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![Treatment
• Systemic Treatment
– NSAIDs
– systemic corticosteroids iv/po
– immunomodulatory drugs
• antimetabolites, such as methotrexate, mycophenolate
mofetil, or azathioprine
• Biologic TNFI infliximab, adalimumab, and rituximab [anti-
CD20]
• Alkylating agents for impending risk of perforation
– subconjunctival injection of low- dose triamcinolone
• topical corticosteroid for iridocyclitis
5/19/2023 80](https://image.slidesharecdn.com/cornealandscleraldisorder-230519123619-0fecba09/75/corneal-and-scleral-disorder-pptx-80-2048.jpg)
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corneal and scleral disorder.pptx
- 1. corneal and scleraldisorder Assefa N. R3 5/19/2023 1
- 2. • outline – bacterilkeratitis – fungal keratitis – protozoa keratitis – viral keratitis – non infectious • neurotrophic • exposure 5/19/2023 2
- 3. Sclera – It isdivided into 3 layers (from outermost inward): • episclera, stroma, and lamina fusca. 5/19/2023 3
- 4. introduction • keratitis – inflammationand tissue destruction within the corneal tissue – bacterial most common supurative • types – microbial • bacteria, fungi, viruses, and parasites – radiation – immuine – exposure – neurotrophic 5/19/2023 4
- 5. Bacterial Keratitis • NormalOcular Flora – varies with the age and geographic location – infant delivered vaginally • Staphylococcus aureus, S epidermidis, streptococci, and Escherichia coli. – first 2 decades Streptococci and pneumococci – gram- negative bacteria increases wth age – Demodex folliculorum and D brevis increases with age. 5/19/2023 5
- 6.
- 7. Defense of theOcular Surface • eyelid – Normal blinking – physical barrier • tear film – lipid layer destabilize microbial cell membranes – proteins IgA,lipocalin, surfactant, complement components – enzymes • lysozyme, lactoferrin, betalysins, orosomucoid, • secretory phospholipase A2, and ceruloplasmin • corneal epithelium • normal ocular flora. • conjunctiva MALT 5/19/2023 7
- 8. Organisms That CanInvade an Intact Epithelium – Corynebacterium diphtheriae – Fusarium spp – Haemophilus influenza – Listeria monocytogenes – Neisseria gonorrhoeae – Neisseria meningitidis – Shigella spp 5/19/2023 8
- 9. risk factors local • OcularSurface Abnormalities • Contact Lens Use – overnight wear ,poor lens hygiene – P. aeruginosa Staph. aureus. – lowest with rigid gas- permeable lenses • adenexal abnormalities • trauma/surgery/FB • topical immunosuppressive systemic • DM • RVI • Chemotherapy • immuine suppresion • cancer • contaminated ocular medi cations • viral keratitis 5/19/2023 9
- 10. Pathogenesis of OcularInfections • exogenous inoculation • adherence to the ocular surface – express adhesins C. albicans and Acanthamoeba tz • host invasion – facilitation Microbial proteases – corneal metalloproteinases – exotoxins streptococci, staphylococci, P.aeruginosa – secrete collagenases Acanthamoeba and fungi – biofilm 5/19/2023 10
- 11.
- 12. • symptoms – Pain,irritation, redness, photophobia, eye discharge, decreased vision, contact lens intolerance • signs – Ciliary and conjunctival injection. – Epithelial defect associated with infiltrate around margin of ulcer. – Secondary sterile hypopyon with anterior uveitis. – Progressive ulceration causing corneal perforation and endophthalmitis. 5/19/2023 12
- 13. • Staph. aureus& Strep. Pneumoniae: – produce oval, yellow-white, densely opaque stromal suppuration surrounded by relatively clear cornea. • Pseudomonas: – causes thick muco-purulent exudate, diffuse iiquefactive necrosis and semi-opaque 'ground glass' appearance. Infection is rapidly progressive with perforation within 48 hours. • Enterobacteriaceae: – causes a shallow ulceration, grey-white pleomorphic suppuration and diffuse stromal opacity. • The endotoxins present in Gram-negative bacteria induces ring-shaped corneal infiltration (corneal rings). 5/19/2023 13
- 14.
- 15. Infectious crystalline keratopathy Mostcommonly α- hemolytic Streptococcus species densely packed, white or crystalline, branching, snowflake- like aggregates with almost no host inflammatory response 5/19/2023 15
- 16. Promotion of re-epithelization: –Lubrication • With artificial tears and ointments. – Lid closure – Bandage soft contact lens • for pain and posterior synchea – PO,atropine,cyclopentolate,tropcamide • Antimicrobial agents 5/19/2023 16
- 17.
- 18. • systemic – ciprofloxacine,augumentine –impending,perforated cornea,scleral extensition – endophthalmitis • Corticosteroid 1% drops – after 48hrs – donot nocardia,fungal or Acanthamoeba • Surgical treatment 5/19/2023 18
- 19. • follow up –reepithelialization – blunting of the perimeter of the stromal infiltrate – decreased density of the stromal infiltrate ) – cessation of corneal thinning – reduction in stromal edema and endothelial inflammatory plaque – reduction in anterior chamber inflammation 5/19/2023 19
- 20. • Atypical mycobacteria –Mycobacterium fortuitum and M chelonae – LASIK occur 1 week or later postsurgically 5/19/2023 20
- 21. Fungal Keratitis • fungi –filamentous • warm, humid regions • septate • non septate – non filamentous • Candida – dimorphic • Blastomyce, Coccidioides,Paracoccidioides,Sporothrix • Ustilago 5/19/2023 21
- 22.
- 23. clinical presentation • severpain disproportionately greater than the amount of corneal inflammation • gray- white, nonsuppurative infiltrate with irregular feathery or filamentous margin • dry, rough, or gritty texture • Multifocal or satellite infiltrates • deep stromal infiltrate with presence of an intact epithelium. • endothelial plaque or hypopyon 5/19/2023 23
- 24.
- 25.
- 26. managenment • Natamycin 5%suspension – filamentous fungal keratitis, particularly those caused by Fusarium species. • Topical amphotericin B 0.15% – yeast keratitis such as Candida species. – filamentous keratitis caused by Aspergillus species • topical voriconazole 1% unresponsive cases 5/19/2023 26
- 27. • Systemic treatment –severe keratitis or keratitis with scleral or intracameral extension – Ketoconazole (200–600 mg/day) – fluconazole (200–400 mg/day), – itraconazole (200 mg/day) – oral voriconazole (200–400 mg/day) and posaconazole (800 mg/day)excellent penetration 5/19/2023 27
- 28. • intrastromal injectionof aqueous – soluble amphotericin B (5–10 µg/0.1 mL) or voriconazole (50–100 µg/0.1 mL) • Corneal crosslinking • debridement of the corneal epithelium • therapeutic LK or PK 5/19/2023 28
- 29. Acanthamoeba keratitis • free-livingamoeba found ubiquitously in water and soil. – A. castellanii with keratitis most common – A. polyphaga and A. hachetti – A. culbertsoni, A. rhysodes, A. lugdunensis, – A. quina, and A. griffini 5/19/2023 29
- 30. • CLINICAL PRESENTATION: – severe ocular pain that is greater than expected from clinical findings – photophobia – a protracted, progressive course • signs – diffuse epitheliopathy – radial perineuritis or radial keratoneuritis – partial or complete central ring infiltrate 5/19/2023 30
- 31.
- 32. • suspect Acanthamoebakeratitis over HSV keratitis – risk factors;contact lens,fresh water,hot tub – sever pain than expected – no improvement with antiviral – a noncontiguous or multifocal pattern of granular epitheliopathy and subepithelial opacities 5/19/2023 32
- 33. MANAGEMENT • Topical agents –diamidines: propamidine, hexamidine – biguanides: polyhexamethylene biguanide (polyhexanide), chlorhexidine – aminoglycosides: neomycin, paromomycin – imidazoles/triazoles: voriconazole, miconazole, clotrimazole, ketoconazole, itraconazole • optical keratoplasty 5/19/2023 33
- 34. Viral Infections • aresmall (10–400 nm in dia meter) obligate intracellular parasites • enveloped or nonenveloped 5/19/2023 34
- 35.
- 36. Diagnostic Techniques • Cellculture – Gold standard adenovirus and HSV • Serology – antibodies • PCR • Immunostaining – Antigen detection adenovirus 5/19/2023 36
- 37. Herpes Simplex VirusEye Diseases • Primary ocular infection – typically manifests as a blepharoconjunctivitis. • follicular conjunctivitis and preauricular lymph node • Vesicles on the skin or eyelid margin – Epithelial keratitis – stromal keratitis and uveitis are uncommon 5/19/2023 37
- 38.
- 39. HSV • dendritic epithelialkeratitis • vesicles on the skin or eyelid margin or ulcers on the bulbar conjunctiva • usually unilateral Adenovirus • conjunctival membranes or pseudomembranes • more commonly bilateral 5/19/2023 39
- 40. PATHOGENESIS • HSV-1 – abovethe waist (orofacial and ocular infection) • HSV-2, – below the waist (genital infection) • both can cause below or above waist. • spread by direct contact • non specific URTI 5% • neonate from active genital infection 5/19/2023 40
- 41. • latent infection –through sensory nerve axons to sensory nerve ganglia – most commonly trigeminal ganglion. – can present in the absence of primary infection – reactivation of the virus • in any of the 3 branches of cranial nerve V – cause of blindness Stromal keratitis 5/19/2023 41
- 42. • Laboratory tests –the clinical diagnosis is uncertain – in all cases of suspected neonatal herpes infection • MANAGEMENT – self- limited condition – Oral antiviral therapy speeds resolution 5/19/2023 42
- 43. • Recurrent ocularinfection – can affect almost any ocular tissue – typically unilateral – only 3% of patients demonstrating bilateral disease. – bilateral disease should increase concern for immune dysfunction • atopic dermatitis 5/19/2023 43
- 44. • PATHOGENESIS – infectionthrough reactivation of the virus – latency within the cornea controversial – triggers for the recurrence of HSV • psychological stress, systemic infection, UV light exposure, the patient’s menstrual cycle, and contact lens wear – recurs more frequently in patients with HIV infection but equal severity – Blepharoconjunctivitis self- limited 5/19/2023 44
- 45. • Epithelial keratitis –punctate epithelial keratitis – dendritic epithelial ulcers – ameoboid ulcer – geographic epithelial ulcer – CLINICAL PRESENTATION • foreign- body sensation, light sensitivity, redness, and blurred vision. • ciliary flush and mild conjunctival injection • Mild stromal edema and subepithelial inflammatory cell infiltration 5/19/2023 45
- 46.
- 47.
- 48. • healed – nonsuppurativesubepithelial infiltration and scarring – ghost opacity, or footprint • Focal or diffuse reduction in corneal sensation • biopsy – Multinucleated giant cells (nonspecific) and intranuclear inclusions (more typical of herpesviruses) 5/19/2023 48
- 49. • MANAGEMENT – epithelialkeratitis resolve spontaneously – antiviral agents alone or in combination with epithelial debridement 5/19/2023 49
- 50.
- 51. • Stromal keratitis –form of recurrent herpetic external disease • types – nonnecrotizing (interstitial or disciform) – necrotizing 5/19/2023 51
- 52. • Herpetic interstitialkeratitis – unifocal or multifocal interstitial haze or whitening of the stroma – Mild stromal edema – no epithelial ulceration – corneal vascularization long term and recurrent 5/19/2023 52
- 53.
- 54. • Herpetic disciformkeratitis – corneal stromal and epithelial edema in a round or oval distribution – keratic precipitates 5/19/2023 54
- 55. • Necrotizing herpetic keratitis –severe, progress rapidly – Epithelial defect – Corneal stromal vascularization • topical corticosteroids twice- daily dosing • oral antiviral 5/19/2023 55
- 56. Herpetic Eye DiseaseStudy – acyclovir prophylaxis minimize HSV recurrences by 50% – Topical corticosteroids effectively treat stromal keratitis – oral acyclovir in addition to treatment with trifluridine and corticosteroids not helpful in treating nonnecrotizing stromal keratitis – oral acyclovir helpful in treating HSV anterior uveitis not conulusive – oral acyclovir for epithelial keratitis to prevent stromal or anterior uveities not beneficial – triggers of HSV recurrences Not confirmed 5/19/2023 56
- 57. • prophylactic antiviraldrugs: – topical trifluridine 4 times daily – an oral agent such as acyclovir 400 mg twice daily – valacyclovir 500 mg once daily • Lifelong antiviral prophylaxis is recommended for patient • with multiple recurrences of HSV stromal keratitis or sight- threatening involvement. • prednisolone 1% drops every 2 hours – tapered every 1–2 weeks – prevent severe epithelial keratitis – antiviral contuened until • completely stopped the corticosteroids, or until the use is <1 drop of prednisolone 1% per day 5/19/2023 57
- 58. • Iridocyclitis – Elevatedintraocular pressure – patchy iris atrophy and prominent pigment dispersion – unilateral presentation 5/19/2023 58
- 59. Complications of herpeticeye disease • Epitheliopathy • diffuse punctate corneal epithelial erosions with conjunctival injection • Limbal stem cell deficiency • Neurotrophic keratopathy – punctate epithelial erosions – chronic epithelial regeneration lines – frank neurotrophic ulcers. – relative absence of rose bengal staining 5/19/2023 59
- 60. • Neurotrophic ulcers –typically round or oval and are located in the central, inferior, or inferonasal cornea. – Corneal epithelium • may appear to roll under itself and typically has a gray, elevated appearance. • Mainstays of treatment – avoid trifluridine – liberal use of nonpreserved lubricating drops, gels, and ointments – punctal occlusion – autologous serum 5/19/2023 60
- 61. Neurotrophic keratitis • degenerativedisease of corneal epithelium characterized by impaired healing • bsence of corneal sensitivity 5/19/2023 61
- 62. • prevent progressivestromal thinning and perforation – bandage or scleral contact lenses – amniotic membrane application, either self- retaining or surgical – use of cenegermin (Oxervate) • a topical recombinant human nerve growth factor – lateral tarsorrhaphy • Metaherpetic ulcers – occur from neurotrophic mechanisms or a devitalized corneal stroma. 5/19/2023 62
- 63. • Persistent bullouskeratopathy • Corneal scarring • Surgical treatment of herpetic eye disease – PK and DALK • without signs of active inflammation for at least 6 months prior to surgery – keratoprosthesis 5/19/2023 63
- 64. Varicella- Zoster Virus •Primary infection – eyelid vesicles and follicular conjunctivitis – Punctate or dendritic epithelial keratitis is uncommon. – direct contact – latency in the sensory ganglia – recurrence in 20% • vaccination – anyone older than 1 year without a history of chickenpox or with a negative serologic test result 5/19/2023 64
- 65. • Recurrent infection –painful vesicular dermatitis typically localized to a single dermatome on the thorax or face. – most commonly affected dermatomes are on the thorax (vertebrae T3 through L3) and those supplied by CN V. – Neurotrophic keratopathy and sectoral iris atrophy 5/19/2023 65
- 66. • Punctate anddendritic epithelial keratitis – do not have central epithelial ulceration (like HSV dendrites) – form branching lesions – resemble raised or “stuck-on” mucous plaques – stain minimally with fluorescein and rose bengal dyes – have blunt ends rather than terminal bulbs 5/19/2023 66
- 67. • Risk Factorsfor Herpes Zoster – sixth to ninth decades of life – HIV infection – Use of immunosuppressive therapy – Major surgery – Systemic malignancy – Trauma – Debilitating disease – Radiation therapy 5/19/2023 67
- 68.
- 69.
- 70. • HZO – oralvalacyclovir 1 g 3 times per day – acyclovir 800 mg 5 times per day – famciclovir 500 mg 3 times per day, for 7–10 days, – best if started within 72 hours of the onset of skin lesions. • disseminated zoster due to immunosuppression – Intravenous acyclovir therapy (10 mg/kg every 8 hours) • Postherpetic neuralgia – amitriptyline, desipramine, clomipramine, or carbamazepine 5/19/2023 70
- 71. Adenoviruses – simple follicular conjunctivitis(multiple serotypes) – pharyngoconjunctival fever (most commonly serotype 3 or 7) – epidemic keratoconjunctivitis (usually serotype 8, 19, or 37, subgroup D) 5/19/2023 71
- 72.
- 73. Scleritis – primary inflammationof the sclera, typically leading to marked pain and congestion of the deep episcleral plexus. – idiopathic (50%) – associated with systemic autoimmune diseases (40%) RA – local or systemic infections (5%−10%) – necrotizing scleritis associated in 50%–60% with systemic disorder • frequently affects older individuals and is more prevalent in women 5/19/2023 73
- 74.
- 75. Pathophysiology • Diffuse anteriorsubtype of scleritis – nongranulomatous response involving macrophages, lymphocytes, and plasma cells – perivascular distribution • nodular scleritis – granulomatous inflammation – direct antibody- mediated damage 5/19/2023 75
- 76.
- 77. Diffuse Anterior Scleritis •inflammation anterior to the recti muscles • the most common and least severe • Recurrences are very common • Systemic associations – RA,SLE,elapsing polychondritis – IBD,reactive artirits,ASP Nodular Anterior Scleritis • rule out infectious etiologies • Up to 10% of patients pro gress to necrotizing disease 5/19/2023 77
- 78. • Necrotizing scleritis withinflammation – 3 types: • (1) vaso- occlusive • (2) granulomatous • (3) postsurgical. 5/19/2023 78
- 79. Infectious scleritis • Pseudomonasorganisms (mostncommon after pterygium excision), • Actinomyces and Nocardia species, • mycobacteria, fungi • gram- positive cocci Posterior Scleritis 5/19/2023 79
- 80. Treatment • Systemic Treatment –NSAIDs – systemic corticosteroids iv/po – immunomodulatory drugs • antimetabolites, such as methotrexate, mycophenolate mofetil, or azathioprine • Biologic TNFI infliximab, adalimumab, and rituximab [anti- CD20] • Alkylating agents for impending risk of perforation – subconjunctival injection of low- dose triamcinolone • topical corticosteroid for iridocyclitis 5/19/2023 80
- 81. • Surgical Treatment –tectonic grafting • Cadaveric donor sclera • autogenous periosteum or donor cornea – scleral debridement • prognosis – good Nonnecrotizing noninfectious anterior (diffuse or nodular) scleritis – poor posterior scleritis, necrotizing scleritis, or infectious scleritis 5/19/2023 81
- 82. Episcleritis • is arelatively benign, self-limiting condition affecting the outer coat of the eye • types – simple acute onset • bilateral in 40% – nodular insidious onset • inner reflection of light will appear undisturbed • the outer reflection will be clearly displaced forward • bilateral 13% – nodular scleritis both • only a watery discharge • injection typically in the interpalpebral area 5/19/2023 82
- 83.
- 84. • phatology – nongranulomatousinflammation with vascular dilation and perivascular infiltration of lymphocytes and plasma cells • ETIOLOGY – idiophatic – systemicassociation • RA the most common • granulomatosis with polyangiitis and Cogan syndrome – ocular • rosacea, keratoconjunctivitis sicca, and atopic keratoconjunctivitis 5/19/2023 84
- 85.
- 86.
Editor's Notes
- #8 Eyelid trauma, poor Bell reflex, or an abnormality of lid closure can compromise this defense mechanism, especially in obtunded or debilitated patients with poor blinking. Chronic infection and inflammation of the eyelid margin can predispose the cornea to bacterial infection
- #10 All types of contact lenses, including hard, gas-permeable, soft, disposable, orthokeratology, and cosmetic
- #17 Tear substitutes should contain no potentially toxic (benzalkonium) or sensitizing (thiomersal) preservatives
- #34 only the biguanides have consistent in vitro and clinical efficacy against cysts and trophozoites; the other agents are effective primarily against trophozoites.
- #44 Recurrent HSV infection can affect almost any ocular tissue, including the eyelid, conjunctiva, cornea, iris, uveal tract, trabecular meshwork, ret ina, and optic nerve.
- #50 Valacyclovir, a prodrug of acyclovir, is just as effective for ocular HSV disease but can cause thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in severely immunocompromised patients such as those with AIDS.
- #62 Reduced corneal sensation renders the corneal surface prone to occult injury and decreases reflex tearing; it also appears to decrease healing rates of corneal epithelial injuries