Corneal ulcer

Cornea

• Classification • Location-superficial /deep• Etiology – infectious,immune mediated,

degenerative, neoplastic, traumatic • Infectious/ non infectious• Ulcerative/ non ulcerative

• A 65year old sweeper comes with history of • Decreased vision• Pain, foreign body sensation• Photophobia• Whiteness of the cornea• Watering and discharge

• h/o ? Dust entering his eye

Signs Lid swelling Diffuse Conjunctival

congestionCiliary congestion Ulcer with raised edges, Poorly defined margin, Slough in the floor, Hypopyon

Hypopyon

Diff Conj Congest

infiltrateEpithelial defect

HYPOPYON

• Bacterial ulcer – sterile hypopyon• Iritis• Outpouring of leucocytes which gravitate to the

bottom of the ant chamber• Mobile• Depends on • Virulence of organisms – Pneumococcus, Pseudomonas• Resistance of host

Hypopyon corneal ulcer

• Organism- pseudomonas pyocyanea, pneumococci

• Ulcus serpens- creep over the cornea in a serpiginous fashion

• One end there is cicatrization and other end active infiltration.

• Perforation likely.

Stages of corneal ulcer

• Progressive

Regressive

Cicatrization Leucocytic infiltration

PMN leucocytic infiltration

vascularisation

Management

Investigations

• Ocular:• Corneal scraping- • Staining-Grams, Giemsa, KOH, • C/S-blood agar, chocolate

agar, SDA• Syringing

• Digital tonometry*• Systemic-• Blood sugars, BP, r/o use of

steroids

Treatment • Specific:• Broad spectrum topical

antibiotics hourly• (quinolones and fortified

aminoglycocides)• Non specific:• Cycloplegics eye drops-

Atropine 1%eye drops• Antiglaucoma- Timolol

maleate eye drops, Acetazolamide tablets

• Hygiene , heat and protection

Complications • Descematocele• Perforation• Iris prolapse• Adherent leucoma• Anterior staphyloma• Corneal fistula• Pseudocornea • Secondary glaucoma• Severe Anterior uveitis• Anterior capsularCataract• Intraocular haemorrhage• Panophthalmitis , • Phthisis bulbi Iris prolapse

Treatment of perforation

• Impending perforation-• Pressure bandage +anti

glaucoma medications• Small perforation-

Cyanoacrylate glue+contact lens

• Conjunctival graft • Large perforation-

Penetrating keratoplasty• If no cornea available-

Evisceration of the eye ball

Causes of non healing corneal ulcer

Ocular • Secondary glaucoma• Associated dacryocystitis• Presence of Foreign body,

trichiasis• Dry eye, corneal anaesthesia• Lagophthalmos,lid abnormalities• Use of topical steroids• Wrong diagnosis, wrong

treatment, poor compliance with medications.

Systemic

• Diabetes mellitus• Immunoc ompromised

state• On systemic steroids or

immuno suppresants.

Fungal corneal ulcer

• History : Injury with vegetable

matter Aspergillus, Fusarium, Candida

Symptoms

•Pain

•Redness

•Tearing

•Photophobia

•Defective vision

•Blepherospasm

signs• Signs out of proportion to

symptoms• Dry• Feathery margins• Immune ring• Satellite lesions• Endothelial plaque

• Hypopyon– immobile– Convex

Diagnosis

• History

• Microbiological investigations– KOH, Calcofluor white, Giemsa

– Sabouraud’s dextrose agar

Treatment • Specific treatment • Topical– Natamycin– Amphotericin B

• Systemic– Ketoconazole

NO CORTICOSTEROID • Therapeutic Keratoplasty• Non specific treatment

Acanthamoeba Keratitis

• Free living amoeboid protozoan• Trophozoites and cysts• Ubiquitous in nature• Found in air, soil & all water sources.

Acanthamoeba Keratitis

• Symptoms out of proportion to signs• More in contact lens wearers , sand

contamination• Epithelium initially intact• Stromal infiltrate• Ring infiltrate• Radial keratoneuritis• Limbitis

Management • Calcofluor white – cysts

• Culture – • non nutrient agar enriched with E coli

• Specific• Propamidine isothionate

0.1 %

( Brolene )• Polyhexamethylene

biguanide (PHMB) • Neomycin• Fluconazole, Micanazole• NO CORTICOSTEROIDS

• Therapeutic Keratoplasty• Non specific treatment