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Understanding Disorders of the Conjunctiva and Cornea

Learn about diagnostic criteria, treatment options for corneal infections, dystrophies, and ectatic diseases. Explore corneal examination steps, biomicroscopic findings, surgical techniques, and the significance of patient pain in corneal epithelial loss.

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Understanding Disorders of the Conjunctiva and Cornea

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  1. DISORDERS OF THE CONJUNCTIVA AND CORNEA Dr. VİLDAN ÖZTÜRK

  2. Aims • Knowsthediagnosticcriteriaandtreatment of cornealinfections, dystrophiesandectaticdiseases • Explainsthesteps of biomicroscopiccornealexaminationandbiomicroscopicfindings in diseases. • To apprehendtheimportance of patientshavingpain in case of cornealepithelialloss. • To be abletocompletelyandcorrectlylisttheindications of cornealsurgicaltechniquesaccordingtothepathology.

  3. Diameter 10-13mm • Micro-megalocornea • 550 micron thickness • clearness • collagen fibril array • stable water rate %70

  4. Corneal nutrition • Tears • Limbal veins • Humour aqueous

  5. Corneal innervation • Ophtalmic branch of trigeminal nerve

  6. Recurrent corneal erosion

  7. Examination

  8. Corneal topography

  9. CORNEAL DİSEASES • Corneal Infections (KERATITIS) • Ectatic Corneal Diseases • Dystrophies and Degenerations • Corneal Surgery

  10. CORNEAL INFECTIONS 1. Bacterial keratitis 2. Fungal keratitis 3. Acanthamoeba keratitis 4. Infectious crystalline keratitis • Herpes simplex keratitis -Epithelial -Disciform 6. Herpes zoster keratitis

  11. Treatment - topical ciprofloxacin 0.3% or ofloxacin 0.3% BACTERIAL KERATITIS Predisposing factors • Contact lens wear • Chronic ocular surface disease • Corneal hypoaesthesia Expanding oval, yellow-white, dense stromal infiltrate Stromal suppuration and hypopyon

  12. FUNGAL KERATITIS Frequently preceded by ocular trauma with organic matter Greyish-white ulcer which may be surrounded by feathery infiltrates Slow progression and occasionally hypopyon Treatment • Topical antifungal agents • Systemic therapy if severe • Penetrating keratoplasty if unresponsive

  13. ACANTHAMOEBA KERATITIS • Contact lens wearers at particular risk • Symptoms worse than signs Perineural infiltrates(radial keratoneuritis) Small, patchy anteriorstromal infiltrates Stromal opacification Ulceration, ring abscess& small, satellite lesions Treatment - chlorhexidine or polyhexamethylenebiguanide

  14. HERPES SIMPLEX EPITHELIAL KERATITIS • Dendritic ulcer with terminal bulbs • May enlarge to become geographic • Stains with fluorescein Treatment • Aciclovir 3% ointment x 5 daily • Trifluorothymidine 1% drops 2-hourly • Debridement if non-compliant

  15. HERPES ZOSTER KERATITIS Acute epithelial keratitis Nummular keratitis • Develops in about 50% within 2 days of rash • Develops in about 30% within 10 days of rash • Small, fine, dendritic or stellate epithelial lesions • Multiple, fine, granular deposits just beneath Bowman membrane • Tapered ends without bulbs • Halo of stromal haze • Resolves within a few days • May become chronic Treatment - topical steroids, if appropriate

  16. CORNEAL ECTASIAS 1. Keratoconus 2. Keratoglobus 3. Pellucid marginal degeneration

  17. Morphological classification of keratoconus Nipple cone Oval cone Globus cone Largest Small and steep curvature Larger and ellipsoidal

  18. Signs of keratoconus Bilateral in 85% but asymmetrical Oil droplet reflex Vogt striae Prominent corneal nerves Bulging of lower lids on downgaze Acute hydrops Munson sign Fleischer ring & scarring

  19. CORNEAL DYSTROPHIES 1. Anterior • Cogan microcystic .. • Reis-Bucklers • Meesmann • Schnyder 2. Stromal • Lattice I, II, III • Granular I, II, III (Avellino) • Macular 3. Posterior • Fuchs endothelial • Posterior polymorphous

  20. Cogan microcystic dystrophy • Most common of all dystrophies • Neither familial nor progressive • Recurrent corneal erosions in about 10% of cases Dots Cysts Fingerprints Maps

  21. Lattice dystrophy Progression Fine, spidery, branching lines within stroma Later general haze may submerge lesions Treatment- penetrating keratoplasty if severe

  22. Granular dystrophy Onset - first decade with recurrent corneal erosions Progression Initial superficial and central crumb-like opacities Later deeper and peripheral spread but limbus spared Eventual confluence Treatment - penetrating keratoplasty if severe

  23. Macular dystrophy Onset - second decade with painless visual loss Progression Initial dense, poorly delineated opacities Later generalized opacification Thinning Treatment - penetrating keratoplasty

  24. Fuchs endothelial dystrophy Inheritance - occasionally autosomal dominant Onset - old age Progression Gradual increase in cornea guttata with peripheral spread Later central stromal oedema Eventually bullous keratopathy Treatment - penetrating keratoplasty if advanced

  25. CORNEAL DEGENERATIONS&DEPOSITS • Age-related Arcus senilis 2. Lipid keratopathy • Band keratopathy • Spheroidal degeneration • Salzmann nodular degeneration • Cornea verticillata • Kayser-Fleischer Ring

  26. Arcus senilis • Innocuous and extremely common in elderly • Occasionally associated with hyperlipoproteinaemia • Peripheral border separated from limbus by clear zone • Bilateral, circumferential bands of lipid deposits • Diffuse central and sharp peripheral border • Clear zone may be thinned ( senile furrow)

  27. Lipid keratopathy Primary Secondary result of cholesterol or fatty acid extravasation • Common, secondary to previous disciform keratitis • Rare, occurs spontaneously in avascular cornea • Usually unilateral stromal deposits without vascularization • Unilateral stromal deposits with vascularization Treatment - coagulation of feeder vessels and/or keratoplasty Treatment: keratoplasty, if severe

  28. Band keratopathy • Common, unilateral or bilateral depending on cause • Subepithelial calcification • Ttrauma, surgery, some eye drops especially Pilocarpine, hipercalsemia with renal failure, sarcoidosis and certain malignancies • Central spread of calcification • Interpalpebral limbal opacification • Small holes within calcified area • Separated by clear zone

  29. Cornea verticillata • Fabry's disease -alpha-galactosidase Adeficiency • Variety of drugs • amiodarone, • chloroquine, • meperidine, • indomethacin, • chlorpromazine • tamoxifen

  30. Kayser-Fleischer Ring -Copper at descemet Wilson disease: abnormalities basal ganglia of the brain, liver cirrhosis, splenomegaly, involuntary movements, muscle rigidity, psychiatric disturbances, dystonia and dysphagia

  31. CORNEAL SURGERY 1. Keratoplasty (Penetrating , lamellar) 2. Keratoprosthesis 3. Refractive surgery • Radial keratotomy (RK) • Photorefractive keratectomy (PRK) • Laser assisted subepithelial keratectomy(LASEK) • Epithelial Laser in-situ keratomileusis (EpiLASIK) • Laser in-situ keratomileusis (LASIK) • Conductive keratoplasty (light-touch) (CK) • Intracorneal ring segments (ICR)

  32. Penetrating Keratoplasty 1. Indications • Optical (e.g. bullous keratopathy, dystrophies) • Tectonic (e.g. severe stromal thinning, descemetocele) • Therapeutic (e.g. severe keratitis) • Cosmetic 2. Adverse prognostic factors • Severe stromal vascularization • Absence of corneal sensation • Progressive conjunctival inflammation (e.g. pemphigoid) • Tear film dysfunction • Glaucoma

  33. Technique of penetrating keratoplasty a, b - Excision of host tissue Excision of donor tissue c - Fixation of donor tissue

  34. Keratoprosthesis Indications Technique Insertion of artificial lenticule into corneal stroma Bilateral blindness from ocular pemphigoid, chemical burns or repeated graft failure Main complications • Retrolenticular membrane formation • Glaucoma

  35. Radial keratotomy • Decreases myopia by flattening cornea • Deep incisions from edge of optical zone to limbus Main indications Main complications • Stable myopia of up to 8D • Accidental perforation • Otherwise normal cornea • Intrastromal epithelial cysts

  36. Photorefractive keratectomy ( PRK ) Indications • Stable myopia up to 6D with astigmatism no more than 3D • Hypermetropia up to 2.5D Technique Main complication Subepithelial haze which usually resolves after 1-6 months Reshaping of cornea by excimer laser ablation of Bowman layer and anterior stroma

  37. Laser in-situ keratomileusis (LASIK) Indications - similar to PRK but corrects higher degrees of myopia Technique Complications • Wrinkles in flap • Thin flap of cornea fashioned • Cellular interface proliferation • Bed treated with excimer laser • Flap repositioned

  38. Non-contact laser thermal keratoplasty Indications • Patients over 40 years with hypermetropia up to 2D • Following overcorrection of myopia • Corneal curvature is steepened by application of laser heat to stroma • Holmium laser spots applied to mid-cornea

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