dr. sushil tripathi - jdosmp.org · recurrent corneal erosion syndrome common disorder involving...
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NONINFECTIOUS SUPERFICIAL KERATOPATHIES
Dr. Sushil Tripathi
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• Recurrent corneal erosion syndrome
• Filamentary keratitis
• Thygeson’s superficial punctate keratitis
• Superior limbic keratoconjunctivitis
• Neurotrophic keratitis
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Recurrent corneal erosion syndrome
Common disorder
involving the corneal
epithelium and
epithelial basement
membrane
characterised by
repeated breakdown
of epithelium.
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Etiology
Previous trauma corneal dystrophies: Diabetes mellitus
Anterior basement membrane corneal dystrophy lattice, Reis-Bücklers’, macular, granular, Meesmann's dystrophies
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Pathophysiology
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Pathophysiology
Trauma or corneal dystrophy
Abnormal attachment complexes
Recurrent corneal erosion
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Pathophysiology
eyes closed
tear evaporation
concentration of dissolved salts in tear fluid
shift of osmotic gradients
corneal epithelial edema
epithelial adhesion
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Clinical manifestations
Symptoms:
• episodic in nature
• Sudden onset
• Mostly in early morning
• Sharp pain, epiphora, FB sensation, lid edema
• Anxiety, depression, fear of falling asleep,
insomnia.
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Diagnosis
• history of previous trauma
• episodes of pain on awakening
• ragged, staining area of
epithelium
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Medical Treatment
• long-term nightly use of hyperosmotic
lubricating ointments
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Medical Treatment
• long-term nightly use of hyperosmotic
lubricating ointments
• Hyperosmotic eyedrops during the daytime
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Medical Treatment
• long-term nightly use of hyperosmotic
lubricating ointments
• Hyperosmotic eyedrops during the daytime
• Patching
• Bandage contact lens
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Surgical Treatment
Anterior stromal puncture:
• In 1986 McLean et al• Also known as epithelial reinforcement,
corneal micropuncture
• highly effective OPD procedure
• For Localized erosions
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Surgical Treatment
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Surgical Treatment
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Surgical Treatment
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Surgical Treatment
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Surgical Treatment
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Surgical Treatment
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Surgical Treatment
superficial keratectomy:
• multiple erosions in different
areas of the cornea
• large areas of loosely adherent
irregular epithelium
• Erosions in visual axis
• no history of trauma
• severe basement membrane
dystrophy
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Surgical Treatment
superficial keratectomy:
• OT procedure
• Dissect the whole epithelium with no. 15
blade
• Leave 1mm peripheral epithelium
• Do not remove Bowman’s membrane
• Scrape it with blade perpendicular
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Surgical Treatment
Postsurgical treatment:
• hyperosmotic ointments and drops
• NSAID drops
• Antibiotics
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Filamentary keratitis
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Associated diseases
Ocular trauma/surgery:
Abrasion/erosion
Contact lens overwear
Cataract extraction
Penetrating keratoplasty
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Associated diseases
Ophthalmic disorders: Keratoconjunctivitis sicca
Superior limbic keratitis
Neurotrophic keratopathy
Prolonged patching
Ptosis
Aniridia
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Associated diseases
Systemic disorders:
Sarcoid
Diabetes mellitus
Hereditary hemorrhagic telangiectasia
Ectodermal dysplasia
Psoriasis
Atopic dermatitis
Brain stem injury
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Pathophysiology
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Clinical Manifestations
• foreign body sensation
• photophobia
• blepharospasm
• epiphora
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Treatment
• Treat the underlying cause
• Mechanical debridement of the filaments
• Tear substitutes
• Punctal oclusion
• 5% sodium chloride ophthalmic solution
• Bandage soft contact lens
• NSAID eye drops
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Thygeson's Superficial Punctate Keratitis
• uncommon epithelial keratopathy of unknown cause• no known association with other ocular or systemic
disease• coarse punctate epithelial keratitis • little or no hyperemia of the bulbar or palpebral conjunctiva• Active and chronic keratitis but no neovascularization• often misdiagnosed.
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Epidemiology
• No sex predilection
• 2.5 years of age to over 70.
• Most common in second and third decades.
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Etiopathogenesis
• Not yet understood
• resemble viral lesions
• Long duration
• exacerbations and remissions
• mononuclear cell response
Viral suspect
• Presence of HLA-DR3 antigens
• Chronic course • Presence of lymphocytes
• Corticosteroid response
Autoimmune suspect
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Clinical manifestations
• Long history of exacerbations and spontaneous
remissions
• Foreign body sensation
• Photophobia
• Burning
• Tearing
• Occasional blurring of vision.
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Clinical manifestations
• Bilateral
• Mild or no conjunctival congestion
• oval or round, punctate
intraepithelial lesions
• evanescent and migratory
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Clinical manifestations
• composed of numerous discrete, fine, granular,
white to gray, dotlike opacities
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Differential Diagnosis Thygeson’SPK Adenoviral SPK
Noninfectious infectious
No other ocular findings Lid edema, congestion, conjunctival follicles
coarse Fine
No subepithelial infiltrates Subepithelial infiltrates
No scarring Scarring ( Visually significant )
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Treatment
• Low-dose topical corticosteroids
• Bandage contact lens
• ciclosporin A
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Superior Limbic Keratoconjunctivitis
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Epidemiology
• Nonfamilial
• Age – 20-67 years mean age - 50 years
• female:male ratio - 3 : 1
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Etiopathogenesis
• etiology is not clear
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Etiopathogenesis
Associations:
• Thyrotoxicosis – 30% of the cases.
• keratoconjunctivitis sicca
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Clinical Presentation
• Long lasting
• Exacerbations and remissions
• foreign body sensation, photophobia, and pain
• Blepharospasm
• Mucoid discharge
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Clinical Presentation
• Signs:• Bilateral • hyperemia of the palpebral conjunctiva and a
fine papillary reaction
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Clinical Presentation
• Signs:• The superior bulbar and limbal conjunctiva shows
sectoral injection and appears thickened and redundant
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Clinical Presentation
• Signs:• application of rose Bengal often shows coarse
punctate staining of the superior bulbar and limbal conjunctiva as well
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Clinical Presentation
• Signs:• Superior corneal and limbic filaments • Thickened limbus
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Management
• Assess
-tear function
-lid tension
-thyroid status
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Management
• local application of 0.5–1% silver nitrate solution to the superior palpebral conjunctiva
• superior bulbar conjunctival resection (patients
with normal Schirmer test)
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Management
• Mondino et al. Reported use of therapeutic soft contact lens
• Udell et al. reported the results of treating SLK with thermal cauterization
• Yang and colleagues found resolution of SLK symptoms in 22 eyes after permanent punctal occlusion
• Ohashi et al. advocated the use of topical vitamin A
• Perry et al. advocated the use of 0.5% topical ciclosporin A as a primary or adjunctive therapy
• Shen et al. treated 20 patients with triamcinolone injection in Supratarsal conjunctiva
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Neurotrophic Keratitis
• degenerative disease of corneal epithelium characterized by impaired healing.
• Absence of corneal sensitivity is the hallmark
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Causes of corneal hypoesthesia
• Infection
- Herpes simplex
- Herpes zoster
- Leprosy
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Causes of corneal hypoesthesia
• Fifth nerve palsy
- Surgery (as for trigeminal neuralgia)
- Neoplasia (such as acoustic neuroma)
- Aneurysms
- Facial traum
- Congenital
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Causes of corneal hypoesthesia
• Topical medications
- Anesthetics
- Timolol
- Betaxolol
- Sulfacetamide 30%
- Topical NSAID
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Causes of corneal hypoesthesia
• Corneal dystrophies
- Lattice
- Granular (rare)
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Causes of corneal hypoesthesia
• Systemic disease
- Diabetes mellitus
- Vitamin A deficiency
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Pathogenesis
Reduced corneal sensation
renders the corneal surface prone to occult injury
decreases reflex tearing
decrease healing rates of corneal epithelial injuries
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Biochemical Basis
acetylcholine
Substance P
prostaglandins
Epithelial mitosis
Adrenergic neurotransmitters
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Clinical Findings
• Stage 1
• Rose Bengal staining of the palpebral
conjunctivae
• Decreased tear break-up time
• Increased viscosity of tear mucus
• Punctate epithelial staining with fluorescein
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Clinical Findings
• Stage 2 • Acute loss of epithelium• Surrounding rim of loose epithelium• Stromal edema• Aqueous cell and flare• Edges of the defect become smooth and rolled with
time
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Clinical Findings
• Stage 3
• Stromal lysis
• corneal perforation
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Management
• topical lubrication
• lateral tarsorrhaphy
• Punctal occlusion
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Management
• topical lubrication
• lateral tarsorrhaphy
• Punctal occlusion
• topical tetracycline and Oral doxycycline
• autologous serum eyedrops
• Bandage contact lens
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Management
• Cyanoacrylate glue
• tectonic lamellar keratoplasty
• conjunctival flaps
• multilayer amniotic membrane transplantation
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Management
• penetrating keratoplasty
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Management
• penetrating keratoplasty
protected by lateral tarsorrhaphy
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Management
• penetrating keratoplasty
protected by lateral tarsorrhaphy
perioperative nonpreserved steroids and
antibiotics
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Management
• penetrating keratoplasty
protected by lateral tarsorrhaphy
perioperative nonpreserved steroids and
antibiotics
long-term maintenance using autologous serum
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Thank You