What is represented in this picture?
Crocodile Shagreen with plaques of fibrous tissue
Why does arcus occur?
There are lipid/cholesterol deposits in Bowman’s
What does the lucid interval in arcus mean?
The superficial lipid deposition ends at Bowman’s layer so it won’t go into the limbus.
What is Type I Limble Girdle of Vogt?
Lucid interval where deposition ends at Bowman’s, looks like swiss cheese holes with sharp edges centrally.
Early form of band keratopathy.
What is type II Limble Girdle of Vogt?
True Vogt’s
Goes to limbus because of elastoid degeneration of subepithelial collagen
Extensions centrally
Vogt I
Vogt I and Calcified Scleral Plaque
What is Farinata?
White dust like particles pre-Descemet’s with aging
What is Furrow Degeneration?
Non inflammatory mild thinning with occasional vessel extensions
What disease is in this picture?
Terrien’s Marginal Deneration
How does Terrien’s Marginal Degeneration present?
Asymtomatic
Bilateral
Epithelium Intact
Marginal opacification with superficial vascularization
Young adult to elderly
How does the peripheral thinning of the cornea progress in Terrien’s Marginal Degeneration and what other complications occur with it?
Starts in the peripheral corneal stroma superior-nasal then goes circumferential
Astigmatism and rarely perforation
What percent of terrien’s patients are male?
75%
At what age does Terrien’s Marginal Degeneration onset?
Young adult to elderly
What is a differential diagnosis to Terrien’s Marginal Degeneration?
Mooren’s Ulcer
What is shown in these photo’s of Terrien’s Marginal Degeneration?
Vascularizatio and a Pseduo-pterygium
What is this disease?
Mooren’s Ulcer
What are the signs and symptoms of Mooren’s ulcer?
Painful
Red Eye
Photophobia
Typically progressive near the limbus
Thinning
Stromal melting
Potential perforation
What is Mooren’s Type I?
Typically older patients, unilateral and responds well to treatment
What is Mooren’s type II?
Younger (indian/african) 20-30 yr old, bilateral and poor response to treatment.
Mooren’s Ulcer
How do you differentiate between Terrien’s and Mooren’s Ulcer?
Terrien’s Does Not/Is Rarely
Stain w/ NaFl
Painful/Inflammatory
Aggressive
Moves Centrally
Perforates
What must you do if you suspect vasculitis or collagen vascular disease?
You must do a mandatory referral to rheumatology for a systemic work up.
What is the course of treatment for Mooren’s Ulcer?
Nothing well established and mostly supportive
Conjunctival resection, radiation
Bandage CL
Topical steroid, cyclosporine or systemic immunosuppression
If perforation: treat with cyanoacrylate or lamellar keratoplasty
What autoimmune diseases is Peripheral Ulcerative Keratitis associated with?
Rheumatoid Arthritis
Wegener’s Granulomatosis
et al
What is Limbal Crescent Ulceration and what disease is it associated with?
It is associated with Peripheral Ulcerative Keratitis (PUK)
It includes an epithelial defect, thinning
Progresses circumferentially & maybe centrally, with potential extensions into sclera
Risk of progressing rapidly to perforation
What disease is Peripheral Ulcerative Keratitis usually associated with?
Episcleritis or Scleritis
What is the main treatment for Peripheral Ulcerative Keratitis?
Rheumatology referral to confirm for systemic immunosuppression
What can you not treat Peripheral Ulcerative Keratitis with?
Topical Steroids
How does polymorphic amyloid degeneration present?
Deep stroma, bilateral appears similar to Lattice Dystrophy
Spheroidal Degeneration
Salzmann’s Nodular Degeneration
Salzmann’s Nodular Degeneration
How does Salzmann’s normally present?
> females
> 50 yo
May be inflammatory
Dry Eye Symptoms
Decreased VA if central
Irregular astigmatism
What are the Salzmann’s nodules made of?
Hyaline nodules that replace Bowman’s that are elevated, and bluish white
What is Salzmann’s Nodular Degeneration often associated with?
Chronic ocular surface disease and/or previous inflammation, especially viral
There is rarely no clear history of preceding eye disease
How do you manage Salzmann’s Nodular Degeneration?
Lubricants, steroid if inflammed, bandage contact lenses
Severe Cases: nodules can be removed by corneal specialist, penetrating keratoplasty
Band Keratopathy
What is band keratopathy?
Interpalpebral Ca++ deposits in Bowman’s with clear zone seperating the limbus
Why does Band Keratopathy have a swiss cheese appearance?
Clear areas and small circular areas where nerve endings perforate the Bowman’s layer are seen within the band.
How to differentiate between Vogts and Band Keratopathy?
Vogt’s II: no lucid interval, no swiss cheese, bilateral, does not spread across central cornea
Vogt’s I: very similar but doesn’t cross centrally
Band Keratopathy
How should you treat and manage Band Keratopathy?
Monitor
Ocular Lubricants for mild cases
Refer for hypercalcemic work up by PCP
Severe Cases: Chelation using 2% EDTA
PTK: Phototherapeutic keratectomy (excimer laser)
What is Phthsis Bulbi?
A degenerative atrophic condition of chronic sick eye that may see band keratopathy involving all layers of the cornea.
How does Keratoconus present?
Bilateral: Forme fruste
After puberty it progresses then stabilizes
Greater in asians
Greater association with Down’s, Ehlers-Danlos, Marfan’s
Oculodigital Sign
Keratoconus
Keratoconus
What kind of pathologies are often associated with Keratoconus?
Irregular epithelium
Breaks in Bowman’s
Fibrosis beneath epithelium
Stromal scarring
Corneal thinning
What kind of test results will make you think Keratoconus? (K values, astimatism, etc.)
Keratometry >47.2
Inferior steepening 1.2D > superior
Skewing of axis of astigmatism > 21 degrees
What is Charleaux’s Sign?
Oil droplet sign upon retroillumination
What sign is this?
Rizutti’s sign (triangle of light on distal iris)
What sign is this?
Munson’s sign
What is in this picture and which one can be reduced with digital pressure?
Vogt Striae and Fleischer Ring
Vogt Striae can be reduced with digital pressure
Fleischer ring under cobalt blue light
Prominent corneal nerves
How to treat keratoconus?
Appropriate optical correction
Speciatly RGP, cleral RPG, hybrid CL Penetrating keratoplasty (20%)
Intacts
Collagen Crosslinking
How do you NOT treat keratoconus?
Refractive surgery
Intacs
Corneal Hydrops
Corneal Hydrops
What are corneal hydrops?
Acute break in Descemet’s
What are the yellow and red arrows pointing at?
Red = break in Descemet’s
Yellow = corneal edema
How does Posterior Keratoconus present?
Posterior curvature increase
Normal anterior surface
Non-inherited
Unilateral
Non-progressive
Females >> male
Keratoglobus
Bilateral
Congenital or Aquired
Diffuse corneal thinning > peripherally
Where does Pellucid Marginal Degeneration most often occur?
Inferior limbus from 4:00 to 8:00
What is a name for how the cornea looks while affected by Pellucid Marginal Degeneration?
“Pot belly” cornea
What kind of topography pattern will be seen with Pellucid Marginal Degeneration?
“kissing dove” topography pattern
Pellucid Marginal Degeneration
Pellucid Marginal Degeneration
Pterygium
Pinguecula
What is this pterygium related feature?
The Pterygium Stocker Line
Hudson-Stahli Line
Iron Lines