management and treatment keratitis

1. Keratitis
Presentor : Dr FS

2. OUTLINES  KERATITIS
 INTRODUCTION
 CLASSIFICATION
 ETIOLOGY
 RISK FACTOR
 PATHOPHYSIOLOGY
 DIAGNOSE
 EXAMINATION
 MANAGEMENT
 COMPLICATION

3. Structure of eye

5. INTRODUCTION
 Keratitis is inflammation of the cornea, the clear window that covers the iris and the
pupil in your eye. Keratitis may cause a corneal ulcer.
 Keratitis can be divided into two categories based on cause:
infectious keratitis or noninfectious keratitis.

6. CLASSIFICATION
Infectious keratitis
noninfectious keratitis

7. Infectious keratitis
 Bacterial keratitis: This type, caused by bacteria, is the most
common.
 Fungal keratitis: This type is caused by fungi, often from
plants.
 Parasitic keratitis: Parasites are organisms that live off
another organism. Acanthamoeba keratitis is caused by a
one-celled parasite called an amoeba.
 Viral keratitis: Viruses like the ones that cause shingles and
herpes simplex can cause keratitis. Herpes simplex keratitis
often recurs

9. Acanthamoeba Keratitis

10. Non-infectious keratitis

11. Noninfectious keratitis
 Injuring your eye.
(This includes having eye surgery, being in an accident and having a
condition where your eyelashes scrape against the surface of your
eye.)
 Wearing contact lenses for too long.
 Having a foreign object in your eye.
 Being exposed to ultraviolet (UV) light for too long.
 Having a vitamin A deficiency.
 Having an eyelid disorder or immune system condition that causes
dry eyes.

12. ETIOLOGY
Bacterial
 Bacteria are the most common cause of infectious keratitis.
 Both gram positive and gram-negative organisms are implicated as causative
agents.
 About 80 % of bacterial keratitis is caused by Staphylococcus, Streptococcus and
Pseudomonas species
 Certain bacteria are known to penetrate the intact epithelium which include
Neisseria, Corynebacterium, Shigella and Listeria.

13. Viral
 HSV keratitis is caused by the herpes simplex virus, a double-
stranded DNA virus made up of an icosahedral shaped capsid
surrounding a core of DNA and phosphoproteins of viral
chromatin.
 HSV- I and HSV- II are differentiated by virus specific
antigens.
 HSV- I typically affects the orofacial region, whereas HSV- II
usually causes genital infections.
 However, studies have shown that both viruses may affect
either location, and mixed infections have been reported
 The majority of ocular HSV infections are caused by HSV type
1 (HSV-1), except in cases of neonatal ocular infections,
which are largely caused by HSV-2 contracted during decent
through an infected birth canal.

14. Fungal
 The list covers many fungi including but not limited to:
yeasts of Candida spp.
filamentous with septae such as Aspergillus spp., Fusarium
spp., Cladosporium,spp., Curvularia
non septated such as Rhizopus
Parasite
 The acanthamoeba causes this eye infection. The amoeba attaches
to the cells on the outer surface of your cornea. It can also invade
the eye by entering through small corneal abrasions (scratches). The
infection destroys the cells and moves further into the cornea.

15. RISK FACTOR
 Wearing contact lens longer than you’re supposed to wear them. This can cause
damage to your eye and possibly allow infection to enter.
 Not cleaning / disinfecting them properly.
 Wearing contact lens while you’re in pools, hot tubs or outdoor water sources.
Other risk factors include:
 Using corticosteroids over a long period of time.
 Having a weakened immune system.
 Having dry eyes.
 Having an injury to your eyes, including surgery.

16. General
Pathology
 keratitis can advance through four stages:
progressive infiltration, active ulceration,
regression, and healing.
 Corneal infections rarely occur in the normal
eye
 They are a result of an alteration in the cornea’s
defense mechanisms that allow bacteria to
invade when an epithelial defect is present
 The process of corneal destruction can take
place rapidly (within 24hrs with virulent
organisms) so that rapid recognition and
initiation of treatment is imperative to prevent
visual loss.

17. Diagnosis

18. History  A detailed history is as important as the examination.
 characteristics and onset of symptoms
 Recent trauma to the eye
 Activities such as swimming in contact lenses
 Patients should be asked about contact lens
 A past ocular history should include whether there was a
history of eye trauma, previous eye diseases (such as viral
keratitis), or eye surgeries
 A past medical history (history of diabetes), a list of
medications and eye drops, a documentation of allergies, a
pertinent family history, substance abuse history, and a
review of systems should be obtained.

19. Physical
examination
 Vision
 intraocular pressure
 pupil assessment
 slit-lamp examination
 Fluorescein-to highlight areas of epithelial cell loss
 Document the location, size and depth of the corneal
infiltrate
 Any anterior chamber reaction
 Dilate and possible posterior pole involvement should be
ruled out
 If the posterior pole is unable to be visualized, an
ultrasound should be performed
 Test corneal sensation, proper eyelid closure, eyelids and
lashes, and nasolacrimal apparatus to look for risk
factors for infection

20. Signs  Conjunctival injection
 Focal white infiltrates (with epithelial demarcation and
underlying stromal inflammation)
 Corneal thinning
 Stromal edema
 Descemet’s folds
 Mucopurulent discharge
 Anterior chamber reaction
 Hypopyon
 Eyelid edema may be present in some cases
 In severe cases, posterior synechiae, hyphema, and
glaucoma may occur.

21. Symptoms
 rapid onset of ocular pain
 Redness
 Photophobia
 Discharge
 decreased vision
 The rate of progression of the symptoms is related to the virulence of the infecting
organism.

22. EXAMINATION
 A complete eye exam Your provider will use bright lights and a microscope to
look at your eyes.
 A culture of discharge from your eye: Your provider will send a swab with the
discharge to a lab for identification.
 Fluorescein stain test: Your provider will put dye into your eye and then look at it
with a blue lamp.

23. slit-lamp examination
The examination can be divided into the following 8
stages:
External Structures and Adnexa
Lids and Lashes
Conjunctiva and Sclera
Cornea
Anterior Chamber
Iris and Pupil
Lens
Anterior Vitreous

25. Herpes Keratitis. Under cobalt-blue illumination,
fluorescein bound to the basement membrane underlying
damaged corneal epithelium fluoresces bright green. This
slit lamp photograph illustrates the unique “dendritic”
branching lesions characteristic of herpes keratitis

26. MANAGEMENT
 If a mild case of keratitis, using lubricant eye drops and letting your eye heal on its
own.
 However, medication normally treats infectious keratitis. If a bacterial infection,
antibiotic eye drops. Give a fungal infection, the eye drops will contain antifungal
medication. If its a virus, prescribe antiviral eye drops.
 After a bacterial or viral infection clears up mostly or completely, its might suggest
steroid eye drops to reduce swelling.
 For pain, your provider might give you eye drops that dilate your eye.
 If you have advanced keratitis, you may need oral medication to treat infections.
 If don’t respond to medication and keratitis is causing scars on your cornea, its
may need a cornea transplant.

30. Diagnostic
procedures
Corneal scrapings for Gram and Giemsa staining and
cultures are performed to determine the causative
organism
Corneal biopsies should be considered if patient is
unresponsive to treatment or cultures are negative
despite high clinical suspicion for infectious etiology
Suture pass cultures can be obtained for deep stromal
ulcers especially if the overlying epithelium appears
intact or uninvolved. A 7-0 or 8-0 vicryl or silk suture
can be passed through the deep abscess, cut into
smaller pieces using sterile scissors and plated onto
culture media

31. Medical therapy
bacterial

32. Medical therapy fungal
Filamentous fungi
Superficial keratitis 1st choice Natamycin 5% ointment
2nd choice Amphotericin B 0.15%
Deep Keratitis Oral itraconazole or
Fluconazole along with
topical therapy
Yeast like fungi
Superficial keratitis 1st choice Amphotericin B 0.15%
2nd choice Fluconazole
2%/Itraconazole
1%/Variconazole 1% drops
Deep keratitis Oral itraconazole or
Fluconazole along with
topical therapy
Non-responders or
presence of desmatocele
PK along with topical and
systemic antifungals

34. Complications scleral extension of the
infection
residual corneal scarring
irregular astigmatism
loss of vision
corneal perforation
endophthalmitis.

35. Case discussion and report

44. Conclusion of presentation
 Keratitis is an inflammation of the cornea the clear, dome-
shaped tissue on the front of your eye that covers the pupil
and iris. Keratitis may or may not be associated with an
infection.
 The simple classification based on clinical findings will help
ophthalmologists, general practitioners to assess patients
with this condition and start an adequate initial investigation
and treatment

45. Input from the MO opthal
 Proper history of the patient with relevant history keratitis
 Able to detect abnormality over the cornea
 Able to do visual acuity
 From the slit lamp examination able to sign of suggestive of fungal / bacterial /
viral
 Confirmatory of test still cornea scraping culture and sensitivity

46. Thank you
46

47. References
 AAO
 Kanski’s Clinical Ophthalmology 8th Edition
 Basics of Bacterial Keratitis, CDC
 https://www1.racgp.org.au/ajgp/2019/august/m
anagement-of-microbial-keratitis-in-general-
pract