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    CORNEAL ULCERS

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    1 : CORNEAL ULCER KARTIKEY SINGH RUTHRAZ’09 KMC, CHENNAI
    2 : Corneal ulcer A corneal ulcer, or ulcerative keratitis, or eyesore is an inflammatory or more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma
    3 : DEFINITION Corneal ulcer is definied as discontinuation of normal epithelial surface of cornea associated with necrosis of surrounding corneal tissues. It is characterised by edemaand cellular infiltration.
    4 : BACTERIAL CORNEAL ULCER
    5 : Bacterial corneal ulcer Etiology Damage to corneal epithelium Infection of eroded area CLINICAL FEATURES: Depends on virulence of organism, its toxins and enzymes and the response of host tissue
    6 : Causative bacteria Staphylococcus aureus and streptococcus pneumoniae Pseudomonas Gonococcus E. Coli Proteus Klebsiella N. Gonorrhea and N. meningitidis C. diptheriae
    7 : BACTERIA THAT CAN INVADE INTACT EPITHELIUM N. gonorrhoeae Corynebacterium diphtheriae N. meningitidis
    8 : Pathogenesis The development corneal ulcer is in 4 stages: STAGE of Progressive Infiltration >>Vasodilation >>Polymorphs >>Lymphocyte Infiltrates 2. STAGE of Active Ulceration >>Necrosis >>Ulcer Borders thickening due to infiltrates and edema
    9 : >>Descemet’s Folding >>Circum Corneal Congestion STAGE of Regression: >> Decrease in necrosis >>Decrease in infiltrates >>Removal Of debris by macrophages. 4. STAGE of Cicatrisation >>Fibroblast Deposition >>Connective Tissue deposition. Then Scar formation occurs.
    10 :
    11 : Signs Edema of lids Corneal edema Descemet’s folding Hypopyon Koppes Nodules And Bussaca’s Nodule Descemetocele (Keratocele) Marked blepharospasm Conjunctival chemosis Corneal Epithelial defect Yellowish white area of ulcer, oval or irregular in shape Margins are swollen & over hanging Floor covered with necrotic material
    12 : Muddy iris Small pupil Stromal edema Increased IOP
    13 : Symptoms Pain Photophobia Redness Watering Congestion Defective Vision Foreign Body Sensation
    14 : Signs And Symptoms
    15 : HYPOPYON CORNEAL ULCER THE CHARACHTERISTIC HYPOPYON ULCER CAUSED BY PNEUMOCOCCUS IS ALSO CALLED AS ULCER SERPENS. SOURCE OF INFECTION: >>USUALLY CHRONIC DACROCYSTITIS.
    16 : PREDISPOSING FACTORS Decreased resistance of tissues Virulence of organism. Older age Debiliated diseases Alcoholic
    17 : CHARACHTERISTIC FEATURES Ulcer serpens is greyish white or yellowish disc shaped ulcer occuring near center of cornea. Creeps over cornea in serpiginous fashion. Violent iridocyclitis is often associated with it. Increases in size very rapidly and leads to SECONDARY GLAUCOMA. Spreads rapidly and has great tendency for PERFORATION.
    18 : BACTERIAL ULCER WITH HYPOPYON HYPOPYON.
    19 : Marginal Catarrhal Ulcer These superficial ulcers are frequently seen in old patients which are found near the limbus. ETIOLOGY: Hypersensitivity to styphylococcal toxins Association with chronic staphylococcal blepharoconjunctivitis. Sometimes Moxarella and Hemophilus species.
    20 : CLINICAL FEATURES: Ocular irritation, pain. Photophobia and watering Shallow, slightly infiltrated and often multiple ulcer. Vascularisation followed by resolution. TREATMENT: Topical corticosteroids + Antibiotics Treatment of associated blepharitis and chronic conjunctivitis.
    21 : CLINICAL EVALUATION LABORATORY INVESTIGATION TREATMENT MANAGEMENT
    22 : Ocular examination Diffused light examination Regurgitation test and syringing Biomicroscopic examination (staining with 2% fluorescein dye)
    23 : BRILLIANTLY FLUORESCIN GREEN COLOUR APPEARANCE WHEN VIEWED IN COBALT BLUE FILTER.
    24 :
    25 : Laboratory investigation Blood CP, ESR, Blood Sugar and Urine DR Microbiological investigation (scrapping from the margins of the ulcer under LA) Gram and Giemsa stain (gram +ve ) 10% KOH (fungal hyphae) Blood agar culture.
    26 : Treatment Specific treatment for the cause Non specific supportive therapy Physical and general measures
    27 : 1. Specific treatment a. Topical antibiotics Ciprofloxacin (0.3%) Ofloxacin (0.3%) b. Systemic antibiotics Ciprofloxacin (750 mg)
    28 : 2. Non specific treatment Cycloplegic drugs 1% atropine ointment 2% homatropine eye drops Systemic analgesics & NSAIDS Vitamin A,B,C
    29 : 3. Physical & general measures Dark goggles Rest, good diet and fresh air Hot fomentation
    30 : Treatment of impending perforation No stain Pressure bandage Lowering of IOP Tissue adhesive glue (cynoacrylate) Conjunctival flap Soft contact lens Bandage Penetrating keratoplasty
    31 : Treatment of non healing ulcer Removal of any known cause. ->LOCAL ->SYSTEMIC Mechanical debridement of ulcer. Cauterisation of ulcer. Bandage soft contact lens Peritomy
    32 : Treatment of perforated corneal ulcer Depends on the size of perforation availability of glues Conjunctival flap Soft bandage Keratoplasty
    33 : MYCOTIC CORNEAL ULCER
    34 : Mycotic corneal ulcer Etiology Filamentous fungi (Aspergillus, fusarium) Yeast (Candida & cryptococcus ) Mode of infection Injury by vegetative material Injury by animal tail. Secondary fungal ulcers basically in immunocompromises patients.
    35 :
    36 : SIGNS. Dry looking, Greyish white Delicate feathery finger like projection. A strerile immune ring (yellow line of demarcation) Multiple small satellite lesion Big hypopyon Rarely perforation can occur. NO CORNEAL VASCULARISATION. (5* point)
    37 : Diagnosis of MCU Clinical manifestation Laboratory investigations with wet KOH, and giemsa stain Treatment: 1. Specific: Topical antifungal (fluconazole 2%, Nystatin 3.5 % ointment) Systemic tab fluconazole 2-3 wks 2. Non specific treatment : Same as bacterial 3. Therapeutic penetrating keratoplasty in nonresponsive cases.
    38 :
    39 : VIRAL CORNEAL ULCER
    40 : VIRAL CORNEAL ULCERS Most of the viruses effect the epithelium of both conjunctival and corneal Hence typical viral lesions constitute the viral kerato conjunctivitis
    41 : Common viral infections Herpes zoaster virus Herpes simplex virus Mode of infection (HSV1 - By kissing, HSV2 – infected genitalia of mothers to the neonates )
    42 : OCULAR LESION OF Herpes simplex. PRIMARY HERPES Conjunctiva-acute follicular conjunctivitis Fine epithelial punctate keratitis Coarse epithelial punctate keratitis Dendritic ulcer.
    43 : RECURRENT HERPES Active epithelial keratitis (punctate epithelial keratitis, dendritic ulcer, Geographical ulcer) Stromal keratitis (Desciform keratitis, diffuse stromal necrotic keratitis) Meta-herpetic keratitis Herpetic iridocyclitis.
    44 : DENDRITIC CORNEAL ULCER.
    45 : HERPES ZOSTER OPHTHALMICUS It’s a acute inflammation of Gasserian ganglion of5th cranial nerve by VZV. CLINICAL FEATURES: Frontal nerve is more frequently affected than lacrimal and nasociliary HUTCHINSON’S RULE: which says ocular involvement is frequent when side of nose or tip presents the vesicles Strictly limited to one side of mid line of head
    46 : CLINICAL PHASES: Acute (totally resolves in few weeks) Chronic (persists for years) Relapsing (where acute and chronic lesions reappear sometimes later)
    47 : HERPES ZOSTER OPHTHALMICUS.
    48 : ACANTHAMOEBA KERATITIS Patient comes wih a complaint of blurred vision and pain. Caused by Acanthamoeba castellani. Most common in Contact lens users. Also by oppurtunistic infection. SYMPTOMS: Asymptomatic to foreign body sensation. mild to severe pain watering, photophobia. Blepharospasm and Blurred vision.
    49 : SIGNS: Initial Lesion: limbitis radial keratoneuritis epitheliopathy Adwanced Cases: Patchy stromal infiltrates Sattelite infiltrates Central or paracentral rings Severe cases: Ring abscess Hypopyon and stromal necrosis
    50 :
    51 : Investigation CULTURE: In non nutrient Agar. STAINING: Using Periodic Acid Schiff Calcofluor white. Confocal microscopy Lactophenol cotton blue staining.
    52 : TREATMENT OF ACANTHAMOEBA KERATITIS Debridement Topical Amoebicides Topical Steroids NSAID’s for pain control Keratoplasty in adwances cases.
    53 : TROPHIC CORNEAL ULCER
    54 : NEUROTROPHIC KERATOPATHY Occurs due to decreased corneal sensation wind to sensory innervation damage. CAUSES Congenital (Riley Day syndrome, CIPA and Anhydrotic ectodermal dysplasia) Acquired (Alcohol block, neoplasm pressing gasserian ganglion, infection of gasserian ganglion, syphilitic neuropathy and injury to gasserian ganglion)
    55 : SYMPTOMS: Red eye swollen eyelid and defective vision Pain is not associated SIGNS: Ciliary congestion Corneal sensation decreased Dull sheen Punctate epithelial erosion. Frank epithelial defect. Corneal ulcer formation.
    56 :
    57 : EXPOSURE KERATOPATHY It occurs when cornea is constantly exposed to outside environment due to insufficient closure of eyelid CAUSES: Extreme proptosis Bell’s palsy (Lagophthalmos) Ectropion Symblepharon causin lagophthalmos Deep coma Physiological lagophthalmos.
    58 : SYMPTOMS: Ocular irritation Burning and foreign body sensation Redness (symptoms usually worse in morning) SIGNS: Drying of cornea Punctate epithelial defect Corneal ulceration.
    59 :
    60 : PERIPHERAL ULCERATIVE KERATOPATHIES PERIPHERAL ULCERATIVE KERATITIS ASSOCIATED WITH CONNECTIVE TISSUE DISORDERS MOOREN’S ULCER (also c/a Chronic serpiginous or rodent ulcer) ROSACEA KERATITIS (approx. 10% of cases of acne rosacea which is a disease of sebaceous gland of skin) MARGINAL KERATITIS (CATARRHAL ULCER) (due to staphylococcal hypersensitivity) TERRIEN MARGINAL DEGENERATION.
    61 : MOOREN’S ULCER.
    62 : ROSACEA KERATITIS.
    63 : PERIPHERAL ULCERATIVE KERATITIS
    64 : Healing of corneal ulcer When an ulcer has become vascularised, cicatrization occurs which is carried out by the regeneration of collagen and the formation of fibrous tissue Bowmans membrane is never regenerated
    65 : Complications Toxic iridocyclitis Secondary glaucoma Descematocele Perforation of corneal ulcer Prolapse of iris Subluxation of lens Anterior capsular cataract Corneal fistula Purulent uveitis, endophthalmitis Intraocular hemorrhage
    66 : Complicated Corneal Ulcer
    67 : Perforated Corneal Ulcer
    68 : Healed Keratocele
    69 :
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