Slides Of Different Types Of Illumination
And Associated Pathologies

Endothelial Dystrophy: (Corneal Guttata)--There are excrescences of hyaline material which replace the normal endothelial and involves most of the entire posterior surface of the cornea. The lesions resemble Hassall-Henle bodies (warts) which are normal irregularities of the peripheral cornea located in the wart-zone of Salzmann. Guttata excrescences produce a characteristic pigskin or orange peel appearance. This endothelial dystrophy usually does not start until adult life (usually around ages 40 to 50) with higher incidence in females and has a dominant hereditary tendency. The condition may remain stationary or lead to combined dystrophy of Fuchs. Fuchs dystrophy ultimately leads to clouding of the cornea and bullous keratopathy of the epithelium which is very painful and vision threatening. These changes are best seen using a parallelepiped, proximal or retro-illumination then viewed using specular reflection.

Band Keratopathy: (Degenerative Process)--It may represent one of the final steps in a secondary corneal degeneration which results from a severe, destructive or damaging intraocular disease or infection; on the other hand it may occur primarily in corneas of patients with hypercalcemia from hyperparathyrodism or vitamin D poisoning. In the first group it is usually unilateral while the second group it is bilateral. There is a deposition of calcium salts in the superficial cornea and replacement of Bowman's membrane by fibrous tissue. This disorder usually occurs secondary to severe ocular inflammation and especially chronic iridocyclitis in young persons. Treatment consist of scraping the cornea with a spatula and applying EDTA (Disodium "Ethylene Diamine Tetra-acetate") which dissolves the calcium salts and hopefully new healthy epithelium will replace the denuded diseased tissue.

Keratoconus: (Degenerative Condition)--Sometimes referred to as a Conical Cornea is a condition beginning about puberty and increases in severity with age some studies contend that females develop this condition more frequently than males. Electro - microscopic studies have shown that primary changes are seen as degenerative fragmentation of the basal membrane of the epithelium associated with breaks in Bowman's membrane. These corneal changes are best seen using direct illumination; parallelepiped and or optic section if there is a corneal scar. Signs and Symptoms: 1.) increase in photophobia; 2.) gradual decrease in VA's; 3.) uniocular polyopia; 4) halos around bright lights; 5) Munson's sign; 6.) Fleischer's ring or Fleischer's line, a brownish olive green pigmentation situated in the region of the basal epithelium, usually incomplete and seen around or near the cone of the keratoconus. It is seen in at least 50% of patients with this condition. 7.) Corneal striae in the area of the cone; 8.) corneal scar in the area of the apex of the cone; 9.) retinoscopy reflex that moves every direction except toward a clear neutrality.

Krukenberg's Spindle: These pigment deposits are best seen using a parallelepiped and either retro-illumination or proximal. This syndrome is associated with pigmentary glaucoma, however, not all patients with this finding will go on to develop glaucoma. It is important that transillumination of the iris be performed, looking for transillumination iris defects (TID's) The syndrome is characterized by the presence of pigment on the endothelium of the cornea. The pigment deposits are aligned in a vertical pattern in the center or the cornea much like the spindle or spoke of a wheel. Because of the association with pigmentary glaucoma these patients should be monitored for IOP and visual field changes. It is somewhat interesting which individuals are more prone to develop this condition. Vaughan & Asbury state that it occurs most often in myopic males between the ages of 25-40 who have deep anterior chambers with wide open angles and yet on another page of the same text they state that it occurs in a small percentage of people over age 20, usually in myopic women. Duke - Elder says it is seen at any age after age 20, but more commonly in the aged, and in the vast majority of cases it occurs in myope, usually females. Evans and Coworkers (Arch Ophth/ Vol 91, May '74) studied 202 cases and found 38% were males and 63% females these figures were reversed in patients less than 30 years of age. It is interesting, however, that in the disease of pigmentary glaucoma, only one in four patients are females and these have a mean age of 48 which seems to indicate there is a hormonal relationship since women of this age group are more likely to be going through menopause. To make matters even more confusing there have been studies where females with Krukenberg's Spindles and pigment accumulation in the angle were put on birth control pills and the whole syndrome cleared. It seems that there really may not be any clear agreement as to who are more likely to develop the condition, however, most text tend to state that young myopic males are the more predisposed. From a clinic observation I have seen more females of all ages with Krukenberg's Spindles and very few had glaucoma.

Corneal Striae: This finding was first reported by Sarver in soft contact lens patients in 1971. The condition results from the whole cornea swelling and buckling back upon itself causing vertical folds or lines in Descemet's membrane. It is best detected using a parallelepiped high magnification and high illumination. It can be made to momentarily disappear by using digital pressure through the lid but returns after the pressure is released. It is best seen using the pupil as a backdrop. With as little as 7% swelling cornea striae will develop and at 5% it no longer is seen, according to a study by Polse & Olson. It is also seen in approximately one out of three, or 33% of diabetic patients, older patients whose metabolic and fluid dynamics have been altered due to aging and in patients with keratoconus. It should be pointed out that application of digital pressure on the globe through the lid will cause the striae lines to momentarily disappear (Sarver, 1971) .

Iris Bombe': This destructive condition results when an anterior uveitis is not properly managed. The failure to dilate the patient results in the continued release of cells and protein into the anterior chamber. This unnatural combination of cells and protein will form a total fibrous sealing of the back surface of the iris to the front surface of the lens (complete posterior synechiae). When the intraocular pressure reaches 50 to 60mmHg and in combination with a complete posterior synechiae the synechiae can not be broken using conventional means. The patient develops a secondary glaucoma that will totally destroy the eye.

Bitot's Spots: This foamy conjunctival appearance is diagnostic of a vitamin A deficiency, however, just because they are present does not mean the patient still has the deficiency. Approximately 60% of these patients, who no longer have a deficiency the spots still remain, while the other 40% the spots resolve. Therefore, one can only say that the patient either has a vitamin A deficiency or has had the deficiency.

Follicles: Follicles are a response to some type of ocular irritation. They are blister like in appearance and are initially filled with clear lymph fluid. They may be found on the conjunctiva or sclera and the upper and lower palpebral conjunctiva of the lids. When they begin to shrink the clear fluid turns yellow and become more firm they are referred to as concretions. In older patients these concretions may calcify causing irritation and have to be removed using an 18 or 20 gauge needle. Follicles are usually arranged in parallel rows in the lower palpebral conjunctiva and fornices. When fluorescein sodium and cobalt blue filter are used these rows become very obvious. Follicles are approximately five times larger than papillae. The characteristic feature is that follicles have several small blood vessels bordering it and ascent the follicle by twining about it.

Papillae: Papillae, characterize the subacute stages of many inflammations, are essentially vascular formations which have undergone lymphoid infiltrations. The characteristic feature is a single vessel growing in the center of the papillae which cascades down over the edges. They may present the characteristic cobblestone appearance found in the palpebral conjunctiva. In the case of giant papillary conjunctivitis (GPC) they are confined, diagnostically, to the upper palpebral conjunctiva. They will and do undergo various stages and changes in their size and overall appearance, from being only a very small red dot to an elevated cobblestone shape. Using Fluorescein sodium, slit lamp and cobalt blue filter make these elevations standout very prominently. GPC can also develop secondary to rigid gas permeable (RGP) lens wear.

Dermoid Tumor or Cyst: This is a benign congenital condition. They may increase in size at puberty or remain unchanged. Hairs are a very common finding when located at the nasal corneal limbal junction. Removal of the dermoid tumor is for cosmetic reasons only.

Tears in Descemet's: These are tears that have resulted secondary to forceps birth delivery. When viewed in retroillumination they appear as glass rods. This is the only time in life when the endothelium and Descemet's membrane can undergo such trauma, the corneas cloud then heal and clear. The main residual effect on vision is a large amount of astigmatism which is secondary to the healing process.

Fingernail Abrasion: This abrasion resulted from being slightly struck by a babies fingernail. Babies have extremely sharp fingernails and in a split second this type of abrasion will occur. Using fluorescein sodium, diffuse illumination and cobalt filter one can see the extent of the abrasion. Using and optic section the depth can be appreciated. The slightly darker grayish area is the basement membrane of the corneal epithelium. This abrasion resulted in a small nebular scar. The mode of treatment in this case was to dilate the patient with 5% homatropine, instill an antibiotic ointment "Polybac", which contains polymyxin B and bacitracin. The eye was pressure patched and the patient seen the following morning. Today's line of thinking is not to patch all patients, this seems to allow faster healing and leaves the patient binocular. A common approach in combination with dilation is the use of ocular lubricates, making the patient more comfortable, plus a antibiotic to protect against infection. This is not the accepted standard of care, but one which is gaining favor and popularity.

Superficial Punctate Keratitis (SPK): The etiology appears to be viral and the course usually is a chronic, remittent one. The term denotes a specific condition characterized by coarse, punctate, epithelial lesions that occur bilaterally and in the absence of conjunctivitis. These lesions stain very slowly with fluorescein and many times are missed because the fluorescein tends to mask the lesions. The condition is self limiting dose not respond to medication and usually runs a course of three to six weeks. The only thing you can do is to try and make the patient more comfortable by having the patient use cold compresses, artificial tears and discontinue any contact lens wear.

Foreign body: An iron foreign body if it remains in the cornea for any length of time will leave a rust deposit in the corneal epithelium. Once the foreign body has been removed with either a 20 gauge needle or spud the rust ring has to be removed. It should go without saying that a topical anesthetic must be used when removing both the foreign body and the rust ring. The iron oxidizes and combines with the corneal tissue and causes a disorganization of the tissue in a degenerative manner. The mode of action after the foreign body has been removed may differ. Some feel the largest amount of the rust ring should be removed at the same time as the foreign body. Others may dilate the pupil, treat the patient prophylactically with a antibiotic and see the patient the following day to remove the rust ring. However one decides to handle the removal of the rust ring it must be done within several days. Again patching of the patient's eye is somewhat of a debatable issue.

Other Slides Discussed:
Girdle of Vogt
Hypopyon
Hyphema
Posterior Embryotoxin
Peripheral Iridotomy
Pterygium
Pinguecula
Neovascularization
Essential Iris Atrophy
Large Keratic Precipitates With Anterior Chamber Cells
Small Keratic Precipitates
Uveitis With Anterior Chamber Membrane
Phthiriasis--Phthirus Pubis--Pubic Crab #1
Pubic Crabs Lash Infestation #2
Pubic Crab Nits #3

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