1. 4/17/2008
Complex Corneal Grand Rounds
William D. Townsend, OD, FAAO
Advanced Eye Care Canyon, TX
Adjunct Professor, UHCO Houston, TX
INTERACTIVE
1.acting one upon or with the other.
2.of or pertaining to a two‐way system of electronic
communications, as by means of television or
computer: interactive communications between
families using two‐way cable television.
This course will be interactive.
Cornea: Anatomical & Physiological
Considerations
• Epithelium
– Protective function
– In abrasions, cells “slide” to cover debrided areas
– Regenerates in 6‐7 days
– Trauma to basal cells may result in irregular basement
membrane
– Nerve concentration 20x that of dental pulp
• Bowman’s layer‐ highly resistant to penetration
– Anchoring filaments based in stroma
• Stroma
– Regular spacing of fibrils results in clarity
– Hydrophilic
– Prone to edema
– Damage is repaired by keratocytes, usually not transparent
1

2. 4/17/2008
Cornea: Anatomical & Physiological
Considerations
• Descemet’s membrane
– Breaks result in inflow of aqueous into stroma
– Capable of self‐healing
• Endothelium
– Transports fluid out of cornea
Transports fluid out of cornea
– 50% of cells lost over a lifetime
– Loss of function results in decompensation
• Tear film
– Protective functions: lysozyme, other enzymes
– Removes potential pathogens
Attack of the Killer Lampshade
A 43 year old female presents with
a history of having struck herself in
the right eye with a lampshade. She
complains of moderate painpain,
photophobia, blurred vision, and lid
edema. Her general health history
is unremarkable; she takes no
systemic medications, and has no
known medication allergies.
Attack of the Killer Lampshade
• VA = OD 20/25 OS 20/20
• SLE:
OD: Abrasion superior cornea
Gr.
Gr II+ injection
No flare or cells
Gr. II+ lid edema
OS: NL
• Pupils NL
2

3. 4/17/2008
Attack of the Killer Lampshade
Assessment:
• Corneal abrasion secondary to
trauma
Plan: pressure patch with:
• 2 gtt Voltaren
• 1 gtt Tropicamide 1%
• 1 gtt Occuflox
• 400 mg Ibuprofen
RTC: 1 day
Attack of the Killer Lampshade
• Day 2: Removed patch in office.
• Subjective: Complains of “shooting pains in
OD, eye feels feverish, swollen”
• VA = OD 20/30 OS 20/20
• SLE:
– Corneal abrasion 95% healed
– A/C: trace cells, flare, decreased injection
• Assessment: The eye looks great, almost
healed
• What is wrong with our management of this
case?
• Plan: ?
Corneal Abrasion: A Model For Trauma
What Went Wrong On Day 2?
Trauma Release of bradykinin
Release of cell membrane phospholipids
Converted by: Phospholipase A
Arachidonic acid
Converted by: cyclooxygenase lipoxygenase
prostaglandins leukotrienes
Vasopermeability, Miosis
Chemotaxis PMN migration
Vasodilation, IOP changes
3

4. 4/17/2008
Pathogenesis of Inflammation
Trauma Release of bradykinin
Release of cell membrane phospholipids
Converted by Phospholipase A
Blocked byy
Side effects!
steroids
Arachidonic acid
converted by: cyclooxygenase lipoxygenase
prostaglandins leukotrienes
Vasopermeability, Miosis
Vasodilation, IOP changes Chemotaxis PMN migration
Nonsalicylate NSAIDs
• Used to manage mild to moderate pain
• Compare well with many narcotic
analgesics in relieving pain
• Effective anti-inflammatory agents- work
anti inflammatory agents
peripherally and centrally
• Central nervous system effect reduces
recognition of pain
• Antipyrexic- (lower body temperature)
• Ceiling effect- dosing above given level
does not further increase pain relief
Ibuprofen
• OTC in 200m tablets, capules, gel caps
• Rx 400mg, 600 mg, 800 mg
• Gel caps give most rapid relief of pain
and inflammation
• Acts centrally and peripherally to reduce:
Sensation of pain
Inflammation
• Requires Q 4hr dosing
• Should be taken with food
• Pediatric syrup available (OK for adults)
• Ceiling effect!
4

5. 4/17/2008
Oral Ibuprofen vs. Tylenol No. 4
Cooper, Steven A. “The relative efficacy
of ibuprofen in dental pain” Compend.
Cont. Ed. Dent. Vol VII, No 8.
“ Ibuprofen 400 mg was significantly
more effective than acetaminophen 300
mg with codeine 60 mg for every
analgesic measure (P < .05).”
Lessons from This Case
Ultimately, patients may remember
how well you managed or
mismanaged their pain rather than
how you managed their disease.
You have a 12 hour window to be a
hero or a heel. Always address pain
proactively rather than reactively.
A Garden Variety Case
A sixty-seven year old female presents with a
history of having been struck in the right eye
with the tip of a cactus while working in the
garden. The episode occurred four days
prior to her visit Since then she has had
visit. then,
persistent watering and foreign body
sensation, but no mucopurulent discharge.
She denies any blurring or loss of vision. Her
general health history is unremarkable. As a
child she suffered a blow to her right eye
without any known permanent sequelae.
5

6. 4/17/2008
Your diagnosis of this patient’s
condition is:
1. Epithelial basement membrane
dystrophy
2. Recurrent corneal erosion
3. Penetrating corneal injury
4. Fuch’s corneal dystrophy
5. Corneal abrasion
6. Townsend’s syndrome
Appropriate management of this
case would include:
1. Referral to corneal specialist
2. Hypertonic saline drops and ointment
3. Bandage contact lens
4. Topical antibiotic drops
5. Topical beta blocker or carbonic
anhydrase inhibitors
6. All the above except 2
The most appropriate antibiotic
for this patient is:
1. Polytrim drops
2. Ciloxan
2 Cilo an ointment
3. Tobramycin drops
4. Tobradex ointment
5. Vigamox drops
6

7. 4/17/2008
How We Would Manage This Case
in 2008
• Bandage contact lens
• Topical Vigamox drops Q 4 hrs
• Topical beta blocker Q24 hrs (do
careful medications, health Hx)
• Daily monitoring of patient
• Emphasize need to report redness,
pain, or blurred vision immediately
The One-eyed Wonder
A 71 year old male presents with pain
and photophobia in his left eye. His
right eye had been enucleated
following trauma years earlier. He
earlier
initially denied any history of trauma,
but later stated he may have
scratched his eye playing with his
dogs. His hypertension was controlled
by medications, and he denied any
history of drug allergy.
The One-eyed Wonder
• VA: OD N/A OS 20/30
• SLE:
– OD coated prosthesis
– OS 2 mm area of epithelial ulceration
OS: f ith li l l ti
midway between limbus and central
cornea.
– Conjunctiva: gr. II+ injection
– A/C: gr. I+ cells, flare
7

8. 4/17/2008
What is your initial plan
1. Start topical fluoroquinolone
2. Start topical fortified antibiotics;
Cefazolin & Tobramycin
3.
3 Perform corneall scraping and culture
P f i d lt
on agar plates
4. Shoot the dogs
5. 1&3
6. 2&3
The One-eyed Wonder
• Assessment: bacterial keratitis
• Plan:
– Obtain cultures: blood and chocolate
agar
– Start Ciloxan per manufacturer’s
recommendations
– Admit to hospital: (patient was from out of
town and had no place to stay)
– RTC x 1 day
The One-eyed Wonder
• Day 2
• All findings stable to slightly worse
• Cultures show no growth after 24 hrs
• Day 3
• All findings stable with slight
enlargement of ulcerated area
• Lab reports no growth
8

9. 4/17/2008
OK, the guy only has one eye, and
it’s getting worse fast…so what are
you going to do?
1. Repeat scraping and culture
2. Consult lab
3. Increase dosage frequency
4. Be patient
5. Shoot the patient
6. Shoot yourself
The one-eyed wonder
• Day 3- it was worse, believe me…..
• A personal visit to the microbiology
lab: culture showed a small colony on
one of the plates; lab staff refers to it
p ;
as “contamination”
• I refer to it as, “my last hope”
• Plan: re-streak “contaminants” on to
additional Sabouraud's agar plates
Your final shot at this case
1. Resistant bacterial strain
2. Atypical herpes simplex lesion
3.
3 Fungal ulcer
l l
4. Corneal melt
5. Dog-scratch fever
9

10. 4/17/2008
The one-eyed wonder
Day 4
• Ulcerated area increasing in size
• Lab reports fungal growth of Aspergillis
• Plan: start patient on natamycin q 1 hour
Day 5
• Ulcerated area beginning to shrink
• Patient reports improvement in symptoms
• Reduce frequency of drops
Final Outcome
• Best corrected VA = 20/30: small scar OS
Wong TY et al “Risk factors and clinical outcomes
between fungal and bacterial keratitis: a
comparative study”. CLAO 1997; 23 (5), p 275-81
Compared relationship of fungal and
bacterial keratitis with respect to:
• Trauma
• Contact lens wear
• Findings: in a five year period,
– 103 cases of infectious keratitis managed;
– Cases definitely identifiable as fungal or bacterial
included
– All others excluded
Wong TY et al
29 of 103 eyes met criteria for fungal keratitis
• Males/females = 3.8/1
• 27% had satellite lesions
• 21% had perforation
• 55% had Hx of trauma
• 7% wore contact lens
• 24 % were using topical steroids
10

11. 4/17/2008
Wong TY et al
51 of 103 eyes met criteria for bacterial
keratitis
• Males/females = 1.8/1
• 0% had satellite lesions
• 4% had perforation
• 31% had Hx of trauma
• 31% wore contact lenses
• 31% were using topical steroids
Wong TY et al
Conclusions
• Trauma a significant risk factor for fungal
keratitis
• Contact lens wear a significant risk factor for
bacterial keratitis
• Use of steroids significantly increases risk for
keratitis of either kind
• Satellite lesions highly suggestive of fungal
keratitis
• Perforation 5x more likely in fungal keratitis
Townsend, W. “A question of culture”.
Contact Lens Spectrum; April 1998
• Monocular individuals with infectious keratitis
• Large ulcerative lesions impinging on the visual axis
• Pediatric ulcerative keratitis, highly purulent keratitis,
suspected Haemophilus conjunctivitis
p p j
• Chronic lesions that fail to respond in
• Bilateral corneal ulceration ( almost exclusively in
immuno-compromised patients)
• Suspected chlamydial infection (use DNA probe w/
PCR sensitivity and selectivity)
• Possible fungal or amoebic infection (biopsy
needed?)
11

12. 4/17/2008
Lessons from One Eyed Wonder
• Think of the worst case scenario when
dealing with corneal conditions
• If in doubt, culture ulcers
• Gi special consideration t one-
Give i l id ti to
eyed individuals with potential disease
• Do not trust labs; they can let you
down at exactly the wrong moment
• Remember fungal keratitis as a
possible etiology in corneal disease
With all this refractive surgery
being done…….
Mr. 20/20 (with help)
A 22 y/o Hispanic male who underwent
LASIK two years ago presents with
blurring in his right eye. He was struck in
right eye by his daughter’s fingernail.
He wants to know why he is blurry, but
has minimal pain.
Mr. 20/20 (with help)
• VA: OD 20/30 OS 20/20
• SLE:
– OD
• Trace injection
• Anterior stromal haze
• Anterior chamber clear NOFC
• Tr. stain w/ NaFL
– OS- all findings unremarkable
• TA OD 17 mm Hg OS 16 mm Hg
• Meds: artificial tears OD for discomfort
(patient did not bring with him)
12

13. 4/17/2008
Mr. 20/20 (with help)
Your diagnosis is:
1. Recurrent corneal erosion
secondary to trauma
2. Diffuse bacterial keratitis
3. Chemical keratitis secondary to
BACL preserved drops
4. Post traumatic DLK
5. Posner-Slossman Syndrome
Your initial treatment would be..
1. D/C present drop & start non-preserved
hypotonic artificial tears
2. Debride corneal epithelium and apply
bandage lens and start Zymar BID along
w/ hypertonic drops QID
3. Start Vigamox 1 drop every three hrs.
4. Start Pred Forte every hour
5. Start gin & tonic every 30 minutes
And the diagnosis is:
Here’s a hint!
Yes, Sahib, there is
something in your
eye…… and it could
d ld
be sand!
13

14. 4/17/2008
Diffuse lamellar keratitis (DLK)
AKA Sands of the Sahara
• Usually occurs within 1-4 days of
procedure
• Inflammatory cells (mononuclear cells
and granulocytes) in the LASIK flap
interface
• Keratocyte activation and altered
extracellular matrix can lead to
irreversible scarring
• Risk factors include
– Use of certain microkeratomes
– Lower corneal endothelial cell density
– Larger palpebral fissure
• Treatment is aggressive regimen of
topical steroids
Post-traumatic Diffuse Lamellar
Keratitis (DLK)
• Can occur months or years after
procedure
• Onset is rapid, signs same as
conventional DLK
• Epithelial damage, reduced pH
postulated to initiate this condition
Aldave AJ, Hollander DA, Abbott RL. Late onset
traumatic flap dislocation and diffuse lamellar
inflammation after laser in situ keratomileusis. Cornea
August 2002
Lessons from 20/20 with Help
Post Traumatic DLK
• Inform LASIK patients that even moderate
trauma can lead to complications years out
• Tell your LASIK patients to report any eye
trauma, no matter how trivial immediately
• If the patient shows signs of DLK, attack this
condition very aggressively; start steroids
every hour
• Inform the refractive surgeon of your findings,
disposition STAT
14

15. 4/17/2008
Macho Man?
• VA = 20/20 OU
• SLE: OD:
– Heavily rusted foreign body 3 mm from the visual
axis
– Gr. II+ cells, flare, Gr. II+ injection
• You anesthetize the eye and attempt to
remove the foreign body. The patient
mumbles that he feels he is about to
collapse, and faints in your arms.
• Diagnosis and management?
Syncope
• Definition: “Transient loss of
consciousness and postural done due to
inadequate cerebral flow with prompt
recovery without resuscitative
measures.
measures ”
• Etiology: May be due to a variety of
processes
– Vasomotor
– Cardiac
– Situational
Syncope
• Vasomotor
• Postural (orthostatic) hypotension
• (Reduction of > 20 mm Hg upon
standing)
t di )
• Anaphylaxis
• Hemorrhage
• Hypovolemia (dehydration)
• Neurocardiogenic (vasovagal)*
15

16. 4/17/2008
Syncope
• Cardiac • Situational
• Tachydysrythmia • Cough
• Bradydysrythmia • Defecation
• Myocardial • Micturation
ischemia
Vasovagal Syncope
• 25% more common in females, 48% of all
individuals report experiencing at some time
• Most common cause of fainting in healthy
individuals
• Cerebral blood flow of 55 ml/100 gm of
brain tissue required for adequate perfusion
• When blood flow drops below 20 ml/ 100
gm, reduced perfusion causes loss of
consciousness
Managing Syncope
• Vasovagal syncope results from an altered
or abnormal “fight or flight” response
• Initial phase occurs when danger, threat
perceived (esp. Pain)
– I
Increased h
d heart rate, cardiac output, blood
t t di t t bl d
pressure, systemic resistance
• Second phase occurs when “nothing
happens” after the initial response
– Rapidly reduced heart rate, cardiac output,
blood pressure,peripheral resistance
accompanying vasodilation, pooling in
extremities
16

17. 4/17/2008
Managing Syncope
• ABC’s of life support plus
• Airway cleared?
• Breathing?
• Cardiovascular function
• Pupillary reflexes intact
• Trendlenberg position: tilt your exam
chair back or recline patient in supine
position and position legs higher than
head
Managing Syncope
• Waft ammonia spirits (smelling salts)
• Cool moistened towel on forehead
• Keep someone with p
p patient at all times
• If total loss of pulse and blood pressure,
0.4 mg atropine subcutaneous
Managing Syncope: Preparation
• Keep ammonia spirits (smelling salts) in every
exam room, CL delivery room
• Identify patients with Hx of syncope
• Teach your staff basic CPR or have them
certified
tifi d
• Ambu-bag or CPR screen available at all
times
Engel G. “Psychologic stress, vasodepressor
(vasovagal) syncope, and sudden death”.
Ann Internal Med 1978; 89:p 43-412
17

18. 4/17/2008
On a Mission
During a medical mission to Mexico,
we encountered a 19 year old
Hispanic male with a history of
progressively diminishing vision He also
vision.
has a history of a chronic skin
condition. The patient complains of
photophobia and glare. He has never
been treated for his ocular or dermal
condition.
On a Mission
• VA s
– OD 10/120 OS 10/100
– Pinhole no improvement
• External,, papules and pustules, and
– Generalized erythema, telangiectasias
– Multiple papules concentrated in the
glabellar and malar area
– Rhinophyma
• SLE
– Bilateral corneal pannus radiating from
the inferior limbus
Man on a Mission
Donaldson KE, Karp CL, Dunbar MT. Evaluation and
Treatment of Children With Ocular Rosacea. Cornea
2007 Volume 26, Number 1,
• Rosacea affects @ 10% of the adult
population
• Pediatric rosacea grossly under
recognized
– Dermatologic changes are often not
present in children
• Demographics: Hispanic 60%,
Caucasian 25%, Black 15%
18

19. 4/17/2008
Ocular Rosacea
• Donaldson KE, Karp CL, Dunbar MT. Evaluation and
Treatment of Children With Ocular Rosacea. Cornea
2007 Volume 26, Number 1,
• 95% have meibomian gland disease
• 49% have chalazia
% i
• 85% have conjunctival injection
Ocular Rosacea
• 2 primary etiologic components;
vascular and inflammatory
• Ocular signs & symptoms may precede
cutaneous changes in 20% of patients
• Pathophysiology unknown; theories
– Type IV hypersensitivity reaction
– Demodex mites initiate inflammation
– Helicobacter pylori has been implicated
Man of Steel
A forty-one year old male presents to
your office with a history of foreign
body sensation OD for the past 24
hours. He works as a welder and
frequently grinds iron and steel, often
with high velocity particles being spun
off the work surface. He cannot
specifically pinpoint the time the
sensation began. His wife noted a
brown spot on the OD cornea.
Additional Hx?
19

20. 4/17/2008
Man of Steel: Examination
VA: OD = 20/20, OS = 20/20
Pupils: PERRLA PANA: negative OU
• SLE: OD • SLE: OS
• Cornea: 1 x 1 mm • All findings nl
foreign body w/
surrounding area of
rust, necrosis
rust
• Conj: generalized
injection, > local to fb
• AC: gr . flare, tr. cells
• Lids: tr edema
• Tears: epiphora
All of the following are
appropriate except
1. X-ray of orbits for retro-bulbar foreign
body
2. Refer to another practitioner for FB
removal
3. MRI of orbits for retro-bulbar foreign
body
4. Removal of foreign body with sterile
spud or needle
5. All the above are appropriate
Your car payment is overdue. You decide to
remove the foreign body. Which instrument
is most appropriate?
1. Spud
2. Bent needle
3. Forceps
4. Alger brush
5. Micro chain saw
6. 1,2, 3, and 4 are appropriate
20

21. 4/17/2008
The best post op management
scheme would include:
1. Tobradex ung, homatropine, and
Acular
2. Vigamox gtt, tropicamide, and
bandage CL
3. Tobradex gtt, homatropine and
Voltaren
4. Vigamox gtt, homatropine, and
bandage CL
5. Beer and an old Elvis Presley movie
Non-Penetrating Corneal Foreign
Bodies
• Etiology: particulate matter that
penetrates the corneal surface
• Speed of impact, type of material and
causative factors important in Hx
• Signs & Symptoms: variable depending
on material; Fe foreign bodies tend to
be more symptomatic
• Pain, FB sensation, photophobia,
epiphora
Non-Penetrating Corneal Foreign
Bodies
• Differential
– Intraocular FB
– Foreign body embedded in lid
– Intra orbital foreign body
Intra-orbital
• No MRI on suspected metallic foreign body
• CT or X-Ray OK
• All vegetative FB carry a risk for fungal
keratitis
21

22. 4/17/2008
Non-Penetrating Ferrous Corneal
Foreign Bodies: Management
• Topical anesthetic
• NSAID gtts
• Cycloplegia (not mydriasis)
• Remove w/ your favorite weapon
• Remove rust w/ spud, needle or *Alger
spud
Brush*
• Broad spectrum antibiotic in office (ung vs
gtts)
• Bandage Cl as indicated
• Non-preserved antibiotic gtt x 5-7 days
• Cover pseudomonas, fungal infection late
Managing the visual axis foreign
body
• Refer
– The better part of valor is discretion, in the
which better part I have saved my life.
William Shakespeare (
p (1564-1616) )
– OR….
• Warn the patient that VA may be
decreased no matter how well the
procedure goes and document it!
Managing the visual axis foreign body
• Remove all foreign material leaving
the “cleanest” possible surface
(remove all rust)
• Start fluoroquinolone- no
aminoglycosides
• Add steroid when lesion is non-staining
• Taper steroid over a period of weeks
– Remember, steroids work by inhibiting
protein synthesis!
• Document all conversations, warnings
22

23. 4/17/2008
Coding
Curly Sue
A sixteen year old female student
presents to your office. She had
been curling her hair when the
cu g o s pped a d
curling iron slipped and passed
across her cornea. Interestingly, her
pain is not reported as being terribly
severe. She also complains of
blurred vision. She has no known
allergies to medications.
Curly Sue: Examination
VA: OD = 20/20 OS = 20/20
Pupils PERRLA
SLE: OD SLE: OS
• All findings nl • Cornea: central area of
burned epithelium w/
loss strands of tissue
damage epithelial
only
• Conj: gr. II+ injection
• Tears: epiphora
• AC: gr. I+ flare, no cells
• Lids: nl
23

24. 4/17/2008
Thermal Corneal Burns
• Etiology
• Any direct flame, high temperature object,
material
• Common causes:
– Curling irons, cigarettes, welding slag, hot liquids,
very bad luck
• Differential
– Chemical burns
– Old scar
– Metaherpetic lesion
Thermal Corneal Burns: Management
• Topical anesthetic
• Topical NSAID pre-debridement
• Debride all damaged epithelium: Kimura spatula,
Wick sponge
• Cycloplegia: 2% - 5% homatropine sol.
• Broad spectrum antibiotic w/ good activity against
P. aeruginosa
• Bandage CL
• Follow patient daily until re-epithelialized
• Continue antibiotic drops minimum 5 days
• Refer if damage extends deeper than epithelium
Eroding Relationships
A 34 year old male presents to your
office with a finger nail injury to the
right cornea. His ocular and general
health are unremarkable. He has no
unremarkable
known medication allergies. There is
no previous history of eye trauma.
24

25. 4/17/2008
Eroding Relationships
• VA: OD 20/40 OS 20/20
• SLE
– OS: NL
– OD: Corneal abrasion: lesion is 3 mm x 5 mm,
loose edges, stromal folds, diffuse edema
• Plan:
– Proparacaine
– Debride edges of lesion to remove loose tissue
– Pressure patch with antibiotic ung, NSAID
– Recheck one day
Eroding
• Follow-up: The patient appeared to
recover nicely from the injury.
• Plan: Muro 128 ung hs x 60 days
•OOne week later: Patient complains of
kl t P ti t l i f
pain, blurring on awakening. Has
been using meds, but had forgotten to
use them the previous night.
Eroding
• SLE: OD
– Epithelium in original area of abrasion has
detached from underlying tissue
– Underlying stromal folds, edema
folds
– Gr. II+ conjunctival injection
• Plan
– Repeat treatment, but use bandage
contact lens in addition to hyperosmotics
and antibiotic.
25

26. 4/17/2008
Recurrent Corneal Erosion
• Etiology: Painful loosening of epithelium
secondary to corneal dystrophy or trauma
• Anatomy
– Epithelium bonded to underlying tissue by
p y g y
hemidesmosomes and intermediate filaments
– Hemidesmosomes anchored to stroma by
anchoring filaments and anchoring plaques
– Ripping or shearing injuries damage the
ultrastructural connection between epithelium
and underlying tissue (finger nail injuries and
paper cuts are the worst)
Corneal Erosion: A Model For
Management of Bad Ocular Pain
• 30 day rule- hemidesmisomes
• 60 day rule- anchoring filaments
Recurrent Corneal Erosion
• Once damage from trauma or
dystrophy occur, epithelium becomes
less firmly attached and may adhere to
tarsal conjunctiva during sleep
• Ti
Tissue may be torn from basement
b t f b t
membrane during REM of on
awakening
• Physiologic edema (nocturnal)
contributes to develop of recurrent
erosions
26

27. 4/17/2008
Recurrent Corneal Erosion
• Signs and symptoms
– Sudden onset pain upon awakening
– Photophobia, lacrimation, injection
– Loosened epithelial tissue, underlying
tissue
stromal edema
– Epithelial cysts
– Brawny edema (actually not edema but
focal concentration of inflammatory cells)
– Stromal dystrophy in fellow eye
Recurrent Corneal Erosion
Management: Initial Presentation
• Debride all loosened tissue
• Voltaren or Nevanac
• Cycloplegia (
y p g (Homatropine 2.5 % or 5%)
p )
• Vigamox or Zymar solution QID
• After re-epithelialized, Muro 128 ung hs for a
minimum of 6 weeks
• Bandage contact lens as indicated
(unpreserved antibiotic)
• Pressure patch only as a last resort
Recurrent Corneal Erosion
Management: Subsequent Presentations
• Lubrication/ hypertonics ( ung and gtts)
• Massage lids prior to opening eyes after
awakening (6 weeks minimum)
• Epithelial debridement- remove all loose
tissue w/ Kimura spatula
• Use NSAIDs and cycloplegics to control pain
• Bandage CL or pressure patch until
epithelialized
• Treat with conventional methods after
stable
27

28. 4/17/2008
Recurrent Corneal Erosion
Management: Subsequent Erosions
• Bandage CL for chronically recurrent cases
• Treat concurrently w/ antibiotic (low
toxicity = Polytrim)
• Watch closely for signs of keratitis and
change lenses regularly in office (hygeine)
• Continue CL therapy for at least 3 months
• Educate patient RE dangers of keratitis and
need to report any signs or symptoms
Recurrent Corneal Erosion Stromal
Micropuncture
• Perform when conventional treatments fail
• Perform at slit lamp- (KEEP PATIENT’S
FOREHEAD FORWARD) avoid vitreous
puncture
• Use bent 25 ga needle (can purchase from
Look, Inc) or bend 0.15 mm from tip away
from bevel
• Puncture should penetrate epithelium and
penetrate 5% to 10% of Bowman’s layer.
• Can be done in area that is already
debrided
• Minimal scarring , but avoid doing on visual
axis
Recurrent Corneal Erosion
Excimer Laser Phototherapeutic
Keratectomy (PTK)
• Initial studies show excellent results
•LLaser depth set for 5 um
d th t f
• “Swirling motion” to reduce change in
refractive error
• Incidence of recurrent erosions after
PTK is very low
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29. 4/17/2008
Make a big splash!
A forty-two year old male presents
to your office for evaluation with
a history of having splashed a
cleaning chemical iinto hi right
l i h i l t his i ht
eye. His eyes were irrigated with
water and he was rushed to your
office. His health and eye history
are unremarkable.
Make a Big Splash
SLE:
• OD:
– Cornea: diffuse superficial punctate
keratitis with partial loss of epithelium
– Conjunctiva: gr. II+ injection, chemosis
– Limbus: injection, no blanching
– Iris: details visible but hazy
– A/C: gr. I+ cells, flare
• OS: nl
Chemical Burns
• Identify agent (Your staff should tell the
patient or contact to bring it with them)
• Identify makeup of agent (1- 800 hotline)
– Detergent, solvent
– Base
– Acid
– Any solids
• Estimated time of injury
• Was there immediate irrigation
• Estimate chemical temperature: hot is
worse
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30. 4/17/2008
Chemical Burns
Solvents and Detergents
Solvents - gasoline, alcohol, acetone,
cleaners
Detergents- BACl, dish washing
detergent, laundering detergents
• Degrade proteins and emulsify lipids,
leads to epithelial dessication, keratitis
• Painful, but usually self limiting
• Greatest risk is for secondary bacterial
infection
Chemical Burns
Solvents and Detergents
Treatment
• Irrigation followed by topical antibiotic
(avoid aminoglycosides)
• Patch only in severe cases with
ointment
• If uveitis present, cycloplegia, topical
NSAID (avoid steroids if at all possible)
• Contact lens wearers should D/C
contact lenses until corneas are clear
Chemical Burns
Acids and Bases
• Acids- (sulfurous, hydrochloric,
phosphoric, sulfuric
phosphoric sulfuric, nitric)
• Epithelial tissue acts as protein buffer;
damage minimized unless pH is < 2.5.
• Greatest damage from sulfurous acid.
30

31. 4/17/2008
Chemical Burns
Acids and Bases
Alkalis (bases)
• Greatest damage if pH is > 11.5
•P d
Produce far more tissue damage than
f ti d th
acids of similar concentration tissue
damage
– Calcium hydroxide (lime)
– Sodium hydroxide (lye)
– Ammonium hydroxide (ammonia) *
Chemical Burns
Acids and Bases
Alkalis
• React with lipids to form soaps, saponify
fats- damage cell membranes and
enhances penetration of underlying
tissue
• Protein buffering system not effective
against alkaline substances
• Even after the substance has been
neutralized, the immune response is
source of damage
Classification of Chemical Burns
Mild to Moderate
• Cornea- SPK to focal epithelial loss
• Limbus & conjunctiva- injection, but no
areas of focal ischemia
• Anterior chamber- clear or minimal
iris/flare
• IOP- normal or near normal
• Skin- mild to 1st or 2nd degree burns
31

32. 4/17/2008
Classification of Chemical Burns
Moderate to Severe
• Cornea- edema with some obscuration
of iris details: entire epithelium may slough
leaving a non-staining surface
• Limbus & conjunctiva- chemosis and
perilimbal blanching
• Anterior chamber- moderate to severe
reaction
• IOP- elevated
• Skin- 2nd degree or 3rd degree burns
Treatment of Acid & Alkali Burns
Mild to Moderate
• Irrigation with saline for minimum of 30 minutes
• Check pH with litmus paper
• Do not use acids to neutralize bases or vice
versa.
• I i t and check fornices for solid particles,
Irrigate d h kf i f lid ti l
necrotic conjunctiva with concentrated
chemical
• Cycloplegia (scopolamine, homatropine)
• Topical antibiotic ointment (erythromycin,
polysporin)
• Control IOP with oral (Diamox, Neptazane)
and/or topical (Timolol, Alphagan)
Treatment of Acid & Alkali Burns
Moderate to Severe
• Irrigation with saline for minimum of
30 minutes
• Check pH with litmus paper
• Patch w/ topical antibiotic after
neutralized
• Refer to anterior segment specialist
32

33. 4/17/2008
Conclusion
• Never before has there been a time
when optometrists were so well
prepared or positioned to manage
trauma.
• Take advantage of our expanded
scope and superb education by
providing your patients with the kind
of trauma management they want
and deserve.
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