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key characteristics of corneal DEGENERATIONS

-peripheral cornea affected more often
-local and systemic diseases associated
-occurs sporadically, can occur in presence of inflammation and neo
-can be unilateral but often bilateral
-progression varies, but can be rapid


list of some age-related corneal degenerations

-Vogt's limbal girdle
-crocodile shagreen
-hassall-henle bodies
-corneal farinata
-polymorphic amyloid degeneration


list of some NON age-related corneal degenerations

-band keratopathy
-terrien marginal degeneration
-spheroidal degeneration
-salzmann nodular degeneration
-pellucid marginal degeneration
-pigmentary iron lines
-coats white ring
-lipid keratopathy
-corneal deposits


what is an Arcus caused by

depositions of lipid in the peripheral corneal stroma


where are lipid deposits first seen in Arcus? (what layers)

near Descemet's membrane and later near Bowman's


what sectoral pattern does the Arcus usually follow? (which area affected first)

(complete ring)


where is the clear zone in an Arcus?

between limbus and lipid deposition


what is "furrow degeneration" in Arcus?

thinning that occurs in clear zone


what are some trends for ages/races/sex affected by Arcus

-100% of men over 80
-women later
-african americans earlier


what if you have a a patient under 40 with arcus

-indication for laboratory testing
-suspect hypercholestereia, lipid abnormalities


what if you have a patient with unilateral arcus?

-eye without arcus is the side where carotid artery disease may be more severe


condition that is a bilateral yellow-white band at the nasal and temporal limbus of the peripheral cornea and incidence increases with age

Vogt's limbal girdle


which type of Vogt's Limbal Girdle:
-well demarcated white band that may have holes
-clear area adjacent to limbus
-early calcific band keratopathy

Type 1


which type of Vogt's Limbal Girdle:
-solid chalky white band without holes or clear zone
-may extend centrally in an irregular linear fashion

Type 2


describe the appearance of the age related Crocodile Shagreen

-cobblestone or crocodile-skin appearance in the anterior or posterior cornea
-polygonal gray to white opacities form and are separated by lucent lines


condition containing sub epithelial calcium deposits in Bowman's layer that is associated with chronic ocular inflammatory disease (such as uveitis, interstitial keratitis, hypercalcemic states, secondary to topical medication use)

Band Keratopathy


what is the appearance and pattern of band keratopathy

-starts as gray-white nasal temporal interpalpebral opacity that advances centrally
-looks like swiss cheese holes in the band


condition that is a slowly progressive peripheral corneal inflammatory and degenerative disorder with overlying superficial vascularization and characterized by ATR astigmatism

Terrien Marginal Degeneration


what is the patient demographic that gets Terrien Marginal Degeneration (age, sex)

-men more affected than women 3:1
-most offen occurs age 20-40


where does Terrien Marginal Degeneration start and what is its appearance

generally starts in the supra nasal peripheral cornea with small white opacities in anterior stroma


rare condition that can occur on the cornea, conj, or both and is from UV exposure, aging, environmental, trauma

spheroidal degeneration


how does spheroidal degeneration begin and what does it look like as it progresses

-begins with interpalpebral small clear droplets under the epithelium at 3/9 o'clock
-spherules enlarge, become gold or brown, progress centrally
-can coalesce into larger droplets and become elevated


what degeneration is characterized by single or multiple white, gray-white, or bluish elevated lesions in the central or peripheral cornea adjacent to an area of corneal scarring, vascularization, edema, or even normal cornea

Salzmann Nodular Degeneration


what patients get Salzmann Nodular Degeneration

-occurs in eyes that have or have had chronic inflammation
-increases with age and higher in women


signs and symptoms of Salzmann Nodular Degeneration

-foreign body sensation
-erosions of the epithelium can occur with notably elevated nodules


corneal thinning and ectatic condition characterized by a crescent shaped band of thinning inferior cornea from 4 to 8 o'clock and high ATR astigmatism

Pellucid Marginal Degeneration


describe the thinning that occurs in Pellucid Marginal Degeneration

-crescent shaped band of thinning inferior cornea from 4 to 8 o'clock
-thinned area 1-2mm wide and clear
-corneal stromal thinning and absence of Bowman's layer in affected area


what is the most common epithelial iron line and where is it located?

Hudson-Stalhi line in the lower one third of the cornea above eyelid margin


what are some key features of corneal DYSTROPHIES

-primary disorders (no systemic involvement)
-bilateral and symmetrical
-early onset, usually by 20s
-involvement of only one layer of the cornea
-central corneal location
-autosomal dominant inheritance (AD)


what are some epithelial, basement membrane, and Bowman's layer dystrophies

-epithelial basement membrane dystrophy (EBMD)
-meesmann epithelial dystrophy
-reis-bucklers dystrophy
-stocker-holt, lisch, grayson-willbrandt
-genetic disease


other names for epithelial basement membrane dystrophy (EBMD)

-map-dot fingerprint
-cogan's microcystic
-anterior basement membrane


signs and symptoms of epithelial basement membrane dystrophy (EBMD)

-age of onset usually 20-40
-about 10% develop painful recurrent epithelial erosions (RCE)
-otherwise asymptomatic or slight blur


why does epithelial basement membrane dystrophy (EBMD) occur?

-abnormal turnover, maturation, and synthesis of the corneal basement membrane
-blocks normal migration of epithelial cells towards the surface


in epithelial basement membrane dystrophy (EBMD), what are the maps and fingerprint lines due to

thickening of the basement membrane


epithelial basement membrane dystrophy (EBMD), what produces the dot appearance

microcysts (trapped cellular debris)


what corneal dystrophy is characterized by a myriad of fine, round, intraepithelial cysts of uniform size and shape, interpalpebral zone

Meesmann's Dystrophy


what is the age of onset and pattern of progression for Meesmann's Dystrophy

-visible by 12 months of age, increase in number throughout life
-asymptomatic until adolescence
-bilateral, symmetric
-minority may experience rupture of corneal micro cysts


what is the dystrophy of Bowman's layer causing thickened epithelium, irregular astigmatic, RCE that occurs in early childhood

Reis-Bucklers Dystrophy


what are some signs and symptoms of Reis-Bucklers Dystrophy

-bilateral, symmetrical
-RCE, photophobia, foreign body sensation, irritation, pain
-anterior stromal haze compromises vision in 2nd and 3rd decades
-honeycomb or fishnet shaped opacities within the central cornea, Bowman's and anterior stroma


what is the most common stromal dystrophy

granular dystrophy


stromal dystrophy from deposition of branching figures containing amyloid and develops in teenage years

lattice dystrophy


signs and symptoms of lattice dystrophy

-thin, centrally located branches associated with sub epithelial opacities and anterior stream haze
-can have painful bilateral RCE
-often requires penetrating keratoplasty in third or fourth decade of life (5% recurrence rate in corneal graft)


stromal dystrophy characterized by grayish white round opacities in the anterior central stroma from hyaline deposition that onsets in the 1st decade

granular dystrophy


signs and symptoms of granular dystrophy

-breadcrumb, snowflake, popcorn looking opacities
-onset in 1st decade but few visual disturbances until 5th decade (after opacities increased in number and size and coalesced)
-photophobia from deposits scattering light
(but RCE episodes are rare)


what stromal dystrophy is autosomal recessive, onsets in first decade, is characterized by progressive visual impairment, and is from MPS accumulation?

macular dystrophy


signs and symptoms of macular dystrophy

-RCE, attacks of severe irritation and photophobia
-diffuse superficial clouding in central cornea (can extend peripheral)
-gray-white opacities with indistinct borders, ground glass haze
-descemet's membrane and endothelium affected (but epithelium spared)


minimum amount of endothelial cells you need

1000-1200 cell/mm^2 (density)


what % of endothelial cell loss can you get with intraocular surgery



what is normal attrition of endothelial cells/year

central cornea loses 100 to 500 cells per year


signs and symptoms of Fuchs

-progressive, guttatae, thickening of Descemet's membrane
-loss of endothelial cell density, stream edema
-blur predominately in the morning
-age of onset 40-60
-women affected more 3:1
-epithelial bull, bullous keratopathy


what genetic testing is a 96% positive predictive value for Fuchs

repeating trinucleotide (TGC in the TCF4 gene)


what are some key features of the rare congenital hereditary endothelial dystrophy (CHED)

bilateral diffuse corneal clouding, hazy to milky
-progression over 1-10 years
-no recurrence in grafted cornea


which type of congenital hereditary endothelial dystrophy (CHED) has:
-onset delayed until first year(s) of life
-photophobia, tearing
-hearing deficient, slowly progressive

(autosomal dominant, more common)


which type of congenital hereditary endothelial dystrophy (CHED) has:
-diagnosed at or shortly after birth (within 1 year)
-nystagmus, ambylopia
-severe edema - corneal thickness 2-3x the normal values

(autosomal recessive, more severe)


what dystrophy is characterized by edematous clouding and secondary sub epithelial band-shaped keratopathy that is slow to non progressive, asymmetric course

posterior polymorphous dystrophy (PPMD)


signs/ symptoms of posterior polymorphous dystrophy (PPMD)

-isolated, confluent or clustered vesicular and blister like lesions as well as "railroad tracks"
-secondary glaucoma secondary to trabecular invasion