Ed&cornea lecture fatima

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Ed&cornea lecture fatima

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

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