Non infectious corneal ulcers

This presentation describes all a clinical aspects of noninfectious corneal ulcers

1. Non Infectious Corneal Ulcers

2. Corneal Ulcers Def : Corneal ulcers are defects in the corneal epithelium with or without stromal infiltration. Types: A) Infectious ulcerative keratitis B) Non infectious ulcerative keratitis

3. Bacteria and Fungi Viruses Acanthamoeba Systemic Autoimmune/ Inflammatory Local Toxic Infectious Non infectious Etiology

4. Non Infectious Ulcerative Keratitis Causes: Local causes: Punctate marginal keratitis: Staphylococci, Streptococci, hypersensitivity to medications Peripheral keratitis associated with blepharitis : Systemic causes: Generally manifestation of systemic, immune-mediated disease Most common: Rheumatoid arthritis, Wegener’s granulomatosis and polyarteritis nodosa

5. Non INFECTIOUS INFECTIOUS No pain Pain No discharge Discharge AC reaction: absent AC reaction: present Peripheral Central Trauma: ------- Trauma : ++++

6. Important Types - Marginal keratitis - Mooren ulcer - Terrien marginal degeneration - Associated with systemic autoimmune diseases - Dellen Other types: Phlyctenulosis

7. Marginal keratitis

8. Marginal Keratitis • Caused by hypersensitivity reaction against Staphylococcal exotoxin and cell wall proteins with deposition of Ag- Ab complex in peripheral cornea • Lesions are culture negative but S. aureus can be isolated from lid margin

9. Signs and symptoms • Chronic Blepheritis • Subepithelial marginal infiltrates seperated from limbus by a clear zone • Conjunctival Injection • Coalescence and circumferential spread • Little or no AC reaction • Resolution usually occurs in 1-4 wks , occasionally there is residual superficial scarring

10. Treatment • Weak topical steroid • May be combined with a topical antibiotic • Tetracycline orally • For children , breastfeeding and pregnancy erythromycin • Treatment of blepheritis

11. Mooren's Ulcer • Rare autoimmune disease • Characterized by – Progressive , – Peripheral,with Limbitis – Circumferential , stromal corneal ulceration Vascularization involving the bed of the ulcer up to its leading edge but not beyond – Later central spread Risk factors for Mooren's ulcer include corneal surgery, previous trauma, and infection.

12. Circumferential Healing

13. Complications • Severe astigmatism due to extensive vascularization & fibrosis • Perforation following minor trauma • Secondary bacterial infection

14. Management • Topical – Steroids – Cyclosporin (weeks to show significant effect) – Artificial tears – Collagenase inhibitors ( acetylcystine ) • bandage contact lenses • Conjunctival resection • Immunosuppression • Systemic collagenase inhibitors such as doxycycline Lamellar keratoplasty, keratoepithelioplasty and conjunctival flap and patch grafts

15. Terrien marginal degeneration • Idiopathic thinning of the peripheral cornea • Young adult to elderly patients • Uncommon • 75% males • Usually bilateral

16. Symptoms • Asymptomatic • Gradual visual deterioration can occur due to astigmatism • A few patients experience episodic pain and inflammation

17. Signs It causes a slowly progressive non-inflammatory, unilateral or asymmetrically bilateral peripheral corneal thinning and is associated with corneal neovascularization, Opacification and lipid deposition

18. - Perforation is rare but may be spontaneous or follow blunt trauma - Pseudopterygia sometimes develop

19. Management • Safety spectacles if thinning is significant • Contact lenses for astigmatism. Scleral or soft lenses with rigid gas permeable • Surgery :- Cresentric excision of the gutter with lamellar or full-thickness corneoscleral patch grafts transplantation

20. Peripheral Ulcerative Keratitis Associated With Systemic Autoimmune Disease

21. Destructive inflammation of the peripheral cornea associated with corneal epithelial sloughing and Keratolysis The mechanism includes immune complex deposition in peripheral cornea, episcleral and conjunctival capillary occlusion with secondary cytokine release and inflammatory cell recruitment, the upregulation of collagenases and reduced activity of their inhibitor s

22. Systemic associations • Rheumatoid arthritis (most common) – PUK is bilateral in 30% and tends to occur in advanced RA • Wegener granulomatosis (2nd most common) – In contrast to RA ocular complications are the initial presentation in 50% • Other conditions include polyarteritis nodosa , relapsing polychondritis ,SLE , Churg – Strauss ,Microscopic Polyangiitis , Inflammatory Bowel Disease

23. Clinically Crescentic ulceration Contact lens cornea

24. Perforation Limbitis , episcleritis or scleritis

25. Peripheral corneal involvement in rheumatoid arthritis Chronic and asymptomatic Circumferential thinning with intact epithelium (‘contact lens cornea’) Acute and painful Circumferential ulceration and infiltration Without inflammation With inflammation

26. Management  Principally with systemic immunosuppression in collaboration with a rheumatologist Topical  Artificial tears (preservative-free)  Antibiotics as prophylaxis  Steroids may worsen thinning so are generally avoided Systemic  Steroids (via pulsed IV administration) are used to control acute disease, with immunosuppressive therapy and biological blockers for longer-term management  Tetracycline for its anticollagenase effect

27. Dellen Localized corneal disturbance associated with drying of a focal area Usually associated with an adjacent elevated lesion as pinguecula or large subconjunctival haemorrhage that impairs physiological lubrication

28. Treatment by lubricants and elimination of cause

29. Phlyctenulosis Uncommon, unilateral - typically affects children Severe photophobia, lacrimation and blepharospasm Delayed hypersensitivity reaction to staphylococcal antigen. In developing countries, the majority are associated with tuberculosis or helminthic infestation

30. Small pinkish-white nodule near limbus Usually transient and resolves spontaneously Starts astride limbus Resolves spontaneously or extends onto cornea Conjunctival phlycten Treatment - Topical steroids Corneal phlycten

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