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Corneal Farinata
Small, grayish-white flecks in deep corneal stroma (not in endothelium).

Interpalpebral limbal region.

Seen with indirect retro, not specular.
Descemet's Striae

More often in elderly.

DDX
• forceps delivery at birth (Descemet’s Rupture)
• congenital glaucoma
• keratoconus (Vogt’s striae)
• keratoglobus
Hassal-Henle Bodies
(Descemet's Warts)
More often in young pt.s

DDX: corneal guttata

Small circular, dark areas projected into endothelium from Descemet's.

Found in peripheral cornea.
Mosaic Shagreen

Mostly aged related.

Anterior type - polygonal pattern of gray-white opacities at the level of Bowman's and basal epithelium.

Posterior type - same as anterior but involving deep stroma and Descemet's membrane.
Hudson Stahli Line

Linear brownish-green deposition of iron on the lower 1/3 cornea where upper and lower lids meet.
Corneal Arcus

Indication of elevated cholesterol, regardless of age.

Located in stroma.

Lipids end at Bowman's, giving a clear zone between limbus and involved cornea.
Dellen

Paralimbal corneal thinning at the base of a corneal/conj. elevation:

Pinguecula
Pterygium
Chemosis
Filtering Bleb
Rectus muscle surgery

Saucer-like depression, where NaFl pools, but does not stain brightly.

Use Lacrilube TID.
Terrien's Marginal Degeneration

Non-inflammatory thinning of peripheral cornea.

Males>females, appears around 20-30

Perilimbal thinning begins superiorly then spreads laterally.

Spec Rx/RGPs
Protective Eyewear
Conjunctival flap resection.
Calcific Band Keratopathy

-Degen. of superficial cornea, esp. Bowman's.
-From chronic inflamm. ocular dz. such as uveitis or keratitis.
-Hyperparathyroidism, vitamin D toxicity, or sarcoidosis
-Elevated serum phosphorus caused by renal failure.
-Decreased VAs and FB sensation.

-Anesthetize cornea
-Apply EDTA, scrape cornea
-CAP and AT
Salzmann's Nodular Degeneration

-Non-inflammatory deposition of hyaline plaques between epi. and Bowman's
-Referral to penetrating keratoplasty or phototherapeutic keratectomy if vision reduced.

Mooren's Degeneration

-Slowly progressive marginal ulcer beginning on teens or early twenties.
-More severe, bilateral in younger people.
-Eye becomes red and painful, spreads to the whole cornea.

-Keratoplasty, conj. resection.
Coat's White Ring

Small corneal opacity indicating the presence of a previous FB.

Deposit containing Fe/Ca.
Degeneration
An acquired loss of function associated with either aging, inflammation, infection, or systemic disease.
Dystrophy
Primary corneal disease not associated with previous inflammatory, infectious, or systemic disease.
Map Dot Fingerprint

-Most common anterior corneal dystrophy.
-Thickened epi. basement membrane causes ridges resembling maps or fingerprints.
-Microcysts resemble dots.
-Negative staining (elevation).

Pt.s with symptoms:
-Hypertonic drops
-Bandage CL
-Epithelial Scraping
Recurrent Corneal Erosions

-Poor hemidesmosomal attachments between epi. and basement membranes.

-1gtt 1% cyclogyl or 2-5% homatropine
-1/2" Polysporin/Genta UNG

Once healing is complete, 6 week Tx:
-5% NaCl UNG, MURO 128 HS
-Lacrilube
-2-5% NaCl gtt's QID, Absorbonac

Macular Stromal Dystrophy - AR

-Gray-white indistinct round opacities in central cornea
-Mucopolysaccharide deposits
-reduced VAs at an early age
Granular Stromal Dystrophy - AD

-Discrete, crystal like granular deposits in central ant. stroma
-Hyaline deposition.
-Dec. VAs starting around 50
Lattice Stromal Dystrophy - AD

-Lattice-work of lines and dots in central ant. stroma
-Amyloid deposition
-Discomfort and decreased VAs due to epi. irregularity and stromal haze.
Fleck Stromal Dystrophy
AD, bilateral

Lesions appear as well demarcated, small, flat, gray-white specks throughout stroma.

May form ring-shaped opacities.

VAs not affected.
Central Crystalline Dystrophy of Schnyder - AD

-Onset during 1st year of life, but often undetected until 3rd/4th decade.
-Occasionally associated with hyperlipidemia.
Cornea Guttata

-Abnormal production of Descemet's collagen by endothelial cells causes areas of thickening in the central corneas.
Fuch's endothelial-epithelial dystrophy

1st stage - guttata spreading toward periphery.

2nd stage - cornea becomes edematous and folds develop in Descemet's membrane.  Bullae are formed.

3rd stage - subepithelial layers may become vascularized and scarred.

-dec. vision due to edema (worse in morning) and scarring.
-pain associated with ruptured bullae and epi. loss.

-5% NaCl 6-8x per day
-Bandage contact lens
-Hair drier held at arm's length
-Antiglaucoma meds
Anterior Keratoconus

-Apical thinning of the cornea typically inferior and nasal, bilateral, during 2nd decade of life.
-Irregular astigmatism
-Vertical striae in Descemet's membrane
-Prominent corneal nerves

-Flescher's ring
-Thinning of corneal stroma
-Acute Hydrops - ruptured Descemet's leading to corneal edema.
-Munson's sign

-Spec Rx for irreg. astig.
-CL
-Keratoplasty
Posterior Embryotoxin

-Anterior displaced Schwalbe's ring, increasing the risk of glaucoma.

Axenfeld's anomaly

-Iris strands extend across AC angle to insert into prominent Schwalbe's ring.

Reiger's Anomaly

-Prominent Schwalbe's ring, anterior synechiae, and hypoplasia of iris stroma.
Megalocornea

Microcornea
-13mm or more
-myopia, high astigmatism, Krukenburg's spindle, congenital glaucoma.

-10mm or less
-20% develop glaucoma
-any type of refractive error
Krukenburg's Spindle

-Melanin deposit
-CB rubs against zonules, release of pigment into AC which deposits in a vertical band.
Adrenochrome

-Melanin deposit on conj. and cornea between Bowman's and epi. basement membrane.
-Due to epinephrine or other glaucoma meds.
Stocker's Line

-Iron deposit on the epi. at the leading edge of pterygium.
Kayser-Fleischer Ring

-Peripheral copper ring in Descemet's peripheral cornea.
-Wilson's disease.
Whorl Deposits

Amiodarone (coronary dilator)
Phenothiazine (antipsychotic)
Chloroquine (antimalarial, lupus)
Indomethacin (arthritis)
Staph Bacterial Keratitis
Exotoxins cause a band of punctate epithelial keratitis across inf. cornea.

-Lid Hygiene
-Erythromycin, Bacitracin, or Polysporin UNG TID-QID or HS in mild cases.
-FQ Q2-3H/QID
-Doxycycline 100 BID
-Minocycline 50 BID

7-14 day therapy
Strep. Bacterial Keratitis
-Diffuse inferior punctate keratitis
-Hemorrages
-Pseudomembrane formation
-Mild mucopurulent exudate
-Associated pre-septal cellulitis
-Associated dacryocystitis

-Erythromycin, Bacitracin, or Polysporin UNG at least QHS
-Polytrim gtt Q2-3H to QID
-FQ Q3H

NO AGs
Hemophilus Bacterial Keratitis
Diffuse punctate keratitis
Limbal infiltrates

-Hemorrhagic conjunctivitis
-Mucopurulent discharge

-Polysporin UNG at least QHS
-Polytrim/FQ gtt Q2-3H
Predisposing factors for corneal ulcers
-Corneal trauma
-Tear film abnormalities
-Corneal degenerations
-Neurotrophic disorders
-Diabetes Mellitus
-Immune disorders
-Use of immunosuppressive medications
Staph. Aureus Corneal Ulcer

Gray-white infiltrated central ulcer

Round or Oval with distinct borders

Occasional sterile hypopyon
Strep Corneal Ulcer

Begins 24-48H after corneal trauma

Gray ulcer that spreads towards central cornea.

Shaggy/indistinct leading edge.

Marked hypopyon common.
Pseudomonas Corneal Ulcer

Infiltration visible as early as 6-8H

Within 24H, grayish, glass ring forms around primary ulcer site

Greenish mucopurulent discharge around ulcer.

Severe AC rxn, hypopyon
Corneal Ulcer Treatment
Gati/Moxifloxacin

1gtt Q30mX12H, then Q1HX2d

0.3% Cipro Q30m-1H

D1 - 2gtt Q15mX6H
D2 - 2gtt Q30m
D3 - 2gtt Q1H

0.3% Ocuflox

D1/2 - 2gtt Q30m WA,
after retiring, 2gtt Q4-6H
D3-7 - 2gtt Q1H WA
D7-9 - 2gtt QID

Cefazolin 33-50 mg/ml
Vancomycin 25 mg/ml
AND
Tobramycin 9-14 mg/ml
Gentamycin 20-40 mg/ml

Q1H ATC

Homatropine 2-5% BID or TID to relieve ciliary spasm and prevent synechia formation.

50mg Minocycline BID
100mg Doxycycline BID

Steroid treatment at 96 hours with signs of improvement.
Gram (+) cocci
Bacitracin 10,000 units/ml
Cefazolin 33mg/ml
Gram (-) cocci
Neisseria
Ceftriaxone 200 mg/kg/day
Gram (-) rods
Pseudomonas, Moraxella, H. Flu
Tobramycin 9.1 mg/ml
Gentamicin 9.1 mg/ml
Marginal Limbal Infiltrates

-Hypersensitivity rxn to staph. and H. aegupticus exotoxins.
-sterile lesion
-grayish oval or linear infiltrate near limbus (small clear area between limbus and lesion)
-vascularization may occur

Tobradex/Zylet/Polypred/Maxitrol

Polysporin + FML
Phlyctenular Keratoconjunctivitis

-delayed type IV rxn
-nodule of lymphocytes which begins near limbus, moves centrally in cornea.
-may have a vascular leash

Combo Tx:
Zylet/Pred-G Q2Hx4d, taper to QIDx3d

Separate steroid/antibiotic:
-Prednisolone acetate Q2Hx4d, taper to QIDx3d
-FQ QID


Verruca
-Common cutaneous wart
-HPV
-Elevated, cauliflower-like lesion with central vascular core
-Begins as diffuse staining, but wart at lid margin may cause superficial staining.
Molluscum Contagiosum
Smooth, elevated nodules with umbilicated central core.

Lesions near lid margin may cause chronic follicular conjunctivitis, keratitis, or corneal pannus.
Pharyngoconjunctival Fever
Adenovirus
-Hx of URI
-Hx of swimming pool exposure
-Purplish-pinkish bulbar hyperemia
-Follicular response
-Palpable, non tender pre aur. node
-Mild SPK, less than EKC
-Mild SEI, less than EKC

Supporting, palliative care:
-Warm compress
-Ocular lubes
-Ocular antihistamine/decongest.
-Aspirin or other analgesics (not for children)
-Cidofovir (Vistide) BID
-Betadine
Epidemic Keratoconjunctivitis
Adenovirus
-Pinkish-purplish bulbar hyperemia
-May have conj. hemorrhages or pseudomembranes
-Follicular response
-Palpable, tender pre aur. nodes
-Rule of 8:
-Most contagious in 1st 8 days
-Diffuse SPK on day 8
-SEI on day 16

If SEI's on visual axis and VA's are lowered, use Pred Forte QID until 20/20, then taper.
Chicken Pox
Varicella
-Red punched-out lesions on lids
-Occasional vesicular lesions on lids, SPK, dendrites, uveitis

-Acyclovir:
2-12yo 20mg/kg QID
13-18yo 800mg QID
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