3. Sclera
– It is divided into 3
layers (from
outermost inward):
• episclera,
stroma, and
lamina fusca.
5/19/2023 3
4. introduction
• keratitis
– inflammation and 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
• Normal Ocular 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
15. Infectious crystalline keratopathy
Most commonly 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
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
23. clinical presentation
• sever pain 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
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 injection of 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-living amoeba 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
32. • suspect Acanthamoeba keratitis 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
37. Herpes Simplex Virus Eye 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
39. HSV
• dendritic epithelial keratitis
• 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
– above the 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 ocular infection
– 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
– infection through 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
51. • Stromal keratitis
– form of recurrent herpetic external disease
• types
– nonnecrotizing (interstitial or disciform)
– necrotizing
5/19/2023 51
52. • Herpetic interstitial keratitis
– 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
56. Herpetic Eye Disease Study
– 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 antiviral drugs:
– 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
59. Complications of herpetic eye 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
62. • prevent progressive stromal 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 bullous keratopathy
• 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 and dendritic 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 Factors for 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
70. • HZO
– oral valacyclovir 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
73. Scleritis
– primary inflammation of 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
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
82. Episcleritis
• is a relatively 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
84. • phatology
– nongranulomatous inflammation 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
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
All types of contact lenses, including hard, gas-permeable, soft, disposable, orthokeratology, and cosmetic
Tear substitutes should contain no potentially toxic (benzalkonium) or sensitizing (thiomersal) preservatives
only the biguanides have consistent in vitro and clinical efficacy against cysts and
trophozoites; the other agents are effective primarily against trophozoites.
Recurrent HSV infection can affect almost any ocular tissue, including the eyelid, conjunctiva, cornea, iris, uveal tract, trabecular meshwork, ret ina, and
optic nerve.
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.
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
