Peripheral or marginal keratitis that must be distinguished clinically among them some may perforate ,some due to hypersensitivity reaction to some toxin and some may be due to autoimmune phenomenon and even lead to perforation.
Some are idiopathic corneal degenerations. And Mya be due to ocular tear interface disturbance by corneal surface localised elevation in corneal margin
2. Deceleration
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• Pictures in this presentation has been collected from
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3.
4.
5.
6. Mrs xxx Devi – seen on 23.4.22
Peripheral Epithelial defect Associated with vascularization and anterior uvitis
7. Mrs xx 36HF
on 11.05.22 on 18.05.22
Peripheral Epithelial defect Associated extreme stromal thinning
11. HYPOTHESIS behind this phenomenon
Hypersensitive reaction against Staphylococcal Endotoxin protein and
their cell wall protein .
Results in Attracting Antibody from peripheral blood vessels and tear
film
Formation of Ag- Ab complex
Results Secondary lymphocytic infiltration
However lesions are culture negative
But Staph. Aures is isolated from lid margin
12. 1. Marginal Keratitis
Subepithelial marginal infiltrate at 10, 2, 4,
8 ‘o’clock, at Eye lid contact at limbus
Ulcerations are located in the marginal
zone and separated from the limbus by a
clear corneal zone.
Fluorescein staining often shows
epithelial defects that are smaller than the
infiltrate area
16. Marginal Keratitis Rosea Acne
Common idiopathic
dermatosis
On sun exposed area
Facial telangiectasia
Facial Rhinophyma
Facial Flushing
* * Black head or white head
are absent as in Acne vulgaris
18. 2. Marginal keratitis –
in Rosea with peripheral vascularization
•Marginal
•Limbal
Vascularization
Rosea Acne
19. 2. Marginal keratitis –
in Rosea with peripheral vascularization
Focal
•Corneal
thinning
Ocular involvement – 6-18%
Rosea Acne
20. 2. Marginal keratitis –
in Rosea with peripheral vascularization
•Severe Scarring
•and
•vascularization
Ocular involvement – 6-18%
Rosea Acne
21. Ocular involvement – 6-18%
Rosea Acne Marginal keratitis
Treatment
Topical antibiotic lid ointment – AZITHRO,ERYTHROMYCIN
Low potency steroid drop - minimize corneal thinning
Oral Tetracycline – Lowers free fatty acid production from lid gland
a. Reduction in lid flora by anti inflammatory effect
b. Reduce activity of collagenase – minimize corneal thinning
c. Doxycycline 100 mg daily for 4 wk followed by 50 mg may be
continued for longer duration, C/I in pregnant, lactating mother
and children
Severe case – immunosuppression by Azathioprine
22. Phlyctenular Kerato-conjunctivitis
• Small white limbal or
conjunctival nodule which may
extend to cornea
• Spontaneous resolution may
leave scar or can cause corneal
thinning and even perforation
24. Phlyctenular Kerato-conjunctivitis
Self limiting / Due to delayed hypersensitivity to Staphy.Ag
In developing country
T.B or helminth infestation may be a cause
Usually affect child and young
Short course of steroid and antibiotic accelerate healing
In recurrent cases – oral tetracycline is indicated
26. Mooren ulcer
• Superiorly 1/3rd thickness of cornea
• No clear zone
• It progress central
• No scleral progression
• Overhanging edge in epithelial defect
• Peripheral thinning
• Circumferential progression
29. Mooren ulcer
Recent Classification
• UM- unilateral Mooren's ulcer - Painful and progressive in elderly
• BAM- Bilateral Aggressive Mooren’s ulcer -Circumferential progression in younger
• BIM- Bilateral indolent Mooren’s ulceration Progressive peripheral in middle aged
Etiology
• It may be caused by an exaggerated immune response due to an autoimmune
dresponse to eye injury or infection.
30. Mooren ulcer
Treatment – if required
Topical treatments to keep tissue from degenerating
1. Moxifloxacin to prevent infections
2. Interferon a2b for hepatitis C infections plus minus antiviral
Ribavirin (Rebetron)
3. Conjunctival resection around ulcer
4. Cryotherapy
5. Tissue adhesion- adhesive materials near the ulcer to stop
spreading
32. Pellucid marginal degeneration
Rare /idiopathic/
Degenerative
BL , Painless
vision loss
d/d keratoconus.
Clear thinning (ectasia) in the inferior
and peripheral region of the cornea,
33. Pellucid marginal degeneration
Diagnosed by
Corneal topography.
• Corneal pachymetry to
confirm.
Treatment
• Glass or contact lens
• Corneal cross linking
• corneal transplant surgery.
As the word "pellucid" means
clear that here retain clarity
Butter fly pattern
34. Furrow degeneration
• Also called as
1. Senile corneal furrow
degeneration of cornea
2. Corneal furrow degeneration, or
3. Age-related marginal corneal
degeneration
1. Safety spectacles (polycarbonate)
2. Contact lens to counter
astigmatism
3. Surgery – Annular excision of
Gutter with lamellar or full
thickness corneal transplantation
35. Terrien
Marginal degeneration
Uncommon , idiopathic
Asymptomatic Peripheral thinning
of cornea
May be with episcleritis or scleritis
Mainly male , BL
Visual deterioration due to
progressive astigmatism
Outer slope of gutter is slopy and central steep
Slowly progressive peripheral circumferential
thinning lead to Gutter
A band of lipid is commonly present on corneal edge
37. Terrien
Marginal degeneration
Treatment
1. Safety spectacles
(polycarbonate)
2. Contact lens to counter
astigmatism
3. Surgery – Annular excision
of Gutter with lamellar or
full thickness corneal
transplantation
Outer slope of gutter is slopy and central steep
Slowly progressive peripheral circumferential
thinning lead to Gutter
A band of lipid is commonly present on corneal edge
39. Dellen
• Dellen occur when the tear film
does not cover the eye. Here we
see
• subconjunctival hemorrhage that
has raised the Conuj. right at the
lumbus.
49. What is PUK?
It is a group of inflammatory destructive disease of peripheral
cornea
Start with crescent shaped epithelial defect in epithelium
Juxta limbal within 2 mm from limbus
Invade deeper in stroma
melting of corneal stroma
corneal necrosis
ultimately lead to and perforation
50. What is PUK?
Mainly UL , may be BL
Age- affects older
Gender- any
Its prevalence is 3 persons per million per year.
Spontaneous or induced by trauma( surgical / non surgical)
Present as– Redness, Pain, Photophobia, Tearing, D.V
51. Simultaneous partner of PUK
• 36-66%- Scleritis
most common necrotizing scleritis
• 9-67%- Anterior uveitis
53. I. Close to sclera
II. Limbal vascular arcade
III.Subconjunctival afferent lymphatics
Why in peripheral cornea?
54. a.Large number of Langerhans cells
b. Reservoir of inflammatory cells
c. More susceptible to immunological changes
Why in peripheral cornea?
55. Langerhans cell BIRBECK GRANULE
Tissue-resident macrophages of the Skin
Absent on cornea but present on limbus
Contain Tennis racket shaped specific granule
In case of infection local Langerhans cells uptake and process microbial Ag and transformed into a
fully functional Ag presenting cell.
56. Pathogenesis of PUK
• PUK is an immunologic condition mediated by both abnormal T-cell and
antibody-mediated pathways
• It is hypothesized that:
an abnormal T-cell pathway may produce Ab that result in Ag-Ab
complex deposition in the cornea
Later on that activate the complement system and recruit harmful
inflammatory cells to the area.
Neutrophils and macrophages then secrete local collagenases and
other proteases which cause destruction of the corneal stroma.
57. Localized conjunctival injection adjacent to the ulcer
supply inflammatory mediators to surrounding infiltrate
Pathogenesis of PUK
64. Course of disease
The disease generally begins with
Intense limbal inflammation
Swelling in the Episcleral
Swelling in Conjunctiva
Later on Corneal involvement
2-3 mm from the limbus
Appears as grey swellings
That rapidly furrow
Affect superior 1/3rd of stroma
65. PUK presentation and stage
Crescentic ulceration at limbus
with stromal infiltration and thinning
Spread Circumferentially and occasionally central to cornea
End stage result in ‘Contact Lens Cornea”
May be associated with Limbitis, Scleritis or Episcleritis
66. PUK in autoimmune disease
This may precede or follow the onset of systemic disease or collagen
vascular disorder
I. Rheumatoid arthritis-
Commonest association- 30 % cases develop PUK in late vasculitis phase
May also present as non ulcerative type where
a. gradual resorption of peripheral stroma leaving epithelium intact
b. Gradual thinking and opacification of corneal stroma around
Scleritis
c. Severe dry eye and central corneal melting
67. PUK in autoimmune disease
This may precede or follow the onset of systemic disease or collagen
vascular disorder
II. Wegener granulomatosis -
Second commonest association- 50 % cases develop PUK in Early
phase
iii. Relapsing polychondritis- More with episcleritis or scleritis rather PUK
iv. Systemic Lupus erythematosus- (SLE)- Rare association
71. PUK treatment - Medical
• Medical
Therapeutic or Prophylactic appropriate antibiotics
to dilute cytokinin in precorneal tear film Enhance Lubrication
Patching and bandage contact lens
Topical collagenase inhibitors
Sodium citrate 10%, Acetylcysteine 20% , Medroxy progestron 1%
Systemic Collagenase inhibitor - Tertacycline
Topical steroid –useful in initial stage
Not effective in WG, PAN rather it enhance collagenase effect
72. PUK treatment
• Medical
Oral corticosteroid
Methyl prednisolone 1m/kg/day is commonly used
Severe progressive cases – pulsed 0.5 to 1gm methylprednisolone consecutive for 3 days
Immunosuppressive –
immunomodulatory
I. Methotrexate
II. Azathioprine
III. cyclosporine A
Cytotoxic like
Cyclophosphamide
73. PUK treatment - medical doses
Immunosuppressive –
in Idiopathic PUK – Cyclosporin A 2.5mg/kg/day
In severe PUK with necrotizing scleritis
First line therapy
Cytotoxic cyclophosphamide 2mg/kg/day with oral or IV methyl
prednisolone
Maintainace by Methotrexate or oral or subcutaneous 7.5 to 12.5 mg
/week
74. PUK treatment - Surgical
Conjunctival resection
Tissue Adhesive – cyanoacrylate glue
Keratoplasty if perforation is larger to be sealed
Surgical lamellar keratectomy to arrest progress
Lamellar tectonic grafting if 7-8 mm cornea unaffected
ulcer more than 1/3rd of periphery – crescent shaped lamellar graft
Ulcer more than 2/3rd of periphery – doughnut shaped lamellar graft
75. PUK treatment - Surgical
Amniotic membrane transposition
Conjunctival flap reposition – not in immune mediated PUK
76. PUK treatment
A. Topical Steroid are warranted increase thinning of sclera
Exception is in Relapsing polychondritis – frequent instillation of
steroid drop is helpful
B. Oral tetracycline 100 mg bd may be helpful as they retard
thinning by anti- collagenase property.
C. Conjunctival excision
D. Corneal Gluing
E. Emergency keratoplasty( lamellar) in Perforation
F. Elective keratoplasty( lamellar or PK) To restore vision
77. PUK treatment
Because PUK is associated with life threatening systemic vasculitis
The must be treated with immunosuppressive agents on onset
Rheumatologist advise or association should be hired.
I. High dose steroid to control disease
II. Cytotoxic drug for log term for maintenance and counter steroid
side effects
Cyclophosphamide is useful in Wegener granulomatosis
Other are Methotrexate, Azathioprine, Mycophenolate mofetil
78. This Photo by Unknown Author is licensed under CC BY-SA