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Corneal Ulcer.pdf
- 1. CORNEALULCER Dr.Md.Ashfakur Rahaman DO Student RangpurMedical College
- 2. Contents • Applied anatomyof the cornea • Definition of corneal ulcer • Classification • Predisposing factors • Pathogenesis • Clinical presentation • Management • Complications
- 3. Defination Refers to cornealtissue excavation associated with an epithelial defect, usually with infiltration and necrosis.
- 4.
- 5. Classification Corneal ulcers Cornealulcers can be classified in three ways : A. On the basis of Aetiology B. On the basis of Location of ulcer C. On the basis of Involvement of the corneal layers
- 6. A.On the basisof Aetiology A. Infective: - Bacterial - Viral - Fungal - Protozoal B. Non-infective/sterile -Neuroparalytic -Neurotrophic -Corneal ulcer due to Vit A deficiency - Mooren ulcer
- 7. B. On thebasis of Location
- 8. C. On thebasis of involvement of the corneal layers
- 9. Predisposing Factors Local Factors:- •Contact lens wear • Ocular trauma • Dry eye • Chronic dacryocystitis • Exophthalmos • Xerophthalmia • Systemic Factors : • Malnutrition • DM • Alcoholism • Malignancy • Immunosuppressive drugs
- 10.
- 11. Clinical feature Symptoms Bacterial FungalViral Pain and Irritation Blurred Vision Redness Photophobia Watering Discharge Eyelid Swelling Blurred Vision Redness Eyelid Swelling Photophobia Pain and Irritation Discomfortand Gritty feeling Photophobia Redness Watering Blurred vision
- 12. Signs Bacterial Fungal Viral -Epithelialdefectwith large infiltrateand circumcorneal injection -Anterior chamber reaction -Hypopyon Grey or Whitish stromal infiltratewith indistinct fluffy margin. -Feathery branch like extensions -Satellitelesion -Hypopyon Punctate/Stellatepattern -Linear branching ulcer with or without terminal buds -Reduced corneal sensation
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- 16. Investigations • Corneal Scrappingfor- Bacterial Fungal Viral Gram staining 10% KOH Giemsa stain PCR Culture and Sensitivity -Blood agar media -Chocolateagar media -McConkayagar media Culture and Sensitivity -Sabouraud Dextrose agar media
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- 18.
- 19. S.Aureus grows onblood agar media
- 20.
- 21. Candida grows onSabouraud dextrose agar media
- 22. Protozoal Corneal Ulcer •Causative organism : -Acanthamoeba • Definitive sign : Perineural infiltrates (radial keratoneuritis) • Investigations : • Corneal scraping for – - Calcofluor white stain - Giemsa stain • Culture and sentivity : - Non-nutrient agar seeded with dead E. coli
- 23.
- 24. Treatment of CornealUlcer Principles of treatment 1.Control of infection 2.Relief of symptoms 3.Promotion of heeling 4.Prevention of complications 5.Treatment of complications A.Generally Measures B.Medical treatment C.Surgical treatment
- 25. General measures • Hospitaladmission • Discontinuation of contact lens wear • Using eye shield/dark glass • Improvement of nutrition (Vit–C )
- 26. Treatment Bacterial Cornealulcer Medical Treatment :- Topical Antibiotic •Antibiotic monotherapy •Antibiotic duotherapy Cycloplegics Analgesic Systemic Therapy – Systemic antibiotic Surgical treatment:- (if medical treatment failed) • Conjuctival hooding • Tarsorrhaphy • Amniotic membrane graft • Keratoplasty
- 27. Treatment Fungal CornealUlcer Topical Therapy : • Topical antifungal • Cycloplegics • Subconjunctival injection • Anterior chamber washout • Removal of the epithelium Systemic Therapy : • Antifungals • Tetracycline/ Doxicycline
- 28. Treatment Viral CornealUlcer Local Therapy :- • Topical Antiviral • Antibiotic prophylaxis • Topical steroids • Cycloplegics Systemic Therapy : • Oral antiviral • Interferon monotherapy
- 29. Treatment Cont... Local care: • Debridement of ulcer • Care of skin lesions - aciclovir cream five times daily • IOP control
- 30. Treatment Protozoal CornealUlcer • Topical amoebicides • Topical antibiotic • Topical steroid • Control of pain • Therapeutic Keratoplasty • Debridement of involved epithelium
- 31. Management of apparent treatmentfailure : - Frequent instillation of fortified aminoglycosides - Review of antibiotic regimen - Re-scraping and additional staining - Corneal biopsy
- 32. Complication Complications of cornealulcer can be described under two headings : 1.Before perforation 2.After perforation
- 33. Before perforation : •Anterior uveitis • Hypopyon • Secondary glaucoma • Descemetocele • Corneal scarring - Nebula - Macula - Leucoma
- 34.
- 35. After perforation : •Anterior synaechiae • Iris prolapse • Adherent leucoma • Complicated cataract • Sublaxation of the lens • Anterior staphyloma • Endophthalmitis • Phthisis bulbi
- 36.
- 37. Treatment of Complication Managementof perforation : -Tissue adhesive glue with bandage contact lens. -Corneal patch graft - Occlusive surface repair techniques - Penetrating keratoplasty
- 38. Treatment of ComplicationCont.. • Management of endophthalmitis • Visual rehabilitation : -Keratoplasty -Rigid contact lens -Cataract surgery
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- 41.
- 42. Neurotrophic keratitis/ neurotrophic keratopathy •Neurotrophic keratopathy is a corneal degenerative disease characterized by a reduction or absence of corneal sensitivity.Usually associated with Herpes keratitis,Topical anesthetic abuse,Corneal surgery.
- 43. Clinical features • Afull cranial nerve examination is mandatory. Symptoms:- -Redness -Swollen lid and defective vison -No pain,No tearing • Sign:- - Reduced Corneal Sensation - Cilliary Congestion - Interpalpebral epithelial irregularity -Rolled and thickened edges -Stromal melting
- 44. Treatment • Discontinuation • Topicallubricant • Anticollagenase agents • Cenegermin
- 45. Exposure Keratopathy • Isresult of incomplete lid closure(lagophthalmos),withdrying of cornea despite normal tear production. • Causes include neuroparalytic, Facial nerve palsy,Parkinsonism,lid scaring,post blepharoplasty,proptosis etc.
- 46. Clinical features Symptoms :- •Irritation • Burning sensation • Foreign body sensation • Intolerance to drafts and winds. Signs:- • Drying of cornea • Punctate epithelial defects • Corneal ulceration
- 47. Treatment • Artificial tears •Instillationof ointment • Soft bandage contact lens • Tarsorrhaphy • Treatment of cause
- 48. Peripheral Ulcerative Keratopathies •Marginal keratitis (catarrhal ulcer) • Mooren‘s ulcer • Terrien marginal degeration • Dellen • Associated with systemic autoimmune diseases
- 49. Marginal Keratitis • Superficialulcers situated near the limbus, Common in old people usually cuased by hypersensitivity reaction to Staphylococcal toxin.
- 50. Clinical features • Mildocular irritation,pain,photophobia and watering. • Ulcer is shallow, slightly infiltrated and often multiple. • Vascularization • Recurrence very common
- 51. Treatment • Topical steroid •Antibiotic
- 52. Mooren’s ulcer/chronic serpiginous /rodentulcer • Rare autoimmune disease • Progressive circumferential peripheral stromal ulceration • Often unilateral • Mainly affect older people
- 53. Clinical features • Symptoms -Pain -Photophobia -BlurredVision • Signs -Peripheral ulceration(involve 1/3 of stroma) -Undermined and Infiltrated edge -Limbitis -Vascularization
- 54.
- 55. Treatment Medical • Topical steroid •Topical Ciclosporin • Tacrolimus ointment • Artificial tears • Collagenase inhibitors • Systemic immunosuppression Surgical • Conjuctival resection • Lamellar keratectomy • Visual rehabilitation -Keratoplasty
- 56. Conclusion Timely diagnosis andproper management of corneal ulcer can save the valuable vision of the patient
- 57.