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 congestion Ciliary congestion Ulcer with raised edges, Poorly defined margin, Slough in the floor, Hypopyon
Epithelial defect infiltrate

Diff Conj Congest

Hypopyon

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

Regressive

Progressive
PMN leucocytic infiltration

Leucocytic infiltration

Cicatrization
vascularisation

Management
Investigations Treatment

Ocular:
Corneal scraping Staining-Grams, Giemsa, KOH, C/S-blood agar, chocolate agar, SDA Syringing Digital tonometry*

Specific:
Broad spectrum topical antibiotics hourly (quinolones and fortified aminoglycocides)

Non specific:
Cycloplegics eye dropsAtropine 1%eye drops Antiglaucoma- Timolol maleate eye drops, Acetazolamide tablets Hygiene , heat and protection

Systemic Blood sugars, BP, r/o use of steroids

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 perforationCyanoacrylate glue+contact lens Conjunctival graft Large perforationPenetrating keratoplasty If no cornea availableEvisceration 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 Specific Propamidine isothionate 0.1 %
( Brolene )

Culture
non nutrient agar enriched with E coli

Polyhexamethylene biguanide (PHMB) Neomycin Fluconazole, Micanazole NO CORTICOSTEROIDS Therapeutic Keratoplasty Non specific treatment