cornea. baby picture of the day! sodium fluorescein used to stain dead or devitalized cells on the...
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Cornea
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Baby picture of the day!
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Sodium Fluorescein
Used to stain dead or devitalized cells on the cornea and conjunctiva
Pooling: green pools of fluorescein caused by dips in the tissue
Negative staining: areas with no staining caused by elevation in the tissue
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Keratopathies
Dellen Exposure
keratopathy Filamentary
keratopathy Superficial punctate
keratitis
Thygeson’s superficial punctate keratopathy
Neurotrophic keratopathy
Recurrent corneal erosion
Thermal/UV keratopathy
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Dellen
Stromal dehydration Fluorescein pooling
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Superficial Punctate Keratitis (SPK)
Non-specific inflammation of epithelium
Causes: contact lenses, infection, dry eye, blepharitis, allergy/toxicity, trichiasis, etc.
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Exposure Keratopathy
Eyelid problem – incomplete closure
#1 cause: nocturnal lagophthalmos
Other causes: surgery, nerve palsy, CVA, thyroid eye disease, floppy eyelid syndrome
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Filamentary Keratopathy
Filaments = epithelial cells + mucous
#1 cause: keratoconjunctivitis sicca
Dryness lids scrape against
cornea friction chronic inflammation
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Thygeson’s Superficial Punctate Keratopathy
Young adult patients White conjunctiva with
“crumb-like” central cornea
Cluster of elevated white lesions in central cornea
Lesions don’t stain (unlike SPK)
Bilateral
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Neurotrophic Keratopathy
Think CN V1 (nasociliary)
Trigeminal neuropathy from damage to the nerve
Decreased corneal sensitivity decreased wound healing
Bad combination!
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Recurrent Corneal Erosion (RCE)
Poor hemidesmosome attachments between epithelium & BM due to previous trauma
Patient awakens with acute pain
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Thermal/UV Keratopathy
UV-C (<300nm) is absorbed by the cornea
Causes: sun, welding, snow, tanning
Signs: SPK Symptoms: pain,
photophobia, blur Symptoms begin 6-12
hours later!
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Dry Eye Syndrome (DES): Definition
A “multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.”
Associated systemic diseases: thyroid, arthritis, Sjogren’s, SLE
Problematic meds: anticholinergic, antihistamines, hormone replacement, diuretics
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DES: Testing
Schirmer 1: no anesthetic, normal >10mm/5min
Schirmer 2: anesthetic, normal >5mm/5min
Phenol red thread: pH sensitive, normal >10mm/15sec
Tear osmolarity Tear film instability (TBUT)
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DES: Categories
Aqueous tear-deficient
Lack of lacrimal secretion Sjogren’s: includes
autoantibodies & dry mouth
Non-Sjogren’s = Lacrimal gland deficiency
Evaporative
Water loss with normal lacrimal secretion
Intrinsic = due to lid pathology
Extrinsic = no lid pathology (vitamin deficiency, preservatives)
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Keratoconus Pellucid Marginal Degeneration (PMD) Keratoglobus
All 3 can cause hydrops (tears in Descemet’s membrane)
Ectasias
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Keratoconus
Presents at puberty History of atopy Collagen fibril
displacement, corneal thinning, corneal protrusion
Fleischer’s ring = iron deposit at base of cone
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Pellucid Marginal Degeneration (PMD)
Presents in young adults
Inferior thinning/protrusion of the cornea
Against the rule (ATR) astigmatism = “kissing doves” / “crab claws” on topography
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Keratoglobus
From birth General corneal
thinning, worst in periphery
Easier to perforate cornea
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Dystrophies
Anterior
EMBD Meesman’s Reis-Buckler
Stromal
Macular Granular Lattice Schnyder’s
Posterior
Fuch’sPosterior Polymorphous
All of these are autosomal dominant (AD) except macular dystrophy (AR)
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EBMD = Map-Dot Fingerprint
Epithelial Basement Membrane Dystrophy (EBMD)
Excessive basement membrane production
Can cause recurrent corneal erosions
Negative staining shaped like map lines or fingerprints
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Fuch’s Endothelial Dystrophy
Older female patients Excess production of
posterior lamina (Descemet’s membrane)
Signs: guttata (clumps of Descemet’s BM), decreased endothelial cell density, stromal edema
Symptoms: blurry vision am
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Congenital Anomalies of the Cornea
Megalocornea Microcornea Cornea plana Aniridia
Haab’s Striae Axenfeld-Rieger
syndrome Peter’s Anomaly Limbal dermoid
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Megalocornea & Microcornea
Megalocornea
X-linked Diameter >13mm Myopic pts
Microcornea
AD or AR inheritance Diameter <10mm Hyperopic pts
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Cornea Plana
AD or AR inheritance Corneal curvature
equals scleral curvature
Flat cornea
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Aniridia
Bilateral, AD inheritance
Lack of iris tissue Often accompanied
by foveal hypoplasia (reduces VA) & colobomas
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Haab’s Striae
Horizontal lines in Descemet’s membrane
Occurs in congenital glaucoma
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Peter’s Anomaly
Present at birth Bilateral White cornea
(leukoma)
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Bacterial Keratitis Fungal Keratitis Acanthamoeba Keratitis Herpes Simplex Virus (HSV) Herpes Zoster Virus (HZV)
Infectious Keratitis
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Bacterial Keratitis
Most common infectious keratitis
Staphylococcus, Pseudomonas, Haemophilus influenzae, Moraxella catarrhalis
Ulcer = infiltrates (immune) + epithelial defect
Infectious ulcers stain
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Fungal Keratitis
Feathery edges Caused by plant
trauma Candida infection
indicates immune compromise
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Acanthamoeba Keratitis
Contact lens abuse (tap water)
Pain out of proportion to signs
Ring ulcer
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DNA virus that infects the trigeminal ganglion (CN5)
Decreases corneal sensitivity Type 1 (top) vs. Type 2 (bottom) Transmission
Herpes Simplex Virus (HSV)
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HSV
Epithelial Disease
Dendritic ulcers (stain)
Geographic ulcers (stain)
Neurotrophic Keratitis
Reduced innervation to cornea
Poor wound healing & reduced sensation
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HSV
Stromal Disease
Interstitial keratitis = neovascularization, immune ring, stromal thinning/scarring
Endotheliitis
Disciform keratitis = most common
Immune reaction causes stromal edema
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Herpes Zoster Virus (HZV)
Varicella Zoster Virus (VZV) Older patients or immune
compromise Pre-zoster prodrome (fever,
malaise, tingling) Active zoster = skin
involvement respecting the vertical midline
Hutchinson’s sign = tip of nose
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Peripheral Ulcerative Keratitis
Staph Marginal Keratitis
Type 3 hypersensitivity Sterile infiltrates where lid
touches cornea
Mooren’s Ulcer
Unilateral peripheral crescent-shaped ulcer
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Corneal Deposits
Whorl Keratopathy Fleischer’s ring Rust rings Hudson-Stahli lines
Stocker’s line Ferry’s line Kayser-Fleischer Ring Band Keratopathy
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Whorl Keratopathy
Caused by systemic disease or medication
No symptoms, no reduction in vision
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Fleischer’s Ring
Keratoconus Iron ring at the base
of the con
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Rust Rings
Form around metallic corneal foreign bodies
Must be removed along with foreign body
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Hudson-Stahli Lines
Iron lines in lower cornea
No symptoms, no reduction in vision
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Stocker’s Line
Iron deposit along edge of pterygium
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Ferry’s Line
Iron deposits along edge of filtering bleb
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Kayser-Fleischer Ring
Copper deposition around edges of cornea
Wilson’s disease (liver)
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Band Keratopathy
Calcium deposition Bowman’s layer
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Arcus Senilis
Corneal degeneration Most common peripheral
corneal opacity Older patient or high
cholesterol
Unilateral arcus indicates contralateral carotid disease
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Corneal Graft Rejection
Type 4 Hypersensitivity
30% rejection rate in first year following transplant
Epithelial, stromal, or endothelial
Look for white blood cells
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Refractive Surgery
Types
RK PRK CK Intact RLE PIOL AK
Contraindications
Age <18, unstable refraction
Keratoconus Active herpes/infection Connective tissue disease Immune compromise
(including diabetes) Large pupils
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Radial Keratotomy (RK)
Radial incisions flatten the corneal stroma
Unstable Hyperopic shifts
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Photorefractive Keratectomy (PRK)
Outer cornea removed (epithelium, Bowman’s, some stroma)
Less myopic because thinner cornea
No flap Healing: 1-2 weeks Problem: stromal haze
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Laser-assisted In Situ Keratomileusis (LASIK)
Flap of cornea moved, laser applied beneath to thin stroma, then flap replaced
Less myopic because thinner cornea
Healing: 1-2 days Problem: dry eye
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LASIK Complications
Initial pain Infection Flap complications Corneal ectasia
(thinning & protrusion, like keratoconus)
Residual refractive error (under-correction)
Glare Dry eye (#1) Epithelial ingrowth Corneal haze
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Conductive Keratoplasty (CK)
Treats hyperopia & presbyopia
Shrink peripheral collagen fibers with radio energy
Problem: regression
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Intacs (Intrastromal corneal rings)
PMMA ring in peripheral stroma
Used for keratoconus Less myopic because
ring flattens cornea Can be removed
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Refractive Lens Extraction (RLE)
Remove natural crystalline lens, replace with new lens (like cataract surgery)
Works because lenses come in varying powers, select appropriate one
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Phakic Intraocular Lens (PIOL)
Lens implanted into an eye in front of the iris (natural crystalline lens remains intact)
Great for high myopia Removable
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Astigmatic Keratotomy (AK)
Blade incisions relax the steeper meridian of the cornea
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Contact Lens-Related Disorders
Solution hypersensitivity/toxicity
Corneal neovascularization
Corneal warpage
Contact lens deposits Superior epithelial
arcuate lesion (SEAL)
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Solution Hypersensitivity/Toxicity
Diffuse SPK (superficial punctate keratitis)
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Corneal Neovascularization
Due to lack of oxygen (hypoxia)
If it’s >1.5mm, switch contact lenses or stop wearing them
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Corneal Warpage
Cornea changes shape due to contact lenses
GP lenses (gas permeable, “hard” lenses)
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Contact Lens Deposits
Deposits of tear components on contact lenses
Clean lenses better!
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Dimple Veiling
Air bubbles trapped under a GP contact lens create divots in the cornea