1. Corneal Path

2. Lecture 08/25/08: Corneal Dystrophies

3. Arcus Senilis Elevated Cholesterol See PCP for blood work-up

4. Arcus Senilis

5. Hudson Stahli Line A brown, horizontal line across the lower third of the cornea, occasionally seen in the aged. No Tx

6. Hudson Stahli Line

7. Band Keratopathy Precipitation of calcium salts on the corneal surface (directly under the epithelium) Patients with band keratopathy complain of the following: –Decreased vision –Foreign body sensation –Ocular irritation –Redness (occasionally) Tx: Debridement

8. Band Keratopathy

9. Limbal Girdle of Vogt Very common, bilateral, age-related condition. Corneal degeneration. Clinical features: Symptoms: asymptomatic and requires no therapy. Signs: Crescenteric, white opacities of the peripheral cornea in the interpalpebral zone along the nasal and temporal limbus May be separated from the limbus by a clear zone or without a clear zone in between

10. Limbal Girdle of Vogt

11. Salzmann’s Nodular Degeneration Usually following trachoma or phlyctenular keratitis Characterized by multiple superficial blue white nodules in the midperiphery of the cornea Medical therapy consists of lubrication, warm compresses, lid hygiene, topical steroids, and/or oral doxycycline

12. Salzmann’s Nodular Degeneration

13. Climatic Droplet Keratopathy Degenerative condition characterized by the accumulation of translucent material in the superficial corneal stroma Sector iridectomy, corneal epithelial debridement, lamellar keratoplasty, and penetrating keratoplasty have all been employed in the treatment of visually incapacitating CDK.

14. Climatic Droplet Keratopathy

15. Corneal Farinata Bilateral speckling of the posterior part of the corneal stromaBilateralposterior partcornealstroma VA unaffected

16. Corneal Farinata

17. Pellucid Marginal Degeneration / Keratoglobus Bilateral, noninflammatory, peripheral corneal thinning disorder characterized by a peripheral band of thinning of the inferior cornea Tx: RGPs / Keratoplasty Surgery needed for Keratoglobus

18. Pellucid Marginal Degeneration

19. Keratoglobus

20. Lecture 09/08/08 EBMD (Bergmanson) Keratoconus (continued) –Making the Dx

21. Voght Striae

22. Fleisher’s Ring Cause: Thickened tear film where lids meet

23. Hydrops Rupture in Descemet’s membrane

24. EBMD Epithelial Basement Membrane Dystrophy

25. Meesmann’s Dystrophy Intraepithelial cysts with amorphous material/cellular debris Tx: usually not needed

26. Map/ Dot/ Fingerprint Dystrophy aka “Anterior Membrane Dystrophy” BM is laid down abnormally by epithelial cells  build up of material Pts > 60 Negative staining

27. Recurrent Corneal Erosion Syndrome

28. Tx: for EBMD –Lubricant/gtts; ung –Bandage CL –Stromal puncture –Epithelial scraping –PTK

29. Surgical Tx PKP (Penetrating) vs. LKP (Lamellar) –Most surgeons tx w/ PKP –Adv of LKP Not intraocular Fewer complications Preserved endothelium Low risk of rejection Preserves global strength

30. Dystrophies of Bowman’s Layer

31. Reis-Buckler’s Dystrophy Autosomal dominant dystrophy Characterized by small discrete opacities centrally just under the epithelium which may have a honeycomb pattern ALL is being replaced by reticular material (scar-like tissue)

32. Honeycomb dystrophy of Thiel and Behnke

33. Inherited Band Keratopathy Tx: Chelating agent EDTA

34. Stromal Dystrophy Granular Dystrophy Lattice Dystrophy Gelatinous drop-like dystrophy

35. Granular Dystrophy

36. Corneal Trauma Management

37. Bacterial Keratitis -WBCs only found in infectious keratitis. -Acute (24-48 hrs), rapidly progressive corneal destructive process or a chronic process. -Caused by corneal epithelial disruption caused by trauma, contact lens wear, contaminated ocular medications and impaired immune defense mechanisms. -Tx. With Polytrim, Vigamox, and broad spectrum antibiotics

38. Radial Keratotomy Problems *Refractive surgery procedure to correct mild to moderate degrees of myopia (2 to 5 D). *Incisions can split open making them vulnerable to corneal infections (fungal/bacterial) -If infection happens w/i 24 -48 hrs, bacterial and not fungal. -Tx aggressively with Polytrim, Vigamox, or broad spectrum antibiotics. -F/U in 1 day.

39. Fungal Keratitis Feathery Borders, w/ hx of plant/vegetable matter trauma. Tx w/ prolonged course of systemic and topical anti-fungal (Natamycin), and frequent scrapings or localized debridement to remove necrotized epithelial tissue.

40. Lecture 09/22/08: Corneal Trauma Mgmt

41. Pseudomonas Keratitis *Pseudomonas can progress fast! Within 24 hours -hypopyon, infiltrates in cornea, KPs, plasmoid aqueous (AC is jello) -pain, decreased VAs, redness

42. Corneal FB *May develop corneal ulcer. *r/o intraocular FB. *Remove FB, unless removal will cause more damage than leaving it undisturbed. -Topical antibiotics after removal -Topical NSAID (Ketorolac) or short acting cycloplegic for relief of symptoms

43. Intraocular Foreign Body *Intraocular FB –passes basement membrane of cornea. -Improper removal can cause collapsed AC, traumatic glaucoma, endophthalmitis if infected. *Refer to surgeon.

44. Traumatic Cataract *Most common complication of non-perforating and perforating injuries to the globe.

45. Hypermature/Morgagnian Cateract *May me caused by severe trauma. *Liquified cat with intact nucleus inferiorly displaced.

46. Bollus Keratopathy *Compromised endothelial cell pump mechanism as the endothelial cell density decreased and decompensated; Folds in stroma from stromal edema. *Can be induced by cataract surgery or other trauma. *Manage w/ NaCl 5% gtts and ung; CL for pain; IOP lowering meds; Penetrating Keratoplasty in advanced cases.

47. RA-associated peripheral ulcerative keratitis *Hx of CT dz. *May cause stromal thinning, descemetocele (only PLL and endothelium left due to corneal thinning) in progressive keratolysis, and perforation. *Promote re-epithelialization by ocular surface lubrication, patching or bandage soft contact lens.

48. Alkaline Burn *Immediate irrigation of eye until the pH of the cul-de-sac has returned to neutrality. (pH= 7.0) *Prophylactic broad spectrum antibiotic; cycloplegic drops; topical steroids to decrease inflammation; lubrication; soft CL…

49. Lecture 09/29/08: Corneal Trauma Mgmt (cont.)

50. Pseudomonas Keratitis Vigamox

51. Bacterial corneal Ulcer gram (+) Vigamox, gram (-) Zymar

52. Fungal Keratitis Natamycin

53. Acanthamoeba keratitis Epithelial debridement

54. Epithelial Herpes Simplex Viroptic

55. Marginal Keratitis Vigamox

56. Bacterial infiltrate 2 nd to RK Vigamox

57. Dellen Artificial tears

58. Pubic lice Bacitracin ointment

59. Iris nevus Asymptomatic, no tx Malignant with growth, refer

60. Lecture 10/06/08: Corneal Dystrophy (cont.)

61. Lecture 10/20/08: Therapeutic Strategy for Ant. Segment Dz

62. Combination Antibiotics Tobramycin Polymixin B Neomycin (hypersensitvity common) Sulfacetamide Bacitracin Medications used to treat ocular inflammation and prevent microbial infection. Also used for superficial burns. Examples: corneal infiltratres, meibomian gland dys., blepharitis

63. Corneal Ulcers TOC: 4 th generation fluoroquinalones - Zymar (gatifloxacin) 0.3% -Vigamox (moxifloxacin) 0.5% -Quixin (levofloxacin) 0.5%-- 3 rd generation -Iquix (levofloxacin 1.5%) qd or bid– 3x conc of Quixin and works better than Zymar and Vigamox without toxicity. Preservative free.

64. Corneal Ulcers (additional treatments) Antibiotics - Gentamycin (ung, gtt) -Ofloxacin (gtt) -Ciprofloxacin (gtt) -Tobramycin sulfate (ung, gtt) Mixes -Polysporin ung ( polymixin B & bacitracin) -Neosporin ung ( poly b/ neomycin / bacitracin) -Polytrim gtt ( poly B & trimethoprim) -- least toxic

65. Bacterial Conjunctivitis - Azasite (azithromycin 1%) bid-tid steroid added post AB treatment to prevent corneal scarring - Vigamox (moxifloxacin) FDA approved for bacterial conjunctivits

66. Topical anit-inflammatories Steroids - Maxidex (Dexamethasone 0.1%) susp - FML (flouromethalone 0.1%) – ung or susp - Pred forte (prednisilone 1%) – susp Soft steroids - Lotepredenol etabonate Alrex 0.2% Lotemax 0.5% NSAIDS (analgesic effect) - Diclofenac (Voltaren 0.1%) soln -Ketorolac (Acular 0.4%) soln

67. Allergic and CLPC- (contact lens induced papillary conjunctivitis) Treat with… - Mast cell stabilizers Crolom bid, Alomide or Alomast qid, Alocril bid - Mast cell stabilizing antihistamines Patanol bid/ Pataday qd, Elestat bid, Zaditor bid, Optivar bid - NSAIDS Acular qid - Steroids (only if severe) Alrex, Lotemax, or Pred Forte qid