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Sailing through cornea part1
The document discusses various types of corneal diseases including congenital, traumatic, inflammatory, degenerative/dystrophic, and neoplastic conditions. It provides details on infectious keratitis caused by bacteria like Staphylococcus, Pseudomonas, and Neisseria as well as fungi and protozoa. Viral keratitis from herpes simplex virus, herpes zoster virus, and adenovirus are also examined. Signs, risk factors, investigations, and treatment approaches are described for each condition. Inflammatory keratitis can be infective or immune-related disorders like marginal keratitis and Mooren's ulcer are also reviewed.
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Sailing through cornea part1
- 1. الرحيم الرحمن هللابسم تبصرون أفال أنفسكم وفي العظيم هللا صدق
- 2. Cornea 1 sailing throughlayers Samhaa Mohammed Abd Elmoneim Zagazig Ophthalmologic Hospital
- 3. Corneal ex. • Assessmentof any sign (diameter, thickness, steepness) • Any sign defect, scar, odema, opacity, infiltrate, precipitate, deposit, filament, guttatta, folds, desmatocele, sensation, PEDAL Site Size Level Surrounding Laterality
- 4. Sailing through cornea Hx,symptoms, signs + assessment + any sign Sailing through eye Lid problem, OSD, scleritis, IOP, infection Sailing through body Age (ulcer), autoimmune, systemic , drug
- 5. Corneal diseases 1. Congenital 2.Traumatic 3. Inflammatory (infective, autoimmune) 4. Degeneration/Dystrophies 5. Neoplastic Sailing through cornea Sailing through eye Sailing through body
- 6. 1. Traumatic keratitis •Any sign (epithelial defect) Site Size Level Surrounding Laterality
- 7. 1. Traumatic keratitis (Sailing)through cornea CL, baby nail, iatrogenic? as PRK, DMEK, DSEK, burn, topical drops(Hx) ….. (Sailing) through eye trichiasis, mass , papillae. Trachoma (Sailing) through body radiotherapy for tumours
- 8. 1. Traumatic keratitis Treatment •Cause(CL) • AB (monotherapy as fluroquinolone) • Steroids (burns) • Lubricant • Cycloplegic
- 9. Corneal diseases 1. Congenital 2.Traumatic 3. Inflammatory (infective, immune related) 4. Degeneration/Dystrophies 5. Neoplastic Sailing through cornea Sailing through eye Sailing through body
- 10. 2. Inflamatory keratitis (infective) •Bacterial • Fungal • Viral • (Protozoal) Acanthamaebal
- 11. Bacterial keratitis Organisms P aeruginosa(CL) s. aureus,streptococci N gonorrhea, N meningitis, H infl……. Penetrate intact epithelial Risk factors: Compromised cornea CL wear Trauma OSD (blepharitis, dry eye, allergy, corneal hypothesia, trichiasis.
- 12. Bacterial keratitis Signs: • Epith.Defect • Descment fold, odema, AU • Chemosis • Severe ulceration • Scleritis • Scarring, vascularization • Dec. sensation • IOP
- 13. Staphylococal • Central, oval,opaque. • Distinct margins. • Surrounding odema. • Mild to moderate Iridocyclitis. • Neglected … corneal abcess.
- 14. Pneumococcal • Sharp greyishwhite or yellowish serpentine ulcer. • Central. • Violent Iridocyclitis • Hypopyon • Tendeny to perforate
- 15. Pseudomonas • Rapidly spreadingto periphery and in depth. • Shaggy surface, necrosis. • Greenish discharge. • Spead cocentrically --- ring ulcer. • Hypopyon.
- 16. Neisseria gonorrhea, meningitis: •Severe purulent conjunctivitis • Ophthalmia neonatorum
- 17. Bacterial keratitis Investigation: Corneal scraping CLand solution culture …… stop AB before C&S (gram stain, geimsa, Zeihl Neelsen stain, blood, chocolate agar, brain heart infusion, lowestein- Jensen) Corneal biopsy
- 18. Bacterial keratitis General measures:hospitalization , stop CL, eye sheild Medical treatment : Topical AB Monotherapy fluroquinolone (ciprofloxacin or ofloxacin)….. Mild Duotherapy (ceftazidime 25-50mg/ml, vancomycin 25-50mg/ml) …… severe Cirofloxacin induce corneal precipitate( delay healing
- 19. Bacterial keratitis SYSTEMIC AB •Severe corneal thinning…..tetracycline(doxycycline 100mg twice/d) • Scleral involovement • Ass. Systemic dis…. N gonorrhea, N meningitidis ( ceftriaxone), H influenza ( amoxicillin , calvulanic acid)
- 20. Bacterial keratitis Other treatmenttrends: • Cyanoacrylate • AM graft • Therapeutic keratoplasty (lamellar or penetrating)
- 21. Fungal keratitis • organisms: 1.Filamentous fungi (fusarium and aspergillus) Multicelluar, tropical, tubular projection. 2. yeast( candida) Ovoid unicellular, temperate, budding. • Risk factors: Trauma involving plant origin Long term topical steroid Cl Immunosuppression, DM
- 22. Fungal keratitis • C/P: Candida: Yellow whitish dense suppurative infiltrate. Collar stud Filamentous : Grey or yellow white infiltrate , indistinct fluffy margin, feathery branch like (satellite) Rapid progression, necrosis Endophthalmitis with intact DM
- 26. Fungal keratitis Investigation: Corneal scraping(staining and culture) …… stop AB before C&S (gram stain, geimsa, PAS stain, sabaraud , blood agars, enriched medium) Corneal biopsy Confocal microscopy
- 27. Fungal keratitis • Generalmeasures : hospitalization , stop CL, eye sheild • Removal of epithelium. • Medical treatment : Filamentous … natamycin Candida …… amphotricin B • AB, cycloplegico • Systemic antifungal fluconazole 200mg/d(near limbus, suspect endoph.) • IOP • Surgical: superficial keratectomy, KP
- 28. Protozoan (acanthamoeba) keratitis •Organism: Acanthamoeba Soil, fresh and brackish water, URT CYSTIC ……. TROPHOZOITE form • Risk factors: CL, rinsing tap water
- 29. Acanthamoebal keratitis • C/P: Pain Pseudodentriticlesion Ring infiltrate Keratoneuritis Scleritis (reactive), melting
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- 32. Acanthamoebal keratitis Investigation: Corneal scraping(staining and culture) …… stop AB before C&S (gram stain, geimsa, PAS, calcflour stains, non nutrient agar) Corneal biopsy PCR Confocal microscopy
- 33. Acanthamoebal keratitis • Generalmeasures : early suspicion (better response in early ttt 4 wk), stop CL. • Debridment of epithelium. • Medical treatment : Poly Hexa Methylene Biguanide 0.02% (PHMB) Brolene • AB, cycloplegico • Pain releif • Surgical: superficial keratectomy, KP
- 34. Viral keratitis 1. HSV 2.HZV 3. Adenoviral
- 35. HSV Viral keratitis •HSV1: above waist… eye associated • HSV2: venreal….. Eye rare (secretion, neonatal) Risk factors: • Atopic eye dis. • Stress • Immunedeficiency • Malnutrition • Crowding, poor hygeine
- 36. HSV Viral keratitis Congenitalinfection: • Common > 6m (Maternal AB) • Skin, eye, CNS 1ry: (droplet) Recurrent: (dermatome, latent in trigemminal G)
- 37. HSV Viral keratitis C/P:epithelial keratitis • Epith swelling • Ulcer: dendritic (central with terminal bulb, bed stained with fluroscein and edges by rose bengal, geographical • Decrease sensation • Lid vesicles • IOP • Epithelial toxicity…. Mild scar Investigation: clinical, viral culture, PCR, immunohhistochemistry TTT: topical acyclovir, depridement, systemic in immunosuppressive, IOP, cycloplegics, toxicity
- 41. HSV Viral keratitis C/P:disciform keratitis • Hypersensitivity reaction • wessely ring : Ag AB complex (sensation?) • Stromal and epith. Odema, descment folds • Granulomatous KPs • IOP • Decrease sensation • Stromal scarring and vascularization TTT: topical steroid with antiviral cover, IOP control, cycloplegic • topical cyclosporin0.05% (restasis) • Oral steroid ( steroid response glaucoma, severe stromal inflamation • Fine needle diathermy in established NV
- 42. Wessely ring KPS& stromal odema
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- 44. HSV Viral keratitis C/P:necrotizing keratitis • Immune mediate challenging with disciform Dx • Hypersensitivity reaction • Stromal and epith. Odema, descment folds • Anterior uveitis, infiltrates, KPs • IOP • Decrease sensation • Stromal scarring and vascularization, lipid keratopathy TTT: topical steroid with antiviral cover, IOP control, cycloplegic • topical cyclosporin 0.05% (restasis) • Oral steroid • Fine needle diathermy in established NV
- 46. HSV Viral keratitis C/P:neurotrophic keratopathy • Loss of sensation • Excerbated by drug toxicity • Non healing epithelium • Stroma is opaque and thin • 2ry infection TTT: • Lubricant , decrease steroid
- 47. HSV Viral keratitis Complication: •2ry infection • Uveitis • Glaucoma ( uveitis, trabeculitis, topical steroid)… inaccurate reading • Cataract • Iris atrophy TTT keratoplasty: • Risky (ttt NV, recurrence, Herbetic eye dis. Atopic eye • Prophylactic oral acyclovir(400mg twice/d) for one year
- 48. HZV Viral keratitis Varicellazoster virus: • Chickenpox (varicella) … children • Shingles (herpes zoster) … eldery Immunity : • Vaccination • Exposure to chicken pox (avoid shingles pt for being contact to a child). Risk factors of ocular involvement: • Age • Immunocompromised • Hutchinson sign (dorsal nasal branch of nasociliary n.)
- 50. HZV Viral keratitis C/P: Skin •Rash and vesicles respect midline.. scrar Acute eye dis: • Acute epith keratitis :(peripheral, fine, stained more with Rose Bengal … topical antiviral • Follicular conjuctivitis, episcleritis … no ttt • Scleritis … NSAIDs oral (thrice/d) steroids?? • Nummular keratitis : subepithelial haze … topical steroid • Disciform , interstitial keratitis …. Topical steroid • AU…… iris atrophy • IOP …..NO PG • Neurological …. CN palsy(3rd) , Ramsay Hunt S • Optic neuritis
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- 55. HZV Viral keratitisC/P: Chroniceye dis: • Neurotrophic keratitis : common 50% but mild • Scleritis : patchy atrophy • Mucous plaque keratitis :topical steroid, acetylcysteine • Lipid filled granulomata :tarsus, sub conjunctiva • Lipid degeneration: over nummular and disciform • Lid scarring… exposure keratopathy • PHN :Persistent pain > 1m of healed rash) , increase sensitivity to minor stimuli , heat, touch…. Suicide
- 56. HZV Viral keratitis TTT: •systemic acyclovir 800mg 5 times/d. • Topical acyclovir 5 times/d. • Topical antiviral for skin lesions. • PHN: cold compress, local lidocaine, analgesic, tricyclic antidepressant.
- 57. Adenoviral keratitis • Hxof recent viral infection • C/P: watery eye Follicular conjuunctivitis Preauricular LN ++ Subepithelial infiltrates, may be epithelial defects • TTT: Self limited, lubricants. Weak topical steroid
- 60. Corneal diseases 1. Congenital 2.Traumatic 3. Inflammatory (infective, immune related) 4. Degeneration/Dystrophies 5. Neoplastic Sailing through cornea Sailing through eye Sailing through body
- 61. 2. Inflamatory keratitis (immunerelated) • Marginal keratitis, Phlyctenulosis , Rosacea (staph hypersensitivity) • Peripheral ulcerative keratitis (PUK). • Mooren ulcer • Ulcer or not (edges). • Site. • Clear zone from limbus. • Sclera involved or not. • Interstitial keratitis.
- 62. Marinal keratitis Hypersensitivity tostaph exotoxin….. Ag-Ab complex Risk factors: • Blepharitis, epithelial erosion, recent LASIK C/P: • Site… inferior (marginal blepharitis), NO ULCER, subepithelial infiltrate. • Clear zone from limbus. • C&S: –ve from cornea. TTT: • Cause (tetracycline not in children and pregnant) Tetracycline ( antibacterial, decrease free lipid, anticollagenase) • Short course of topical steroid
- 65. Phlyctenulosis Delayed hypersensitivity tostaph Risk factors: • Age( child) • Rosacea • TB, Helminthic infestation C/P: • Small white elevated superficial nodule with hyperemia… scar. • NO ULCER • Site … Conjunctiva, limbus, cornea. • Lacrimation, photophobia, blepharospasm. • Stool analysis, tuberculin test (endemic areas and RF) TTT: • Topical steroid , treat cause. • Recurrent … tetracycline.
- 71. Rosacea Skin dermatosis Risk factors:Unknown cause • Staph epidermidis, Demodex mites • Trigger factors( sun exposure, alcohol, spicy and hot food) C/P: (triad) • Erythematous telangectasia • Papulo pastular rash • Phymatous … rhinophyma. TTT: • Tetracycline (pregnant, children), metrondiazole
- 72. Ocular rosacea C/P: • Lidmargin telangectasia, recurrent MG cysts. • Conj hyperemia. • Marginal keratitis --inferior… circumferential. • Corneal melting and thinning. TTT: • Systemic (Tetracycline, Doxycline 100mg once/d) • Ocular.. Mild ------- lubricant, hot fomentation Moderate to severe ------- fusidic acid oint once for 1m. steroids
- 74. (Peripheral Ulcerative Keratitis(PUK Collagn vascular diseases(immune complex deposition on peripheral cornea, conj, episclera) • RA • Wegner granulomatosis • Relapsing polychondritis, SLE, PAN
- 80. PUK C/P • Peripheral thinning,ULCER (CL cornea), perforation. • NO clear zone from limbus(as mooren ulcer) • Sloping edges, sclera involved. TTT • Rheumatologist consultation, systemic steroid. • Topical steroid??, lubricant, tetracycline. • Surgical.
- 81. Mooren ulcer Old age….Unilateral Younger…. Bilateral C/P • Pain • Site ---- peripheral ULCER (undermined edges), perforation, bl.vs at bed and margins. • No clear zone from limbus (but there is limbitis) • Sclera not involved (no scleritis) • NB: Dx by exclusion.
- 83. Mooren ulcer TTT • Topicalsteroid/h with AB cover • Topical cyclosporin • Exclude collagen vascular dis. • Systemic steroid, immunosuppresive • Systemic collagenase inhibitors • Surgical (conj. resection, lamellar KP, cyanoacrylate, tectonic, AMG)
- 85. Interstisial keratitis Stromal inflamationwithout epithelium or endothelium affection. Causes: • Infectious as syphilis, herpes, TB, lyme. • Non infectious as sarcoidosis, Cogan syndrome C/P • Mid-stromal feathery scarring with gost vessels. • Early phase is incidental
- 86. Interstisial keratitis Syphilis Congenital (morecommon) or acquired C/P • Systemic (saddle nose, sabre tibia, Hutchinson teeth, deafness) • Ocular (IK, ant uveitis, salt and pepper fundus, argyll robertson pupil) • IK: limbitis, feathery stromal infiltrate, deep stromal vascularization, ghost vs, thinning, band keratopathy.
- 88. Interstisial keratitis Cogan syndrome Rarevestibulo-auditory-ocular autoimmune disease. C/P: Triad • Vertigo • Tinnitus • IK TTT • Rheumatologist, ENT consultation, systemic steroid. • Topical steroid .
- 90. Other non infectiouskeratitis • Terrin Marginal Degeneration(TMD) • Filamentary keratitis • Neurotrophic keratopathy • Exposure keratopathy Lagophthalmos, facial palsy, cicatricial, mechanical. • Dellen
- 91. TMD Idiopathic peripheral cornealthining c/p • Male, 20-40y, bilateral, visual change • Site … Superior … ATR or oblique astigmatism • NO ULCER (thinning)--- peripheral gutter • Sclera not involved • Clear zone from limbus • Pseudoptergium. TTT • Polycarbonate safety glasses, soft or rigid CL for astigmatism. • Surgical … crecenteric annular excision with lamellar keratoplasty.
- 95. Filamentary keratitis Loose epitheliumwith mucous and cellular debris. Causes • Keratoconjunctivitis sicca, neurotrophic, exposure ,bullous keratopathy, epithelial instability • Prolonged CL use or eye closing. c/p • Pain, photophobia, blepharospasm, Fb sensation. • Fine strands with one end attached to epithelium. • Stainned filament and base. TTT • Cause, bandage CL. • topical mucolytics (acetylcysteine5%). • Hypertonic saline. • Mechanical removal.
- 98. Neurotrophic keratopathy Loss oftrigeminal innervation results in persistent ulceration, odema, exfoliation and Causes • HSV, HZV, peripheral neuropathy, stroke, TG ablation, topical drug abuse. c/p • Asses all cranial nerves. • Loss of sensation, tiny epithelial defects, persistent ulcer • Central punched out ulcer with odema, scar. • Stromal melting , perforation. TTT • Stop topical drugs, lubricant (preservative free) • Anticollagenase (tetracycline, acetylcysteine) • Taping, therapeutic Cl • Botulinum toxin, tarsoraphy • TTT .. Perforation ( amniotic, cyanoacrylate, tectonic graft, KP?.
- 102. Exposure keratopathy Incomplete lidclosure (lagophthalmos) Causes • Facial n palsy, neuroparalytic diseases. • Mechanical, cicatricial, proptosis. c/p • Inferior epithelial changes, ulcer. • Stromal melting, 2ry infection. • Fibrovascular, filamentary, salzmann nodular degeneration changes TTT • Reversible causes: taping, artificial tears, bandage or scleral CL, temporary tarsoraphy, orbital decompression. • Irreversible causes: permenant tarsorraphy , gold weight in UL
- 105. Dellen Peripheral corneal thinningadjacent to elevated conjunctival mass due to dryness.
- 109. Corneal diseases 1. Congenital 2.Traumatic 3. Inflammatory (infective, immune related) 4. Degeneration/Dystrophies 5. Neoplastic Sailing through cornea Sailing through eye Sailing through body
- 110. Corneal diseases to becontinued., Samhaa Mohammed Best wishes
- 111. Now, lets gofor sailing in sea not in cornea Thanks ALLAH Thank you