Cornea Lecture Transcription

If you have a corneal problem, just call.  We can help or help you find the best cornea doctor for your problem.

 

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Moran CORE
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Title: Introduction to Cornea
Author: Amy Lin MD
Date: 7/15/2019
From Moran CORE Collection: http://morancore.utah.edu​
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Transcript

00:00
a lot of kind of basic things about
00:02
cornea let’s feel free to stop me at any
00:04
time so I’ll go over the basics of
00:07
corneal anatomy
00:08
Assaf is some basic slit map techniques
00:12
and really common corneal conditions
00:15
that you’ll see primarily you’re on call
00:17
and also in the clinic and then some
00:19
special cases most particularly with
00:22
burn unit pathology which is see here so
00:26
as you know cornea is an AE vascular
00:28
transparent tissue that measures about
00:30
1112 milliliters horizontally and it has
00:33
a orientation it’s called a prolate kind
00:36
of configuration where it is actually
00:38
steeper kind of in the center part of
00:41
the cornea and less steep in the
00:43
periphery so serum prolly if a cornea
00:47
has undergone say myopic refracted
00:49
coronal refractive surgery it will
00:51
become flatter in the center steeper in
00:53
the periphery and that’s termed an elite
00:55
cornea
00:56
now the cornea has a very high density
00:58
of nerve endings which is why when
00:59
there’s any sort of injury it’s very
01:02
very painful so this is a cross-section
01:05
of the cornea so the epithelium has
01:07
about 4 to 5 cell layers thick of
01:10
stratified squamous epithelium that’s
01:11
held together by tight junctions and
01:14
then the there’s a basic membrane to
01:17
this epithelium and then there’s an
01:19
unlabeled structure underneath that’s
01:21
called Bowman’s layer and this is an
01:24
acellular structure which sometimes
01:27
called Bowman’s membrane but it’s not a
01:28
true membrane but it’s actually a
01:30
cellular the bulk of the cornea is
01:33
comprised of the stroma which has
01:36
several grata sites which have to be
01:38
specifically arranged so that the cornea
01:42
can remain transparent and also it needs
01:44
a very tightly regulated kind of
01:48
of water so that it also remains clear
01:52
the endothelium has an allele cell pump
01:56
which pumps out fluid out of the cornea
02:00
to keep it clear and the basement
02:01
membrane through the endothelium is just
02:03
amazing em brain so this is a true
02:05
basement membrane Bowman’s membrane
02:07
isn’t really a real membrane
02:10
alright so next the cheer film also has
02:12
layers there’s a top lipid layer then
02:16
there’s an aqueous layer and a bottom
02:17
usin layer the top lipid layer is
02:19
produced by the meibomian glands and the
02:22
eyelids this is responsible for
02:24
preventing the t2 layer from evaporating
02:27
so it’s very important and we’ll talk
02:29
about conditions where the meibomian
02:31
glands can be affected aqueous layer
02:34
comprises the main bulk of the tear film
02:36
and is produced by the main lacrimal
02:39
gland and also the accessory lacrimal
02:41
glands of Krauss and Wolf ring the
02:44
bottom layer is the mucin layer which is
02:47
produced by the contractile goblet cells
02:49
it is very important to actually allow
02:51
the tear film to stick to the ocular
02:54
surface because otherwise the tears
02:55
would be made they just fall off the
02:57
ocular surface and they’re not really
02:59
hydrating the ocular surface and the
03:03
mucin layer is stuck down to the ocular
03:07
surface to the epithelial cells it’s
03:10
shown here
03:13
again this is kind of a potpourri of
03:14
various topics in cornea so we’re gonna
03:16
switch gears to slit lamp exam and here
03:21
are the common techniques for examining
03:24
the eye so you so usually you know when
03:29
you first start out looking at an eye
03:30
you want to start with kind of a lower
03:32
mag not super intense light kind of a
03:36
broad beam of diffuse illumination this
03:38
is just to get an idea of is there
03:41
anything there that I need to
03:43
concentrate on so just kind of get a
03:44
broad overview so then you can get down
03:48
to slit-lamp illumination where we
03:51
actually have the beam at a with a slit
03:54
and at an angle and this allows you to
03:56
see depth and to it you can go on high
03:59
bag to identify more subtle findings so
04:02
diffuse illumination and some lamp
04:04
illumination are by far the most common
04:05
techniques that are used in examining in
04:09
the slit lamp examination specular
04:11
reflection is sometimes is most commonly
04:14
used to examine really fine details
04:18
around endothelium so what’s done is
04:21
that you have the beam at a very high
04:25
intensity at about a 60 degree angle and
04:29
then you kind of have to superimpose the
04:31
light the light bulb reflex with the
04:34
actual slip beam so they’re together
04:36
then you focus in
04:38
and you can kind of see reflections
04:40
around there’s a very bright light to
04:43
look at endothelial cells sclerotic
04:45
scatter is a method where you again have
04:48
a very intense bright beam at an angle
04:51
and you shine it right at the limbus and
04:54
it you have it that’s such an angle that
04:55
you can actually light up a little bit
04:58
of the whole cornea and so this picture
05:00
is showing a light corneal scar that’s
05:04
lit up by sclerotic scatter so the scar
05:06
isn’t like the beam isn’t really on the
05:08
scar it’s just kind of highlighted
05:11
I like that scattered from the limbus
05:13
retro elimination is something that I
05:16
use fairly commonly most commonly I use
05:20
it to look at iris defects so this just
05:22
showing some diffuse iris defects here
05:25
so it’s a good way to look at to see
05:28
whether or not you have a Paton
05:29
peripheral or ADATA me you can also see
05:32
fine details in the lens and the cornea
05:35
with retro illumination and what you do
05:37
is you have your beam kind of straight
05:41
on it’s the eye going into the pupil and
05:44
so what reflects back you can see
05:49
kind of reflected back here corneal
05:54
stains most commonly by far we use
05:56
fluorescein it comes in solution or
05:58
strips and this stains basement membrane
06:01
I’ve shown here Rose Bengal stains
06:05
devitalized cells and it’s easy to see
06:09
not only do vitalize cells in the cornea
06:11
but also the conjunctiva listening green
06:14
I probably would use rather than rose
06:18
mineral does the same thing it stains
06:20
divide stains to violet cell to finalise
06:22
cells but it’s much less irritating than
06:25
Rose bangle Rose Bengal people feel it
06:27
actually stings even with topical
06:30
anesthetic assuming green doesn’t stain
06:33
staying quite as much and you can see
06:34
they’re very very green highlighting
06:37
some conjunctival staining here
06:41
um kind of this is I’m sure you guys
06:43
know this on call but just to review
06:45
some miscellaneous exam things
06:47
especially on call so you want to remove
06:49
soft contact lenses
06:51
prior to instilling any fluorescein so
06:53
you always want to ask the patient just
06:55
to be sure you want to keep track of
06:57
your prepare cane tetra cane and your
06:59
fluorescein solutions because patients
07:03
can steal them and leads to topical
07:05
anaesthetic abuse anyone with especially
07:09
like a unilateral red eye you want to
07:11
flip their upper lids effect someone
07:13
does a corneal abrasion or flip
07:15
sometimes you were surprised by what you
07:17
find underneath you might find a foreign
07:18
body or some other cause of their
07:21
corneal abrasion
07:24
so I’ll go into some common core neon
07:27
content type issues both acute and
07:29
chronic so conductive itis is classified
07:35
typically into three categories
07:37
bacterial viral and allergic and there’s
07:40
various bumps that you’ll see on the
07:41
tarsal conjunctiva with the various
07:43
conditions with bacterial conjunctivitis
07:47
typically you’ll see a very purulent
07:49
discharge follicles are shown here these
07:53
are actually clusters of lymphocytes
07:55
where you see kind of the vascular
07:59
vascularity kind of surrounding a
08:01
follicle so you see the vascular kind of
08:03
on the periphery and you’ll see
08:04
follicles typically in viral
08:07
conjunctivitis and and in viral
08:09
conjunctivitis there’s typically a
08:11
history of either upper respiratory
08:14
symptoms or sick content contacts and
08:18
they’ll typically have the symptoms in
08:20
one eye and then it goes to both eyes
08:22
papilio shown here some papillae are
08:25
actually dilated capillaries which kind
08:29
of are in the middle of each bump of
08:31
each papillae and then each capillary is
08:34
surrounded by edema so follicles you see
08:37
the vascular area in the periphery in
08:39
papilla you’ll see the vascularity in
08:41
the center and you’ll see papillae
08:44
typically with allergic conjunctivitis
08:46
oftentimes you don’t get a nice
08:48
classification
08:49
like this where you see all follicles
08:50
and all I feel like it’s common to see a
08:53
mixture of both so you don’t always get
08:55
this nice distinction but if you do see
08:59
you know kind of a bigger concentration
09:03
of the follicles or papillae then you
09:04
don’t kind of clue you in to what the
09:06
diagnosis is and this is an example of
09:10
giant papillary conjunctivitis which is
09:13
seen commonly in as a reaction in
09:16
contact lenses so again very important
09:18
to flip the upper lids because you could
09:20
find something like this next is epi
09:25
sclerosis so this is defined as a benign
09:27
transient inflammation of the ocular
09:29
surface and epi sclera the history is
09:32
that they’ll have patients will have a
09:34
red eye but there’s not really much pain
09:37
it’s pretty minimal if there’s any pain
09:38
and on exam when you put in something
09:41
all different it typically will Blanche
09:43
I don’t usually work up at beefs
09:46
chloride as patients unless they are
09:48
recurrent it can be associated with
09:51
autoimmune conditions as well as other
09:53
conditions here so here are some
09:55
systemic associations again these were
09:57
kind of single digit percentages of
09:59
systemic associations with herpes zoster
10:01
collagen vascular disease gout and
10:03
syphilis so you can check lab work if
10:06
needed a piece chloride this is
10:08
typically self-limited so it should go
10:10
away without any treatment but you might
10:13
consider some pio NSAIDs or some topical
10:17
medicines or steroid to maybe speed the
10:20
resolution
10:23
in contrast glorious is something that’s
10:26
very different
10:28
so since chloride is there is typically
10:31
very an intense pain is very very tender
10:34
so you know you can also you can push if
10:37
you’re not sure you have got a riotous
10:39
or a beast glorious you can just kind of
10:41
push on the globe through the lid and
10:43
ask them if it’s tender or not and with
10:45
school or itis it’s gonna be you know
10:47
they’ll be gonna be jumping out of their
10:48
seat if you do that when you put in
10:51
phenylephrine there’s typically no
10:53
blanching scene and there are a few
10:55
types of slow itis here you got non
10:58
necrotizing necrotizing without
11:01
inflammation or sclera malaysia
11:03
preference which is actually painless
11:05
it’s the one type of sclerosis which is
11:07
painless and then you have necrotizing
11:09
slaw riotous as seen here’s where
11:12
there’s severe thinning of the sclera
11:14
and this is typically seen in Waggoner’s
11:18
which is Holly and she itis I can’t
11:21
remember the new name for it and school
11:25
or itis is a very very high association
11:28
with systemic disease so yeah here are
11:32
the systemic associations which are
11:34
arthritis lupus and closing spondylitis
11:36
psoriasis Crohn’s vascular disease
11:40
syphilis TV’s always on the differential
11:42
with slow raita so you always want to
11:45
work it up even if it’s a first-time
11:47
episode of slur itis and you can use
11:50
history to guide testing seen here
11:53
occasionally vibez labs are negative you
11:56
could consider repeat testing and one
11:58
year
12:01
with non necrotizing sclerosis is the
12:03
least severe form you’ll see a
12:05
violaceous hue and there is a 50%
12:08
association with systemic systemic
12:10
disease and 50% of cases are bilateral
12:12
and this does not go away if you don’t
12:15
treat it so it’s gonna remain until it’s
12:17
actually treated sclera Malaysia
12:20
preference again this is the type of
12:22
school artist that’s without
12:23
inflammation where it’s actually
12:24
painless so you see a painless white
12:27
white eye with thin sclera typically
12:29
seen in the elderly it’s very typically
12:31
bilaterally 50% of these cases are
12:33
actually from rheumatoid arthritis
12:35
Sparrow rupture is a rare and it rarely
12:39
needs surgical repair but there does
12:41
need to be obviously systemic umino
12:43
suppression which I’ll talk about later
12:45
I think necrotizing is chloride is with
12:48
inflammation is painful
12:49
it’s bilateral in most cases this is the
12:52
most destructive type with vision loss
12:54
and 40% high association with systemic
12:57
vasculitis and the mortality rate of
12:59
this is high it’s actually 20% at five
13:02
years so it’s really important to
13:04
diagnose this so they can start
13:06
treatment
13:09
contact lens abuse something that will
13:11
very commonly see on call you’ve got a
13:14
history where someone is wearing their
13:16
contact lenses long periods of time
13:19
during the day most commonly they’re
13:21
sleeping in their lenses they’ve got
13:22
poor hygiene and this is you know I’ll
13:26
talk about corneal ulcers but this is
13:27
not quite ulcers stage you’ll see these
13:30
small fine some epithelial opacities
13:33
that look like this they’ll typically be
13:35
bilateral there’ll be some country type
13:38
of injection treatment of this will be
13:40
with artificial tears having them stop
13:43
their contact lenses until symptoms
13:44
resolved you could consider a mild
13:47
steroid drop but really important to get
13:51
these patients in for follow-up in the
13:53
clinic so that we can see that their
13:56
symptoms have resolved and that it’s not
13:58
turning into an ulcer which leads me
14:02
into the next topic of corneal ulcers so
14:04
this the most frequent risk factor to a
14:07
corneal ulcer is contact lens use other
14:10
risk factors include previous eye injury
14:13
previous trauma if they are a health
14:16
care worker or a nursing home
14:18
concurrent ocular surface disease like
14:21
severe dry eye if they are
14:23
immunosuppressed and you do want to get
14:25
a history of the degree of their pain
14:27
the duration if they’ve been using any
14:30
other eyedrops at all or if they’ve been
14:32
seen by other practitioners and and
14:34
receive any prescription drops bacterial
14:38
etiology czar the most common and
14:40
typically there’s very quick onset may
14:43
also see Kay
14:45
of viral ulcers fungal and also
14:50
parasitic with Acanthamoeba so when you
14:54
look at a corneal ulcer there are
14:56
different characteristics that you want
14:57
to look out for you want to look at the
14:59
location is it central is a pair of
15:02
centrioles a peripheral typically it’s
15:04
helpful to have a clock hour on there so
15:06
that you look at that will stir later on
15:09
you can find it again ascertain the
15:12
shape is it round is it oval is it
15:15
stellate you want to measure the size
15:18
you want to assess the depth is it pan
15:21
stromal is it anterior meaning it’s just
15:25
kind of very superficial is it only deep
15:28
or endothelial and a density or
15:31
consisteth consistency is it really
15:33
dense as I could super white and opaque
15:35
or is it kind of light and feathery and
15:39
noticing kind of the borders of it as
15:42
important as well and I also like to
15:46
know whether or not there’s an
15:47
Associated inflammatory response like is
15:49
the surrounding cornea very kind of hazy
15:52
and kind of dimittis or is the
15:54
surrounding cornea very very clear and
15:56
that gives you an idea of how much
15:58
inflammation there is so if there’s a
15:59
lot of haze around it there’s a lot of
16:00
inflammation if there’s not really any
16:02
haze you know maybe this is an ulcer
16:05
that’s either very indolent or very
16:07
concentrated or maybe it’s kind of
16:08
turning more into a scar so when do you
16:12
wanna call culture a corneal ulcer so if
16:16
it’s large and I guess large as relic is
16:18
relative but I’d say if you’ve got
16:21
something at least 2 millimeters that
16:22
would be considered large is that vision
16:24
threatening meaning is it in the central
16:26
visual axis or close to it
16:28
even if it’s a small sir I would culture
16:31
if any time there’s a hypo peon you do
16:33
want a culture and any post-operative
16:36
patient like a post cataract or post
16:39
corneal transplant you definitely want a
16:40
culture
16:41
so if in doubt just culture and there
16:47
are different ways of culturing
16:50
traditionally when you read kind of in
16:53
the text books about culturing they use
16:55
something called a camera spatula or you
16:58
can use something called a calcium
17:00
alginate swab which is like a kind of a
17:02
smaller q-tip you use this to scrape
17:05
into the infiltrate and then you played
17:08
it out in a thin layer onto culture
17:10
plates and you use a separate swab for
17:12
each plate and you can send off the
17:15
cultures for Gram stain blood agar which
17:19
is aerobic bacteria chocolate agar which
17:21
is written I Syria and him offal Asst
17:22
sab Rhodes auger for fungi v glycol a
17:27
broth for anaerobic bacteria pages media
17:30
something we use here for a kept amoeba
17:32
so if you ever want to culture a cath
17:35
amoeba you do have to get this kind of
17:38
separate thing called pages media which
17:40
comes in the tube it does not have its
17:42
own swab so you have to kind of hunt
17:44
down a separate swab I’ve heard of
17:46
people opening up the viral Culture
17:48
Media just because that comes with the
17:50
swab so you can use that swab for the
17:53
pages media so kind of confusing
17:56
typically nowadays I don’t use the
17:59
traditional plates I use something
18:02
called the e swab and this is very easy
18:05
because everything’s kind of all-in-one
18:07
and everything means kind of the
18:09
non-viral not a cath amoeba so the east
18:12
wob is a nylon tip swab which has kind
18:17
of these kind of longer fibers which can
18:20
improve sample collection because
18:22
there’s more kind of grabs on to the
18:25
culture whatever your culturing a little
18:28
better and this is placed in a medium
18:31
and to you that looks like this and then
18:34
when you send it to the lab you put in
18:36
your orders and the lab will actually
18:38
aliquot it for culture it is not
18:41
inferior to traditional collection
18:43
methods with regards to culture
18:44
positivity rate I first started using
18:47
these maybe three or four years ago and
18:49
when I first started using it I actually
18:50
would culture same patient twice like
18:53
once with traditional and once with swab
18:56
and I found that the East web would
18:58
actually have yield whereas the
19:02
traditional plating may not have yield
19:04
so might get a better yield with the
19:06
east wall so how do you want to treat a
19:09
corneal sir it’s gonna depend on how bad
19:12
it is
19:12
so typically I would start if it’s not
19:18
too severe just with a fourth-generation
19:21
fluoroquinolone
19:22
you know if it’s tiny and peripheral
19:25
microscope uid
19:26
it’s a little more severe Kyogoku one
19:28
hour or if it’s more large or severe i
19:32
would go with the fortified antibiotics
19:34
which can be compounded at the Moran
19:36
pharmacy and also our inpatient pharmacy
19:38
and there’s it’s in on formulary so you
19:42
can just type in back of my single
19:43
tobramycin
19:44
and it’ll come up as these
19:46
concentrations we need to want to choose
19:48
these and using these every q one to two
19:51
hours
19:53
you can’t consider a psychologic agent
19:55
and here are the most commonly used ones
19:57
cycle Jill lasts about 12 hours so use a
20:01
be ID at Eid home atropine typically is
20:06
B ID and atropine 1% you can use once or
20:09
twice a day of atropine home atropine I
20:12
don’t think people can find very much
20:14
anymore so I’m usually using a cyclic
20:17
gel or jumping to atropine it with
20:18
atropine I always tell them you know
20:20
make sure you don’t accidentally put it
20:21
in your other eye because they’re gonna
20:23
be dilated for like 7 to 10 days so
20:25
really important that you tell them to
20:26
keep me know you always have to keep
20:29
their jobs than one eye
20:30
whatever eye that’s supposed to be but
20:31
with atropine in particular I’ve had
20:33
patients accidentally put it in their
20:35
good eye and then they’re wondering why
20:36
they’re dilated any patient who you know
20:42
may be homeless or has a questionable
20:44
home life and may be not able to get in
20:46
there drops cue one hour you might
20:48
consider admitting as an inpatient
20:51
herpes simplex keratitis is very common
20:54
symptoms are kind of nonspecific its
20:56
redness blurry vision some irritation or
20:59
you could have severe pain with it
21:01
there is diminished corneal sensation so
21:04
you want to check this prior to placing
21:05
anaesthetic and I’d like to check
21:07
corneal sensation by taking like a
21:10
cotton swab and you know with clean
21:12
hands you can kind of rip or kind of
21:15
kind of wisp off like a little top layer
21:18
of it so you have a little wispy kind of
21:20
edge and then have a patient look
21:22
straight ahead and touch both sides and
21:24
ask them just once I’d feel more
21:27
irritating to the other or you can kind
21:28
of see on their reaction like you’re
21:30
touching and they’re not even blinking
21:32
you know they have decreased corneal
21:33
sensation
21:35
so on exam there’s very type various
21:37
types of herpes simplex keratitis
21:39
there’s epithelial disease where you see
21:42
a dendrite here and classically you’ll
21:44
see terminal end bulbs at the end of the
21:46
each dendrite stromal HSV keratitis is
21:51
actually the most common cause of
21:52
infectious corneal blindness in the US
21:54
there’s not really a I mean a specific
21:58
characteristic a look is just kind of
22:00
more of some haziness and oftentimes
22:01
it’s kind of patchy as seen here disc
22:04
form keratitis you actually see corneal
22:06
edema so it’s affecting the endothelium
22:09
so classically you’ll see stroma edema
22:11
and a round distribution is kind of oval
22:14
here and it’s associated with curette ik
22:16
precipitates and it’s also been termed
22:19
endo fili itís so the treatment of core
22:23
of epithelial disease most cases
22:25
actually resolves spontaneously I don’t
22:28
typically have them go off without
22:29
treatment so you want to use some kind
22:32
of antiviral treatment classically
22:36
topical trifler adeney times a day I’ve
22:39
kind of shied away from this just
22:41
because it can be quite toxic you can
22:44
use organ gel five times a day
22:46
unfortunately it tends to be quite
22:47
expensive so usually with oral treatment
22:52
with either a cycle beer or valtrex
22:54
you can’t achieve good penetration to
22:58
the cornea classically with HSV the dose
23:01
is 400 milligrams five times a day I’ve
23:04
seen people do 800 PID just to kind of
23:07
consolidate things and make things
23:08
easier typically don’t wanna use a
23:11
steroid any topical stared with
23:14
these you could consider epithelial
23:17
debridement if it’s not resolving with
23:20
treatment
23:22
there’s the head study which is a study
23:25
which looked at the use of topical
23:28
trifler edema and steroids and a sec and
23:32
acyclovir so the purpose of it was to
23:34
evaluate if efficacy of treatment in HSV
23:39
stromal keratitis and HSV Yodo psych
23:41
lightest so they looked at seeing
23:43
whether or not topical steroids steroids
23:45
with topical tri fluoro dean was
23:48
effective in stromal keratitis if oral
23:50
acyclovir with topical steroids and try
23:54
fluorine was effective and whether oral
23:57
acyclovir with steroids and the Tri
23:58
Floridian or effective in irritable
24:00
psyche lightest so the results showed
24:03
that when you have HSV stromal keratitis
24:05
when you give topical steroids with
24:08
topical try Floridian it actually
24:10
reduced the progression and shorten the
24:13
duration there’s no benefit of adding
24:16
oral acyclovir when you already have
24:20
when you have stromal keratitis and
24:22
you’re already treating with topicals
24:24
steroids and antiviral typically I do
24:27
like adding oral acyclovir just because
24:31
later on it kind of helps prophylaxis
24:34
that there was a trend to suggest a
24:36
benefit of oral acyclovir with topical
24:38
steroids and try flirting in HSV or dose
24:40
like cleitus but I don’t think the head
24:42
study had enough patients in this arm to
24:45
really say for sure but I think
24:46
typically people do add oral antiviral
24:49
treatment for this
24:51
so these are doses of prophylactic doses
24:56
for each SV keratitis for acyclovir Pham
25:00
vir and valtrex so with acyclovir again
25:04
the treatment dose was 400 milligrams
25:06
five times a day and the prophylactic
25:08
dose is 400 milligrams two times a day
25:12
valtrex treatment dose would be one gram
25:15
VI D prophylactic dose is one gram once
25:19
a day late complications of HSV
25:23
keratitis are neutral for cornea you can
25:25
have severe drive and have non healing
25:27
epithelial defects you can have severe
25:29
corneal scarring neovascularization
25:31
recurrent inflammation and corneal
25:33
thinning and its sister disease shingles
25:37
is very similar the so zoster is a
25:41
reactivation of latent bzv and there is
25:46
when it’s affecting the eye there is
25:49
involvement of the ophthalmic division
25:52
of cranial nerve five and the classic
25:54
sign is Hutchison sign where if there’s
25:56
involvement of a shingles rash at the
25:58
tip of the nose that means the nasal
25:59
ciliary nerve is involved and the nasal
26:02
ciliary nerve innervates conjunctiva
26:04
cornea sclera iris choroid and the skin
26:06
of both eyelids and so it’s a very
26:08
strong predictor of ocular information
26:10
if you see a positive hutchings of the
26:12
sign shingles is most ARS Auster’s more
26:17
commonly elderly although we are seeing
26:19
it more and more in young patients
26:21
there’s a wide range of ocular
26:23
involvement in severity and may be acute
26:25
chronic or relapsing and you’ll see a
26:27
pseudo dendrites oh and unlike HSV or
26:29
you see a very classic nice kind of
26:31
pretty tree in this is with pseudo
26:34
dendrites and shingles kind of more of a
26:36
stuck on appearance there aren’t any
26:39
terminal end bulbs
26:41
and you can’t see stromal keratitis
26:45
like it HSV there’s gonna be decreased
26:47
corneal sensation so if the zoster
26:52
symptoms started within the previous 72
26:54
hours you want to start and actually out
26:58
I don’t even wait
26:59
you know if it’s beyond being even
27:01
beyond 72 hours I would probably start
27:03
this dose so this is double the dose of
27:05
HSV keratitis so with zoster you want to
27:09
go to 800 milligrams five times a day
27:12
for ten days and we think that there is
27:15
a role for a reduced dose long-term
27:17
which is the topic of a clinical trial
27:21
going on right now called the Zed’s
27:22
trial which we are a site there may be a
27:26
role for a topical antiviral treatment
27:28
and topical steroids are highly highly
27:32
recommended for andrew segment
27:34
inflammation and keratitis and often
27:36
times you need a very slow taper of
27:37
topical steroids or even chronic use to
27:39
prevent recurrent inflammation and with
27:44
shingles you see post herpetic neuralgia
27:46
which is kind of severe pain even after
27:49
all the kind of the signs of zoster have
27:54
gone and this pain can be very severe
27:57
and can be treated with gabapentin
28:00
tricyclic antidepressants and lyrica so
28:02
I will always refer patients out to see
28:05
their primary care doctor and maybe also
28:07
a pain specialist help manage these
28:09
symptoms you get the same late
28:12
complications in
28:13
ah stir as you do with each sv so new
28:17
atrophic cornea scarring
28:19
neovascularization recurrent
28:20
inflammation unicornio thinning next
28:24
corneal trauma so the most common type
28:27
of coin no trauma that you see is a
28:28
corneal abrasion I’ll treat with a
28:30
fluoroquinolone four times a day I don’t
28:32
change my treatment based on the size of
28:36
the cornea operation per se as far as
28:38
the antibiotics go so don’t do like
28:40
fluoroquinolones q an hour when it’s
28:43
really just abrasion no no infiltrate
28:46
based on the sides like if it’s a total
28:48
corneal epithelium on I just do photo
28:50
coil on four times okay you can’t
28:53
consider a cyclic cyclic allegic agent
28:56
for pain control you can also consider a
28:59
bandage contact lens or a pressure patch
29:01
you want to follow closely for any
29:04
infiltrates that can develop down the
29:07
line
29:08
if there’s no trauma history you don’t
29:10
want to examine for exposure is there
29:12
any like o’the Alice or is there
29:15
something under the lid that might be
29:17
scratching so you want to examine for
29:18
other causes for a corneal abrasion corn
29:23
foreign cornea foreign bodies are very
29:24
common Oh
29:33
I mean I guess you could use like a poly
29:36
trim is that what you’re thinking of all
29:38
right yeah just like if it’s like your
29:40
ground source versus a like a burn or
29:42
something like that I usually like the
29:45
fluoroquinolones yeah I usually do if
29:48
it’s um the only times I don’t is if
29:51
there’s allergy if there’s like an
29:53
insurance kind of cost issue
29:55
I’ll go poly trim typically do four
29:58
lokos
30:02
cornea foreign bodies metals most common
30:05
if it’s superficial you can remove these
30:09
with a 27 or 30 gauge needle you can
30:12
consider using a burr as well afterwards
30:15
you treat it like an abrasion but it is
30:17
common to have like this kind of kind of
30:19
a white almost looks like an infiltrate
30:21
that’s usually sterile and they’ve been
30:23
in the spot where the foreign body was
30:25
so if there is a little bit of a kind of
30:28
a white appearance there you can use a
30:30
combination antibiotic and steroid but
30:32
you want to follow these patients to
30:33
make sure they’re not developing
30:35
infection if it’s really deep you don’t
30:37
want to pursue that and you always want
30:39
to counsel patients on eye protection
30:42
corneal lacerations so you want to
30:45
determine very importantly if it’s
30:46
partial full thickness like is this a
30:48
ruptured globe are not erupted your
30:49
globes so you can use a side delt test
30:51
to tell that you can look at the
30:53
anterior chamber depth like it’s a if
30:55
it’s shallow you know it’s a clue that
30:57
there is a full thickness situation
31:00
going on if you’re not sure about the
31:02
depth like you know what’s normal for
31:04
this I look at the patient’s other eye
31:06
and so if the other eyes you know kind
31:09
of the same AC depth as the affected I
31:11
feel good if the other eye is a lot
31:13
deeper then there’s probably a
31:15
full-thickness laceration going on
31:18
obviously there speaking of the pupil or
31:20
iris prolapse then it’s very obvious
31:22
sign of full-thickness laceration if
31:25
there’s a partial thickness laceration
31:26
you want to remove or irrigate any out
31:29
any foreign body material depending on
31:32
how deep it is you know obviously if
31:35
it’s full thickness that means to
31:36
prepare in the O are if it’s partial and
31:38
superficial you can leave them alone
31:40
they’re a little deeper you probably
31:41
still want to take them back to the or
31:42
for suturing you want to place a shield
31:45
on the eye prior to going back to the oh
31:47
are you could consider IV antibiotics
31:51
but more importantly you want to make
31:53
sure the patient is NPO so if you’re you
31:56
know you get a call from a community er
32:00
that there’s a patient coming in with a
32:01
ruptured globe you want to tell them
32:02
make sure they’re in view okay so moving
32:07
on to chronic diseases blepharitis
32:09
there’s anterior and posterior types
32:11
with anterior you’ll see collar EPS
32:14
around the eyelashes and so when I see
32:16
this lid scrubs are very effective if
32:18
it’s posterior you’ll see my bohmian
32:20
gland inspiration or blockage and warm
32:23
conferences are effective for this and
32:26
artificial tears are going to be the
32:28
main scene of treatment in addition to
32:29
warm compresses you can also consider
32:32
fish oil oral fish oil oral doxycycline
32:35
or minocycline and an antibiotic
32:38
ointment to the lashes dry eyes often
32:41
times is there is concurrent blepharitis
32:45
or meibomian gland dysfunction and the
32:48
symptoms of this are going to be tearing
32:49
dryness redness foreign body sensation
32:51
if there’s fluctuating vision during the
32:54
day that’s a hint that this is dry eye
32:57
classically there’s an evaporative
32:59
etiology where between glands get
33:03
clogged and so that lipid layer is not
33:07
really present and the tears are
33:09
evaporating very quickly you can also
33:11
have diminished tear secretion as seen
33:14
with sarcoidosis and collagen vascular
33:15
diseases and there’s a high association
33:20
of dry eyes with ocular surface
33:22
inflammation so clinically you’ll see
33:24
inter palpebral staining this is showing
33:27
rose bengal staining there will be a low
33:30
tear film oftentimes you’ll see mucous
33:33
floating around and in the tear film
33:34
that’s a sign that there’s
33:35
and you’ll see a load to your breakup
33:37
times the way you do this test of to
33:39
break up times you put in a drop of
33:41
fluorescein you get in them up to the
33:43
slit lamp put on the cobalt blue light
33:45
and you tell them you kind of time it
33:46
and you can even time it in your head
33:49
ask them to stare and not blink and so
33:51
you count in your head how many seconds
33:53
go by before you start seeing break up
33:56
of the tear film which is seen as a dark
33:58
spot on the cobalt blue light and if
34:02
that breakup time is less than 10
34:04
seconds that is a low – break of time if
34:07
it’s greater than 10 seconds it’s normal
34:09
you can also do a schirmer’s test I
34:11
typically have abandoned schirmer’s just
34:14
because you can see if there is dry eye
34:17
based on other other exam findings but
34:23
if you do a short test I do use it with
34:26
anesthetic and if you so you put the
34:29
filter paper strips in and then you wait
34:31
five minutes and if it is less than ten
34:34
millimeters then that is the low
34:36
schirmer’s finding treatment various
34:41
treatments ranging from just taking
34:43
breaks when you’re reading with a
34:44
computer humidifier artificial tears gel
34:48
or even at night you can you consider
34:51
topical anti-inflammatory treatment with
34:53
ruh stasis or zai dry but these do take
34:55
time to work
34:56
oral fish oil or olive oil can be
35:00
effective and can consider Moisture
35:03
chamber goggles if there’s a component
35:04
of nighttime lag of phallus
35:06
I’ll typically suggest gel anointment
35:08
and humidifier for those cases and you
35:11
can also consider puncture plugs and
35:13
cautery down the road lots more to say
35:17
about these conditions I’m just kind of
35:18
breezing through so they’ll be hopefully
35:21
more electors in the future about these
35:23
with fuchs dystrophy there is this is an
35:26
autosomal dominant corneal dystrophy
35:28
that appears typically around age 40 to
35:31
50 s and fuchs dystrophy is a
35:33
progressive loss of endothelial cells
35:35
which leads to corneal edema and it is
35:38
asymptomatic in mild cases and later on
35:40
there is Morning Glory vision that
35:43
improves later in the day the reason why
35:45
you get that particular symptom is that
35:48
there’s basically edema in the morning
35:50
so eyes are closed all night there’s
35:53
kind of a more kind of humid environment
35:56
and there’s more those endothelial cells
35:58
are just there’s not enough of them to
36:00
pump out all the fluid so when they wake
36:02
up they were looking through maybe just
36:04
a little bit of a cloudy cornea and this
36:06
is a pathologic slide showing that
36:10
there’s few endothelial cells here and
36:12
then you see these little bumps and
36:14
decimates membrane and these are the
36:16
katate like you’ll see in fuchs
36:18
dystrophy so go tell your guitarra the
36:21
first sign you’ll see these little bumps
36:23
it looks almost like a kind of an orange
36:25
peel appearance on the endothelium and
36:28
then later on you’ll see cornea pilet
36:30
and edema and there’s two ways you can
36:34
see these goo tada they’re it’s hard to
36:36
find especially when if you’re kind of
36:39
medical student or just kind of
36:41
beginning in your residency and the
36:42
easiest way is that you have to turn the
36:44
beam on to the higher intensity you’re
36:46
not gonna see goo tada on the kind of
36:48
lower intensity beam so higher intensity
36:51
put it at a slip beam focus on the
36:54
endothelium and you’ll see kind of this
36:57
appearance here this is retro
37:00
illumination so you can the beam on
37:02
retro illumination and that can also
37:03
highlight goo tada
37:06
typically in more say moderate to
37:09
advanced foods dystrophy you’ll have a
37:10
thick cornea that will be greater than
37:12
600 microns and you can do a specular
37:15
microscopy which is a way to image the
37:17
corneal endothelium and there’ll be a
37:19
lower than normal corneal endothelial
37:22
cell count so treatment if there is
37:25
asymptomatic I do nothing but I’ll
37:28
mention that they have this condition
37:29
and that they will need some routine eye
37:32
exams to monitor if they start getting
37:34
blurry vision in the morning I recommend
37:36
the use of hypertonic saline which is
37:38
mira 1:28 and this hypertonic saline can
37:42
decrease corneal edema and since
37:44
patients will have these symptoms more
37:46
in the morning I tell them to kind of
37:48
use more of us in the morning there are
37:50
special considerations in cataract
37:52
surgery you want to protect the
37:53
endothelium as much as possible you want
37:56
to decrease fecal time kind of coat the
37:58
endothelium so there’s things that you
38:01
want to watch out for with cataract
38:02
surgery if the fukes dystrophy is
38:04
visually significant then endothelial
38:06
character otoplasty is recommended
38:09
so lastly I want to go over kind of
38:11
special cases that you’ll see in the
38:13
burn unit so you’ll see there were no
38:15
chemical burns as well as SJS and so
38:21
with thermal burns I mean it’s kind of
38:24
obvious what the causes are usually the
38:27
globe is not involved because of the
38:29
eyelid reflex so people you know you’re
38:31
gonna close your eyes so usually there’s
38:33
more eyelid involvement with thermal
38:35
burns and which can be you quite
38:37
extensive chemical burns can be from any
38:41
form solids liquids or gases alkali
38:43
agents will usually penetrate deeper
38:45
than acids the reason for this is that
38:48
acids actually cause a coagulation
38:50
necrosis that prevents deeper
38:53
progression of that acid alkali agents
38:56
cost saponification of fatty acids which
38:58
actually caused cellular disruption and
39:01
allows that alkali agent to penetrate
39:03
deeper into the tissues so acutely
39:08
definitely want to irrigate you can
39:11
check the pH I think there was someone
39:15
was asking me the other day about pH
39:16
paper
39:16
I don’t you guys ever find it and forget
39:18
who it was who has asked me it’s
39:21
somewhere hopefully and I’ve had like
39:24
kind of defective pH paper that showed
39:27
like a very base number regardless of
39:30
what was added so you can always check
39:31
it on your own i if you’re not sure so
39:34
the test if it’s actually working
39:36
you’re gonna do a complete eye exam look
39:39
at the eyelids look for edema and like
39:41
vamos and lash loss you want to check to
39:44
see if there’s a good Bell’s reflux if
39:46
there is like abdominal so this is a
39:47
patient with very extensive facial burns
39:50
but thankfully he has a good Bell’s
39:52
reflux even though he has a lot of like
39:54
abdominals
39:56
you want to look at the country type of
39:58
cornea and foursie’s assess the epic
40:01
effects clean out many foreign bodies
40:03
can see if there’s any opacities and
40:06
then most importantly with chemical
40:07
burns you want to note the level of
40:10
limbo ischemia and lebowski mia means
40:13
that there’s a loss of level stem cells
40:14
and portions of poor prognosis so here
40:17
are two pictures of two different eyes
40:19
one with this limbo blanching one that
40:22
looks very red and so the eye that
40:25
actually looks very red and beefy has a
40:27
better prognosis than the one that’s not
40:30
red
40:32
there are several late complications to
40:34
ocular burns you can get persistent
40:36
cornea epithelial defects because of the
40:38
most up cell deficiency you can get
40:40
corneal athenian perforation cornea
40:42
neovascularization and the conduct i
40:44
value can see scarring and some Bufferin
40:46
formation on the eyelids that can be
40:48
progressive scarring psyche tricia
40:50
ectropion trichiasis and lag of panels
40:55
so the treatment vitamin C and
40:59
doxycycline can be effective the
41:01
doxycycline actually has oral
41:03
doxycycline he has an anti-inflammatory
41:04
effect the eyelids do need to be
41:09
lubricated and you can use over throw my
41:12
son pointment
41:13
use a topical fluoroquinolone if there
41:16
isn’t any corneal epithelial defect and
41:18
if there is I actually highly consider
41:21
using a topical steroid especially in
41:22
the first couple weeks after a burn to
41:25
reduce inflammation if there is a
41:27
persistent epi defect you can consider
41:29
bench contact lenses
41:31
I’m Yannick membrane ether sutured or
41:33
non sutured such as a pro Kara if there
41:36
is lag of thymos then you want to do a
41:38
very aggressive lubrication like wingman
41:40
cue an hour moisture chamber goggles
41:42
around the clock
41:44
you want to get oculoplastic sin volved
41:46
unfortunately you can’t really go in
41:49
surgically acutely because there’s
41:51
oftentimes a lot of scarring that occurs
41:54
late so if there is like alpha most
41:57
often the patients do need a wait a
41:58
while before they can get their eyelids
42:00
treated so in severe cases consider the
42:03
inpatient use of sclera lenses which
42:06
we’ll talk about
42:07
so Garland’s threaten patient use so we
42:11
use this for exposure cure top of the
42:13
we’re three current or non-healing up
42:15
with yellow defects or if there’s
42:17
cornell thinning scarring that are
42:19
effective refractory to other treatments
42:22
there is a much less risk of infection
42:25
with sclera lenses than with soft
42:27
bandage contact lenses we do have a
42:29
protocol here I think it’s on the box
42:32
resident folder correct so let me know
42:38
personally if you’re thinking about
42:40
using sclera lenses I feel like it got
42:43
you used me you only once or twice
42:44
though maybe once last year it doesn’t
42:46
come up very often
42:48
oh yeah two years ago so maybe none last
42:50
year maybe not okay so hopefully the
42:54
sclera lenses are somewhere I don’t know
42:56
if they’re in the resident room
42:57
hopefully they’re somewhere safe so it
43:02
sounds like we need ask Tina if make
43:04
sure they’re still around because
43:06
there’s a whole protocol about what you
43:08
need to do to take care of the sclera
43:09
lenses next we’re gonna switch gears to
43:13
stevens-johnson syndrome / toxic
43:16
epidermal necrolysis so this is a rare
43:18
potentially life-threatening
43:19
hypersensitivity condition that’s
43:21
triggered by medications or infections
43:23
there is sloughing of the skin and
43:25
mucous membranes and the definitive
43:26
diagnosis is by skin biopsy which is
43:29
done in patient SJS involves typically
43:32
10 to 30 percent of total body surface
43:34
area whereas TENS involves greater than
43:36
30 percent and this is a patient who
43:39
actually looks this way it’s not that
43:43
her her face is red she actually has no
43:45
skin so there’s no epithelium here
43:47
that’s why they have this look so it’s
43:49
very very severe I mean they’re in the
43:50
burn unit because it’s almost like they
43:53
have burns because they you know have
43:55
their skin has left off there is a high
43:58
association of ocular involvement in SJS
44:01
you see content type of inflammation
44:03
pseudo membranes content type on corneal
44:06
epithelial defects late complications
44:08
are severe there is severe dry eyes
44:10
because of loss of goblet cells and
44:12
often meibomian glands
44:14
there’s keratinization of the eyelid
44:16
margin there was scarring of the
44:19
content-type of corneas and blarin
44:21
corneal opacity s corneal thinning and
44:23
perforation and corneal new vascular
44:25
ization the treatment will be
44:29
lubrication and topical steroids and
44:32
then you want to consider amniotic
44:33
membrane transplantation over the bulb
44:36
our enthalpy palpebral conduct IVA
44:38
cornea and over the eyelid margins if
44:41
there is significant inflammation in
44:43
sloughing and this amniotic memory is
44:46
human amniotic membrane it is harvested
44:49
from women who undergone have undergone
44:52
c-sections and have elected to donate to
44:54
their placentas and so the amniotic
44:56
membrane contains both factors anti
44:58
inflammatory mediators to promote
45:00
healing and reduce inflammation and it
45:02
also prevents these very late
45:04
complications so there is a new grading
45:08
system for when to do amniotic membrane
45:11
transplantation based on the exam so
45:14
notice that it is classified into mild
45:18
moderate severe and extremely severe if
45:21
you want to look at the lid margin if
45:22
there is staining of less than one third
45:25
of the lid margin you can just do
45:27
medical and close observation anything
45:30
bigger than that and want to consider
45:31
and you want to do a membrane
45:34
transplantation in addition to the
45:35
medical therapy if there’s any corneal
45:38
epithelium that would be considered
45:40
severe if there’s staining on the bull
45:43
bar and palpebral conjunctiva of greater
45:46
than one centimeter that is considered
45:48
severe so you know basically let us know
45:52
about any SJS patients that are out
45:54
there
45:57
here are some pictures of Austria’s
45:59
patients this is the pictures showing
46:01
severe keratinization so the sustained
46:04
with fluorescein but there’s as you can
46:06
imagine this can cause chronic and
46:11
sometimes even debilitating pain and
46:13
irritation and this is just showing that
46:16
there’s kind of a little irregularity of
46:18
the lid margin there and so when you
46:20
pull it back you’ll see this this is a
46:22
patient who had a really good result she
46:24
had young patient with SJS who underwent
46:27
amniotic membrane transplant and I think
46:31
it was about a month later I can’t tell
46:33
that anything even really happened so
46:35
she looks great
46:36
this is another patient who kept very
46:40
late
46:41
emerenc membrane i’m transplantation
46:42
with chronic scarring and inflammation
46:45
so there’s a lot of scarring of the how
46:48
people conduct iva a lot of chronic
46:50
inflammation of the conjunctiva in
46:52
general I think he had some corny only a
46:55
vascular ization as well so that is it
46:59
any questions on anything
47:05
well we’re always around we’ve got some
47:07
great coin you fellows this year and
47:08
also always helped as well so I think
47:11
that’s about
47:12
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