Download corneal desease

Corneal Disease
Anatomy of the Eye
Thygeson’s Superficial
Punctate Keratopathy
Symptoms
Foreign-body sensation
 Photophobia
 Tearing
 No history of recent conjunctivitis
 Usually bilateral and has a chronic course
with exacerbations and remissions

Thygeson’s Superficial
Punctate Keratopathy
Critical sign:

Course punctate
gray-white corneal
epithelial opacities,
often central with
minimal or no
staining with
fluorescein
Corneal Abrasion
Symptoms:





Pain
Photophobia
Foreign-body
sensation
Tearing
History of scratching
the eye
Corneal Abrasion
Critical sign:

Epithelial staining
defect with
fluorescein
Other signs:



Conjunctival injection
Swollen eyelid
Mild anteriorchamber reaction
Corneal Abrasion
Work-up:

Slit-lamp exam

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Use fluorescein
Measure size of
abrasion
Diagram its location
Evaluate for anteriorchamber reaction
Evert eyelids and
make certain no
further FB
Treatment:

Non-contact lens
wearer:



Cycloplegic
Antibiotic ointment or
drops
Contact lens wearer:


Cycloplegic
Tobramycin drops 46x/day
Corneal Abrasion
Follow-up

Non-contact lens wearer
with a small-noncentral
abrasion:



Ointment/drops x 5
days
Return if symptoms
worsen
Central or large abrasion:

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
Recheck 24 hours
If improvement,
continue top abx
If no change, repeat
initial treatment
Follow-up:

Contact lens wearer


Recheck daily until
epithelial defect
resolves
May resume contact
lens wearing 3-4 days
after eye feels
completely normal.
Corneal Foreign Body
Symptoms:





Foreign-body
sensation
Tearing
Blurred vision
Photophobia
Commonly, a history
of a foreign body
Corneal Foreign Body
Critical sign:

Corneal foreign body,
rust ring, or both.
Other signs:




Conjunctival injection
Eyelid edema
Superficial Punctate
Keratitis (SPK)
Possible small infiltrate
Corneal Foreign Body
Work-up:




History – metal,
organic, finger, etc
Visual acuity before
any procedure
Slit-lamp
With history of high
velocity FB – dilate
the eye and examine
the vitreous and
retina
Treatment:




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Topical anesthetic
Remove foreign body
Remove rust ring
(Ophthalmology
recommended)
Document size of
epithelial defect
Cycloplegic
Antibiotic
ointment/drops
Corneal Foreign Body
Follow-up:
Small (<1-2 mm in diameter), clean,
noncentral defect after removal: antibiotics
for 5 days and follow-up as needed.
 Central or large defect or rust ring: followup ophthalmology within 24 hours to
reevaluate.

Corneal Laceration
Partial-thickness
laceration

The anterior
chamber is not
entered and,
therefore, the globe
is not penetrated
Corneal Laceration
Work-up:



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Complete ocular
examination
Slit-lamp to rule out
ocular penetration
IOP
Seidel test

Fluorescein stain
over site shows
streaming. + full
thickness.
Corneal Laceration
Treatment:

Intact anterior
chamber




Cycloplegic
Antibiotic
Ophthalmology
follow-up
Ruptured anterior
chamber

Immediate optho
consult
Follow-up:

Reevaluate daily
until healed
Thygeson’s Superficial
Punctate Keratopathy
Other signs:


No conjunctival
injection
No corneal edema
Treatment:

Mild:


Artificial tears
Moderate/severe

Mild topical steroid for
1 week, then taper
slowly.
Follow-up


Every week during
exacerbations, then
every 3-12 months
If on topical steroids,
check IOP
Pterygium
Patients present with complaint of tissue
growing over their eye.
Caused by exposure to ultraviolet light
More commonly encountered in warm,
dry climates or smoky/dusty
environments.
Pterygium
Symptoms:

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Irritation
Redness
Decreased vision
Usually
asymptomatic
Pterygium
Critical signs:

Wing-shaped fold of
fibrovascular tissue
arising from the
interpalpebral (90%)
conjunctiva and
extending onto the
cornea
Work-up:

Slit-lamp exam to identify
lesion.
Treatment



Protect eyes from sun,
dust, and wind
Artificial tears, mild
vasoconstrictor or topical
decongestant/
antihistamine
combination
Moderate/severe – mild
topical steroid
Pterygium
Follow-up

Asymptomatic patients may be checked
every 1-2 years
If treating with topical vasoconstrictor, the
check in 2 weeks. Discontinue when
inflammation subsides.
 If topical steroid, check 1-2 weeks and check
IOP. Taper and discontinue over several days
once resolution.

Infectious Corneal
Infiltrate/Ulcer
White infiltrate/ulcer that may/may not
stain with fluorescein must always be
ruled out in contact lens patients with
eye pain.
Can occur in patients with recent
history of eye trauma.
Slit-lamp beam cannot pass through
infiltrate.
Infectious Corneal
Infiltrate/Ulcer
Symptoms:



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
Red eye
Mild-to-severe ocular
pain
Photophobia
Decreased vision
Discharge
Infectious Corneal
Infiltrate/Ulcer
Critical sign:

Focal white opacity
in the corneal stroma
Other signs:

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
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Conjunctival injection
Inflammation
surrounding infiltrate
Corneal thinning
Possible anteriorchamber reaction
Etiology:



Bacterial
Fungal
Acanthamoeba


(contact lens
wearers)
Herpes Simplex
Virus
Infectious Corneal
Infiltrate/Ulcer
Work-up:



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History: contact lens
wear and regimen,
trauma, foreign body.
Slit-lamp exam: stain with
fluorescein to assess
epithelial loss.
Document size, depth,
and location.
Assess anterior chamber
Check IOP
Treatment:


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Generally treated as
bacterial unless there is a
high index of suspicion
for another form.
Cycloplegic
Topical antibiotics
No contact wearing
Pain med if needed
Ophthalmology consult
Herpes Simplex Virus
Symptoms:



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Usually unilateral red
eye
Pain
Photophobia
Tearing
Decreased vision
Skin rash
Herpes Simplex Virus
Work-up:

History:

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External exam
Slit-lamp with IOP

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Previous episode
Contact lens
Recent steroids
Dendritic lesion
Check corneal sensation
prior to anesthetic
Viral culture
Herpes Simplex Virus
Treatment:




Topical acyclovir tid
Warm soaks tid (if
eyelid involved)
Ophthalmology
referral
(oral acyclovir if
primary herpetic
disease)
Examination Techniques
Slit Lamp Examination
Extremely useful instrument
Can reveal pathologic conditions that
would otherwise be invisible
Permits detailed evaluation of external
eye injury and is definitive tool for
diagnosing anterior chamber
hemorrhage and inflammation
Slit Lamp Examination
Indications:


Diagnosis of abrasions,
foreign body, and iritis
Facilitate foreign body
removal
Contraindicated:

Patients who cannot
maintain upright position,
unless using portable
device
Slit Lamp Examination
Set up


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Patient’s chin is in
chin rest and
forehead is against
headrest
Turn on light source
Low to medium light
source is appropriate
for routine exam
Start on low power
microscopy
Slit Lamp Examination
1ST setup:



For examination of right
eye, swing light source
out 45º.
Slit beam is set at
maximum height and
minimal width using white
light.
Scan across at level of
conjunctiva and cornea,
then push slightly forward
and scan at level of iris.
Slit Lamp Examination
Basic setup used to
examine for:


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
Conjunctiva traumatic
lesions
Inflammation
Corneal FB
Lids for

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
Hordeolum
Blepharitis
Complete lid eversion

Examine undersurface
Slit Lamp Examination
2nd setup:

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
Same as first, only
uses blue filter.
Beam is widened to
3 or 4 mm.
Examine for uptake
of fluorescein.
Slit Lamp Examination
3rd setup:

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Search for cells in anterior
chamber.
Height of beam should be
shortened to 3 or 4 mm.
Switch to high power.
Focus on center of cornea
and the push slightly
forward, focus on anterior
surface of lens
Keep beam centered over
pupil.
Look for searchlight affect
in anterior chamber
Questions?