Corneal ulcer bact & fungal n

Infective keratitis

1. INFECTIVE KERATITIS PROF. DR. ANUPAMA MANOHARAN 2 nd year Dip. In Ophthal GOVT. STANLEY MEDICAL COLLEGE HOSPITAL

2. Corneal ulcer A discontinuation in the normal epithelial surface of the cornea + necrosis of the surrounding corneal tissue Edema & cellular infiltration

3. Etiological classification of infective kerATITIS Bacterial Viral Fungal Chlamydial Protozoal Spirochetal

4. BACTERIAL CORNEAL ULCER

5. Organisms causing bacterial corneal ulcer Staphylococcus aureus Pneumococcus ( ulcus serpens ) Pseudomonas pyocynaea Staphylococci Streptococcus pneumoniae Streptococci E.coli Gonococci Proteus Moraxella Klebsiella Pseudomonas pyocyanea N.gonorrhoea N.meningitidis C.diphtheria Organisms causing hypopyon corneal ulcer

6. Stages of bacterial corneal ulcer

7. 1) Stage of progressive infiltration Infiltration of lymphocytes into the epithelium from peripheral circulation & stroma . Necrosis of tissue occurs.

8. 2) Stage of active ulceration Results from necrosis & sloughing of the epithelium, Bowman’s membrane & stroma . Exudation into the anterior chamber from vessels of iris & ciliary body lead to hypopyon formation Ulcer may further progress as follows : ( i ) by lateral extension resulting diffuse superficial ulceration. (ii) by deeper penetration leading to descemetocele & corneal peforation .

9. 3) Stage of regression Induced by natural host defence mechanisms. Accompanied by vascularisation that increases the immune response. The ulcer now begins to heal & epithelium begins to grow over the edges.

10. 4) Stage of cicatrization Healing continues by progressive epithelialization . Beneath the epithelium , fibrous tissue is laid down by fibroblasts & endothelium of the new vessels. The degree of scarring varies : Superficial ulcer involving only epithelium heals without scar. Ulcer involving Bowman’s membrane Nebula Ulcer involving half of stroma Macula Ulcer involving more than half of stroma Leucoma

11. CORNEAL OPACITY GRADES develops as Healed Corneal Ulcers corneal opacity NEBULA : Faint opacity due to superficial scars involving Bowman’s layer & superficial stroma . MACULA : Semi dense opacity. Scarring involves half the corneal stroma . LEUCOMA : Dense white opacity. Scarring more than half of stroma

12. Corneal opacity

13. a. Nebular b. macular c. leucoma D. adherent leucoma

14. BACTERIAL CORNEAL ULCER WITH HYPOPYON

15. COMPLICATIONS OF CORNEAL ULCER Toxic Iridocyclitis due to absorption of toxins in the chamber. Secondary glaucoma due to fibrinous exudates blocking the anterior chamber. Descematocele due to effect of IOP the Descemet’s membrane herniates . A sign of impending perforation. Perforation of corneal ulcer sudden strain due to cough, sneeze or spasm of orbicularis muscle. Following perforation pain reduces and hot fluid (Aqueous) comes out of eyes.

16. descemetocele

17. investigations Routine – hemogram , blood sugar Specific – corneal scrapping gram stain culture & antibiotic sensitivity Ocular examination – Regurgitation test & syringing

18. treatment Treatment of uncomplicated corneal ulcer 1) Specific treatment 2) Non specific treatment 3) Physical & general measures

19. treatment 1. SPECIFIC TREATMENT Topical antibiotics Fortified cefazoline 50 mg/ml and Fortified tobramycin 13.6 mg/ml Alternative – fortified vancomycin 50 mg/ml Systemic antibiotics Cephalosporin Aminoglycoside Oral ciproflox

20. treatment 2. NON SPECIFIC TREATMENT Cycloplegic drugs – atropine Systemic analgesics & anti-inflammatory – paracetamol / brufen Vitamins – A,B,C 3. GENERAL MEASURES Hot fomentation Dark goggles Rest, good diet

21. Causes of non healing corneal ulcer Local causes IOP, concretions, misdirected cilia, impacted foreign body, dacrocystitis , lagophthalmos , excessive corneal vascularization . Systemic causes DM severe anemia malnutrition patients on systemic steroids

22. Treatment of non healing ulcer Removal of known causes Mechanical debridement of ulcer Cauterisation of ulcer Bandage of soft contact lens Peritomy

23. Treatment of impending perforation

24. Treatment of perforated corneal ulcer

25. FUNGAL CORNEAL ULCER

26. MYCOTIC CORNEAL ULCER Etiology :-- Filamentous - 1. Causative Fungi Yeast - 2. Modes of infection Aspergillus , Fusarium , Alternaria , Cephalosporium , Curvularia , Penicillium Candida , Cryptococcus Injury by vegetative material Injury by animal tail Secondary fungal ulcers

27. FUNGAL CORNEAL ULCER WITH SATELLITE LESIONS , RING INFILTRATE & HYPOPYON

28. IMMUNE RING

29. FUNGAL CORNEAL ULCER IN CONTACT LENS WEARERS

30. IMMOBILE HYPOPYON

31. Clinical picture Bacterial corneal ulcer Viral corneal ulcer Symptoms more marked Pain & FB sensation Watering Photophobia Blurred vision Redness of eyes Signs Wet looking, yellowish green Swelling of lids Blepharospam Conjunctival hyperemia Mobile hypopyon Symptoms less marked Signs more marked Dry looking, greyish white , rolled out margins Feathery finger like extensions Sterile immune ring Satellite lesions Immobile hypopyon

32. INVESTIGATIONS STAINING KOH mount Periodic Acid Schiff Calcofluor white Methenamine silver

33. Koh mount – aspergillus Aspergillus fumigatus Aspergillus flavus Aspergillus niger

34. culture Corneal scrapes should be plated on Sabouraud dextrose agar. Most fungi also grow on blood agar or in enrichment media . Sensitivity testing for antifungal agents. Contact lenses and cases should be sent for culture.

35. Newer methods Immunoflourescence staining electron microscopy PCR Confocal microscopy frequently permits identification of organisms in vivo .

36. TREATMENT Hospitalization Discontinuation of contact lens wear Empirical treatment initiated before microscopy results Cycloplegics - to reduce pain, prevents posterior synechiae Control blood sugar levels broad spectrum antibiotic Treat lacrimal apparatus

37. TREATMENT TOPICAL ANTIFUNGAL DRUGS . Initial drug of choice – 5% natamycin hrly – for 2 weeks Amhotericin B 0.15% with or without fluconazole 2% voriconazole 1% Nystatin eye ointment SYSTEMIC ANTIFUNGALS – Tablet fluconazole or ketoconazole Intracameral fluconazole .

38. Surgical treatment Perforation – actual or impending: Tissue adhesives- cyanoacrylate glue – small perforations <3mm Conjunctival flap- patch graft – large perforations 5mm Therapeutic keratoplasty (penetrating or deep anterior lamellar ) Superficial keratectomy can be effective to de-bulk a lesion