corneal ulcer.pptx

BIPIN KOIRALA MASTER’S OF OPTOMETRY, HIMALAYA EYE INSTITUTE
CORNEAL
ULCER

Contents
 Introduction
 Pathogenesis
 Sign/ symptoms
 Investigation
 Treatment

Infective keratitis
 Bacterial
 Viral
 Fungal
 Chlamydial
 Protozoal
 Spirochaetal

Definition
 Corneal ulcer may be defined as discontinuation in
normal epithelial surface of cornea associated with
necrosis of the surrounding corneal tissue
 Pathologically it is characterized by edema and
cellular infiltration.

 Infective corneal ulcer may develop when:
 Either the local ocular defence mechanism is
jeopardised
 There is some local ocular predisposing disease, or
host's immunity is compromised
 The causative organism is very virulent

Bacterial corneal ulcer
 There are two main factors in the production of
purulent corneal ulcer:
1. Damage to corneal epithelium
2. Infection of the eroded area

Common causative organisms
 Staphylococcus aureus
 Pseudomonas pyocyanea
 Streptococcus pneumoniae
 E. coli
 Proteus, Klebsiella
 N. gonorrhoea, N. meningitidis
 C. diphtheriae.

Pathogenesis (Stages)
 Stage of infiltration
 Stage of Active ulceration
 Stage of Regression
 Stage of Cicatrization

Perforated Ulcer
 Perforation of corneal ulcer occurs when the
ulcerative process deepens and reaches up to
Descemet's membrane.
 Exertion on the part of patient, such as coughing,
sneezing, straining for stool etc. will perforate the
corneal ulcer
 Adherent leucoma is the commonest end result
after such a catastrophe

Pseudo Cornea Formation
 When the infecting agent is highly virulent and/or
body resistance is very low
 Exudates block the pupil and cover the iris surface;
thus a false cornea is formed.
 Ultimately these exudates organize and form a thin
fibrous layer over which the conjunctival or corneal
epithelium rapidly grows and thus a pseudocornea
is formed.

Pseudocornea / Ant. Staphyloma

Bacterial Corneal Ulcers
Manifestation
 Broadly as:
1. Purulent corneal ulcer without hypopyon
2. Hypopyon corneal ulcer.

Symptoms
 1. Pain and foreign body sensation
 2. Watering (Hyperlacrimation)
 3. Photophobia
 4. Blurred vision
 5. Redness ( congestion of circumcorneal vessels)

Signs
 Lids are swollen
 Marked blepharospasm
 Conjunctiva is chemosed
 Conjunctival hyperaemia
 Ciliary congestion

 Greyish-white circumscribed infiltrate
 Stromal oedema
 Margins of the ulcer are swollen and over hanging
 Floor of the ulcer is covered by necrotic material.

Characteristic features produced by
some of the causative bacteria
 Staphylococal aureus and streptococcus (yellowish
white)
 Pseudomonas (greenish mucopurulent exudate
liquefactive necrosis)
 Enterobacteriae (E. coli, Proteusand Klebsiella sp.)
(Greyish white)

 Anterior chamber may or may not show pus
(hypopyon).
 Hypopyon corneal ulcer for the ulcer caused by
pneumococcus (ulcus serpens)
 Corneal ulcer with hypopyon for the ulcers
associated with hypopyon due to other causes

Complications
 Toxic iridocyclitis
 Secondary glaucoma
 Descemetocele
 Perforation of corneal ulcer
 Corneal scarring

 Thorough history taking
 General physical examination
 Ocular examination
1. Diffused light exam
2. Regurgitation test
3. Slit lamp

Laboratory investigations
 Routine laboratory investigations such as
haemoglobin, TLC, DLC, ESR, blood sugar, complete
urine and stool examination
 Microbiological investigations
1. Scraping
2. Swab

Treatment
 Treatment of corneal ulcer can be discussed under
three headings:
1. Specific treatment for the cause.
2. Non-specific supportive therapy.
3. Physical and general measures.

Specfic treatment
 Topical antibiotics (Fortified antibiotics)
 Ciprofloxacin (0.3%) eye drops,Ofloxacin (0.3%) eye
drops, Moxifloxacin (0.3%) eye drops.
 Systemic antibiotics

 Fortified cephazoline 5% ( 50mg/ml)
 Fortified tobramycine ( 1.3%)
 Fortified vancomycin 5% (50mg/ml)

Non-specific treatment
 Cycloplegic drugs
 Systemic analgesics and anti-inflammatory drugs
 Vitamins (A, B-complex and C)
 Goggles darker

MYCOTIC CORNEAL ULCER
 The incidence of suppurative corneal ulcers caused
by fungi has increased in the recent years:
1. Injudicious use of antibiotics
2. Steroids

Causative fungi
 The fungi which may cause corneal infections are :
 Filamentous fungi: Aspergillus, Fusarium,
Alternaria, Cephalosporium, Curvularia and
Penicillium.
 Yeasts: Candida and Cryptococcus

Mode of infection
 Injury by vegetative material
 Injury by Animal tail
 Secondary fungal ulcers

Signs and Symptoms
 Symptoms are similar to the central bacterial corneal
ulcer
 But in general they are less marked than the equal-
sized bacterial ulcer
 Overall course is slow and torpid.

Signs
 Corneal ulcer is dry-looking, Greyish white
 Feathery finger-like extensions are present into
the surrounding stroma under intact epithelium.
 A sterile immune ring
 Multiple, small satellite lesions around the ulcer

 Big hypopyon
 Perforation in mycotic ulcer is rare
 Corneal vascularization is rare

Laboratory investigations
 Wet KOH,
 Calcofluor white,
 Gram's and Giemsa- stained films for fungal
hyphae
 Culture on Sabouraud's agar medium

Treatment
 Topical antifungal eye drops should be used for a
long period (6 to 8 weeks).
 These include :
1. Natamycin (5%) eye drops
2. Fluconazol (0.2%) eye drops
3. Nystatin (3.5%) eye ointment.

 Systemic antifungal drugs may be required for
severe cases of fungal keratitis.
 Tablet fluconazole(200mg..bid) or ketoconazole
may be given for 2-3 weeks
 Non-specific treatment and general measures are
similar to that of bacterial corneal ulcer

Viral corneal ulcer :
 Typically affects both cornea and conjunctiva-
keratoconjunctivitis .
 Common viral infections-
1. Herpes simplex(DNA virus)
2. Herpes zoster
3. Adenovirus

Herpes simplex:
 Mode of Infection:
1. HSV-I : face, lips, eyes.(kissing)
2. HSV- II : genital herpes (infection from genital secretion)
 Primary Herpes:
1. Skin lesions
2. Conjunctiva - Acute follicular conjunctivitis
3. Corneal signs:
Fine epithelial punctate keratitis, coarse epithelial
punctate keratitis, dendritic ulcer.

Primary Ocular Herpes
 Basically seen during first attack b/w 6months to
teenagers.
 Clinical features
1. Skin lesions. (Vesicular lesions)
2. Acute follicular conjunctivitis
3. Keratitis ( Coarse punctate/ diffused branching
involving epithelium only)

Recurrent ocular herpes
 Fever such as malaria, flu, exposure to ultraviolet rays,
 General ill- health, emotional or physical exhaustion
 Mild trauma, menstrual stress
 Following administration of topical or systemic steroids
and immunosuppressive agents.

 Epithelial keratitis
i. Punctate epithelial keratitis
ii. Dendritic ulcer (knobbed )
iii. Geographical ulcer

 Stromal keratitis
1. Disciform keratitis
2. Necrotizing interstitial keratitis
 Meta herpetic keratitis

Treatment
 Specific treatment
1. Antiviral drugs are the first choice presently.
 Oint. Aciclovir 3 percent : 5 times a day until ulcer
heals and then taper to 3 times a day for 5 days.
OR
 Ganciclovir (0.15% gel)
 Triflurothymidine 1% dp (QID)
2. Mechanical debridement of involved area

 Systemic Antiviral
Tab .Acyclovir 400mg po tid/ bid for 10 to 21 days
In non responsive cases and recurrent cases.

 Stromal keratitis
(a) Disciform keratitis
(b) Diffuse stromal necrotic keratitis.
Treatment :
 Diluted steroid eye drops instilled 4-5 times a day
with an antiviral cover (aciclovir 3%) twice a day.

Herpes Zoster Ophthalmicus
 Herpes zoster ophthalmicus is an acute infection of
Gasserian ganglion of the fifth cranial nerve by the
varicella-zoster virus (VZV).
 It is neurotropic in nature
 The infection is manifests as chickenpox and the
child develops immunity. The virus then remains
dormant in the sensory ganglion of trigeminal
nerve

Clinical features
 Frontal nerve is more frequently affected than the
lacrimal and nasociliary nerves.
 50 percent cases of herpes zoster ophthalmicus get
ocular complications
 Hutchinson's rule

 General features.
 Cutaneous lesions
 Ocular lesions.
1. Conjunctivitis
2. Zoster keratitis
3. Episcleritis and scleritis
4. Iridocyclitis
5. Anterior segment necrosis and phthisis bulbi.

Treatment
 Systemic therapy for herpes zoster
 Oral antiviral drugs.
1. Acyclovir in a dose of 800 mg 5 times a day for 10
days, or
2. Valaciclovir in a dose of 500mg TDS
 Analgesics.
 Systemic steroids.

 Local therapy for ocular lesion
1. Topical steroid eye drops 4 times a day.
2. Cycloplegics such as cyclopentolate eyedrops BD
or atropine eye ointment OD.
3. Topical acyclovir 3 percent eye ointment should
be instilled 5 times a day for about 2

 Any queries???
 THANK YOU

corneal ulcer.pptx

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