sign, symptoms and treatment of corneal ulcers grading of corneal signs

1. Corneal ulcer

2. Corneal ulcers
• Discontinuation in normal epithelial surface of cornea
associated with necrosis of the surrounding corneal
tissue
• It can be:
• Bacterial corneal ulcer
• Fungal corneal ulcers
• Viral corneal ulcers
• Protozal corneal ulcers

3. Causative agent
Bacterial Fungal Viral Protozoal
Staphylococcus
aureus
FILAMENTOUS YEAST HSV I Acanthamoeb
a
Pseudomonas
pyocyanea
Fusarium Candida HSV II
Streptococcus
pneumoniae
Alternaria Cryptococcus
E. Coli Penicillium
N. Meningitidis Aspergillus
N. Gonorrhoea
Cornybacterium
diphtheriae

4. Pathophysiology(Bacterial)
Stage of progressive infiltration
• Lymphocytes infiltrates in epithelium
• Necrosis
Stage of active ulceration
• Greyish infiltration with circumcorneal hyperaemia
• Hypopyon and descemetocele
Stage of regression
• Phagocytosis
• Ulcers begin to heal
Stage of cicatrization
• Epithelium covers the ulcers
• Scars and opacities formation

5. Bacterial ulcer

6. Pathophysiology (Fungal)
▫ Severe inflammatory response
▫ Stromal necrosis
▫ Filamentous fungi can penetrate the intact
Descement’s membrane
▫ Corneal perforation
Fungal ulcer

7. Risk factors
▫ CL wearers
▫ Trauma
▫ Ocular surface diseases
▫ Immuno-compromised diseases
▫ Trauma with vegetable matter
▫ Diabetes
▫ Injury with animal tail

8. Symptoms
 Pain
 Photophobia
 Blurred vision
 Discharge
 Foreign body sensation
 Watering
 Redness

9. Signs
Bacterial Fungal Viral Protozoal
Swelling of lids Dry greyish-white stromal
infiltrate
Punctate epithelial keratitis Irregular and greyish
eipthelial surface
Blepharospasm Elevated rolled out margins Dendritic ulcers Epithelial pseudodendrites
Conjunctival chemosis Satellite lesion Geographical ulcers Focal anterior stromal
infiltrates
Conjunctival hyperaemia Yellowish-white infiltrate Virus-laden cells at margin
of ulcer stain with rose
bengal stain
Radial keratoneuritis
Ciliary congestion Dense suppuration Reduced corneal sensation Enlargement and
coalescence of infiltrates
from ring abscess
Greyish-white
circumscribed infiltrate
Hypopyon Scleritis may develop
Yellowish-white
oval/irregular area of ulcer
Corneal melting
stromal necrosis
Stromal oedema
Hypopyon
Corneal perforation
Endophthalmitis

10. Dendritic ulcer
Superficial punctate keratitis

11. Hypopyon
Acanthamoeba keratitis

12. Corneal oedema
Endophthalmitis

13. Geographic ulcer
Satelite lesion

14. features Mild Moderate Severe
Size < 2 mm 2-5 mm > 5 mm
Depth of ulcer < 20% 20-50% > 50%
Stromal infiltrate Dense
Superficial
Dense upto mid
stroma
Dense deep
stromal
Scleral
involvement
- - present
Grading of corneal ulcers

15. Grading
Grade AC cells
Grade 0 None
Grade 1 1-15 cells
Grade 2 15-25 cells
Grade 3 > 25 cells
Grade Aqueous flares
Grade 0 Absent
Grade 1 Mild (barely detected)
Grade 2 Moderate (iris and lens seen)
Grade 3 Severe (iris and lens not seen)

16. Grade Corneal oedema
Grade 0 Absent
Grade 1 Mild
Grade 2 Moderate
Grade 3 Severe
Grade Conjunctival congestion
Grade 0 None
Grade 1 Mild (some vessels injected)
Grade 2 Moderate (diffusely injected)
Grade 3 Severe (intensely injected)

17. Treatment
Bacterial Fungal Viral Protozoal
Topical antibiotics:
Ciprofloxacin
Vancomycin
Ofloxacin
Moxifloxacin
Removal of eithelium Antiviral agent:
Acyclovir e/d (3%)
Gancyclovir e/d (0.15%)
Trifluorothymidine e/d (1%)
Antiamoebic agent
Propamidine isoethionate
(0-1%)
Polyhexamethylene
biguanide (0.02%)
Ciprofloxacin Clotrimazole
Miconazole
Oral antibiotics:
T. Ciprofloxacin
Topical-
Filamentous:
Natamycin (5%)
Econazole (1%)
Amphotericin B (0.15%)
Miconazole (1%)
Debridement
For dendritic ulcers
Debridement
Mydriatics:
Atropine (1%)
cyclopentolate (1%)
Candida:
Econazole (1%)
Natamycin (5%)
Fluconazole (2%)
Clotrimazole (1%)
Oral ketoconazole (200mg)
Topical steroids: Subconjunctival fluconazole
Systemic antifungals:
Itraconazole (100mg)
Voriconazole (100mg)
Excisional penetrating
keratoplasty

18. Thank you…