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: Other signs: Epithelial staining defect with fluorescein Other signs: Conjunctival injection Swollen eyelid Mild anterior-chamber reaction

Corneal Abrasion Work-up: Treatment: Slit-lamp exam Use fluorescein Measure size of abrasion Diagram its location Evaluate for anterior-chamber reaction Evert eyelids and make certain no further FB Treatment: Non-contact lens wearer: Cycloplegic Antibiotic ointment or drops Contact lens wearer: Tobramycin drops 4-6x/day

Corneal Abrasion Follow-up: Follow-up Contact lens wearer Non-contact lens wearer with a small-noncentral abrasion: Ointment/drops x 5 days Return if symptoms worsen Central or large abrasion: 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: Other signs: 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: Treatment: 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: 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: follow-up 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: Complete ocular examination Slit-lamp to rule out ocular penetration IOP Seidel test Fluorescein stain over site shows streaming. + full thickness.

Corneal Laceration Treatment: Follow-up: 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: Irritation Redness Decreased vision Usually asymptomatic

Pterygium Critical signs: Work-up: 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: 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: Conjunctival injection Inflammation surrounding infiltrate Corneal thinning Possible anterior-chamber reaction Etiology: Bacterial Fungal Acanthamoeba (contact lens wearers) Herpes Simplex Virus

Infectious Corneal Infiltrate/Ulcer Work-up: 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: 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: Usually unilateral red eye Pain Photophobia Tearing Decreased vision Skin rash

Herpes Simplex Virus Work-up: History: External exam Previous episode Contact lens Recent steroids External exam Slit-lamp with IOP 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: Contraindicated: 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 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: Conjunctiva traumatic lesions Inflammation Corneal FB Lids for Hordeolum Blepharitis Complete lid eversion Examine undersurface

Slit Lamp Examination 2nd setup: 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: 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

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