Transcript Ocular Pathology Case Presentation

Ocular Pathology Case
Presentation
Jeffrey Healey, M.D.
Leela Raju, M.D.
March 2011
Case Presentation
• 49 y.o male history of severe atopic disease
presents with corneal pannus and thinning
inferiorly OU
• Initial treatment aimed to preserve native
corneal tissue:
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doxycycline PO
Vitamin C
E-mycin ointment
Patanol
Preservative free artificial tears
Punctal occlusion
Clinical History
• Despite medical management progressive corneal
thinning present
• Patient underwent corneal gluing OS and tectonic graft
inferiorly OD
• Lab work-up:
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PPD negative
VDRL/HSV/HIV negative
RPR positive
LP: high glucose and high protein in CSF
ANA/WBC/CRP/C-ANCA normal
RF positive
ESR slightly elevated (17)
FTAbs positive
CXR and Chest CT normal
H&E slides
SPECIMEN: CORNEA, RIGHT EYE, PENETRATING TRANSPLANT
1. MIXED ACUTE AND CHRONIC KERATITIS WITH ULCERATION
(see comment)
2. EXTENSIVE STROMAL SCARRING AND VASCULARIZATION
3. KERATINIZATION OF THE CORNEAL EPITHELIUM
4. PAUCITY OF CORNEAL ENDOTHELIAL CELLS
5. RETROCORNEAL FIBROSIS/GRANULATION TISSUE WITH
ABUNDANT PIGMENT CELLS
Ulcer
H&E slides
Epithelial Surface
Acute and chronic
lymphocytic corneal
infiltration with stromal
thinning
Retrocorneal fibrosis and granualtion material
H&E
Corneal
vascularization
Epithelial Surface
H&E slides
Loss of corneal
endothelial cells
Polys
Normal
corneal
endothelium
H&E slides
Corneal
keratinization
Normal corneal
epithelium
H&E slides
Lymphocyte infiltration
into corneal stroma
Clinical diagnosis
• PUK (Peripheral ulcerative keratitis)
– Occurs most commonly in association with
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Rheumatoid arthritis
Wegeners granulomatosis
SLE
Polyarteritis nodosa
Ulcerative colitis
Relapsing polychondritis
Clinical Diagnosis
• Conjunctival biopsy typically demonstrates
evidence of vaso-occlusive vasculitis
• Presentation:
– May be bilateral but usually presents
unilaterally
– Usually limited to one sector of the peripheral
cornea
– Limbic vaso-occlusion present
– +/- infiltrate present
Management
• Primary goal is to minimize corneal
melting
– Corneal wetting
– Promote re-epithelialization
– Suppressing systemic-mediated inflammation
• Corticosteroid therapy
• Cytotoxic agents (cyclophosphamide,
methotrexate)
Management
• Surgical Intervention
– Penetrating keratoplasty
– Tectonic graft
– Lamellar graft
Discussion Questions
• 1) What other corneal disease states will
give you endothelial cell loss similar to that
seen in this case?
• 2) What features seen in the pathology of
this cornea are risk factors for graft
failure?