Undergrduate ophthalmology lecture

1. RA, SLE, Wegner, …

2. • Site: Limbus or corneal periphery
• Size: small, 1-3 mm
• Shape: round
• Colour: Greyish red
• Number: Solitary or multiple
• Surrounded by hyperemia

3. Treatment
• Tonsillitis
• Intestinal parasites
• TB
• Topical steroids
• Topical antibiotics to guard
against 2ry bacterial
infection
• Topical cycloplegics
A. Chemical cauterisation of the ulcer with
Carbolic acid
B. Diathermy & Peritomy of the feeding vessels

4. Aetiology
• Coalescence of punctate erosions in VKC leading to large epithelial defect
• If not treated properly, a plaque containing fibrin and mucus deposits (Shields) on
this epithelial defect which hampers the re-epithelialization of shield ulcer

5. Treatment
• Steroids
• Mast cell stabilisers
• Anti histamine
• Antibiotics
• Tear substitutes
• Debridement of the fibrin & mucus deposits
• Amniotic membrane transplantation (AMT)

6. Definition
Rapidly progressive painful ulcerative keratitis initially affecting
corneal periphery then spread circumferentially & centrally
Aetiology
Unknown, may be:
• Auto-immune disease Limbal vasculitis Ischemic necrosis

7. C/P
• Crescent shaped ulcer
• Starts at corneal periphery
(Limbal vasculitis)
• Creeps Circumferentially &
Centrally
• Has two edges:
1. Advancing edge: undermined,
creeps over the cornea
2. Peripheral Edge: Healed,
Vascularized

8. Treatment
• Steroids
• Cyclosporin A
• Antibiotics, Cycloplegics, Tear substitutes
• Immune-suppressors: Steroids, non steroids
• Conjunctival resection (Peritomy)
• Keratoplasty (lamellar or penetrating) Poor Prognosis !!

9. Caused by loss of corneal sensation (V)
C/P
• Painless
• Loss of corneal sensation
• Resistant corneal ulcer
Treatment
• Preservative free tear substitutes
• Soft bandage contact lens
• Topical neurotrophic substances
• Vit A supplement
• Amniotic membrane transplantation
• Conjunctival flap

10. Incomplete closure of the palpebral fissure when lids are gently closed
A. Lid coloboma
B. Ectropion
C. Post ptosis
surgery
D. Proptosis
Severe illness

11. Pain
Epithelial Defect
Discharge
AC activity
Location

12. Filamentary Keratitis
Filamentary keratitis is a condition in which strands (“filaments”) composed of degenerated epithelial cells
and mucus develop on and adhere to the corneal surface causing pain and foreign body sensation.
Aetiology
1.Dry Eye
2.Neurotrophic
Keratopathy
3.Long term ocular
patching
4.Superior limbic kerato-
conjunctivitis

13. Filaments stained with rose
Bengal
Strands of mucus admixed with
epithelium,
attached at one end to the
corneal surface
C/P

14. Treatment
1) Topical therapy with lubricant drops and
ointment.
2)Bandage soft contact lenses.
3)Prophylactic topical antibiotic
4)Mucolytic agent such as 10% N-
Acetylcysteine can be used topically to
decrease the viscosity of the mucinous
component of the tear film.
5)Topical Hypertonic sodium chloride 5%
drops may also help by deturgescing and
compacting the corneal epithelium.
Medical Treatment Surgical Treatment
1) Manual removal of the corneal
filaments using forceps to temporarily
alleviate pain.
2)Punctal plug

15. Inflammation of the corneal stroma without involvement of epithelium or endothelium
A. Bacteria: Syphilis, TB
B. Virus: HSV, HZV
C. Idiopathic: Cogan’s
syndrome
A. HSV
B. HZV
Cogan’s syndrome:
• Cochlear Deafness
• Optical (interstitial keratitis)
• Glucocorticoids for ttt
• Aortic involvement
• Nerve deafnes

16. Aetiology
Treponema pallidum (Spirochaete)
• Congenital: Common - Bilateral - Young age
• Acquired: Rare - Unilateral - 10 years after 1ry infection - Sexually transmitted
Pathogenesis
Hypersensitivity to Treponema pallidum antigen

17. C/P
1. Progressive stage (2 weeks):
• Severe corneal symptoms (Pain, …) & signs (Ciliary injection, …)
• Salmon Pink corneal patch ( dull pink hazy cornea with deep corneal
vascularisation)

18. 2. Florid stage (2 months):
• Severe corneal symptoms & signs with diminution of vision
• Increased vascularisation & infiltration

19. 3. Regressive stage (2 years):
• Corneal interstitial opacities & ghost vessels
• Uveitis

20. Investigations
A. Wasseman reaction
B. Venereal Disease Research Lab (VLDL)
C. Treponema Pallidum Hemagglutination Test (TPHA)
D. Fluorescent Treponema Antigen (FTA)
Treatment
1. Treat Keratitis: Topical steroids, antibiotics, cycloplegics
2. Treat Syphilis: Penicillins
3. Treat complications: Keratoplasty

21. Inflammation of the deep layers of corneal stroma & endothelium
A. Bacteria: Posterior abscess
B. Virus: HSV, HZV
C. Fungi

22. • An opaque ring, grey to white in
colour, that surrounds the periphery of
the cornea and separated from the
limbus by an area of clear cornea
• Occurs primarily in elder people
• Due to a lipid infiltration of the corneal
stroma
• Innocuous, need no treatment other
than investigate for poor lipid profile

23. • A greyish white band-shaped corneal opacity in
the inter palpebral zone
• Calcium deposits at the level of Bowman
membrane
• Causes:
A. Ocular:
❖ chronic inflammation (Keratitis, Uveitis)
❖ Phthisis Bulbi
B. Systemic: metastatic calcification (hyper-
parathyroidism, renal failure, sarcoisosis,
malignancies, …)
• Symptoms: pain, diminution of vision
• Traetment:
1. Chemical chelation: di sodium edta
2. Mechanical scraping of the calcium deposits
3. PTK (Excimer laser)

24. • Greenish brown ring in the corneal periphery
• Wilson Disease (Hepato-lenticular
degeneration) (Not pathognomonic)
• Due to deficiency in ceruloplasmin (Copper
carrier)
• Copper deposits in Cornea, lens, liver,...

25. • Sympyoms: Stitching pain, lacrimation, photophobia,
..
• Treatment: FB removal (Search for other FBs)

26. • Trachoma
• Floppy eyelid syndrome
• Superior limbic keratoconjunctivitis
• Lagophthalmos
• Chronic blepharitis, Entropion
• Toxicity to topical medications
• Dry eye
• Neurotrophic keratitis
Punctate Epithelial Erosions

27. • Acute, Rapidly progressive
• Central, usually single
• Hypopyon
• Start limbal, spread central & circumferential
• Chronic course
• Limbal
• Single or multiple

29. Definition
Progressive conical distortion of the
cornea with:
• irregular astigmatism
• axial stromal thinning
• apical protrusion
• increasing myopia.

30. Aetiology & Pathogenesis
❖ Unknown, may be:
• Repeated corneal trauma (eye
rubbing)
• Corneal stromal abnormalities
(Collagen disorders e.g. Marfan,
Down)
• Hereditary (AD)

32. Symptoms
❖ Age: Early adulthood
❖ Gradual, progressive, painless
diminution of vision:
• Myopia
• Astigmatism
• Corneal opacities
❖ Frequent change of glasses
❖ Sudden Painful diminution of vision
(Acute Hydrops)

33. • No Evident Clinical signs
• Typical Topographic changes
• Discovered accidentally e.g. patient seeking for LASIK
Signs
• No Evident Clinical signs
• Typical Topographic changes
• Scissoring on retinoscopy

34. Scissoring reflex in retinoscopy

35. • Boat shape angulation of
the lower lid in down
gaze

36. • Sharply focused beam of
light near the nasal limbus
,produced by lateral
illumination of the cornea in
advanced keratonous

37. • The apex of the cone
• Usually inferior to the
pupillary axis

38. • Fine vertical lines in the
deep stroma
• Parallel to the axis of the
cone
• Disappears on gentle
digital pressure
Vogt ==== Vertical

39. • At the base of the cone
• Hemosiderin pigment
deposited in corneal
epithelium

40. • Superficial linear scars
• At corneal apex
• Caused by ruptures in Bowman layer

42. Apex
Base
Apex
Apex

43. Complications
• Acute rupture of Descemet’s membrane, leading to corneal edema
• Sudden, painful diminution of vision
DDx: Disciform keratitis

44. Investigations
• A series of concentric rings is projected onto the cornea and their reflection viewed by the
examiner through a small hole in the centre of the disk.
• A regular-shaped cornea should show equally spaced symmetric reflections.
• If the patient is suffering from astigmatism, the rings will be distorted.

45. • To measure the curvature of the anterior surface of the cornea, particularly
for assessing the extent and axis of astigmatism.

46. • A rotating camera that evaluate:
1. Corneal thickness (Pachymetry)
2. Corneal curvature & Power (Keratometry)

48. Grading of KCN

49. Treatment
• Early cases with mild astigmatism

51. • Using Riboflavin Eye Drops
• Ultraviolet A increases the cross links between
the corneal stromal collagen, thus strengthens
the cornea and prevents KCN progression

52. • Thin plastic, semi-circular rings inserted into the mid layer
of the cornea.
• They flatten the cornea, changing the shape and location of
the cone.

53. • Corneal transplantation to replace the diseased cornea by a healthy
donor cornea
• Penetrating (Whole thickness) (PKP)
• Anterior Lamellar keratoplasty
• Endothelial Keratoplasty

54. • Therapeutic; to restore the damaged cornea, e.g. corneal scar,
vascularisation
• Optical; to restore the transparency & improve VA
• Cosmetic; to improve or correct the distortions and any defects subjected to
the cornea

55. • Donor cornea:
❖ Free from transmissible diseases e.g. HIV, Hepatitis
❖ Transparent with good endothelial count & morphology (Specular microscopy)

56. • Diseased Recipient Cornea is trephined & removed
Femto laser might be used instead of the corneal trephine

57. • Graft is sutured

58. • Early: Astigmatism, Lost Anterior Chamber (Seidel)
• Recurrence of the disease; e.g. HSV
• Corneal graft rejection
• Infection; e.g. endophthalmitis
• Inflammations (Uveitis), IOP elevation

59. Definition
Bilateral corneal disease
characterised by:
• thinning and protrusion of the
entire corneal surface apical
protrusion
• irregular astigmatism

60. Aetiology & Pathogenesis
❖ Unknown, may be:
• Congenital
• Associated diseases; e.g. blue sclera, hyoer-extensibilty of joints

61. DDx
Keratoconus Keratoglobus
Conical Protrusion
Protrusion of Entire
Cornea
Keratectasia Keratoglobus
Unilateral Bilateral
Corneal scar No scar
Inflammatory Congenital

62. Treatment