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
InfectiousNon 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 INFECTIOUSINFECTIOUS
No painPain
No dischargeDischarge
AC reaction: absentAC reaction: present
PeripheralCentral
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

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

12. 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.

14. Circumferential Healing

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

16. 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

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

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

19. 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

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

22. 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

23. Peripheral Ulcerative Keratitis
Associated With Systemic
Autoimmune Disease

24. 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 inhibitors

25. 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

26. Clinically
Crescentic ulceration Contact lens cornea

27. Perforation Limbitis, episcleritis or scleritis

28. 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

29. 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

30. 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

31. Treatment by lubricants and elimination of cause

32. 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

33. • 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

34. Thank you