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GWR

GWR. 27 th Sep. History. 55 yr old lady, Accidentally poked LE with finger on morning of consult Developed subsequent LE redness and tearing VR 6/21  6/7.5, VL 6/15  6/7.5 IOP R 18, L 14. Approach to peripheral corneal thinning. History Pain Conjunctival injection vs quiet eye

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GWR

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  1. GWR 27th Sep

  2. History • 55 yr old lady, • Accidentally poked LE with finger on morning of consult • Developed subsequent LE redness and tearing • VR 6/21  6/7.5, VL 6/15  6/7.5 • IOP R 18, L 14

  3. Approach to peripheral corneal thinning • History • Pain • Conjunctival injection vs quiet eye • Systemic review • Preceding trauma / inciting injury • Examination • VA • Unilateral/Bilateral • Location of thinning • AC activity • Associated scleritis • Posterior segment exam • Systemic examination

  4. Systemic Involvement Bacterial Viral - TB - HIV - Syphilis - Hep C - Gonococcus - Shigella - Salmonella Infectious Non-infectious Autoimmune Malignancy - RA - Leukaemia - SLE - WG - PAN - Relapsing polychondritis - Sarcoidosis - IBD

  5. Systemic Involvement Bacterial Viral - TB - HIV - Syphilis - Hep C - Gonococcus - Shigella - Salmonella Infectious Non-infectious Autoimmune Malignancy - RA - Leukaemia - SLE - WG - PAN - Relapsing polychondritis - Sarcoidosis - IBD

  6. Systemic bacterial infections • TB • History of chronic cough, fever, night sweats • ? Previous vaccination • Granulomatous uveitis • Scleritis • Retinitis • Vasculitis • Choroidal granulomas • Optic neuritis • FBC for leucocytosis • Mantoux • CXR: Infective foci, apical lesions • Syphilis • Gonococcus • Shigella • Salmonella

  7. Systemic bacterial infections • TB • Syphilis • Sexual history • Granulomatous uveitis • Interstitial keratitis • Periphlebitis • Salt and pepper fundus • Optic neuritis • FBC for leucocytosis • VDRL • FTA • HIV serology • Gonococcus • Shigella • Salmonella

  8. Systemic Involvement Bacterial Viral - TB - HIV - Syphilis - Hep C - Gonococcus - Shigella - Salmonella Infectious Non-infectious Autoimmune Malignancy - RA - Leukaemia - SLE - WG - PAN - Relapsing polychondritis - Sarcoidosis - IBD

  9. Autoimmune • RA • Morning stiffness lasting > 1hour • Symmetrical arthropathy, involving hand joints • Rheumatoid nodules • Scleritis, inflammation mainly affects anterior segment • Rheumatoid factor • Radiographic changes • SLE • WG • PAN • Relapsing polychondritis • Sarcoidosis • IBD

  10. Autoimmune • RA • SLE • Photosensitivity • Malar rash • Mucosal ulcers • Arthritis • Scleritis • Anterior uveitis • Vasculitis, retinal hemorrhages, CWS • CRAO, CRVO • Optic neuritis, AION • FBC for leuco/lymphopenia, anemia, thrombocytopenia • U/E/Cr for renal involvement • ANA, Anti-ds DNA • WG • PAN • Relapsing polychondritis • Sarcoidosis • IBD

  11. Autoimmune • RA • SLE • WG • recurrent epistaxis • sinus discharge • haemoptysis • deafness • cerebral vascular accidents • orbital inflammatory disease • NLD obstruction • Scleritis • Post segment: Arteritis, CRAO, BRAO • AION • C-ANCA • Urinalysis: Hematuria, proteinuria • CXR: Lung granulomas • PAN • Relapsing polychondritis • Sarcoidosis • IBD

  12. Autoimmune • RA • SLE • WG • PAN • Arthritis • Nephritis • Interstitial keratitis • Scleritis • Posterior segment: Arteritis, CRAO, BRAO • AION • CN palsies • P-ANCA • Relapsing polychondritis • Sarcoidosis • IBD

  13. Autoimmune • RA • SLE • WG • PAN • Relapsing polychondritis • Tinnitus • Vertigo • Deafness • Swollen ear lobes • Otitis media • Saddle-shaped nose • Polyarthritis • Scleritis • CXR: Calcification of cartilaginous structures • Sarcoidosis • IBD

  14. Autoimmune • RA • SLE • WG • PAN • Relapsing polychondritis • Sarcoidosis • Serum Ca • 24 hour urine Ca • Serum ACE level • Mantoux: Anergy • CXR: Perihilar lymphadenopathy • IBD

  15. Local Bacterial Viral FungalParasitic - HSV - Acanthamoeba - VZV Infectious Non-infectious Inflammatory Corneal DegenOthers - SJS - Mooren’s - Trauma - Chemical injury - Terrien’s - Neurotrophic - Marginal keratitis - PMD - Exp keratopath - Rosacea - Furrow degen - Dellen - Nutri def

  16. Management • Dependent on cause • Treat systemic condition • Treat infections accordingly • Systemic immunosuppressives for inflammatory conditions • Prednisolone • Azathioprine • Cyclophosphamide • Methotrexate • Prevent corneal perforation • Conjunctival recession/resection • Judicious topical steroid use in the treatment of patients with PUK associated with systemic disease as may aggravate corneal melt due to collagen synthesis inhibition. • Systemic collagenase inhibitors (tetracycline 250 mg tab qds or doxycycline 100 mg tab bd) may help slow progression. • AMT • In event of perforation • Corneal glue (<2mm) • Tectonic patch graft

  17. Corneal dellen found in 16% of pts who had undergone repeat strabismus surgery, and 18% in pts after transposition procedures. Fresina M, Campos EC. Corneal dellen as a complication of strabismus surgery. Eye 2007 • More frequent in limbal approach surgeries. Authors suggest careful trimming of conj to avoid bunching and monitoring postoperatively. Tessler HH, Urist MJ. Corneal dellen in the limbal approach to rectus muscle surgery. Br J Ophthalmol 1975;59:377-9. • Found in association with large filtering blebs. Post operative topical steroids may also contribute to its formation. Soong HK, Quigley HA. Dellen associated with filtering blebs. Arch Ophthalmol 1983;101:385-7.

  18. Case report of development of central corneal dellen after tarsotomy for cicatricial entropion due to a buckled upper lid defect causing suboptimal lid-globe apposition. Kwok SK, Tse DT. Central corneal dellen: a complication of upper eyelid tarsotomy. Ophthal Plast Reconstr Surg 2000;16:237-40. • Paracentral corneal dellen secondary to Grave’s ophthalmopathy. Yan J, Wu Z. Paracentral corneal dellen: a rare sign of Graves ophthalmopathy. Yan Ke Xue Bao 2003;19:174-5. • Case report of a patient with coughing paroxysms a/w SCH and dellen formation. Reisli I, Keles S. Arch Pediatr Adolesc Med 2006;160:53-5.

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