Cornea Flashcards

Question

Posterior Polymorphous Dystrophy * Characteristics * What are the 3 patterns? * Associations?

Answer 1

* AD * Disorder at the level of Descemet's membrane & endothelium * Bilateral, asymmetric * Presents in 2nd-3rd decade * **3 patterns** * **Vesicle-like lesions** - hallmark \*\* * 0.1-1.0 mm diameter * Sharply demarcated round area * **Band lesions** * ****typically horizontal with parallel scalloped edges that do not taper at the ends * Mostly found just inferior to visual axis * **Diffuse opacity** * ****Small, macular, gray-white lesions * Large sinuous geography lesions * 0.5-2.0mm * **Associations** * **Corneal edema** * Minimal stromal thickening to bullous keratopathy * Unclear if keratoconus or similar variant * **Symptoms** * ****Stable & asymptomatic * Secondary glaucoma * Rarely may be progressive & debilitating * **Treatment** * ****None * PK - PPD can recur * Treat associated conditions

Answer 2

* Reactivation along CN V1 * **Cutaneous lesions** * 25% involvement of ophthalmic division of CN V * Acute, painful vesicular eruptions * **Prodromal period not uncommon** * ****Fever, malaise, HA, eye pain or pressure, tearing, ocular redness, decreased vision * Pain occurs along affected dermatome most commonly * **Clinical course 2-6 weeks for vesicle to clear** * Corneal involvement may take longer * Ocular involvement begins within 3 weeks of rash * Virus presumably reaches eye via ciliary nerves * \*\*Pt presents to you initially with rash on lids and skin lesions without involvement of the globe = must follow pt weekly for minimum of 3 weeks

Answer 3

* Donor cells (graft) mount an immune response against recipient (host) * **Affected tissues** * Skin * GI system * Liver * Mouth * Lungs * Eyes (60-90% with GVHD) * **Occurs in wide range of pt** * Age * Histocompatibility * Prophylaxis * Host environment * **Clinical diagnosis** * Thorough hx regarding nature of transplant & systemic presentation of GVHD * Systemic medications = including immunosuppressants * Complete ocular exam * **Symptoms** * ****FBS * Itching * Burning * Moderate conjunctival redness * Advanced disease * Decreased vision * Pain * Photophobia * Exacerbated by wind, blinking or prolonged reading * **Signs** * ****Conjunctival * Hyperemia * Chemosis * Pseudomembranous conjunctivitis * Mucoid discharge * Cornea * Decreased tear lake * KCS * Filamentary keratitis * Corneal erosions * **Complications** * ****Corneal scarring * Neovascularization * Cicatricial changes of conjunctiva * **Goals** * ****Lubrication * Control evaporation * Decreased ocular surface inflammation * **Treatment** * ****Treat associated systemic disease * Coordination of care with transplant team * Lubrication * Punctal occlusion * Humidifiers * Sleep masks * Tarsorrhaphy * Immunosuppression * Directed at affected organ system * Restasis, topical steroids

Answer 4

* Typically unilateral * Bilateral disease in about 3% * Can affect all levels of cornea * Epithelium * Infectious epithelial keratitis * Neurotrophic keratopathy * Stroma * Immune stromal (Interstitial) keratitis * Necrotiizing stromal keratitis * Endothelium * Disciform endotheliitis * Diffuse endotheliitis * Linear endotheliitis

Answer 5

* Acanthomoeba

Answer 6

* **Staphylococcus aureus** * Gram + cocci * MOST COMMON cause of ulcers & conjunctivitis * Occurs in normal ocular flora * Rapidly progressive corneal infiltration & AC reaction with hypopyon * Ulcers centrally located * **Streptococcus pneumoniae** * ****Gram + diplococci * ****Acute, purulent, & rapidly progressive * Severe AC reaction with hypopyon * Perforation common (7-10 days without tx) * Ulcer centrally located * **Pseudomonas areuginosa** * ****Gram - bacillus * Ubiquitous organism * Ability for proteolysis * MOST COMMON cause of bacterial keratitis in CL wearers * Central or paracentral ulcers * Highly destructive * Adherent greenish mucopurulent discharge * Dense stromal infiltration & necrosis * Stromal melting with early descemetocele * Perforation within 72 hours if untrated * Intense AC reaction w/ hypopyon * **Moraxella lacunata** * ****Gram - coccobacilli * Paracentral ulcer * Older, debilitated individuals & homeless pt * Perforation in days to 1 week without tx

Answer 7

* LCAT deficiency * Progressive arcus which begins in adolescence * May result in complete opacification of cornea * AR inheritance * ~30 cases described

Answer 8

* **Inflammatory infiltration that may lead to ulceration** * Antibody response to toxins rather than bacteria * Type III hypersensitivity * Associated with staphylococcal blepharoconjunctivitis * Most common disorder of peripheral cornea\*\*\*\* **_Symptoms_** * Mild discomfort to pain * Conjunctival injection * Lacrimation * Photophobia **_Presentation_** * **Peripheral stromal infiltrates** - separated by 1-2mm clear zone * Develop where lid crosses limbus * Ulceration & necrosis possible * May develop vascularization between limbus & infiltrate or area of necrosis * **Often chronic blepharitis** * ****Staphylococcal blepharitis most common\*\*\* * Angular blepharitis or strep species possible\*\*\* **_Treatment_** * Lid hygiene - tx underlying cause * Weak topical steroid * Antibiotic * Oral doxycycline - recurrence or maintenance

Answer 9

* AD inheritance * PIP5K3 gene mutation * Bilateral, asymmetric * Flat, gray-white, discrete flecks throughout stroma * May be oval, circular, comma, or stellate shaped * Fine, granular texture * Limbus to limbus * Little progression * **Symptoms** * ****Generally asymptomatic * VA unaffected * Mild photophobia occasionally * Decreased corneal sensation occasionally * **Treatment** * ****None

Answer 10

Collagen fibers Transparent refracting surface 10% outer coat of eye

Answer 11

* One of the most common ophthalmic injuries * Removal of all or part of corneal epithelium * If Bowman's layer undisturbed = no scarring **_Symptoms_** * Pain- generally out of proportion to injury * UV/CL keratitis delayed onset of pain * Photophobia * FBS * Lacrimation * Decreased VA if central or significant edema **_Presentation_** * Variable size/shape epithelial defect * Loose flap of epithelium possible * Conjunctival injection * Lid edema possible **_Examination_** * **History** - pts generally specific about injury * **VA** - may or may not be reduced * **SLE** - best to use anesthetic & NaFL * Evert lids! * **DFE** - any risk of penetrating injury **_Treatment_** * Antibiotic * Cycloplegia * Patching/BCL

Answer 12

* Rheumatoid arthritis * Phlyctenular keratoconjunctivitis * Marginal staphylococcal keratitis * Mooren's Ulcer

Answer 13

* Rare * Bilateral * Globular cornea which leads to high myopia & astigmatism * Congenital & acquired variants * Often present at birth * Associated conditions * Leber's congenital amaurosis * Ehlers-Danlos syndrome type VI * Cornea clear, normal size to slightly large * Stroma diffusely thinned 1/3 - 1/5 normal thickness * More pronounced in mid-peripheral cornea * **Corneal Structure** * ****Fragmented or absent bowmans layer * Diffusely thinned stroma * Thinned Descemet's membrane * Normal endothelium * Thinned sclera * **Breaks in Descemet's membrane possible** * ****leads to opaque, edematous cornea * Takes weeks to months to heal * **Characteristics findings in KCN not present** * ****No striae * No iron lines * No subepithelial * Keratometry readings 60-70D * Acute hydrops rare * Perforation may ocur after minimal trauma * **Treatment** * ****Spectacle correction * Keratoplast - difficult, should be delayed when possible * CLs considered - esp scleral, but must consider increased risk for rupture

Answer 14

* **Reactivation of virus following a dermatome** * Must have prior exposure to virus to develop shingles - either wild-type or vaccine * Replicates in nerve cells & sends virions down the axon to the skin * Presentation is the result of immune response to virions (not the virions themselves) * **Prodrome** (early signs/sx) * Fever, malaise, HA, pain in the dermatome * Affective disorder possible - anorexia, lassitude (lack of energy) , mood changes, antisocial behavior, severe depression, insomnia * **Presents as acute, painful, vesicular eruptions** * **Rash progression**: erythematous → macules → papules → vesicle → pustules → crusting * Generally occurs in cluster * Lesion formation occurs ~3-7 days * Resolution in 2-6 weeks

Answer 15

* Phototherapeutic keratotomy * **Ablative photodecomposition of epithelium to eliminate surface irregularities** * Laser ablation to depth of anterior stroma * **Indications** * Corneal dystrophies or degenerations * Scars * Band keratopathy * Infectious * Therapeutic & visual improvements

Answer 16

* AD * Late onset - 5th decade * Slowly progressive * Women \> men * Earlier presentation * More severe * **Guttata** - refractile excrecences on the posterior cornea * Abnormal functioning endothelial cells * **Begins centrally & spreads peripherally** * **Leads to corneal edema** * ****Worse in am, improves throughout the day * **Symptoms** * ****None in early disease * Blurred vision - worse upon waking * Improves throughout the day * Bullae formation -\> pain, photophobia * **Treatment** * ****None early disease * hypertonic solutions * Muro128 gtt or ung (dehydrates cornea) * Hair-dryer aimed at eyes - pts find this uncomfortable * Reduction of IOP - only at higher IOP levels * Bandage CL, if pt has bullae formation * DSAEK/DMEK (corneal surgery/endothelial transplant)

Answer 17

* Rare, more severe presentation * Symptoms * Pain * Photophobia * Injection * Decreased vision * Clinical course similar to disciform * Responds well to tx

Answer 18

* Primary infections occurs in childhood is chickenpox * Reactivation infection occur as shingles * Generally in older or immunocompromised patients * In otherwise healthy young adults, be suspicious for generalized immunosuppressive diseases * Virus remains latent in sensory ganglions * Reactivation follows a dermatome

Answer 19

* Posterior polymorphous dystrophy * Fuch's endothelial dystrophy * Congenital hereditary endothelial dystrophy

Answer 20

* AKA: Juvenile hereditary epithelial dystrophy * AD inheritance * Intraepithelial microcysts/vesicles * Most prominent interpalpebral zone * Central & mid-peripheral * Slowly progressive * Bilateral, symmetric * First 1-2 years of life * **Symptoms** * ****Mild to nonexistent * Vision good initially * Worsens as cyst increase in size & number which leads to irregularity of corneal surface * Glare sensitivity * FBS * Erosions or PEK not common * **Treatment** * ****Bandage CL * Lubrication * Superficial corneal debridement * PTK (photo therapeutic keratectomy)

Answer 21

* AKA: * Corneal arcus * Gerontoxon * **Degenerative change involving depostion of lipid in the peripheral cornea** * Grey/white arc that as it progresses becomes a ring around cornea * Near limbus with clear intervening zone * **Normal older adults** * Men \> Women * Extremely common * **60%** in 50-60yo pts * **Nearly 100%** affected by age 80 * **May indicate disruption in lipid metabolism** * Young pts should warrant a visit to PCP for lipid panel testing * **Begins inferiorly then superiorly** * Spreads circumferentially * Bilateral * Symmetric * **Symptoms** * ****None, Cosmesis * **Treatment** * ****None, Refer to PCP for lipid panel testing in young pt

Answer 22

* AD inheritance * TGFB1 gene mutation * Leads to deposition of hyaline-like material in stroma * Presents 1st-2nd decade * Bilateral * Grayish white opacities form in CENTRAL anterior stroma with clear intervening space * Drop-shaped, crumb-shaped, ring-shaped * **Symptoms** * ****Glare * Decreased vision late (_\>_40) * **Treatment** * ****None until late * Lamellar or penetrating keratoplasty if vision reduced

Answer 23

* **Autosomal dominant inheritance** * ****Granular dystrophy * Avellino dystrophy * Lattice dystrophy * Schneider's crystalline dystrophy * Fleck corneal dystrophy * Posterior amorphous corneal dystrophy * **Autosomal recessive inheritance** * ****Congenital hereditary stromal dystrophy * Has both AR & AD inheritance patterns * Macular dystrophy * **Unknown inheritance pattern** * ****Central cloud dystrophy of Francois * Pre-Descemet's corneal dystrophy

Answer 24

* Accounts for 20-48% of recurrent disease * Primary involvement * Necrotizing stromal keratitis * Direct viral invasion of stroma * Immune stromal keratitis * Immune reaction in stroma * Secondary involvement * Sequelae of epithelial, neurotrophic or endothelial infection

Answer 25

* **Definition**: Deterioration & decrease in function * May be unilateral or bilateral * Often asymmetric * Often considered aging changes * Often eccentric or peripheral & correspond with vascularity * Progression variable * Local & systemic disease associations often

Answer 26

* Reis-Buckler corneal dystrophy (CBD I) * Thiel-Behnke Honeycomb dystrophy

Answer 27

* Avascular * Vascular arcade in the limbal region provides nutrition to the cornea * Anterior ciliary artery anastomoses with facial branch of external carotid artery * Glucose obtained by diffusion from aqueous humor * Oxygen obtained by diffusion from tears

Answer 28

* Blocks action of estrogen * Used in tx of breast cancer * Ocular side effects * Decreased VA * Corneal microdeposits * Retinopathy

Answer 29

* Rare * Direct viral invasion of stroma * Presentation * Necrosis * Dense stromal infiltration with overlying epithelial defect * Thinning & perforation possible after short period of time

Answer 30

* Superficial keratectomy * Removal of epithelium with alcohol & manual scraping * USed to improve epithelium * Corneal dystrophies & degenerations * Recurrent corneal erosions

Answer 31

* Photorefractive intrastromal corneal cross-linking * Non-surgical tx for low myopia * ~0.75D myopia correction potential * 2 studies have shown good results after 12 months * Not approved in US & not currently in clinical trials

Answer 32

* FDA approved for moderate to high myopia correction * Not currently approved for hyperopic or astigmatic correction * Reversible * Increased risk for cataract development * Possible corneal decompensation * **ICL (Implantable collamer Lens)** * Visian * Lens placed between lens & iris * -3D to -20D * Cannot see with naked eye * Verisyse * Lens to anterior chamber * -5 to -20

Answer 33

* 2nd gen * Ciprofloxacin 0.3% * Ofloxacin 0.3% * 3rd gen * Levofloxacin 0.5% * Levofloxacin 1.5% * 4th gen * Moxifloxacin 0.5% * Besifloxacin 0.6% = no systemic equivalent * 2nd & 3rd generation * Single agent therapy * Available in commercial prep * Bactericidal activity * Broad antimicrobial spectrum * Low incidence of resistance * 4th gen * Improved gram + coverage with maintenance of gram - coverage * Excellent potency against atypical mycobacteria * Effective against MRSA & fluoroquinolone resistant pseudomonas * Better penetration * Less likely to develop resistance

Answer 34

* AR inheritance * Mutation in CHST6 gene * Intra & extracellular deposits within the stroma * Least common stromal dystrophy * Most severe * Most prevelent in Iceland & Saudia Arabia * Characterized by attacks of irritation & photophobia * **Anterior stroma becomes hazy 1st decade, progressing to opacified lesions** * Haze extends to peripheral cornea * Involves entire thickness by 2nd decade * Vision loss by 20s to 30s * Treatment * Variable, depends on severity of tx * Tinted CL to reduce photophobia * Tx of recurrent erosions * PK - reccurence possible in graft

Answer 35

* ~6% of pt manifest disease, therefore 94% of pt do not * Neonatal infection * HSV II * Acquired during vaginal delivery * Post-neonatal infection * HSV I * Acquired from exposure to infectious secretions * Incubation period * 1-28 days * **Presentation** * ****Nonspecific URI - often not recognized as HSV * Variable ocular presentation * Periocular skin vesicles * Follicular conjunctivitis * Keratitis * Preauricular adenopathy * Blepharoconjunctivitis - unilateral vesicular lesions on lid or adnexa, follicular conjunctivitis & PAN

Answer 36

* Copper deposition in Descemet's layer at corneo-scleral junction * Begins at Schwalbe's line & extends into cornea \<5mm * Deposit and extend into trabecular meshwork * Golden to green-brown band in peripheral cornea * Gonioscopy necessary in early disease cases * Bilateral * Begins superiorly, then inferiorly & moves circumferentially * **_Wilson's hepatolenticular degeneration_** * AR * 1st & 4th decades * Inborn error copper metabolism * ATB7B gene * Sx typically present in teens to 20s * Leads to retained copper in the body causing liver & brain damage * Cirrhosis, renal disease, neurologic dysfunction * 95% WD with neurologic signs have KF ring * 65% WD with hepatic signs have KF ring * Fatal if left untreated * Dissappears with treatment * **Treatment** * ****Copper chelation to fade ring * Low copper diet * Systemic treatment of Wilson's disease * Copper chelators * Zinc therapy * Surgical treatment * Liver transplant in severe cases

Answer 37

* Thin walled small yeast * Found in soil, inanimate objects, food & hospital environments * Part of microbiota

Answer 38

* White rings in cornea \<1mm diameter at the level of Bowmans layer * May be oval or incomplete * Discrete white dots with areas of coalescence * Granular * Usually inferior position * Iron or calcium deposit * Often associated with previous trauma - espc metalic FB * Asymptomatic, incidental finding

Answer 39

* **Faint yellow to dark brown discoloration in the epithelium** * Easier to see with cobalt filter * Etiology unclear * **Types** * Hudson-Stahili line * Fleischer ring * Stocker's line * Ferry's line

Answer 40

* Descemet's Stripping Automated Endothelial Keratoplasty * Replaces diseases corneal endothelium w/ donor tissue * 100-200um donor tissue * Final vision approx 1-6 months

Answer 41

* Enveloped, DS, DNA virus * Occurs as primary & reactivation infections * Undergoes true latency in trigeminal ganglion * Orofacial lesion is most common manifestation = cold sore * Genital herpes is 2nd most common venereal disease in US * Major cause of blindness worldwide * Prevalence * 80% of population over age 20 infected, about 6% manifest clinically * 100% of population in pts \>60yo * **Type I** * ****Eye, mouth, skin * Less commonly affects genitals * Transmission - direct contact * **Type II** * ****Genitals * Less commonly affects eye, but more severe * Sexual & neonatal transmission

Answer 42

* Radial keratotomy/Astigmatic keratotomy * Introduced in 1980's Myopic correction * **Creates incision to flatten cornea** * RK - radial incisions for myopic correction * AK - arc incisions for astigmatism correction * **Count & note location of incisions for documentation** * 4-24 RK * Generally 1 or 2 AK * **Complications** * Progressive flattening * Refractive fluctations * Challenge with ocular surgeries * **Considerations** * Corneal cross linking

Answer 43

* **Goals**: * Quickly eradicate organism * Control inflammation * Minimizes scarring * Promote healing * **Hospitalization** * ****If impending perforation * If pt unable to use meds as indicated - often around the clock initially (q30min-1hr) * If failure to respond to out-patient tx * Often not necessary * **Antibiotic therapy administration** * ****Solution vs ointment * Subconjunctival injection (children) * Continuous lavage (impractical) * Collagen shield delivery * Fortified antibiotic or fluoroquinolone given every 30 mins to 1 hour around the clock initially * **Close follow-up essential!!** * See next day * **Initial antibiotic selection** * Broad spectrum therapy vs selection based on gram staining results * Cefazolin 33-50 mg/ml with tobramycin 11 mg/ml * May substitute bacitracin 9600 u/ml for cefazolin if PCN sensitive * Require extemporaneous preparation - not commercially available * **Fluoroquinolone antibiotics** * 2nd generation * 3rd generation * 4th generation \*\*\* best choice * **Initial therapy** * ****Antibiotic - initially every 30 mins - 1 hr around the clock = wake up at night for meds * Concomitant cycloplegic * Cyclopentalate * Homatropine * Follow at least q24 hrs first 2-3 days * **Modification of therapy** * ****Change antibiotic * Based on preliminary culture results * Further modified by final identification and susceptibility testing * Tapering antibiotic * With signs of improvement after 2-3 days * Decreased infiltration, edema, blunting of perimeter, re-epithelialization, corneal vascularization or scarring * Double time between drops * Do not use less frequently than QID - higher risk of resistance * Switch to commercial strength if using fortified * Treat QID until total epithelial healing then another week * **Steroids** * ****Decreases cornea toxic inflammation and stromal loss * Helps prevents scarring * Must give sufficient time for antibiotic to sterilize ulcer before beginning therapy * \*\* NOT given on first day

Answer 44

* Antimalarial * Used in autoimmune disease * RA, SLE * Ocular side effects * Blurred vision - accommodative weakness * Transient corneal edema * Corneal microdeposits * Decreased corneal sensation * Retinal/optic nerve complications

Answer 45

* Defenses to infection * Eyelids * Tearfilm * Make proteins with antimicrobial properties * Intact corneal epithelium * Epithelial cells capable of phagocytosis & intracellular transport of ingested particles * Most bacteria cannot penetrate intact corneal epithelium * Normal ocular flora * Staphylococcus epidermidis * Aerobic & anaerobic diptheroids * Transient pathogens * **Predisposing factors** * ****CL wear - MOST COMMON risk factor in developed countries, 1/5% chance bacterial keratitis in lifetime * Trauma * Corneal surgery * Ocular surface disease * Systemic disease * Immunosuppression * Antibiotic overuse

Answer 46

* Loss of trigeminal innervation to the cornea resulting in anesthesia (partial or complete) * Degeneration of corneal epithelium * **Causes** * Acquired CN V damage * Systemic disease * Ocular disease * Congenital * Toxicity from long term medication use **Stages** * **Stage 1** * ****Mild, nonspecific sn/sx * Rose bengal staining of inferior palpebral conjunctiva * Increased viscosity of tears with decreased TBUT & subsequent dry patches on the cornea * Stain with NaFL * Vascularization & scarring occur if progression not halted * **Stage 2** * ****Non-healing corneal epithelial defect with surrounding loosening of epithelial tissue * Folds in Descemet's develop as stromal edema increases * Punched-out lesion develops * **Stage 3** * ****Stroma melting which leads to perforation * No pain due to decreased corneal sensation **** **_Complications_** * Intracellular edema * Exfoliation of epithelial cells * Impairment of epithelial healing * Loss of goblet cells * Persistent ulceration **_Signs_** * Interpalpebral punctate keratopathy * Epithelial opacification * Persistent epithelial defect with rolled edges * Enlargement of defect with stromal edema & infiltration * Stromal corneal melting * Perforation uncommon, generally a result of secondary infection **Treatment** * D/C toxic medication * Topical lubrication * PFAT drops or ointment * Punctal occlusion * Protect ocular surface * Lid taping at night * Prophylactic antibiotic * BOTOX injection to induce ptosis * Tarsorrhaphy * Therapeutic CL * Amniotic membrane * Corneal transplant in late disease

Answer 47

* Episodic erosion/ denuding of corneal epithelium * Complete resolution between attacks * Unpredictable & variable presentation * Abnormally weak attachment between basal cell in corneal epithelium and basement membrane **Symptoms** * Begins in late evening/early morning hours * Abrupt ripping/tearing sensation * Severe pain * Photophobia * Redness * Blepharospasm * Watering * Decreased vision * Epithelial defect often present, although may be healing when pt presents to clinic **_Risk Factors_** * Prior corneal trauma\*\* * EBMD\*\* * Epithelial, Bowman's & stromal dystrophies * Lid margin disease &/or dry eye * Bullous keratopathy * Diabetes **_Presentation_** * Area of epithelial irregularity * Punctate defects * Large area of absent epithelium with ragged edges * Conjunctival injection * More dense near area of abrasion * Lid edema possible * Significant watering * Rarely mild anterior chamber reaction * Pt likely comes in with sunglasses or eyes closed **_Treatment_** * **Acute management** * ****Lubrication * Antibiotics ointment * Cycloplegia * Tropical/oral NSAID * Debridement of loose epithelial edges * Bandage CL * Hypertonic saline * **Recurrent/maintenance** * ****Tropical ointment or gel prior to sleep * **Others** * ****Autologous serum * Doxycycline * **Surgical** * ****Anterior stromal micropuncture * Debridement & super-K * PTK

Answer 48

* **Topical steroids** * Mild to moderate disciform or diffuse endotheliitis * **Oral steroids** * Severe disciform or diffuse endotheliitis * All cases of linear endotheliitis * **Oral antivirals** * ****Select cases of disciform or diffuse endotheliitis * All cases of linear endotheliitis

Answer 49

* Dense, yellow-white opacity that may fan out with feathery edges from blood vessels * Deposit consist of cholesterol, fats & phospholipids * Multicolored crystals may be seen at the edge of opacity * **Primary** * Rare, spontaneous development * Not associated with vascularization * No previous trauma * Serum lipids in normal range * Lipid deposition central or peripheral * Lesion consists of cholesterol, triglycerides, & phospholipids * Theorized that may be due to increased vascular permeability of limbal vessels * Women \> Men * **Secondary** * ****More common * Develops rapidly in an area with long-standing vascularization * Grey to yellow-white lesion * **Variable appearance to lesions** * Sea-fan shaped with feathery edges (post-inflammatory) * Dense discoid (active inflammation) * Regression possible with normalization of lipids or decrease of inflammation * **Secondary Disease Associations** * ****Trauma * Ulceration * Hydrops * Interstitial keratitis * HZO * **Complication** * ****Cosmesis * Decreased vision * ****May be rapid onset * **Treatment** * ****Argon laser to feeder vessels * Needle point cautery to feeder vessels * PK - may recur in graft

Answer 50

* AR & AD * Congenital to 1-2 years * Saudia Arabia & India * Bilateral, symmetric * **Noninflammatory corneal clouding** * Extends to limbus without clear zones * No other anterior segment anomalies * Dx of exclusion * **Sx** * Blurred vision * Photophobia * Tearing * Nystagmus - in AR cases * **Signs** * Level of clouding variable * Mild haze to dense clouding * Increased corneal thickness & thickening of Descemet's * **Treatment** - PK

Answer 51

* Recurrent corneal erosion * Filamentary keratitis * Thygeson's superficial punctate keratitis * Neurotrophic keratitis * Graft vs Host Disease (GVHD)

Answer 52

* Laser-Assisted in Situ keratomileusis * NOT LASIX (furosemide) = diuretic used in HTN * Approved for myopic, hyperopic, astigmatism correction * **Procedures** * Flap created * Laser ablation of stromal tissue * Flap returned to position * **Benefits** * Wide range of corrections * Fast recovery period * **Complications** * Incomplete or excessive correction * Flap dislocation * DLK * Photophobia * Glare/haloes * Transient increased IOP * Epithelial ingrowths * Corneal ectasia * Dryness * Regression

Answer 53

* Bilateral, central, grey-white opacification in anterior or posterior cornea * Mosaic or cracked ice pattern * **Anterior form** = senile change or associated with ocular trauma/inflammatory conditions * **Posterior form** = solely senile change generally not visually significant * Tx = none

Answer 54

* Uncommon, usually bilateral * Asymmetric * Idiopathic keratopathy * Viral & immunologic mechanisms speculated * Most commonly affects young adults, but can occur at any age * Female\>men - slight **_Characteristics_** * Coarse punctate epithelial keratitis * Often occur in central cornea * Little or no hyperemia of the bulbar or palpebral conjunctiva * Episodes of exacerbations & remissions * Episode can last 1-2 months * Remissions ~6 weeks **_Features_** * Chronic, bilateral punctate epithelial keratitis * Long duration with remission & exacerbations * Healing without scars * Lack of response to systemic or topical antibiotics sulfonamides or to the removal of the corneal epithelium * Striking symptomatic response to topical steroids **_Symptoms_** * Recurrent attacks * FBS * Photophobia * Blurred vision * Watering * Minimal decrease VA **_Signs_** * Oval to round grouped punctate intraepithelial deposits * Numerous, discrete, granular, white/grey opacities * Slightly elevated * May have stellate appearance * Often in/near visual axis * No staining during inactive phase * Staining with NaFL/Rose Bengal during active phase * Mild epithelial/subepithelial edema or haze * No infiltration * White eye **_Treatment_** * Lubrication in mild cases * Steroids with gradual tapering * Restasis * CLs - if steroids contraindicated or in addition * PTK

Answer 55

* Forms at base of keratoconus, may progress to full ring * Ferritin deposits in cytoplasm of corneal epithelial cells & in widened epithelial intercellular space

Answer 56

* Conjunctivitis * Keratitis * Iridocyclitis * Retinal involvement

Answer 57

* AKA: Avellino Dystrophy * AD inheritance * TGFBI gene mutation * **Combined granular-lattice corneal dystrophy** * Early diseases has granular appearance & develops lattice lines later * Presents in 2nd decade * **Characteristics** * ****Anterior stromal discrete white-grey granular deposits * Become larger & coalesce with age * Mid to posterior stromal lattice lesions * Move more centrally with age * Anterior stromal haze * **Symptoms** * ****FBS * Pain * Photophobia * **Treatment** * ****Lubrication/BCL for epi erosions * PK

Answer 58

* Reactivation of live virus * **Epithelial dendrite** * Most common presentation in herpes simplex keratitis * Linear, branching ulcerated lesion with terminal end bulbs * Ulcerations = represent areas of epithelial breakdown due to cytopathic effects of herpes simplex virus * Terminal end bulbs * Intact, virally-infected epithelium * Lead edge of the dendrite * Stain with NaFL & Rose Bengal * **Symptoms** * Tearing * Photophobia * Pain * Blurred vision * If cenral lesions present * Decreased corneal sensation * Intense ciliary injection * \*\*Most painful at first manifestation * **Signs** * ****Corneal vesicles * Ulcer develop within 24 hrs * Dendritic ulcers * Linear, branching ulcerated lesion with terminal end bulbs * Most common presentation of HSV keratitis * Stains w/ NaFL along length of lesion & Rose Bengal at base of lesion * Ulcerations * Represent areas of epithelial breakdown due to cytopathic effects of herpes simplex virus * Terminal end bulbs * Intact, virally-infected epithelium * Leading edge of the dendrite * ****Geographic ulcers * Enlarged, non-linear ulcer with scalloped borders * Associated with longer duration of sx & longer healing time * Marginal ulcer * Ulceration near limbus * Stromal infiltrate directly under ulcer * Adjacent limbal injection uncommon

Answer 59

* **Goals** * Determine appropriate treatment of ocular involvement using topical steroids or oral antivirals * **Outcomes** * Oral antiviral prophylaxis reduces epithelial & or stromal keratitis * Use of topical steroids is of benefit of stromal keratitis * Use of oral acyclovir may be of help in iridocyclitis * Prophylactic oral acyclovir helps prevent recurrences of herpetic keratitis, particularly stromal with a history of recurrence (herpes gift of giving)

Answer 60

* Formed in inferior 1/3 of cornea in band zone where the lids meet * Iron deposition in cytoplasm of epithelial cells * Normal aging process * 5th-6th * Association with chronic DES

Answer 61

* **Antiviral ointment q2hr until total epithelial helaing then q4hr x 7 days** * Lesion generally heal in 3-7 days * **Oral antiviral optional** * Acyclovir 400mg 5x/day * Valacyclovir 500mg TID * Famciclovir 250mg TID * **Cycloplegic** for comfort (decrease photophobia & pain) * **Frequent artificial tears** * **AVOID STEROIDS** \*\*\*\* (Can cause geographic keratitis, contraindicated in epithelial keratitis) * **Initial follow-up 24 hours, then 4-5 days**

Answer 62

* **Management** * **** Varies based on severity of disease & risk of progression * More aggressive treatment in younger pt * Tailored to the individual * Depends on degree of visual impairment & likelihood of progression * Avoid eye rubbing * No corneal refractive surgeries * Vision correction * Corneal cross-linking (removing epithelium layer off eye) * Surgical procedures * Intacts * Penetrating keratoplasty * **Treatment** * ****Spectacle correction * Good for early disease * Contact lens correction * RGP Scleral or mini-scleral * Hybrid designs * Specialty soft lenses * Piggyback lenses * Surgical options * PK * full thickness transplant * Highly successful, but last resort * Intacs * PMMA rings inserted into stroma * Goal is central flattening to improve vision * DOES NOT halt progression * Corneal cross linking * FDA approved april 2016 * Increases corneal rigidity to halt progression of disease * **Follow up** * ****Variable depending on status of disease & tx protocal used * **Generally** * ****young pt: see every 4-6 mo * 20-30s: see every 6-12 months * 40+: annual exams usually sufficient

Answer 63

* Immune response to viral antigen * **Features** * ****Stromal & epithelial edema without infiltrate * Keratic precippitates * Iritis * **Types** * ****Disciform * Diffuse * Linear

Answer 64

* Oral antiviral * Oral antiviral * Topical steroid * Oral in severe cases * Cyclopegic comfort * IOP management

Answer 65

* **Small ulcer away from visual axis** * Treat with broad spectrum commercial antibiotic * May not need initial culture * **Large ulcer on visual axis** * Treat with broad spectrum fortified antibiotic * Culture immediately * Must follow pt carefully * **Medical-legal standpoint** * Standard of care in community is usually ok, but universal precautions better

Answer 66

* AD * TGFB1 gne mutation * Considered a variant of Reis-Bucklers * Born with normal cornea * Develops in 1st & 2nd decades * VA retained later than Reis-Bucklers * **Presentation** **** * ****Corneal opacification * Severe recurrent erosions * Reticular corneal scarring * Honeycomb changes in Bowman's layer * Normal corneal sensation * Smooth epithelial surface * **Symptoms** * ****Pain, photophobia, from corneal erosion * Decreased vision * VA retained later in life compared to CBD I * **Treatment** * Superficial debridement * PTK * PK *

Answer 67

* Area of localized thinning located adjacent to a paralimbal elevation * **Cause** * Age-related change * Local dehydration of the cornea * **Short-lived - usually last 24-48 hrs** * **Treatment** * Lubrication (tears or ointments) * Pressure patch

Answer 68

* **Forme fruste** * Early or incomplete * Disease barely detectable & often missed * **Modest keratoconus** * ****Generally begin to have vision difficulties in softs CLs or spectacles * **Advanced keratoconus** * ****obvious clinical signs * Poor vision with spectacle correction * **Severe keratoconus** * Significant clinical signs * Consideration of surgical therapies * **Acute keratoconus/corneal hydrops** * ****Only occurs with severe diseases * Rupture in descemet's membrane leads to severe stromal swelling * Must be manged clinically before surgery considered

Answer 69

* Forms in front of filtering bleb * Iron deposited in cytoplasm of basal epithelial cells * Only forms in elevated bleb

Answer 70

* Descemet's warts * Excresence of descemet's membrane in peripheral cornea * Localized thickening occurring in peripheral cornea * Histologically identical to guttata * DO NOT signify cornea disease * One of the most common age-related corneal changes

Answer 71

* X-linked recessive disorder * Males = full expression * Females = carriers, can exhibit disease characteristics * Multisystemic disorder that ultimately results in irreversible, potentially life-threatening disease of kidney, heart & brain * Deficiency of a-galactosidase A * Lysosomal storage disorder * **Disease characteristics** * ****Angiokeratomas * Febrile crises with peripheral extremity pain * Renal failure * CVD * Neurologic changes * Symptoms generally appear in childhood, but go unrecognized until adulthood * damage already ocurred * Corneal changes are earliest & most consistent ocular abnormality * Affected males & females carriers * **Systemic** * Progressive &/or unexplained kidney disease * Premature cardiac disease * Premature stroke * Burning pain in hands/feet * Hypohydrosis/Anhydrosis * Angiokeratomas * **Ocular** * ****Corneal verticillata * Posterior subcapsular cataracts * Whitish spoke-like deposits of granular material * Aneurysmal dilation of venules on bulbar conjunctiva * Mild to marked tortuosity & angulation of retinal vessels

Answer 72

* Albinism * Congenital rubella * Crouzon syndrome * Down syndrome * Ehlers-Danlos syndrome * Marfan syndrome * Neurfibromatosis * Osteogenesis imperfecta * Retinitis pigmentosa * \*\* DM has decrease risk of KCN (DM x II has increase risk of KCN)

Answer 73

* Bacterial keratitis * Viral keratitis * Herpes simplex keratitis * Herpes zoster keratitis * Less common viral infection * Fungal keratitis * Parasitic corneal infection * Acanthomoeba

Answer 74

* One of the most ubiquitous organisms in the environment, rarely causes infection * Infections serious & vision threatening * Increased risk: CL use * 80% cases associated with CL use * Using tap water to clean CLs or CL case * Swimming with CLs in, esp in lakes & rivers * Poor CL hygiene * Any age of onset * No sex predilection * Usually Unilateral **_Acanthomoeba keratitis_** * Severe, incapaciting pain * Ring infiltrate * Decreased VA * Radial keratoneuritis * Photophobia * Limbitis * Scleritis * Uveitis * Eyelid edema * Dacryoadenitis (inflammation of lacrimal glands) **_Radial keratoneuritis_** * Inflammatory response of the corneal nerves * Infiltrate along corneal nerves * Clinical appearance * Thickened corneal nerves with ragged borders * Located in the anterior or mid-stroma * Distributed in a linear radial pattern * Occurs early in acanthamoeba corneal infection

Answer 75

**Highly vascularized** and contains **pluripotent stem cells**

Answer 76

* Fabry disease * Drug induced * Chloroquine * Amiodarone * Tamoxifen

Answer 77

**_Complications_** * Exposure keratitis * Neurotrophic keratitis * Motor nerve involvement * **Post-herpetic neuralgia** * 7% all zoster pt * Chronic pain, variable duration * Approximately half of pt describe their pain as "horrible" or excruciating", ranging in duration from a few mins to constant, on a daily or almost daily bases * There have been reports of suicide in elderly pt because of the unbearable pain **_Maangement_** * **Oral antiviral for 7-10 days** * ****Acyclovir 800mg 5x/day x 10 days * Valacyclovir 100mg TID x 7 days * Famciclovir 500mg TID x 7 days * Decreases incidence of ocular involvement from 70% to 40% * Most effective when start within **72 hours** onset * **Topical antiviral** * **Steroids** * Decreased severity **_Prevention_** * **Varicella vaccine** * Children * Introduce in 1995 * 2 doses - between 12-15 months & between 4-6yrs * **Shingles vaccine** * Adults * Introduced in 2006 * CDC recommends in adults _\>_60yo (approved for pt over 50) * Protections last ~yrs * Reduces risk of development of shingles by 51% * Reduces risk of post herpetic neuralgia by 67%

Answer 78

* Meesmann's dystrophy * Epithelial basement membrane dystrophy (EBMD)

Answer 79

* **Uknown inheritance** * AD supsected * Bilateral, symmetric * Non-progressive * **Cloud central polygonal or rounded stromal opacities** * Occur in central 1/3 of cornea * Deep stromal layers * Develops in 1st decade * Symptoms - Mostly asymptomatic * Treatment - None

Answer 80

Herpes simplex, Herpes zoster, Less common

Answer 81

* Sx similar to other forms of endothelitis * MOST SEVERE presentation & hardest to get them undercontrol * **Presentation** * ****Line of KPs that progress centrally from the limbus * May be sectoral or circumferential * Peripheral stromal & epithelial edema * **Tx difficult**

Answer 82

* **Heavly innervated & sensitive tissue** * Density of nerve endings about 300-400x greater in cornea than in skin * **Derived from ciliary nerves** * Penetrate cornea in deep peripheral stroma radially and move anteriorly * Lose myelination shortly after entering cornea * Penetrate Bowman's layer * Terminate in wing cells of corneal epithelium * **Sensation helps maintain functional integrity of the cornea** * Reflex tearing * Blinking * **Innervation** * ****Enlarged, prominent corneal nerves

Answer 83

* **Unknown Inheritance** * AD, sporadic, age-related theorized * Bilateral, symmeric * **Older adults** * _\>_30yo * Focal, fine gray opacities in deep stroma * Some lesions larger * Variable shape - snowflake * **Symptoms** * ****Asymptomatic - VA not affected * **Treatment** * ****None

Answer 84

**_Epithelium_** * Surface layer * 55um * Barrier function: block debris, bacteria & foreign substances * Constantly regnerating & sloughed **_Bowman's Layer_** * Basement membrane * 5um * Prevents forward corneal swelling **_Stroma_** * Majority of cornea * 485um * Strength elasticity **_Dua's Layer_** * newly discovered * 10-15um **_Descemet's membrane_** * basement membrane * 10um * endothelial cell health **_Endothelium_** * innermost layer * 5um * Barrier pump maintaining proper hydration of cornea * single cell layer thickness

Answer 85

* AKA: Schnyder's crystalline dystrophy, central stromal crystalline dystrophy * AD inheritance * **Rare** * \<100 case reported * Large cohort from central MA * Presents 1st decade * **Mutation in UBIAD1 gene** * Leads to improper metabolism of corneal keratocytes and deposition of crystalline cholesterol & phospholipids in the stroma * Strong association with hypercholesterolemia * **Ring-shaped accumulation of fine needle shaped polychromatic crystal deposits** * Throughout entire stroma * **Symptoms** * ****Vision loss in middle age * Decreased corneal sensation possible * **Treatment** * ****PTK - ablate crystals * PK - deeper involvement

Answer 86

* Rare * Bulging, opaque cornea lined with uveal tissue that protrudes beyond normal plane of lids * Unilateral or bilateral * Variable thinning of cornea * Deep, disorganized anterior chamber * Lens may be adherent to cornea * **Cause** * ****Abnormal migration of neural crest cells into developing cornea * Abnormal differentiation of mesodermal cells * Intrauterine keratitis * Bilateral anterior staphyloma * B-scan showing iris adherent to cornea * T₂MRI showing enlarged globes & lens displaced into vitreous cavity * **Complication** * ****Blind eye * High risk of glaucoma * **Treatment** * ****Penetrating keratoplasty * Graft failure common due to size * Boston K-pro * Glaucoma filtering surgery * Enucleation

Answer 87

* Acute infectious exanthema (skin rash) with vesicular eruptions of the skin * Acompanied by * Fever, sore throat, myalgia, anorexia, HA * Ocular manifestations possible * Mild conjunctivitis & episcleritis * Less commonly: micro-dendritic keratitis, nummular keratitis, disciform keratitis, mucous plaque keratitis, sclerokeratitis & iritis * Infection in childhood generally self-limiting * Infection in neonates, adults or elderly generally severe * Can lead to pneumonia or encephalitis * Routine vaccination now common

Answer 88

* corneal opacity or alteration which is most often bilateral & progressive, occurs after birth, & is not inflammatory * Characterized by layer affected * Epithelial * Bowman's layer * Stromal * Descemet's & Endothelial layer

Answer 89

* Auto-immune inflammatory condition mostly affecting joints * Chronic, progressive disease * Inadequate tx leads to 40-50% mortality at 5 years * Women \> Men * 4th-6th decades * Ocular complications indicate more severe presentation **_Ocular Complications_** * **Keratitis** * **Sclerosis keratitis** * ****Occurs mostly in area adjacent to area of active scleritis * Peripheral cornea thickens & becomes vascularized * May extend circumferentially as disease progresses * **Acute stromal keratitis** * **Limbal guttering** * **Peripheral ulcerative keratitis** * ****Often associated with necrotizing scleritis * Juxtalimbal thinning of stromal tissue with an overlying epithelial defect * Crescent shaped corneal ulceration within 2-5mm from limbus * Thinning may be severe enough to cause perforation * Pts c/o pain, redness, tearing, photophobia, decreased vision **_Treatment_** * **Systemic disease** * Immunomodulators * NSAIDs * **Ocular Treatment** * ****Lubrication * Restasis * Topical steroids * Oral NSAIDs * PK * Amniotic membrane therapy

Answer 90

* **Contraindications** * Fuch's dystrophy * EBMD * Peripheral retinal thinning or tears * Systemic autoimmune disease * Pregnancy or nursing * Severe dry eye or lid margin disease should be addressed & managed prior to surgery * **Evaluation** * ****VA: corrected/uncorrected * Refraction: Including cycloplegic * Keratometry * Pupil testing * Evaluation of pupil size in bright & dim conditions * Pachymetry * Complete dilated eye exam * Dry eye testing * Corneal topography * **Refractive surgery** * ****Determination of power correction & residual stromal tissue * **t = S² x D/3** * t = thickness, S = diameter of correction, D = dioptric power * Average treatment diameter of 6mm = 12um removed * **pachy - (flap - t) = residual** * Residual stromal bed of at least 250um

Answer 91

* Vertical line that forms at advancing edge of pterygium * Color yellow to golden brown * Role in development of pterygia is unknown

Answer 92

* Arcus Senilis * Lipid degeneration * Spheroid degeneration * Climatic proteoglycan stromal keratopathy * Amyloid degeneration * Salzmann's nodular degeneration * Corneal keloids * Limbal girdle of Vogt * Band keratopathy * Iron lines * Coat's White ring * Hassall-Henle bodies * Crocodile shagreen * Senile furrow * Corneal farinata * Dellen

Answer 93

* **Yellow-white crescent-shaped band in interpalpebral limbus** * Nasal \> Temporal * Inferior possible * **Incidence increases with age** * ****_\<_ 20 yo = 0 * 40-60 yo = 55% * _\>_80 yo = 100% * **Types** * **Calcific - lucid interval at limbus** * May contain holes * Central border sharply defined with no extensions * Thought to represent early calcific band keratopathy * **Elastotic** **- no lucid interval** * ****True limbal girdle * Chalky band * No holes * Central irregular linear extension

Answer 94

* AD inheritance * Gene mutation has not been determined * Appears in 1st decade * Slow progression * Bilateral, symmetric * Diffuse, gray-white, sheet-like opacities in the posterior stroma * Central corneal thinning * Flat topography * **Symptoms** * ****Mild vision reduction * \>20/40 * **Treatment** * ****None

Answer 95

* **Group of proteins with starch-like staining characteristics** * Stains w/ congo red * Exhibits birefringence in polarized light * Exhibits dichromism in green light * **_Local or systemic_** * Systemic rarely has ocular manifestations * **_Primary or Secondary_** * **Primary** * **Pleomorphic amyloid degeneration** * Pleomorphic punctate of filamentous opacities in the central cornea * Refractile, polygonal grey-white opacities in central cornea * _\>_50 yo age related change * No visual effect * Not associated with systemic disease * **Conjunctival amyloidosis** * Yellow or pinkish mass located in eyelids or conjunctival fornix * Rarely occurs on bulbar conj * Warrants a referral to r/o life-threatening disease * **Secondary** * ****Occur in association with trauma or prolonged inflammatory conditions * Most common cause of corneal amyloidosis involvement * Associations * Trauma * ROP * Trachoma * Phlyctenular disease * **_Amyloid Degeneration: Systemic Associations_** * **Primary** * Cardiomyopathy * GI disease * Peripheral neuropathies * Facial nerve palsies * **Secondary** * Tuberculosis * Osteomyelitis * Rheumatoid arthritis * Syphilis * Leprosy * **Treatment** * Depends on presentation, patients sx & visual significance * Conjunctival * Conservative therapy * Liquid nitrogen cryotherapy * Monitor/treat IOP * Vitreal * Pars plana vitrectomy (PPV)

Answer 96

* Corneal opacification * Endothelial disease * Ectasic disease

Answer 97

* Rare, development condition * More commonly unilateral * Usually present at birth * Non-progressive * Thinning due to increased curvature of posterior cornea * Guttata occasionally seen within lesion * Pigment occasionally present at edge of lesion * Mild to moderate corneal astigmatism * Decrease vision * Corneal scarring * Associated ocular disease * Amblyopia * **Forms** * ****Generalized * Increased posterior curvature with shorter radius * Normal anterior curvature * Central cornea may be thinned * Cornea clear * Focal * More common * One or more localized, crater-like lesions in central or peripheral posterior cornea * Corneal clouding common * Thinning variable * Associated with ocular or systemic anomalities * **Complications** * ****corneal clouding possible * Rarely affects VA * Myopic astigmastims most frequent * **Treatment** * ****None * Spectacle correction * Penetrating keratoplasty (PK)

Answer 98

* Painful, progressive, idiopathic chronic ulcerative keratitis * Begins peripherally & moves circumferentially & central * No associated systemic disease or scleritis * Men \> Women * 40-70yo, but any age possible * More common unilateral **_Presentation_** * Grey-white crescent shaped infiltrate & ulceration in peripheral cornea * Progressive circumferential & central stromal thinning * Vascularization involving bed of ulcer up to the lead age * Thinning, vascularization & scarring **Types** * **Unilateral Mooren's Ulceration** * ****Painful, progressive ulceration in ELDERLY pts * Associated w/ non-perfusion of superfical plexus of the anterior segment * **Bilateral, aggressive Mooren's ulceration** * ****YOUNG pts * Ulceration that progresses circumferentially, then centrally * Vascular leakage & neovascularization extending to the base of the ulcer * **Bilateral, indolent Mooren's ulceration** * ****Middle-AGED pts * Bilateral, progressive peripheral guttering * Little inflammatory response * No vascular changes or neovascularization **_Symptoms_** * Pain - often out of proportion to inflammation * Photophobia * Injection * Lacrimation * Blurred vision - due to 2^iritis, central corneal involvement or irreg. astigmatism **_Complications_** * Severe irregular astigmatism * Perforation from minor trauma * More common in peripheral ulceration, compared to total ulceration * Infection * Cataract * Glaucoma **_Treatment_** * Tropical steroids - hourly * Prophylactic antibiotic Restasis - takes weeks to become effective * Restasis - takes weeks to become effective * Supportive therapy * Conjunctival resection * Systemic immunosuppression * Doxycycline * Lamellar/penetrating keratoplasty

Answer 99

* **Periocular** * ****Viscular rash on upper lid, forehead & scalp of affected side * Hutchinson sign * **Lids** * ****Ptosis * Blepharitis * Edema * Trichiasis, madarosis, lash loss * **Conjunctiva** * ****Chemosis * Mucopurulent conjunctivitis * Scleritis or episcleritis * **Cornea** * ****PEK * Infiltrates * Pseudodendrites * Nummular keratitis * **Uvea** * ****Chronic non-granulomatous uveitis * Most common presentation\*\*\*\*\*\* * Often with elevated IOP * **Other** * ****Retinitis * Acute retinal necrosis * Choroiditis

Answer 100

* May occur with ocular involvement or as only sign * Clinical manifestation * Often very mild cell/flare with grossly elevated IOP * IOP responds well to tx with B-blocker * Inflammatory vs infectious * PGA contraindicated

Answer 101

* Keratoconus * Pellucid marginal degeneration * Keratoglobus * Posterior keratoconus * Congenital anterior staphyloma

Answer 102

* Penetrating keratoplasty * Corneal transplant * Highly successful surgery * \>90% success of restoring vision

Answer 103

* AKA: corneal whorls * Whorl-like pattern of powdery, white, yellow or brown corneal epithelial depositis * Form in a vortex pattern in inferocentral cornea & swirls outward sparing the limbus * Cause * Amiodarone * Chloroquine * Tamoxifen * Fabry's disease

Answer 104

* **Varies by organism** **Similar sx to bacterial uclers** * Pain * Initially FBS x several days that worsens to increasing pain * Photophobia * Decreased VA * Redness * Lid swelling * Discharge * Pt report of "white spot" on eye **Sign** * ****Feathery, poory defined borders of infiltrate\*\*\* * Unifocal or multifocal infiltrate * Rough looking surface texture * Ulcer may be elevated & exhibit branching lines * White PMN ring often present * Possible neovascularization * Superficial epithelium may heal while organism continues to invade deeper into tissue * Hypopyon * Keratitis 1-3 weeks after trauma * \*\*Definitive diagnosis of bacterial vs fungal keratitis cannot be made by clinical appearance alone **_Management_** * Culture! * Sabouraud's agar without cyclohexamide * Thioglycolate broth * PCR * Confocal microscopy * Therapy usually not begun until microbial evidence * Usually lasts 6 weeks * Daily mechanical debridement because antifungals have poor corneal penetration * **Filamentous fungi** * Natamycin * only commercially available antifungal * Q1hr around the clock * Yeast * Q30 mins x 1st 24 hrs * Q1hr x 2nd 24 hrs * Slow taper according to clinical response * Oral antifungals * Usually maintained x 12 weeks * NO STEROIDS * Subconjunctival injection for severe keratitis or keratoscleritis * Considered hospitalization

Answer 105

* **Post-op meds** * ****Topical antibiotics - generally given for 1 wk * Topical steroids - tapered * Topical NSAID possible * depends on surgeon & procedure varaible duration * PFATs * Used frequently to improve ocular surface comfort & healing * Other * Eyeshield at bedtime * Avoidance of water in eye

Answer 106

* Goal: describe the clinical course of KCN & identify risk & protective factors that influence severity & progression * Weak association with CT disease than originally thought * 50 % of pt reported eye rubbing or atrophy * Presentation ocurring earlier in life at higher risk of progression * Progression slows by the 4th decade * Decrease in high & low contrast acuity * Acuity **\<20/40** report decreased quality of life scores

Answer 107

* Results from impaired corneal innervation & decreased tear production * **Presentation** * ****Corneal irregularity * Lack of normal corneal luster * Oval shaped epithelial defect with smooth borders * Leads to stormal ulceration * **Complications** * ****Corneal neovascularization * Necrosis * Perforation * Secondary Infection

Answer 108

* **Progressive thinning and protrusion of cornea leading to conical shape** * Cone apex usually just below visual axis * Bilateral, often asymmetric * **Onset around puberty** * Progression x 10-20 yrs until gradually stabilizes * Rate of progression variable * Generally stabilizes by 40s * No gender predilation * Affects all races - some to higher degree * Inheritance unknown * Incidence ~1:2000 * **Symptoms** * Progressive visual blurring * Snellen acuity initially preserved * Contrast sensitivity descreases earlier * Distortion * Photophobia * Glare * Monocular diplopia * Ocular irritation * **Keratoconus Signs** * High, irregular astigmatism * Scissor reflex with retinoscopy * Munson's sign (V-shaped indentation observed in the lower lid) * Fleischer ring (Iron deposition) * Corneal thinning * 1/2 to 1/5 normal thickness * Prominent corneal nerves * Vogt Striae in posterior stroma * Corneal scars at apex - ruptures in Bowmans layer * Corneal hydrops (caused by acute disruption of descemet's membrane in setting of corneal ectasia, abnormal accumulation of fluid ina . body tissue or cavity)

Answer 109

* Occurs in ~20% of chronic recurrent HSV * Inflammation due to retained viral antigen in stromal tissue * Presentation * Stromal inflammation * Intact epithelium * Stromal infiltration * Immune ring * Stromal neovascularization

Answer 110

* Filamentous * Ubiquitous fungus found in nature * Commonly isolated from soil, plant debris, & indoor air environment

Answer 111

* **Management** * **Goal**: decrease toxic corneal exposure, improve lubrication * D/C all unnecessary topical medications * Esp. antivirals * Frequent PFATs * Prophylactic antibiotic therapy (Prevent disease) * Soft steroid may be necessary (Weak steroids) * Corneal debridement in severe cases * BCL * Tarsorrhaphy * Tape, Botox, surgical

Answer 112

* Peripheral inflammatory condition * Rare, etiology unkown * Men 3:1 * 20-40 yo most common * any age possible * Bilateral & symmetric * **Non-inflammatory peripheral thinning with pannus** * Grey/white band 1-2mm width * Starts supernasally & spreads circumferentially * Fine punctate opacities in anterior stroma * Rarely involves inferior limbus * Epithelium remains intact * Gutter forms between opacity & limbus * Slowly progressive stromal thinning over many years * Extends circumferentially or centrally * Rarely causes perforation * Easy perforation with mild trauma * Lipid deposits at leading (central) edge of pannus * **Types** * **Quiescent** * ****More common * Older pt * Painless lesions * **Inflammatory** * ****Less common * Younger pts * Recurrent episodes of inflammation, episcleritis * **Presentation** * ****Leading edge of lipid * Steep central edge * Sloping peripheral edge * Intact epithelium * Superficial vascularization * High against the rule of oblique astigmatism * Peripheral thinning from collagen degeneration * May develop aqueous pockets * **Symptoms** * ****Painless * Blurred vision due to astigmatic changes * Rare perforations * **Treatment** * ****CL or spectacle correction * Keratoplasty if risk of perforation

Answer 113

* Antiarrhythmic drug * Used in tx of ventricular tachycardia or ventricular fibrillation * Ocular side effects * Blurred vision/Halos * Corneal microdeposits * 69-100% * Lenticular changes * Madarosis * Retinal/optic nerve complications

Answer 114

* Bilateral * Peripheral cornea ectatic disorder * Characterized by a band of thinning 1-2mm typically in inferior cornea * Inferior thinning at 4 & 8 o clock * Max corneal protrusion usually just superior to area of thinning * Protruding cornea is of NORMAL thickness * No gender or racial predilection * Present in 2nd-5th decade * 2nd most common ectatic disorder * **Signs** * ****Kissing doves, lobster claw * Irregular astigmatism * No iron rings * No Striae * Scarring at level of Descemet's * Hydrops possible * **Treatment** * ****Same as KCN

Answer 115

* Ocular trauma involving foreign body entering the eye * Males 3:1 * Younger 15-35 yo * Size/damage depends on nature of injury **Signs of open globe** * Seidel sign * Prolapsed uveal tissue * Low IOP * Decreased vision * Shallow or flat anterior chamber * Hyphema * Iris deformities * Dislocated lens * Retinal detachment **_Complications_** * Infection * Endophthalmitis * Panophthalmitis * Hypotyony * Hypotony maculopathy * Secondary glaucoma * Damage to angle structures * Corneal scarring * Retinal complications **_Symptoms_** * Pain * Lacrimation * Injection * Photophobia * Decreased vision **_Signs_** * Entrance wound * Corneal edema * Seidel leak * Hyphema * Moderate to severe anterior chamber reaction * Prolapsed uveal tissue * Peaked pupil * Irodialysis **_Treatment_** * ****Bandage CL * Sutures * Cataract extraction * Retinal repair * Antibiotic * Cycloplegia

Answer 116

* Photorefractive keratectomy * Approved for * **Procedure** * Epithelium removed w/ alcohol * Laser ablation of stromal tissue * BCL inserted to allow for reepithelialization * **Pros** * No flap complications * Tx of thinner cornea possible * **Cons** * Longer healing time * Significantly more discomfort

Answer 117

* Fungi are opportunistic invaders which rarely infect healthy cornea * **Predisposing factors** * Trauma, esp associated with vegetative material * Ocular surface disease * Systemic disease/immunosuppression * Improper use of corticosteroids * CL wear * **Most common species that cause keratitis & ulceration** * Fusarium: south * Aspergillus: north * Candida: north * **Incidence varies by** * Geographic location: tropical latitudes * Age: 30-40s * Gender: males\>females

Answer 118

* **Closed injury:** Corneoscleral wall of globe is inteact * Blunt trauma * **Open injury:** full-thickness wound of corneoscleral envelope * **Contusion:** closed injury resulting from blunt trauma * Damage may occur distant to impact site * **Rupture:** Full-thickness wound caused by blunt trauma * Globe give way at weakest point, may be away from injury site * **Laceration:** Full-thickness defect in eye wall produced by a tearing injury * Direct impact * **Lamellar laceration**: partial thickness laceration * **Incised injury:** caused by sharp object * Glass, knife * **Penetarting injury:** single, full-thickness wound WITHOUT an exit wound * Often from sharp object * **Perforation:** 2 full-thickness wounds- one entry, one exit * Projectile

Answer 119

* Fusarium * Aspergillus * Candida

Answer 120

* AKA: anterior basement membrane dystrophy, map-dot fingerprint dystrophy, Cogan dystrophy * **Most common** anterior corneal dystrophy * Affects 2% of population * Variable onset * Microcyst formation in the epithelium with alterations in basement membrane * Defect in formation & maintenance of epithelial basement membrane adhesion complex * Leads to thickened, multilaminar or redundant, & misdirected into epithelium * **Symptoms** * ****Spontaneous corneal erosion * Blurred vision * Variable * Dry eye * Photophobia * Slowed healing time after surgery * **Treatment** * ****None - most pts asymptomatic * Bandage CL * Lubrication * Punctal occlusion * Hypertonic solution * RGP/Scleral lenses * **Medical therapy** * ****FreshKote * Steroids * Restasis * Low dose oral doxycycline * **Surgical** * ****PTK * Super-K * \*\* Lasik NOT recommended due to increased risk of epithelial sloughing & other complications

Answer 121

* Most common form of recurrence * 83% * Clinical manifestation * Acute follicular conjunctivitis * Lid lesions possible * Keratitis possible * Conjunctival dendritic ulcer possible

Answer 122

* Innumberable centrally located tiny, dust-like grey dots & flecks in the deep stroma * Flour-dust appearance * Usually bilateral * No decrease in VA

Answer 123

* Phlyctenulosis * Non-infectious inflammatory nodule occuring on conjunctiva or cornea * Type IV hypersensitivit reaction to bacterial antigen * Staphylococcus * Tuberculosis * Requires sensitization of cornea to antigen * Repeated exposure to antigen **_Symptoms_** * FBS * Tearing * Mild itching * +/- photophobia **_Presentation_** * **Conjunctiva** * Pink, fleshy nodule, 1-2mm dia. * Mostly occur near limbus * **Cornea** * ****Small white nodule with adjacent conj. Injection * Often ulcerate forming a marginal ulcer → stromal scarring * Pannus may develop (abnormal layer of fibrovascular tissue) * Subsequent phlyctenules occur at edge of pannus * Move centrally across the cornea **_Treatment_** * **Short term management** * Steroids * Topical antibiotics if corneal ulceration * Cycloplegic agent * **Long term management** * Eyelid hygiene - address cause * Oral tetracyclines * PK in severe scarring