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Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
Ed&cornea lecture fatima
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Ed&cornea lecture fatima
Ed&cornea lecture fatima
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  • 1. 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
  • 2. Eyelid Disease
    • 1. Meibomian Gland Dysfunction
    • 2. Staphylococcal Blepharitis
    • 3. Seborrheic Keratosis
    • 4. Angular Blepharitis
    • 5. Molluscum Contagiosum
    • 6. Hordeolum
    • 7. Chalazion
    • 8. Viral Papilloma
  • 3. Eyelid Disease
    • 9. Seborheic Keratosis
    • 10. Xanthelasma
    • 11. Basal Cell Carcinoma
    • 12. Squamous Cell Carcinoma
    • 13. Capillary Hemangioma
    • 14. Allergic Contact Dermatitis
  • 4. Meibomian Gland Dysfunction
    • Sebaceous glands of posterior lamella of the eyelids
    • Abnormal lipid composition & secretion
    • Enlargement, inspissations of orifices
    • Chronic burning, foreign body sensation, filmy vision, tearing, crusting of the eyelids
  • 5. 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 corneal infiltrates, punctate epitheliopathy
    • Chronicity causes thickened & scarred lids
  • 6. Seborrheic Keratosis
    • This disorder is often associated with seborrheic dermatitis
    • Patients complain of redness, burning, and mattering of the eyelids
    • Usually bilateral
    • Often associated with meibomian gland dysfunction
    • The lashes are covered with yellow, greasy scales
    • The scales are translucent and easily removed
  • 7. 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
  • 8. Molluscum Contagiosum
    • Poxvirus by direct contact
    • Often seen in children & young adults
    • Single lesion as papule to waxy nodule with umbilicated center
    • In AIDS multiple, large
    • Associated with toxic follicular conjunctivitis, SPK, SEI, vascular pannus
    • Self limited but may need Treatment
  • 9. Hordeolum or “stye”
    • Local infected abscess of a hair follicle or gland on the lid margin
    • External- anterior eyelid margin, often Gland of Ziess
    • Internal- meibomian gland
  • 10. Chalazion
    • Chronic Lipogranuloma of meibomian gland
    • Forms as a discrete mass
  • 11. Viral Papilloma
    • Human papilloma virus
    • Painless, keratinized cutaneous lesion usually without inflammation
    • May cause papillary conjunctivitis
  • 12. Seborrheic Keratosis
    • Mainly in elderly
    • Benign, pigmented well demarcated, slightly elevated, warty, crusted, stuck on appearance, with visible keratotic plugs
    Pseudocyst with keratin
  • 13. Xanthelasma
    • Superficial dermis contain histiocytes filled with cholesterol esters
    • Elevated serum cholesterol or hyperlipidemia syndrome
  • 14. Basal Cell Carcinoma
    • These slow-growing tumors are found in sun-exposed areas
    • They are the most common eyelid malignancy
    • Usually located on the lower eyelid
    • Edges are raised and pearly, with a central ulceration
    Basophilic nests of cells with peripheral palisading
  • 15. Squamous Cell CA
    • Rare malignancy of the eyelids
    • Commonly arises in sun-exposed areas and may resemble other lesions of the eyelid, such as keratoacanthoma, basal cell carcinoma, and seborrheic keratosis
    • The inset shows pearly raised margins of a small squamous cell carcinoma
  • 16. Squamous Cell CA
    • Eosinophilic cells with large cytoplasms are shown. Keratin pearls (1) and dyskeratotic cells (2) are seen within the lesion. Dyskeratotic cells have small, dark nuclei and produce keratin
  • 17. Capillary Hemangioma
    • Appear at or soon after birth
    • Strawberry nevus
    • Usually involute spontaneously
    • May cause amblyopia if in visual axis
    • Intralesional steroid injection
  • 18. Allergic Contact Dermatitis
    • Environmental or externally applied agents
    • Cell mediated type IV reaction
    • Neomycin, atropine
  • 19. Royce Hall, University of California, Los Angeles
  • 20. Lacrimal System Disorders
    • 1. Canaliculitis
    • 2. Dacryocystitis
    • 3. Normal Tear Film
    • 4. Keratoconjuctivitis sicca
  • 21. Canaliculitis
    • Tearing, prominent punctum
    • Anaerobic bacteria (Actinomyces israelii)
  • 22. Dacryocystitis
    • Acute or chronic
    • S. pneumoniae or S. aureus
    • Bacterial infection following obstruction at either end of the nasolacrimal canal
    • Nasal trauma, scarring from ocular suface disease or a developmental anomaly
  • 23. Dacryocystitis
    • Acute – treatment is topical antibiotics
    • Chronic- produces permanent scarring or fistula formation
    • Treatment is DCR
  • 24.  
  • 25. 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
  • 26. Conjunctival Disease
    • 1. Follicular Conjunctival Reaction
    • 2. Papillary Conjunctival Reaction
    • 3. Epidemic Keratoconctivitis
    • 4. Membranous Conjunctivitis
    • 5. Gonococcal Conjunctivitis
    • 6. Chlamydial Conjunctivitis
  • 27. Conjunctival Disease
    • 7. Trachoma
    • 8. Allergic (Hay Fever) Conjunctivitis
    • 9. Atopic Keratoconjunctivitis
    • 10. Vernal Keratoconjunctivitis
    • 11. Giant Papillary Keratoconjunctivitis
  • 28. Conjunctival Disease
    • 12. Superior Limbic Keratoconjunctivitis
    • 13. Stevens-Johnson Syndrome
    • 14. Conjunctival Nevus
    • 15. Adenochrome Deposits
    • 16. Pinguecula
    • 17. Pterygium
  • 29. Conjunctival Disease
    • 18. Pyogenic Granuloma
    • 19. Phlyctenulosis
    • 20. Conjunctival Viral Papilloma
    • 21. Conjunctival/Corneal Intraepithelial Neoplasia
    • 22. Conjunctival Lymphoma
    • 23. Primary Acquired Melanosis (PAM)
  • 30. Follicular Conjunctival Reaction
    • Follicles = lymphoid germinal centers
    • Smooth nodules which are avascular at the apices sorrounded by fine vessels at their bases
    • Can be a normal variant if found in the lower conjunctiva without infection
  • 31. Follicular Conjunctival Reaction
    • Etiology
      • Adenoviral conjunctivitis
      • Infection from primary herpes simplex virus
      • Molluscum contagiosum
      • Enterovirus
      • Chlamydia
      • Toxicity from medications
  • 32. Papillary Conjunctival Reaction
    • Non-specific response caused by many agents
    • Usually seen on the upper tarsal conjunctiva
    • Fine mosaic pattern of dilated telangiectatic blood vessels
    • Each has a central firovascular core that gives rise to a vessel branching out in a spokelike pattern
    • Cojunctival septae sorrounding the papillae are anchored by pale tissue when papllary hypertrophy occurs
  • 33. Epidemic Keratoconjunctivitis (EKC)
    • Syndrome of external ocular adenovirus infection
    • Serotypes 8, 11, and 19 most common
    • Acute onset of watery discharge, photophobia, and mild foreign body sensation
    • Preauricular lymphadenopathy and mixed papillary-follicular conjunctivitis
    • May present with subconjunctival hemorrhage, chemosis, and pseuodomembrane or membrane formation
  • 34. Epidemic Keratoconctivitis
    • Mucopurulent discharge when membranous reaction develops
    • Maximum intensity in 5-7 days after onset of symptoms
    • Keratitis is characterized initially by diffuse punctate intraepithelial lesions , followed by fine or coarse punctate epithelial keratitis and finally by subepithelial infiltrates (SEIs)
    • SEI develop until after at least 2 weeks after the onset of symptoms
    • SEI results from a host immune response
  • 35. Membranous Conjunctivitis
    • Conjunctival membrane or pseudomembrane can occur in association with severe viral or bacterial conjunctivitis or following chemical burn, or Stevens-Johnson syndrome, ocular cicatricial pemphigoid
    • Produced when an inflammatory discharge of fibrin with PMN’s and fibrin coagulates on the conjunctival surface
    • True membrane incorporates the epithelium an bleeds when removed
    • Pseudomembrane is more superficial and can be peeled or scraped away without bleeding
    • Healing can result in conjunctival scaring
  • 36. Bacterial Conjunctivitis - Gonococcal
    • Neissera gonorrheae
    • Hyperacute purulent conjunctivitis
    • Direct contact with infected genital secretions or from genital-hand-ocular transmission
    • GC and meningococci are the only bacteria causing conjunctivitis with preauricular LAD and conjunctival membranes
  • 37. Gonococcal Conjunctivitis
    • Corneal involvement may consist of diffuse epithelial haze, epithelial defects, marginal infiltrates, and peripheral ulcerative keratitis that rapidly progress to perforation
    • Classic cause of neonatal conjunctivitis
  • 38. Gonococcal Conjunctivitis
    • Systemic + topical antibiotics
    • Ceftriaxone 1 gram IM
    • With corneal perforation- admitted with IV ceftriaxone q 12 x 3 days
    • Cotreatment for chlamydia
  • 39. Chlamydial or Inclusion Conjunctivitis
    • C. Trachomatis D-K
    • Sexually active & in conjunction with urethritis or cervicitis, although urogenital symptoms may not be present
    • Characterized by prominent follicular response with non tender preauricular LAD
  • 40. Chlamydial or Inclusion Conjunctivitis
    • Punctate epithelial keratitis often noted superiorly & can evolve to marginal or subepithelial infiltrates
    • Micropannus can occur
    • One of the most common forms of neonatal conjunctivitis in the newborn assoicated with pneumonitis
    • Neonates have no follicular response making diagnosis more difficult
    • Oral tetracyline 250 mg qid for 3 weeks, erythromycin 500 mg qid for 3 weeks, azithromycin
  • 41. Trachoma
    • Caused by chronic & recurrent chlamydial infections
    • Serotypes A-C
    • Acute phase: follicular conjunctivitis & epithelial keratitis
    • These lead to conjunctival scarring & pannus formation
    • Dry eye, trichiasis & entropion
    Arlt’s lines
  • 42. Trachoma
    • Herbert’s pits are small depressions at the limbus that represent areas of slight thinning at the site of necrotic follicles
    • Can lead to 2ndary bacterial keratitis
  • 43. Allergic (Hay Fever) Conjunctivitis
    • Reaction to airbone allergens and is mediated by IgE antibodies
    • Hallmark is itching
    • Signs: hyperemia, chemosis and mucoid discharge
    • Attacks are usually short lived & episodic
  • 44. Atopic Keratoconjunctivitis
    • Associated with atopic dermatitis
    • Ocular itching, photophobia, and watery or mucoid discharge
    • Small to emdium-sized papillae both upper & lower conjuctivae, milky bulbar conjunctiva, or corneal vascularization & opacification
    • Conjunctival scarring and can lead to symblepharon formation
    • Develop posterior subcapsular or shield shape anterior subcapsular lens opacities
  • 45. Vernal Keratoconjunctivitis
    • Seasonally recurring bilateral inflammation of the conjunctiva seen mainly in young males 4-16 years old with strong history of atopy
    • Tropical climates
    • Intense itching, blepharospasm, photophobia, blurred vision, and copius mucoid discharge
    • Palpebral = upper tarsus where a diffuse papillary hypertrophy develops with giant (cobblestone) papilae
  • 46. Vernal Keratoconjunctivitis
    • Limbal vernal more in superior limbus is more common in blacks & asian
    • Limbus appears thickened, gelatinous appearance with scattered opalescent mounds and vascular injection
    • Horner-Trantas’ dots (collection of active & degenerated eosinophils)
    • can be observed in hypertrophic limbal tissues
    • Sterile epithelial ulcers with an oval or shield shape, & underlying stromal opacification, may develop in the mid superior cornea
  • 47. Giant Papillary Keratoconjunctivitis
    • Chronic inflammation of the conjunctiva with prominent papillary hypertrophy of the superior tarsus
    • Associated with soft contact lens material, protein debris accumulating on the lens surface, or chemicals involved in lens cleaning
    • Also seen in ocular prosthesis, loose nylon sutures, filtering blebs
  • 48. Superior Limbic Keratoconjunctivitis
    • Chronic, idiopathic recurrent condition characterized by ocular irritation & redness
    • Women between ages 20 & 70
    • Recurrences of disease can occur over 1 to 10 years
    • Can sometimes resolve spontaneously
    • Often bilateral but 1 eye more severely affected
    • Signs: fine papillary reaction on the superior conjunctiva & hypertrophy of the superior limbus
    • Filamentary keratitis involving the superior 5 th of the cornea is seen frequently
    • Associated with hyper or hypo thyroidism
  • 49. Stevens-Johnson Syndrome (erythema multiforme major)
    • Acute, inflammatory, vesiculobullous reaction of the skin & mucous membranes
    • Children & young adults, and more prevalent in females
    • Acute onset of fever, arthralgia, malaise, and upper or lower respiratory tract symptoms
    • Cutaneous eruptions follows within days
  • 50. Stevens-Johnson Syndrome (erythema multiforme major)
    • Bullous eruptions with membranes or pseudomembranes formation occur
    • Mucopurulent discharge is common
    • Late ocular complications include symblephara, trichiasis, dry eye
  • 51.  
  • 52. Conjunctival Nevus
    • Congenital hamartomas that consist of nests of modified melanocytes (nevus cells)
    • Junctional, compound, & subepithelial nevi occur in the conjunctiva
    • An important variation in the conjunctiva is the frequent occurrence ofsmall epithelial inclusion cysts within nevi particularly within compound or subepithelial ones
    • Rarely undergo malignant transformation
  • 53. Pinguecula
    • These elevated, fleshy conjunctival masses are located in the interpalpebral region, most commonly on the nasal side
    • Yellow or light brown
    • Associated with chronic actinic exposure, repeated trauma, and dry and windy conditions
    • Histologically, they are composed of abnormal collagen bundles with staining characteristics similar to elastic tissue
    • Elastotic degeneration , but the tissue is not actually composed of elastin
  • 54. Pterygium
    • Benign proliferation of fibrovascular tissue covered by conjunctival-like epithelium extending onto the peripheral cornea
    • Risk factor: UV light, wind & dust
    • Histopath: subepithelial fibrovascular tissue and elastotic degeneration of collagen
    • Can occur above or within bowman’s layer
    • Corneal epithelial iron line (Stocker’s line) can be seen in advance of the head of a pterygium on the cornea
    • Indications or removal: reduced vision due to invasion of visual axis, irregular astigmatism, & significant ocular irritation
  • 55. Pyogenic Granuloma
    • Misnomer because the lesion does not represent granulomatous inflammation
    • Rather a reactive proliferation of vascular endothelial cells and granulation tissue
    • Raised, fleshy, red pedunculated lesion can arise from skin or conjunctiva
    • Often accompanied by mucopurulent discharge
    • After inflammatory conditions such as chalazia or chemical burns, or after conjunctival surgery
  • 56. Suture Granuloma
    • Clinically appears similar to a pyogenic granuloma
    Suture granuloma after strabismus surgery
  • 57. Conjunctival / Corneal Phlyctenules
    • Focal transluent lymphocytic nodules located at the limbus
    • Neutrophils enter the nodule a few days after onset as necrosis develops
    • Result from delayed cell-mediated hypersensitivity reaction to Staphylococcal antigens or tubercle bacilli
    • Limbal may result in fibrosis and vascluarization of the peripheral cornea
    • may wander across the cornea producing vascularization & scarring
  • 58. Conjunctival Viral Papilloma
    • Benign lesion of the conjunctiva consists of multiple fibrovascular connective tissue cores with an overlying epithelium
    • Lesions may be sessile or pedunculated
    • They are caused by a papilloma virus
    • In older adults, these lesions can be premalignant
    • Excision, cryotherapy
    • Sessile more in older patients and to be premalignant
  • 59. Conjunctival/Corneal Intraepithelial Neoplasia
    • Localized to the epithelium and do not invade the epithelial basement membrane
    • Spectrum of malignant change from a benign appearance to severe dysplasia & anaplasia throughout the entire epithelial thickness
    • Gelatinous, sessile appearance w/ numerous superficial corkscrewlike blood vessels typically located at the limbus
  • 60. Conjunctival/Corneal Intraepithelial Neoplasia
    • Corneal inolvement appears as irregular opalescent appearance with small, white, intraepithelial opacities and a central fimbriated edge
    • Leukplakia (white plaque of keratin protein) may overlie a portion of the CIN
    • Stains with rose bengal
    • HPV strains have been detected inmany o these lesions
    • Invasion to BM= squamous cell carcinoma
  • 61. Benign Lymphoid Hyperplasia
    • Composed of a mixture of T and B lympocytes
    • Looks similar to a malignant lymphoma
    • Similar histopath appearance, immunohistochemical studies
  • 62. Conjunctival Lymphoma
    • Localized lymphoma on the bulbar conjunctiva
    • Biopsy was consistent with B-cell lymphoma
    • Composed of a monoclonal B-lymphoproliferation
    • Southern blot hybridizatio studies looking for Ig gene rearrangements are often required to diagnose lymphoma
    • R/O systemic lymphoma
  • 63. Systemic Lymphoma
    • Conjunctival lesion in a patient with systemic lymphoma
    • Lesions elevated and salmon colored
    • The surrounding tissue is uninflamed
    • Treated with systemic chemotherapy
  • 64. Primary Acquired Conjunctival Melanosis (PAM)
    • Intraepithelial melanocytes proliferate to produce multiple flat, brown patches of unilateral pigmentation within the superficial conjunctiva
    • Acquired, occurs in midddle age
    • PAM is different from acquired racial melanosis & from secondary acquired melanosis caused by Addison’s disease, radiation, pregnancy, or other causes
    • PAM have malignant potential, melanoma develops in 20-30%
    • Nodules that develop in previously flat lesions
  • 65. Racial Melanosis
    • PAM is different from acquired racial melanosis & from secondary acquired melanosis caused by Addison’s disease, radiation, pregnancy, or other causes
  • 66. Conjunctival Concretions
    • Represent trapped foreign body such as dust in the conjunctival epithelium
    • Present as foreign body sensation if numerous and very elevated
  • 67. Kaposis Sarcoma
    • 20% of patients with AIDS
    • 7% affect the conjunctiva
    • The lesion is elevated and highly vascular
    • Conjunctival lesions are nodular or diffuse, blue-red or deep-brown, and often elevated
    • Kaposi's sarcoma arises from vascular elements, including endothelial cells and pericytes
  • 68. Chemical Injuries
    • Acid
    • Alkali
  • 69. Conjunctival Sarcoid
    • Sarcoidosis is a multisystem disorder
    • more common in blacks than whites
    • Characterized by the presence of noncaseating granulomas
    • Multiple sarcoid nodules in the inferior fornix
    • Pulmonary involvement is the most frequent form of the disease and usually presents as bilateral hilar adenopathy with or without parenchymal involvement.
    • Ocular involvement is the second most common manifestation, seen in up to 50% of affected patients
    Multiple sarcoid nodules in the inferior fornix resembling follicles
  • 70. Subconjunctival Hemorhage
    • Rupture of conjunctival blood vessel due to trauma, valsalva, or blood dyscrasia
  • 71.  
  • 72. Scleral Disease
    • 1. Episcleritis
    • 2. Scleritis
    • 3. Scelromalacia Peforans
    • 4. Congenital Melanosis Oculi
  • 73. Episcleritis
    • Inflammation & vasodilation of episclera
    • Not associated with systemic disease
    • Self-limited disease generally seen in young to middle age adults
    • Nodular or diffuse
    • No tenderness or pain
  • 74. Scleritis
    • Anterior
      • Sectoral
      • Nodular
      • Diffuse
      • Necrotizing
    • Posterior
  • 75. Scleritis
    • Associated with numerous autoimmune 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, scleral thining, marginal keratolysis, and scleral perforation
  • 76. Scleromalacia Peforans
    • Nodular Scleritis
      • Commonly seen in rheumatoid arthritis
    • Scleromalacia perforans
      • Painless form with no obvious inflammatory sign
      • Seen in severe RA
  • 77. Jules Stein Eye Institute, University of California, Los Angeles
  • 78. Corneal Disease - Infectious
    • 1. Bacterial Keratitis: S. pneumonia
    • 2. Bacterial Keratitis: P. aeruginosa
    • 3. Fungal Keratitis
    • 4. Acanthamoeba Keratitis
    • 5. Primary Herpes Simplex Virus Infection
    • 6. Herpes Simplex Virus Dendritic Keratitis
  • 79. Corneal Disease - Infectious
    • 7. Herpes Simplex Virus Geographic Keratitis
    • 8. Herpes Simplex Virus Necrotizing Stromal Keratitis
    • 9. Herpes Zoster Dendritiform Keratitis
    • 10. Marginal Keratitis Associated with Staphylococcal Blepharitis
  • 80. Corneal Dystrophies/Inherited Diseases
    • 11. Luetic Intersitial Keratitis
    • 12. Corneal Epithelial Membrane Dystrophy (Map-Dot-Fingerprint Dystrophy)
    • 13. Lattice Corneal Dystrophy
    • 14. Granular Dystrophy
    • 15. Macular Dystrophy
  • 81. Corneal Degeneration
    • 16. Fuchs’ Endothelial Dystrophy
    • 17. Keratoconus
    • 18. Corneal Arcus
    • 19. Calcific Band Keratopathy
    • 20. Secondary Lipid Kertopathy
    • 21. Salzmann’s Nodular Degeneration
  • 82. Corneal Degeneration
    • 22. Neurotrophic Keratopathy
    • 23. Mooren’s Ulcer
    • 24. Corneal Foreign Body
    • 25. Alkali Burn
    Other Corneal Conditions
  • 83. Bacterial Keratitis
    • Etiology
      • trauma
      • contact lens wear
      • dry eye
      • use of contaminated topical medications
    • Lab confirmation essential
    S. aureus
  • 84. Bacterial Keratitis
    • Virulent gram- negative organisms
    • Rapid evolution
    • Tenacious mucopurulent discharge
    • Opacification & edema adjacent to ulcer
    • Stromal necrosis due to proteolytic enzymes
    • Seen among contact lens wearer
    P. aeruginosa
  • 85. Fungal Keratitis
    • Filamentous ( Fusarium ) or Yeast ( Candida spp)
    • Dirty gray white, dry infiltrate with feathery borders
    • Multiple or satellite infiltrates
    • Large ulcers have endothelial plaque & hypopyon
    • Can extend into the anterior chamber & perforation
  • 86. Acanthamoeba Keratitis
    • Seen in contact lens wearer who make 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 infiltrate in late phase
    • Commonly misdiagnosed as HSV
  • 87. Primary Herpes Simplex Virus Infection
    • Acquired from the environment
    • Unilateral vesicular blepharoconjunctivitis
    • Pruritic vesicles of the lids, skin, & eyelid margin
    • Follicular conjunctivitis & palpable preauricular lymph node
    • Treatment: oral ACV & topical TFT or ACV`
  • 88. Herpes Simplex Virus Dendritic Keratitis
    • Majority of patients have a recurrent ocular disease
    • Asymptomatic, mild foreign body sensation, photophobia, redness & blurred vision
    • Starts as discrete punctate epithelial keratitis, coalesce, dendritic lesion (swollen opaque epithelial cells) commonly in the center
    • Characteristic terminal bulbs
  • 89. Herpes Simplex Virus Geographic Keratitis
    • Lysis of desquamated cells result to an ulcer
    • Stains with rose bengal dye
    • Geographic map ulcers develop by centrifugal spread of HSV
    • Sub-epithelial infiltrates serve as markers of past infection and leave as scars
    • Sectoral or diffuse reduction in corneal sensation
    • Diagnosis mainly on signs
    • Tissue culture or Antigen detection techniques
  • 90. Herpes Simplex Virus Disciform Keratitis
    • Focal circular area of microcystic edema overlying a mild stromal inflammatory infiltrate & edema with descemets folds & underlying kp’s
    • Photophobia & decreased vision
    • Cell mediated immune response to viral antigens in the stroma
  • 91. Neurotrophic or metaherpetic ulcer
    • Recurrent HSV can damage the epithelial basement membrane & anterior stroma
    • Postinfectious (sterile) keratopathy
    • Round or oval ulcer with smooth, thickened edges that often overlie an area of stromal inflammation or inactive stromal scarring
    • Risk for stromal melting & perforation
  • 92. Herpes Zoster Dendritiform Keratitis
    • Pseudodendrites
    • Have heaped up epithelium with unusual branching patterns but lack the terminal bulbs
    • Represent lytically infected corneal epithelial cells
  • 93. HZO
    • Complication:
      • Mucous plaques
      • Nummular keratitis
      • Disciform keratitis
      • Deep stromal keratitis
      • Perforation
      • Postherpetic Neuralgia
  • 94. Ocular Rosacea
    • Oculodermatologic disease by facial telangiectasia & erythema
    • Sebaceous gland dysfunction of the face, neck, & shoulders
    • Type IV hypersensitivity reaction
    • Racalcitrant meibomian gland dysfunction &/or staphylococcal blepharitis
    • Corneal neovascularization
  • 95.  
  • 96. Corneal Epithelial Basement Membrane Dystrophy (Map-Dot-Fingerprint Dystrophy)
    • Most common anterior corneal dystrophy
    • Bilateral & can have dominant inheritance (often incomplete penetrance)
    • Women, 2% of general pop
    • Gray patches, microcysts, or fine lines are seen in the central epithelium
    • Abnormal epithelial turnover, maturation, and production of basement membrane
  • 97. Corneal Epithelial Basement Membrane Dystrophy (Map-Dot-Fingerprint Dystrophy)
    • Histologically:
      • Map: Thickened basement membrane with extension to the epithelium
      • Dot: Abnormal epithelial cells with microcysts (Cogan’s microcystic dystrophy)
      • Fingerprint: fibrillar material between the basement membrane & bowman’s layer
    • Symptoms of recurrent: pain, photophobia, tearing, and blurred vision
    • More common after age 30
    • 10% of these patients have recurrent erosion
    • 50% of patients with RES have MDF dystrophy
  • 98. Lattice Corneal Dystrophy
    • Auto dominant with variable expression
    • First decade of life
    • Type I (commonest)
    • Cornea has refractile lines, small white dots, & haze in the central superficial stroma
  • 99. Lattice Corneal Dystrophy
    • Represent amyloid deposit in the axial anterior stroma
    • Can present as RES
    • Vision dimished by 30’s
    • Birefringence of the Congo red stain is seen with polarized light.
  • 100. Granular Dystrophy
    • Auto dominant
    • Discrete, chalky, granular opacities in the axial cornea with clear areas of intervening stroma
    • Granular deposits represent hyaline deposits (by E/M granules with phospholipid & microfibrillar protein)
    • Blurred vision middle to late 30
    • The hyaline material stains red with Masson's trichrome stain
  • 101. Macular Dystrophy
    • Least common
    • Auto recessive
    • Early loss of vision
    • Deposits of glycosaminoglycans (mucopolysaccharides)
    • Gray white irregular feathery lesions in the axial stroma going deep & peripheral
    • Alcian blue staining of extracellular and intracellular mucopolysaccharides occurs in all layers of the cornea, including the epithelium, endothelium, and Descemet's membrane
    • Requires PKP
  • 102. Cornea Guttata
    • Peripheral- Hassall-Henle bodies
    • Central- Cornea guttae
    • No inheritance pattern
    • Round, dark, drop-like prominences at Descemet’s membrane & endothelium
    • Fine, brown, pigment granules on the posterior surface of the cornea
    • Guttae represent thickened & localized anvil-shaped excrescences of descemet’s membrane
    • Beaten-metal appearance resembling skin of an orange
    endothelial mosaic
  • 103. Fuchs’ Endothelial Dystrophy
    • Hereditary atrophy of the endothelium
    • 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 cataract surgery
  • 104. Posterior Polymorphous Dystrophy
    • Posterior polymorphous dystrophy
    • Autosomal dominant disorder of the corneal endothelium is almost always bilateral
    • Broad bandlike opacities can occur at the level of Descemet's membrane and the endothelium
  • 105. Keratoconus
    • Central or paracentral cornea undergoes progressive thinning & bulging
    • Cone shape cornea
    • No associated inflammation
    • Unknown cause relation to atopy, down syndrome, congenital amaurosis & eye rubbing
    • Tends to progress during adolescent years
    • Cone shape induces myopia, irregular astigmatism, & decreased vision
    • Corneal findings: Vogt’s striae, Flesicher’s rings, irregular scissoring
  • 106. Vogt’s Limbal Girdle
    • Mild form of limbal calcific band keratopathy
    • Usually irregular and slightly elevated and may contain small "Swiss cheese" holes
  • 107. Spheroidal Degeneration
    • Spheroidal degeneration, mild
    • Multiple golden-brown spherules in the superficial cornea
    • Spheroidal degeneration, advanced
    • Brownish-yellow deposits are more confluent and are located in the central cornea in this case
    • Spheroidal degeneration characteristically occurs in the interpalpebral zones
    • Associated with chronic actinic exposure and dry and windy conditions
    • Similar to band keratopathy, it may also be associated with chronic localized ocular inflammation
  • 108. Calcific Band Keratopathy
    • Characteristically this occurs in the interpalpebral region
    • Calcium deposits in this region result from localized elevations of pH favoring calcium precipitation and increased evaporation, which increases the local concentration of calcium
    • This condition may be idiopathic but is usually associated with localized ocular inflammatory processes or systemic hypercalcemia
  • 109. Salzmann’s Nodular Degeneration
    • These elevated bluish-white superficial nodules
    • More common in females and most commonly occur in the fifth decade of life or later
    • The condition may be associated with localized corneal inflammation
    • Histopathology shows subepithelial hyaline nodules that replace Bowman's layer
  • 110. Neurotrophic Keratopathy
    • Involves the central or inferior paracentral cornea
    • Epithelial defects stains with fluorescein heavily
    • Horizaontal oval
    • Raised rolled-up gray edges
    • Progressive sterile ulceration or superinfection can result in perforation
    • Factors leading to this are: decreased sensitivity to corneal trauma, dessication, and cellular functional impairment due to a loss of the trophic influence from the nerves
    • Etiology: Cranial + peripheral nerve problems, Anesthetic abuse, neurosurgical procedures
  • 111. Mooren’s Ulcer
    • Chronic, progressive, idiopathic necrotizing ulceration of the peripheral cornea stroma & epithelium
    • Spreads circumferentially and then centripetally with a leading undermined edge of deepitehlialized tissue
    • Inflammed ey, intense pain
    • Spontaneous perforation
    • Autoimmune disease
  • 112. Mooren’s Ulcer
    • Both HMI & CMI mechanisms play a role
    • The epithelium is absent in areas of active ulceration
    • Vascularized pannus leading up to areas of active ulceration
    • Abrupt transition between involved and uninvolved cornea with an overhanging edge
  • 113. Corneal Foreign Body
    • Common
    • Etiology
    • Imperative to evert the upper lid
    • Removal essential
    • Cause abrasion linear, fine , vertical
    • May cause secondary bacterial infection
  • 114. Vitamin A Deficiency
    • Bitot spot, a white-gray irregular plaque that usually occurs near the limbus in the interpalpebral region
    • A gas-producing bacteria, Corynebacterium xerosis , is responsible for the foamy appearance in this lesion
    • Marked keratinization of the inferior cornea
    • Corneal surface is dry, and the light reflex is irregular
    • Goblet cell function is impaired in this disorder, and there is a lack of mucin
  • 115. Corneal Abrasion
    • Epithelium of cornea removed by trauma or foreign body
    • Pain, photophobia & blurred vision
  • 116. Thyroid Eye Disease
    • Infiltration of the extraocular muscles and connective tissue can result in severe proptosis and orbital inflammation
    • Patient had chronic exposure keratitis and developed an indolent ulcer
    • Exophthalmos and lid retraction predispose to corneal exposure
  • 117. THANK YOU Thank you