1. Cornea
Remove: Thygeson’s, dystrophies? (2), peripheral ulcerative keratitis (2), surgery (intacs, CK, AK, PIOL, RLE, RK, etc.)
Add NaFl photo

2. Baby picture of the day!

4. 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

5. Keratopathies Dellen Exposure keratopathy Filamentary keratopathy
Superficial punctate keratitis
Thygeson’s superficial punctate keratopathy
Neurotrophic keratopathy
Recurrent corneal erosion
Thermal/UV keratopathy

6. Dellen
Stromal dehydration
Fluorescein pooling

7. Superficial Punctate Keratitis (SPK)
Non-specific inflammation of epithelium
Causes: contact lenses, infection, dry eye, blepharitis, allergy/toxicity, trichiasis, etc.

8. Exposure Keratopathy Eyelid problem – incomplete closure
#1 cause: nocturnal lagophthalmos
Other causes: surgery, nerve palsy, CVA, thyroid eye disease, floppy eyelid syndrome

9. Filamentary Keratopathy
Filaments = epithelial cells + mucous
#1 cause: keratoconjunctivitis sicca
Dryness 
lids scrape against cornea
friction
chronic inflammation

10. 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

11. Neurotrophic Keratopathy
Think CN V1 (nasociliary)
Trigeminal neuropathy from damage to the nerve
Decreased corneal sensitivity  decreased wound healing
Bad combination!

12. Recurrent Corneal Erosion (RCE)
Poor hemidesmosome attachments between epithelium & BM due to previous trauma
Patient awakens with acute pain

13. 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!

14. 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

15. 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)

16. Aqueous tear-deficient
DES: Categories
Aqueous tear-deficient
Evaporative
Lack of lacrimal secretion
Sjogren’s: includes autoantibodies & dry mouth
Non-Sjogren’s = Lacrimal gland deficiency
Water loss with normal lacrimal secretion
Intrinsic = due to lid pathology
Extrinsic = no lid pathology (vitamin deficiency, preservatives)

17. Ectasias Keratoconus Pellucid Marginal Degeneration (PMD) Keratoglobus
All 3 can cause hydrops (tears in Descemet’s membrane)

18. Keratoconus Presents at puberty History of atopy
Collagen fibril displacement, corneal thinning, corneal protrusion
Fleischer’s ring = iron deposit at base of cone

19. 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
25min through PMD

20. Keratoglobus From birth General corneal thinning, worst in periphery
Easier to perforate cornea

21. Dystrophies Anterior Stromal Posterior EMBD Meesman’s Reis-Buckler
Macular
Granular
Lattice
Schnyder’s
Fuch’s
Posterior Polymorphous
All of these are autosomal dominant (AD) except macular dystrophy (AR)

22. 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

23. 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

24. Congenital Anomalies of the Cornea
Megalocornea
Microcornea
Cornea plana
Aniridia
Haab’s Striae
Axenfeld-Rieger syndrome
Peter’s Anomaly
Limbal dermoid

25. Megalocornea & Microcornea
X-linked
Diameter >13mm
Myopic pts
AD or AR inheritance
Diameter <10mm
Hyperopic pts

26. Cornea Plana AD or AR inheritance
Corneal curvature equals scleral curvature
Flat cornea

27. Aniridia Bilateral, AD inheritance Lack of iris tissue
Often accompanied by foveal hypoplasia (reduces VA) & colobomas

28. Haab’s Striae Horizontal lines in Descemet’s membrane
Occurs in congenital glaucoma

29. Peter’s Anomaly
Present at birth
Bilateral
White cornea (leukoma)

30. Infectious Keratitis Bacterial Keratitis Fungal Keratitis
Acanthamoeba Keratitis
Herpes Simplex Virus (HSV)
Herpes Zoster Virus (HZV)

31. Bacterial Keratitis Most common infectious keratitis
Staphylococcus, Pseudomonas, Haemophilus influenzae, Moraxella catarrhalis
Ulcer = infiltrates (immune) + epithelial defect
Infectious ulcers stain

32. Fungal Keratitis Feathery edges Caused by plant trauma
Candida infection indicates immune compromise

33. Acanthamoeba Keratitis
Contact lens abuse (tap water)
Pain out of proportion to signs
Ring ulcer

34. Herpes Simplex Virus (HSV)
DNA virus that infects the trigeminal ganglion (CN5)
Decreases corneal sensitivity
Type 1 (top) vs. Type 2 (bottom)
Transmission

35. Neurotrophic Keratitis
HSV
Epithelial Disease
Neurotrophic Keratitis
Dendritic ulcers (stain)
Geographic ulcers (stain)
Reduced innervation to cornea
Poor wound healing & reduced sensation

36. HSV Stromal Disease Endotheliitis
Interstitial keratitis = neovascularization, immune ring, stromal thinning/scarring
Disciform keratitis = most common
Immune reaction causes stromal edema

37. 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

38. Peripheral Ulcerative Keratitis
Staph Marginal Keratitis
Mooren’s Ulcer
Type 3 hypersensitivity
Sterile infiltrates where lid touches cornea
Unilateral peripheral crescent-shaped ulcer

39. Corneal Deposits Whorl Keratopathy Fleischer’s ring Rust rings
Hudson-Stahli lines
Stocker’s line
Ferry’s line
Kayser-Fleischer Ring
Band Keratopathy

40. Whorl Keratopathy Caused by systemic disease or medication
No symptoms, no reduction in vision

41. Fleischer’s Ring
Keratoconus
Iron ring at the base of the con

42. Rust Rings Form around metallic corneal foreign bodies
Must be removed along with foreign body

43. Hudson-Stahli Lines Iron lines in lower cornea
No symptoms, no reduction in vision

44. Stocker’s Line
Iron deposit along edge of pterygium

45. Ferry’s Line
Iron deposits along edge of filtering bleb

46. Kayser-Fleischer Ring
Copper deposition around edges of cornea
Wilson’s disease (liver)

47. Band Keratopathy
Calcium deposition
Bowman’s layer

48. Arcus Senilis Corneal degeneration
Most common peripheral corneal opacity
Older patient or high cholesterol
Unilateral arcus indicates contralateral carotid disease

49. Corneal Graft Rejection
Type 4 Hypersensitivity
30% rejection rate in first year following transplant
Epithelial, stromal, or endothelial
Look for white blood cells

50. Refractive Surgery Types Contraindications RK PRK CK Intact RLE PIOLAK
Age <18, unstable refraction
Keratoconus
Active herpes/infection
Connective tissue disease
Immune compromise (including diabetes)
Large pupils

51. Radial Keratotomy (RK)
Radial incisions flatten the corneal stroma
Unstable
Hyperopic shifts

52. 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

53. 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

54. 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

55. Conductive Keratoplasty (CK)
Treats hyperopia & presbyopia
Shrink peripheral collagen fibers with radio energy
Problem: regression

56. Intacs (Intrastromal corneal rings)
PMMA ring in peripheral stroma
Used for keratoconus
Less myopic because ring flattens cornea
Can be removed

57. 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

58. Phakic Intraocular Lens (PIOL)
Lens implanted into an eye in front of the iris (natural crystalline lens remains intact)
Great for high myopia
Removable

59. Astigmatic Keratotomy (AK)
Blade incisions relax the steeper meridian of the cornea

60. Contact Lens-Related Disorders
Solution hypersensitivity/toxicity
Corneal neovascularization
Corneal warpage
Contact lens deposits
Superior epithelial arcuate lesion (SEAL)

61. Solution Hypersensitivity/Toxicity
Diffuse SPK (superficial punctate keratitis)

62. Corneal Neovascularization
Due to lack of oxygen (hypoxia)
If it’s >1.5mm, switch contact lenses or stop wearing them

63. Corneal Warpage Cornea changes shape due to contact lenses
GP lenses (gas permeable, “hard” lenses)

64. Contact Lens Deposits Deposits of tear components on contact lenses
Clean lenses better!

65. Dimple Veiling
Air bubbles trapped under a GP contact lens create divots in the cornea