Corneal Ulcer (bacterial, fungal, acanthamoeba).pptx

Corneal Ulcer (bacterial, fungal, acanthamoeba)

1. COrneal ulcer Moderator : Dr Rajesh R Nayak Presenter : Dr Sriraj Alapati

2. ETIOLOGY

3. SOURCE Exogenous Endogenous : immunological Phlyctenular - TB IK – Syphilis Contiguous: Conjunctiva – trachoma, VKH Sclera – sclerosing scleritis Uveal – HSV endothelitis STAGES Progressive : infiltrates Active : ulceration Regressive : resolution of infiltrates Cicatrizing : scarring LOCATION Superficial Deep Impending perforation Perforation ETIOLOGY Infection, immune, degenerative, neoplastic, traumatic PATHOLOGY Suppurative (purulent) – bacteria, fungi Non Suppurative (non purulent) – virus, parasitic

4. Rapidly Progressive Suppurative Infiltrate • Bacteria: S. aureus S. pneumoniae Pseudomonas N. Gonorrhoea Viral • Mixed Infection Slowly Progressive Localized Infiltrate • Bacteria: S. epidermidis Alpha hemolytic Streptococci Actinomycetales Moraxella ATM  Fungi  Protozoa Clinical Evaluation

5. BACTERIAL ULCER

6. Penetrate intact epithelium: Neisseria Corynebacterium diptheria H. influenzae Shigella Listeria  Etiology Gram positive cocci: Staphylococci (MC) Streptococci Gram negative cocci: Neisseria Gram positive bacilli: Actinomyces Corynebacterium Listeria Gram negative bacilli: Pseudomonas E.coli

7. Trauma  Contact lens ( PSEUDOMONAS ) Loose sutures Steroids Dry eye Misdirected cilia Lagophthalmos  Dacrocystitis Recurrent epithelial erosions Predisposing Factors Disruption of integrity of corneal epithelium

8. Symptoms: Pain Redness Photophobia Blurred vision Mucopurulent discharge Signs: Eyelid swelling Chemosis Epithelial defect with infiltrate Circumcorneal injection Stromal oedema DM folds Hypopyon ( STERILE & MOBILE ) Posterior synechiae Clinical features

9. Organism specific features Gram positive cocci: (staph, strepococci ) Well defined margins Localized, deep penetration Gram negative bacilli: (pseudomonas) Ill defined margins due to more tissue destruction (Exotoxins)

10. ULCUS SERPANS S. Pneumococcus One edge - infiltration , other – cicatrization Healing at leading edge, progress at advancing edge

11. Needle-like, crystalline opacities, arborizing without cellular infiltrate or ocular inflammation. Corneal grafts, contact lens wear, topical anesthetic , steroids abuse. Streptococci viridans Infectious crystalline keratopathy (ICK)

12. Gram negative cocci: (N. goncocci ) Rapidly progressive Corneal melting <24 hrs STD Systemic treatment Moraxella: Steroids Mild reaction Well defind lesion

13. Nocardia: Beaded, branching, slender, AFB, filamentous bacteria. Multiple calcareous elevations Wreath ulcer (ring) / cracked wind shield app. Rx : AG’s

14. NTM: (M. chelonae ) Aerobic, non motile, AFB, non - sporing bacteria. Sx , trauma, keratoplasty Cracked wind shield app Persistent infiltrates On & off S/S Rx : Macrolides / AG’s

15. Corneal ulcer scrapings to be taken before starting treatment Margins (More bacteria) & base of ulcer with 15 blade or kimura spatula Sac syringing RBS Investigations PCR FUNGI

16. GRAM staining

17. Antibiotic Susceptibility Testing

18. Treatment Topical antibiotics : Eye drops Eye ointment ( To compensate night lag period ) Atropine (mydriatic – break PS & cycloplegic – reduce pain) NSAIDS AGM T. VIT C 500 MG ( Improves wound healing ) Collagen cross linking System antibiotics (no role) are indicated only in case of: Endophthalmitis Perforated corneal ulcer Ulcer extended beyond limbus Gonococci

19.  Gram Positive- Cephalosp orins : Cefazolin 50 mg/ml – 5% Ceftazidime 50 mg/ml– 5% Vancomycin 50 mg/ml– 5% Chloramphenicol 2 nd gen fluroquinolones: Gatifloxacin / Moxifloxacin Gram Negative- Aminoglycosides : Tobramicin 14 mg/ml – 1.4% Getamicin 14 mg/ml– 1.4% Amikacin 50 mg/ml – 5% 1st gen fluroquinolones: Ciprofloxacin / ofloxacin Aminoglycosides for nocordia & NTM

20. MOXI : G+>G- GATI : G->G+ Topical : no vitreous penetration Oral GATI : vitreous penetration OFLOX : CORNEAL PERFORATION CIPLOX : CORNEAL DEPOSITS LEVO, NOR, BESIFLOXACIN 0.6% GENTA – nephro , oto , retinotoxic Sofra , neo, tobra , amikacin

21. Empirical Therapy: {Fluoroquinolone monotherapy / fortified vancomycin + ceftazidime} Initial treatment Small non-severe ulcers Close follow up Perform microbiology if worsens All severe (> 3 mm) cases must be treated based on microbiology G+ COCCI G- RODS Q1H for 48 hours Q2H in morning, Q4H in night Q6H (healing)

22. Ceftazidime : 50mg/ml(5%) Method: Reconstitute parenteral Ceftazidime 500mg with 2ml sterile water/BSS available with the injection and add to 8ml of artificial tears. Storage: Refrigerate in 4 degrees C. Shelf Life: week under refrigeration at 4 degrees C and 3 days in room temperature. Vancomycin : 50mg/ml(5%) Method: Reconstitute 500mg of vancomycin powder for injection with 2 ml sterile water/BSS. Add to 8ml of artificial tears. Storage: Refrigerate at 4 Degrees C. Shelf Life: 28 days at 4 Degrees C. Preparation of Fortified antibiotic eye drops

23. FUNGAL ULCER

24. Classification of Fungi: • Yeasts (Candida)  Yeast like fungi  Filamentous  Dimorphic (Blastomyces) Etiology

25. Candida Immunocompromised hosts (ICU, DM)  Alcoholics  Vitamin deficiency  Protracted epithelial ulceration Predisposing factors Filamentous fungi • Immunocompetent hosts Trauma with vegetative matter  Agricultural & warehouse workers  June – September ( humid )

26. Pathogenesis ADHERANCE PENETRATION HOST RESPONSE Disruption of integrity of corneal epithelium Parallel growth of hyphae to stroma  Release of : Mycotoxins Proteolytic enzymes Soluble fungal antigen Release of lysosomal substances by PMN Destruction of corneal stroma

27. Clinical features SIGNS > SYMPTOMS ( large organisms, Inflammation process takes time ) Dry, greyish, elevated, irregular margins  Feathery edges ( HALLMARK) Satellite lesions ( multiple small ulcers ) Hyphae Hypopyon ( non sterile, non mobile ) Non specific infiltrate  Pseudodendrite ( knobs absent ) Endothelial plaques Immune ring of wessely Pigmentation

28. Flower pot - pseudodendrite on FS Feathery edges

29. Satellite lesions ( multiple small ulcers ) Endothelial plaques

30. Immune ring Pigmentation ( Aspergillus. Niger )

31. Investigations Corneal ulcer scrapings feels gritty Helps in debulking & improves drug penetration Staining Methods- A. Light Microscopy: 10% KOH ( dissolves the tissue so fungi are visualized ) , Gram’s, Giemsa, Grocott-Gomori Methenamine Silver (GMS) Stains, PAS B. Fluorescent Microscopy: Calcofluor White (CCF) staining

32. GMS CCF 10% KOH Gram’s

33. Culture : SDA,PDA, BHI, cooked meat broth

34. Confocal microscopy Only fungi & acanthamoeba are visualized

35. Treatment Filamentous fungi – NATAMYCIN Yeast - NYSTATIN + AMP.B

36. Intrastromal / intracameral injections: Voriconazole : 50 microgram in 0.1ml Amphotericin B: 5-10 microgram in 0.1ml Oral antifungal therapy: Indication: Scleritis, Endophthalmitis Drugs : Ketoconazole 200-600mg Voriconazole 200-400mg Fluconozole 200-400mg Itraconazole 200mg Duration of treatment : 14-21 days. LFT & Hallucinations

37. TST Protocol ( Topical, Systemic, Targeted therapy )  First line of Rx: Topical Natamycin 5%.  Addition of Oral Ketoconazole / Voriconazole in severe ulcers. Second Line of Rx: Addition of topical Voriconazole 1%. Third line of Rx: Intrastromal + Intracameral antifungals. Fourth Line of Rx: TPK.

38. BACTERIAL FUNGAL Diffusion of bacterial toxins Invasion of fungal hyphae Sterile Non sterile Fluid Fibrinous network Mobile (gravity, head position) Non mobile Easily absorbed Not absorbed HYPOPYON (PMN’S) Virulence of organism Resistance of tissues

39. ACANTHAMOEBIC KERATITIS

40. Free living amoeba 2 forms : trophozoite ( active ) cyst ( dormant ) Risk factors: Contact lens users ( pseudomonas > acanthamoeba ) Swimming pool Trauma with soiled matter

41. Clinical features Severe pain, watering and photophobia Ring infiltrate / ulcer Radial Perineuritis / Perineural Infiltrate Punctate Epitheliopathy Pseudodendrite Limbitis Hypopyon Anterior Scleritis

42. Investigations Giemsa, GMS , CCF, PAS Stains Non nutrient agar with E.COLI

43. Confocal microscopy Bright spots (89 %) Double walled cysts (83%) Signet rings (17%) Bacteria cant be visualized

44.  Biguanides: Poly Hexa Methylene Biguanide (PHMB) 0.02% - 0.06 % Chlorhexidine 0.02% - 0.2% Diamidines: Propamidine Isethionate 0.1% Hexamidine 0.1% MOA : Highly charged cationic molecules bind to negatively charged phospholipid membrane of amoeba causing denaturation of proteins. Aminoglycosides: Neomycin MOA : inhibition of protein synthesis Treatment Duration : 6- 9 months

45. MICROSPORIDIA Epithelial keratitis Typical stuck on appearance of SPK Treatment : 0.3% fluconazole

46. Complications A. Small perforation B. Large perforation Pseudocornea Anterior staphyloma Adherent leucoma

47. Keratectasia Keratocoele / descemetocoele (DM herniates through ulcer) Perforation Coughing, sneezing, straining, spasm of orbicularis Rise in BP Rise in IOP Perforation Prolapse of iris <2mm : tissue adhesive (cyanoacrylate) 2-4mm : patch graft/ tenoplasty >4mm : tectonic keratoplasty

48. Secondary glaucoma (iris & cicatricial tissue are too weak to support the restored IOP) Anterior staphyloma ASCC (contact with ulcer) Corneal fistula Pseudocornea Spontaneous expulsion of lens and vitreous Expulsive hemorrhage (sudden reduction in IOP) Endophthalmitis Panophthalmitis Scarring (irregular astigmatism)

49. Non healing ulcer always check for: Diabetes mellitus (immunocompromised) Chronic dacryocystitis Contamination of medications Drug resistance Atypical microorganisms Incomplete treatment Improper diagnosis

50. Non infectious causes: Chronic epithelial defect Autoimmune disease Rheumatoid arthritis Mooren's ulcer Terrien's marginal degeneration Staphylococcal marginal disease Phlyctenulosis Contact lens-related infiltration Vernal keratoconjunctivitis ( shield ulcer ) Smokable drug-induced Anesthetic abuse Xerophthalmia, keratomalacia

51. Confocal microscopy

52. COLOUR CODING OF CORNEAL ULCER

53. THANK YOU