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NONINFECTIOUS SUPERFICIAL KERATOPATHIES Dr. Sushil Tripathi

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Page 1: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

NONINFECTIOUS SUPERFICIAL KERATOPATHIES

Dr. Sushil Tripathi

Page 2: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

• Recurrent corneal erosion syndrome

• Filamentary keratitis

• Thygeson’s superficial punctate keratitis

• Superior limbic keratoconjunctivitis

• Neurotrophic keratitis

Page 3: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Recurrent corneal erosion syndrome

Common disorder

involving the corneal

epithelium and

epithelial basement

membrane

characterised by

repeated breakdown

of epithelium.

Page 4: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Etiology

Previous trauma corneal dystrophies: Diabetes mellitus

Anterior basement membrane corneal dystrophy lattice, Reis-Bücklers’, macular, granular, Meesmann's dystrophies

Page 5: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Pathophysiology

Page 6: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Pathophysiology

Trauma or corneal dystrophy

Abnormal attachment complexes

Recurrent corneal erosion

Page 7: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Pathophysiology

eyes closed

tear evaporation

concentration of dissolved salts in tear fluid

shift of osmotic gradients

corneal epithelial edema

epithelial adhesion

Page 8: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical manifestations

Symptoms:

• episodic in nature

• Sudden onset

• Mostly in early morning

• Sharp pain, epiphora, FB sensation, lid edema

• Anxiety, depression, fear of falling asleep,

insomnia.

Page 9: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Diagnosis

• history of previous trauma

• episodes of pain on awakening

• ragged, staining area of

epithelium

Page 10: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Medical Treatment

• long-term nightly use of hyperosmotic

lubricating ointments

Page 11: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Medical Treatment

• long-term nightly use of hyperosmotic

lubricating ointments

• Hyperosmotic eyedrops during the daytime

Page 12: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Medical Treatment

• long-term nightly use of hyperosmotic

lubricating ointments

• Hyperosmotic eyedrops during the daytime

• Patching

• Bandage contact lens

Page 13: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Anterior stromal puncture:

• In 1986 McLean et al• Also known as epithelial reinforcement,

corneal micropuncture

• highly effective OPD procedure

• For Localized erosions

Page 14: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Page 15: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Page 16: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Page 17: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Page 18: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Page 19: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Page 20: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

superficial keratectomy:

• multiple erosions in different

areas of the cornea

• large areas of loosely adherent

irregular epithelium

• Erosions in visual axis

• no history of trauma

• severe basement membrane

dystrophy

Page 21: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

superficial keratectomy:

• OT procedure

• Dissect the whole epithelium with no. 15

blade

• Leave 1mm peripheral epithelium

• Do not remove Bowman’s membrane

• Scrape it with blade perpendicular

Page 22: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Surgical Treatment

Postsurgical treatment:

• hyperosmotic ointments and drops

• NSAID drops

• Antibiotics

Page 23: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Filamentary keratitis

Page 24: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Associated diseases

Ocular trauma/surgery:   

Abrasion/erosion

   Contact lens overwear

   Cataract extraction

   Penetrating keratoplasty

  

Page 25: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Associated diseases

Ophthalmic disorders:    Keratoconjunctivitis sicca

   Superior limbic keratitis

   Neurotrophic keratopathy

   Prolonged patching

   Ptosis

   Aniridia  

Page 26: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Associated diseases

   Systemic disorders:   

Sarcoid

   Diabetes mellitus

   Hereditary hemorrhagic telangiectasia

   Ectodermal dysplasia

   Psoriasis

   Atopic dermatitis

   Brain stem injury

  

Page 27: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Pathophysiology

Page 28: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Manifestations

• foreign body sensation

• photophobia

• blepharospasm

• epiphora

Page 29: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Treatment

• Treat the underlying cause

• Mechanical debridement of the filaments

• Tear substitutes

• Punctal oclusion

• 5% sodium chloride ophthalmic solution

• Bandage soft contact lens

• NSAID eye drops

Page 30: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Thygeson's Superficial Punctate Keratitis

• uncommon epithelial keratopathy of unknown cause• no known association with other ocular or systemic

disease• coarse punctate epithelial keratitis • little or no hyperemia of the bulbar or palpebral conjunctiva• Active and chronic keratitis but no neovascularization• often misdiagnosed.

Page 31: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Epidemiology

• No sex predilection

• 2.5 years of age to over 70.

• Most common in second and third decades.

Page 32: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Etiopathogenesis

• Not yet understood

• resemble viral lesions

• Long duration

• exacerbations and remissions

• mononuclear cell response

Viral suspect

• Presence of HLA-DR3 antigens

• Chronic course • Presence of lymphocytes

• Corticosteroid response

Autoimmune suspect

Page 33: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical manifestations

• Long history of exacerbations and spontaneous

remissions

• Foreign body sensation

• Photophobia

• Burning

• Tearing

• Occasional blurring of vision.

Page 34: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical manifestations

• Bilateral

• Mild or no conjunctival congestion

• oval or round, punctate

intraepithelial lesions

• evanescent and migratory

Page 35: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical manifestations

• composed of numerous discrete, fine, granular,

white to gray, dotlike opacities

Page 36: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Differential Diagnosis Thygeson’SPK Adenoviral SPK

Noninfectious infectious

No other ocular findings Lid edema, congestion, conjunctival follicles

coarse Fine

No subepithelial infiltrates Subepithelial infiltrates

No scarring Scarring ( Visually significant )

Page 37: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Treatment

• Low-dose topical corticosteroids

• Bandage contact lens

• ciclosporin A

Page 38: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Superior Limbic Keratoconjunctivitis

Page 39: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Epidemiology

• Nonfamilial

• Age – 20-67 years mean age - 50 years

• female:male ratio - 3 : 1

Page 40: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Etiopathogenesis

• etiology is not clear

Page 41: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Etiopathogenesis

Associations:

• Thyrotoxicosis – 30% of the cases.

• keratoconjunctivitis sicca

Page 42: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Presentation

• Long lasting

• Exacerbations and remissions

• foreign body sensation, photophobia, and pain

• Blepharospasm

• Mucoid discharge

Page 43: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Presentation

• Signs:• Bilateral • hyperemia of the palpebral conjunctiva and a

fine papillary reaction

Page 44: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Presentation

• Signs:• The superior bulbar and limbal conjunctiva shows

sectoral injection and appears thickened and redundant

Page 45: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Presentation

• Signs:• application of rose Bengal often shows coarse

punctate staining of the superior bulbar and limbal conjunctiva as well

Page 46: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Presentation

• Signs:• Superior corneal and limbic filaments • Thickened limbus

Page 47: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• Assess

-tear function

-lid tension

-thyroid status

Page 48: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• local application of 0.5–1% silver nitrate solution to the superior palpebral conjunctiva

• superior bulbar conjunctival resection (patients

with normal Schirmer test)

Page 49: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• Mondino et al. Reported use of therapeutic soft contact lens

• Udell et al. reported the results of treating SLK with thermal cauterization

• Yang and colleagues found resolution of SLK symptoms in 22 eyes after permanent punctal occlusion

• Ohashi et al. advocated the use of topical vitamin A

• Perry et al. advocated the use of 0.5% topical ciclosporin A as a primary or adjunctive therapy

• Shen et al. treated 20 patients with triamcinolone injection in Supratarsal conjunctiva

Page 50: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Neurotrophic Keratitis

• degenerative disease of corneal epithelium characterized by impaired healing.

• Absence of corneal sensitivity is the hallmark

Page 51: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Causes of corneal hypoesthesia

• Infection   

- Herpes simplex

- Herpes zoster

- Leprosy

Page 52: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Causes of corneal hypoesthesia

• Fifth nerve palsy   

- Surgery (as for trigeminal neuralgia)

   - Neoplasia (such as acoustic neuroma)

   - Aneurysms

   - Facial traum

   - Congenital

  

Page 53: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Causes of corneal hypoesthesia

• Topical medications   

- Anesthetics

  - Timolol

  - Betaxolol

  - Sulfacetamide 30%

   - Topical NSAID

Page 54: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Causes of corneal hypoesthesia

• Corneal dystrophies   

- Lattice

   - Granular (rare)

Page 55: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Causes of corneal hypoesthesia

• Systemic disease   

- Diabetes mellitus

   - Vitamin A deficiency

Page 56: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Pathogenesis

Reduced corneal sensation

renders the corneal surface prone to occult injury

decreases reflex tearing

decrease healing rates of corneal epithelial injuries

Page 57: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Biochemical Basis

acetylcholine

Substance P

prostaglandins

Epithelial mitosis

Adrenergic neurotransmitters

Page 58: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Findings

• Stage 1

• Rose Bengal staining of the palpebral

conjunctivae

• Decreased tear break-up time

•  Increased viscosity of tear mucus

• Punctate epithelial staining with fluorescein

Page 59: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Findings

• Stage 2   • Acute loss of epithelium• Surrounding rim of loose epithelium• Stromal edema• Aqueous cell and flare• Edges of the defect become smooth and rolled with

time

Page 60: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Clinical Findings

• Stage 3   

• Stromal lysis

• corneal perforation

Page 61: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• topical lubrication

• lateral tarsorrhaphy

• Punctal occlusion

Page 62: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• topical lubrication

• lateral tarsorrhaphy

• Punctal occlusion

• topical tetracycline and Oral doxycycline

• autologous serum eyedrops

• Bandage contact lens

Page 63: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• Cyanoacrylate glue

• tectonic lamellar keratoplasty

• conjunctival flaps

• multilayer amniotic membrane transplantation

Page 64: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• penetrating keratoplasty

Page 65: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• penetrating keratoplasty

protected by lateral tarsorrhaphy

Page 66: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• penetrating keratoplasty

protected by lateral tarsorrhaphy

perioperative nonpreserved steroids and

antibiotics

Page 67: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

Management

• penetrating keratoplasty

protected by lateral tarsorrhaphy

perioperative nonpreserved steroids and

antibiotics

long-term maintenance using autologous serum

Page 68: Dr. Sushil Tripathi - jdosmp.org · Recurrent corneal erosion syndrome Common disorder involving the corneal epithelium and epithelial basement membrane characterised by repeated

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