Corneal UlcerCorneal Ulcer

Bacterial KeratitisBacterial Keratitis

Natural defenses Natural defenses Eyelids Eyelids Epithelial barrier Epithelial barrier TearsTears

Risk factorsRisk factors Lid abnormalities; Dry eye; Steroids ; Lid abnormalities; Dry eye; Steroids ; prior herpetic infection; Contact lens user; prior herpetic infection; Contact lens user; LASIK; Immune compromise LASIK; Immune compromise Trauma Trauma lagophthalmos; neurotrophic keratitislagophthalmos; neurotrophic keratitis

PathophysiologyPathophysiology

Interruption of an intact corneal Interruption of an intact corneal epithelium -> entrance of epithelium -> entrance of microorganisms into the corneal microorganisms into the corneal stroma -> proliferate and cause stroma -> proliferate and cause ulceration -> inflammation, necrosis -ulceration -> inflammation, necrosis -> corneal perforation/ scar tissue> corneal perforation/ scar tissue

PathophysiologyPathophysiology

OrganismsOrganisms – – staphylococcusstaphylococcus streptococcus,streptococcus, pseudomonas,pseudomonas, EnterobacteriaceaeEnterobacteriaceae (including (including Klebsiella, Klebsiella,

Enterobacter, Serratia,Enterobacter, Serratia, and and ProteusProteus)) Moraxella Moraxella

..

Clinical Features Clinical Features Rapid onset of pain, photophobia Rapid onset of pain, photophobia Decreased vision.Decreased vision. Lid erythema, edema; Lid erythema, edema; Conjunctival congestion; chemosis; lacrimation;Conjunctival congestion; chemosis; lacrimation; Mucopurulent dischargeMucopurulent discharge Ulceration of the epithelium; Ulceration of the epithelium; Corneal infiltrate Corneal infiltrate Dense, suppurative stromal inflammation and Dense, suppurative stromal inflammation and

surrounding stromal edemasurrounding stromal edema Stromal tissue loss; Stromal tissue loss;

Small ulcer with active area towards the center. The central cornea is hazy and shows Descemet's folds. There is a hypopyon

Clinical FeaturesClinical Features

Anterior chamber – inflammation; Anterior chamber – inflammation; hypopyonhypopyon Esp. with pseudomonas pyocyanea and Esp. with pseudomonas pyocyanea and

pneumococci -> called hypopyon ulcerspneumococci -> called hypopyon ulcers Regressive stage -> vascularization Regressive stage -> vascularization

-> cicatrization -> opaque scar -> cicatrization -> opaque scar

DiagnosisDiagnosis

Clinical history & examinationClinical history & examination Slit lamp examination – size/depth/ Slit lamp examination – size/depth/

location/ AC reactionlocation/ AC reaction Fluorescein stainFluorescein stain

Confirmation – corneal scraping for smear Confirmation – corneal scraping for smear and culture and culture SScrapings including the edges -> plated in crapings including the edges -> plated in

blood, chocolate, and Sabouraud agar platesblood, chocolate, and Sabouraud agar plates Stained smears with gram, Giemsa,KOH Stained smears with gram, Giemsa,KOH

Treatment Treatment

Initial therapy – broad spectrum Initial therapy – broad spectrum topicaltopical

Antibiotics, (Antibiotics, (no organisms in slide smear)no organisms in slide smear) Fluoroquinolones include ciprofloxacin, Fluoroquinolones include ciprofloxacin,

ofloxacin, moxifloxacin or gatifloxacin.ofloxacin, moxifloxacin or gatifloxacin. Fortified Tobramycin 1 drop every hour Fortified Tobramycin 1 drop every hour

alternating with.alternating with. Fortified Cefazolin 1 drop every hour.Fortified Cefazolin 1 drop every hour. Fortified Vancomycin eye drops – reserved Fortified Vancomycin eye drops – reserved

drugdrug

TreatmentTreatment

The frequency of antibiotic administration The frequency of antibiotic administration should be tapered off parameters: should be tapered off parameters: Decreased density of infiltrateDecreased density of infiltrate Decreased anterior chamber inflammationDecreased anterior chamber inflammation Reepithelialization of the corneal epithelialReepithelialization of the corneal epithelial Improvement in painImprovement in pain

Corneal Ulcer, Bacterial, Under Treatment No longer hypopyon, thus indicating effective antiinfectious therapy.

TreatmentTreatment

Cycloplegic agents – atropine, Cycloplegic agents – atropine, Homatropine, CyclopentolateHomatropine, Cyclopentolate Relieve ciliary spasmRelieve ciliary spasm Prevent synechiaePrevent synechiae

Oral pain medicationsOral pain medications Oral antibiotics – scleral expansionOral antibiotics – scleral expansion Repeated scrapingRepeated scraping

ComplicationsComplications

Descematocele Descematocele Perforation – iris prolapse Perforation – iris prolapse Pseudocornea Pseudocornea Secondary glaucoma Secondary glaucoma Anterior capsular cataract Anterior capsular cataract Spontaneous expulsion of lens and Spontaneous expulsion of lens and

vitreousvitreous EndophthalmitisEndophthalmitis

Descemetcele, Old

In the center the tissue has melted away and a Descemetocele has developed.

Treatment of Treatment of complicated ulcerscomplicated ulcers

Perforated ulcers – Perforated ulcers – Firmly applied bandage; Bandage contact Firmly applied bandage; Bandage contact

lenses lenses forced expiration avoided forced expiration avoided Tissue adhesives Tissue adhesives antiglaucomasantiglaucomas Corneal transplant Corneal transplant

Secondary glaucoma – iv mannitol/ Secondary glaucoma – iv mannitol/ Acetazolamide; Topical antiglaucomasAcetazolamide; Topical antiglaucomas

Late management – Corneal grafts; Late management – Corneal grafts; Cosmetic CL; TattoingCosmetic CL; Tattoing

Perforated Corneal Ulcer, Keratoplasty