This PPT is beneficial for undergraduate Medical students

1. Dr. Atul Kumar Anand
Senior Resident
AIIMS Patna

2.  CORNEAL ULCER MAY BE DEFINED AS A
DISCONTINUATION/BREACH IN THE
EPITHELIAL SURFACE OF THE CORNEA
ASSOCIATED WITH NECROSIS &
INNFLAMMATION OF THE SURROUNDING
CORNEAL TISSUE.
 CHARACTERISED BY EDEMA & CELLULAR
INFILTRATION

3.  Most of viruses tend to affect epithelium of both the
conjunctiva & cornea, hence typical viral lesions
constitute the viral keratoconjunctivitis.
 Common viral infections include:-
 Herpes simplex keratitis
 Herpes Zoster Ophthalmicus(HZO)
 Adenovirus keratitis

4. i. HERPES SIMPLEX KERATITIS
 Ocular infections with herpes simplex virus (HSV)
are extremely common & constitute herpetic
keratoconjunctivitis & iritis.
ETIOLOGY:
Herpes simplex virus (HSV):
 It is a DNA virus.
 Its only natural host is man.
 According to different clinical & immunological
properties, HSV is of two types: HSV type I typically
causes infection above the waist & HSV type II
below the waist (herpes genitalis).

5. Mode Of Infection:
1. HSV-I infection: It is acquired by kissing or coming in
close contact with a patient suffering from herpes
labialis.
2. HSV-II infection: It is transmitted to eyes of neonates
through infected genitalia of the mother.
Ocular Lesions Of Herpes Simplex:
[A] Primary herpes:
1. Skin lesions
2. Conjunctiva-acute follicular conjunctivitis
3. Cornea:-
a. Fine epithelial punctate keratitis
b. Coarse epithelial punctate keratitis
c. Dendritic ulcer

6. [B] Recurrent herpes:
1. Active Epithelial keratitis:
i. Punctate epithelial keratitis
ii. Dendritic ulcer
iii. Geographical ulcer
2. Stromal keratitis
i. Disciform keratitis
ii. Diffuse stromal necrotic keratitis
3. Meta-herpetic (Trophic) keratitis
4. Herpetic iridocyclitis

7. [A] Primary Ocular Herpes
 Primary infection (first attack) involves a nonimmune
person.
 It typically occurs in children betn 6 months & 5 yrs & in
teenagers.
Clinical Features:
1. Skin lesions: Vesicular lesions may occur
involving skin of lids, periorbital region & the lid
margin(vesicular blepharitis).
2. Acute follicular conjunctivitis with regional
lymphadenitis is the usual.
3. Keratitis: Cornea is involved in about 50% of the
cases. The keratitis can occur as a coarse
punctate or diffuse branching epithelial keratitis
that does not involve the stroma.

8. [B] Recurrent Ocular Herpes
 The virus which lies dormant in the trigeminal
ganglion, periodically reactivates & causes
recurrent infection.
1. Epithelial keratitis:
i. Punctate epithelial keratitis:
 The initial epithelial lesions of recurrent herpes
resemble those seen in primary herpes & may
be either in the form of fine or coarse
superficial punctuate lesions.
ii. Dendritic ulcer:
 Dendritic ulcer is a typical lesion of recurrent
epithelial keratitis.
 The ulcer is of an irregular, zigzag linear
branching shape.

9. iii. Geographical ulcer:
Sometimes, the branches of dendritic ulcer
enlarge & coalesce to form a large
epithelial ulcer with a ‘geographical’ or
‘amoeboid’ configuration, hence the name.
Symptoms
i. Photophobia
ii. Lacrimation
iii. Pain/mild discomfort.
iv. Redness
v. Blurring of vision

10. • Central desquamation results in a linear-branching
(dendritic) ulcer
• The ends of the ulcer have characteristic terminal
buds and the bed of the ulcer stains well with
fluorescein
• Margin of the ulcer stain with rose Bengal
• Corneal sensation is reduced
• Elevated IOP may occur
• Following healing mild subepithelial scarring may
develop.

12. Linear branching
Ulcer stains with Fluorescein
Reduced corneal sensation

14. Rose bengal stain

15. Topical
• Aciclovir 3% ointment or ganciclovir 0.15% gel (5 times
daily)
• Trifluridine (up to nine times a day)
• cycloplegics
 Debridement
Protect adjacent healthy epithelium from infection
 Oral antiviral
• Probably indicated in most immunodeficient patients,
poorly tolerated, or in resistant cases
 Skin lesions
• Treated with acyclovir cream five times daily
 IOP control
• If glaucoma treatment is necessary, prostaglandin derivatives should
probably be avoided

16. 2. Stromal keratitis:
i. Disciform keratitis:
 Due to delayed hypersensitivity reaction to HSV antigen.
Low grade stromal inflammation & damage to underlying
endothelium. Endothelium damage results in corneal
oedema due to imbibition of aqueous humour.
Signs:
i. Focal disc-shaped patch of stromal oedema w/o necrosis
ii. Folds in descemet’s membrane
iii. Keratic precipitates
iv. Ring of stromal infiltrate(Wessley immune ring) B/W viral
antigen & host antibody
v. Corneal sensations are diminished
vi. IOP may be raised.
vii. In severe cases marked anterior uveitis

18. Topical steroids (prednisolone 1% or
dexamethasone 0.1%) with antiviral
cover(acyclovir3%)
 Steroids tapered over a period of several
weeks
With active epithelial ulceration
 Antiviral started 5-7 days before steroids

19. Diffuse Stromal Necrotic Keratitis:
 It is a type of interstitial keratitis caused by active
viral invasion & tissue destruction.
Symptoms:
i. Pain, Photophobia, Redness
Signs:
i. Anterior uveitis with keratic precipitates underlying the area of active
stromal infiltration
ii. Stromal necrosis and melting, often with profound interstitial
opacification
Treatment: Similar to that of disciform keratitis, but frequently
unsatisfactory
Keratoplasty when eye become quiet, otherwise recurrence in
graft.

21. Metaherpetic Keratitis
 It is not an active viral disease, but is a
mechanical healing problem which occurs at the
site of a previous herpetic ulcer.
Clinically it represents as an indolent linear or
ovoid epithelial defect.
Treatment :- aimed at promoting healing by
i. Lubricants (artificial tears)
ii. Bandage soft contact lens
iii. Lid closure (tarsorrhaphy).

22. HERPES ZOSTER OPHTHALMICUS
 Herpes zoster ophthalmicus is an acute infection
of Gasserian ganglion of the Vth cranial nerve by
the varicella-zoster virus (VZV).
 It constitutes approx 10% of all cases of herpes
zoster.
ETIOLOGY
Varicella-zoster virus:
 It is a DNA virus & produces acidophilic
intranuclear inclusion bodies.
 It is neurotropic in nature.

23.  Chicken pox- Varicella
Zoster virus
Virus dormant in Gasserian
ganglion
Immunity depressed
Infection activates and virus
travels down the branches
of ophthalmic division of
trigeminal nerve(supra
orbital aupre and infra
trochlear)

24. Clinical Features
i. Frontal nerve is more frequently affected than
the lacrimal & nasociliary nerves.
ii. About 50% cases of herpes zoster ophthalmicus
get ocular complications.
iii. The Hutchinson’s rule, which implies that ocular
involvement is frequent if the side or tip of nose
presents vesicles, is useful but not infallible.
iv. Lesions of herpes zoster are strictly limited to
one side of the midline of head.

25. Clinical Phases of H. zoster ophthalmicus
are:
i. Acute, which may totally resolve.
ii. Chronic, which may persist for years.
iii. Relapsing, where the acute or chronic
lesions reappear sometimes years later.

26.  Primary infection occurs before the age of 10,
manifests as chickenpox (varicella)
 The virus then establishes a latent state in the
sensory ganglia
 When there is diminished virus-specific and
cell-mediated immunity, the virus may
reactivate and spread to the corresponding
dermatome along a spinal or cranial nerve to
generate the characteristic unilateral vesicular
exanthema

27.  Begins with a prodrome of influenza-like
illness -fatigue, malaise, nausea and mild
fever accompanied by progressive pain and
skin hyperesthesia
 A diffuse erythematous or maculopapular
rash then appears over a single dermatome
3–5 days later
 These eruptions progress to form clusters of
papules and clear vesicles, which then evolve
through stages of pustulation and crusting

29.  Usually appear at the subsidence of skin
eruptoions & may be as follows
Conjuctivitis:- one of the M/C manifestation of HZO, as
mucopurulent conjunctivitis with petechial haem’ge,
follicular conjunctivitis with lymphadenopathy
Keratitis:- punctate epithelia keratitis, microdendritic
epithelial ulcers, nummular keratitis, disciform keratitis
 Episcleritis & scleritis
 Iridocyclitis
 Secondary glaucoma
 Anterior segment necrosis & phthisis bulbi
 Acute retinal necrosis, optic neuritis, CN palsy

30. Oral Acyclovir 800mg 5 times/day for 10 days
Analgesics
Topical acyclovir ointment & cycloplegics
Topical antibiotics, lubricants
In case of iridocyclitis add topical steroids and
cycloplegics
Amitriptyline
For sec. glaucoma- timolol, acetazolamide
Keratoplasty