what is the most common underlying systemic etiology of PUK
rheumatoid arthritis
pathophysiology:
- immune complex deposition in peripheral cornea
- cytokine release & inflammatory cell recruitment
- upregulation of collagenases
→ causing destruction of peripheral stroma
peripheral ulcerative keratitis (PUK)
signs:
- crescentic ulceration with epithelial defect
- thinning & stromal infiltration at limbus
- limbitis, episcleritis, or scleritis can be present
peripheral ulcerative keratitis (PUK)
what specialists would you refer someone with PUK to & why
- rheumatology → requires systemic immunosuppression
- corneal specialist → may need surgery to prevent perforation
what kind of topical lubricant is used to treat PUK aggressively
preservative-free
if PUK has a large epithelial defect, what would you treat it with
prophylactic topical antibiotic
what medication has anti-collagenase effect that is used to treat PUK
doxycycline
why can’t you use topical steroids to treat PUK
promotes corneal melting
PUK vs. Mooren’s ulcer:
which is rapidly progressive & which is slowly progressive
PUK - rapidly progressive
Mooren’s - slowly progressive
PUK vs. Mooren’s ulcer:
which has trauma-induced perforation & which has spontaneous perforation
PUK - spontaneous
Mooren’s - trauma-induced
PUK vs. Mooren’s ulcer:
which one can you treat with topical steroids
Mooren’s ulcer
PUK vs. Mooren’s ulcer:
which is a diagnosis of exclusion & which has an underlying systemic disease
Mooren’s - diagnosis of exclusion
PUK - underlying systemic disease
what are other ways CL-related corneal sequelae can be called & which one is a misnomer
- tight lens syndrome
- CLARE: contact lens acute red eye
- CLPU: contact lens peripheral ulcer → misnomer
what is a non-infectious corneal inflammatory consequence of CL wear
CL-related corneal sequelae
what are the causes of CL-related corneal sequelae
- hypoxia (usually after sleeping in CLs)
- hypersensitivity reaction to cleaning solutions
- CL deposits from overwear
- tight lens
clinical findings:
- superficial punctate w/ NaFl staining
- circumlimbal hyperemia
- peripheral infiltrates (aka marginal keratitis)
- corneal neovascularization
CL-related corneal sequelae
what topical antibiotics would you treat CLARE (CL-related corneal sequelae with & why
4th gen fluoroquinolone → broad-spectrum
if significant inflammation is present after treating CLARE with a topical antibiotic, what would you give the patient & when should they apply it
topical steroid → after 24h of antibiotic use
an antibiotic/steroid combo can be used to treat CLARE when
there is mild/no epithelial staining is present
if significant photophobia is present in CLARE, what should you consider
a cycloplegic
we have to monitor CLARE daily for development of what
infectious keratitis
a non-ulcerating inflammation of the stroma leading to neovascularization caused by an immune-mediated process triggered by an antigen
interstitial keratits (IK)
what is the most common etiology of interstitial keratitis
congenital syphilis in chronic phase
acquired syphilis, Cogan’s syndrome, HSV/HZV & tuberculosis are etiologies for what corneal disorder
interstitial keratitis (IK)
which form of syphilis is bilateral
congenital syphilis
which two causes of IK is presents typically as unilateral
acquired syphilis & tuberculosis
a rare autoimmune vasculitis that targets inner ear & cornea
Cogan’s syndrome
in Cogan’s, how does intraocular inflammation & neurosensory hearing loss present
they are often separated by a long period of time
what intraocular inflammations present in Cogan’s
- active IK
- uveitis
- scleritis
- retinal vasculitis
what are the symptoms of Cogan’s that involves the ear
- vertigo
- tinnitus
- profound deafness
does IK affect the epi & endo
no
bloodwork that may reveal elevated ESR & CRP is associated with what condition
Cogan’s syndrome
who would you refer a patient with IK to & why
- immediate to rheumatology → for systemic steroids to prevent deafness & rule out vasculitis
- audiology → evaluate the level of hearing loss
which phase of IK has these signs:
- pain & photophobia
- stromal infiltrates & edema → leading to decreased VA
- anterior chamber inflammation
- conjunctival hyperemia
acute phase → active inflammation is occurring
which phase of IK has these signs:
- deep corneal haze/scarring
- corneal ghost vessels
chronic phase → occurs when active phase is not accurately & rapidly treated
IK bilateral signs indicate which etiology -
- deafness
- salt & pepper retinopathy
- anterior uveitis
- Argyll Robertson pupils
- cataract
congenital syphilis
which type of IK are these treatments used for:
- topical steroid
- cycloplegic
- urgent infectious disease referral for systemic antibiotic treatment
active syphilitic IK
what is the management for chronic syphilitic IK
- blood work to rule out current systemic infection
- monitor for any corneal changes
an ingrowth of tissue from the limbus into the peripheral cornea
pannus
in pannus, where does the ingrowth of tissue penetrate
between epithelium & Bowman’s layer
in pannus, what does the ingrowth consist of?
collagen & vessels into the superficial cornea
these all cause what corneal disorder
- hypoxia from CL wear
- chemical burns
- ocular rosacea
- chronic blepharitis
pannus
superior pannus is indicative of what
trachoma
cellular deposits on corneal endothelium seen in anterior segment inflammation
keratic precipitates (KPs)
what is Arlt’s triangle & how is it caused
- typical distrubution of KPs in inferior 1/3 of cornea
- apex of triangle points up
- caused by gravity & aqueous humor currents
an immunologic response of host to donor corneal tissue after keratoplasty (corneal graft)
corneal graft rejection
when does corneal graft rejection usually occur
most common in the first 6 months after transplantation
what can significantly increase the risk of a corneal graft rejection & why
corneal vascularization → blood vessels have immune cells & the cornea is avascular
how can a corneal graft rejection decrease vision
graft becomes opacified
clinical findings:
- corneal edema
- KPs on corneal graft but not on peripheral recipient cornea
- stromal infiltrates
- anterior chamber inflammation
corneal graft inflammation
how can corneal graft rejections be reversed
topical & systemic steroids
