Corneal Findings, Pathology, and Deposits - Student PDF

Lecture 10 Corneal Staining, Edema, Deposits and Other Findings Pierce Kenworthy OD, FAAO September 18, 2024 Photo credit Justin Burk ‘22  Dyes Used in Eye E...

Lecture 10 Corneal Staining, Edema, Deposits and Other Findings Pierce Kenworthy OD, FAAO September 18, 2024 Photo credit Justin Burk ‘22  Dyes Used in Eye Examinations NaFl staining NaFl Fluorescein staining of healthy cells is limited, but fluorescein diffuses rapidly into the intercellular spaces or stroma when disruption of cell–cell junctions occurs. Ocular surface squamous neoplasia stained with rose Rose Bengal Bengal. May also be useful in the evaluation of keratoconjunctivitis sicca, epithelial dendrites, and dysplastic or neoplastic lesions Lissamine green staining in Lissamine Green a 33-year-old patient with Better tolerated than rose Bengal by patients severe keratoconjunctivitis sicca. May be useful for conjunctival staining Types of Corneal Staining Punctate epithelial erosions (PEE) Punctate epithelial keratitis (PEK) Superficial punctate keratitis (SPK)  Some prefer to indicate any corneal staining as “SPK” (superficial punctate keratitis)… But technically…… Punctate Epithelial Erosions Punctate Epithelial Keratitis “PEE” “PEK” Minute focal defects, visualized as Epithelial lesions with focal small green dots at the slit lamp inflammatory infiltrates within the after fluorescein instillation epithelium have punctate staining (Ex. Dry eye) (Ex. Viral Infection) Punctate Epithelial Erosions (PEE)  Punctate Epithelial Erosions (PEE) Tiny epithelial defects that stain with fluorescein and rose Bengal Non-specific sign, generally an early sign of epithelial compromise Seen in early stages of wide variety of keratopathies, especially dry eye syndrome Tiny, slightly depressed, gray-white spots PEE – like a golf ball divot 73 yo male, referred to dry eye for advanced dry eye and amniotic membrane placement How does this cornea look in this 88 yo female w/ history of filamentary keratitis? Punctate Epithelial Keratitis (PEK)  Punctate Epithelial Keratitis (PEK) Granular, discrete, grayish epithelial cells with focal intraepithelial infiltrates Visible without stain But will stain with Rose Bengal and variably with NaFl Non-specific sign but hallmark of viral infections Causes include: Adenoviral Chlamydial Early herpes simplex and herpes zoster Eyedrop toxicity 30 yo male with resolving HSV corneal infection  58 yo female, was just here two weeks ago for glaucoma check, compliant with glaucoma eye drops, but now has red, watery eyes as of this morning. IOP 21 and 22. Thinks maybe got soap in eyes, or has bad eye drops?? What do you want to do? Lotemax (unavailable – so pharmacy did pred acetate tid OU) Superficial Punctate Keratitis (SPK)  Superficial Punctate Keratitis (SPK) Corneal inflammation characterized by scattered, fine, punctate corneal epithelial loss or damage Non-specific term describing any corneal epithelial disturbance of dot- like morphology Ex. Thygeson’s SPK  The lesions are entirely intraepithelial, although there may be associated Thygeson’s SPK is notable for Ex. Thygeson’s SPK subepithelial haze or mild edema. small, central epithelial opacities Uncommon epithelial keratopathy of unknown cause, usually bilateral It is characterized by a coarse punctate epithelial keratitis The conjunctiva may be mildly injected or completely quiet It has no known association with other ocular or systemic diseases. Each discrete lesion is composed of many It appears to be an active keratitis but smaller grains, making a round to vertically incites no neovascularization or oval translucent to opaque deposit Coarse, punctate lesions seen in inflammation in the chronic phase. Thygeson's SPK Patients usually have a long history (decades) of exacerbations and spontaneous remissions of foreign body sensation. Other symptoms include photophobia, burning, tearing, and blurring of vision. Artificial tears may relieve symptoms, but may also use low dose corticosteroids and/or bandage contact lens for more severe manifestations  Superficial Punctate Keratitis of Thygeson (A) shows the opacities elevated above the (B) shows the opacities with fluorescein superficial epithelium during an exacerbation. What is your diagnosis? 26 yo female with slightly reduced VA in both eyes. Eyes are not very red, but they are irritated. Distribution of Corneal Staining  The location of the lesions may give an indication of etiology Inferior staining can be secondary Extensive diffuse to exposure, staining caused blepharitis, by BAK lagophthalmos or (benzalkonium trichiasis choride) Superior staining Exposure consistent with keratopathy superior limbic secondary to keratoconjunctivitis thyroid eye disease Contact lens Foreign body overwear tracking What about this student, hx of dry eye and MGD? Right Eye Left Eye Right Eye Left Eye Right Eye Left Eye Slow Mo of Who?? Left Eye Other Superficial Signs of Corneal Disease Subepithelial infiltrates (SEI) Neovascularization Lipid Deposition Pannus Subepithelial Infiltrates (SEI) Subepithelial Infiltrate (SEI) Tiny, focal inflammatory infiltrates Appear below epithelium Do not stain May be associated with a variety of conditions: Adenoviral keratoconjunctivitis Herpes zoster keratitis Adult inclusion conjunctivitis Marginal keratitis Ocular rosacea Other inflammatory conditions  2021-08-03, 77 yo female, OD was red 3 weeks ago, then her left eye became red more recently. Eyes are crusty and eyelids are red. OD Notice the SEI’s present from presumed EKC (adenoviral infection)  What will OD Cornea 8-3-2021 you do? We did: Maxitrol ung qhs Prednisolone acetate tid x 14 days (w/ taper) 2021-08-10, one week follow up, pt feeling much better Tell your neighbor What do the following acronyms mean? PEE PEK SPK SEI Corneal Vascularization Because the normal cornea is avascular, the appearance of blood vessels in the cornea is always abnormal Superficial neovascularization is a Vascularization occurs in response to a wide variety of feature of chronic ocular surface irritation stimuli. Venous channels are easily seen, whereas arterial or hypoxia, as in contact lens wear feeding vessels are smaller and require higher magnification. Non-perfused deep vessels appear as ‘ghost vessels’, best detected by retroillumination.  24 yo female optometry student, contact lens wearer, with superficial corneal neovascularization Note the movement of the red blood cells under high magnification  26 yo female, overwears her contact lenses and complains of irritated, scratchy feeling eyes. Neovascularization secondary to contact lens wear Lipid Deposition Lipid Deposition Lipid deposition may follow chronic inflammation with leakage from new corneal vessels lipid deposition with vascularization HSV recurrence in 57 yo female, with corneal neo, scarring and lipid deposition 2024-09-11, 31yo WF referred for confocal. Corneal ulcer OD 1 year ago, was treated, and continues using 1gtt prednisolone acetate QID OD for last year. Pt reports recent vision loss OD and ocular pain when not using the steroid.  2022-09-27, 49 yo female with hx of HZO keratitis OD. Has been followed frequently by Dr. Fintelmann. Hx of lipid deposition in chart and neovascularization No more lipid deposition, good news today! Pannus Pannus Superficial neovascularization with subepithelial degenerative changes 47 yo diabetic female, no symptoms. What do you think?  July 14, 2021 – OD3PC3, 41 yo female, hx of VKC two years ago, just had red irritated eyes last week, was dx’d with episcleritis and Rx’d Pred acetate bid OU and patanol qam. OS superior OS inferior  Clinical Comment: Limbal Stem Cell Deficiency  Limbal Stem Cell Deficiency Problems with the limbal stem cell population result in a decrease in the ability of the corneal epithelium to repopulate itself. In these situations, patients often complain of redness, irritation, photophobia, and decreased vision. Early slit lamp findings include loss of the palisades of Vogt late staining of the epithelium with fluorescein corneal neovascularization development of peripheral pannus. Why!? It is not unusual for the ordered corneal epithelium to be replaced by one that is phenotypically similar to conjunctival epithelium, a process called conjunctivalization. In a process that is not well understood, this invasion is somehow facilitated by the absence of those limbal stem cells that form a barrier to this conjunctival migration. It is this replacement of corneal with conjunctival tissue that is responsible for many of the clinical findings of limbal stem cell deficiency. Because the cellular interconnections of conjunctival epithelium are looser than those seen in corneal epithelium, the tissue is more permeable, resulting in the typical late staining with fluorescein These looser connections are probably the histologic etiology for the hazy, gray appearance of the affected corneal surface In addition, these connections may allow penetration of leukocytes from the tear film into the corneal stroma, causing signs and symptoms consistent with inflammation The lack of normal hemidesmosomal attachments at the base of these conjunctival cells increases the likelihood for patients to develop erosions Evidence also exists that these conjunctival cells are unable to secrete antiangiogenic factors found in normal corneal epithelium, thus allowing for the development of corneal neovascularization 2021-10-13, 46 yo male, 1 day post op combined cataract surgery and pterygium excision (hx of limbal stem cell deficiency) Example of corneal vascularization in LCSD  Deep Signs of Corneal Disease Infiltrates Ulceration Corneal Necrosis and Melt Corneal Infiltrates  Corneal Infiltrates Infiltrates are grey–white opacities Hypersensitivity located initially within the anterior reaction stroma usually associated with limbal or conjunctival hyperemia Represents acute inflammation composed of inflammatory cells Why!? Adaptive immunity, which may take several days, responds to specific pathogens and antigens by mediating B and T lymphocytes that proliferate This cellular immune response leads to Contact-lens the migration of white blood cells— induced including polymorphonuclear leukocytes and mononuclear cells—arising from the limbal arcades and the precorneal tear film into within the cornea, resulting in an infiltrate 3-30-2021, 29 y/o male patient c/o eye stinging and pain OD on Friday evening while watching TV. Pt reports no insult or injury to the eye, and removed contact lenses and rinsed it out on Friday evening with some relief but since then has noticed blurry vision in the distance and photophobia OD. What was done? Tobradex q2hrs 3-31-21, 1 day f/u 4-7-21, 1 week f/u, pt says all pain is gone, vision getting better, but still not quite as good as left eye Infiltrate resolved, patient now has a central corneal scar, and he is a -6.00 myope. What now? Consider PRK?  Corneal Ulceration Ulceration Ulceration refers to tissue excavation associated with an epithelial defect, usually with infiltration and necrosis. 2023-12-08, 67 yo female, hx of corneal ulcer OS x 3 months. Is down to steroid about once or twice a day (stings upon instillation). Pt is also using Valtrex 1gram qd. Using vancomycin and tobramycin alternating every hour. Pt reports light sensitivity. Also has occasional stabbing pain with 8 out of 10 pain. Vision poor, with minimal change/improvement. Pt has hx of CL use from 6am to 3pm. Referred for confocal 2022-07-30, about to leave, but patient calls asking if he can be seen for exam (I thought just for glasses). When he arrived, he said he woke up with red eye after sleeping in daily contacts last night. Corneal Necrosis & Melt  Corneal Necrosis Corneal Melt significant corneal death secondary to sterile necrosis of the corneal stroma trauma, infection, anesthetic abuse, etc. may lead to perforation Bacillus keratitis Corneal melt causing aggressive after NSAID use peripheral stromal necrosis Corneal ulcer with necrosis Corneal melt with peforation (Arrow indicating hypopyon) 49 yo male, failing corneal graft. What does corneal necrosis look like? 2022-05-17, 45 yo male. Hx of acanthamoeba in January 2022. Had a therapeutic PKP in March because cornea became necrotic. Graft is failing. Back for confocal to rule out acanthamoeba. Confocal at time of initial diagnosis 1-4-2022 Corneal Edema Corneal Edema Example #1 Microcystic Corneal Edema From High IOP Epithelial edema Corneal edema with bullae Abundant tiny epithelial vesicles may be seen in cases of corneal edema Bullae form in moderate–severe cases Microcystic corneal The cause is usually endothelial edema in patient with elevated IOP decompensation, but it can follow acute elevation of IOP 68 yo female, 1 day cataract Post-op, high IOP Immediate reduction in epithelial Microcystic epithelial corneal edema with reduction in IOP after edema at one day post-op “burp” – anterior chamber paracentesis IOP = 38 mmHg IOP = 16 mmHg 1 day cataract post op IOP 36, dropped to 16 Corneal Edema Example #2 Corneal Edema From Trauma and Endothelial Decompensation  2018-09-19, 70 yo male, 1 day cataract post op OS, VA only 20/70. Why? Endothelial decompensation and trauma from cataract surgery Clinical Comment: Bullous Keratopathy Injury to the endothelium during intraocular surgery can result in corneal edema, and potentially the formation of bullae, commonly known as bullous keratopathy. Corneal edema secondary to endothelial injury is a major cause of poor visual outcomes after intraocular surgery and a leading indication for keratoplasty. Bullous keratopathy may present gradually in the setting of aphakia, and pseudophakia Corneal Edema Example #3 Corneal Infections and Inflammations 2022-08-03, 42 yo female presents with red, painful eye OS. Three weeks ago, urgent care diagnosed her with a corneal abrasion OS and gave her “antibiotic drops“. Symptoms didn't improve so pt went to OD who suspected bacterial keratitis and put her on Ofloxacin gtts. Days later still not improving so OD referred her to large OD/MD group, and they switched her to a steroid. Symptoms started to get "very bad.” "worst pain I've ever experienced" (History of sleeping and swimming in contact lenses) Descemet’s Folds Folds in Descemet membrane , also known as striate keratopathy may result from corneal edema Causes include inflammation, trauma (including surgery) and ocular hypotony. Corneal Edema Example #4 Hydrops in Keratoconus Corneal Hydrops Diffuse corneal edema with epithelial bullous elevations from a Corneal hydrops in keratoconus: spontaneous break in Ruptures in the Descemet membrane Descemet membrane permit the stromal imbibition of aqueous and endothelium in and result in the marked corneal edema keratoconus (corneal seen in this slit lamp photograph (can lead hydrops). to epithelial bulla) Histopathology shows an epithelial bulla with fluid separation of corneal epithelium from Bowman’s layer (asterisks). Breaks in Descemet membrane may be due to corneal enlargement (Haab striae in infantile glaucoma) or deformation such as keratoconus and birth trauma. Acute influx of aqueous into the corneal stroma (acute hydrops) can follow. Corneal Deposits Iron & Copper  Iron Hudson-Stahli Line Ferry’s Line Stocker’s Line Fleischer Ring Metallic Foreign Body The most common intraepithelial deposit is iron Iron deposits in the epithelium have a yellow-brown coloration Iron found in tears  Hudson Stahli Line Found interpalpebral junction of normal cornea Normal finding in elderly patients, found where eyelids meet upon blinking Iron usually deposits in horizontal line 2019-07-08, 70 yo male, routine vision exam. What is your finding?  Ferry’s Line Iron at the head of a filtering bleb Bleb is a surgically created “bubble” to help flow of aqueous and treat glaucoma  Stocker’s Line Iron at the leading edge of a pterygium  Fleischer’s Ring Iron found at base of a cone in keratoconus  Foreign Body Rust Metallic foreign bodies may lead to deposition of iron in the cornea Coat’s white ring is a superficial ring of iron deposition that remains after a metallic foreign body is removed These rings develop when a rust ring from a metallic foreign body is not entirely removed Copper Kayser-Fleischer Ring Kayser-Fleischer Ring Deep stromal copper deposition Bilateral Yellow-brown or green ring at the level of Descemet Membrane in peripheral cornea Copper deposition begins peripherally at Schwalbe’s line and progresses centrally Associated with Wilson’s disease  Wilson’s Disease Kayser-Fleischer ring is present in approximately 95% of patients with Wilson’s disease: AR disorder that results in the accumulation of copper in most body tissues Deficiency in ceruloplasmin (enzyme involved in copper metabolism) Also associated with sunflower cataract Sunflower Cataract Tell your neighbor What are 5 iron deposits just discussed? What’s the 1 copper deposit discussed and it’s systemic association? What’s the difference between a Fleischer Ring and a Kayser- Fleischer Ring!!!! Vortex Keratopathy “Cornea Verticillata”  Vortex Keratopathy Also called “cornea verticillata” Linear opacities located within corneal epithelium that assume a whorl-like pattern Golden brown epithelial deposits (Color varies from white to brown) Arranged in curvilinear pattern from a point Swirl outward Spare limbus Classically associated with Fabry’s disease X-linked lysosomal storage disease Much more common as 2º finding with pharmaceuticals Vortex Keratopathy Secondary to Systemic Medication Amiodarone Most common Anti-arrhythmia Antimalarial Chloroquine Hydroxychloroquine Also used for certain rheumatologic conditions Chlorpromazine Sedative / antipsychotic Indomethacin NSAID Drug induced vortex keratopathy often will resolve after discontinuation Amiodarone induced vortex keratopathy 11-2016, one month cataract post-op patient, my first time seeing him. Was that from surgery? No Tell your neighbor What medications can cause vortex keratopathy?  Corneal Endothelial Pigmentation  Corneal Endothelial Pigmentation Pigment Dispersion syndrome Mostly affects Caucasians Bilateral liberation of pigment granules from iris pigmented epithelium Deposited throughout anterior segment  Pigment Dispersion Syndrome Posterior bowing of iris Etiology Mechanical rubbing of posterior iris on lens zonules Due to posterior bowing of iris Exercise induced episodes Acute elevated IOP Flattening of iris following laser iridotomy  Corneal Endothelial Pigmentation Pigment Dispersion syndrome Cornea Endothelium in vertical pattern (Krukenberg spindle) Anterior Chamber Krukenberg Spindle Pigment floating in aqueous Angle TM hyperpigmentation Iris Fine surface pigment granules Transillumination defects Lens Line or ring of pigment on posterior peripheral surface Scheie line Scheie Line Transillumination Defect  Varying Degrees of Pigmentation Mild Pigment Moderate Pigment Significant Pigment 28 yo white female, eyes appear a little darker, reports light sensitivity How much light should you use to check for TID? Right Eye Left Eye Brightened Right and Left Eye OD OS What is the pigment line on the lens called? Scheie Line 28 year old routine eye exam, IOP OD 19, OS 20 Name That Finding! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!! Name that finding!!