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Cornea, External Disease & Refractive Surgery
Richard L. Nepomuceno, MD, DPBO
Fatima Medical Center . St. Lukes Medical Center . Capitol Medical Center East Avenue Medical Center . Manila Central University Cardinal Santos Medical Center . Manila Doctors Hospital
1. 2. 3. 4. 5. 6. 7. 8. Meibomian Gland Dysfunction Staphylococcal Blepharitis Seborrheic Keratosis Angular Blepharitis Molluscum Contagiosum Hordeolum Chalazion Viral Papilloma
R. NEPOMUCENO, MD
9. Seborheic Keratosis 10. Xanthelasma 11. Basal Cell Carcinoma 12. Squamous Cell Carcinoma 13. Capillary Hemangioma 14. Allergic Contact Dermatitis
R. NEPOMUCENO, MD
NEPOMUCENO. crusting of the eyelids R. foreign body sensation. inspissations of orifices Chronic burning. tearing. filmy vision. MD .Meibomian Gland Dysfunction Sebaceous glands of posterior lamella of the eyelids Abnormal lipid composition & secretion Enlargement.
Staphylococcal Blepharitis Infection of lid margin. crusting Can cause: recurrent hordeola. collarettes. fibrin. MD . conjunctivitis. punctate epitheliopathy Chronicity causes thickened & scarred lids R. lash bases. redness. marginal corneal infiltrates. mattering of lashes Ulceration. NEPOMUCENO. FBS. follicles Burning.
and mattering of the eyelids Usually bilateral Often associated with meibomian gland dysfunction The lashes are covered with yellow.Seborrheic Keratosis This disorder is often associated with seborrheic dermatitis Patients complain of redness. greasy scales The scales are translucent and easily removed R. NEPOMUCENO. burning. MD .
Candida R.Angular Blepharitis Maceration & crusting of the skin at lateral canthus Maceration due to proteolytic enzymes Injection of conjunctival & epibulbar vessels Caused by: Staphylococcus. MD . NEPOMUCENO. Herpes. Moraxella.
often Gland of Ziess Internal. NEPOMUCENO.Hordeolum or “stye” Local infected abscess of a hair follicle or gland on the lid margin External.meibomian gland R.anterior eyelid margin. MD .
NEPOMUCENO.Chalazion Chronic Lipogranuloma of meibomian gland Forms as a discrete mass R. MD .
MD . NEPOMUCENO.Xanthelasma Superficial dermis contain histiocytes filled with cholesterol esters Elevated serum cholesterol or hyperlipidemia syndrome R.
NEPOMUCENO. with a central ulceration R. MD Basophilic nests of cells with peripheral palisading .Basal Cell Carcinoma These slow-growing tumors are found in sunexposed areas They are the most common eyelid malignancy Usually located on the lower eyelid Edges are raised and pearly.
Squamous Cell CA Rare malignancy of the eyelids Commonly arises in sunexposed areas and may resemble other lesions of the eyelid. MD . basal cell carcinoma. and seborrheic keratosis The inset shows pearly raised margins of a small squamous cell carcinoma R. such as keratoacanthoma. NEPOMUCENO.
Capillary Hemangioma Appear at or soon after birth Strawberry nevus Usually involute spontaneously May cause amblyopia if in visual axis Intralesional steroid injection R. MD . NEPOMUCENO.
Allergic Contact Dermatitis Environmental or externally applied agents Cell mediated type IV reaction Neomycin. atropine R. NEPOMUCENO. MD .
NEPOMUCENO. MD . University of California. Los Angeles R.Royce Hall.
NEPOMUCENO. blurring of vision.Keratoconjuctivitis sicca Aqueous tear deficiency Acquired disorder mostly women > or = 40 years old Dryness. MD . or photophobia Worse at the end of day and with dry windy weather R.
NEPOMUCENO. MD . 6. 3. 2. Follicular Conjunctival Reaction Papillary Conjunctival Reaction Epidemic Keratoconctivitis Membranous Conjunctivitis Gonococcal Conjunctivitis Chlamydial Conjunctivitis R.Conjunctival Disease 1. 5. 4.
Trachoma 8. Atopic Keratoconjunctivitis 10. Giant Papillary Keratoconjunctivitis R. MD . Vernal Keratoconjunctivitis 11.Conjunctival Disease 7. Allergic (Hay Fever) Conjunctivitis 9. NEPOMUCENO.
14. Superior Limbic Keratoconjunctivitis Stevens-Johnson Syndrome Conjunctival Nevus Adenochrome Deposits Pinguecula Pterygium R. 13. 17. MD .Conjunctival Disease 12. NEPOMUCENO. 16. 15.
20. NEPOMUCENO. MD . Conjunctival Lymphoma 23. Pyogenic Granuloma Phlyctenulosis Conjunctival Viral Papilloma Conjunctival/Corneal Intraepithelial Neoplasia 22. 19. 21.Conjunctival Disease 18. Primary Acquired Melanosis (PAM) R.
NEPOMUCENO.Follicular Conjunctival Reaction Follicles = lymphoid germinal centers Smooth nodules which are avascular at the apices sorrounded by fine vessels at their bases Can be a normal variant if found in the lower conjunctiva without infection R. MD .
MD .Follicular Conjunctival Reaction Etiology Adenoviral conjunctivitis Infection from primary herpes simplex virus Molluscum contagiosum Enterovirus Chlamydia Toxicity from medications R. NEPOMUCENO.
MD .Papillary Conjunctival Reaction Non-specific response caused by many agents Usually seen on the upper tarsal conjunctiva Fine mosaic pattern of dilated telangiectatic blood vessels Each has a central firovascular core that gives rise to a vessel branching out in a spokelike pattern Cojunctival septae sorrounding the papillae are anchored by pale tissue when papllary hypertrophy occurs R. NEPOMUCENO.
11. NEPOMUCENO. and pseuodomembrane or membrane formation R. chemosis.Epidemic Keratoconjunctivitis (EKC) Syndrome of external ocular adenovirus infection Serotypes 8. MD . and mild foreign body sensation Preauricular lymphadenopathy and mixed papillary-follicular conjunctivitis May present with subconjunctival hemorrhage. photophobia. and 19 most common Acute onset of watery discharge.
MD .Epidemic Keratoconctivitis Mucopurulent discharge when membranous reaction develops Maximum intensity in 5-7 days after onset of symptoms Keratitis is characterized initially by diffuse punctate intraepithelial lesions. NEPOMUCENO. followed by fine or coarse punctate epithelial keratitis and finally by subepithelial infiltrates (SEIs) SEI develop until after at least 2 weeks after the onset of symptoms SEI results from a host immune response R.
NEPOMUCENO.Membranous Conjunctivitis Conjunctival membrane or pseudomembrane can occur in association with severe viral or bacterial conjunctivitis or following chemical burn. ocular cicatricial pemphigoid Produced when an inflammatory discharge of fibrin with PMN’s and fibrin coagulates on the conjunctival surface True membrane incorporates the epithelium an bleeds when removed Pseudomembrane is more superficial and can be peeled or scraped away without bleeding Healing can result in conjunctival scaring R. or Stevens-Johnson syndrome. MD .
MD .Bacterial Conjunctivitis Gonococcal Neissera gonorrheae Hyperacute purulent conjunctivitis Direct contact with infected genital secretions or from genital-handocular transmission GC and meningococci are the only bacteria causing conjunctivitis with preauricular LAD and conjunctival membranes R. NEPOMUCENO.
epithelial defects. NEPOMUCENO. and peripheral ulcerative keratitis that rapidly progress to perforation Classic cause of neonatal conjunctivitis R. marginal infiltrates.Gonococcal Conjunctivitis Corneal involvement may consist of diffuse epithelial haze. MD .
MD .Gonococcal Conjunctivitis Systemic + topical antibiotics Ceftriaxone 1 gram IM With corneal perforationadmitted with IV ceftriaxone q 12 x 3 days Cotreatment for chlamydia R. NEPOMUCENO.
NEPOMUCENO. MD .Chlamydial or Inclusion Conjunctivitis C. although urogenital symptoms may not be present Characterized by prominent follicular response with non tender preauricular LAD R. Trachomatis D-K Sexually active & in conjunction with urethritis or cervicitis.
Chlamydial or Inclusion Conjunctivitis Punctate epithelial keratitis often noted superiorly & can evolve to marginal or subepithelial infiltrates Micropannus can occur One of the most common forms of neonatal conjunctivitis in the newborn assoicated with pneumonitis Neonates have no follicular response making diagnosis more difficult Oral tetracyline 250 mg qid for 3 weeks. erythromycin 500 mg qid for 3 weeks. NEPOMUCENO. azithromycin R. MD .
chemosis and mucoid discharge Attacks are usually short lived & episodic R.Allergic (Hay Fever) Conjunctivitis Reaction to airbone allergens and is mediated by IgE antibodies Hallmark is itching Signs: hyperemia. NEPOMUCENO. MD .
blepharospasm. MD . blurred vision. NEPOMUCENO.Vernal Keratoconjunctivitis Seasonally recurring bilateral inflammation of the conjunctiva seen mainly in young males 416 years old with strong history of atopy Tropical climates Intense itching. photophobia. and copius mucoid discharge Palpebral = upper tarsus where a diffuse papillary hypertrophy develops with giant (cobblestone) papilae R.
or chemicals involved in lens cleaning Also seen in ocular prosthesis.Giant Papillary Keratoconjunctivitis Chronic inflammation of the conjunctiva with prominent papillary hypertrophy of the superior tarsus Associated with soft contact lens material. loose nylon sutures. protein debris accumulating on the lens surface. MD . NEPOMUCENO. filtering blebs R.
and more prevalent in females Acute onset of fever.Stevens-Johnson Syndrome (erythema multiforme major) Acute. vesiculobullous reaction of the skin & mucous membranes Children & young adults. malaise. MD . arthralgia. and upper or lower respiratory tract symptoms Cutaneous eruptions follows within days R. NEPOMUCENO. inflammatory.
NEPOMUCENO. MD . dry eye R. trichiasis.Stevens-Johnson Syndrome (erythema multiforme major) Bullous eruptions with membranes or pseudomembranes formation occur Mucopurulent discharge is common Late ocular complications include symblephara.
R. NEPOMUCENO, MD
Congenital hamartomas that consist of nests of modified melanocytes (nevus cells) Junctional, compound, & subepithelial nevi occur in the conjunctiva An important variation in the conjunctiva is the frequent occurrence ofsmall epithelial inclusion cysts within nevi particularly within compound or subepithelial ones Rarely undergo malignant transformation
R. NEPOMUCENO, MD
These elevated, fleshy conjunctival masses are located in the interpalpebral region, most commonly on the nasal side Yellow or light brown Associated with chronic actinic exposure, repeated trauma, and dry and windy conditions Histologically, they are composed of abnormal collagen bundles with staining characteristics similar to elastic tissue Elastotic degeneration, but the tissue is not actually composed of elastin
R. NEPOMUCENO, MD
wind & dust Histopath: subepithelial fibrovascular tissue and elastotic degeneration of collagen Can occur above or within bowman’s layer Corneal epithelial iron line (Stocker’s line) can be seen in advance of the head of a pterygium on the cornea Indications or removal: reduced vision due to invasion of visual axis. NEPOMUCENO. MD . irregular astigmatism. & significant ocular irritation R.Pterygium Benign proliferation of fibrovascular tissue covered by conjunctival-like epithelium extending onto the peripheral cornea Risk factor: UV light.
red pedunculated lesion can arise from skin or conjunctiva Often accompanied by mucopurulent discharge After inflammatory conditions such as chalazia or chemical burns. NEPOMUCENO. MD .Pyogenic Granuloma Misnomer because the lesion does not represent granulomatous inflammation Rather a reactive proliferation of vascular endothelial cells and granulation tissue Raised. fleshy. or after conjunctival surgery R.
MD .Suture Granuloma Clinically appears similar to a pyogenic granuloma Suture granuloma after strabismus surgery R. NEPOMUCENO.
MD . NEPOMUCENO.Conjunctival / Corneal Phlyctenules Focal transluent lymphocytic nodules located at the limbus Neutrophils enter the nodule a few days after onset as necrosis develops Result from delayed cell-mediated hypersensitivity reaction to Staphylococcal antigens or tubercle bacilli Limbal may result in fibrosis and vascluarization of the peripheral cornea may wander across the cornea producing vascularization & scarring R.
MD . radiation. pregnancy. or other causes R. NEPOMUCENO.Racial Melanosis PAM is different from acquired racial melanosis & from secondary acquired melanosis caused by Addison’s disease.
Conjunctival Concretions Represent trapped foreign body such as dust in the conjunctival epithelium Present as foreign body sensation if numerous and very elevated R. NEPOMUCENO. MD .
Chemical Injuries Acid Alkali R. NEPOMUCENO. MD .
MD . valsalva. or blood dyscrasia R.Subconjunctival Hemorhage Rupture of conjunctival blood vessel due to trauma. NEPOMUCENO.
NEPOMUCENO.Scleral Disease 1. 2. 4. Episcleritis Scleritis Scelromalacia Peforans Congenital Melanosis Oculi R. 3. MD .
MD .Episcleritis Inflammation & vasodilation of episclera Not associated with systemic disease Self-limited disease generally seen in young to middle age adults Nodular or diffuse No tenderness or pain R. NEPOMUCENO.
NEPOMUCENO.Scleritis Anterior Sectoral Nodular Diffuse Necrotizing Posterior R. MD .
and scleral perforation R. scleral thining. cataract.Scleritis Associated with numerous autoimmune disease Deep. NEPOMUCENO. marginal keratolysis. MD . glaucoma. constant pain Bilateral in 50% Predominantly in women Active-sclera has a violaceous hue Vessels don’t move when applicator applied to conjunctiva Complications:Keratitis. uveitis.
MD .Scleromalacia Peforans Nodular Scleritis Commonly seen in rheumatoid arthritis Scleromalacia perforans Painless form with no obvious inflammatory sign Seen in severe RA R. NEPOMUCENO.
MD . Los Angeles R. NEPOMUCENO.Jules Stein Eye Institute. University of California.
Herpes Simplex Virus Dendritic Keratitis R. MD . pneumonia 2. aeruginosa 3. Acanthamoeba Keratitis 5. Fungal Keratitis 4. NEPOMUCENO.Corneal Disease .Infectious 1. Primary Herpes Simplex Virus Infection 6. Bacterial Keratitis: P. Bacterial Keratitis: S.
Corneal Disease . Marginal Keratitis Associated with Staphylococcal Blepharitis R. Herpes Zoster Dendritiform Keratitis 10. NEPOMUCENO. Herpes Simplex Virus Geographic Keratitis 8.Infectious 7. Herpes Simplex Virus Necrotizing Stromal Keratitis 9. MD .
Corneal Dystrophies/Inherited Diseases 11. Granular Dystrophy 15. MD . Macular Dystrophy R. Corneal Epithelial Membrane Dystrophy (Map-Dot-Fingerprint Dystrophy) 13. Luetic Intersitial Keratitis 12. Lattice Corneal Dystrophy 14. NEPOMUCENO.
21. NEPOMUCENO. Fuchs’ Endothelial Dystrophy Keratoconus Corneal Arcus Calcific Band Keratopathy Secondary Lipid Kertopathy Salzmann’s Nodular Degeneration R. MD . 17. 19. 18.Corneal Degeneration 16. 20.
NEPOMUCENO. Mooren’s Ulcer Other Corneal Conditions 24.Corneal Degeneration 22. Neurotrophic Keratopathy 23. Alkali Burn R. Corneal Foreign Body 25. MD .
NEPOMUCENO.Bacterial Keratitis Etiology trauma contact lens wear dry eye use of contaminated topical medications Lab confirmation essential S. MD . aureus R.
MD P. NEPOMUCENO.negative organisms Rapid evolution Tenacious mucopurulent discharge Opacification & edema adjacent to ulcer Stromal necrosis due to proteolytic enzymes Seen among contact lens wearer R.Bacterial Keratitis Virulent gram. aeruginosa .
NEPOMUCENO. MD .Fungal Keratitis Filamentous (Fusarium) or Yeast (Candida spp) Dirty gray white. dry infiltrate with feathery borders Multiple or satellite infiltrates Large ulcers have endothelial plaque & hypopyon Can extend into the anterior chamber & perforation R.
Photophobia. protracted progressive course Early.dendritiform Enlarged corneal nerves Stromal – gray white superficial infiltrate in central cornea Partial or complete ring infiltrate in late phase Commonly misdiagnosed as HSV R. NEPOMUCENO. MD .Acanthamoeba Keratitis Seen in contact lens wearer who make their own solutions Severe pain.
Primary Herpes Simplex Virus Infection Acquired from the environment Unilateral vesicular blepharoconjunctivitis Pruritic vesicles of the lids. & eyelid margin Follicular conjunctivitis & palpable preauricular lymph node Treatment: oral ACV & topical TFT or ACV` R. MD . skin. NEPOMUCENO.
photophobia. dendritic lesion (swollen opaque epithelial cells) commonly in the center Characteristic terminal bulbs R. coalesce. mild foreign body sensation. NEPOMUCENO. redness & blurred vision Starts as discrete punctate epithelial keratitis. MD .Herpes Simplex Virus Dendritic Keratitis Majority of patients have a recurrent ocular disease Asymptomatic.
NEPOMUCENO. MD .Herpes Simplex Virus Geographic Keratitis Lysis of desquamated cells result to an ulcer Stains with rose bengal dye Geographic map ulcers develop by centrifugal spread of HSV Sub-epithelial infiltrates serve as markers of past infection and leave as scars Sectoral or diffuse reduction in corneal sensation Diagnosis mainly on signs Tissue culture or Antigen detection techniques R.
NEPOMUCENO.Herpes Simplex Virus Disciform Keratitis Focal circular area of microcystic edema overlying a mild stromal inflammatory infiltrate & edema with descemets folds & underlying kp’s Photophobia & decreased vision Cell mediated immune response to viral antigens in the stroma R. MD .
R. NEPOMUCENO. MD .
Hassall-Henle bodies Central. brown. pigment granules on the posterior surface of the cornea Guttae represent thickened & localized anvil-shaped excrescences of descemet’s membrane Beaten-metal appearance resembling skin of an orange R. drop-like prominences at Descemet’s membrane & endothelium Fine.Cornea guttae No inheritance pattern Round. dark. MD endothelial mosaic .Cornea Guttata Peripheral. NEPOMUCENO.
MD . NEPOMUCENO.Fuchs’ Endothelial Dystrophy Hereditary atrophy of the endothelium Auto dominant Women > 50 and older Significant density of cornea guttae Attenuation & dysfunction of endothelial cells leading to corneal edema Stromal then epithelial edema Risk of corneal decompensation after cataract surgery R.
MD . irregular astigmatism.Keratoconus Central or paracentral cornea undergoes progressive thinning & bulging Cone shape cornea No associated inflammation Unknown cause relation to atopy. irregular scissoring R. congenital amaurosis & eye rubbing Tends to progress during adolescent years Cone shape induces myopia. Flesicher’s rings. NEPOMUCENO. & decreased vision Corneal findings: Vogt’s striae. down syndrome.
which increases the local concentration of calcium This condition may be idiopathic but is usually associated with localized ocular inflammatory processes or systemic hypercalcemia R. NEPOMUCENO. MD .Calcific Band Keratopathy Characteristically this occurs in the interpalpebral region Calcium deposits in this region result from localized elevations of pH favoring calcium precipitation and increased evaporation.
NEPOMUCENO. fine .Corneal Foreign Body Common Etiology Imperative to evert the upper lid Removal essential Cause abrasion linear. vertical May cause secondary bacterial infection R. MD .
Corynebacterium xerosis. a white-gray irregular plaque that usually occurs near the limbus in the interpalpebral region A gas-producing bacteria. is responsible for the foamy appearance in this lesion Marked keratinization of the inferior cornea Corneal surface is dry. and the light reflex is irregular Goblet cell function is impaired in this disorder. NEPOMUCENO. and there is a lack of mucin R. MD .Vitamin A Deficiency Bitot spot.
MD . NEPOMUCENO.Corneal Abrasion Epithelium of cornea removed by trauma or foreign body Pain. photophobia & blurred vision R.
MD . NEPOMUCENO.Thyroid Eye Disease Infiltration of the extraocular muscles and connective tissue can result in severe proptosis and orbital inflammation Patient had chronic exposure keratitis and developed an indolent ulcer Exophthalmos and lid retraction predispose to corneal exposure R.
THANK YOU R. NEPOMUCENO. MD .