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Corneal ulcer(bactrial,fungal) 25.02.16, dr.k.n.jha

Corneal ulcer(bactrial,fungal) 25.02.16, dr.k.n.jha

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Corneal ulcer(bactrial,fungal) 25.02.16, dr.k.n.jha

  1. 1. DR K N Jha,MS Professor of Ophthalmology Email : kirtinath.jha@gmail.com
  2. 2. Learning Aim  What is corneal ulcer ?  Etiology, pathology, symptoms and signs  Differential diagnosis  Laboratory diagnosis  Treatment  Complications
  3. 3. Corneal ulcer ● Loss of corneal epithelium with inflammation in the surrounding cornea is called corneal ulcer. ● Corneal ulcer is one the common cause of blindness. ● It is an ocular emergency.
  4. 4. Causative Organisms  Infections are almost always exogenous  Causative organism: S.aureus, S.epidermidis, S. pneumoniae, Pseudomonas aeruginosa,.  Uncommon: Neisseria gonorrhoeae, E. coli  Fungi : Aspergillus and Fusarium sp
  5. 5. Predisposing factors • Trauma: e.g. Contact lenses, trichiasis, surgery • Topical steroids • Dry eye syndrome • Lagophthalmos : e.g. Facial nerve palsy • Neurotrophic keratitis resulting from viral infections and lesions of ophthalmic division of Trigeminal nerve • Deficiency states ( Vit. A ) and metabolic diseases ( DM) • Poor local hygiene, and local infection ( chronic dacryocystitis)
  6. 6. Pathogenesis of Bacterial Ulcers  Bacterial adherence, proliferation, and invasion of corneal stromal lamellae  Corneal inflammation with local production of cytokines and chemokines  Diapedesis and migration of neutrophils into the peripheral cornea from limbal vessels  Release of bacterial proteases. Enzymes released by neutrophils and activation of matrix metallopreoteinases exacerbate inflammatory necrosis.  Healing begins with control of microbial replication.
  7. 7. Pathology of Corneal Ulcer • Localized necrosis of the anterior layers of the cornea • Desquamation of the epithelium and damage to the Bowman’s membrane • Formation of the slough and purulent infiltration • Regeneration of the epithelium
  8. 8. Clinical Features of Corneal ulcer  Symptoms : Painful red eye, diminution of vision, photophobia  Signs: Circumcorneal congestion, ulceration, inflammation, and necrosis of corneal layers
  9. 9. Fungal Corneal ulcer  History of trauma with vegetable matter e.g., eye trauma during harvesting of crops.  Ulcer appears dry; it has feathery edges.  Satellite lesions may be seen.  Endothelial plaque may be visible.  Hypopyon is common.
  10. 10. Fungal corneal ulcer
  11. 11. Differential Diagnosis - Acute conjunctivitis - Acute iridocyclitis - Acute congestive glaucoma
  12. 12. Complications of Corneal Ulcer • Descematocele • Perforation and its complications - Anterior synechia , Iris prolapse, expulsion of lens and vitreous, Intraocular hemorrhage, Endophthalmitis / panophthalmitis • Secondary glaucoma • Anterior capsular cataract • Staphyloma formation
  13. 13. Assessment of Corneal ulcer  History, general, and systemic examination  - Visual acuity: may be low - Eye and Ocular adnexa: Eye lid , lacrimal sac Conjunctiva: circumcorneal congestion Corneal ulcer: size, site ,surface, margin, slough, corneal sensation, thinning , satellite lesions Anterior chamber: Cells, flare, hypopyon Pupil
  14. 14. Microbiological Investigations  The majority are managed without smears or cultures.  Scraping from the ulcer margins and the base of the ulcer  Examination of Smear stained with Gram stain, Giemsa stain, KOH mount for fungi  Culture on blood agar, chocolate agar, thioglycollate broth, and Sabouraud’s dextrose agar
  15. 15. Management Principles: • Control of infection • Symptomatic relief • Prevention of complications
  16. 16. Control of Infection Topical antibiotics • Fortified cephazolin eye drop 50 mg / ml 1/4/6 hourly • Fortified tobramycin eye drop 14 mg/ ml 1/4/6 hourly Alternatives Fortified vancomycin eye drop 25-50 mg/ml drop Fluoroquinolone eye drop ( Cipro/ oflo/ moxifloxacin/ gatifloxacin) 0.3 % drop  Dose: 1 drop every 5-15 min for 1 hour . ½ to 1 hourly thereafter. Reduce the dose later.
  17. 17. Antimicrobials for Fungal corneal ulcer  Topical antifungal drops: - Natamycin 5 % 1 hourly by day and 2 hourly by night for 6 weeks to 6 mo - Amphotericin B 0.15/ 0.3 % frequent instillation  Oral antifungal agents; Ketoconazole 200-600 mg/ day Fluconazole 200-400mg/ day
  18. 18. Supportive Therapy  Cycloplegics : Atropine 1 % eye drop t.i.d.  Debridement of the ulcer  Treatment of complications: perforation, secondary glaucoma
  19. 19. Outcome of corneal ulcer  Healing with out opacity  Healing with opacity  Staphyloma  Secondary glaucoma  Cataract  Phthisis bulbi
  20. 20. Complete healing
  21. 21. Point to remember  Corneal ulcer causes painful red eye.  Trauma often is the predisposing event.  Community acquired infection often does not require microbiological work-up.  Fluoroquinolone 0.3 % eye drop 1-2 hourly, is adequate for small, peripheral ulcers.  Atropine ointment 1% tds relieves pain, prevents synechia.  All cases must be referred to ophthalmologist.
  22. 22. Can you recall ?  Definition of a corneal ulcer  Causative organisms  Symptoms and Signs  Microbiological investigation  Treatment of corneal ulcer  Complications of corneal ulcer  Outcome of corneal ulcer

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