H16.211-213 Exposure Keratoconjunctivitis

Exposure keratoconjunctivitis is an inflammatory disease of the cornea and conjunctiva caused by inadequate wetting of the ocular surface.  Abnormal clinical findings include the following:

• Conjunctival epitheliopathy
• Corneal epitheliopathy (punctate erosions)
• Conjunctival redness
• Corneal delle formation

A corneal delle is a form of exposure keratoconjunctivitis.  It represents an area of localized corneal thinning that usually appears as a small depression in the corneal periphery.  The natural history of corneal delle formation is characterized by the following clinical events:

• Delle is produced when the corneal stroma loses an excessive amount of water
• Loss of water leads to stromal dehydration and reduced stromal thickness
• Loss of water is caused by improper wetting of the corneal surface by the tear film
• Poor wetting is usually caused by an elevated mass on the conjunctiva directly adjacent to the limbus
• The elevated mass prevents the eyelid from wetting the corneal surface with the blink

Structural Damage to the Eye

• Corneal thinning
• Corneal warping
• Epithelial abnormalities
• Conjunctival abnormalities

Functional Damage to the Eye

• Blurred vision
• Tear film insufficiency
• Eye pain
• Sensitivity to light

The main goal of the diagnostic evaluation in a patient with exposure keratoconjunctivitis is to accomplish the following:

• To establish the diagnosis of exposure keratoconjunctivitis
• To determine WHY there is poor wetting of the ocular surface
• To establish appropriate therapy
• To relieve discomfort
• To prevent complications
• To educate patients and involve them in managing their dry eye disease

To obtain the information required to determine a clinical diagnosis of exposure keratoconjunctivitis and to prescribe a treatment plan, the following service components of a medical eye examination should be performed:

• Patient history
• General medical observation
• Adnexal examination
• External ocular examination with biomicroscopy

Patient History

Patients with exposure keratoconjunctivitis may present with any of the following abnormal clinical symptoms:

• Dry eyes
• Itchy eye
• Burning eyes
• Scratchy eyes
• Stinging eye
• Watery eyes
• Light sensitivity
• Gritty sensations
• Eye pain
• Blurred vision

In addition to physiological conditions, symptoms can be worsened by exposure to environmental conditions such as wind, air conditioning, and temperature extremes.  Activities that reduce blink rate (e.g., extended periods of reading, computer viewing, or driving) can produce more severe symptoms.

External Ocular Examination with Biomicroscopy

Patients with exposure keratoconjunctivitis may present with abnormal clinical signs in any of the following anatomical areas:

• Tear film
• Eyelid
• Conjunctiva
• Cornea

		Clinical Appearance of the Cornea Punctate keratopathy in the lower one-third of the cornea Poor ocular surface wetting is secondary to incomplete eyelid closure during sleep Note the straight line of demarcation separating the normal corneal tissue from the damaged tissue that is pathognomonic for this condition
		Clinical Appearance of the Cornea Exposure keratopathy characterized by coalescence of multiple punctate epithelial erosions Note the linear pattern of the epithelial damage that suggests incomplete eyelid closure as a component of the condition
		Clinical Appearance of the Cornea Multiple punctate epithelial erosions inferiorly
		Clinical Appearance of the Cornea Contact lens-induced exposure keratopathy on the peripheral cornea Contact lens overwear, tight lens sydrome, solution toxicity and giant papillary conjunctivitis can produce a superficial punctate keratopathy
		Clinical Appearance of the Conjunctiva Conjunctival epitheliopathy on elevated section of bulbar conjunctiva
		Clinical Appearance of the Conjunctiva Fine, punctate conjunctival epitheliopathy on the surface of elevated lesion

		Exposure Keratopathy Secondary To Surgery-Induced Lagophthalmous — Day 1 Geographic loss of epithelial tissue Treatment with bandage contact lens
		Exposure Keratopathy Secondary To Surgery-Induced Lagophthalmous — Day 2 Cornea is slowly re-epithelializing Continue bandage contact lens wear for another day

There is no classification system for exposure keratoconjunctivitis.

This would include other diseases that present with a superficial punctate keratopathy or conjunctival epitheliopathy.

		Blepharitis Toxins related to the release of inflammatory mediators can produce superficial punctate keratopathy on the inferior cornea
		Keratoconjunctivitis Sicca Abnormal increase in epithelial sloughing results in immature conjunctival epithelial cells moving onto the surface of the eye Immature cells do not have the surface cell coating of glycoprotein (mucin) needed for tear film bonding Uncoated cells are subject to an increase in dessication and injury due to poor tear film bonding Lissamine green dye stains the areas of the conjunctival surface that are not protected by mucin As the conjunctival desquamation accelerates, the damaged cells release inflammatory mediators onto the surface of the eye and the inflammatory process begins
		Chemical Burn Mild to moderate burns can produce superficial punctate keratopathy or sloughing of the entire epithelium
		Topical Drug Toxicity Any eyedrops with preservatives that are used frequently may produce a superficial punctate keratopathy
		Contact Lens-Induced Superficial Punctate Keratopathy Contact lens overwear, tight lens sydrome, solution toxicity and giant papillary conjunctivitis can produce a superficial punctate keratopathy
		Retained Conjunctival Foreign Body A foreign body under the eyelid can produce linear epithelial defects in a vertical orientation
		Conjunctivitis Mucous discharge associated with bacterial conjunctivitis can mimic the appearance of dehydrated mucous that collects in the inner canthus of dry eye patients
		Trichiasis Misdirected lashes cam produce superficial keratopathy In entropion or ectropion, an eyelid margin turned in or out can mechanically damage the cornea and cause superficial keratopathy
		Trauma Habits such as chronic eye rubbing can mechanically damage the corneal epithelium resulting in superficial punctate keratopathy

To begin the treatment of exposure keratoconjunctivitis, the eye doctor must firmly establish the underlying etiology.  In most cases, primary treatment of the resultant corneal condition is either supportive (moisturize) or prophylactic (antibiosis).  But in most cases, unless the underlying causative factor is addressed, the condition tends to become chronic and more severe.  Increased wetting of the cornea can be accomplished by prescribing artificial tears, lubricating ointments, or punctal occlusion.

Punctal Occlusion with Collagen Plug Implant Minor surgical procedure used to treat ocular surface disease The goal of the procedure is to occlude the nasolacrimal drainage system with a lacrimal duct implant in order to decrease the outflow of tears from the ocular surface Successful closure of the lacrimal punctum increases wetting of the cornea

Protection of the irritated cornea can be accomplished with a standard bandage contact lens or application of an amnionic membrane insert.  Depending of the severity of corneal compromise, prophylactic antibiosis can be considered.  Keratotoxic preparations should be avoided, especially aminoglycosides.  Erythromycin or polysporin drops or ointment are excellent choices.  To assist corneal healing, especially if waiting on a more permanent solution to the underlying eyelid pathology, taping the eyelids shut at night can be considered.  Taping is rarely a definitive therapy and should be considered only for short-term treatment.

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