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Corneal ulcers

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

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Corneal ulcers

  1. 1. Corneal ulcer
  2. 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. 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. 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. 5. Bacterial ulcer
  6. 6. Pathophysiology (Fungal) ▫ Severe inflammatory response ▫ Stromal necrosis ▫ Filamentous fungi can penetrate the intact Descement’s membrane ▫ Corneal perforation Fungal ulcer
  7. 7. Risk factors ▫ CL wearers ▫ Trauma ▫ Ocular surface diseases ▫ Immuno-compromised diseases ▫ Trauma with vegetable matter ▫ Diabetes ▫ Injury with animal tail
  8. 8. Symptoms  Pain  Photophobia  Blurred vision  Discharge  Foreign body sensation  Watering  Redness
  9. 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. 10. Dendritic ulcer Superficial punctate keratitis
  11. 11. Hypopyon Acanthamoeba keratitis
  12. 12. Corneal oedema Endophthalmitis
  13. 13. Geographic ulcer Satelite lesion
  14. 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. 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. 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. 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. 18. Thank you…