Zoltan Z. Nagy Department of Ophthalmology, Mária u....IV. 1. A.) Bacterial keratitis Keratitis...
Transcript of Zoltan Z. Nagy Department of Ophthalmology, Mária u....IV. 1. A.) Bacterial keratitis Keratitis...
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Diseases of the cornea
Zoltan Z. Nagy
Department of Ophthalmology, Mária u.
Budapest
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The human cornea
Transparent, contains no blood vessel
Special spherical shape
Represents the largest refractive power within the
eye (cc. +43,0 D)
Only 0,5 mm thick in the center
Elastic, during trauma non-linear behaviour
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I. Morphology of the cornea (macroscopic and
microscopic)
II. Developmental anatomy of the cornea, developmental
anomalies
III. Methods of corneal examination
IV. Diseases of the cornea
– Inflammation, degenerations, dystrophies, tumors, trauma
V. Keratoplasty (corneal transplantation)
VI. Refractive surgery of the cornea
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I. Morphology of the cornea
Macroscopic
Microscopic
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Macroscopic anatomy
– Special attachment to the sclera
– Corneal radius: 7,8 mm
– Horizontal diameter: 11,7 mm
– Vertical diameter: 10,6 mm
– Thickness at the center: 530 µm, in limbus 700 to 1000 µm
– Adult size achieved in the age of 2 years
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Microscopic anatomy
– Epithelium
– Lamina limitans anterior (Bowman layer)
– Substantia propria (stroma)
– Lamina limitans posterior (Descemet layer)
– Endothelium
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II. Developmental anatomy of the
cornea
Epithelium: ectodermal, others layers:
mesodermal.
Following lens vesiculum, superficial ectoderma
differentiates to corneal epithelium.
Mesenchyma cells appear between the lens and
epithelium, producing collagen fibers.
Endothelium originates from the distal part of the
mesenchyma.
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Developmenal anomalies
Microcornea
Megalocornea
Embryotoxon posterius
Cornea plana
Leucoma corneae congenitalis
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III. Examination of the cornea
Slit lamp
Topography
Pachymetry (optical and ultrasonic)
Ultrasound biomicroscopy (UBM)
Specular microscopy
Measurement of corneal sensitivity
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IV. Diseases of the cornea
1. Inflammation
2. Degenerations and dystrophies
3. Proliferative diseases and tumors
4. Corneal scars
5. Trauma
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IV. 1. Corneal inflammations
(Keratitis)
A.) Bacterial (pus)
B.) Viral
C.) Fungal
D.) Trophic
E.) Immuno-specific
F.) Unknown origin
G.) Other
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General symptoms of keratitis:
– Pain, photophobia, epiphora (tear)
– Epithelial opacities, infiltrates in stroma and between
the endothel cells
– Corneal neovascularisation.
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IV. 1. A.) Bacterial keratitis
Keratitis punctata superficialis
Ulcus corneae
– Staphylococcus epidermidis
Ulcus serpens corneae cum hypopyo
– Diplococcus pneumoniae, Moraxella lacunata
Abscessus annularis
– Pseudomonas pyocyanea, Acanthamoeba
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IV. 1. B.) Viral keratitis
Pathogens:
– Herpes simplex virus (HSV)
– Varicella zoster virus
– Adenoviruses
– Cytomegalia (rare)
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HSV keratitis
Three main forms:
Superficial form
– Keratitis dendritica, stellata, punctata
Stromal form (deep inflammation)
– Keratitis interstitialis
Endothelial form
– Keratitis disciformis, endotheliitis
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Keratitis dendritica
– Pain, foreign body sensation, tearing
– Usually affects one eye, conjunctivitis is also present
– Objective symptoms: dendrit-like infiltrations in the
epithelium, epithelial defects, staining with fluorescein
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Keratitis herpetica interstitialis
– Visual deterioration depending the localization of the
infiltrates.
– Objective symptoms: irregular stromal infiltrates with
whitish-greyish colour. No epithelial defect.
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Keratitis disciformis
– Subjective symptoms: visual deterioration.
– Objective symptoms: disciform stromal infiltrates,
where stromal edema is present. On the posterior
surface of the infiltrate there are Descemet folds (loss
of endothel cells). Precipitates on the posterior surface
of the cornea.
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Keratitis metaherpetica
– Due to basal membrane damage, epithelial adhesion decreases.
– Edema in the epithelium, bullae may appear under the epithelium.
– If there is an epithelial defect, the process may be ulcerative.
– It is difficult to differentiate from real recurrance.
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Therapy
– Acyclovir (Zovirax, Virolex)
– Trifluorthymidin (Triherpin)
– Iod-dezoxy-uridin (IDU)
– Local corticosteroids
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Herpes zoster ophthalmicus
– Varicella zoster, characteristic changes in skin
– Always one-sided (n. trigeminus)
– Slit lamp finding is similar to HSV keratitis
– Other: trabeculitis (sec. gl.), optic nerve inflammation,
paralysis of the ocular muscles
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Keratoconjunctivitis epidemica
– Type 8 and 19 of Adenovirus (incubation time: 8
days)
– Foreign body sensation, photophobia
– First one-sided, serous discharge with
pseudomembrane formation. Edema and red colour of
the caruncule and semilunar plica
– Keratitis punctata spf, subepithelial whitish-greyish
infiltrates (maybe permanent).
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IV. 1. C.) Fungal keratitis
Possible pathogens: Candida albicans, Apergillus
fumigatus, Actinomyces
Features: dense whitish-greyish infiltrate in
stroma, base is dry, satellit infiltrates, corneal
ulcer, hypopyon
Therapy: Nystatin, Natamycin, Amphotericin-B
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IV. 1. D.) Trophic dystrophies
Keratitis e lagophthalmo
Keratitis neuroparalytica
Corneal damage due to local anaesthetic therapy
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IV. 1. E.) Immunospecific, or
endogenous keratitis
Atopic keratitis
Keratoconjunctivitis phlyctenulosa, ekzematosa
Keratitis interstitialis (parenchymatosa)
Keratitis rosacea
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Atopic keratitis
– Usually together with allergic reaction of the
conjunctiva, symptoms similar to superficial keratitis.
– Therapy: antiallergic eye drops.
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Keratoconjunctivitis phlyctenulosa
– Tuberculotoxic, allergic-hyperergic reaction
– Poor hygene
– Severe photophobia, epiphora, facies scrofulosa, rhagads,
blepharospasmus (spastic entropium)
– Near to limbus: small pin-like infiltrates, sectoral conjunctivitis.
Phlyctenas may wander.
– Pannus formation (neovascularisation)
– Therapy: corticosteroids, antibiotic drpos
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Keratitis interstitialis (parenchymatosa)
– Hyperergic reaction due to connatal lues
– Diffuse, deep keratitis (round or tongue like infiltretes
with intact epithelium). Later, deep neovascularisation
(red or brownish opacity). Later blood vessels closing.
– Hutchinson-trias: keratitis, barrel-shaped teethes,
perception hypacusis
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Keratitis rosacea
– Rosacea-like skin changes on the face
– In the superficial layer of the cornea: whitish
infiltrates, ulceration, superficial and deep corneal
neovascularisation. Frequent recurrences.
– Therapy.: local antibiotic drops, corticosteroid drops.
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IV. 1. F.) Keratitis of unknown
origin
Ulcus rodens (Mooren-ulcer)
– Progressive necrotizing keratitis, starts from limbus
and advancing toward the center.
– Blood vessels may grow in, thereafter scar formation.
– Prognosis: bad
– Therapy: difficult, limited keratotomy, keratoplastica,
immunosuppression, conjunctiva/amniotic membrane
transplantation.
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IV. 1. G.) Other keratitis
Keratoconjunctivitis sicca (Sjögren sy)
– Cause: unknown
– Symptom: foreign body sensation, pain
– Schirmer-test
– Filaments on the surface of the cornea
– Therapy: arteficial tear products
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IV. 2. Corneal degenerations
Arcus senilis (gerontoxon)
– Lipid deposition in stroma around the limbus
Kayser-Fleischer ring (Wilson-disease)
– Organic copper deposition in Descemet layer
Opacitas zonularis corneae (Band keratopathy)
– Calcium deposition in Bowman layer
Nodular corneal degeneration (Salzmann-degeneration)
Keratomalacia
– Vitamin-A deficiency
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IV. 2. Corneal dystrophies
Features:
– Abnormal metabolism of cells and tissues
– Symptoms in early adulthood
– Bilateral and symmetric
– No corneal neovascularisation
– Affect the central 6-8 mm diameter of the cornea
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IV. 2. Corneal dystrophies
Epithelium, Bowman layer
– Basal membrane dystrophy, Reis-Bückler dystrophy
Corneal stroma (dominant inheritance, except macular
dystrophy)
– Macular dystrophy (Groenouw I)
– Granular dystrophy (Groenouw II)
– Reticular dystrophy (Haab-Dimmer)
Endothelium
– Endo-epithelial dystrophy (sec. Fuchs)
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IV. 2. Corneal dystrophies
Keratoconus
Keratoglobus
Keratotorus
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IV. 3. Proliferative diseases of the
cornea and tumors
Dermoid (at the limbus)
Pterygium, pinguecula
Papilloma
Granuloma
Intraepithelial epithelioma (morbus Bowen)
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IV. 4. Corneal scars
Nubecula
Macula
Leucoma
Leucoma corneae vascularisata
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IV. 5. Trauma of the cornea
Epithelial erosion of the cornea
Recurrent erosion
Photoelectric keratitis
Chemical injuries (acid and base)
Burn
Foreign body (corpus alien. corneae)
Perforating injuries
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V. Keratoplasty
(Corneal transplantation)
First lamellar keratoplasty: von Hippel, 1888
First penetrating keratoplasty (PKP): Zirm, 1906
Indication:
– Keratoconus, other corneal dystrophies, bullous
keratopathy, scars, herpetic infection, rejection
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VI. Refractive surgery of the
cornea
History of the optical correction
13th century
– Glass blow masters from Murano and Pisa
– Correction of presbyopia
15th century
– First myopic correction
Later
– Newton and Descartes (basic laws of optics)
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Surgical interventions
Bates (1894) USA
Lans (1898) Germany
– Treatment of astigmatism and keratoconus
Fukala-procedure
– Lens extraction (only for high myops)
Sato (1953)
Fjodorov, Yenaliev (1979)
Bores (1983) USA
– Radial keratotomy (RK)
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Excimer laser
1975. Velazco
– Xenon reacts with halogen atoms
1976. Hoffmann
– ArF molecule
– Excimer = „EXCited diMER”
1983. Srinivarsan és Trokel
– Surgical use
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Mechanism of action
Fotochemical
Fotodecomposition, or photoablation
– Laser energy: 6,4 eV
– carbon – hydrogen bonds: 4,3 eV
– Depth only: 1 µm !!
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Clinical studies, animal experimetns
– 1983. Trokel, New York (USA)
– 1983. Marshall, London (Anglia)
First human treatments
– 1988. M. McDonald, New Orleans (USA)
– 1988. T Seiler, Berlin (Germany)
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Features of ArF molecule
High energy, 193 nm of wavelength photon
radiation
Ultraviolet-C range of electromagnetic spectrum
Fotoablation effect
Nanosec treatment time („cold laser”)
1 µm-es effective depth
Corneal sculpting
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Treatment modalities with the
excimer lasers
PRK (photorefractive keratectomy)
PTK (phototerapeutic keratectomy)
LASIK (Laser in situ keratomileusis)
LASEK (Laser intraepithelial keratomileusis)
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