CORNEAL

ULCER

DR MAY DSOUZA
ANATOMY AND PHYSIOLOGY
• Corneal diameter-H- 11.7mm& V-10.6mm
• Ant Curvature - 7.8mm
• Corneal thickness- 0.5-0.6mm in center &
1.2 in the periphery
• RI - 1.38
LAYERS OF
CORNEA
• EPITHELIUM
• BOWMAN’S MEMBRANE
• STROMA
• DESCEMET’S MEMBRANE
• ENDOTHELIUM
TRANSPARENCY OF CORNEA
• AVASCULARITY

• REGULAR ARRANGEMENT OF COLLAGEN FIBRILS

• LOSS OF MYELIN SHEATH

• RELATIVE DEHYDRATION DUE TO ENDOTHELIAL PUMP ACTIVITY

• ROLE OF TEAR FILM

DEFINITION

• A corneal ulcer is a corneal epithelial defect with underlying inflammation usually

due to invasion by bacteria, fungi, viruses, or Acanthamoeba
CORNEAL INFLAMMATION
(KERATITIS)
• Ulcerative and Non ulcerative

• Infective

Bacterial
Viral
Fungal
Chlamydial
Protozoal
Spirochetal
• Allergic • Non ulcerative
Superficial
• Trophic Deep
Exposure Non suppurative
Neurotrophic Interstitial
Disciform
• Traumatic Sclerosing
• Keratitis associated Suppurative
with skin and mucous
membrane diseases
• Keratitis associated with
collagen vascular disorders
BACTERIAL CORNEAL ULCER
• AETIOLOGY
• Usually Exogenous
• Staph Aureus & Albus
• Pneumococcus
• N Gonorrhoeae
• Pseudomonas
• E Coli,Proteus,Klebsiella
Pathogenesis and pathology
• Minute abrasions-> damage to epith
• Stage of Progressive infiltration
• Stage of active ulceration
• Stage of regression
• Stage of healing (Cicatrization)
SYMPTOMS AND SIGNS
• Pain • Lid swelling
• Discharge • Conjunctival
• Diminished vision congestion

• Redness of eye • Corneal signs

• Photophobia
• CORNEAL SIGNS
• Yellowish white ,oval densely
opaque ulcer with clear
surrounding cornea in Staph and
Strepto
• Irregular ulcer with thick
mucopurulent discharge,greenish
in Pseudo

• Shallow ulcer with greyish white

pleomorphic suppuration in
enterobacteria
Other signs

• Hypopyon in AC

• Iris changes
COMPLICATIONS
Scarring-.Ectatic cicatrix
Nebula,Macula Leucoma
Keratocoele or Descemetocele
Perforation
Ant synechae
Iris prolapse
Ant staphyloma
Endophthalmitis
Pseudocornea
IO Hge
Sec Glaucoma and toxic Iridocyclitis
• Investigations
• Staining of Ulcer
• Corneal scraping from edges
and base of ulcer
• Culture of scrapings in blood
agar, chocolate agar,
thioglycolate broth >ABST
• KOH mount
• Sabourad’s agar media for
fungus
• Gram stain Giemsa stain for
morphology of cells
TREATMENT
• CONTROL OF INFECTION
• SYMPTOMATIC RELIEF
• CLEANLINESS
• REST
• PROTECTION
CONTROL OF INFECTION
• Antibiotic drops
-Frequent admn
-Guided by staining
-Reduce frequency after epithelial
healing
-Start with broad spectrum, then
change according to ABST
• Moxifloxacin 0.5%
• Gatifloxacin
• Ciprofloxacin 0.3% hrly
for 48 H, then 2-4hrly,
After epith healing 4-
6hrly
• Tobramycin 1.4%
• Fortified antibiotic drops OTHER MEASURES

Cephazolin 5% • Role of bandaging

Vancomycin 5%
• Role of local heat
Gentamycin 1.4%
• Role of NSAIDs
• Symptomatic relief & Rest
• Cycloplegics
1% Atropine drops-> ensure
dilatation then maintain it with
short acting cycloplegics
HYPOPYON CORNEAL ULCER
AETIOLOGY
• Staphylococcus • Source of infection
• Streptococcus • FB
• Gonococcus • Old age
• Moraxella • Debility
• Pseudomonas • Alcoholism
• Pneumococcus
• CLINICAL FEATURES
• Ulcus serpens
Creeping ulcer-Greyish white or yellowish disc,
greater at edges,cornea lustreless, tendency for
perforation

• Hypopyon in AC
Change in position
NON HEALING ULCER
• Causes
-Local : IOP, Cilia, Concretions, Infections of sac, FB wrong diagnosis, inadequate
therapy, drug toxicity
-Systemic : DM, Malnutrition, Immunocompromise
TREATMENT
• Mechanical debridement
• Cauterisation->10-20%Trichloroacetic acid
• Keratoplasty
TREATMENT OF PERFORATED ULCER
• Rest, AB, Cycloplegics, Pressure bandage, BCL
• Avoid all forced expiration
• Tissue adhesives
• Treat raised IOP
• Keratoplasty
FUNGAL CORNEAL ULCER
ETIOLOGY
• Filamentous fungi
Aspergillus, Fusarium,
• Yeasts
Candida Albicans,
• Vegetative injury
• Immunosuppression
• Dry eye, Bullous keratopathy
• Role of Steroids
CLINICAL FEATURES
• Symptoms milder than signs
• Slowly progressive
• Dry leathery surface
• Greyish white
• Feathery extensions
• Yellow line of demarcation
• Hypopyon
Thick and immobile
Not sterile
• Endothelial plaque
• Satellite lesions
INVESTIGATIONS
• KOH Mount
• Giemsa stain of corneal scraping
• Culture on Sabourad’s agar
• Methanamine silver staining
• High degree of suspicion
TREATMENT
•Same Principles • Triazoles
Fluconazole 0.2-2%
•Anti fungals Iatraconazole 1%
Polyenes 100-200mg BD
Natamycin 5% Suspension
Amphotericin B 0.1-0.25%
• Fluorinated Pyrimidines
Nystatin suspension 1000000 units/G Flucytosine 1-2%
•Imidazoles 50-150mg/kg BD
Clotrimazole 1%
Ketoconazole 5%
Keratoplasty
300mg/day
Therapeutic
Miconazole 1%
THANK YOU