Corneal Path by JY9Knp

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									Corneal Path
Lecture 08/25/08: Corneal Dystrophies
            Arcus Senilis
• Elevated Cholesterol
• See PCP for blood work-up
Arcus Senilis
        Hudson Stahli Line
• A brown, horizontal line across the
  lower third of the cornea, occasionally
  seen in the aged.
• No Tx
Hudson Stahli Line
             Band Keratopathy
• Precipitation of calcium salts on the corneal
  surface (directly under the epithelium)
• Patients with band keratopathy complain of the
  following:
  –   Decreased vision
  –   Foreign body sensation
  –   Ocular irritation
  –   Redness (occasionally)
• Tx: Debridement
Band Keratopathy
          Limbal Girdle of Vogt

• Very common, bilateral, age-related condition.
  Corneal degeneration.
  Clinical features:
  Symptoms: asymptomatic and requires no
  therapy.
  Signs:
  Crescenteric, white opacities of the peripheral
  cornea in the interpalpebral zone along the
  nasal and temporal limbus
  May be separated from the limbus by a clear
  zone or without a clear zone in between
Limbal Girdle of Vogt
Salzmann’s Nodular Degeneration

• Usually following trachoma or phlyctenular
  keratitis
• Characterized by multiple superficial blue
  white nodules in the midperiphery of the
  cornea
• Medical therapy consists of lubrication,
  warm compresses, lid hygiene, topical
  steroids, and/or oral doxycycline
Salzmann’s Nodular Degeneration
  Climatic Droplet Keratopathy
• Degenerative condition characterized by
  the accumulation of translucent material in
  the superficial corneal stroma
• Sector iridectomy, corneal epithelial
  debridement, lamellar keratoplasty, and
  penetrating keratoplasty have all been
  employed in the treatment of visually
  incapacitating CDK.
Climatic Droplet Keratopathy
           Corneal Farinata
• Bilateral speckling of the posterior part of
  the corneal stroma
• VA unaffected
Corneal Farinata
  Pellucid Marginal Degeneration /
            Keratoglobus
• Bilateral, noninflammatory, peripheral
  corneal thinning disorder characterized by
  a peripheral band of thinning of the inferior
  cornea
• Tx: RGPs / Keratoplasty
     • Surgery needed for Keratoglobus
Pellucid Marginal Degeneration
Keratoglobus
 Lecture 09/08/08 EBMD (Bergmanson)


• Keratoconus (continued)
  – Making the Dx
Voght Striae
  Fleisher’s Ring




Cause: Thickened tear film where lids meet
        Hydrops




Rupture in Descemet’s membrane
         EBMD

Epithelial Basement Membrane
            Dystrophy
Meesmann’s Dystrophy




Intraepithelial cysts with amorphous material/cellular debris
Tx: usually not needed
Map/ Dot/ Fingerprint Dystrophy
      aka “Anterior Membrane Dystrophy”




 BM is laid down abnormally by epithelial cells build up of material
 Pts > 60
 Negative staining
Recurrent Corneal Erosion
       Syndrome
             Tx: for EBMD

– Lubricant/gtts; ung
– Bandage CL
– Stromal puncture
– Epithelial scraping
– PTK
                  Surgical Tx
• PKP (Penetrating) vs. LKP (Lamellar)
  – Most surgeons tx w/ PKP
  – Adv of LKP
    •   Not intraocular
    •   Fewer complications
    •   Preserved endothelium
    •   Low risk of rejection
    •   Preserves global strength
Dystrophies of Bowman’s Layer
          Reis-Buckler’s Dystrophy




Autosomal dominant dystrophy
Characterized by small discrete opacities centrally just under the epithelium which
may have a honeycomb pattern
ALL is being replaced by reticular material (scar-like tissue)
Honeycomb dystrophy of Thiel and
           Behnke
Inherited Band Keratopathy




     Tx: Chelating agent EDTA
         Stromal Dystrophy
• Granular Dystrophy
• Lattice Dystrophy
• Gelatinous drop-like dystrophy
Granular Dystrophy
Corneal Trauma
 Management
                      Bacterial Keratitis




-WBCs only found in infectious keratitis.
-Acute (24-48 hrs), rapidly progressive corneal destructive process or a chronic process.
-Caused by corneal epithelial disruption caused by trauma, contact lens wear,
contaminated ocular medications and impaired immune defense mechanisms.
-Tx. With Polytrim, Vigamox, and broad spectrum antibiotics
        Radial Keratotomy Problems




   *Refractive surgery procedure to correct mild to moderate degrees of myopia (2 to 5 D).
*Incisions can split open making them vulnerable to corneal infections (fungal/bacterial)
           -If infection happens w/i 24 -48 hrs, bacterial and not fungal.
           -Tx aggressively with Polytrim, Vigamox, or broad spectrum antibiotics.
           -F/U in 1 day.
                      Fungal Keratitis




•   Feathery Borders, w/ hx of plant/vegetable matter trauma.
•   Tx w/ prolonged course of systemic and topical anti-fungal (Natamycin), and
    frequent scrapings or localized debridement to remove necrotized epithelial
    tissue.
Lecture 09/22/08: Corneal Trauma Mgmt
            Pseudomonas Keratitis




*Pseudomonas can progress fast! Within 24 hours
         -hypopyon, infiltrates in cornea, KPs, plasmoid aqueous (AC is jello)
         -pain, decreased VAs, redness
                             Corneal FB




*May develop corneal ulcer.
*r/o intraocular FB.
*Remove FB, unless removal will cause more damage than leaving it undisturbed.
           -Topical antibiotics after removal
           -Topical NSAID (Ketorolac) or short acting cycloplegic for relief of symptoms
            Intraocular Foreign Body




*Intraocular FB –passes basement membrane of cornea.
           -Improper removal can cause collapsed AC, traumatic glaucoma, endophthalmitis if
           infected.
*Refer to surgeon.
                   Traumatic Cataract




*Most common complication of non-perforating and perforating injuries to the globe.
Hypermature/Morgagnian Cateract




     *May me caused by severe trauma.
     *Liquified cat with intact nucleus inferiorly displaced.
                  Bollus Keratopathy




*Compromised endothelial cell pump mechanism as the endothelial cell density decreased
and decompensated; Folds in stroma from stromal edema.
*Can be induced by cataract surgery or other trauma.
*Manage w/ NaCl 5% gtts and ung; CL for pain; IOP lowering meds; Penetrating
Keratoplasty in advanced cases.
            RA-associated peripheral
               ulcerative keratitis




*Hx of CT dz.
*May cause stromal thinning, descemetocele (only PLL and endothelium left due to corneal
thinning) in progressive keratolysis, and perforation.
*Promote re-epithelialization by ocular surface lubrication, patching or bandage soft contact
lens.
                              Alkaline Burn




*Immediate irrigation of eye until the pH of the cul-de-sac has returned to neutrality. (pH= 7.0)
*Prophylactic broad spectrum antibiotic; cycloplegic drops; topical steroids to decrease
inflammation; lubrication; soft CL…
Lecture 09/29/08: Corneal Trauma Mgmt
                (cont.)
    Pseudomonas Keratitis




Vigamox
        Bacterial corneal Ulcer




gram (+) Vigamox, gram (-) Zymar
            Fungal Keratitis




Natamycin
      Acanthamoeba keratitis




• Epithelial debridement
    Epithelial Herpes Simplex




• Viroptic
        Marginal Keratitis




• Vigamox
            Bacterial infiltrate
               2nd to RK




• Vigamox
                     Dellen




• Artificial tears
               Pubic lice




• Bacitracin ointment
                    Iris nevus




• Asymptomatic, no tx
• Malignant with growth, refer
Lecture 10/06/08: Corneal Dystrophy (cont.)
Lecture 10/20/08: Therapeutic Strategy for
            Ant. Segment Dz
            Combination Antibiotics
•   Tobramycin
•   Polymixin B
•   Neomycin (hypersensitvity common)
•   Sulfacetamide
•   Bacitracin
Medications used to treat ocular inflammation and prevent microbial
  infection. Also used for superficial burns.
Examples: corneal infiltratres, meibomian gland dys., blepharitis
                Corneal Ulcers
TOC: 4th generation fluoroquinalones
-Zymar (gatifloxacin) 0.3%
-Vigamox (moxifloxacin) 0.5%
-Quixin (levofloxacin) 0.5%-- 3rd generation
-Iquix (levofloxacin 1.5%) qd or bid– 3x conc of Quixin and
   works better than Zymar and Vigamox without toxicity.
   Preservative free.
                  Corneal Ulcers
                 (additional treatments)
Antibiotics
-Gentamycin (ung, gtt)
-Ofloxacin (gtt)
-Ciprofloxacin (gtt)
-Tobramycin sulfate (ung, gtt)
Mixes
- Polysporin ung ( polymixin B & bacitracin)
- Neosporin ung ( poly b/ neomycin / bacitracin)
- Polytrim gtt ( poly B & trimethoprim) -- least toxic
            Bacterial Conjunctivitis
- Azasite (azithromycin 1%) bid-tid
 steroid added post AB treatment to prevent corneal scarring




- Vigamox (moxifloxacin)
 FDA approved for bacterial conjunctivits
    Topical anit-inflammatories
•   Steroids
- Maxidex (Dexamethasone 0.1%) susp
- FML (flouromethalone 0.1%) – ung or susp
- Pred forte (prednisilone 1%) – susp
•   Soft steroids
- Lotepredenol etabonate
  Alrex 0.2%
  Lotemax 0.5%
•   NSAIDS (analgesic effect)
-   Diclofenac (Voltaren 0.1%) soln
-   Ketorolac (Acular 0.4%) soln
              Allergic and CLPC-
       (contact lens induced papillary conjunctivitis)

   Treat with…
- Mast cell stabilizers
    Crolom bid, Alomide or Alomast qid, Alocril bid
- Mast cell stabilizing antihistamines
    Patanol bid/ Pataday qd, Elestat bid, Zaditor bid,
    Optivar bid
- NSAIDS
    Acular qid
- Steroids (only if severe)
    Alrex, Lotemax, or Pred Forte qid

								
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