Lecture about corneal diseases from RCSI

1. CORNEA
Ms. A Bobart Hone
RCSI- 2009

2. Corneal Anatomy
Microscopic Anatomy
• Composed of five layers
– Epithelium
– Bowman’s membrane
– Stroma
– Descemets Membrane
– Endothelium
Nerve Supply of Cornea
Fifth cranial nerve
Avascular

3. Corneal Disease
– Drug associated keratopathy
– Trauma
– Infection
– Allergic
– Autoimmune or Systemic associated
– Dystrophy
– Corneal Transplantation and Refractive Surgery

4. Corneal keratopathies
• Drug induced
– Amiodarone,Indomethacin, Tamoxifen
• All cause corneal verticillata or vortex keratopathy
• Reversible if drug stopped early on

5. Corneal verticillata a.k.a. as vortex
keratopathy

6. Trauma
Trauma
Corneal abrasions
-Superficial Trauma e.g. fingernail scratch to the eye
Signs and Symptoms
-Sloughing of the corneal epithelium.
-Foreign body sensation
-Painful red eye
-Tearing
-Photophobia

7. Corneal abrasion stained with
Fluorescein

8. Trauma Continued
• Diagnosis-
made by using fluorescein to detect the corneal abrasion.
• Treatment
• -Topical cycloplegic
• -Topical antibiotic ointment e.g. chloromycetin
• -Pressure patch for 24 hours
• -Pad removed in 24 hours, (most small abrasions are healed in 24-48
hours)

9. Trauma
• Recurrent corneal Erosions
-Characterized by spontaneous sloughing of corneal epithelium
-Past history of abrasion often present
-Some patients have epithelial basement membrane dystrophy
• Signs and symptoms
Acute onset of pain on wakening (recurring)
Minimal signs and symptoms of original abrasion
• Treatment
Acute episode managed by patching with antibiotic ointment
Long-term- nightly application of lubricating eye ointment to prevent recurrent episode
Resistant cases.-treat with one or a combination of the following: bandage contact lens, anterior stromal
puncture, manual debridement, phototherapeutic keratectomy (PTK) with excimer laser

10. Recurrent Corneal Erosion

11. Other Trauma: Corneal Foreign
Body

12. Infection
• Bacterial
• Viral
• Fungal
• Protozoan

13. Bacterial Corneal Infection
Predisposing factors
-Contact lens wear
-Chronic ocular surface disease (post-herpetic, trauma, dry eyes, corneal exposure)
-Corneal hypoaesthesia
Causative organisms
-Streptococcus
-Staphylococcus
-Pseudomonas
-Enterobacteria
Clinical features
-pain, photophobia
-Marked conjunctival injection, discharge
-Expanding, oval, yellow , stromal infiltrate, hypopyon

14. Bacterial corneal infection
Corneal abscess
Investigations
-Conjunctival swabs for culture and sensitivity
-Gram stain
-Corneal scrapings for culture and sensitivity
-culture contact lenses, case and solutions if a wearer for ‘any’ suspected eye infection
Treatment (rely on cultures /sensitivity)
-Topical antibiotics (Exocin etc) up to 1 hourly drops
-Topical cycloplegies
-topical +/- systemic antibiotics
Staphyloccal keratitis
Hypersensitivity to toxins associated with blepharitis
-marginal corneal infiltrates
Treatment: (1)hygiene
(2)Topical antibiotics +/- steroids

15. Corneal Ulcer with Hypopyon

16. Viral
• HERPES SIMPLEX
– BLEPHARITIS
– CONJUNCTIVITIS
– CORNEAL ULCER- DENDRITIC ULCER
– STROMAL KERATITIS
– ANTERIOR UVEITIS
– ‘MOTH’ EATEN APPEARANCE OF THE IRIS CALLED IRIS ATROPHY
– TRABECULITIS
– RAISED IOP
– ACUTE RETINAL NECROSIS
– OPTIC NEURITIS
– CRANIAL NERVE PALSIES

17. Herpes Simplex
• SIMPLEX INDUCED CONJUCTIVITIS,
BLEPHARITIS, DENDRITIC ULCER
– TREAT WITH TOPICAL ZOVIRAX OINTMENT
5 TIMES A DAY
– CAN GIVE ORAL ZOVIRAX 400MG 5 TIMES A DAY
IF ALLERGIC TO THE OINTMENT

18. Herpes Simplex
• SIMPLEX INDUCED STROMAL KERATITIS, UVEITIS
– TOPICAL OR ORAL ZOVIRAX
– CAN ADD TOPICAL STEROID IF NO EPITHELIAL ULCER PRESENT
– NEVER PRESCRIBE STEROIDS IN THE PRESENCE OF AN EPITHELIAL HERPETIC
DEFECT AND NEVER WITHOUT THE CONCURRENT USE OF ZOVIRAX OR EYE
WILL GET GEOGRAPHIC ULCERATION AND CAN PERFORATE
• CAN USE IV ZOVIRAX IN RETINAL NECROSIS, NEURO
HERPETIC DISEASE

19. Dendritic ulcer

20. HS CORNEAL DISEASE
• IN IRELAND CAN USE THE UNLICENSED DROP
TRIFLUOROTHYMIDINE AS AN ALTERNATIVE TO TOPICAL
ZOVIRAX IN RESISTANT CASES
• CAN USE VALCICLOVIR OR FAMVIR AS ALTERNATIVES TO
ZOVIRAX ORALLY

21. Varicella Zoster Corneal Disease
• HERPES ZOSTER
– BLEPHARITIS
– CONJUNCTIVITIS
– MICRODENDRITES ON CORNEA
– DISCIFORM KERATITIS
– TRABECULITIS
– ANTERIOR UVEITIS
• IRIS ATROPHY
– ACUTE RETINAL NECROSIS
– VII PALSY

22. Varicella Zoster Corneal Disease
– BLEPHARITIS, CONJUNCTIVITIS, MICRODENDRITES
ON CORNEA,
• TOPICAL ZOVIRAX X 5 TIMES A DAY OR ORAL ZOVIRAX
IF INTOLERANT OF THIS 800MG X 5 TIMES A DAY
– DISCIFORM KERATITIS
• AS FOR SIMPLEX BUT NOTE THE DOSE FOR ZOSTER

23. Varicella Zoster Corneal Disease
• VII PALSY SECONDARY TO ZOSTER
– HUTCHINSON’S SIGN
• IF THE TIP OF THE NOSE IS INVOLVED THERE IS MORE
THAN LIKELY TO BE ANTERIOR SEGMENT OF THE EYE
INVOLVEMENT
– ZOVIRAX PO 800MG X 5 TIMES A DAY

24. HERPES INFECTIONS
• HUTCHINSONS SIGN

25. Geographic ulcer from use of unopposed
steroids in Ocular Herpes

26. AdenoViral corneal Disease
Adenovirus
Causative organism Adenovirus (Type 8,19)
Causes conjunctivitis and keratitis (80%)
Does not respond to antivirals
Diagnose with PCR
Treatment
Symptomatic and supportive
Topical Steroid for stromal disease
Preventitive as highly contagious

27. Fungal Corneal Infection
Fungal keratitis
-Frequently preceded by ocular trauma with organic/ plant matter- History very
important
-Is not dissimilar to a bacterial ulcer but also may look like a greyish white ulcer and
may be surrounded by feathery infiltrate
-Slow progression and occasionally hypopyon seen
Scrapings for PAS, Sabourads and PCR
Treatment
-Topical antifungal agents
-Systemic therapy if severe ie endophthalmitis
-Corneal graft ie Penetrating keratoplasty if unresponsive and significant scarring and
continue anifungal Rx

28. Acanthamoeba Corneal Infection
Acanthamoebal Keratitis
-Contact lens wearer at particular risk
-Symptoms worse than signs (severe pain, photophobia)
-small patchy infiltrates
-linear infiltrates (radial keratoneuritis) along distribution of nerves
-Ulceration, ring abscess, satellite lesions.
-Stromal opacification
Diagnosis
-History re lens wera. Tap water, pools, saunas, jacuzzis, old water systems very important
-Corneal scrapings ASAP for stain and culture pcr and electron Microscopy preferably prior to anti-protozoan
Rx
Treatment
-Chlorhexidine, Biguanide- (PHMB), propamidine (BROLENE) drops. The latter is only effective against the
trophozoite form

29. Acanthamoeba Keratitis

30. Allergic disease and the Cornea
Symptoms and signs
-Pain, photophobia
-Lacrimation, mucus discharge
-Conjunctival hyperaemia
-Enlarged papillae on tarsal conjunctiva (cobblestone)
-Punctate keratitis
-Shield ulcer- (epithelial defect covered with mucus plaques)
Treatment
-Identification and elimination of allergens
-Tear substitutes
-Topical mast cell stabilizers
-Topical antihistamines, mucolytics
-Topical steroids in severe cases

31. Allergic Disease and the eye
Atopic Keratoconjunctivitis (AKC)
-Rare, affects young adults
-History of atopic dermatitis, eczema, asthma, etc
Vernal keratoconjunctivitis (VKC, spring catarrh)
Young males
Seen in the Middle east
Association with atopy
Clinical features
-Thickened lid skin and margins
-Associated blepharitis
-Cicatrizing conjunctivitis, symblepharon formation
-varying keratitis
-corneal ulceration
-cataract 10%

32. Allergic Disease and the eye
Treatment:
-topical steroids (short term)
-mast cell stabilizers
-oral antihistamines
-systemic steroids
-subtarsal steroid injection
- immunosuppression (e.g steroids) when indicated
REFER TO CONJUNCTIVAL LECTURE ON ALLERGY

33. AUTOIMMUNE
RHEUMATOID HANDS SCLEROMALACIA
PERFORANS

34. AUTOIMMUNE
• SCLERITIS

35. Corneal Melt

36. Systemic Disease and the Eye- corneal
opacity

37. Dry eye
• Some causes
– Age
– Contact lenses
– Thyroid
– Autoimmune
– Post corneal laser
– Rx the same for all
but treat cause if
possible

38. CORNEAL DISEASE
• CORNEAL DYSTROPHIES
– BILATERAL, PROGRESSIVE CORNEAL DYSTROPHY OF
EPITHELIUM, BOWMAN’S MEMBRANE, STROMA OR
ENDOTHELIUM
– EPITHELIAL
– (MAP,DOT, FINGERPRINT) DYSTROPHY
– PRESENTS WITH RECURRENT EROSONS
– STROMAL
– GRANULAR, LATTICE, MACULAR DYSTROPHY
– ALL OF THE ABOVE PRESENT WITH EROSIONS AND PROGRESSIVE OPACITY
– ENDOTHELIAL
– FUCH’S ENDOTHELIAL DYSTROPHY
– TREATED WITH CORNEAL GRAFTING

39. CORNEAL DYSTROPHIES
• TREATMENT OF THE DYSTROPHIES
– TREAT THE SYMPTOMS OF EROSION
• PATCH WITH PAD OR TRANSPARENT BANDAGE CONTACT LENS
• LIBERAL USE OF LUBRICANTS
• PUNCTAL PLUGS
• SURGERY
– THERAPEUTIC EXCIMER LASER
– CORNEAL GRAFT
– IN FUCH’S A DSAEK CAN BE PERFORMED RATHER THAN A FULL
THICKNESS CORNEAL GRAFT

40. CORNEAL DYSTROPHIES
• Keratoconus
– Ectasia- CHARACTERIZED BY STROMAL THINNING AND APICAL PROTRUSION OF THE
CORNEA
– Axial myopia
– Associated with Down’s Syndrome and Atopia and
excessive eye rubbing

41. CORNEAL DYSTROPHIES
• Keratoconus
– SIGNS ON EXAMINATION
• ‘OIL DROPLET’ SIGN WITH OPHTHALMOSCOPE INSPECTION OF THE RED REFLEX AT ARM’S LENGTH
• STROMAL STRIAE OR VOGT’S STRIAE
• FLEISCHER RING
• MUNSON’S SIGN- BULGE OF THE LOWER LID ON DOWN GAZE
– COMPLICATION
• ACUTE HYDROPS- whitening as fills with fluid because of breaks in Descemets
– TREATMENT
• SPECTACLES
• THEN HARD CONTACT LENS
• TOPICAL TREATMENT WITH RIBOFLAVIN – CROSS LINKING SURGERY
• CORNEAL TRANSPLANTATION
– REFRACTIVE LASER SURGERY CONTRAINDICATED

42. Keratoconus

43. Corneal Transplant
Corneal transplant
Donor tissue to replace unhealthy tissue.
Corneal Graft OR Transplant:
Partial (lamellar) or
Full thickness transplants
Indications
Corneal opacification (scars etc), keratoconus
Main surgical risks include infection, rejection, or astigmatism

44. Corneal Transplant- full thickness

45. Rejected Corneal Graft- full thickness

46. Endothelial Graft

47. Refractive Surgery
• See end of Cataract Lecture