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treatment of non healing corneal ulcer

treatment of non healing corneal ulcer

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treatment of non healing corneal ulcer

  1. 1. .. TREATMENT OF NONTREATMENT OF NON HEALING CORNEALHEALING CORNEAL ULCERULCER ..
  2. 2. Superficial abrasions onSuperficial abrasions on the surface of thethe surface of the eye that faileye that fail to heal after 7 to 10to heal after 7 to 10 days.days.
  3. 3. In humans, physicians have identified several etiologies. Two common ones are trauma from a sharp superficial cut (paper or fingernail) that can lacerate the epithelium and excise a piece of basement membrane. Some patients then do not replace this lost piece of basement membrane and their lesion becomes indolent.
  4. 4. The second most common etiology is a basement membrane dystrophy of known or unknown etiology or secondary to aging where the basement membrane duplicates with collagen packets in between resulting in abnormal epithelial adhesions.
  5. 5. Defense of Ocular SurfaceDefense of Ocular Surface Normal Defense mechanismsNormal Defense mechanisms :: 1.1. EyelidsEyelids 2.2. Tear film proteins (SecretoryTear film proteins (Secretory immunoglobulins, complementimmunoglobulins, complement components, and various enzymescomponents, and various enzymes including lysozyme, lactoferrin,including lysozyme, lactoferrin, betalysins, orosomucoid andbetalysins, orosomucoid and ceruloplasmin have antibacterial effect)ceruloplasmin have antibacterial effect) 3.3. Corneal epitheliumCorneal epithelium 4.4. Normal ocular floraNormal ocular flora
  6. 6. Risk FactorsRisk Factors 1.1. Compromised normal ocularCompromised normal ocular surface(proptosis,bell`ssurface(proptosis,bell`s palsy,ectropion,deep coma,lagophthalmos)palsy,ectropion,deep coma,lagophthalmos) 2.2. Chronic colonization and infection of theChronic colonization and infection of the eyelid margin and lacrimal outflow systemeyelid margin and lacrimal outflow system can predispose corneacan predispose cornea 3.3. Chronic epiphora by reducing concentrationChronic epiphora by reducing concentration of certain antibacterial substances.of certain antibacterial substances. 4.4. Dry eyeDry eye
  7. 7. Risk FactorsRisk Factors 5. Presence of N Gonorrhoeae, C5. Presence of N Gonorrhoeae, C Diphtheriae, Hemophilus Aegyptius andDiphtheriae, Hemophilus Aegyptius and Listeria Monocytogenes – they canListeria Monocytogenes – they can penetrate intact corneal epithelium.penetrate intact corneal epithelium. 6. Compromised corneal epithelium as in6. Compromised corneal epithelium as in cases of contact lenses users, cornealcases of contact lenses users, corneal trauma, corneal surgery bulloustrauma, corneal surgery bullous keratopathy.keratopathy. 7. Absence of normal conjunctival flora.7. Absence of normal conjunctival flora.
  8. 8. Risk FactorsRisk Factors 8 Biofilm- is a slimy layer composed of8 Biofilm- is a slimy layer composed of organic polymers produced by embeddedorganic polymers produced by embedded bacteria on contact lens, it protectsbacteria on contact lens, it protects bacteria from antibacterial substances andbacteria from antibacterial substances and provide a nidus for infection.provide a nidus for infection. 9. Corneal anaesthesia(neuroparalytic9. Corneal anaesthesia(neuroparalytic keratitis)keratitis) 10. Abuse of topical anaesthetic solution10. Abuse of topical anaesthetic solution
  9. 9. Risk FactorsRisk Factors 11. Local immune suppression as due to11. Local immune suppression as due to topical corticosteroidstopical corticosteroids 12. Previous viral infection12. Previous viral infection
  10. 10. External Risk FactorsExternal Risk Factors 1.1. Trauma (Nocardia)Trauma (Nocardia) 2.2. Exposure to contaminated water orExposure to contaminated water or solutionssolutions 3.3. Chronic abuse of topical anaestheticChronic abuse of topical anaesthetic solutionsolution 4.4. Crack Cocaine smoking (disruptingCrack Cocaine smoking (disrupting corneal epithelium via associated cellularcorneal epithelium via associated cellular and neuronal toxicity.and neuronal toxicity.
  11. 11. Predisposing Systemic ConditionsPredisposing Systemic Conditions 1.1. MalnutritionMalnutrition 2.2. DiabetesDiabetes 3.3. Collagen vascular diseasesCollagen vascular diseases 4.4. Chronic alcoholismChronic alcoholism
  12. 12. Symptoms of Corneal UlcerSymptoms of Corneal Ulcer  Symptoms are usually marked, they are:Symptoms are usually marked, they are: 1. Diminution of vision, depending on location of1. Diminution of vision, depending on location of corneal ulcercorneal ulcer 2. Watering (lacrimation)2. Watering (lacrimation) 3. Difficulty in opening eyes especially in bright3. Difficulty in opening eyes especially in bright light (photophobia and blepharospasm)light (photophobia and blepharospasm) 4. Pain and foreign body/ gritty sensation usually4. Pain and foreign body/ gritty sensation usually intermittentintermittent  5. There may be discharge (Mucopurulent /5. There may be discharge (Mucopurulent / purulent)purulent)
  13. 13. PresentationPresentation Clinical signs and symptoms are variableClinical signs and symptoms are variable dependent on the virulence of thedependent on the virulence of the organism, duration of infection, pre-organism, duration of infection, pre- existing corneal conditions, immune statusexisting corneal conditions, immune status of host and previous use of antibiotics/of host and previous use of antibiotics/ steroidsteroid Acanthamoeba can cause masqueradingAcanthamoeba can cause masquerading syndrome mimicking bacterial keratitis.syndrome mimicking bacterial keratitis.
  14. 14. A corneal epithelial erosion that tends toA corneal epithelial erosion that tends to remain superficial and is not healing.remain superficial and is not healing. The presence of a redundant or looseThe presence of a redundant or loose undermined epithelial margin or bleb.undermined epithelial margin or bleb. Fluorescein stain will undermine theFluorescein stain will undermine the redundant border or pass through a fineredundant border or pass through a fine epithelial break and be retained under theepithelial break and be retained under the epithelium beyond the edge of theepithelium beyond the edge of the surface break.surface break.
  15. 15. The loose epithelial margin may even beThe loose epithelial margin may even be rolled or folded upon itself.rolled or folded upon itself. The eye may not be consistently painfulThe eye may not be consistently painful and it usually is intermittently painful.and it usually is intermittently painful.  Initially and even chronically there isInitially and even chronically there is usually a lack of an inflammatory responseusually a lack of an inflammatory response characterized by a lack or scarcity ofcharacterized by a lack or scarcity of blood vessels.blood vessels. These lesions rarely become infected.These lesions rarely become infected.
  16. 16. SignsSigns 6. Colour and pattern of iris may be disturbed6. Colour and pattern of iris may be disturbed 7. Cornea: loss of transparency the ulcer appears7. Cornea: loss of transparency the ulcer appears yellowish/ grayish pale lesion of varying shapeyellowish/ grayish pale lesion of varying shape /size, breach in continuity of corneal surface,/size, breach in continuity of corneal surface, ulcer with irregular floor and margins, floorulcer with irregular floor and margins, floor appears grayish / grayish pale/ grayish yellow,appears grayish / grayish pale/ grayish yellow, zone of infiltration with projecting swollen edges.zone of infiltration with projecting swollen edges. The surrounding cornea may appear groundThe surrounding cornea may appear ground glass like due to corneal edemaglass like due to corneal edema
  17. 17. Corneal UlcerCorneal Ulcer Peripheral Corneal Ulcer Central Corneal ulcer involving Lower periphery also
  18. 18. Clinical ExaminationClinical Examination Evaluation of predisposing and aggravatingEvaluation of predisposing and aggravating FactorsFactors 1.1. A detailed historyA detailed history 2.2. Prior ocular historyPrior ocular history 3.3. Review of related medical problems,Review of related medical problems, current ocular medications and history ofcurrent ocular medications and history of medication allergymedication allergy
  19. 19. ExaminationExamination 1.1. Visual acuityVisual acuity 2.2. An external ocular examinationAn external ocular examination Facial appearance, eyelids, lid closureFacial appearance, eyelids, lid closure Conjunctiva, Nasolacrimal apparatus,Conjunctiva, Nasolacrimal apparatus, corneal sensationcorneal sensation
  20. 20. ExaminationExamination 3. Slit Lamp Biomicroscopy: For3. Slit Lamp Biomicroscopy: For Eyelid marginEyelid margin Tear filmTear film ConjunctivaConjunctiva ScleraSclera Cornea (epithelial defects, punctateCornea (epithelial defects, punctate keratopathy, edema, stromalkeratopathy, edema, stromal infiltrates/ulceration, thinning orinfiltrates/ulceration, thinning or perforation)perforation)
  21. 21. Slit Lamp Examination… ContdSlit Lamp Examination… Contd Location of lesionLocation of lesion Density, Size , shape , depth, colourDensity, Size , shape , depth, colour EndotheliumEndothelium Anterior chamberAnterior chamber Loose or Broken suturesLoose or Broken sutures Signs of corneal dystrophySigns of corneal dystrophy Signs of previous inflammationSigns of previous inflammation
  22. 22. Steroids must not be used in presence ofSteroids must not be used in presence of active infected corneal ulceractive infected corneal ulcer In cases of progressive corneal ulcerIn cases of progressive corneal ulcer despite routine therapeutic treatment, thedespite routine therapeutic treatment, the following measures be considered:following measures be considered: Scraping of ulcer floor followed byScraping of ulcer floor followed by cauterization with pure (100%) carbolic acidcauterization with pure (100%) carbolic acid or 10-20% trichloracetic acid. Povidone Iodineor 10-20% trichloracetic acid. Povidone Iodine can also be used for cauterizationcan also be used for cauterization
  23. 23. Systemic TreatmentSystemic Treatment 1.1. Systemic Antibiotics: consider in severSystemic Antibiotics: consider in sever cases with scleral or intra-ocularcases with scleral or intra-ocular extension of infection or with impendingextension of infection or with impending or frank perforation of the corneaor frank perforation of the cornea Systemic antibiotic therapy is necessarySystemic antibiotic therapy is necessary in cases of Gonococcal keratitis due toin cases of Gonococcal keratitis due to its fulminating nature and systemicits fulminating nature and systemic involvementinvolvement
  24. 24. Systemic TreatmentSystemic Treatment 2. Analgesic anti-inflammatory2. Analgesic anti-inflammatory 3. Supportive treatment3. Supportive treatment 4. Acetazolamide Tab ,iv mannitol4. Acetazolamide Tab ,iv mannitol BD,0.5%timolol BD is added in cases ofBD,0.5%timolol BD is added in cases of impending perforation or perforatedimpending perforation or perforated corneal ulcer and in cases where there iscorneal ulcer and in cases where there is raised intra-ocular tension (in dosage ofraised intra-ocular tension (in dosage of 250 mgm upto four times a day)250 mgm upto four times a day)
  25. 25. Non-responsive / Progressive Corneal UlcerNon-responsive / Progressive Corneal Ulcer TREATMENTTREATMENT Re-evaluate forRe-evaluate for Drug toxicityDrug toxicity Non-infectious causes orNon-infectious causes or Unusual organisms such as non-tubercularUnusual organisms such as non-tubercular mycobacteria, Nocardia or acanthamoebamycobacteria, Nocardia or acanthamoeba should be suspectedshould be suspected Modification of anti-microbial therapyModification of anti-microbial therapy Therapeutic keratoplasty may be undertakenTherapeutic keratoplasty may be undertaken
  26. 26. Indolent / Non-healing UlcerIndolent / Non-healing Ulcer Consider debridement of necrotic cornealConsider debridement of necrotic corneal stroma andstroma and Frequent lubrication and/orFrequent lubrication and/or Temporary tarsorrhaphyTemporary tarsorrhaphy
  27. 27. Mechanical Sterile Cotton TippedMechanical Sterile Cotton Tipped Applicator (CAT's) debridement.Applicator (CAT's) debridement.  Scraping with a corneal spatulaScraping with a corneal spatula  Superficial Lamellar KeratectomYSuperficial Lamellar KeratectomY Beaver blade under general anesthesiaBeaver blade under general anesthesia Micropuncture with a 25 or 27 gaugeMicropuncture with a 25 or 27 gauge hypodermic needle.hypodermic needle.
  28. 28. After the cornea has been debrided, softAfter the cornea has been debrided, soft contact lens should be used. Be sure thecontact lens should be used. Be sure the Schirmer values are greater than 15Schirmer values are greater than 15 mm/min.).mm/min.). The contact lens will protect the corneaThe contact lens will protect the cornea from the movements of the overlyingfrom the movements of the overlying eyelids andeyelids and splint the new epithelium tight up againstsplint the new epithelium tight up against the anterior stroma.the anterior stroma.
  29. 29. when a contact lens is in placewhen a contact lens is in place Topical ophthalmicTopical ophthalmic solutions ONLYsolutions ONLY because ointments will clog poresbecause ointments will clog pores of lens andof lens and reduce or eliminate the passage ofreduce or eliminate the passage of respiratory gases, tear components, etc.respiratory gases, tear components, etc. through the lens.through the lens. Corneal edema will result when a lensCorneal edema will result when a lens blocks respiration and seriousblocks respiration and serious complications could occur rapidly.complications could occur rapidly.
  30. 30. FLUORESCEIN STAININGFLUORESCEIN STAINING If a Contact lens is in place - fluoresceinIf a Contact lens is in place - fluorescein will stain the lens and the lens will glowwill stain the lens and the lens will glow fluoresceDo not leave a contact lens influoresceDo not leave a contact lens in place longer than 14 days!(due to buildupplace longer than 14 days!(due to buildup of protein and mucin material in the lensof protein and mucin material in the lens pores leading to blockage of cornealpores leading to blockage of corneal respiration)Remove lens using ciliarespiration)Remove lens using cilia forcepsforceps
  31. 31. Cyanoacrylate ApplicationCyanoacrylate Application In patients where a contact lens can notIn patients where a contact lens can not be used because a lens does not fit or onebe used because a lens does not fit or one isis not available; a thin layer of Cyanoacrylatenot available; a thin layer of Cyanoacrylate can be applied to act as a custom contactcan be applied to act as a custom contact lenslens
  32. 32. DrugsDrugs · Antibacterial: Either a triple antibiotic· Antibacterial: Either a triple antibiotic such as neomycin, bacitracin, polymyxin;such as neomycin, bacitracin, polymyxin; gentamicin; or ciprofloxacin.gentamicin; or ciprofloxacin. · Mydriatic-cycloplegic: Mydriatic-· Mydriatic-cycloplegic: Mydriatic- cycloplegic such as 1% atropine sulfatecycloplegic such as 1% atropine sulfate should only be used in the face of ashould only be used in the face of a uveitis.uveitis.
  33. 33. Surgical TreatmentSurgical Treatment 1.1. Conjunctival flap; In recalcitrant bacterialConjunctival flap; In recalcitrant bacterial keratitiskeratitis 2.2. Penetrating Keratoplasty (PKP):Penetrating Keratoplasty (PKP): Large central ulcer , presenting lateLarge central ulcer , presenting late History of previous ocular surgeryHistory of previous ocular surgery Injudicious use steroid treatmentInjudicious use steroid treatment 3.3. Peritomy when excessive vascularisationPeritomy when excessive vascularisation hinders healinghinders healing

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treatment of non healing corneal ulcer

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