Cornea Disease

OD2 Winter

Functions of the tear film

• Refractive qualities

• Comfort and lubrication

• Oxygen supply

• Immunity

• Disposal 

What’s the difference between DEWS I (2007) and DEWS II (2017) ?

• DEWS I: Initial report describing dry eye as a disease

• DEWS II:

  • Newest definition of dry eye

  • Multifactorial nature of dry eye with a loss of homeostasis of tear film

  • Neurosensory abnormalities

  • Patient-centered approach

  • Most patients have a mix of aqueous deficient DED and evaporative DED

What are the different types of Dry Eye Disease?

• Aqueous tear deficient

• Evaporative

• Exposure

• Neurosenseory

  • Neurotrophic

  • Neuropathic

What’s the difference between neurotrophic vs. neuropathic?

• Neurotrophic: Stain with no pain

• Neuropathic: Pain with no stain

  • Psychopathic, why are you feeling pain with no stain?

If a patient has a true aqueous issue, what else should you ask about?

Sjrogren’s Syndrome

• Symptoms: Dry eyes, dry mouth 

• Generally associated with rheumatologic disorder 

• Difficult to treat since glands are already destroyed 

• Known as lymphoma proliferative disease (likely to develop lymphoma - cancer of lymph nodes)

Commonly associated conditions with gland not producing tears? 

Dry surfaces, problems with glands: 

• Medications (beta blockers, antihistamines - designed to dry surfaces) 

• Sjogren’s Syndrome 

• Rheumatologic/connective tissue disorder 

• Sarcoidosis - causes issues within gland tissues 

• HIV (+) 

• Graft vs. host disease 

• Familial dystautonomia 

• Xerophthalmia 

Commonly associated conditions with ducts not transporting tears? 

Problems with mucous membranes:

• Mucous membrane pemphigoid - adhesions blocking flow

• Stevens-Johnson Syndrome

Commonly associated conditions with insufficient hormonal stimulation

Tends to affect women more:

• Menopause 

• Oral BC 

• Pregnancy 

• Androgen deficiency 

Commonly associated conditions with insufficient neural stimulation

Problems with corneal sensitivity: 

• Neurotrophic keratitis: HZO, HS, Diabetic peripheral neuropathy 

• Stroke 

• Radiation 

• Ocular surgery: LASIK, cataract extraction

What is the significance of Matric Metalloproteinases (MMP) in dry eye disease? 

MMP are proteolytic enzymes produced by stressed epithelial cells on the ocular surface 

• In Tears: 

  • Non specific inflammatory markers

  • Normal ranges (3-41 ng/ml) 

• High levels of MMP in ocular surface diseases like dry eyes 

  • Corneal ulcers, erosions, keratitis, MGD, ocular rosacea, Sjogren’s syndrome 

What is the first, second, & third line treatment of dry eyes? ( A Midterm Q) 

• First:

  • Artificial tears 

• Second:

  • Seborrheic blepharitis

    • Eyelid margin scrubs

    • Culture, than antibiotics 

  • MGD

    • Warm compress

    • Mmega 3 supplements

    • oral low dose doxycycline 

• Third (for all types of dry eyes): 

  • Topical Steroids (short tern) short-term

  • Immunomodulating medications (Cequea, Restasis) 

What is the difference between the Fluorescein Dye Appearance Jones 1 and the Lacrimal Dilation and Irrigation Jones 2 Test?

• Jones 1: Have the patient blow their nose onto a tissue and look at it with cobalt blue filter. To check if there is drainage of tears or is it blocked? 

• Jones 2: Irrigate with saline and ask if they can taste it. We’re trying to push out the blockage before testing for dye appearance again 

Main differences between episcleritis and scleritis

• Episcleritis: Doesn’t hurt

  • Blanches with 10% of 2.5% Neosynephrine or Phenylephrine

• Scleritis: Painful

  • Blue Sclera 

Corneal Involutional Degenerations (Due to Age):

• Limbal Girdle of Vogt 

• Corneal Farinata 

• Descemet’s Striae 

• Hassal-Henle Bodies (Descemet’s “Warts”) 

• Mosaic Shagreen (crocodile skin)

• Hudson Stahli Line

• Generally asymptomatic and not visually significant

• Limbal Girdle of Vogt:

  • Below epithelium at Bowman’s level 

  • Looks like parenthesis 

  • 4th year said you have this 

• Corneal Farinata: 

  • Flour dust deposits deep in the corneal stroma 

  • Almost exclusively at the central interpalpebrel limba region 

  • Normal endothelial “mosaic” underneath 

• Descemet’s Striae: 

  • DDX: Vogt’s striae (vertical), Hobbes striae (horizontal)

• Hassal-Henle Bodies (Descemet’s “Warts”): 

  • Buildup of hyaline material on the endothelium

• Mosaic Shagreen (crocodile skin): 

  • Anterior: b/w Basal Epithelium and Bowman’s

  • Posterior: b/w Stroma and Descemet’s 

• Hudson Stahli Line: 

  • Iron deposits on the lower 1/3 of the cornea

Corneal Degenerations (Related to something) 

• Corneal Arcus

• Calcific Band Keratopathy

• Dellen

• Terriens Marginal Degeneration (Gutter Degeneration)

• Salzmann’s Nodular Degeneration

• Mooren’s Ulcer

• Corneal Arcus: 

  • Lipid deposit in stroma 

• Calcific Band Keratopathy

  • Calcific degeneration in Bowman’s layer 

• Dellen:

  • Near an elecation

• Terriens Marginal Degeneration (Gutter Degeneration):

  • Superior peripheral corneal thinning, sub-epithelial degen

• Salzmann’s Nodular Degeneration: 

  • Hyaline plaques b/w Epithelium and Bowman’s membrane 

• Mooren’s Ulcer: 

  • Marginal ulcer, autoimmune