CORNEA.

DR NI LUH MURNIATI SpM. UPF MATA RSUD SANJIWANI GIANYAR.

CORNEA.
Physiology: function: - protective barrier. - window [light rays retina]. transparansy due to: - uniform structure. - avascularity. - deturgescent [relative dehydration].

 Destruction endothelial cell edema, loss of transparancy. Damage epithelium edema localized, trantient rapid regeneration. Penetration drug> intact cornea biphasic. - fat soluble intact cornea. - water soluble intact stroma. Drug must be fat and water soluble.

 Phisiology of symptome: - cornea many pain fibre corneal lession painful contraction inflamed iris--> photophobia. - irritation corneal nerve ending dilatation iris vessel [reflex phenomenon]. - photophobia severe corneal damage, minimal herpetic keratitis [hypesthesia]. - as window corneal lession blur vision [centrally].

Symptome and sign.

Hystory is important: - trauma foreign bodies, abration. - keratitis herpes simplex recurrent. - recurrent erosion extremely painful. - topical medication corticosteroid bacterial, fungal, viral disease. - immunosupression systemic diseases, DM, AIDS, malignant diseases.

 Keys to exam : - adequate illumination. - magnification [loupe,slitlamp] Fluorescein staining. Local anaesthesi [ steril drop ]. LABORATORY: Scraping GramS, Giemsas staining bacteri. Culture.

Mophologic diagnosis of corneal lession:

Epithelial keratitis. Subepithelial keratitis [secondary to epithelial keratitis]. Stromal keratitis. Endothelial keratitis.

BACTERIAL KERATITIS. Serious. Potentially-sight threatening corneal infection. Predisposing factor: - contact lens wear. - ocular surface diseases: dry eyes syndrome, trichiasis ect. - topical immunosuppressive therapy [corticosteroid].

- postoperative [corneal wound, suture related] E/: - staphylococcus. - streptococcus. - pseudomonas. - moraxella. Symptomes: - pain, irritation, redness, photophobia. - discharge, decreased vision, contact lens intolerance.

 Sign: - vary severity causative organism. - white stromal infiltrate pcvi epithelial defectstromal loss [ulcer]. - stromal edema descemet fold secondary reactive iritis hypopion. - staphylococcal keratitis stromal abcsess. - streptococcal keratitis severe ant uveitis hypopion.

- Streptocccus pneumoniae[pneumococcal] corneal ulcer: 24 48 jam setelah inokulasi. Ulcus abu-abu, bulat cepat melebar kearah sentral creeping effect [acute serpiginous ulcer]. Cornea sekitar jernih, hypopion sering. Scrapping gram positive lancet-shaped diplococci.

- Pseudomonas aeruginosa corneal ulcer: Gray or yellow infiltrate, cepat melebar kesemua arah[proteolytic enzyme]perforasi severe intra ocular infection Hypopion sering. Infiltrat dan exudate bluish-green [pigmen yang diproduksi-> khas] Sangat nyeri.

- contact lenses extended-wear lenses. scraping thin gram negtive rods Laboratory: - scraping Grams stain, Giemsa stain. - culture. Therapy: - antibiotic unfortified topical, [ 2mm], levofloxacin, ciprofloxacin, ofloxacin.

- Large ulcer, visual axis, hypopion, fortified AB drop [cefazolin, vancomycin, tobramycin. - oral AB. Prognosis: - verry good small ulcer. - good moderate. - poor severe.

FUNGAL KERATITIS.
E/: - nonfilamentous: rare, unilateral. preexisting factor: chronic corneal ds.[dry eyes synd., herpes keratitis ect] features: = bacterial keratitis ant. Chamber reaction hypopion.

 Filamentous: Aspergillus, Fusarium. - rare, unilateral, insidious/aggressive. - normal eye ocular trauma vegetative matter, SCL. - features:- grayish-white infiltrate, feathery borders. - finger like satellite inf. stroma. - infiltrate defect ant chamb.react hypopion.

 Symptome: - pain, tearing, decreased vision. Hystory: trauma, contact lens user, corticosteroid ed user. DD/: bacterial/herpetic keratitis conventional therapi respond -. Dx. Evaluation: - trauma[vegetative matter]. - corneal scraping Grams, Giemsa stain, culture. - corneal biopsy

 Treatment: - anti fungi topical, oral. Prognosis: - fair for mild to moderate inf. - poor severe inf.

HERPES SIMPLEX KERATITIS.

Extremely common. Most inf. subclinical. Primary/recurrent ds. E/: - HSV type 1: fase, lips,eyes close contact. - HSV type 2: genitalia transmitted sexually. neonatus + vaginal delivery.

PRIMARY OCULAR HERPES.

Uni/bilateral facial and/or eye inf. E/ and epidemiology: - primary contact with HSV. - children or adolescents. Symptome: - fever, flulike sympt. - facial vesicular rash, ocular redness, pain, decreased vision, tearing.

 Sign:- vesicular blepharoconjunctivitis. - periorbital dermatitis - vesicular crust. - acute foll conjunctivitis + preauricuar lymphadenopathy. Treatment: - anti viral drop, oral. Prognosis: -good benign, self-limited condition. - latent trigeminal ganglion recurrent.

RECURRENT OCULAR HERPES SIMPLEX.

Infectious ep keratitis. Non/ necrotizing stromal keratitis. Neurotropic keratitis. Keratouveitis. E/: - reactivation latent inf fisical/emotional stress. Children, adult. Bi/unilateral

HSV: EPITHELIAL KERATITIS[DENDRITIC ULCER].

Common, unilateral. Virus within corneal ep cells. Symptomes: - redness, tearing, irritation, decreased vision, photophobia, hystory of previous episodes. Sign: - single/multiple branching, ulcerating ep lession.

- enlargment of ulcer- amebic shaped geografic ulcer. - fluorescein + built up,swollen, opalescent margin. - anterior stromal haze ghost dendrites - corneal sensation diminish. DD/: - herpes zoster keratitis[ hystory HZ ophth] Treatment: antiviral drop/oral. Prognosis: good. Recurrent are common.

HERPES ZOSTER KERATITIS.

HZV inf [dorsal root ganglion] migrated downsensory nerve skin V1 trigeminal nerve HZ ophthalmicus. E/, epidemiology: - varicella zoster virus. - young adult, adult: immunocompromised [Ca, HIV].

 Symptomes: - fever, malaise, headache. - few days rash. - dermatonal skin rash, tingling, burning, itching sensation, pain. - eye redness,irritation, tearing, decreased vision, photophobia. Sign: - vesicle skin rash, unilat [not cross midle] blister, crust heal[scarring].

- Hutchinsonsign [vesicles on tip of the nose] naso cilliary nerve ocular disease. - periocullar dermatitis, conjunctivitis, episcleritis, scleritis. - Superficial punctate keratitis, microdendritic keratitis, nummular/disciform/neurotrophic keratitis. neurotrophic ulcer sec inf thinning perforation.

- iritis, glaukoma, retinitis, optik neuritis, cranial nerve palsy. - zosterpseudodendrites fluorescein -. - post herpetic neuralgia [3 months]. DD/: - herpetic simplex keratitis.[young, recurrent, fluoresein +, dendrites terminal bulb]. Treatment: - skin involvment: oral , ointment antiviral.

- conjungtivitis, scleritis: cool compress, artifisial tears, AB oint. - scleritis: + nonsteroidal anti inflamatory.
Prognosis: - good to poor severity, corneal involvment.

ARCUS SENILIS.
Extremely common, bilateral. Benigna pheripheral corneal degeneration. Assotiated: - age. - hypertriglycerdemia. Pathologycally: lipid droplets entire cornea. Symptoms: Clinically: hazy gray ring, 2 mm width[a clear space between it and limbus]. Treatment/complication: no.

CONTACT LENSES.
SOFT LENSES: - Cosmetic soft lenses. hydroxymethyil metacrilate[ HEMA ], or silicon. removed each day, cleaned, desinfected, stored over night 1 year. disposible daily wear, weekly [2-4 weeks]

- Therapeutic soft lenses. External eye diseases protection trichiasis, exposure. Treatment recurrent erosions epithelial healing. Pain bullous keratopathy. Seal small corneal perforation/wound leaks.

- Contact lens care: Aware of the risk extended-wear lenses. Removed imediately uncomfortable, inflamed. Regular cleaning, desinfecting, removal protein deposit [ except daily]. Contact lens care system no preservative [ hypersensitivity reaction] pseudomonas, acanthamoeba.

CORNEAL TRANSPLANTATION.
= KERATOPLASTY. Indicated: scarring, edema, thinning, distortion [serious corneal condition]. Penetrating keratoplasty[PK]: full thickness. Lamellar keratoplasty: partial thickness. Deep lamellar[DLK] / deep lamellar endothelial keratoplsty[DLEK].

REFRACTIVE SURGERY.
Inconvenience of spectacles, complication contact lenses surgical solution problem of refractive error. Radial keratotomy: full-thickness radial incision. Keratomieleusis: flattened laser insitu keratomileousis[LASIK].

 Clear lens removal and phakic lens implantation: - high myopia, presbiopia. - without lens removal corneal endothelial damage, catarract. Laser: eximer laser, femtosecond laser. - PRK[photorefractive keratectomy, LASEK[laser epithelial keratectomy, surface ablation techniques.

 LASIK: - for up to 10 D, myopia. More comfortable than surface ablation. Complications: fluctuating refraction, irr. astigmatisma, regression,epithelial flap, stromal haze, infection. Conductive keratoplasty[CK] hypermetropia, presbiopia.

Fluoresein positif

pcvi

dendrite

Ulcus cornea central

Ulcus cornea cum hypopion

keratoplasty

LASIK