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Clinical pearls (Anterior Segment)
- 1. Clinical Pearls on Anterior Segment Suraj Chaurasiya, B.Optom, PGDOVS (LVPEI) Assistant Optometrist Contact Lens and Cornea specialist CL Gupta Eye Institute, Moradabad
- 2. Clinical pearls Lorin, Martin I., Debra L. Palazzi, Teri L. Turner, and Mark A. Ward. "What is a clinical pearl and what is its role in medical education?." Medical teacher 30, no. 9-10 (2008): 870-874.
- 3. Red Eye • History of occurrence • History of previous ophthalmological and medical history • Onset • Pain • Area and type of congestion • Cornea • AC reaction • Lids Bal, Sharon K., and Gary R. Hollingworth. "Red eye." Bmj 331, no. 7514 (2005): 438.
- 4. How to make etiological diagnosis of corneal ulcer based on clinical examination? • Detailed history Occurrence Trauma Duration Onset Pain • Slit lamp examination Size of epithelial defect & infiltrate Nature, depth and edges of infiltrate Associated thinning Surrounding cornea
- 5. Sterile Vs Infective infiltrate Sterile Infiltrate Infectious Infiltrate Smaller lesion (<1mm) Larger lesion( >1mm) More peripheral More central Minimal epithelial damage (Defect size compared to underlying infiltrate) Significant epithelial defect (Size of staining defect closely mirrors size of underlying stromal lesion) No mucous discharge Mucopurulent discharge Less pain and photophobia Pain and photophobia Little to no anterior chamber reaction Anterior chamber reaction No lid involvement Lid oedema Stein, Raymond M., Thomas E. Clinch, Elisabeth J. Cohen, Gail I. Genvert, Juan J. Arentsen, and Peter R. Laibson. "Infected vs sterile corneal infiltrates in contact lens wearers." American journal of ophthalmology 105, no. 6 (1988): 632-636.
- 6. Bacterial Fungal Viral Protozoal Eye lid edema Dry greyish white infiltrate Punctate epithelial keratitis Irregular and greyish epithelial surface Conjunctival hyperemia with a papillary reaction Feathery Margins Dendritic ulcers which may or may not have terminal bulbs Epithelial pseudo dendrites Epithelial defect with adherent exudate Satellite lesions Geographic ulcers Focal anterior stromal infiltrates Stromal infiltrate Dense suppuration Reduced corneal sensation Enlargement and coalescence of infiltrates from ring abscess Hypopyon Hypopyon Corneal melting stromal necrosis Copeland and Afshari’s Principles and Practice of Cornea_2013_Vol 1;page no. 313
- 7. Courtesy: Kanski’s book, cornea chapter
- 8. Non-severe Vs Severe corneal ulcer Features Non-severe Severe Progression Slow Rapid Infiltrate area <6mm >6mm depth Sup 2/3 inner 1/3 Perforation unlikely imminent or present Scleral involvement absent present
- 9. Notes: - CFW (calcoflour white): both clinical mycology (study of fungus) and parasitology - CA and BA (for fastidious organism bacteria): it will grow only if specific nutrients are present - BHI (Brain heart infusion): used for bacteria - THI (sodium thio-glycolate) (on the top of the tube aerobic bacteria will grow (as they needs more O2, anaerobic bacteria will grow in the buttom of the tube where )2 concentration less - Saboraud Dextrose agar (for fungus)- acidic PH 5 that’s why bacteria can not grow in this media Microbiology Workup Smearing on glass slides Smearing on glass slide BA CA BHI Thio SDA Gram
- 10. Thank you
Editor's Notes
- *When did the condition start? Is the condition unilateral or bilateral? • A foreign body or trauma is usually unilateral, whereas conjunctivitis may start as unilateral and then become bilateral. Was the onset of the symptoms acute or gradual? • Acute onset may indicate a corneal foreign body or abrasion or foreign body trauma. If the patient reports a foreign body sensation, the possible diagnoses are conjunctivitis, conjunctival/subtarsal foreign body, corneal foreign body, keratitis, and corneal ulcer If the patient wears contact lenses, contact lens-related red eye should be referred for further ophthalmological review, as corneal ulceration must be excluded. If the patient is photophobic, this can indicate possible underlying anterior uveitis or corneal epithelial disturbance. *The physician should consider whether the patient has had previous similar episodes or whether there are any underlying systemic associations of conditions known to cause red eye, such as: • HLA-B27 histocompatibility complex-positive patients • Tuberculosis, syphilis • Connective tissue disorders (including rheumatoid arthritis, Sjogren's syndrome, and systemic lupus erythematosus) • Granulomatosis with polyangiitis (Wegener's) • Relapsing polychondritis • Hypertension. * The most important associated symptoms to note in the history are the presence of reduced visual acuity or a deep aching pain within the eye, indicating the presence of a more serious underlying diagnosis, such as angle-closure glaucoma, anterior uveitis, or scleritis.
- polymerase chain reaction (PCR) for viral
- Kimura spatula (blade stand) CFW (calcoflour white): both clinical mycology (study of fungus) and parasitology CA and BA (for fastidious organism bacteria): it will grow only if specific nutrients are present BHI (Brain heart infusion: (bacteria) THI (sodium thio-glycolate) (on the top of the tube aerobic bacteria will grow (as they needs more O2, anaerobic bacteria will grow in the buttom of the tube where )2 concentration less Saboraud Dextrose agar (for fungus)-acidic PH 5 that’s why bacteria can not grow in this media