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Approach to a case of Corneal
Opacity
 Loss of transparency of cornea due to scarring.
 Any disease which interferes with corneal clarity
leads to an opacity.
History
 Congenital or Acquired
 Onset and duration
 Unilateral or bilateral
 Trauma or chemical injury
 Recurrent ep...
“STUMPED” Classification
 S – Sclerocornea
 T – Tears in descemet’s membrane
Congenital Glaucoma
Birth trauma
 U – Ulce...
Classification continued…
 P – Posterior corneal defect
Peter’s anomaly
Posterior keratoconus
Staphyloma
 E – Endothelia...
Symptoms
 Diminution of vision
 Pain,
 Redness
 Photophobia
Examination Of Corneal Opacity-
Clinical Assessment
 Assessment of vision-Refraction
 Systemic Evaluation
 Torch Light ...
 Depending upon the density, corneal opacity is
graded as:
 Nebular: faint opacity due to superficial scar
involving bow...
 Macular: Semi dense opacity d/t scar involving
half of stroma.
 Leucomatous: Dense white opacity d/t scarring of
more than half of stroma
Examination Of Corneal opacity -
Overview
Evaluation Of Visual Potential And Prognostication
Laboratory Investigations And...
Examination of Corneal Opacity-
Clinical Assessment
Adnexal Evaluation
Slit Lamp Examination- Corneal
Opacity
 Location
 Size
 Depth
 Vascularisation
 Epithelial defect
 Infiltrates
 Foc...
Corneal Opacity-
Slit lamp Examination
Direct
Illumination
Diffuse
Illumination
Focal
Illumination
Indirect
Illumination
S...
Slit Lamp Examination-
Diffuse Illumination
Slit Lamp Examination-
Focal Illumination
Slit Lamp Examination-
Retro Illumination
Slit Lamp Evaluation-
Sclerotic Scatter
 Corneal opacities
 Interstitial
deposits
 Perforating scars
Sclerotic Scatter
 Less transparent
areas scatter the
internally
reflected light.
 Useful for
detecting subtle
corneal o...
Indirect Lateral Illumination
Slit Lamp Examination-
Specular Reflection
 Morphology of
endothelial cells
 Assessment for
corneal
decompensation
Documentation
 Generally corneal pathologies are documented as
frontal view and in cross sectional view
 Black colour is used to document
 Limbus
 Scars
 Degenerations
 Foreign bodies
 Sutures
 Contact lens
 Band kerat...
.
 Brown colour is used to document
 Pigmentation-iron or melanin
 Pupil and iris
 Blue colour is used to document
 O...
.
 Red colour is used to document
 Blood vessels (see figures)
 Rose Bengal staining
 Haemorrhages
.
 Orange colour is used to document (in many
centres, yellow colour is used instead of orange)
 Hypopyon
 Keratic prec...
 Alternatively a monochromatic system of lines
can be used for documentation of corneal
diseases.(Adapted from Bron AJ. B...
Documentation Of Corneal Opacity
 Vascularisation: Superficial and deep
Examination of Corneal Opacity- Tear
Film Evaluation
Tear Film
Function Test
TBUT
Schirmer’s test
Tear Meniscus
Height
Tea...
Tear Film Evalaution-
Schirmer’s Test
 Tear production –
Aqueous component
 Basal Schirmer Test
 Schirmer I - < 15 mm
...
Tear Film Evalaution-
Tear Film Breakup Time
Tear Film Evaluation-
Tear Meniscus Height
 Pathological
<0.3 mm height
 Aqueous deficiency
 Poor lid to globe
appositi...
 Anterior segment examination
 Pupillary reactions-direct and consensual
(Optic nerve status).
 Fundus examination.
 C...
Esthesiometry
Investigations
 Assessment of visual potential – VA prior to
opacity, macular function tests, laser
interferometry, VER
...
Laboratory Investigations-
Corneal Scraping
Corneal Scraping
Smear
Gram’s stain
10% KOH
mount
Culture
Bacterial
Fungal
Oth...
Advanced Diagnostic Techniques
Advanced
Diagnostic
Techniques
Corneal
Topography
Confocal Scan
Specular Count
ASOCT
UBM
Advanced Diagnostic Techniques -
ASOCT
Indications
 Monitoring of corneal ulcers
 Lasik flaps
 Pannus morphology
 Plan...
Advanced Diagnostic Techniques
Ultrasonic Biomicroscopy
 Indications
 Keratoplasty work-up
 Limbal mass
 Dermoids
 OS...
Advanced Diagnostic Techniques
Specular Count
 Indications
 Fuch’s endothelial dystrophy
 Posterior polymorphous
dystro...
Treatment
 Treatment is targeted first at any ongoing disease
process such as
 Infectious keratitis
 Ocular surface dis...
 Cosmetic treatment : if there is poor visual
potential
 Cosmetic contact lenses
 Tattooing
Visual- Non surgical
 Refraction and glasses
 Rigid gas permeable contact lenses : If VA is less
because of irregular as...
Surgical
 Optical iridectomy- in case of central opacities
with clear periphery, preferably in children and
one eyed indi...
Thank you
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Corneal Opacity

Clinical Approach to a case of corneal opacity

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Corneal Opacity

  1. 1. Approach to a case of Corneal Opacity
  2. 2.  Loss of transparency of cornea due to scarring.  Any disease which interferes with corneal clarity leads to an opacity.
  3. 3. History  Congenital or Acquired  Onset and duration  Unilateral or bilateral  Trauma or chemical injury  Recurrent episodes of pain and redness  Long term topical medication  Contact lens use  Previous ocular surgery  Systemic illness  Socioeconomic status
  4. 4. “STUMPED” Classification  S – Sclerocornea  T – Tears in descemet’s membrane Congenital Glaucoma Birth trauma  U – Ulcer Herpes simplex virus Bacterial Neurotrophic  M – Metabolic (rarely present at birth) Mucopolysaccharidoses Mucolipidoses Tyrosinosis
  5. 5. Classification continued…  P – Posterior corneal defect Peter’s anomaly Posterior keratoconus Staphyloma  E – Endothelial dystrophy Congenital hereditary endothelial dystrophy Stromal : Congenital hereditary stromal dystrophy  D- Dermoid
  6. 6. Symptoms  Diminution of vision  Pain,  Redness  Photophobia
  7. 7. Examination Of Corneal Opacity- Clinical Assessment  Assessment of vision-Refraction  Systemic Evaluation  Torch Light Examination  Ocular Movements  Fixation , nystagmus  Deviations
  8. 8.  Depending upon the density, corneal opacity is graded as:  Nebular: faint opacity due to superficial scar involving bowman’s layer and superficial stroma
  9. 9.  Macular: Semi dense opacity d/t scar involving half of stroma.
  10. 10.  Leucomatous: Dense white opacity d/t scarring of more than half of stroma
  11. 11. Examination Of Corneal opacity - Overview Evaluation Of Visual Potential And Prognostication Laboratory Investigations And Corneal Imaging Bedside Tests Clinical Evaluation Of Cornea And External Eye Clinical History
  12. 12. Examination of Corneal Opacity- Clinical Assessment
  13. 13. Adnexal Evaluation
  14. 14. Slit Lamp Examination- Corneal Opacity  Location  Size  Depth  Vascularisation  Epithelial defect  Infiltrates  Focal thickening or thinning of cornea  Edema  Staining
  15. 15. Corneal Opacity- Slit lamp Examination Direct Illumination Diffuse Illumination Focal Illumination Indirect Illumination Sclerotic scatter Retro illumination Specular Reflection
  16. 16. Slit Lamp Examination- Diffuse Illumination
  17. 17. Slit Lamp Examination- Focal Illumination
  18. 18. Slit Lamp Examination- Retro Illumination
  19. 19. Slit Lamp Evaluation- Sclerotic Scatter  Corneal opacities  Interstitial deposits  Perforating scars
  20. 20. Sclerotic Scatter  Less transparent areas scatter the internally reflected light.  Useful for detecting subtle corneal opacities.
  21. 21. Indirect Lateral Illumination
  22. 22. Slit Lamp Examination- Specular Reflection  Morphology of endothelial cells  Assessment for corneal decompensation
  23. 23. Documentation  Generally corneal pathologies are documented as frontal view and in cross sectional view
  24. 24.  Black colour is used to document  Limbus  Scars  Degenerations  Foreign bodies  Sutures  Contact lens  Band keratopathy
  25. 25. .  Brown colour is used to document  Pigmentation-iron or melanin  Pupil and iris  Blue colour is used to document  Oedema,  Small circles for epithelial oedema  Wavy lines to document folds in Descemet’s membrane
  26. 26. .  Red colour is used to document  Blood vessels (see figures)  Rose Bengal staining  Haemorrhages
  27. 27. .  Orange colour is used to document (in many centres, yellow colour is used instead of orange)  Hypopyon  Keratic precipitates  Green colour is used to document  Fluorescein staining of cornea  Punctuate epithelial keratopathy (dots)  Filaments (small lines)  Lens and vitreous haze
  28. 28.  Alternatively a monochromatic system of lines can be used for documentation of corneal diseases.(Adapted from Bron AJ. Br J Ophthalmol1973;57:629–34.)
  29. 29. Documentation Of Corneal Opacity
  30. 30.  Vascularisation: Superficial and deep
  31. 31. Examination of Corneal Opacity- Tear Film Evaluation Tear Film Function Test TBUT Schirmer’s test Tear Meniscus Height Tear Clearance rate Tear Osmolarity And Composition
  32. 32. Tear Film Evalaution- Schirmer’s Test  Tear production – Aqueous component  Basal Schirmer Test  Schirmer I - < 15 mm  Schirmer II- < 10 mm  < 5 mm - severe dry eye
  33. 33. Tear Film Evalaution- Tear Film Breakup Time
  34. 34. Tear Film Evaluation- Tear Meniscus Height  Pathological <0.3 mm height  Aqueous deficiency  Poor lid to globe apposition  Raised if naso- lacrimal obstruction
  35. 35.  Anterior segment examination  Pupillary reactions-direct and consensual (Optic nerve status).  Fundus examination.  Corneal sensations  Intraocular pressure
  36. 36. Esthesiometry
  37. 37. Investigations  Assessment of visual potential – VA prior to opacity, macular function tests, laser interferometry, VER  Pachymetry  USG A-B scan- Retinal detachment Endophthalmitis  ASOCT- Depth of opacity, evaluation of anterior chamber.  Corneal Scraping
  38. 38. Laboratory Investigations- Corneal Scraping Corneal Scraping Smear Gram’s stain 10% KOH mount Culture Bacterial Fungal Others PCR Viral Acanthamoeba
  39. 39. Advanced Diagnostic Techniques Advanced Diagnostic Techniques Corneal Topography Confocal Scan Specular Count ASOCT UBM
  40. 40. Advanced Diagnostic Techniques - ASOCT Indications  Monitoring of corneal ulcers  Lasik flaps  Pannus morphology  Planning and management of lamellar keratoplasties  Descemet membrane detachment
  41. 41. Advanced Diagnostic Techniques Ultrasonic Biomicroscopy  Indications  Keratoplasty work-up  Limbal mass  Dermoids  OSSN  Ocular surface diseases-  Evaluation  Planning of surgery
  42. 42. Advanced Diagnostic Techniques Specular Count  Indications  Fuch’s endothelial dystrophy  Posterior polymorphous dystrophy  Follow-up of keratoplasty  Eyes with glaucoma, uveitis, pseudo-exfoliation  Assessment of contralateral eye important
  43. 43. Treatment  Treatment is targeted first at any ongoing disease process such as  Infectious keratitis  Ocular surface disorder  Raised IOP  Definitive treatment is planned later
  44. 44.  Cosmetic treatment : if there is poor visual potential  Cosmetic contact lenses  Tattooing
  45. 45. Visual- Non surgical  Refraction and glasses  Rigid gas permeable contact lenses : If VA is less because of irregular astigmatism.
  46. 46. Surgical  Optical iridectomy- in case of central opacities with clear periphery, preferably in children and one eyed individuals, poor visual potential cases to salvage some vision.  Phototherapeutic keratectomy/ photorefractive keratectomy in cases of superficial opacities  Lamellar keratoplasty  Penetrating keratoplasty  Keratoprosthesis - in patients with poor ocular surface where chances of graft survival are less specially if patient has poor vision in other eye also.
  47. 47. Thank you

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