This document provides an overview of infectious and non-infectious keratitis. It discusses the classification, clinical presentation, microbiology, and management of various types of keratitis including bacterial, fungal, acanthamoeba, viral, post-surgical, and sterile ulcer keratitis. Empirical and microbiology-guided treatment approaches are outlined. Common causative organisms, clinical features, and treatment options for different forms of infectious keratitis are also summarized.

1. Keratitis
Hala Fathi Hannot

2. Index
1. Classification of keratitis
2. Infectious
3. Non infectious
4. Post ppt quizzes
5. Take home Msg
1. History
2. Bacterial
3. Fungal
4. Microsporoidal
5. Acanthameba
6. Viral

3. Infectious Keratitis
• Bacterial
• Gram +ve
• Gram –ve
• Atypical
• Fungal
• Acanthameba
• Viral
Non Infectious Keratitis
• Post LASIK
• Post PKP
• Post Cataract
• Interstitial keratitis
• Peripheral ulcerative keratitis PUK

4. Infectious keratitis

5. Focal white opacity (infiltrate) in the corneal stroma associated with
an epithelial defect and underlying stromal thinning.

7. Work-up

8. History
•Contact lens wear and care regimen should always be discussed. Sleeping in contact lenses? Daily or extended-wear lenses? Conventional, frequent replacement, or
single use? Disinfecting solutions used? Recent changes in routine? Water exposure (swimming or hot tub use) with lenses?
•Improper handling > overnight wear, hygiene problems, duration of continuous wear
- Contact lens type > daily-wear soft lenses more liable to microbial growth than gas-permeable rigid lenses
•Extended wear has higher risk - contact lens hygiene protocol; tap-water rinsing of contact lenses; swimming, using a hot tub, or showering while wearing contact
lenses; method of purchase, such as over the Internet; and decorative contact lens use
•Pseudomonas
Contact lens
•pythium, microsporoidal
Water exposure, bath in the pond or exposed in the rain water
•Soil , dust, decaying vegetation, Agriculture worker Fusarium
Trauma, corneal foreign body
Past Surgery
•antimicrobials or topical steroids)? Previous corneal disease? Ocular Surface Disease
•Eye lids,
•Corneal surgery including refractive surgery
Ocular medical or surgical history
•Candida - Systemic illness?
Systemic immunosuppression

9. • Keratitis with Contact lens wear
• Ocular trauma
• Ocular surface disease
• Systemic immunosuppression
• Post LASIK
• Eyelid disease: Entropion Lagophthalmos Trichiasis
• Lacrimal: Chronic dacryocystitis
Contact lens Common Microorganisms
Bacteria: Pseudomonas aeruginosa is the most frequently
isolated bacterium Acanthamoeba
Fungi: Fusarium species, Aspergillus species and Candida
species
Immunocompromised patients Common Microorganisms
Bacteria: mycobacteria
Fungi: Candida, microsporidial
Viral:HZ
Ocular trauma with Vegtative material
Fungi: Fussarium
• Post LASIK
mycobacteria
• Post keratoplasty

10. Examination

11. • document the size, depth, and location of the corneal infiltrate and
epithelial defect.
• Anterior chamber for depth and the presence of inflammation, including
cell and flare, hypopyon, fibrin, hyphemia
Slit lamp examination of cornea
• Diffuse illumination
• direct illumination
• sclerotic scatter
• specular reflection
Stain with fluorescein
epithelium,
Bowman’s layer,
stroma,
Descemet’s membrane,
endothelium,
blood vessel extension from limbal arcades
Fluorescein or rose bengal/lissamine green staining

12. Common slit lamp techniques for corneal examination
Diffuse illumination
Parallelepiped illumination.
Sclerotic scatter.
Specular illumination.
Retroillumination.
This is useful in detecting subtle corneal opacities. A beam of light is focused on the limbus (to achieve this you need
to loosen the screw that links the illumination to the microscope ie. uncoupling). These gives rise to internal reflection
and if there is no opacity the cornea will appear uniformly dark. Otherwise, the opacity will scatter the light.
The beam of light and the microscope are placed at equal angles from the normal to thecornea. Useful
particularly for observing the endothelium. High magnification is needed andthe view is monocular.
It is used to examine the cornea by reflecting light off solid body (the iris, lens and the retina)
This gives the effect of haying the light source arising from behind the object observed.
A beam of light with a width of about 2 mm is shown on cornea at about 45 degrees from the microscope position.
This allows one to view a "3-dimensional" block of cornea. The posterior surface of the cornea can be examined for
keratitic precipitates or pigment.
The light is shown on the cornea with a wide slit at about 45 degrees from the microscope position and the illuminated area is
viewed through microscope. (initial examination.)

14. Bacterial Keratitis

15. Bacterial
Keratitis
Gram positive Bacteria (Staph- Strept)
Localized round or oval gray-white lesions
Central or paracentral Minimal surrounding epithelial edema
Advancing border with active infiltrate & undermined edges, the trailing
edge with signs of healing.
Leveled hypopyon
Gram negative bacteria (pseudomonas)
Rapid course, severe inflammation, dense stromal suppuration and
corneal haze e.g. Pseudomonas keratitis Thick mucopurulent greenish
discharge
Marked stromal oedema Untreated > perforate within 2-3 days
Suppurative ulcerative keratitis
caused by P aeruginosa.

16. No cardia
Keratitis
Typical wreath shaped pattern
Tunnel infiltrates
Endophthalmitis
spread more in the superficial plane

17. Fungal Keratitis

18. Early pseudo dendritic keratitis pseudo geographic keratitis
Fungal
Keratitis
Filamentous fungi
• Minimal lid edema
• Feathery borders
• Satellite lesions Immune ring
• Unlevelled hypopyon> convex upper border
• Raised dry surface Pigmented ulcer
• Endothelial plaque
Yeast keratitis: Small oval ulceration Discrete,
sharply demarcated, dense, yellowish – white
stromal suppuration
Early
Classic
Fusarium keratitis.
gray-white, dry-appearing stromal infiltrate
with feathery margins and satellite lesions

19. deep endothelial plaques
abscess formation
limbal involvement
frank corneal perforation
Advanced

20. Microsporoidal
Keratitis
Epithelial disease
— coarse, multifocal, granular punctate epithelial keratitis
with mild follicular or papillary conjunctivitis
Stromal disease
— middle to deep stromal infiltrates
— mimicking herpetic disciform keratitis with no epithelial
or endothelial lesions

21. Pythium
Keratitis
Tentacle like projections
Peripheral Gutter

22. Ill- defined feathery
border
Yellowish raised
Fungal
Bacterial
Well defined
White
flat

23. Acanthameba Keratitis

24. Acanth
Keratitis
Pain level is out of proportion to the physical findings
Epithelial haze Pseudo dendrites
Punctate epithelial erosions -Multifocal infiltrates and microabscess
Fine epithelial and subepithelial curvilinear opacities (early)
Radial keratoneuritis (Along nerves of anterior stroma)
Ring stromal infiltrate
•In early cases, mimics herpetic epithelial keratitis
(Dentritiform appearance) Complication: Scleritis, secondary
bacterial keratitis
ring infiltrate and small hypopyon.

26. Viral Keratitis

27. HSV
Herbetic
Keratitis
• Primary - Blepharoconjunctivitis corneal involvement
• Recurrent – Epithelial keratitis ( Trigeminal ganglion –
latent)
Infectious epithelial keratitis
• Recurrent attacks
• Punctate epithelial Keratitis
• Dendritic Keratitis with linear branches and terminal bulbs,
central or paracentral, typically anesthetic (Rose Bengal)
double stain sign
• Geographic Ulcers
Stromal Herpetic keratitis
immune reaction to viral
• Necrotisizing
• Non nectrotizing
antigen causes stromal infiltration with intact epithelium
HSV Endothelitis
Disciform , Diffuse or Linear
Trabeculitis (IOP rise –)

28. HSV & HZV
Differentiation
• Obvious skin lesions
• Immunocompromise/ DM
Zoster
Herbetic
Keratitis
Herbes zoster
• Epithelial punctate keratitis
• Thick ropy dendrites with no terminal bulbs
• Stromal keratitis

29. Post
LASIK
Keratitis
Infectious keratitis
Focal area of infiltration surrounded by diffuse inflammation
1 week after LASIK
infiltrate, ciliary injection, hypopyon, and flap melt in severe cases.
Diffuse lamellar keratitis (DLK) Shifting sands of Sahara
Sterile inflammation of the lamellar interface
Characteristic diffuse white sand-like deposits, typically begins at flap
periphery
Occurs within the first within first 24h few days after LASIK

30. marginal
Keratitis
Blepharitis, inferior SPK, phlyctenule (a wedge-shaped, raised,
vascularized sterile infiltrate near the limbus, usually in children).
Peripheral scarring and corneal neovascularization.
Findings often present in the contralateral eye or elsewhere in the
affected eye.
• Singular or multiple, unilateral or bilateral,
• peripheral corneal stromal infiltrates often with a clear
space between the infiltrates and the limbus.
• Variable staining with fluorescein.
• Minimal anterior chamber inflammation.
• Sectoral conjunctival injection typically occurs.

33. A 72-year-old man is referred by his family physician for evaluation of
decreasing vision and increasing erythema of the right eye over the
last 24 hours. The patient also has had pain of the right scalp and
several new "pimples" on his forehead. Which of the following is the
most likely ocular finding in this case?
1. Dendritic ulcer with terminal bulbs
2. Pars planitis
3. Retinitis
4. Iritis with ocular hypertension

35. -More pinpoint
-Smaller
-Lesser in number
-At the plane of epithelium
-H/o Conjunctivitis
– More common No H/o water
Exposure
Microsporoidal
Viral

36. Non-Infectious keratitis
Sterile Ulcers Keratitis

37. Non infectious keratitis- sterile Ulcers
 Interstitial keratitis
• Cogan
• Syphilis
 Immune-mediated PUK
 Connective tissue diseases:
Rheumatoid arthritis
Wegener’s granulomatosis
Systemic lupus erythematosus
Polyarteritis nodosa
 Mooren’s, Terrien’s
 Marginal keratitis
 Allergic conjunctivitis -> Shield
ulcer
 Exposure keratitis
• VII CN palsy
• Lagophthalmos
• Proptosis
 Neurotrophic keratitis
• DM
• Trigeminal VCN
palsy
• Herpes zoster
Iatrogenic
Trauma
 Chemical, thermal, radiation
injury
Topical eyedrops
Postsurgical
• POST cataract Bullous keratopathy
• Post LASIK
• Post PKP
 Resolved infectious keratitis
 Nutritional keratitis (Vitamin A deficiency)

38. idiopathic or related to systemic connective tissue disease:
• Rheumatoid arthritis, GPA,
• relapsing polychondritis,
• polyarteritis nodosa,
• systemic lupus erythematosus, others.
• Peripheral (unilateral or bilateral) corneal thinning/ulcers may
be associated with sterile inflammatory infiltrates.
• The sclera may be involved.
• May progress circumferentially to involve the entire peripheral
cornea. Perforation may occur.
• This may be the first manifestation of systemic disease
Peripheral ulcerative keratitis (PUK)

39. Terrien marginal degeneration:
• Usually bilateral, often asymptomatic.
• Slowly progressive thinning of the peripheral cornea;
• typically superior;
• more often in men.
• The anterior chamber is quiet, and the eye is typically not injected although
may be associated with inflammatory signs and symptoms secondary to
epithelial breakdown and inflammatory or infectious infiltrates. A yellow line
(lipid) may appear, with a fine pannus along the central edge of the thinning.
The thinning may slowly spread circumferentially. Refractive changes, including
irregular and against-the-rule astigmatism are often present.
• The epithelium usually remains intact, but perforation may occur with minor
trauma.

40. Mooren ulcer
• Unilateral or bilateral.
• Painful corneal thinning and ulceration with inflammation.
• Initially starts as a focal area in the peripheral cornea, nasally or
temporally with involvement of the limbus; later extends circumferentially
or centrally.
• Unlike PUK, Mooren ulcer usually does not involve the sclera. An epithelial
defect, stromal infiltrate/thinning, and an undermined leading edge are
typically present.
• Limbal blood vessels may grow into the ulcer, and perforation can occur.
Mooren-like ulcer has been associated with
• Bilateral cases are more resistant to treatment than unilateral cases.
Idiopathic (autoimmunity may play a key role); systemic
hepatitis C virus infection.
diagnosis of exclusion after ruling out the aforementioned
systemic causes of PUK.

41. Staphylococcal hypersensitivity
marginal keratitis:
• Peripheral, white corneal infiltrate(s) with limbal clearing that may
have an epithelial defect and mild thinning.

42. Exposure/neurotrophic keratopathy:
• the inferior interpalpebral portion of the cornea without signs of
significant inflammation.
• May be associated with an eyelid abnormality, a fifth or seventh
cranial nerve defect, or proptosis.
• The ulcer may become superinfected.

43. Management of
Infectious Keratitis

44. Empirical TTT Vs Microbiology?

45. Low –moderate risk
High risk
Empirical treatment
Combined therapy
• Specimen
• Stain
• Culture
• Never patch infected cornea
• Topical Antibiotics Choice according to common pathogen; epidemiology, clinical
presentation & availability.,Systemic or Subconj scleral,..)
• Started before obtaining microbiology ,continued even if no microorganism is identified
• No steroids
• Cycloplegic agents (- synechiae and-pain )
• Collagen shields or soft contact lenses soaked in antibiotics (++drug delivery).
1. unusual history ( trauma with
organic vegetable matter or
contact lenses while in a hot tub
or history of corneal surgeries.
2. corneal infiltrate is central, large
>2mm, and/or is associated with
significant stromal involvement
(deep) or melting, infiltrates are in
multiple locations on the cornea.
3. chronic or unresponsive to broad-
spectrum antibiotic
4. atypical clinical features
suggestive of fungal, amoebic, or
mycobacterial keratitis
Empirical treatment
Monotherapy

46. Bacterial
Keratitis
First line:
- Topical 4th generation fluoroquinolones > Moxifloxacin 0.5% &
. Gatifloxacin 0.5%
- Suspected Gram –ve > Ciprofloxacin 0.3% & Ofloxacin 0.3%
Second line: - When severe & non-responsive to 1st line
fortified
preparation of
(Cefazolin / Cefuroxime 5% and tobramycin
/ Penicillin 0.3% gentamicin 1.4%)
• Vancomycin if MRSA/ severe Staph
• Penicillin if streptococcal infection is suspected.
• Gentamicin 1.5% Toxic Not n ocular surface disease.
 Systemic antibiotics:
• Systemic infection such as gonorrhea> ceftriaxone + azithromycin
• Scleral involvement /perforated e.g. Ciprofloxacin 500 mg BID
• Subconjunctival antibiotics :imminent scleral spread or perforation
• Hourly topical application improvement > reduce to
2 hourly then according to response.
• Central or severe keratitis: loading dose such as
every 5-15 minutes then every hour.
• Daily examination till improved
Monotherapy
Combined Therapy

47. Mycobacteria
Keratitis
• amikacin, + fourth generation fluoroquinolone.
• Systemically, we tend to give amikacin injection also if the
lesions are more limbal Or tunnel infiltrates. orally, we
can give sulfamethoxazole, trimethoprim combination
Nocardia
Keratitis
Topical amikacin. Either you can use 2 or 4%, along with
fluoroquinolone.
Azithromycin orally on day one you can do 500
milligrams, followed by 250 for 5 days.
at least one month for this medical therapy to heal.
If it doesn’t heal with medical therapy for one month->
LASIK flap amputation.
And if it doesn’t get healed ->a therapeutic graft.

48. Follow up
 STOP Antibiotics for 12:24 hrs
 hospital admission for eye drop administration
 then Repeat cultures Selected media for atypical organisms
Shift to non preservative eyedrops
Features suggest a positive response to antibiotic therapy:
Reduced pain
Reduced amount of discharge
Lessened eyelid edema or conjunctival injection
Consolidation and sharper demarcation of the stromal infiltrate
Decreased density of the stromal infiltrate
Reduced stromal edema and endothelial inflammatory plaque
Reduced anterior chamber cells, fibrin, or hypopyon
Initial re-epithelialization
Cessation of progressive corneal thinning
most infectious keratitis is culture negative after 48–72 hours.
Treatment failures
Treatment is effective
• In general, the initial therapeutic regimen should be modified when the
eye shows a lack of improvement or stabilization within 48 hours.
Effectively treated,
 Shift to appropriate Monotherapy
is due to
• antibiotic-resistant pathogens.
• Toxicity from medications
• if patients are unable to administer eye drops.

49. Corneal scraping
•topical aesthesia. Kimura spatula, No. 15 blade, or 25g needle.
• Scrape both the base and leading edge of the ulcer (from uninvolved to
involved cornea).
• Place material onto glass slide for microscopy and staining, Plate on agar
 when plating small samples, rows of ‘C streaks
 use separate needles for each agar dish.
1. Specimen:
• Corneal scraping; most important
• Contact lens, case and solution
• Conjunctival swab& eyelid swab less helpful
• Anterior chamber paracentesis > in deep infiltration
2. Smear & stain
3. Culture and sensitivity
Smear and Stain Culture & Sensitivity

51. ED hourly
Systemic- limbal inj

53. How to reduce the inflammatory response??
Anticollagenases (Tetracyclines )
Inhibit collagenases and have anti-metalloproteinase effect 
Reduce necrosis, perforations, and therapeutic
keratoplasty
Steroids
Steroids for Corneal Ulcers Trial (SCUT)
debate
 Pros: reduce inflammation, reducing scarring, neovascularization, and
stromal melt
 Cons: Delayed re-epithelialization, worsening of infection.
Never use in
• No cardia
• Fungal
• Viral epithelial
- Start Steroids after 48 hrs AB use
- It has role in the following :
• pseudomonas
• Acanthamoeba
• Viral : stromal not epithelial
Alternatives:
• Tacrolimus
• Cyclosporine

54. •Anesthesia ,a small trephine (e.g., a 2- to 3-mm dermatic punch) or blade
is used to excise a small piece of stromal tissue at base and the active edge
of the infiltrate (as far from the center of the cornea as possible) that is large
enough to allow bisection so that one portion can be sent for culture and the
other for histopathology.
•Perform a lamellar dissection while avoiding the visual axis and
thinnest part
•Specimen divided and sent for stain and culture
•Stop antibiotics for 24 hours
•Re-scrape and/or corneal biopsy
•Re-start intensive antibiotics
•Consider other diagnosis (e.g. sterile
ulcers?)
•Consider therapeutic penetrating
keratoplasty
 Nb1 A corneal biopsy taken from the center of the cornea may result in a significant refractive error from the irregular surface.
 Taking the biopsy from the edge of the infiltrate will increase the yield of viable pathogen, whereas a biopsy from the center of
an infiltrate may only yield nonviable pathogen and debris.
Corneal biopsy indication :
• if the response to treatment is poor
• or if repeated cultures have been negative and the clinical picture continues to
strongly suggest an infectious process.
• Corneal biopsy may also be indicated if the infiltrate is located in the mid or deep
Resistant keratitis: Non responsiveness over 2 weeks of medical treatment
Corneal biopsy procedure:

55. Confocal
Microscopy
Anterior segment
OCT
•Acanthamoeba
•Filamentary fungus
•Nocardia
To objectively measure the size of the
infiltrate and monitor thinning during
treatment
Fusarium
Aspergillus
Acanthameba
No cardia

56. Next Generation sequencing
•Does not require primers like PCR
High sensitivity compared to culture and stain
• Potentially lower specificity compared to cultre and stain
• Need for narrow list of causative agents to use specific primers
• confirmation of viral infections (high sensitivity)
PCR

57. Thinning & Perforation Endophthalmitis
Complications:
• Frequent lubrication, punctal occlusion and/or tarsorrhaphy in cases of aqueous deficient dry eye
• Systemic antimicrobials in cases of perforation
• Topical aqueous suppressant
• Bandage contact lens >promote corneal healing and re-epithelialization in impending or small corneal perforations or
lacerations that have good apposition of edges and alignment, and no prolapse of uveal tissue
• -Anti-collagenase medications, such as systemic (oral) tetracyclines , Vitamin C, systemic, stimulate collagen
production - - Immunosuppressive agents (oral or topical cyclosporine, systemic methotrexate, cyclophosphamide) >
in progressive corneal ulceration secondary to corneal inflammatory diseases. (After control with antimicrobials)
-Corneal gluing with cyanoacrylate glue (Histoacryl glue) > in impending corneal perforations or frank corneal
perforations that are small (< 3 mm), concave, and located away from the limbus .
- Patch Grafts:
In peripheral corneal perforations and descemetoceles, when the perforation is relatively small (i.e., it does not require
full-sized penetrating keratoplasty but is too large for tissue adhesive; 2.5-5 mm) so tectonic corneoscleral patch grafting
is sutured or glued to the cornea after trephining the infected portion of the cornea.
- Therapeutic keratoplasty: in large areas of perforation or necrotic tissue and progressive resistant infection despite
maximal medications

58. Cross Linking in infectious keratitis
•Antimicrobial effect
•Increases resistance to tissue necrosis
Fungal infections possible increase in perforation risk
benefit in bacterial keratitis

59. Rose Bengal photodynamic antimicrobial therapy
•Rose Bengal (0.1% or
0.2% RB in BSS) to the
deepithelized cornea for 30
minutes followed by
irradiation
progressive infectious
keratitis unresponsive to
standard medical therapy

60. Fungal
Keratitis
Microsporidial
Keratitis
- Filamentous
Natamycin 5% is the initial treatment of choice for fusarium keratitis. (superior to
voriconazole ) – doesn’t work deep (MUTT trial)
If deep ulcers (+ systemic ketoconazole or oral Voriconazole or intrasotromal injections of
amphotrecin B)
- Suspected yeast Candida
Amphotricin b 0.3% - 0.5% or fluconazole 0.3% preparation
- Aspergillus
 Natamycin +Voriconazole 1% preparation (MUTT trial)
Never use voriconazole as a monotherapy. Always in combination natamycin or any
antifungal. (risk of perforation and need of TPK)
Pythium :topical linezolid hourly, oral azithromycin. antifungals (itraconazole, voriconazole)
Hourly topical > reduce to 2 hourly then Continue
drops at least 3 hourly for at least 2 weeks after
healing (FU Every 2 days till improved )
Debridement by moistened cotton
fluconazole 0.3% preparation
Voriconazole 1%
Modified TST protocol. That is the topical, systemic, and
targeted therapy
• Debridement
• Adjuvants according to symptoms
• oral doxycycline (perforation)
• IOP lowering
• Antiinflammatory : (tacrolimus ,cyclosporine could be) Never steroids
• No cross linking (perforation)
• Maxium medical therapy 2 weeksEarly TPK

61. Acanth
Keratitis
- First lines:
Chlorhexadine 0.02%
+ Propamadine isethionate 0.1% (brolene)
- Second line:
Polyhexamethyline biguanide [PHMB] 0.02%-0.06%
Hexamidine isethionate 0.1%
- Third line:
Topical ketaconazole or fluconazole 1% or voriconazole
Topical neomycin 10mg/ml
(not gentamicin)
Surgeries: early DALK/ Therapeutic keratoplasty
Hourly topical application for 2-3 days around the clock, then
hourly while awake for 3 days, then tapered to 4 times a day
Adjuvant
• Steroids
(Reduce vascularization ,melting, scleritis, lid edema)
• Pain killer (Amitriptyline 25 mg BID

62. Herpes S
Keratitis
Zoster Keratitis
Epithelial keratitis
Ganciclovir 0.15% eye drops (preferred)
Acyclovir 3% ointment
Oral antivirals Alternative to topical in epithelial keratitis:
Acyclovir: 400 mg 3–5 times daily for 7–10 days in dendritic
Acyclovir: 800 mg 5 times daily for 14–21 days in geographic
Stromal keratitis:
Topical Prednisolone 1% + oral Acyclovir: 400 mg
- Herpes zoster ophthalmicus
acyclovir 800 mg
5 times daily until healing, then 3 times a day for 7 days
Prophylaxis of recurrent HSV keratitis
(Acyclovir 400 mg twice daily for one year) in:
- Multiple recurrences especially stromal keratitis
- Post-keratoplasty or any surgery in herpetic cornea
- Herpetic keratitis with immunosuppressive treatmen
Caution taken in renal patients> nephrotoxic
5 times a day for 7-10 days,
6–8 times daily tapered over 10 weeks twice daily over 10 weeks

64. Management of Non
Infectious Keratitis

65. coordinated with an internist or rheumatologist.
• glasses (or protective glasses [e.g., polycarbonate lens])
during the day and an eye shield at night.
• Ophthalmic antibiotic ointment
• preservative-free artificial tear ointment q2h.
• Punctal occlusion if dry eye syndrome is present.
• Topical cyclosporine 0.05% to 2% b.i.d. to q.i.d. or lifitegrast
5% b.i.d. may also be helpful.
• Cycloplegic drop (anterior chamber reaction or pain is
present).
• Consider doxycycline 100 mg p.o. b.i.d. for its
metalloproteinase inhibition properties and ascorbic acid
vitamin C 1 to 2 g daily) as a collagen synthesis promoter.
• Systemic steroids (e.g., prednisone 60 to 100 mg p.o. daily;
(if progressive corneal thinning, but not for perforation).
• An immunosuppressive agent (e.g., methotrexate,
mycophenolate mofetil, infliximab, azathioprine,
cyclophosphamide) is often required, especially for GPA.
• Excision or recession of adjacent inflamed conjunctiva
• Consider cyanoacrylate tissue adhesive or corneal
transplantation surgery A conjunctival flap or amniotic
membrane graft ( impending corneal perforation).
PUK associated with auto-immune disease
Refer to an internist (and/or rheumatologist
Systemic workup :
1. serum erythrocyte sedimentation rate,
2. complete blood count with differential,
3. rheumatoid factor,
4. antinuclear antibody,
5. antineutrophilic cytoplasmic antibody levels,
6. angiotensin-converting enzyme,
7. chest x-ray or CT to rule out connective tissue
disease and leukemia.

66. Terrien marginal degeneration:
• Correct astigmatism with glasses or contact lenses if possible.
• Protective eyewear should be worn if significant thinning is present.
• Lamellar grafts can be performed if thinning is extreme.
Moorenulcer:
• Underlying systemic diseases must be ruled out before this diagnosis can be made.
• Topical steroids, topical cyclosporine 0.05% to 2%,
• limbal conjunctival excision, corneal gluing, and lamellar or penetrating keratoplasty may be beneficial.
• Systemic immunosuppression (e.g., oral steroids, methotrexate, cyclophosphamide, and cyclosporine)

67. Mild
• Warm compresses and eyelid hygiene.
• Antibiotic drop q.i.d. fluoroquinolone
• Antibiotic ointment q.h.s. (e.g., bacitracin, erythromycin, bacitracin/polymyxin B).
Moderate to Severe
• Warm compresses and eyelid hygiene.
• Antibiotic drop q.i.d. fluoroquinolone
• A combination antibiotic/steroid can also be used q.i.d. (e.g., loteprednol 0.5%/tobramycin 0.3%,
dexamethasone 0.1%/tobramycin 0.3% or dexamethasone 0.05%/tobramycin 0.3%).
If episodes recur, add
Systemic doxycycline (100 mg p.o. b.i.d., for 2 weeks, and then daily for 1 month, and then 50 to 100 mg )
until the ocular disease is controlled for several months.
(anti-inflammatory effect on the sebaceous glands in+antimicrobial action).
Topical azithromycin q.h.s., erythromycin q.h.s. or cyclosporine b.i.d. may be helpful in controlling eyelid
inflammation.
Marginal keratitis Staphylococcal Hypersensitivity

68. Post ppt Qizzes

69. Keratitis in immunocompromised patients
Immunocompromised patients Common
Microorganisms
Bacteria: mycobacteria
Fungi: Candida, microsporidial
Viral:HZ
1

70. Keratitis in contact lens disease
Bacteria: Pseudomonas aeruginosa is the most frequently isolated
bacterium Acanthamoeba
Fungi: Fusarium species, Aspergillus species and Candida
2

71. Keratitis in case of water contact
pythium, microsporoidal
3

72. Which bacterial organism causes rapid
progression and corneal melting?
1. Staphylococcus.
2. Pseudomonas.
3. Streptococcus.
4. No cardia
Which bacterial organism causes rapid
progression and corneal melting?
1. Staphylococcus.
2. Pseudomonas.
3. Streptococcus.
4. No cardia
4

73. In which of the following organisms are
topical steroids contraindicated?
A. Acahthamoeba
B. Pseudomonas
C. Nocardia
D. Stahpylococcus
In which of the following organisms are
topical steroids contraindicated?
A. Acahthamoeba
B. Pseudomonas
C. Nocardia
D. Stahpylococcus
5

74. What is the treatment of choice for MRSA keratitis?
A.Vancomycin
B. Linezolid
C. Moxifloxacin
D. Tobramycin
What is the treatment of choice for MRSA keratitis?
A.Vancomycin
B. Linezolid
C. Moxifloxacin
D. Tobramycin
treatment of choice today for methicillin resistant staphylococcus aureus.
6

75. Over-the-counter steroids are the most common
cause for…
1. Bacterial keratitis,
2. allergic conjunctivitis,
3. fungal keratitis
4. Viral keratitis
Over-the-counter steroids are the most common
cause for..?
1. Bacterial keratitis,
2. allergic conjunctivitis,
3. fungal keratitis
4. Viral keratitis
7

76. What is the topical treatment of choice for
fusarium keratitis?
A.Voriconazole
B. Natamycin
C. Caspofungin
D.Miltefosine
What is the topical treatment of choice for
fusarium keratitis?
A.Voriconazole
B. Natamycin
C. Caspofungin
D.Miltefosine
Natamycin is superior to voriconazole in all
filamentous species
8

77. Regarding voriconazole in fungal keratitis treatment:
1. It is recommended to use as a monotherapy.
2. Always use it in combination with the natamycin
or any other antifungal.
Regarding voriconazole in fungal keratitis treatment:
1. It is recommended to use as a monotherapy.
2. Always use it in combination with the natamycin
or any other antifungal.
Mutt study , Never give voriconazole as a
monotherapy, the perforation rate was higher.
9

78. What is the indication for therapeutic keratoplasty ?
A. Impending Corneal Perforation
B. Limbal Involvement
C. Deep stromal ulcers – Not responding to Max Med Therapy
D. All the above
What is the indication for therapeutic keratoplasty ?
A. Impending Corneal Perforation
B. Limbal Involvement
C. Deep stromal ulcers – Not responding to Max Med Therapy
D. All the above
10

79. Take Home MSG

82. Thank you