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