Transcript Arcus Senilis - Jonovan Ottenbacher

Corneal Path
Lecture 08/25/08: Corneal Dystrophies
Arcus Senilis
• Elevated Cholesterol
• See PCP for blood work-up
Arcus Senilis
Hudson Stahli Line
• A brown, horizontal line across the
lower third of the cornea, occasionally
seen in the aged.
• No Tx
Hudson Stahli Line
Band Keratopathy
• Precipitation of calcium salts on the corneal
surface (directly under the epithelium)
• Patients with band keratopathy complain of the
following:
–
–
–
–
Decreased vision
Foreign body sensation
Ocular irritation
Redness (occasionally)
• Tx: Debridement
Band Keratopathy
Limbal Girdle of Vogt
• Very common, bilateral, age-related condition.
Corneal degeneration.
Clinical features:
Symptoms: asymptomatic and requires no
therapy.
Signs:
Crescenteric, white opacities of the peripheral
cornea in the interpalpebral zone along the
nasal and temporal limbus
May be separated from the limbus by a clear
zone or without a clear zone in between
Limbal Girdle of Vogt
Salzmann’s Nodular Degeneration
• Usually following trachoma or phlyctenular
keratitis
• Characterized by multiple superficial blue
white nodules in the midperiphery of the
cornea
• Medical therapy consists of lubrication,
warm compresses, lid hygiene, topical
steroids, and/or oral doxycycline
Salzmann’s Nodular Degeneration
Climatic Droplet Keratopathy
• Degenerative condition characterized by
the accumulation of translucent material in
the superficial corneal stroma
• Sector iridectomy, corneal epithelial
debridement, lamellar keratoplasty, and
penetrating keratoplasty have all been
employed in the treatment of visually
incapacitating CDK.
Climatic Droplet Keratopathy
Corneal Farinata
• Bilateral speckling of the posterior part of
the corneal stroma
• VA unaffected
Corneal Farinata
Pellucid Marginal Degeneration /
Keratoglobus
• Bilateral, noninflammatory, peripheral
corneal thinning disorder characterized by
a peripheral band of thinning of the inferior
cornea
• Tx: RGPs / Keratoplasty
• Surgery needed for Keratoglobus
Pellucid Marginal Degeneration
Keratoglobus
Lecture 09/08/08 EBMD (Bergmanson)
• Keratoconus (continued)
– Making the Dx
Voght Striae
Fleisher’s Ring
Cause: Thickened tear film where lids meet
Hydrops
Rupture in Descemet’s membrane
EBMD
Epithelial Basement Membrane
Dystrophy
Meesmann’s Dystrophy
Intraepithelial cysts with amorphous material/cellular debris
Tx: usually not needed
Map/ Dot/ Fingerprint Dystrophy
aka “Anterior Membrane Dystrophy”
BM is laid down abnormally by epithelial cells build up of material
Pts > 60
Negative staining
Recurrent Corneal Erosion
Syndrome
Tx: for EBMD
– Lubricant/gtts; ung
– Bandage CL
– Stromal puncture
– Epithelial scraping
– PTK
Surgical Tx
• PKP (Penetrating) vs. LKP (Lamellar)
– Most surgeons tx w/ PKP
– Adv of LKP
•
•
•
•
•
Not intraocular
Fewer complications
Preserved endothelium
Low risk of rejection
Preserves global strength
Dystrophies of Bowman’s Layer
Reis-Buckler’s Dystrophy
Autosomal dominant dystrophy
Characterized by small discrete opacities centrally just under the epithelium which
may have a honeycomb pattern
ALL is being replaced by reticular material (scar-like tissue)
Honeycomb dystrophy of Thiel and
Behnke
Inherited Band Keratopathy
Tx: Chelating agent EDTA
Stromal Dystrophy
• Granular Dystrophy
• Lattice Dystrophy
• Gelatinous drop-like dystrophy
Granular Dystrophy
Corneal Trauma
Management
Bacterial Keratitis
-WBCs only found in infectious keratitis.
-Acute (24-48 hrs), rapidly progressive corneal destructive process or a chronic process.
-Caused by corneal epithelial disruption caused by trauma, contact lens wear,
contaminated ocular medications and impaired immune defense mechanisms.
-Tx. With Polytrim, Vigamox, and broad spectrum antibiotics
Radial Keratotomy Problems
*Refractive surgery procedure to correct mild to moderate degrees of myopia (2 to 5 D).
*Incisions can split open making them vulnerable to corneal infections (fungal/bacterial)
-If infection happens w/i 24 -48 hrs, bacterial and not fungal.
-Tx aggressively with Polytrim, Vigamox, or broad spectrum antibiotics.
-F/U in 1 day.
Fungal Keratitis
•
•
Feathery Borders, w/ hx of plant/vegetable matter trauma.
Tx w/ prolonged course of systemic and topical anti-fungal (Natamycin), and
frequent scrapings or localized debridement to remove necrotized epithelial
tissue.
Lecture 09/22/08: Corneal Trauma Mgmt
Pseudomonas Keratitis
*Pseudomonas can progress fast! Within 24 hours
-hypopyon, infiltrates in cornea, KPs, plasmoid aqueous (AC is jello)
-pain, decreased VAs, redness
Corneal FB
*May develop corneal ulcer.
*r/o intraocular FB.
*Remove FB, unless removal will cause more damage than leaving it undisturbed.
-Topical antibiotics after removal
-Topical NSAID (Ketorolac) or short acting cycloplegic for relief of symptoms
Intraocular Foreign Body
*Intraocular FB –passes basement membrane of cornea.
-Improper removal can cause collapsed AC, traumatic glaucoma, endophthalmitis if
infected.
*Refer to surgeon.
Traumatic Cataract
*Most common complication of non-perforating and perforating injuries to the globe.
Hypermature/Morgagnian Cateract
*May me caused by severe trauma.
*Liquified cat with intact nucleus inferiorly displaced.
Bollus Keratopathy
*Compromised endothelial cell pump mechanism as the endothelial cell density decreased
and decompensated; Folds in stroma from stromal edema.
*Can be induced by cataract surgery or other trauma.
*Manage w/ NaCl 5% gtts and ung; CL for pain; IOP lowering meds; Penetrating
Keratoplasty in advanced cases.
RA-associated peripheral
ulcerative keratitis
*Hx of CT dz.
*May cause stromal thinning, descemetocele (only PLL and endothelium left due to corneal
thinning) in progressive keratolysis, and perforation.
*Promote re-epithelialization by ocular surface lubrication, patching or bandage soft contact
lens.
Alkaline Burn
*Immediate irrigation of eye until the pH of the cul-de-sac has returned to neutrality. (pH= 7.0)
*Prophylactic broad spectrum antibiotic; cycloplegic drops; topical steroids to decrease
inflammation; lubrication; soft CL…
Lecture 09/29/08: Corneal Trauma Mgmt
(cont.)
Pseudomonas Keratitis
Vigamox
Bacterial corneal Ulcer
gram (+) Vigamox, gram (-) Zymar
Fungal Keratitis
Natamycin
Acanthamoeba keratitis
• Epithelial debridement
Epithelial Herpes Simplex
• Viroptic
Marginal Keratitis
• Vigamox
Bacterial infiltrate
2nd to RK
• Vigamox
Dellen
• Artificial tears
Pubic lice
• Bacitracin ointment
Iris nevus
• Asymptomatic, no tx
• Malignant with growth, refer
Lecture 10/06/08: Corneal Dystrophy (cont.)
Lecture 10/20/08: Therapeutic Strategy for
Ant. Segment Dz
Combination Antibiotics
•
•
•
•
•
Tobramycin
Polymixin B
Neomycin (hypersensitvity common)
Sulfacetamide
Bacitracin
Medications used to treat ocular inflammation and prevent microbial
infection. Also used for superficial burns.
Examples: corneal infiltratres, meibomian gland dys., blepharitis
Corneal Ulcers
TOC: 4th generation fluoroquinalones
-Zymar (gatifloxacin) 0.3%
-Vigamox (moxifloxacin) 0.5%
-Quixin (levofloxacin) 0.5%-- 3rd generation
-Iquix (levofloxacin 1.5%) qd or bid– 3x conc of Quixin and
works better than Zymar and Vigamox without toxicity.
Preservative free.
Corneal Ulcers
(additional treatments)
Antibiotics
-Gentamycin (ung, gtt)
-Ofloxacin (gtt)
-Ciprofloxacin (gtt)
-Tobramycin sulfate (ung, gtt)
Mixes
- Polysporin ung ( polymixin B & bacitracin)
- Neosporin ung ( poly b/ neomycin / bacitracin)
- Polytrim gtt ( poly B & trimethoprim) -- least toxic
Bacterial Conjunctivitis
- Azasite (azithromycin 1%) bid-tid
steroid added post AB treatment to prevent corneal scarring
- Vigamox (moxifloxacin)
FDA approved for bacterial conjunctivits
Topical anit-inflammatories
•
Steroids
- Maxidex (Dexamethasone 0.1%) susp
- FML (flouromethalone 0.1%) – ung or susp
- Pred forte (prednisilone 1%) – susp
•
Soft steroids
- Lotepredenol etabonate
Alrex 0.2%
Lotemax 0.5%
•
NSAIDS (analgesic effect)
-
Diclofenac (Voltaren 0.1%) soln
Ketorolac (Acular 0.4%) soln
Allergic and CLPC(contact lens induced papillary conjunctivitis)
Treat with…
- Mast cell stabilizers
Crolom bid, Alomide or Alomast qid, Alocril bid
- Mast cell stabilizing antihistamines
Patanol bid/ Pataday qd, Elestat bid, Zaditor bid,
Optivar bid
- NSAIDS
Acular qid
- Steroids (only if severe)
Alrex, Lotemax, or Pred Forte qid