Corneal disorders (PEARLS)

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

Cataract	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 bacteria, viruses, 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 infection, injury, or other eye disorders. Keratitis is a more general term for inflammation of the cornea. It can be caused by infection, injury, autoimmune diseases, dry eye, and other conditions Corneal Ulcer as visualized with and without stain
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 inflammation of the cornea that can lead to vision loss if not treated promptly, and may be infectious or non-infectious in origin. Common causes include bacterial, viral (especially HSV), fungal, and amoebic infections Non-infectious causes include contact lens overuse, UV exposure, and trauma Symptoms include eye pain, redness, photophobia, tearing, blurred vision, and foreign body sensation Physical exam may reveal conjunctival injection, corneal opacity or ulcer, and ciliary flush; fluorescein staining shows corneal epithelial defects Herpes simplex keratitis presents with dendritic ulcers on fluorescein staining; avoid steroids unless under ophthalmology supervision Bacterial keratitis is often associated with contact lens wear and may present with a corneal ulcer and hypopyon Pseudomonas aeruginosa – most common in contact lens wearers Diagnosis is clinical, supported by slit-lamp exam with fluorescein staining; corneal scrapings may be needed for gram stain and culture in severe or atypical cases TX: Depends on etiology: Bacterial: Topical antibiotics (e.g., fluoroquinolones)—(ideally after obtaining cultures) Viral: Topical or oral antivirals (e.g., acyclovir) Fungal: Antifungal drops (e.g., natamycin) Amoebic: Requires antiparasitic treatment Urgent ophthalmology referral is essential to prevent corneal scarring and vision loss
Pterygium (ReelDx)	ReelDx Virtual Rounds (Pterygium) Pterygium You are called to see a 50-year-old with a growth extending over the cornea Patient Gender: Male Age: 50 years Signs and Symptoms Eye pain: growth inside conjunctive and extending over the cornea Click here to work through this patient case simulation. 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: Observation: for small, asymptomatic pterygia not threatening the visual axis Lubricating eye drops: artificial tears for symptomatic relief (dryness, irritation) Topical corticosteroids: short-term for inflammation/redness reduction Surgical excision: indicated when threatening visual axis (<3 mm from pupil), causing astigmatism, persistent symptoms unresponsive to drops, or cosmetically significant; conjunctival autograft transplantation reduces recurrence rate Mitomycin C (adjunct to surgery): antimetabolite applied during excision to reduce recurrence Prevention: UV-blocking sunglasses, hat with brim, artificial tears in dry/dusty environments Superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in the inner corner/nasal side of the eye)