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Vernal Keratoconjunctivitis merupakan penyakit rekuren, dengan peradangan tarsus dan konjungtiva bilateral.

Penyebabnya tidak diketahui dengan pasti, akan tetapi didapatkan terutama pada musim panas dan mengenai anak sebelum berusia 14 tahun. Laki-laki dikenai lebih sering disbanding perempuan. This disease, also known as "spring catarrh" and "seasonal conjunctivitis" or "warm weather conjunctivitis," is an uncommon bilateral allergic disease that usually begins in the prepubertal years and lasts for 510 years. It occurs much more often in boys than in girls. The specific allergen or allergens are difficult to identify, but patients with vernal keratoconjunctivitis usually show other manifestations of allergy known to be related to grass pollen sensitivity. The disease is less common in temperate than in warm climates and is almost nonexistent in cold climates. It is almost always more severe during the spring, summer, and fall than in the winter. It is most commonly seen in sub-Saharan Africa and the Middle East. The patient usually complains of extreme itching and a ropy discharge. There is often a family history of allergy (hay fever, eczema, etc), and sometimes there is a history of allergy in the young patient as well. The conjunctiva has a milky appearance, and there are many fine papillae in the lower tarsal conjunctiva. The upper palpebral conjunctiva often has giant papillae that give a cobblestone appearance (Figure 511). Each giant papilla is polygonal, has a flat top, and contains tufts of capillaries. Vernal keratoconjunctivitis. "Cobblestone" papillae on superior tarsal conjunctiva.

A stringy conjunctival discharge and a fine, fibrinous pseudomembrane (Maxwell-Lyons sign) may be noted, especially on the upper tarsus on exposure to heat. In some cases, especially in persons of black African ancestry, the most prominent lesions are located at the limbus, where gelatinous swellings (papillae) are noted. A pseudogerontoxon (arcus-like haze) is often noted in the cornea adjacent to the limbal papillae. Trantas' dots are whitish dots seen at the limbus in some patients with vernal keratoconjunctivitis during the active phase of the disease. Many eosinophils and free eosinophilic granules are found in Giemsa-stained smears of the conjunctival exudate and in Trantas' dots. Micropannus is often seen in both palpebral and limbal vernal keratoconjunctivitis, but gross pannus is unusual. Conjunctival scarring usually does not occur unless the patient has been treated with cryotherapy, surgical removal of the papillae, irradiation, or other damaging procedure. Superficial corneal ("shield") ulcers (oval and located superiorly) may form and may be followed by mild corn scarring. A characteristic diffuse eal epithelial keratitis frequently occurs. None of the corneal lesions respond well to standard treatment. The disease may be associated with keratoconus. Treatment Since vernal keratoconjunctivitis is a self-limited disease, it must be recognized that the medication used to treat the symptoms may provide short-term benefit but long-term harm. Topical and systemic steroids, which relieve the itching, affect the corneal disease only minimally, and their side effects (glaucoma, cataract, and other complications) can be severely damaging. Newer mast cell stabilizer-antihistamine combinations are useful prophylactic and therapeutic agents in moderate to severe cases. Vasoconstrictors, cold compresses, and ice packs are helpful, and sleeping (and, if possible, working) in cool, air-conditioned rooms can keep the patient reasonably comfortable. Probably the best remedy of all is to move to a cool, moist climate. Patients able to do so are benefited if not completely cured.

The acute symptoms of an extremely photophobic patient who is unable to function can often be relieved by a short course of topical or systemic steroids followed by vasoconstrictors, cold packs, and regular use of histamine-blocking agents as eyedrops. Nonsteroidal anti-inflammatory medications, including ketorolac and lodoxamide, may provide significant symptomatic relief yet may slow the reepithelialization of a shield ulcer. (See discussion in Chapter 3.) As has already been indicated, the prolonged use of steroids should be avoided. Recent clinical studies have shown that topical 2% cyclosporine eye drops are effective in severe unresponsive cases. Supratarsal injection of depot corticosteroids with or without surgical excision of giant papillae has been demonstrated to be effective for vernal shield ulcers. Desensitization to grass pollens and other antigens has not been rewarding. Staphylococcal blepharitis and conjunctivitis are frequent complications and should be treated. Recurrences are the rule, particularly in the spring and summer; but after a number of recurrences, the papillae disappear completely, leaving no scars. Giant Papillary Conjunctivitis Giant papillary conjunctivitis with signs and symptoms resembling those of vernal conjunctivitis may develop in patients wearing plastic artificial eyes or contact lenses. It is probably a basophil-rich delayed hypersensitivity disorder (Jones-Mote hypersensitivity), perhaps with an IgE humoral component. Use of glass instead of plastic for prostheses and spectacle lenses instead of contact lenses is curative. If the goal is to maintain contact lens wear, additional therapy will be required. Careful contact lens care, including preservative-free agents, is essential. Hydrogen peroxide disinfection and enzymatic cleaning of contact lenses may also help. Alternatively, changing to a weekly-disposable or daily-disposable contact lens system may be beneficial. If these treatments are unsuccessful, use of contact lenses should be discontinued. Pemeriksaan oftalmologikus: VOD: 6/15 ph (+) 6/6 VOS: 6/30 ph (+) 6/6

S-1,00 6/6 S-1.25 C-0.50

90o

6/6

Pada myopia panjang bola mata anteroposterior dapat terlalu besar atau kekuatan pembiasan media refraksi terlalu kuat. a. Miopia refraktif, bertambahnya indeks bias media penglihatan seperti terjadi pada katarak intumesen dimana lensa menjadi lebih cembung sehingga pembiasan lebih kuat. Sama dengan myopia bias atau myopia indeks, myopia yang terjadi akibat pembiasan media penglihatan korneadan lensa yang terlalu kuat. b. Miopia aksial, myopia akibat panjangnya sumbu bola mata, dengan kelengkungan kornea dan lensa yang normal. Menurut derajat beratnya myopia dibagi dalam:

a. b. c. d. e.

Miopia ringan, dimana myopia kecil daripada 1-3 dioptri Miopia sedang, dimana myopia lebih antara 3-6 dioptri Miopia berat atau tinggi, dimana myopia lebih besar dari 6 dioptri Cylindrical Lenses A planocylindrical lens (Figure 2010) has one flat surface and one cylindrical surface, producing a lens with no optical power in the meridian of its axis and maximum power in the meridian 90 degrees away from the axis meridian. The total effect is the formation of a line image, parallel to the axis of the lens, from a point object. The orientation of a planocylindrical lens is specified by the meridian of its axis. The ophthalmic convention for specifying the orientation of the axis of a cylindrical lens is shown in Figure 2011. Zero begins nasally in the right lens and temporally in the left lens and proceeds in a counterclockwise direction to 180 degrees.

A planocylindrical lens with axis in the horizontal meridian.

Top: Illustration of prism base notation. Bottom: Illustration of cylinder axis notation.

In a spherocylindrical lens, the cylindrical surface is curved in two meridians but not to the same extent. In ophthalmic lenses, these principal meridians are at 90 degrees to each other. The effect of a spherocylindrical lens on a point object is to produce a geometric figure known as the conoid of Sturm (Figure 2012), consisting of two focal lines separated by the interval of Sturm. The position of the focal lines relative to the lens is determined by the power of the two meridians and their orientation by the angle between the meridians. Cross-sections through the conoid of Sturm reveal lines at the focal lines and generally ellipses elsewhere. In one position, the cross-section will be a circle that represents the circle of least confusion.

The conoid of Sturm, formed by light refracted by an astigmatic lens. A spherocylindrical lens can be thought of as a combination of a spherical lens and a planocylindrical lens. It can then be specified by the orientation of principal meridians and the power acting in each (Figure 2013). In a cross diagram, the arms are drawn parallel to the principal meridians and labeled with the relevant power. In longhand notation, the cylinder is specified by the orientation of its axis, which is 90 degrees away from the meridian of maximum power.

Cross diagram and equivalent combinations, including longhand notations, for a spherocylindrical lens. Writing prescriptions for spherocylindrical lenses uses longhand notation, and the lens can be specified in either plus or minus cylinder form (Figure 2013). The procedure for transposing between these forms is as follows: (1) algebraically sum the original sphere and cylinder; (2) reverse the sign of the cylinder; and (3) change the axis of the cylinder by 90 degrees. If their principal meridians correspond, combinations of spherocylindrical lenses can be summed mathematically. Otherwise, trigonometric formulas are required. Alternatively, the power of such combinations can be determined by placing them together in a lensometer. The principal meridians of any such combination will be 90 degrees apart. Konjungtiva tarsal : hipertrofi papil (giant papil), cobble stones Papillary hypertrophy is a nonspecific conjunctival reaction that occurs because the conjunctiva is bound down to the underlying tarsus or limbus by fine fibrils. When the tuft of vessels that forms the substance of the papilla (along with cellular elements and exudates) reaches the basement membrane of the epi thelium, it branches over the papilla like the spokes in the frame of an umbrella. An inflammatory exudate accumulates between the fibrils, heaping the conjunctiva into mounds. In necrotizing disease (eg, trachoma), the exudate may be replaced by granulation tissue or connective tissue. When the papillae are small, the conjunctiva usually has a smooth, velvety appearance. A red papillary conjunctiva suggests bacterial or chlamydial disease (eg, a velvety red tarsal conjunctiva is characteristic of acute trachoma). With marked infiltration of the conjunctiva, giant papillae form. Also called "cobblestone papillae" in vernal keratoconjunctivitis because of their crowded appearance, giant papillae are flat-topped, polygonal, and milky-red in color. On the upper tarsus, they suggest vernal keratoconjunctivitis and giant papillary conjunctivitis with contact lens sensitivities; on the lower tarsus, they suggest atopic keratoconjunctivitis. Giant papillae may also occur at the limbus, especially in the area that is normally exposed when the eyes are open (between 2 and 4 o'clock and between 8 and 10 o'clock). Here they appear as gelatinous mounds that may encroach on the cornea. Limbal papillae are characteristic of vernal keratoconjunctivitis but are rare in atopic keratoconjunctivitis. Konjungtiva bulbi : nodul mukoid/ trantas dot di daerah dekat limbus kornea. Trantas dot merupakan degenerasi epitel kornea atau eosinofildi bagian epitel limbus kornea, terbentuknya pannus, dengan sedikit eosinofil