cornea clinic interactive part 1.ppt
TRANSCRIPT
![Page 1: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/1.jpg)
CORNEA CLINIC
INTERACTIVEMassimo Busin
![Page 2: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/2.jpg)
![Page 3: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/3.jpg)
???
???
![Page 4: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/4.jpg)
DIFFERENTIAL DIAGNOSIS
Infections Ocular Surface
Diseases Immunologic
Diseases Tumors Dystrophies and
Degeneratons
![Page 5: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/5.jpg)
History Associated Diseases
(ocular and extraocular)
Characteristics of the Lesion (site, morphology, number)
DIFFERENTIAL DIAGNOSIS
![Page 6: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/6.jpg)
CLINICAL HISTORY
Onset Duration Response to
Treatment Previous Eye
Surgery
![Page 7: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/7.jpg)
ASSOCIATED DISEASES
Ocular Innervation Eyelids
(Trichiasis) Adnexa (Tear
Production) Sytemic Diseases
![Page 8: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/8.jpg)
MYTH # 1:CORNEAL ULCER = INFECTION
CORNEAL INFECTIONS
![Page 9: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/9.jpg)
FACT # 1:DIFFERENT MECHANISMS !!!
Microbial ActivityComplement (Immune-Complexes)Mechanical ActionExposureNeurotrophic Damage
CORNEAL INFECTIONS
![Page 10: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/10.jpg)
MYTH # 2:ULCER TREATMENT = ANTIBIOTICS
CORNEAL INFECTIONS
![Page 11: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/11.jpg)
FACT # 2:DIFFERENT TREATMENT !!!
Antibiotics Steroids Lid Surgery (Lubricants)
CORNEAL INFECTIONS
![Page 12: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/12.jpg)
SITE OF THE LESION !!!Periphery Center
Imm. Mech. Infection
Sup. 1/3 Inf.1/3
UpperEyelid
ExposureTrichiasis
DIFFERENTIAL DIAGNOSIS
![Page 13: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/13.jpg)
![Page 14: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/14.jpg)
SITE OF THE LESION !!!
Peripheral
Immunologic Mechanism
DIFFERENTIAL DIAGNOSIS
![Page 15: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/15.jpg)
Mooren’s Peripheral Ulcer
Uni- or BilateralAutoimmunePrevious TraumaNegative Serology
(R.A. -)
![Page 16: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/16.jpg)
Peripheral Ulcer in R.A.Peripheral Ulcers Are
Sustained by an Immunologic Mechanism (Antigene-Antibody Complexes with Complement Activation)
![Page 17: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/17.jpg)
![Page 18: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/18.jpg)
Staphyilococcal Infiltrates/UlcersBLEPHARITIS with Growth of Staphylococcus Species and Formation of Immune Complexes (Endotoxin - Antigen)
Steroids Block the Formation of Immune Complexes. TETRACYCLINES Are Causative Treatment !!! Other Antibiotics Are Less Effective
![Page 19: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/19.jpg)
Acnes Rosacea
![Page 20: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/20.jpg)
Blepharitis
HYPERMETROPIA !!!
![Page 21: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/21.jpg)
![Page 22: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/22.jpg)
Terrien’s Degeneration
Peripheral Thinning
Neovessels Lipids Astigmatism
![Page 23: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/23.jpg)
![Page 24: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/24.jpg)
Bowen’s Carcinoma
RemovalCryotherapyMitomycin
![Page 25: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/25.jpg)
Corneal Pterygoid62-Year-Old Hispanic Male
2-year-History of “Pterygion”
Progressive Visual Loss (<20/400)
![Page 26: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/26.jpg)
Solid Mass Optical Zone
Involvement Infiltrating Abnormal
Vascularization
Corneal Pterygoid
![Page 27: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/27.jpg)
Squamous Cell Carcinoma
Clinical Features +
Biopsy
Corneal Pterygoid
![Page 28: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/28.jpg)
Two-Step Surgical Treatment
Extensive Mass Removal (Including Superficial Cornea + Sclera)
Cryoapplication
Conjunctivoplasty
Step 1
![Page 29: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/29.jpg)
Post Step 1
Week 2 Week 4
![Page 30: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/30.jpg)
Histology
Carcinoma Infiltrated Cornea
![Page 31: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/31.jpg)
Two-Step Surgical Treatment
LARGE LK (“Small Bubble Technique”)
Step 2
![Page 32: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/32.jpg)
Week 2
BCVA 0.8 No Recurrence
Post Step 2
Month 12
![Page 33: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/33.jpg)
![Page 34: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/34.jpg)
SITE OF THE LESION !!!
Central (Non-Peripheral)
Infection
DIFFERENTIAL DIAGNOSIS
![Page 35: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/35.jpg)
CORNEAL INFECTIONS External
Inflammation Non-Peripheral
Ulceration Stromal
Infiltration (Hypopion)
![Page 36: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/36.jpg)
![Page 37: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/37.jpg)
SITE OF THE LESION !!!
Superior 1/3
Upper Eyelid
DIFFERENTIAL DIAGNOSIS
![Page 38: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/38.jpg)
DERMATITIS ATOPICA
![Page 39: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/39.jpg)
SHIELD ULCER
STEROIDS !!!
![Page 40: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/40.jpg)
![Page 41: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/41.jpg)
SITE OF THE LESION !!!
Inferior 1/3
Exposure/Trichiasis
DIFFERENTIAL DIAGNOSIS
![Page 42: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/42.jpg)
EXTRAOCULAR ORIGIN Ocular Innervation Eyelids
(Trichiasis) Eyelids
(Lagophthalmos) Adnexa (Tear
Production)
![Page 43: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/43.jpg)
LESION MORPHOLOGY!!!DIFFERENTIAL DIAGNOSIS
Crystalline Dendritic Arborescent Multiple Sites
![Page 44: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/44.jpg)
![Page 45: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/45.jpg)
![Page 46: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/46.jpg)
SaltzmannDegeneration
Multiple Lesions Epithelial“Cysts” Mechanical Removal
![Page 47: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/47.jpg)
Aspergillus fumigatusSatellite Lesions!!!
Fusarium solaniDendrites
![Page 48: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/48.jpg)
CLINICAL CASE
Arborescent ± One Site Vessels - Non-Peripheral Inflammation ±
60-Year-Old Woman, CL Wearer
![Page 49: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/49.jpg)
![Page 50: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/50.jpg)
Low Virulent Bacteria, Fungi (Streptococcus, Candida, etc.)
SteroidsImmunity +/-Post-PKResistance to AB
![Page 51: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/51.jpg)
MYTH # 3:
HSK = DENDRITES
CORNEAL INFECTIONS
![Page 52: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/52.jpg)
FACT # 3:HSK = CAN MIMIC ANYTHING !!!
CORNEAL INFECTIONS
Interstitial Keratitis
Limbal Vasculitis
EndothelitisHypopyon
![Page 53: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/53.jpg)
HSV KERATITISHSV KERATITIS
Direct Cytolytic Effect of HSV
Abnormal Immunologc Reaction
![Page 54: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/54.jpg)
ANTIVIRALS
STEROIDS
HSV KERATITIS
![Page 55: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/55.jpg)
HSV & CORNEA (EYE) Infectious Epithelial Ulcer (Dendrite) Trophic Epithelial Ulcer
(“Metaherpetic”) Stromal Keratitis (Complees Antigen-
Antibody or [T]Cell- Mediated) Uveitis and Trabeculitis
![Page 56: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/56.jpg)
HSV EYE DISEASEInfectious Epithelial Ulcer
(Dendrite) Virus +++
SPK
Dendrites
Geographic Ulcers
![Page 57: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/57.jpg)
Trophic Epithelial Ulcer (“Metaherpetic”)
Virus - (Sterile)
Basement Membrane Damage
Innervation Damage
HSV EYE DISEASE
![Page 58: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/58.jpg)
HSV & Type III Reaction
Interstitial Keratitis
HSV EYE DISEASE
![Page 59: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/59.jpg)
HSV & Type III Reaction
Wessely Ring
HSV EYE DISEASE
![Page 60: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/60.jpg)
HSV & Type III Reaction
Limbal Vasculitis
HSV EYE DISEASE
![Page 61: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/61.jpg)
Limbal Vasculitis Atypic
Presentation Resistant to Tx
HSV EYE DISEASE
![Page 62: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/62.jpg)
HSV & Type IV Reaction Disciform Edema
HSV EYE DISEASE
![Page 63: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/63.jpg)
CLINICAL CASE
Arborescent - One Site Vessels + Non-Peripheral Inflammation +
13-Year-Old Male, CL Wearer
![Page 64: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/64.jpg)
CLINICAL CASE
Smears - Cultures - Fortified Drops -
(Ceftazidime, Vancomycin, AMikacin, Voriconazole)
DAY 1 DAY 15
![Page 65: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/65.jpg)
CLINICAL CASEDAY 1 DAY 15
Neutrophilic Infiltration
No Microrganisms
![Page 66: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/66.jpg)
CLINICAL CASE
Acyclovir Systemic (800 mg x 5 daily)
Acyclovir topical (2 hourly)
Prednisone Systemic (1/2 mg/Kg x 2 daily)
DAY 16
![Page 67: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/67.jpg)
CLINICAL CASE
Month 1 Month 3 Month 6
![Page 68: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/68.jpg)
CLINICAL CASE
“Mushroom” PK
![Page 69: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/69.jpg)
CLINICAL CASE
VA=LP(DAY 0)
VA=1.0 (Year 2)
![Page 70: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/70.jpg)
CLINICAL CASE
Diffuse Edema No Surgery2-Year History Peripheral Vessels Inflammation ±
90-Year-Old Man, BK (Fuchs???)
![Page 71: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/71.jpg)
CLINICAL CASE
Other Eye Normal
Endothelium !!!
90-Year-Old Man, BK (Fuchs???)
![Page 72: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/72.jpg)
CLINICAL CASE
Treat HSV!!!Systemic & Topical
ANTIVIRALSSystemic (Topical)
STEROIDS
90-Year-Old Man, BK (Fuchs???)
![Page 73: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/73.jpg)
DAY 0 Month 6
HSV ENDOTHELITIS
![Page 74: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/74.jpg)
VA=HM(DAY 0) VA=0.3(s/p Phaco)
HSV ENDOTHELITIS
![Page 75: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/75.jpg)
Medical Therapy
ANTIVIRAL Acyclovir topical (ointment) Gancyclovir topical (gel) Systemic Therapy?
(deep involvement)
HSV EYE DISEASE
![Page 76: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/76.jpg)
Medical Therapy
ANTIINFLAMMATORY Steroids topical (IOP!!!) Steroids systemic Antiviral Coverage (topical
e/o systemic)
HSV EYE DISEASE
![Page 77: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/77.jpg)
Vaccine Prophyilaxis Treatment of Recurrences
J.S. Pepose et al. Am. J. Ophthalmology 2006
HSV EYE DISEASE
![Page 78: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/78.jpg)
Herpetic VaccineProphylaxis
Protection against NS Infection Antibody- and Cell- Mediated
Immunity Viral Adhesion, Lysis of
Infected Cell, Citokines
J.S. Pepose et al. Am. J. Ophthalmology 2006
![Page 79: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/79.jpg)
Therapy Stimulate Immune Response Reduce “Shedding” Immune-Mediated HSV
Disease !!! (Uveitis, Stromal Keratitis, ecc.)
J.S. Pepose et al. Am. J. Ophthalmology 2006
Herpetic Vaccine
![Page 80: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/80.jpg)
HSV & Conventional PK
Medium-Term Success ± 60%
Frequent Recurrences
HSV EYE DISEASE
![Page 81: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/81.jpg)
HSV Recurrence in PK: Epithelial Defect
Often Not Dendrite
!!!L. Remeijer et al. Ophthalmology 1997
HSV EYE DISEASE
![Page 82: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/82.jpg)
Prophylaxis of HSV Recurrences
Acyclovir 400 mg. bid p.o.
Acyclovir oint. qd ?!
J. Van Rooij et al. Ophthalmology 2003
HSV EYE DISEASE
![Page 83: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/83.jpg)
PK SURGERY
SMALL Grafts
LOWER
Rejection Rate
HIGHER Refractive Error
LARGE Grafts
HIGHER
Rejection Rate
LOWER Refractive Error
![Page 84: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/84.jpg)
“MUSHROOM” PK
ANTERIOR LK = “HAT”(thickness = 250 m; diameter = 9-9.5 mm)
POSTERIOR LK = “STEM”
(thickness = 300 m; diameter = 5-6 mm)
![Page 85: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/85.jpg)
HSV & “Mushroom” PK Minimal Endothelial
Transplantation Reduced Postoperative
Refractive Errore(Anterior Diameter 9 mm !!!)
HSV EYE DISEASE
![Page 86: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/86.jpg)
![Page 87: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/87.jpg)
Adenoviral InfectionAdenovirus: DNA-Virus (Cell
Nucleus) Icosahedral Capside >40 Serotypes
(Capsomere Ag)
VIRIONS
CELL NUCLEUS
![Page 88: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/88.jpg)
Epidemiology:Almost All Serotypes Associated with Ocular DiseaseSerotypes 1,2,4,5 e 6 Light SymptomsSerotypes 3,7,8,10,19 e 30 Severe Symptoms
Adenoviral Infection
![Page 89: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/89.jpg)
Transmission:Direct ContactWater (Pool)SexualOphthalmic Examination !!!
The Virus Can Survive on Non-Porous Surfaces, i.e. Tonometer, up to 34 Days !!!
Adenoviral Infection
![Page 90: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/90.jpg)
Clinical Entities Epidemic Keratoconjunctivitis
(Serotypes 8 e 19) Pharyngeal Conjunctival Fever (Serotypes 3 e 7)
Adenoviral Infection
![Page 91: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/91.jpg)
Epidemic Keratoconjunctivitis
Conjunctivitis Keratitis Lid ChemosisPreauricular Swelling (Lymph Node)No Systemic Symptoms
Findings:
![Page 92: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/92.jpg)
Ocular Findings: External Inflammation Usually Bilateral (non simultaneous) 2nd Eye Less Severly
Affected
Epidemic Keratoconjunctivitis
![Page 93: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/93.jpg)
Conjunctivitis: Follicular Pseudomembranous Haemorrhagic
Epidemic Keratoconjuntivitis
Follicules
Pseudomembrane
![Page 94: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/94.jpg)
Keratitis:
SPK Focal Epithelial Keratitis Active Viral Infection
Epidemic Keratoconjuntivitis
![Page 95: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/95.jpg)
Subepithelial Infiltrates: Lymphocytic Spontaneous Resolution May Persist Very Long
(up to 10 Years !!!) Immunologic Response
to Viral Ag
Epidemic Keratoconjuntivitis
![Page 96: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/96.jpg)
Clinical Course of Corneal Lesions
![Page 97: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/97.jpg)
CLINICAL CASE
Previous Adenoviral Infection
Recurrent Pain and Redness
Scattered Superficial Infiltrates
Responsive to Steroids
42-Year-Old Male
![Page 98: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/98.jpg)
CLINICAL CASE
Thygeson KeratitisCLSteroids Tapered off
Very Slowly
42-Year-Old Male
![Page 99: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/99.jpg)
Treatment (Initial): Prevention !!! Antiviral Efficacy ??? Antibiotics Unnecessary Palliative Care
(Hot Compresses, Cycloplegics, ecc.)
Epidemic Keratoconjunctivitis
![Page 100: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/100.jpg)
Steroids Are Only Symptomatic !!! Only for Very Severe
Symptoms !!! Addiction & Rebound Side Effects
Epidemic Keratoconjunctivitis
Treatment (Late):
![Page 101: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/101.jpg)
CORNEAL INFECTIONS External
Inflammation Ulcer Stromal
Infiltration Hypopion
![Page 102: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/102.jpg)
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
Establish Diagnosis (D.D. with Other Corneal Lesions)
Identify Pathogen Select Proper
Treatment
![Page 103: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/103.jpg)
Corneal Smears & Coltures (Confocal Micr.)
Multi-antibiotic Therapy (wide spectrum)
Corneal Biopsy Surgery (Conjunctival
flap, PK “a chaud”)
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
![Page 104: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/104.jpg)
MYTH # 4:GIVE SYSTEMIC ANTIBIOTICS
CORNEAL INFECTIONS
Hypopyon Is Sterile in Corneal Infections, Unless the Ulcer Perforates
![Page 105: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/105.jpg)
FACT # 4:
EFFECTIVE ROUTE
CORNEAL INFECTIONS
Topical Eyedrops every 1hSubconj.
SystemicInfiltration
+/-
NO???
![Page 106: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/106.jpg)
Mono- vs Polyantibiotic
Topical Therapy
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
![Page 107: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/107.jpg)
Aminoglycosides (vs gyrase inhibitors)Cephalosporines (cephtazidime vs
cephazoline)Vancomycin (Meth. Res. Staphylococcus)Anphothericine B (Fungi !)
Polyantibiotic Topical Therapy :
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
![Page 108: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/108.jpg)
Stefani, Meditime 2007
CORNEAL PHARMACOKINETICS OF NETILMICIN
Concentration after Single Administration
in vivo animal
model
![Page 109: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/109.jpg)
Sensitivity and Resistance of 146 Gram- strains
Vanzzini V et al, Rev Mex Oftalmol 83(1): 1-5, 2009
NETILMICIN - Sensitivity Spectrum
![Page 110: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/110.jpg)
0 20 40 60 80 100
Acinetobacter
Citrobacter
EnterobacterE. Coli
Klebsiella
P. mirabilis
P.morgani/P. vulgaris
Providencia
Pseudomonas
Salmonella
Serratia
staphylococcus
14.3 %
100 %
94.6 %80.6 %
87.2 %
63.2 %
21.8 %
2.2 %
46.3 %
8.3 %
44.4 %
91.5 %
Cumulative % susceptible
Activity against 907 AG-Resistant Strains
Muller et al, Chemotherapy, 1981
NETILMICIN – Low Incidence of Resistance
![Page 111: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/111.jpg)
**
**
***
0.08 0.16 0.3 0.6 1.25 2.5 5.0
Concentration (mg/ml)
0
30
60
90
120
MTT
(% o
f con
trollo
)
Ofloxacina
Netilmicina
Papa et al, JOP&T 19(6): 535-545, 2003
Human Corneal
Epithelium (HCE)
*p<0.01, **p<0.001 (two way-ANOVA)
in vitro Corneal ToxicityEffect of Increasing AB Concentration on Vitality
NETILMICIN - Safety
Commercially Available Concentration(3.0 mg/ml)
![Page 112: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/112.jpg)
0.3% Ofloxacina – 8 h0.3% Netilmicina – 72 h
Scuderi et al, Cornea 22(5): 468-472, 2003
Rabbit Corneal Epithelium (SIRC)
NETILMICIN - Safety
in vitro Corneal ToxicityEffect of Increasing AB Concentration on Cell Morphology
![Page 113: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/113.jpg)
Clinical Evaluation
Initial Therapy
BETTER WORSE
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
![Page 114: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/114.jpg)
BETTER
PathogenNot Identified
PathogenIdentified
Continue Therapy Add Therapy
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
![Page 115: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/115.jpg)
HYPOPYON ↓↓↓BETTER
Day 0 Day 3
![Page 116: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/116.jpg)
BETTERINFILTRATE ↓↓↓
Day 0 Day 7
![Page 117: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/117.jpg)
BETTEREPITHELIUM ↑↑↑
Day 3 Day 7
![Page 118: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/118.jpg)
Worse
Pathogen Does Not Respond to TX
PathogenNot Identified
Change Therapy Change Approach
SYSTEMATIC APPROACH TO CORNEAL INFECTIONS
![Page 119: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/119.jpg)
![Page 120: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/120.jpg)
Confocal MicroscopySectional Images of Corneal Structures
Epithelium Basal Epi. Nerves
AnteriorStroma Endothel.
MiddleStroma
![Page 121: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/121.jpg)
DIAGNOSIS (INFECTION/INFESTATION) EVALUATION OF CLINICAL COURSE EVALUATION OF STROMA
Keratocyte Density Structure of sub-epithelial nerve plexus Monitoring of haze
Confocal Microscopy
![Page 122: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/122.jpg)
Confocal Microscopy
![Page 123: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/123.jpg)
18 µm
DAY 1
AMOEBIC KERATITIS
![Page 124: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/124.jpg)
AMOEBIC KERATITIS
18 µm
DAY 14
![Page 125: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/125.jpg)
2-Year-History of Transient Corneal Edema Disappears with Topical Steroids VA = 20/20
![Page 126: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/126.jpg)
CONFOCAL MICROSCOPY (43µm)
![Page 127: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/127.jpg)
AMOEBIC KERATITIS
DAY 1 DAY 20
![Page 128: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/128.jpg)
AMOEBIC KERATITIS
DAY 1 DAY 20
![Page 129: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/129.jpg)
CULTURESAgar, Sabouraud, thioglycolate, E. Coli
Acanthamoeba
PHMB (Biguanide) SIFIHexamidine
![Page 130: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/130.jpg)
MICROSPORYDIUM KER.
338 µm
![Page 131: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/131.jpg)
AFTER SALK
1 Day 20 Days ???VAcc = 20/50 !!!VAcc = 20/50 !!!
![Page 132: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/132.jpg)
THx• Topical:‣Fumagillin
(Galenical) • Systemic:
Albendazole (Antihelmintic)
• Test HIV: -
30 Days
![Page 133: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/133.jpg)
FINAL RESULT
BCVA=CFBCVA=CF BCVA=20/60BCVA=20/60
18 Months
![Page 134: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/134.jpg)
65-Year-Old White Female
Immunesuppression, Diabetes
No CL Wear or HSV History
BSCVA ↓ ↓ ↓ 1/20
“COLD” ULCER
![Page 135: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/135.jpg)
VancomycinCeftazidimeAmikacinVoriconazole
Day 4 after Tx“COLD” ULCER
q 2 h
![Page 136: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/136.jpg)
CORNEAL BIOPSY
![Page 137: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/137.jpg)
Repeat Culture + BiopsyCandida
Voriconazole+
FLUCONAZOLEq 2h
![Page 138: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/138.jpg)
Adjusted Tx: Day 1
![Page 139: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/139.jpg)
Adjusted Tx: Week 2
![Page 140: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/140.jpg)
Adjusted Tx: Week 2
![Page 141: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/141.jpg)
CORNEAL BIOPSY
Tissue Gram, Giemsa, PAS, other
Acanthamoeba
![Page 142: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/142.jpg)
61-Year-Old White Female
PBK No Response to
Multiantibiotic/Antifungal
Treatment
“Tx Resistant” ULCER
![Page 143: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/143.jpg)
CONJUNCTIVAL FLAP
![Page 144: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/144.jpg)
PK after Conjunctival
Flap
s/p Conjunctival
Flap
![Page 145: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/145.jpg)
Corneal“Patch”+
ConjunctivalFlap
Perforated Corneal
Ulcer(Sterile)
![Page 146: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/146.jpg)
CORNEAL PATCH
![Page 147: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/147.jpg)
PK “a Chaud”
(1 week)
Perforated Corneal Ulcer
(Staphylococcus Aureus)
![Page 148: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/148.jpg)
PK “a Chaud” (4 weeks)
PK “a Chaud” (2 weeks)
![Page 149: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/149.jpg)
Re-PK (1 year)
PK “a Chaud” (4 months)
![Page 150: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/150.jpg)
MYTH # 5:ALWAYS STOP STEROIDS
EPITHELIAL DEFECT
![Page 151: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/151.jpg)
FACT # 5:DIFFERENT MECHANISMS !!!
Mechanical Friction “Dry Eye” Condition Drug Toxicity Exposure Neurotrophic Damage
EPITHELIAL DEFECT
![Page 152: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/152.jpg)
No Scientific Evidence of Steroidal Detrimental Effect on
Epithelial Growth !!!
EPITHELIAL DEFECT
![Page 153: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/153.jpg)
Ointment
CL + Ointment
(Eye Patch)
Botox (Tarsorrhaphy)
EPITHELIAL DEFECT
![Page 154: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/154.jpg)
EPITHELIAL DEFECT
![Page 155: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/155.jpg)
EPITHELIAL DEFECT Autoserum (Physical/Chemical?)
Amniotic Membrane (never for Infection!)
![Page 156: Cornea Clinic Interactive Part 1.ppt](https://reader038.vdocument.in/reader038/viewer/2022103104/577c808b1a28abe054a925d2/html5/thumbnails/156.jpg)
BREAK !!!