Infective corneal ulcers
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This presentation describes the background of the cornea and the corneal diseases in general, also it describes in detailed manner how to manage the corneal ulcer with its different causes.
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Infective corneal ulcers
- 1. Diseases of the Cornea BY Amr Mounir.MD
- 2. 1.OUTER COAT 2.MIDDLE COAT 3.INNER COAT Three Coats of Eye Ball
- 3.
- 4. Tough Fibrous Coat Post 5/6th of Globe White & Opaque Sclera Radius---12mm Outer Coat
- 5. Tough Fibrous Coat Ant 1/6th of Globe Transparent Cornea Radius---8mm Outer Coat
- 7. Vertical-------10.6 mm Horizontal---11.7 mm Thickness Central portion----0.52 mm Peripheral portion----1 mm Size of Cornea
- 8. Three Layers 1.Epithelium & its Basement 2.Stroma & its ant condensation ( Bowman Zone( 3.Endothelium & its Basement (Descemet Membrane( Structure
- 9.
- 10. From Anterior to Posterior 1.Epithelium 2.Bowman Zone 3.Stroma 4.Descemet Membrane 5.Endothelium Structure
- 11. 50-60µm thick Covers the stroma anteriorly Continuous with epithelium of conjunctiva Life of epithelial cells is 7 days Prevent aqueous solutions to penetrate Epithelium
- 12. Surface cell layer Wing cell layer Basal cell layer Basement membrane Epithelium
- 13. 90%of the corneal thickness Bowman Zone Lamellar Stroma Once deformed its typical structure is not restored Stroma
- 14. Descemet membrane )Regenerates( Endothelium Single layer of cells Cells are tightly bound together Responsible for dehydration Never regenerates Inner Lining
- 15. Central cornea is avascular Corneoscleral limbus is generously supplied by anterior conjunctival branches of the anterior ciliary arteries Aqueous humor and tear film provides nutrients Blood supply
- 16. Branches of the ophthalmic division of trigeminal nerve and are solely sensory Most are concentrated in the anterior stroma beneath the Bowman zone and send branches forward into epithelium Descemet membrane and endothelium are not innervated Nerve Supply
- 17. The microvilli of the anterior surface of the squamous cell layer are wet by the mucin of tear film These cells are joined by tight junctions that exclude water soluble substances Cornea
- 18. Tight junctions of the epithelial cells Endothelial pump mechanism Absence of blood vessels Absence of pigments Scarcity of cell nuclei in stroma Regular structure of stroma Transparency
- 19. Superficial 1.Punctate epithelial erosions Tiny ,slightly depressed, epithelial defects which stain with flourescein but not with rose Bengal PEE are non specific and may develop in a wide variety of keratopathies Signs of Corneal Disease
- 20.
- 21. Superficial 2.Punctate epithelial keratitis It is the hallmark of viral infections. Swollen epithelial cells Visible unstained Stains with rose bengal Signs of Corneal Disease
- 22. Superficial 3.Epithelial Oedema Sign of Endothelial decompensation Severe acute elevation of IOP Signs of Corneal Disease
- 23.
- 24. Superficial 4.Filaments Small coma shaped mucus strands lined with epithelium. One end attached with epithelium Signs of Corneal Disease
- 25. Superficial 5.Pannus Inflammatory or degenerative ingrowth of fibro vascular tissue from limbus Signs of Corneal Disease
- 26.
- 27. Stromal Lesions 1.Infiltrates Focal areas of active stromal inflammation 2.Edema Increased corneal thickness Decreased transparency 3.Vascularization Signs of Corneal Disease
- 28. Lesions of Descemet Membrane 1.Breaks Corneal enlargement Keratoconus Birth trauma 2.Folds (Striate Keratopathy( Surgical trauma Ocular hypotony Stromal oedema Signs of Corneal Disease
- 29.
- 30. A corneal ulcer is an ocular emergency that raises high stakes of questions about diagnosis and management. When a large corneal ulcer is staring you in the face time isn't in your side. Despite varying etiologies and presentations, as well as different treatment approaches , corneal ulcers have one thing in common : the potential to cause devastating loss of vision. Important Facts
- 31. 1-Control of infection 2-Control of inflammation 3-Promotion of re-epithelialization – lubrication – lid closure – bandage soft contact lens 4-Prevention of perforation – tissue adhesive glue – conjunctival flap – systemic immunosuppressive agents Corneal grafting PRINCIPLES OF MANAGEMENT OF CORNEAL DISEASE
- 32. Ocular surface disease: Trauma, post-herpetic corneal disease, bullous keratopathy, corneal exposure, dry eye and diminished corneal sensation. Contact lens wear MICROBIAL KERATITIS ( Bacterial(
- 33. Pathogens which can produce corneal infection in intact epithelium. 1.Neisseria gonorrhoeae 2.Corynebacterium diphtheriae 3.Listeria 4.Haemophilus MICROBIAL KERATITIS ( Bacterial(
- 34. Oval, yellow-white, densely opaque stromal suppuration surrounded by relatively clear cornea Staph. aureus and strep. pneumoniae
- 36. History Clinical examination (including staining and sensitivity( Hospitalization Corneal scrapping Treatment MANAGEMENT
- 37. Acute painful injected eye. Profuse tearing and discharge. Decrease visual acuity. Large F.B Stromal invasion with epithelial excavating edge. Differentiators
- 38. 1. Fluroquinolones Every 5 mins / hour Hour / 24 hs 2 hour / 24 hs 2. Fortified eye drops ulcer < 2 ws , improvement not obvious. (N.B)Don’t miss resistant bacteria. 1. Steriods Treatment
- 39. Wrong diagnosis Wrong treatment Drug toxicity Poor response to treatment
- 40. Filamentous fungal keratitis –Aspergillus - Fusarium FUNGAL KERATITIS
- 41. Greyish-white ulcer with indistinct margins Surrounded by feathery infilterates Ring infilterate Endothelial plaque Hypopyon History of vegetable matter injury
- 42. Dull grey infiltrate. Satellite lesions. Awareness of those ulcers resembling bacterial keratitis Awareness of those caused by yeast better defined borders Real flags Differentiators
- 44.
- 45. Usually develops in pre-existing corneal disease or immunocompromised patient Yellow-white ulcer Dense suppuration Candida keratitis
- 46.
- 47. Suppurative bacterial keratitis Herpetic stromal necrotic keratitis D/D of fungal keratitis
- 48. Culture Biopsy Antifungal therapy – Initially broad- spectrum econazole 1% topically – Then depending upon sensitivity natamycin or imidazole for 6 weeks Systemic ketoconazole Therapeutic penetrating keratoplasty MANAGEMENT
- 49. Protozoan –active (trophozoite) –dormant (cystic( Common in swimmers and CL wearers ACANTHAMOEBA KERATITIS
- 50. Blurred vision and disproportionate pain Patchy anterior stromal infilterates Perineural infilterates (radial keratoneuritis( Infilterates coalesce –ring abcess, ulceration and hypopyon White satellite lesions CLINICAL FEATURES
- 52. History: Ulcer simulators resemble HS in shape but ?? Light sensitive ( Jacket- over- the head sign) Treatment : Differentiators
- 53.
- 54. Corneal scrappings stained with calcoflour white Corneal biopsy Treatment with chlorhexidine, polyhexamethylenebiguanide drops, dipropamidine and propamidine. Therapeutic penetrating keratoplasty MANAGEMENT
- 55. Primary ocular herpes: -Primary ocular herpes: - Blepharoconjunctivitis -Blepharoconjunctivitis - Keatitis (punctate epithelialKeatitis (punctate epithelial((
- 56. Opaque cells arranged in a course punctate or stellate pattern Central desquamation leads to a linear branching ulcer. –Fluorescein stain – Rose Bengal stain –Diminished corneal sensitivity Anterior stromal infilterates Geographical or amoeboid ulcer DENDRITIC ULCER
- 57.
- 58.
- 59. Herpes zoster keratitis Healing corneal abrasion Pseudodendrites due to soft contact lens Acanthamoeba keratitis Drug toxicity Differential diagnosis
- 60. Dentritic ulcer. Loss of corneal sensation. Photophobia. Types of HSV keratitis: Primary Recurrent Dentritic , Geographic , Metaherptica Diabetic foot in the eye Neurotrophic Differentiators
- 61. Antiviral therapy – Acycloguanosine 3% ointment – Trifluorothymidine 1% drops – Adenine arabinoside 3% ointment, 0.1% drops Idoxuridine Debridement (with sterile cotton-tipped bud 2mm beyond the edge of ulcer( TREATMENT
- 62. Stromal necrotic keratitis Disciform keratitis OTHER ENTITIES
- 63. Predominantly affects children Etiology – Tuberculosis – Delayed hypersensitivity reaction to staphylococcal or other bacterial antigen PHLYCTENULOSIS
- 65. Conjunctival: Pinkish-white nodule surrounded by hyperaemia Corneal: May resolve spontaneously or extend radially to the cornea. May cause severe ulceration or perforation. SIGNS
- 66.
- 67. Short course of topical steroids Topical antibiotics TREATMENT
- 68. Thank you