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Counting Coins!

Nummular (coin-like) Keratitis/ Scars⁣

● Feature of viral keratoconjunctivitis, commonly Adenoviral (Epidemic Keratoconjunctivitis/EKC)⁣

● Other causes: HSV, HZO, Brucellosis, Acanthamoeba, Lyme disease, EBV, Adult inclusion conjunctivitis⁣

● It is a corneal sign, not diagnosis⁣

● Subepithelial infiltrates (SEI), can also be anterior stromal⁣

● Can be unilateral/bilateral⁣

● Tiny granular deposits surrounded by a stromal haze in infective stage⁣

● After healing, nummular scars remain⁣

● Precedes disciform keratitis⁣

● SEI represent host immune response to presence of viral antigens in superficial stroma, reaching diffusion during the epithelial infection stage⁣

Treatment in cases of EKC:⁣

● Steroids use may increase adenoviral replication→ viral diffusion into anterior stroma⁣

● Steroids avoided in initial management of EKC to decrease occurrence of SEI⁣

● But untreated SEIs, with increased accumulation of immune cells and mediators in the anterior stroma, can result in the destruction of corneal collagen and stromal scarring → So, steroid use should be considered when appropriate to protect corneal clarity⁣

● Indications for steroid use:⁣

1. Central SEI affecting vision⁣

2. Occupation requirements for lear vision⁣

3. Confluence of SEI with overlap of adjacent spots⁣

● Peripheral lesions can be observed → clear as the immune defense removes the viral antigen → 3 episodes occur at 6-8 weeks, 3-4 months, 9-12 months and then the episodes becomes shorter and less severe⁣ ⁣ ● Commonly used steroids: Lotepredonal or FML, Severe cases: Dexamethasone⁣

● Topical cyclosporine A or Tacrolimus ointment can be added to reduce recurrence rate ⁣

Other treatment options:⁣

● Established SEI: Surface ablation⁣

● Scars: Rigid contact lens/ Superficial anterior lamellar keratectomy⁣

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