Keratitis Dr FS.pptx

management and treatment keratitis

1. Keratitis Presentor : Dr FS

2. OUTLINES KERATITIS INTRODUCTION CLASSIFICATION ETIOLOGY RISK FACTOR PATHOPHYSIOLOGY DIAGNOSE EXAMINATION MANAGEMENT COMPLICATION

3. Structure of eye

4. INTRODUCTION Keratitis is inflammation of the cornea, the clear window that covers the iris and the pupil in your eye. Keratitis may cause a corneal ulcer. Keratitis can be divided into two categories based on cause: infectious keratitis or noninfectious keratitis.

5. CLASSIFICATION Infectious keratitis noninfectious keratitis

6. Infectious keratitis Bacterial keratitis:  This type, caused by bacteria, is the most common. Fungal keratitis:  This type is caused by fungi, often from plants. Parasitic keratitis:  Parasites are organisms that live off another organism. Acanthamoeba keratitis is caused by a one-celled parasite called an amoeba. Viral keratitis:  Viruses like the ones that cause shingles and herpes simplex can cause keratitis. Herpes simplex keratitis often recurs

7. Acanthamoeba Keratitis

8. Non-infectious keratitis

9. Noninfectious keratitis Injuring your eye. (This includes having eye surgery, being in an accident and having a condition where your eyelashes scrape against the surface of your eye.) Wearing contact lenses for too long. Having a foreign object in your eye. Being exposed to ultraviolet (UV) light for too long. Having a vitamin A deficiency. Having an eyelid disorder or immune system condition that causes dry eyes.

10. ETIOLOGY Bacterial Bacteria are the most common cause of infectious keratitis. Both gram positive and gram-negative organisms are implicated as causative agents. About 80 % of bacterial keratitis is caused by Staphylococcus, Streptococcus and Pseudomonas species Certain bacteria are known to penetrate the intact epithelium which include Neisseria, Corynebacterium, Shigella and Listeria.

11. Viral HSV keratitis is caused by the herpes simplex virus, a double- stranded DNA virus made up of an icosahedral shaped capsid surrounding a core of DNA and phosphoproteins of viral chromatin.  HSV- I and HSV- II are differentiated by virus specific antigens. HSV- I typically affects the orofacial region, whereas HSV- II usually causes genital infections. However, studies have shown that both viruses may affect either location, and mixed infections have been reported The majority of ocular HSV infections are caused by HSV type 1 (HSV-1), except in cases of neonatal ocular infections, which are largely caused by HSV-2 contracted during decent through an infected birth canal.

12. Fungal The list covers many fungi including but not limited to: yeasts of Candida spp. filamentous with septae such as Aspergillus spp., Fusarium spp., Cladosporium,spp ., Curvularia non septated such as Rhizopus Parasite The acanthamoeba causes this eye infection. The amoeba attaches to the cells on the outer surface of your cornea. It can also invade the eye by entering through small corneal abrasions (scratches). The infection destroys the cells and moves further into the cornea.

13. RISK FACTOR Wearing contact lens longer than you’re supposed to wear them. This can cause damage to your eye and possibly allow infection to enter. Not cleaning / disinfecting them properly. Wearing contact lens while you’re in pools, hot tubs or outdoor water sources. Other risk factors include: Using corticosteroids over a long period of time. Having a weakened immune system. Having dry eyes. Having an injury to your eyes, including surgery.

14. General Pathology keratitis can advance through four stages: progressive infiltration, active ulceration, regression, and healing. Corneal infections rarely occur in the normal eye They are a result of an alteration in the cornea’s defense mechanisms that allow bacteria to invade when an epithelial defect is present The process of corneal destruction can take place rapidly (within 24hrs with virulent organisms) so that rapid recognition and initiation of treatment is imperative to prevent visual loss.

15. Diagnosis

16. History A detailed history is as important as the examination. characteristics and onset of symptoms Recent trauma to the eye Activities such as swimming in contact lenses Patients should be asked about contact lens A past ocular history should include whether there was a history of eye trauma, previous eye diseases (such as viral keratitis), or eye surgeries A past medical history (history of diabetes), a list of medications and eye drops, a documentation of allergies, a pertinent family history, substance abuse history, and a review of systems should be obtained.

17. Physical examination Vision intraocular pressure pupil assessment slit-lamp examination Fluorescein-to highlight areas of epithelial cell loss Document the location, size and depth of the corneal infiltrate Any anterior chamber reaction Dilate and possible posterior pole involvement should be ruled out If the posterior pole is unable to be visualized, an ultrasound should be performed Test corneal sensation, proper eyelid closure, eyelids and lashes, and nasolacrimal apparatus to look for risk factors for infection

18. Signs Conjunctival injection Focal white infiltrates (with epithelial demarcation and underlying stromal inflammation) Corneal thinning Stromal edema Descemet’s folds Mucopurulent discharge Anterior chamber reaction Hypopyon Eyelid edema may be present in some cases In severe cases, posterior synechiae,  hyphema , and glaucoma may occur.

19. Symptoms rapid onset of ocular pain Redness Photophobia Discharge decreased vision The rate of progression of the symptoms is related to the virulence of the infecting organism.

20. EXAMINATION A complete eye exam  Your provider will use bright lights and a microscope to look at your eyes. A culture of discharge from your eye : Your provider will send a swab with the discharge to a lab for identification. Fluorescein stain test : Your provider will put dye into your eye and then look at it with a blue lamp.

21. slit-lamp examination The examination can be divided into the following 8 stages: External Structures and Adnexa Lids and Lashes Conjunctiva and Sclera Cornea Anterior Chamber Iris and Pupil Lens Anterior Vitreous

22. Herpes Keratitis. Under cobalt-blue illumination, fluorescein bound to the basement membrane underlying damaged corneal epithelium fluoresces bright green. This slit lamp photograph illustrates the unique “dendritic” branching lesions characteristic of herpes keratitis

23. MANAGEMENT If a mild case of keratitis, using lubricant eye drops and letting your eye heal on its own. However, medication normally treats infectious keratitis. If a bacterial infection, antibiotic eye drops. Give a fungal infection, the eye drops will contain antifungal medication. If its a virus, prescribe antiviral eye drops. After a bacterial or viral infection clears up mostly or completely, its might suggest steroid eye drops to reduce swelling. For pain, your provider might give you eye drops that dilate your eye. If you have advanced keratitis, you may need oral medication to treat infections. If don’t respond to medication and keratitis is causing scars on your cornea, its may need a cornea transplant.

24. Diagnostic procedures

25. Medical therapy bacterial

26. Medical therapy fungal Filamentous fungi Superficial keratitis 1 st choice Natamycin 5% ointment 2 nd choice Amphotericin B 0.15% Deep Keratitis Oral itraconazole or Fluconazole along with topical therapy Yeast like fungi Superficial keratitis 1 st choice Amphotericin B 0.15% 2 nd choice Fluconazole 2%/Itraconazole 1%/ Variconazole 1% drops Deep keratitis Oral itraconazole or Fluconazole along with topical therapy Non-responders or presence of desmatocele PK along with topical and systemic antifungals

27. Complications scleral extension of the infection residual corneal scarring irregular astigmatism loss of vision corneal perforation endophthalmitis  .

28. Case discussion and report

29. Conclusion of presentation Keratitis is an inflammation of the cornea the clear, dome-shaped tissue on the front of your eye that covers the pupil and iris. Keratitis may or may not be associated with an infection . The simple classification based on clinical findings will help ophthalmologists, general practitioners to assess patients with this condition and start an adequate initial investigation and treatment

30. Input from the MO opthal Proper history of the patient with relevant history keratitis Able to detect abnormality over the cornea Able to do visual acuity From the slit lamp examination able to sign of suggestive of fungal / bacterial / viral Confirmatory of test still cornea scraping culture and sensitivity

31. Thank you 46

32. References AAO Kanski’s Clinical Ophthalmology 8th Edition Basics of Bacterial Keratitis, CDC https://www1.racgp.org.au/ajgp/2019/august/management-of-microbial-keratitis-in-general-pract