Download - Corneal ulcer
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Corneal UlcerCorneal Ulcer
Bacterial KeratitisBacterial Keratitis
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Natural defenses Natural defenses Eyelids Eyelids Epithelial barrier Epithelial barrier TearsTears
Risk factorsRisk factors Lid abnormalities; Dry eye; Steroids ; Lid abnormalities; Dry eye; Steroids ; prior herpetic infection; Contact lens user; prior herpetic infection; Contact lens user; LASIK; Immune compromise LASIK; Immune compromise Trauma Trauma lagophthalmos; neurotrophic keratitislagophthalmos; neurotrophic keratitis
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PathophysiologyPathophysiology
Interruption of an intact corneal Interruption of an intact corneal epithelium -> entrance of epithelium -> entrance of microorganisms into the corneal microorganisms into the corneal stroma -> proliferate and cause stroma -> proliferate and cause ulceration -> inflammation, necrosis -ulceration -> inflammation, necrosis -> corneal perforation/ scar tissue> corneal perforation/ scar tissue
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PathophysiologyPathophysiology
OrganismsOrganisms – – staphylococcusstaphylococcus streptococcus,streptococcus, pseudomonas,pseudomonas, EnterobacteriaceaeEnterobacteriaceae (including (including Klebsiella, Klebsiella,
Enterobacter, Serratia,Enterobacter, Serratia, and and ProteusProteus)) Moraxella Moraxella
..
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Clinical Features Clinical Features Rapid onset of pain, photophobia Rapid onset of pain, photophobia Decreased vision.Decreased vision. Lid erythema, edema; Lid erythema, edema; Conjunctival congestion; chemosis; lacrimation;Conjunctival congestion; chemosis; lacrimation; Mucopurulent dischargeMucopurulent discharge Ulceration of the epithelium; Ulceration of the epithelium; Corneal infiltrate Corneal infiltrate Dense, suppurative stromal inflammation and Dense, suppurative stromal inflammation and
surrounding stromal edemasurrounding stromal edema Stromal tissue loss; Stromal tissue loss;
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Small ulcer with active area towards the center. The central cornea is hazy and shows Descemet's folds. There is a hypopyon
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Clinical FeaturesClinical Features
Anterior chamber – inflammation; Anterior chamber – inflammation; hypopyonhypopyon Esp. with pseudomonas pyocyanea and Esp. with pseudomonas pyocyanea and
pneumococci -> called hypopyon ulcerspneumococci -> called hypopyon ulcers Regressive stage -> vascularization Regressive stage -> vascularization
-> cicatrization -> opaque scar -> cicatrization -> opaque scar
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DiagnosisDiagnosis
Clinical history & examinationClinical history & examination Slit lamp examination – size/depth/ Slit lamp examination – size/depth/
location/ AC reactionlocation/ AC reaction Fluorescein stainFluorescein stain
Confirmation – corneal scraping for smear Confirmation – corneal scraping for smear and culture and culture SScrapings including the edges -> plated in crapings including the edges -> plated in
blood, chocolate, and Sabouraud agar platesblood, chocolate, and Sabouraud agar plates Stained smears with gram, Giemsa,KOH Stained smears with gram, Giemsa,KOH
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Treatment Treatment
Initial therapy – broad spectrum Initial therapy – broad spectrum topicaltopical
Antibiotics, (Antibiotics, (no organisms in slide smear)no organisms in slide smear) Fluoroquinolones include ciprofloxacin, Fluoroquinolones include ciprofloxacin,
ofloxacin, moxifloxacin or gatifloxacin.ofloxacin, moxifloxacin or gatifloxacin. Fortified Tobramycin 1 drop every hour Fortified Tobramycin 1 drop every hour
alternating with.alternating with. Fortified Cefazolin 1 drop every hour.Fortified Cefazolin 1 drop every hour. Fortified Vancomycin eye drops – reserved Fortified Vancomycin eye drops – reserved
drugdrug
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TreatmentTreatment
The frequency of antibiotic administration The frequency of antibiotic administration should be tapered off parameters: should be tapered off parameters: Decreased density of infiltrateDecreased density of infiltrate Decreased anterior chamber inflammationDecreased anterior chamber inflammation Reepithelialization of the corneal epithelialReepithelialization of the corneal epithelial Improvement in painImprovement in pain
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Corneal Ulcer, Bacterial, Under Treatment No longer hypopyon, thus indicating effective antiinfectious therapy.
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TreatmentTreatment
Cycloplegic agents – atropine, Cycloplegic agents – atropine, Homatropine, CyclopentolateHomatropine, Cyclopentolate Relieve ciliary spasmRelieve ciliary spasm Prevent synechiaePrevent synechiae
Oral pain medicationsOral pain medications Oral antibiotics – scleral expansionOral antibiotics – scleral expansion Repeated scrapingRepeated scraping
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ComplicationsComplications
Descematocele Descematocele Perforation – iris prolapse Perforation – iris prolapse Pseudocornea Pseudocornea Secondary glaucoma Secondary glaucoma Anterior capsular cataract Anterior capsular cataract Spontaneous expulsion of lens and Spontaneous expulsion of lens and
vitreousvitreous EndophthalmitisEndophthalmitis
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Descemetcele, Old
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In the center the tissue has melted away and a Descemetocele has developed.
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Treatment of Treatment of complicated ulcerscomplicated ulcers
Perforated ulcers – Perforated ulcers – Firmly applied bandage; Bandage contact Firmly applied bandage; Bandage contact
lenses lenses forced expiration avoided forced expiration avoided Tissue adhesives Tissue adhesives antiglaucomasantiglaucomas Corneal transplant Corneal transplant
Secondary glaucoma – iv mannitol/ Secondary glaucoma – iv mannitol/ Acetazolamide; Topical antiglaucomasAcetazolamide; Topical antiglaucomas
Late management – Corneal grafts; Late management – Corneal grafts; Cosmetic CL; TattoingCosmetic CL; Tattoing
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Perforated Corneal Ulcer, Keratoplasty
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