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corneal edema & opacification - Coggle Diagram
corneal edema & opacification
HISTORY
Symptoms/Signs
Onset
rapid
↑IOP (ex. steroid)
moderate~severe inflammation
keratoconus (or other ectatic disorders)
trauma
infection
medication-related band keratopathy
gradual
non-infection
scarring
deposition
Persistence
transient
inflammation
pressure-related
neonatal forceps injury
(Descemet break)
endothelium dysfunction
improve with
low humidity+modest air movement
metabolic deposits
(ex. cysteine crystals, mucopolysaccharides)
Unilateral or Bilateral?
Ocular history
corneal edema
AACG
chemical / traumatic injury
infection
inflammation
intra-ocular / kerato-refractive surgery
laser iridotomy
keratoconus
corneal opacification
chemical / thermal / traumatic injury
infection
inflammation
intra-ocular / kerato-refractive surgery
Medical history
corneal opacification
Developmental
o Metabolic/hereditary (e.g., mucopolysaccharidosis, cystinosis)
o Immune-mediated diseases (e.g., rheumatoid arthritis, interstitial keratitis, Stevens-Johnson syndrome, ocular mucous membrane pemphigoid [OMMP])
o Malabsorption syndromes (e.g., following colon resection, bowel surgery, hepatobiliary illness)
corneal edema
Inflammatory conditions associated with uveitis (e.g., sarcoidosis, ankylosing spondylitis)
Medical history
corneal edema
Amantadine
(for neurologic disease may produce a reversible endothelial dysfunction if used for a short period or a permanent problem if used long term.)
chlorhexidine preparation during surgery
(When used in surgical preparation for facial trauma or reconstructive and cosmetic facial surgery, inadvertent exposure of the cornea to topical chlorhexidine preparation may cause toxicity that predisposes to endothelial failure.)
Topical carbonic anhydrase inhibitors(CA inhibitor)
Bupropion
corneal opacification
Amiodarone
Dietary calcium supplementation
Periocular radiation
Various chemotherapeutic agents
Rho kinase inhibitor verticillate changes
contact lens?
Family history
Social / Personal history
Sun exposure at work (e.g., farming, construction) or leisure activity (e.g.,
boating, golfing) may be related to pterygium development.
Travel may increase exposure to unusual infectious agents.
Exposure to domesticated and nondomesticated animals may increase exposure to unusual infectious agents (e.g., Brucella, Borellia burgdorferi/Lyme disease).
Diet or dietary deficiencies (e.g., vitamin A deficiency from malabsorption syndromes) may predispose to nutritional problems.
Chemical exposure (longstanding and new)
PE
(Ocular examination)
Visual acuity, Glare testing
external examination (eyelid, facial, dry eye, corneal diameter, pupil response....)
Slit-lamp
IOP
Goldmann applanation tonometry: less reliable in abnormal cornea.
其他ok
Fundus examination
Chronic serous choroidal detachment or retinal detachment may lead to hypotony and secondary corneal edema.
B-scan: posterior segment
Gonioscopy
do more...
Pachymatry
Rigid contact lens over-refraction
wearing a slightly flatter RGP lens
Over-refraction with spherical lenses
Mire-pattern irregularity
+
vision: RGP lens > eyeglasses
Potential acuity meter
Topography
irregular astigmatism
the depth of opacification
(help surgical planning)
Specular microscopy
density of endothelial cells (cells per mm2)
uniformity of the cell population【polymegathism】
shape (percent hexagonality)【pleomorphism】
→ sampling >20% provide accurate representation of the full endothelial surface
Confocal microscopy
(在edema時，比specular microscopy更為有效）
Iridocorneal endothelial (ICE) syndromeepithelial
fibrous ingrowth
PPCD
ungal hyphae
Acanthamoeba cysts
→ distinct appearance, help pre-op identify underlying cause for decompensation
ant. segment OCT
(spectral domain高解析度 & time domain波長較長 看較深)
corneal thickness
ant. chamber angle configuration
ant. chamber depth
Ultrasound biomicroscopy
usual 10MHz; higher frequency 35-80MHz resolution 更高
MANAGEMENT
GOAL
control underlying causes
↑ quality of life
chronic edema
topical NaCl 5% drops / ointment / hairdryer
DC if no benefit after weeks of use
topical antibiotics
↓ IOP , but ...
Avoid
Prostaglandin analogue for inflammatory character
carbonic anhydrase inhibitor(CAi)
NOT
1st-choice, might interfere with endothelial pump
topical steroid to control inflammation
(once infection is controlled)
therapeutic contact lens + artificial tears + prophylactic antibiotics
better with:
high water content + high oxygen diffusion coefficients
flat lens, movement during blinking
inform the risk of
infectious keratitis
periodic exchange if long-term use
acute hydrop
supportive management:
topical steroid
cycloplegic agents
hyperosmotic drops
topical antibiotics
Surgery
conjunctiva flap
amniotic membrane
intentional scarification of corneal surface
(to re-create subepithelial scar tissue, ↓ bull production + ↓pain)
intentional scarification requires caution!!
over-treatment: necrosis, corneal melt
