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Cornea Flashcards

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1
Q

What is marginal keratitis?

A

Peripheral corneal inflammation caused by a reaction to bacterial exotoxins. Often caused by recurrent bacterial bleph

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2
Q

What are the symptoms of marginal keratitis?

A

FB sensation
Pain
Lacrimation
Red eye
Photophobia
sxs are variable

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3
Q

What are the signs of marginal keratitis?

A

Stromal infiltrates (usually close to limbus)
Epithelial loss leading to ulcer formation

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4
Q

How should marginal keratitis be managed?

A

Self limiting but treatment can help to reduce sxs/time
Address predisposing factors (e.g. treat bleph)
Lubricants
Systemic painkillers
Topical antibiotic (chloramphenicol) and topical steroid (presnisolone) for 2 weeks to reduce inflam
If persistent or recurrent: referral to secondary care

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5
Q

What are CL-associated infiltrative events (CIEs)?

A

Anterior stromal inflammation (poss epithelial involvement)
e.g. CLPU, CLARE, CL associated infiltrative keratitis

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6
Q

What are some predisposing factors for CIEs?

A

Px related: bleph, male, under 25, smoker, prev CIE occurrence
CL related: long term wear, EW, SiH, tight fit, MP sols, poor lens hygiene, bioburden (lens and case)

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7
Q

What are the sxs for CIEs?

A

Red eye
Watery eyes
FB sensation
Photophobia
Poss asymptomatic

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8
Q

What are the signs for CIEs?

A

Peripheral anterior stromal infiltrate(s) less than 1mm
Epithelial staining
Conj and limbal redness (sectoral near the infiltrates)
Epiphora
Poss mild inflam in AC
Unilateral
No lid oedema

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9
Q

What is the management for CIEs?

A

Address modifiable RFs
Temporary cease of lens wear
Avoid EW
Check compliance and fit
Remind px of hygiene/compliance/wearing schedule
Warn about poss recurrence (switch to dailies)
Lid hygiene if bleph
Lubricants for sx relief
Poss topical antibiotic if bleph

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10
Q

What is bacterial keratitis? What are the most common causes?

A

Bacterial infection of the cornea
Most common causes: staph and strep, pseudomonas

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11
Q

What are some predisposing factors for bacterial keratitis?

A

CL wear
Ocular surface disease
Ocular trauma or surgery
Immunocompromisation
Lid margin infection

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12
Q

What is fungal keratitis? What are the most common causes?

A

Fungal infection
Most common causes: candida, fusarium, aspergillus

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13
Q

What are some predisposing factors for fungal keratitis?

A

Trauma involving organic matter
CL or solution biofilm
Immunocompromisation

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14
Q

What are the signs of fungal keratitis that separate it from bacterial keratitis?

A

Slower progression than bacterial
Deep lesion with feathery edge and raised profile
Satellite lesions and endothelial plaque

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15
Q

What are the symptoms of bacterial and fungal keratitis?

A

Pain (acute onset and rapid progression, mod-severe)
Redness
Photophobia
Discharge
Blurred vision
Unilateral
Can see lesion in mirror

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16
Q

What are the signs of bacterial and fungal keratitis?

A

Epiphora
Discharge
Conj redness
Corneal infiltrates
Corneal lesion (central or mid-periph)
Tissue necrosis (epithelial/bowman’s layer/stroma)
Stromal infiltration under lesion
Stromal oedema
Folds in Descemet’s membrane
AC activity

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17
Q

What is the management for bacterial and fungal keratitis?

A

Remove CLs (keep case and CLs for culture)
Emergency referral if: infiltrate >1mm, 2 or more adjacent lesions, lesion 3mm or less from central cornea, AC reaction, anything suggestive of fungal or AK.

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18
Q

What is the aetiology of acanthamoeba keratitis? What are the two forms?

A

Bacteria is present in water, dust and soil
Forms: Motile and Dormant

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19
Q

What are the predisposing factors for AK?

A

CL wear
Poor compliance
Corneal trauma + exposure to water or soil

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20
Q

What are the sxs of AK?

A

Pain (likely severe and out of proportion to signs)
Redness
Epiphora
Photophobia
Visual disturbance/loss

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21
Q

What are the non-corneal signs of AK?

A

Conj and limbal redness
Epiphora
Reduced VA (later stages)

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22
Q

What are the corneal signs of AK?

A

Early: punctate staining, epithelial/subepithelial infiltrates, pseudodendrites, radial keratoneuritis, recurrent epithelial breakdown
Late: deep inflam (stromal, central or paracentral, or abscess), stromal thinning, scleral inflam, AC activity, hypopyon

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23
Q

What is the management for AK?

A

Remove CLs, keep with case for culture
Emergency referral to secondary care

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24
Q

What is the cause of Herpes simplex keratitis?

A

Infection of mucous membranes by Herpes simplex

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25
What are some predisposing factors for HSK?
Poor general health Immunodeficiency/suppression Fatigue Steroids prev HSV infection
26
What are some aggravating factors for HSK?
UV light Fever Extreme heat or cold Infection Trauma
27
What are the sxs for HSK?
Pain Burning Irritation Photophobia Blurred vision Redness Reduced VA (Variable) Usually unilateral
28
What are the signs for HSK?
Epithelial: reduced corneal sensitivity and dendritic ulcer Stromal: infiltrates, vascularization, oedema, opacification Endothelial: raised IOP, uveitis, keratic precipitates, stromal thickening, fold in DM and epithelial oedema (central or eccentric)
29
What is the management for HSK?
Epithelial: Aciclovir 3% ointment until 3 days post healing or Gangoclovir 0.15% gel until 7 days post healing Referral
30
When should HSK be referred?
Acute or recurring epithelial and not healed after 7 days (urgent referral) Stromal involvement/CL wearer/child/bilateral (emergency referral)
31
What is Herpes Zoster ophthalmicus?
Human herpes virus 3 (HHV-3) involvement in ophthalmic division of trigeminal nerve
32
What are some predisposing factors for HZO?
Age Immunocompromisation
33
What are the sxs of HZO?
Pain and altered sensation on one side of forehead Rash on forehead/eyelid 1-7 days later General malaise Headaches Fever Ocular: discomfort, discharge, redness, pain, photophobia (all acute)
34
What are the dermatological signs of HZO?
Unilateral painful red rash on forehead and eyelid (doesn't cross midline, and crusts after 2-3 weeks) Skin lesions on side of nose tip (Hutchinson's sign)
35
What are the ocular signs of HZO?
Lesion within 1 month of skin rash (pseudodendrites) Mucopurulent conjunctivitis Keratitis (punctate, then pseudodendrites, then disciform) Reduced corneal sensation Episcleritis
36
What is the management for HZO?
Rest, drink lots and good diet Avoid elderly, pregnant, children and babies (if not prev exposed), immunodeficient Topical lubricants Systemic pain relief (poss via GP for stronger) Referral
37
What type of referral should be sent for HZO?
Urgent: if deeper cornea involved, ant uveitis present or IOP raised Emergency to GP: if acute skin lesions - for systemic ati viral tx
38
What are dellen?
Localised corneal disturbance due to focal drying Usually assoc with nearby elevated lesion (lubrication impaired) Generally mild
39
What is exposure keratopathy?
Area of corneal drying with normal tear production, due to incomplete lid closure
40
What are some causes of exposure keratopathy?
Facial nerve palsy Reduced muscle tone Mechanical (lid scars, proptosis, blepharoplasty)
41
What are the signs of exposure keratopathy?
Mild punctate epithelial changes in inferior corneal third Epithelial breakdown Stromal melt/perforation Inferior fibrovascular change Secondary infection
42
What are the sxs for exposure keratopathy?
(same as dry eye) Grittiness Burning Epiphora Dryness Discomfort Irritation FB sensation Redness Fluctuating vision
43
What are the reversible treatments for exposure keratopathy?
Unpreserved artificial tears in daytime Ointment at night Lid taping at night Bandage CLs Manage proptosis by orbital decompression Temporary tarsorrhaphy (lids stitched together)/frost surface/overlay amniotic membrane graft
44
What are the permanent treatments for exposure keratopathy?
Permanent tarsorrhaphy Gold weight upper lid insertion (facial nerve palsy) Amniotic membrane graft/conj flap/central permanent tarsorrhaphy (if vision poor)
45
What is recurrent corneal epithelial erosion?
Epithelial detachment caused by abnormally weak attachment between basal epithelial cells and basement membrane. Can detach with corneal-lid interaction during sleep.
46
What are some predisposing factors for recurrent corneal epithelial erosion?
Superficial trauma history Corneal dystrophy Dry eye Diabetes Prev refractive surgery
47
What are the sxs for recurrent corneal epithelial erosion?
Unilateral, typically present on waking or can wake px up Feeling of lid being stuck to eye Severe, sharp pain Photophobia Redness Watering Blepharospasm
48
What are the signs of recurrent corneal epithelial erosion?
Fluor pooling near loose epithelium Rapid TBUT Greyish sloughed and rolled epithelium Microcysts/punctate/linear/fingerprint opacities
49
What is the treatment for acute corneal epithelial erosion?
Antibiotic ointment 4x daily Cyclopentolate 1% 2x daily Bandage CL if severe Debridement of heaped epithelium Topical diclofenac 0.1% to reduce pain Topical anaesthetic while in clinic Hypertonic sodium chloride 5% drops 4x daily (ointment at night) Topical lubricant 3-4x daily for several months once healed
50
What is the treatment for recurrent corneal epithelial erosion? (same as cogan)
Lubricant gel/ointment at night Oral antibiotic and topical steroid (stop disease pathway) Long term EW bandage CLs Debridement of heaped epithelium Anterior stromal puncture (if far from visual axis)
51
What is the management for recurrent corneal epithelial erosion?
Alleviate sxs If severe: also routine referral for pharm tx
52
What are the differential diagnoses for recurrent corneal epithelial erosion?
Herpes simplex keratitis Exposure keratopathy Other corneal dystrophies CL related epithelial conditions
53
What is pellucid marginal degeneration (PMD)?
Progressive peripheral corneal thinning Usually inferior and bilateral and presents in adulthood Rare
54
What are the sxs of PMD?
Slow, progressive vision blurring (due to astig)
55
What are the signs of PMD?
Bilateral Inferior corneal thinning (1mm thick, 1mm away from limbus, from 4-8 o'clock) Epithelium in tact Area above thinning shows ectasia and looks flat Butterfly pattern on topography Severe astigmatism Diffuse steeping of inferior cornea
56
What is the treatment for PMD?
Specs CLs Surgery (if nothing else worked)
57
What is keratoconus?
Progressive central or paracentral corneal thinning Apex of cornea protrudes Irregular astig caused Non-inflam Bilateral (initially unilateral) Asymmetrical
58
What systemic conditions are associated with keratoconus?
Marfan's syndrome Down's syndrome Ehlers-Danlos
59
What ocular conditions are associated with keratoconus?
Keratoconjunctivitis Leber's congenital amaurosis RP Persistent eye rubbing
60
What are some predisposing factors for keratoconus?
Hot, dusty, dry, tropical or subtropical climates Male gender FH
61
What are some RFs for keratoconus?
FH Atopy Sleep apnoea Floppy eyelid syndrome South Asian ethnicity
62
What are the sxs of keratoconus?
Vision impairment due to myopia and astig progression (initially unilateral) Acute hydrops - AH enters cornea due to rupture in DM (rarely). Causes pain, watery eyes, photophobia.
63
What are the early signs of keratoconus?
Oil drop red reflex Scissor reflex on ret Prominent corneal nerves Steep k readings
64
What are the later signs of keratoconus?
Vogt striae (disappear with pressure on the globe) Fleischer ring (epithelial iron deposits around cone base) Progressive cone shaped cornea (thinnest at apex) Munson's sign (lower lid bulge in downgaze) Acute hydrops Inferotemporal steep cone on topography
65
What is classed as a mild form of keratoconus?
<45D >7.50mm
66
What is classed as a moderate form of keratoconus?
45-52D 6.50-7.50mm
67
What is classed as an advanced form of keratoconus?
52-65D 6-6.50mm
68
What is classed as a severe form of keratoconus?
>62D <6.00mm
69
What should a px with keratoconus be advised?
No eye rubbing
70
What are the treatment options for early keratoconus?
Specs Soft toric CLs Corneal cross linking
71
What are the treatment options for moderate keratoconus?
RGPs Piggyback CLs Hybrid CLs Intacs
72
What are the treatment options for advanced keratoconus?
Corneoscleral or scleral CLs PK/DALK
73
How does corneal cross-linking work?
Strengthens cornea by increasing no of collagen bonds in stroma - reducing cone progression
74
How is corneal cross-linking performed?
Epithelium is removed Riboflavin drops applied UVA light applied to cornea
75
What is the minimum corneal thickness needed for corneal cross-linking?
400nm
76
What is the full name for intacs?
Intrastromal corneal ring segments
77
How are intacs inserted?
Laser creates incision and channel Ring inserted to flatten cornea
78
What is PK?
Penetrating keratoplasty Full thickness transplant of central 2/3 of cornea
79
What is DALK?
Deep Anterior Lamellar Keratoplasty Removal of 95% of cornea - healthy endothelium required
80
When should you fit CLs for keratoconus?
Poor VA (<6/9 or symptomatic)
81
What are the differential diagnoses for keratoconus?
Pellucid marginal degeneration Keratoglobus Iatrogenic keratectasia
82
What is Cogan (epithelial basement membrane) dystrophy?
Thickening of basement membrane Deposition of fibrillary protein between BM and Bowman's layer
83
What causes Cogan?
Trauma Degeneration Rarely, inherited
84
What are the symptoms of cogan?
Most asymptomatic
85
What are the signs of cogan?
Dot-like epithelial lesions Micro-cystic epithelial lesions Subepithelial map-like patterns (faint haze around it) Whorled fingerprint-like lines Bleb-like subepithelial pebbled glass pattern
86
What is the treatment for cogan? (same as recurrent corneal erosions)
Lubricant gel/ointment at night Oral antibiotic and topical steroid (stop disease pathway) Long term EW bandage CLs Debridement of heaped epithelium Anterior stromal puncture (if far from visual axis)
87
What is arcus senilis?
Peripheral corneal opacity due to build up of lipid
88
What is arcus senilis (actually juvenilis) a sign of in younger pxs?
Dyslipidaemia
89
What are the signs of arcus senilis?
Stromal lipid deposition ~1mm wide in perilimbal cornea Peripheral edge sharply defined Central border diffuse Usually wider in vertical meridian
90
What is Vogt limbal girdle?
Whitish crescent near limbus Chalk-like flecks at 9 and/or 3 o'clock
91
Who is more likely to have Vogt limbal girdle?
Women Over 40s
92
What is the difference between type 1 and type 2 of Vogt limbal girdle?
Type 1: clear area of separation from sclera, and 'swiss cheese' pattern Type 2: usually no clear area, no holes (more common)
93
What are the two types of lattice corneal dystrophy?
TGFB1 Gelsolin
94
Which genes are lattice corneal dystrophy inherited via?
TGFB1 GSN
95
What are the sxs of lattice corneal dystrophy?
Recurrent erosions (TGFB1 type) Blurred vision Ocular irriatation (Gelsolin type)
96
What are the signs of lattice corneal dystrophy?
Reduced corneal sensation Anterior stromal dots coalescing into lattice, doesn't spread to periphery (TGFB1) Generalised stromal haze (TGFB1) Sparse stromal lattice spreads from periphery (Gelsolin)
97
What is the treatment for lattice corneal dystrophy?
PK/DALK (TGFB1) Keratoplasty (rare for Gelsolin)
98
What gene is granular corneal dystrophy inherited via?
TGFB1
99
What are the sxs of granular corneal dystrophy?
Glare and photophobia (Type 1) Blurring and VI as progresses Recurrent erosions (Type 2)
100
What are the signs of granular corneal dystrophy?
Discrete white central anterior stromal deposits which gradually increase in size and number and coalesce (type 1) Impaired corneal sensation (type 1) Fine superficial opacities which progress to stellate (star) or annular (ring) lesions (type 2)
101
What is the treatment for granular corneal dystrophy?
PK/DALK Superficial recurrences can have excimer laser keratectomy None for type 2
102
What is Fuch's endothelial corneal dystrophy?
Non-inflam accelerated endothelial cell loss Bilateral
103
What are the sxs of Fuch's?
Gradually worsening blurring (worse in am due to corneal oedema) Glare Diurnal refractive changes
104
What are the signs of Fuch's?
Corneal guttata 'Beaten metal' appearance on endothelium Thickened Descemet's membrane Central stromal oedema Reduced CS Advanced cases: epithelial oedema and microcysts and bullae Longstanding cases: subepithelial scarring and peripheral vascularization
105
What is the treatment for Fuch's?
Topical sodium chloride 5% Reduce IOP Reduce hairdryer use Bandage CLs or cycloplegia, antibiotic ointment and lubricants if bullae ruptured PK or PLK Conjunctival flaps or amniotic membrane transplantation (poor visual potential) Transcorneal endothelial cryotherapy and topical Rho-kinase inhibitor
106
What is band keratopathy?
Age-related deposition of calcium salts in Bowman's layer, epithelial BM and anterior stroma
107
What causes band keratopathy?
Chronic anterior uveitis Glaucoma Chronic corneal oedema Severe chronic keratitis Phthisis bulbi Silicone oil in AC Age Metabolic Hereditary
108
What are the signs of band keratopathy?
Peripheral interpalpebral calcification Gradual central spread Nodules and elevation in advanced lesions (can cause discomfort)
109
When is treatment considered for band keratopathy?
If vision threatened If eye uncomfortable
110
What is the treatment for band keratopathy?
Treat any underlying condition Chelation Diamond burr Excimer laser keratectomy Laser keratoplasty

Abnormal Ocular Conditions (17 decks)

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