Post on 02-Jun-2018
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Reported by:
Mae Argailyn I. Guzman
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Review:
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Outline
Physiology
Symptoms
Laboratory Studies
Corneal ulceration Infectious
Non infectious
Epithelial keratitis
Degenerative corneal conditions
Miscellaneous corneal disorders
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Endothelium- edema of the cornea
- loss of transparency, persists
Epithelium- transient, localized edema
- clears with rapid regeneration
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Penetration by drugs
- biphasic
- fat-solubleepithelium
-water-solubleintact stroma
- THUS, to pass through cornea,
drugs must be water and lipid
soluble
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Resistance to Infection
Traumatized epithelium > avascularstroma and Bowmans layer become
susceptible to infection
Streptococcus pneumoniaetruebacterial pathogen
Corticosteroids modify host immune
reaction
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Symptoms
Keys to exam: adequate illumination,instillation of local anesthetic and
magnification (slit lamp)
Painpain fibers, worsened bymovement of lids,
Photophobiadue to painful
contraction of inflamed iris Blurred vision
No discharge except in purulent
bacterial ulcers
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Investigation of Corneal Disease
Past medical history:
Trauma
Two most common lesion: foreign
bodies, abrasionHistory corneal disease
Use of topical medications
Systemic diseases
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Laboratory Studies
Appropriate therapy is instituted assoon as the necessary specimens
have been obtained
Examination of corneal scrapings(Gram and Giemsa stain)
PCR
Culture
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Morphologic Diagnosis of Corneal
Lesions
Epithelial Keratitis
- most types
- edema, vacuolation to minute
erosions, filament formation, partial
keratinization
Subepithelial Keratitis- secondary
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Stromal Keratitis- infiltration- edemamanifested by corneal
thickening, opacification- melting/ necrosis- thinning/ perforation- vascularization
Endothelial Keratitis
- edema- initially involving the stroma thenepithelium
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I. Corneal Ulceration
Major cause of blindness and impairedvision throughout the world.
May be:
A. InfectiousB. Non-infectious
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A. Infectious Corneal Ulcers
- lesion situated centrally
- Hypopyoncollection of inflammatory
cells seen as a pale layer in the inferioranterior chamber
-contact lens wearmost common
predisposing factor
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Hypopyon
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A. Infectious Corneal Ulcers
1. Bacterial Keratitis
2. Fungal Keratitis
3. Viral Keratitis4. Acanthamoeba Keratitis
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1. Bacterial Keratitis
Streptococcus pneumoniae- manifests in 24-48 hrs
- gray, fairly well-circumscribed ulcer that tends
to spread erratically from original site to center
- Acute serpiginous ulcer
- superficial corneal layers, deep parenchyma
- scrapings: gram positive lancet- shaped
diplococci- Moxifloxacin, Gatifloxacin, Cefazolin
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Pseudomonas aeruginosa- gray or yellow infiltrate at the site of a break
- severe pain
- spread rapidly in all directions due to
proteolytic enzymes
-superficial, entire cornea
-consequences: corneal perforation and
severe intraocular infection- infiltrate and exudatebluish-green colors
(pathognomonic)
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-Associated with soft contact lenses (espextended-wear lenses)
-Scrapings: long, thin, gram-neg rods
-Tx: Moxifloxacin, gatifloxacin,ciprofloxacin, tobramycin, gentamicin
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Moraxella liquefaciens- diplobacillus of Petit
-indolent oval ulcer
- inferior cornea, deep stroma in days- no hypopyon or a small one
- surrounding cornea clear
- alcoholics, DM, immunosuppression
- scrapings: large, square-ended Gram negdiplobacilli
- Tx: moxifloxacin, gatifloxacin, tobramycin
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Group A Streptococcus Corneal Ulcer- no identifying features
- surrounding corneal stroma often
infiltrated and edematous- moderately large hypopyon
- Scraping: gram positive cocci in chains
- Tx: Vancomycin
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Staphylococcus aureus, epidermidis, andAlpha-Hemolytic Streptococcus
-central corneal ulcer
-compromised by topical corticosteroids
-indolent, hypopyon, surrounding cornealinfiltration
-superficial, ulcer bed feels firm when scraped
-scrapings: gram positive coccisingly, in pairsor chains
-Infectious crystalline keratopathy - in long termtherapy with topical steroids
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Mycobacterium fortuitum-chelonei andNocardia
-rare
- follow trauma, contact with soil- indolent, bed of ulcer has a radiating lines
make it look like cracked windshield
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Infectious crystalline keratopathy
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2. Fungal Keratitis
Agricultural workers, urban population
Use of corticosteroids not indicated
Gray infiltrate with irregular edges
Marked inflammation of the globe,
superficial ulceration
Satellite lesions
Endothelial plaque assoc with a severe
anterior chamber reaction
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Scrapings (except candida): Hyphalelements
Candida: pseudohyphae or yeast forms
with characteristic budding Tx: HyphaeNatamycin or voriconazole
CandidaVorionazole, Ampotericin B
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3. Viral Keratitis
Herpes Simplex Keratitis- primary or recurrent
- most common cause of both corneal ulcerationand corneal blindness
- immunocompetent: self-limited;immunocompromised: chronic and damaging
- HSV I - establishes latency in trigeminalganglion
- scrapings: multinucleated giant cells
- Dx: dendritic or geographic ulcers and greatlyreduced/ absent sensation
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- attacks of recurrent type triggered by:- fever, overexposure to UV light, trauma,onset of menstruation,immunosuppression
- unilateralityis the rule; bilateral (4-6%)- first symptoms: irritation, photophobia,
tearing, anesthesia- Dendritic ulcer- most characteristic lesion
-Geographic ulceration- Tx: debridement, Ganciclovir and
Anyclovir, penetrating keratoplasty,control of trigger mechanisms
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Varicella- Zoster Viral Keratitis2 forms: primary(varicella) and recurrent
(herpes zoster)
-Eye lesions-Varicella: pocks on the lids and lid margins
-Herpes zoster: accompanied by keratouveitis
-Affects stroma and anterior uvea at onset
-Epithelial lesions: blotchy and amorphous
except for occassional linear pseudodendrite
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- Loss of corneal sensation, with risk ofneurotrophis keratitis
- Tx: acyclovir, valacyclovir, famciclovir
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4. Acanthamoeba Keratitis
- free-living protozoan in polluted water- assoc. withsoft contact lens wear
-pain, redness, photophobia- characteristic clinical signs: indolentcorneal ulceration, stromal ring, perineuralinfiltrates
-Tx: epithelial debridement (early), 1%
propamidine isethionate,polyhexamethylene biguanide, fortifiedneomycin, keratoplasty
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B. Non-Infectious Corneal Ulcers
1. Marginal Infiltrates and Ulcers
2. MoorensUlcer
3. Phlyctenular Keratoconjunctivitis
4. Marginal Keratitis in autoimmune
disease
5. Corneal Ulcer due to Vit A deficiency
6. Neurotrophic Keratitis
7. Exposure Keratitis
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B. Non-Infectious Corneal Ulcers
Marginal Infiltrates and Ulcersbenign but extremely painful
- sensitization to bacterial products
-self-limited, 7-10 days
-Tx: topical corticosteroid
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MoorensUlcer- unknown, may be autoimmune
-unilateral- painful, progressive excavation of thelimbus and peripheral cornea that oftenleads to loss of the eye
-unresponsive to both antibiotics and
corticosteroids- Tx: surgical excision, lamellar tectonickeratoplasty
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Phlyctenular Keratoconjunctivitis-delayed hypersensitivity response
- associated with a transient increase in
the activity of childhood TB-spontaneously regress after 10-14 days
-Tx: topical corticosteroid
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Marginal Keratitis in autoimmunedisease
- changes secondary to scleralinflammation
- vascularization, infiltration and
opacification, peripheral guttering
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Corneal Ulcer due to Vit A deficiency- centrally located, bilateral, gray and indolent, with
a definite lack of corneal luster in the surrounding
area
-keratomalaciacornea becomes soft andnecrotic
-Bitotsspot- keratinized epithelium of the
conjunctiva
-Lack of vitamin A causes a generalizedkeratinization of the epithelium throughout the body
-conjunctival + corneal changes together are
known as xerophthalmia
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Tx: Treat underlying cause
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Neurotrophic Keratitis- trigeminal nerve dysfunction
- corneal anesthesia with loss of blink reflex
- Tx:keep eyes closed
Exposure Keratitis
- drying of cornea and its exposure to minor
trauma- Tx: Provide protection and moisture for entire
corneal surface
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II. Epithelial Keratitis
1. Chlamydial keratitis2. Drug-induced epithelial Keratitis
3. Keratoconjunctivitis Sicca
4. Adenovirus Keratitis
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Chlamydial Keratitis
Chlamydial conjunctivitis accompanied bycorneal lesions
Corneal lesions of trachoma
1. Epithelial microerosions affecting theupper third of the cornea
2. Micropannus
3. subepithelial round opacities, commonly
called trachoma pustules4. limbal follicles and their cicatricial remains,
known as Herbert's peripheral pits
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5. gross pannus6. extensive, diffuse, subepithelial
cicatrization
Tx:systemic tetracyclines, topicalsulfonamides, tetracycline,
erythromycin, rifampin
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Drug-inducedEpithelialKeratitis
Coarse, superficial keratitis affectingpredominantly the lower half of the
cornea and interpalpebral fissure, may
cause permanent scarring Causes: preservatives in eyedrops
(benzalkonium chlorideand thimerosal)
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Keratoconjunctivitis Sicca (Sjgren's
Syndrome)
autoimmune disease Cardinal signs: epithelial filaments in the
lower quadrants of the cornea
secretion of the lacrimal and accessorylacrimal glands is diminished or eliminated
blotchy epithelial keratitis that affects
mainly the lower quadrants
Severe cases: mucous pseudofilaments
that stick to the corneal epithelium
Tx:frequent use of tear substitutes and
lubricating ointments
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AdenovirusKeratitis
accompanies all types of adenoviralconjunctivitis
peak 57 days after onset of the
conjunctivitis fine epithelial keratitis best seen with the
slitlamp after instillation of fluorescein
Corticosteroid not recommended
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III. Degenerative Corneal Conditions
1. Keratoconus
2. Corneal Degeneration
3.Arcus Senilis
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Keratoconus
- 2nddecade of life- blurred visiononly symptom
- disruptive changes in Bowmanslayer with keratocyte
degeneration and ruptures of
descemetsmembrane- cone-shaped cornea
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-Vogts lineslinear narrow foldscentrally in Descemetsmembrane
(pathognomonic)
- Fleischers ringiron ring around baseof the cone
- Munsons signindentation of the lower
lid by the cornea when patient looks
down
- Tx:Rigid contact lens, surgery
(transplant)
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CornealDegeneration
a. TerriensDisease- marginal thinning of the upper nasal
quadrants of the cornea
- men- irritation during occasional inflammatory
episodes
- Tx:Tectonic Keratoplasty
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b. Band (Calcific) Keratopathy- deposition of calcium saltsin a band-
like pattern in the anterior layers of the
cornea- Clear margin separates calcific band
from limbus and clear holes
- juvenile idiopathic arthritis
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c. Climatic Droplet Keratopathy
- outdoors- UV light
- early stages of fine subepithelial yellowdroplets in peripheral cornea.
- clouding
- Tx: transplant
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d. Salzmanns Nodular Degeneration- preceded by inflammation
-degeneration of superficial cornea
- superficial whitish gray elevatednodules sometimes occurring in chains
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ArcusSenilis
- extremely common, bilateral, benign
peripheral corneal degeneration- assoc. with hypercholesterolemia and
hypertrigylceridemia
- hazy gray ring about 2 mm in width and
with clear space between it and the
limbus
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Miscellaneous Corneal Disorders
Interstitial Keratitis due to congenitalsyphilis- late manifestation of congenital syphilis- ages 5-20
- edema, infiltration and vascularization- Hutchinsons triad- interstitial keratitis,deafness, notched upper central incisors- saddle nose- another sign
- pain, photophobia and blurring of vision- salmon patchgrayish-pink cornea
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Thank You!