Conquering corneal infiltrates is something clinicians have attempted to do for decades. Despite continued research and elevated clinical acumen, if you were to put 20 clinicians in front of 20 slit lamps and ask them to properly distinguish between sterile and infectious corneal infiltrates (whether bacterial, viral, fungal or protozoan), you would hear many differing opinions.
Optometrists must rely on patient history, symptoms and clinical presentation when determining the type of corneal infiltrate. Once we know what we are dealing with, only then can we choose the proper treatment and management regimen. Here is a look at the processes that lead to infiltrates and how to distinguish the various types you will encounter in your practice.
Q: I have an 11-year-old patient with refractory severe vernal keratoconjunctivitis (VKC) and significant corneal staining, mostly in the left eye. I tried the typical topical agents such as low-dose steroids and mast-cell stabilizer/antihistamine drops. There is no shield ulcer yet, but I’m concerned it might happen. Are there any heroic options for this case?
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Corneal metabolism and wound healing are crucial to properly maintaining the cornea’s integrity and functionality. When an insult occurs to the corneal surface, creating an epithelial defect, the complex re-epithelialization process involves limbal stem cells, cell differentiation, proliferation, migration and remodeling of the extracellular matrix. Researchers believe growth factors involved in the process include epidermal, keratinocyte, hepatocyte and basic fibroblast growth factors. In normal, healthy corneas, supportive therapy can help the body resolve an epithelial defect rapidly. However, healing may be delayed or halted altogether in compromised conditions, leaving the underlying stroma exposed and vulnerable to further trauma, infiltrates, infection, scarring or perforation. A persistent epithelial defect, defined as a defect that has not resolved after two weeks of standard treatment, is a significant long-term management problem for ODs.
Q: I have a Sjögren’s disease patient with a dry eye flare up and complications. No topical treatments have helped. What’s next?
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The term corneal transplant is no longer synonymous with full-thickness penetrating keratoplasty (PKP). It is now divided into subcategories with different tissue layers. This family of procedures includes traditional PKP, deep anterior lamellar keratoplasty, Descemet’s stripping endothelial keratoplasty, Descemet’s membrane endothelial keratoplasty and pre-Descemet’s endothelial keratoplasty.
This article reviews these options, what patients need to know and the optometrist’s role in comanagement.