Inflammatory Corneal Disorders

Question 1

what disorder is caused by a hypersensitivity reaction to staphylococcal exotoxins & cell wall proteins

Answer 1

marginal keratitis

Question 2

marginal keratitis is frequently associated with what two conditions

Answer 2

blepharitis & ocular rosacea

Question 3

sign:
subepithelial infiltrate w/ adjacent conjunctival hyperemia
infiltrates are usually separated from limbus by a clear zone

Answer 3

marginal keratitis

Question 4

what do you use to treat marginal keratitis to stop the toxins

Answer 4

antibiotic-steroid combo for 1-2 weeks

Question 5

what corneal disorder has an acute & rapid onset of a subepithelial inflammatory nodule

Answer 5

phlyctenulosis

Question 6

what are the implicated organisms in phlyctenulosis

Answer 6

staph aureus – in US
active mycobacterium tuberculosis – in developing countries
chlamydia trachomatis – in adults

Question 7

sign:

small white limbal or conjunctival nodule w/ adjacent redness & hyperemia

Answer 7

phlyctenulosis

Question 8

if the phlyctenulosis nodule extends past the limbus, what will occur

Answer 8

corneal haze & formation of superficial vessels

Question 9

phlyctenulosis is common in

Answer 9

children (usually staph) & adolescents

Question 10

what is the associated findings in phlyctenulosis

Answer 10

blepharitis

Question 11

why do we still need to treat phlyctenulosis if it can self-resolve

Answer 11

because we don’t know which ones will self-resolve & which ones won’t

Question 12

prognosis:

upon resolution → a wedge-shaped fibrovascular scar may remain on the cornea

Answer 12

phlyctenulosis

Question 13

what steroid-antibiotic combinations can we use to treat phlyctenulosis

Answer 13

tobradex, zylet

Question 14

when phlctenulosis has significant corneal involvment, how do we treat it & what medication

Answer 14

aggressive steroid therapy w/ slow taper

prednisone acetate 1% ophth susp q2h

Question 15

what underlying etiology should be managed to prevent phlyctenulosis from recurring

Answer 15

blepharitis

Question 16

what condition is a localized non-infectious type IV reaction to a bacterial antigen

Answer 16

phlyctenulosis

Question 17

a rare autoimmune reaction against corneal stromal tissue

Answer 17

Mooren’s ulcer

Question 18

which corneal disorder is a diagnosis of exclusion (no underlying systemic disease present)

Answer 18

Mooren’s ulcer

Question 19

which corneal disorder may be associated with Hep. C infection

Answer 19

Mooren’s ulcer

Question 20

these complications are related to which corneal disorder –
severe astigmatism
perforation after minor tumors; not likely on its on
secondary bacterial infections

Answer 20

Mooren’s ulcer

Question 21

these signs can help you differentiate which corneal disorder from others:

• infiltrated WBC’s on leading edge
• no scleritis present

Answer 21

Mooren’s ulcer

Question 22

peripheral corneal ulceration & thinning which then spreads centrally is a clinical finding in which corneal disorder

Answer 22

Mooren’s ulcer

Question 23

why are topical steroids used to treat Mooren’s ulcers

Answer 23

to control inflammation (may need frequent dosage)

Question 24

what treatment would you use for immunosuppression of a Mooren ulcer

it should be used especially when

Answer 24

topical cyclosporine (Restasis)

especially when there’s an IOP spike

Question 25

when a Mooren's ulcer has significant epithelium compromise, what would you use to treat it

Answer 25

prophylactic topical antibiotic

Question 26

using doxycycline to treat a Mooren's ulcer inhibits what

Answer 26

collagenase

Question 27

what corneal disorder can precede or follow onset of systemic collegen-vascular autoimmune disease

Answer 27

peripheral ulcerative keratitis (PUK)

Question 28

what is the most common underlying systemic etiology of PUK

Answer 28

rheumatoid arthritis

Question 29

pathophysiology: - immune complex deposition in peripheral cornea - cytokine release & inflammatory cell recruitment - upregulation of collagenases → causing destruction of peripheral stroma

Answer 29

peripheral ulcerative keratitis (PUK)

Question 30

signs: - crescentic ulceration with epithelial defect - thinning & stromal infiltration at limbus - limbitis, episcleritis, or scleritis can be present

Answer 30

peripheral ulcerative keratitis (PUK)

Question 31

what specialists would you refer someone with PUK to & why

Answer 31

- rheumatology → requires systemic immunosuppression | - corneal specialist → may need surgery to prevent perforation

Question 32

what kind of topical lubricant is used to treat PUK aggressively

Answer 32

preservative-free

Question 33

if PUK has a large epithelial defect, what would you treat it with

Answer 33

prophylactic topical antibiotic

Question 34

what medication has anti-collagenase effect that is used to treat PUK

Answer 34

doxycycline

Question 35

why can't you use topical steroids to treat PUK

Answer 35

promotes corneal melting

Question 36

PUK vs. Mooren's ulcer: | which is rapidly progressive & which is slowly progressive

Answer 36

PUK - rapidly progressive | Mooren's - slowly progressive

Question 37

PUK vs. Mooren's ulcer: | which has trauma-induced perforation & which has spontaneous perforation

Answer 37

PUK - spontaneous | Mooren's - trauma-induced

Question 38

PUK vs. Mooren's ulcer: | which one can you treat with topical steroids

Answer 38

Mooren's ulcer

Question 39

PUK vs. Mooren's ulcer: | which is a diagnosis of exclusion & which has an underlying systemic disease

Answer 39

Mooren's - diagnosis of exclusion | PUK - underlying systemic disease

Question 40

what are other ways CL-related corneal sequelae can be called & which one is a misnomer

Answer 40

- tight lens syndrome - CLARE: contact lens acute red eye - CLPU: contact lens peripheral ulcer → misnomer

Question 41

what is a non-infectious corneal inflammatory consequence of CL wear

Answer 41

CL-related corneal sequelae

Question 42

what are the causes of CL-related corneal sequelae

Answer 42

- hypoxia (usually after sleeping in CLs) - hypersensitivity reaction to cleaning solutions - CL deposits from overwear - tight lens

Question 43

clinical findings: - superficial punctate w/ NaFl staining - circumlimbal hyperemia - peripheral infiltrates (aka marginal keratitis) - corneal neovascularization

Answer 43

CL-related corneal sequelae

Question 44

what topical antibiotics would you treat CLARE (CL-related corneal sequelae with & why

Answer 44

4th gen fluoroquinolone → broad-spectrum

Question 45

if significant inflammation is present after treating CLARE with a topical antibiotic, what would you give the patient & when should they apply it

Answer 45

topical steroid → after 24h of antibiotic use

Question 46

an antibiotic/steroid combo can be used to treat CLARE when

Answer 46

there is mild/no epithelial staining is present

Question 47

if significant photophobia is present in CLARE, what should you consider

Answer 47

a cycloplegic

Question 48

we have to monitor CLARE daily for development of what

Answer 48

infectious keratitis

Question 49

a non-ulcerating inflammation of the stroma leading to neovascularization caused by an immune-mediated process triggered by an antigen

Answer 49

interstitial keratits (IK)

Question 50

what is the most common etiology of interstitial keratitis

Answer 50

congenital syphilis in chronic phase

Question 51

acquired syphilis, Cogan's syndrome, HSV/HZV & tuberculosis are etiologies for what corneal disorder

Answer 51

interstitial keratitis (IK)

Question 52

which form of syphilis is bilateral

Answer 52

congenital syphilis

Question 53

which two causes of IK is presents typically as unilateral

Answer 53

acquired syphilis & tuberculosis

Question 54

a rare autoimmune vasculitis that targets inner ear & cornea

Answer 54

Cogan's syndrome

Question 55

in Cogan's, how does intraocular inflammation & neurosensory hearing loss present

Answer 55

they are often separated by a long period of time

Question 56

what intraocular inflammations present in Cogan's

Answer 56

- active IK - uveitis - scleritis - retinal vasculitis

Question 57

what are the symptoms of Cogan's that involves the ear

Answer 57

- vertigo - tinnitus - profound deafness

Question 58

does IK affect the epi & endo

Answer 58

no

Question 59

bloodwork that may reveal elevated ESR & CRP is associated with what condition

Answer 59

Cogan's syndrome

Question 60

who would you refer a patient with IK to & why

Answer 60

- immediate to rheumatology → for systemic steroids to prevent deafness & rule out vasculitis - audiology → evaluate the level of hearing loss

Question 61

which phase of IK has these signs: - pain & photophobia - stromal infiltrates & edema → leading to decreased VA - anterior chamber inflammation - conjunctival hyperemia

Answer 61

acute phase → active inflammation is occurring

Question 62

which phase of IK has these signs: - deep corneal haze/scarring - corneal ghost vessels

Answer 62

chronic phase → occurs when active phase is not accurately & rapidly treated

Question 63

IK bilateral signs indicate which etiology - - deafness - salt & pepper retinopathy - anterior uveitis - Argyll Robertson pupils - cataract

Answer 63

congenital syphilis

Question 64

which type of IK are these treatments used for: - topical steroid - cycloplegic - urgent infectious disease referral for systemic antibiotic treatment

Answer 64

active syphilitic IK

Question 65

what is the management for chronic syphilitic IK

Answer 65

- blood work to rule out current systemic infection | - monitor for any corneal changes

Question 66

an ingrowth of tissue from the limbus into the peripheral cornea

Answer 66

pannus

Question 67

in pannus, where does the ingrowth of tissue penetrate

Answer 67

between epithelium & Bowman's layer

Question 68

in pannus, what does the ingrowth consist of?

Answer 68

collagen & vessels into the superficial cornea

Question 69

these all cause what corneal disorder - hypoxia from CL wear - chemical burns - ocular rosacea - chronic blepharitis

Answer 69

pannus

Question 70

superior pannus is indicative of what

Answer 70

trachoma

Question 71

cellular deposits on corneal endothelium seen in anterior segment inflammation

Answer 71

keratic precipitates (KPs)

Question 72

what is Arlt's triangle & how is it caused

Answer 72

- typical distrubution of KPs in inferior 1/3 of cornea - apex of triangle points up - caused by gravity & aqueous humor currents

Question 73

an immunologic response of host to donor corneal tissue after keratoplasty (corneal graft)

Answer 73

corneal graft rejection

Question 74

when does corneal graft rejection usually occur

Answer 74

most common in the first 6 months after transplantation

Question 75

what can significantly increase the risk of a corneal graft rejection & why

Answer 75

corneal vascularization → blood vessels have immune cells & the cornea is avascular

Question 76

how can a corneal graft rejection decrease vision

Answer 76

graft becomes opacified

Question 77

clinical findings: - corneal edema - KPs on corneal graft but not on peripheral recipient cornea - stromal infiltrates - anterior chamber inflammation

Answer 77

corneal graft inflammation

Question 78

how can corneal graft rejections be reversed

Answer 78

topical & systemic steroids