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Bacterial keratitis

Case Study with one of the differential diagnosis is bacterial keratitis

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Bacterial keratitis

  1. 1. Bacterial keratitis By: Chong Chen Yee Noor Munirah binti Awang Abu Bakar -Optometrist-
  2. 2. Case: • 23 years old lady, presented with 4 days history of redness of the LE associated with pain. The RE BCVA is 6/6, LE BCVA 6/24. • 23 years old, young • Lady • 4 days • Unilateral reduced vision LE • With complaints of redness and pain
  3. 3. Differential Diagnosis
  4. 4. Corneal disease- Cause Bacterial infection causes acute ocular pain, redness & reduced vision
  5. 5. Bacterial keratitis • What is bacterial keratitis? • An infection of the cornea due to bacteria • Causes pain, redness, reduced vision, light sensitivity, corneal infiltrates, ulcerations, anterior chamber inflammation and tearing or discharge from eye. • A sight-threatening process • Usually develops very quickly, and if left untreated, can cause blindness. • The bacteria usually responsible: • Staphylococcus Aureus (Infection) • Pseudomonas Aeruginosa(CL wearer)
  6. 6. Bacterial keratitis • Superficial keratitis: • Affects uppermost layers of the cornea. • Once healed, there is usually no scar on the cornea. • Deep keratitis: • Affects deeper corneal layers. • Once healed, can be a scar left after healing which may or may not affect vision, depending on where the scar is located.
  7. 7. Etiologies
  8. 8. Symptoms: Patients with bacterial keratitis usually complain of rapid onset (acute) of :
  9. 9. Signs: (Chronological order) (Kanski, 2003)
  10. 10. Other Signs: • Folds in the Descemet membrane • Upper eyelid edema • Posterior synechiae • Conjunctival hyperemia • Adherent mucopurulent exudate • Endothelial inflammatory plaque
  11. 11. Pathogenesis (Endothelium) Within hours to 48 hours
  12. 12. Pathogenesis (Endothelium-stroma)
  13. 13. Pathogenesis
  14. 14. Investigation 1 • History taking Important step in management of corneal infection. Corneal ulcer and Corneal abrasion (what, when, where, how?)
  15. 15. • Clinical Signs (must document them carefully which helpful in management) Eyelid abnormalities (trichiasis, lagophthalmos) Corneal sensation Corneal epithelial defects (fluorescein staining, size and shape) Corneal inflammatory infiltrate (size and shape) Thinning or perforation of the cornea (complications) Hypopyon Investigation 2
  16. 16. • Role of laboratory culture Investigation 3
  17. 17. Culture Media for Bacteria Keratitis Standard Media Common Isolates Blood agar Anaerobic bacteria (P. aeruginosa, S. aureus, S. epidermidis, S. pneumoniae) Chocolate agar Anaerobic bacteria (H. influenzae, N. gonorrhoeae, Bartonella species) Thioglycollate broth Anaerobic bacteria • Topical anesthetics (minimal inhibitory effects on organism recovery) • Multiple samples from the advancing borders of representative area of the ulcer are often required to achieve maximal yield of organisms.
  18. 18. Gram stain To confirm the presence of microorganism with sensitivity 55-79%. To distinguish bacteria from fungi Gram-positive retain the gentian violet-iodine complex and appear bluish-purple. Gram-negative lose the gentian violet-iodine complex by decolorization with acid alcohol and appear pink when counterstained with safranin.
  19. 19. Management Central or severe keratitis Loading dose of fluoroquinolone eye drops every 5 to 15 mins for 1st hour, hourly day and night (48 hours) hourly day and 2H night (3rd day) 2H day and 4H night (4th & 5th day) 4H day and night (6th & 7th day) After 7th day, tapered to 6H and stopped when appropriate. Cycloplegic agents use to decrease shynechia formation and decrease pain and ciliary spasm. Use of topical corticosteroids with topical antibiotics. The corticosteroids used to achieve control of inflammation.
  20. 20. Management
  21. 21. Management
  22. 22. Conclusion • In this case, this young lady presented with 4 days painful unilateral reduced vision LE associated with redness. • The differential diagnosis for this case can uveitis, scleritis, corneal infection and trauma. • For corneal infection, among all the possible microorganisms (Bacteria, virus, fungi, acanthamoeba etc), only bacterial infection can cause acute ocular pain, redness and reduced vision. • The laboratory culture must be made in order to confirm the diagnosis. • For other possible diagnosis, special investigations must be conducted.
  23. 23. References: • Bartolomei, A. 2014. Bacterial Keratitis.American Academy of Ophthalmology. From http://eyewiki.aao.org/Bacterial_Keratitis • Murillo-Lopez, F.H. 2014. Bacterial Keratitis. Medscape. From http://emedicine.medscape.com/article/1194028 • Kanski, J,J. 2003. Clinical Ophthalmology: A Systematic Approach. Butterworth-Heinemann. • Jay H. Krachmer, MD, Mark J. Mannis MD, and Edward J. Holland. Cornea (Fundamentals, diagnosis and management). 3rd edition. 2011. Elsevier.
  24. 24. Thank You