Corneal ulcer

Corneal ulcers

• Discontinuation in normal epithelial surface of cornea associated with necrosis of the surrounding corneal tissue

• It can be:• Bacterial corneal ulcer• Fungal corneal ulcers• Viral corneal ulcers• Protozal corneal ulcers

Causative agent Bacterial Fungal Viral Protozoal Staphylococcus aureus

FILAMENTOUS

YEAST HSV I Acanthamoeba

Pseudomonas pyocyanea

Fusarium Candida HSV II

Streptococcus pneumoniae

Alternaria Cryptococcus

E. Coli PenicilliumN. Meningitidis Aspergillus

N. GonorrhoeaCornybacterium diphtheriae

Pathophysiology(Bacterial) Stage of progressive infiltration• Lymphocytes infiltrates in epithelium• Necrosis

Stage of active ulceration• Greyish infiltration with circumcorneal

hyperaemia• Hypopyon and descemetoceleStage of regression• Phagocytosis • Ulcers begin to heal

Stage of cicatrization• Epithelium covers the ulcers• Scars and opacities formation

Bacterial ulcer

Pathophysiology (Fungal) ▫Severe inflammatory response ▫Stromal necrosis▫Filamentous fungi can penetrate the intact

Descement’s membrane▫Corneal perforation

Fungal ulcer

Risk factors▫CL wearers▫Trauma▫Ocular surface diseases ▫Immuno-compromised diseases▫Trauma with vegetable matter▫Diabetes▫Injury with animal tail

Symptoms Pain Photophobia Blurred vision Discharge Foreign body sensation Watering Redness

Signs Bacterial Fungal Viral Protozoal Swelling of lids Dry greyish-white

stromal infiltratePunctate epithelial keratitis

Irregular and greyish eipthelial surface

Blepharospasm Elevated rolled out margins

Dendritic ulcers Epithelial pseudodendrites

Conjunctival chemosis Satellite lesion Geographical ulcers Focal anterior stromal infiltrates

Conjunctival hyperaemia Yellowish-white infiltrate Virus-laden cells at margin of ulcer stain with rose bengal stain

Radial keratoneuritis

Ciliary congestion Dense suppuration Reduced corneal sensation

Enlargement and coalescence of infiltrates from ring abscess

Greyish-white circumscribed infiltrate

Hypopyon Scleritis may develop

Yellowish-white oval/irregular area of ulcer

Corneal melting stromal necrosis

Stromal oedemaHypopyonCorneal perforationEndophthalmitis

Dendritic ulcer

Superficial punctate keratitis

Hypopyon

Acanthamoeba keratitis

Corneal oedema

Endophthalmitis

Geographic ulcer

Satelite lesion

features Mild Moderate Severe

Size < 2 mm 2-5 mm > 5 mm

Depth of ulcer < 20% 20-50% > 50%

Stromal infiltrate

Dense Superficial

Dense upto mid stroma

Dense deep stromal

Scleral involvement

- - present

Grading of corneal ulcers

Grading Grade AC cellsGrade 0 NoneGrade 1 1-15 cellsGrade 2 15-25 cellsGrade 3 > 25 cells

Grade Aqueous flares

Grade 0 Absent

Grade 1 Mild (barely detected)

Grade 2 Moderate (iris and lens seen)

Grade 3 Severe (iris and lens not seen)

Grade Corneal oedema

Grade 0 Absent

Grade 1 Mild

Grade 2 Moderate

Grade 3 Severe

Grade Conjunctival congestion

Grade 0 None

Grade 1 Mild (some vessels injected)

Grade 2 Moderate (diffusely injected)

Grade 3 Severe (intensely injected)

Treatment Bacterial Fungal Viral Protozoal Topical antibiotics:Ciprofloxacin Vancomycin Ofloxacin Moxifloxacin

Removal of eithelium Antiviral agent:Acyclovir e/d (3%)Gancyclovir e/d (0.15%)Trifluorothymidine e/d (1%)

Antiamoebic agentPropamidine isoethionate (0-1%)Polyhexamethylene biguanide (0.02%)

Ciprofloxacin Clotrimazole Miconazole

Oral antibiotics:T. Ciprofloxacin

Topical-Filamentous: Natamycin (5%)Econazole (1%)Amphotericin B (0.15%)Miconazole (1%)

Debridement For dendritic ulcers

Debridement

Mydriatics:Atropine (1%) cyclopentolate (1%)

Candida:Econazole (1%)Natamycin (5%)Fluconazole (2%)Clotrimazole (1%)

Oral ketoconazole (200mg)

Topical steroids: Subconjunctival fluconazole

Systemic antifungals:Itraconazole (100mg)Voriconazole (100mg)

Excisional penetrating keratoplasty

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