Dr. Szentgáli Zsolt ÁOTE Sebészet 1 - kisallatsebeszet.hu · Dr. Szentgáli Zsolt ÁOTE...

Dr. Szentgáli Zsolt ÁOTE Sebészet 1Dr. Szentgáli Zsolt ÁOTE Sebészet 1

CORNEACORNEACORNEA


ANATOMY and PHYSIOLOGYANATOMY and PHYSIOLOGY

Praecorneal tear filmPraecorneal tear filmEpitheliumEpitheliumStromaStromaDescemet Descemet -- membranemembraneEndotheliumEndothelium

Completely transparent and Completely transparent and avascular!avascular!

Layers of the corneaLayers of the corneaEPEP

SS

DDENEN


PATHOPHYSIOLOGY of the PATHOPHYSIOLOGY of the CORNEACORNEA

oedemaoedemavascularisationvascularisationpigmentationpigmentationulcerationulcerationinfiltrationinfiltrationaccumulation of foreign materialsaccumulation of foreign materialsscar formationscar formation


OedemaOedemaaccumulation of fluid in accumulation of fluid in the stromathe stromaimpaired function of the impaired function of the epiepi-- and/or endotheliumand/or endotheliumwater molecules water molecules enforce fibers and cellsenforce fibers and cellsgrayishgrayish--bluish diffuse bluish diffuse or focal opacityor focal opacity


VascularisationVascularisationduring both pathologic during both pathologic and healing processesand healing processessuperficialsuperficial or or deepdeep or or mixedmixed–– types of vascularisation types of vascularisation

depends on depth of the depends on depth of the corneal processcorneal process


PigmentationPigmentationpigment deposition in pigment deposition in the epithelium and the epithelium and stromastroma–– migration of migration of

melanocytes and melanocytes and macrophags with full of macrophags with full of pigment from the limbuspigment from the limbus

due to chronic corneal due to chronic corneal irritation, desiccation, irritation, desiccation, expositionexposition


UlcerationUlcerationsuperficialsuperficial or or deepdeepexcavation in the excavation in the corneal tissuecorneal tissueat the site of the ulcer at the site of the ulcer corneal tissue is lost corneal tissue is lost deep ulcers may lead deep ulcers may lead to cornal perforation!to cornal perforation!


InfiltrationInfiltrationfeatures of infiltration features of infiltration is depends on the is depends on the causecause–– leucocytes, leucocytes,

granulocytesgranulocytes: infection: infection–– eosinophilseosinophils: allergen, : allergen,

antigenantigen


Scar formationScar formationreparation of gaps in the reparation of gaps in the stroma by scarringstroma by scarringafter scar formation after scar formation arrangement of collagen arrangement of collagen fibers irregular: fibers irregular: opacityopacity

Kerectasia or Kerectasia or keratectasiakeratectasia: severe : severe granulation due to granulation due to chronic irritationchronic irritation


Developmental abnormalityDevelopmental abnormalitySkin tissue in the corneaSkin tissue in the corneaSurgical therapySurgical therapy

I.Corneal dermoidI.Corneal dermoid



Classification of keratitis

Etiology Depth Appearance • Infectious • Traumatic • Allergic • Due to: mechanical, chemical

irritation, desiccation, innervation abnormalities, chronic corneal edema

• Associated to systemic diseases • Unknown

• Superficial • Interstitial • Deep

• Ulcerative • Non ulcerative

II. INFLAMMATION OF THE II. INFLAMMATION OF THE CORNEACORNEA–– KERATITISKERATITIS


1. Ulcerative keratitis

Ulcer formation in the corneaUlcer formation in the corneaCorneal ulcer:Corneal ulcer:

superficial or deep excavation, hole in the superficial or deep excavation, hole in the corneal epithelium and the stromacorneal epithelium and the stroma


Superficial DeepDeep

Uncompli-cated, simply

Indolent UncompliUncompli--cated or non cated or non meltingmelting

MeltingMelting DescemeDesceme--toceletocele

Corneal ulcer

Special forms of ulcerative keratitisSpecial forms of ulcerative keratitis


A. Uncomplicated, superficial corneal ulcer

SignsSignsmild lacrimationmild lacrimationblepharospasmusblepharospasmusperifocal oedema perifocal oedema if the upper stroma if the upper stroma is exposed: is exposed: fluorescein positive!fluorescein positive!


TreatmentTreatmentelimination of the elimination of the causecauseantibiotic eyedroppesantibiotic eyedroppeshealing in 10healing in 10--14 days14 days


B. Indolent, superficial corneal ulcer

heals slowly or poorly (or not improve heals slowly or poorly (or not improve at all), tend to recurat all), tend to recurEtiologyEtiology–– separation of the stroma and epithelium is separation of the stroma and epithelium is

due to the inadequat development of due to the inadequat development of hemidesmosomes hemidesmosomes -- hereditaryhereditary

(superficial corneal erosion syndrome; indolent corneal ulcer; refractory corneal erosio; Boxer ulcer)


SignsSignslacrimationlacrimationblepharospasmusblepharospasmusundermined lip or rolled undermined lip or rolled up appearance of the up appearance of the epitheliumepitheliumstroma is exposedstroma is exposedfluorescein positivefluorescein positivevascularisation is rarely vascularisation is rarely stimulatedstimulated


TreatmentTreatmentsurgery:surgery: grid or grid or multipuncture keratotomy,multipuncture keratotomy,superficial keratectomysuperficial keratectomy + + third eyelid flapthird eyelid flap(post op. management!)(post op. management!)medical th. is contraindicated!medical th. is contraindicated!

Grid keratotomyGrid keratotomy


Superficial keratectomy of indolent Superficial keratectomy of indolent ulcerulcer


Superficial (erosio) DeepDeep


Indolent UncompliUncompli--cated or cated or non meltingnon melting

MeltingMelting DescemeDesceme--tokeletokele

Corneal ulcer



C. Non melting, deep corneal ulcer

painpain–– enophtalmus, prolaps of enophtalmus, prolaps of

the third eyelid, the third eyelid, blepharospasmus blepharospasmus

mucopurulent, purulent mucopurulent, purulent dischargedischargedeep excavation in the deep excavation in the cornea with well defined cornea with well defined edge; fluorescein pos.edge; fluorescein pos.perifocal or diffuse perifocal or diffuse corneal oedemacorneal oedemacircumcorneal circumcorneal vascularisationvascularisation(secunder uveitis)(secunder uveitis)

SignsSigns





TreatmentTreatmentelimination of the causeelimination of the causemedical th. is not contraindicated medical th. is not contraindicated –– AtropinAtropin–– AntibioticsAntibiotics–– VitaminsVitamins

surgerysurgery




Indolent UncompliUncompli--catedcated--non non meltingmelting

MeltingMeltingDescemeDesceme--tokeletokele

Corneal ulcer



D. Melting, deep corneal ulcer

potential danger to the eyeglobe!potential danger to the eyeglobe!proteases and collagenases are from:proteases and collagenases are from:–– Leucocytes of the PTFLeucocytes of the PTF

•• malfunction of the normal secretionmalfunction of the normal secretion–– Destroyed corneal epithelial cells and Destroyed corneal epithelial cells and

fibroblastsfibroblasts•• endogen enzymes exogenendogen enzymes exogen

–– Bacterias (eg.: Pseudomonas /secretion, Bacterias (eg.: Pseudomonas /secretion, distruption/)distruption/)


irregular and excessive exogen ballance irregular and excessive exogen ballance of enzymesof enzymes

solving of the stroma melting of the solving of the stroma melting of the cornea deep, melting corneal ulcer cornea deep, melting corneal ulcer

corneal perforationcorneal perforation


severe painsevere pain–– severe blepharospasm, severe blepharospasm,

photophobiaphotophobiapurulent dischargepurulent dischargediffuse corneal oedemadiffuse corneal oedemagrayishgrayish--white, gelatinwhite, gelatin--like material at the base like material at the base and edge of the ulcer; and edge of the ulcer; hypopyonhypopyon(secunder uveitis)(secunder uveitis)

SignsSigns




Emergency intervention!Emergency intervention!

Elimination of the cause Elimination of the cause

Medical th. contraindicated!Medical th. contraindicated!

Surgical therapy!Surgical therapy!–– operation+elimination of the operation+elimination of the

enzymes: chemical enzymes: chemical coagulation coagulation

•• jodine alcoholjodine alcohol

•• phenolphenol

TreatmentTreatment




Indolent UncompliUncompli--catedcated--non non meltingmelting

MeltingMelting DescemeDesceme--toceletocele

Corneal ulcer



E. Descemetocele

bottom of the ulcer is bottom of the ulcer is formed by the formed by the protruded Descemet protruded Descemet membranemembraneblackish and shiningblackish and shiningmucopurulent mucopurulent dischargedischargepainpainsecunder uveitissecunder uveitis

SignsSigns


DESCEMETOCELE


Emergency interventionEmergency intervention

Elimination of the causeElimination of the cause

Medical th. is contraindicatedMedical th. is contraindicated

Surgery!Surgery!

TreatmentTreatment


Surgery of deep corneal Surgery of deep corneal ulcersulcers

1, grid keratotomy 1, grid keratotomy (small animals only, non melting (small animals only, non melting only!)only!)

2,2, pedicle conjunctival graft transpositionpedicle conjunctival graft transposition3, 3, free island conjunctival graft transplantation free island conjunctival graft transplantation

(small animals only)(small animals only)4, 4, direct suturing of the cornea direct suturing of the cornea (descemetocele)(descemetocele)5, cornea transplantation5, cornea transplantation6, using tissue glue6, using tissue glue7, 7, ……


1, GRID KERATOTOMY


2, PEDICLE CONJUNCTIVAL GRAFT 2, PEDICLE CONJUNCTIVAL GRAFT TRANSPOSITIONTRANSPOSITION


3, FREE ISLAND CONJUNCTIVAL 3, FREE ISLAND CONJUNCTIVAL GRAFT TRANSPLANTATIONGRAFT TRANSPLANTATION







4, DIRECT SUTURING OF DESCEMETOCELE

••small small descemetocele descemetocele onlyonly

••max. 3 mm in max. 3 mm in diameterdiameter


Supporting technics in the Supporting technics in the surgery of deep corneal ulcerssurgery of deep corneal ulcers

third eyelid flapthird eyelid flaptarsoraffy, (subpalpebral drainage)tarsoraffy, (subpalpebral drainage)post op medicationpost op medication–– atropin atropin –– antibiotics antibiotics –– NSAIDsNSAIDs–– antikollagenic agentantikollagenic agent

physical protection of the eyephysical protection of the eye


SPECIAL FORMS OF ULCERATIVE KERATITIS

Infectious bovine Infectious bovine keratoconjunctivitiskeratoconjunctivitisMultipunctional keratitisMultipunctional keratitisHerpetic keratitsHerpetic keratitsCorneal sequestrumCorneal sequestrum......


2. Non ulcerative keratitis

Def:Def: inflammation of the superficial or inflammation of the superficial or deeper layers of the cornea without deeper layers of the cornea without ulcer formationulcer formation–– ÜÜberreiterberreiter’’s syndromes syndrome

–– Pigmentary kereatitisPigmentary kereatitis

–– Endothelial syndromeEndothelial syndrome

–– ......


Überreiter’s syndromeSynonymsSynonyms:: chronic immunechronic immune--mediated mediated keratoconjunctivitis sicca; chronic keratoconjunctivitis sicca; chronic superficial keratitis; (pannus)superficial keratitis; (pannus)dog: German shepherddog: German shepherd

EtiologyEtiologyunknown; autoimmun diseaseunknown; autoimmun diseaserole of UV radiation and viruses??role of UV radiation and viruses??proliferation of epithelial cells proliferation of epithelial cells ++ infiltration infiltration of the spf. stroma by plasma cells and of the spf. stroma by plasma cells and lymphocytes lymphocytes ++ vascularisation, lipid depos., vascularisation, lipid depos., pigmentation, edema, scar tissue formationpigmentation, edema, scar tissue formation


SignsSignsbilateralbilateralfirstfirst:: temporaltemporal ((nasalnasal) ) inferiorinferiorcornealcorneal quadrantquadrant willwill be be opaqueopaquethethe opacityopacity graduallygradually movemovecentrallycentrally, , finallyfinally thethe wholewhole corneacorneamaymay be be involvedinvolvedthethe opacityopacity: : redishredish--greyishgreyish ororblackblackfluoresceinfluorescein negneg.! .! „„thirdthird eyelideyelid formform””




TreatmentTreatmentcancan’’t be curedt be curedmedical:medical:–– subconj. and topical subconj. and topical

steroidssteroids–– topical cyclosporintopical cyclosporin

surgical:surgical:–– spf. keratectomyspf. keratectomy–– post op. th.post op. th.

Total (360 Total (360 degree) spf. degree) spf. keratectomykeratectomy



III. TRAUMATIC INJURIESEtiologyEtiology

biting, scratching, kicking, accident, biting, scratching, kicking, accident, foreign body, surgery etc.foreign body, surgery etc.

SignsSignsspf.:spf.: loss of the epithelium, edema, painloss of the epithelium, edema, paindeep:deep: deep gap in the stroma, diffuse deep gap in the stroma, diffuse edema, severe pain, dischargeedema, severe pain, discharge–– perforationperforation–– lacerationlaceration


perforation:perforation: full thicknes full thicknes injury of the cornea with injury of the cornea with outflow of the aqueousoutflow of the aqueous(and prolaps of the iris)(and prolaps of the iris); ; severe painsevere painlaceration: laceration: perforation perforation with widespread rupture: with widespread rupture: prolaps of the irisprolaps of the iris--lenslens--vitreous; severe painvitreous; severe pain, , bleeding, uveitisbleeding, uveitis–– horse: near the limbus; 360horse: near the limbus; 360°°



TreatmentTreatmentspf. and deep injury:spf. and deep injury:–– similar to ulcer therapysimilar to ulcer therapy

perforation, laceration :perforation, laceration :–– surgsurgeryery (conj. graft(conj. graftss, ,

direct suturing)direct suturing)removal of foreign body:removal of foreign body:–– adequate magnification!adequate magnification!





IV. TUMORSIV. TUMORS

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Dr. Szentgáli Zsolt ÁOTE Sebészet 1 - kisallatsebeszet.hu · Dr. Szentgáli Zsolt ÁOTE...

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