This document discusses corneal ulcers, including their definition, causes, microbiology, pathogenesis, stages, grading, symptoms, clinical examination, investigations, treatment, and complications. Key points include: - Corneal ulcers are tissue excavations associated with epithelial defects, edema, infiltration and necrosis. They are usually caused by injury or foreign materials that allow microbial infection. - Common microbes include bacteria (e.g. streptococcus, pseudomonas), fungi (e.g. candida, fusarium), protozoa (e.g. acanthamoeba), and viruses (e.g. herpes). - Treatment involves local and systemic antibiotics, antifungals, or antiv

1. CORNEAL ULCER
Dr SHREEJI SHRESTHA.

2. Definition
• Tissue excavation associated with
epithelial defect usually with infiltration
and necrosis characterized by edema,
cellular infiltration and ciliary
congestion
(kanski)

3. Injury and foreign material
binds to iron used in microbial metabolism
Lysis of bacterial cell wall
Degrades CW of GPB
Prevent bacterial adherence
Activation of T cell and secretion of IgA

4. Microbiology
Eukaryotes Prokaryotes
protozoa
fungi
toxoplasma,
acanthamoeba
yeast like
Filamentous
candida, cryptococcous, rhinosporidium
Septate
Aseptate
Aspergillous, fusarium
Mucor, rhizopus
Gram positive cocci
gram negative cocci
Gram positive rods
gram negative rods
True bacteria
Filamentous bacteria
Actinomyces, mycobacterium
nocardia
Virus
HSV, HZV, EBV, CMV, Kaposi, HHV8

5. Enterococcus- endophthalmitis
P. Acne-post op endophthalmitis
B cerus- explosive endophthalmitis(soil)
H influenza- glaucoma Sx
M chelonei-immunocompromised patient
P aeruginosa- Contact lens
Acanthamoeba- swimming pool, hot tubs, tap water
Streptococcus Pneumococcus- dacryocystitis
Actinomyces - cannaliculits
Atypical mycobacteria- post LASIK sx
Moraxella - chronic alcoholism

6. Pathogensis
• corneal insult- PMN and phagocytes-
collagenase, elastase, cathepsin, oxygen free
radicals- destruction of cornea
• Reactive fibroblast- collagen - repair of cornea

7. Stages of corneal ulcer
• stage 1- Progressive stage
Saucer shaped, gray zone of infiltration.
Microbes adhere- PMN (tears & limbal vessel)-
invasion of cornea- necrosis & sloughing of
epithelium, BM, Stroma- ulcer progress by lateral
extension- deep penetration

8. stage 2 - Regressive stage
• Natural defense mechanism and antimicrobial
treatment
line of demarcation forms & margin and floor -
smooth & transparent
Enlargement of ulcer(digestion of necrotic material)
Superficial vascularization

9. Stage 3- healing stage
• Epithelization
• Kerotocyte - fibroblast- scar (ghost vessel)
• Cicatrization - collagen repair & fibrous tissue
(fibers arenot laid in regular manner- scar)

10. Complications
Pneucoccous

12. Staphyloma
Cicatrix

14. Hemorrhage

16. risk factor
Systemic
• Diabetes mellitus
• Sjögren’s syndrome
• Steven-Johnson syndrome
• AIDS
• Advanced malignancies
• Connective tissue disorders
• Alcoholics
• Extremes of age
• Measles malnutrition
Occupational
• Farmers
• Animal handlers
• Gardeners
Ocular
• Trauma
• Contact lenses
• Lid and adnexal
infections
• Ocular surface disease
• Allergic eye disorders
• Bullous keratopathy
• Topical medications
• Prior ocular surgery

17. Symptoms
• pain- superficial ulcer > deep ulcer
Onset
Acanthamoeba (radial keratoneuritis)> herpes simplex/fungal
relief pain-perforation
• Redness and photophobia
• Blurring of vision- central (staph,pseudomonas,fusarium)-
hypopyon, cataract, glaucoma
• discharge(mucopururlent, membranous)

18. clinical examination
• lacrimal sac- R/O dacryocystitis
• Eyelid - blisters, abnormal blink rate, lid swelling,
trichiasis, ectropion, lagophthalmous, blepharitis,
foreign body
• Conjunctiva -Circumciliary congestion,
hemophilus, pneumococcal, gonococcal-
chemosis,
• Precorneal tear film- filaments, dry eye

19. Cornea
location - central / paracentral / peripheral
shape - punched out/ dry looking-hyphae/ dendritic/ geographic /
ring shaped
Margin - well defined, indistinct, overhanging
Epithelial defect
Infiltration-single, multiple
corneal vascularization, thinning, desmatocele, perforation
corneal sensation- herpes, neurotrophic keratopathy, chronic
surface Disease

20. Grading
Feature Mild Moderate Severe
Size of ulcer (mm) < 2 2-5 > 5
Depth of ulcer (%) < 20 20-50 > 50
Infiltrate
Density Dense Dense Dense
Extent Superficial Extension upto mid
stroma
Deeper than mid
stroma
Scleral involvement Not involved Not involved May be involved

23. • Anterior chamber- mild flare- severe hypopyon,
fixed and immobile
• IRIS- synechiae, uveal prolapse
• Sclera- acanthamoeba
• Posterior segment - USG- endophthalmitis
• IOP- monitor- digital/tono-pen

24. work out- microbiological
• corneal scrapping(anesthesia-proparacaine)-
Kimura spatula/23-gauge needle/, edges(strep)
and base(moraxella)avoid contact with lash- gm
stain , giemsa, PAS, GMS,KOH, blood,
chocolate, SDA( row of c)

25. Blood agar Expect neisseia, hemophilus
Chocolate Neisseria, hemophilus,, moraxella
SDA Fungi
Non-nutrient with ecoli Acanthamoeba
Cooked meat Anaerobic
LJ Mycobacterium
Thioglycolate Diphtheria
Thayer Martin Neisseria

26. Types of
stain
Organism
Color
Gm Bacteria Purple, pink
Calcoflour
white
Fungi Bright green
acid fast Mycobacteria
Acridine
Bacteria , fungi,
acanthamoeba
Yellow-orange

27. • Conjunctival swab- corneal scrape is negative
• Contact lens cases
• corneal biopsy- absense of clinical improvement
(4 days)

28. • Bacterial - single suppurative inflitrate, sharp
Epithelial demarcation, stromal infiltration,
mycobacterium- nonsuppurative infiltrate, intact
epithelium
• Fungi - less inflammatory sign, less conjunctival
injection, pain out of proportion that of inflamed
cornea, irregular feathery/filamentous margin,
satellite (multiple) infiltrate, more AC inflammation,
rapid progression with necrosis, yellow-white
suppurative infiltrate, sterile immune ring

29. Staphylococcus ulcer
Pseudomonas
diffuse epithelial graying which characteristically occurs away
from the main site of epithelial and stromal infiltration
Moraxella

30. Streptococcus viridans

31. Streptococcus pneumonias
leading edge forming a serpiginous contour

32. Acanthamoeba

33. Candida (collar stud)Curvularia
Acremonium

34. Treatment
• General considerations
• Hospital admission
• Discontinue contact lens wear
• eye shield
• Decision to treat- clinically sterile, small infiltrate-
low frequency topical antibiotics

35. parameter to monitor clinical
therapy
• Blunting / decrease density of stromal infiltrate
• Dec AC reaction
• Dec stromal edema
• Reepithelization
• Cessation of corneal thinning

36. local therapy
• 1)antibiotic monotherapy- fluoroquinolone
• 2) antibiotic duotherapy- aggressive/streptococci-
Cephalorosporin 50mg/ml(fortified) and
aminoglycoside 14mg/ml (fortified)
• 3) Subcutaneous antibiotic- poor compliance with
topical treatment
• 4)mydriatics
• 5) ascorbate

37. • Steroid
1) steroids should not be used initially or if the eye is improving
(2) steroids should be used after several days of antibiotics if
there is persistent inflammation
(3) continue use of concomitant antibiotics
(4) steroids should not be used if there is corneal thinning

38. Systemic antibiotics
• Indications
• Potential for systemic involvement
• Severe corneal thinning
• scleral involvement

39. Causes of non healing ulcer
• Local - concretions, misdirected cilia, FB,
dacryocystits, inadequate therapy, wrong
diagnosis, lagopthalmos
• Systemic- DM, severe anemia, malnutrition,
chronic debilitating disease, patient on systemic
steroid

40. Mx of treatment failure
• + if no improvement (48hrs)- review antibiotic, contact lab
• + culture- resistance but clinically improving- no change in
therapy
• + still no improvement- rescrapping
• + culture - neg - corneal biopsy- histology and culture
• + resistant to medical therapy —excisional Keratoplasty

41. Antifungal• Epithelial debridement- mucus, necrotic tissue,
penetration
• Topical treatment- (filamentous)natamycin 5% -
fungistatic hourly day and 2 hourly at night +
fluroquinolone, once infiltrate decrease in size 2hourly
till complete resolution and continued for 2 weeks after
resolution——(candida) amphotericin0.15%(fungicidal)
12weeks
• decrease pain, infiltrate, satellite, rounding out of
feathery margins

42. • Subconjunctival fluconazole- severe case
• Intracameral/intrastromal - amphotericin B
• Systemic antifungal(6-8wks)—
lesion near limbus and enophthalmitis, scleritis, deep keratitis -
fluconazole 200mg/day or itraconazole 200mg/day or ketoconazole
600mg/day
• Tetracycline- thinning(collagenase inhibitor)

43. Promotion of epithelial
healing
• Reduce toxic exposure
• Lubrication, punctual plugs, cholinergic enhancer
(pilocarpine 5-10mg TID)
• Bandage soft contact lens- high water content
• surgical eyelid closure- neurotropic keratopathy,
persistent defect, botulinum LPS, lat tarsorrhaphy
• autologous serum drops, Amniotic membrane patch ,
tissue adhesive, limbal stem cell transplantation

44. Viral(HSV) keratitis
• Primary infection
Occurs in childhood, spread by droplet
uncommon (6 months)- maternal antibodies
• Recurrent infection
Primary infection — virus (trigeminal
ganglion)(latent infection)

45. • Subclinical reactivation - contagious- shed in tear
film
• Clinical reactivation - fever, hormonal, UV
trauma,— clinical reactivation—virus transported
to periphery

46. Epithelial keratitis
• Dendritic ulcer(centrally), terminal buds
(fluorescein)(loss of cellular integrity), margin stain with rose
bengal(loss of mucin binding cells), sub epithelial haze
• Corneal sensation
• Inadvertent Steroid-
geographical ulcer

47. immune mediated Stromal
keratitis
• central stromal edema + epithelial edema
• KP, DM folds, wessely immune ring(deposition of Ag-Ab
complex and PMN infiltration), IOP maybe Inc, sensation
decreased, stormal vascularization

48. Necrotizing stromal keratitis
• stromal necrosis and melting
• Anterior uveitis with KP, epithelial defect (+/_)
• Progress to scaring, vascularization

49. Herpetic endothelilitis
• Delayed type 4 hypersensitivity
reaction(disciform keratitis, diffuse keratitis or
linear endothelitis)

50. Neurotrophic ulceration
• Failure of re-epithelization from corneal
anesthesia, decrease tear formation,
exacerbation by chronic use of topical
medication(BM damage)
Recurrent corneal erosion
Non healing sterile ulceration, stromal is grey and
rolled up margin

51. Lab investigation
• Giemsa Staining
• Polymerase Chain Reaction (PCR)
• Viral Culture
• Immunological Tests- ELISA

52. Treatment
• topical acyclovir 3%/ganciclovir 0.15%
5times/Trifluridine 1%(9 times)- tapered- 3weeks
- (hydroxypropylmethycellulose)
• Debridement - (dendritic) eliminates antigenic stimuli to stromal inflammation
• Oral antiviral - immunodeficient patient, necrotizing stromal keratitis
• topical steroid - used only in stromal- keratitis - (2-4)hrly and tapered over 6
weeks

53. HEDS study
do topical steroid treat stromal
keratitis
Yes. also decrease duration of
keratitis
Is oral acyclovir ( steroid+trifluridine) helpful
in stormal keratitis No
Is oral acyclovir helpful in HSV
iritis
Favoring use of oral acyclovir
does oral acyclovir prevent epithelial
to stormal keratitis
No
Does oral acyclovir decrease
HSV recurrence
Yes
any triggers of HSV
reoccurence
No

54. herpes zoster ophthalmicus
• chicken pox- VZV- (retrograde axoplasmic
flow)dorsal root+ cranial nerve sensory ganglia-
axonal transport(latent state)- mucous
membrane and skin
• HZO(ophthalmic division of trigeminal nerve)
• Direct invasion — epithelial keratitis
• Reactivation —necrosis and inflammation in
ganglia — corneal anesthesia— neurotrophic
keratitis

55. Signs
• Hutchinson sign
• Age
• AIDS - more severe

56. Features
• Prodromal phase(3-5)- itching, burning
sensation—severe deep boring pain, fever
• skin lesion - midline, erythematous area with
maculopapular vesicular rash (lower lid not
affected, doesn't cross midline), edema of lower
lid- depigmented scar

57. Differentiation between dendrites of herpes
simplex and zoster
Feature HSV VZV
Over all fine, lacy (dendrite) Thick, ropy(pseudodendrite)
Epithelium
central Linear defect with
bared storm surrounded by
edematous epithetlial cells
small Elevated, painted-on
appearance
Staining Base stains with fluorescein min staining
Terminal bulb Frequent None
Dermatome Incomplete(epidermis) Complete(deep dermis)
skin scar - +
PHN - +
BL Uncommon(2%) _
Corneal
hypesthesia
Sectoral Severe

58. Zoster sine herpete
• Iritis, disciform keratitis, and facial palsy (Bell’s
palsy)
• defined as reactivated VZV which causes only
neurologic symptoms such as dermatomal
neuralgia or neuropathy, and, on occasion,
ocular inflammation - no rash

59. Treatment
• oral acyclovir 800mg 5 times a day(72hrs) - 7-10
days
• Encephalitis - IV acyclovir 5-10mg/kg
• Systemic steroids- accelerate skin healing
• Skin - warm compress BD followed by complete
drying

60. Reference
•Jacobiek Principles and Practive of
Ophthalmology 3rd Edition Vol 1
•Section 08 - External Disease And Cornea -
American Academy Of Ophthalmology –
2012
•Corneal Ulcers Diagnosis and management-
Jaypee- Namrata sharma, Rasik B Vajpayee
•Kanski Clinical Ophthalmology 7 Ed