cornea lecture

7/28/2019 cornea lecture

http://slidepdf.com/reader/full/cornea-lecture 1/76

Cornea & External Disease

Richard L. Nepomuceno, MD, DPBO

Cornea, External Disease & Refractive Surgery

Fatima Medical Center . St. Lukes Medical Center . Capitol Medical Center

East Avenue Medical Center . Manila Central University

Cardinal Santos Medical Center . Manila Doctors Hospital



R. NEPOMUCENO, MD

Eyelid Disease

1. Meibomian Gland Dysfunction2. Staphylococcal Blepharitis

3. Seborrheic Keratosis

4. Angular Blepharitis

5. Molluscum Contagiosum

6. Hordeolum7. Chalazion

8. Viral Papilloma



R. NEPOMUCENO, MD

Eyelid Disease

9. Seborheic Keratosis

10. Xanthelasma

11. Basal Cell Carcinoma

12. Squamous Cell Carcinoma

13. Capillary Hemangioma14. Allergic Contact Dermatitis



R. NEPOMUCENO, MD

Meibomian Gland Dysfunction

Sebaceous glands of posterior lamella of theeyelids

Abnormal lipidcomposition & secretion Enlargement,

inspissations of orifices Chronic burning, foreign

body sensation, filmyvision, tearing, crusting of the eyelids



R. NEPOMUCENO, MD

Staphylococcal Blepharitis

Infection of lid margin,lash bases, follicles

Burning, FBS, redness,

mattering of lashes Ulceration, fibrin,

collarettes, crusting Can cause: recurrent

hordeola, conjunctivitis,

marginal cornealinfiltrates, punctateepitheliopathy

Chronicity causesthickened & scarred lids



R. NEPOMUCENO, MD

Seborrheic Keratosis

This disorder is oftenassociated with seborrheicdermatitis

Patients complain of

redness, burning, andmattering of the eyelids

Usually bilateral Often associated with

meibomian gland

dysfunction The lashes are covered

with yellow, greasy scales

The scales are translucentand easily removed



R. NEPOMUCENO, MD

Angular Blepharitis

Maceration & crusting of the skin at lateral canthus

Maceration due to

proteolytic enzymes Injection of conjunctival

& epibulbar vessels Caused by:

Staphylococcus,

Moraxella, Herpes,Candida



R. NEPOMUCENO, MD

Hordeolum or “stye”

Local infected abscess of a hair follicle or gland onthe lid margin

External- anterior eyelidmargin, often Gland of Ziess

Internal- meibomiangland



R. NEPOMUCENO, MD

Chalazion

ChronicLipogranuloma of

meibomian gland Forms as a discrete

mass



R. NEPOMUCENO, MD

Xanthelasma

Superficial dermiscontain histiocytesfilled with cholesterolesters

Elevated serumcholesterol orhyperlipidemiasyndrome



R. NEPOMUCENO, MD

Basal Cell Carcinoma

These slow-growingtumors are found in sun-exposed areas

They are the mostcommon eyelidmalignancy

Usually located on thelower eyelid

Edges are raised andpearly, with a centralulceration

Basophilic nests of cells withperipheral palisading



R. NEPOMUCENO, MD

Squamous Cell CA

Rare malignancy of theeyelids

Commonly arises in sun-

exposed areas and mayresemble other lesions of the eyelid, such askeratoacanthoma, basalcell carcinoma, andseborrheic keratosis

The inset shows pearlyraised margins of a smallsquamous cell carcinoma



R. NEPOMUCENO, MD

Capillary Hemangioma

Appear at or soon after birth

Strawberry nevus

Usually involute spontaneously

May cause amblyopia if in visual axis Intralesional steroid injection



R. NEPOMUCENO, MD

Allergic Contact Dermatitis

Environmental orexternally applied

agents Cell mediated type IV

reaction

Neomycin, atropine



R. NEPOMUCENO, MD

Royce Hall, University of California, Los Angeles



R. NEPOMUCENO, MD

Keratoconjuctivitis sicca

Aqueous tear deficiency Acquired disorder mostly

women > or = 40 years

old Dryness, blurring of

vision, or photophobia Worse at the end of day

and with dry windy

weather



R. NEPOMUCENO, MD

Conjunctival Disease

1. Follicular Conjunctival Reaction

2. Papillary Conjunctival Reaction

3. Epidemic Keratoconctivitis

4. Membranous Conjunctivitis

5. Gonococcal Conjunctivitis6. Chlamydial Conjunctivitis



R. NEPOMUCENO, MD

Conjunctival Disease7. Trachoma8. Allergic (Hay Fever) Conjunctivitis

9. Atopic Keratoconjunctivitis

10. Vernal Keratoconjunctivitis11. Giant Papillary Keratoconjunctivitis



R. NEPOMUCENO, MD


12. Superior Limbic Keratoconjunctivitis

13. Stevens-Johnson Syndrome

14. Conjunctival Nevus

15. Adenochrome Deposits

16. Pinguecula17. Pterygium



R. NEPOMUCENO, MD


18. Pyogenic Granuloma

19. Phlyctenulosis

20. Conjunctival Viral Papilloma

21. Conjunctival/Corneal IntraepithelialNeoplasia

22. Conjunctival Lymphoma

23. Primary Acquired Melanosis (PAM)



R. NEPOMUCENO, MD

Follicular Conjunctival Reaction

Follicles = lymphoidgerminal centers

Smooth nodules which

are avascular at theapices sorrounded by finevessels at their bases

Can be a normal variant if found in the lowerconjunctiva withoutinfection



R. NEPOMUCENO, MD

Follicular Conjunctival Reaction

Etiology

Adenoviralconjunctivitis

Infection from primaryherpes simplex virus

Molluscumcontagiosum

Enterovirus Chlamydia

Toxicity frommedications



R. NEPOMUCENO, MD

Papillary Conjunctival Reaction

Non-specific response causedby many agents

Usually seen on the uppertarsal conjunctiva

Fine mosaic pattern of dilatedtelangiectatic blood vessels

Each has a centralfirovascular core that givesrise to a vessel branching out

in a spokelike pattern Cojunctival septae

sorrounding the papillae areanchored by pale tissue whenpapllary hypertrophy occurs



R. NEPOMUCENO, MD

Epidemic Keratoconjunctivitis

(EKC) Syndrome of external ocular

adenovirus infection Serotypes 8, 11, and 19 most

common Acute onset of watery

discharge, photophobia, andmild foreign body sensation

Preauricular lymphadenopathyand mixed papillary-follicular

conjunctivitis May present with

subconjunctival hemorrhage,chemosis, andpseuodomembrane ormembrane formation



R. NEPOMUCENO, MD

Epidemic Keratoconctivitis

Mucopurulent discharge whenmembranous reaction develops

Maximum intensity in 5-7 daysafter onset of symptoms

Keratitis is characterized initiallyby diffuse punctateintraepithelial lesions, followedby fine or coarse punctateepithelial keratitis and finally bysubepithelial infiltrates (SEIs)

SEI develop until after at least 2weeks after the onset of symptoms

SEI results from a host immuneresponse



R. NEPOMUCENO, MD

Membranous Conjunctivitis Conjunctival membrane or

pseudomembrane can occur inassociation with severe viral orbacterial conjunctivitis orfollowing chemical burn, orStevens-Johnson syndrome,ocular cicatricial pemphigoid

Produced when an inflammatorydischarge of fibrin with PMN’sand fibrin coagulates on theconjunctival surface

True membrane incorporates theepithelium an bleeds when

removed Pseudomembrane is more

superficial and can be peeled orscraped away without bleeding

Healing can result in conjunctivalscaring



R. NEPOMUCENO, MD

Bacterial Conjunctivitis -

Gonococcal Neissera gonorrheae Hyperacute purulent

conjunctivitis

Direct contact withinfected genital secretionsor from genital-hand-ocular transmission

GC and meningococci are

the only bacteria causingconjunctivitis withpreauricular LAD andconjunctival membranes



R. NEPOMUCENO, MD

Gonococcal Conjunctivitis Corneal involvement may

consist of diffuseepithelial haze, epithelialdefects, marginal

infiltrates, and peripheralulcerative keratitis thatrapidly progress toperforation

Classic cause of neonatal

conjunctivitis



R. NEPOMUCENO, MD

Gonococcal Conjunctivitis Systemic + topical

antibiotics Ceftriaxone 1 gram IM With corneal perforation-

admitted with IVceftriaxone q 12 x 3 days

Cotreatment forchlamydia



R. NEPOMUCENO, MD

Chlamydial or Inclusion

Conjunctivitis C. Trachomatis D-K

Sexually active & inconjunction with urethritis

or cervicitis, althoughurogenital symptoms maynot be present

Characterized byprominent follicularresponse with non tenderpreauricular LAD



R. NEPOMUCENO, MD

Chlamydial or Inclusion

Conjunctivitis Punctate epithelial keratitis often

noted superiorly & can evolve tomarginal or subepithelialinfiltrates

Micropannus can occur One of the most common forms

of neonatal conjunctivitis in thenewborn assoicated withpneumonitis

Neonates have no follicularresponse making diagnosis moredifficult

Oral tetracyline 250 mg qid for 3weeks, erythromycin 500 mg qidfor 3 weeks, azithromycin



R. NEPOMUCENO, MD

Allergic (Hay Fever)

Conjunctivitis Reaction to airbone

allergens and is mediatedby IgE antibodies

Hallmark is itching Signs: hyperemia,chemosis and mucoiddischarge

Attacks are usually short

lived & episodic



R. NEPOMUCENO, MD

Vernal Keratoconjunctivitis

Seasonally recurring bilateralinflammation of the conjunctivaseen mainly in young males 4-16 years old with strong historyof atopy

Tropical climates Intense itching, blepharospasm,

photophobia, blurred vision,and copius mucoid discharge

Palpebral = upper tarsus wherea diffuse papillary hypertrophydevelops with giant(cobblestone) papilae



R. NEPOMUCENO, MD

Giant Papillary Keratoconjunctivitis

Chronic inflammation of the conjunctiva withprominent papillaryhypertrophy of thesuperior tarsus

Associated with softcontact lens material,protein debrisaccumulating on the lens

surface, or chemicalsinvolved in lens cleaning Also seen in ocular

prosthesis, loose nylonsutures, filtering blebs



R. NEPOMUCENO, MD

Stevens-Johnson Syndrome

(erythema multiforme major) Acute, inflammatory,

vesiculobullous reaction of the skin & mucousmembranes

Children & young adults,and more prevalent infemales

Acute onset of fever,arthralgia, malaise, andupper or lower respiratorytract symptoms

Cutaneous eruptionsfollows within days



R. NEPOMUCENO, MD

Stevens-Johnson Syndrome

(erythema multiforme major) Bullous eruptions with

membranes orpseudomembranesformation occur

Mucopurulent discharge iscommon

Late ocular complicationsinclude symblephara,trichiasis, dry eye



R. NEPOMUCENO, MD



R. NEPOMUCENO, MD

Conjunctival Nevus

Congenital hamartomas thatconsist of nests of modifiedmelanocytes (nevus cells)

Junctional, compound, &

subepithelial nevi occur in theconjunctiva An important variation in the

conjunctiva is the frequentoccurrence ofsmall epithelialinclusion cysts within neviparticularly within compound orsubepithelial ones

Rarely undergo malignanttransformation



R. NEPOMUCENO, MD

Pinguecula

These elevated, fleshyconjunctival masses are locatedin the interpalpebral region, mostcommonly on the nasal side

Yellow or light brown Associated with chronic actinic

exposure, repeated trauma, anddry and windy conditions

Histologically, they are composed

of abnormal collagen bundleswith staining characteristicssimilar to elastic tissue

Elastotic degeneration , but thetissue is not actually composed of elastin



R. NEPOMUCENO, MD

Pterygium Benign proliferation of fibrovascular

tissue covered by conjunctival-likeepithelium extending onto theperipheral cornea

Risk factor: UV light, wind & dust

Histopath: subepithelial fibrovasculartissue and elastotic degeneration of collagen

Can occur above or within bowman’slayer

Corneal epithelial iron line (Stocker’s

line) can be seen in advance of thehead of a pterygium on the cornea Indications or removal: reduced

vision due to invasion of visual axis,irregular astigmatism, & significantocular irritation



R. NEPOMUCENO, MD

Pyogenic Granuloma

Misnomer because the lesiondoes not representgranulomatous inflammation

Rather a reactive proliferation of

vascular endothelial cells andgranulation tissue Raised, fleshy, red pedunculated

lesion can arise from skin orconjunctiva

Often accompanied bymucopurulent discharge After inflammatory conditions

such as chalazia or chemicalburns, or after conjunctivalsurgery



R. NEPOMUCENO, MD

Suture Granuloma

Clinically appearssimilar to a pyogenic

granuloma

Suture granuloma after strabismus surgery



R. NEPOMUCENO, MD

Conjunctival / Corneal Phlyctenules

Focal transluent lymphocyticnodules located at the limbus

Neutrophils enter the nodule a fewdays after onset as necrosis

develops Result from delayed cell-mediated

hypersensitivity reaction toStaphylococcal antigens or tuberclebacilli

Limbal may result in fibrosis andvascluarization of the peripheralcornea

may wander across the corneaproducing vascularization & scarring



R. NEPOMUCENO, MD

Racial Melanosis

PAM is different fromacquired racial melanosis& from secondary

acquired melanosiscaused by Addison’sdisease, radiation,pregnancy, or other

causes



R. NEPOMUCENO, MD

Conjunctival Concretions

Represent trappedforeign body such as dustin the conjunctival

epithelium Present as foreign body

sensation if numerousand very elevated



R. NEPOMUCENO, MD

Chemical Injuries

Acid

Alkali



R. NEPOMUCENO, MD

Subconjunctival Hemorhage

Rupture of conjunctival blood

vessel due to trauma,valsalva, or blooddyscrasia



R. NEPOMUCENO, MD

Scleral Disease

1. Episcleritis

2. Scleritis

3. Scelromalacia Peforans

4. Congenital Melanosis Oculi



R. NEPOMUCENO, MD

Episcleritis

Inflammation & vasodilation of episclera

Not associated withsystemic disease

Self-limited diseasegenerally seen in youngto middle age adults

Nodular or diffuse

No tenderness or pain



R. NEPOMUCENO, MD

Scleritis

Anterior Sectoral

Nodular Diffuse

Necrotizing

Posterior



R. NEPOMUCENO, MD

Scleritis

Associated with numerousautoimmune disease

Deep, constant pain Bilateral in 50% Predominantly in women Active-sclera has a violaceous

hue Vessels don’t move when

applicator applied to conjunctiva Complications:Keratitis, uveitis,

cataract, glaucoma, scleralthining, marginal keratolysis, andscleral perforation



R. NEPOMUCENO, MD

Scleromalacia Peforans

Nodular Scleritis Commonly seen in

rheumatoid arthritis

Scleromalacia perforans Painless form with no

obvious inflammatory sign

Seen in severe RA



R. NEPOMUCENO, MD

Jules Stein Eye Institute, University of California, Los Angeles



R. NEPOMUCENO, MD

Corneal Disease - Infectious

1. Bacterial Keratitis: S. pneumonia

2. Bacterial Keratitis: P. aeruginosa

3. Fungal Keratitis4. Acanthamoeba Keratitis

5. Primary Herpes Simplex Virus Infection

6. Herpes Simplex Virus Dendritic Keratitis



R. NEPOMUCENO, MD

Corneal Disease - Infectious

7. Herpes Simplex Virus Geographic Keratitis

8. Herpes Simplex Virus Necrotizing Stromal

Keratitis9. Herpes Zoster Dendritiform Keratitis

10. Marginal Keratitis Associated with

Staphylococcal Blepharitis



R. NEPOMUCENO, MD

Corneal Dystrophies/InheritedDiseases

11. Luetic Intersitial Keratitis

12. Corneal Epithelial Membrane Dystrophy

(Map-Dot-Fingerprint Dystrophy)13. Lattice Corneal Dystrophy

14. Granular Dystrophy

15. Macular Dystrophy



R. NEPOMUCENO, MD

Corneal Degeneration

16. Fuchs’ Endothelial Dystrophy

17. Keratoconus

18. Corneal Arcus

19. Calcific Band Keratopathy

20. Secondary Lipid Kertopathy

21. Salzmann’s Nodular Degeneration



R. NEPOMUCENO, MD

Corneal Degeneration

22. Neurotrophic Keratopathy

23. Mooren’s Ulcer

24. Corneal Foreign Body

25. Alkali Burn

Other Corneal Conditions



R. NEPOMUCENO, MD

Bacterial Keratitis

Etiology trauma

contact lens wear dry eye

use of contaminatedtopical medications

Lab confirmationessential

S. aureus



R. NEPOMUCENO, MD

Bacterial Keratitis

Virulent gram- negativeorganisms

Rapid evolution

Tenacious mucopurulentdischarge

Opacification & edemaadjacent to ulcer

Stromal necrosis due toproteolytic enzymes

Seen among contact lenswearer P. aeruginosa



R. NEPOMUCENO, MD

Fungal Keratitis

Filamentous (Fusarium ) or Yeast (Candida spp)

Dirty gray white, dry infiltratewith feathery borders

Multiple or satellite infiltrates Large ulcers have endothelial

plaque & hypopyon Can extend into the anterior

chamber & perforation



R. NEPOMUCENO, MD

Acanthamoeba Keratitis

Seen in contact lens wearer whomake their own solutions

Severe pain. Photophobia,protracted progressive course

Early- dendritiform Enlarged corneal nerves Stromal – gray white superficial

infiltrate in central cornea

Partial or complete ring infiltratein late phase Commonly misdiagnosed as HSV



R. NEPOMUCENO, MD

Primary Herpes Simplex VirusInfection

Acquired from theenvironment

Unilateral vesicular

blepharoconjunctivitis Pruritic vesicles of the

lids, skin, & eyelid margin Follicular conjunctivitis &

palpable preauricular

lymph node Treatment: oral ACV &

topical TFT or ACV`



R. NEPOMUCENO, MD

Herpes Simplex Virus DendriticKeratitis

Majority of patients have arecurrent ocular disease

Asymptomatic, mild foreignbody sensation,photophobia, redness & blurred vision

Starts as discrete punctateepithelial keratitis, coalesce,dendritic lesion (swollen

opaque epithelial cells)commonly in the center Characteristic terminal bulbs



R. NEPOMUCENO, MD

Herpes Simplex Virus GeographicKeratitis

Lysis of desquamated cellsresult to an ulcer

Stains with rose bengal dye Geographic map ulcers

develop by centrifugalspread of HSV Sub-epithelial infiltrates

serve as markers of pastinfection and leave as scars

Sectoral or diffuse reductionin corneal sensation Diagnosis mainly on signs Tissue culture or Antigen

detection techniques



R. NEPOMUCENO, MD

Herpes Simplex Virus DisciformKeratitis

Focal circular area of microcystic edemaoverlying a mild stromal

inflammatory infiltrate & edema with descemetsfolds & underlying kp’s

Photophobia & decreasedvision

Cell mediated immuneresponse to viral antigensin the stroma



R. NEPOMUCENO, MD



R. NEPOMUCENO, MD

Cornea Guttata

Peripheral- Hassall-Henle bodies Central- Cornea guttae No inheritance pattern

Round, dark, drop-like prominencesat Descemet’s membrane & endothelium

Fine, brown, pigment granules onthe posterior surface of the cornea

Guttae represent thickened & localized anvil-shaped excrescencesof descemet’s membrane

Beaten-metal appearanceresembling skin of an orange

endothelial mosaic



R. NEPOMUCENO, MD

Fuchs’ Endothelial Dystrophy

Hereditary atrophy of theendothelium

Auto dominant Women > 50 and older Significant density of cornea

guttae Attenuation & dysfunction of

endothelial cells leading to corneal edema Stromal then epithelial edema Risk of corneal

decompensation after cataractsurgery

K t



R. NEPOMUCENO, MD

Keratoconus

Central or paracentral corneaundergoes progressive thinning & bulging

Cone shape cornea No associated inflammation Unknown cause relation to atopy,

down syndrome, congenitalamaurosis & eye rubbing

Tends to progress duringadolescent years

Cone shape induces myopia,

irregular astigmatism, & decreased vision Corneal findings: Vogt’s striae,

Flesicher’s rings, irregularscissoring



R. NEPOMUCENO, MD

Calcific Band Keratopathy

Characteristically this occurs inthe interpalpebral region

Calcium deposits in this regionresult from localized elevations of pH favoring calcium precipitationand increased evaporation, whichincreases the local concentrationof calcium

This condition may be idiopathic

but is usually associated withlocalized ocular inflammatoryprocesses or systemichypercalcemia

C l F i B d



R. NEPOMUCENO, MD

Corneal Foreign Body

Common Etiology Imperative to evert the

upper lid Removal essential Cause abrasion linear,

fine , vertical May cause secondary

bacterial infection



R. NEPOMUCENO, MD

Vitamin A Deficiency

Bitot spot, a white-gray irregularplaque that usually occurs near thelimbus in the interpalpebral region

A gas-producing bacteria,

Corynebacterium xerosis , isresponsible for the foamyappearance in this lesion

Marked keratinization of the inferiorcornea

Corneal surface is dry, and the lightreflex is irregular Goblet cell function is impaired in

this disorder, and there is a lack of mucin



R. NEPOMUCENO, MD

Corneal Abrasion

Epithelium of cornearemoved by traumaor foreign body

Pain, photophobia & blurred vision



R. NEPOMUCENO, MD

Thyroid Eye Disease

Infiltration of theextraocular muscles andconnective tissue canresult in severe proptosisand orbital inflammation

Patient had chronicexposure keratitis anddeveloped an indolent

ulcer Exophthalmos and lid

retraction predispose tocorneal exposure



THANK YOU

cornea lecture

Documents

Transcript of cornea lecture