Corneal Path. Lecture 08/25/08: Corneal Dystrophies.

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Corneal Path

Transcript of Corneal Path. Lecture 08/25/08: Corneal Dystrophies.

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 limbusMay 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

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 debrisTx: usually not needed

Map/ Dot/ Fingerprint Dystrophyaka “Anterior Membrane Dystrophy”

BM is laid down abnormally by epithelial cells build up of materialPts > 60Negative 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 dystrophyCharacterized 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

Acanthamoeba keratitis

• Epithelial debridement

Epithelial Herpes Simplex

• Viroptic

Marginal Keratitis

• Vigamox

Bacterial infiltrate2nd to RK

• Vigamox

Dellen

• Artificial tears

Pubic lice

• Bacitracin ointment

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• BacitracinMedications used to treat ocular inflammation and prevent microbial

infection. Also used for superficial burns.

Examples: corneal infiltratres, meibomian gland dys., blepharitis

Corneal UlcersTOC: 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