ae a —~ Cornea : 7% Anatomy The comes Is a transparent, avascular. forms antertor 1/6 of outer laver of eye. Surrounded by sclera (separated from sclera by Simbus) Sigbus) semaine so | Diameter Wertieal-ae 11.5 mm - -Horizontal=—> 12enm- = Thickness ~™ Central am 0.5 mM Peripheral ae 1 Refractive index 1.37 Refractive power 42 D( Main refractive power are etree -~ PRewe nappy [Navocliary neve Sexe pbthalemlc branch of Tigerninal nerve OF cornea Notrition OF comea | )-Aqueous hurnor (2)-Tesr film @}Aimbus Function of | -Main refractory power of eye Comea Sensation. gin -Cold « Te ly Zartes avaieulor strocture . derive ifs nutrition by diffusion From | + Histology (MCO+++) Epithelium | -Stratified squarnous non Keratinized (5-6 ayers) E ‘ -High ability of regeneration. 5 z Bowmenls | Elevtic Ageliolar membrane, (Represent superficial stromat fiber) | membrane | -Not capable of regeneration (i.e. any damage eating by fibrosis} Tubstantia | Form 9096 of corneal thickness. propria | Its formed regular arrangement of larmeliae of collagenous bundle, ({siroma})_| Keratacyte . macrophages .ground substance -Not capable of regeneration (Le. any damage healing by fibrosis) Descment | -Batement membrane ‘of the endothelium. £ | membrane | -Elestic acellular membrane, 5 3 “Capable of regeneration (secreted by enclothellum) 2 tt is very resistant to chemical agents, traurna and pathological processes Endiothellum | -Singlel ayer of polygonal (mainly hexagonal) it’s number 2000 — 3000/mm?(dlecrease with age} lt al 4th yaar(aphthalmology) 2012-2013lin “NO abllity of regeneration, (Not divide gffer bith) fepalt Is limited to enlargement of existing cells to All the space -tt's eesponsible for maintaining the deturgescence of the comea by act as ion pump (active process}to remove water from stroma -Failure of endothelial function (increase of IOP, traurns, Keratitis) leads to corneal edema, = Endothelium is the most metabolically active laver of cornea Why Is The Cornea Transparent? ((MCQ+++)) 1-Relative dehydration (Comeal Deturgescence) (MOST IMPORTANT FACTOR) Endothelial pump removes fluids from stroma 2-Epithelium NOT keratinized 3-Reguler arrangement of lamellae of collagenous bundle 4-NQ blood (avascular) or lymphatic vessels S-Nerves (NOT myelinated), Relative acellular (Low number of cell}, th year{aphthalmolopy) 2012-2013 3 | Facebook group:Definition: -(t's Inflammation of comes i * dassification 1- Uleerative (superficial) keratitis 2- Non ulcerative (deep) keratitls 1- Ulcerative (superficial) keratitis Types 1- Primary corneal ulcer ‘Ac Infective (Bacterist, Viral, Fungal, Protozoa} B- Non infective 1- Traumatic i I 2- Exposure keratitis (lagophthalmas) 3- Neuroparalytic 2- Secondary corneal ulcer Secondary to conjunctivitis, Blepharitis [Facebook group: 4th year(ophthalmolagy)2012-209init lt” A-Infective corneal ulcer | acterial corneal ulcer -Over 90% of all cornea! inflammation ts caused by boclarla “Mast bacteria ara unable to penetrate the cornea us ing as ‘ha splthefium remain intact « Only A gunoerhonae, N. maningltidis, diphtheria, and H, Influonzagcen panatrete intact connsal epithelium. The most common pathogens are the following: 1 Preudomonas aeruginoss - Gram-negative bacillus (rod) + ‘The infection is typically aggressive > Responsible for over 60% of contact tens-related keratitis, 2 Staphylococeus a Gram-positive and coagutase-positive Commensal of the nares, skin and conjunctiva, 3 Streptococe. = § Byogenes ls a common gram-positive commensal of the throat and vagina, | Sopneumoniae (preumacoccus} Is a gram-positive commensal of the URT «Infections with streptocorel are often aggressive. © Risk factors 1 Contact lens wear is the most Important risk factor 2 Trauma 3 Ocular surface diseases such as dry eye, blepharitls, trichiasis and entroplon 4 Other factors Include Immunosuppression, diabetes and vitarnin A deficlency § th yaar(ophthalmology) 2012-2013——_¥ Cinical teatures Prerentation Rapid painfut foss of viston, Photophobla, Lacrimetion 2. Signsin chronsiegieal order: + Anepithetial defect assodated with 6 iarger infiltrate © Entargemient of the infiltrate and the epithelial defect. + Stromat oedema {Comeai edema), folds in Descemet membrane and : anterior uveltis, a cere | = Chemosis and eyelid swelling in severe cases. ; = ‘Hypopyon Red eye (Ciliary infection). Epithelium defect >> Fluorescein test (+} Severe ulceration may lead to descemetocete formation and perforation, particularly in Pseudomonas infection = Endophthalmitis is rare in the absence of perforation. = Scarring, vascularization and spacification. Im provement Is usually heralded by a reduction of eyelid oedema and chemosis, as well as shrinking of the epithelial defect and decreasing infiltrate density. Reduced corneal sensation may suggest associated herpetic disease or neurotrophic keratopathy. Intraocular pressure should be monitored % Investigations Comeal scraping Conjunctival swabs Contact lens cases, a5 well as bottles of solution and lenses themselves should be obtained when possibte and sent to the taboratory for culture. Gram steiningi E Mediunt | Notes Spedficty Mom bacteria and fungi except Neisre Blood egar 5-10% sheep or horre blood Haemophilus and Moraxella Chocolate agar Blood agar in which the cell {4 yoftueraae, Nelsen have been lysed by heating. senza \ nd Moraxetla \ \ Tow pHand antibiotic to i id dextros Fungl | Ssbouraud destrose 28ar | deter bacterial growth ee | Nomnatiast ager seaded | F. coliisa food source for aaa | _with E eoti Acanthamoeba Rw Treatment Hospital admission Discontinuation of contact lens wear is mandatory. _ Decision to treat Local therapy TOPICAL Antibiotic monotherapy Antibiotic duotherapy Subconjunctivat antibiatics only if there is poor compliance with topical Ireatment Mydriatics & Cyctoptegic (stropine 19) are used to prevent the formation of posterior synechlae and to reduce pain. Steroids. The evidence for an optimal steroid regimen has yet to be established and practice varies. ¢ Proponents argue that steroids reduce host Inflammation, improve comfort, and minimize cornea! scarring. Hawever, evidence that they Improve the final visual outcome Is limited, *® Steroids promote replication of some milero-organisms. particularly fungi, herpes simplex and mycobacteria and are contraindicated if a fungal or mycobacterial agent Is suspected th year(ophthalmology)201 7 =| Facebook grouser. Systemic antibiotics Systemic antibiotics nat usually given, but given {n following droumstances 1 Potential for systemic Invatvement such as the following: * Ne meningitides with intramuscular benzyipenieliiin, ceftriaxone, or arat siprofloxacin. +H, influenzae infection treated with amoxicillin with clavulanic acid, +N. gonorrhoeae requires a third-generation cephalosporin such a ceftriaxone. 20 Severe corneal thinning with threatened or actual perforation requires: * Ciprofloxacin for its antibacterial activity. ® A tetracycline for its anticollagenase effect, 4 Scleratinvolvement may respond to oral or intravenous treatment. +> NON HEALING CORNEAL ULCER (RESISTANT CASES) ‘L:Therspeutlc keratoplasty (Definitive treatment) +) TREATMENT OF COMPLICATION OF CORNEAL ULCER 1., Comeal opacity J- Nebula {according to ste) Peripheral: - Conservative & Hard contact lens if symptomatic Central: - Lametlar keratoplasty 2-Macula {(in between)) 3-Non-Adherent Leucoma/aceording to site] Peripheral; - Conservative & Hard contact lens if symptomatic Central: - Penetrating keratoplasty 9 | Facebook group:- 4th year(ophthalmology) 202-2013Comeal Opacity (Fibrosts) A. Mebula its tight corneal opacity involves Bowman's membrane and superficial lever of stroma, The finer details of iris are clearly visible through opadty. 3. Macula tts dense corneal opacity involves about half the thickness of the stroma. The fine details of the deeper structure are observed perttally. > Nop-Agherent Lewcoma al opacity involves almost full thickness of stroma. it's very dense totally come Nothing can be seen through the beucoma. NB Corneal opacity affects vision Central by opacity when cover pupll, Peripheral by induce irregulor astigmatism - Any entat Comeal, opacity Healed by weratoplasty _ Gamy peripiral. Coratel Opoty tented by Gonsevalive Po Harel Covtnch leat. th yapr( ophthalmology) 2012-2013ences. 2-Fungal & Parasitic corneal ulcer Fungal ulcer {keratomycosis) Parasitic ulcer Predisposing | 1. Trauma with objea of plant sources factors (legricuttural workers as farmer Y 2.- more common In the urban 3- Immunccompramised patient -Contact tens wear with bad cleaning ((use of tap water to clean lens )) occur In non-contact lens wearers after exposure to contaminated water or soil Causative | Aspergillus (most cammon cause), Acanthamoeba 3 Candida (Normally lives in tap water} organism Symptoms & | As previous + Rypopyon Epithelial pseudodendrites . As previous signs Diagnosis [-Culture Culture ‘ -Cormeal scraping stained with Gram's and Giemsa's stains, may allow identification of the organism > Corneal scraping stained with Gram's and Giemsa's stains. may allow identification of the “organism Prognosis [Bad Bad ital admission Treatment J-Topicat treatment:-natamycin 2-Systemic treatment:-Amphotericin B 4-Therapeutic keratoplasty esterold contrsindlcation Te) A Therapeutic keratoptasty hospital admission 1 Debridement 2-Topical treatment: Polyhexamethylenebiguanide (PHMB) 4- Topleal sterold should be avoided if possible although lowe dose therapy may be useful for Persistent inflammation 10 ] Facebook proup:- 4th yaar Dolithalmolagy) 2012-2013f 3-Viral corneal ulcer — Herpes simplex keratitis Herpes zoxter keratitis (( Dendrite uleer }) Herpes zoster ophthalmicus : Causative Herpes simplex typel Variealle-zorter virus I organism (CEpithettotrepic)) ((Neurotrapic)) Herpar simplex keratitis occurs th primary (Varicella) and two forms: primary and recurrent | recurrent (herpes zoster}. Age Primary herpes in children’ Mainly affect elderly people Secondary herpes In young edult | But may occur at any ege Laterality ‘Usually unilateral (bilateral rare) Almost always unilateral Predisposing Fever, Overexposure fo ullraviolet light, frauma, onset oF ! factor menstruation, stress, Immunosuppression, wf For recurrence : Neuralgia Not preceded Preceded it = ey Follow No Yer distribution of nerve Ocular 1+ Bye lid = vesicle ‘L-Skin:-Multiple vesteles + manifestation | 2-Conjunctiva :- conjunctivitis &Coniunctiva:-conjunctivitis AsSclera:-scleritis episeleritis 3- Cornea :- keratitis 4-Comen :-keratitis a-Superficial punctuate keratitis S-Uveal tract;-uveltis lead to b-Dendritle ulcer Glaucoma 6 Iris atrophy AGtunerficini-branching -recurrence- | 6-Optic nerve :-0) ptle neuritls | HO Vas | Z-Reting :-Retinal necrosis, 11 | Facebook group:- 4th year(ophthalmology) 2012-2113e-Geographle uleer d-Disc form ulcer cr rr | (8%. 40.604 709 34> > Paralytic squint . Prose ih, Gth>S Paralytle squint 4-Uveal tract :- uvaitls Th> > Ectropion , Lagophthalmos Permanent scar No Yes on skin en Inmunity No solid immunity Solid immunity Recurrence Recurrence No Recurrence Treatment Medical treatment:- Medical treatment:- As previous + As previous + & Topical antiviral s+ ‘Toplcal antiviral Acyclovir 3% eye ointment Acyclovir 3%eye ointment 5 times/day for (7-10 days) 5 times/day for (7-10 days) Systemic antiviral % Systemic antiviral Acyclovir 800mg 5 times/day Acyclovir 800mg 5 times/day Far (7 days} For (7 days) Steroid contraindication used for —_| Steroid contra-indication used eye (EXCEPT in. Disc form ulcer can | for eye be used) Steroid topically only for skin i ia err ae f a rrr ore Sn ermine inet % Hutchinson's nile (Hutchinson's signs) Ocular involvement i¢ usually associated with ery tion of vesicles on the skin of ti (Nasocitiary branch) during attack of herpes xoster mot pefinete 12> | Facabook group::- 4th year(ophthalmalogy)2012-2013we Mechanisms of acular involvement in HZzv {Direct viral Invasion may lead to conjunetvitls and epithelal kere 2 Secondaty Inflammation ancl ocelusive vasculitis may cause eplsclerttls, sclerltis, keratitis, uveltfs, aptic neuritis and cranial nerve palsies. 4 Reactivation causes necrost afd Inflammation in the affected sensory ganglia, causing corneal anaesthesia that may result in neurotrophic keratitis, Herpes simplex virus (HSV) Herpetic eye disease is the most common Infectlous catse of comeal blindness in developed countries. Disciform keratitis The exact aetiology of disciform keratitis is controversial. It may be active HSV infection, ora hypersensitivity reaction to viral antigen 1 Presentation fs with a gradual onset of blurred vision which may be associated with — haloes around lights, Discamfart and redness are commen 2° Signs = central zone of stromat oedama often with overlying epithelial oedema » Keratle precipitatas underlying the oedema + Falds in Descemet membrarte ih severe cates. Stayin «The fOP may be elevated, ot. Sevan * Reduced corneal sensation, Treatment — NoaVterotine 1 Inttlal treatment Is with topical steroids (prednisolone 1%) with antiviral cover 2 Subsequently prednisolone 0.5% once daily 4 Topical ciclosporin, th year (ophthalmology) 2012-2013Definition | It's corneal ulceration which occur in Lagophthalmos Causes | Causer of Lagophthaima “Famed Worrt Paty «prep boris Clinical _ | Uleeration Involve the Iqwer 73 of comes which is expoied during night picture | 2 eve rel up (bells phenomenon) Treatment | ¥-Treat underling cause (cause of Lagophthalmos) Din case aetiictal ears + antbiotle TS ro prylAcHts patible 3- Sever care{ Lateral Tarsorrhaphy} a Taophthainare” Se nanerton oF upper @ iatwngense 2- Neurotrophic Keratitis (Neuroparalytic keratitis) Definition | Comeal ulceratlon due to loss of corneal sensation Aetiology | Trigeminal nerve dysfunction, due to trauma, surgery, tumor, inflammation. herpes zoster, herpes simplex, DM, Leprosy Clinical feature Th the absence of corneal sensation, even a severe keratitis may produce litle discomfort , reduced vislon Treatment Tarsorrhaphy, or by menns of ptosls. Induced witt Gotutmurs toxin) EE -Treatment underlying cause ——— Definition x It's NON Inflammatary conical ectasia of cornea due to central {usually} or Peracentral weakness of stroma, (central ar Paracentral corneal thinning) -Keratoconus is slowly progressive bilateral asymmetrical disease that may be nherlted as an (AD) tralt. Symptoms appear In the second decade of life. “The disease affects all races. More commen In female . + Arrest In progression of the keratoconus may occur at anytime Risk factors |-Cause Unkngwn BUT Keratoconus has been associated with Systemic dliease: - Down's syridrome, Turner syndrome, Atopic dermatitis, Marfan's syndrome, Apert's syndrome, and Ehlers-Danlos syndrome, Asthma Qaalar dseate:-Retinits pigmentosa, Ectopic lentis, Spring catarrh, Anitidia, rigid contact lens wear & constant eye rubbing ‘Symptoms | Gradual painless loss of ulsion Is the only symptom. Inregulac myopic sstlgmatism (myopia curvature type) Signs 1- Direct ophthalmoscope show an “Oil droplet" reflex, 2. Retinorcapy show Imegular *Sclssor reflex, i 3+ Slit lamb. vertical, deep stromal striag (Vogts tines}, Pathognomonte Fecabonk araupe- 4th year{ophthalmology 2012-2018res: | a 5. Topography is the most sensitive method detecting very early keratoconus 6 (Eletschier's ring):- iron ting around the bese of the cone 7 (Munson’s sign): bulging of the lower lid in down gaze (V shape) api] aod J 8: Acute hydrops of the comea may occur, manifested by sudden diminution of vision aselated with central corneal edema, This arises as a result of rupture of Descemet's membrane and may be triggered by the patfent rubbing the eve. Acute hydrops usually clears gradually with treatment by hypertonic (5%) saline cintrsent but offen leaves apical scarring. Treatment me Spectacias in early cases, 3 4a Rigid contact lenses s = Keratoplasty, either penetrating or deep anterior lamellar (BALK), may be necessary In patients with advanced disease 4. Intracorneal ring segment (lntacs) implantation using laser or mechanical. channel creation Is relatively safe, and typleally provides at least a moderate visual improvement, facilitating contact lens tolerance in advanced cases. 5 Comeal collagen cross-linking, using riboflavin drops to photosensttize the eve followed by exposure to ultraviolet-A light, ts & newer treatment which offers promise of stablllzation, 7 | Facebook group:- 4th yaar(ophthalmology) 2012-2013Keratoplasty (Corneal Transplantation) It's operation in which abnormal comeal host tissue fs replaced by healthy donor comea > Types 1-Full-Thickness Penetrating} kerataplasty 2-Partial-Thickness (Lamellar) keratoplasty at Types indications (MCQ +45) i | 1- Visual ~Comeal decompensation , keratoconus. Central Cra! coreal opacity (Leucoma), corneal dystraphy COMMON | ,corneal degeneration , INDICATION Pp 2B Z-Structural | - Descematocele, Perforated comea s & a 2 [-F Therepautic | Ure to remove of infected corel tinue in the 2 5 eye not respond to treatment (Fungal .Viral , - Acanthamoeba , Bacterial , Disk form keratitis) 4 Cosmetic preformed to Improve the appearance of the eye (Rare) bo 1- Central corneal opacity (Nebuta, macula) s § s a | 2-Recurrent pterygium 5 2 nN E 3-Descemetacele 4- Keratoconus a 1@ | Facebook group:- 4th year(ophthalmology) 2012-2013a r ~ “Poor pr rognastle facter of | keratoplasty LDryeye . Wachee 2-Coreal vascularization 3-Uncontrolled Glaucoma 4-Actlve ocular or adnexal Infeetion Properties donor cornea 1-Should,be preferable adult cornes (20-50 ) not from Jnfani(small dismeter and felable Comeas are diffcult to hendie)& not from elderly (due to low ndothellum cell count) 2-The denor should free from [Syphilis ,AIDe Viral hepatitis Septcemie {ubsrculesis Creulzfeld-Jacob dlyease, CMV encephalitis, Congenital rubella, Malignancies) 3-The donor should free from fntrinsle eye disease {.g. Intto-eaular tumor, astiye Inflammation or previous Intra-oculsr surgery) 4-Donar theue should be removed within 12-24 hours of deathN.B Complications of Keratoplasty 1 Wound leek S—> shallow anterior chamber 2- Endophthaimttle 3- Uveitis + Elevated IOP (Glaucoma) 5- Graft failure 6-Other Irritation by protru ding sutures 1-Graft rejection 2-Glaucoma 3-Astigmatiom 4 Recurrence of disease (with herpes simplex) L-Graft rejection rotes are usually less than 10% 2-Large grafts more likely to reject than small graft A Prognosis The chance of tong-term transplant success is 20 Fecebonk group: > 90% for Keratoconus. comeal opacity 80 to 90% for inactive viral keratitls, 0 to 50% Jor chemical (alkaling) oF radiation inlury, 4th year{anhthalmplogy) 2012-2018