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Mechanical Injury

Key Concepts A complete history of the event leading to the injury is a key component of the evaluation of a patient with corneal trauma. Bandage contact lenses or antibiotics alone may offer advantages over patching in the setting of corneal abrasion. In the setting of a partial-thickness corneal flap, a contact lens may offer significant benefit over sutures in allowing healing with minimal keratorefractive sequelae.…

Mooren Ulcer

Key Concepts Mooren ulcer is an idiopathic peripheral ulcerative keratitis with the absence of scleral involvement and associated systemic diseases. An autoimmune reaction is the most accepted theory of its pathogenesis. There are several classifications of this disorder, but the epidemiology seems to show considerable overlap and the pathogenesis is poorly understood. Watson classified Mooren ulcer into unilateral, bilateral aggressive, and bilateral indolent forms in young,…

Phlyctenular Keratoconjunctivitis and Marginal Staphylococcal Keratitis

Key Concepts Phlyctenular keratoconjunctivitis (PKC) and staphylococcal marginal keratitis are both hypersensitivity reactions to a microbial antigen. PKC is most likely a type IV hypersensitivity reaction (cell mediated) that causes nodular lesions on the conjunctiva and cornea. Staphylococcal marginal keratitis is most likely a type III hypersensitivity reaction (immune complex) that causes peripheral corneal infiltrates separated from the limbus by a clear zone. External inocula (bacterial…

Corneal Disease Associated With Nonrheumatoid Collagen-Vascular Disease

Key Concepts Collagen-vascular diseases can affect almost every layer of the eye. Etiology is largely unknown but involves autoimmune and possibly genetic factors. Anterior segment manifestations are most severe in granulomatosis with polyangiitis. Systemic lupus erythematosus is a common cause of secondary Sjögren syndrome. Ocular manifestations can be the presenting sign of systemic diseases; the ophthalmologist needs to be familiar with these disorders to expedite diagnosis…

Corneal Disease in Rheumatoid Arthritis

Key Concepts Early diagnosis and aggressive treatment of rheumatoid arthritis (RA) is imperative for the prevention of substantial disability and increased mortality. Extra articular manifestations of RA including ocular diseases are often found late in the disease course and are predictors for poor life prognosis in those patients. The primary goals of RA treatment include pain relief and slowing or reducing the inflammatory process to minimize…

Factitious Keratoconjunctivitis

Key Concepts Factitious keratoconjunctivitis is an uncommon and difficult diagnosis to make. It can often be missed if not included in the differential diagnosis of any case in which the trauma sustained arises under suspicious or poorly explained circumstances. Injury from factitious keratoconjunctivitis should be distinguished from other similar, though distinct, entities of self-induced injuries such as malingering, topical anesthetic abuse, and other forms of self-induced…

Neurotrophic Keratitis

Key Concepts Corneal sensation should be assessed in any poorly healing cornea. Topical anesthetic abuse should be considered if no other cause is found. Careful and close follow-up is essential. Lid defects should be corrected early. Removal of toxins such as preservatives followed by aggressive lubrication is the best first step. Escalation to autologous serum tears and/or preservative-free, antibiotic/steroid combination drops may be necessary. Consider topical…

Superficial Punctate Keratitis of Thygeson

Key Concepts Superficial punctate keratitis of Thygeson (SPKT) is characterized by a long course of exacerbations and remissions. Clinical findings include multiple fine, elevated, white to gray, central corneal dot-like opacities. The conjunctiva is usually quiet. During exacerbations, the elevated opacities stain with fluorescein and rose Bengal. Low-dose topical corticosteroids are used for treatment, with cyclosporine A and tacrolimus as other good options. The etiology and…

Filamentary Keratitis

Key Concepts Filamentary keratitis is an ocular surface disease characterized by the presence of filamentous material attached to the corneal surface. The development of filaments is multifactorial and can be associated with various ocular surface diseases, most notably dry eye disease. Management can be challenging, and recurrences are common. Treatment of underlying ophthalmic or systemic conditions is crucial to successful management. Medical therapy includes topical tear…

Nonsyphilitic Interstitial Keratitis

Key Concepts Interstitial keratitis (IK) is a rare but potentially blinding disease. Telling symptoms of IK are nonulcerating inflammation and vascularization of the corneal stroma, notably without primary involvement of either the epithelium or the endothelium. IK is a common endpoint for a number of diseases. IK is a leading cause of blindness and loss of visual acuity around the world. Topical therapy is generally effective,…

Syphilitic Keratitis

Key Concepts Syphilis is a cause of stromal keratitis. Syphilitic keratitis is often bilateral in children with late congenital syphilis but unilateral in adults with late latent syphilis. Corneal opacification with neovascularization, iridoschisis, and secondary glaucoma are possible consequences. Diagnostic testing involves a treponemal serologic test such as Treponema pallidum particle agglutination (TPPA). Epidemiology Ophthalmic signs of syphilis were spotted in the early 16th century when…

Corneal Diseases in the Developing World

Key Concepts Corneal diseases are a major cause of unilateral as well as bilateral blindness. The magnitude of corneal blindness is highest in countries of Asia and Africa. Causes vary between adults and children, and also between developed and developing countries. Hence different strategies are needed to address the problems of each group. In adults, the main causes are infectious keratitis, trauma, dystrophies, and neglected tropical…

Acanthamoeba and Other Parasitic Corneal Infections

Key Concepts Acanthamoeba keratitis is the most common exogenous parasitic infection of the cornea in the United States with the significantly greatest risk seen in contact lens wearers of all types. Acanthamoeba keratitis has a wide spectrum of clinical presentations that often mimics herpetic keratitis and other forms of infectious and noninfectious keratitis. The greatest hurdle to diagnosis is recognition of the possibility of Acanthamoeba keratitis…

Fungal Keratitis

Key Concepts Fungi are eukaryotic, unicellular (yeasts) and multicellular (filamentous) microorganisms, ubiquitous in nature. They acquire food and nutrition by feeding on biotic (living tissue) or abiotic (dead tissue, plant debris). Few, if any, fungi can penetrate intact corneal tissue. Risk factors for invasion and infection include breach of epithelium (overt, minor trauma), chronic use of antimicrobials, topical steroids, and increasingly contact lens wear. Spectrum and…

Less Common Viral Corneal Infections

Key Concepts Cytomegalovirus (CMV) corneal endotheliitis presents with corneal edema, keratic precipitates, and mild anterior chamber inflammation. Epstein-Barr virus can cause a monocular follicular conjunctivitis, conjunctival nodules, and a multifocal stromal keratitis. Acute hemorrhagic conjunctivitis can be caused by enterovirus 70 and coxsackie A24. Zika virus is an emerging entity that has affected millions worldwide and can cause nonpurulent conjunctivitis, congenital glaucoma, anterior and posterior uveitis,…

Herpes Zoster Keratitis

Key Concepts Herpes zoster ophthalmicus (HZO) involves reactivation of latent varicella-zoster virus from the trigeminal sensory ganglia along the V1 distribution of the trigeminal nerve with ocular manifestations. Severe corneal complications from HZO may include a secondary infectious keratitis, ulceration with hypopyon, ulceration with mild to moderate keratolysis, or corneal perforation. Approximately 10%–20% of herpes zoster cases involve the ophthalmic nerve division, with 20%–70% developing ocular…

Herpes Simplex Keratitis

Key Concepts Herpes simplex virus (HSV) keratitis is one of the most common infectious causes of corneal blindness. HSV keratitis has multiple presentations that can be challenging for clinicians. The main corneal manifestations include infectious epithelial keratitis, neurotrophic keratopathy, necrotizing stromal keratitis, immune stromal keratitis, and endotheliitis. Similar presentations between neurotrophic keratopathy and infectious epithelial keratitis may confuse clinicians and result in prolonged or inappropriate treatment.…

Nontuberculous Mycobacteria Keratitis

Key Concepts Nontuberculous mycobacterial (NTM) keratitis commonly occurs after trauma or refractive surgery, and can masquerade as fungal, herpetic, or amoebic keratitis, often delaying the diagnosis. NTM keratitis has been most commonly reported following laser in situ keratomileusis (LASIK). Mycobacterium chelonae and Mycobacterium fortuitum are the most commonly identified species. Diagnosis of NTM keratitis is difficult and often causes a delay in initiation of treatment. NTM…

Bacterial Keratitis

Key Concepts Bacterial keratitis is a common and potentially sight-threatening corneal infection. Ocular trauma and contact lens use are the most common risk factors. The most frequent causative organisms are gram-positive cocci, whereas gram-negative bacilli are more commonly associated with contact lens wear. Antibiotic resistance among etiologic pathogens is increasing, that is, increased incidences of methicillin-resistant Staphylococcus aureus (MRSA) and topical fluoroquinolones-resistant Pseudomonas aeruginosa. The majority…

Corneal and Conjunctival Degenerations

Key Concepts Degenerations represent a deterioration resulting in impaired function and structure of the affected tissue. Degenerations are either related to aging or secondary to a wide variety of adverse internal or external influences. Characteristics of a degenerative process: later onset; variable rate of progression; peripheral location; association with neovascularization and inflammation. Chronic exposure to ultraviolet radiation is associated with secondary degenerations of the cornea and…