Infective keratitis workup

1. Infective keratitis
Samhaa Mohammed Abd Elmoneim
Zagazig Ophthalmic Hospital
2021

2. Keratitis
• Describe any lesion systematically to reach DD &
Dx.
• Differentiate different infectious types clinically by
Hx, Ex.
• Construct your plan for appropriate initial Tx to
each case.
• Justify your plan in work up of the recalcitrant
cases

3. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic
What are the main differences?

4. Infective keratitis
C/P:
• Pain, photophobia, blurred vision, discharge
• Epithelial defect
• Anterior chamber reaction (complicated cases,
associated anterior uveitis)
• Infiltrate, immune Wessely ring
• Scar, odema, melting, abscess, NV,
descemetocele, perforation)
‫التشابه‬ ‫أوجه‬
How to differentiate despite
C/P similarities?

5. What discriminate infectious keratitis?
History Examination Investigation Treatment

6. Examination/ Describe
Site (centration, depth)
size/ shape
Surrounding
Laterality

7. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

8. Viral keratitis
HSV
(local manifestation
↑)
Adenoviral
Kerato-
conjunctivitis
HZV
(systemic ↑)

9. Is investigation crucial in herbetic keratitis
Dx?
• Yes
• No

10. Does herbetic keratitis lead to blindness?
• Yes
• No

11. Is topical steroid used in treatment of
herbetic eye disease?
• Yes
• No

12. Case
32 y old F, came to outpatient clinic with Rt eye
pain, photophobia, red eye, decreased vision
No Present Hx Trauma, CL
Past Hx of CL since 4y
DD

13. What discriminate Herbetic keratitis?
History Examination Investigation Treatment
Atopy,
immunosuppression,
recurrence, stress,
poor hygeine

14. Examination/ Describe
Site (centration, depth)
size/ shape
Surrounding
Laterality

15. HSV
Epithelial
- Dendritic/
Geographical
- Post footprints
Stromal
- Immune keratitis
- Necrotizing
- lipid keratopathy
Endothelial/
Disciform
Keratouveitis
- Anterior
- ARN
Metaherpetic
- Neurotrophic
- superinfection
Lid vesicles
Follicular Conjunctivitis

16. - Dendritic, terminal
bulbs, unilateral
- Bilateral → (immune-
compromised eye, Atopy)
• Tx to decrease n.
damage, other layers
involvement, recurrence.
• Topical Ganvir/ Zovirax
(less toxic) OR oral
Acyclovir 400mg (1*5/d
for 10d - 2wks)
• Lubricant
• ±Topical AB/ cycloplegic
• Epithelial debridement?
Recurrent > once / year
Prophylactic oral Acyclovir
400mg twice/day for 1 year

17. Footprint faint sub-epithelial
opacities
(corresponding to dendritic
epithelial defects)
Follow up with same Tx
DD: stromal keratitis
Geographical ulcer
Coalesced multi dendritic
ulcers
Tx: Stop topical steroids

18. Transmission
Contact with secretion of lid lesions
conjunctivitis

19. HSV
Epithelial
- Dendritic/
Geographical
- Post footprints
Stromal
- Immune keratitis
- Necrotizing
- lipid keratopathy
Endothelial/
Disciform Keratouveitis
- Anterior
- ARN
- PORN
Metaherpetic
- Neurotrophic
- superinfection
Same Tx
Lid vesicles
Follicular Conjunctivitis

20. • Ab complement # viral Ag
• Mid- deep stromal Haze →
Scarring/ nv/ lipid keratopathy
• Epithelial defect in (epithelial
dendritic, or necrotizing type)
• Tx, of epithelial keratitis
1st (if present) for 1-2 d
• Definite Tx: Topical
steroid 4-8 times (NO
taper till being inactive)
+ topical OR oral Ayclovir
400mg 5 times/ d.
Prophylactic oral
Acyclovir 400mg twice/day
for 1 year (from 1st episode of
stromal, disciform keratitis and
keratouveitis)
Immune stromal keratitis

21. Lipid
keratopathy
Corneal scarring
and vascularization

22. • Cell mediated immune reaction to
endothelium
• KPs, odema → decompensation
• Tx, of epithelial keratitis 1st (if
present) for 1-2 d.
• Definite Tx: Topical steroid
4-8 times (NO taper till being
inactive)
+ topical OR oral Ayclovir
400mg 5 times/ d.
• Prophylactic oral Acyclovir
400mg twice/day for 1 year
Disciform keratitis

23. • Cell mediated immune reaction to
endothelium
• KPs, odema → decompensation
• Tx, of epithelial keratitis 1st (if
present) for 1-2 d.
• Definite Tx: Topical steroid
4-8 times (NO taper till being
inactive)
+ topical OR oral Ayclovir
400mg 5 times/ d.
• Prophylactic oral Acyclovir
400mg twice/day for 1 year
Disciform keratitis

24. Prophylactic oral Acyclovir
400mg twice/day for at least 1 year
• (If> 2 episodes of epithelial keratitis/ y)
• (from 1st episode of stromal, disciform keratitis
and keratouveitis)
Pre- PKP (for at least 1y)
Post-PKP (for 2y-indefinite)
Post-PRK (1y)

25. HSV
Epithelial
- Dendritic/
Geographical
- Post footprints
Stromal
- Immune keratitis
- Necrotizing
- lipid keratopathy
Endothelial/
Disciform
Keratouveitis
- Anterior
- ARN
Metaherpetic
- Neurotrophic
- superinfection
Lid vesicles
Follicular Conjunctivitis

26. Neurotrophic ulcer
No pain
No gain
Assess sensation

27. Scarring
Melting
• Lubricant, autologous serum
• BCL, Lid closure.
• Urgent cyanoacrylate, AMT,
tectonic graft., Gunderson
flap
• PTK/ PKP

28. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

29. Is bacterial keratitis treatable?
• Yes
• No

30. Does infiltrate size affect your plan of Tx
and hospitalization?
• Yes
• No

31. Is hypopyon always indicate
endophthalmitis?
• Yes
• No

32. Case
62y old M, came to outpatient clinic with Rt
eye pain, photophobia, red eye, decreased
vision
No Present Hx Trauma, CL
Past Hx: frequent lash epilation
DD

33. • Describe
• Your work up?

34. What discriminate bacterial keratitis?
History Examination Investigation Treatment
CL, trauma (+ FB, lid
conditions, loose suture,
chemical injuries), OSD
corneal disease/ surgery,
Medication

35. What discriminate bacterial keratitis?
History Examination Investigation Treatment

36. Examination/ Describe
Site (centration, depth)
size/ shape
Surrounding
Laterality

37. What discriminate bacterial keratitis?
History Examination Investigation Treatment
Early
recognition
Timely Tx
instillation
Follow up

38. Treatment
Empiric
Fortified AB
Prophylactic,
RF
Systemic
Tx
Complication
Tx
Other
modalities
(XCXL…)

39. Mild, early,
peripheral or non-
complicated
EmpiricTx./
Monotherapy
(Fluroquinolones)
Gatifloxacin > ciprofloxacin
Majority of cases respond
+/- cycloplegic ,
lubricant
Not responding TO
monotherapy
Duotherapy
Fortified
(Vancomycin 25mg/ml,
Ceftazidime 50mg/ml)
(pseudomonas, MRSA)
Systemic AB
scleral involvement
(Ciprofloxacin 750mg),
Melting/ perforation
(Doxycycline 100mg 2/d * 10ds
Vit c 500mg 2/d
Clinical
response
?

40. Improvement criteria (clinical response)
• Decrease pain, lid odema, discharge,
conjunctival injection
• Epithelization
• Decreased density of infiltrates/ sharpened
demarcated infiltrate, stromal odema
• Decreased AC reaction
• Decreased melting, thinning

41. After eradication of microbe?
• Steroids?
• Glasses, RGPCL for astigmatism
• Optical PTK, DALK, PKP

42. Mild, early,
peripheral or non-
complicated
EmpiricTx./
Monotherapy
(Fluroquinolones)
Gatifloxacin > ciprofloxacin
Majority of cases respond
+/- cycloplegic ,
lubricant
Not responding TO
monotherapy
Duotherapy
Fortified
(Vancomycin 25mg/ml,
Ceftazidime 50mg/ml)
(pseudomonas, MRSA)
Systemic AB
scleral involvement
(Ciprofloxacin 750mg),
Melting/ perforation
(Doxycycline 100mg 2/d * 10ds
Vit c 500mg 2/d
No
Clinical
response
x

43. Scraping indications
• Central, large infiltrate > 1.5 mm
• Melting, deep stromal involvement
• Chronic, unresponsive to Tx.
• Multiple location of infiltrates
• Atypical presentation (mycobacteria)
• Reluctant organism: Neisseria, Pseudomonas
• Unusual history: post-surgeries, trauma with
vegetable

44. Indication of hospital admission
• Ulcer: Severe (central, large infiltrate > 1.5
mm, hypopyon, purulent exudate)
• Patient: poor compliance, single eye, cannot
come for follow up
• Complication: melting, perforation,
endophthalmitis

45. • Describe
• Your work up?

46. • Describe
• Your work up?

47. • Describe
• Your work up?

48. • Describe
• Your work up?
Sterile
hypopyon?

49. • Describe
• Your work up?
Pseudomonas
(large epithelial defect,
ring-like infiltrate,
ground-glass
surrounding)

50. • Describe
• Your work up?

51. • Describe
• Your work up?

52. • Describe
• Your work up?
BCL, IOP suppressant
Urgent cyanoacrylate,
AMT, tectonic graft.,
PKP
Therapeutic

53. What discriminate bacterial keratitis?
History Examination Investigation Treatment
No response to
empiric Tx
Scrape C&S
(Kimura spatula,
blade, forceps)
Biopsy
(punch, blade,
FS)

54. Scraping for smear and culture
Oxford

55. Scraping for smear and culture
Yanoff

56. Scraping for smear and culture
Yanoff

57. Infective keratitis
Bacterial
Viral
Fungal
Amaebic
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

58. Is Candida type more common in Egypt &
tropical areas?
• Yes
• No

59. Can topical anti-fungal be used as an
initial empiric Tx?
• Yes
• No

60. Does CXL play a role in Tx of fungal
keratitis more than bacterial keratitis?
• Yes
• No

61. Case
44y old M, came to outpatient clinic with Rt
eye pain, photophobia, red eye, decreased
vision
Present Hx Trauma while threshing wheat
DD

62. What discriminate fungal keratitis?
History Examination Investigation Treatment
Trauma (vegetable
matter), CL, OSD, FB
immunosuppression,
topical steroid

63. Examination/ Describe
Site (centration, depth)
size/ shape
Surrounding
Laterality

64. Candida non-Filamentous
• White to yellow suppurative
infiltrate
• Amphotricin 0.15% (Fungizone
50mg in 30 saline)
Filamentous (Fusarium)
• Feathery edges
• AC reaction, satellite stromal
infiltrate, Wessely ring
• Empiric Natamycin
(Natamet/ Hosptam) 5%
(/h till response then taper
over 6-8 wks)

65. What discriminate fungal keratitis?
History Examination Investigation Treatment
Consider early
scraping for C&S in
highly suspected
cases

66. Scraping from edges and take from deep infiltrate for
Microscopy using KOH, calcflour white, Gram/ Geimsa
stains.
Culture on Sabaraud dextrose, chocolate, blood agars
Will you stop anti-fungal Tx
in case of –ve scrape result
If you suspect it clinically?
‫اإلنسان‬ ‫أن‬ ‫األصل‬
‫لها‬ ‫عبد‬ ‫ال‬ ‫اآللة‬ ‫سيد‬

67. • Empiric Hosptam/
Natamycin 5% (/h till
response then taper over 6-8
wks)
• Vit C
• Doxycycline 100mg 2/d
• +/- systemic anti-fungal
(Fluconazole (Diflucan)
200mg 2/d)
• Anti-glaucoma
Wessely immune ring

68. • Epithelial and necrotic
tissue debridement/ 48h (to
enhance Tx absorption)
• Intrastomal, topical,
subconjunctival Antifungal
(Fluconazole 2mg/ml)
• Therapeutic and diagnostic
(sent for pathology &
culture) keratoplasty DALK
or PKP (Glycerol Preserved
Cornea)
(in Severe, no response, deep
penetration, perforation)

69. Infective keratitis
Bacterial
Viral
Fungal
Protozoal
Non infective
Marginal/ phlycten/ rosacea
PUK
Mooren
Interstitial (non infectious )
Exposure, lipid, neurotrophic

70. Case
22y old F, came to outpatient clinic with both
eyes severe pain, photophobia, red eye,
decreased vision
Present Hx of swimming while wearing CL
DD

71. What discriminate acanthamaebal
keratitis?
History Examination Investigation Treatment
Soft CL,
Hot tub, trauma
CL/ optics solution

72. Examination/ Describe
Site (centration, depth)
size/ shape
Surrounding
Laterality

73. Acanthamaebal
• Early: Irregular epithelium,
infiltrate (epith, ant stromal),
pseudodendrites
• Ring-shaped infiltrate, radial
keratoneuritis
• Scleritis, AC reaction/
hypopyon, glaucoma,
Perforation, melting
Radial keratoneuritis
DD?
Pseudodendrites
DD?
Subtle epithelial
irregularities

74. Radial keratoneuritis
DD prominent corneal nerves?

75. Acanthamaebal
• Early: Irregular epithelium,
infiltrate (epith, ant stromal),
pseudodendrites
• Ring-shaped infiltrate, radial
keratoneuritis
• Scleritis, AC reaction/
hypopyon, glaucoma,
Perforation, melting
Primary prevention, early Dx/Tx
(why important?)
• The worst prognosis among other
infective keratitis
• Tx is toxic & lengthy for 8 months
• Recurrence on graft Ring abcess
DD?
Melting
DD?

76. Acanthamaebal
• Early: Irregular epithelium,
infiltrate (epith, ant stromal),
pseudodendrites
• Ring-shaped infiltrate, radial
keratoneuritis
• Scleritis, AC reaction/
hypopyon, glaucoma,
Perforation, melting
Primary prevention, early Dx/Tx
(why important?)
• The worst prognosis among other
infective keratitis
• Tx is toxic & lengthy for 8 months
• Recurrence on graft
Hypopyon
DD?
Keratouveitis
DD?

77. NV Ring infiltrate
Paracentral
stromal odema
Central scarring

78. Scraping & biopsy
History Examination Investigation Treatment
Consider early scraping
for C&S in highly
suspected cases, NO
response to AB in 1st day

79. Erupt from cyst and
penetrate tissue
Feed on bacteria,
yeast
Dividing and cyst
forming
Double-walled
Dormant for years
Resistant to AB, low
temperature, UVR

80. Scraping from (edges and take from deep infiltrate,
CL, CL solution) for
Microscopy using PAS, calcflour white (Cysts & fungi).
Culture on E. coli plated over non-nutrient agar
(Trophozoite/ vegetative form)

81. History Examination Investigation Treatment
Early cases
Advanced cases

82. Early cases (Tx for months)
Epithelial debridement (cyst removal) with alcohol,
Topical Propamide (Acanthoprop)/ Hexamidine
(Brolene ED)/ h for 2 wks
Topical AB Neomycin (Neopol)
Topical Antifungal Voriconazole 1% (VFEND)
Systemic NSAID (analgesic)
+/- lubricant, cycloplegic

83. Resistant cases
CXL? (> bacterial cases)
AMT (persistant epithelial
defect, perforation)
PKP (NO response to
medical Tx, encroachment
to sclera, vascularization,
melting, perforation
(continue Tx post op.)

84. Our goals
• Control infection (primary prevention, early &
proper Tx)
• Manage complication of (infection, post
infection eradication, drug toxicity)
• Surgical management (be cautious about
recurrence)

85. Tell me one thing from What we
discussed today…

86. Bacterial
Lid abnormalities/ OSD
(Trichiasis, blepharitis,
surgery, dry ye,
dystrophies,allergy,
hypothesia)
Trauma/ CL
Variable according to
organism (describe!)
Gram, Geimsa,
Zeil Nelsen / Lownstein
Jensen media
(mycobacteria)
Blood/ chocolate agar
Monotherapy (Gatiflox,
Fortymox, Gatistar)/
Duotherapy(fortified
vancomycin, ceftazidime)
CXL
Herbetic
Atopy
Immunedefiency dis,
Poor hygeine,
malnutrition, stress
Recurrence
Epith. (dedritic,
hypothesia)
Stromal (Interstititial,
disciform)
IOP / iris atrophy
PCR
Viral culture
immunehistochemistry
Epithelial (acyclovir)
Stromal/ endothelial
(topical steroid, oral
acyclovir)
Fungal
Trauma (vegetable)
CL
Long term steroid use
immunesuppresion
Filamentous (feathery
edges)
Candida (collar stud)
Gram, Geimsa, calcflour
Sabaraud/ blood,
chocolate agar
Natamycin 5%
(Filamentous
Amphotricin (Candida)
Intrastromal, debridement
Acanthamaeb
al
CL
Hot Tub
Ring infiltrate
Psudodendrite
Keratoneuritis
Gram, Geimsa
KOH, clacflour
Non nutrient
Brolene
Neomycin, antifungal
Epith.. depridement
(cystic form)
Hx
Ex
In
v
Tx

87. Thank you