The document provides an overview of corneal ulcers, detailing their definitions, classifications, and types—both infectious and non-infectious. It highlights important facts regarding the management of corneal diseases, including treatment principles and specific management strategies for various etiologies such as bacterial, fungal, and viral keratitis. The document emphasizes the urgency of corneal ulcers as ocular emergencies that potentially lead to significant vision loss.

1. Infectious Corneal
Ulcers

2. Corneal Ulcers
Def: Corneal ulcers are defects in the corneal epithelium
with or without stromal infiltration.
Types:
A) Infectious ulcerative keratitis
B) Non infectious ulcerative keratitis

3. Bacteria and
Fungi Viruses Acanthamoeba
Systemic
Autoimmune/
Inflammatory
Local Toxic
InfectiousNon infectious
Etiology

4. Non Infectious Ulcerative Keratitis
Causes:
Local causes:
Punctate marginal keratitis: Staphylococci, Streptococci, hypersensitivity to
medications
Peripheral keratitis associated with blepharitis:
Systemic causes:
Generally manifestation of systemic, immune-mediated disease
Most common: Rheumatoid arthritis, Wegener’s granulomatosis and
polyarteritis nodosa

5. Non INFECTIOUSINFECTIOUS
No painPain
No dischargeDischarge
AC reaction: absentAC reaction: present
PeripheralCentral
Trauma: -------Trauma : ++++

8. Infectious keratitis

9. Important Facts
 A corneal ulcer is an ocular emergency that
raises high stakes of questions about diagnosis
and management.
 When a large corneal ulcer is staring you in the
face time isn't in your side.
 Despite varying etiologies and presentations,
as well as different treatment approaches ,
corneal ulcers have one thing in common : the
potential to cause devastating loss of vision.

10. PRINCIPLES OF MANAGEMENT OF CORNEAL
DISEASE
1- Control of infection
2- Control of inflammation
3- Promotion of re-epithelialization
– lubrication
– lid closure
– bandage soft contact lens
4- Prevention of perforation
Tissue adhesive glue
Conjunctival flap
Systemic immunosuppressive agents
Corneal grafting

11. MICROBIAL KERATITIS ( Bacterial)
Predisposing factors:
Ocular surface disease: Trauma,
post-herpetic
corneal disease,
Bullous Keratopathy,
Corneal exposure,
Dry eye
Diminished corneal sensation
Contact lens wear

12. Causative Organisms
80 % of cases >>>>Staphylococcus aurous, Streptococcus
pneumonia and Pseudomonas species
Pseudomonas aeruginosa
is the most frequent and the most pathogenic ocular
pathogen which can cause corneal perforation in just 72
hours

13. MICROBIAL KERATITIS ( Bacterial)
Pathogens which can produce corneal infection in intact
epithelium.
1.Neisseria gonorrhoeae
2.Corynebacterium diphtheriae
3.Listeria
4.Haemophilus

14. Staph. aureus and strep. pneumoniae
Oval, yellow-white, densely opaque stromal suppuration
surrounded by relatively clear cornea

15. MANAGEMENT
History
Clinical examination
Hospitalization
Corneal scrapping

16. Differentiators
 Acute painful injected eye.
 Profuse tearing and discharge.
 Decrease visual acuity.
 Large F.B
 Stromal invasion with epithelial
excavating edge.

17. Treatment
1. Fluroquinolones 
 Every 5 mins / hour
 Hour / 24 hs
 2 hour / 24 hs
2. Fortified eye drops  ulcer < 2 ws ,
improvement not obvious.
(N.B)Don’t miss resistant bacteria.
3. Steriods????

18. FUNGAL KERATITIS
Filamentous fungal keratitis
–Aspergillus - Fusarium
Yeasts candida

19. Clinically
History of vegetable matter injury
Greyish-white ulcer with indistinct margins
Surrounded by feathery infiltrates
Ring infiltrate
Endothelial plaque
Hypopyon

20. Differentiators
 Dull grey infiltrate.
 Satellite lesions.
 Awareness of those ulcers resembling
bacterial keratitis
 Awareness of those caused by yeast  better
defined borders
 Real flags

21. Candida keratitis
Usually develops in pre-existing corneal disease or
immunocompromised patient
Yellow-white ulcer
Dense suppuration

22. Filamentous fungal keratitis
Firm elevated necrotic slough, “hyphate” lines that extend beyond the
edge of the ulcer into the normal cornea,
multifocal granular (or feathery) gray-white “satellite” infiltrates in the
corneal stroma

23. MANAGEMENT
Culture
Biopsy
Antifungal therapy
– Initially broad-spectrum econazole 1%, voriconazole 1% topically
– Then depending upon sensitivity Natamycin or imidazole for 6 weeks
Systemic ketoconazole
Therapeutic penetrating keratoplasty

24. ACANTHAMOEBA KERATITIS
Protozoan
–Active (trophozoite)
–Dormant (cystic)
Common in swimmers
and CL wearers

25. Clinically
Blurred vision and disproportionate pain
Patchy anterior stromal infilterates
Perineural infilterates (radial keratoneuritis)
Infilterates coalesce –ring abcess, ulceration and
hypopyon
White satellite lesions

26. Acanthamoeba Keratitis

27. MANAGEMENT
Corneal scrappings stained with calcoflour white
Corneal biopsy
Treatment with chlorhexidine,
polyhexamethylenebiguanide drops,
dipropamidine and propamidine.
Therapeutic penetrating keratoplasty

28. VIRAL KERATITIS
HERPES SIMPLEX VIRUS
Basically it is epitheliotropic and
may become neurotropic
Two types-HSV-1 & HSV-2
Primary HSV-1 infection occurs
most commonly in the mucocutaneous
distribution of the trigeminal nerve

29. Classification
1. Epithelial keratitis
2. Disciform keratitis (localized endotheliitis)

30. 4.Metaherpitic ulcer
Necrotizing keratitis
Keratouveitis

31. Differentiators
 Dentritic ulcer.
 Loss of corneal sensation.
 Photophobia.
Types of HSV keratitis:
 Primary
 Recurrent
 Dentritic , Geographic , Metaherptica
 Diabetic foot in the eye  Neurotrophic

32. TREATMENT
Epithelial keratitis is treated with topical antivirals
Aciclovir ophthalmic ointment and Trifluridine eye drops
Herpetic stromal keratitis is treated initially with prednisolone
drops every 2 hours accompanied by a prophylactic antiviral drug
Metaherpetic ulcer treated by artificial tears and eye lubricants,
stopping toxic medications, performing punctal occlusion, bandage
contact lens and amniotic membrane transplant

33. Herpes Zoster Keratitis
Caused by Varicella zoster virus
Causes-varicella(chickenpox) & herpes zoster(shingles)
RISK FACTORS:
• Increasing risk(>70 years)
• Neoplastic diseases
• Immunosuppressive drugs
• Organ transplant recipients
• HIV

34. Herpes Zoster Ophthalmicus
(HZO)
Unilateral painful skin rash in one or more dermatome distributions of
the fifth cranial nerve (trigeminal nerve)
HUTCHINSON’S sign:
Vesicles at the side or
tip of
the nose are potential
indicators of
ocular diseases

35. ACUTE EYE DISEASES
Acute epithelial keratitis:
Dendritic lesions with tapered ends without terminal bulbs

36. Nummular keratitis:
Fine granular subepithelial deposits
Episcleritis:
Scleritis and sclerokeratitis:
Stromal (interstitial) keratitis:
Anterior uveitis

37. Posterior uveitis
Neurotrophic keratopathy
Scleritis

38. Eyelid scarring
POST HERPETIC NEURALGIA
Neurological complications

39. Treatment
Oral acyclovir 800 mg five times daily for 7 to 10 days is the
standard treatment
Topical antiviral ttt
Topical steroids in uveitis
Pain should be treated with narcotics
Topical skin ointment

40. Thank you