1
Q
SPK: symptoms?
A
pain, photophobia, red eye, FBS, mildly decreased vision
2
Q
SPK: signs?
A
pinpoint K epi defects that stain with fluorescein.
- may be confluent if severe
- staining pattern may allude to etiology
- pain is relieved by anesthetic drops
3
Q
What conditions are a/w SPK with a superior staining pattern?
A
- CL-related disorder
- FB under upper eyelid
- Superior limbic keratoconjunctivitis
- Vernal conjunctivitis
4
Q
What conditions are a/w SPK with an interpalpebral staining pattern?
A
- Dry eye syndrome
- Neurotrophic keratopathy
- UV burn/ photokeratopathy
5
Q
What conditions are a/w SPK with an Inferior staining pattern?
A
- Blepharitis
- Exposure keratopathy
- Topical drug toxicity (eg. neomycin, gentamicin, trifluridine, atropine, preservatives)
- Conjunctivitis
- Trichiasis/distichiasis (may be superior SPK as well)
- Entropion or ectropion (may be superior SPK as well)
6
Q
SPK: what history should be specifically asked about?
A
Trauma, CL wear, eye drops, discharge or eyelid matting, chemical or UV exposure, snoring or sleep apnea, time of day when worse
7
Q
SPK: physical exam to specifically look for?
A
evaluate K, eyelid margin, tear film with fluorescein, evert upper and lower lids
-check for eyelid closure, position, laxity, look for inward growing lashes
8
Q
Recurrent Corneal Erosion: signs on exam?
A
- Localized irregularity and mobility of the K epithelium (fluorescein may outline the area with negative or positive staining)
- K abrasion
- Epithelial changes may resolve w/in hours of symptom onset so abnormalities may be subtle or absent on presentation
9
Q
Recurrent Corneal Erosion: results from damage to the corneal epithelium or epithelial basement membrane from one of the following:
A
- Anterior corneal dystrophy: EBMD (MC), Reis-Bucklers, Thiel-Behnke, and Meesmann dystrophies
- Previous traumatic corneal abrasion - may have been years prior
- Stromal K dystrophy: Lattice, granular, and macular dystrophies
- Corneal Degeneration: Band Keratopathy, Salzmann nodular degeneration
- Keratorefractive, K transplant, cataract surgery, or any surgery in which the K epithelium is removed
10
Q
What history should you ask a patient with Recurrent Corneal Erosions?
A
Hx of K abrasion? Ocular surgery? Family history (corneal dystrophy)?
11
Q
Dry Eye Syndrome: Symptoms?
A
- Burning, dryness, FBS, mildly-moderately decreased vision, excess tearing
- Usually bilateral and chronic
- Discomfort often out of proportion to clinical signs
12
Q
Dry Eye Syndrome: symptoms are often exacerbated by what?
A
Smoke, wind, heat, low humidity, or prolonged use of the eye (eg. working on computer/reading w/ decreased blink rate)
13
Q
Dry Eye Syndrome: Signs?
A
- Scanty or irregular tear meniscus (normal is > or = 0.5mm height with convex shape on inf lid margin - best to examine prior to instilling eye drops)
- Decreased TBUT (<10sec indicates tear film instability)
- PEEs, +rose bengal or lissamine green staining
14
Q
Isolated areas of repeated early tear break-up may indicate what?
A
Focal K surface irregularity
Tear film instability should show up as randomly located tear film defects
15
Q
Dry Eye Syndrome: what are the lifestyle related etiologies?
A
Arid climate, allergen exposure, smoking, extended periods of reading/computer work/TV viewing
16
Q
Dry Eye Syndrome: what are the connective tissue disease -related etiologies?
A
- Sjogren syndrome,
- RA,
- Granulomatosis with polyangiitis,
- SLE
17
Q
Dry Eye Syndrome: what are the main categories of etiologies?
A
- Idiopathic (evaporative, aqueous deficient, combination)
- Lifestyle related
- Connective tissue disease
- Conjunctival Scarring
- Drugs
- Infiltration of the lacrimal glands (sarcoidosis, tumor)
- Postradiation fibrosis of lacrimal glands
- Vitamin A deficiency
- S/p K refractive surgery
18
Q
Dry Eye Syndrome: what are the drug etiologies?
A
- Oral contraceptives
- anticholinergics
- antihistamines
- antiarrhythmics
- antipsychotics
- antispasmodics
- tricyclic antidepressants
- beta blockers
- diuretics
- retinoids
- SSRIs
- Chemotherapy
19
Q
Idiopathic Dry Eye Syndrome is typically found in menopausal and post-menopausal women. What are the 3 categories of idiopathic DES?
A
- Evaporative
- Aqueous deficient
- Combination: evaporative and aqueous deficiency, may include a mucin layer tear deficiency
20
Q
Evaporative DES (subcategory of Idiopathic DES): describe the characteristics
A
Evaporative:
- lipid layer tear deficiency, 2. often a/w blepharitis or MGD.
- Sxs may be worse in the AM, w/ blurry vision upon awakening
21
Q
Aqueous deficient DES (subcategory of Idiopathic DES): describe the characteristics
A
Aqueous deficient:
- Aqueous layer tear deficiency,
- aqueous production decreases with age.
- Sxs frequently worse later in the day or after extensive use of the eyes
22
Q
Combination DES (subcategory of Idiopathic DES): describe the characteristics
A
Combination:
- evaporative and aqueous deficiency,
- may include a mucin layer tear deficiency
23
Q
Describe the technique for the Anesthetized Schirmer test
A
- Apply topical anesthetic
- Dry excess tears from the eye
- Place Schirmer filter paper at the unction of middle and lateral 1/3 of lower eyelid in each eye for 5 minutes
- Eyes remain open with normal blinking
24
Q
The Anesthetized Schirmer test measures what?
How is it interpreted?
A
- measures Basal Tearing only
- Abnormal is wetting of 5mm or less in 5 minutes
- <10mm is borderline
25
The Unanesthetized Schirmer test measures what?
| How is it interpreted?
1. measures Basal AND reflex tearing
| 2. Normal is wetting of at least 15mm in 5 minutes
26
How do levels of MMP-9, tear osmolarity and tear lactoferrin relate to dry eye?
1. Elevation of MMP-9 and tear osmolarity suggest dryness and inadequate tear film
2. Low levels of tear lactoferrin suggest aqueous deficient dry eye disease
27
Dry Eye Syndrome Management: in what order do you scale up treatment?
1. ATs QID
2. PFATs q1-2h
3. Lubricating ung or gel qhs
4. Lifestyle modification (eg. humidifiers and smoking cessation)
5. Cyclosporine 0.05% BID
6. Punctal occlusion
7. Lubricating ung/gel BID - QID PRN
8. Moisture chamber
9. Oral flaxseed oil, omega-3 FAs
10. Autologous serum tears
28
In a patient with severe DES w/ mucus strands or filaments present, what treatment might you consider?
1. Remove strands/filaments with foreceps
| 2. consider 10% acetylcysteine QID
29
Cyclosporine 0.05% BID is effective for patients with chronic DES and decreased tears 2/2 ocular inflammation - how long does it usually take to improve symptoms?
1-3 months for significant clinical improvement
- To hasten improvement and lessen side effects (burning for first several weeks of use), may treat concomitantly with mild topical steroid (eg. loteprednol 0.5%) bid -qid for 1 month while starting cyclosporine
30
What symptoms are suggestive of Sjogren's syndrome?
| Sjogren's is a/w increased incidence of what other problems?
1. Dry eyes, Arthritis, dry mouth
| 2. Increased incidence of lymphoma and mucous membrane problems
31
What are the SXS of Filamentary keratopathy?
1. Moderate to severe pain
2. Red eye
3. FBS
4. Tearing
5. Photophobia
32
What are the SIGNS of Filamentary keratopathy?
1. Short fluorescein-staining strands of degenerated epithelial cells surrounding a mucus core adherent to the anterior corneal surface
2. Conj injection
3. Poor tear film
4. PEEs
33
What are the etiologies of filamentary keratopathy?
1. Severe ocular dryness (most common)
2. SLK
3. Recurrent K Erosions
4. Adjacent to irregular K surface (postop, near surgical wound)
5. Patching or ptosis
6. Neurotrophic keratopathy
34
What is the treatment for filamentary keratopathy?
1. Treat underlying condition/etiology
2. Consider debridement of filaments - gently remove filaments at their base with fine foreceps or a cotton-tipped applicator
3. Lubricate: PFATs 6-8x daily and ung qhs, punctal occlusion, acetylcysteine 10% qid
4. BCL may be considered - concomitant topical abx (fluoroquinolone) are given
35
Exposure Keratopathy: Signs?
1. Inadequate blinking or closure of the eyelids
| 2. PEEs found in the lower 1/3 of the K or as a horizontal band in the region of the palpebral fissure
36
Exposure Keratopathy: Etiologies?
1. 7th nerve palsy: orbicularis oculi weakness (eg. Bell Palsy)
2. Sedation or Altered Mental Status
3. Eyelid deformity
4. Nocturnal lagophthalmos
5. Proptosis
6. After ptosis repair or blepharoplasty procedures
7. Floppy eyelid syndrome
8. Poor blink (eg. Parkinson disease, neurotrophic cornea)
37
In a patient with signs of exposure keratopathy, what history should you ask about?
1. Previous Bell Palsy
2. Hx of eyelid surgery
3. Thyroid disease
4. Eyelid trauma
38
In a patient with signs of exposure keratopathy, what should you check on exam?
1. Evaluate eyelid closure and K exposure
2. Assess Bell phenomenon
3. Check eyelid laxity
4. Check K sensation before giving anesthetic drops
4. Evaluate tear film and corneal integrity w/ fluorescein, look for signs of infection
5. Investigate any underlying disorder (eg. etiology of 7th nerve palsy)
39
What is are the treatment recommendations for Exposure Keratopathy?
1. Correct any underlying disorder
2. PFATs q2-6h
3. Lubricating ung qhs to qid
4. Consider eyelid taping or patching qhs, if severe- consider taping lateral 1/3 of the lids closed during daytime
5. Placement of Amniotic membrane tissue covered by a BCL or Prokera)
6. When above fail, surgical procedures may be beneficial - eg. tarsorrhaphy
40
What surgical procedures may be beneficial in Exposure Keratopathy when maximal medical therapy fails?
1. Partial tarsorrhaphy
2. Eyelid reconstruction (eg. for ectropion)
3. Eyelid gold or platinum weight implant (eg. for 7th nerve palsy)
4. Orbital decompression (eg. for proptosis)
5. Conjunctival flap or sutured/glued amniotic membrane graft
41
Pt presents with corneal ulcer w/o infectious infiltrate, w/ gray, heaped-up epithelial border in the lower half of the cornea, and is horizontally oval - what is the most likely diagnosis?
Neurotrophic keratopathy
- check K sensation
- early signs include perilimbal injection, intrapalpebral PEEs, stromal edema/D folds
- late signs include K ulcer
42
Neurotrophic keratopathy: what are the possible etiologies?
1. Post-infection with VZV or HSV
2. Following ocular surgery, esp. after corneal incisional or laser sx (eg. keratoplasty, LASIK, PRK)
3. Tumor or any insult/disease of the 5th cranial nerve
4. Chronic CL wear
5. Diabetic neuropathy
6. Extensive PRP (may damage long ciliary nerves)
7. Complication of trigeminal nerve or dental surgery
8. Complication of radiation therapy to the eye or adnexal structures
9. Chronic topical medications (eg. timolol, topical NSAIDs)
10. Topical anesthetic abuse
11. Crack keratopathy: often bilateral
12. Chemical injury or exposure to hydrogen sulfide or carbon disulfide (used in manufacturing)
43
Neurotrophic keratopathy: treatment for mild-moderate PEEs?
1. PFATs q2-4h and AT ung qhs,
| 2. consider punctal plugs and qhs patching
44
Neurotrophic keratopathy: treatment for small corneal epithelial defect?
1. Antibiotic ointment (eg. erythromycin or bacitracin qid to q1-2h) for 3-5 days or until resolved
2. Usually requires prolonged AT treatment
3. Consider placement of BCL with prophylactic antibiotic eyedrops tid to qid
45
Neurotrophic keratopathy: treatment for corneal ulcer?
1. Treat as bacterial keratitis if secondarily infected ulceration
2. Abx ointment q2h
3. Tarsorrhaphy
4. Sutureless amniotic membrane tissue
5. Sutured/glued amniotic membrane graft or conj flap
6. Oral doxycycline 100mg bid, systemic ascorbic acid (eg. vitamin C 1-2g daily)
46
UV Keratopathy: what are the typical symptoms and history?
1. Moderate to severe ocular pain, FBS, red eye, tearing, photophobia, blurred vision, usually bilateral
2. History of using a sunlamp or welding without adequate protective eyewear. Symptoms typically worsen 6-12 hours after exposure.
47
DDx for UV keratopathy?
1. Toxic epithelial keratopathy
2. Thermal burn/keratopathy
3. Exposure keratopathy: poor eyelid closure
4. Floppy eyelid syndrome
48
What is a neutral pH for the tear lake?
6.8-7.5
49
UV Keratopathy: what is the treatment?
1. Cycloplegic drop (eg. cyclopentolate 1%)
2. Antibiotic ung (eg. erythromycin or bacitracin) 4-8x per day
3. Consider a pressure patch for the more affected eye for 24hrs in a reliable patient
4. Oral analgesics PRN
5. BCL w/ prophylactic broad-spectrum abx drop may be used in place of patch or abx ung
50
Thygeson Superficial Punctate Keratitis: What are the symptoms?
1. Mild-moderate FBS
2. Photophobia
3. Tearing
4. No hx of Red eye
5. Usually Bilateral w/ chronic course of exacerbations and remissions
51
Thygeson Superficial Punctate Keratitis: What are the signs?
1. Coarse stellate gray-white corneal epithelial opacities that are often central, slightly elevated, and stain lightly w/ fluorescein
2. Underlying subepithelial infiltrates may be present
3. Minimal to no conj injection, K edema, AC reaction, or eyelid abnormalities
52
Thygeson Superficial Punctate Keratitis: What are the treatment recs?
Mild: ATs 4-8x daily, AT ung qhs
Moderate-severe:
1. mild topical steroid (FML 0.1% or loteprednol 0.2% to 0.5% qid for 1-4 wks, followed by slow taper
2. consider BCL if no improvement with topical steroids
3. consider cyclosporine 0.05% drops daily to qid
53
DDx for pinguecula/pterygium?
1. CIN (papillomatous jelly-like velvety, or leukoplakic (white) mass, often vascularized
2. Limbal dermoid- congenital, rounded, white lesion, usually IT limbal location
3. Other conj tumors- eg. papilloma, nevus, melanoma
4. Pseudopterygium -
5. Pannus
6. Sclerokeratitis
54
Pinguecula/pterygium: are ____ (what type) of degeneration of deep conj layers resulting in fibrovascular tissue proliferation, and are related to what type of exposure?
1. Elastotic Degeneration
| 2. Related to Sunlight exposure and chronic irritation
55
What is the treatment for pinguecula/pterygium?
1. Protect the eyes from sun, dust, and wind (eg. UV blocking sunglasses or goggles)
2. Lubrication with ATs 4-8x daily
3. If moderate-severely inflamed, use a mild steroid (eg. FML 0.1% qid or loteprednol 0.2 or 0.5% qid) a NSAID drop, or a topical antihistamine +/- mast cell stabilizer
4. If a delle is present, apply AT ung q2h
5. Surgery
56
When is surgical removal of a pterygium/pinguecula indicated?
1. Pterygium threatens the visual axis or induces significant astigmatism
2. Patient is experiencing excessive irritation not relieved by medical treatment
3. Lesion is interfering with CL wear
4. Consider removal prior to cataract or refractive surgery
57
Pterygia can recur after surgical excision, what methods may be used to reduce recurrence rate?
1. bare sclera dissection with conjunctival autograft or amniotic membrane graft
2. Intraoperative application of an antimetabolite (MMC) - a/w increased risk of corneoscleral thinning/necrosis
58
What are the Signs of Band Keratopathy?
1. Anterior corneal plaque of calcium at the level of Bowman membrane
2. typically w/in the interpalpebral fissure
3. typically separated from the limbus by clear cornea
4. Lucid spaces are often present in the plaque giving it a "swiss-cheese" appearance
5. Plaque usually begins at the 3 and 9 oclock positions
59
What are the MC causes of Band Keratopathy?
1. Chronic uveitis (eg. JIA)
2. Interstitial keratitis
3. K edema
4. Trauma
5. Pthisis bulbi
6. Long-standing glaucoma
7. Dry eye
8. Ocular surgery (esp RD repair with SO)
9 . Idiopathic
10. Also, HyperCalcemia, Hyperphosphatemia, gout
60
Band Keratopathy: If there are no signs of anterior segment disease or long-standing glaucoma and the BK can't be accounted for, what workup should be considered?
1. Serum Calcium, Albumin, Magnesium, Phosphate
2. BUN, creatinine
3. Uric acid if gout is suspected
Wills Eye Manual
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