Cornea (pt 5, Inflammatory Conditions)

Inflammatory corneal conditions are caused by…

• Staph hypersensitivity

• Autoimmune

Marginal keratitis

Hypersensitivity to staph exotoxins and cell wall proteins

Risk factors: Bleph

Marginal keratitis clinical findings

• Peripheral small subepithelial marginal infiltrates (more superficial)

• Sectoral conj hyperemia adjacent to infiltrates

• Inferior PEEs

• Minimal ant chamb rxn

Marginal keratitis complications

• Corneal scarring

• Pannus

Marginal keratitis Tx

• Topical steroids and/or antibiotic combo if there is a lot of staining

• Bleph Tx

Marginal keratitis hallmark signs

Marginal subepithelial infiltrates with PEEs

Infectious vs Marginal keratitis

Infectious:

• Deep central stromal infiltrate with staining equal in size, ant chamb rxn, diffuse hyperemia

• Corneal perforation

• Tx: Topical anti-infective and cycloplegic

Marginal:

• Peripheral subepithelial infiltrate with small staining, no ant chamb rxn, sectoral hyperemia

• Corneal scarring

• Tx: Topical steroid and/or antibiotic combo

Phlyctenulosis

Caused by delayed hypersensitivity reaction to staph antigens or TB

Risk factors: Bleph

Phlyctenulosis clinical findings

• Small white limbal or conj nodule that may travel into cornea

• Sectoral conj hyperemia adjacent to nodule

Half conj half cornea presentation

Phlyctenulosis complications

Corneal scarring and neovascularization

Phlyctenulosis Tx

• Topical steroids and/or antibiotic combo if there is a lot of staining

• Bleph Tx

Refer to infectious disease if TB related

Phlyctenulosis hallmark signs

Limbal or conj nodule that may extend into cornea

Mooren Ulcer

Rapidly, progressive, painful peripheral ulcerative keratitis

No infection or autoimmune etiologies → Dx of exclusion seen with PUK (which is linked with Rheumatoid arthritis)

Resistant to therapeutic interventions → Refer out

Mooren ulcer risk factors

• Autoimmunity

• Intestinal parasite infection

• Hep C infection

• Ocular trauma/Sx

• Genetic

Mooren ulcer clinical findings

• Peripheral crescent shaped ulceration around limbus, around and in

• NO scleritis

• Stromal thinning and neovascularization

• Conj hyperemia adjacent to ulcer

Mooren ulcer complications

• Corneal perforation

• Vision loss

Mooren ulcer Tx

Tx early to prevent progression

Local immunosuppression → Systemic immunosuppression → Surgical resection of adjacent conj → Urgent surgical management → Management of complications when inactive

Peripheral ulcerative keratitis

Associated with autoimmune conditions, RA most common

Seen with ocular infections, trauma, or dermatologic conditions

More common in middle-older adults

PUK clinical findings

• Crescent shaped ulcer with overlying epi defect within 2mm of limbus

• Scleritis (necrotizing)

• Ant chamb rxn

PUK complications

Melting and perforation

PUK Tx

• Artificial tears (prevent crater from drying out)

• Topical immunomodulators

• Topical antibiotics (prophylactic)

• Oral steroids and immunomodulators (systemic)