Viral corneal ulcer

viral corneal ulcer

1. VIRAL CORNEAL ULCER

2. Incidence of viral corneal ulcer has become much greater due to the role of antibiotics in eliminating pathogenic bacterial flora. Epithelium of both conjunctiva and cornea is affected . Typical viral lesions constitute the viral keratoconjunctivitis

3. Common viral infections Herpes simplex keratitis Herpes zoster ophthalmicus Adenovirus keratitis

4. Herpes simplex keratitis Etiology Herpes simplex virus DNA virus natural host man , Epitheliotropic may become neurotropic Types 1.HSV-I 2.HSV-II

5. Ocular lesions of herpes simplex Primary herpes Skin lesions Conjunctiva-acute follicular conjunctivis Cornea Fine epithelial punctate keratitis Coarse epithelial punctate keratitis Dendritic keratitis

6. Continued B. Recurrent herpes Active epithelial keratitis Punctate epithelial keratitis Dendritic ulcer Geographical ulcer 2. Stromal keraitis i . Disciform keratitis ii. Diffuse sromal necrotic keratitis 3. Trophic keratitis <meta-herpetic> 4. Herpetic iridocyclitis

7. Primary ocular herpes Initial infection due to direct contact of mucous membrane with infected secretions First attack involves non-immune person Child of 6 months to 5 yrs and in teenagers.

8. Clinical features Systemic features> mild fever ,malaise and non- suppurative lymphadenopathy . fetal when encephalitis develops 2. Skin lesions> seen in face, lips ,lids , periorbital region 3. Ocular lesion> acute follicular keratitis with regional lymphadenitis, keratitis -involve 50% of cornea

9. Recurrent ocular herpes Virus which lies dormant in trigeminal ganglion, periodically reactivates and replicates . Reactivated virus travels down along trigeminal nerve to cause recurrent infection. Its is typically unilateral disease. Predisposing stress stimuli like malarial fever, flu, uv radiation exposure, general ill health, emotional or physical exhaustion, mild trauma, menstrual stress and immunosuppressive agent.

10. 1. Epithelial keratitis Symptoms > redness ,pain, photophobia, tearing and decreased vision. Signs> punctate epithelial keratitis , dendritic ulcer and geographical ulcer

11. Treatment Specific treatment Antiviral drugs Acycloguanosine < Aciclovir > 3% ointment ,5 times a day for 14-21 days Ganciclovir 0.15% gel , 5times a day and then 3 times a day for 5 days Triflurothymidine 1% drops , 2 hourly and then 4 times a day for 5 days Adenine arabinoside 3% ointment 5 times a day and then 3 times a day for 5 days

12. Continued 2. Mechanical debridement> involved area along with a rim of surrounding healthy epithelium with the help of sterile cotton applicator under magnification helps by removing the virus-laden cells 3. Systemic antiviral drugs> for 10-21days Acyclovir 400mg p.o.tid to bid or Famcyclovir 250mg p.o . bid or Valacyclovir 500mg p.o . bid

13. Continued B. Non specific supportive therapy Cycloplegic drugs 1% atropine eye drops or ointmemnt Systematic analgesics and anti-inflammatory drugs< paracetamol and ibuprofen Vitamins <A,B- complex,C >

14. 2. Stromal keratitis Disciform keratitis Pathogenesis Delayed hypersensitivity to HSV antigen forms endothelitis disciform corneal oedema due to imbibition of aqueous humour

15. Symptoms> photophobia, mild or moderate ocular discomfort , reduction of visual acuity Signs Focal disc-shaped patch 2. Keratic precipitates 3. Ring of stromal infiltrate< wessley immune ring> 4. Corneal sensation diminished. 5. IOP may be raised

16. Treatment Diluted steroid eye drops instilled 4-5 times a day with an antiviral cover<acyclovir 3%> twice a day and steroid should be tapered over a period of several weeks. Antiviral drugs should be started 5-7 days before steroids Non specific supportive therapy.

17. B. Stromal necrotic keratitis Type of interstitial keratitis <IK> caused by active viral invasion and tissue destruction. Symptoms pain, photophobia and redness

18. Continued Signs Corneal lesions include necrotic, blotchy, cheesy white infiltrates Mild iritis and keratic precipitates are usually associated<herpetic keratouveitis > Stromal vascularization

19. Treatment Similar to disciform keratitis but results are unsatisfactory Systemic antiviral drugs for 10-21 days is considered in recurrent cases and associated with herpetic uveitis . Keratoplasty should be delayed until eye has quiet with little or steroidal treatment for several months, because viral interstitial keratitis is the form of herpes which is most likely to recur in a new graft.

20. 3.Metaherpetic keratitis Occurs at the site of previous herpatic ulcers. Persistent defect in BM of corneal epithelium. Clinical features 1. Indolent linear or ovoid epithelial defect 2. margin grey thickened

21. Continued Treatment lubricants<artificial tears> Bandage soft contact lens Lid closure< tarsorrhaphy >

22. Herpes zoster ophthalmicus An acute infection of gasserian ganglion of 5 th nerve by varicella zoster virus<VZV> 10% of all cases of herpes zoster Occurs in immuno -compromised individuals. Etiology VZV is DNA virus and produces acidophilic intranuclear inclusion bodies Neurotropic in nature.

23. Clinical features Frontal nerve is frequently affected than lacrimal and nasociliary nerve Ocular complications occurs in about 50% cases hutchinson’s rule, which implies that ocular involvement is frequent if the side or tip of nose presents vesicles, is useful but not infallible.

24. Continued Lesions are strictly limited to one side of the midline of head.

25. Clinical phases Acute phase – resolve within few weeks Chronic phase – persist for years Relapsing phase – reappear

26. 1.Acute phase lesion General features illness is sudden with fever, malaise , and severe neuralgic pain B. Cutaneous lesions usually after 3-4 days of the onset of disease the skin of eye lids and other affected areas become red and edematous followed by vesicle formation .

27. Cutaneous lesions continued Vesicles change into pustules Burst to become crusting ulcers. Permanent pitted scar are left. Severe neuralgic pain diminishes with the subsidence of eruptive phase.

28. C. Ocular lesions May present as a combination of two or more of the following lesions. Conjunctivitis – mucopurulent conjunctivitis with petechial haemorrhages with regional lymphadenopathy . Zoster keratitis – occurs in 40% of cases and in several forms.

29. Continued Epithelial keratitis Microdendritic keratitis Nummular keratitis-1/3 of cases Disciform keraitis-50% of cases

30. Continued 3. Episcleritis and scleritis - ½ cases 4. Iridocyclitis - may / may not associated with keratitis associated with hypopyon and hyphaema 5. Acute retinal necrosis 6. Secondary glaucoma 7. Anterior segment necrosis and phthisis bulbi

31. D. Associated neurological complications Motor nerve palsies-3 rd ,4 th ,6 th or 7 th nerve optic neuritis in 1% of cases Encephalitis <rare>

32. 2. Chronic phase lesion Post herpetic neuralgia-persistent pain even after subsidence of eruptive phase, pain is mild to moderate in intensity worsens at night and aggravated by touch and heat. Lid lesions- sequelae of scarring include ptosis , trichiasis , entropion and notching. Conjunctival lesions- chronic mucous secreting conjunctivitis

33. Continued IV. Corneal lesion Neuroparalytic ulceration-acute infection and gasserian ganglion Exposure keratitis - supervene in some cases due to associated facial palsy. Mucous plaque keratitis -in 5%, stain with rose bengal . V.Scleritis and uveitis

34. 3. Relapsing phase lesions May recur even after 10 years of acute phase include nummular keratitis , episcleritis , scleritis , mucous plaque keratitis and secondary glaucoma.

35. Treatment Systemic therapy Oral antiviral drugs- acyclovir 800 mg 5 times a day for 10 days , or valaciclovir 500 mg tds II. Analgesics- combination of mephenamic acid and paracetamol or pentazocin or even pethidine III. Systemic steroids- given cases developing neurological complications such as 3 rd nerve palsy and optic neuritis.

36. Continued IV. Cimetidine - 300 mg qid for 2-3 weeks starting within 48-72 hours of onset V. Amitriptyline - relieve depression in acute phase. 2.Local therapy for skin lesions Antibiotic –corticosteroid skin ointment or lotion- 3 times a day

37. 3. Local therapy of ocular lesion For zoster keratitis , iridocyclitis and scleritis Topical steroid eyedrops 4 times a day Cyclopentolate eyedrops bd or atropine eye ointment od Topical acyclovir 3% eye ointment 5 times a day for 2 weeks ii.To prevent secondary infections topical antibiotics are used.

38. Continued iii. For secondary glaucoma- 0.5% timolol or 0.5% betaoxol drops bd , acetazolamide 250 mg qid iv. For mucous plaque-topical mucolytics e.g acetyl cysteine 5 to 10% ,3 times a day. v.For persistent epithelial defects lubricating artificial tear drops Bandage soft contact lens.

39. Surgical treatment For neuroparalytic corneal ulcer caused by herpes zoster. Lateral tarsorrhaphy Amniotic membrane transplantation or conjunctival flap for non healing cases Tissue adhesive with bandage contact lens for corneal perforation Keratoplasty – visual rehabilitation of zoster patient with dense scarring .