Cornea part 1 by Samhaa Mohammed

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
‫تبصرون‬ ‫أفال‬ ‫أنفسكم‬ ‫وفي‬
‫العظيم‬ ‫هللا‬ ‫صدق‬

2. Cornea 1
sailing through layers
Samhaa Mohammed Abd Elmoneim
Zagazig Ophthalmologic Hospital

3. Corneal ex.
• Assessment of any sign (diameter, thickness,
steepness)
• Any sign defect, scar, odema, opacity, infiltrate,
precipitate, deposit, filament, guttatta, folds,
desmatocele, sensation, PEDAL
Site
Size
Level
Surrounding
Laterality

4. Sailing through cornea
Hx, symptoms, signs
+ assessment + any sign
Sailing through eye
Lid problem, OSD, scleritis, IOP, infection
Sailing through body
Age (ulcer), autoimmune, systemic , drug

5. Corneal diseases
1. Congenital
2. Traumatic
3. Inflammatory (infective, autoimmune)
4. Degeneration/Dystrophies
5. Neoplastic
Sailing through cornea
Sailing through eye
Sailing through body

6. 1. Traumatic keratitis
• Any sign (epithelial defect)
Site
Size
Level
Surrounding
Laterality

7. 1. Traumatic keratitis
(Sailing) through cornea
CL, baby nail, iatrogenic? as PRK, DMEK, DSEK,
burn, topical drops(Hx) …..
(Sailing) through eye
trichiasis, mass , papillae. Trachoma
(Sailing) through body
radiotherapy for tumours

8. 1. Traumatic keratitis
Treatment
• Cause(CL)
• AB (monotherapy as fluroquinolone)
• Steroids (burns)
• Lubricant
• Cycloplegic

9. Corneal diseases
1. Congenital
2. Traumatic
3. Inflammatory (infective, immune related)
4. Degeneration/Dystrophies
5. Neoplastic
Sailing through cornea
Sailing through eye
Sailing through body

10. 2. Inflamatory keratitis
(infective)
• Bacterial
• Fungal
• Viral
• (Protozoal) Acanthamaebal

11. Bacterial keratitis
Organisms
P aeruginosa (CL)
s. aureus,streptococci
N gonorrhea, N meningitis, H infl……. Penetrate intact
epithelial
Risk factors:
Compromised cornea
CL wear
Trauma
OSD (blepharitis, dry eye, allergy, corneal hypothesia,
trichiasis.

12. Bacterial keratitis
Signs:
• Epith. Defect
• Descment fold, odema, AU
• Chemosis
• Severe ulceration
• Scleritis
• Scarring, vascularization
• Dec. sensation
• IOP

13. Staphylococal
• Central, oval, opaque.
• Distinct margins.
• Surrounding odema.
• Mild to moderate
Iridocyclitis.
• Neglected … corneal
abcess.

14. Pneumococcal
• Sharp greyish white or
yellowish serpentine
ulcer.
• Central.
• Violent Iridocyclitis
• Hypopyon
• Tendeny to perforate

15. Pseudomonas
• Rapidly spreading to
periphery and in depth.
• Shaggy surface,
necrosis.
• Greenish discharge.
• Spead cocentrically ---
ring ulcer.
• Hypopyon.

16. Neisseria gonorrhea, meningitis:
• Severe purulent conjunctivitis
• Ophthalmia neonatorum

17. Bacterial keratitis
Investigation:
Corneal scraping
CL and solution culture
…… stop AB before C&S
(gram stain, geimsa, Zeihl Neelsen stain, blood,
chocolate agar, brain heart infusion, lowestein-
Jensen)
Corneal biopsy

18. Bacterial keratitis
General measures: hospitalization , stop CL,
eye sheild
Medical treatment :
Topical AB
Monotherapy fluroquinolone (ciprofloxacin or
ofloxacin)….. Mild
Duotherapy (ceftazidime 25-50mg/ml, vancomycin
25-50mg/ml) …… severe
Cirofloxacin induce corneal precipitate( delay
healing

19. Bacterial keratitis
SYSTEMIC AB
• Severe corneal
thinning…..tetracycline(doxycycline 100mg
twice/d)
• Scleral involovement
• Ass. Systemic dis…. N gonorrhea, N
meningitidis ( ceftriaxone), H influenza (
amoxicillin , calvulanic acid)

20. Bacterial keratitis
Other treatment trends:
• Cyanoacrylate
• AM graft
• Therapeutic keratoplasty (lamellar or
penetrating)

21. Fungal keratitis
• organisms:
1. Filamentous fungi (fusarium and aspergillus)
Multicelluar, tropical, tubular projection.
2. yeast( candida)
Ovoid unicellular, temperate, budding.
• Risk factors:
Trauma involving plant origin
Long term topical steroid
Cl
Immunosuppression, DM

22. Fungal keratitis
• C/P:
Candida :
Yellow whitish dense suppurative infiltrate.
Collar stud
Filamentous :
Grey or yellow white infiltrate , indistinct fluffy
margin, feathery branch like (satellite)
Rapid progression, necrosis
Endophthalmitis with intact DM

26. Fungal keratitis
Investigation:
Corneal scraping (staining and culture)
…… stop AB before C&S
(gram stain, geimsa, PAS stain,
sabaraud , blood agars, enriched medium)
Corneal biopsy
Confocal microscopy

27. Fungal keratitis
• General measures : hospitalization , stop CL, eye
sheild
• Removal of epithelium.
• Medical treatment :
Filamentous … natamycin
Candida …… amphotricin B
• AB, cycloplegico
• Systemic antifungal fluconazole 200mg/d(near
limbus, suspect endoph.)
• IOP
• Surgical: superficial keratectomy, KP

28. Protozoan (acanthamoeba) keratitis
• Organism:
Acanthamoeba
Soil, fresh and brackish water, URT
CYSTIC ……. TROPHOZOITE form
• Risk factors:
CL, rinsing tap water

29. Acanthamoebal keratitis
• C/P:
Pain
Pseudodentritic lesion
Ring infiltrate
Keratoneuritis
Scleritis (reactive), melting

30. Keratoneuritis Ring abcess

32. Acanthamoebal keratitis
Investigation:
Corneal scraping (staining and culture)
…… stop AB before C&S
(gram stain, geimsa, PAS,
calcflour stains, non nutrient agar)
Corneal biopsy
PCR
Confocal microscopy

33. Acanthamoebal keratitis
• General measures : early suspicion (better
response in early ttt 4 wk), stop CL.
• Debridment of epithelium.
• Medical treatment :
Poly Hexa Methylene Biguanide 0.02% (PHMB)
Brolene
• AB, cycloplegico
• Pain releif
• Surgical: superficial keratectomy, KP

34. Viral keratitis
1. HSV
2. HZV
3. Adenoviral

35. HSV Viral keratitis
• HSV1: above waist… eye associated
• HSV2: venreal….. Eye rare (secretion, neonatal)
Risk factors:
• Atopic eye dis.
• Stress
• Immunedeficiency
• Malnutrition
• Crowding, poor hygeine

36. HSV Viral keratitis
Congenital infection:
• Common > 6m (Maternal AB)
• Skin, eye, CNS
1ry: (droplet)
Recurrent: (dermatome, latent in trigemminal G)

37. HSV Viral keratitis
C/P: epithelial keratitis
• Epith swelling
• Ulcer: dendritic (central with terminal bulb, bed stained with
fluroscein and edges by rose bengal, geographical
• Decrease sensation
• Lid vesicles
• IOP
• Epithelial toxicity…. Mild scar
Investigation: clinical, viral culture, PCR,
immunohhistochemistry
TTT: topical acyclovir, depridement, systemic in
immunosuppressive, IOP, cycloplegics, toxicity

41. HSV Viral keratitis
C/P: disciform keratitis
• Hypersensitivity reaction
• wessely ring : Ag AB complex (sensation?)
• Stromal and epith. Odema, descment folds
• Granulomatous KPs
• IOP
• Decrease sensation
• Stromal scarring and vascularization
TTT: topical steroid with antiviral cover, IOP control, cycloplegic
• topical cyclosporin0.05% (restasis)
• Oral steroid ( steroid response glaucoma, severe stromal
inflamation
• Fine needle diathermy in established NV

42. Wessely ring KPS & stromal odema

43. Scarring and
vascularization

44. HSV Viral keratitis
C/P: necrotizing keratitis
• Immune mediate challenging with disciform Dx
• Hypersensitivity reaction
• Stromal and epith. Odema, descment folds
• Anterior uveitis, infiltrates, KPs
• IOP
• Decrease sensation
• Stromal scarring and vascularization, lipid keratopathy
TTT: topical steroid with antiviral cover, IOP control,
cycloplegic
• topical cyclosporin 0.05% (restasis)
• Oral steroid
• Fine needle diathermy in established NV

46. HSV Viral keratitis
C/P: neurotrophic keratopathy
• Loss of sensation
• Excerbated by drug toxicity
• Non healing epithelium
• Stroma is opaque and thin
• 2ry infection
TTT:
• Lubricant , decrease steroid

47. HSV Viral keratitis
Complication:
• 2ry infection
• Uveitis
• Glaucoma ( uveitis, trabeculitis, topical steroid)…
inaccurate reading
• Cataract
• Iris atrophy
TTT keratoplasty:
• Risky (ttt NV, recurrence, Herbetic eye dis. Atopic eye
• Prophylactic oral acyclovir(400mg twice/d) for one
year

48. HZV Viral keratitis
Varicella zoster virus:
• Chickenpox (varicella) … children
• Shingles (herpes zoster) … eldery
Immunity :
• Vaccination
• Exposure to chicken pox (avoid shingles pt for being contact
to a child).
Risk factors of ocular involvement:
• Age
• Immunocompromised
• Hutchinson sign (dorsal nasal branch of nasociliary n.)

50. HZV Viral keratitis
C/P:
Skin
• Rash and vesicles respect midline.. scrar
Acute eye dis:
• Acute epith keratitis :(peripheral, fine, stained more with Rose Bengal …
topical antiviral
• Follicular conjuctivitis, episcleritis … no ttt
• Scleritis … NSAIDs oral (thrice/d) steroids??
• Nummular keratitis : subepithelial haze … topical steroid
• Disciform , interstitial keratitis …. Topical steroid
• AU…… iris atrophy
• IOP …..NO PG
• Neurological …. CN palsy(3rd) , Ramsay Hunt S
• Optic neuritis

51. Nummular keratitis
coin shaped

52. Sclerokeratitis

53. Optic neuritis

54. Ramsy Hunt syndrome

55. HZV Viral keratitisC/P:
Chronic eye dis:
• Neurotrophic keratitis : common 50% but mild
• Scleritis : patchy atrophy
• Mucous plaque keratitis :topical steroid,
acetylcysteine
• Lipid filled granulomata :tarsus, sub conjunctiva
• Lipid degeneration: over nummular and disciform
• Lid scarring… exposure keratopathy
• PHN :Persistent pain > 1m of healed rash) , increase
sensitivity to minor stimuli , heat, touch…. Suicide

56. HZV Viral keratitis
TTT:
• systemic acyclovir 800mg 5 times/d.
• Topical acyclovir 5 times/d.
• Topical antiviral for skin lesions.
• PHN: cold compress, local lidocaine, analgesic,
tricyclic antidepressant.

57. Adenoviral keratitis
• Hx of recent viral infection
• C/P:
watery eye
Follicular conjuunctivitis
Preauricular LN ++
Subepithelial infiltrates, may be epithelial defects
• TTT:
Self limited, lubricants.
Weak topical steroid

60. Corneal diseases
1. Congenital
2. Traumatic
3. Inflammatory (infective, immune related)
4. Degeneration/Dystrophies
5. Neoplastic
Sailing through cornea
Sailing through eye
Sailing through body

61. 2. Inflamatory keratitis
(immune related)
• Marginal keratitis, Phlyctenulosis , Rosacea
(staph hypersensitivity)
• Peripheral ulcerative keratitis (PUK).
• Mooren ulcer
• Ulcer or not (edges).
• Site.
• Clear zone from limbus.
• Sclera involved or not.
• Interstitial keratitis.

62. Marinal keratitis
Hypersensitivity to staph exotoxin….. Ag-Ab complex
Risk factors:
• Blepharitis, epithelial erosion, recent LASIK
C/P:
• Site… inferior (marginal blepharitis), NO ULCER, subepithelial
infiltrate.
• Clear zone from limbus.
• C&S: –ve from cornea.
TTT:
• Cause (tetracycline not in children and pregnant)
Tetracycline ( antibacterial, decrease free lipid, anticollagenase)
• Short course of topical steroid

65. Phlyctenulosis
Delayed hypersensitivity to staph
Risk factors:
• Age( child)
• Rosacea
• TB, Helminthic infestation
C/P:
• Small white elevated superficial nodule with hyperemia… scar.
• NO ULCER
• Site … Conjunctiva, limbus, cornea.
• Lacrimation, photophobia, blepharospasm.
• Stool analysis, tuberculin test (endemic areas and RF)
TTT:
• Topical steroid , treat cause.
• Recurrent … tetracycline.

71. Rosacea
Skin dermatosis
Risk factors: Unknown cause
• Staph epidermidis, Demodex mites
• Trigger factors( sun exposure, alcohol, spicy and hot
food)
C/P: (triad)
• Erythematous telangectasia
• Papulo pastular rash
• Phymatous … rhinophyma.
TTT:
• Tetracycline (pregnant, children), metrondiazole

72. Ocular rosacea
C/P:
• Lid margin telangectasia, recurrent MG cysts.
• Conj hyperemia.
• Marginal keratitis --inferior… circumferential.
• Corneal melting and thinning.
TTT:
• Systemic (Tetracycline, Doxycline 100mg once/d)
• Ocular.. Mild ------- lubricant, hot fomentation
Moderate to severe -------
fusidic acid oint once for 1m.
steroids

74. (Peripheral Ulcerative Keratitis (PUK
Collagn vascular diseases(immune complex
deposition on peripheral cornea, conj,
episclera)
• RA
• Wegner granulomatosis
• Relapsing polychondritis, SLE, PAN

80. PUK
C/P
• Peripheral thinning, ULCER (CL cornea),
perforation.
• NO clear zone from limbus(as mooren ulcer)
• Sloping edges, sclera involved.
TTT
• Rheumatologist consultation, systemic steroid.
• Topical steroid??, lubricant, tetracycline.
• Surgical.

81. Mooren ulcer
Old age…. Unilateral
Younger…. Bilateral
C/P
• Pain
• Site ---- peripheral ULCER (undermined edges),
perforation, bl.vs at bed and margins.
• No clear zone from limbus (but there is limbitis)
• Sclera not involved (no scleritis)
• NB: Dx by exclusion.

83. Mooren ulcer
TTT
• Topical steroid/h with AB cover
• Topical cyclosporin
• Exclude collagen vascular dis.
• Systemic steroid, immunosuppresive
• Systemic collagenase inhibitors
• Surgical (conj. resection, lamellar KP, cyanoacrylate,
tectonic, AMG)

85. Interstisial keratitis
Stromal inflamation without epithelium or
endothelium affection.
Causes:
• Infectious as syphilis, herpes, TB, lyme.
• Non infectious as sarcoidosis, Cogan syndrome
C/P
• Mid-stromal feathery scarring with gost vessels.
• Early phase is incidental

86. Interstisial keratitis
Syphilis
Congenital (more common) or acquired
C/P
• Systemic (saddle nose, sabre tibia, Hutchinson
teeth, deafness)
• Ocular (IK, ant uveitis, salt and pepper fundus, argyll
robertson pupil)
• IK: limbitis, feathery stromal infiltrate, deep stromal
vascularization, ghost vs, thinning, band
keratopathy.

88. Interstisial keratitis
Cogan syndrome
Rare vestibulo-auditory-ocular autoimmune
disease.
C/P: Triad
• Vertigo
• Tinnitus
• IK
TTT
• Rheumatologist, ENT consultation, systemic steroid.
• Topical steroid
.

90. Other non infectious keratitis
• Terrin Marginal Degeneration(TMD)
• Filamentary keratitis
• Neurotrophic keratopathy
• Exposure keratopathy
Lagophthalmos, facial palsy, cicatricial, mechanical.
• Dellen

91. TMD
Idiopathic peripheral corneal thining
c/p
• Male, 20-40y, bilateral, visual change
• Site … Superior … ATR or oblique astigmatism
• NO ULCER (thinning)--- peripheral gutter
• Sclera not involved
• Clear zone from limbus
• Pseudoptergium.
TTT
• Polycarbonate safety glasses, soft or rigid CL for
astigmatism.
• Surgical … crecenteric annular excision with lamellar
keratoplasty.

95. Filamentary keratitis
Loose epithelium with mucous and cellular debris.
Causes
• Keratoconjunctivitis sicca, neurotrophic, exposure ,bullous
keratopathy, epithelial instability
• Prolonged CL use or eye closing.
c/p
• Pain, photophobia, blepharospasm, Fb sensation.
• Fine strands with one end attached to epithelium.
• Stainned filament and base.
TTT
• Cause, bandage CL.
• topical mucolytics (acetylcysteine5%).
• Hypertonic saline.
• Mechanical removal.

98. Neurotrophic keratopathy
Loss of trigeminal innervation results in persistent ulceration,
odema, exfoliation and
Causes
• HSV, HZV, peripheral neuropathy, stroke, TG ablation, topical drug abuse.
c/p
• Asses all cranial nerves.
• Loss of sensation, tiny epithelial defects, persistent ulcer
• Central punched out ulcer with odema, scar.
• Stromal melting , perforation.
TTT
• Stop topical drugs, lubricant (preservative free)
• Anticollagenase (tetracycline, acetylcysteine)
• Taping, therapeutic Cl
• Botulinum toxin, tarsoraphy
• TTT .. Perforation ( amniotic, cyanoacrylate, tectonic graft, KP?.

102. Exposure keratopathy
Incomplete lid closure (lagophthalmos)
Causes
• Facial n palsy, neuroparalytic diseases.
• Mechanical, cicatricial, proptosis.
c/p
• Inferior epithelial changes, ulcer.
• Stromal melting, 2ry infection.
• Fibrovascular, filamentary, salzmann nodular degeneration
changes
TTT
• Reversible causes: taping, artificial tears, bandage or scleral
CL, temporary tarsoraphy, orbital decompression.
• Irreversible causes: permenant tarsorraphy , gold weight in
UL

105. Dellen
Peripheral corneal thinning adjacent to elevated
conjunctival mass due to dryness.

109. Corneal diseases
1. Congenital
2. Traumatic
3. Inflammatory (infective, immune related)
4. Degeneration/Dystrophies
5. Neoplastic
Sailing through cornea
Sailing through eye
Sailing through body

110. Corneal diseases
to be continued.,
Samhaa Mohammed
Best wishes

111. Now, lets go for sailing in sea
not in cornea
Thanks ALLAH
Thank you