Cornea
Published on Nov 18, 2015
A short introduction to common cornea conditions
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PRESENTATION OUTLINE
Why is the cornea > all
- Seeing vs. perceiving
- Gives insight into the eye
- Quality of life
1) talk about even though its in plain sight, you won't see the subtle clues unless you know what you are looking for (little skill needed to look at the cornea--unlike retina or gonioscopy)
2) Without a nice clear cornea you cannot visualize the other structures of the eye.
3) Corneal disorders can be very painful. Additionally they can be associated with sudden, treatable loss of vision.
2) Without a nice clear cornea you cannot visualize the other structures of the eye.
3) Corneal disorders can be very painful. Additionally they can be associated with sudden, treatable loss of vision.
Photo by Vox Efx
Untitled Slide
Discuss different layers of the cornea and what they do (include mention of Dua's layer)
Untitled Slide
Discuss idea of slit-lamp and how it can be used to determine level of pathology
10 y/o boy
1 week of blisters and redness of the right eye
10 y/o boy with 1 week of blisters popping up around the right eye. Been red for about 3 days. Patient looks to be in no distress.
dendrite
They stain with fluorescein in an irregular pattern.
Note the irregular shape to the dendrite, with terminal bulbs. They look like clubs on a playing card
dendrite
They also stain with rose bengal or lissamine green.
Rose bengal stains dead and devitalized cells. Cells that are contaminated with live virus stain and tend to cluster around the periphery of the abrasion.
HSV take home points
- Initially presents as a blepharoconjunctivitis
- Unlikely to be HSV-2 (genital herpes)
- Avoid placing topical anesthetic
- Pertinent history--canker sores, atopy, steroids
1) Blepharoconjunctivitis is primary presentation, but can occur as recurrence as well
2) HSV-1 much more likely than HSV-2
3) Can't check corneal sensation if you put in an anesthetic drop
4) Canker sores in the mouth or lips is highly suggestive of recurrent HSV-1. A history of topical or oral steroids can indicate immunosuppression as can a history of eczema. These can also lead to bilateral herpes keratitis.
2) HSV-1 much more likely than HSV-2
3) Can't check corneal sensation if you put in an anesthetic drop
4) Canker sores in the mouth or lips is highly suggestive of recurrent HSV-1. A history of topical or oral steroids can indicate immunosuppression as can a history of eczema. These can also lead to bilateral herpes keratitis.
Raja's Rules of Order #2:
A good focused history will take you places.
A great history may already tell you what the diagnosis is. You can just confirm with your physical exam.
Photo by highersights
more HSV take home points
- Treated with topical Zirgan or Viroptic
- Oral acyclovir and valacyclovir also effective.
- NEVER give steroids during an active dendrite
- Notoriously hard to culture
- Can also present with iritis or even retinitis
1) Zirgan much less toxic than Viroptic. Unfortunately, it is more expensive and not covered by many insurances.
2) Oral valacyclovir has better bioavailability than acyclovir.
3) Steroids will make counteract any prescribed antivirals.
2) Oral valacyclovir has better bioavailability than acyclovir.
3) Steroids will make counteract any prescribed antivirals.
29 y/o man
1 week of right sided headache
29 y/o man who complains of a 1 week history of right sided headache followed by a 3 day history of rash over the right forehead and brow. The rash is vesicular in nature and in the right V1 distribution. Note that the rash doesn't cross midline. There does appear to be any lesion on the nose (Hutchinson's sign). Also, there is no associated facial cellulitis.
Photo by Community Eye Health
Pseudodendrite
May stain with fluorescein but not rose bengal.
Irregular epithelium in a healing line can appear like a dendrite. It will not stain appropriately with rose bengal or lissamine green, however. Therefore, it is a pseudodendrite.
nummular keratitis
Coin-shaped areas of inflammation in cornea
Approximately 3-4 weeks after the onset of symptoms, the patient may develop glare, decreased vision and light sensitivity. The lesions are usually of a larger size and are subepithelial in nature. They result from an immune reaction to residual viral particles in the cornea.
Shingles take home points
- Varicella zoster = herpes zoster = chicken pox
- Vaccine decreases risk but doesn't eliminate it
- Pertinent history--pain in scalp precedes rash
- May have decreased corneal sensation
- Look for concomitant cellulitis
1) multiple names
2) Vaccine is not completely protective and has no role immediately after patient has shingles
3) Upon specific questioning, patient may relate that pain preceded rash by a few days. Scalp is usually tender to touch.
4) Corneal sensation can be diminished, especially later on
5) Patients may have facial cellulitis from vesicles getting infected with bacteria. This can cloud the overall clinical picture and make the rash not as noticeable.
2) Vaccine is not completely protective and has no role immediately after patient has shingles
3) Upon specific questioning, patient may relate that pain preceded rash by a few days. Scalp is usually tender to touch.
4) Corneal sensation can be diminished, especially later on
5) Patients may have facial cellulitis from vesicles getting infected with bacteria. This can cloud the overall clinical picture and make the rash not as noticeable.
MOre Shingles take home points
- Hutchinson's sign is a good predictor
- Pseudodendrites are not infected
- Autoimmune problems after 1 month
- Oral acyclovir or valacyclovir
- Topical antibiotic ointment
1) Hutchinson's sign indicates that the nasociliary nerve has been affected, which increases the risk of having the eye affected later.
2) Pseudodendrites are indicative of dry eyes
3) Immune reactions like iritis or keratitis generally occur about a month after onset.
4) Valacyclovir better bioavailability than acyclovir
5) Important to treat with ophthalmic antibiotic ointment to the skin lesions to prevent bacterial superinfection.
2) Pseudodendrites are indicative of dry eyes
3) Immune reactions like iritis or keratitis generally occur about a month after onset.
4) Valacyclovir better bioavailability than acyclovir
5) Important to treat with ophthalmic antibiotic ointment to the skin lesions to prevent bacterial superinfection.
40 y/o man
Recurrent pain and irritation in the left eye
40 y/o man complains of awakening with pain and irritation in the left eye. He states this has been recurring off and on for the past 3 years. Exam shows an abrasion that stains with fluorescein.
Photo by Community Eye Health
May see cysts, lines, or maps
Besides examining the affected eye, it is important to look at the other eye. Because the anatomy is compromised in the affected eye, visualization of subtle structures can be difficult. You may seen signs of map-dot-fingerprint dystrophy. Things like cysts, lines, or maps.
res take home points
- Pertinent history--wake up with symptoms
- Ask about prior injury--fingernail, twig, LASIK
- Acquired vs. congenital
- Most common corneal dystrophy
- May have a positive family history
more ReS take home points
- Symptomatic eyes are often dry
- Treat dry eyes
- Muro drops or ointment
- Consider a few months of oral doxycycline
- Superficial keratectomy, PTK, stromal micropuncture
55 y/o woman
7 month history of blurry vision in both eyes
55 y/o woman comes in for annual exam and is noted to have blurry vision in both eyes, not amenable to refraction. She states her vision has been worsening for the past 7 months. On exam, you can see paracentral white elevated nodules, best appreciated with fluorescein.
Look for flattening
Corneal topography shows disruption in the mires where the nodules are. It is usually associated with flattening and adjacent areas of irregular astigmatism.
snd take home points
- Salzmann's associated with dry eyes
- Typically occurs in older women
- Needs chronic treatment of dry eyes
- Superficial keratectomy curative
Untitled Slide
Raja's rules of order #3
Always treat the underlying disorder
You can treat the Salzmann's Nodular Degeneration, but if you don't treat the dry eyes, it will come back again.
Photo by Key Foster
32 y/o Woman
10 day history of red teary eyes, left eye first
32 y/o Woman with a 10 day history of red teary eyes. The left eye started first, followed by the right eye 4 days later. The hemorrhages started soon thereafter.
follicles
Follicles in lower palpebral conjunctiva
Follicles can be noted inferiorly in the palpebral conjunctiva.
Pseudomembrane
Consider flipping lids in inflammatory cases
In especially inflamed or longstanding cases, consider a pseudomembrane in the upper or lower palpebral conjunctiva. This stains with fluorescein and has a yellow-whitish color.
pseudomembrane
Removal facilitated by cotton-tipped applicator
Earlier on, it can peel off relatively easily. Later on, it can be difficult to remove. It tugs on the underlying conjunctival vessels and can bleed profusely. Patients often feel much better the day after removal.
infiltrates
SEIs can occur after 1-3 weeks
Approximately 1-3 weeks after onset, patients can develop severe light sensitivity and decreased vision. Subepithelial infiltrates can be seen. Like shingles, this is an immune response to viral particles. They are exquisitely sensitive to topical steroids but often recur when the steroids are tapered off.
EKC take home points
- Starts in one eye, proceeds to other eye
- May be associated with sore throat
- Ask about sick contacts
- Check for preauricular lymphadenopathy
EKC take home points
- Bloody tears = pseudomembrane
- SEIs respond well to Restasis
- Clean down room and doorknobs
- Treat with NSAIDs, Zirgan
Photo by ecstaticist
Raja's rules of order #4
Give the MD a heads-up about a possible EKC.
We don't like to get EKC, so please give us a heads-up. I usually walk into the room and shake the patient's hand upon entering. When the room is dark, I can't appreciate a bright red eye.
Photo by Kalexanderson
22 y/o man
3 day history of pain in the right eye after sleeping in CLs
22 y/o man who slept in his contact lenses c/o of a 3 day history of pain and decreased vision in the right eye. Note the fairly discrete paracentral infiltrate in the cornea. There is no surrounding edema, no hypopyon and no satellite lesions.
ulcer take home points
- Find out about CL use
- Trauma history
- Surgery history
- Hot tubs
- Get Gram stain, blood and chocolate agar
1) Ask about sleeping in contact lenses. Even Night and Day lenses increase the risk of ulcers.
2) A history of being hit with a contaminated tool or instrument can certainly predispose to infection.
3) A history of surgery with and ulcer--especially if there is a hypopyon--can be suggestive of an endophthalmitis.'
4) Hot tub use can be associated with Pseudomonas. This accelerates very quickly.
2) A history of being hit with a contaminated tool or instrument can certainly predispose to infection.
3) A history of surgery with and ulcer--especially if there is a hypopyon--can be suggestive of an endophthalmitis.'
4) Hot tub use can be associated with Pseudomonas. This accelerates very quickly.
More ulcer take home points
- Cycloplegic for light sensitivity
- Topical NSAID for pain
- Fortified Tobramycin and Ancef/Vancomycin
- Need a hospital/compounding pharmacy
Untitled Slide
This cornea shows a large central ulcer with small extensions (looks like a filamentous fungi like Fusarium). Patients typically have a lot of intraocular inflammation and hypopyons are not uncommon. Occasionally people will try to treat these with steroids. That will only make the fungal infection worse longterm, though they might feel better in the short-term.
fungal ulcer take home points
- Concerned about contact with fungus
- History of topical steroid use
- Typically has a massive inflammatory reaction
- Diagnose with KOH stain, Sabaroud's agar
- May need voriconazole drops or Natamycin
Untitled Slide
This cornea shows a characteristic ring infiltrate. I cannot appreciate any swelling of the nerves at this time.
acanthamoeba take home points
- Ask about swimming in fresh water
- Homemade CL solution
- Early epitheliopathy can be debrided
- Associated with severe pain (nerves)
- Almost impossible to culture/stain
acanthamoeba take home points
- Can get a ring infiltrate
- Associated with topical anesthetic abuse
- Treated with oral ketoconazole
- Topical PHMB, Chlorhexadine
- May need a therapeutic PK
“Tell me and I forget, teach me and I may remember, involve me and I learn.”
Photo by cliff1066™
