Clinical Approach to a case of corneal opacity

1. Approach to a case of Corneal
Opacity

2.  Loss of transparency of cornea due to scarring.
 Any disease which interferes with corneal clarity
leads to an opacity.

3. History
 Congenital or Acquired
 Onset and duration
 Unilateral or bilateral
 Trauma or chemical injury
 Recurrent episodes of pain and redness
 Long term topical medication
 Contact lens use
 Previous ocular surgery
 Systemic illness
 Socioeconomic status

4. “STUMPED” Classification
 S – Sclerocornea
 T – Tears in descemet’s membrane
Congenital Glaucoma
Birth trauma
 U – Ulcer
Herpes simplex virus
Bacterial
Neurotrophic
 M – Metabolic (rarely present at birth)
Mucopolysaccharidoses
Mucolipidoses
Tyrosinosis

5. Classification continued…
 P – Posterior corneal defect
Peter’s anomaly
Posterior keratoconus
Staphyloma
 E – Endothelial dystrophy
Congenital hereditary
endothelial dystrophy
Stromal : Congenital hereditary
stromal dystrophy
 D- Dermoid

6. Symptoms
 Diminution of vision
 Pain,
 Redness
 Photophobia

7. Examination Of Corneal Opacity-
Clinical Assessment
 Assessment of vision-Refraction
 Systemic Evaluation
 Torch Light Examination
 Ocular Movements
 Fixation , nystagmus
 Deviations

8.  Depending upon the density, corneal opacity is
graded as:
 Nebular: faint opacity due to superficial scar
involving bowman’s layer and superficial stroma

9.  Macular: Semi dense opacity d/t scar involving
half of stroma.

10.  Leucomatous: Dense white opacity d/t scarring of
more than half of stroma

11. Examination Of Corneal opacity -
Overview
Evaluation Of Visual Potential And Prognostication
Laboratory Investigations And Corneal Imaging
Bedside Tests
Clinical Evaluation Of Cornea And External Eye
Clinical History

12. Examination of Corneal Opacity-
Clinical Assessment

13. Adnexal Evaluation

14. Slit Lamp Examination- Corneal
Opacity
 Location
 Size
 Depth
 Vascularisation
 Epithelial defect
 Infiltrates
 Focal thickening or thinning of cornea
 Edema
 Staining

15. Corneal Opacity-
Slit lamp Examination
Direct
Illumination
Diffuse
Illumination
Focal
Illumination
Indirect
Illumination
Sclerotic
scatter
Retro
illumination
Specular
Reflection

16. Slit Lamp Examination-
Diffuse Illumination

17. Slit Lamp Examination-
Focal Illumination

18. Slit Lamp Examination-
Retro Illumination

19. Slit Lamp Evaluation-
Sclerotic Scatter
 Corneal opacities
 Interstitial
deposits
 Perforating scars

20. Sclerotic Scatter
 Less transparent
areas scatter the
internally
reflected light.
 Useful for
detecting subtle
corneal opacities.

21. Indirect Lateral Illumination

22. Slit Lamp Examination-
Specular Reflection
 Morphology of
endothelial cells
 Assessment for
corneal
decompensation

23. Documentation
 Generally corneal pathologies are documented as
frontal view and in cross sectional view

24.  Black colour is used to document
 Limbus
 Scars
 Degenerations
 Foreign bodies
 Sutures
 Contact lens
 Band keratopathy

25. .
 Brown colour is used to document
 Pigmentation-iron or melanin
 Pupil and iris
 Blue colour is used to document
 Oedema,
 Small circles for epithelial oedema
 Wavy lines to document folds in Descemet’s
membrane

26. .
 Red colour is used to document
 Blood vessels (see figures)
 Rose Bengal staining
 Haemorrhages

27. .
 Orange colour is used to document (in many
centres, yellow colour is used instead of orange)
 Hypopyon
 Keratic precipitates
 Green colour is used to document
 Fluorescein staining of cornea
 Punctuate epithelial keratopathy (dots)
 Filaments (small lines)
 Lens and vitreous haze

28.  Alternatively a monochromatic system of lines
can be used for documentation of corneal
diseases.(Adapted from Bron AJ. Br J
Ophthalmol1973;57:629–34.)

29. Documentation Of Corneal Opacity

30.  Vascularisation: Superficial and deep

31. Examination of Corneal Opacity- Tear
Film Evaluation
Tear Film
Function Test
TBUT
Schirmer’s test
Tear Meniscus
Height
Tear Clearance
rate
Tear Osmolarity
And
Composition

32. Tear Film Evalaution-
Schirmer’s Test
 Tear production –
Aqueous component
 Basal Schirmer Test
 Schirmer I - < 15 mm
 Schirmer II- < 10 mm
 < 5 mm - severe
dry eye

33. Tear Film Evalaution-
Tear Film Breakup Time

34. Tear Film Evaluation-
Tear Meniscus Height
 Pathological
<0.3 mm height
 Aqueous deficiency
 Poor lid to globe
apposition
 Raised if naso-
lacrimal obstruction

35.  Anterior segment examination
 Pupillary reactions-direct and consensual
(Optic nerve status).
 Fundus examination.
 Corneal sensations
 Intraocular pressure

36. Esthesiometry

37. Investigations
 Assessment of visual potential – VA prior to
opacity, macular function tests, laser
interferometry, VER
 Pachymetry
 USG A-B scan- Retinal detachment
Endophthalmitis
 ASOCT- Depth of opacity, evaluation of anterior
chamber.
 Corneal Scraping

38. Laboratory Investigations-
Corneal Scraping
Corneal Scraping
Smear
Gram’s stain
10% KOH
mount
Culture
Bacterial
Fungal
Others
PCR
Viral
Acanthamoeba

39. Advanced Diagnostic Techniques
Advanced
Diagnostic
Techniques
Corneal
Topography
Confocal Scan
Specular Count
ASOCT
UBM

40. Advanced Diagnostic Techniques -
ASOCT
Indications
 Monitoring of corneal ulcers
 Lasik flaps
 Pannus morphology
 Planning and management
of lamellar keratoplasties
 Descemet membrane
detachment

41. Advanced Diagnostic Techniques
Ultrasonic Biomicroscopy
 Indications
 Keratoplasty work-up
 Limbal mass
 Dermoids
 OSSN
 Ocular surface
diseases-
 Evaluation
 Planning of surgery

42. Advanced Diagnostic Techniques
Specular Count
 Indications
 Fuch’s endothelial dystrophy
 Posterior polymorphous
dystrophy
 Follow-up of keratoplasty
 Eyes with glaucoma, uveitis,
pseudo-exfoliation
 Assessment of
contralateral eye
important

43. Treatment
 Treatment is targeted first at any ongoing disease
process such as
 Infectious keratitis
 Ocular surface disorder
 Raised IOP
 Definitive treatment is planned later

44.  Cosmetic treatment : if there is poor visual
potential
 Cosmetic contact lenses
 Tattooing

45. Visual- Non surgical
 Refraction and glasses
 Rigid gas permeable contact lenses : If VA is less
because of irregular astigmatism.

46. Surgical
 Optical iridectomy- in case of central opacities
with clear periphery, preferably in children and
one eyed individuals, poor visual potential cases
to salvage some vision.
 Phototherapeutic keratectomy/ photorefractive
keratectomy in cases of superficial opacities
 Lamellar keratoplasty
 Penetrating keratoplasty
 Keratoprosthesis - in patients with poor ocular
surface where chances of graft survival are less
specially if patient has poor vision in other eye
also.

47. Thank you