Corneal Keratitis- Infectious Keratitis and Mooren's Ulcer- Clinical Features, Complications and Management .pptx

Corneal Keratitis-
Basics of Infectious Keratitis-
Bacterial, Corneal Ulcer (including brief description of Ulcus Serpens), Viral (Herpes Zoster Ophthalmicus and Herpes Simplex Keratitis) , Fungal and Parasitic (Acanthamoeba) causes of Keratitis/ Ulcers- Clinical features, Complications and Management

Brief Description of Mooren's Ulcer- a diagnosis of exclusion

Sources
1. Kanski’s Clinical Ophthalmology
2. Ophthalmology- Yanoff & Duker
3. Parson’s Diseases of the Eye
4. Comprehensive Ophthalmology by A.K. Khurana
5. various sources on Google and eyewiki search

1. Corneal Keratitis Dr. Tanvi Gupta

2. Stages- 1. Progressive Infiltration 2. Ulceration 3. Regression 4. Vascularisation

3. Symptoms l id swelling , p ain, lacrimation , photophobia , blepharospasm , discharge and varying degrees of diminution of vision Signs C onjunctival and circumcorneal congestion H azy cornea with an epithelial defect that stains with fluorescein dye , surrounded by corneal infiltration and oedema N ecrotic slough at base of the ulcer H ypopyon

4. V ascularization E ncapsulated corneal abscess C orneal thinning P rolapse of uveal tissue with hypotony if perforated

5. BACTERIAL KERATITIS

6. DENSE CENTRAL NECROTIC ULCER AND INFILTRATE

7. Blood Agar- Most bacteria except Neisseria, Hemophilus Moraxella Sabouraud Dextrose Agar Chocolate Agar

8. Lab Diagnosis Corneal scraping- edge and base- for diagnostic procedures/ reduce the load of bacteria Scraped material – Gram Stain and KOH

9. Ulcus Serpens also called as hypopyon corneal ulcer (Pneumococcus) Source of Infection : commonly chronic Dacryocystitis Symptoms : during initial stage of ulcus serpens there is remarkably little pain. Signs : Ulcus serpens is a greyish white or yellowish disc shaped ulcer occuring near the centre of cornea The ulcer has a tendency to creep over the cornea in a serpiginous fashion. One edge of the ulcer, along which the ulcer spreads, shows more infiltration. The other side of the ulcer may be undergoing simultaneous cicatrization and

10. the edges may be covered with fresh epithelium. Violent iridocyclitis is commonly associated with a definite hypopyon . Hypopyon increases in size very rapidly and often results in secondary glaucoma. Ulcer spreads rapidly and has a great tendency for early perforation . Dacryocystectomy / Dacryocystorhinostomy should be done if it is due to Chronic Dacryocystitis

11. Management of Bacterial Corneal Ulcers 1. Topical Antibiotic Eyedrop Moxifloxacin- gram negative, fair to good against gram positive Fortified antibiotics hourly for 1-2 weeks Fortified Cefazolin (1 st gen) – gram positive / Ceftazidime+ Fortified Aminoglycoside (Tobramycin/ Gentamycin) Fortified Vancomycin for resistant bacteria 2. Homide TDS 3. Antiglaucoma medication 4. Systemic Antibiotic- Ciplox 500 mg BD or i /v cephalosporin

12. Tetracycline (Doxycycline for its anti-collagenase effect) in threatened perforation 5. Painkiller/ anti-inflammatory- Systemic administration advised only when keratitis is complicated by S cleritis Risk of perforation Risk of endophthalmitis Risk of systemic involvement- Neisseria Gonorrhoea, Neisseria meningitidis, H. influenzae

13. VIRAL KERATITIS

14. Herpes Zoster

15. HUTCHINSON SIGN Involvement of skin supplied by external nasal nerve, a branch of nasociliary nerve supplying tip, side and root of nose- correlates with ocular involvement Reduced corneal sensation

16. Acyclovir 800 mg five times daily for 10 days or Valacyclovir 1g TDS (Nephrotoxic- do baseline KFT) Topical antiviral and antibiotic ointment applied on skin and lids 1. Acute epithelial keratitis/ Dendritic lesions Smaller and finer than herpes simplex dendrites Tapered end with non terminal bulbs 2. Scleritis- oral NSAIDS Oral steroids with antiviral cover if severe 3. Nummular keratitis- topical steroids Large coin-shaped sub-epithelial lesions- Nummular Keratitis with KPs

17. 4. Stromal keratitis- topical steroids 5. Endothelitis - - topical steroids, with or without topical antiviral 6. Anterior uveitis- with raised iop (due to trabeculitis) , sectoral iris atrophy- topical steroids , aqueous suppressants for raised iop 7. Progressive retinal necrosis- systemic antiviral (oral or intravenous)/ oral steroids /intravitreal antiviral Gancyclovir or Foscarnet 8. Optic Neuritis- i /v followed by oral steroids 9. Third, Fourth, Sixth C.N.Palsy - self limiting mostly

18. Herpes Simplex Blepharitis, Conjunctivitis, Keratitis, Iridocyclitis Linear, dichotomously branching with terminal bulbs Cornea- epithelial, stromal, endothelial

19. Symptoms- blurred vision, photophobia, pain, redness, and/or tearing. Ocular pain is often a hallmark Decreased corneal sensation Diagnosis is mostly clinical, Lab diagnosis- IFA/ PCR Treatment decrease inflammatory damage to cornea (mostly resolves spontaneously within 2-3 weeks) 1. Acyclovir 3%/ Ganciclovir 0.15% - 5 times a day (14-21 days)- 2. Lubricants

20. 3. Cycloplegics +/- 4. Debridement at the edges Geographic Ulcer- Immunocompromised/ atopy/ on topical steroids/ long standing non treated ulcers Large epithelial defects with dichotomous branching and terminal bulbs often seen at periphery- topical antiviral+ topical antibiotic

21. Stromal Keratitis, Endothelial Keratitis, iridocyclitis – combination of topical steroids (tapered weekly), topical antivirals, oral antiviral Oral antiviral agents- Especially useful in Prophylaxis- Post-operative in PK operated for viral keratitis 2. Recurrences twice or more a year

22. FUNGAL KERATITIS Aspergillus Fusarium

23. Dry looking ulcer, feathery margins, thick hypopyon Satellite lesions

24. Slow, indolent Signs> Symptoms Feathery infiltrates, greyish Satellite lesions Immobile, convex hypopyon, non-sterile (bacterial corneal ulcer is sterile) Dry looking Pigmented ( dematicious ) / Ring- ulcer

25. Risk of endophthalmitis without perforation Absence of vascularisation Aspergillus - Ring infiltrate Lab Diagnosis Staining- KOH Mount Culture- Sabouraud Dextrose Agar

26. Management of Fungal Corneal Ulcers Topical antifungals Hourly for 48 hours- Natamycin 5%/ Fortified Voriconazole/ Fortified Amphotericin B 2. Cycloplegia 3. Systemic Antifungals- Fluconazole ( hepatotoxic ) if severe with hypopyon/ perforation/ risk of endophthalmitis Tetracycline (Doxycycline) for anti-collagenase effect 4. Anti-glaucoma medication

27. Complications of Corneal Ulcers Keratectasia - bulging of cornea at site of thinning 2. Descemetocele- when only Descemet Membrane and few corneal lamellae remain 3. Perforation- Small- Pseudocornea formation- formation of adherent leucoma, iris may detach later Large- Iris prolapse into defect covered by grey or yellow exudate 5. Staphyloma 6. Anterior capsular cataract

28. 4. Secondary Glaucoma- inflammatory glaucoma/ Peripheral anterior synechiae formation 5. Staphyloma- ectatic cicatrix in which iris is incarcerated The bands of scar tissue on the staphyloma vary in breadth and thickness, producing a lobulated surface often blackened with iris tissue which resembles a bunch of black grapes. 6. Anterior Capsular Cataract- When perforation occurs opposite the pupil and if after perforation lens remains in contact with cornea for long time 7. Corneal fistula- formed when the perforation in the pupillary area is not

29. plugged by iris and is lined by epithelium which gives way repeatedly. There occurs continuous leak of aqueous through the fistula. 8. Spontaneous expulsion of lens and vitreous if perforation occurs suddenly, breaking of suspensory ligament 9. Hemorrhage - sudden reduction of IOP dilates intra-ocular vessels Retinal vessels- Vitreous hemorrhage Subretinal/ Choroidal h’ge / Expulsive h’ge 10. Purulent iridocyclitis/ Endophthalmitis/ Panophthalmitis

30. Therapeutic Keratoplasty- Lamellar or full thickness Done if not responding to medical management and progressive Should be done sooner rather than later to maximise probability of obtaining infection free margin To minimise risk of extension to anterior chamber and sclera To prevent occurrence of Endophthalmitis

31. Management after perforation Nebular corneal scars- RGP contact lens BCL/ Tissue Glue (<2-3mm )- Cyanoacrylate glue with soft contact lens over it when it dries Amniotic Membrane Transplant Corneal Patch graft (2-4 mm) or Tenonplasty if peripheral Tectonic Keratoplasty (>4mm) Conjunctival flaps Cosmetic Contact lens/ Tattooing Corneal scars with no visual potential

32. ACANTHAMOEBA KERATITIS

33. Epithelitis with marked radial perineuritis

34. Source of infection Associated with contact lens wear(solution used to store or clean the contact lenses) Swimming or bathing in contaminated water Symptoms Ocular pain is severe, perhaps due to deep linear stromal infiltrates localized along the corneal nerves. Signs Initial lesions Greyish irregular epithelial sur face Limbitis A nterior stromal infiltrates Radial keratoneuritis (pathognomonic)

35. Advanced Gradual enlargement and coalescence of infiltrates to form a ring abscess Reactive scleritis Slowly progressive stromal opacification and vascularization. Corneal melting may occur at any stage when there is s tromal disease.

36. Lab Diagnosis Culture – Non Nutrient Agar with E. coli Treatment- Debridement of involved epithelium P olyHexamethylene biguanide (PHMB) 0.02%- hourly at first and gradually reduced. Clear response may take 2 weeks Low- strength topical steroids after atleast 2 weeks of ant-amoebic treatment for persistent inflammation Oral NSAIDs for pain

37. Mooren Ulcer

38. Chronic Serpiginous Ulcer (Rodent Ulcer, Mooren Ulcer) This is a rare, chronic, degenerative, superficial ulcer, starting at the corneal margin and spreading circumferentially and axially Aetiology Autoimmune Mooren ulcer is a diagnosis of exclusion after all other systemic disorders predisposing to marginal ulceration are ruled out. Types Benign : milder, usually unilateral, less painful form is seen in elderly patients, more responsive to treatment Malignant : Bilateral involvement with severe pain and relentless progression is more common in young adults

39. Symptoms It is accompanied by severe and persistent neuralgic pain and lacrimation. Signs: It commences as one or more grey infiltrates , which break down, forming small ulcers that spread and sooner or later coalesce . And undermined and infiltrated leading edge is characteristic forming a whitish overhanging edge which is characteristic, while the base quickly becomes vascularized. Limbitis may be present Progressive circumferential and central stromal thinning over 4-12 months ○ The healing stage is characterized by thinning, vascularization and scarring ○ Iritis is not uncommon.

40. Vascularization involving the bed of the ulcer up to its leading edge but not beyond. Treatment Topical Steroids 1 hrly Topical cyclosporin drops and ointment Topical antibiotics Artificial tears

41. Systemic Systemic immunosuppression with steroids Systemic collagenase inhibitors such as doxycycline may be beneficial If perforation occurs, management described as above for perforated corneal ulcers Surgical Conjunctival resection Excision of a 4–7 mm strip of adjacent conjunctiva may prove successful by eliminating conjunctival sources of inflammatory mediators. Lamellar keratoplasty with intravenous methotrexate (immunosuppressive cover) may halt the process.

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