PANCE Blueprint EENT (7%)

Corneal disorders (PEARLS)

NCCPA™ PANCE Eyes, Ears, Nose, and Throat Content Blueprint eye disorders ⇒ corneal disorders

Patient presents as → a 78-year-old man who complains of slowly progressive vision loss over the last several years. He describes his vision as if he is looking through “dirty glass” and reports seeing a white halo around lights. On physical exam, there is a clouding of the lens and no red reflex.

Blurred vision over months or years, halos around lights. Clouding of the Lens (versus clouding of cornea = glaucoma)

  • Risk factors: aging, hypoparathyroid, steroid use, lovastatin

DX: is by fundoscopy "black on red background⇒ cataract appears dark against the red reflex on exam

  • Slit-lamp to magnify, difficult to see the fundus

Tx: Surgical removal is definitive

Corneal ulcer
Patient will present as → a 34-year-old contact lens wearer with severe pain, redness, and photophobia. Eyes are injected with cloudy discharge unilaterally. A dense corneal infiltrate is visible with fluorescein staining. 

Contact lens wearers - caused by a deep infection in the cornea by bacteriaviruses, or fungi.

  • White spot on the surface of the cornea that stains with fluorescein: round "ulceration" versus "dendritic" pattern like herpes
  • In developing countries, children with vitamin A deficiency are at high risk for developing corneal ulcers

DX: Fluorescein stain is diagnostic

  • Corneal cultures should be obtained before starting antibiotics

TX: Immediate referral - if an immediate referral is not possible, it is reasonable to start topical ophthalmic antibiotics without delay

Corneal Ulcers vs. Keratitis

The main difference between a corneal ulcer and keratitis is that a corneal ulcer is an open sore on the cornea, while keratitis is a general term for inflammation of the cornea. Not all cases of keratitis lead to corneal ulcers, but a corneal ulcer is always accompanied by keratitis!

  • A corneal ulcer is an open sore on the cornea, the clear front part of the eye. It is caused by a loss of corneal tissue, which can be caused by infectioninjury, or other eye disorders.
  • Keratitis is a more general term for inflammation of the cornea. It can be caused by infectioninjuryautoimmune diseases, dry eye, and other conditions
Keratitis and infectious corneal disorders
Patient will present as → a 37-year-old female with intense, tearing pain in her right eye. She was recently placed on topical corticosteroids for suspected allergic conjunctivitis. On visual inspection, the conjunctiva appears red. A fluorescein stain of the eye exhibits a shallow ulcer with a dendritic appearance and irregular borders.

Keratitis is a condition in which the cornea becomes inflamed and is often marked by pain, impaired eyesight, photophobia, and redeye

  • Infectious keratitis can be caused by bacteria, viruses, fungi, or parasites
  • Viral infection of the cornea is often caused by the herpes simplex virus, which causes a dendritic ulcer with fluorescein stain
  • Bacterial infectious keratitis - improper contact lens wear is the largest risk factor and commonly presents with a corneal opacity or infiltrate (typically a round white spot)

DX: With fluorescein staining of the cornea, epithelial herpes keratitis is characterized by the presence of dendritic lesions

  • The diagnostic finding in bacterial keratitis is a corneal opacity or infiltrate (typically a round white spot) in association with red eye, photophobia, and foreign body sensation.

TX: Treat herpes keratitis with topical antiviral

  • Bacterial keratitis requires urgent ophthalmological referral and prompt initiation of topical bactericidal antibiotics (ideally after obtaining cultures)
Pterygium (ReelDx)
ReelDx Virtual Rounds (Pterygium)
Patient will present as → a 65-year-old male Hispanic farmworker who is brought to you by his concerned wife. She reports he has had this “thing” on his left eye for years and refuses to seek care. He denies pain or discharge from the affected eye. Physical exam reveals an elevated, superficial, fleshy, triangular-shaped fibrovascular mass in the inner corner/nasal side of the left eye.

Elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in the inner corner/nasal side of the eye).

  • Pterygium is associated with increased sun exposure and climates where there is wind, sand, and dust

DX: This is a clinical diagnosis

TX: Only surgically remove when vision is affected

Subconjunctival hemorrhage (Prev Lesson)
(Next Lesson) Cataract (Lecture)
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